Bilateral periorbital ecchymoses. An often missed sign of amyloid purpura.

Immunoglobulin light chain (AL) amyloidosis is a systemic disease caused by a plasma cell clone synthesizing an unstable light chain, which forms amyloid fibrils. Deposition of amyloid fibrils affects primarily kidney, heart, nervous system, spleen, liver, gastrointestinal tract and the skin. Skin bleeding in these patients is called amyloid purpura. Classically, it occurs spontaneously and bilaterally in the periorbital region. Vessel wall fragility and damage by amyloid are the principal causes of periorbital and gastrointestinal bleeding. Additionally, coagulation factor inhibitory circulating paraprotein, hyperfibrinolysis, platelet dysfunction or isolated acquired factor X deficiency may contribute to even more severe, diffuse bleedings. Early diagnosis remains essential for improving prognosis of patients with AL amyloidosis. Although pictures of amyloid purpura have been often reported in the literature, the clinical diagnosis may be delayed. We report a case of cutaneous manifestation of AL amyloidosis diagnosed not until one year after the appearance of the first symptoms. Diagnostic work-up revealed that the patient suffered from multiple myeloma with secondary AL amyloidosis. Atraumatic ecchymoses at the face, particularly the eyelids as well as in the neck should raise the suspicion of AL amyloidosis.

Cyanogenesis and the onset of tapping panel dryness in rubber tree

The objective of this work was to study the influence of cyanogenesis on the onset of irreversible tapping panel dryness (TPD) and the physiological and histological aspects of secondary phloem in the trunk (tapping panel) of rubber trees (Hevea spp.). Two cyanogenic compounds, linamarin and KCN, were applied separately on the trunk bark of healthy mature trees belonging to two Brazilian clones (Fx 4098 and Fx 3899). Changes in histology, latex pressure potential (ΨP) and cyanogenic potential (HCNp) were followed in the trunk inner barks. In addition, the HCNp levels were determined in TPD-affected plants of both clones. The applications of linamarin or KCN in healthy plants decreased latex ΨP, and formed tylosoids associated with in situ coagulation of latex. The clone Fx 4098 had the higher HCNp and showed the quicker and stronger responses to the cyanogenic compounds. Plants with TPD syntoms had a higher HCNp than the untreated healthy ones. Since histological changes are also structural markers of early TPD, it can be inferred that excessive release of cyanide can induce it in sensitive rubber clones

Mesenteric venous thrombosis : MDCT features according to the underlying etiology : P1

Purpose: To work out certain, well-defined aetiologies frequently associated with mesenteric venous thrombosis (MVT) in order to predict a typical population at risk, since MVT is nowadays often incidentally detected on cross-sectional imaging. To demonstrate the MDCT features, frequency and extent of associated bowel ischemia according to the underlying pathology. Methods and materials: Our electronic database revealed 71 patients (25 women, mean age 55) with thrombosis of the superior and/or inferior mesenteric vein detected by MDCT between 2000 and 2008. Two radiologists jointly reviewed the corresponding MDCT features including intraluminal extension, underlying aetiology and associated bowel ischemia, if present. Results: MVT was associated with carcinoma in 31 (43.7%) patients (pancreas 21.1%, liver 9.9%, others 12.7%). Concomitant inflammation was seen in 15 (21.1%) patients (pancreatitis 11.3%, diverticulitis 4.2%, others 5.6%), whereas coagulation/hematologic disorders were found in 7 (9.9%) patients, liver cirrhosis in 6 (8.5%), mixed/miscellaneous causes in 5 (7%) and still unknown aetiologies in 5 patients (7%). MVT resulted from recent operations in 2 (2.8%) patients. MDCT features of venous bowel ischemia were present in 15 patients (21.1%). 46.5% of MVT were (sub) acute, while 53.5% chronic. The luminal extension was complete in 52.1%, subtotal (>50% of lumen) in 22.5% and partial (<50% of lumen) in 25.4% of patients, consisting either of blood clots (76.1%) or tumoral tissue (23.9%), the latter mainly due to pancreas adenocarcinoma (76.4%). Conclusion: MDCT features of MVT are seen with a wide range of underlying diseases. Signs of intestinal ischemia are infrequently associated, mostly occurring with coagulation/hematologic disorders (40%).

Red blood cell-derived microparticles isolated from blood units initiate and propagate thrombin generation.

BACKGROUND: Red blood cell-derived microparticles (RMPs) are small phospholipid vesicles shed from RBCs in blood units, where they accumulate during storage. Because microparticles are bioactive, it could be suggested that RMPs are mediators of posttransfusion complications or, on the contrary, constitute a potential hemostatic agent. STUDY DESIGN AND METHODS: This study was performed to establish the impact on coagulation of RMPs isolated from blood units. Using calibrated automated thrombography, we investigated whether RMPs affect thrombin generation (TG) in plasma. RESULTS: We found that RMPs were not only able to increase TG in plasma in the presence of a low exogenous tissue factor (TF) concentration, but also to initiate TG in plasma in absence of exogenous TF. TG induced by RMPs in the absence of exogenous TF was neither affected by the presence of blocking anti-TF nor by the absence of Factor (F)VII. It was significantly reduced in plasma deficient in FVIII or F IX and abolished in FII-, FV-, FX-, or FXI-deficient plasma. TG was also totally abolished when anti-XI 01A6 was added in the sample. Finally, neither Western blotting, flow cytometry, nor immunogold labeling allowed the detection of traces of TF antigen. In addition, RMPs did not comprise polyphosphate, an important modulator of coagulation. CONCLUSIONS: Taken together, our data show that RMPs have FXI-dependent procoagulant properties and are able to initiate and propagate TG. The anionic surface of RMPs might be the site of FXI-mediated TG amplification and intrinsic tenase and prothrombinase complex assembly.

Functional renal failure and haemorrhagic gastritis associated with endotoxaemia in cirrhosis

Forty-three patients with cirrhosis and ascites, 21 with normal renal function, 10 with a progressive functional renal failure (FRF), and 12 with a steady FRF, were investigated for the presence of endotoxaemia by the Limulus lysate test. Endotoxaemia was found in nine patients with FRF and in none of the 21 with normal renal function (P less than 0-01). A positive Limulus test was almost exclusively associated with a progressive FRF (eight of 10 patients) and all but one of them died. Renal function improved as endotoxaemia disappeared in the survivor. Endotoxaemia was also associated with haemorrhage due to acute erosions of the gastric mucosa, being present in six of the seven patients who had this complication. Intravascular coagulation was not found in any patient. The Limulus test was positive in the ascitic fluid in 18 of 21 patients tested, although only two of them had peritonitis. These results suggest that endotoxaemia may play a critical role in the development of progressive renal failure and haemorrhagic gastritis in cirrhosis, and emphasise the potential risk of procedures involving reinfusion of ascitic fluid.

Flotaatio jätevedenpuhdistamon tertiäärivaiheena eräässä paperitehtaassa

Työn tavoitteena oli selvittää, kuinka tehokkaasti pystytään aktiivilieteprosessin läpikäynyttä, jälkiselkeytettyä vettä edelleen puhdistamaan flotaatiolla ennen sen johtamista vesistöön. Tarkoituksena oli löytää sellaiset kemikaalit ja näiden annokset, joilla tehtaalle asetetut jätevesien lupa-arvot voitaisiin huonossa tilanteessa, jätevesikuormitushuippujen aikana alittamaan. Työn kirjallisessaosassa tarkasteltiin lyhyesti, minkälaista jätevesikuormaa mekaanista massaa valmistavalta tehtaalta yleensä syntyy ja millaiset ovat tavanomaiset puhdistusmenetelmät. Myös flotaation teoriaa esiteltiin. Kokeellinen osa koostui kolmesta päävaiheesta: esi- eli niin sanotuista kuppikokeista, pilot-flotaatiokoeajoista jalaitosmittakaavan flotaatiokoeajoista. Esikokeet tehtiin niin kutsutulla Jar Test -laitteistolla ja pilot-flotaatiolaitteistona työssä käytettiin YIT:n valmistamaa pilot-flotaattoria. Laitosmittakaavan flotaatioaltaat olivat aikaisemmin biolietteen tiivistykseen käytettyjä, myöhemmin tertiääripuhdistukseen modifioituja flotaatioaltaita. Laitosmittakaavan flotaatiokoeajoissa testattiin neljän eri saostuskemikaalin ¿ polyalumiinikloridin (KEMPAC 18), rautapitoisen alumiinisulfaatin (AVR), ferrisulfaatin ja alumiinisulfaatin ¿ tehokkuutta tertiäärivaiheessa käsiteltävän veden puhdistajana. Esi- ja pilot-kokeiden perusteella laitosmittakaavan kokeisiin valittiin saostuskemikaalien rinnalle polymeeriksi Superfloc C 491. AVR- ja alumiinisulfaattiannokset laitosmittakaavan kokeissa olivat 200 ppm ja 400 ppm. KEMPAC 18- ja ferrisulfaattiannokset olivat 200ppm, 400 ppm ja 600 ppm. Polymeeriannos kokeissa oli pääasiassa 1,2 ppm. Tertiäärivaiheeseen tulevasta vedestä ja poistuvasta kirkasteesta määritettiin kiintoaine, pH, liukoinen ja kokonais-COD, liukoinen ja kokonaisfosfori sekä liukoinen ja kokonaistyppi. Laitosmittakaavan koeajojen tulosten mukaan eniten tertiäärivaiheessa saatiin käsiteltävästä vedestä erotettua fosforia ja toiseksi eniten COD:ta. Typpireduktiot olivat verrattain alhaiset ja myös kiintoainereduktiot jäivät usein pieniksi tai olivat jopa negatiiviset. Kaikki saostuskemikaalit saostivat COD- ja ravinnekuormaa. Eniten kuormaa saostuskemikaaleista saatiin erotettua AVR:llä ja toiseksi eniten KEMPAC 18:lla. Laitteistojen käyttökustannuksia huomioimatta AVR olisi edullisin vaihtoehto saostuskemikaaaliksietenkin pidempiaikaisessa käytössä. Lisäksi työssä tutkittiin polymeeriannoksen kasvattamisen 1,2 ppm:stä 2,5 ppm:ään vaikutusta puhdistustulokseen, kun saostuskemikaaliannos pidettiin vakiona. Tulosten mukaan polymeeriannoksen kasvattaminen kasvatti kokonais-COD- ja kokonaisfosforireduktiota. Myöslaitosmittakaavan flotaatioaltaiden pohjaputkistoja vertailtiin kiintoainereduktioiden perusteella. Kokeissa saatujen tulosten mukaan ei voitu sanoa, oliko toisen altaan pitkä kirkasteenpoistoputki vai toisen altaan lyhyt kirkasteenpoistoputki parempi vaihtoehto.

Hématome des muscles ilio-psoas: rappel des éléments diagnostiques

Introduction: La survenue d'une hémorragie dans les muscles iliopsoasconstitue une pathologie grave, dont le diagnostic est souventtardif et grevé d'une morbidité importante. Sa présentation cliniquedoit être reconnue précocement, en particulier par les médecins depremier recours.Cas clinique: Un patient de 65 ans est admis aux urgences en raisonde douleurs invalidantes de la jambe droite, prédominant sur la faceantérieure de la cuisse. Les douleurs irradient dans le pli inguinal, leflanc, la région lombaire, ainsi que la hanche droite. Elles sont associéesà une parésie du quadriceps droit. Le patient a bénéficié en2006 d'un remplacement de valve aortique, avec implantation d'unevalve mécanique motivant une anticoagulation par acenocoumarol.Il présente par ailleurs une parésie sur le territoire du nerf sciatiquedroit, après fracture du bassin en 1970. Le diagnostic est évoqué auvu d'une antioagulation supra-thérapeutique (INR 5).Un CT-scan de l'abdomen confirmera un important hématome(11 x 7 cm) du muscle iliaque droit (fig. 1) qui sera drainé chirurgicalement,après réversion partielle de la crase, permettant une évolutionfavorable.Discussion: Les hématomes des muscles ilio-psoas surviennentclassiquement de manière spontanée. Les symptômes sont peu spécifiques,à type de douleurs diffuses abdominales, lombaires ou crurales,de paresthésies, de limitation fonctionnelle ou de chute isoléede l'hémoglobine (Hb). Les patients sous anticoagulants (héparine,acenocoumarol) ou présentant des troubles de la coagulation (hémophilie,thrombopathie, maladie de von Willebrand) sont particulièrementà risque. Les complications sont fréquentes: compressions dunerf fémoral (avec hypoesthésie, parésie du quadriceps ou abolitiondu réflexe rotulien), anémie, état de choc. Le traitement implique lacorrection des troubles de la coagulation, ainsi qu'un suivi clinique,radiologique et biologique (Hb) régulier. Le traitement conservateurest proposé lors d'hématome de petite taille, si le patient est stable etpeu symptomatique. Dans les autres cas, un drainage chirurgical parvoie ouverte ou par voie percutanée est recommandé. L'embolisationartérielle s'affiche comme une future option thérapeutique.Conclusions: Ce cas illustre les différents éléments cliniques etbiologiques qui orientent précocement vers le diagnostic d'hématomedes muscles ilio-psoas. Il devrait favoriser l'évocation d'une pathologierare, permettant de garantir un diagnostic précoce.

Sellu ja paperiteollisuuden jätevesien tertiäärikäsittelyn kemikaloinnin optimointi

Kuluneen vuosikymmenen aikana metsäteollisuuden päästöt ympäristöön ovat pienentyneet huomattavasti tuotantomäärien kasvustahuolimatta. Lainsäädännön myötä lupa-arvot tiukentuvat edelleen joten olemassa olevia puhdistus prosesseja on parannettava ja niiden rinnalle on kehitettävä uusia, yhä tehokkaampia menetelmiä. Aquaflow Oy suunnittelee jäteveden puhdistamoja sellu- ja paperiteollisuuteen. Kilpailun kiristyessä kilpailuetua haetaan jatkuvan kehittymisen kautta. Yhä useammilla jäteveden puhdistamoilla tarvitaan teriäärikäsittely biohajoamattoman aineksen poistamiseen. Tertiäärikäsittely on käyttökustannuksiltaan kallis kemikaali kulutuksensa vuoksi. Tässä työssä pyrittiin optimoimaan tertiääriprosessin kemikaalien syöttöä. Lisäksi selvitettiin millaisissa oloissa keskeiset saostus ja flokkaus prosessit toimivatparhaiten, sekä mitkä tekijät vaikuttavat merkittävästi jäteveden kemiallisen käsittelyn tulokseen. Saatujen tulosten perusteella kemikaalien sekoituksen tehostuksen seurauksena kemikaali määriä voidaan pienentää, samalla puhdistustulos paranee ja jäännöskemikaalien määrä pienenee. pH:n säätö on olennainen osa prosessin toiminnan kannalta, jos pH ei ole kemikaalien toiminta alueella ei puhdistusta tapahdu ja kemikaalit kulkeutuvat luontoon. Tertiäärikäsittelyyn tulevan jäteveden online seurannan avulla juuri oikea kemikaaliannos olisihelpompaa määrittää kuin päivän viiveellä tulevien laboratorio analyysien perusteella ja yli-/ali annostukselta vältyttäisiin

Assessing Patient's belief on HIV testing before elective surgery: place for improvements in Switzerland

Background and aim of the study: In Switzerland no HIV test is performed without the patient's consent based on a Voluntary Counseling and Testing policy (VCT). We hypothesized that a substantial proportion of patients going through an elective surgery falsely believed that an HIV test was performed on a routine basis and that the lack of transmission of result was interpreted as being HIV negative. Material and method: All patients with elective orthopedic surgery during 2007 were contacted by phone in 2008. A structured questionnaire assessed their belief about routine preoperative blood analysis (glycemia, coagulation capacity, HIV serology and cholesterol) as well as result awareness and interpretation. Variables included age and gender. Analysis were conducted using the software JMP 6.0.3. Results: 1123 patients were included. 130 (12%) were excluded (i.e. unreachable, unable to communicate on the phone, not operated). 993 completed the survey (89%). Median age was 51 (16-79). 50% were female. 376 (38%) patients thought they had an HIV test performed before surgery but none of them had one. 298 (79%) interpreted the absence of result as a negative HIV test. A predictive factor to believe an HIV test had been done was an age below 50 years old (45% vs 33% for 16-49 years old and 50-79 years old respectively, p <0.001). No difference was observed between genders. Conclusion: In Switzerland, nearly 40% of the patients falsely thought an HIV test had been performed on a routine basis before surgery and were erroneously reassured about their HIV status. These results should either improve the information given to the patient regarding preoperative exams, or motivate public health policy to consider HIV opt-out screening, as patients are already expecting it.

Wet Oxidation of Concentrated Wastewaters: Process Combination and Reaction Kinetic Modeling

The accumulation of aqueous pollutants is becoming a global problem. The search for suitable methods and/or combinations of water treatment processes is a task that can slow down and stop the process of water pollution. In this work, the method of wet oxidation was considered as an appropriate technique for the elimination of the impurities present in paper mill process waters. It has been shown that, when combined with traditional wastewater treatment processes, wet oxidation offers many advantages. The combination of coagulation and wet oxidation offers a new opportunity for the improvement of the quality of wastewater designated for discharge or recycling. First of all, the utilization of coagulated sludge via wet oxidation provides a conditioning process for the sludge, i.e. dewatering, which is rather difficult to carry out with untreated waste. Secondly, Fe2(SO4)3, which is employed earlier as a coagulant, transforms the conventional wet oxidation process into a catalytic one. The use of coagulation as the post-treatment for wet oxidation can offer the possibility of the brown hue that usually accompanies the partial oxidation to be reduced. As a result, the supernatant is less colored and also contains a rather low amount of Fe ions to beconsidered for recycling inside mills. The thickened part that consists of metal ions is then recycled back to the wet oxidation system. It was also observed that wet oxidation is favorable for the degradation of pitch substances (LWEs) and lignin that are present in the process waters of paper mills. Rather low operating temperatures are needed for wet oxidation in order to destruct LWEs. The oxidation in the alkaline media provides not only the faster elimination of pitch and lignin but also significantly improves the biodegradable characteristics of wastewater that contains lignin and pitch substances. During the course of the kinetic studies, a model, which can predict the enhancements of the biodegradability of wastewater, was elaborated. The model includes lumped concentrations suchas the chemical oxygen demand and biochemical oxygen demand and reflects a generalized reaction network of oxidative transformations. Later developments incorporated a new lump, the immediately available biochemical oxygen demand, which increased the fidelity of the predictions made by the model. Since changes in biodegradability occur simultaneously with the destruction of LWEs, an attempt was made to combine these two facts for modeling purposes.

The year in cardiology 2014: peripheral circulation.

In 2014, the debate on the indication of revascularization in case of asymptomatic carotid disease continued, while another one regarding the use of surgery vs. stenting addressed some new issues regarding the long-term cardiac risk of these patients. Renal arteries interventions trials were disappointing, as neither renal denervation nor renal artery stenting was found associated with better blood pressure management or outcome. In contrast, in lower-extremities artery disease, the endovascular techniques represent in 2014 major alternatives to surgery, even in distal arteries, with new insights regarding the interest of drug-eluting balloons. Regarding the aorta, the ESC published its first guidelines document on the entire vessel, emphasizing on the role of every cardiologist for screening abdominal aorta aneurysm during echocardiography. Among vascular wall biomarkers, the aorta stiffness is of increasing interest with new data and meta-analysis confirming its ability to stratify risk, whereas carotid intima-media thickness showed poor performances in terms of reclassifying patients into risk categories beyond risk scores. Regarding the veins, new data suggest the interest of D-dimers and residual venous thrombosis to help the decision of anti-coagulation prolongation or discontinuation after the initial period of treatment for deep vein thrombosis.

Médecine d'urgence [Emergency medicine: updates 2013].

New evidences published this year are susceptible to change the management of several medical emergencies. Combined antiplatelet therapy might be beneficial for the management of TIA or minor stroke and rapid blood pressure lowering might improve the outcome in patients with intracerebral hemorrhage. A restrictive red cell transfusion strategy is indicated in case of upper digestive bleeding and coagulation factors concentrates are superior to fresh frozen plasma for urgent warfarin reversal. Prolonged systemic steroid therapy is not warranted in case of acute exacerbation of BPCO, and iterative physiotherapy is not beneficial after acute whiplash. Finally, family presence during cardiopulmonary resuscitation may reduce post-traumatic stress disorder among relatives.

Flokkulaation seuraaminen partikkelikokoanalysaattorilla

Tässä työssä tutkittiin kahden erilaisen partikkelikokoanalysaattorin, PSyA:n ja PIA:n soveltuvuutta flokkuloinnin online-seurantaan. Kummallekin menetelmälle määritettiin raja-arvot, kuten lietteen maksimisakeus. Lisäksi tutkittiin flokkulanttiannostuksen, sekoitusnopeuden, sekoitusajan ja lietteen kiintoainepitoisuuden vaikutusta flokkikokojakaumaan. Kirjallisuusosassa tarkasteltiin kolloidisen suspension ominaispiirteitä, koaguloinnin ja flokkuloinnin teoriaa, flokkulaation kokeellista tutkimista sekä prosessin jatkuvatoimiseen seurantaan soveltuvia laitteita. Lisäksi esitettiin taustaa hydrometallurgisesta prosessista, johon työ liittyy. Flokkauskokeissa käytettiin jätevettä, jonka koostumus vastasi metalliteollisuuden peittausjätevesien tyypillistä koostumusta. Tutkittava jätevesimäärä käsiteltiin ensin kalkkimaidolla, jonka jälkeen saostunut kiintoaine flokattiin synteettisellä polymeeriflokkulantilla. Lietteen keskimääräinen kiintoainepitoisuus oli n. 10 g/l. Esikokeiden perusteella PSyA:lla voitiin mitata ilman laimennusta, mutta PIA:lla tuloksia ei saatu ilman laimentamista kiintoainepitoisuuteen n. 2,5 g/l. Kokeiden aikana havaittiin, että flokit muodostuivat erittäin nopeasti. Flokkien hajoaminen alkoi pian sen jälkeen, kun flokkulantin annostelu lopetettiin. Sekoitusnopeudella 40 r/min tai alle flokit alkoivat laskeutua astian pohjalle sekoituksesta huolimatta ja ne pysyivät pitempään koossa kuin suuremmilla sekoitusnopeuksilla. 5 - 10 minuutin kuluttua flokkulantin lisäämisestä saavutettiin tasapaino, jolloin flokkien kokojakauma ei enää muuttunut. Sekoitusnopeuksilla 80 r/min ja 120 r/min tasapainotilanteen koko-jakauma oli selvästi kapeampi kuin pienimmällä sekoitusnopeudella. Alkuperäisessä lietteessä flokit olivat suurempia kuin laimennetussa lietteessä. PSyA:lla jännepituusjakaumien määrittäminen oli varsin hidasta prosessissa tapahtuviin muutoksiin verrattuna, ja tuloksissa oli suurta hajontaa. PIA:lla saadut partikkelikokojakaumat sitä vastoin olivat johdonmukaisempia, vaikka suurimpien flokkien määrittäminen osoittautuikin epämääräiseksi. Menetelmän suurimmaksi puutteeksi todettiin soveltumattomuus sakeiden lietteiden analysointiin. Kumpikaan menetelmä ei ilman modifiointia sovellu tutkitun lietteen kaltaisten prosessilietteiden flokkuloinnin seurantaan.

Fetal laser therapy: applications in the management of fetal pathologies.

Fetoscopic coagulation of placental anastomoses is the treatment of choice for severe twin-to-twin transfusion syndrome. In the present day, fetal laser therapy is also used to treat amniotic bands, chorioangiomas, sacrococcygeal teratomas, lower urinary tract obstructions and chest masses, all of which will be reviewed in this article. Amniotic band syndrome can cause limb amputation by impairing downstream blood flow. Large chorioangiomas (>4 cm), sacrococcygeal teratomas or fetal hyperechoic lung lesions can lead to fetal compromise and hydrops by vascular steal phenomenon or compression. Renal damage, bladder dysfunction and lastly death because of pulmonary hypolasia may be the result of megacystis caused by a posterior urethral valve. The prognosis of these pathologies can be dismal, and therapy options are limited, which has brought fetal laser therapy to the forefront. Management options discussed here are laser release of amniotic bands, laser coagulation of the placental or fetal tumor feeding vessels and laser therapy by fetal cystoscopy. This review, largely based on case reports, does not intend to provide a level of evidence supporting laser therapy over other treatment options. Centralized evaluation by specialists using strict selection criteria and long-term follow-up of these rare cases are now needed to prove the value of endoscopic or ultrasound-guided laser therapy.