Weak D type 42 cases found in individuals of European descent

Patient samples were referred to our immunohematology reference laboratory to investigate the presence of a weak D antigen. In the last 3 years, 26 samples were received. Serology and molecular analyses were performed to identify the weak D variant. RHD mRNA from all patients was reverse transcribed, and cDNA was sequenced. The results were compared with a normal RHD sequence to identify the polymorphisms causing the weak D phenotype. Five different already known RHD variants were observed: weak D type 1 (5 individuals), weak D type 2 (1 individual), weak D type 42 (17 individuals), weak D type 45 (1 individual), and partial D DNB (2 individuals). Surprisingly, weak D type 42 was prevalent in our population, whereas weak D type 1, 2, and 3 are the most prevalent variants elsewhere. Anti-D was found in six cases of weak D type 42. The higher prevalence of weak D type 42 could be the result of a founder effect. Additional studies are needed to estimate the frequency of this variant in the general population.

[Popliteal venous thrombosis associated with a false aneurysm revealing femoral exostosis in a child]

Recent unprovoked and symptomatic thrombosis of the left popliteal vein was diagnosed in a 9-year-old girl. Treatment with low-molecular-weight heparin was initiated in association with vitamin K antagonist (INR 2.5), and compressive stockings. Two and a half months later, the ultrasound examination revealed a false aneurysm of the left distal superficial femoral artery. Knee X-rays showed a distal femoral exostosis. MRI clarified the relationship between the false aneurysm and the exostosis. Bone scintigraphy eliminated multiple exostoses. Resection of the false aneurysm associated with end-to-end femoro-popliteal saphenous bypass and exostosectomy in the same operative time were performed. On histopathological examination there was no sign of malignant transformation. Vascular complications of exostoses are infrequent and the association with deep venous thrombosis and false aneurysm is exceptional. This case report illustrates the contribution of knee X-rays to unravel this unusual clinical presentation.

Lessons from French National Guidelines on the treatment of venous thrombosis and central venous catheter thrombosis in cancer patients

Increased prevalence of Venous thromboembolism (VTE), as defined by deep-vein thrombosis (DVT), central venous catheter (CVC) related thrombosis or pulmonary embolism (PE) in cancer patients has become a major therapeutic issue. Considering the epidemiology and each national recommendations on the treatment of VTE in cancer patients, we analysed guidelines implementation in clinical practice. Thrombosis is the second-leading cause of death in cancer patients and cancer is a major risk factor of VTE, due to activation of coagulation, use of long-term CVC, the thrombogenic effects of chemotherapy and anti-angiogenic drugs. Three pivotal trials (CANTHANOX, LITE and CLOT) and several meta-analysis led to recommend the long term (3 to 6 months) use of LMWH during for treating VTE in cancer patients with a high level of evidence. The Italian Association of Medical Oncology (AIOM), the National Comprehensive Cancer Network (NCCN), the American Society of Clinical Oncology (ASCO), the French "Institut National du Cancer" (INCa), the European Society of Medical Oncology (ESMO) and the American College of Chest Physicians (ACCCP) have published specific guidelines for health care providers regarding the prevention and treatment of cancer-associated VTE. Critical appraisal of these guidelines, difficulties in implementation of prophylaxis regimen, tolerance and cost effectiveness of long term use of LMWH may account for large heterogenity in daily clinical practice. Homogenization of these guidelines in international consensus using an adapted independent methodological approach followed by educational and active implementation strategies at each national level would be very valuable to improve the care of VTE in cancer patients.

Extinction of Harrington's mountain goat

Keratinous horn sheaths of the extinct Harrington's mountain goat, Oreamnos harringtoni, were recovered at or near the surface of dry caves of the Grand Canyon, Arizona. Twenty-three separate specimens from two caves were dated nondestructively by the tandem accelerator mass spectrometer (TAMS). Both the TAMS and the conventional dates indicate that Harrington's mountain goat occupied the Grand Canyon for at least 19,000 years prior to becoming extinct by 11,160 +/- 125 radiocarbon years before present. The youngest average radiocarbon dates on Shasta ground sloths, Nothrotheriops shastensis, from the region are not significantly younger than those on extinct mountain goats. Rather than sequential extinction with Harrington's mountain goat disappearing from the Grand Canyon before the ground sloths, as one might predict in view of evidence of climatic warming at the time, the losses were concurrent. Both extinctions coincide with the regional arrival of Clovis hunters.

Allergic transfusion reactions from blood components donated by IgA-deficient donors with and without anti-IgA: a comparative retrospective study

BACKGROUND AND OBJECTIVES

IgA deficiency is common (1/500) and up to 40% of affected individuals will develop anti-IgA. A few studies suggested that passive transfusion of anti-IgA was not associated with an increased risk of allergic reactions. This study was designed to assess the safety of transfusing blood components containing anti-IgA.

MATERIALS AND METHODS

IgA-deficient blood donors with and without anti-IgA were identified from Héma-Québec's (HQ) computerized database. IgA deficiency was confirmed by an ELISA method and the presence of anti-IgA by a passive hemagglutination assay. Blood donations from IgA-deficient donors issued to hospitals between March 1999 and December 2004 were retrieved. Medical charts of recipients were reviewed for the occurrence of a suspected transfusion reaction. Presence and nature of transfusion reactions were assessed blindly by an adjudicating committee.

RESULTS

A total of 323 IgA-deficient blood products were issued by HQ to 55 hospitals. Of these, 48 agreed to participate [315 blood products (97.5%)]. A total of 272 products were transfused: 174 contained anti-IgA, and 98 did not. Only two minor allergic reactions occurred in each group. Incidence of allergic reactions was 1.15% in the anti-IgA group and 2.04% in the group without anti-IgA (P = 0.91). There was no anaphylactic reaction in either group.

CONCLUSIONS

This study indicates that the proportion of allergic reactions does not appear to be greater in recipients of blood components containing anti-IgA compared to recipients of non-anti-IgA-containing components. Allowing donations from IgA-deficient donors with anti-IgA may therefore be contemplated.

[Digital arterial embolization from a previously thrombosed arteriovenous access: a rare and misdiagnosed complication]

Surgical removal of a hemodialysis access after thrombosis is generally not performed as it remains clinically well tolerated. However, it may be the source of distal embolization. We report the case of a 43-year-old patient, kidney recipient, who presented with digital ischemia of the right hand. He had a forearm arteriovenous fistula at the right wrist which thrombosed 5 years ago. Digital ischemia was due to thrombus formation at the anastomotic site and migration into the downstream arterial bed. Heparine was initiated together with antiplatelet treatment. The ischemia resolved after a few days, no recidive was observed. Surgical ligation of the arteriovenous fistula was rapidly performed and antiplatelet treatment was maintained after surgery. After a follow-up of 6 months, the patient remained asymptomatic without new embolization. This observation underlines the necessity of clinical monitoring after access thrombosis and preventive surgical ligation might be discussed when the risk of distal embolization is high.

Biotransformation of benzaldehyde by Saccharomyces cerevisiae: characterization of the fermentation and toxicity effects of substrates and products

Although higher initial rates of phenylacetyl carbinol formation were observed in fermentations containing a high starting benzaldehyde level, a massive reduction in yeast viability was observed resulting in early cessation of production formation. Pulse feeding to maintain lower benzaldehyde concentrations resulted in a lower initial reaction rate, but prolonged yeast viability and the biotransformation. This resulted in higher overall product tilers. As benzaldehyde concentration was increased, yeast growth rate was reduced (0.5 g/L), inhibited (1-2 g/L), or cell viability reduced (3 g/L). Benzaldehyde appeared to alter the cell permeability barrier to substrates and products. Reductions in yeast biomass levels and especially protein and lipid content were observed during the biotransformation. The effects of benzaldehyde and reaction products on yeast pyruvate decarboxylase and alcohol dehydrogenase stability were determined. Homogenized yeast cells produced similar phenylacetyl carbinol levels to whole yeast only if supplemented with thiamine pyrophosphate and magnesium.

Depression: a psychiatric nursing theory of connectivity

This paper presents a theory of connectivity, which was formulated from the findings of a Classical Grounded Theory study that was designed to capture a sample of people's perceptions of living with depression or caring for individuals with depression. Data were collected from: (1) a focus group consisting of people with depression (n = 7), of which five were patients in the community and two were nurses; (2) one-to-one interviews with patients in the community (n = 5) and nurses (n = 5), three of whom had experienced depression from both sides of the caring process; and (3) two 'happy accident' focus groups (n = 25; n = 18) comprising of healthcare workers with a shared understanding of depression. Purposeful sampling was used initially. Thereafter, in keeping with one of the key tenets of grounded theory, theoretical sampling was used until theoretical saturation occurred. Data were analysed using the constant comparative approach together with the NVivo qualitative analysis software package. The core category that emerged was 'connectivity' relating to the connections and disconnections, which people make in their lives. Six key categories emerged all of which were integrated with the core category. Hence, connectivity provided a significant platform for understanding and responding to the life experience of depression. They were: (1) life encounters on the journey to naming; (2) depression: What's in a name? The silent thief; (3) tentative steps to health care; (4) connective encounters and challenges; (5) connecting with self; and (6) self-connection maintenance. Subsequently, a theory, 'Depression: a psychiatric nursing theory of connectivity', surfaced from the overall findings. We argue that this theory of connectivity provides a framework that people working in the field of holistic treatment and care could use to better understand and respond to the life experience of people living with depression.

[Peripheral arterial disease with lower limb claudication: Medical treatment]

Whereas the complaint from a patient with intermittent arterial claudication is walking impairment, prognosis is linked to an increased risk of cardiovascular ischemic events due to the diffuse nature of the atherosclerosis. The objectives of the medical treatment therefore include improvement of walking limit, prevention of myocardial infarction, stroke and cardiovascular death, and preventive measures to avoid progression to critical lower limb ischemia. The key areas of treatment focus on smoking cessation, exercise rehabilitation, with supervised therapy if possible, cardiovascular risk prevention with antiplatelet drugs, statins and angiotensin converting enzymes, and correction of atherosclerotic risk factors with well-defined targets (LDL less than 1g/L, HDL greater than 0.4g/L, HbA(1c) less than 6.5%, brachial blood pressure less than 140/90 or 130/80mmHg in case of diabetes or renal insufficiency, body mass index less than 25kg/m(2)). Limitation or avoidance of progression to local critical ischemia requires control of atherosclerotic risk factors and proper foot care. The patient with arterial claudication needs to understand the local and general risks of arterial atherosclerotic disease, and to be involved in his/her own treatment. Obtaining patient compliance to medical care is fundamental: specific educational workshops are of great value for this.

Pelioid hepatocellular carcinoma in an adult Eurasian badger (Meles meles)

A mass was identified within the left lateral lobe of the liver of a 10-year-old Eurasian badger (Meles meles). The mass was friable and multilobulated, with blood-filled spaces between the lobules. Microscopically, the lesion consisted of sheets and trabeculae of neoplastic hepatocytes often forming cystic spaces containing erythrocytes, fibrin and necrotic debris. The histological appearance was consistent with hepatocellular carcinoma (HCC). Immunohistochemically, the neoplastic cells expressed cytokeratin 18 but not von Willebrand factor. Multiple intranuclear (amphophilic or acidophilic) inclusion bodies were observed in hepatocytes at the junction between the tumour and normal hepatic tissue. HCCs have also been reported in other domestic and wild animals. As hepadnavirus infection has been associated with HCC in woodchucks, further histochemical and transmission electron microscopical studies were performed; however, these demonstrated that the inclusions consisted of lipid droplets and not viral particles. To our knowledge, this is the first report of a naturally occurring HCC in a Eurasian badger.

Interferon (IFN)-ß1a and IFN-ß1b Block IFN-?-Induced Disintegration of Endothelial Junction Integrity and Barrier

Recent clinical trials indicate the efficacy of interferon (IFN)-beta 1b in reducing relapse rate in relapsing-remitting multiple sclerosis (MS), whereas a surge of IFN-gamma precedes and provokes acute relapses. Disruption of the cerebral endothelial barrier and transendothelial migration of inflammatory cell migration into the brain play a significant role in pathogenesis of MS and may be driven by this surge in IFN-gamma. However, the molecular mechanisms underlying the beneficial effects of IFN-beta 1b against the deleterious effects of IFN-gamma on the barrier formed by the junctional proteins remain to be characterized. The authors investigated the effects of IFN-beta 1b, IFN-beta 1a, and IFN-gamma on the integrity of two endothelial junctional proteins, occludin and vascular endothelial-cadherin (VE-cadherin). Human umbilical vein endothelial cell (HUVEC) layers were treated with IFN-beta 1b, IFN-beta 1a, IFN-gamma, IFN-beta 1b plus IFN-gamma, or IFN-beta 1a plus IFN-gamma. IFN-beta 1b, IFN-beta 1a, and IFN-gamma effects on occludin and VE-cadherin integrity and electrical resistance were assessed by Western blotting and immunofluorescence. IFN-gamma significantly reduced occludin expression and produced gaps in endothelial monolayers. VE-cadherin expression was decreased to a lesser extent in endothelial cells exposed to IFN-gamma. IFN-beta 1b significantly attenuated the IFN-gamma-induced decrease in occludin and VE-cadherin expression. The protective effects of IFN-beta 1a on IFN-gamma-treated endothelial cells were similar to those of IFN-beta 1b. IFN-gamma also significantly reduced endothelial monolayer electrical resistance; this effect was blocked by either IFN-beta 1a or IFN-beta 1b. IFN-beta 1a and IFN-beta 1b effectively prevent the IFN-gamma-induced disintegration of the endothelial tight junctions and sustain barrier against the effects of IFN-gamma. The protective effects of IFN-beta on occludin and VE-cadherin stability appear to represent molecular mechanisms for the therapeutic effects of the IFN-beta on blood brain barrier in MS.

Medical management of first trimester miscarriage (blighted ovum and missed abortion): is it effective?

This prospective study of 104 women investigated the dose-related efficacy of mifepristone combined with oral misoprostol in the management of first trimester miscarriage (missed abortion and blighted ovum). Forty-four women (group A) received 600 mg of oral mifepristone and 60 women (group B) received 200 mg of mifepristone, followed after 48 hours by oral misoprostol. Successful treatment was an empty uterus on scan and no bleeding after 10 days. This was achieved in 70.5% of group A and 66.7% of group B. Also studied were amount and time to cessation of bleeding, pain scores, analgesic requirements, adverse effects and infections. Of group A, 54.5% had heavy bleeding and bleeding stopped on average by 8 days. Median pain scores were 5.5 on a linear scale and 18% of women received intramuscular opiate analgesia. Adverse effects were nausea in 25% of women and diarrhoea in 16%. Of group B, 38.3% had heavy bleeding and bleeding stopped on average by 7 days. Median pain scores were 4.5 with 25% of women receiving intramuscular opiates. Nausea occurred in 7% of women and diarrhoea in 7%. We concluded that 200 mg of mifepristone and oral misoprostol is as effective and better tolerated than 600 mg mifepristone with oral misoprostol. Medical management of miscarriage is a valid option for those women seeking an alternative to traditional surgical management.

Medical management of first trimester incomplete miscarriage using misoprostol

This prospective study looked at the effectiveness of 400 microg oral misoprostol in the management of women with a first trimester incomplete miscarriage with retained products of conception measuring between 15 mm and 50 mm on transvaginal ultrasound scan. Of 164 eligible women, 131 agreed to participate. Successful treatment, defined as an empty uterus on scan after 10 days with no bleeding, was achieved in 77.7% of women. Some women with retained products opted to have further misoprostol or conservative management instead of surgical evacuation and in total 92.4% of women completed their miscarriage without requiring surgery. Most bleeding was mild (31.3%) to moderate (38.9%), lasting on average 6.4 days. Forty-five per cent of women needed no pain relief, 51% received oral analgesia and 4% intramuscular opiates. Adverse effects included nausea (10.93%), diarrhoea (2.34%), vomiting (7.8%) and hypotension (4.68%). There were no infections. We concluded that a single dose of 400 microg of oral misoprostol was an effective treatment for women presenting with an incomplete miscarriage.

[Abdominal aortic aneurysms in elderly subjects]

Abdominal aortic aneurysms (AAA) preferentially affect elderly subjects, especially men. Its pathogenesis is complex and multifactorial and even if clinical and fundamental research has led to a better understanding of the disease, several aspects remain unknown. Natural history consists of progressive aneurismal expansion leading to rupture which is associated with a high mortality rate (48.5% in-hospital and 80% global mortality). Screening for AAA and regular follow-up have been recognized as efficient strategies in order to prevent rupture, and screening programs have now to include women because the prognostic of the disease is more severe in women. Medical management of patients with AAA includes both limitation of aneurismal expansion rate and treatment of associated cardiovascular risk factors. Intervention is proposed when the maximal diameter of AAA reaches 50-55mm in men, and 45-50mm in women and the choice between open or endovascular repair depends on comorbidities and AAA anatomy. New therapies including specific therapy of the aneurismal wall such as cell or gene therapy could be proposed in the future.

Interleukin-1beta release in the supraoptic nucleus area during osmotic stimulation requires neural function

Interleukin (IL)-1beta is present throughout the magnocellular neuroendocrine system and co-depletes with oxytocin and vasopressin from the neural lobe during salt-loading. To examine whether IL-1beta is released from the dendrites/soma of magnocellular neurones during osmotic stimulation, microdialysis adjacent to the supraoptic nucleus (SON) in conscious rats was combined with immunocapillary electrophoresis and laser-induced fluorescence detection to quantify cytokine in 5-min dialysates collected before (0-180 min; basal), and after (180-240 min), hypertonic saline injected s.c. (1.5 m NaCl). Osmotic release of IL-1beta was compared after inhibiting local voltage-gated channels for Na+ (tetrodotoxin) and Ca2+ (cadmium and nickel) or by reducing intracellular Ca2+ stores (thapsigargin). Immunohistochemistry combined with microdialysis was used to localise cytokine sources (IL-1beta+) and microglia (OX-42+). Under conditions of microdialysis, the basal release of IL-1beta+ in the SON area was measurable and stable (pg/ml; mean +/- SEM) from 0-60 min (2.2 +/- 0.06), 60-120 min (2.32 +/- 0.05) and 120-180 min (2.33 +/- 0.06), likely originating locally from activated microglia (OX42+; IL-1beta+; ameboid, hypertrophied) and magnocellular neurones expressing IL-1beta. In response to osmotic stimulation, IL-1beta increased progressively in dialysates of the SON area by a mechanism dependent on intracellular Ca2+ stores sensitive to thapsigargin and, similar to dendritic secretion of oxytocin and vasopressin, required local voltage-gated Na+ and Ca2+ channels for activation by osmoregulatory pathways from the forebrain. During osmotic stimulation, neurally dependent release of IL-1beta in the SON area likely upregulates osmosensitive cation currents on magnocellular neurones (observed in vitro by others), to facilitate dendritic release of neurohypophysial hormones.

[Cystic lymphangioma: an unusual cause of lower limb lymphedema]

We report an unusual cause of unilateral lymphedema of the right limb rapidly increasing in a young woman. Ultrasonography ruled out the diagnosis of iliac deep venous thrombosis or extrinsic compression: the B mode scan revealed a mass located below the aortic bifurcation and along the iliac vessels, without any compressive effect. The lesion was heterogeneous associating both tissular and cystic aspects. The lower limb lymphoscintigraphy showed an interruption of the colloid circulation at the right iliac level. Computed tomography did not give any additional information. Magnetic resonance imaging before then after gadolinium showed typical aspects of cystic lymphangioma and confirmed the ultrasonography hypothesis. Considering that this tumor is benign, that surgery would be difficult because of the anatomic situation of the mass, and that post-operative involution of the edema is uncertain, the treatment was based on compressive stockings and regular follow up.