Inhibition of an anti-Pr1d cold agglutinin by citrate present in commercial red cell preservative solutions

A patient with known cold autoimmune hemolyticanemia was admitted for surgery. Routine cold agglutinin evaluations, using commercial red cells (RBCs) in modified Alsever's preservative solution, revealed a cold agglutinin titer of 4 to 16. However, using RBCs washed four times with saline, a high-titer (greater than 2000 at 4 degrees C) cold autoagglutinin was demonstrated. The cold agglutinin was shown to be an IgM kappa paraprotein with anti-Pr1d specificity. The addition of Alsever's solution to washed RBCs inhibited the cold agglutinin. Each major component of Alsever's solution (neomycin, chloramphenicol, inosine, dextrose, and citrate) was tested individually; only citrate inhibited the patient's cold agglutinin. Various compounds structurally related to citrate were tested and found to cause various degrees of inhibition. The strongest inhibition correlated with the presence of either three carboxyl groups on molecules devoid of double-bonded carbon atoms or two carboxyl groups in cis configuration. A panel of 54 cold agglutinins, including 7 with anti-Pr specificity, was analyzed. None was significantly inhibited by Alsever's solution, although one with anti-Pr2 specificity was weakly inhibited. In summary, these studies describe an anti-Pr1d cold autoagglutinin that was inhibited by citrate in RBC preservative solutions. The failure to detect such a cold agglutinin can result from not washing RBCs free of citrate before testing.     

The effect of physical activity on pelvic organ prolapse

Objective  The objective of this study was to determine whether pelvic organ prolapse increases after physical activity.
Design  Prospective observational study.
Setting  St Mary's Hospital, Manchester, UK.
Sample  Women undergoing surgery for pelvic organ prolapse.
Methods  Fifty-four women were recruited to the study. Symptoms and POPQ findings were assessed after a period of prescribed activity and overnight bedrest.
Main outcome measures  Primary outcome was an increase in Pelvic Organ Prolapse Quantification (POPQ) measurements with activity. Secondary outcomes were association of symptoms or quality-of-life scores (Pelvic Floor Distress Inventory [PFDI] and Pelvic Floor Impact Questionnaire [PFIQ]) with an increase in POPQ measurements.
Results  There was a significant increase in POPQ stage and five vaginal parameters (Aa, Ba, C, Ap and Bp) with physical activity ( P < 0.001). Reported symptoms, higher PFDI and PFIQ scores and higher individual symptom bother scores were not more common in the women with greater pelvic organ descent (measured by the POPQ system) following physical activity.
Conclusions  Greater pelvic organ prolapse was found on POPQ examination following physical activity, but this was not associated with worsening of symptoms and greater impairment of quality of life.     

Service users' experiences of obtaining and giving information about disorders of sex development

Objective  To quantify participants' experiences of obtaining and giving information about disorders of sex development (DSD).
Design  Cross-sectional survey study that asked people about their current and past experiences relating to DSD disclosure.
Setting  A large tertiary referral centre for DSD management in the UK.
Population  One hundred of 126 people with a confirmed diagnosis of DSD who were invited to participate in the study formed the usable sample.
Methods  All people who attended clinic for follow-up during the study period and members of a patient support group whose annual meeting fell within the study period were asked to complete the Middlesex Communication Survey.
Main outcome measures  The Middlesex Communication Survey.
Results  Younger participants were more likely to report having been appropriately informed about their diagnosis than older people. Nearly half of the former had been fully informed about their diagnosis by age 15 years, compared with 0% of the older age group. In terms of information sharing, mothers were most likely to be the person with whom the participant had shared (almost/all) DSD information (74%), followed by current partners (71%). Information relating to genital surgery, presence of testes and clitoral anomalies were the least likely aspects to have been unambiguously shared with even the most informed person.
Conclusions  Our results suggest that difficulties in obtaining DSD information from care providers were common, and that communication has improved for younger participants. The study also confirmed that many people with DSD continue to struggle with confiding, even in those closest to them, about aspects of their diagnosis. Care protocol needs to centralise psychological adaptation, which should also be a primary focus for future research.     

Impact of bowel obstruction at the time of initial presentation in women with ovarian cancer

Objective  To determine whether the presence of bowel obstruction at the time of initial presentation has any prognostic significance in these women.
Design  Retrospective cohort study.
Setting  Dedicated gynaecological oncology service of a large tertiary institution.
Population  Women who had a bowel obstruction as part of their initial presentation of ovarian cancer were identified between 1995 and 2007. Each woman was matched with four control women (with disease but no obstruction).
Methods  Women with disease were compared with controls to determine the impact, if any, of bowel obstruction at presentation. Several prognostic variables including bowel obstruction were also evaluated in a Cox proportional hazard model.
Main outcome measures  Progression-free survival (PFS) and overall survival (OS).
Results  Forty-eight women with disease and 192 controls were identified during the study period. The median follow-up period was 19 months among women with disease versus 20 months in controls. No differences were seen in demographics and clinical characteristics of the women. Optimal cytoreduction rate was similar between the two groups (75% versus 78%, P  = 0.7). Patients with bowel obstruction had a shorter PFS and OS compared with controls [19 months versus 21 months ( P  = 0.01) and 22 versus 35 months ( P  = 0.008)], respectively. Bowel obstruction at presentation was an independent prognostic variable with a hazard ratio of 1.5 ( P  = 0.009). Other prognostic variables were age, stage and extent of surgical cytoreduction.
Conclusions  Bowel obstruction at the time of initial presentation is an adverse prognostic factor in women with ovarian cancer.     

Modified silicone sling assisted temporalis muscle transfer in the management of lagophthalmos

Aim:

To evaluate the efficacy of modified temporalis muscle transfer (TMT) by silicone sling for the management of paralytic lagophthalmos.

Settings and Design:

Prospective interventional study.

Materials and Methods:

Ten patients of lagophthalmos due to facial palsy underwent modified TMT using silicone sling. The patients were followed-up for a period of 3 months. Palpebral aperture in primary gaze and during eye closure were assessed both pre- and postoperatively along with problems associated with lagophthalmos like exposure keratopathy and lacrimation.

Statistical Analysis:

Paired t-test was applied to measure the statistical outcome.

Results:

Eight patients achieved full correction of lagophthalmos with no lid gap on closing the eye. The mean (standard deviation (SD)) lid gap on eye closure was 7.7 (0.86) mm preoperatively, 0.5 (0.47) mm at 1^st postoperative day, and 0.7 (0.75) mm at 3^rd month. There was a reduction in mean lid gap on eye closure of 7 mm at 3 months (P < 0.0001) which is highly significant. The mean (SD) vertical interpalpebral distance during primary gaze was 12.05 (1.12) mm preoperatively, 10 (0.94) mm at 1^st postoperative day, and 10.35 (1.08) mm at 3^rd month. There was a reduction in mean vertical inter palpebral distance of 1.7 mm at 3 months (P = 0.001) which is significant. Exposure keratitis decreased in five out of six patients at 3 months.

Conclusion:

Modified TMT by silicone sling is a useful procedure with lesser morbidity and good outcomes for the treatment of paralytic lagophthalmos due to long standing facial palsy.     

Viral aetiology of lower respiratory tract infection in young Malaysian children

OBJECTIVE: To study the viral aetiology of lower respiratory tract infection (LRTI) in young Malaysian children. METHODOLOGY: A retrospective review was performed of LRTI patients aged less than 24 months who were admitted to the University Malaya Medical Centre between 1982 and 1997. Respiratory viruses in their nasopharyngeal secretion were identified by indirect immunofluorescence, viral culture, or both. RESULTS: A total of 5691 children were included in the study. The mean age was 8.6 +/- 6.6 months and the M:F ratio was 1.6:1. The most common diagnosis was pneumonia (52%) followed by bronchiolitis (45%) and croup (2%). Positive viral isolation rate was 22.0%. Respiratory syncytial virus (RSV) was the commonest virus isolated (84%), followed by parainfluenza virus (8%), influenza virus (6%) and adenovirus (2%). Patients with positive virus isolation were younger (7.8 +/- 6.2 vs 8.7 +/- 6.7 months, P = 0.0001) and were more likely to have bronchiolitis. CONCLUSION: Young Malaysian children admitted with LRTI had a 22% viral isolation rate and RSV was the commonest virus isolated.     

Human thrombopoietin levels are high when thrombocytopenia is due to megakaryocyte deficiency and low when due to increased platelet destruction

Thrombopoietin (TPO), the ligand for c-mpl, stimulates proliferation of committed megakaryocytic progenitors and induces maturation of megakaryocytes. To better understand factors regulating TPO levels, we measured blood levels of TPO in patients with impaired platelet production due to aplastic anemia (AA) and with platelet destructive disorders, including idiopathic thrombocytopenic purpura (ITP), posttransfusion purpura (PTP), drug purpura (DP), and X-linked thrombocytopenia (XLTP). The TPO receptor capture enzyme immunoassay (EIA) used had a detection limit of integral of approximately-150 to 200 pg/mL. TPO was undetectable in 88 of 89 normal individuals. Eighteen of 19 patients with AA and a mean platelet count (MPC) of 18,000/microliters (2,000 to 61,000/microliters) had markedly elevated TPO levels (mean, 1,467 pg/mL; range, 597 to 3,834 pg/mL). Eight AA patients who responded to immunosuppressive therapy with their MPC increasing to 140,000/microliters (92,000 to 175,000/microliters) had substantial decreases in TPO (mean, 440 pg/mL; range, 193 to 771 pg/mL). Initial TPO levels did not differ significantly between responders and nonresponders. In contrast, all 21 patients with ITP and an MPC of 16,000/microliters (1,000 to 51,000 /microliters) had undetectable TPO levels, as did 6 patients with acute PTP or DP and 2 patients with XLTP. Megakaryocyte mass, reflected in the rate of platelet production, appears to be the major determinant of TPO levels in thrombocytopenic patients rather than circulating platelet levels per se. Measurement of serum TPO may be useful in differentiating thrombocytopenias due to peripheral destruction from those due to thrombopoietic failure.     

REPAIR OF ABDOMINAL AORTIC ANEURYSM AFTER RENAL TRANSPLANTATION WITHOUT RENAL PROTECTION

SUMMARY The successful resection is reported of an abdominal aortic aneurysm after renal transplantation without the use of bypass or cooling procedure to preserve the kidney.