Blood Coagulation Profile Research Articles

Blood coagulation and metabolic profiles in middle-aged male and female ob/ob mice.

Obese and diabetic states in humans are associated with an increased incidence of thrombotic diseases caused by various coagulation abnormalities. Genetically obese ob/ob mice produce metabolic abnormalities similar to those associated with type 2 diabetes. However, little is known about their coagulation features or sex differences. The present study aimed to determine the effects of obese and diabetic complications on blood coagulation and vascular diseases by exploring correlations between blood coagulation and metabolic profiles in middle-aged male and female ob/ob mice. Plasma levels of plasminogen activator inhibitor 1 (PAI-1) were significantly increased, whereas those that of platelet factor-4 (PF-4) was slightly, but significantly increased in male and female ob/ob mice compared with lean counterparts. Prothrombin time (PT) was significantly shortened in female ob/ob mice and activated partial thrombin time (APTT) significantly differed between male and female ob/ob mice. Plasma levels of antithrombin (AT) were significantly increased in male and female ob/ob mice. None of the other coagulation and fibrinolytic factors examined significantly differed between ob/ob mice and lean counterparts. On the contrary, factors such as body weight and cholesterol levels significantly differed between ob/ob and lean mice, whereas glucose, fructosamine and insulin levels significantly differed only in one sex of each strain. These results provided fundamental information about blood coagulation and metabolic features for exploring the function of altered blood coagulation states in ob/ob mice.

Transient Global Amnesia as a Presenting Manifestation of Cerebral Venous Thrombosis

Transient Global Amnesia as a Presenting Manifestation of Cerebral Venous Thrombosis

Circular anastomotic experimental fibrin sealant protection in deep colorectal anastomosis in pigs in a randomized 9-day survival study.

The reported rate of clinically apparent anastomotic leakage (AL) in a low anterior resection of the rectum (LAR) (≤7cm from the anal verge) using a circular double-stapled anastomosis (CDSA) without defunctioning stoma is up to 37.5%. Since AL may result in life-threatening peritonitis, sepsis, and multiple organ failure, LAR and CDSA are regularly combined with defunctioning stoma. Accordingly, we now evaluated whether LAR and CDSA without defunctioning stoma but with extraluminal anastomotic application of an experimental fibrin sealant reduce the AL rate. This might prevent humans from defunctioning stoma increasing quality of life and decreasing surgical costs. Forty 8-week-old pigs underwent LAR and CDSA in an end-to-end technique (descendo-rectostomy). Animals were randomized into a therapy and control group (gr.). The therapy gr. (n = 20) received an additional extraluminal circular application of an experimental fibrin sealant to the anastomosis. The objective was to assess the incidence of clinically apparent and non-clinically apparent leakage through the ninth postoperative day. Double-contrast barium CT radiographs of the colorectal region were performed on the ninth postoperative day or earlier, in case there were clinical signs of AL. All remaining animals were sacrificed on the ninth postoperative day and the anastomotic region was histopathologically analyzed. In case of earlier diagnosed AL, animals were sacrificed immediately. Blood samples were taken for complete blood count, chemistry, and coagulation profile prior to surgery and on the first, third, fifth, seventh, and ninth postoperative day. A circular extraluminal anastomotic application of an experimental fibrin protection decreased the rate of clinically and non-clinically apparent AL from 20% (n = 4) in the control group to 5% (n = 1) in the treatment group. Ulcerations were also observed in both gr. (control gr.-5 animals, therapy gr. -3 animals). All animals with AL showed necrosis surrounding the hole at the anastomoses. Three additional animals had a full wall defect at the anastomotic region that was blocked by the experimental fibrin sealant. The fibrin sealant was present at necropsy in all treated animals. Circular anastomotic protection with the experimental fibrin sealant blocked anastomotic full wall defects, preventing peritonitis and significantly reducing the AL rate from 25 to 5%.

Effect of Recombinant Lubricin on Coagulation Parameters in Human Blood

Lubricin (proteoglycan 4; PRG4) is a proteoglycan which acts as a joint lubricant. Lubricin is present in synovial fluid and plays a major role in synovial homeostasis. A recombinant form of lubricin, rhPRG‐4 is developed to treat a variety of inflammatory diseases. (Lubris Pharmaceutical). The purpose of this study is to determine the effect of rhPRG‐4 on blood coagulation utilizing various experimental studies.rhPRG‐4 was supplemented with citrated whole blood from normal human donors (n = 10) to obtain concenration range of 0 ‐ 200 mg/mL. Activated clotting time (ACT), thrombelastographic analysis (TEG), and whole blood prothrombin time (PT), partial thromboplastin time (aPTT), and thrombin times (TT) were measured. Similarly, citrated plasma was supplemented with rhPRG‐4 at 0‐200 mg/ML to determine PT, aPTT and TT. The effect of this agent was also studied on the generation of proteases. In addition, rhPRG‐4 was also studied for its effect on platelet aggregation.rhPRG‐4 did not produce any effect on the whole blood clotting assays, such as the PT, aPTT and TT. Similarly, in the citrated plasma, none of the clotting assays were altered. rhPRG‐4 did not produce any inhibition of thrombin generation in plasma. Furthermore, it did not produce any inhibition or augmentation of agonist‐induced platelet aggregation. These studies suggest that rhPRG‐4 does not modify whole blood and plasma coagulation profile and produce and more relation of platelet function.These studies suggest that because of no potential alteration of the coagulation system, lubricin is not expected to modulate bleeding or thrombotic processes in clinical indications.

English

Central retinal artery occlusion following blunt trauma a 19-year-old patient presented with complaints of severe loss of vision in the right eye following a high pressure compressor gas injury of 1 day duration. External ocular examination revealed ecchymosis in the right eye and relative afferent pupillary defect. Fundus examination showed whiteout retina and a cherry red spot at the macula in the right. A clinical diagnosis of right central retinal arterial obstruction (CRAO) was made. CRAO in young is a rare disease usually found in patients with cardiac embolic diseases, coagulopathies or systemic vascular inflammations and rarely following trauma. Despite active intervention the visual loss persisted. Hence the case report. INTRODUCTION: A 19 year old male presented with history of trauma to the right eye at his work place with a high pressure gas compressor at his work place of 1 day duration. He complained of sudden loss of vision in the right eye. He also complained of redness, watering and pain on eye movements. He did not complain of flashes of light or floaters in the affected eye. There was no history of headache, vomiting, loss of consciousness or nasal bleed. On examination the visual acuity in the right eye was perception of light. Projection of rays was absent in the superior and inferior quadrants and visual acuity in the left eye was 6/6. Examination of the right eye showed ecchymosis in the lids, sub conjunctival hemorrhage, congestion. (Fig. 1) There was a conjunctival laceration from 9-1 clock hours (Fig. 2) with a relative afferent pupillary defect (Grade 3). Fundus examination of the right eye – Media was clear. Disc appeared hyperemic; margins were well defined with a flame shaped hemorrhage at the disc. There was arteriolar attenuation and venous dilatation. Pale whitish edematous retinal area noted in all quadrants with significant edema concentrated over posterior pole. Small area of normal retina noted in nasal and temporal aspect of disc. Vascularity around the macula was obscured and a cherry red spot was seen at the macula (Fig. 3). The intraocular pressure by applanation tonometry was 24mmHg in the right eye and 14 nn Hg in the left eye. The examination of the anterior and posterior segments of the left eye was within normal limits. A diagnosis of traumatic central retinal occlusion was made. Routine blood investigations and coagulation profile was done which was normal. CT orbit showed extensive areas of air pockets in extraconal and intraconal area along with extension into the optic canal and suprasellar areas. (Fig. 4) (Fig. 5). Treatment was initiated with ocular massaging, paracentesis, vasodilators-nitrates, topical antibiotic-NSAID combination, topical timolol malleate BD and oral acetazolamide 500mg BD. Oral steroids were started 1mg/Kg per body weight. Vision improved to hand movements on the first day after treatment. 4 weeks later the vision improved to counting fingers close to face and 4/60 in the temporal quadrant. Rapd remained in the right eye, the fundus showed a paler disc with retinal whitening and a cherry red spot at the macula. DOI: 10.14260/jemds/2014/3954

Effects of magnesium sulphate on coagulation after laparoscopic colorectal cancer surgery, measured by rotational thromboelastometry (ROTEM® ).

We investigated the effects of magnesium sulphate on blood coagulation profiles using rotational thromboelastometry in patients undergoing laparoscopic colorectal cancer surgery. Patients were randomly allocated to the magnesium group (n = 22) or control group (n = 22). The magnesium group received intravenous magnesium sulphate (50 mg.kg(-1) followed by a continuous infusion of 15 mg.kg(-1) .h(-1) ), whereas the control group received the same volume of isotonic saline. Mean (SD) postoperative serum magnesium levels were 1.60 (0.13) mmol.l(-1) in the magnesium group compared with 0.98 (0.06) mmol.l(-1) in the control group (p < 0.001). All maximum clot firmness values of ROTEM analysis were significantly lower on the third postoperative day in the magnesium group compared with the control group (p < 0.05). We conclude that ROTEM analysis demonstrated that intra-operative administration of intravenous magnesium sulphate reduces blood hypercoagulability in patients undergoing laparoscopic colorectal cancer surgery.

Continuous passive motion for preventing venous thromboembolism after total knee arthroplasty.

Total knee arthroplasty (TKA) is a common form of orthopaedic surgery. Venous thromboembolism (VTE), which consists of deep venous thrombosis (DVT) and pulmonary embolism (PE), is a major and potentially fatal complication after TKA. The incidence of DVT after TKA is 40% to 80% and the incidence of PE is approximately 2%. It is generally agreed that thromboprophylaxis should be used in patients who undergo TKA. Both pharmacological and mechanical methods are used in the prevention of DVT. Pharmacological methods alter the blood coagulation profile and may increase the risk of bleeding complications. When pharmacological methods cannot be used the mechanical methods become crucial for VTE prophylaxis. Continuous passive motion (CPM) is provided through an external motorised device which enables a joint to move passively throughout a preset arc of motion. Despite the theoretical effectiveness and widespread use of CPM, there are still differing views on the effectiveness of CPM as prophylaxis against thrombosis after TKA. This is an update of the review first published in 2012. The aim of this review was to determine the effectiveness of continuous passive motion (CPM) therapy for preventing venous thromboembolism (VTE) in patients after total knee arthroplasty (TKA). For this update the Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator searched the Specialised Register (last searched February 2014), CENTRAL (2014, Issue 1), Ovid MEDLINE (to week 1 February 2014) and EMBASE (to Week 07 2014). Randomised controlled trials (RCTs) comparing the use of CPM with control in preventing DVT or PE after TKA. People aged 18 years and older who had undergone TKA were included in this review. We excluded studies of patients who presented with DVT at baseline. The experimental and control groups received similar postoperative care and therapy other than the CPM. Two review authors independently assessed the citations retrieved by the search strategies for reports of relevant RCTs. They independently selected trials that satisfied the inclusion criteria, extracted data and undertook quality assessment. Effects were estimated as risk ratios (RRs), mean differences or standardised mean differences with 95% confidence intervals (CIs). Meta-analyses were performed using a fixed-effect model for continuous variables. Where heterogeneity existed (determined by the I(2) statistic) a random-effects model was used. Eleven RCTs involving 808 participants met the inclusion criteria. The methodological quality of the included studies was variable and most of the predefined outcomes were reported by only one or two studies, therefore the quality of the evidence was low. Five studies with a total of 405 patients reported the incidence of DVT. In the CPM group (205 patients) 36 developed DVT (18%) compared to 29 (15%) in the control group (200 patients). The results of the meta-analysis showed no evidence that CPM had any effect on preventing VTE after TKA (RR 1.22, 95% CI 0.84 to 1.79). One trial (150 participants) did not find PE in any of the patients during hospitalisation or in the subsequent three months. PE was not reported in the other included studies. None of the trials reported deaths among the included participants. There is not enough evidence from the available RCTs to conclude that CPM reduces VTE after TKA. We cannot assess the effect of CPM on mortality because no such events occurred amongst the participants of these trials. The quality of the evidence was low. The results are supported by only a small number of studies, most of which are of low to moderate quality.

Prognostic value of brain natriuretic peptide in acute pulmonary embolism

BackgroundPlasma levels of brain natriuretic peptide (BNP) correlate closely with the pressure and mural tension of the right ventricle and with pulmonary arterial pressure. The relationship between brain natriuretic peptide increase in acute pulmonary embolism (APE) and the increase in mortality and morbidity has frequently been suggested in small studies but its global prognostic performance remains largely undefined. MethodsBNP levels were determined among the 30 consecutive patients arriving at the emergency department with shortness of breath and moderate to high probability of pulmonary embolism. All patients were subjected to a thorough clinical and physical examination, 12 lead electrocardiography, chest X-ray, echocardiography, laboratory tests including complete blood count, coagulation profile, renal and liver functions, brain natriuretic peptide and multiline computed tomography. Results20 patients were diagnosed with APE. Among them, 7 were diagnosed with massive embolism (group 1) and 13 had mild to moderate embolism (group 2). Among the first group 6 patients died while only 2 patients from the second group died. BNP levels were significantly higher in group 1 (130±15pg/ml) compared to group 2 (91±7pg/ml) (P<0.05) and this was associated also with an increased mortality in group 1. ConclusionBNP levels can help predict the severity and possible outcome in patients with pulmonary embolism.

Predictors of Obstetrical Complications: A Prospective Cohort Study

Background: The objective was to identify predictors of obstetrical complications. Methods: A prospective cohort study, a state-run obstetrical hospital, Omsk, Russia. Out of a total 2,497 pregnant women with a gestation age of less than 12 weeks, 2,356 women with singlet pregnancies were selected. Data at gestation outcome were available for 2,177 women. Medical and social factors were evaluated and blood coagulation screening was performed in women in the first trimester. Ordered logistic regression was used to assess risks of obstetrical complications. The following obstetrical complications were evaluated after 28 weeks of gestation: preeclampsia, abruptio placentae, preterm labor, intrauterine growth restrictio n a nd intrauterine hypoxia. Results: A prognostic model comprised of 21 predictors (P < 0.001) with strong association (0.82) between the studied parameters and the obstetrical complications was obtained. Probability of obstetrical complications (91.1%) was associated with the following parameters in women: age, education, parity, medical history, heredity (family history ) and blood coagulation profile. Increased fibrinogen concentrations and reduced thrombin clotting time in the first trimester w ere associated with severe obstetrical complications late in pregnancy. Conclusions: Women with late obstetrical complications were found to have increased blood viscosity and an increase in coagulation potential early in pregnancy. The prognostic model obtained may have great significance and requires further validation. J Clin Gynecol Obstet. 2014;3(1):14-21 doi: http://dx.doi.org/10.14740/jcgo202w

Trans-thoracic biopsy of lung lesions: FNAB or CNB? Our experience and review of the literature

This study was performed to determine the type and incidence of complications of fine-needle aspiration biopsy (FNAB) and core biopsy (CNB) performed under computed tomography (CT) guidance to characterise lung lesions, and assess the diagnostic accuracy of the two techniques. In 2009-2011, we performed 124 lung biopsies (66 CNB and 56 FNAB) on 121 patients with a mean age of 72.4 years. Exclusion criteria were pulmonary resection, pleural lesions and/or effusions, and inadequate blood-coagulation profile. All examinations were acquired after contrast-agent administration in a craniocaudal direction from the lung apex to base during a single inspiratory breath-hold, with standardised parameters. Each lesion was scanned with 13-15 slices that could be repeated whenever necessary to document the needle track and for lesion centring, by positioning a metallic marker perpendicular to the centring light to indicate the point of needle access. Unless otherwise clinically indicated, 4 h after the procedure chest radiography was performed. Age was found to be a factor influencing the complications: pneumothorax in young subjects (31 %) and parenchymal haemorrhage in the elderly (30 %), with CNB but not with FNAB. We had more complications with the right lung: 50 % of pneumothorax cases in the upper lobe with CNB and 40 % of cases of haemorrhage in the lower lobe with FNAB. The anterior approach gave rise to more complications with CNB, while the posterior approach with FNAB. CNB had more complications than FNAB for lesions ≤ 3.5 cm (31 vs. 18 % pneumothorax), and >3.5 cm (34 vs. 9 % haemorrhage). There was no significant correlation with lesion histology, needle calibre or number of passes (probably due to the small number of procedures done with needles other than 18 G in CNB or 22 G in FNAB or involving more than one needle pass). The diagnostic accuracy of FNAB, done with a pathologist's extemporaneous assessment of sample adequacy, was 94.83 % against 81.82. % of CNB. FNAB under CT guidance is subject to a lower rate of complications and, if performed in the presence of the pathologist, has a greater diagnostic accuracy compared to CNB.

Indication of preoperative tests according to clinical criteria: need for supervision

Background and objectivesThe indiscriminate order for additional tests on pre-anesthetic evaluation is common in clinical practice, which entails additional costs and the possibility of false-positive results. The aim of this study was to analyze whether preoperative tests in elective surgeries are ordered according to clinical criteria and assess the unnecessary costs for the institution. MethodsEvaluation of preoperative investigations in adult patients undergoing elective non-cardiac surgery. Tests were ordered by surgeons according to the Anesthesia Service protocol. Demographic data, physical status, comorbidities, and type of ordered supplementary examination were evaluated. The tests performed were compared with the indicated tests. The cost of screening was based on Datasus’ table. Results1063 patients were evaluated. It was found that 41.9% of the tests performed on patients classified as ASA-I were not indicated. In ASA II group, 442 tests (17.72%) were made unnecessarily. The ordered percentages of blood count, creatinine, coagulation profile, chest X-ray, and ECG were high in groups ASA I–II. Only 40 (5.25%) of the examinations made in ASA III group were not indicated. In ASA IV group, 22.5% of the required tests were not performed. We highlight an annual saving of 13% (R$ 1923.13) if tests were done according to the protocol. ConclusionsPreoperative tests are not always ordered according to clinical criteria, which results in higher costs for the institution.

Role of Vascular Endothelial Growth Factor (VEGF) in the Neurological Manifestations of Dengue: A Preliminary Study

This study reports on vascular endothelial growth factor (VEGF) in dengue patients with neurological manifestations. Their bleeding diathesis, hypotension, edema, flushing, and hepatosplenomegaly were noted. Complete blood counts, serum chemistry, coagulation profile, liver and kidney function tests, creatine kinase (CK), and MRI in encephalopathic patients were carried out. Serum VEGF was estimated by ELISA in 21 dengue patients and 14 controls. Twelve patients had dengue fever (DF), eight dengue hemorrhagic fever (DHF), and one dengue shock syndrome (DSS). Fifteen patients had neurological manifestation, 12 had muscle involvement (raised CK with or without weakness), and 3 had encephalopathy. The VEGF level in dengue patients was 50.0 ± 56.1 pg/mL and in the controls, 60.6 ± 20.3 pg/mL. The VEGF level neither correlated with the severity nor with the neurological involvement. Thrombocytopenia, however, correlated with the severity of dengue and neurological manifestations. The VEGF level is not related to the severity of dengue and neurological syndrome.

Differential clinical characteristics of acute liver failure caused by hemophagocytic lymphohistiocytosis in children

Children with acute liver failure (ALF) caused by hemophagocytic lymphohistiocytosis (HLH) may be at risk of undergoing unnecessary liver transplantation (LT). The aim of this study was to compare the characteristics of ALF caused by HLH with those of ALF of unknown etiology in children. The clinical features and laboratory findings for eight children with ALF caused by HLH (ALF-HLH group) and 27 children with ALF of unknown etiology (ALF-UK group) were retrospectively compared by reviewing medical records. The ALF-HLH group had a higher incidence of pleural effusion, C-reactive protein elevation (especially >5 mg/dL), thrombocytopenia, anemia, fever, splenomegaly, and hypoalbuminemia (<2.5 mg/dL), and a higher in-hospital mortality rate. No significant differences were found in the white blood cell count, liver enzymes, coagulation profile, or incidence of hepatomegaly. LT should be performed only after it is proven that ALF is not caused by HLH, if a child with ALF shows the differential clinical features of ALF caused by HLH. Further research with larger sample sizes, however, is needed.

Dapsone-Induced Isolated Acute Pancreatitis in a Child with Linear IgA Dermatitis

To the Editor: Dapsone has long been used to treat leprosy. Nowadays, it is also used in the treatment of a variety diseases. Many side effects have been described, the most frequent at pediatric age being methemoglobinemia [1, 2]; other side effects include Dapsone hypersensitivity syndrome (DHS) [1]. To date, only three cases of isolated acute pancreatitis have been described with the use of Dapsone [1, 3]. A boy, aged 3 y and 5 mo presented with vomiting and abdominal pain for 48 h. Linear IgA dermatitis had been diagnosed at two and a half years of age, and had been well controlled with Dapsone (18 mg/d). He had two previous admissions with similar symptoms improving after Dapsone withdrawal. Physical examination showed diffuse abdominal pain, with no signs of peritoneal irritation. A complete blood cell count and coagulation profile were normal. Serum chemistries showed: C-reactive protein 32.9 mg/dL; pancreatic amylase 236 IU/L [normal: 60–80 UI/L]; lipase 318 IU/L [normal: 23–250 UI/L]; total calcium, hepatic profile, electrolytes, glucose, lipid profile, urea and serum creatinine within normal limits. Infections and celiac disease were dismissed. Abdominal ultrasound revealed diffuse enlargement of the pancreas, with homogeneous echogenicity and absence of focal lesions. Computed tomography (CT) suggested mild acute pancreatitis (CT Severity Index:1) (Fig. 1). Dapsone was interrupted, along with NPO and fluid and electrolyte replacement. Gastrointestinal symptoms disappeared within 24 h. Five days after admission the biochemical parameters became normal (amylase 36 IU/L; lipase 73 IU/L). Although the outcome is generally good, internal organ complications, and deaths can occur with Dapsone treatment [4]. Frequently, adverse effects become evident 2–7 wk after the beginning of treatment [1–3, 5]. In our patient, the occurrence of repeated episodes of abdominal pain and vomiting and their improvement after interruption of Dapsone, the increased levels of pancreatic enzymes and the comprehensive exclusion of other possible causes of pancreatitis led us to suspect isolated acute pancreatitis induced by Dapsone. This was confirmed by the clinical and biochemical improvement observed after discontinuation. For ethical reasons, the patient was not re-exposed to the drug (Naranjo Scale Score: 8). To our knowledge this is the first report of isolated acute pancreatitis probably induced by Dapsone at pediatric age. This entity should be borne in mind, considering the increased use of this drug in recent years. A. Navarro-Mingorance :A. J. Castellanos-Alcarria : S. Ibanez-Mico :A. Cervantes-Pardo Department of Pediatrics, Universitary Hospital Virgen Arrixaca, Murcia, Spain

Changes in blood acid-base balance parameters and coagulation profile during diarrhea in calves

The purpose of this study was to investigate possible alterations in acid-base balance parameters and the coagulation profile in neonatal diarrheic calves. Twenty neonatal diarrheic and 20 clinically healthy neonatal calves aged between 1 week to 10 days were used. All blood samples were taken on the third day from the onset of diarrhea symptom. Venous blood samples were collected from each animal to determine platelet numbers, pH, pCO2, pO2, HCO(3-), BE, O2SAT, ctCO2 and electrolytes (K+, Na+ and Cl(-)). Plasma samples were collected from each animal for the measurement of prothrombin time (PT), activated partial thromboplastin time (APTT), thrombin time (TT), the concentrations of fibrinogen, D-dimer and the activity of antithrombin III (AT III). Blood pH (7.19), BE (-10.6 mmol/l), HCO3(-) (25.15 mmol/l), pO2 (3.33 kPa), O2SAT (24.12 %) were significantly lower and serum concentration of K+ (6.55 mmol/l) was significantly higher in diarrheic calves. These changes indicate the state of uncompensated metabolic acidosis with accompanying hyperkalemia. TT (32.05s) and APTT (39.9s) values were more prolonged in calves with diarrhea than in the control group. D-dimer (587.25 microg/l) concentrations were significantly increased while a visible drop in AT III (103.75%) activity and platelets counts (598 x10(9)/l) were observed in diarrheic group of calves. The results suggest that a consumptive type of disseminated intravascular coagulation (DIC) developed in diarrheic calves.

Complementary effect of fibrinogen and rFVIIa on clotting ex vivo in Bernard-Soulier syndrome and combined use during three deliveries

Women with Bernard-Soulier syndrome (BSS) are considered to be at high risk of serious bleeding during childbirth. Due to the frequently occurring platelet transfusion refractoriness, alternative prophylactic therapy is required. Using rotational thromboelastometry, we evaluated the whole blood coagulation profile of a pregnant woman with BSS before and after spiking ex vivo with different concentrations of recombinant activated factor VII (rFVIIa) and fibrinogen. As experiments suggested improved clotting with clinically applicable concentrations of both agents in a complementary manner, the findings were confirmed on blood from a non-pregnant woman and three men suffering from BSS. During delivery, bleeding refractory to platelets occurred and immediately following delivery she received both rFVIIa and fibrinogen intravenously. Immediate cessation of bleeding occurred, and no postpartum hemorrhage was seen. Another woman with BSS later also received the same rFVIIa and fibrinogen treatment prophylactically after delivery without any postpartum bleeding. Eventually, the first woman during her second delivery received the same treatment again prophylactically without any bleeding. No side effects were observed during these three deliveries. Our observations suggest that rFVIIa combined with fibrinogen may provide a beneficial clinical hemostatic effect partly by separate but complementary mechanisms.

Differentiating pulmonary cavities

To the Editor: We present the case of a patient with pulmonary cavitation of extremely unusual aetiology, which presented a significant diagnostic challenge despite multidisciplinary involvement. A 54-year-old male presented with a 6-week history of haemoptysis associated with fatigue, night sweats and dyspnoea. His past medical history was significant for coronary artery stenting (treated with aspirin). There was no history of exposure to tuberculosis. He had a 50-pack-year smoking history, prior excessive alcohol consumption and had worked in construction, though denied asbestos exposure. On physical examination, vital signs were normal, his dentition was poor, there was no digital clubbing and chest auscultation was unremarkable. Initial chest radiography showed a right upper lobe (RUL) cavity. Laboratory testing confirmed a normal full blood count, and renal, bone and coagulation profiles. An anti-neutrophil cytoplasmic antibody (ANCA) test was negative. Levels of γ-glutamyltransferase (91 IU·L−1, normal range 11–67 IU·L−1), C-reactive protein (215 mg·L−1, normal range <7 mg·L−1) and lactate dehydrogenase (334 IU·L−1, normal range 120–220 IU·L−1) were elevated. Candida albicans was cultured from sputum; blood cultures were sterile and urinalysis was normal. Thoracic computed tomography (CT) demonstrated a 7×5×5-cm RUL thick-walled cavity abutting the pleura with adjacent nodular lesions (fig. …

Unremitting pyrexia, pancytopenia, hepatosplenomegaly, and extreme hyperferritinemia

Unremitting pyrexia, pancytopenia, hepatosplenomegaly, and extreme hyperferritinemia

Fibrohistiocytoma: a rare tumour of the trachea

### Learning Point for Clinicians Fibrohistiocytomas of the trachea are rare tumours of the trachea. It may be difficult on histology to distinguish benign and malignant disease and expert opinion is required. These tumours can be successfully excised through interventional rigid bronchoscopy. A 54-year-old Caucasian male was referred with haemoptysis. There was no associated dyspnoea, noisy breathing or loss of weight. His medication consisted of montelukast and loratidine for allergic rhinitis. Family history included his father having a pituitary tumour and grandfather having a liver tumour. He had no known allergies, and he had never smoked. He was a retired electronics engineer and may have been exposed to asbestos and beryllium in the past. Examination of the pharynx, cardiovascular, respiratory and gastrointestinal systems was normal. Investigations revealed a normal full blood count, coagulation profile, inflammatory markers and biochemistry. A postero-anterior chest radiograph was unremarkable, and the patient had flexible bronchoscopy to identify a cause of his haemoptysis. At bronchoscopy, an exophytic lesion of the trachea just below the vocal cords …

Videothoracoscopy in pleural effusions: A review of 41 cases

This study aimed to evaluate the diagnostic and therapeutic value of videothoracoscopy in patients with pleural effusion. A total of 41 patients underwent video-assisted thoracic surgery (VATS) were analyzed, 25 male and 16 female. The mean age was 52.1 years (ranged between 18 and 92 years). Pleural effusion was left sided in 19 cases (46.4%), right sided in 14 cases (34.1%) and bilateral in eight cases (19.5%). Subjects with exudative and hemorrhagic pleural effusions in thoracentesis were included in the study. In all cases; complete blood count, electrocardiography (ECG), arterial blood gas, coagulation profile and respiratory function test (RFT) were performed. Two view chest X-ray and computed tomography scans were done to determine the localization of fluid and to decide the access point to thorax prior to procedure. One-lung ventilation was achieved in 20 patients under general anestesia, whereas double lung ventilation was preferred in 13 cases intolerant of one-lung ventilation. The procedure was carried out under local anesthesia in eight cases due to their high risk for general anesthesia. An approximately 50cc of pleural fluid and at least two pieces of pleural biopsy specimen for cytopathological examination were collected in all cases. Among the study population, 33 of cases were diagnosed with a benign disease and the remaining eight cases with a malign disease. Taking age ranges into account, non-specific pleuritis and tuberculosis pleuritis were most commonly diagnosed between 20 to 40 years of age whereas malign pathologies between 40-60 years of age. Diagnostic success of the procedure was found to be 97.6%. Patients with malign effusion underwent chemical pleurodesis with talc powder. No complication developed in our cases. VATS seems to be an effective method in the diagnosis and treatment of patients with pleural effusion. J. Exp. Clin. Med., 2013; 30:35-37