CARDIOVASCULAR JOURNAL OF AFRICA: VOLUME 25, ISSUE
5, SEP/OCT 2014
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- Title: From the Editor's desk
Authors: Commerford, Patrick
From: Cardiovascular Journal of Africa, Vol 25, Issue 5, September/October
Published: 2014
Pages: 199
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Abstract: This issue contains useful information on patterns of disease presentation in Africa. Grimaldi and colleagues (page 204) document the pattern of structural heart disease causing heart failure in patients presenting to a tertiary hospital in Kampala. Many were young and suffered from rheumatic heart disease (RHD) and congenital heart disease (CHD). One suspects this was a highly selected group as the patients were identified during NGO missions, presumably aimed at identifying suitable candidates for surgery. Nonetheless the article reflects the importance of RHD as a cause of disability and death in the young in Uganda, as in many other parts of Africa, and emphasises the need for efforts to improve primary and secondary prevention of this eminently preventable disease.
- Title: Diagnostic value of plasma
C-type natriuretic peptide levels in
determination of the duration of mesenteric
ischaemia : cardiovascular topic
Authors: Demirtas, Sinan; Karahan, Oguz; Yazici, Suleyman; Guclu, Orkut; Caliskan, Ahmet; Tezcan, Orhan; Yavuz, Celal
From: Cardiovascular Journal of Africa, Vol 25, Issue 5, September/October
Published: 2014
Pages: 200-203
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DOI Number: 10.5830/CVJA-2014-033
DOI Citation Reference Link: dx.doi.org/10.5830/CVJA-2014-033
Abstract: Objective : Mesenteric arteries release C-type natriuretic peptide (CNP), which hyperpolarises vascular smooth muscle. We measured the levels of this peptide after inducing mesenteric ischaemia over a series of time intervals, so as to determine its predictive value in demonstrating the severity of ischaemia in a rat model.
Methods : A total of 32 rats were allocated to four groups containing eight rats each. Basal CNP reference levels were measured in the control group, which was not exposed to any intervention. In groups I, II and III, mesenteric ischaemia was induced over three, six and nine hours, respectively, and plasma CNP levels were measured afterwards. Mesenteric ischaemia was induced by clamping the superior mesenteric artery.
Results : In comparison with the controls (2.38 ± 0.18 pg/ml), CNP levels were relatively lower in group I (2.54 ± 0.42 pg/ml). However, significant increases in plasma CNP levels were observed over longer periods of ischaemia in group II, at 5.23 ± 0.22 pg/ml, and in group III, at 6.19 ± 0.67 pg/ml (p < 0.05). A significant direct relationship was determined between plasma CNP levels and prolonged intervals of mesenteric ischaemia (R = 0.56, p < 0.001).
Conclusion : Measuring plasma CNP levels in patients with acute mesenteric ischaemia may be beneficial in estimating the time period over which the ischaemic injury has occurred.
- Title: Cardiac surgery for patients with heart failure due to
structural heart disease in Uganda : access to surgery and outcomes :
cardiovascular topic
Authors: Grimaldi, Antonio; Ammirati, Enrico; Karam, Nicole; Vermi, Anna Chiara; De Concilio, Annalisa; Trucco, Giorgio; Aloi, Francesco; Arioli, Francesco; Figini, Filippo; Ferrarello, Santo; Sacco, Francesco Maria; Grottola, Renato; D'Arbela, Paul G.; Alfieri, Ottavio; Marijon, Eloi; Freers, Juergen; Mirabel, Mariana
From: Cardiovascular Journal of Africa, Vol 25, Issue 5, September/October
Published: 2014
Pages: 204-211
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DOI Number: 10.5830/CVJA-2014-034
DOI Citation Reference Link: dx.doi.org/10.5830/CVJA-2014-034
Abstract: Objective : Few data are available on heart failure (HF) in sub-Saharan Africa. We aimed to provide a current picture of HF aetiologies in urban Uganda, access to heart surgery, and outcomes.
Methods : We prospectively collected clinical and echocardiographic data from 272 consecutive patients referred for suspected heart disease to a tertiary hospital in Kampala during seven non-governmental organisation (NGO) missions from 2009 to 2013. We focused the analysis on 140 patients who fulfilled standardised criteria of HF by echocardiography.
Results : Rheumatic heart disease (RHD) was the leading cause of HF in 44 (31%) patients. Among the 50 children included (age ≤ 16 years), congenital heart disease (CHD) was the first cause of HF (30 patients, 60%), followed by RHD (16 patients, 32%). RHD was the main cause of HF (30%) among the 90 adults. All 85 patients with RHD and CHD presented with an indication for heart surgery, of which 74 patients were deemed fit for intervention. Surgery was scheduled in 38 patients with RHD [86%, median age 19 years (IQR: 12-31)] and in 36 patients with CHD [88%, median age 4 years (IQR 1-5)]. Twenty-seven candidates (32%) were operated on after a median waiting time of 10 months (IQR 6-21). Sixteen (19%) had died after a median of 38 months (IQR 5-52); 19 (22%) were lost to follow up.
Conclusions : RHD still represents the leading cause of HF in Uganda, in spite of cost-efficient prevention strategies. The majority of surgical candidates, albeit young, do not have access to treatment and present high mortality rates.
- Title: Effects of rosuvastatin on ADMA, rhokinase,
NADPH oxidase, caveolin-1, hsp 90 and NFkB levels in a rat model of myocardial
ischaemia-reperfusion : cardiovascular topic
Authors: Burma, Oktay; Onat, Elif; Uysal, Ayhan; Ilhan, Necip; Erol, Deniz; Ozcan, Mete; Sahna, Engin
From: Cardiovascular Journal of Africa, Vol 25, Issue 5, September/October
Published: 2014
Pages: 212-216
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DOI Number: 10.5830/CVJA-2014-038
DOI Citation Reference Link: dx.doi.org/10.5830/CVJA-2014-038
Abstract: Aim : Endothelial dysfunction, oxidative stress and inflammation are among the most important mechanisms of ischaemia-reperfusion (I/R) injury. Besides their cholesterol-lowering effects, statins are known to provide protection against myocardial dysfunction and vascular endothelial injury via nitric oxide-dependent mechanisms. The aim of this study was to investigate the effects of rosuvastatin on certain intermediates involved in the generation of nitric oxide (asymmetrical dimethyl arginin, ADMA, caveolin-1 and hsp 90), oxidative stress (rhokinase, NADPH oxidase) and inflammation (NFkB), using an in vivo model of myocardial infarction in the rat.
Methods : Adult male Sprague Dawley rats were divided into three groups (control, I/R and I/R after 15 days of rosuvastatin administration). Reperfusion was applied for 120 min following left anterior descending coronary artery ischaemia for 30 min. Caveolin-1, hsp 90 and NFkB levels were evaluated with the quantitative reverse transcriptase polymerase chain reaction (qRT-PCR) and ADMA, rhokinase and NADPH oxidase levels were evaluated with ELISA.
Results : While NFkB and hsp 90 levels were higher in the I/R group, their levels were significantly lower in the rosuvastatin group. While ADMA and NADPH oxidase levels significantly increased with I/R, they were lower in the rosuvastatin-treated group, but not statistically significant. Rhokinase levels were significantly lower in the rosuvastatin group. Caveolin-1 levels were not different between the groups.
Conclusion : Our results suggest that ADMA, rhokinase, NADPH oxidase, hsp 90 and NFkB could facilitate I/R injury, and rosuvastatin significantly reduced levels of these parameters. These results indicate that rosuvastatin may have a protective role in I/R injury via mechanisms targeting inflammation, endothelial dysfunction and oxidative stress.
- Title: Short-term outcomes after hospital discharge in patients
admitted with heart failure in Abeokuta, Nigeria : data from the Abeokuta Heart
Failure Registry : cardiovascular topic
Authors: Ogah, Okechukwu S.; Stewart, Simon; Falase, Ayodele O.; Akinyemi, Joshua O.; Adegbite, Gail D.; Alabi, Albert A.; Durodola, Amina; Ajani, Akinlolu A.; Sliwa, Karen
From: Cardiovascular Journal of Africa, Vol 25, Issue 5, September/October
Published: 2014
Pages: 217-223
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DOI Number: 10.5830/CVJA-2014-040
DOI Citation Reference Link: dx.doi.org/10.5830/CVJA-2014-040
Abstract: Background : Compared to other regions of the world, there is a paucity of data on the short-term outcome of acute heart failure (AHF) in Africa's most populous country, Nigeria. We examined the six-month outcomes (including case fatalities) in 285 of 309 AHF subjects admitted with HF to a tertiary hospital in Abeokuta, Nigeria.
Methods : The study cohort of 285 subjects comprised 150 men (52.6%) and 135 women (47.4%) with a mean age of 56.3 ± 15.6 years and the majority in NYHA class III (75%).
Results : There were a number of differences according to the subject's gender; men being older and more likely to present with hypertensive heart disease (with greater left ventricular mass) while also having greater systolic dysfunction. Mean length of stay was 10.5 ± 5.9 days. Mean follow up was 205 days, with 23 deaths and 20 lost to follow up. At 30 days, 4.2% (95% CI: 2.4-7.3%) had died and by 180 days this had increased to 7.5% (95% CI: 4.7-11.2%); with those subjects with pericardial disease demonstrating the highest initial mortality rate. Over the same period, 13.9% of the cohort was re-admitted at least once.
Conclusions : The characteristics of this AHF cohort in Nigeria were different from those reported in high-income countries. Cases were relatively younger and presented with non-ischaemic aetiological risk factors for HF, especially hypertensive heart disease. Moreover, mortality and re-admission rates were relatively lower, suggesting region-specific strategies are required to improve health outcomes.
- Title: Thrombolysis risk prediction : applying the SITS-SICH and
SEDAN scores in South African patients : cardiovascular topic
Authors: Von Klemperer, A.; Bateman, K.; Owen, J.; Bryer, A.
From: Cardiovascular Journal of Africa, Vol 25, Issue 5, September/October
Published: 2014
Pages: 224-227
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DOI Number: 10.5830/CVJA-2014-043
DOI Citation Reference Link: dx.doi.org/10.5830/CVJA-2014-043
Abstract: At present, the only specific medical treatment for acute ischaemic stroke is intravenous administration of recombinant tissue plasminogen activator within 4.5 hours of stroke onset. In the last year, two scores for risk stratification of intracranial haemorrhage have been derived from multicentric European trial groups, the Safe Implementation of Treatment in Stroke - Symptomatic IntraCerebral Haemorrhage risk score (SITS-SICH) and the SEDAN score. The aim of this study was to pilot their use in a cohort of patients treated at a South African tertiary hospital.
Prospectively collected data were used from a cohort of 41 patients who underwent thrombolysis at Groote Schuur Hospital from 2000 to 2012. Computerised tomography brain imaging was available for review in 23 of these cases. The SITS-SICH and SEDAN scores were then applied and risk prediction was compared with outcomes.
Two patients suffered symptomatic intracranial haemorrhage (SICH), representing 4.9% (95% CI: 0-11.5%) of the cohort. This was comparable to the SICH rate in both the SITS-SICH (5.1%) and SEDAN (6.5%) cohorts. Patient scores in the Groote Schuur Hospital cohort appeared similar to those of the validation cohorts of both SITS-SICH and SEDAN.
With increasing use of thrombolysis in a resource-constrained setting, these scores represent a potentially useful tool in patient selection of those most likely to benefit from intravenous thrombolysis, reducing risk for SICH and with the added benefit of curtailing cost.
- Title: Hypertensive retinopathy and its association with
cardiovascular, renal and cerebrovascular morbidity in Congolese patients :
cardiovascular topic
Authors: Kabedi, Nelly N.; Mwanza, Jean-Claude; Lepira, Francois B.; Kayembe, Tharcisse K.; Kayembe, David L.
From: Cardiovascular Journal of Africa, Vol 25, Issue 5, September/October
Published: 2014
Pages: 228-232
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DOI Number: 10.5830/CVJA-2014-045
DOI Citation Reference Link: dx.doi.org/10.5830/CVJA-2014-045
Abstract: Background : Signs indicating hypertensive retinopathy can help determine the extent of hypertensive cardiovascular, renal and cerebrovascular damage.
Objectives : To study the association between hypertensive retinopathy and cardiovascular, renal and cerebrovascular changes, and to determine the predictors of hypertensive retinopathy in Congolese patients.
Methods : A total of 159 hypertensive subjects (mean age: 58.9 ± 13.2 years) were enrolled from the cardiology out-patient clinic. Retinopathy grade was assessed on direct ophthalmoscopy. Hypertensive cardiovascular, renal and cerebrovascular changes were indicated by left ventricular hypertrophy (LVH), chronic kidney disease (CKD) and stroke, respectively.
Results : Hypertensive retinopathy was present in 83.6% of the patients (grade 1: 42.1%; grade 2: 11.3%; grade 3: 23.3%; grade 4: 6.9%). There was no association between hypertensive retinopathy and the presence or absence of LVH (86.5 vs 73.3%, χ2 = 1.53, p = 0.21), chronic kidney disease (89.3 vs 83.3%, χ2 = 0.12, p = 0.73) or stroke (85.7 vs 83.2%, χ2 > 0.001, p = 0.99). On multivariate logistic regression, CKD was the most significant predictor of severe hypertensive retinopathy, with an odds ratio of 4.4.
Conclusion : No association was found between hypertensive retinopathy and LVH, CKD or stroke. CKD was the most significant predictor of hypertensive retinopathy and there was a tendency toward increased risk of target-organ damage among patients with advanced hypertensive retinopathy.
- Title: The proposed role of plasma NT pro-brain natriuretic peptide
in assessing cardiac remodelling in hypertensive African subjects :
cardiovascular topic
Authors: Ojji, Dike B.; Opie, Lionel H.; Lecour, Sandrine; Lacerda, Lydia; Adeyemi, Olusoji M.; Sliwa, Karen
From: Cardiovascular Journal of Africa, Vol 25, Issue 5, September/October
Published: 2014
Pages: 233-238
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DOI Number: 10.5830/CVJA-2014-050
DOI Citation Reference Link: dx.doi.org/10.5830/CVJA-2014-050
Abstract: Aim : Although plasma NT-proBNP differentiates hypertension (HT) with or without left ventricular hypertrophy (LVH) from hypertensive heart failure (HHF), most of the published data are based on studies in Western populations. Also, most previous studies did not consider left ventricular (LV) diastolic function and right ventricular (RV) function. We therefore examined the relation between NT-proBNP on LV and RV remodelling in an African hypertensive cohort.
Methods : Subjects were subdivided into three groups after echocardiography: hypertensives without LVH (HT) (n = 83); hypertensives with LVH (HT+LVH) (n = 50); and those with hypertensive heart failure (HHF) (n = 77).
Results : Subjects with HHF had significantly higher NT-proBNP levels compared to the HT+LVH group (p < 0.0002). NT-proBNP correlated positively with right atrial area, an indirect measure of RV function.
Conclusions : NT-proBNP is proposed as a useful biomarker in differentiating hypertension with or without LVH from hypertensive heart failure in black hypertensive subjects.
- Title: Troubleshooting techniques for the Endurant™ device in
endovascular aortic aneurysm repair : cardiovascular topic
Authors: Georgiadis, George S.; Antoniou, George A.; Trellopoulos, George; Georgakarakos, Efstratios I.; Argyriou, Christos; Lazarides, Miltos K.
From: Cardiovascular Journal of Africa, Vol 25, Issue 5, September/October
Published: 2014
Pages: 239-243
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DOI Number: 10.5830/CVJA-2014-049
DOI Citation Reference Link: dx.doi.org/10.5830/CVJA-2014-049
Abstract: Endovascular aortic aneurysm repair with the Endurant™ stent-graft system has been shown to be safe and effective in high-risk surgical patients with complex suprarenal and/or infrarenal abdominal aortic aneurysm anatomy. The wire-formed M-shaped stent architecture and proximal springs with anchoring pins theoretically permit optimal sealing in shorter and more angulated proximal aneurysm necks even under off-label conditions. Nonetheless, extremely difficult anatomical situations and inherent graft system-related limitations must be anticipated. Herein, we describe our techniques to overcome the capture of the tip sleeve within the suprarenal bare-stent anchoring pins, other endograft segments, and native vessels.
- Title: How to approach aortic valve disease in the elderly : a
25-year retrospective study : cardiovascular topic
Authors: Aydin, Ebuzer; Yerlikhan, Ozge Altas; Tuzun, Behzat; Ozen, Yucel; Sarikaya, Sabit; Kirali, Mehmet Kaan
From: Cardiovascular Journal of Africa, Vol 25, Issue 5, September/October
Published: 2014
Pages: 244-248
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DOI Number: 10.5830/CVJA-2014-051
DOI Citation Reference Link: dx.doi.org/10.5830/CVJA-2014-051
Abstract: Objective : In the last decade, the number of elderly patients suffering from aortic valve disease has significantly increased. This study aimed to identify possible factors that could affect surgical and long-term outcomes in the light of a literature review regarding the management of aortic valve disease in the elderly.
Methods : Between January 1990 and December 2012, a total of 114 patients (64 males, 50 females; mean age 76.6 ± 3.6 years; range 70-87 years) with aortic valve replacement (AVR) alone, or combined with coronary artery bypass grafting (CABG) or mitral surgery in our hospital, were retrospectively analysed.
Results : In-hospital mortality was seen in 19 patients. The major causes of in-hospital mortality were low-cardiac output syndrome in eight patients (42.1%), respiratory insufficiency or infection in six (31.5%), multi-organ failure in four (21%), and stroke in one patient (5.2%). The main postoperative complications included arrhythmia in 26 patients (22.8%), renal failure in 11 (9.6%), respiratory infection in nine (7.9%), and stroke in three patients (2.6%). The mean length of intensive care unit and hospital stays were 6.4 ± 4.3 and 18 ± 12.8 days, respectively. During follow up, late mortality was seen in 28 patients (29.4%). Possible risk factors for long-term mortality were type of prosthesis, EuroSCORE ≥ 15, postoperative pacemaker implantation, respiratory infection, and haemodialysis. Among 65 long-term survivors, their activity level was good in 53 (81.5%) and poor in two.
Conclusions : Our study results demonstrated that an individually tailored approach including scheduled surgery increases short- and long-term outcomes of AVR in patients aged ≥ 70 years. In addition, shorter cardiopulmonary bypass time may be more beneficial in this high-risk patient population.
- Title: Efficacy and safety of sirolimus-eluting stents versus
bare-metal stents in coronary artery disease patients with diabetes : letter to
the editor
Authors: Jing, Juehua
From: Cardiovascular Journal of Africa, Vol 25, Issue 5, September/October
Published: 2014
Pages: 249
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Abstract: I read with great interest the recent article titled 'Efficacy and safety of sirolimus-eluting stents versus bare-metal stents in coronary artery disease patients with diabetes: a meta-analysis' by Qiao et al., published online in the Cardiovascular Journal of Africa. I believe this is a well-conducted meta-analysis that compared the major cardiac events, target-lesion revascularisation, myocardial infarction and mortality rate in coronary arterial disease (CAD) patients with diabetes who were treated with sirolimus-eluting stents (SES) or bare-metal stent (BMS). However, there are some issues I would like to point out.
- Title: The way forward for clinical research in Cameroon : First
scientific and research day in Douala, 2014 : conference report
From: Cardiovascular Journal of Africa, Vol 25, Issue 5, September/October
Published: 2014
Pages: 250-252
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Abstract: There is a huge need for health research to support contextually relevant health service and policy solutions to better the health of populations in sub-Saharan Africa. This need contrasts with the very timid engagement of healthcare practitioners in research in the region.
It is against this background that the Douala General Hospital (a tertiary-care hospital in Cameroon), under the stewardship of its chief executive officer, organised the first annual scientific and research day in October 2014. This maiden event saw the participation of local research leaders and the eminent director of the South African Hatter Institute for Cardiovascular Research in Africa, who co-chaired the event. The aim was to educate students, clinicians and junior researchers on the importance of clinical research and evidence-based medicine around the leading theme of the event: action for clinical research and good medical practice.
Several abstracts were presented, covering various aspects of medicine, including cardiology, rheumatology, paediatrics, pulmonology, HIV medicine, and obstetrics and gynaecology, together with key lectures on cardiac disease and pregnancy, and plenary sessions on research methodology, scientific writing and publishing. It is hoped that this event will enhance clinical research and the dissemination of research findings to improve evidence-based clinical practice in the country.
- Title: Surgical treatment of post-infarct left ventricular
pseudo-aneurysm with on-pump beating heart technique : online article - case
report
Authors: Korkmaz, Kemal; Lafci, Gokhan; Gedik, Hikmet Selcuk; Budak, Ali Baran; Yener, Ali Umit; Ecevit, Ata Niyazi; Yalcinkaya, Adnan; Kadirogullari, Ersin; Cagli, Kerim
From: Cardiovascular Journal of Africa, Vol 25, Issue 5, September/October
Published: 2014
Pages: e1-e4
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DOI Number: 10.5830/CVJA-2014-026
DOI Citation Reference Link: dx.doi.org/10.5830/CVJA-2014-026
Abstract: Left ventricular pseudo-aneurysms develop when cardiac rupture is contained by pericardial adhesions or scar tissue due to myocardial infarction, surgery, trauma or infection. Left ventricular pseudo-aneurysms are uncommon, difficult to diagnose and prone to cardiac rupture. Urgent surgical repair is recommended. Here we report on a case of a large left ventricular pseudo-aneurysm on the anterolateral wall due to a previous anterior myocardial infarction, and its successful repair using the on-pump beating-heart technique.
- Title: Traumatic aortic regurgitation combined with descending
aortic pseudo-aneurysm secondary to blunt chest trauma : online article - case
report
Authors: Kim, Siho; Park, Joon Suk; Yoo, Seung Min; Kim, Kyung Ho; Yang, Woo-In; Sung, Jung-Hoon; Kim, In Jai; Lim, Sang-Wook; Cha, Dong-Hun; Moon, Jae-Youn
From: Cardiovascular Journal of Africa, Vol 25, Issue 5, September/October
Published: 2014
Pages: e5-e8
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DOI Number: 10.5830/CVJA-2014-039
DOI Citation Reference Link: dx.doi.org/10.5830/CVJA-2014-039
Abstract: Rupture of the aorta is a relatively rare complication of blunt chest trauma, and traumatic rupture of the aortic valve is even rarer. Even though both result from blunt chest trauma, the causative mechanisms of aortic valve injury differ from those of descending aortic rupture. There are no previous reports in the literature of simultaneous injuries to both the descending aorta and the aortic valve. We report a case of a 70-year-old man who presented with traumatic aortic regurgitation combined with traumatic pseudo-aneurysm of the aortic isthmus following blunt chest trauma, and its successful repair with a hybrid surgical strategy.
- Title: Sustained ventricular tachycardia in a patient with isolated
non-compaction cardiomyopathy : online article - case report
Authors: Alihanoglu, Yusuf Izzettin; Kilic, Ismail Dogu; Yildiz, Bekir Serhat; Kartin, Mustafa; Evrengul, Harun
From: Cardiovascular Journal of Africa, Vol 25, Issue 5, September/October
Published: 2014
Pages: e9-e12
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DOI Number: 10.5830/CVJA-2014-037
DOI Citation Reference Link: dx.doi.org/10.5830/CVJA-2014-037
Abstract: Isolated non-compaction of the left ventricular myocardium (INVM) was first described in 1984 as an unclassified cardiomyopathy, not being dilated, hypertrophic or restrictive. It is assumed to occur as a result of an arrest in endomyocardial morphogenesis during normal development of the heart. The disease is characterised by heart failure due to systolic and diastolic left ventricular (LV) dysfunction, systemic emboli and ventricular arrhythmias. Echocardiography has been shown to be the method of choice in diagnosis. INVM is a rare congenital cardiomyopathy and only a few cases of this condition have been reported. It is characterised by prominent and excessive trabeculation in a ventricular wall segment, with deep inter-trabecular spaces perfused from the ventricular cavity. We report a case of INVM with ventricular tachycardia induced during electrophysiological study in a 24-year-old female patient with a family history of sudden death.
- Title: Coronary artery bypass grafting in a Behçet's disease patient
: online article - case report
Authors: Tasar, Mehmet; Eyileten, Zeynep; Arici, Burcu; Uysalel, Adnan
From: Cardiovascular Journal of Africa, Vol 25, Issue 5, September/October
Published: 2014
Pages: e13-e14
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DOI Number: 10.5830/CVJA-2014-052
DOI Citation Reference Link: dx.doi.org/10.5830/CVJA-2014-052
Abstract: Behçet's syndrome is a chronic, multisystemic, inflammatory, vasculitic disorder characterised by oral aphta, ocular lesions, genital ulcers and the involvement of other systems. Although vascular involvement is seen frequently, coronary artery disease is extremely rare in Behçet's disease and it is generally treated with invasive or conservative procedures. In this case, we aimed to present a successful bypass grafting of three vessels using cardiopulmonary bypass in a patient with Behçet's disease.
