Treatment of refractoriness to platelet transfusion by protein A column therapy

Ten thrombocytopenic patients (platelets < 10–24 × 10(9)/L) who were refractory to platelet transfusion were investigated for their responsiveness to staphylococcal protein A column therapy. Nine patients had previously been treated with steroids, intravenous immune globulin, and/or other forms of immunosuppressive therapy without improvement in their transfusion response. All patients were receiving multiple platelet transfusions without achieving 1-hour corrected count increments (CCIs) > or = 7500. Eight patients had antibodies that reacted with platelets and were directed against HLA class I antigens, ABO antigens, and/or platelet-specific alloantigens. Plasma (500-2000 mL) from each patient was passed over a protein A silica gel column and then returned to the patient. Patients received from 1 to 14 treatments. A positive response to protein A therapy was defined as at least a doubling of the pretreatment platelet count and/or two successive 10- to 120-minute posttransfusion CCIs > or = 7500. Following plasma treatments, 6 of 10 patients responded with daily platelet counts that averaged 48 +/− 11 × 10(9) per L as compared with counts of 16 +/− 7 × 10(9) per L (p < 0.0005) before treatment. Posttransfusion CCI values determined in four of these patients averaged 2480 +/− 810 and 10,010 +/− 3540 (p < 0.005) before and after treatment, respectively. In contrast, among the four unresponsive patients, platelet counts averaged 10 +/− 9 and 13 +/− 10 × 10(9) per L (p = NS), respectively, while posttransfusion CCIs were 700 +/− 1410 and 1520 +/− 2460 (p = NS), respectively.(ABSTRACT TRUNCATED AT 250 WORDS)     

Perforated colorectal neoplasms: correlation of clinical, contrast enema, and CT examinations

Results of clinical, contrast enema (CE), and computed tomographic (CT) examinations in 39 patients with perforated colorectal neoplasms were retrospectively reviewed. Twenty patients were toxemic at initial presentation, but in only four patients was the diagnosis of perforated colorectal neoplasm initially suspected clinically. CE study was performed in 22 patients and enabled the diagnosis of perforated neoplasm in 11 cases, neoplasm alone in eight, and neither neoplasm nor perforation in three. CT was performed in 38 patients and enabled the diagnosis of perforated neoplasm in 36; pericolic phlegmon but no mass lesion was evident in two. In 16 patients, CT also demonstrated metastatic disease. Because of its reliability in establishing the diagnosis and staging the extent of the inflammatory and neoplastic disease, CT is indicated in cases of suspected or proved perforated colorectal neoplasm and in cases in which CE study findings are indeterminate or suggestive of perforated neoplasm.     

Interaction between central alpha 1- and alpha 2-adrenoceptors on sympathetic tone in rats

The interaction between piperoxan and alpha 2-agonists on sympathetic tone was studied in rats. The sympatho-inhibitory effect of alpha 2-agonists (clonidine, guanfacine, B-HT 933) was assessed by recording heart rate in normotensive bilaterally-vagotomized rats. Clonidine (3 micrograms/kg, i.c.v.) and B-HT 933 (100 micrograms/kg, i.c.v.) induced a bradycardia which was fully reversed by piperoxan (30 micrograms/kg, i.c.v.). However, in rats treated with guanfacine, piperoxan induced a partial recovery of the bradycardic effect. The injection of a small dose of the specific alpha 1-adrenoceptor blocking drug, AR-C 239 (10 micrograms/kg, i.c.v.) which, by itself did not modify heart rate, completely inhibited the reversal effect of piperoxan in rats treated with clonidine, B-HT 933 or guanfacine. In rat brainstem membranes, B-HT 933 was found to bind to both alpha 1- and alpha 2-adrenoceptors and was as potent as clonidine in competing for alpha 1-sites bound by [3H]prazosin. On the other hand, in bilaterally vagotomized rats, piperoxan (30 micrograms/kg, i.c.v.) induced an increase in blood pressure and heart rate which was inhibited by previous administration of AR-C 239 (10 micrograms/kg, i.c.v.). These data suggest that, by inhibiting central alpha 2-adrenoceptors, piperoxan unmasks central alpha 1-adrenoceptor stimulation by endogenous catecholamines leading to an increase in the sympathetic tone, but a full recovery in heart rate could be observed only with the mixed alpha 1- and alpha 2-adrenoceptor agonists, clonidine and B-HT 933. In addition, these data further indicate that alpha 1-adrenoceptors are implicated in a tonic control of the sympathetic nerve activity in normotensive rats.     

Value of the esophageal approach in the diagnosis, treatment and therapeutic surveillance of arrhythmia in children

For the past few years, a new method for the investigation and treatment of arrhythmias has been used: transoesophageal atrial pacing and recording (TAPR). In the light of 6 cases observed recently, we review the technical aspects and the indications for TAPR. A bipolar stimulation catheter is inserted in the oesophagus and positioned in the area where the atrial wave of greater amplitude is recorded. Atrial stimulation is done with impulses of long duration obtained with a special stimulator. Two cases validated this technique which was effective to correct atrial flutter in a neonate with heart failure resistant to medical treatment as well as in a 5 year-old child. The value of TAPR as a diagnostic tool in cases of tachycardia is discussed in the context of 2 cases: a 5 week-old with wide QRS and a 14 month-old with narrow QRS. Finally, the value of TAPR for monitoring the efficacy of anti-arrhythmia medications is illustrated by 4 cases of supraventricular tachycardia, in whom the optimal dosage of the anti-arrhythmic drug used was determined with the help of TAPR-induced tachycardia. The current literature concerning the technique, indications and results of TAPR are reviewed. This method is likely to take a great importance for the study and treatment of supraventricular arrhythmias in children.     

Tumours of Oddi: Diagnosis and Surgical Treatment

A retrospective review of 56 patients operated upon for tumours of Oddi was performed in order to determine optimal diagnostic and therapeutic procedures. Common presenting symptoms were jaundice (86%) and anemia (21%). Mean size of the tumour was 2.3 cm. Five tumours were benign and 51 were malignant. According to the classification of Martin, five were grade I: 10 grade II; 18 grade III; and 18 grade IV. Forty-seven patients underwent resection of the tumour: three local excisions for small benign tumors, six ampullectomies (followed in three by a Whipples’ procedure for recurrence) and 41 Whipples’ procedures. The hospital mortality was 5.3%, minor complications appeared in 21%. The overall five years survival was 41%. It was 75% in grade I, 50% in grade II, 40% in grade III and 10% in grade IV. The patients who received ampullectomies were alive with a follow-up of one, two and three years. All patients operated upon for a benign tumour were alive except one who died of cardiac failure. Ultrasonography and duodenoscopy are the most useful tests for the diagnosis of tumours of Oddi. Prognosis depends on the degree of infiltration of the duodenal wall and the presence of positive lymph nodes. Whipples’ procedure is best but ampullectomy can be used in elderly or poor risk patients. Malignant tumours of the ampullary region are infrequent and reported to constitute betwee 0.02 and five percent of all cancers of the digestive tract. With wider application of endoscopic techniques, there has been an increasing interest in this group of tumours during recent years. In the literature tumours of Oddi are usually reported in the group of periampullary tumours, including tumours of the ampulla itself, duodenal wall surrounding the ampulla, the distal part of the common bile duct and head of the pancreas. We have wanted to distinguish specifically the tumours of the ampulla of Vater and have adopted the term tumour of Oddi introduced by Marchal and Hureau.The sphincter of Oddi exactly delineates the junction between the bile duct, pancreatic duct and duodenum. We wanted to avoid using the anatomic term ampulla of Vater, since this structure rarely appears as an ampulla. This then excludes tumours in the head of pancreas, common bile duct above ths phincter of Oddi and tumours of the duodenal wall adjacent to the papilla. These tumours seem to behave differently from other pancreatic tumours, as they carry a different prognosis and need special attention. We have therefore reviewed retrospectively 56 patients with tumours of Oddi with special reference to diagnosis, histopathologic examination and surgical therapy.     

Epidermal growth factor excretion in burned rats

Evidence for epidermal growth factor (EGF) involvement in the physiological response to burns was sought from urinary levels of EGF, urea and creatinine in male rats using a standardized thermal skin injury model (25 per cent body surface) and treated with fluid resuscitation. Postmortem, the skin lesions were studied by microscopy to guarantee the absence of inflammatory complications. Statistically significant differences were observed in body weight, urea and creatinine excretion when compared to the basal values. When EGF excretion results were evaluated as raw data (expressed as ng/mg of creatinine or ng/day) compared to basal levels, no statistically significant differences were observed. However, when the results were expressed as percentage increases with respect to the basal values, a statistically significant increase was found over the first 7 days postinjury (P = 0.029).