Recombinant factor VIIa in the management of a pseudotumour in acquired haemophilia

Bleeding in nonhaemophilic patients with high-titre factor VIII autoantibodies is often severe, life-threatening and refractory to treatment with factor VIII concentrates. In this report, we describe an elderly woman who required surgical excision of a large haemophilic pseudotumour adjacent to the left gluteal muscle. The Bethesda titre of 11 U precluded treatment with human factor VIII, and the patient had an anaphylactic reaction to porcine factor VIII. However, haemostasis was successfully achieved with recombinant factor VIIa and the pseudotumour was removed. The patient was treated with repeated cycles of cyclophosphamide, vincristine, and prednisone. The Bethesda titre eventually declined to 0.7 U and the factor VIII rose to 20%. During an 18-month follow-up period there has been no recurrence of bleeding or of the pseudotumour.     

Differential Expression of VLAβ1 (CD29) on Monocytes From Patients With Endometriosis

PROBLEM : Previous studies have established that in vitro proliferation of endometrial cells is enhanced by peripheral blood monocytes (PBM) and suppressed by peritoneal macrophages (PM) from patients with endometriosis but only suppressed by PBM and PM obtained from normal subjects. The functional activity of PBM and PM is influenced by the engagement of numerous cell surface receptors with their respective physiological ligands. METHOD : In this study, PBM and PM from fertile women (Group 1), women with unexplained infertility (Group 2), and women with limited (Group 3) or severe (Group 4) endometriosis were isolated in order to analyze these cells for the expression of CD54, CD58 and HLA-DR (immunoglobulin supergene antigens) CD18 and CD29 (integrins) and CD44 (an addresin). These cell surface antigens are involved in monocyte/macrophage trafficking, activation, signal transduction and/or adhesion. RESULTS : No differences were detected in the percentage of PBM expressing CD18, CD44, CD54, CD58, or HLA-DR among the four groups of subjects. Furthermore, the density of these antigens expressed on PBM was identical in patients and control subjects. In contrast, the percentage of PBM expressing CD29 (also known as VLAβ1) and the density of CD29 expressed per cell were significantly reduced (P < 0.01) in patients with limited endometriosis compared to controls and patients with severe disease. Interestingly, although the percentage of CD29+ PBM from women with severe endometriosis was not statistically different from the percentage of CD29+ PBM from controls, the density of CD29 expressed per cell was significantly elevated among patients with severe disease. Analysis of PM from the four subject groups revealed no differences in CD29 expression or density. However, the percentage of PM expressing CD18 was significantly decreased in patients with limited (but not severe) endometriosis. CONCLUSION : Since both CD18 and CD29 play a role in cell trafficking and/or adhesion, alterations in their expression among patients with endometriosis suggest that these integrin β chains may play a role in the pathogenesis of the disease.     

ACCURACY OF SERUM – ASCITES ALBUMIN GRADIENT IN THE AETIOLOGICAL DIAGNOSIS OF ASCITES

50 adults with ascites admitted to our hospital were studied. Simultaneous samples of ascitic fluid and blood were collected and subjected to analysis including ascitic fluid total protein and serum ascites albumin gradient The cut off value of serum-ascites albumin gradient for differentiating between high and low gradient was taken as 1.1 gm % and of ascitic fluid protein for differentiating exudate and transudate as 2.5 gm%. The sensitivity, specificity, positive predictive value and negative predictive value of high gradient and transudative ascites in diagnosing portal hypertension were 943%, 60%, 84.6%, 81.8% and 62.9%, 133%, 91.7% and 50% respectively. High gradient ascites is a sensitive test in the diagnosis of portal hypertension as a cause of ascites. The exudate-transudate approach has severe limitations in the differential diagnosis of ascites.KEY WORDS: Albumin Gradient, Ascites, High Gradient Ascites, Serum-Ascites     

Pattern of Fatal Injuries in Counter Terrorist Operations: An Innovative Analysis through Embalming Services

Background

Mortal remains of the soldiers killed in counter-terrorist operations in Kashmir valley are sent to their home after undergoing mandatory embalming.

Methods

Injuries on the mortal remains of the soldiers killed in counter terrorist operations between Jan 1999 to Dec 2006 were analysed with respect to the agent, mode of injury, age, rank structure, body parts involved, seasonal variations and changing trends. Fatalities consequent to enemy action across line of control and fatalities of Kargil war were also analysed for comparison. Statistical analysis was done using chi square test for difference in proportions.

Result

Over the study period, terrorist induced injuries accounted for 8.16 deaths per thousand troops deployed whereas enemy action from across the line of control accounted for 0.63 deaths per thousand. Terrorist induced fatalities peaked in 2001 and thereafter revealed a declining trend (‘p’ < 0.001). Fatalities due to enemy action across line of control declined to zero since 25 Nov 2003 consequent to effective ceasefire. Of the total fatalities, 89.5% were killed in action (KIA) while 10.5% died of their wounds after reaching the hospital. Fatality to total injured ratio peaked to 29% in 2001 and than stabilized to about 23%. Mean KIA to total casualty ratio was 21%. The rank structure of the fatalities was officers 8.6%, JCOs 7.3%, and Other Ranks 84.1%. Most of the soldiers died young, 51% being below 25 years of age. Out of the terrorist induced fatalities, 78.2% died of gunshot wounds and 21.5% by splinters and improvised explosive devices (IED). The ratio was reversed in enemy induced fatalities and in Kargil war. Fatalities peaked during June to November and declined in winters. Body region wise, 23.4% of all deaths were due to head injury, 8.4% due to neck and maxillofacial injury, 18.4% due to injury to lungs and 11% due to heart injury. Most frequent target of the fatal bullet was brain (25.4%), closely followed by lungs (22.5%) and heart (12.3%). When soldier died of splinters / IED, multiple body parts were injured in 57.5%, brain in 17.3%, face & neck in 3.5%, heart in 6.6%, lungs in 5.3%, abdomen in 3.5% and limbs in 5.8%. Fatality due to head and heart injury peaked in 2001, while multiple injuries peaked in 2000, declined in 2001 and peaked again in 2004 and 2005 (‘p’ < 0.001). In fatalities of Kargil war, chest injuries were less but multiple injuries were more.

Conclusion

Most of the fatalities were due to gunshot wounds selectively aimed at head, face, neck and thorax. Therefore, a lightweight flexible and effective bulletproof protection for this area will conserve manpower.Key Words: Fatal injuries, Counter terrorist operations, Combat medical statistics     

Mitogen Induced Production of Polyclonal IgG is Decreased in Women With Severe Endometriosis

PROBLEM: The etiology and/or pathogenesis of endometriosis may involve aspects of both humoral and cellular immunity. METHOD: In this investigation, we analyzed the ability of B lymphocytes from distinct patient groups for production of IgGl, IgG2, and IgG3 following in vitro stimulation with polyclonal B-cell mitogens (pokeweed mitogen and Staphylococcus aureus Cowan strain I) after in vitro stimulation with polyclonal B-cell activators. RESULTS: We observed that the in vitro production of IgGl, IgG2, and IgG3 was identical among fertile controls (no endometriosis; N = 22), infertile women without endometriosis (N = 22), infertile women without endometriosis (N = 20) and patietns with stage 1 or 2 endometriosis (N = 31). In contrast, in vitro IgG2 production was significantly reduced among women with stage 3 or 4 endometriosis (N = 11) compared to controls (P < 0.001). CONCLUSION: Since the number of circulating B cells was similar in each patient group studied, the reduced production of IgG2 in patients with stage 3 or 4 disease was not merely due to fewer antibody producing cells in those subjects, and we speculate that the observed decrease in polyclonal IgG2 production among these patients is due to a primary defect. In additional studies, we observed that polyclonal IgG2 production was normal among stage 3 or 4 patients treated with danazol (N=ll), but significantly reduced in patients treated with gonadotropin releasing hormone agonists (N = 8). Although not conclusive, these data suggest that danazol may have the capacity to correct the defective production of polyclonal IgG2 in patients with severe endometriosis.     

持续性心房颤动患者左心房结构和炎性因子变化分析

目的 研究持续性心房颤动患者炎性因子与心房结构重构的关联性.方法 研究对象为45例持续性心房颤动组和45例对照组.研究对象行超声心动图检测左心房直径,行超声背向散射测定技术检测房间隔和左心房后壁背向散射积分值（integrated backscatter,IBS）和背向散射积分周期变化值（cyclic variation of integrated backscatter,CVIB）.行免疫比浊法和酶联免疫吸附法检测患者血清高敏C-反应蛋白（high-sensitivity C-reactionprotein,hs-CRP）,白细胞介素（interleukin,IL）-6和肿瘤坏死因子（tumor necrosis factor,TNF-α）浓度.结果 持续性心房颤动组左心房直径和血清Hs-CRP、IL-6、TNF-α浓度均高于对照组,差异有统计学意义（P＜0.05）.心房颤动患者左心房直径与各血清炎性因子浓度（hs-CRP、IL-6和TNF-α）呈正相关（r=0.825,P＜0.01;r=0.432,P＜0.01;r=0.357,P＜0.01）.左心房直径＞40 mm亚组血清hs-CRP、IL-6和TNF-α浓度均高于左心房直径≤40 mm亚组,差异有统计学意义（P＜0.05）.结论 炎性因素参与了心房颤动的发病过程,血清hs-CRP、IL-6和TNF-α浓度与心房颤动的持续状态有关,心房纤维化和心肌重构也参与了心房颤动的发生和维持.