Acute Blood Loss Anemia in the Setting of Abdominal Aortic Aneurysm Rupture in a Jehovah's Witness.

Acute blood loss anemia occurs due to many variants. The standard of care in managing acute blood loss anemia is challenged in this case. Jehovah's Witnesses's (JW) management of blood loss anemia continues to remain a controversy in medicine since they do not allow the use of blood products. This case highlights the management of acute blood loss anemia, utilizing a multidisciplinary bloodless approach in a JW who underwent an endovascular aneurysmal repair (EVAR) of an impending rupture of abdominal aortic aneurysm (AAA). The severity of anemia with hemoglobin of 2.7 g/dL and survival outcome is unique; however, the minimal hemoglobin level required to sustain life is still unclear.

Iliolumbar Vein: Anatomy and Surgical Importance During Lateral Transpsoas and Oblique Approaches to Lumbar Spine.

OBJECTIVE: Safe surgical approaches to the anterolateral lumbar spine require a good working knowledge of the anatomy and anatomic variations of this region. As the iliolumbar vein is in the vicinity of both oblique and lateral transpsoas approaches to the lower lumbar spine, the following study was performed to better elucidate its anatomy, variations, and position during such surgical procedures. METHODS: Fifteen (30 sides) fresh frozen adult cadavers underwent dissection of the iliolumbar vein (ILV). The origin, course, variants, relations, and morphometrics of each vein were documented. Fluoroscopy of the vessels was performed. Lastly, anterior oblique and lateral transpsoas approaches to the lumbar spine were carried out in order to evaluate for potential ILV injury. RESULTS: An ILV was found on all but 2 sides (93.3%). It arose as a common trunk from the common iliac vein on 14 sides. Left ILVs tended to have a more distal origin than right ILVs. ILVs had a mean length of 3.7 cm and a mean width of 0.9 cm and were significantly larger on right versus left sides (P < 0.05). Left-sided ILVs tended to have more branches than right-sided veins. The majority of vertical branches of the ILV traveled anterior to the ventral rami of the lumbar spinal nerves, most commonly L4. The ILV and, in particular, its vertical branches coursed next to the L4 and L5 vertebrae. CONCLUSIONS: The ILV should be considered during both oblique and lateral transpsoas approaches to the lumbar spine.

Pineal Gland Agenesis: Review and Case Illustration.

Agenesis of the pineal gland has rarely been reported in the medical literature. Herein, we report a cadaveric specimen found to have agenesis of the pineal gland. The remaining gross examination of the brain was normal. A review of the literature was performed on this unusual finding.

A Previously Unreported Variant of a Thoracic Vertebra.

Pathology associated with anomalous transverse processes is uncommon and usually involves elongated C7 transverse processes in the so-called cervical rib syndrome. We report a single adult thoracic vertebra found to have duplicated transverse processes on the left side. We believe this to be the first report of a duplicated transverse process in man. The clinician and anatomist who view osteological material or imaging should consider this an extremely rare anatomical variation of the thoracic spine.

A multicomponent yoga-based, breath intervention program as an adjunctive treatment in patients suffering from generalized anxiety disorder with or without comorbidities.

OBJECTIVES: The aim of this study is to evaluate the efficacy and tolerability of Sudarshan Kriya Yoga (SKY) course in generalized anxiety disorder (GAD) outpatients, who after eight weeks of an appropriate dose of traditional therapy had not yet achieved remission. SUBJECTS: The adult participants (18-65 years) were outpatients with a primary diagnosis of GAD with or without comorbidities on the Mini-International Neuropsychiatric Interview (MINI). Participants had a minimum of eight weeks standard treatment with an appropriate dose of a standard prescription anxiolytic, a clinician global impression-severity (CGI-S) score of 5-7, a Hamilton anxiety scale (HAM-A) total score ≥20 including a score of >2 on the anxious mood and tension items. MATERIALS AND METHODS: Forty-one patients were enrolled in an open-label trial of the SKY course as an adjunct to standard treatment of GAD at the START Clinic for Mood and Anxiety Disorders, a tertiary care mood and anxiety disorder clinic in Toronto. The SKY course was administered over five days (22 h total). Subjects were encouraged to practice the yoga breathing techniques at home for 20 min per day after the course and were offered group practice sessions for 2 h once a week led by certified yoga instructors. The primary outcome measure was the mean change from pre-treatment on the HAM-A scale. Psychological measures were obtained at baseline and four weeks after completing the intervention. RESULTS: Thirty-one patients completed the program (mean age 42.6 ± 13.3 years). Among completers, significant reductions occurred in the pre- and post-intervention mean HAM-A total score (t=4.59; P<0.01) and psychic subscale (t=5.00; P≤0.01). The response rate was 73% and the remission rate 41% as measured on the HAM-A. CONCLUSION: The results of this small pilot trial suggest that the SKY course represents a potentially valuable adjunct to standard pharmacotherapy in patients with GAD or treatment-resistant GAD, and warrants further investigation. In particular, changes in worry and body symptoms showed significant improvements that may further our understanding of the mechanism of change in the tolerance of anxiety and worry.

Aggregation of a monoclonal antibody induced by adsorption to stainless steel.

Stainless steel is a ubiquitous surface in therapeutic protein production equipment and is also present as the needle in pre-filled syringe biopharmaceutical products. Stainless steel microparticles can cause the aggregation of a monoclonal antibody (mAb). The initial rate of mAb aggregation was second order in steel surface area and zero order in mAb concentration, generally consistent with a bimolecular surface aggregation being the rate-limiting step. Polysorbate 20 (PS20) suppressed the aggregation yet was unable to desorb the firmly bound first layer of protein that adsorbs to the stainless steel surface. Also, there was no exchange of mAb from the first adsorbed layer to the bulk phase, suggesting that the aggregation process actually occurs on subsequent adsorption layers. No oxidized Met residues were detected in the mass spectrum of a digest of a highly aggregated mAb, although there was a fourfold increase in carbonyl groups due to protein oxidation.