Many patients with Thrombotic Thrombocytopenic Purpura-Hemolytic Uremic Syndrome(TTP-HUS) satisfactorily respond to plasma exchange. Some patients, however, respond either not at all or only transiently and incompletely. In the refractory case, endothelial cell-derived unusually large von Willebrand factor multimers(ULvWFM) have an important role in the formation of microthrombi. As the ULvWFM may be removed in the cryoprecipitate, we reason the plasma depleted of cryoprecipitate(the plasma cryosupernatant) should be considered for effectiveness in the treatment of refractory TTP- HUS. We experienced a 48 year old woman presented with diarrhea, jaundice and oliguria. She had microangiopathic hemolytic anemia, renal impairment, platelets of 21,000/mm3 and LDH 3,258U/L. She had not improved after plasma exchange with fresh frozen plasma(FFP)(1.5 plasma volumeX7 days). On hospital day 8, her HUS had not responded, platelets of 37,000/mm3 and LDH 1,588U/L. Substitution of cryosupernatant for FFP was associated with prompt increased in the platelet count to normal and complete resolution of HUS. Therefore. the cryosupernatant fraction of plasma should be considered as an alternative to whole FFP for plasma exchange if there is continuing platelet consumption and microvascular thrombosis in spite of intensive conventional plasma therapy.
Anemia, Hemolytic ; Blood Platelets ; Diarrhea ; Female ; Hemolytic-Uremic Syndrome* ; Humans ; Jaundice ; Middle Aged ; Oliguria ; Plasma Exchange* ; Plasma* ; Platelet Count ; Thrombosis ; von Willebrand Factor

STUDY DESIGN: Intra-articular injections of long acting steriod and local anesthetics after lumbar facet joint(LFJ) arthrography are routinely used for therapeutic purposes in selected patients for relief of chronic low back pain. However, because of the difficulty in finding an accurate position of the symptomatic joint, the possibility of complication and the placebo effect, there are doubts about the clinical application of this treatment. OBJECTIVES: This study was designed to assess the diagnostic value and clinical benefits of lumbar facet joint arthrogram & injection of long acting steriod and local anesthetics in patients with facet joint syndrome. SUMMARY OF LITERATURE REVIEW: The radiological relationship and the diagnostic elements of facet joint syndrome need to be analyzed and evaluated for increasing the effectiveness of lumbar injection. MATERIALS AND METHODS: Fifty two patients with low back pain were enrolled in the trial and they met the following criteria: pain for more than 3 months, no root signs and no history of back surgery. The response to facet joint injection was analyzed according to the chief complaints, a provocative test, the Visual Analogue Scale(VAS), the Helbig & Lee(HL) score, the facet block procedure and the arthrogram findings. A questionnaire with a pain scale was administered immediately or the day after injection, and then after 1, 3, 6 and 12 weeks. The arthrograms were reviewed by a radiologist & orthopedic specialist. RESULTS: One hundred sixty nine joint injections were performed in 52 patients (L 3-4, n=33; L4-5, n=64; L5-S1, n=72). Thirty one patients had a chief complain of back pain that was aggravated by extension/rotation of the trunk and the provocative test was positive in 73.1%. The rates of a good response in the study group were 69.2% after one day, 44.2% after 3 weeks and 36.5% after 12 months. Arthrograms revealed synovial cysts in 1 of these patients and 5 patients had abnormal communication with spondylolysis. Two patients had contrast extravasated into the epidural space during injection. CONCLUSIONS: Lumbar arthrography showed a low diagnostic value. Lumbar injections, as a useful procedure to diagnosis facet joint syndrome, could be a useful palliative treatment modality for treating chronic lower back pain. But strict diagnostic criteria through a scoring system is needed to achieve a higher degree of predictability and effectiveness of facet joint injection.
Anesthetics, Local ; Arthrography ; Back Pain ; Epidural Space ; Humans ; Injections, Intra-Articular ; Joints ; Low Back Pain ; Orthopedics ; Palliative Care ; Placebo Effect ; Surveys and Questionnaires ; Spondylolysis ; Synovial Cyst ; Zygapophyseal Joint

Although hemodialysis using heparin bound Hemophan(HBH-HD) has been reported to be a possible modality that can be used in patients at high risk of bleeding, the efficiency of HBH-HD is not certain. To investigate the efficiency of HBH- HD, we compared the total blood compartment volume(TBCV), Kt/V and urea clearance of dialyzer(K) of HBH-HD with those of routine hemodialysis with systemic heparinization(R-HD) in the same patients. HBH-HD was switched to R-HD as soon as the bleeding risk had ceased. Before each HBH-HD, heparin solution(1liter, 20IU/ml saline) was recirculated through the Hemophan(Gambro dialyzer, GFS Plus 11) for 1 hour while removing saline solution(700ml/hr) by applying transmembrane pressure gradient, followed by a single pass rinse with 1 liter of saline solution. Then we performed 10 HBH-HD on 10 patients at risk of bleeding. The dilayzer had to be changed due to severe clotting in one patient during HBH-HD so the comparison of above parameters was possible in 9 patients. The duration of each dialysis was possible in 9 patients. The duration of each dialysis was standardized to 4 hours at blood flow of 200 to 250ml/min. During HBH-HD, there was a slight increase in activated partial thromboplastin time(aPTT)(45.02.6 sec) at 15 min after initiation of dialysis from predialysis level (35.81.3 sec), but no increase in aPTT was observed at 60min, 120min, and the end of dialyses. The loss of TBCV(%) of dialyzers was greater in HBH-HD (174%) than in R-HD(51%). The Kt/V and K of HBH-HD, however, were 1.25+/-0.10 and 143+/-3ml/ min, respectively, which did not differ from those of R-HD which were 1.28+/-0.07 and 145+/-4ml/min, respectively. We conclude that the use of heparin bound Hemophan can be an efficient hemodialysis technique in patients at high risk of bleeding, but clotting of the dialyzer should be observed carefully during hemodialysis(values are mean+/-SE).
Dialysis* ; Hemorrhage ; Heparin* ; Humans ; Renal Dialysis* ; Sodium Chloride ; Thromboplastin ; Urea