Effect of HLA Bw4/Bw6 compatibility on platelet transfusion responses of refractory thrombocytopenic patients

Platelet transfusions from donors matched for cross-reactive antigens have been shown to be effective in providing hemostasis in alloimmunized thrombocytopenic patients. A significant number of these transfusions, however, fail to provide posttransfusion platelet recoveries. We investigated incompatibility in the Bw4/bw6 system as a possible explanation for these failures. The Bw4/Bw6 system is a biallelic antigen system closely associated with HLA-B. HLA-B locus antigens that are cross-reactive frequently differ in their Bw4/Bw6 specificity. Posttransfusion platelet recoveries from 21 alloimmunized thrombocytopenic patients homozygous for Bw4 or Bw6 and transfused with both Bw4/Bw6 compatible and incompatible platelets were analyzed. The mean 1-hr posttransfusion recovery was 84% following Bw4/Bw6-compatible platelets versus 52% with Bw4/Bw6-incompatible platelets (p less than 0.02). Twenty-four hours following transfusion, mean recoveries were 44% and 24%, respectively, (p less than 0.01). A subgroup of 8 patients (38%) was identified who had markedly lower responses following Bw4/Bw6- incompatible transfusions as compared to Bw4/Bw6-compatible transfusions (mean recoveries: 1 hr--compatible 100%, incompatible 27%, p less than 0.001; 24 hr--compatible 45%, incompatible 7%, p less than 0.01). These data suggest that the Bw4/Bw6 antigen system has clinical significance for some patients requiring platelet transfusion therapy and, when appropriate, should be considered in the selection of donors.     

Neutrophil adhesiveness during prostacyclin and heparin hemodialysis

We evaluated neutrophil adhesive function in patients undergoing chronic hemodialysis using either prostacyclin or heparin as antithrombotic agents. Patients underwent successive hemodialyses with prostacyclin (4 ng/kg/min) and heparin. There were no significant differences noted in neutrophil adhesive function during either dialysis: transient neutropenia developed in each case; impaired neutrophil adhesiveness to plastic developed during both dialyses; neutrophil aggregation was diminished when compared to predialysis responses during both dialyses. Furthermore, the number of circulating Fc-receptor-bearing neutrophils fell significantly during both prostacyclin and heparin hemodialysis. Our study demonstrates that substitution of prostacyclin for heparin in doses that do not cause hypotension, does not prevent neutropenia or alter the diminished neutrophil adhesiveness that occurs during heparin hemodialysis.     

Neurologic complications after allogeneic marrow transplantation for sickle cell anemia [see comments]

Seven of 21 patients with sickle cell anemia developed neurologic complications 5 to 243 days (median, 33 days) after allogeneic marrow transplantation. Among these 7 patients, indications for transplantation included either a past history of stroke (4 patients) or recurrent severe vaso-occlusive events (3 patients). All received marrow from an HLA-identical sibling after preparation with busulfan and cyclophosphamide, and in 4 patients with antithymocyte globulin. Five of 6 patients developing seizures received anticonvulsant and supportive treatment with resolution of neurologic abnormalities. Three patients experienced intracranial bleeding, which was fatal in two. Of the 14 patients free of neurologic complications, 4 patients had experienced stroke before transplantation. However, among all patients with prior stroke, the incidence of intracranial hemorrhage was 38% (3/8), whereas none of the 13 patients without prior stroke developed posttransplant intracranial bleeding (P = .026). We conclude that patients with sickle cell anemia are at increased risk for neurologic complications after marrow ablative therapy and that patients with prior stroke are at increased risk for intracranial hemorrhage. Transplantation of patients before the onset of overt stroke may reduce this risk.     

Crohn's disease with spontaneous ileoumbilical and ileovesical fistulae

Summary A 17-year-old male with Crohn's disease involving the terminal ileum and cecum developed an umbilical fistula in the absence of previous surgery. While on intravenous hyperalimentation he developed an enterovesical fistula and was successfully treated by surgical resection. This combination of an enterovesical and umbilical fistula has not been previously reported. An aggressive approach to treatment is suggested.     

Acute pseudo-obstruction of the colon in thermally injured patients

Summary and Conclusions Five (1 per cent) of 529 thermally injured patients experienced pseudo-obstruction of the colon over a two-year period. All patients had classic non-painful abdominal distention. Infection was the most common associated problem and possible triggering mechanism in these patients. After confirmation of the colonic dilation on a plain abdominal roentgenogram, distal obstruction was ruled out by contrast enema. Occasionally, Gastrografin enema seemed to ameliorate the distention. Conservative medical management should be attempted initially. Colonoscopy should be employed at the earliest possible time. Exploratory laparotomy and tube cecostomy are usually adequate when surgical decompression is necessary. Patients who have accompanying small-intestinal distention seemed to tolerate this condition better, possibly due to a decompressing effect of an incompetent ileocecal valve. “Hinge-type” kinks, which occur in time at both hepatic and splenic flexures, become obstructing in themselves, and can be a barrier to conservative treatment. Read at the meeting of the American Society of Colon and Rectal Surgeons, San Diego, California, June 11 to 15, 1978. The opinions or assertions contained herein are the private view of the authors and are not to be construed as official or as reflecting the view of the Department of the Army or the Department of Defense.     

Localization of erythropoietin synthesizing cells in murine kidneys by in situ hybridization

In situ hybridization was used to localize the cells that produce erythropoietin (EP) in anemic murine kidneys. Kidneys from anemic and nonanemic mice were fixed and processed for paraffin embedding. Sections were hybridized with a 35S-labeled RNA probe complementary to mRNA coding for EP. An uncommon, but specific type of cell was intensely labeled in the cortices of anemic kidneys. The labeled cells were clearly nonglomerular and nontubular. Their location outside of the tubular basement membrane was consistent with that of a subset of interstitial cells or capillary endothelial cells.     

Enzymatic digestion of esophageal meat impaction

While a solution of Adolph's Meat Tenderizer^® (AMT) is commonly used to treat esophageal meat impaction, few studies describe its clinical effects. We examined AMT with regard to (1) its papain activity; (2) its ability to digest meat cubesin vitro; and (3) its effect on rabbit esophageal mucosa. A standard papain assay was developed against which the activity of AMT was compared. Proteolytic activity was detected in AMT only when the papain activators, 0.02 M cysteine and 0.008 M EDTA, were added to the system. Meat cubes incubated in AMT solution exhibited no evidence of digestion as determined by protein release or change in sample weight. A solution of AMT had no adverse effect on normal esophageal mucosa in rabbits, but significantly increased esophagitis when infused onto previously inflamed mucosa. We conclude that AMT solution has no inherent capacity to digest or to reduce the size of an impacted meat bolus, and may, in fact, worsen existing esophagitis.The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense.Presented at the Twelfth Annual William Beaumont Gastrointestinal Symposium, March 23–25, 1983, El Paso, Texas.Address for reprint requests: Technical Publications Editor, Letterman Army Medical Center, Presidio of San Francisco, California 94129.