DIAGNOSING DISSEMINATED INTRAVASCULAR COAGULATION IN ACUTE INFECTION : CAN WE DO WITHOUT FDP & D-DIMER

Alterations in coagulation profile viz. platelet count, prothrombin time (PT), partial thromboplastin time with kaolin (PTTK), thrombin time (TT) and fibrinogen were studied in 96 patients (73 males and 23 females) of acute infections. Fibrin/fibrinogen degradation products (FDP) level >25µg fibrinogen equivalent unit (FEU)/ml along-with D-dimer >1.0µg FEU/ml was considered criteria for diagnosis of disseminated intravascular coagulation (DIC). Normal values were established using plasma from 12 healthy voluntary blood donors. Out of these 96 patients, 15 had infection with Gram positive bacteria, 23 with Gram negative bacteria and 38 with Dengue. In 20 patients, nature of infection was not defined. Mean platelet count per cubic millimetre was 2.14 lac in Gram positive infection and 1.74 lac in Gram negative infection (p=0.07). There was no significant difference in other coagulation parameters in Gram positive and Gram negative infection. Platelet counts were low in 71% of Dengue patients but there was no significant alteration in PT, PTTK and TT. None of the Dengue patients had hypofibrinogenemia or DIC though hyperfibrinogenemia was present in 21% of Dengue patients. 20 patients had features of septicemia (Gram +ve 7, Gram -ve 8, undefined 5); 10 had concomitant DIC. DIC was present in additional 4 patients of acute infection without septicemia. PTTK was raised in 60% of the septicemia patients. 20 out of 82 non-DIC acute infection patients had subnormal PTTK. Commonest alteration in 14 DIC patients was raised PTTK with a sensitivity of 78.6% and specificity of 81.7%. Low fibrinogen levels though specific for DIC, were present in only 21.4% of the DIC patients. Combinations of PTTK >38 sec with PT >15 sec or platelet count < 1.5 lac/mmm³ were good screening tests for DIC and detected 11 and 10 patients out of 14 with three and two false positives respectively.KEY WORDS: D-dimer, Disseminated Intravascular Coagulation, Fibrinogen degradation products, Partial thromboplastin time, Prothrombin time, Thrombin time     

Direct argon laser exposure for recanalization of peripheral arteries: early results

Direct laser light, in combination with percutaneous transluminal angioplasty (PTA), was used to recanalize atherosclerotic peripheral arteries. Argon laser energy was controlled with an optical assembly and aligned with a special centering/dilation balloon so that plaque tissue absorbed laser energy directly and was vaporized. A channel was thereby created with multiple 10-W laser exposures (2-10 seconds), and conventional angioplasty was then performed. Recanalization was achieved in 33 of 36 procedures (92%), in 23 femoropopliteal (mean length, 9 cm) and three iliac total occlusions and ten femoropopliteal high-grade stenoses, with the three failures occurring in the first group. Complications included two emboli, six moderate groin hematomas, and one laser perforation. While these results are preliminary (mean follow-up, 3 months), direct laser angioplasty appears to be a useful adjunct to PTA for treating atherosclerotic arteries.     

Structure, function, and degeneration of bovine hyaline cartilage: assessment with MR imaging in vitro

The basic magnetic resonance (MR) imaging pattern of normal and degenerated hyaline articular cartilage was studied in vitro in 40 fresh bovine patellae. With the use of an ample spectrum of strongly T1- to T2-weighted sequences, two zones of cartilage with different signal intensities were observed in all specimens. A superficial cartilaginous layer in the MR image with higher water content and longer T1 and T2 correlated with the tangential and transitional zones of normal articular cartilage, whereas a second MR imaging zone with shorter T1 and T2 was identified in the depth of the articular cartilage. Different functional properties in pressure resistance were observed in the two layers. In early cartilage degeneration without thinning, there was increased hydration of the superficial cartilage layer. This study suggests that strongly T1- and T2-weighted images are indispensable for evaluating details in articular cartilage degeneration.     

Chronic myelogenous leukemia: a multivariate analysis of the associations of patient characteristics and therapy with survival

The prognostic importance of patient pretreatment clinical and laboratory features was investigated in a group of 303 patients with Philadelphia chromosome-positive benign-phase chronic myelogenous leukemia. Intensive chemotherapy was given to 97 patients, and 78 underwent an early elective splenectomy. The overall median survival time, dated from hospital admission, was 39 months. Patient characteristics associated with shortened survival were age 60 years or older, black race, the presence of hepatomegaly, splenomegaly, symptoms, weight loss, and poor performance status. Adverse blood and bone marrow parameters were anemia, thrombocytosis or thrombocytopenia, a high proportion of peripheral blasts plus promyelocytes or of basophils, a high proportion of marrow blasts or basophils, decreased marrow megakaryocytes, and cytogenetic abnormalities in addition to the Philadelphia chromosome. Several of these factors were interrelated. A multivariate regression analysis demonstrated that the combination blood basophilia, race, additional cytogenetic abnormalities, age and marrow basophilia had the strongest predictive relationship to survival time. This resulted in a model segregating patients into low-, intermediate-, and high-risk groups, with median survivals of 53, 39, and 25 months, respectively. Another model was derived that did not include the marrow features and identified splenomegaly and platelet counts as adding to the prognosis prediction by blood basophilia, race, and age. Evaluation of the effect of therapy, after adjusting for differences in prognostic characteristics, showed that intensive chemotherapy was associated with survival prolongation among patients at intermediate and high risk of death. We conclude that a combination of pretreatment factors identifies different risk subcategories in patients with chronic myelogenous leukemia and is helpful in assessing overall prognosis and treatment effect.     

Endonasal treatment of postsaccal stenoses of lacrimal ducts: intranasal retrograde probing in congenital stenosis

Congenital stenosis of nasolacrimal duct is a common medical problem affecting up to 20% of newborn infants. When symptoms persists for more than 5 to 6 months the lacrimal ducts should be subjected to probing and irrigation. Anterograde probing through inferior lacrimal punctum using a rigid Bowman probe is the standard approach to such cases. We could not find reports of a retrograde endonasal probing of the lacrimal ducts in the available literature published in the last five years. MATERIAL AND METHODS: Between 1992 and 2002, we treated 328 children (136 boys and 192 girls) with congenital stenoses of the lacrimal passageways. The mean age of the children was 7.4 (Sx +/- 13) months. Endonasal probing and retrograde irrigation of lacrimal ducts were performed in all children, taking into consideration the individual peculiarities of the obstruction and the anatomical accessibility of the opening of ductus nasolacrimalis in the inferior nasal passageway. RESULTS: Outflow of irrigation fluid from lacrimal puncta was observed at the first probing in 90% out of a total number of 401 primary probings. Because of persistent membranes in the inferior lacrimal punctum in 3 cases (0.8%) we had to repeat the initial dilatation. The repeated probing failed to ensure reliable establishment of lacrimal duct patency only in 1% of the cases. In such children we recommended and performed endonasal dacryocystorhinostomy with balloon intubations placing a catheter and this restored lacrimal drainage to the nasal cavity. CONCLUSION: Endonasal probing and irrigation of lacrimal ducts used in the treatment of congenital stenoses is a highly effective (99%), physiologically consistent and little traumatic method of reestablishing the patency of the tear draining system. If it fails, endonasal dacryocystorhinostomy with stents is the definitive treatment of children's dacryocystitis.