Hussain Isma’eel

Prevalence of thromboembolic events among 8,860 patients with thalassaemia major and intermedia in the Mediterranean area and Iran

Beta-thalassaemia is a congenital haemolytic anaemia characterized by partial (intermedia, TI) or complete (major, TM) deficiency in the production of beta-globin chains. The primary aim of this study was to determine the prevalence of thromboembolic events in patients with beta-thalassaemia. To achieve this, a multiple choice questionnaire was sent to 56 tertiary referral centres in eight countries (Lebanon, Italy, Israel, Greece, Egypt, Jordan, Saudi Arabia and Iran), requesting specific information on patients who had experienced a thromboembolic event. The study demonstrated that thromboembolic events occurred in a clinically relevant proportion (1.65%) of 8,860 thalassaemia patients (TI - 24.7% or TM - 75.3%) from the Mediterranean and Iran. Thromboembolism occurred 4.38 times more frequently in TI than TM (p < 0.001), with more venous events occurring in TI and more arterial events occurring in TM. Thrombosis in thalassaemia was also more common in females, splenectomized patients and those with profound anaemia (haemoglobin <9 g/dl). Due to the increased risk of thromboembolic events, the rationale for splenectomy should perhaps be re-assessed and the role of transfusion therapy for the prophylaxis of thrombosis, among other complications, be evaluated prospectively.

Association of plaque in the carotid and coronary arteries, using MDCT angiography

OBJECTIVE Associations between various plaque types in coronary and carotid arteries using multidetector row computed tomography (MDCT) have not yet been reported. We evaluated MDCT correlation of total plaque and various plaque subtypes in carotid and coronary arteries. METHODS We studied 62 patients who had both carotid and cardiac computed tomography angiography (CTA). The plaque in each vascular segment was classified as non-calcified, calcified or mixed. RESULTS The average age of this population was 68+/-22 years, 63% males. Total plaque in the carotid artery correlated with total, calcified and mixed plaque in the coronary artery (all P<0.001). Calcified plaque in the carotid artery was associated with total and calcified plaque in the coronary bed (P<0.001). Non-calcified coronary plaque was not associated with carotid plaque. CONCLUSION Total plaque in coronary and carotid arteries are highly correlated.

Massive pulmonary embolism in a Lebanese patient doubly heterozygous for MTHFR and Factor V Leiden presenting with syncope and treated with tenecteplase

A 54-year-old man, with a past history of hypertension and non-insulin-dependent diabetes, presented to the emergency department following a collapse at home. The patient had reported to his family left calf pain after driving for several hours. The patient denied the presence of history of varicose veins, history suggestive of episodes of thrombotic events in the legs or strokes and family history was negative for thrombotic events. Thereafter the patient fell down after standing up and developed severe shortness of breath with chest compressive feeling. On examination, he was plethoric and diaphoretic, but apyrexial. His pulse rate was 115 per min and regular, with a systolic blood pressure of 60 mmHg. His respiratory rate was 28 per min, and oxygen saturation was 91% on room air. Auscultation of his lungs and heart was unremarkable, as was the examination of his abdomen. His left lower leg was noted to be 3 cm larger in diameter than the right, 3 cm below the level of the anterior tibial tuberosity. A large bore intravenous cannula was sited in each antecubital fossae. Arterial blood gas analysis (performed at the above level of oxygen supplementation) revealed a pH of 7.36, with a pCO2 of 30.6, pO2 of 60.5, and HCO3 of 17. An electrocardiogram demonstrated sinus tachycardia, with minor anterolateral ST segment depression, with T wave inversion in lead V I, an ‘SI, QIII, TIII’ pattern, and an incomplete right bundle branch block (IRBBB) (figure 1). Chest X-ray was unremarkable. A bedside ultrasound scan revealed left popliteal vein thrombosis, and a bedside echocardiography

A minimally processed dietary pattern is associated with lower odds of metabolic syndrome among Lebanese adults

Objective To (i) estimate the consumption of minimally processed, processed and ultra-processed foods in a sample of Lebanese adults; (ii) explore patterns of intakes of these food groups; and (iii) investigate the association of the derived patterns with cardiometabolic risk. Design Cross-sectional survey. Data collection included dietary assessment using an FFQ and biochemical, anthropometric and blood pressure measurements. Food items were categorized into twenty-five groups based on the NOVA food classification. The contribution of each food group to total energy intake (TEI) was estimated. Patterns of intakes of these food groups were examined using exploratory factor analysis. Multivariate logistic regression analysis was used to evaluate the associations of derived patterns with cardiometabolic risk factors. Setting Greater Beirut area, Lebanon. Subjects Adults ≥18 years (n 302) with no prior history of chronic diseases. Results Of TEI, 36·53 and 27·10 % were contributed by ultra-processed and minimally processed foods, respectively. Two dietary patterns were identified: the ‘ultra-processed’ and the ‘minimally processed/processed’. The ‘ultra-processed’ consisted mainly of fast foods, snacks, meat, nuts, sweets and liquor, while the ‘minimally processed/processed’ consisted mostly of fruits, vegetables, legumes, breads, cheeses, sugar and fats. Participants in the highest quartile of the ‘minimally processed/processed’ pattern had significantly lower odds for metabolic syndrome (OR=0·18, 95 % CI 0·04, 0·77), hyperglycaemia (OR=0·25, 95 % CI 0·07, 0·98) and low HDL cholesterol (OR=0·17, 95 % CI 0·05, 0·60). Conclusions The study findings may be used for the development of evidence-based interventions aimed at encouraging the consumption of minimally processed foods.

Sodium intake reduction efforts in Lebanon

Sodium intake reduction efforts in Lebanon are quite recent and have just started to take effect on the national level. Starting out from an academic institution, the Lebanese Action on Sodium and Health (LASH) campaign was established to counter the increasing prevalence of hypertension and associated adverse health effects. The campaigns strategy was based on four pillars: research, health communication, advocacy, and monitoring. The LASH group set out with determining: baseline sodium intake of the population, main sources of sodium intake, and the knowledge, attitudes, and behaviors (KAB) of the population as a situation analysis that prompts for action. This gave LASH tangible evidence of the magnitude of the problem and the need for the government, the food industry, and the consumers, to be mobilized to take part in devising a solution. Currently, Lebanon is at a stage of technically working to reduce the sodium content in the major sources of sodium, namely local bread and bread-like products. The next steps will include implementation of a plan for monitoring industry compliance, while studying other food targets, including dairy products and processed meat. Meanwhile, the health communication plan is ongoing and the Salt Awareness Week is celebrated every year with media appearances of LASH researchers to raise the issue to the public eye.

Discrepancies between two lipid-lowering guidelines for CVD prevention in seemingly healthy individuals-case study Lebanon.

BACKGROUND In deciding on optimal interventions for cardiovascular disease (CVD) prevention, more than one set of guidelines are available. HYPOTHESIS The aim of the study was to assess the agreement between the European Society of Cardiology (ESC) 2011 Guidelines for CVD Prevention and the Canadian Cardiovascular Society (CCS) 2009 Guidelines in recommending lipid lowering interventions in a seemingly healthy cohort of Lebanese persons. METHODS A nationally representative cohort of Lebanon was identified according to the World Health Organization (WHO) Steps Criteria. From this cohort, a group of 283 adult individuals not known to have chronic illnesses was selected. Using the algorithms present in each guideline, lipid lowering recommendations for each individual were determined. Agreement between the two guideline recommendations was determined using the Kappa test. RESULTS As per ESC, 3.9% of the participants required immediate drug therapy, 15.5% should be considered for drug therapy, and 80.1% required lifestyle intervention. As per the CCS, however, 19.4% required drug therapy. The overall level of agreement between the ESC and CCS for recommending lipid lowering was moderate (Kappa 0.77), and better in males (Kappa 0.82). In contrast, 37.5% of females recommended drug therapy as per the CCS guidelines would not be per the ESC guidelines (Kappa 0.63). CONCLUSIONS Significant discrepancies exist in recommendations for lipid-lowering therapy between CCS and ESC guidelines when applied to Lebanese individuals, particularly for women. Local healthcare authorities and the WHO should attend to this issue in order to unify treatment approaches and limit disparities in care.

Short Telomere Length is Associated with Aging, Central Obesity, Poor Sleep and Hypertension in Lebanese Individuals

In Lebanon, data stemming from national cross-sectional surveys indicated significant increasing trends in the prevalence of cardiovascular diseases and associated behavioral and age-related risk factors. To our knowledge, no data are available on relative telomere length (RTL) as a potential biomarker for age-related diseases in a Lebanese population. The aim of this study was to evaluate whether there is an association between RTL and demographic characteristics, lifestyle habits and diseases in the Lebanese. This was a cross-sectional study of 497 Lebanese subjects. Peripheral blood RTL was measured by amplifying telomere and single copy gene using real-time PCR. Mean ± SD RTL was 1.42 ± 0.83, and it was categorized into 3 tertiles. Older age (P=0.002) and wider waist circumference (WC) (P=0.001) were statistically significantly associated with shorter RTL. Multinomial logistic regression showed that subjects who had some level of sleeping difficulty had a statistically significantly shorter RTL when compared to those with no sleeping difficulties at all [OR (95% CI): 2.01 (1.11-3.62) in the first RTL tertile]. Importantly, statistically significantly shorter RTL was found with every additional 10 cm of WC [OR (95% CI): 1.30 (1.11-1.52) for first RTL tertile]. In addition, and after performing the multivariate logistic regression and adjusting for “predictors” of RTL, the odds of having hypertension or being treated for hypertension were higher in patients who had shorter RTL: OR (95% CI): 2.45 (1.36-4.44) and 2.28 (1.22-4.26) in the first RTL tertiles respectively with a similar trend, though not statistically significant, in the second RTL tertiles. This is the first study in Lebanon to show an association between age, central obesity, poor sleep and hypertension and RTL. It is hoped that telomere length measurement be potentially used as a biomarker for biological age and age-related diseases and progression in the Lebanese.

‘Longitudinal’ topics in Cardiovascular Diagnosis and Therapy (CDT)

Traditional ‘Focus Issues’ of print journals simultaneously publish several manuscripts centered on a common topic, with the goal to provide a comprehensive, timely update. In contrast to this traditional approach, publishing a series of articles focused on specific topics over extended periods of time (multiple consecutive issues) has potential advantages.

Disparity in spatial distribution of pericardial calcifications in constrictive pericarditis

Background Pericardial calcification is seen among patients with constrictive pericarditis (CP). However, the pattern of pericardial calcium distribution and the association with clinical outcomes and imaging data are not well described. Methods This was a retrospective study from 2007 to 2013 to evaluate the pattern of pericardial calcium distribution by CT in CP using a semiquantitative calcium scoring system to calculate total pericardial calcium burden and distribution. Calcium localisation was allocated to 20 regions named after the corresponding heart structure. Baseline clinical data, imaging data and clinical outcomes were collected and compared between the calcified pericardium and non-calcified pericardium groups. We assessed the effect of pericardial calcium on clinical outcomes and echocardiographic data between the two groups. Results Of the 123 consecutive patients with CP (93 male; mean age 61±13 years) between 2007 and 2013, 49 had calcified pericardium and 74 had non-calcified pericardium. Distribution of calcium on the left ventricle (LV) basal anterior, mid-anterior and apical segments in addition to right ventricle (RV) apical segment was involved in <30% of the cases with the remaining segments involved in >35% of cases. A potential protective role of RV calcium on regional myocardial mechanics was noted. Conclusion Preferential distribution of calcium in CP in a partial band-like pattern (from basal anterolateral LV going inferiorly and then encircling the heart to reach the RV outflow tract) with extension into the mitral and tricuspid annuli was noted. Pericardial calcium was not significantly associated to clinical outcomes.

Impact of a hospital-based educational intervention on dietary salt-related knowledge and behaviour in a cardiac care unit population in Lebanon

Background Cardiovascular disease is the most common cause of morbidity and mortality worldwide. Numerous strategies have been effective in reducing cardiovascular disease risk, from pharmacological approaches to lifestyle modification interventions. One of these strategies includes the reduction in dietary sodium which in turn reduces cardiovascular risk by reducing high blood pressure, perhaps the most important cardiovascular risk factor. Methods We evaluated an educational dietary salt reduction intervention in a cardiac care unit population in Lebanon, assessing salt related knowledge and behaviours before and after administering an evidence-based educational leaflet to patients. Results Salt-related knowledge improved significantly immediately post-intervention and subsequently fell on 4-week follow-up, but remained above baseline. Three of the four salt-related behaviours measured improved on 4-week follow-up: trying to buy low-salt foods increased from 54% to 74% (P=0.007), adding salt at the table reduced from 44% to 34% (P=0.03) and trying to buy food with no added salt increased from 24% to 52% (P=0.02) of the cohort. Adding salt during cooking did not differ significantly. A trend towards improved behavioural risk category in the cohort overall was observed on follow-up (P=0.07), 32% of participants were categorised as high behavioural risk pre-intervention, reducing to 17% on follow-up. Multi-ordered regression modelling identified being in the high-risk behavioural category at baseline as a predictor of being in the high-risk or moderate-risk category on follow-up. Conclusions This hospital-based educational intervention had a modestly positive impact on salt-related knowledge and behaviour, with participants in the highest behavioural risk category at baseline being most resistant to behavioural improvement.