Alloimmunization and autoimmunization in adult transfusion-dependent thalassemia patients: a report from a comprehensive center in Israel

Patients with beta thalassemia major (TM) are transfusion-dependent (TD) since early childhood and for life. Development of alloantibodies and autoantibodies against red blood cell (RBC) antigens is increasingly recognized as a significant transfusion hazard, especially among heavily transfused patients. The aim of this study is to assess RBC alloimmunization and autoimmunization rates in TD TM patients treated in our Comprehensive Center of Adult Thalassemia, Hemoglobinopathies and Rare Anemias. TD TM patients, regularly transfused every 2-3 weeks, were included in the study. Clinical and RBC transfusion records, including RBC antibodies, since diagnosis in early childhood, were retrieved from patients' files and from the blood bank database. Forty TD TM patients, > 18 years of age, were included in the study. Alloimmunization was demonstrated in 17 (42.5%) patients. Thirty-four alloantibodies were detected, with the most frequent being RH related (12 of 34, 35.3%) followed by those of the Kell system (8 of 34, 23.5%). Age at first transfusion was positively related to the probability of developing alloantibodies (p = 0.02). Splenectomy was found to be correlated with developing alloantibodies (p = 0.016). Logistic regression analysis of the lifelong probability of developing alloantibodies on the age at first transfusion and splenectomy demonstrates a strong positive relationship (p = 0.002). A substantially high rate of alloimmunization was found among adult TD TM patients. Early initiation of RBC transfusions, avoidance of splenectomy and extended Rh and K antigen matching, can reduce the incidence of alloimmunization in TD TM patients.

[Immune enhancing diet]

Immunonutrition contains nutritional elements which generally carry a positive effect on the immune system when given in large amounts. The main nutrients included in immunonutrition are: L-arginine, L-glutamine, nucleotides, and polyunsaturated fatty acids. Patients fed with immunonutrition had less infectious complications, were mechanically ventilated for shorter periods of time, and their hospitalization period was shorter. Mortality rates were generally not improved. In 2001, the U.S. Summit on Immune-Enhancing Enteral Therapy listed groups of patients who would benefit from immunonutrition. The article includes these recommendations. In conclusion, physicians should familiarize themselves with the issue of immunonutrition and consider using it in specific groups of hospital patients.

[The current approach to hemangiomas and vascular malformations of the head and neck]

Though most hemangiomas do not need treatment, a significant minority are associated with complications and external deformities that demand intervention. Steroids play an important role in therapy, but not infrequently afford only partial and temporary benefit. Thanks to improvements in the surgical approach and equipment, hemostasis control devices and laser techniques, we can now treat patients who would otherwise go untreated. Moreover, in certain cases, we can now recommend earlier intervention, saving patients from years of living with deformities and the concomitant psychosocial problems. Vascular anomalies of the head and neck include venular, venous and arteriovenous malformations. These lesions are slow growing vascular ectasia that never involute spontaneously and almost always require intervention. Treatment includes laser therapy, injection of sclerosing agents, embolization through angiography and surgery, which in many cases is the only definitive treatment. We present the current treatment approach and describe our experience in the treatment of 16 patients.

Randomized comparison of diode laser photocoagulation versus cryotherapy for threshold retinopathy of prematurity: seven-year outcome

PURPOSE

To report the structural and functional outcomes at a minimum of 7 years postmenstrual age after randomized treatment of threshold retinopathy of prematurity with laser ablation or cryotherapy.

METHODS

Nineteen patients were entered into a prospective, randomized protocol, in which one eye received cryotherapy, while the other eye received diode laser photocoagulation. Asymmetric eyes were randomly assigned. Two patients have died, and seven were no longer available for 7-year outcome examinations, leaving 10 children for analysis.

RESULTS

Six males and four females with a mean birthweight of 631 g and a mean gestational age of 24.8 weeks were examined. Eight were symmetrical cases and treated in both eyes. Of these, there were six concordant and two discordant structural outcomes. The laser-treated eyes had the favorable outcome in each instance. The geometric mean visual acuity of the paired eyes after laser photocoagulation was 20/33, and after cryotherapy it was 20/133 (P =.03). The mean refractive error was -6.50 diopters after laser photocoagulation and -8.25 diopters after cryotherapy (P =.27), although one of the cryotherapy eyes could not be refracted because of phthisis.

CONCLUSIONS

Laser photocoagulation appears to be associated with a structural and functional outcome at least as good as cryotherapy 7 years after therapy. Visual acuity and refractive error data suggest that laser photocoagulation may have an advantage over cryotherapy.

Restoration of fusion in children with intracranial tumors and incomitant strabismus

PURPOSE

Intracranial tumors may cause eye misalignment and interruption of sensory fusion. The ocular misalignment may be permanent or may be corrected after tumor treatment with or without specific strabismus treatment. This report analyzes the binocular vision outcome of children with misaligned eyes from brain tumors who regain orthotropia.

DESIGN

A retrospective noncomparative case series.

PARTICIPANTS

Twenty-three surviving children less than 18 years of age with a new heterotropia and absence of fusion associated with the development of a brain tumor.

INTERVENTIONS

Tumor resection/radiation/chemotherapy and necessary strabismus management.

MAIN OUTCOME MEASURE

Stereopsis (>/= 4 of 10 circles) measured with the Randot II stereo test at near fixation.

RESULTS

Fourteen children regained orthotropia either after tumor therapy, strabismus treatment, or both. Ten of these 14 children with realigned vision regained high-grade stereovision. Nine patients did not regain orthotropia and were excluded. The mean age at tumor diagnosis of the fusing group was 9.9 years (range, 3-17 years) compared with 8.5 years (range, 6-12 years) in the four realigned nonfusing patients. The mean duration of misalignment was 12 months (range, 2-51 months) for the fusing group, and 45 months (range, 14-120 months) for the nonfusing group.

CONCLUSIONS

Children and adolescents with brain tumor-associated eye misalignment may regain the ability to fuse if their misalignment can be corrected. An improved prognosis was noted for those patients when the misalignment had been present for a shorter duration. These data suggest that the outcome may be better for incomitant strabismus than that reported for acute comitant esotropia.

Mitomycin C and 5-fluorouracil antimetabolite therapy for pediatric glaucoma filtration surgery

PURPOSE

To evaluate the efficacy and safety of augmented trabeculectomy with 5-fluorouracil (5-FU) and mitomycin C (MMC) compared to 5-FU only for the treatment of pediatric glaucoma.

PATIENTS AND METHODS

In a prospective randomized clinical trial, 8 children (12 eyes) with pediatric glaucoma, either congenital or secondary to: lens aspiration, Sturge-Weber syndrome, or steroids underwent augmented trabeculectomy. Six patients (8 eyes) underwent augmented trabeculectomy with 5-FU plus MMC and 2 patients (4 eyes) underwent augmented trabeculectomy with 5-FU only.

MAIN OUTCOME MEASURES

Between-group comparison of postoperative parameters: change in intraocular pressure (IOP), dependence on antiglaucoma medication, number of 5-FU injections, cup-disc ratio, corneal diameter, drug-induced complications.

RESULTS

In the 5-FU/MMC group, 7/8 eyes showed good control of postoperative IOP (9-16 mm Hg), which was independent of antiglaucoma therapy; only 2 injections of 5-FU were needed. By contrast, in the 5-FU group, no control of the postoperative IOP (21-23 mm Hg) was achieved in 4/4 eyes, and these patients remained dependent on antiglaucoma medication; up to 6 injections of 5-FU were used. There was no deterioration in the cup-disc ratio or the corneal diameter in either group. Results were maintained on follow-up (23-27 months). No significant drug-induced complications were noted.

CONCLUSION

Augmented trabeculectomy with adjunctive 5-FU/MMC may be an option for the control of pediatric glaucoma in patients with a poor surgical prognosis.

Slanted lateral rectus recession for exotropia with convergence weakness

OBJECTIVE

To evaluate the efficacy of slanted recession of the lateral rectus (LR) muscle for exotropia (XT) with convergence weakness.

DESIGN

Predesigned, nonrandomized, comparative trial.

PARTICIPANTS

Twelve study patients and six control subjects with XT greater at near than at distance by > or =10 prism diopters (PD).

INTERVENTION

Twelve consecutive patients underwent slanted LR recession, and six consecutive control subjects underwent standard LR recession.

MAIN OUTCOME MEASURES

Between-groups comparison of the postoperative ocular alignment at distance and near, and the difference between them, as well as the stereopsis.

RESULTS

Slanted LR recession reduced the XT to <8 PD in all patients at distance and in 11/12 patients at near. Additionally, the mean difference between the distance and near exodeviation was reduced from 14+/-4.5 PD preoperatively to 2.9+/-2.4 PD postoperatively. All patients in the control group demonstrated postoperative deviations of <8 PD at distance, but all had residual exodeviations >8 PD at near. Three of the study patients gained gross stereopsis postoperatively.

CONCLUSIONS

Slanted recession of the LR is superior to standard recession in reducing both distance and near XT and in collapsing the difference between them. This technique may also have a positive impact on gross stereopsis.

Intraocular pressure fluctuations during strabismus operations and the postoperative period

PURPOSE

To evaluate the intraocular pressure (IOP) variations which occur during and after strabismus surgery.

METHOD

We measured the IOP in 34 eyes of 20 pediatric patients undergoing primary strabismus surgery under general anesthesia. Measurements were performed by the Tono-Pen (Mentor O&Q Inc. Norwell, MA) prior to surgery, immediately after suturing of the conjunctive, and 1 week and 4 weeks after surgery. All patients received the same local antibiotics and steroid solutions postoperatively.

RESULTS

IOP decreased from baseline to the end of surgery by a mean of 8.26 +/- 1.8 mmHg and increased from baseline to 4 weeks after surgery by a mean of 3.6 +/- 1.8 mmHg. Thirty-eight percent of the eyes had an IOP of 21 mmHg or more during the postoperative period.

CONCLUSION

IOP variations are prevalent during and after strabismus surgery. Careful postoperative measurements are recommended in order to identify individuals who may be prone to iatrogenically increased IOP.