Preventing severe infection after splenectomy

The Diagnosis and Management of Pediatric Blunt Abdominal Trauma-A Comprehensive Review

Blunt abdominal trauma in childhood has always been full of diagnostic and therapeutic challenges that have tested the clinical and radiological skills of pediatric surgeons and radiologists. Despite the guidelines and the studies carried out so far, to this day, there is no absolute consensus on certain points of view. Around the world, a paradigm shift towards non-operative treatment of hemodynamically stable children, with low complication rates, is noticeable. Children with blunt abdominal trauma require a standardized methodology to provide the best possible care with the best possible outcomes. This comprehensive review systematizes knowledge about all aspects of caring for children with blunt abdominal trauma, from pre-hospital to post-hospital care.

Giant splenic cyst: A case series of rare and challenging cases from the last 22 years

INTRODUCTION AND IMPORTANCE

Splenic cyst is a rare disease, with reported incidences ranging from 0.07 to 0.3 %. A splenic cyst is typically discovered inadvertently and may not cause any symptoms until it grows to a significant size. In some cases, complications such as acute abdomen may be brought on by an intracystic hemorrhage, rupture, or infection. As a rare disease, diagnosing a splenic cyst is still precarious because only a few cases have been reported.

CASE PRESENTATION

The first case is a 23-year-old Asian man without a significant history of illness who complains of a left upper quadrant mass that he discovered 10 years prior. Since then, the mass had been gradually growing and had been accompanied by severe pain. Walking made the pain worse; lying down made it lessen. A computed tomography (CT) scan of the abdomen showed a 20.05 × 15.95 × 26.71 cm splenic cyst. Surgery for a peri-cystic splenectomy was done. A primary splenic cyst was identified in the specimen after microscopic and macroscopic examination. After 10 days, the patient was released from the hospital without complications. The second case is that of a 28-year-old Asian man who complained of a mass in their abdomen that was getting bigger in size. Four years prior to the complaint, the patient had fallen while driving a motorcycle, and the left side of his abdomen collided with the sidewalk. In this patient, a splenectomy-the complete removal of all spleen parts-was done. The specimen's macroscopic and microscopic examination revealed a splenic pseudocyst. The patient was discharged after three days without complications.

CLINICAL DISCUSSION

Splenic cysts are considered rare and challenging to diagnose, as there have been only a limited number of reports. Nevertheless, proper management is still needed, as it carries the risk of rupturing and causing complications such as peritonitis and anaphylactic reactions. Considering the risk of overwhelming post-splenectomy infection (OPSI), conservative treatment can be the gold standard for splenic cysts. However, considering the risk from the size of the cyst, splenectomy or peri-cystic splenectomy is an appropriate surgery option for a splenic cyst.

CONCLUSION

Splenectomy, or peri-cystic splenectomy, is a surgery option for a splenic cyst with significant size and rupture risk.

Labyrinthitis Ossificans in a Post-Splenectomy Patient With Meningitis: A Case Report and Review of Literature

This report describes a case of cochlear implantation to treat profound deafness three months after a diagnosis of bacterial meningitis in a patient with a remote history of splenectomy. A 71-year-old woman with a remote history of a splenectomy over 20 years before presented with bilateral profound deafness that occurred as sequela from pneumococcal meningitis three months prior. The patient had been vaccinated against the 23-valent polysaccharide pneumococcal vaccine (PPV-23). The audiometric evaluation revealed no response in either ear. Imaging was suggestive of complete ossification of the right cochlea with partial ossification of the basal turn of the left cochlea. She underwent successful left-sided cochlear implantation. Standard post-implantation speech outcomes include consonant-nucleus-consonant (CNC) word and phoneme scores and Az-Bio in quiet and noise. The patient noted subjective improvement in her hearing. Performance measures markedly improved when compared to her pre-operative evaluation, which showed no aided sound detection. This case report highlights the possibility of meningitis many years after splenectomy that can result in profound deafness with labyrinthitis ossificans and the potential for hearing rehabilitation for cochlear implantation.

Depletion of circulating IgM memory B cells predicts unfavourable outcome in COVID-19

Impaired immune responses have been hypothesised to be a possible trigger of unfavourable outcomes in coronavirus disease 2019 (COVID-19). We aimed to characterise IgM memory B cells in patients with COVID-19 admitted to an internal medicine ward in Northern Italy. Overall, 66 COVID-19 patients (mean age 74 ± 16.6 years; 29 females) were enrolled. Three patients (4.5%; 1 female) had been splenectomised and were excluded from further analyses. Fifty-five patients (87.3%) had IgM memory B cell depletion, and 18 (28.6%) died during hospitalisation (cumulative incidence rate 9.26/100 person-week; 5.8-14.7 95% CI). All patients who died had IgM memory B cell depletion. A superimposed infection was found in 6 patients (9.5%), all of them having IgM memory B cell depletion (cumulative incidence rate 3.08/100 person-week; 1.3-6.8 95% CI). At bivariable analyses, older age, sex, number of comorbidities, and peripheral blood lymphocyte count < 1500/µl were not correlated with IgM memory B cell depletion. A discrete-to-marked reduction of the B-cell compartment was also noticed in autoptic spleen specimens of two COVID-19 patients. We conclude that IgM memory B cells are commonly depleted in COVID-19 patients and this correlates with increased mortality and superimposed infections.

New Insights in Autoimmune Hemolytic Anemia: From Pathogenesis to Therapy Stage 1

Autoimmune hemolytic anemia (AIHA) is a highly heterogeneous disease due to increased destruction of autologous erythrocytes by autoantibodies with or without complement involvement. Other pathogenic mechanisms include hyper-activation of cellular immune effectors, cytokine dysregulation, and ineffective marrow compensation. AIHAs may be primary or associated with lymphoproliferative and autoimmune diseases, infections, immunodeficiencies, solid tumors, transplants, and drugs. The direct antiglobulin test is the cornerstone of diagnosis, allowing the distinction into warm forms (wAIHA), cold agglutinin disease (CAD), and other more rare forms. The immunologic mechanisms responsible for erythrocyte destruction in the various AIHAs are different and therefore therapy is quite dissimilar. In wAIHA, steroids represent first line therapy, followed by rituximab and splenectomy. Conventional immunosuppressive drugs (azathioprine, cyclophosphamide, cyclosporine) are now considered the third line. In CAD, steroids are useful only at high/unacceptable doses and splenectomy is uneffective. Rituximab is advised in first line therapy, followed by rituximab plus bendamustine and bortezomib. Several new drugs are under development including B-cell directed therapies (ibrutinib, venetoclax, parsaclisib) and inhibitors of complement (sutimlimab, pegcetacoplan), spleen tyrosine kinases (fostamatinib), or neonatal Fc receptor. Here, a comprehensive review of the main clinical characteristics, diagnosis, and pathogenic mechanisms of AIHA are provided, along with classic and new therapeutic approaches.

Laparoscopic splenectomy in children with sickle cell disease younger than 5 years old

Background

The purpose of this paper is to evaluate the feasibility, safety, efficacy, benefits, and outcome of elective laparoscopic splenectomy for children younger than 5 years with sickle cell disease (SCD) who needed splenectomy. We conducted a retrospective review for a prospective data on patients younger than 5 years with SCD requiring splenectomy from January 2007 to June 2019. Patients were evaluated with regard to patient demographics, operative time, presence of accessory spleens, blood loss, length of hospital stay, morbidity, mortality, and clinical outcome.

Results

A total of 71 patients younger than 5 years with SCD underwent laparoscopic splenectomy (LS) at our institution from January 2007 to June 2019. There were 28 boys and 43 girls. The age at LS is from 2 years to less than 5 years (mean 3.2 years). The mean operating time was 65 min. There was no conversion to open surgery; all the cases were successfully performed laparoscopically. Twelve patients (17%) underwent a concomitant cholecystectomy. The hospital stay ranged from 2 to 6 days (median, 3 days). The mean follow-up was 86 months (range, 17 to 161 months). Postoperative follow-up revealed no cases of overwhelming postsplenectomy sepsis infection (OPSI).

Conclusion

Laparoscopic splenectomy in young children less than 5 years of age with sickle cell disease is a safe and effective treatment. When patients are given preoperative vaccination and penicillin prophylaxis, OPSI rarely occurs.

Contribution of Extramedullary Hematopoiesis to Atherosclerosis. The Spleen as a Neglected Hub of Inflammatory Cells

Cardiovascular diseases (CVDs) incidence is becoming higher. This fact is promoted by metabolic disorders such as obesity, and aging. Atherosclerosis is the underlying cause of most of these pathologies. It is a chronic inflammatory disease that begins with the progressive accumulation of lipids and fibrotic materials in the blood-vessel wall, which leads to massive leukocyte recruitment. Rupture of the fibrous cap of the atherogenic cusps is responsible for tissue ischemic events, among them myocardial infarction. Extramedullary hematopoiesis (EMH), or blood cell production outside the bone marrow (BM), occurs when the normal production of these cells is impaired (chronic hematological and genetic disorders, leukemia, etc.) or is altered by metabolic disorders, such as hypercholesterolemia, or after myocardial infarction. Recent studies indicate that the main EMH tissues (spleen, liver, adipose and lymph nodes) complement the hematopoietic function of the BM, producing circulating inflammatory cells that infiltrate into the atheroma. Indeed, the spleen, which is a secondary lymphopoietic organ with high metabolic activity, contains a reservoir of myeloid progenitors and monocytes, constituting an important source of inflammatory cells to the atherosclerotic lesion. Furthermore, the spleen also plays an important role in lipid homeostasis and immune-cell selection. Interestingly, clinical evidence from splenectomized subjects shows that they are more susceptible to developing pathologies, such as dyslipidemia and atherosclerosis due to the loss of immune selection. Although CVDs represent the leading cause of death worldwide, the mechanisms involving the spleen-atherosclerosis-heart axis cross-talk remain poorly characterized.

Use of single-dose perioperative antimicrobial therapy is acceptable in recipients of living-donor renal transplants in the rituximab era

OBJECTIVE

The aim of this study was to evaluate the efficacy of single-dose perioperative antimicrobial therapy as infection prophylaxis in recipients of living-donor renal transplants in the rituximab era.

PATIENTS AND METHODS

Between 2009 and 2017, 84 recipients underwent living-donor renal transplantation (LDRT) at Okayama University Hospital; 3 with vascular/urinary complications requiring additional surgery were excluded from this analysis. Data including recipient characteristics, antimicrobial prophylaxis and administration of rituximab were retrospectively examined for an association with perioperative infections. Prophylactic antimicrobial agents, selected according to the Results of preoperative urine cultures, were administered just before incision. Perioperative infections, which consisted of surgical site infections, remote infections, and urinary tract infections, were defined as a positive culture indicating required administration of additional antimicrobial agents.

RESULTS

Among the 81 recipients, prophylactic cefazolin, ampicillin/sulbactam, and others were administered to 66 (82%), 13 (16%), and 2 (3%) recipients, respectively. Twenty-one (26%) received single-dose antimicrobial prophylaxis, while 60 (74%) received multiple doses up to 7 days. Rituximab was used in 59 (72.8%) recipients. The incidence of urinary tract infection, surgical site infection and remote infection was 13 (16%), 1 (1%), and 0, respectively. Univariate analysis could not demonstrate any significant risk factors for postoperative urinary tract infections, including a single dose vs multiple doses of antimicrobial therapy (P = 0.069) and administration of rituximab (P = 0.717).

CONCLUSIONS

Our data suggest that the use of single-dose perioperative antimicrobial therapy is acceptable for prophylaxis of infections in patients undergoing LDRT, even in the rituximab era.

Effectiveness of Haemophilus influenzae type b vaccination after splenectomy - impact on selected immunological parameters

Splenectomy is a surgery indicated in case of splenic rupture after injury, when there are tumors in the spleen, or as a treatment for certain diseases, such as idiopathic thrombocytopenic purpura and spherocytosis. The aims of the study were to assess the immunological response to the Haemophilus influenzae type b (Hib) vaccine and the post-vaccination changes in lymphocyte subsets and cell activation markers in splenectomized patients and healthy volunteers. Blood samples were collected from 25 patients that had undergone splenectomy and from 15 healthy, non-splenectomized volunteers. All participants received a single dose of Hib vaccine. The concentration of specific Hib antibodies was assessed by an enzyme-linked immunosorbent assay. Selected immune cell populations were evaluated using flow cytometry. The analysis of the antibody titers against Hib showed statistically significant differences in both groups. There was a significantly higher percentage (p = 0.0012) and absolute value (p = 0.0003) of natural killer T (NKT)-like cells (CD3+/CD16+ CD56+) in the study group, compared to the control group. The levels of natural killer (NK) and NKT cells did not change relative to the cause and age of splenectomy. The quantity and percentage of regulatory T (Treg) cells were higher in the study group compared to the control group (p < 0.0001). No significant correlations were found between the time elapsed since splenectomy, the age of the patients, and the Treg levels. Our study showed that spleen resection results in an important deterioration of Treg cells and Th17 cell balance which may contribute to an incomplete immunological response.

FilmArray® meningitis/encephalitis (ME) panel, a rapid molecular platform for diagnosis of CNS infections in a tertiary care hospital in North India: one-and-half-year review

BACKGROUND

Acute meningitis and encephalitis (AME) is a syndrome of central nervous system (CNS) infections, which could lead to neurological damage and fatality. This study evaluates the multiplex FilmArray® ME Panel which is aimed to diagnose agents causing suspect CNS infections in north India.

METHODS

A total number of 969 cerebrospinal fluid (CSF) samples collected between August 2016 and January 2018 from patients who showed clinical symptoms of CNS infections were analyzed using the FilmArray® ME Panel. Also a comparison of molecular diagnosis and various laboratory and radiological findings for Streptococcus pneumoniae, Enterovirus and Cryptococcus neoformans positive cases was done.

RESULT

Out of the 969 CSF samples, 101 cases were found to be positive for viral (n = 55), bacterial (n = 38), fungal (n = 7), and poly-microbial (n = 1) agents. Out of the 55 viral positive cases, the most detected pathogen was Enterovirus (n = 23) with predominance in the age group of 2-17 years, followed by Varicella Zoster virus (n = 14) and HSV1(n = 9) cases. Streptococcus pneumoniae (n = 26) was found to be the predominant bacterial pathogen, of which 17 were detected in the age group above 35 years. Cryptococcus neoformans was found in 7 cases.

CONCLUSION

The FilmArray® ME Panel aids in rapid detection of 14 pathogens directly from CSF. When compared to gram stain, culture, antigen detection, and CSF biochemical analysis, the FilmArray® ME Panel has detected more cases, some of which are difficult to diagnose by conventional methods. This rapid technology will help the clinicians in case of early patient management, outcomes and provide aid in antimicrobial stewardship.

The Spleen as an Optimal Site for Islet Transplantation and a Source of Mesenchymal Stem Cells

This review demonstrates the unique potential of the spleen as an optimal site for islet transplantation and as a source of mesenchymal stem cells. Islet transplantation is a cellular replacement therapy used to treat severe diabetes mellitus; however, its clinical outcome is currently unsatisfactory. Selection of the most appropriate transplantation site is a major factor affecting the clinical success of this therapy. The spleen has long been studied as a candidate site for islet transplantation. Its advantages include physiological insulin drainage and regulation of immunity, and it has recently also been shown to contribute to the regeneration of transplanted islets. However, the efficacy of transplantation in the spleen is lower than that of intraportal transplantation, which is the current representative method of clinical islet transplantation. Safer and more effective methods of islet transplantation need to be established to allow the spleen to be used for clinical transplantation. The spleen is also of interest as a mesenchymal stem cell reservoir. Splenic mesenchymal stem cells contribute to the repair of damaged tissue, and their infusion may thus be a promising therapy for autoimmune diseases, including type 1 diabetes mellitus and Sjogren’s syndrome.

Vaccination coverage and mortality after splenectomy: results from an Italian single-centre study

Splenectomy is a well-recognised risk factor for life-threatening overwhelming post-splenectomy infection (OPSI). To prevent OPSI, immunisations against encapsulated bacteria (S. pneumoniae, N. meningitidis, H. influenzae) and influenza virus are recommended. However, there is still a lack of uniformity and poor compliance with these recommendations. Following a local physicians' awareness campaign regarding the importance of vaccine prophylaxis of splenectomised patients, we aimed to register vaccination coverage, mortality and infection rates in all patients who underwent splenectomy at our hospital, over a six-year time span. Reasons for splenectomy, patients' compliance with vaccinations, mortality and infectious events were recorded. The reasons for splenectomy in the 216 identified patients (mean age 58.2 ± 14; M:F ratio 1.4:1) were haematologic disorders (38.8%), solid tumours (28.7%), traumatic rupture (22.7%) and other causes (9.7%). A total of 146 patients (67.6%) received at least one of the four vaccines. Overall, the mortality rate was significantly greater in unvaccinated compared to vaccinated patients (p < 0.001), although after the adjustment for the cause of splenectomy the statistical significance was lost (p = 0.085) due to the burden of solid tumour-related mortality. Among the 21 reported cases of OPSI, eight were fatal and five were potentially vaccine-preventable. Our results show that two-thirds of splenectomised patients comply with vaccine prophylaxis. Future interventional studies or ad hoc registries might overcome barriers to vaccination or intentional non-compliance.

Exploration of the therapeutic potential effect of Sepia officinalis in animal model of sepsis induced by cecal ligation and puncture

OBJECTIVE

The present investigation explored the therapeutic potential effect of Sepia officinalis body tissue (SOBT) and Sepia officinalis polysaccharide (SOP) extracts, in animal model of sepsis [induced by cecal ligation and puncture (CLP)].

MATERIALS AND METHODS

Experimental animals were divided into 4 groups, Group 1: Sham control rats. Group 2: Septic rats. Group 3: Septic rats treated with methanolic extract of Sepia officinalis body tissue (SOBT) (500mg/kg body weight) for 2days. Group 4: Septic rats treated with Sepia officinalis polysaccharide (SOP) extract (200mg/kg body weight) for 2days.

RESULTS

The antioxidant activity of SOBT and SOP was proven by DPPH test. CLP-induced liver and kidney toxicities showed by an increase in the ALAT, ASAT, γGT, ALP, creatinine, BUN and uric acid concentrations in serum. Moreover, CLP-induced oxidative stress in liver and kidney evidenced by the increase of MDA levels, decrease in GSH concentrations and decrease in the enzymatic antioxidants (SOD, CAT, GST). In addition, CLP caused decrease in CYP1A2 content in liver.

CONCLUSIONS

Our findings demonstrate the therapeutic efficacy of SOBT and SOP in liver and kidney disorders. Therefore this study suggests that SOBT and SOP could be a potential therapeutic agents for sepsis treatment.

Immunization coverage among splenectomized patients: Results of an ad hoc survey in Puglia Region (South of Italy)

Patients with anatomic or functional asplenia have a 10-50 times higher risk than general population to develop Overwhelming Post-Splenectomy Infection. Evidences are unanimous in recommending splenectomised patients to receive meningococcal, antipneumococcal and Haemophilus influenzae type B vaccinations according to a specific timing. In Italy there are no current data on the immunisation coverage in these patients. This study aims to investigate immunisation coverage in patients undergoing elective or urgent splenectomy for 2012-2013 in the 3 Apulian hospitals. The patients discharged with the code ICD-9-CM 41.5 - "Total splenectomy" were enrolled. The administration of vaccines was verified through consultation of medical records, archives of general practitioners and vaccination offices. In the study period, 166 subjects underwent splenectomy and none of them received vaccinations during hospitalization. 25 splenectomised patients (15.1%) received at least one of the recommended vaccinations. 21 patients (12.6%) received vaccine against Streptococcus pneumonia, 13 (7.8%) meningococcal vaccine, 10 patients (6%) Haemophilus influenzae type B vaccine. The low vaccination coverage could be due both to poor perception of the risk of infection and to a lack of knowledge on vaccinations by surgeons. For this reason it is necessary to draw up and share operational protocols that establish the administration of vaccines.

Current Management of Primary Immune Thrombocytopenia

Primary immune thrombocytopenia is an autoimmune disorder of unknown cause affecting both children and adults. The low peripheral blood platelet count is caused by premature platelet destruction by self-reacting antibodies in addition to an impairment of platelet production. The disease is heterogeneous in its pathophysiology, clinical features and responses to treatment. To date, most of the treatments used have been immune-modulating drugs and these contribute to increased morbidity and mortality in patients. A new class of drugs, the thrombopoietin receptor agonists, has been developed for use in ITP. These have gone through randomised controlled trials in large numbers of patients with ITP. These drugs have high efficacy and are well tolerated. In addition, around 30% of patients receiving these drugs are able to stop them and maintain a safe or normal platelet count. Older treatments such as splenectomy are being used less than before, largely because of the introduction of the thrombopoietin receptor agonists. Currently there are trials underway evaluating novel therapies for ITP that will become available over the next few years once the trials are complete.

Methods of rapid diagnosis for the etiology of meningitis in adults

Infectious meningitis may be due to bacterial, mycobacterial, fungal or viral agents. Diagnosis of meningitis must take into account numerous items of patient history and symptomatology along with regional epidemiology and basic cerebrospinal fluid testing (protein, etc.) to allow the clinician to stratify the likelihood of etiology possibilities and rationally select additional diagnostic tests. Culture is the mainstay for diagnosis in many cases, but technology is evolving to provide more rapid, reliable diagnosis. The cryptococcal antigen lateral flow assay (Immuno-Mycologics) has revolutionized diagnosis of cryptococcosis and automated nucleic acid amplification assays hold promise for improving diagnosis of bacterial and mycobacterial meningitis. This review will focus on a holistic approach to diagnosis of meningitis as well as recent technological advances.

Treatment of autoimmune hemolytic anemias

Autoimmune hemolytic anemia (AIHA) is a relatively uncommon disorder caused by autoantibodies directed against self red blood cells. It can be idiopathic or secondary, and classified as warm, cold (cold hemagglutinin disease (CAD) and paroxysmal cold hemoglobinuria) or mixed, according to the thermal range of the autoantibody. AIHA may develop gradually, or have a fulminant onset with life-threatening anemia. The treatment of AIHA is still not evidence-based. The first-line therapy for warm AIHA are corticosteroids, which are effective in 70-85% of patients and should be slowly tapered over a time period of 6-12 months. For refractory/relapsed cases, the current sequence of second-line therapy is splenectomy (effective approx. in 2 out of 3 cases but with a presumed cure rate of up to 20%), rituximab (effective in approx. 80-90% of cases), and thereafter any of the immunosuppressive drugs (azathioprine, cyclophosphamide, cyclosporin, mycophenolate mofetil). Additional therapies are intravenous immunoglobulins, danazol, plasma-exchange, and alemtuzumab and high-dose cyclophosphamide as last resort option. As the experience with rituximab evolves, it is likely that this drug will be located at an earlier point in therapy of warm AIHA, before more toxic immunosuppressants, and in place of splenectomy in some cases. In CAD, rituximab is now recommended as first-line treatment.

B-Cell Targeted Therapies in Autoimmune Cytopenias and Thrombosis

Ever since the advent of Rituximab and subsequently the emergence of other compounds targeting B cells, a cornucopia of medical applications have been found for this family of compounds. After their establishment as standard of care in many conditions such as rituximab in lymphoma and rheumatoid arthritis, they have been progressively found to aid in the treatment of many other conditions. This area constituted a fertile area of research in the past 12 years. Physicians have investigated the B-cell depleting agents use in cases of autoimmune hematologic cytopenias such as immune thrombocytopenia, Evans syndrome, cold and warm autoimmune hemolytic anemia, and other thrombophilic disorders such as the antiphospholipid syndrome and thrombocytopenic purpura. This chapter presents a historical perspective reviewing the various studies that have been published in this field. In addition, it offers a current assessment of the evidence regarding the use of B-cell depleting agents in the aforementioned conditions.

Bacterial meningitis in adults after splenectomy and hyposplenic states

OBJECTIVE

To examine the occurrence, disease course, prognosis, and vaccination status of patients with community-acquired bacterial meningitis with a history of splenectomy or functional hyposplenia.

PATIENTS AND METHODS

Patients with bacterial meningitis proven by cerebrospinal fluid culture were prospectively included in a nationwide cohort study between March 1, 2006, and September 1, 2011. Splenectomy or diseases associated with functional hyposplenia were scored for all patients. Vaccination status, clinical features, and outcome of patients with a history of splenectomy or functional hyposplenia were analyzed and compared with patients with normal spleen function.

RESULTS

Twenty-four of 965 patients (2.5%) had an abnormal splenic function: 16 had a history of splenectomy and 8 had functional hyposplenia. All patients had pneumococcal meningitis. Pre-illness vaccination status could be retrieved for 19 of 21 patients (90%), and only 6 patients (32%) were adequately vaccinated against pneumococci. Pneumococcal serotype was known in 21 patients; 52% of pneumococcal isolates had a serotype included in the 23-valent vaccine. Vaccine failure occurred in 3 patients. Splenectomized patients more often presented with signs of septic shock compared with patients with a normal spleen (63% vs 24%; P=.02). Outcome was unfavorable in 14 patients (58%), and 6 patients died (25%).

CONCLUSION

Splenectomy or functional hyposplenia is an uncommon risk factor for bacterial meningitis but results in a high rate of mortality and unfavorable outcome. Most patients were not adequately vaccinated against Streptococcus pneumoniae.

Effectiveness and immunogenicity of pneumococcal vaccination in splenectomized and functionally asplenic patients

The aim of the present study was to evaluate the effectiveness and immunogenicity of pneumococcal vaccination in 145 splenectomized and 2 functionally asplenic patients receiving the 23-valent pneumococcal polysaccharide vaccine and/or the 7-valent pneumococcal conjugate vaccine (PCV7) during the period 1996-2009. Progression of underlying malignant disease was the main cause of death in 68% of the 53 deceased patients, followed by septic shock in 13.2%. Twelve of 94 living patients developed post-vaccine complications: pneumonia in 9 patients, otitis media in 2, pneumococcal sepsis in 4. Compared with a non-splenectomized non-vaccinated control group (n=34), splenectomized patients vaccinated in the previous five years (n=15) had significantly higher GMCs (P<0.05) against serotypes 4, 6B, 9V, 14, 18C, 19F and 23F. Our data demonstrated strong serological responses in splenectomized patients within the first 5 years after pneumococcal vaccination by PCV7. Nevertheless, post-vaccine pneumococcal sepsis was still diagnosed in 3.3% of splenectomized survivors.

Contemporary pediatric splenectomy: continuing controversies

PURPOSE

We undertook the current study to update the literature on pediatric splenectomy in the age of minimally invasive proficiency among pediatric surgeons. The study is designed to address specific concerns among surgeons about the suitability of the laparoscopic approach in specific situations and among hematologists about the relative benefits and risks of splenectomy in children.

METHODS

Retrospective analysis of clinicopathologic data for 118 children who underwent open (OS) or laparoscopic (LS) splenectomy at an urban tertiary children's hospital from January 2000 to July 2008.

RESULTS

One hundred and three cases (87%) were started as LS. Operative times were equivalent for LS and OS (P = 0.8). In the LS group, there were four conversions (3.9%) from LS to OS and five early post-operative complications (4.9%). Median length of stay was 2 days for LS and 4 days for both OS and LS converted to OS (P < 0.0001). The ten largest spleens removed by LS had greater mass (P = 0.02) and tended to have greater volume (P = 0.1) than those removed by OS. Children with hereditary spherocytosis, ITP, and hemoglobinopathy had favorable clinical outcomes, regardless of operative approach. There were no cases of overwhelming post-splenectomy sepsis in this series.

CONCLUSIONS

Laparoscopic splenectomy is the preferred approach for splenectomy in children with hematological diseases, with or without splenomegaly. Compared to open splenectomy, laparoscopic splenectomy has equivalent operative time and improved length of stay. Both approaches have excellent therapeutic outcomes for appropriate indications.

Rituximab therapy for autoimmune haematological diseases

Autoimmune haematological diseases are characterized by the production of antibodies against blood proteins or cells, and comprise primary immune thrombocytopenia, autoimmune haemolytic anaemia, acquired haemophilia, and thrombotic thrombocytopenic purpura. Current treatments for these disorders include corticosteroids, cytotoxic drugs and splenectomy, which may be associated with significant systemic toxicity and/or morbility. B cells play a key role in both the development and perpetuation of autoimmunity, since they produce autoantibodies but also function as antigen-presenting cells, and release immunomodulatory cytokines. Rituximab, an anti-CD20 monoclonal antibody that specifically depletes B cells, may be an effective treatment strategy for patients with autoimmune disorders. This article reviews data of the literature, showing that patients with autoimmune haematological diseases can respond to rituximab irrespective of age and number or type of prior treatments. These data suggest that rituximab provides an effective and well-tolerated treatment option for these conditions.

Autoimmune hemolytic anemia: classification and therapeutic approaches

Autoimmune hemolytic anemia (AIHA) is a relatively uncommon cause of anemia. Classifications of AIHA include warm AIHA, cold AIHA (including mainly chronic cold agglutinin disease and paroxysmal cold hemoglobinuria), mixed-type AIHA and drug-induced AIHA. AIHA may also be further subdivided on the basis of etiology. Management of AIHA is based mainly on empirical data and on small, retrospective, uncontrolled studies. The therapeutic options for treating AIHA are increasing with monoclonal antibodies and, potentially, complement inhibitory drugs. Based on data available in the literature and our experience, we propose algorithms for the treatment of warm AIHA and cold agglutinin disease in adults. Therapeutic trials are needed in order to better stratify treatment, taking into account the promising efficacy of rituximab.

International consensus report on the investigation and management of primary immune thrombocytopenia

Previously published guidelines for the diagnosis and management of primary immune thrombocytopenia (ITP) require updating largely due to the introduction of new classes of therapeutic agents, and a greater understanding of the disease pathophysiology. However, treatment-related decisions still remain principally dependent on clinical expertise or patient preference rather than high-quality clinical trial evidence. This consensus document aims to report on new data and provide consensus-based recommendations relating to diagnosis and treatment of ITP in adults, in children, and during pregnancy. The inclusion of summary tables within this document, supported by information tables in the online appendices, is intended to aid in clinical decision making.

Effect of splenectomy and autologous spleen transplantation on the serum platelet-activating factor acetylhydrolase (PAF-AH) activity and acute phase response (APR) in a porcine model

The aim of this study was to evaluate the inflammatory response after total splenectomy and spleen autotransplantation in a porcine model by measuring serum platelet-activating factor acetylhydrolase activity, C-reactive protein and albumin concentrations. Nineteen piglets were used in the experiment. After induction of anesthesia, animals were randomly divided into three groups: sham-operation with spleens intact (n = 6), total splenectomy (n = 6), and splenic autotransplantation (n = 7) with small fragments of the spleen autotransplanted into the greater omentum. The blood samples were taken just before surgery and on day 1st, 5th, 12th, 26th and 40th postoperatively. PAF-AH activity, CRP and albumin concentrations were assayed in the sera. After total splenectomy, PAF-AH activity was significantly increased on day 5th, while there was no significant increase after spleen autotransplantation or the sham-operation. CRP was significantly increased after surgery in all experimental groups. Albumin was significantly decreased after surgery from day 5th until day 40th in splenectomized and autotransplanted pigs. Increased PAF-AH activity after splenectomy and spleen autotransplantation might be attributed to inflammatory conditions due to the loss of splenic tissue and trauma. Time-course increase of CRP, in all groups after surgery suggests post-injury inflammatory response due to tissue lesion during operation.

Primary Aortoappendicular Fistula Arising from an Infected, Chronic, Contained, Ruptured Abdominal Aortic Aneurysm

Gastrointestinal bleeding can be caused by a variety of pathologies. Primary aortoappendicular fistula is rare and, in our case, arose in addition to a chronic contained rupture sac of an abdominal aortic aneurysm. Clinical diagnosis is difficult. Aortic aneurysmorrhaphy along with extensive debridement and emphasis on antibiotic therapy is curative.

Prevention and treatment of travel-related infections in compromised hosts

PURPOSE OF REVIEW

The numbers of international travelers and complexity of their underlying medical conditions continue to increase. Traveling with compromised immunity warrants special consideration regarding the prevention and treatment of travel-related diseases, ideally with the help of a travel medicine specialist. There is a need for careful weighing of the potential health risks in persons with severe immunosuppression, including that related to HIV, use of immunomodulating agents, malignancy and cancer chemotherapy, solid organ and bone marrow transplantation, and asplenia.

RECENT FINDINGS

Over the past year, a number of articles and texts have been published addressing the health risks and management strategies for travelers with underlying immune compromise, including the potential interactions between HIV and malaria, and transplant outcomes for those receiving transplants through medical tourism.

SUMMARY

Tailored advice and treatment strategies for compromised travelers can help facilitate safe travel for individuals who choose risk-taking travel.

Splenectomy for Trauma Increases the Rate of Early Postoperative Infections

Little is known what effect splenectomy for trauma has on early postoperative infectious complications. Our aim was to determine if splenectomy increases early postoperative infections in trauma patients undergoing laparotomy. We reviewed all trauma patients undergoing splenectomy from June 2002 through December 2004. Each splenectomy patient was matched to a unique trauma patient who underwent laparotomy without splenectomy based on age, gender, mechanism of injury, injury severity score, and presence of colon or other hollow visceral injury. Outcomes included infectious complications including pneumonia, urinary tract infection, bacteremia, and intra-abdominal abscess, as well as mortality. There were 98 splenectomy patients and 98 controls. The splenectomy patients had more overall infectious complications (45% vs 30%, P = 0.04) trended toward more urinary tract infections (12% vs 5%, P = 0.12), and more often had pneumonia (30% vs 14%, P = 0.02). Additionally, more splenectomy patients developed multiple infections (20% vs 7%, P = 0.01). There was no difference in mortality (11% vs 8%, P = 0.63). Splenectomy is associated with an increase in infectious complications after laparotomy for trauma. More specifically, splenectomy patients more often develop pneumonia and multiple infections. This increase in infections is not associated with increased mortality.

Acupuncture and self acupuncture for long-term treatment of vasomotor symptoms in cancer patients--audit and treatment algorithm

INTRODUCTION

Since hormone replacement therapy given for long periods is now recognised to produce serious side effects, patients with troublesome vasomotor symptoms are increasingly using non-hormonal treatment including acupuncture. Several randomised controlled trials have shown that acupuncture reduces menopausal symptoms in patients experiencing the normal climacteric. It may have this effect by raising serotonin levels which alter the temperature set point in the hypothalamus. Vasomotor symptoms can be extreme in breast cancer patients and patients with prostate cancer who are undergoing anticancer therapy. The safety of some herbal medicines and phytoestrogens has been questioned, as they could potentially interfere adversely with the bioavailability of tumouricidal drugs. A previous study reports short term benefit from acupuncture, and the aim of this report is to describe our approach to long term treatment.

ACUPUNCTURE APPROACH

After piloting several approaches, six weekly treatments were given initially at LI4, TE5, LR3 and SP6 and two upper sternal points, but avoiding any limb with existing lymphoedema or prone to developing it. If there were no contraindications, patients were given clear instructions on how to perform self acupuncture using either semi-permanent needles or conventional needling at SP6, weekly for up to six years, for long term maintenance.

AUDIT METHODS AND RESULTS

A retrospective audit of electronic records was carried out by a doctor not involved in treatment. A total of 194 patients were treated, predominantly with breast and prostate cancer. One hundred and eighty two patients were female. The number of pre-treatment hot flushes per day was estimated by the patient: in the 159 cases providing adequate records, the mean was 16 flushes per day. Following treatment, 114 (79%) gained a 50% or greater reduction in hot flushes and 30 (21%) a less than 50% reduction. Treatment was abandoned in those who responded poorly or not at all. The duration of treatment varied from one month to over six years with a mean duration of nine months. Seventeen patients (9%) experienced minor side effects over the six year period, mostly minor rashes; one patient described leg swelling but this was likely to be due to a concurrent fracture.

CONCLUSION

Acupuncture including self acupuncture is associated with long-term relief of vasomotor symptoms in cancer patients. Treatment is safe and costs appear to be low. An algorithm is presented to guide clinical use. We recommend the use of self acupuncture with needles at SP6 in preference to semi-permanent needles in the first instance, but poor responders use indwelling studs if they fail to respond adequately to self acupuncture with regular needles. Point location may be of less importance than the overall 'dose', and an appropriate minimum dose may be required to initiate the effect.