Koch, Cody A.

Abstract In a prospective study of 100 subjects, an ELISA assay was used to measure platelet-rich plasma (PRP) serotonin levels in patients with polycythemia vera (PV; n=26), essential thrombocythemia (ET; n=14), myelofibrosis with myeloid metaplasia (MMM; n=26), secondary or spurious polycythemia (SP; n=20) and controls (n=14). Neutrophil PRV-1 expression was concurrently assayed by real-time PCR in 69 patients (23 PV, 17 SP, 12 ET, 7 MMM, 10 controls). Table 1 outlines the median and range of measured values across the different study groups. Table 1 Controls SP PV ET MMM Age in years N/A 49 (18–77) 64 (32–83) 52 (18–81) 60 (22–80) Plt count x 109/L N/A 249 (157–371) 509 (191–940) 613 (284–1100) 259 (64–955) PRP serotonin; ng/109 plts 567 (360–1071) 609 (369–1780) 205 (0–496) 385 (137–1026) 90 (0–278) PRV-1/GAPDH ratio 1.28 (1.20–1.43) 1.23 (1.13–1.38) 1.03 (0.84–1.28) 1.24 (0.99–1.44) 1.25 (1.11–1.40) A highly significant difference (p < 0.0001), in PRP serotonin levels, was seen among the different disease categories and control group (table 1). The lowest levels were registered for MMM and PV with a statistically significant difference between the two groups (p = 0.015) but a large degree of overlap. The results in both were significantly as well as markedly lower than those of controls as well as SP with only slight overlap in the PV group and no overlap in the MMM group (p < 0.0001; table 1). The PRP serotonin levels in patients with ET were significantly reduced compared to both controls (p = 0.019) and SP (p = 0.002) and significantly increased compared to both PV (p = 0.0008) and MMM (p < 0.0001). However, there was a substantial degree of overlap in values between ET and other disease categories and controls. Neither aspirin nor cytoreductive therapy correlated with PRP serotonin levels (p = 0.116 and p = 0.148, respectively). Similarly, within a specific disease category, PRP serotonin level did not significantly correlate with platelet count, hemoglobin level, leukocyte count, spleen size, disease duration, or gender. However, an inverse correlation with age was noted only in MMM. In general, there was not a significant correlation between PRP serotonin level and neutrophil PRV-1 expression in each of the three myeloproliferative disease variants. Tests of sensitivity, specificity, and accuracy in distinguishing PV from SP were 92, 95, and 93% for the PRP serotonin assay and 78, 95, 86% for neutrophil PRV-1 assay, respectively. The current study suggests that PRP serotonin concentration might be considered as one of several biological markers that complement each other for the diagnosis of PV.

Nasal septal abscesses (NSAs) occur between the mucoperichondrium and the nasal septum. They most often arise when an untreated septal hematoma becomes infected. The most commonly reported sequela is a loss of septal cartilage support, which can result in a nasal deformity. Other sequelae include potentially life-threatening conditions such as meningitis, cavernous sinus thrombosis, brain abscess, and subarachnoid empyema. We report the case of a 17-year-old boy who developed an NSA after he had been struck in the face with a basketball. He presented to his primary care physician 5 days after the injury and again the next day, but his condition was not correctly diagnosed. Finally, 7 days after his injury, he presented to an emergency department with more serious symptoms, and he was correctly diagnosed with NSA. He was admitted to the intensive care unit, and he remained hospitalized for 6 days. Among the abscess sequelae he experienced was septic arthritis, which has heretofore not been reported as a complication of NSA. He responded well to appropriate treatment, although he lost a considerable amount of septal cartilage. He was discharged home on intravenous antibiotic therapy, and his condition improved. Reconstruction of the nasal septum will likely need to be pursued in the future.

Abstract When activated on or in the vicinity of cells, complement usually causes loss of function and sometimes cell death. Yet the liver, which produces large amounts of complement proteins, clears activators of complement and activated complexes from portal blood without obvious injury or impaired function. We asked whether and to what extent hepatocytes resist injury and loss of function mediated by exposure to complement. Using cells isolated from porcine livers as a model system, we found that, in contrast to endothelial cells, hepatocytes profoundly resist complement-mediated lysis and exhibit normal synthetic and conjugative functions when complement is activated on their surface. The resistance of hepatocytes to complement-mediated injury was not a function of cell surface control of the complement cascade but rather an intrinsic resistance of the cells dependent on the PI3K/Akt pathway. The resistance of hepatocytes to complement might be exploited in developing approaches to the treatment of hepatic failure or more broadly to the treatment of complement-mediated disease.

Abstract Humoral immunity, as a cause of damage to blood vessels, poses a major barrier to successful transplantation of organs. Under some conditions, humoral immunity causes little or no damage to an organ graft. We have referred to this condition, in which a vascularized graft functions in the face of humoral immunity directed against it, as “accommodation.” In this paper, we review changes in the graft and in the host that may account for accommodation, and we consider that what we call accommodation of organ grafts may occur widely in the context of immune responses, enabling immune responses to target infectious organisms without harming self-tissues.

Abstract The fetus has pluripotent stem cells that when transferred to mature individuals can generate tumors. However, for reasons yet unknown, tumors form rarely in the fetus and/or the mother during normal gestation. We questioned whether the complement system might protect against tumor formation by pluripotent stem cells. Murine embryonic stem cells were notably more susceptible than cardiomyocytes differentiated from those cells to lysis by complement in heterologous and homologous sera. Treatment of embryonic stem cells with heterologous serum averted tumor formation after residual cells were transplanted into mice. Confirming the importance of homologous complement in preventing formation of tumors, untreated embryonic stem cells formed tumors more quickly in C3-deficient than in wild-type mice. Susceptibility of embryonic stem cells to complement required an intact alternative pathway and was owed at least in part to a relative deficiency of sialic acid on cell surfaces compared with differentiated cells. Susceptibility to complement and resistance to tumors was inversely related to the number of cells transferred. These findings show that formation of tumors from embryonic stem cells is controlled in part by the alternative pathway of complement and suggest that susceptibility to complement might represent a general property of pluripotent stem cells that can be exploited to prevent tumor formation.

ObjectiveThe harvest of some microvascular free flaps for head and neck reconstruction entails tedious and time‐consuming dissection of multiple perforating vessels and/or muscular attachments. The objective of this study is to investigate the use of ultrasonic shears as a means to decrease operative time and increase surgical efficiency in the harvest of microvascular free flaps.Study DesignProspective cohort study.SettingTertiary referral center.Subjects and MethodsA prospective study of all people undergoing fibula (FFF) or anterolateral thigh (ALT) free flap reconstruction of head and neck defects was conducted from October 1, 2005, through December 30, 2009.ResultsThere were 69 FFF and 39 ALT free flaps performed by a single surgeon during the study period. Ultrasonic shears were used in 53 (76.8%) FFF and 26 (80.6%) ALT free flaps, whereas traditional dissection techniques were used in 16 (23.2%) FFF and 13 (19.4%) ALT free flaps. The use of ultrasonic shears significantly decreased the harvest time of FFF and ALT free flaps an average of 14.5 and 16.3 minutes, respectively. The average cost savings associated with the use of ultrasonic shears was $492 for FFF and $543 for ALT free flaps compared to traditional dissections techniques. Similar rates of complications were observed when ultrasonic shears were used compared to traditional techniques.ConclusionsThe use of ultrasonic shears in the harvest of microvascular free flaps decreases operative time, leading to significantly decreased costs without an increased risk of complications compared to traditional dissection techniques.

Cysts of the vallecula are rare, accounting for 10.5% to 20.1% of all laryngeal cysts. Vallecular cysts may present with diverse symptoms affecting the voice, airway, and swallowing. We describe the evaluation and treatment of a 70-year-old woman who presented with dysphagia caused by large bilateral vallecular cysts.

Hemorrhage into the soft tissues of the airway represents a potentially life-threatening complication of long-term anticoagulation. We report the case of a chronically anticoagulated 37-year-old male who developed a spontaneous hematoma of the epiglottis secondary to a supra-therapeutic INR. Epiglottic hematoma should be considered in the differential of any anticoagulated patient presenting with upper airway compromise. The airway should be secured in a controlled fashion, and the coagulopathy should be rapidly corrected.