Aboul Ella Hassanien (Abo)

n/a

BACKGROUND: Folate and methionine metabolism is involved in DNA synthesis and methylation. Polymorphisms in the genes of folate metabolism enzymes have been associated with some forms of cancer. In the present study, 2 polymorphisms were evaluated for a folate metabolic enzyme, methylene-tetrahydrofolate reductase (MTHFR), and one was evaluated for methionine synthase (MS). The 2 polymorphisms MTHFR 677 C-->T and MTHFR 1298 A-->C, are reported to reduce the enzyme activity, which causes intracellular accumulation of 5, 10- methylene-tetrahydrofolate and results in a reduced incidence of DNA double strand breakage. The MS 2756 A-->G polymorphism also reduces the enzyme activity and results in the hypomethylation of DNA.

PATIENTS AND METHODS: To test this hypothesis, genetic polymorphisms in the folate metabolic pathway were investigated using the DNA from a case-control study on 31 patients having malignant lymphoma from the Oncology Outpatient Clinic of the New Children's Hospital, Cairo University and 30 controls who were actually normal children attending for vaccination to the same hospital.

RESULTS: We found that there is a higher susceptibility with the MTHFR 677CC and MTHFR 1298 AA genotypes (OR=4.3, 95% CI 1.12-16). When those harbor at least one variant allele in either polymorphism of MTHFR they were defined as reference. For the MS 2756 AG genotype polymorphism there was also a higher susceptibility to developing malignant lymphoma (OR=2.6; 95% CI 1.1- 6.4).

CONCLUSION: Results suggest that folate and methionine metabolism may play an important role in the pathogenesis of malignant lymphoma. Further studies to confirm this association and detailed biologic mechanisms are now required.

Bladder cancer is still the most frequent malignant tumor among Egyptian males. It has a peculiar biologic, clinico-pathologic features and responsiveness to chemotherapy profile than that observed in Western countries. The current review aims to demonstrate the present state-of- art in using systemic therapy as part of the management options available to treat such patients at different stages of their disease. Individualizing therapy for these patients based on more rationale basis is the challenge that oncologists must face in the near future.

BACKGROUND: Tumor markers in the early detection of tumors are promising tools that could improve the control and treatment of tumors. While alpha-fetoprotein (AFP) is a commonly used tumor marker in the detection of hepatocellular carcinoma (HCC), its sensitivity and specificity are insufficient to detect HCC in all patient samples.

METHODS: We compared AFP with serum levels of vascular endothelial growth factors (VEGF and VEGF-A), insulin-like growth factor-2 (IGF-II), and the activity of the lysosomal enzyme alpha-L-fucosidase (AFU) in the sensitivity of detection of HCC and cirrhosis in Egyptian patients.

RESULTS: The sensitivity of tumor detection using AFP was 68.2%. This level of detection was increased to 88.6% when AFP was evaluated in conjunction with AFU. The combined use of AFP and VEGF increased the sensitivity of detection to 95.5% in patients with HCC. The combination of the three markers yielded 100% detection sensitivity. VEGF-A showed a low specificity (20%), and IGF-II showed extremely low sensitivity (4.5%).

CONCLUSIONS: We suggest that AFU or VEGF or both be measured with AFP to improve the detection sensitivity of HCC.

BACKGROUND: Tumor markers in the early detection of tumors are promising tools that could improve the control and treatment of tumors. While alpha-fetoprotein (AFP) is a commonly used tumor marker in the detection of hepatocellular carcinoma (HCC), its sensitivity and specificity are insufficient to detect HCC in all patient samples.

METHODS: We compared AFP with serum levels of vascular endothelial growth factors (VEGF and VEGF-A), insulin-like growth factor-2 (IGF-II), and the activity of the lysosomal enzyme alpha-L-fucosidase (AFU) in the sensitivity of detection of HCC and cirrhosis in Egyptian patients.

RESULTS: The sensitivity of tumor detection using AFP was 68.2%. This level of detection was increased to 88.6% when AFP was evaluated in conjunction with AFU. The combined use of AFP and VEGF increased the sensitivity of detection to 95.5% in patients with HCC. The combination of the three markers yielded 100% detection sensitivity. VEGF-A showed a low specificity (20%), and IGF-II showed extremely low sensitivity (4.5%).

CONCLUSIONS: We suggest that AFU or VEGF or both be measured with AFP to improve the detection sensitivity of HCC.

Of the various indices used in the assessment of dialysis adequacy, fractional urea clearance controlled for volume of distribution "Kt/V" remains the most widely used. Its determination is best performed by formal urea kinetic modeling (UKM), which is laborious and cumbersome, and the computational softwares are largely unavailable, particularly in developing countries. Consequently, different equations have been developed that approximate the formal UKM determination. Of the available formulae, that from second-generation logarithmic equation have been found to approximate values derived from formal UKM closely. We set out to determine the clinical utility of percent reduction of urea and Kt/V formulae derived from it, using the logarithmic equation as the standard.

The triangular cord sign (TC sign) is a sensitive and specific tool in prompt diagnosis of extrahepatic biliary atresia. The objective of this study is to evaluate post-operative TC sign presence in outcome prediction of infants with biliary atresia after Kasai hepato-portoenterostomy 27 infants and children with biliary atresia underwent 122 ultrasound examinations using both 5 MHz and 7 MHz convex linear transducers in 33 months follow up. For all infants TC sign identification was included pre-operatively, ultrasound was done 2 weeks post-operatively then bimonthly for 3 months, monthly for 2 months and every 3 months thereafter. 14 (53.8%) had post-operative TC sign. Once post-operatively positive, it remained positive throughout the study. It did not reappear in an initially post-operatively TC sign negative infant. Those having post-operative TC sign had statistically worse outcomes (0 became anicteric, 2 improved, 7 had progressive disease and 6 died) than those with a negative TC sign (p = 0.04) (3 became anicteric, 5 improved, 2 progressed and 1 died). Presence of TC sign post-operatively correlated with measure of removal of all fibrous cone at porta-hepatis during portoenterostomy (p = 0.026). Post-portoenterostomy TC sign is associated with more morbidity and mortality; and reflects inadequate surgical technique.

The triangular cord sign (TC sign) is a sensitive and specific tool in prompt diagnosis of extrahepatic biliary atresia. The objective of this study is to evaluate post-operative TC sign presence in outcome prediction of infants with biliary atresia after Kasai hepato-portoenterostomy 27 infants and children with biliary atresia underwent 122 ultrasound examinations using both 5 MHz and 7 MHz convex linear transducers in 33 months follow up. For all infants TC sign identification was included pre-operatively, ultrasound was done 2 weeks post-operatively then bimonthly for 3 months, monthly for 2 months and every 3 months thereafter. 14 (53.8%) had post-operative TC sign. Once post-operatively positive, it remained positive throughout the study. It did not reappear in an initially post-operatively TC sign negative infant. Those having post-operative TC sign had statistically worse outcomes (0 became anicteric, 2 improved, 7 had progressive disease and 6 died) than those with a negative TC sign (p = 0.04) (3 became anicteric, 5 improved, 2 progressed and 1 died). Presence of TC sign post-operatively correlated with measure of removal of all fibrous cone at porta-hepatis during portoenterostomy (p = 0.026). Post-portoenterostomy TC sign is associated with more morbidity and mortality; and reflects inadequate surgical technique.

The triangular cord sign (TC sign) is a sensitive and specific tool in prompt diagnosis of extrahepatic biliary atresia. The objective of this study is to evaluate post-operative TC sign presence in outcome prediction of infants with biliary atresia after Kasai hepato-portoenterostomy 27 infants and children with biliary atresia underwent 122 ultrasound examinations using both 5 MHz and 7 MHz convex linear transducers in 33 months follow up. For all infants TC sign identification was included pre-operatively, ultrasound was done 2 weeks post-operatively then bimonthly for 3 months, monthly for 2 months and every 3 months thereafter. 14 (53.8%) had post-operative TC sign. Once post-operatively positive, it remained positive throughout the study. It did not reappear in an initially post-operatively TC sign negative infant. Those having post-operative TC sign had statistically worse outcomes (0 became anicteric, 2 improved, 7 had progressive disease and 6 died) than those with a negative TC sign (p = 0.04) (3 became anicteric, 5 improved, 2 progressed and 1 died). Presence of TC sign post-operatively correlated with measure of removal of all fibrous cone at porta-hepatis during portoenterostomy (p = 0.026). Post-portoenterostomy TC sign is associated with more morbidity and mortality; and reflects inadequate surgical technique.

The triangular cord sign (TC sign) is a sensitive and specific tool in prompt diagnosis of extrahepatic biliary atresia. The objective of this study is to evaluate post-operative TC sign presence in outcome prediction of infants with biliary atresia after Kasai hepato-portoenterostomy 27 infants and children with biliary atresia underwent 122 ultrasound examinations using both 5 MHz and 7 MHz convex linear transducers in 33 months follow up. For all infants TC sign identification was included pre-operatively, ultrasound was done 2 weeks post-operatively then bimonthly for 3 months, monthly for 2 months and every 3 months thereafter. 14 (53.8%) had post-operative TC sign. Once post-operatively positive, it remained positive throughout the study. It did not reappear in an initially post-operatively TC sign negative infant. Those having post-operative TC sign had statistically worse outcomes (0 became anicteric, 2 improved, 7 had progressive disease and 6 died) than those with a negative TC sign (p = 0.04) (3 became anicteric, 5 improved, 2 progressed and 1 died). Presence of TC sign post-operatively correlated with measure of removal of all fibrous cone at porta-hepatis during portoenterostomy (p = 0.026). Post-portoenterostomy TC sign is associated with more morbidity and mortality; and reflects inadequate surgical technique.

UNLABELLED: Substance P is the most powerful endogenous vasodilator peptide produced by the enteric nervous system and partly cleared by the liver. Failure of the diseased liver to metabolize a vasodilator substance may be responsible for the rebound increased plasma level of vasoconstrictor intestinal peptide.

AIM: To investigate the plasma level of Substance P and to study its relationship to aldosterone and plasma renin activity changes occurring in pediatric patients with chronic liver disease.

METHODS: Forty patients with chronic liver disease and 10 healthy children were tested for AST, ALT, total and direct bilirubin, creatinine, aldosterone, plasma renin activity and plasma level of Substance P.

RESULTS: The plasma level of Substance P was increased in all patients with chronic liver disease (119.5+/-68.2 pg/ml) compared to controls (16.2+/-4.6 pg/ml). The aldosterone concentration and plasma renin activity were significantly higher in patients [(84.1+/-38.3 ng/dl) and (11.1+/-7.3 ng/ml/h)] than controls [(8.2+/-3.9 ng/dl) and (2.0+/-1.1 ng/ml/h)]. The highest level of Substance P and aldosterone were observed in glycogen storage disease patients.

CONCLUSION: Substance P was found to be increased in chronic liver disease patients; this increase was accompanied by an increase of aldosterone and plasma rennin activity. This correlation raises its potential use as a prognostic marker in chronic liver diseases.

UNLABELLED: Since 1990, 110 retrograde ventriculo-sinus (RVS) shunts were implanted; 98 patients (89.1%) benefited - 1 of them (0.9%) after shunt revision. The manifestations of high intra cranial pressure (ICP) disappeared, there were no problems related to improper cerebrospinal fluid (CSF) drainage, and the transcranial Doppler (TCD) resistive index (RI) measurements decreased to within normal ranges. Radiologically, the ventriculomegaly showed no regression in patients with open craniums and variable degrees of mild regression in patients with rigid craniums. Complications that needed shunt removal or revision occurred in 13 patients (11.8%); 1 patient (0.9%) died before shunt revision; they were all due to technical errors committed during the stages of evolution of the surgical technique for shunt implantation. The follow-up ranged between 4 months and 11 years (mean 3.42 years).

CONCLUSION: the RVS shunt is a simple, minimally invasive, physiological procedure for treatment of hydrocephalus and is suitable for all ages.

BACKGROUND: To assess the effect of intravitreal triamcinolone acetonide (iTA) as an adjunctive treatment to transpupillary therapy (TTT) for new subfoveal choroidal neovascular membranes (CNV) in age-related macular degeneration (AMD).

METHODS: This prospective randomized controlled pilot study comprised 26 patients scheduled to receive TTT, due to either absent indications for photodynamic therapy or financial issues. Patients were assigned into; Group A (n = 14) received TTT alone and Group B (n = 12) received iTA (4 mg) followed by TTT within one week. Follow ups were at 2 weeks, and 1, 3 and 6 months for; best-corrected visual acuity (BCVA) by ETDRS chart at 4 meters, intraocular pressures (IOP), fluorescein angiography (FAG), and central foveal thickness by optical coherence tomography (OCT).

RESULTS: All 26 patients completed 6 months of follow ups. The average age for both groups was 74 years. Occult CNV formed 64% and 41%; classis/predominately classic 21% and 16.6%; and minimally classic 15% and 42.4% of group A and B respectively. At baseline; the mean BCVA was 0.045 for group A and 0.04 for group B; mean CNV size was 6.15 disc diameter (DD) and 2.44 DD; mean OCT foveal thickness was 513 um and 411 um for group A and B respectively with no statistical differences (P = 0.8, 0.07, and 0.19). At six months the proportion of patients gained > or = 1 lines was 14% and 25% (P = 0.136) and stabilization was 86% and 66% (P = 0.336); the mean size of the CNV was 5.63 DD and 2.67 DD (P = 0.162); rate of CNV closure was 64% and 83% (P = 0.275); and the mean OCT central foveal thickness was 516.36 um and 453.67 um (P = 0.341), for group A and B respectively.

CONCLUSION: The use of iTA as an adjunctive to TTT for new subfoveal CNV in AMD showed a tendency towards better functional results. However due to the small sample size of the study a statistically significant results could not be reached.

BACKGROUND: The non-structural protein 3 (NS3P) of hepatitis C virus (HCV) genome was linked to the neoplastic transformation of normal hepatocytes in chronically infected patients. However, the exact mechanisms involved in this process are unidentified yet, especially in the Egyptian population where the commonest type is genotype 4.

METHODS: We investigated 32 HCV reverse transcriptase-polymerase chain reaction (RT-PCR) positive hepatocellular carcinoma (HCC) cases and 18 morphologically normal hepatic tissues distant to tumors (MNT) for the correlation between HCV-NS3P, p53, p21(waf), mdm2, p21ras and c-erbB2 and DNA content by immunohistochemistry and image analysis.

RESULTS: The NS3P expression was lower in HCC (65.6%) than in MNT (94.4%) patients. The expression level of studied genes in HCC was: p53 (56.25%), p21(waf) (43.7%), mdm2 (59.4%), p21-ras (73.3%) and c-erbB2 (75%). Whereas in MNT, it was 22.2, 61.1, 44.4, 41.2 and 77.8%, respectively. The NS3P expression showed a significant correlation with the presence of cirrhosis, chronic active hepatitis (CAH) and tumor grade (P < 0.05). c-erbB2 overexpression and p21(waf) loss were higher in MNT than in HCC patients, however, this did not reach a statistically significant level. There was a statistically significant correlation between NS3P, c-erbB2 and p21(waf) (P < 0.01). There was also a significant correlation between p21(waf) loss and CAH (P = 0.01) as well as between mdm2, c-erbB2 and cirrhosis (P = 0.025 and 0.001) in HCC cases. There was a statistically significant difference in the ploidy status between HCC and MNT, but there was no significant relationship between the ploidy status and other clinicopathological features.

CONCLUSION: The carcinogenic effect of NS3P is probably exerted at an early stage of HCC possibly through a pathway involving c-erbB2 and p21(waf) alterations. In contrast, p53, p21ras and mdm2 alterations are late events in hepatocarcinogenesis and are usually associated with an aggressive phenotype.

PURPOSE: Obstruction of the vas deferens in the inguinal canal may occur as a sequel of inguinal surgery. The condition is occurs in 26.7% of cases following childhood herniotomy. Open surgery in the inguinal region for anastomosing the remnants of the vas is difficult and associated with high morbidity. We have previously reported an alternative based on anastomosing the pelvic vas deferens (harvested laparoscopically) to the scrotal vas deferens and bypassing the inguinal vas. This technique, termed Shaeer pelviscrotal vasovasostomy, is easier to perform with much less morbidity. In this study we present the results of performing the procedure bilaterally at the same session as well as technique troubleshooting.

MATERIALS AND METHODS: A total of 25 patients with azoospermia due to inguinal obstruction of the vas deferens underwent unilateral (15) or bilateral (10) surgery. Patients were followed for 1 year.

RESULTS: Of the 25 patients 17 (68%) had a sperm concentration of between 11.88 and 17 million per ml. Some patients who remained azoospermic underwent reoperation and the obstacles to a successful anastomosis were analyzed and resolved.

CONCLUSIONS: Shaeer vasovasostomy is a practical approach to inguinal obstruction of the vas deferens. It enables a reliable anastomosis, simultaneous bilateral repair and lower morbidity in terms of wound healing and hernia as well as a shorter convalescence.

Two sensitive spectrophotometric and atomic absorption spectrometric procedures have been developed for determination of cinchocaine hydrochloride (Cin.Cl) in pure form and in pharmaceutical formulation. The spectrophotometric method was based on formation of an insoluble colored ion-associate between the cited drug and tetrathiocyanatocobaltate (CoTC) or hexathiocyanatochromate (CrTC) which dissolved and extracted in an organic solvent. The optimal experimental conditions for quantitative extraction such as pH, concentration of the reagents and solvent were studied. Toluene and iso-butyl alcohol proved to be the most suitable solvents for quantitative extraction of Cin-CoTC and Cin-CrTC ion-associates with maximum absorbance at 620 and 555 nm, respectively. The optimum concentration ranges, molar absorptivities, Ringbom ranges and Sandell sensitivities were also evaluated. The atomic absorption spectrometric method is based on measuring of the excess cobalt or chromium in the aqueous solution, after precipitation of the drug, at 240.7 and 357.9 nm, respectively. Linear application ranges, characteristic masses and detection limits were 57.99-361.9, 50.40 and 4.22 microg ml(-1) of Cin.Cl, in case of CoTC, while 37.99-379.9, 18.94 and 0.81 microg ml(-1) in case of CrTC.

BACKGROUND: Thrombopoietin (TPO) is a growth factor that controls platelet production. Despite the known association of chronic hypoxia and acute asphyxia with hematologic changes, TPO had not been studied in neonatal asphyxia.

OBJECTIVE: To assess TPO concentrations in the serum of asphyxiated and nonasphyxiated neonates, and examine any correlation with the severity of asphyxia.

DESIGN/METHODS: This prospective study was carried out on 32 asphyxiated neonates and 30 control subjects admitted at Cairo University Medical Center. Asphyxia was defined if two of the following were found: (1) Apgar score /=-10 and (3) clinical evidence of perinatal asphyxia. Encephalopathy was classified clinically according to Sarnat's stages during the first day of life. Platelet count and TPO level (pg/ml) were measured at 1st, 3rd and 7th day of life.

RESULTS: : TPO measured on the first day of life did not differ between cases and controls (900.2+/-526.4 vs 726.6+/-441.9 pg/ml, p=0.2). It increased on the 3rd day of life and was significantly higher in asphyxiated infants compared to controls (1291.4+/-627.9 vs 885.5+/-400.3 pg/ml, respectively; p=0.004). This difference remained significant in a logistic regression model controlling for birth weight, sex and mode of delivery (regression coefficient=476.9+/-146.8; p=0.002). In asphyxiated infants (n=32), encephalopathy was classified as mild (n=17), moderate (n=10) and severe (n=5). TPO correlated with the degree of clinical severity on the 7th day of life (r=0.59, p=0.003). TPO did not differ between survivors (n=24) and nonsurvivors (n=8) within the asphyxia group (1197.1+/-596.8 vs 1613.1+/-605.9 pg/ml; p=0.09). Platelet counts correlated negatively with TPO measured on day 1 (r=-0.415; p=0.02), day 3 (r=-0.64; p=0.001) and day 7 (r=-0.562; p=0.007).

CONCLUSIONS: TPO increased and correlated with severity of asphyxia at 3 and 7 days of life. It correlated negatively with the platelet count at all times.

OBJECTIVES: We aimed to investigate whether patients after tetralogy of Fallot (TOF) repair with right bundle branch block have left ventricular (LV) asynchrony and to assess the influence of ventricular asynchrony on regional and global LV function.

BACKGROUND: Patients after TOF repair usually have right bundle branch block. However, no data regarding LV asynchrony in this group are available.

METHODS: Twenty-five patients after TOF repair and 25 age-matched healthy control subjects were studied. The regional myocardial deformation of the interventricular septum (IVS) and the LV lateral wall were examined using tissue-Doppler-derived strain. The time interval between the onset of QRS complex and the peak strain was measured for each wall. According to the difference between LV and septum time intervals among the normal subjects, a normal range (mean +/- 2 SD) was plotted, and TOF patients in whom the difference was beyond the normal range were considered to have LV asynchrony. The Tei index was used to assess global LV function.

RESULTS: Thirteen (52%) of the examined patients after TOF repair had LV asynchrony. Patients after TOF repair with LV asynchrony had a significantly reduced regional septal systolic strain (p < 0.001) and significantly elevated Tei index (p < 0.001) compared with those without.

CONCLUSIONS: Left ventricular asynchrony may exist in patients after TOF repair with right bundle branch block. This LV asynchrony is associated with a reduction of both regional and global LV function.

INTRODUCTION: Construction of a neoglans penis may be required following glans amputation at circumcision, strangulation by a hair coil, or self-mutilation, among other indications. It may also be combined with phalloplasty to imitate the natural appearance and to support a penile prosthesis.

AIM: This is a report on a novel technique of neoglans construction for a patient with an amputated glans penis as a result of circumcision injury.

METHODS: A rectus abdominis myofascial flap was used. The flap was designed to be a 12 x 4 cm segment of the infraumbilical portion of the muscle, based on the inferior epigastric vessels. The flap was harvested through a paramedian incision. The penis was partially degloved through a circumferential incision 1 cm below its summit. The distal penile skin was utilized to elongate the urethra, so that the urethral meatus would be at the tip of the neoglans. The flap was reflected and tunneled underneath the mons veneris and alongside the penis, to emerge distal to the summit of the penis. The flap was fashioned into the shape of a glans and secured in place around the neourethra. The impression of a corona was achieved by tucking the proximal edge of the flap to its undersurface.

RESULT: Six months following surgery, the patient had a neoglans penis, a corona, and a urethral meatus at the very tip. The neoglans had similar consistency, color, and shape to the normal glans.

CONCLUSION: Construction of a neoglans penis is possible using the described sculpturing techniques, with satisfactory cosmetic results.

Hepatitis C virus genotypes and subtypes determination is an important factor for understanding the epidemiology of the virus, in the pre-treatment evaluation of the patients and in defining better treatment strategies. In the present study, we compared two commercially available assays for HCV genotyping: the reverse hybridization based Innogenetics INNO-LiPA HCV II and the direct sequencing by TRUGENE assay. The study included 31 HCV-RNA positive Egyptian patients; 18 patients with chronic active hepatitis, 8 with HCC, and 5 with cirrhosis. Using the TRUGENE genotyping test, all the samples had genotype 4 (100%) and subtyped as 4a in 18/31(58%), 4c in 10/31 (32%), 4e in 1/31 (3%), 4a/c in 1/31 (3%), and 4g in 1/31 (3%). Using the INNO-LiPA assay, 30 samples had genotype 4 (97%), and 1 sample had genotype 1e (3%). One sample showed mixed infection with type 4f and type 1. Only six samples were subtypable by INNO-LiPA, three were genotype 4c/d, and the other three were 4f, 4e, and 1e. Seven samples gave reactivity in the INNO-LiPA of lines 5, 6, 16, 17, 18, which are considered untypable by the interpretation chart but considered to be a rare HCV genotype 4 by the manufacturer. At the genotype level, there was a 97% concordance between TRUGENE sequencing and INNO-LiPA, but at the subtype level the concordance rate was 3% only. We conclude that the TRUGENE genotyping assay is a reliable test for HCV genotyping for the detection of major types and subtypes detection, while INNO-LiPA is a good test at the genotype level but unreliable for subtyping especially in the Egyptian population. This is mainly due to the high diversity of genotype 4, which is the most prevalent genotype in Egypt.

Mycobacterium ulcerans, the causative agent of Buruli ulcer, produces a macrolide toxin, mycolactone A/B, which is thought to play a major role in virulence. A disease similar to Buruli ulcer recently appeared in United States frog colonies following importation of the West African frog, Xenopus tropicalis. The taxonomic position of the frog pathogen has not been fully elucidated, but this organism, tentatively designated Mycobacterium liflandii, is closely related to M. ulcerans and Mycobacterium marinum, and as further evidence is gathered, it will most likely be considered a subspecies of one of these species. In this paper we show that M. liflandii produces a novel plasmid-encoded mycolactone, mycolactone E. M. liflandii contains all of the genes in the mycolactone cluster with the exception of that encoding CYP140A2, a putative p450 monooxygenase. Although the core lactone structure is conserved in mycolactone E, the fatty acid side chain differs from that of mycolactone A/B in the number of hydroxyl groups and double bonds. The cytopathic phenotype of mycolactone E is identical to that of mycolactone A/B, although it is less potent. To further characterize the relationship between M. liflandii and M. ulcerans, strains were analyzed for the presence of the RD1 region genes, esxA (ESAT-6) and esxB (CFP-10). The M. ulcerans genome strain has a deletion in RD1 and lacks these genes. The results of these studies show that M. liflandii contains both esxA and esxB.

We compared the left ventricular Tei index measured by tissue Doppler imaging (TDI) to that obtained by pulsed Doppler (PW) in patients with congenital heart disease. In 40 consecutive patients with a variety of congenital and acquired heart diseases, the left ventricular (LV) PW Doppler-derived Tei index was assessed on-line as previously described. TDI-derived anatomic curved M-mode and the unprocessed velocity trace from the basal septum were used to time the opening and closure of the mitral and aortic valves in one cardiac cycle, respectively. The TDI Tei index was calculated off-line according to the equation (isovolumetric relaxation time + isovolumetric contraction time)/ ejection time. The Tei index calculated from TDI correlated significantly with that measured by pulsed Doppler (r = 0.92, p = 0.001). The mean difference (range) between pulsed Doppler-derived Tei index and TDI-derived Tei index was 0.005 (-0.07-0.06), which was within the limits of agreements. Interobserver variability for the TDI-derived Tei index was 5 +/- 3%. The TDI Tei index can be used to assess the global LV function in patients with congenital heart disease. In contrast to the PW Doppler-derived Tei index, the TDI-derived Tei index obtained from the same cardiac cycle may help to differentiate systolic from diastolic dysfunction by providing specific information on the isovolumetric intervals.