Case report. Duplication of the portal vein: a rare congenital anomaly

Complex developmental changes occur during embryonic life as the vitelline veins evolve into the portal vein. Duplication of the portal vein is an uncommon anomaly. Complications of this anomaly include variceal bleeding, portal hypertension and duodenal obstruction. We report a case of this uncommon anomaly and present an embryological perspective as to the cause for this abnormal configuration of the portal veins.

Subperiosteal Osteoid Osteoma of the Neck of Talus

Juxta-articular, subperiosteal osteoid osteomas arising around the ankle are unusual. Tumors arising on the neck of the talus commonly produce symptoms mimicking monoarticular arthritis. Patients are usually treated for arthritis or ankle sprain, which often leads to a delay in definitive diagnosis. Here we present a case of osteoid osteoma of neck of talus which was presented as ankle pain. It puzzled us until MRI was done. Diagnostic dilemma and delay can be avoided by high index of suspicion. The patient was treated with open removal of the tumor. We also present brief review of literature about juxta-articular, subperiosteal osteoid osteoma which is uncommon from the typical osteoid osteoma occurring elsewhere in the body.Keywords: juxta-articular, subperiosteal, osteoid osteoma, talus neck

Subperiosteal osteoid osteoma of the neck of talus

Juxta-articular, subperiosteal osteoid osteomas arising around the ankle are unusual. Tumors arising on the neck of the talus commonly produce symptoms mimicking monoarticular arthritis. Patients are usually treated for arthritis or ankle sprain, which often leads to a delay in definitive diagnosis. Here we present a case of osteoid osteoma of neck of talus which was presented as ankle pain. It puzzled us until MRI was done. Diagnostic dilemma and delay can be avoided by high index of suspicion. The patient was treated with open removal of the tumor. We also present brief review of literature about juxta-articular, subperiosteal osteoid osteoma which is uncommon from the typical osteoid osteoma occurring elsewhere in the body.

Multiplexed Assays by High-Content Imaging for Assessment of GPCR Activity

G-protein-coupled receptors (GPCR) participate in many disease pathways and represent the largest family of therapeutic targets. Thus, great investments are made to discover drugs modulating GPCR-mediated events. Among functional assays for screening GPCRs, the Transfluor®imaging assay is based on redistribution of cytosolic β-arrestin to an activated GPCR and has become widely used in high-content screening. However, assessing Transfluor®alone has limitations: relying on a single mechanistic step of β-arrestin redistribution during GPCR activation, providing no information on the stimulated GPCR's intracellular fate, and using only a single fluorescent color (green fluorescent protein). Taking full advantage of high-content imaging to screen approximately 2000 compounds, the authors multifplexed the Transfluor®assay with an immunofluorescence-based quantification of GPCR internalization. This approach identified and classified 377 compounds interfering with agonist-induced activation of the Transfluor®assay, receptor internalization, or both. In addition, a subset of compounds was analyzed for their performance across imaging, cell-based calcium release (fluorometric imaging plate reader [FLIPR]), and biochemical receptor binding assays (scintillation proximity assay). This indicated that the imaging assays have even better predictive power for direct inhibition of receptor binding than the FLIPR assay. In conclusion, compounds inducing unique responses can suggest novel mechanisms of action and be used as tools to study GPCR activation and internalization. ( Journal of Biomolecular Screening 2008:449-455)

Incidence and risk factors for development of venous thromboembolism in Indian patients undergoing major orthopaedic surgery: results of a prospective study

INTRODUCTION

The incidence of venous thromboembolism (VTE) in Western populations undergoing major orthopaedic surgery without any thromboprophylaxis has been reported to range from 32% to 88%. There is however limited information on incidence of VTE in Indian patients and most of the Indian patients undergoing these surgeries do not receive any form of prophylaxis regardless of their risk profile.

METHODS

A prospective study was performed on 147 patients undergoing major orthopaedic surgery for total knee replacement (TKR), total hip replacement (THR), and proximal femur fracture fixation (PFF) without any prophylaxis. These patients were profiled for presence of the known risk factors responsible for development of VTE. A duplex ultrasound on both lower limbs was done 6 to 10 days after surgery. Twenty three patients underwent THR, 22 patients underwent TKR, and 102 underwent surgery for PFF. The patients were assessed clinically for any signs of deep venous thrombosis (DVT) and pulmonary embolism (PE). A helical CT scan was done in case of suspicion of PE and a duplex ultrasound was done in case of clinical suspicion of DVT irrespective of the stage of study.

RESULTS

The overall incidence of VTE was 6.12% and that of PE was 0.6%. The risk factors that were found to be significantly responsible for development of VTE (p < 0.05) were: immobility greater than 72 hours, malignancy, obesity, surgery lasting more than two hours.

CONCLUSION

The study reconfirms the belief that DVT has a lower incidence in Indian patients as compared with other ethnic groups.

Management of end-stage renal disease patients with antiphospholipid antibody syndrome

AIMS

End-stage renal disease (ESRD) patients with antiphospholipid antibody syndrome (APAS) remain at high risk for the development of posttransplant renal thrombosis without the benefit of anticoagulation therapy. This study describes the clinical management of these high-risk patients on anticoagulation therapy.

METHODS

In this study period, 802 patients awaiting renal transplantation were screened for APAS. Twenty-seven of these patients (3%) had APAS. Of these 27, nine patients received cadaveric kidney transplants along with 409 patients who did not have APAS. Of the nine patients, seven were treated with coumadin and the remaining two were treated with heparin.

RESULTS

Of the seven patients treated with coumadin, five did not have thrombotic complications posttransplant. However, three of these patients were taken off coumadin due to bleeding complications at 6 months to 1 year posttransplant. They all returned to dialysis shortly thereafter. The remaining two patients have maintained their allografts on coumadin therapy for 3 and 5 years posttransplants. The other two patients had posttransplant renal thrombosis within 24 hours of their transplant despite coumadin therapy. Of the two patients treated with heparin, one is doing well at 6 years posttransplant while the other had early allograft loss due to thrombosis.

CONCLUSIONS

ESRD patients with APAS may benefit from anticoagulation therapy; however, early allograft loss and bleeding complication are two serious side effects of this therapy.

Synthesis of New and Memory HLA Antibodies From Acute and Chronic Rejections Versus Pregnancies and Blood Transfusions

BACKGROUND

This study compared HLA antibody (abs) production following acute (AR) and chronic (CR) rejection with HLA abs production following blood transfusions (TF) or pregnancies (P) among kidney and kidney pancreas transplant candidates.

METHODS

Serum samples from 145 patients were screened for anti-HLA abs by flow cytometry using beads coated with purified HLA molecules. Among these patients, nine had lost their graft due to AR; 13, CR; six had been immunized by a single P; 20 by no more than two TF; 28 had no documented immunization; and 69 had multiple immunizations. A Fisher exact test was used for the statistical analysis.

RESULTS

Neither a single P nor a couple of TF by themselves immunized primary transplant recipients (P = .17, and P = .42, respectively). However, multiple P and TF together provided a potent immunogenic stimulus (P = .00001). In contrast, a single allograft loss induced a strong anti-HLA response (P = 1.03 x 10(-8)). Following AR, anti-class I and II abs (P = .001), and following CR, anti-class II abs developed (P = .03). Waitlisted female candidates had significantly high PRA values than men (P = .00005), possibly because women had received significantly more immunizations than men (P = 4.0 x 10(-10)).

SUMMARY

Patients are likely to produce both class I and II HLA abs following AR and only class II abs following CR. A couple of TF or a P may not be immunogenic; however, together they have great potential to sensitize female candidates. Perhaps that is why waitlisted women are far more immunized than waitlisted men.

Reassessing autotransplantation for acute myeloid leukaemia in first remission – a matched pair analysis of autologous marrow vs peripheral blood stem cells

The role of autologous stem cell transplantation in adult patients with acute myeloid leukaemia (AML) in first remission is unclear, yet it has become standard treatment for myeloma and this paper explores whether the source of transplanted stem cells may explain this paradox. In total, 57 patients from the Royal Marsden Hospital who received an unpurged bone marrow transplant (ABMT) were matched with 114 patients from the EBMT registry who had undergone peripheral blood stem cell transplantation (PBSCT). Patients were matched for karyotype, FAB type, remission-autograft interval and age. In the PBSCT group, haematopoietic recovery was significantly faster and nonrelapse mortality at 4 years was significantly lower (13 vs 1%, P=0.04). The relapse rate and overall survival at 4 years (20 vs 31% and 77 vs 63%) were also better with PBSCT, although the differences were not statistically significant. Autografting should be reassessed in a randomised trial for first remission AML patients using peripheral blood as a source of stem cells rather than bone marrow.

Effect of heat on phycoerythrin fluorescence: Influence of thermal exposure on the fluorescence emission of R-phycoerythrin

The goal of this work was to measure and model the effect of thermal exposure on the fluorescence emission of R-phycoerythrin (R-PE). The long-term objective of our work is to assess the feasibility of encapsulating R-PE for use as the critical component of a time-temperature integrator (TTI) for ascertaining the degree of inactivation of food pathogens such as Salmonella. In this article we present a study to measure and model the thermally induced fluorescence emission decay of R-PE in several isothermal experiments. We used the isothermal data to determine the kinetic parameters, based on a general n(th) order reaction, and evaluated the utility of the resulting model by using it to predict R-PE fluorescence emission decay for several nonisothermal experiments based on published USDA safe harbor guidelines for cooked beef products. The transient experiments were conducted over the same temperature range used in the isothermal study. Very good agreement was obtained between theory and experiment at temperatures of 62.8 degrees C and above, although the model slightly underpredicted the extent of fluorescence emission decay at 60 degrees C. Our results indicate that R-PE fluorescence emission decay kinetics is well behaved and that the protein is a strong candidate for use as a time-temperature integrator.

The effect of dentine on fluorescence measurements of enamel lesions in vitro

This study aimed to determine the contribution of the underlying dentine and the enamel-dentine junction to measurements of mineral loss from enamel recorded using quantitative light fluorescence (QLF). Sixteen square blocks (5 x 5 mm) were cut from the labial surfaces of extracted bovine incisor teeth. A dental drill was used to remove dentine and the enamel-dentine junction from half of each specimen. All specimens were embedded in epoxy resin and ground to produce a smooth, flat enamel surface. Half of the enamel surface of the block, perpendicular to where the dentine had been removed, was demineralised for 72 h prior to undertaking QLF measurements from the enamel surface to compare fluorescence loss from different areas of the block. QLF readings taken from lesions with no underlying dentine or enamel-dentine junction were very similar to readings from lesions with underlying dentine. A comparison of the two data sets demonstrated a linear relationship with a gradient of 0.95 and a y intercept of -1.24 (r(2) = 0.936). From these data, the underlying dentine and enamel-dentine junction did not influence mineral loss in enamel measured using QLF.

Role of anti-beta 2 glycoprotein 1 antibodies in ESRD patients with antiphospholipid antibody syndrome

INTRODUCTION

End stage renal disorder (ESRD) patients with antiphospholipid antibody syndrome (APAS) are at high risk for the development of post-transplant renal thrombosis. Positive titre of anticardiolipin antibodies (ACA) is considered a major characteristic of APAS. However, several studies have suggested that ACA in patients with APAS do not bind to phospholipids alone. Beta 2 glycoprotein 1 (beta 2gp1), a 40-kD plasma protein is required. In this study, we have tested a hypothesis that significant portions of our ESRD patients with APAS have antibodies only to beta 2gp1.

METHODS

Serum samples from each of 169 ESRD patients waiting for cadaver renal transplant in August 2000 were tested for ACA and anti-beta 2gp1 antibodies by enzyme-linked immunoabsorbent assay (ELISA) method. Twenty-four of these patients had clotting disorders that met the criteria established by the Eighth International Symposium on Antiphospholipid Antibodies. They included frequent arterio-venous (a-v) shunt thrombosis, cerebrovascular thrombosis, lupus, frequent abortions and microrenal angiopathy.

RESULTS

Thirty-three of the patients (20%) had positive titre of either ACA or beta 2gp1 or both. Twenty-eight patients had ACA antibodies, of which eight had no evidence of clotting disorder while remaining 20 patients had various clotting disorders. Fourteen of these 20 patients with APAS had the positive titre of ACA only; the remaining six patients had both the antibodies, i.e. anti-beta 2gp1 as well as ACA. There were four patients with APAS that had positive titres of only beta 2gp1 antibodies. In total there were 11 patients with beta 2gp1 antibodies, 10 of which had APAS, the remaining one did not. The sensitivity and the specificity of ACA test were 83 and 94%, respectively, and the sensitivity and specificity of beta 2gp1 antibody test were 71 and 99%, respectively. The chi-square analysis demonstrated that there was statistically significant correlation between positive titres of both the antibodies and the presence of APAS.

CONCLUSION

The APAS in the ESRD patients should be characterized by not only the positive titre of ACA but also the positive titres of anti-beta 2gp1 antibodies in association with history of clotting disorder.

Thrombotic thrombocytopenic purpura and systemic lupus erythematosus

Thrombotic thrombocytopenic purpura (TTP) is a rarely seen complicating systemic lupus erythematosus (SLE). The diagnosis of TTP in a setting of SLE is challenging since both share common features including thrombotic microangiopathy. We report two cases of SLE with TTP one with a good response when cyclophosphamide was given early with plasmapheresis and steroids; the other with a poor outcome in a patient given cyclophosphamide late in the course of the disease.

Evaluation of anti-atherosclerotic and vasculoprotective effect of long acting nifedipine in patients after PTCA

The anti-atherosclerotic and vasculoprotective effect of long acting nifedipine (nicardia retard 20) was evaluated on patients undergoing percutaneous transluminal coronary angioplasty (PTCA). This was a randomised, controlled, prospective clinical trial. A total of 30 patients fulfilling inclusion criteria were divided randomly in 2 groups of 15 each. One group was given long acting nifedipine while other group did not receive long acting nifedipine. The rest of the treatment was similar for both the groups. Clinical and angiographic parameters were evaluated regularly for a period of one year. The group receiving long acting nifedipine showed 20% restenosis as against 33% in group not receiving long acting nifedipine. Thus, from this trial, it can be concluded that long acting nifedipine can reduce the progress of reocclusion and thus demonstrates the anti-atherosclerotic and vasculoprotective action.

Anti-cardiolipin antibodies, Raynaud's phenomenon with digital ischemia, and non small cell carcinoma of the lung

Raynaud's phenomenon, digital ischemia, antinuclear antibodies and anticardiolipin antibodies are uncommon features of malignancy. The association of all of these in a patient with malignancy has not previously been reported. We describe a 52 year old woman with non small-cell carcinoma of the lung who also had Raynaud's phenomenon, digital ischemia, anti-nuclear antibodies and anticardiolipin antibodies.

Improved flow cytometric detection of HLA alloantibodies using pronase: potential implications in renal transplantation

BACKGROUND

Flow cytomeric crossmatch (FCXM) has grown in popularity and has become the "standard of practice" in many programs. Although FCXM is the most sensitive method for detecting alloantibody, the B cell FCXM has been problematic. Difficulties with the B cell FCXMs have been centered around high nonspecific fluorescence background owing to Fc-receptors present on the B cells and autoantibodies. To improve the specificity and sensitivity of the B cell FCXM, we utilized the proteolytic enzyme pronase to remove Fc receptors from lymphocytes before their use in FCXM.

METHODS

Lymphocytes isolated from peripheral blood, spleen, or lymph nodes were treated with pronase and then used in a three-color FCXM. A total of 167 T- and B cell FCXMs using pronase-treated and untreated cells were performed. Testing used serial dilutions of HLA allosera (22 class I and 6 class II), with the titer of each antibody at one dilution past the titer at which the complement-mediated cytotoxicity anti-human globulin crossmatch became negative.

RESULTS

After pronase treatment, the actual channel values of the negative control in both T cell and B cell FCXMs declined from 78+/-10 to 57+/-4 (P<0.05) and 107+/-11 to 49+/-3 (P<0.00001), respectively. Pronase treatment resulted in improved sensitivity of the T and B cell FCXM in detecting class I antibody by 20% and 80%, respectively. In no instance was a false-positive reaction observed. In this study, pronase treatment improved the specificity of B cell FCXM for detecting class II antibodies from 75% to 100% (P=0.03). In no instance was a false-negative reaction recorded. Lastly, on the basis of these observations we re-evaluated three primary transplant recipients who lost their allografts because of accelerated rejection. One of the patients was transplanted across negative T and B cell FCXM, whereas the other two patients were transplanted across a positive T cell, but negative B cell, FCXM. After pronase treatment, T and B cell FCXMs of each patient became strongly positive, and donor-specific anti-HLA class I antibody was identi. fied in each case.

CONCLUSION

Utilization of pronase-treated lymphocytes improves both the sensitivity and specificity of the FCXM.