No Pharmacokinetic Interaction Between the Hepatitis C Virus Inhibitors Elbasvir/Grazoprevir and Famotidine or Pantoprazole.

Use of agents to suppress gastric acid secretion is common among patients with hepatitis C virus (HCV) infection. The aims of this open-label, three-period, fixed-sequence study were to evaluate the effect of famotidine and pantoprazole on the pharmacokinetics and safety of elbasvir/grazoprevir fixed-dose combination (FDC) in 16 healthy subjects. Elbasvir and grazoprevir each exhibited similar pharmacokinetics following single-dose administration of elbasvir/grazoprevir with or without famotidine or pantoprazole. Geometric mean ratios (GMRs) of grazoprevir AUC(0,∞), Cmax , and C24 (elbasvir/grazoprevir + famotidine or elbasvir/grazoprevir + pantoprazole vs. elbasvir/grazoprevir) ranged from 0.89-1.17. Similarly, GMRs of elbasvir AUC(0,∞), Cmax , and C24 (elbasvir/grazoprevir + famotidine or elbasvir/grazoprevir + pantoprazole vs. elbasvir/grazoprevir) ranged from 1.02-1.11. These results indicate that gastric acid-reducing agents do not modify the pharmacokinetics of elbasvir or grazoprevir in a clinically relevant manner and may be coadministered with elbasvir/grazoprevir in HCV-infected patients without restriction.

Laser removal of tattoos.

Tattoos are placed for different reasons. A technique for tattoo removal which produces selective removal of each tattoo pigment, with minimal risk of scarring, is needed. Nonspecific methods have a high incidence of scarring, textural, and pigmentary alterations compared with the use of Q-switched lasers. With new advances in Q-switched laser technology, tattoo removal can be achieved with minimal risk of scarring and permanent pigmentary alteration. There are five types of tattoos: amateur, professional, cosmetic, medicinal, and traumatic. Amateur tattoos require less treatment sessions than professional multicolored tattoos. Other factors to consider when evaluating tattoos for removal are: location, age and the skin type of the patient. Treatment should begin by obtaining a pre-operative history. Since treatment with the Q-switched lasers is painful, use of a local injection with lidocaine or topical anaesthesia cream may be used prior to laser treatment. Topical broad-spectrum antibacterial ointment is applied immediately following the procedure. Three types of lasers are currently used for tattoo removal: Q-switched ruby laser (694 nm), Q-switched Nd:YAG laser (532 nm, 1064 nm), and Q-switched alexandrite laser (755 nm). The Q-switched ruby and alexandrite lasers are useful for removing black, blue and green pigments. The Q-switched 532 nm Nd:YAG laser can be used to remove red pigments and the 1064 nm Nd:YAG laser is used for removal of black and blue pigments. The most common adverse effects following laser tattoo treatment with the Q-switched ruby laser include textural change, scarring, and pigmentary alteration. Transient hypopigmentation and textural changes have been reported in up to 50 and 12%, respectively, of patients treated with the Q-switched alexandrite laser. Hyperpigmentation and textural changes are infrequent adverse effects of the Q-switched Nd:YAG laser and the incidence of hypopigmentary changes is much lower than with the ruby laser. The development of localized and generalized allergic reactions is an unusual complication following tattoo removal with the Q-switched ruby and Nd:YAG lasers. Since many wavelengths are needed to treat multicolored tattoos, not one laser system can be used alone to remove all the available inks and combination of inks. While laser tattoo removal is not perfect, we have come a long way since the advent of Q-switched lasers. Current research is focusing on newer picosecond lasers, which may be more successful than the Q-switched lasers in the removal of the new vibrant tattoo links.

Dynamics of nuclear localization sites for COX-2 in vascular endothelial cells.

We investigated the relationships among expression, activity, and spatial organization of cyclooxygenase (COX-1 and COX-2) in endothelial cells from porcine and human cerebral microvessels and from human umbilical vein. In quiescent cells, COX-1 was detected in the perinuclear zone and the cytoplasm, while COX-2 was mainly a nuclear resident possibly connected with the nuclear matrix. COX-2 immunogold labeling was situated in the nuclear envelope, at the nuclear pores, and in connection with the perichromatin regions of the nucleus, considered to be the sites of active transcription. In human endothelial cells transcriptionally activated by interleukin (IL)-1beta, the nucleus remained a major COX-2 localization site during the first 12 h of stimulation, when COX-2 expression was maximally induced. The continuous rise in prostanoid synthesis at 17-23 h of stimulation was associated with COX-2 relocation from the nucleus to the nuclear envelope and the cytoplasm. IL-1beta did not affect COX-1 expression, activity, and localization. COX-2 nuclear localization sites and trafficking between the nucleus and the cytoplasm in endothelial cells may indicate a novel function of COX-2 in regulating gene expression.

Er:YAG laser for the treatment of actinic keratoses.

BACKGROUND: There is no single optimal treatment for multiple facial actinic keratoses. The existing therapies such as topical 5-fluorouracil, chemical peels, cryotherapy, dermabrasion, and CO2 laser resurfacing can produce prolonged recovery time or are often operator dependent. OBJECTIVE: The purpose of this study was to investigate another therapeutic modality which provides a shorter recovery time with uniform results. We performed a prospective pilot study investigating the use of the Er:YAG laser for the treatment of multiple facial actinic keratoses. METHODS: Five patients with multiple facial actinic keratoses were treated with two to three passes of Er:YAG laser. Anesthesia was achieved in all cases by topical application and local infiltration when indicated. All patients were treated with 2.0 J, 5 mm spot size, and a fluence of 10 J/cm2. Clinical and histologic evaluations were performed both pre- and postoperatively. RESULTS: All patients showed a decrease in the total number of clinical actinic keratoses on the face ranging from 86 to 96%. In addition to the reversal of actinic damage in the epidermis, histologic evidence revealed increased fibroplasia and decreased superficial solar elastosis 3 months after the laser resurfacing. Reepithelialization occurred in 5-8 days, and erythema lasted for about 3-6 weeks after the procedure. There was no evidence of scarring or pigmentary changes in any of the patients during the follow-up period. CONCLUSION: Er:YAG laser skin resurfacing is a safe and effective treatment for multiple facial actinic keratoses. Histologic data suggest a new zone of collagen deposition occurs in the superficial papillary dermis. Under our current parameters, Er:YAG laser skin resurfacing has a relatively short recovery period and a low risk of scarring. Unlike the CO2 laser, Er:YAG laser skin resurfacing can be performed with topical anesthesia alone.

Preservation of cerebrovascular tone and reactivity by sodium channel inhibition in experimental prolonged asphyxia in piglets.

Sodium channels using cAMP as a second messenger play a role in the regulation of cerebral circulation and metabolism. Cerebrospinal fluid (CSF) cAMP levels have been shown to correlate with the degree and duration of hypoxic injury and outcome and to be an indicator of cerebral vascular reactivity. We hypothesize that sodium channel inhibition either before or at termination of experimental asphyxia will attenuate cerebrovascular alterations and maintain CSF cAMP levels. Three groups of piglets with closed cranial windows were studied: asphyxia or group 1 (n = 5) and two treatment groups. Pigs were treated with 50 mg/kg of sodium channel blocker before asphyxia (group 2, n = 6) and after the termination of asphyxia and start of reventilation (group 3, n = 6). Asphyxia was sustained over 60 min by ventilating piglets with 10% O2 gas mixture and decreasing minute ventilation followed by 60 min of reventilation with room air. Every 10 min, pial arterial diameters were measured, and CSF samples were collected for cAMP determination. Vascular reactivity to topically applied isoproterenol (10(-4) M) was evaluated 60 min after recovery. During asphyxia, cAMP levels in group 2 peaked and declined at a later time with mean values remaining significantly higher than those of groups 1 and 3. During reventilation, CSF cAMP concentrations were highest in group 3 and lowest in group 1. Pial arteriolar dilation occurred during asphyxia in all three groups but to a lesser degree in the pretreated group compared with groups 1 and 3. Pial arteriolar reactivity to isoproterenol postasphyxia was preserved in both groups 2 and 3. In summary, in newborn pigs, pretreatment with sodium channel blocker resulted in higher CSF cAMP levels and a lesser degree of pial arteriolar dilation during prolonged asphyxia. Pretreatment or treatment at reventilation restored vascular tone and reactivity.

Comparative study of the efficacy of four topical anesthetics.

BACKGROUND: With the emergence of new laser and dermatologic procedures, the need for more effective topical anesthesia continues to grow. There are now several topical anesthetics that are being used prior to laser and surgical procedures. OBJECTIVE: To compare the degree and duration of anesthesia produced by four commonly used topical anesthetics, we performed a prospective study investigating the efficacy of EMLA (eutectic mixture of local anesthetics), ELA-Max, 4% tetracaine gel, and betacaine-LA ointment (formerly eutectic-LA). METHODS: Equal amounts of the above topical anesthetics plus a control (eucerin cream) were applied to 10 test sites under occlusion on the volar forearms of 12 adult volunteers. After a 60-minute application time, the degree of anesthesia was assessed immediately by a Q-switched Nd:YAG laser at 1064 nm. Pain testing was also performed 30 minutes after the 60-minute application period. Volunteer responses to pain stimuli were recorded using an ordinal scale of 0 (no pain) to 4 (maximal pain). The mean scores for the time intervals were obtained. Analysis of the data was performed using analysis of variance (ANOVA), Newman-Keuls test, Friedman rank order test, and paired t-tests. RESULTS: ELA-Max, EMLA, and tetracaine were statistically superior to control after the 60-minute application period. Thirty minutes later, ELA-Max, EMLA, tetracaine, and betacaine-LA were all statistically superior to the control. Comparing individual anesthetics, ELA-Max and EMLA were the superior anesthetics at both time intervals. Although the mean pain scores for each anesthetic were lower 30 minutes after their removal, the differences did not reach statistical significance. CONCLUSION: This is the first prospective study comparing the efficacy of several new topical anesthetic agents. Using the methodology of this study, in which the anesthetics were applied under occlusion, ELA-Max and EMLA were the superior anesthetics after a 60-minute application time and 30 minutes later. In addition, there was a clinical increase in efficacy suggested with all of the anesthetics 30 minutes after their removal.

Pulsed dye laser treatment of warts: an update.

BACKGROUND: Warts are a therapeutic challenge. New studies indicate that pulsed dye laser therapy may be effective, with clearance rates of 72 to 93%. OBJECTIVE: To determine clearance rate in pulsed dye laser treatment of warts and compare our rate to those of other published studies. METHODS: Thirty-three patients with 96 warts received pulsed dye laser treatment for recalcitrant plantar, digital, peri- and subungual, and body warts. RESULTS: Forty-eight percent of patients had complete wart clearance; 45% partially cleared. Sixty-nine percent of those who cleared remained wart-free for an average of 11 months. Mean fluence was 9.4 J/cm2, with an average of 3.4 treatments. Body and palmar warts responded best, digital and peri- and subungual next, and plantar lesions worst. No significant side effects were observed. CONCLUSION: Pulsed dye laser is an effective treatment option for recalcitrant warts with an excellent side effect profile. However, our response rates were not as high as those previously reported, and we feel that further studies would be useful.

Use of point-of-care test in identification of patients who can benefit from desmopressin during cardiac surgery: a randomised controlled trial.

BACKGROUND: Platelet dysfunction is a major cause of excessive microvascular bleeding after cardiac surgery. A new point-of-care test (hemoSTATUS) can identify patients at risk of excessive bleeding. We aimed to find out whether patients who can benefit from desmopressin during cardiac surgery can be identified by this test. METHODS: We enrolled 203 patients scheduled for elective cardiac surgery in a prospective, double-blind, placebo-controlled trial. Patients with abnormal hemoSTATUS clot-ratio results (<60% of maximum in channel 5) after discontinuation of cardiopulmonary bypass were randomly assigned desmopressin (n=50) or placebo (n=51). Patients with normal clot ratios were included in an untreated control group (n=72). FINDINGS: Intraoperative platelet counts and clot ratios were significantly higher in the untreated control group than in the study-drug groups. In intensive care, clot ratios in patients who received desmopressin were similar to those in the untreated control group, despite significantly lower platelet counts, but were lower in the placebo group than in the other two groups (p=0.0001). Compared with the placebo group, patients who received desmopressin had less blood loss in 24 h (mean 624 [SD 209] vs 1028 mL [682] p=0.0004) and required less transfusion of red blood cells (1.1 [022] vs 2.2 U [0.32] p=0.009), platelets (0.1 [0.04] vs 1.9 U [4.5] p=0.0001), and fresh-frozen plasma (0.1 [0.07] vs 0.75 U [0.21] p=0.0008), and had less total blood-donor exposures (1.56 [0.31] vs 5.2 [0.8] p=0.0001). Placebo patients also had substantially higher blood loss and transfusion requirements than untreated control patients. INTERPRETATION: Patients identified with hemoSTATUS as being at increased risk of excessive bleeding after cardiac surgery can benefit from administration of desmopressin. Further studies are, however, needed to confirm these findings as well as to identify the mechanism of action and safety of desmopressin in the clinical setting.

Treatment of mature striae with the pulsed dye laser.

INTRODUCTION: Striae are a common cosmetic problem with no effective treatment options. A recent study has shown improvement in the appearance of mature striae following a single 585-nm pulsed dye laser (PDL) treatment at low fluence. OBJECTIVE: To evaluate the effectiveness of treating mature striae with the 585-nm PDL. METHODS: Five patients with mature striae on the abdomen were prospectively treated with the 585-nm PDL at 2-month intervals for 1-2 years. The response of the striae to laser treatment was evaluated in each patient through sequential clinical, photographic, textural, and histologic assessment. RESULTS: All five patients reported a slight overall improvement in the appearance of the striae following multiple PDL treatments. Comparison of pre- and post-treatment photographs, however, failed to reveal improvement in any patients. Optical profilometry performed on striae impressions showed mild improvement in the surface texture of striae in three patients. Histologic comparison of pre- and post-treatment biopsy specimens failed to reveal normalization of skin architecture. CONCLUSIONS: Serial treatment of mature striae with the PDL results in mild, subjective, clinical improvement but no significant photographic, textural or histologic improvement.

Basal cell carcinoma of the genitalia.

BACKGROUND: Basal cell carcinomas (BCC) arising on the genitalia are exceedingly rare with an unclear pathogenesis. OBJECTIVE: To better understand risk factors, tumor characteristics, and the possible role of human papillomavirus (HPV) in the development of BCC of the genitalia. METHODS: 1543 records of Mohs micrographic surgery performed during a 6-year period were reviewed to identify cases of BCC arising on the genitalia. Tumor tissue was analyzed for HPV DNA by in situ hybridization. RESULTS: Four patients with BCC of the genitalia were treated with Mohs micrographic surgery. The malignancies were located on the scrotum, perineum, and perianal areas in the three male patients and on the vulva in the female patient. The mean age was 67 years. None of the patients had prior history of skin cancers. Histologic evaluation of the tumors revealed two nodular subtypes, one superficial subtype, and one with follicular differentiation. In situ hybridization failed to reveal DNA of HPV types 6, 11, 16, 18, 30, 31, 33, 35, 45, 51, and 52. CONCLUSION: In this small series, genital BCC occurred in an older age group with no identifiable predisposing risk factors and did not show evidence of HPV infection.

Comparison of high-energy pulsed carbon dioxide laser resurfacing and dermabrasion in the revision of surgical scars.

BACKGROUND: Both dermabrasion and high-energy pulsed carbon dioxide (CO2) laser resurfacing can improve the appearance of surgical scars. Although the results of these two procedures have been compared using historical data, a prospective evaluation has never been performed in humans. OBJECTIVE: To prospectively compare the clinical effects of dermabrasion and high-energy pulsed CO2 laser resurfacing in the revision of surgical scars. METHODS: Facial surgical scars in four patients were prospectively revised using a split scar model. One half of the scar was dermabraded and the other half was resurfaced with the high-energy pulsed CO2 laser. Comparisons of the two treatment modalities were performed through clinical assessment, photographic evaluation, and textural analysis of the scars. RESULTS: The high-energy pulsed CO2 laser-resurfaced halves of the scar were bloodless with less postoperative crusting in comparison with the dermabraded halves. Reepithelialization time and degree and duration of postoperative erythema were similar for both treatment halves. Photographic evaluation and textural analysis showed comparable improvement in the clinical appearance and surface texture of the scars with both treatment modalities. CONCLUSIONS: Both the high-energy pulsed CO2 laser and dermabrasion can achieve comparable clinical improvement in the revision of surgical scars. The high-energy pulsed CO2 laser offers the advantage of a bloodless field and a more precise method of tissue ablation. Postoperative erythema, however, is an expected finding with both treatment modalities.

Epidemiology of AIDS and tuberculosis among United States Veterans.

SETTING: US veterans. OBJECTIVE: To evaluate the frequency of the acquired immune-deficiency syndrome (AIDS) and tuberculosis (TB) among US veterans. DESIGN: Analysis of statistics for 1984-1993 from the Department of Veterans Affairs and the Centers for Disease Control and Prevention (CDC). RESULTS: For the first time in the available literature the incidence of AIDS and TB per 100000 were calculated for US veterans receiving health care from Veterans Administration Medical Centers (VAMC). Among these veterans, the incidence of AIDS in 1993 was 2.5-fold (P < 0.001) and the incidence of TB at least 1.3-fold (P < 0.001) higher than among the corresponding general population. The higher the incidences of AIDS and TB among general population of a state, the higher are the incidences of the diseases among veterans of this state (P < 0.001). A high correlation (r = 0.6, P < 0.001) between AIDS and TB among veterans was found. CONCLUSION: The study shows that US veterans receiving health care at VAMC are a high risk group for both AIDS and TB, and increased preventive measures are recommended. The spread of AIDS and TB among veterans of a state is probably determined by the spread of these diseases among the general population of that state.

Squamous cell carcinoma of the penis in a circumcised man: a case for dermatology and urology, and review of the literature.

Squamous cell carcinoma of the penis is most frequent in uncircumcised men. Other contributing factors include human papillomavirus infection, phimosis, balanitis, and smoking. We present a patient, circumcised at birth, who showed penile squamous cell carcinoma in situ and was treated with carbon dioxide laser ablation. Squamous cell carcinoma rarely presents in patients circumcised as infants. Factors contributing to chronic inflammation may predispose to this disease. Carbon dioxide and neodymium:YAG lasers are two modalities that are successful in the treatment of in situ and probably early invasive penile carcinoma. Optimal treatment includes coordination with a urologist if urethral disease is present.

Short-pulse carbon dioxide laser resurfacing in the treatment of rhytides and scars. A clinical and histopathological study.

BACKGROUND: Previous studies have shown the efficacy of short-pulse carbon dioxide (CO2) lasers in the treatment of rhytides and scars. To date, there have been few studies examining the histological aspects of these treatments. OBJECTIVE: The purpose of this study was to perform a prospective clinical and histopathological study of CO2 laser resurfacing for improvement of facial rhytides and scars. METHODS: A total of 23 patients were studied. Clinical improvement was evaluated both pre- and postoperatively using photographs and optical profilometry. Skin biopsies of rhytides were also obtained. RESULTS: Postoperatively, rhytides and scars both demonstrated significant increases in clinical improvement scores. Results from optical profilometry studies reflected these results. Skin biopsies from rhytides posttreatment demonstrated increases in collagen layer thickness. Improvement was sustained as late as 1 year following treatment. CONCLUSIONS: Histopathological studies suggest improvement of rhytides and scars by CO2 laser resurfacing may be attributed to new collagen formation following treatment.

A comparison between continuous infusion versus standard bolus administration of heparin based on monitoring in cardiac surgery.

This study was designed to determine prospectively if stable heparin concentrations can be maintained during extracorporeal circulation by using a continuous infusion technique, compared with a bolus regimen based on whole blood heparin concentration monitoring. Forty patients were assigned randomly to either an infusion or a monitoring group. The reference heparin concentration was defined as the whole blood heparin concentration associated with a kaolin activated clotting time (ACT) of approximately 480 s prior to institution of cardiopulmonary bypass (CPB) for both cohorts. For infusion patients, doses of heparin were administered using a continuous infusion based on the initial patient-specific heparin dose per unit weight; heparin was also added to solutions administered after the initiation of CPB based on the reference heparin concentration. For monitoring patients, the dose of heparin administered during CPB was calculated by the Hepcon instrument. Blood specimens collected prior to and during the CPB period were used to measure anti-Xa plasma heparin concentration and complete blood counts, kaolin ACT and whole blood heparin concentration. Doses of heparin and protamine administered and transfusion requirements were similar in patient cohorts. The apparent rate of clearance of heparin from plasma was variable among patients in the monitoring group prior to CPB. Stable heparin concentrations were maintained using whole blood heparin measurements, whereas mean heparin concentrations were slightly lower using the continuous infusion technique. Therefore, an optimal approach might involve the combined use of these regimens.

Antithrombin III during cardiac surgery: effect on response of activated clotting time to heparin and relationship to markers of hemostatic activation.

UNLABELLED: This study was designed to determine if, and to what extent, antithrombin III (AT) levels affect the response of the activated clotting time (ACT) to heparin in concentrations used during cardiac surgery, and to characterize the relationship between AT levels and markers of activation of coagulation during cardiopulmonary bypass (CPB). After informed consent, blood specimens obtained from eight normal volunteers (Phase I) were used to measure the response of the kaolin and celite ACT to heparin after in vitro addition of AT (200 U/dL) and after dilution with AT-deficient plasma to yield AT concentrations of 20, 40, 60, 80, and 100 U/dL. In Phase II, blood specimens collected before the administration of heparin and prior to discontinuation of CPB, were used to measure the response of the kaolin ACT to heparin (preheparin only), AT concentration, and a battery of coagulation assays in 31 patients undergoing repeat or combined cardiac surgical procedures. In Phase I, strong linear relationships were observed between kaolin (slope = 1.04 AT - 2, r2 = 0.78) and celite (slope = 1.36 AT + 6, r2 = 0.77) ACT slopes and AT concentrations below 100 U/dL. In the pre-CPB period of Phase II, only factors V (partial r = -0.49) and VIII (partial r = -0.63) were independently associated with heparin-derived slope using multivariate analysis; an inverse relationship was observed between AT and fibrinopeptide A levels (r = -0.41) at the end of CPB. Our findings indicate that the responsiveness of whole blood (ACT) to heparin at the high concentrations used with CPB is progressively reduced when the AT concentration decreases below 80 U/dL. Because AT is variably, and sometimes extensively, reduced in many patients before and during CPB, AT supplementation in these patients might be useful in reducing excessive thrombin-mediated consumption of labile hemostatic blood components, excessive microvascular bleeding, and transfusion of blood products. IMPLICATIONS: Heparin, a drug with anticoagulant properties, is routinely given to patients undergoing cardiac surgery to prevent clot formation within the cardiopulmonary bypass circuit. However, when levels are reduced, heparin is not as effective. Findings within this study indicate that administration of antithrombin III may help to preserve the hemostatic system during cardiopulmonary bypass.

Relationship between leukocyte count and patient risk for excessive blood loss after cardiac surgery.

OBJECTIVE: To evaluate the relationship between leukocyte counts and risk for excessive blood loss after cardiac surgery when including numerous demographic, operative, and laboratory factors in the comparison. DESIGN: A prospective, clinical evaluation. SETTING: A point-of-care laboratory and the cardiac surgical unit of a university-affiliated tertiary center. PATIENTS: Patient-related and hematologic variables were measured, using blood specimens obtained from 89 hospitalized patients who underwent cardiac surgery involving cardiopulmonary bypass. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Demographic, operative, and transfusion-related data were recorded for each patient. Routinely obtained measurements of laboratory-based prothrombin time, partial thromboplastin time, complete blood count, and bleeding time were recorded. Hemoglobin concentration, platelet count, and red and white blood cell counts were measured with an on-site instrument before initiation (pre-cardiopulmonary bypass) and before discontinuation (end-cardiopulmonary bypass) of cardiopulmonary bypass. Hematocrit was calculated using recorded variables, and white blood cell percent change values were calculated using white blood cell counts from both periods, using the following formula: [(end-cardiopulmonary bypass - pre-cardiopulmonary bypass)/pre-cardiopulmonary bypass] x 100. When we excluded four patients who had a surgical source of post-cardiopulmonary bypass bleeding, significant (p < .0001) relationships were observed between white blood cell count (r2 = .46) and white blood cell percent change values (r2 = .71) and cumulative mediastinal chest tube drainage in the first 4 postoperative hours in 85 patients. Bayes theorem was used to evaluate the predictive ability of hematologic measurements in identifying patients with excessive bleeding (n = 24), defined as >1000 mL of cumulative chest tube drainage in the first 24 postoperative hours, when compared with patients without excessive bleeding (n = 61). Demographic and operative variables were similar between these patients except that patients with excessive bleeding required more red blood cell, platelet, and plasma transfusions during the postoperative interval. Significantly (p < .0001) greater white blood cell percent change values were obtained in the excessive bleeding cohort (119 +/- 93 percent change) when compared with patients without excessive bleeding (28 +/- 36 percent change). CONCLUSIONS: On-site measurements of white blood cell count, as an index of the inflammatory response to extracorporeal circulation, may be useful in identifying patients at increased risk for excessive bleeding. Further studies are needed to examine whether white blood cell counts during multiple cardiopulmonary bypass periods may identify patients with an exaggerated inflammatory response to extracorporeal circulation. By using this information, physicians may be able to intervene with anti-inflammatory medications and blood preservation techniques.

Laser treatment of acquired vascular lesions.

Several quasi-continuous wave and pulsed lasers can effectively treat a variety of vascular lesions. The PDL follows the theory of selective photothermolysis, is safe for infants and children, and has a low incidence of side effects. It is successful in treating telangiectasias, spider and cherry angiomas, pyogenic granulomas, venous lakes, and poikiloderma of Civatte, as well as small leg telangiectasias. Quasi-continuous wave lasers such as the APTDL, copper vapor, krypton, and KTP lasers can be used to treat telangiectasias and other vascular lesions as well. Although they carry a higher risk of complications, they may prove more useful in treating larger caliber vessels. Although the PDL often produces superior clinical results than the quasi-continuous wave lasers, some patients may prefer these latter lasers because of the lack of post-operative purpura. Lastly, newer lasers, as well as noncoherent light sources, are being developed for the treatment of leg telangiectasias. Continuing advances in laser technology will enhance results, decrease side effects, improve equipment, and reduce costs, with great benefit to an increasing patient population.

Effects of platelets and white blood cells and antiplatelet agent C7E3 (Reopro) on a new test of PAF procoagulant activity of whole blood.

This study was designed to evaluate the effects of varying concentrations of platelets, white blood cells (WBC) and Fab fragments of a monoclonal antibody (c7E3, Reopro) directed at the platelet GpIIb-IIIa receptor complex on ACT-based clot ratio values (hemoSTATUS assay) in healthy volunteers. These measurements were made in heparinized whole blood from 10 normal volunteers in which either platelet or WBC concentrations had been varied by differential centrifugation. In addition, blood collected in either heparin or argatroban was incubated with varying concentrations of c7E3 (Reopro). Clot ratio values (%Maximal) in normal blood did not decrease until average platelet counts were less than 50,000. A marked reduction in clot ratios was observed when WBC concentration increased above or decreased below baseline clot ratios within each patient. Strong linear relationships were observed between white cell concentration and clot ratio values when white cell concentrations were either less or greater than baseline values. When argatroban was used as an anticoagulant, inverse relationships were demonstrated between clot ratio values and increasing c7E3 concentration (Ch 3: r = -0.33, Ch4: r = -0.84, Ch5: r = -0.87, Ch 6: r = -0.71). ACT-based clot ratio values determined in heparinized whole blood presumably reflecting PAF inducible platelet procoagulant activity, are affected by platelet concentration when counts are less than 50,000/microliter. The hemoSTATUS test was also found to be affected by WBC concentration since clot ratio values decreased when WBC counts were below 4,000/microliter or above 9,000/microliter. A dose-dependent reduction in clot ratio values was also observed with increasing concentrations of c7E3. This test can reliably detect platelet dysfunction only if the platelet count is > 50,000 and the WBC is normal.