DIAGNOSIS OF HEMORRHAGIC DISEASES—Evaluation of Procedures—Part II Preoperative Tests

Routine preoperative tests such as the determination of bleeding time and coagulation time are unnecessary and are not recommended. Rulings which require routine preoperative tests result in the adoption of inferior and unreliable time-saving methods in the laboratory. If the clinical staff insists that laboratory procedures to predict hemorrhage be performed on every patient scheduled for operation, approved methods of performing the tests should be employed.Preoperative procedures should include a personal and a family history, a careful and complete physical examination and screening laboratory tests such as urinalysis, hematocrit, leukocyte count and smear examination, including estimation of the number of thrombocytes.Special hemorrhagic studies are indicated on selected patients. These selected patients include those who have a history of abnormal bleeding, those who consider themselves “easy bleeders” or who have apprehension concerning hemorrhage at the time of operation, and those who have physical signs of hemorrhage. Special hemorrhagic studies should also be performed on patients who have diseases that are known to be associated with vascular and coagulation abnormalities, infants who have not been subjected to tests of trauma and on patients from whom a reliable history cannot be obtained.Extra precaution should be taken if operation is to be performed in hospitals or clinics that do not have adequate blood banking facilities and if the operation to be performed is one in which difficulty in hemostasis is anticipated.The preoperative tests that are indicated on selected patients should include as a minimum: The thrombocyte count, determination of the bleeding time by the Ivy method, determination of the coagulation time by the multiple tube method and the observation of the clot. Where facilities are available, the hemorrhagic study should also include the plasma and serum prothrombin activity tests.     

Severe Colonic Bleeding

Patients requiring emergency operation for severe acute colonic hemorrhage usually arrive in the operating room inadequately studied and the point of bleeding not known. A well planned procedure for making an operative diagnosis is lacking.The fact that diverticular disease is the most common cause of massive colonic bleeding, dominates the surgical management of this problem. A critical interpretation of the color and the consistency of the stools must be made by the surgeon. Since the bleeding lesion is usually otherwise clinically silent, the character of the stools may be the only indication of the level of bleeding and the rate and the amount of the blood loss. A proctoscopic examination, followed by an emergency barium enema study if possible, is always done before subjecting a patient to laparotomy.The indications for emergency operation include acute exsanguinating hemorrhage, less severe but persistent colonic bleeding and recurrent colonic bleeding. The steps for the operative diagnosis and the surgical procedure utilized for a specific situation are discussed.     

CEREBRAL ANGIOGRAPHY—Its Use in Acute Head Injuries and Undiagnosed Coma

One of the major factors in treating a patient with acute alteration of consciousness is to determine if progressive intracranial hemorrhage is present. Similar problems are encountered in cases of cerebrovascular disease where increasingly effective medical and surgical methods of treatment are available. Progressive cerebral thrombosis can be arrested by anticoagulants, intracranial hemorrhage can be controlled and atheromatous occlusion of a major artery can be corrected. Intracranial mass lesions can be detected when the history is not available or is misleading.Cerebral angiography is a relatively safe diagnostic test that is certainly preferable to delayed or haphazard treatment when an exact diagnosis is uncertain in an unconscious patient.     

Hemorrhage induces an increase in serum TNF which is not associated with elevated levels of endotoxin

Although tumor necrosis factor (TNF) and interleukin 6 (IL 6) are purported to be important mediators of inflammatory responses following trauma, it is not known if the serum levels of these cytokines are altered by simple hemorrhage. The objective of this study therefore was to determine whether or not: 1) there is any elevation of TNF or IL 6, and 2) if endotoxin, an important upregulator of these cytokines, is also increased following hemorrhage. To study this, C3H/HeN mice were bled to, and maintained at a mean blood pressure of 35 mmHg for 60 min, and then resuscitated with their own shed blood and adequate fluid. Mice were sacrificed at 30 min into hemorrhage and at 2, 4 or 24 hr post-hemorrhage to obtain serum samples. IL 6 and TNF levels were measured using cytokine dependent cellular assays. Using a quantitative Limulus amebocyte lysate assay, endotoxin levels were determined. TNF levels were significantly elevated at 30 min into hemorrhage, remaining so at 2 hr after resuscitation, but absent by 4 hr. Although there was a trend toward elevated IL 6 levels at 2 hr following hemorrhage, which was sustained up to 24 hr, the values were not significantly different from sham controls. When compared to controls, no marked increase in endotoxin was seen at any time point during or following hemorrhage. These results indicate that hemorrhage, in the absence of significant tissue trauma, causes enhanced TNF release which is not the result of increased endotoxin.     

Hepatocerebral dysfunction

Routine preoperative tests such as the determination of bleeding time and coagulation time are unnecessary and are not recommended. Rulings which require routine preoperative tests result in the adoption of inferior and unreliable time-saving methods in the laboratory. If the clinical staff insists that laboratory procedures to predict hemorrhage be performed on every patient scheduled for operation, approved methods of performing the tests should be employed. Preoperative procedures should include a personal and a family history, a careful and complete physical examination and screening laboratory tests such as urinalysis, hematocrit, leukocyte count and smear examination, including estimation of the number of thrombocytes. Special hemorrhagic studies are indicated on selected patients. These selected patients include those who have a history of abnormal bleeding, those who consider themselves "easy bleeders" or who have apprehension concerning hemorrhage at the time of operation, and those who have physical signs of hemorrhage. Special hemorrhagic studies should also be performed on patients who have diseases that are known to be associated with vascular and coagulation abnormalities, infants who have not been subjected to tests of trauma and on patients from whom a reliable history cannot be obtained. Extra precaution should be taken if operation is to be performed in hospitals or clinics that do not have adequate blood banking facilities and if the operation to be performed is one in which difficulty in hemostasis is anticipated. THE PREOPERATIVE TESTS THAT ARE INDICATED ON SELECTED PATIENTS SHOULD INCLUDE AS A MINIMUM: The thrombocyte count, determination of the bleeding time by the Ivy method, determination of the coagulation time by the multiple tube method and the observation of the clot. Where facilities are available, the hemorrhagic study should also include the plasma and serum prothrombin activity tests.     

LABORATORY DIAGNOSIS OF TYPHOID FEVER—With Notes on Treatment

As indicated by a study of 41 cases of typhoid fever treated in three years, blood culture alone is often sufficient for the diagnosis of the disease if a large (30 cc.) specimen is used. Demonstration of the organism is the only completely diagnostic measure, but this was also achieved by the Widal reaction, by fecal or urine culture, or by aspirated bile culture, which in one case gave the only positive response.Chloramphenicol is the drug of choice in treating typhoid fever. Since only 25 per cent of patients develop immunity, immunizing injections should be started a week after therapy is discontinued.     

SPONTANEOUS SUBARACHNOID HEMORRHAGE

Sudden development of pain in the head followed by evidences of meningeal irritation, with or without motor or sensory symptoms or signs, is almost pathognomonic of subarachnoid hemorrhage. The final diagnosis rests upon the demonstration of blood in the cerebrospinal fluid. If the hemorrhage is massive, or from an aneurysm of an unprotected arterial trunk, the patient may die in a comparatively short time. If the bleeding is less abundant and from an aneurysm which is protected by adjacent structures the patient may survive. Angiography should probably be done early in most cases. If neurological signs or the results of angiography indicate that the aneurysm is in such a location that surgical treatment is feasible it should probably be undertaken. If medical treatment is to be carried out the patient should have protracted rest, frequent spinal drainage so long as the cerebrospinal fluid contains blood or is under materially increased pressure, sedatives and analgesics, and passive movements of the neck and limbs to forestall limitation of motion of joints.     

Laboratory diagnosis of typhoid fever with notes on treatment

As indicated by a study of 41 cases of typhoid fever treated in three years, blood culture alone is often sufficient for the diagnosis of the disease if a large (30 cc.) specimen is used. Demonstration of the organism is the only completely diagnostic measure, but this was also achieved by the Widal reaction, by fecal or urine culture, or by aspirated bile culture, which in one case gave the only positive response. Chloramphenicol is the drug of choice in treating typhoid fever. Since only 25 per cent of patients develop immunity, immunizing injections should be started a week after therapy is discontinued.     

CONTROL OF PULMONARY HEMORRHAGE BY INTRAVENOUS USE OF PITUITRIN

Pituitrin® is the best available drug for control of severe pulmonary hemorrhage. It must be used intravenously to be effective. Untoward effects are minimal and transient if the technique described is scrupulously followed.It can be used immediately for control of pulmonary hemorrhage from whatever cause. An adequate diagnosis of the pulmonary condition responsible for the hemorrhage must then be made.     

Correlation study of benign cytomorphology and final clinical diagnosis

OBJECTIVE: To assess significance of cytologically benign vitreous samples and identify cellular patterns that may correspond to specific clinical entities. STUDY DESIGN: Vitreous fluids with "negative for malignancy" cytologic diagnosis were identified from pathology department records, cytologic slides reviewed and clinical and follow-up information obtained. RESULTS: Fifty-four cytologically benign samples were identified (1994-2004). The main indication for vitrectomy was confirmation of intraocular inflammatory process. Malignant process was included in the differential diagnoses of most samples. Macrophages or lymphocytes were the predominant cell types in 76% of cases. Most cases with macrophage or lymphocyte predominance were diagnosed as chronic uveitis or vitritis of unknown etiology. Infectious agents were identified in 7 cases with macrophage or lymphocyte predominance, 2 with abundant neutrophils and 1 with eosinophils. One had a diagnosis of malignant lymphoma, based on vitreous fluid from the opposite eye at another hospital. Three cases had blood only and 1 had lens fragments, both consistent with the diagnosis. CONCLUSION: Most cytologic features of benign vitreous fluids did not correspond to specific clinical entities. Abundant eosinophils suggested parasitic infection; the almost exclusive presence of blood indicated hemorrhage. Based on our study, negative predictive value of a benign vitreous sample is 98%.     

Effects of citrated whole blood transfusion in response to hemorrhage.

BACKGROUND AND PURPOSE: Standard treatment for massive hemorrhage in dogs is infusion of whole blood or of packed red blood cells with fresh frozen plasma if whole blood is not available. Although most whole blood is collected using a citrate-based anticoagulant, knowledge of citrate's relevant non-anticoagulant effects is not widespread. Citrate's anticoagulant activity is achieved through chelation of divalent metal cations (e.g., magnesium, calcium), which may exacerbate cardiovascular and metabolic insults attributable to hemorrhage. METHODS: Blood pressures, gas tensions, metabolites, and electrolytes; myocardial metabolites, pressures, and contractility; cardiac output; and left cranial descending and circumflex coronary artery flows were measured in 21 anesthetized dogs after hemorrhage was induced by collection of blood into a citrated reservoir to mean arterial pressure of 45 mm Hg for approximately 60 min (until arterial lactate concentration was 7.0 mmol/L), followed by a 1-h transfusion and 2 h of maintenance. RESULTS: Arterial ionized calcium concentration, total peripheral resistance, and myocardial function decreased significantly during hemorrhage. All aforementioned responses but myocardial function continued to decrease during the initial 20 min of transfusion, then began to recover. Total peripheral resistance and end-systolic elastance were the only factors significantly related to calcium concentration. CONCLUSION: Transfusion with citrated whole blood may significantly alter calcium concentration, negatively affecting myocardial and vascular function.     

Rectal examination in general practice.

OBJECTIVE--To investigate factors influencing a general practitioner''s decision to do a rectal examination in patients with anorectal or urinary symptoms. DESIGN--Postal questionnaire survey. SETTING--General practices in inner London and Devon. SUBJECTS--859 General practitioners, 609 (71%) of whom returned the questionnaire. MAIN OUTCOME MEASURES--Number of rectal examinations done each month; the indication score, derived from answers to a question asking whether the respondent would do a rectal examination for various symptoms; and the confidence score, which indicated the respondent''s confidence in the diagnosis made on rectal examination. RESULTS--279 General practitioners did five or fewer rectal examinations each month and 96 did more than 10 each month. Factors significantly associated with doing fewer rectal examinations were a small partnership and being a female general practitioner, and the expectation that the examination would be repeated. Lack of time in the surgery, and a waiting time of less than two weeks for an urgent outpatient appointment were also important. General practitioners were deterred from doing rectal examinations by reluctance of the patient (278), the expectation that the examination would be repeated (141), and lack of time (123) or a chaperone (39). Confidence in diagnosis was significantly associated with doing more rectal examinations, the perception of having been well taught to do a rectal examination at medical school, and being a male general practitioner. CONCLUSIONS--Factors other than clinical judgment influence the frequency of rectal examination in general practice. Rectal examination may become commoner with the trend towards larger group practices and if diagnostic confidence is increased and greater emphasis put on rectal examination in undergraduate and postgraduate teaching.     

Hemodynamic effects of blood loss during a passive response to a stressor in the conscious rabbit

In the conscious rabbit, exposure to an air jet stressor increases arterial pressure, heart rate, and cardiac output. During hemorrhage, air jet exposure extends the blood loss necessary to produce hypotension. It is possible that this enhanced defense of arterial pressure is a general characteristic of stressors. However, some stressors such as oscillation (OSC), although they increase arterial pressure, do not change heart rate or cardiac output. The cardiovascular changes during OSC resemble those seen during freezing behavior. In the present study, our hypothesis was that, unlike air jet, OSC would not affect defense of arterial blood pressure during blood loss. Male New Zealand White rabbits were chronically prepared with arterial and venous catheters and Doppler flow probes. We removed venous blood until mean arterial pressure decreased to 40 mmHg. We repeated the experiment in each rabbit on separate days in the presence and absence (SHAM) of OSC. Compared with SHAM, OSC increased arterial pressure 14 +/- 1 mmHg, central venous pressure 3.3 +/- 0.4 mmHg, and hindquarter blood flow 34 +/- 4% while decreasing mesenteric conductance 32 +/- 3% and not changing heart rate or cardiac output. During normotensive hemorrhage, OSC enhanced hindquarter and renal vasoconstriction. Contrary to our hypothesis, OSC (23.5 +/- 0.6 ml/kg) increased the blood loss necessary to produce hypotension compared with SHAM (16.8 +/- 0.6 ml/kg). In nine rabbits, OSC prevented hypotension even after a blood loss of 27 ml/kg. Thus a stressful stimulus that resulted in cardiovascular changes similar to those seen during freezing behavior enhanced defense of arterial pressure during hemorrhage.     

Hypoxémies sévère en cours de CEC : démarches diagnostiques et conduite à tenir

The occurring of hypoxemia during CPB is a potentially serious event that requests emergency correction. Hypoxemia can be documented by repeated arterial blood gases, either systematic, or performed because of a dark red coloration of arterial blood or a drop in venous oxygen saturation, pulse oximetry or near infrared spectroscopy. The continuous surveillance of PaO₂, if available, will provide the earliest diagnosis. Except hypoxemia due to operating troubles (low flow on a canulation problem, acute haemorrhage, insufficient anaesthesia, etc.), hypoxemia during CPB is linked either to a defect in the administering of gases at the oxygenator, or to a deficient oxygenator. The analysis of the fraction of oxygen at the oxygenator exit (FeoO₂) will prove the defect in the administering of gases. The treatment consists in the use of a spare oxygen cylinder in case of hospital supply failure, the use of the accessory anaesthesia circuit in case of a flaw in the flow meter, or the identification and repair of leaks. In case of a deficient oxygenator, the measure of resistances will differentiate an obstruction associated to a shunt (caused by a lack in anticoagulation, or by platelet activation phenomenon, whether transitional or not) from a loss in the membrane transfer properties, which will most often request a replacement of the oxygenator.     

IDIOPATHIC PULMONARY HEMOSIDEROSIS

Idiopathic pulmonary hemosiderosis is a rare condition manifested by recurrent pulmonary hemorrhage of unknown cause, diffuse radiologic abnormalities, cough, hemoptysis and moderate to severe hypochromic anemia. Diagnosis can be confirmed by iron stains of the sputum or lung aspiration or by biopsy. Prolonged spontaneous remission may occur without the use of corticosteroid therapy. Studies here reported indicated that the anemia is hypochromic and microcytic anemia of blood loss and iron deficiency, in spite of the presence of large amounts of iron in the pulmonary tissue. Correction of the anemia by intensive iron therapy and transfusion is considered an important part of therapy.     

Fetal exsanguination associated with antepartum hemorrhage.

Fetal bleeding in utero is infrequent. It is usually life-threatening but can be treated successfully in most cases if recognized early. Four cases are described and it is suggested that screening for fetal blood be done in all instances of antepartum hemorrhage.     

Blood Levels of Glial Fibrillary Acidic Protein (GFAP) in Patients with Neurological Diseases

Background and Purpose

The brain-specific astroglial protein GFAP is a blood biomarker candidate indicative of intracerebral hemorrhage in patients with symptoms suspicious of acute stroke. Comparably little, however, is known about GFAP release in other neurological disorders. In order to identify potential “specificity gaps” of a future GFAP test used to diagnose intracerebral hemorrhage, we measured GFAP in the blood of a large and rather unselected collective of patients with neurological diseases.

Methods

Within a one-year period, we randomly selected in-patients of our university hospital for study inclusion. Patients with ischemic stroke, transient ischemic attack and intracerebral hemorrhage were excluded. Primary endpoint was the ICD-10 coded diagnosis reached at discharge. During hospital stay, blood was collected, and GFAP plasma levels were determined using an advanced prototype immunoassay at Roche Diagnostics.

Results

A total of 331 patients were included, covering a broad spectrum of neurological diseases. GFAP levels were low in the vast majority of patients, with 98.5% of cases lying below the cut-off that was previously defined for the differentiation of intracerebral hemorrhage and ischemic stroke. No diagnosis or group of diagnoses was identified that showed consistently increased GFAP values. No association with age and sex was found.

Conclusion

Most acute and chronic neurological diseases, including typical stroke mimics, are not associated with detectable GFAP levels in the bloodstream. Our findings underline the hypothesis that rapid astroglial destruction as in acute intracerebral hemorrhage is mandatory for GFAP increase. A future GFAP blood test applied to identify patients with intracerebral hemorrhage is likely to have a high specificity.     

Spontaneous retroperitoneal hemorrhage caused by segmental arterial mediolysis

Spontaneous retroperitoneal hemorrhage is a rare clinical entity; signs and symptoms include pain, hematuria, and shock. Spontaneous retroperitoneal hemorrhage can be caused by tumors, such as renal cell carcinoma and angiomyolipoma; polyarteritis nodosa; and nephritis. The least common cause is segmental arterial mediolysis. Although computed tomography is used for the diagnosis of spontaneous retroperitoneal hemorrhage, it can miss segmental arterial mediolysis as the cause of the hemorrhage. The diagnosis of segmental arterial mediolysis as a cause of spontaneous retroperitoneal hemorrhage requires angiography, with pathologic confirmation for a definitive diagnosis.     

Impaired hemorrhage tolerance in the obese Zucker rat model of metabolic syndrome.

As obese Zucker rats (OZR) manifesting the metabolic syndrome exhibit enhanced vascular adrenergic constriction and potentially an enhanced adrenergic activity vs. lean Zucker rats (LZR), this study tested the hypothesis that OZR exhibit an improved tolerance to progressive hemorrhage. Preliminary experiments indicated that, corrected for body mass, total blood volume was reduced in OZR vs. LZR. Anesthetized LZR and OZR had a cremaster muscle prepared for in situ videomicroscopy and had renal, splanchnic, hindlimb, and skeletal muscle perfusion monitored with flow probes. Arterial pressure, arteriolar reactivity to norepinephrine, and tissue/organ perfusion were monitored after either infusion of phentolamine or successive withdrawals of 10% total blood volume. Phentolamine infusion indicated that regional adrenergic tone under control conditions differs substantially between LZR and OZR, whereas with hemorrhage OZR exhibit decompensation in arterial pressure before LZR. Renal, distal hindlimb, and skeletal muscle perfusion decreased more rapidly and to a greater extent in OZR vs. LZR after hemorrhage. In contrast, hemorrhage-induced reductions in splanchnic perfusion in OZR lagged behind those in LZR, although a similar maximum reduction was ultimately attained. With increasing hemorrhage, cremasteric arteriolar tone increased more in OZR than LZR, and this increase in active tone was entirely due to an elevated adrenergic contribution. Norepinephrine-induced arteriolar constriction was greater in OZR vs. LZR under control conditions and during hemorrhage, with arterioles from OZR demonstrating early closure vs. LZR. These results suggest that a combination of reduced blood volume and elevated peripheral adrenergic constriction contribute to impaired hemorrhage tolerance in OZR.     

VOMITING AS A SYMPTOM OF SERIOUS DISEASE IN INFANTS AND CHILDREN

Vomiting or its lesser stages—anorexia, nausea—is a prime symptom of the most serious surgically curable diseases of childhood.In the newborn, when vomitus is green, abdomen scaphoid, and erect roentgen view shows air-fluid levels in stomach and duodenum with gas beyond, partial duodenal obstruction is present and midgut volvulus with malrotation is likely enough to justify immediate exploration.In infancy, vomiting is a clear sign of intussusception when associated with intermittent colicky pain, palpable mass and “currant-jelly” feces. These symptoms are not always present, and if there is blood in the feces, barium enema study must follow. In further doubt, exploration may be justified.In childhood, a common early symptom of appendicitis is vomiting accompanied by pain without any complete remission. Constipation is frequent but diarrhea may occur and contribute to an impression of gastroenteritis. Complete and repeated physical examination, with a history of the above symptoms, should lead to correct diagnosis.