Perioperative problems and treatment of a teenager with a juvenile angiofibroma refusing blood transfusion

Objectives

Juvenile angiofibroma is a benign, non-encapsulated neoplasm, consisting of vascular and connective tissue. Its main feature is a local malignancy. In its clinical course it destroys adjoining structures, without metastasizing. It appears rarely, and is mainly found in boys at puberty.Among theories about the aetiology of juvenile angiofibroma, we must consider a haematoma-like lesion, an angioma with an extended fibrous component, or type of inflammatory allergic polyp. In the development of the lesion the participation of hormonal disorders on the pituitary gland-gonad axis is also suggested. According to the latest research, juvenile angiofibroma is regarded as a developmental defect, affecting the embryonic vascular network surrounding the sphenoid bone.

Methods

If the patient or his/her parents refuse blood transfusion and use of blood products, it is necessary to apply modifications in the routine perioperative treatment. In the case of the patient refusing blood and blood products transfusion because of their beliefs, it is possible to get consent to use different, highly processed products like albumins or a cryoprecipitate, as well as applying some blood-saving techniques.

Conclusions

1.

Removal of juvenile angiofibroma with minimal bleeding is possible.

2.

Applying erythropoietin and iron preparations prior to surgery increases erythropoiesis and reduces the risks in transfusion.

3.

Applying intraoperative normovolaemic haemodilution is a safe method and allows avoidance of transfusion of blood-derived products.

     

Dentate total molecular layer interneurons mediate cannabinoid‐sensitive inhibition

Activity of the dentate gyrus, which gates information flow to the hippocampus, is under tight inhibitory regulation by interneurons with distinctive axonal projections, intrinsic and synaptic characteristics and neurochemical identities. Total molecular layer cells (TML‐Cs), a class of morphologically distinct GABAergic neurons with axonal projections across the molecular layer, are among the most frequent interneuronal type in the dentate subgranular region. However, little is known about their synaptic and neurochemical properties. We demonstrate that synapses from morphologically identified TML‐Cs to dentate interneurons are characterized by low release probability, facilitating short‐term dynamics and asynchronous release. TML‐Cs consistently show somatic and axonal labeling for the cannabinoid receptor type 1 (CB₁R) yet fail to express cholecystokinin (CCK) indicating their distinctive neurochemical identity. In paired recordings, the release probability at synapses between TML‐Cs was increased by the CB₁R antagonist AM251, demonstrating baseline endocannabinoid regulation of TML‐C synapses. Apart from defining the synaptic and neurochemical features of TML‐Cs, our findings reveal the morphological identity of a class of dentate CB₁R‐positive neurons that do not express CCK. Our findings indicate that TML‐Cs can mediate cannabinoid sensitive feed‐forward and feedback inhibition of dentate perforant path inputs. © 2015 The Authors Hippocampus Published by Wiley Periodicals, Inc.     

Functional and genomic profiling of effector CD8 T cell subsets with distinct memory fates

An important question in memory development is understanding the differences between effector CD8 T cells that die versus effector cells that survive and give rise to memory cells. In this study, we provide a comprehensive phenotypic, functional, and genomic profiling of terminal effectors and memory precursors. Using killer cell lectin-like receptor G1 as a marker to distinguish these effector subsets, we found that despite their diverse cell fates, both subsets possessed remarkably similar gene expression profiles and functioned as equally potent killer cells. However, only the memory precursors were capable of making interleukin (IL) 2, thus defining a novel effector cell that was cytotoxic, expressed granzyme B, and produced inflammatory cytokines in addition to IL-2. This effector population then differentiated into long-lived protective memory T cells capable of self-renewal and rapid recall responses. Experiments to understand the signals that regulate the generation of terminal effectors versus memory precursors showed that cells that continued to receive antigenic stimulation during the later stages of infection were more likely to become terminal effectors. Importantly, curtailing antigenic stimulation toward the tail end of the acute infection enhanced the generation of memory cells. These studies support the decreasing potential model of memory differentiation and show that the duration of antigenic stimulation is a critical regulator of memory formation.     

Monitoring of plasma concentration of pyrimethamine (PYR) in infants with congenital Toxoplasma gondii infection--own observations

The study objective was to determine plasma concentration of pyrimethamine in 24 infants aged 1-5 months, treated for congenital toxoplasmosis. Pyrimethamine was used in a single daily dose at an amount of 0.35-0.98 mg/kg daily, with sulfadiazine (50-100 mg/kg/day) in divided doses 2-3 times a day, and folinic acid given twice a week (7.5 mg). This regimen was continued for 2-6 months, then Fansidar was administered. Pyrimethamine concentration in plasma was measured using high-performance liquid chromatography method (HPLC). A total of 70 tests were performed. Concentration of pyrimethamine ranged from 0.01 to 1.2 microg/ml. In 14 children (58 tests) the concentration of pyrimethamine achieved therapeutic value. In 7 patients (8 tests) the concentration was below therapeutic level, and in 3 patients (4 tests) above therapeutic level. In 11/24 (46%) children transient moderate neutropenia was observed. Modification of therapy was necessary in 12 patients. Monitoring of pyrimethamine concentration in plasma improves safety and effectiveness of the therapy and is useful in obtaining correct individual dose of the drug. Neutropenia is the most common side-effect of pyrimethamine observed even when using the recommended dose.     

Epidemiological study of scabies in different environmental conditions in central poland

PURPOSE: The goal of the research was to determine the spreading of Sarcoptes scabiei and the incidence of scabies in the residents of particular districts of the Swietokrzyskie Voivodeship (Central Europe) from 1990 to 1998. METHODS: An epidemiological analysis of scabies incidents was performed, with a focus on the age and sex patterns of the population, seasonal incidence, and environmental conditions. In the entire area covered in the period studied, a total of 2064 cases of scabies were reported. The incidence of scabies was typically higher in rural areas than in cities. The most cases of scabies were noted in children and teenagers between 6 and 15 years of age. RESULTS: The research indicated that prevalence of the disease within a family is an important factor in scabies epidemiology in the Swietokrzyskie Voivodeship. The incidence of scabies is seasonal in its nature, as the majority of cases occurred in the autumn and winter months. CONCLUSION: The incidence of the disease can be reduced by improving socioeconomic and hygienic conditions and by implementing a proper system of social education, as well as by promoting more efficient health service.     

Wild game as a reservoir of Anaplasma phagocytophilum in north-western Poland

BACKGROUND: The aim of the study was to determine the role of game animals as reservoirs of Anaplasma phagocytophilum, a bacteria species transmitted by Ixodes ricinus ticks, from north-western Poland (Zachodniopomorskie vovoidship). The area under question is endemic for A. phagocytophilum. MATERIAL AND METHODS: Blood and spleen samples were taken from 72 roe deer between April and December 2003. Animals culled during winter did not harbour ticks, on the other hand 155 individuals of Ixodes ricinus were collected from 35 of 43 animals taken during spring. We tested all samples for A. phagocytophilum by PCR amplification of the msp2 gene. An individual was considered infected if pathogens were detected in at least one isolate (blood or a tissue sample). RESULTS: DNA from A. phagocytophilum was not found in isolates from ticks collected from the animals. The general level of infection for the roe deer was 31.94% (23/72). DNA of A. phagocytophilum was most commonly detected in blood samples; only in three cases was anaplasma DNA detected in spleen and not in blood. Ruminants seem to be the most competent reservoir for A. phagocytophilum in north-western Poland.     

Composition of inflammatory infiltrate and its correlation with HBV/HCV antigen expression

AIM： To study the composition of liver inflammatory infiltrate in biopsy material from patients chronically infected with hepatotropic viruses and to evaluate the correlation of inflammatory infiltrate with hepatitis B virus （HBV） and hepatitis C virus （HCV） viral antigen expression in chronic B and C hepatitis.
METHODS： The phenotype of inflammatory cells was evaluated by the EnVision system, using a panel of monoclonal antibodies. HBV and HCV antigens were detected with the use of monoclonal anti-HBs, polyclonal anti-HBc and anti-HCV antibodies, respectively. RESULTS： The cellular composition of liver inflammatory infiltrate was similar in the patients with B and C hepatitis： ～50%-60% of cells were T helper lymphocytes. Approximately 25% were T cytotoxic lymphocytes; B lymphocytes comprised 15% of inflammatory infiltrate; other cells, including NK, totalled 10%. Expression of HLA antigens paralleled inflammatory activity. Portal lymphadenoplasia was found more often in hepatitis C （54.5%） than in hepatitis B （30.6%）. Expression of HB-cAg was found more often in chronic B hepatitis of moderate or severe activity. Overall inflammatory activity in HBV-infected cases did not correlate with the intensity of HBsAg expression in hepatocytes. Inflammatory infiltrates accompanied the focal expression of HCV antigens. A direct correlation between antigen expression and inflammatory reaction in situ was noted more often in hepatitis C than B.
CONCLUSION： Irrespective of the etiology and activity of hepatitis, components of the inflammatory infiltrate in liver were similar. Overall inflammatory activity did not correlate with the expression of HBsAg and HCVAg; HBcAg expression, however, accompanied chronic hepatitis 8 of moderate and severe activity.