Use of Factor VIII in the Treatment of Hemophilia

This publication describes the results obtained by treatment of haemophiliacs with factor VIII preparations isolated from Cohn fraction I by use of tannic acid, FI-O-Ta.

The authors stress the rapidity of the disappearance of factor VIII after injection. Transfusions are generally well tolerated. One reaction of the pyrogen type has been observed and also a case of activation of the fibrinolytic system.

A second purification method by means of chromatography on DEAE-cellulose is described.

Pattern of Anesthetic Diffusion during Peribulbar Infiltration: A Ct Evaluation

PURPOSE

The aim of this study was to evaluate the changes undergone by orbital structures during peribulbar anesthesia.

METHODS

CT-thin slices were acquired and 8-9 ml of anesthetic, with a small part of low-density non-ionic water-soluble contrast medium were injected under CT guide once to follow extraconal spreading and diffusion to intraconal structures and above all, the surgically important structures such as recti muscles, orbicular and optic nerve sheath. Conjunctival sack involvement was assessed and conjunctival chemosis was rated. Induced ptosis was evaluated, verifying change before and after eyepressure.

RESULTS

The results help in optimizing anesthetic technique, above all concerning the site, materials and quantity, and suggest the amount of anesthesia could be reduced.

CONCLUSIONS

The peribulbar anesthetic technique proved effective and safe for patients.

[Screening of the risk of functional decline performed by an inpatient geriatric consultation team in a general hospital]

The Mobile Geriatric Team (MGT) is part of the Geriatric Care Program and aims to provide interdisciplinary geriatric expertise to other professionals for old patients hospitalized outside geriatric department. Our hospital has a MGT since 2008. Our objective is to retrospectively describe the population of patients of 75 years and older hospitalized outside the geriatric ward and screened for the risk of functional decline by the MGT between 1 October 2009 and 30 September 2011. We recorded the risk of functional decline, as indicated by the Identification of Senior At Risk score (ISAR) performed within 48 h after admission, place of living, discharge destination, Mini Mental State Examination (MMSE) and Geriatric Depression Scale (GDS) scores. In two years, 1.568 patients > or = 75 Y were screened with the ISAR score (mean age 82.5 Y, 60.7% of women). We identified 833 patients with a high-risk of functional decline (ISAR > or = 3). The majority of high-risk subjects (78%) were living at home before hospitalization and 58.7% returned home after discharge. Depression and cognitive impairment were identified among respectively 41% and 59% of high-risk subjects. Only 128 patients were admitted for fall. Most of the faller patients were living at home prior hospitalization and had an ISAR score > or = 3. The MGT allowed identifying many patients > or = 75 Y living at home and presenting with high-risk of functional decline and geriatric syndromes, confirming that good screening procedures are necessary to optimize management of hospitalized olders. Most of faller patients have an ISAR score > or = 3 and should benefit a comprehensive geriatric assessment.

Relief influence on the spatial distribution of the Atlantic Forest cover on the Ibiúna Plateau, SP

Several studies suggest that, on a large scale, relief conditions influence the Atlantic Forest cover. The aim of this work was to explore these relationships on a local scale, in Caucaia do Alto, on the Ibiúna Plateau. Within an area of about 78 km(2), the distribution of forest cover, divided into two successional stages, was associated with relief attribute data (slope, slope orientation and altitude). The mapping of the vegetation was based on the interpretation of stereoscopic pairs of aerial photographs, from April 2000, on a scale of 1:10,000, while the relief attributes were obtained by geoprocessing from digitalized topographic maps on a scale of 1:10,000. Statistical analyses, based on qui-square tests, revealed that there was a more extensive forest cover, irrespective of the successional stage, in steeper areas (>10 degrees) located at higher altitudes (>923 m), but no influence of the slope orientation. There was no sign of direct influence of relief on the forest cover through environmental gradients that might have contributed to the forest regeneration. Likewise, there was no evidence that these results could have been influenced by the distance from roads or urban areas or with respect to permanent preservation areas. Relief seems to influence the forest cover indirectly, since agricultural land use is preferably made in flatter and lower areas. These results suggest a general distribution pattern of the forest remnants, independent of the scale of study, on which relief indirectly has a strong influence, since it determines human occupation.

[Prevention of falls in the elderly and physiotherapy]

Frequency and dangerousness of falls in elderly people are a public health problem because of its prevalence and its consequences. Because of its high frequency a program designed to avoid the risk of fall and to restore the balance is of importance. Nowadays in Belgium, only the ones belonging to the F-pathology list are reimbursed for the walking functional reeducation. The troubles of walking and balance increasing the risk of falls, are evaluated by different tests like: Tinetti's test (POMA), Time-up-and-go tests. To screen the patient in its physical psychological and environmental sides is mandatory. The physiotherapist is the key to evaluate the patient globally. The main aim is to restore the patient's independence after a fall and to ensure an optimal quality of live. A functional reeducation including the relearning of walking, balance, standing up and proprioception is a must. A preventive way should be more adequate for the patient at risk and the society. A prevention program for fall involving a multidisciplinary team could be the solution of the public health's problem. A lost still remains to be done! In some countries such programs do exist. They inform the elderly about falls' risks and the sometimes tragic consequences. To prevent falls, GP's, ergotherapists, physiotherapists, nurses and social workers have to work together.

Examining the effect of intervention to nutritional problems of hospitalised elderly: a pilot project

BACKGROUND

Up to 65% of elderly patients are protein-energy undernourished at admission or acquire nutritional deficits while hospitalised.

OBJECTIVES

The aims of this project were: 1) to assess the quality of care concerning nutrition among geriatric units; 2) to assess the impact of implementive nutritional interventions on nutritional status and on the length of hospitalisation.

DESIGN

Two hundred and six patients consecutively admitted in a geriatric unit of a general hospital were studied prospectively for 6 months (from January to June 2001). All patients underwent a comprehensive geriatric assessment. For the first 3 months the nutritional status of the patients on admission and at discharge were assessed without particular recommendations for nutritional intervention. A standardised nutritional intervention was proposed for the last 3 months.

RESULTS

Median value of Mini-Nutritional Assessment was 19 points (ranged from 9 to 29), mean admission s prealbumin concentration (PAB) was 0.179 g/l, and C-reactive protein 5.9 2.8 mg/100ml. Hospitalisation stay was significantly lower during the interventional period than during the observational period. A higher mean PAB variation was observed during the interventional period as compared to the observational period.

CONCLUSIONS

Nutritional assessment should be part of routine clinical practice in elderly hospitalized patients. A comprehensive screening tool for assessment of nutritional status is needed that is clinically relevant and cost-effective to perform. If malnutrition is suggested by such screening tests, implementations of nutritional intervention allow to ameliorate discharge nutritional status and to reduce hospitalization stay.

[Analysis of risk of biological accidents at a urban health area]

The makers have examined 455 fingerprint cards of accidents at biologic risk needed in a sanitary structure from the month of november 1995 to the month of december 1998. After they have described the protocol of the sanitary supervision applied, the procedure of the accidents, the qualifications, and the departments mainly interested by the subject of study event, they have pointed out the need of a greater vaccinable covering against the virus B, parvying attention to the "non responders" subjects, thinking also it's necessary bigger resources for the personnel, training and information.

[Sarcoma of the endometrial stroma]

BACKGROUND

To evaluate the most important risk factors and the efficacy of endometrial stromal sarcoma therapy.

METHODS

During a period of 9 years, 5 cases of ESS have been observed at the IInd Obstetrical and Gynecological Institute of the University of Bari. The patients were staged according to the FIGO classification of endometrial carcinoma and studied from an epidemiological, histopatological and clinical point of view. All patients firstly received uterine courettage and then total simple laparohysterectomy. In 4 cases bilateral salpingo-oophorectomy and then polychemotherapy. Only in 1 case total hysterectomy and monolateral salpingo-oophorectomy were performed.

RESULTS

Two patients were affected by low grade ESS malignancy respectively at Ib and Ic stage and received only surgery. High grade ESS malignancy was diagnosed in 3 patients at stage IIIa and they received surgery followed by chemotherapy. These 3 patients survived for 14, 25 and 30 months. The other two are still alive, with no evidence of the disease at 25 and 36 months.

CONCLUSION

ESS is a rare neoplasm; the low grade malignancy may survive from 80-100%, while the high ones can have a fatal prognosis with exitus in 12-30 months.

[A case of Leydig cell virilizing tumor of the ovary]

A case of Leydig cell virilizing tumor of the ovary in a 68 year old woman, with clinical signs of virilization, clitoromegaly and androgenic alopecia is described. An RMN of encephalon and an abdominal ultrasound were normal. Following total abdominal hysterectomy and bilateral salpingo-oophorectomy, the patient had regression of hirsutism, and plasma testosterone dropped to normal level.

Anatomy of the lumbar epidural region using magnetic resonance imaging: a study of dimensions and a comparison of two postures

Many techniques used to investigate the epidural region may alter the anatomy. Magnetic resonance imaging (MRI) has been introduced as a non-invasive diagnostic technique. The aim of this study was to investigate the anatomy of the lumbar epidural region using MRI, studying the morphology, the dimensions and the modification that may result from a change of position. Ten young, healthy female volunteers were studied to obtain results relevant to obstetric anesthesia. The following measurements were made: anterior epidural space (AES); posterior epidural space (PES); ligamenta flava; distance between the PES and the skin (S-ES); and interspace distance (ISD). All these distances were measured with the subject supine and the lumbar spine either in a neutral or a non-lordotic (flexed) position. The S-ES ranged from 2.7 to 8.1 cm. This distance was greater in the lower than in the upper lumbar segments. No differences were observed in AES, PES and ligamenta flava between the neutral and flexed positions. Flexion of the spine did not affect the S-ES but increased the ISD (P < 0.05). The S-ES at any lumbar segment or interspace and the thickness of ligamenta flava at the L2/3 interspace correlated significantly with body weight (respectively, P < 0.01 and P < 0.02). In conclusion, MRI may clearly reveal the anatomy of the epidural region. The circumferentially and metamerically segmented compartments of the epidural space were clearly noted and measured. Ligamenta flava seem to be thinner in younger than in older subjects. This may partly explain a reduced loss of resistance sometimes perceived in obstetric patients.

[Biomechanical changes in and lesions of the lumbosacral spine in horse riding. Magnetic resonance assessment]

Spinal injuries account for 5-15% of sport-related traumas. Equestrian sports are considered, together with rugby, motor sport and diving, the riskiest sport for severe spinal injuries. We investigated the biomechanical changes and repeated microtraumas in equitation. We examined with MR the lumbar spines of 12 professional horsewomen and horsemen, 18-51 years old (mean: 33.4 years), belonging to F.I.S.E. (the Italian Federation for Equestrian Sports) and classified as Olympic riders, Senior and Young European riders. An 0.3-T resistive and an 0.2-T permanent magnets with dedicated surface coils were used. We also examined a control group of non-professional healthy volunteers homogeneous by age. MR findings were classified as follows: 1) changes in normal bending and angles of the lumbar spine; 2) injuries and changes in lumbar disks; 3) changes in spinal ligaments; 4) vertebral body injuries. MR was very sensitive in the assessment of all lumbosacral components in all the athletes; besides yielding useful findings to integrate with clinical results, MR also has a predictive value relative to both the continuation of sports activity and the possible damage at the end of it.

A light and electron microscope study of rat abducens nucleus neurons projecting to the cerebellar flocculus

Injection of horseradish peroxidase (HRP) into the cerebellar flocculus of the rat was employed to identify neurons in the abducens nucleus that project to the flocculus. The number, ultrastructural features and precise localisation of these neurons in the nucleus were examined. They were present bilaterally and represented about 7% of the total neuronal population of each nucleus. They were localised principally in the dorsomedial area of the cranial half of each nucleus and did not display the typical ultrastructural features of motoneurons. It is concluded that the localisation and ultrastructural characteristics of these HRP-positive neurons are useful for distinguishing them from other neuronal populations within the nucleus.

[Intra-osseus hidden fractures of the knee in athletes: assessment with magnetic resonance imaging]

The diagnostic capabilities of Magnetic Resonance Imaging (MRI) were investigated in the study of occult intraosseous fractures of the knees in athletes; this pathologic condition is difficult to assess with conventional diagnostic techniques. Twelve athletes were considered and submitted to MR examinations 1-8 days after trauma. All patients had undergone plain films, 6 of them CT and 3 scintigraphy. Four patients were followed with MRI at 15 and 30 days. Plain films were negative in all patients. On CT, in one case only an area of segmental osteoporosis was identified at the anterolateral tibial plateau. Scintigraphy provided positive but aspecific results in all three patients. MRI demonstrated all lesions: 3 at the tibial plateau, 5 at the lateral femoral condyle and 2 at the medial femoral condyle. Double localizations were observed in two patients, femorotibial and tibiopatellar, respectively. In no case lesions of meniscal and/or capsuloligamentous structures of the knee were associated. Arthroscopy, which was employed in two patients, confirmed MR diagnosis. Thanks to its high spatial and contrast resolution and to its multiplanar capabilities, MRI can be considered the method of choice in the study of occult intraosseous fractures of athletes' knees. Beside localizing the lesion site, MRI allows the evaluation of its extent (linear or reticulo-geographic patterns) and the exclusion of possible involvement of meniscal and/or capsulo-ligamentous structures. MRI follow-up of this condition showed the "restitutio ad integrum" of the medullary trabecular bone as early as at 15 and 30 days, depending on lesion pattern and extent. On the basis of our experience, MRI emerges as the only diagnostic technique allowing the accurate evaluation of occult intraosseous fractures of the knee in athletes, because it provides early and detailed information which is valuable for the therapeutic approach, which is of fundamental importance to resume sports activity quickly.

Popliteal artery entrapment: MR findings

A 35-year-old woman with a history of claudication was examined by means of echodoppler, angiography, and MR imaging using gradient rephased sequences, performed at rest and during stress. Magnetic resonance imaging allowed the evaluation of the relationships between the gastrocnemius muscle and the popliteal artery at rest and the evidence of the occlusion during stress. This combined morphological and functional evaluation makes MR a procedure of choice for assessment of young adults with intermittent claudication.

[Pathologic dilatation of the thoracic aorta: a study using magnetic resonance]

Magnetic resonance (MR) imaging provides detailed evaluation of cardiovascular structures, due to high intrinsic contrast between flowing blood and vessel's lumen. Early application have shown the clinical validity of the technique, with non-invasive, multiplanar imaging of large and medium sized vessels. In this study we evaluate the capabilities of MR in screening out patients with thoracic aorta enlargement. Examination has been performed in 16 patients, employing a 0.5 T superconductive unit, and acquiring images on axial, sagittal and coronal planes with 7 mm slice thickness. In 15 cases it was possible to detect the pathology and to characterize it according to type, location and extension. In 1 case it was no possible to make an accurate diagnosis for the presence of movement artefacts, due to poor patient's cooperation. In dissecting aneurysms the true and false lumen may be differentiated, with a good visualization of the intimal flap. The relation between the origin of the aortic branches and the aneurysm may also be ascertained.

[Magnetic resonance in the characterization of atherosclerotic lesions]

Fifty-one patients with occlusive and dilating vascular diseases were evaluated with MR imaging, using T1 and T2-weighted sequences and an 0.5 T superconducting magnet. Atheromatous plaques were detected in the carotids and on the aortic walls. Fatty lesions had high signal intensity on T1-weighted sequences and could be well distinguished from older thrombotic depositions which presented with medium signal intensity on T1-weighted scans and low signal on T2-weighted images. Thrombotic depositions in aneurysmal dilatation of the aorta and carotid arteries could be distinguished from patent internal lumen; inside them, areas of different signal intensity were demonstrated, which were related to the paramagnetic effect of hemoglobin degradation products (hemosiderin and methemoglobin).

[Subarachnoid hemorrhage as initial manifestation of polyarteritis nodosa]

The polyarteritis nodosa (P.A.N.) is frequently responsible of neurological disorders, both central and peripheral. However an involvement of the Central Nervous System is unusual at the beginning of the disease. Such particular case is reported having occurred in a man aged 49, struck by a subarachnoidal hemorrhage, which was an initial symptom of P.A.N. The differential diagnosis is not always easy in such cases, since the clinical findings could be mistaken for those of a subarachnoidal hemorrhage due to a malformed vessel rupture.

[Contribution to our knowledge of Thévenard's ulcero-mutilating acropathy]

Four patients presenting ulcerative mutilating acropathy (UMA) (Thévenard's disease or Denny-Brown's hereditary sensory neuropathy) are reported: in 3 cases (2 of them are siblings) the neuropathy was familiar with a dominant transmission, the fourth case was sporadic. A fifth patient, member of one of the families with UMA, had a sensory motor neuropathy (type I of Charcot Marie Tooth disease) without acropathies. Following examinations have been performed: EMG and motor and sensory nerve conduction velocities in 4 cases, investigation of content of free aminoacids in serum and cerebrospinal fluid in 3 cases, kinetic arteriographies of the legs in 1 case, histology of sural nerve in 1 case. All patients had a mixed motor and sensory impairment. Neurophysiological tests showed in some cases a neural damage, in others a neuronal compromission, this suggesting different diseases. The presence of kiphoscoliosis, oligophrenia and loss of hearing, in some siblings of one family, is ascribed to an overlap with Friedreich disease. Links between Thévenard, Charcot Marie Tooth and Friedreich diseases are discussed.

Polyvinylpyrrolidone (PVP): a new precipitating agent for human and bovine factor VIII and fibrinogen

The PVP precipitating properties for human and bovine factor VIII and fibrinogen were studied and a new technique for the fractionation of factor VIII and fibrinogen was developed. The precipitation was performed at different temperatures and different PVP concentrations and the best conditions for the technique were chosen. The technique consists of two steps: (a) precipitation of factor VIII from undiluted plasma with PVP and (b) washing of the precipitate with a glycine--saline solution. The final concentrate contains 90% of the factor VIII and 20% of the fibrinogen of the original plasma.

[Sleep disturbances in a case of Morvan's chorea (author's transl)]

Six nocturnal polygraphic recordings were carried out in a young man with fibrillary chorea of Morvan, during the acute period of the disease. Sleep was remarkably fragmented by numerous and brief awakenings but the total sleep time fluctuated between 157 and 312 mins.; the sleep structure was altered by the almost total absence of stages 3,4 and REM. During the day, the subject had one or two periods of sleep (1-2 hours) and complained of being tired. The nocturnal awakenings were correlated by the patient with pain and burning dysaesthesiae of distal distribution that were more severe than those occurring during the day. The patient improved gradually, and five month later both sleep disturbances and other signs of disease had disappeared.

Physical, chemical and immunological studies on bovine factor VIII

Highly purified bovine factor VII prepared according to our technique and having a specific activity of 500 U/mg protein has been studied. The chemical analysis of the preparation revealed it to be composed of amino acids, lipids (8-10%) and carbohydrates (7%). The lipid moiety can be removed by chromatography. Different mechanism of inactivation of bovine factor VII and the possible molecular changes induced by the inactivating agents were studied. EDTA and EGTA provoke a weakening of the bonds linking the structural elements of the molecule, which allows for the separation of two different components of the molecule by gel filtration. Upon treatment with thrombin, the carbohydrate content of bovine factor VIII decreases without any apparent degradation of the protein moiety of the molecule. The fact that precipitating and neutralizing antisera against factor VIII were obtained, shows that the molecules modified by EDTA and thrombin still have the antigenic properties of factor VIII. The inhibitor developed by hemophiliacs transfused with human factor VIII is bound to bovine factor VIII, forming a complex reveal that it is composed of bovine factor VIII and human gamma-globulin. Bovine factor VIII in the complex retains some antigenic determinants which bind rabbit antiserum against bovine factor VIII, as shown by neutralization of the antiserum and by precipitation studies.