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Post-splenectomy infection has a mortality rate of up to 70%. Previously we have published data confirming the poor adherence to best practice guidelines with relation to management of the asplenic patient. A defined protocol of care was established, staff education commenced and a ‘patient information leaflet’ made available. To ascertain whether management of the asplenic patient has improved since the implementation of a structured programme of care. Retrospective chart review of all splenectomies performed in Beaumont Hospital between 2002 and 2008. Overall, 75.9% of patients were documented as having received the recommended vaccinations. Of these, 48.7% were not timed according to recommended guidelines. Prophylactic antibiotics were documented as prescribed in all but five patients discharged. These results demonstrate an improvement in post-splenectomy care between 2002 and 2008. However, further improvements are necessary.

Postsplenectomy bacterial sepsis may be fatal, due to defects in both cellular and humoral immune responses. The objective of this study was to assess the efficacy of peritoneal macrophage antibacterial function in the early postsplenectomy period. Murine models of splenectomy and sham operation were characterized and peritoneal macrophages were harvested 24 h to 1 wk after surgery. Cells from splenectomized animals demonstrated a nonsignificant delay in phagocytosis of Escherichia coli at 24 h with, however, significantly impaired killing of intracellular organisms at 24 h and 1 wk compared to the sham group. Paradoxically, the production of the macrophage antibacterial product superoxide anion was not impaired at either time point in the splenectomy group compared with sham-operated and control mice. Nitric oxide release was significantly lower in the splenectomized group (p = 0.006), a possible explanation for reduced bacterial killing. Mortality from bacterial peritonitis was significantly higher with concomitant splenectomy than in the sham splenectomy group at 24 h (p < 0.02). The production of TNF from macrophages was up-regulated immediately following splenectomy, a cytokine which may contribute to mortality from bacteremic shock. Local defects in macrophage antimicrobial function may contribute significantly to bacteremia and to subsequent mortality in the early postsplenectomy period.

Postsplenectomy septic sequelae may be fatal, but the mechanisms are unclear. We hypothesized that peritoneal macrophage (PM phi) antimicrobial function is abnormal following splenectomy and that this may predispose to increased mortality from the fungal pathogen Candida albicans. Study 1 (in vivo): female CD-1 mice were randomized into control (C), laparotomy (L), or laparotomy+splenectomy (L + S) and inoculated with C. albicans (10(7) organisms, ip) and were studied for mortality. Study 2 (in vitro): mice were randomized to C, L, or L + S groups. Twenty-four hours later, PM phi were harvested and studied for their antifungal activity, including percentage PM phi ingestion of C. albicans and vacuolar sealing of C. albicans within PM phi, percentage C. albicans killing, and superoxide anion (O2-) generation, the mechanism by which candida are killed. Results showed decreased phagocytosis and killing of C. albicans in the L + S group (P < 0.05 vs C) and reduced vacuolar sealing (P < 0.05 vs C) but significantly higher O2- release compared to that in other groups (P < 0.05). Mortality in the L + S group from C. albicans sepsis was significantly higher than that in the other groups (60% compared to 20% in the L group and 13% in C, P < 0.02). This may have resulted from L + S-induced defective phagocytosis of C. albicans and depressed C. albicans killing but increased O2- release in response to candida. This discrepancy between decreased killing and increased O2- may result from increased leakage of O2- from more unsealed vacuoles in the L + S group. Thus, L + S may predispose to candida-induced mortality through defective PM phi intracellular candida killing while enhancing the release of O2- extracellularly from unsealed vacuoles, causing tissue injury.

SummaryA case is reported of cervical vertebra plana presenting with many typical features of eosinophilic granuloma, but ultimately proving to be Ewing's sarcoma. The proper diagnostic approach to vertebra plana lesions in children is presented.

Thalidomide has become an important agent in the treatment of myeloma. However, thalidomide induced erectile dysfunction is a serious complication which has received very little attention. In our hematology department, 6 out of 11 male patients developed erectile dysfunction (grade 3 in 5/6) within 4 weeks of starting thalidomide. Our results suggest that thalidomide induced impotence is a common complication in male hematology patients.

Raised percentage hypochromic red cells (%HRC) were detected at diagnosis in 10 of 34 consecutive patients with low-risk myelodysplastic syndrome (MDS) [refractory anemia (RA) (4/26) and RA with ring sideroblasts (6/8)], all of whom had normal or increased serum ferritin and bone marrow iron stores. Elevated %HRC has persisted in all 10 cases and subsequently developed in another RA patient who later had a complete remission of MDS with normalisation of %HRC after a respiratory tract infection. A strong positive correlation was found between %HRC and erythrocyte zinc protoporphyrin levels in 11 MDS patients tested (p=0.01), suggesting that functional iron deficiency contributes to ineffective erythropoiesis in cases of MDS with raised %HRC. Five of seven patients with elevated %HRC had satisfactory haemoglobin responses to a trial of human recombinant erythropoietin without iron supplementation.

The Space Technology 7 (ST7) experiment will perform an on‐orbit system‐level validation of two specific Disturbance Reduction System technologies: colloidal micronewton thrusters and drag‐free control. The ST7 Disturbance Reduction System (DRS) is designed to maintain the spacecraft’s position with respect to a free‐floating test mass while limiting the residual accelerations of that test mass over the frequency range of 1 to 30 mHz. This paper presents the overall design and analysis of the spacecraft drag‐free and attitude controllers, with particular attention given to its primary mission mode. These controllers close the loop between the drag‐free sensors and the colloidal micronewton thrusters.

A retrospective analysis was performed of all patients who received operative intervention for subdural haematoma at the Beaumont neurosurgical unit between 1994 and 1997 inclusive. There were 123 spontaneous (mean age 74 +/- 5 years) and 77 traumatic haematomas (mean age 43 +/- 23 years) in the series. Ninety three patients (76%) in the spontaneous group were on antiplatelet agents or anticoagulants (78 aspirin, 15 warfarin) and the indication for their use was unknown in twenty four patients (19%). The re-operation rate in the group on aspirin and anticoagulants was twice that in the non aspirin / non anticoagulant group. These results highlight a significant medical problem and emphasise the need for cautious use of antiplatelet and anticoagulant agents, particularly in the elderly.

We describe only the second reported case of ulcerative colitis to develop autoimmune haemolytic anaemia following previous subtotal colectomy. After an unsatisfactory trial of corticosteroids and azathioprine, the haemolysis responded to splenectomy and removal of rectal stump and anal canal.

CD38 expression on B-cell chronic lymphocytic leukemic cells is strongly correlated with vascular endothelial growth factor expression

Postsplenectomy bacterial sepsis may be fatal, due to defects in both cellular and humoral immune responses. The objective of this study was to assess the efficacy of peritoneal macrophage antibacterial function in the early postsplenectomy period. Murine models of splenectomy and sham operation were characterized and peritoneal macrophages were harvested 24 h to 1 wk after surgery. Cells from splenectomized animals demonstrated a nonsignificant delay in phagocytosis of Escherichia coli at 24 h with, however, significantly impaired killing of intracellular organisms at 24 h and 1 wk compared to the sham group. Paradoxically, the production of the macrophage antibacterial product superoxide anion was not impaired at either time point in the splenectomy group compared with sham-operated and control mice. Nitric oxide release was significantly lower in the splenectomized group (p = 0.006), a possible explanation for reduced bacterial killing. Mortality from bacterial peritonitis was significantly higher with concomitant splenectomy than in the sham splenectomy group at 24 h (p0.02). The production of TNF from macrophages was up-regulated immediately following splenectomy, a cytokine which may contribute to mortality from bacteremic shock. Local defects in macrophage antimicrobial function may contribute significantly to bacteremia and to subsequent mortality in the early postsplenectomy period.

This study was undertaken to survey the current practice for venous thromboembolism (VTE) prophylaxis in Irish hospitals. A questionnaire was completed by 293 Irish consultant hospital doctors for the period October 1991 to December 1992 regarding their policy for VTE prophylaxis. Of the doctors surveyed, 36.85% are physicians, 27.3% are surgeons, 20.1% obstetricians and gynaecologists and 15.7% anaesthetists. 94% of physicians initiated DVT prophylaxis in their 'at risk' patients. 94% of the surgeons and 92% of the obstetricians/gynaecologists had used VTE prophylaxis and usage in both groups was more common in high risk patients. Anaesthetists reported VTE prophylaxis being used in an average of 20% of operations. Physicians considered the most important risk factors to be immobility, the period post myocardial infarction and a history of previous DVT. Other factors considered important by surgeons included advancing patient age and malignancy while obstetricians thought obesity to be a major risk factor. The most favoured prophylactic measures used by all doctors surveyed were subcutaneous heparin and elastic (TED) stockings.

B19 parvovirus infection is a principal cause of transient bone marrow suppression in patients with chronic haemolytic anaemias. Acute infection is described in a family of five individuals with hereditary spherocytosis; three of them developed marked hypoplastic anaemia.

16527 The term Hypereosinophilic syndrome (HES) refers to a heterogeneous group of disorders characterised by marked blood (>1500/cu mm) and tissue eosinophilia resulting in end organ damage.Several visceral complications like cardiomyopathies and cerebrovascular accidents are common. Treatment of HES includes corticosteroids,chemotherapeutic agents (hydroxyurea, cyclophosphamide, vincristine), interferon-alpha. Newer treatment modalities,including tyrosine kinase inhibitors (eg Imatinib) and monoclonal anti IL5 antibodies are now available. We report a case series of patients with HES which demonstrate the variable clinical response to above therapeutic options. Case 1: A 43 year old man who presented with a right lacunar infarct had a eosinophil count of 1200/cu mm. No cause was found. He also had Mitral valve endocarditis. Following initial treatment with Methylprednisolone, the eosinophil count came down to 3500/cu mm, but the eosinophilia persisted. He was given a trial of Imatinib. In 2 months time his eosinophilia resolved. However, he was negative for FILIPI-PDGFRa. Case 2: A 37 year old lady with history of Splenectomy (due to trauma) presented with a eosinophil count of 2660/cu mm. Result of the FILIPI-PDGFRa was equivocal. There was no response to Imatinib. A trial of Prednisolone (1 mg/Kg) was ineffective. She did not respond to Interferon-alpha. However when given a combination of Prednisolone (0.5 mg/kg) and Interferon-alfa, her counts were normal in a month. Case 3: A 63 year old man with history of Atrial Fibrillation had persistent eosinophilia (>1500/cu mm). His serum Tryptase was raised but he was negative for FILIPI-PDGFRa. A trial of Imatinib failed He responded partially to high dose of Hydroxyurea. Prednisolone, Interferon-alpha or a combination of both are future options for him. Case 4: A 80 year old man with background history of Alzheimer’s Disease was found to have persistent unexplained eosinophilia. He had no complains of joint symptoms but his ANF was positive in low titres. A bone marrow showed no evidence of lymphoma or a myeloproliferative disorder. Karyotype was normal. He was given a trial of Hydroxyurea to which he responded in two weeks. Thus, response of HES patients to treatment is variable often unpredictable. No significant financial relationships to disclose.

Two cases in which digital arteritis antedated malignant disease are reported. The literature concerning this rare association is reviewed. Cryoimmunoglobulinaemia is suggested as a possible mechanism for digital arteritis.

Bronchial hyperresponsiveness can be produced experimentally after inhalation of numerous nonimmunospecific stimuli; our objective was to determine whether acrolein, a component of cigarette smoke, could increase bronchial reactivity to intravenously administered acetylcholine in guinea pigs. Bronchial responsiveness was assessed twice before and 1, 2, 6, and 24 h after exposures to less than or equal to 0.01 (sham), 0.31, 0.67, 0.94, or 1.26 parts per million for 2 h (5–7 guinea pigs/group). To examine the possible relationships of responsiveness to inflammatory mediator release and cellular infiltration, bronchoalveolar lavage was performed in another 30 guinea pigs before (control) and 0, 1, 2, 6, or 24 h after exposures. Pulmonary resistance was increased immediately after exposure (5 min) and returned to control values within 30–60 min. Increased bronchial responsiveness was evident within 1 h and became maximal 2–4 h after exposure. The acetylcholine dose necessary to double resistance decreased from 104.2 +/- 7.3 to 79.6 +/- 15.9 at 1 h and was 32.5 +/- 7.9 at 2 h and 32.8 +/- 7.6 micrograms.kg-1 at 6 h. Increases in two eicosanoids, thromboxane B2 (from 167 +/- 21 to 314 +/- 77 pg/ml) and prostaglandin F2 alpha (from 98 +/- 20 to 285 +/- 62 pg/ml) occurred immediately after exposure, whereas an influx of neutrophils occurred 24 h later (from 2.2 +/- 1.2 to 11.3 +/- 3.6%). These temporal relationships suggest that neutrophil infiltration may be a sufficient but not a necessary condition for the onset of bronchial hyperresponsiveness and that injury to cells normally present in the lung are responsible for the mediators thought to influence bronchial responsiveness.

A case report of agnogenic myeloid metaplasia (AMM) is presented in which a patient had a preliminary 18-month period characterized by leukemoid reactions to repeated infections alternating with normal health, throughout which an acquired Pelger-Huet anomaly persisted. This is the only reported case of the anomaly as a premonitory hematologic marker of AMM. The literature concerning the acquired Pelger-Hut anomaly is reviewed.

A case report of agnogenic myeloid metaplasia (AMM) is presented in which a patient had a preliminary 18-month period characterized by leukemoid reactions to repeated infections alternating with normal health, throughout which an acquired Pelger-Huët anomaly persisted. This is the only reported case of the anomaly as a premonitory hematologic marker of AMM. The literature concerning the acquired Pelger-Hut anomaly is reviewed.

Acute pulmonary artery occlusion is frequently a dramatic occurrence with a well recognized clinical spectrum. In contrast, a chronic occlusion of the pulmonary artery often awaits post-mortem diagnosis. We present a case diagnosed by chest radiograph. A nine-year-old male presented in August 1976 with areas of ischaemic necrosis of two toes on the left foot for which a lumbar sympathectomy was performed with regression of symptoms which did not recur. Five months later the patient developed acute myeloid leukaemia in the course of which consolidation of the right middle lobe occurred.

Doses of oral anticoagulants in 50 patients on long term treatment were easily and satisfactorily monitored over six months by an automated chromogenic assay of prothrombin (CPA). It is suggested that chromogenic assay of one or more of the vitamin K dependent coagulation factors would provide a readily standardised alternative to those conventional tests which depend on human brain derived reagents, now regarded as a biohazard.

A 34-year-old woman developed acute myelogenous leukaemia in the course of pregnancy and, after delivery of a normal baby, developed multiple bilateral breast masses composed of myelogenous tissue.

SummaryA 20-year-old male who required splenectomy following abdominal trauma was subsequently shown to have primary thrombocythaemia. This report illustrates the diagnostic problems associated with a refractory post-splenectomy thrombocytosis, and the therapeutic difficulties in the management of primary thrombocythaemia are discussed.

In a controlled, randomized study, survival of patients with small cell carcinoma of the lung (SCCL) was prolonged on addition of warfarin sodium to combination chemotherapy plus radiation therapy. Median survival for 25 control patients was 24 weeks and for 25 warfarin-treated patients was 50 weeks. This difference could not be accounted for by differences between groups in performance status, extent of disease, age, or sex. The survival advantage associated with warfarin administration was observed both for patients with extensive disease and for those who failed to achieve complete or partial remission. The warfarin-treated group also demonstrated a significantly increased time to first evidence of disease progression. These results suggest that warfarin may be useful in the treatment of SCCL and also support the hypothesis that the blood coagulation mechanism may be involved in the growth and spread of cancer in man.