Altered color of plasma component - Unnecessary wastage of a precious resource.

BACKGROUND AND OBJECTIVES: The present study was conducted to evaluate the etiology of altered color of plasma component of blood in transfusion practice. MATERIALS AND METHODS: The study was conducted at the blood center of a tertiary care teaching hospital in western India for a period of 6 months. After component separation, all the plasma units with altered color were segregated and samples were taken for further evaluation. Altered colored plasma units were divided into three - green discoloration, yellow discoloration, and lipemic plasma. Donors were called, their detailed history was taken, and necessary investigations were done accordingly. RESULTS: Forty plasma units out of 20,658 (0.19%) donations showed discoloration. Out of which, 3 plasma units showed green discoloration, 9 plasma units showed yellow discoloration, and the remaining 28 plasma units were lipemic. Among three donors whose plasma showed green discoloration, one female donor had a history of oral contraceptive pill usage and had higher values of copper and ceruloplasmin. All donors with yellow plasma had a higher value of unconjugated bilirubin. All the donors with lipemic plasma gave a history of intake of fatty meal prior to donating blood and showed higher values of triglyceride, cholesterol, and very-low-density lipoprotein. CONCLUSION: Plasma component with altered color restricts its issue to the patient and also for use in fractionation. In our study, many of the altered color plasma units were safe to transfuse, but the decision regarding transfusion was debatable on consultation with the treating doctor. Further studies with a large sample size are recommended for the use of these plasma components.

Maternal allo anti-M antibody-induced hemolytic disease of newborn.

Hemolytic disease of the fetus and newborn is a syndrome associated with immune destruction of the fetal and newborn red cells by maternal red cell alloantibodies. The detection of anti-M in antenatal screening can be responsible for neonatal red cell aplasia. A 32-h-old full-term neonate admitted with inconsolable cry and mild fever. Laboratory tests revealed progressive anemia and hyperbilirubinemia on day 3. The peripheral blood smear showed evidence of hemolysis and reticulocyte count was reduced. Intensive phototherapy and antibiotics were started after ruling out other causes of hyperbilirubinemia. Blood group typing and advanced red cell serology workup were done. Antibody screening and identification was suggestive of the presence of anti-M antibody in both mother and baby. Intravenous immunoglobulin and red blood cell transfusions were given. Anti-M is capable of causing hemolytic disease of the fetus and newborn and prolonged anemia. Newborns with anemia should be evaluated for all the possible causes to establish a diagnosis.

Antibody screening and identification in donors and general patients at a tertiary care teaching hospital in Western India.

BACKGROUND AND OBJECTIVES: The aim of the blood transfusion service should be to provide effective blood and blood components, which are as safe as possible and adequate to meet patient's need. To achieve safe blood transfusion practice, many blood transfusion center in India follow routine type and screen protocol for all patient's and donor's blood samples to detect unexpected alloantibodies. The present study is aimed at assessing the frequency and type of unexpected red cell alloantibodies in general patient population and donors at a tertiary care teaching hospital in western India. MATERIALS AND METHODS: In this prospective study, samples of patients as well as blood donors were processed for ABO and Rh "D" grouping as well as antibody screening with three cell screening panel on fully automated immunohematology analyzer. Positive sample in three cell screening panel was further evaluated for identification of specific alloantibody with eleven cell identification panel by column agglutination technique. Results were recorded, and data were analyzed to calculate the frequency of unexpected alloantibody. RESULTS: A total of 74,214 patient samples and 80,173 donor samples were processed for type and screen. Out of which, 512 patients and 11 donors were identified with alloantibody. Most common alloantibody found in the present study is anti-D (0.075%), followed by anti-E (0.041%), anti-c (0.021%), anti-K (0.0205%) in Rh and Kell blood group system. CONCLUSION: Antibody screening and identification of specific alloantibody help in identifying most appropriate blood unit that lacks the corresponding antigen and prevent alloimmunization.

Fusarium vascular graft infection.

A 37-year-old African American male with a past medical history significant for end stage renal disease on hemodialysis via a femoral arteriovenous graft, systemic lupus erythematous, with a recent hospitalization for cavitary Candida pneumonia treated with micafungin, presented with a fever of 102° F for 3 days and worsening left groin pain. He also complained of chills, nausea, and malaise. On physical examination, the patient was hemodynamically stable with swelling and tenderness at the site of the graft. He was started on vancomycin, piperacillin/tazobactam and micafungin. Computed tomography scan and duplex scan of the left lower extremity showed diffuse swelling and attenuation of the graft material consistent with thrombosis of the graft. Excision of the graft and thrombectomy was performed and the graft thrombus was sent for culture. Examination of the sample showed fungal hyphae (Figure). Micafungin was switched to voriconazole; however, the patient did not show any improvement of his groin pain. On day 5 of hospitalization, culture showed Fusarium, and hence amphotericin B was added resulting in subsequent clinical improvement. We are presenting an unusual site of Fusarium infection which responded to combination therapy, a case which has not been reported.

Pain Perception and the Opioid Receptor Delta 1.

Genetic factors play an integral role in the perception of pain, and studies have only recently begun to explore the degree to which these factors affect clinical decisions. The process of prescribing opioids is greatly influenced by an individual's pain perception, which can vary based on several factors including genetic variation. Opioid receptor delta 1 (OPRD1) plays a significant role in the perception of both pain and its relief via opioids, and it shows significant variability between individuals. Herein, we discuss the nature of the OPRD1 receptor and the value of further research into its effects, particularly in the realm of pain management.

Impact of Electrophysiological and Clinical Variants, and Timing of Plasmapheresis on Outcome of Guillain-Barré Syndrome.

INTRODUCTION: Guillain-Barré syndrome (GBS) is an autoimmune polyneuropathy causing acute flaccid paralysis and it is known to improve with plasmapheresis. OBJECTIVE: To study effects of electrophysiological type of GBS, clinical variant of GBS and time taken for initiation of plasmapheresis on outcome of disease. METHODS: 50 consecutive patients of GBS attending tertiary care hospital underwent clinical examination and electrophysiological studies. Disability grade was calculated and patients were observed for full functional recovery for 6 months. RESULTS: In this study, patients in whom plasmapheresis was started within 7 days (n=39) were observed to have significantly better improvement in terms of smaller peak disability and rapid functional recovery compared to those in whom plasmapheresis was started after 7 days (n=11). (p<0.002). Demyelinating pattern on electrophysiology was observed to have better outcome in terms of all parameters compared to axonal. AIDP variant was observed to have best outcome and AMSAN variant was associated with worst outcome. CONCLUSIONS: Rapid institution of plasmapheresis is the most important outcome determining factor. Irrespective of the variant specific comorbidity, early plasmapheresis improves outcome in all parameters.

Partial phenotyping in voluntary blood donors of Gujarat State.

INTRODUCTION: Partial phenotyping of voluntary blood donors has vital role in transfusion practice, population genetic study and in resolving legal issues. The Rh blood group is one of the most complex and highly immunogenic blood group known in humans. The Kell system, discovered in 1946, is the third most potent system at triggering hemolytic transfusion reactions and consists of 25 highly immunogenic antigens. Knowledge of Rh & Kell phenotypes in given population is relevant for better planning and management of blood bank; the main goal is to find compatible blood for patients needing multiple blood transfusions. The aim of this study was to evaluate the frequency of Rh & Kell phenotype of voluntary donors in Gujarat state. MATERIALS AND METHODS: The present study was conducted by taking 5670 samples from random voluntary blood donors coming in blood donation camp. Written consent was taken for donor phenotyping. The antigen typing of donors was performed by Qwalys-3(manufacturer: Diagast) by using electromagnetic technology on Duolys plates. RESULTS: Out of 5670 donors, the most common Rh antigen observed in the study population was e (99.07%) followed by D (95.40%), C (88.77%), c (55.89%) and E (17.88%). The frequency of the Kell antigen (K) was 1.78 %. DISCUSSION: The antigen frequencies among blood donors from Gujarat were compared with those published for other Indian populations. The frequency of D antigen in our study (95.4%) and north Indian donors (93.6) was significantly higher than in the Caucasians (85%) and lower than in the Chinese (99%). The frequencies of C, c and E antigens were dissimilar to other ethnic groups while the 'e' antigen was present in high frequency in our study as also in the other ethnic groups. Kell antigen (K) was found in only 101 (1.78 %) donors out of 5670. Frequency of Kell antigen in Caucasian and Black populations is 9% & 2% respectively. The most common Kell phenotype was K-k+, not just in Indians (96.5%) but also in Caucasians (91%), Blacks (98%) and Chinese (100%). CONCLUSION: Phenotype and probable genotype showed wide range of variations in different races and religion. Reliable population based frequency data of Rh & Kell antigens has vital role in population genetic study, in resolving medico legal issues and in transfusion practice.

Therapeutic plasma exchange in pediatric patients of Guillain-Barre syndrome: Experience from a Tertiary Care Centre.

BACKGROUND AND OBJECTIVE: Therapeutic Plasma Exchange (TPE) is performed effectively and safely in adult patients, but the use of TPE is limited in paediatric patients due to lack of universally accepted indications and technical challenges like establishment of adequate vascular access, low blood volume, increased incidence of adverse events during procedure and poor co-operation of patients during procedure. We present our experience of TPE in paediatric patients to assess the effectiveness and safety of TPE in paediatric patients. MATERIALS AND METHODS: A total 122 TPE procedures were performed in 40 paediatric patients between 3 to 15 years of age group with Guillain Barre Syndrome (GBS). TPE procedures were performed on alternate days depending on the clinical condition of the patient. Patient's total blood volume was calculated as per Nadler's formula and processed through central double lumen catheter. 1-1.5 plasma volume was exchanged with normal saline and fresh frozen plasma. RESULTS: A total of 122 TPE procedures (with an average of three procedures per patient) were performed on 40 paediatric patients. More than three TPE procedures were performed in 29 patients, of which 27 patients showed improvement from grade-0 and grade-I to grade-III. One did not show any response and succumbed to the disease. Complications were observed in 14 patients which were well managed. Inadequate vascular access was most common complication observed in 11 patients. CONCLUSION: TPE in paediatric patients has been increasing and has been shown to be effective as first line or adjunctive therapy in selected diseases. It is safe procedure when volume shifts, calcium supplementation and venous access are taken care.

Guillain - Barre syndrome in a patient with acute myocardial infarction with ventricular septal defect repair treated with plasma exchange.

Guillain - Barre syndrome (GBS) is an acute, frequently severe progressive illness of peripheral nervous system that is autoimmune in nature. GBS after myocardial infarction (MI) with ventricular septal defect (VSD) is uncommon with high mortality rate if not treated promptly.[1] We report a successful outcome of GBS post MI with VSD in a 60-year-old male patient who was on a ventilator treated successfully with therapeutic plasma exchange.

Hepatitis E seroprevalence among blood donors: A pilot study from Western India.

BACKGROUND: Hepatitis E virus (HEV) is emerging as a potential threat to blood safety after several cases of transmission by transfusion or transplantation have been described. Currently, blood donors in India are not screened for HEV. The studies conducted on HEV in recent times in India have focused on epidemiology and future perspectives, but there is no published study on blood donors. To address possible issues surrounding blood safety and risk of HEV transmission within the Indian blood supply, HEV seroprevalence study was conducted in blood donors at our center. MATERIALS AND METHODS: A total of 460 male voluntary blood donors were selected for the study and after taking their written consent. Serum anti-HEV IgM was detected by Dia.Pro HEV kit (Diagnostic Bioprobes Srl, Milano, Italy). RESULTS: The study population was composed of 460 male voluntary blood donors and their age ranged from 18 to 60 years with a mean age of 30.48 years. Out of 460 donors, 22 (4.78%) donors were tested positive for IgM anti-HEV and the mean value alanine aminotransferase (ALT) was 26.06 IU/L, the highest being 93.5 IU/L. Normal reference value of ALT in our center was 40 IU/L. Out of 22 anti-HEV positive donors, 19 (86.36%) had ALT values above 40 IU/L. CONCLUSION: HEV seroprevalence of 4.78% in our center. Though reports of HEV transmission through blood has been reported from various parts of the world, before making it as a mandatory screening test among blood donors in India, further studies with confirmatory assay of HEV need to be done.

Glomus Tumor of the Stomach: Depiction by Multidetector CT and Three-Dimensional Volume Rendering Imaging.

Glomus tumors are uncommon tumors which can occur anywhere within the gastrointestinal tract but have been shown to occur most commonly in the gastric antrum. On CT, these tumors demonstrate hyperenhancement which may help distinguish them from other gastric masses.

Persistent hyperprolactinemia following mammoplasty: a rare association.

Breast augmentation surgery is one of the most commonly performed plastic surgery procedures. Several reported cases linked onset of transient hyper prolactinemia and galactorrhea to breast implant surgery. These prior studies did not corroborate that bioactive (monomeric prolactin) was responsible for the prolactin excess. We report a patient with galactorrhea and hyperprolactinemia following breast augmentation, with several unique features. We used monomeric prolactin in the diagnosis of hyperprolactinemia and macro prolactinemia was specifically excluded. Common causes of prolactin excess such as prolactinoma, hypothyroidism and renal dysfunction were excluded. The close temporal relationship of the galactorrhea and apparent prolactin elevation shortly after augmentation mammoplasty strongly suggests a causal link. Patient continued to have galactorrhea, and prolactin level rose for two years without any apparent identified cause, except breast implantation surgery. These persistently elevated levels of prolactin contradict previously reported transient character of prolactin elevation. The submuscular location of the implant, which in theory is less likely to cause direct stimulation of the breast compared to subglandular placement, did not prevent prolactin elevation in our patient. The possibility of the breast implant resulting in neurogenic stimulation of prolactin secretion exists but remains unproven. While the definitive pathophysiologic link remains to be elucidated and could have been assisted by removal of the prostheses, the patient declined to have the implants removed. We advise all healthcare providers to be cognizant of this rare cause of prolactin excess.

Catheter-directed gastric artery chemical embolization suppresses systemic ghrelin levels in porcine model.

PURPOSE: To prospectively test, in a porcine model, the hypothesis that catheter-directed gastric artery chemical embolization (GACE) can result in suppression of systemic ghrelin levels and affect weight gain. MATERIALS AND METHODS: This study, which had Animal Care and Use Committee approval, was performed in healthy, growing swine (weight range, 40-45 kg; n = 10). GACE was performed in five swine with the infusion of sodium morrhuate (125 mug) selectively into the gastric arteries that supply the fundus. Five control animals underwent a sham procedure with 5 mL of saline. Weight and fasting plasma ghrelin levels were obtained in animals at baseline and in weeks 1-4. Statistical testing for substantial differences in ghrelin blood levels over time and between treated and untreated animals was performed by using a cross-sectional time-series linear model with feasibility generalized least squares. RESULTS: The pattern of the change in ghrelin levels over time was significantly different between control and treated animals (P < .004). In treated animals, ghrelin levels were significantly reduced at week 1 (mean, 664.1 pg/mL +/- 103.1 [standard error of the mean], P < .02), week 2 (mean, 618.1 pg/mL +/- 180.4, P < .001), week 3 (mean, 578.4 pg/mL +/- 214.9, P < .001), and week 4 (mean, 876.6 pg/mL +/- 228.6, P < .03) relative to baseline (mean, 1006.3 pg/mL +/- 190.1). The percentage change in serum ghrelin values in swine treated with GACE decreased from baseline to -34%, -38.6%, -42.5%, and -12.9% during weeks 1-4, respectively. In control swine, percentage change in serum ghrelin was -1.7%, -9.7%, +2.6%, and +18.2% during weeks 1-4, respectively. At the end of 4 weeks, control swine continued to gain weight, with a 15.1% increase from their original weight, while the weight in swine treated with GACE plateaued at an increase of 7.8% from the original weight. CONCLUSION: Catheter-directed GACE can suppress the appetite hormone ghrelin and affect weight gain.

Blood brain barrier (BBB) dysfunction associated with increased expression of tissue and urokinase plasminogen activators following peripheral thermal injury.

Emerging data suggests the serine proteases, tissue plasminogen activator (tPA), and urokinase plasminogen activator (uPA), may play a detrimental role in traumatic states leading to compromise of the blood brain barrier (BBB). The purpose of our study was to define the role of endogenous tPA and uPA on the BBB following peripheral burn injuries. Adult male Sprague-Dawley rats (n=46) were studied in control and thermal injury groups. Rats were anesthetized and submerged in 100 degrees C water for 6s producing a third degree burn affecting 60-70% of the total body surface area. BBB dysfunction was then evaluated by measuring the amount of Evans blue and by calculating the water content in the brain. Levels of tPA and uPA mRNA in the brain were determined with real-time polymerase chain reaction (PCR) at 3 and 7h post-injury. Results showed an increase in the brain water content and the presence of Evans blue in the brain tissue of thermally injured rats, temporally associated with an increased expression of endogenous tPA and uPA. Our study demonstrates that peripheral thermal injury does induce an increase in the permeability of the BBB. A possible mechanism may be an increased expression of tPA and uPA.

Role of image-guided vascular intervention in therapeutic angiogenesis translational research.

Therapeutic angiogenesis, the process of growing collateral blood vessels to better perfuse ischemic tissue, has been hailed as an up-and-coming treatment for symptomatic lower-extremity peripheral arterial occlusive disease. A minimally invasive durable treatment would be welcome since current treatment options for this disease carry high risk, limited efficacy or limited durability. Unfortunately, as evidenced by disappointing results in multiple clinical trials, therapeutic angiogenesis has yet to deliver in humans the success it has seen in animal models. In this review, we discuss the challenges of translating therapeutic angiogenesis into effective clinical treatments for lower-extremity peripheral arterial occlusive disease and we highlight the role that experts in image-guided vascular interventions can play in advancing the field.

Catheter-directed gastric artery chemical embolization for modulation of systemic ghrelin levels in a porcine model: initial experience.

PURPOSE: To prospectively test, in a porcine model, the hypothesis that use of catheter-directed gastric artery chemical embolization (GACE) can result in substantial suppression of systemic ghrelin levels. MATERIALS AND METHODS: The institutional animal care and use committee approved this study. Adult healthy swine (40-45 kg, n=8) were tested. GACE was performed by infusing morrhuate sodium selectively into the left gastric artery. Six swine (animals A-F) underwent left GACE by using a dose-escalating regimen of morrhuate sodium, whereas two control swine underwent a sham procedure. Weight and fasting plasma ghrelin levels were compared in swine at baseline and at weeks 1-4. At week 4, stomachs were excised and analyzed. Analysis of the change in ghrelin values and weight was performed with both paired t test and unpaired Student t test. RESULTS: In control swine (n=2), there was no significant difference in ghrelin values before (844.8 pg/mL +/- 40 [standard deviation]) and after (997 pg/mL +/- 93) the procedure (P=.5). Swine that received a low dose of morrhuate sodium (animals A-D) showed a significant increase in serum ghrelin values from 683.7 pg/mL +/- 241 to 1555.9 pg/mL +/- 312 (P=.002). At a higher dose, the mean baseline ghrelin values decreased from 466 pg/mL to 187 pg/mL +/- 162. Weight changes of +1.4% and +8.6% were seen in swine that underwent GACE and control swine, respectively. Histochemical staining showed preservation of overall tissue architecture and parietal cells. CONCLUSION: Use of GACE can result in increased or suppressed ghrelin levels.

Who needs the surgical headlight?

OBJECTIVE: The use of surgical headlights may lead to awkward posture and limit the mobility and visibility of the operating team. Despite the vast availability of fiber-optic instruments, many surgeons continue to use the surgical headlight, which may be harmful to their health and career. We report the use of the Lumitex LightMat surgical illuminator instead of the conventional surgical headlight in cleft palate surgery. METHODS: The LightMat is a disposable single-use device that is bright, flexible, and malleable and attaches easily to most retractors. Twenty cleft palate and five pharyngeal flaps cases were performed in which the LightMat was attached to the Dingman mouth retractor with biocompatible two-sided adhesive tapes. RESULTS: The LightMat was successfully used in all 25 cases. No cases required the surgeon to put on additional lighting such as a headlight. In addition, no cases required the LightMat surgical illuminator to be replaced. CONCLUSION: The LightMat provides excellent surgical light for cleft palate surgery and pharyngeal procedures. It affords the surgeon several advantages: it provides a cool operative light, flexibility in surgical position, and improved visibility and mobility; the surgeon avoids the delay in obtaining an appropriate working headlight; and, more importantly, it may prevent postural problems that could lead to spinal sprain and disability.