Qatar Foundation Annual Research Conference Proceedings Volume 2014 Issue 1

Abstract Introduction Bleeding is a common complication after cardiac surgery. However, lower gastrointestinal bleeding is not usually associated with this type of surgery. Case presentation A 50-year-old man with a history of aortic regurgitation underwent elective mechanical valve replacement under cardiopulmonary bypass. He experienced a complicated intraoperative course involving unexplained cardiac arrest following induction of anesthesia. He also developed two episodes of massive lower gastrointestinal bleeding secondary to mucosal ischemia while convalescing in the cardiothoracic surgery intensive care unit. After unsuccessful attempts to control the bleeding, exhaustion of blood products, and consideration of the high risk of mortality associated with surgery and the possibility of early- and long-term surgical complications, the decision was made to administer two successive doses of recombinant activated factor VII at 60 mcg/kg. Hemostasis was achieved without adverse systemic or valvular effects. Conclusions A favorable outcome was achieved after administration of recombinant activated factor VII, which controlled the patient's severe lower gastrointestinal bleeding. This outcome suggests the need to raise awareness about the use of this drug in dire circumstances when other conventional measures fail or are unsuitable.

Introduction: Intractable bleeding is one of common adverse events after cardiac surgeries. Recombinant activated factor VII (rVIIa) showed efficiency in controlling postoperative intractable bleeding (1). Its usage after cardiac surgeries should be more investigated. Patients and methods: - All patients received rVIIa post cardiac surgeries over a period of two years were included in a retrospective descriptive study. All patients were evaluated for base line laboratory results and comorbidities, operative details, dose of rVIIa received, total chest drains pre and post rVIIa administration, total blood and blood products given pre and post rVIIa, post rVIIa laboratory results, complications of rVIIa, length of stay in intensive care unit. Results: -. We recruited 19 patients with a mean age of 49±18 years who received RVIIa in a dose of 90 mcg/kg. Packed red blood cells transfusion post rVIIa administration was decreased from mean of 10±6 units to 3.7±1.7 units P<0.0001. Chest drains post rVIIa administration were decreased from median of 2000 ml and IQR of 1200 to median of 500 ml and IQR of 500 P<0.1 .No complications related to rVIIa administration were observed. Discussion: - The study highlight the following findings: Efficiency and safety of rVIIa in the control of intractable bleeding post cardiac surgeries. Usage of rVIIa saves blood bank resources, decreases the need of surgical reopening and decreases morbidity. More studies needed to elaborate clinical guidelines for the usage of rVIIa in the management of intractable bleeding post cardiac surgeries. Conclusion: - There is increase need for clinical guidelines for the usage of rVIIa post cardiac surgeries. In our experience at Qatar heart hospital recombinant activated factor VII is safe and efficient treatment to control intractable bleeding post cardiac surgeries. Reference: - (1) Conrad V. Bishop, William E.P. Renwick, Chris Hogan, Michael Haeusler, Annabel Tuckfield and James Tatoulis: Recombinant Activated Factor VII: Treating Postoperative Hemorrhage in Cardiac Surgery. Ann Thorac Surg 2006; 81:875-879.

Background: Small RNAs play an essential role in fundamental biological processes such as differentiation, proliferation, apoptosis and homeostasis. Evidence suggests that small RNAs may also play function in Cancer progression. The conventional in-vitro two-dimensional (2D) monolayer cell culture models are not sufficient to explain the exact mechanism behind tumor invasion and metastasis. The objective of this study is to analyze the role of small RNAs in tumor invasion and metastasis using in vitro 2D and anchorage independent (3D) models in ovarian cancer cell lines. Methods: Total RNA samples were isolated from several 2D and 3D ovarian cancer cell lines. Small RNA libraries were prepared and sequenced using Next-Generation Sequencing. Results: Gene expression levels of 3D culture differ from 2D culture, especially in epithelial and mesenchymal target genes. We were able to identify the predominant pathways that small RNAs regulate in 3D cultures. These pathways were involved in cellular invasion, migration, metastasis, proliferation, and tumor growth. Conclusion: The Results from this experiment suggest that small RNAs play a crucial role in controlling tumor invasion and metastasis in the studied phenotypes. Therefore, small RNAs may offer a critical target for the development of anti-cancer drugs.

Background and Objective: In the Middle East and North Africa, hepatitis C virus (HCV) infection distribution appears to present a wide range of prevalence. The scale and nature of HCV infection exposure in Yemen is poorly known. The objective of this study was to establish the national population-level HCV prevalence in Yemen and to characterize the epidemiology of this infection in the Yemeni population. Methods: We conducted a systematic literature review following the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Sources of data included PubMed and Embase databases. Our analysis included all primary studies reporting HCV antibody prevalence or incidence measures in Yemen. Extracted measures were then classified and analyzed on the basis of the study population's risk of acquiring HCV. Meta-analyses were conducted incorporating inverse variance weighting and using a random-effects model to pool summary estimates of HCV prevalence among general population groups. Results: We identified 28 studies providing a total of 46 measures on HCV prevalence and none on incidence in Yemen. Pooled HCV prevalence in the general population was 1.8% (95% confidence interval (CI): 1.05-2.75). Among blood donors the prevalence ranged from 0.2 to 3.0% depending on governorate of origin. The highest prevalence within the general population groups was reported among pregnant women in one study (8.5%) followed by a study of African migrant community living in a Shanty town in Sana'a (5.2%). Among high risk populations, HCV prevalence among hemodialysis patients was 40.0% in 1999 and 62.7% in 2007. Among patients with acute and chronic liver disease it was 74.1%. Conclusions: National-level HCV prevalence in Yemen is slightly higher than that in developed countries, but comparable to several other countries in the Middle East and North Africa. The high prevalence found among high risk groups may indicate limitations in implementation of infection control and blood screening protocols, or possibly dates back to exposures before these measures were expanded. These findings are of particular relevance for resource allocation and HCV public health programming in Yemen. HCV prevention policy in Yemen should focus mainly on prevention and infection control in settings of exposure such as in medical care and among people who inject drugs.

Background It is widely perceived that little is known about the epidemiology of HIV infection among people who inject drugs (PWID) in the Middle East and North Africa (MENA). The primary objective of this study was to assess the status of the HIV epidemic among PWID in MENA by describing HIV prevalence and incidence. Secondary objectives were to describe the risk behavior environment and the HIV epidemic potential among PWID, and to estimate the prevalence of injecting drug use in MENA. Methods This was a systematic review following the PRISMA guidelines and covering 23 MENA countries. PubMed, Embase, regional and international databases, as well as country-level reports were searched up to December 16, 2013. Primary studies reporting 1) the prevalence/incidence of HIV, other sexually transmitted infections, or hepatitis C virus (HCV) among PWIDs; or 2) the prevalence of injecting or sexual risk behaviors, or HIV knowledge among PWID; or 3) the number/proportion of PWID in MENA countries, were eligible for inclusion. The quality, quantity, and geographic coverage of the data were assessed at country level. After multiple level screening, 192 eligible reports were included in the review. There were 197 HIV prevalence measures on a total of 58,241 PWID extracted from reports, and an additional 226 HIV prevalence measures extracted from the databases. Findings We estimated that there are 626,000 PWID in MENA (range: 335,000-1,635,000, prevalence of 0.24 per 100 adults). We found evidence of HIV epidemics among PWID in at least one-third of MENA countries, most of which are emerging concentrated epidemics and with HIV prevalence overall in the range of 10-15%. Some of the epidemics have however already reached considerable levels including some of the highest HIV prevalence among PWID globally (87.1% in Tripoli, Libya). The relatively high prevalence of sharing needles/syringes (18-28% in the last injection), the low levels of condom use (20-54% ever condom use), the high levels of having sex with sex workers and with men who have sex with men (15-30% and 2-10% in the last year, respectively), and of selling sex (5-29% in the last year), indicate a high injecting and sexual risk environment. The prevalence of HCV (31-64%) and of sexually transmitted infections suggest high levels of risk behavior indicative of the potential for more and larger HIV epidemics. Conclusions Our study identified a large volume of HIV-related biological and behavioral data among PWID in the MENA region. The coverage and quality of the data varied between countries. There is robust evidence for HIV epidemics among PWID in multiple countries, most of which have emerged within the last decade and continue to grow. The lack of sufficient evidence in some MENA countries does not preclude the possibility of hidden epidemics among PWID in these settings. With the HIV epidemic among PWID in overall a relatively early phase, there is a window of opportunity for prevention that should not be missed through the provision of comprehensive programs, including scale-up of harm reduction services and expansion of surveillance systems.

Background: Type II Diabetes Mellitus (DM) is one of the leading chronic diseases in Qatar as well as worldwide. However, the risk factors for DM in Qatar and their prevalence are not well understood. We conducted a case-control study with the specific aim of estimating, based on data from outpatients with DM in Qatar (cases) and inpatient/outpatient controls, the association between demographic/lifestyle factors and DM. We also estimated the contribution of these factors to the occurrence of DM cases among Qatari nationals and non-Qatari expatriate population. Methods: A total of 459 patients with DM from Hamad Medical Corporation Hospital (HMC) outpatient adult diabetes clinics and 342 control patients from various outpatient clinics and inpatient departments at HMC were identified using rigorous sampling methodologies and recruited between the years 2006 and 2008. The association between risk factors and DM was evaluated using bivariate and multivariate logistic regression analyses, and for the population at large and for only Qatari nationals. In addition to odds ratios (OR) and 95% confidence intervals (95% CI), we calculated the population attributable risk fractions for demographic and lifestyle factors in relation to DM. Results: Qatari nationality was the strongest risk factor for DM (adjusted OR=5.5; 95% CI=3.5-8.6), followed by higher monthly income (defined as ≥ 3000 riyals, OR=5.1; 95% CI=3.0-8.7), age > 65 years (OR=3.3; 95% CI=0.9-11.4), male gender (OR=2.9; 95% CI=1.8-4.8), obesity (body mass index ≥ 30, OR=2.2; 95% CI=1.5-3.2), no college education (OR=1.7; 95% CI=1.2-2.6), and no daily vigorous/moderate activity (OR=1.5; 95% CI=0.9-2.3). Among Qatari nationals, obesity was revealed as the main risk factor for DM (unadjusted OR=3.0; 95% CI=1.6-5.6) followed by no college education (OR=2.7; 95% CI=1.5-5.1), while consanguinity did not appear to play a major role in predicting DM (OR=1.5; 95% CI=0.8-2.8). Our findings further suggested that eliminating obesity and improving access to education could reduce DM cases by up to one third in the population at large (31.7% and 26.8%, respectively) and up to half (46.9% and 49.3%, respectively) among only Qatari nationals. Promoting physical activity may as well reduce the burden of DM by up to 9.4% in the population at large and up to 17.3% among Qatari nationals. Conclusions: Demographic and lifestyle factors were revealed as the main risk factors for the high DM levels observed in Qatar, with a contribution that appears to outweigh that of genetic risk factors. While further evaluation of these factors among the Qatari population (as opposed to the population at large) is important and of interest, these findings highlight the need to focus short-term DM interventions on addressing demographic and lifestyle risk factors to achieve substantial and timely declines in DM levels.

Background: Negative Pressure Wound Therapy (NPWT) is well-established in the management of infected surgical wounds. However, it is a relatively new modality of treatment for the protection of clean surgical sites. This study was aimed at developing guidelines for the use of negative pressure incision management to prevent surgical wound complications after heart surgery. Methods: In this prospective study, we included 134 patients at high risk for sternotomy wound complications from September 2011 to June 2014. Selection criteria included: obesity, diabetes, smoking and COPD, fragile sternum, bilateral mammary arteries, delayed primary closure and repeated operations. We applied negative pressure of - 125 mm Hg on the wounds of 67 patients immediately following skin closure, the dressing was removed after 5 to 7 days. The results were compared to a control group with matching criteria (n=67) who had standard dressings. The primary end point of the study was the development of wound complications including surgical site infection, hematoma formation and sternal dehiscence within 30 days. Results: 2 of the 67 patients who underwent negative pressure incision management developed superficial surgical site infection within the 30 days postoperative period (2.99%). The wound infection of the two patients settled with regular dressings and oral antibiotics. While in the control group with conventional wound dressings (n=67), 5 patients developed superficial surgical site infection and one patient suffered a deep sternal wound infection (total 6 out of 67 patients, 8.96%). Based on our experience, we have proposed some selection criteria for the use of negative pressure incision management following heart surgery (table1). Conclusions: Negative pressure is potentially beneficial in the reduction of wound complications. There are no published criteria so far for the application of negative pressure on clean surgical sites post cardiac surgery. Therefore, we proposed some guidelines for the use of negative pressure incision management to protect high risk sternotomy wounds.

Background: a 30 year old gentleman was referred to our in thoracic surgery clinic with an incidental finding of an abnormal shadow around the apical region of the heart on the chest radiograph. He was asymptomatic and non smoker and he had no chronic medical illness in the past. He had no specific findings on physical examination. Echocardiogram revealed rounded cyst in the pericardium around the hear apex measuring 5.9 by 4.1cm. Chest CT Angiography revealed no evidence of coronary artery disease. Magnetic Resonance Imaging (MRI) showed a well defined round pericardial cyst close to the left ventricular apex but there was no evidence of infiltration the left ventricle or wall abnormal enhancement. Procedure and Findings: He underwent robotic excision of the cardiac apical cyst. An inflamed 5 by 6cm cystic mass was found densely adherent to the apical pericardium. There were no adhesions or pleural effusion and the lungs and pleural surfaces were looking normal. The cyst was excised and the cavity was irrigated with hypertonic saline. A chest drain was left in the left pleural cavity. Postoperatively the patient had no complications.Bethadine diluted in normal saline was instilled into the pleural space via the chest drain for washing any remains of the infection. The drain was removed after 48hrs and the patient was discharged from the hospital on antiparasitic treatment (Albendazole tablets). Results: the patient had an uneventful recovery from surgery; he was reviewed in the clinic and had no evidence of recurrence of the disease. Histopathology report revealed laminated membranes with few protoscolices consistent with hydatid cyst (Eccinococcal infection). Conclusion : this is an unusual presentation of cystic echinococcosis (hydatid disease) which was excised robotically. Cystic Echinococcosis is a parasitic disease caused by infection with the larval stage of a tiny tapeworms of Echinococcus granulosus which usually grows in dogs (definitive host), sheep, cattle, goats, and pigs (intermediate hosts). Although most infections in humans are asymptomatic, hydatid disease can lead to the development of harmful, slowly enlarging cysts mainly in the liver and lungs. However, it might rarely affect other organs but it often remains unnoticed and neglected for years.

Rational: Heart failure is a common, costly, and frequently fatal disease. One in three cases of heart failure is due to dilated cardiomyopathy. NHE1 expression and activity are increased in this cardiac defect. We have previously shown that elevated activity of NHE1 in the cardiomyocytes induced cardiac hypertrophy in transgenic mice. However, it protected the myocardium following ischemia/reperfusion. This overexpression of active NHE1 elicited modulation of gene expression in cardiomyocytes including an up regulation of myocardial osteopontin (OPN) expression and a decrease of peroxisome proliferator-activated receptor (PPAR)γ. Since transgenic mice phenotype is very often influenced by the integration position of the transgene, we decide to create new transgenic mice to ascertain our previous data and to test the role of modulated genes. Method and results: We have created 5 new mouse lines overexpressing a constitutively active form of NHE1 specifically in cardiomyocytes (KNHE1+). We have evaluated by echocardiography the cardiac phenotypes and function of two of these new mouse lines. Then heart were harvested and submitted to histological, immunohistological and QRT-PCR analysis. Our data showed that in the both KNHE1 studied lines, a number of mice demonstrated heart remodeling identified by a significant decrease in diastolic interventricular septal (IVSd) and diastolic left ventricular posterior wall (LVPW) thickness and an increased diastolic left ventricular internal dimension (LVIDd) (see table 1). Moreover these hearts demonstrated impaired function with a decreased fraction shortening (<21 % vs 31% in wild type mouse) and ejection fraction. However, the proportion of 12 weeks old mice demonstrating this defect is different in both lines 13% (3/24) in line #4 and 58% (11/19) in line#1 vs 0% (0/37). ANP and BNP up regulation in line #1 confirmed heart suffering. Current experiment is designed to perform a longitudinal study examining evolution of these proportions with the age of the animals. Conclusions: We have developed an interesting comparative model of active NHE1 transgenic mouse lines with low and high rate dilated cardiomyopathy identifying evidence of early and late mechanisms. Further studies will be conducted to evaluate the phenotypes of the other mouse lines and the mechanism by which these changes are occuring.

The endoplasmic reticulum (ER) functions as a storehouse for intracellular calcium. STIM1, a calcium sensor, localizes mostly to the ER membrane. Following Ca2+ store depletion, STIM1 forms puncta that localize to the cortical ER and bind Orai1, a plasma membrane Ca2+ channel, to allow Ca2+ influx. This is the predominant pathway for Ca2+ influx in non-excitable cells and is referred to as Store-Operated Calcium Entry (SOCE). Mutations in STIM1 and Orai1 cause severe combined immunodeficiencies and are linked to several forms of cancers. Tight regulation of the levels of STIM1 and Orai1 is crucial for maintaining the subcellular levels of Ca2+ required for its numerous functions. We are interested in mechanisms of post-transcriptional regulation of STIM1. We have developed a system that allows us to test miRNA-mediated regulation by transfecting different cell types using a GFP and a 3'UTR transcriptional fusion and GFP with no 3'UTR as a control. mCherry expressed from the same vector is used as an internal control of transfection efficiency. The stoichiometry of GFP and mCherry levels in the experimental conditions for Stim1 3' UTR was found to be significantly different from those in the control. Knockdown of Ago2, an important mediator of the miRNA pathway, by siRNA restored GFP expression from these constructs suggesting miRNA-mediated regulation. We have identified a miRNA that regulates Stim1 expression in HEK 293 (embryonic kidney), MCF7 (non-metastatic breast cancer) but not in MDA-MB231 (metastatic breast cancer) cell lines. The mechanisms by which this occurs will be discussed.