Replacement therapy in patients with severe haemophilia A is associated with the development of inhibitory antibodies in about 15% [1,2]. The presence of inhibitors of factor VIII greatly complicates and compromises the treatment of these patients because of the lack of any completely satisfactory product to treat them. Haemostatic management for surgery in patients with inhibitors is very difficult. A product frequently used to treat bleeding episodes in such patients is prothrombin complex concentrate (PCC) [3] or its activated derivative (APCC) [4]. Activated recombinant human factor VII is another option [5]. For both these modalities of treatment, there are no laboratory tests that can be used to monitor clinical efficacy [5, 6]. Porcine factor VII is therefore the preferred product for surgery in patients with high-responding factor VIII inhibitors [7]. Unfortunately, none of these products are readily available in most developing countries, including India. We report the management of a patient with high-responding factor VIII inhibitor using low doses of FEIBA(R) (Immuno, Austria) in the post-operative period.
Summary:We describe a case of disseminated nocardiosis in a 53-year-old male allogeneic marrow recipient with chronic GVHD, 15 years post BMT. Six months prior to admission he was treated for recurrent chronic GVHD with corticosteroids with a good response. He deteriorated subsequently while still on steroids requiring admission for fever, anorexia, weight loss, productive cough and progressive dyspnoea. On admission he had multiple nodular lesions on chest roentgenogram and subsequently grew Nocardia farcinica in blood culture. N. farcinica is rare post BMT, has a high mortality, is resistant to various antibiotics and needs prolonged antimicrobial therapy. We report the successful management of our patient with single agent trimethoprimsulphamethoxazole.
Study DesignA single-center prospective study.PurposeA magnetic resonance imaging (MRI) scan is undeniably the gold standard for the diagnosis of a lumbar disc prolapse. Unfortunately it shares a strong association with incidental findings. In this study, we aimed to determine the extent to which a 1.5 Tesla MRI correlates with the clinical features and intraoperative findings in cases of lumbar disc prolapse.Overview of LiteratureFew studies have correlated MRI with clinical findings, and none have extended this correlation to intraoperative findings.MethodsOver a 2-year period, 50 consecutive patients with lumbar disc herniation requiring discectomy were studied. The MRI findings we observed consisted of the prolapse level, type, position, migration, high-intensity zones (HIZ), lateral recess, and foraminal stenosis. A logistic regression analysis was performed to determine the significance for the various MRI findings. Finally, the MRI observations were confirmed with intraoperative findings and inferences were drawn.ResultsMRI scan sensitivity and specificity for determining surgically significant levels was 100% and 94.94%, respectively. Straight leg raising test was positive in 74% of patients, with 85%, 43%, and 75% for paracentral, central, and foraminal levels, respectively. A foraminal compromise was the only MRI parameter to share a significant association with neurological deficits. Patients with a HIZ on the MRI had a significant increase in back pain and 63% exhibited identifiable annular tears intraoperatively. The intraoperative anatomical findings correlated extensively with the MRI findings.ConclusionsMRI findings strongly correlate with intraoperative features and can serve as a useful tool when planning surgery due to the accurate depiction of the morphometric features. However, the decision for surgery should be made only when detailed clinical findings in conjunction with MRI findings allow for an accurate identification of the culprit fragment and pain generators.
Background:Flexible ureterorenoscopies continue to assume an increasing role in the armamentarium of the endourologist. In many centers around the world, prior stenting is carried out before retrograde intrarenal surgery (RIRS) to passively dilate the ureter, which facilitates passage of a flexible ureteroscope with or without an access sheath. In our series, the first stage of passive dilatation with prior stenting was totally avoided without compromising the success of the procedure.Materials and Methods:From January 2004 to December 2007, 54 patients with 55 renal units underwent RIRS. The patients were between 28 and 65 years old. All patients had renal stones ranging in size from 8 mm to 22 mm. The mean serum creatinine level was 1.1 mg%. The lower ureter was dilated under ‘C - arm’ fluoroscopy guidance up to 14 FR. An access sheath of 10/12 Fr was passed over the working guide wire. RIRS (7.5/9.3 Fr) was introduced into the access sheath. The stones were fragmented using a holmium laser. The mean operating time was 85 mins (45-130 mins).Results:In 52 out of 55 renal units (94.5%), a flexible ureteroscope could be passed successfully into the kidney through an access sheath. In 3 of the cases (5.4%), the lower ureter could not be dilated. In these patients, the procedure was staged after passing a 6/26 JJ stent. An X-ray KUB was done at the 3-month follow-up visit. A total of 50 renal units (94.3%) were stone free at the 3-month follow-up visit.Conclusion:In a majority of the cases, RIRS could be accomplished successfully during the first sitting. Single stage RIRS did not alter the subsequent stone clearance or increase the incidence of morbidity or complications.
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