Recommendations for the evaluation and treatment of neonatal autoimmune and alloimmune thrombocytopenia. The Working Party on Neonatal Immune Thrombocytopenia of the Neonatal Hemostasis Subcommittee of the Scientific and Standardization Committee of the ISTH

The following recommendations of the Neonatal Hemostasis Subcommittee of the Scientific and Standardization Committee of the ISTH for the management of neonatal immune thrombocytopenia were prepared by the working party on neonatal immune thrombocytopenia. Evaluation, diagnosis, and treatment of the mother and neonate with alloimmune and autoimmune thrombocytopenia are discussed and current recommendations provided. This document is likely to require frequent future revision(s).     

The use of laser-light scattering and controlled shear in platelet aggregometry

Laser-light scattering was used to observe and quantify the dynamics of human blood platelet aggregation in platelet-rich plasma (PRP). Aggregation was performed in a controlled shear environment by placing the PRP in the annular space between a rotating cylindrical rod and a stationary cylindrical tube. The instrument was capable of very sensitive continuous semi-quantitative measurements of chemically-induced microaggregation. As a demonstration of the technique, results are presented for ADP-induced aggregation at doses of 10, 1, and 0.1 microM and collagen-induced aggregation at a dose of 5 micrograms/ml, each at shear rates of 1,000 s-1 and 500 s-1. Extensive aggregation was observed in response to ADP at even the low dose of 0.1 microM, indicating a high sensitivity to microaggregates. The sensitivity of the ultimate size of the ADP-induced aggregates to ADP concentration was shear dependent. The formation of microaggregates by collagen stimulation was shown to be almost immediate, as contrasted with a 10-20 s typical lag when observed turbidometrically. Disaggregation was observed with 1 microM ADP, but this was only partial, as contrasted with the complete recovery of transmittance observed in the turbidometric technique. Electronic particle sizing and counting was employed to semiquantitatively verify the aggregate size distributions found from mathematical conversion of the laser-light scattering data.     

Teaching the plantar reflex.

The efficacy of an instructional videotape about the interpretation of the plantar response was evaluated during a two week neurological clerkship. Experimental groups saw the videotape, control groups did not. All students (n = 65) assessed plantar responses of two to four different patients. Their judgment was compared with that of one senior neurologist. Only the students who had seen the videotape showed a significant improvement in performance on a second test (t-test, t = -2.26, p = 0.031). In addition, these students more frequently took account of the flexion synergy (Fisher exact test, p less than 0.001). Video can be an efficient tool in medical education.     

Changes in glial fibrillary acidic protein mRNA expression after corticospinal axotomy in the adult hamster

We examined changes in the expression of glial fibrillary acidic protein (GFAP) mRNA during Wallerian degeneration in the corticospinal system of the adult Golden hamster following axotomy. GFAP is the product of a type III intermediate filament (IF) gene that is expressed specifically in mature astrocytes. A well-studied component of a complex response termed reactive astrogliosis that occurs after various types of CNS injury is the increased production of astrocytic processes filled with GFAP-containing IFs. While increased expression of GFAP during reactive astrogliosis has been well established at the protein level, little is known about whether or not changes in GFAP mRNA levels occur after CNS injury. In the present study we used in situ hybridization methods to examine this issue. A 35S-labeled mouse GFAP cDNA probe was used for in situ hybridizations of sections of the brain stem obtained 2, 7, and 14 days after unilateral transections of the corticospinal tract in the caudal medulla. Film as well as emulsion autoradiography showed a dramatic increase in GFAP mRNA labeling associated with the degenerating corticospinal tract. GFAP mRNA levels were already dramatically increased in the injured corticospinal tract by 2 days post axotomy and remained elevated at 14 days. Interestingly, in addition to the robust increase in GFAP mRNA levels specifically associated with the degenerating tract, a diffuse increase in GFAP mRNA labeling was observed throughout the grey matter of the brain stem at 2 days post-axotomy, but not after this time. Immunoblotting and immunocytochemical experiments verified that the increased GFAP mRNA levels in the degenerating corticospinal system were accompanied by an increased expression of the protein. These results demonstrate that an increase in GFAP mRNA levels occurs during Wallerian degeneration in the CNS and suggest that increased expression of the GFAP gene is a major contributor to CNS scarring that results after direct traumatic injury.     

Dopaminergic transmission in the hypothalamic arcuate nucleus to produce acupuncture analgesia in correlation with the pituitary gland

Acupuncture analgesia (AA) caused by low frequency stimulation of the acupuncture point (AP) was abolished by hypophysectomy and adrenalectomy. Termination of the AA producing pathway from the AP to the pituitary gland was in the medial hypothalamic arcuate nucleus (M-HARN). The origin of the descending pain inhibitory system associated with AA was in the posterior HARN (P-HARN). AA in the hypophysectomized rats, and enhanced neuronal activity in the P-HARN that were abolished during acupuncture stimulation, were both restored by intraperitoneal microinjection of 0.5 mg/kg morphine or 0.1 micrograms beta-endorphin into the P-HARN during acupuncture stimulation. Of the analgesia produced by dopamine or beta-endorphin injected into the P-HARN, that caused by beta-endorphin disappeared after denervation of the M-HARN. The P-HARN neurons that responded to acupuncture stimulation also responded to iontophoretic dopamine, but not to iontophoretic morphine nor ultramicroinjected beta-endorphin. The transmission between the M-HARN and P-HARN may be dopaminergic, and beta-endorphin might presynaptically modulate this transmission. Reduction of sodium ions may have been the reason for abolition of AA after adrenalectomy.     

Functional activity of the neutrophils in the bronchoalveolar space in chronic bronchitis and bronchiectasis]

Bronchoalveolar lavage fluid neutrophils were studied by the cytologic methods in 58 patients with chronic bronchitis, 63 ones with bronchiectasis, and 8 normal controls. The study included cytospectrophotometry of myeloperoxidase and alkaline phosphatase activity and estimation of active oxygen-producing cells in the NBT test. Neutrophilic functional activity was different in the patients with chronic bronchitis and bronchiectasis. Neutrophilic myeloperoxidase and alkaline phosphatase activities were lower in the patients with chronic bronchitis than in those with bronchiectasis, whereas the counts of cells active in the NBT test were low in both patient populations.     

A correlation between muscular strength and hydroxyproline concentration in human patellar tendon

The connective tissue of the knee is frequently injured by athletes, especially those involved in contact sports. It would be important in the prevention of injury as well as the strategy of physical fitness training to know whether the connective tissue is modified in response to athletic stress or training. The potential modification investigated was variability in the concentration of hydroxyproline, a post-translationally modified imino acid found principally in collagen protein. A correlation was sought between this variability and the leg strength parameters torque (expressed as ft-lbs), torque/body weight and work (expressed as ft-lbs). In a preliminary study of five subjects, no correlation was found between hydroxyproline concentration of the patellar tendon and any of the leg strength parameters. These results suggest that this modification of the collagen in connective tissue does not occur in response to athletic stress or training, but rather, for the small number of subjects investigated, appeared to be relatively constant across a range of leg strengths.     

Measurement of intrahepatic shunt using Rutland method

Intrahepatic shunt ratio was calculated from the fraction of the uptake constant and the blood background, analyzing the data of 99mTc-(Sn)-N-pyridoxyl-5-methyltryptophan (99mTc-PMT) hepatobiliary imaging by Rutland method. Shunt flow and total hepatic blood flow (THBF) were also calculated from the values for the effective hepatic blood flow (EHBF) estimated from the blood clearance technique. In 15 cases of normal volunteer, the average of the shunt ratio, shunt flow, and THBF were 18.4 +/- 5.4 (S.D.)%, 137.8 +/- 49 ml/min, and 753 +/- 83.2 ml/min, respectively. In 8 cases of chronic hepatitis, the values were 35.2 +/- 2.6%, 276 +/- 55.4 ml/min, and 794.1 +/- 119.4 ml/min, respectively. In 12 cases of liver cirrhosis, the values were 51.4 +/- 12.6%, 353.9 +/- 141.3 ml/min, and 685.6 +/- 174.8 ml/min, respectively. In cases of chronic hepatitis and liver cirrhosis, in comparison with normal cases, the values for the shunt ratio and shunt flow were significantly increased (p less than 0.001) and those for EHBF were significantly decreased (p less than 0.001), but those for THBF were not significantly altered. There was a significant inverse correlation between the shunt ratio and EHBF (r = -0.842) in all 35 cases. This method is considered to be useful for differential diagnosis, estimation of the grade of the diseases, and evaluation of pathophysiology of various diffuse liver diseases.     

Toxic effects of colloids in the intensive care unit.

Colloid fluid solutions are frequently used as plasma volume expanders in the critically ill. As a group, these nonblood volume replacement solutions have in common a number of potential adverse effects. Intravascular volume overload, dilutional coagulopathy, extravascular extravasation across leaky capillary membranes, and anaphylactoid reactions may all occur with administration of any colloid. In addition, individual agents have unique toxic effects. Renal dysfunction has been associated with dextran 40, myocardial depression with albumin, hypotension with purified plasma protein, and hyperamylasemia with hetastarch. Because no ideal colloidal solution exists, knowledge of type, severity, and clinical significance of adverse effects is important in determining the appropriate plasma volume expander and monitoring its effects.