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VASOPRESSIN RESPONSE TO PNEUMOPERITONEUM: MECHANICAL OR NOCICEPTIVE STIMULATION?
452 MATERNAL ANTIBODIES AND NEONATAL
VASOPRESSIN RESPONSE TO PNEUMOPERITONEUM: MECHANICAL OR NOCICEPTIVE STIMULATION?
THROMBOCYTOPENIA
SiR,-We agree with Sharon and Amarl that thrombocytopenia is seldom a problem in babies born to mothers with anti-HLA antibodies. However, these workers blame ABO incompatibility or sepsis for the neonatal thrombocytopenia and seem to neglect the importance of specific platelet antibodies. We describe here three patients with immune thrombocytopenia caused by Zwa platelet antibodies. From June, 1979, to June, 1981, we saw three babies with unexplained generalised petechiae. Platelet counts were low and varied during the first days after delivery between 5 x 109 and 28 x 109/1. Previously all the mothers had been healthy and did not have thrombocytopenia. Pregnancy and labour were uncomplicated. HLA typing of the mothers was done by the microscale N.I.H. lymphocytotoxicity test and lymphocytotòxic antibodies were sought against a panel of highly selected lymphocytes from fourteen donors possessing most known HLA A, B, and C specificities. For demonstration of platelet antibodies and platelet typing of the parents we used a platelet complement fixation test (PCFT)2 and a platelet suspension immunofluorescence test (sift).3To define the specificity of the platelet antibody we used selected ABOgrouped and HLA-typed Zw(a -) and Zw(a +) platelet donors. As seen in the table, two of the children were ABO incompatible with their mothers. The red blood cells of the babies were not sensitised with ABO or other antibodies. All three mothers with anti-Zwa had HLA-B8. One of the mothers had weak lymphocytotoxic antibodies reacting with four of the selected fourteen panel donors. We thus found free platelet antibody in the sera of all three mothers delivered of a child with neonatal thrombocytopenia. The platelet antibody was anti-Zwa in all three cases. This finding was supported by the Zwa negativity in the mothers and Zwa positivity in the fathers. Only 2% of the population are Zw(a _).2 The significance of ABO incompatibility in relation to neonatal thrombocytopenia is not clear. It has been suggested that ABO compatibility between mother and child is a prerequisite for neonatal However, von dem Borne et al: found ABO incompatibility in five out of thirty-one cases.3 Our results point in the same direction since we found ABO incompatibility in two of the three cases. Our Zw(a -) mothers had the HLA-B8 tissue antigen, which supports the reported connection between anti-Zwa immunisation and HLA-B8.5
thrombocytopenia.4
P. G. SØRENSEN
Department of Blood Grouping and Immunology, Odense University Hospital,
HANS MICKLEY HANS DIEDERICHSEN NIELS GRUNNET
DK 5000 Odense C, Denmark 1. Sharon
R, Amar A. Maternal anti-HLA antibodies and neonatal thrombocytopenia. Lancet 1981; i: 1313. 2. Svejgaard A. Iso-antigenic systems of human blood platelets. Thesis, Aarhus (Backhausen A, Sorensen HJ) 1971. 3. von dem Borne AEGK, van Leeuwen EF, von Riesz LE, van Boxtel CJ, Engelfriet CP. Neonatal alloimmune thrombocytopenia: Detection and characterization of the responsible antibodies by the platelet immunofluorescence test. Blood 1981; 57: 649-56. 4. Gratwohl AA, Shulman NR. ABO-Kompatibilität und isoimmune neonatale Thrombopenie. Schweiz Med Wochenschr 1977; 107: 1464. 5. Reznikoff-Etievant MF, Dangu C, Lobet R. HLA-B8 antigen and alloimmunization. Tissue Antigens 1981; 18: 66-68.
anti-P1A1
SIR,-Dr Punnonen and Dr Viinamaki (Jan. 16,
p. 175) suggest abdominal pressure induced by a pneumoperitoneum stimulates vasopressin release. During abdominal surgery, visceral traction dramatically raises plasma vasopressin levels, and painful stimuli were thought to be the main factor.’ Vagotomy, which suppresses only a few nociceptive pathways, cannot prevent the vasopressin hypersecretion induced by gastrectomy in dogs.2By contrast, disruption of spinal pain pathways by dorsal rhizotomy blocked the vasopressin secretory response to gastrectomy.2We have noted inhibition of vasopressin stimulation during surgery under epidural anaesthesia, thus confirming the experimental data.3Furthermore, high doses of morphine produce the same effect during cardiac surgery.4The fentanyl doses used by Punnonen and Viinamaki are certainly far less important than those used during cardiac surgery. We suggest that high plasma levels of vasopressin found after a pneumoperitoneum are secondary to nociceptive stimulation.
that
the
rise
in
Department of Anaesthetics, G.H. Pitié-Salpétrière, 75013
Paris, France
F. BONNET A. HARARI M. THIBONNIER
BONE IMPLANTS AND INDUCED OSTEOGENESIS
StR,-The title of our May, 1981 paper5 stresses that the biological principle of induced osteogenesis is different from the mechanism of healing of fresh grafts or banked implants. We and others think of demineralised bone not as just another implant but as a controlled way to induce bone growth from the recipients’ connective tissue. Lieutenant Matthews and colleagues (Nov. 7, p. 1041) raise several important issues derived from their experience at the U.S. Navy Tissue Bank. There is no controversy that lyophilised allograft bone has proved safe and useful. Indeed the purpose of our paper was not to review the experience with other materials nor to assert superiority of one material over others. We chose to report on the use of demineralised allogeneic bone implants for craniofacial reconstruction and construction in patients. Many of the defects were too large to be treated with small amounts of lyophilised bone made available by banks. Other patients volunteered for this study to avoid harvesting procedures; in many of these, harvesting would have been of greater magnitude than the correction of the skeletal defect. Second, Matthews et al. suggest the need for non-irradiated controls to determine the effect of irradiation. We were not permitted to use non-irradiated implants because we do not have the facilities to guarantee uniform sterility after the demineralisation process. Third, the cadaver bones used were provided by the InterHospital Organ Bank from donors accepted as kidney donors. Most of the patients included in our first report had unique deformities and would not have been appropriate for a randomised comparison of efficacy of different types of grafts or implants. Future efforts will be directed towards comparative trials in an
appropriate patient population. JULIE GLOWACKI LEONARD B. KABAN
ABO, HLA, AND ZWa TYPING AND ANTIBODY DETERMINATION
Department of Surgery, Harvard Medical School, Children’s Hospital Medical Center, Boston, Massachusetts 02115, U.S.A.
JOSEPH E. MURRAY JUDAH FOLKMAN JOHN B. MULLIKEN
1. Moran
WH, Zimmermann B. Mechanisms of antidiuretic hormone (ADH) control of importance to the surgical patient. Surgery 1967; 62: 639. 2. Ukai M, Moran WH, Zimmermann B. The role of visceral afferent pathways on vasopressin secretion and urinary excretory patterns during surgical stress Ann
Surg 1968; 168: 16. 3. Bonnet
F, Harari A, Thibonnier M, Viars P. Suppression of antidiuretic hormone hypersecretion during surgery by extradural anaesthesia. Br J Anaesth (in press) 4 Philbin DM, Coggins CH. Plasma antidiuretic hormone levels in cardiac surgical patients during morphine and halothane anesthesia. Anesthesiology 1978, 49: 95 5. Glowacki J, Kaban LB, Murray JE, Folkman J, Mulliken JB. Application of the biological principle of induced osteogenesis for craniofacial defects. Lancet 1981; i. *M1 was,
in
addition, A3, A9; M2
was
Al, A24, B27;
and M3
was
Al.
959-62.
VASOPRESSIN RESPONSE TO PNEUMOPERITONEUM: MECHANICAL OR NOCICEPTIVE STIMULATION?
THROMBOCYTOPENIA
SiR,-We agree with Sharon and Amarl that thrombocytopenia is seldom a problem in babies born to mothers with anti-HLA antibodies. However, these workers blame ABO incompatibility or sepsis for the neonatal thrombocytopenia and seem to neglect the importance of specific platelet antibodies. We describe here three patients with immune thrombocytopenia caused by Zwa platelet antibodies. From June, 1979, to June, 1981, we saw three babies with unexplained generalised petechiae. Platelet counts were low and varied during the first days after delivery between 5 x 109 and 28 x 109/1. Previously all the mothers had been healthy and did not have thrombocytopenia. Pregnancy and labour were uncomplicated. HLA typing of the mothers was done by the microscale N.I.H. lymphocytotoxicity test and lymphocytotòxic antibodies were sought against a panel of highly selected lymphocytes from fourteen donors possessing most known HLA A, B, and C specificities. For demonstration of platelet antibodies and platelet typing of the parents we used a platelet complement fixation test (PCFT)2 and a platelet suspension immunofluorescence test (sift).3To define the specificity of the platelet antibody we used selected ABOgrouped and HLA-typed Zw(a -) and Zw(a +) platelet donors. As seen in the table, two of the children were ABO incompatible with their mothers. The red blood cells of the babies were not sensitised with ABO or other antibodies. All three mothers with anti-Zwa had HLA-B8. One of the mothers had weak lymphocytotoxic antibodies reacting with four of the selected fourteen panel donors. We thus found free platelet antibody in the sera of all three mothers delivered of a child with neonatal thrombocytopenia. The platelet antibody was anti-Zwa in all three cases. This finding was supported by the Zwa negativity in the mothers and Zwa positivity in the fathers. Only 2% of the population are Zw(a _).2 The significance of ABO incompatibility in relation to neonatal thrombocytopenia is not clear. It has been suggested that ABO compatibility between mother and child is a prerequisite for neonatal However, von dem Borne et al: found ABO incompatibility in five out of thirty-one cases.3 Our results point in the same direction since we found ABO incompatibility in two of the three cases. Our Zw(a -) mothers had the HLA-B8 tissue antigen, which supports the reported connection between anti-Zwa immunisation and HLA-B8.5
thrombocytopenia.4
P. G. SØRENSEN
Department of Blood Grouping and Immunology, Odense University Hospital,
HANS MICKLEY HANS DIEDERICHSEN NIELS GRUNNET
DK 5000 Odense C, Denmark 1. Sharon
R, Amar A. Maternal anti-HLA antibodies and neonatal thrombocytopenia. Lancet 1981; i: 1313. 2. Svejgaard A. Iso-antigenic systems of human blood platelets. Thesis, Aarhus (Backhausen A, Sorensen HJ) 1971. 3. von dem Borne AEGK, van Leeuwen EF, von Riesz LE, van Boxtel CJ, Engelfriet CP. Neonatal alloimmune thrombocytopenia: Detection and characterization of the responsible antibodies by the platelet immunofluorescence test. Blood 1981; 57: 649-56. 4. Gratwohl AA, Shulman NR. ABO-Kompatibilität und isoimmune neonatale Thrombopenie. Schweiz Med Wochenschr 1977; 107: 1464. 5. Reznikoff-Etievant MF, Dangu C, Lobet R. HLA-B8 antigen and alloimmunization. Tissue Antigens 1981; 18: 66-68.
anti-P1A1
SIR,-Dr Punnonen and Dr Viinamaki (Jan. 16,
p. 175) suggest abdominal pressure induced by a pneumoperitoneum stimulates vasopressin release. During abdominal surgery, visceral traction dramatically raises plasma vasopressin levels, and painful stimuli were thought to be the main factor.’ Vagotomy, which suppresses only a few nociceptive pathways, cannot prevent the vasopressin hypersecretion induced by gastrectomy in dogs.2By contrast, disruption of spinal pain pathways by dorsal rhizotomy blocked the vasopressin secretory response to gastrectomy.2We have noted inhibition of vasopressin stimulation during surgery under epidural anaesthesia, thus confirming the experimental data.3Furthermore, high doses of morphine produce the same effect during cardiac surgery.4The fentanyl doses used by Punnonen and Viinamaki are certainly far less important than those used during cardiac surgery. We suggest that high plasma levels of vasopressin found after a pneumoperitoneum are secondary to nociceptive stimulation.
that
the
rise
in
Department of Anaesthetics, G.H. Pitié-Salpétrière, 75013
Paris, France
F. BONNET A. HARARI M. THIBONNIER
BONE IMPLANTS AND INDUCED OSTEOGENESIS
StR,-The title of our May, 1981 paper5 stresses that the biological principle of induced osteogenesis is different from the mechanism of healing of fresh grafts or banked implants. We and others think of demineralised bone not as just another implant but as a controlled way to induce bone growth from the recipients’ connective tissue. Lieutenant Matthews and colleagues (Nov. 7, p. 1041) raise several important issues derived from their experience at the U.S. Navy Tissue Bank. There is no controversy that lyophilised allograft bone has proved safe and useful. Indeed the purpose of our paper was not to review the experience with other materials nor to assert superiority of one material over others. We chose to report on the use of demineralised allogeneic bone implants for craniofacial reconstruction and construction in patients. Many of the defects were too large to be treated with small amounts of lyophilised bone made available by banks. Other patients volunteered for this study to avoid harvesting procedures; in many of these, harvesting would have been of greater magnitude than the correction of the skeletal defect. Second, Matthews et al. suggest the need for non-irradiated controls to determine the effect of irradiation. We were not permitted to use non-irradiated implants because we do not have the facilities to guarantee uniform sterility after the demineralisation process. Third, the cadaver bones used were provided by the InterHospital Organ Bank from donors accepted as kidney donors. Most of the patients included in our first report had unique deformities and would not have been appropriate for a randomised comparison of efficacy of different types of grafts or implants. Future efforts will be directed towards comparative trials in an
appropriate patient population. JULIE GLOWACKI LEONARD B. KABAN
ABO, HLA, AND ZWa TYPING AND ANTIBODY DETERMINATION
Department of Surgery, Harvard Medical School, Children’s Hospital Medical Center, Boston, Massachusetts 02115, U.S.A.
JOSEPH E. MURRAY JUDAH FOLKMAN JOHN B. MULLIKEN
1. Moran
WH, Zimmermann B. Mechanisms of antidiuretic hormone (ADH) control of importance to the surgical patient. Surgery 1967; 62: 639. 2. Ukai M, Moran WH, Zimmermann B. The role of visceral afferent pathways on vasopressin secretion and urinary excretory patterns during surgical stress Ann
Surg 1968; 168: 16. 3. Bonnet
F, Harari A, Thibonnier M, Viars P. Suppression of antidiuretic hormone hypersecretion during surgery by extradural anaesthesia. Br J Anaesth (in press) 4 Philbin DM, Coggins CH. Plasma antidiuretic hormone levels in cardiac surgical patients during morphine and halothane anesthesia. Anesthesiology 1978, 49: 95 5. Glowacki J, Kaban LB, Murray JE, Folkman J, Mulliken JB. Application of the biological principle of induced osteogenesis for craniofacial defects. Lancet 1981; i. *M1 was,
in
addition, A3, A9; M2
was
Al, A24, B27;
and M3
was
Al.
959-62.