ABSTRACTS FROM MRC/BH
ABSTRACTS OF PAPERS PRESENTED AT THE 100TH RESEARCH MEETING OF THE MEDICAL RESEARCH CENTRE OF BOMBAY HOSPITAL ON MONDAY 9TH SEPTEMBER 2002, 2.30 PM, SP JAIN AUDITORIUM (CONVENOR DR. HL DHAR)
1. PREVENTION OF DEEP VEIN THROMBOSIS WITH SEQUENTIAL COMPRESSION DEVICE
To avoid embolism after Post Operative Surgery and complications of High Risk Patient sequential device and sleeves of different sizes and connecting tubings. SCD Controller is fixed to the bed of the patient, Sleeves of proper sizes are tied to the legs and connecting tubes are joined to the Sleeves and Controller. Switch on the Controller, it adjusts the pressure to 45 mm Hg. Then it inflates and deflates. By inflating it compresses the veins and activates the blood flow.
So far 103 patients of High Risk are treated. 85 patients of TKR and 11 patients of THR, 5 CABG and 2 Vascular Surgery. 20 were very High Risk Patients with Fluctuatory Diabetes, Obesity, Hypertension, Rheumatoids, Severe OA. Fractures and Parkinsonians. They all came up without problems fully Rehabilitated and went home walking, before said period. Moderate High Risk 60 others also recovered.
I find SCD application provides comfort cooling to patients. This indicates that in subsequent cycle of air flows through cooling chambers of the Sleeves on the patients legs. While the chambers deflected during compression. This maintains the venous flow. Cooling effect on operated leg, reduces the oedema, pain and discomfort. Patient sleeps. SCD is applied for 24 to 48 hours, sometimes more if required. So often I find patients are refusing to remove the SCD after the duration period as they like to have the same.
Patients are ready to walk and do all exercises without much pain, recover faster than before. This reduces the time of Hospitalization and saves money.
This shows prevention of Deep Vein Thrombosis with SCD is essential in High Risk Patients. This treatment is introduced a year before in our hospital physiotherapy Dept. It is new in our country.
2. EXTENDED NEUROLYSIS OF POSTERIOR TIBIAL NERVE TO IMPROVE SENSATION IN DIABETIC NEUROPATHIC FEET
SR Tambwekar, K Mansukhani, SV Khadilkar, K Khadalia, VS Tambwekar
Neurolysis has been attempted in the past in diabetic peripheral neuropathy with good but inconsistent results. Dr. A Lee Dellon reported improvement by decompression of affected nerves in diabetic peripheral neuropathy. He did not get the expected result in a few cases. Based on the intra-operative electrodiagnostic studies in leprosy, it was felt that the proximal extent of the decompression was not scientifically defined.
Decompression was performed on the patients having stocking type of sensory loss with palpable peripheral pulses. Since the intention was to return sensation to the plantar aspect of the foot, the posterior tibial nerve was selected. We have done extended neurolysis of thirteen posterior tibial nerves in eleven cases of diabetic peripheral neuropathy since 1994. The nerve must be decompressed over the entire segment of involvement and preferably under magnification. Decompression involves extra-neural and intra-neural neurolysis. The closure is done only in one layer. This extent of
release gives consistently good results. There was improvement of sensation in all the cases. The improvement was not just in the posterior tibial nerve territory but extended beyond it. The results, ever since 1994, have been encouraging. Improvement is seen in the electrodiagnostic studies in some cases.
Nerve Conduction Study of L Posterior Tibial nerve. The CMAP is obtained from the Abductor Hallucis after stimulatingthe nerve at the ankle and at the knee.
Case No. 7 : Ankle above, knee below; Case 8 : Ankle
3. MEGALENCEPHALIC LEUKODYSTROPHY WITH SUBCORTICAL CYSTS IN INDIAN ETHNIC
GROUP - CLINICAL, IMAGING AND GENETIC STUDIES
Megalencephalic leukodystrophy is an autosomal recessive disorder characterized by macrocephaly, deterioration of motor functions resulting in spasticity and ataxia and cognitive decline. It is associated with extensive white matter changes with subcortical cysts. Since our first presentation in Japan in 1991, the condition has now been described from widespread regions including Turkey and Europe. To-date, we have studied 70 patients of whom 63 belong to the Indian ethnic group namely Agarwals.
Of the 34 patients whose genetic studies were done, the MLC1 gene identified on chromosome 22qtel region. Thirtytwo (31 Agarwals and 1 non-Agarwal) were homozygous for insertion of cytosine in exon 2 between nucleotides 250 and 251 indicative of a recessive disorder with a founder effect. One patient was homozygous for C 585 A. He was adopted and parental details were not known. In one patient the gene defect could not be identified suggesting that there could be genetic heterogeneity. Besides, despite the same genetic defect there was considerable phenotypic variability suggestive of possible environmental factors or modifier genes.
It an Agarwal child any where in the world presents with the above mentioned clinical syndrome, mutation in the MLC1 gene should be sought.
4. POSTERIOR LAMELLAR KERATOPLASTY - MODIFICATIONS IN THE PRESENT TECHNIQUE
RC Patel, A Jayshree
Keratoplasty has been the boon the corneally blind people. Till 10 years back Keratoplasty was performed in the conventional technique. Recently posterior lamellar keratoplasty was practised in some scandinavian countries but the only drawback was the requirement of hi-tech instruments. This particular procedure can be done only in damaged endothelial layer of the cornea. It is particularly useful in conditions like fuch’s endothelial dystrophy and post-operative
decompensated endothelium. Our’s is a modified technique practised at Bombay Hospital Institute of Medical Sciences.
The note of this particular type is not noted anywhere else.
During this procedure we require a whole eye ball. First let’s come to the preparation of recipient eye. Depending upon the damaged endothelium first the cornea is trephined partially, it is split midstromal with a crescent, by giving a nick at the superior edge of trephine we extend the wound about 4 to 5 mm and the diseased endothelium is either cut with the corneal extension forceps or with a capsulo rhexsis forceps snipped off.
Now let us come to the donor cornea - In a similar fashion we first trephine it partially, then split midstromal with a crescent, by giving a nick at the superior edge of trephine. Then inject blurhex dye between the stromal layers for easy identification of he stromal and endothelial layer. Grasping the eyeball trephine the button completely, now separate the midstromal layers. The epithelium and the midstromal layer is discarded and stromal and endothelial layer part is preserved on teflon block. The sheets glide has been designed in such a fashion that its entry has been facilitated easily in the recipient cornea. The stromal side sticks easily to the sheets glide, the sheets glide is inverted and its entry facilitated into the recipient cornea. Without damaging the endothelium the graft has been pushed gently with an iris repositor through the superior edge of the pocket created in the recipient eye. With the 15 no. blade give a nick at the limbus, introduce air or moisol so that the graft sticks to the midstromal remaining graft. Full chamber air bubble would serve a better mediumfor its attachment.
Patch the eye for 2 days and complete bed rest is advised to the patient. Remove patch after 2 days. The endothelium has taken up well with the anterior chamber formed. We have done very few cases. In 2 cases we have seen that the graft
was partially displaced in AC, then we tried to inject air and saw that it helped to a great extent in attachment. It requires a steep learning curve. It is modified by Dr. RC Patel with the routine instruments and we hope that in years to come a head it would be a boon to corneally blind people with endothelial layer involvement.
5. GASTROINTESTINAL LUMINAL TUBERCULOSIS - ESTABLISHING THE DIAGNOSIS
DN Amarapurkar, ND Patel
Despite various diagnostic modalities, treatment of gastrointestinal luminal tuberculosis (GITB) is presumptive in many patients. Increasing incidence of Crohn’s disease (CD) necessitates early and definite diagnosis of GITB.
To determine the percentage of patients with presumed GITB (PGITB) and compare their profile with that of confirmed GITB (CGITB) and CD.
A retrospective analysis from yr 1994 to 2002 was done on 250 patients of GITB; suspected on clinical, radiological, endoscopic studies and in whom antitubercular therapy was successful. Presence of caseating granuloma on biopsy and positive AFB culture or smear were considered criteria for CGITB and diagnosis without these features was considered PGITB. We also compared both the groups with CD (10 patients) in whom earlier antitubercular treatment was unsuccessful and subsequently diagnosis of CD was made. Out of 250 patients (mean age 35.68 ± 5.09 yrs, sex M:F = 1.22:1), 173 (70%) had CGITB, while 77 had PGITB. There was no significant difference in clinical and radiological features in them. Involvement of oesophagus was seen in 3%, stomach 2%, duodenum 1.6%, small intestine 16%, ileocaecal region 52%, and colon in 34%. CGITB was 100% in UGI tract while it was 40%, 65%, and 66% in small bowel, IC region and colon respectively. Simultaneous peritoneal involvement was in 9%, pulmonary 18%, renal 0.8%, liver 1.2% and lymph node 2.8%. Proof of CGITB was obtained from extraluminal sites in 21%. Histological confirmation was obtained in 100% of ulcerated mass lesions 68% of ulcerative lesions and < 15% of pseudopolyps and strictures.
While comparing with CD (mean age 34.1 ± 6.42 yrs, sex M:F = 1.5 : 1), diarrhoea (60 vs 22%), bleeding per rectum (30 vs. 4%), fistula (20 vs. 0%) and perianal lesion (10 vs 0%) were commoner in CD; fever being uncommon (10 vs. 64%). In CD, 50% had colonic involvement, 20% ileum alone, 30% IC region and 10% oesophagus. On endoscopy, 60% of CD showed ulcers, 20% pseudopolyps, 50% colitis and 20% strictures. Histopathology study demonstrated non-caseating
granuloma in 30% of CD. Extraluminal manifestations were present in 40% of CD.
With routinely available diagnostic modalities, diagnosis of GITB still remains presumptive in 30% cases. Hence methods to reach the lesion (enteroscopy/laparoscopy) and to enhance microbiological yield (tissue PCR) are required.
6. SLEEP MEDICINE - ITS TIME WE WORK UP
We present an overview of various sleep disorders with an emphasis on early detection and correction. Sleep medicine is the newest and fastest growing branch of medicine. For a long time sleep disorders were ignored and patients received fragmented care at the hands a multitude of specialists with a lack of an organized and focussed approach. With the dvent of specialized sleep studies like polysomnography (PSG), maintenance of wakefulness test (MWT) and multiple sleep latency test (MSLT) detailed measurement of different physiologic parameters during sleep are now available. Newer medications have become available to treat various types of sleep disorders effectively and safely. Sleep disorders areextremely common in all age groups and contribute to daytime sleepiness and fatigue with associated complication like poor work and school performance, depression, substance abuse as well as traffic and industrial accidents. Sleep disorders have also been linked in multiple epidemiological studies to increased morbidity such as hypertension, cardiovascular disease as well as shortened life span. The morbidity and mortality attributable to sleep disorders amounts to billion of dollars worldwide. We present six cases of sleep disorders where the chief complaint was excessive daytime sleepiness each of which received a different work up and final diagnosis for each case was different (Table 1). Thus we have 6 patients with similar chief complaints of excess daytime sleepiness, where with the help of a detailed sleep history and appropriately directed specialized sleep tests six different diagnoses were made and corresponding treatment given with excellent results in all cases. Mean time to presentation to our centre for sleep disorders after onset of symptoms was an astounding 10 years. These patients had seen a multitude of specialists and all had extensive and expensive workups including metabolic screen, endocrine work up, and CT and MRI scans, none of which led to any specific diagnosis. We conclude that it is the time the Indian medical community joins the rest of the world and wakes up to sleep disorders and includes a sleep history in evaluating their patients. Patients with suspected sleep disorders should be referred early on to centres where the facility and expertise exists for a comprehensive and appropriate work up and treatment in these cases, including the use of polysomnography.
TABLE1 Case 1 2 3 4 5 6 Age 14, male 15, male 22, female 24,male 29, female 52, male History Excess day
sleep for 14
times during the
day and disturbed
sleep at night
Gets up from
to sleep vague
sensation in her
gets up with
4 hours after
Mildly obese Normal Normal Normal Cachectic Duration 10 years 4 years 4 years 14 years 10 years 18 years Sleep study Overnight PSG PSG MSLT Sleep EEG PEG* PSG* Diagnosis Obstructive
Narcolepsy REM Behavioral
Treatment CPAP therapy Lithium and
Methyl phenidate Clonazepam Gabapentin Surgery -
Outcome Resolution Improvement Resolution Resolution Resolution Resolution
[*If done would have clinched the diagnosis. Diagnosis was empiric.]
7. VITAMIN B12 DEFICIENCY
DN Amarapurkar, N Patel
Background : Vitamin B12 deficiency (VBD) is common but under diagnosed. It occurs due to various aetiologies
and has protean manifestations.
Aim : To study clinical features, causes, endoscopic and laboratory features in VBD.
Methods : Total of 225 patients of VBD was studied over period of 1994 to 2002. All the patients were evaluated by clinical history, examination, haemogram, liver profile, B12 levels, folate levels, iron studies, OGDscopy and bone marrow studies. In suspected pernicious anaemia, parietal cell antibodies and intrinsic factor antibodies were done. We also analyzed 76 patients with normal B12 levels for comparison, as a control group.
Results : Total 225 patients with mean age 43.08 ± 3.8 yrs (range 17-100 yrs) and M : F = 3.6 : 1 were studied. Amongst clinical features, neurological-neuropathy or myelopathy 47%, mental symptoms 14%, anaemia related symptoms 14%, pallor 42%, oral ulcers 38%, hyper pigmentation 25%, diarrhoea 24%, vomiting 19%, and epigastric pain 28%. Mean duration of symptoms was 7 months. Mean Hb was 11.6 gms/dL with MCV of 100. Transaminases were mildly elevated 1.17 X ULN. Serum LDH was 3.25 X ULN, S B12 was 88.8 pg/ml with associated folic acid deficiency in 40% and iron deficiency in 38%, megaloblastic bone marrow was found in 94%. Amongst endoscopic features, gastritis 52%, gastric atrophy 2% and normal 23%. In those with atrophic gastritis, GAVE in 0.58%, carcinoid 1.7% and multiple polyps 4.7%, H. Pylori positivity in 15%. 20% were alcoholics, 32% tobacco and 52% gutkha. Amongst various aetiologies, pernicious anaemia in 5.6%, chronic atrophic gastritis 14%, Crohn’s disease 0.46%, TB 2.3%, tropical sprue 19%, pure vegetarian iet 54%. In 76 patients of control group (age 46.1 ± 3.1 yrs, sex M:F = 1.1:1), 13% were alcoholic, 30% tobacco and 5.3% gutkha. There was statistically significant difference between the 2 groups in consumption of gutkha (p < 0.001).
Conclusion : Common predisposing factors are pure vegetarian diet and gutkha consumption while pernicious anaemia is uncommon. Weight loss, pallor, diarrhoea, oral ulcers, hyper pigmentation and neurological symptoms with high MCV and LDH levels should raise suspicion of VBD. Consumption of gutkha was associated with VBD.
8. SCREENING AND DEFERRAL OF BLOOD DONORS
Maya Parihar-Malhotra*, Ritu Bhanot-Wadhera, Sister Mary Paul
Introduction : In selecting individuals for blood donation the main purpose is to determine whether the person is in good health, in order to protect the donor against damage to his/her own health, and to protect the recipient against Transmission of diseases of drugs which could be detrimental to him/her.
Procedure for donor screening : To select donors who are in normal health one has to rely upon the donor’s answers to some simple questions concerning his/her medical history and general health, combined with a brief medical examination and simple laboratory tests. A pre-printed questionnaire is given to all the donors, which is filled up and signed by the donor. Based on his answers, the donor is either accepted and registered (computer registration is also done) or deferred.
All deferrals/rejections are entered in the mandatory rejection register as per FDA guidelines.
Type of Deferrals : The deferrals may be temporary or permanent.
Temporary : Last donation less than 3 months, blood transfusion, surgery, typhoid, malaria, pregnancy, abortions and
breast feeding, tattoo, anaemia, etc.
Permanent : Heart disease, cancer, diabetes, etc.
Material and Methods : The donor deferrals over a period of one year were studied and the results were analysed to see the distribution of the deferrals in our blood bank. The total no of donors during this period were 12925 and 829 (6.4%) were rejected.
Findings : 34.5% of the deferred donors had high blood pressure, 16.64% had low Hb, 23.75% had cough and cold,
6.39% had undergone dental treatment and 28.72 were rejected due to other causes. (Other causes being asthma medication, skin diseases, malaria, jaundice, low BP, diabetes). Males constituted 78% and females 22% of the rejections. 65% of all rejections were in the 20-40 year age group.
Comments : 1) The most common cause of rejection was high BP. Many donors are detected first time as having high BP in our blood bank 2) The next common cause was low Haemoglobin. In females however this was the largest group (61%). The CuSo4 method used for routine screening in the blood bank is only a rapid screening method (Hb > 12.5). Therefore the importance of QBC or specific methods for Haemoglobin estimation cannot be ignored. 3) Maintaining online computer records is essential 4) 100% of safe blood does not exist. Therefore we have to rely on accurate donor history and screening (pre-donation screening) to decrease the window period and ensure a safer and better quality blood for our patients. The role of the MSW/Counsellor is very important as she can conduct a private and personal interview. 5) Will have to increase our voluntary donations and plan to conduct Voluntary Blood donation Camps/Drives.
9. A BREAKTHROUGH ADVANCE IN CONVENTIONAL IMAGING : DIGITAL IMAGING
Satyajit Deshpande, Kiran Talekar, DB Modi
Digital imaging is a major long awaited breakthrough in X-ray imaging. It has passed the path for major advances in conventional imaging. In digital imaging, the image is divided into discrete picture elements; the pixels. Pixels are regularly sized and spaced squares. The data is stored in pixels as a string of binary digits or bits. Thus strictly speaking digital image exists only in electronic storage. For display the data is converted back into visible analogue. This is how it causes difference from conventional imaging. Digital imaging differs from conventional imaging in the way images are represented and stored.
Digital imaging systems consists of various equipments which at as transducers. They turn the energy parts through the
body or emanating from it into a directly visible analogue or digital pixel array. This is the basic fundamental difference
between analogue and digital imaging systems. In digital imaging, the data conversion devices and system consists of
ADC : analogue to digital converter.
Video Detector and video Frame Grabber.
The digital data acquired is put into communication network by:
PACS : picture archiving and communication systems.
DICOM : digital imaging and communication in medicine.
DICOM : provides a standard way to send and receive information through PACS networks. Its structure is extensible
so that image types and operations can be added.
Advantages : Wide range of information stored.
Exact duplicates can be made.
Carry out extremely difficult techniques.
Substantial reduction in need to repeat the study.
Increase diagnostic capability.
Timely decision by faster communication with clinicians.
Disadvantages : Details in the information smaller than the pixel size cannot be represented.
Increase amount of data required. Costly.
10. ROLE OF HOUSE DUST MITE (HDM) SENSITIVITY AND INTERLEUKIN - 4 IN EXERCISE
SVJoshi, DM Tripathi, SR Kankonkar, HL Dhar
The prevalence of exercise induced bronchospasm (EIB) in patients with asthma has been reported to range from 40-90% however, recently we have reported high incidence in HDM sensitized asthmatics. It is known that cytokines are released in early phase but actions are mostly confined in late phase and that treatment with leukotriene receptor antagonists reduces cytokine (IL-4).
Purpose of present study was to establish the role of IL-4 in HDM sensitive asthmatics. Five hundred cases referred to Department of Allergy, Bombay Hospital were screened and 100 atopic asthmatics were selected for this study. Standardized extracts of house dust mite and pollens were used for modified prick test to detect allergen specific IgE. It was observed that potent allergen responsible for asthma was House Dust Mite (HDM) in 83% followed by various pollens (40%) and that 64% of HDM sensitive asthmatics developed exercise induced bronchospasm.
Five ml blood was collected from these patients (n=38) who developed bronchospasm induced by cycling and serum interleukin 4 was estimated employing Elisa method. It was observed that only 21.05% asthmatics who developed EIB were positive for interleukin 4. It has been reported that histamine and leukotrienes are primarily involved in early phase of asthmatic response followed by cytokines in late phase. Present study shows that 21.05% of subjects shows presence of IL-4 in blood in early phase. It is possible that some amount of cytokines are also formed and released along histamine on exercise inducing bronchospasm.
Present study shows that increased exercise induced bronchospasm in HDM sensitive individuals might partly be due to release of cytokine particularly IL-4.
ABSTRACTS OF PAPERS PRESENTED AT THE 101ST RESEARCH MEETING OF THE MEDICAL RESEARCH CENTRE OF BOMBAY HOSPITAL ON MONDAY 14TH OCTOBER 2002, 2.30 PM, SP JAIN CAFETERIA (CONVENOR DR. HL DHAR)
1. ANTIBIOTICS SUSCEPTIBILITY PROFILE OF METHICILLIN RESISTANT STAPHYLOCOCCUS AUREUS (MRSA)
Indiscriminate use of antibiotics has led to the emergence of a new global problem - Methicillin Resistant Staphylococcus aureus (MRSA) infection. To combat this infection, the glycopeptides were used as weapons. Soon in Western Countries, glycopeptide resistant strains of Staphylococcus aureus were encountered. In the month of September 2002, a sudden ise in the number of MRSA infections prompted us to carry a survey into the incidence of the same. A total of 74 isolates of Methicillin Resistant Staphylococcus aureus from various clinical specimens of hospitalised patients were evaluated for Methicillin sensitivity. Thirty seven of these were Methicillin Resistant i.e. 50%. Respiratory samples had about 85% of the Staphylococcus aureus isolates as MRSA. Isolation of MRSA from catheters, Pus and Blood were 64.7%, 60% and 50%, respectively. Though 100% sensitivity of these strains were seen to Vancomycin, Linezolid and Netilmycin, about 85-91% sensitivity was also observed to Amikacin, Chloramphenicol, and Amoxycillin and Clavulinic acid combinations. Why ump toxic drugs like Vancomycin into patients when other safer drugs are effective? This can be answered only on clinical evaluation of Netilmycin, Amikacin, Chloramphenicol and Amoxycillin plus calvulinic acid combinations on MRSA infections.
2. IMPORTANCE OF PROSTATE SPECIFIC ANTIGEN AS A TUMOUR MARKER, AND STUDY OF BONE SCAN ALKALINE PHOSPHATASE IN PROSTATE CANCER
Eric Soares, K Hema, JN Kulkarni, SR Kankonkar
Of late prostate cancer has become the most common cancer, amongst men in all over the world. Prostate specific antigen (PSA) was discovered in 1979, but only recently has the serum concentration of PSA become generally recognized as an important tumour marker for carcinoma of the prostate. Serum concentration of PSA increases with tumour progression and usually reaches the highest levels when tumour becomes metastasized, reflecting on the aggressiveness of the tumour and predicting the prognosis of a patient. In majority of cases untreated prostate cancer leads to bone metastases. Bone scan in frequently used to detect skeletal metastases. Alkaline phosphatase is one of the older biochemical tools for investigating and monitoring prostate cancer, and a reliable indicator of osteoblastic activity, as in bone metastases.
The purpose of this work was to study prostatic carcinoma, using serum prostate specific antigen (PSA) as a tumour
marker, bone scan, and alkaline phosphatase (APO4).
25 patients with age range of 52-87 yrs, (mean age 69.5 yrs), newly diagnosed with prostate cancer were studied. Clinical data on grade and APO4 normal 50-136 mu/ml. was obtained from medical charts; PSA was carried out by IMx system of Abbott Laboratories normal range was taken as 0-4 ng/ml. Bone scans carried out by using 99MTc-methylene diphosphonate.
7 out of 10 patients, in the age group of 70-79 yrs, had bone metastases, and were positive for bone scans. The PSA values of these patients in this age group were also high, (417.6 ng/ml.)
Out of 35 patients studied, 21 (60%) were having bone metastases and were also positive for bone scans, while 11 (31%) were negative for bone scans. Three (9%) patients were not referred for bone scans.
As the PSA levels increased in bone metastatic cases, positivity for bone scans was also increased. Biopsy was performed on 30 patients. Nineteen of these were positive for bone scans of which 5 had Gleason grade below 7, and 14 had a Gleason grade for 7 and above.
Alkaline phosphatase was studied in 25 patients. Eleven patients had abnormal APO4 and were positive bone scan.
Seven patients with normal APO4 levels were positive for bone scan, and remaining 7 patients with normal APO4 levels
were negative for bone scan.
From the present study, it was observed that the tumour marker PSA is a better parameter in the diagnosis, prognosis, monitoring treatment, and detection of prostate cancer. Annual routine PSA should be encouraged. Bone scans, alkaline phosphatase can be used for patients with advanced age having PSA values more than 20 ng/ml with or without symptoms of involvement of bones.
3. AN UNUSUAL CASE OF COAGULOPATHY IN ADULT FEMALE
Rahul Jain, MK Gupta
This is a case of a 52 years female presenting with large, painful swelling in the neck. The patient was a hypertensive and also had haemorrhoids. She gave a history of undergoing surgery twice previously without any bleeding complications.FNAC and biopsy of the lesion showed it to be a Multinodular Goitre of Thyroid. Pre-operative investigations of the patient showed a normal complete blood count with normal platelet count. Bleeding time, clotting time and prothrombin time of the patient was also found to be within normal range but she had an unusually prolonged activated partial thromboplastin time (control - 28 seconds; patient - 85 seconds). Repeated tests performed showed similar results in the absence of a history of any drug intake. Coagulation profile, including Prothrombin Consumption time and Thromboplastin Generation test, performed showed all the parameters to be within normal range except the prolonged aPTT. On performing the Specific factor assay, the patient was found to have Factor XII deficiency.
Factor XII, also known as Hageman Factor, is a major point of integration of several defence systems of the body including fibrinolysis, complement, and inflammation. The prevalence of factor XII deficiency in the normal population has been estimated to be 2-5% (according to western literature). It is mostly inherited as autosomal recessive disorder though occasional cases with autosomal dominant inheritance have also been reported. Patients who are factor XII deficient have prolonged surface - activated clotting of their plasma in the absence of any other coagulation disorder. These patients do not suffer from any bleeding diathesis. Since the condition is not associated with any haemostatic abnormalities, the detection in most cases is coincidental. The diagnosis can be confirmed by the specific assay for factor XII.
4. BLOOD DONOR REJECTIONS
Maya Parihar-Malhotra, Charulata Murudkar
Providing safe blood to patients is a challenging task. For the last many years the hospitals have made the patient and
their relatives responsible for their blood requirement. When the surgery is planned and the patient is well informed he himself can give his blood for the surgery-Autologous Blood Donation. When the patients relatives arrange the blood donors for replacement, we select the donors who is in good health, will not face any health problem after donation and who will not transmit any disease to the patient via his/her blood. Any donor who does fulfil the criteria is rejected. screening procedure starts with ensuring that the information provided by the donor about himself like date of last donation, age, weight etc is correct. Following this the donor has to answer the questionnaire regards his medical history like h/o high blood pressure, diabetes, malaria, jaundice, blood transfusion. Female donor has to provide specific information regards pregnancy or abortion. Based on the above information the donor is either rejected or sent for the further tests like Haemoglobin, Blood group and a brief physical examination. Following this the donor is registered (computer registration is also done) for the donation or rejected either Temporarily or Permanently. All rejections are entered in the Manual Donor deferral register and in the computer.
Role of MSW
The Social worker has a very important role to play in the blood bank as the counsels the donor and she makes the
donor understand the whole questionnaire. She stresses on the importance of truthful answers, motivates those who are
hesitant or scared to donate. Sometimes she has to actually persuade the very enthusiastic individual who insists on
donating though he is unfit. The temporary rejections e.g. cough and cold have to be counseled that they will be able to
donate after their illness is cured. The voluntary donor, who is the safest donor is personally looked after by the blood
bank staff. Motivation and creating awareness among donors is very crucial for us to have a long term and long lasting
solution for the shortage of blood.
5. ANTI GLOBULIN TEST
Maya Parihar-Malhotra, Pradeep Sakhalkar
The Antiglobulin test (Coombs test) was first described in 1945 by Coombs, Mourant and Race. They described a
test for detecting non-agglutinating (coating), Rh antibodies in serum. Two major classes of antibodies which react with
“Complete” or “Saline agglutinins” agglutinate rbc’s suspended in saline - these are usually IgM
“Incomplete” or “Immune agglutinins” do not react in saline and require special techniques to agglutinate rbc’s these are IgG.
Other antibodies are the IgE, IgA, IgD class
Types of Antiglobulin Tests
Two forms of antiglobulin testing are used in immunohaematology, the direct antiglobulin test (DAT) and the indirect
antiglobulin test (IAT)
Direct Antiglobulin Test (DAT)
DAT is a diagnostic procedure used to demonstrate in vivo coating of rbc’s with antibody and or complement. The DAT test is used to detect in vivo sensitization of rbc’s clinical conditions that can result in vivo coating of RBC with antibody and/or complement
1. Haemolytic disease of new born (HDN) - detection of maternal antibody coating the fetal rbc’s.
2. Haemolytic transfusion reaction (HTR) - detection of recipients antibodies coating the donor rbc
3. Autoimmune or Drug Induced haemolytic Anaemia (AIHA) - Auto Antibody coating the individuals
- Red cells are washed 3 to 4 times with large volume of saline and a 5% cells suspension is made.
- Two tubes marked T1 and T2, and 5% cells suspension is added in both.
- Put 1 drop of AHG in T1 and add drop of saline in T2, mix and keep for 5 mins.
- After 5 mins centrifuge at 1000 rpm for 1 min and see for agglutination.
- Negative or doubtful reaction should be confirmed under microscope.
- Tube containing rbc’s and saline serves as a negative control.
- To all negative Antiglobulin tests add one drop of Coomb’s control cells and look for agglutination if no
agglutination - suspect error.
Indirect Antiglobulin test (IAT)
It is used to demonstrate in vitro reaction between rbc’s and coating antibodies.
It is used in antibody detection antibody identification and blood grouping and compatibility tests.
Interpreting the significance of a positive DAT/IAT result requires knowledge of patient’s diagnosis, drug therapy and recent transfusion history. A positive DAT may occur without clinical manifestation of immune mediated haemolysis. One
must be aware of the inherent errors in the procedure due to faulty technique or operator error.