Treatment of a Giant Haemangioma of the Liver With Kasabach-Merritt Syndrome by Orthotopic Liver Transplant

We describe a case of giant cavernous haemangioma of the liver with disseminated intravascular coagulopathy (Kasabach-Merritt syndrome) which was cured by orthotopic liver transplant.A 47 year old man presented with bleeding and tender massive hepatomegaly after tooth extraction. Investigations showed disseminated intravascular coagulopathy and a giant hepatic haemangioma involving both lobes of the liver. Initial treatment failed to resolve the coagulopathy and liver resection was attempted. At laparotomy the turnout was unresectable and the only option for cure was to offer a liver transplantation. The orthotopic liver transplant was performed 20 days after initial laparotomy. Subsequently, all coagulation parameters returned to normal and the patient remains well after 12 months. Orthotopic liver transplant can be considered for giant hepatic haemangioma with Kasabach-Merritt syndrome when resection is necessary and a partial hepatectomy is not technically feasible.     

Selective inhibition of T cell proliferation but not expression of effector function by human alveolar macrophages

BACKGROUND: Alveolar macrophages are thought to play an important part in regulating lung immune responses. While it is clear that human alveolar macrophages suppress T cell proliferation in vitro, the mechanisms by which this is achieved are not clear, nor is it known whether alveolar macrophages also inhibit other aspects of T cell function. METHODS: Peripheral blood mononuclear cells were stimulated with phytohaemagglutinin or house dust mite allergen, and cultured with variable numbers of autologous alveolar macrophages obtained by bronchoalveolar lavage from 20 normal subjects. RESULTS: Alveolar macrophages induced a reversible inhibition of T cell proliferation in response to both mitogen and allergen stimulation, with the latter being considerably more susceptible to inhibition. This was achieved via heterogenous mechanisms, involving both soluble factors derived from alveolar macrophages and cell-cell contact. Despite inhibiting proliferation, alveolar macrophages had little or no effect on T cell calcium flux, the characteristic changes in CD3, CD2, CD28 and interleukin-2 (IL-2) receptor expression which accompany normal T cell activation, and IL-2 and interferon gamma secretion. In contrast, alveolar macrophages inhibited the tyrosine phosphorylation of proteins which may be involved in IL-2 receptor-associated signal transduction. CONCLUSIONS: The immunoregulatory properties of alveolar macrophages are relatively selective, allowing T cell activation and cytokine secretion while inhibiting T cell proliferation within the lung.


     

Change management in a group dental practice. A consideration of management issues that may arise in a larger dental practice.

The drive for quality assurance in general dental practice has arisen as a response to changing standards and demands. Dentists need to develop skills in change management in this new culture of change. Groups of practitioners often encounter difficulties when managing change, yet it is essential that they lead the process. Such problems are common among groups of professionals. A wide range of topics is presented that may, from one point of view, represent challenging or problem areas (obstacles) for a group practice but may also, from a different point of view, provide a framework of opportunities for improvement, and facilitate the management processes within the practice and the management of change in particular (tools). The range of skills required to assist a professional group is such that individual dentists or advisers may not be able to achieve much on their own. The best way forward may be to interpret the problems as a professional training need and to organise training as a group. These issues will be considered under the following headings: partners and teams; introduction: the need for change management; the challenge for group practices; obstacles and tools; conclusion: the way forward--a case for training.     

Percentile regression analysis of correlated antibody responses

Antibody responses following vaccination usually are analysed by comparing geometric mean concentrations across levels of relevant covariates and by comparing the proportions of vaccinees responding. In the regression setting, the analyses are done on log-transformed concentrations, estimating geometric mean responses conditional on a vector of covariates. More detailed analyses examining the relationship of covariates to different parts of the response distribution may be performed through the application of asymmetric least squares estimation of regression percentiles. We present a method for accounting for correlation in percentile regression analyses of longitudinal antibody response data. We illustrate the procedures with measles antibody response data from Haitian children who participated in a randomized trial of high titre vaccines. The strongest dose and strain effects were seen in the low end of the antibody concentration distributions.     

Candida septicaemia and abscess formation following multiple injuries with blunt rupture of the stomach

A case of multiple injuries including blunt rupture of the stomach is reported. It demonstrates that Candida needs to be considered as a possible cause of continued sepsis following a ruptured viscus in the presence of multiple trauma. Surgical drainage is required in this situation, in the same way that abscesses caused by more conventional organisms require aggressive surgical treatment.     

Intestinal and metabolic responses to an α-glucosidase inhibitor in normal volunteers

Postprandial hyperglycemia in diabetic patients can be modified by delaying the digestion and/or absorption of dietary carbohydrates. We have studied an orally active α-glucosidase inhibitor, Bay 1099, in normal volunteers to determine whether these inhibitors can decrease postprandial rises in serum glucose without causing gastrointestinal symptoms or significant fecal caloric wastage. Six subjects were given 25, 50, or 100 mg of Bay 1099 or placebo before meals for 1 week, each with a 1-week washout period. Fasting and postprandial concentrations of glucose, insulin, glucagon, enteroglucagon, and gastrointestinal inhibitory peptide (GIP) were measured after the first and last dose of Bay 1099, and the fecal excretions of protein, fat, fiber, and total calories were measured on the last three days of each diet. The passage of unabsorbed carbohydrate into the colon was determined by breath hydrogen analysis three times during each study week. Increasing doses of Bay 1099 were found to decrease the postprandial rise in serum glucose concentration, delay the time to peak insulin concentration, and decrease the output of GIP after the meal. No adaptation was apparent after 1 week of therapy. A dose of inhibitor (50 mg tid), which greatly improves postprandial glucose and hormone output in diabetes, was associated with minimal symptoms and no excess fecal caloric losses. Thus, glucosidase inhibitors such as Bay 1099 may be useful in the management of patients with carbohydrate intolerance.     

Mesenteric and retroperitoneal cysts.

Mesenteric and retroperitoneal cysts are rare intra-abdominal tumors. Ten new patients are presented as well as 152 other cases reported in the English literature. These 162 cases were then analyzed for significant trends. Patients under 10 years of age were significantly different from the older group with respect to a shorter duration of symptoms, a higher number of patients requiring an emergency operation, a lower number of recurrences and the location of the cyst. Patients with retroperitoneal cysts were more likely to have incomplete excision of the cyst and therefore had a higher incidence of recurrence. They also required marsupialization more often. Retroperitoneal cysts should be considered a different entity from mesenteric cysts even though they present clinically in a similar fashion. The outcome of surgical treatment is less satisfactory in patients with retroperitoneal cysts.     

Ear canal cholesteatoma.

Although cholesteatomas are more commonly found in the middle ear and the mastoid, the disease can occur in the external ear canal. All cases of ear canal cholesteatoma treated by the author were reviewed. There were nine ears in seven patients, who had an average age of 62 years. The lesions ranged in size from a few millimeters to extensive mastoid destruction. Smaller lesions can be managed by frequent cleaning as an office procedure. Larger lesions require surgery, either canaloplasty or mastoidectomy. The otolaryngologist should suspect this disease in the elderly. Microscopic examination of the ear with meticulous cleaning of all wax, especially in elderly patients, is most useful in detecting early disease. Frequent applications of mineral oil to the canal should be used in the management of the disease and to prevent recurrence.