Splenic Syndrome due to Sickle Cell Trait amongst Indian Soldiers Serving in Kashmir

Background

Heterozygous transmission of gene for Haemoglobin S leads to sickle cell trait. Mostly the trait remains silent with no additional morbidity or mortality. When these persons migrate to higher altitudes, in times of high oxygen demand, some of them develop splenic infarction. This is a rare phenomenon and only 47 such cases had been reported till 2005.

Methods

This study was conducted at an Indian military hospital serving the troops deployed in Kashmir valley at altitudes ranging from 5500 ft to 13000 ft. When two consecutive splenectomies for splenic abscesses, turned out to be sickling induced infarction histopathologically, we reviewed splenectomy specimens received in last six years for evidence of sickling.

Result

Out of 33 splenectomies performed during the period of study, 22 were due to trauma (gun shot injury 11; splinter injury one and blunt injury 10). Of the rest eleven, who presented without any history of trauma, seven had evidence of vascular occlusion with aggregates of sickled red blood cells. In none, Gram stain or Periodic Acid Schiff stain revealed any bacterial or fungal colonies. One patient of splenic syndrome was found to have unrecognised sickle cell trait and he was managed conservatively.

Conclusion

Sickle cell trait should be excluded before considering splenectomy in ethnically vulnerable patients presenting with splenic syndrome. An uncomplicated splenic infarction can be managed conservatively.Key Words: Sickle cell trait, Splenic infarction, Splenic syndrome     

Complement activation in stored platelet concentrates

Activation of platelets during preparation and/or storage of platelet concentrates in plastic containers at room temperature has recently been recognized. Many different biologic causes of this activation have been postulated. Activated complement, as a multi-enzyme system, is one of the possible sources of molecules leading to platelet activation. To detect complement activation, functional complement activity and the generation of complement-derived ligands were investigated in platelet concentrate supernatant plasma during 5 days of storage at room temperature. Hemolytic tests for functional classical and alternative pathway activity were used, as was the kinetic test for complement- mediated inhibition of immune complex precipitation. The presence of C3 activation products (C3, C3c, C3dg) was investigated in plasma by sodium dodecyl sulfate-polyacrylamide gel electrophoresis and Western blotting procedures and on platelets by immunofluorescence. Activation of complement was evident during storage, and C3c and C3d fragments were clearly demonstrated in plasma. The amount of C3d fragments on platelets gradually rose during the first 3 days of storage. At the end of 5 days of storage, the platelets became C3d negative. There are two possible mechanisms of C3d disappearance–shedding and/or further degradation of C3d fragments. Those results indicated that complement activation and the generation of complement-dependent ligand-receptor interaction may be mechanisms for platelet activation in concentrates stored at room temperature.     

New and underutilised technologies to reduce maternal mortality and morbidity: what progress have we made since Bellagio 2003?

In 2003, maternal health experts met in Bellagio, to consider new and underutilised technologies vital to pregnancy-related health services in low-resource settings. Five years later, we examine what progress has been made and what new opportunities may be on the horizon. Based on a review of literature and consultation with experts, we consider technologies addressing the five leading causes of maternal mortality: postpartum haemorrhage, eclampsia, obstructed labour, puerperal sepsis, and unsafe abortion (pregnancy termination and miscarriage). In addition, we consider technologies related to obstetric fistula, which has received more attention in recent years.     

Reproducibility of 99mTc-mercaptoacetyltriglycine renography: population comparison

PURPOSE: To evaluate reproducibility of diuretic renography, performed according to current guidelines in adult and pediatric patient populations. MATERIALS AND METHODS: Fifty adult and 50 pediatric renograms were processed twice by each of three observers. For differential renal function (DRF) assessment, intraclass correlation coefficient (ICC), standard deviation of DRF calculation and the repeatability parameter were calculated. For drainage assessment, ICC was calculated. Intraobserver and interobserver analysis was performed for both parameters. Patient groups and subgroups (age, DRF asymmetry, drainage) were compared by analysis of variance. RESULTS: Interobserver analysis, adult patient group: DRF-repeatability 4.20%, ICC 0.99. Drainage-ICC 0.92/1.00 (left/right kidney). Pediatric patient group: DRF-repeatability 7.80%, ICC 0.97. Drainage-ICC 0.93/0.85 (left/right kidney). Intraobserver analysis, adult patient group: DRF-repeatability 2.61%, ICC 0.99. Drainage-ICC 0.92/1.00 (left/right kidney). Pediatric patient group: DRF-repeatability 4.76%, ICC 0.98. Drainage-ICC 0.92/0.88 (left/right kidney). Highest repeatability and thus highest DRF dispersion was found in the subgroup of patients with poor/impaired kidney drainage and reduced DRF (repeatability 11.3%, analysis of variance, P<0.001). CONCLUSION: Reproducibility of DRF estimation was excellent in adults in both intraobserver and interobserver analysis. In pediatric patients, intraobserver DRF reproducibility was very good, whereas variation in interobserver analysis was rather high with a potential influence on patient management, but occurred mainly in a subgroup of patients with impaired drainage and ipsilaterally reduced DRF. Drainage assessment was highly reproducible in both patient groups; factors confounding drainage interpretation in discordant patient cases remained unidentified.     

Secondary glaucoma after intravitreal dexamethasone implant (Ozurdex) injection in patients with retinal disorder: A retrospective study

Purpose:To investigate the rate of secondary glaucoma after intravitreal (IV) dexamethasone implant (ozurdex) 0.7 mg injection in a retinal disorder over a clinical treatment period of 2 years in a tertiary eye care center.Methods:Retrospective study based on the records of patients receiving IV ozurdex 0.7 mg implant for T/t of cystoid macular edema (CME), diabetic macular edema (DME), macular edema due to central retinal vein occlusion/branch retinal vein occlusion (CRVO/BRVO), and choroidal neovascular membrane (CNVM) at a tertiary eye care hospital for 2 years with 6 months of follow-up. The post-T/t intraocular pressure (IOP) and antiglaucoma medication (AGM) required was recorded at day 1, 1 week, 1, 2, 3, 4, and 6 months and analyzed for secondary IOP spike or ocular hypertension defined as IOP >21 mmHg at any point in time. The patients with pre-existing glaucoma and lost to follow-up were excluded.Results:A total of 102 eyes of 80 patients were included in the study. The mean baseline IOP was 14.40 + 2.97 mmHg, post-injection was 15.01 + 3.22 mmHg at day 1, 15.15 + 3.28 mmHg at 1 week, 15.96 + 3.62 mmHg at 1 month, 16.26 + 3.95 mmHg at 2 months, 15.41 + 3.33 mmHg at 3 months, 15.38 + 3.28 mmHg at 4 months, and 14.27 + 2.69 mmHg at 6 months. No significant difference was seen from baseline IOP at day 1 (P = 0.163), 1 week (P = 0.086), and 6 months (P = 0.748). Statistically significant difference was seen at 1 month (P = 0.0009), 2 months (P = 0.0001), 3 months (P = 0.023), and 4 months (P = 0.026). The mean IOP peak at 2 months recovered to baseline by 6 months subgroup IOP trend shows a similar variation and the results are consistent with the studies in the literature. About 19/102 (18.62%) eyes showed an IOP spike post-T/t. The maximum was seen at 2 months; 16 eyes showed a rise in the range 22–25 mmHg; 8 in the range 26–30 mmHg; and 1 eye had 34 mmHg and required multiple AGM—no surgical intervention was needed.Conclusion:A secondary IOP spike post-IV ozurdex 0.7 mg seen in 18.62% of the cases require AGM. The IOP monitoring should be meticulously performed for the variations and secondary IOP spike management to prevent irreversible damage to the optic nerve and visual field.     

Image Reconstruction Using Small-voxel Size Improves Small Lesion Detection for Positron Emission Tomography

BackgroundPET/CT imaging is widely used in oncology and provides both metabolic and anatomic information. Because of the relatively poor spatial resolution of PET, the detection of small lesions is limited. The low spatial resolution introduces the partial-volume effect (PVE) which negatively affects images both qualitatively and quantitatively. The aim of the study was to investigate the effect of small-voxel (2 mm in-line pixel size) _vs. standard-voxel (4 mm in-line pixel size) reconstruction on lesion detection and image quality in a range of activity ratios.Materials and methodsThe National Electrical Manufacturers Association (NEMA) body phantom and the Micro Hollow-Sphere phantom spheres were filled with a solution of [¹⁸F]fluorodeoxyglucose ([¹⁸F]FDG) in sphere-to-background ratios of 2:1, 3:1, 4:1 and 8:1. In all images reconstructed with 2 mm and 4 mm in-line pixel size the visual lesion delineation, contrast recovery coefficient (CRC) and contrast-to-noise ratio (CNR) were evaluated.ResultsFor smaller (≤ 13 mm) phantom spheres, significantly higher CRC and CNR using small-voxel reconstructions were found, also improving visual lesion delineation. CRC did not differ significantly for larger (≥ 17 mm) spheres using 2 mm and 4 mm in-line pixel size, but CNR was significantly lower; however, lower CNR did not affect visual lesion delineation.ConclusionsSmall-voxel reconstruction consistently improves precise small lesion delineation, lesion contrast and image quality.Key words: PET/CT, voxel size, contrast recovery coefficient, contrast-to-noise ratio     

Focused parathyroidectomy without intraoperative parathormone testing is safe after pre-operative localization with 18F-Fluorocholine PET/CT

A focused surgical approach based on pre-operative localization replaced the classical four-gland exploration in patients with primary hyperparathyroidism (PHP). Sestamibi scanning and ultrasound are most often used localization modalities with reported sensitivity of 54–100% for identification of single gland disease.The aim of this study was to analyze the results of pre-operative localization with ¹⁸F-Fluorocholine PET/CT (FCh-PET) in patients with PHP.A retrospective review of 151 patients with PHP who underwent surgery after pre-operative localization with FCh-PET was performed. Only a focused parathyroidectomy without ioPTH testing had been done in patients with single adenoma on FCh-PET. Primary outcome was operative failure, defined as persistent PHP.According to pre-operative FCh-PET 126 (83,4%) patients had single adenoma, 22 (14,5%) multiglandular disease and the test was negative in only two patients. Intraoperative failure experienced 4/126 patients (3,3%) with single adenoma. Removed parathyroid glands were normal in three and hyperplastic in one patient with intraoperative failure. A limited bilateral neck exploration with ioPTH testing was used in 14/22 patients with double adenoma and a classical four-gland exploration without ioPTH testing was used in 8/22 patients with more than two pathological glands according to pre-operative FCh-PET. Intraoperative failure experienced 2/22 patients (9,1%). In two patients with negative FCh-PET a classical four-gland exploration without ioPTH testing was used and one experienced intraoperative failure.A preoperative localization with FCh-PET is a reliable test in patients with PHP. Patients with a single adenoma on FCh-PET can safely undergo a focused parathyroidectomy without ioPTH testing.