Postdural-puncture headache (PDPH) may be seen in patients after violation of the dura such as is seen with lumbar punctures for drain placement or epidural anesthetic. The leakage of cerebrospinal fluid (CSF) from the dural hole results in a decreased volume of CSF, which cushions the brain. This results in tension on the meninges leading to subsequent headaches. Conservative management involves bed rest, increased oral fluid intake, analgesic drugs and caffeine. If symptoms persist, an epidural blood patch is often considered. The epidural blood patch forms a gelatinous tamponade, which prevents further leakage of spinal fluid, allowing the dura to undergo normal healing [1]. Anticoagulated patients face additional risk from epidural hematoma, either after the initial dural violation or with the blood patch procedure itself. Lovenox (enoxaparin sodium injection) is an antithrombotic agent that falls under the class of low molecular weight heparins (LMWH). LMWHs pose a threat to the aforementioned patient population due to the increased likelihood of development of spinal epidural hematoma (SEH), a blood clot around the spinal region that can cause compression of the spinal cord and can lead to paralysis. Placement of an epidural blood patch in anticoagulated patients suffering from PDPH presents a particular conundrum because of the increased risk of developing SEH when taking enoxaparin combined with the potential that their blood will not clot or afford the clot strength required. This case report focuses on such a situation, where a patient on enoxaparin suffering from PDPH, despite conservative medical management, was administered an epidural blood patch with positive results.

Bone marrow examination is commonly used in the evaluation of hemato-oncological disorders and in patients with cancer of solid organs to detect metastases. This study reviews clinical, hematological and pathological data of nine cases with bone marrow metastases from solid tumors. The significance of bilateral bone marrow aspirations and biopsy has also been highlighted. Out of 784 bone marrow aspirations performed during a 69 months period, 9 patients showed metastatic bone marrow involvement. Fever (4), generalised weakness (5), loss of appetite (4) and loss of weight (4) were the main symptoms. Anemia (7) was the main hematological finding. Bilateral involvement was present in all but one patient. Fibrosis was also a significant finding on biopsy. Relevant literature review was also done. Bilateral bone marrow aspiration and trephine biopsy are an effective and cheap method for evaluating metastatic bone marrow tumors.

As a resource, the need for allogeneic red cell has never been more in demand than it is today. Escalating elective surgery, an ageing population, periodic shortages arising from a fall in supply, old and emerging threat of transfusion –transmissible infections and spiralling costs due to various safety introductions have all conspired to ensure that allogeneic red cell remains very much a vital but limited asset in healthcare delivery. Conserving blood makes sense. Effective stewardship of our red cell stock is important for economic, supply/ demand reasons and to protect the national inventory at times of national blood shortage. There is the need for all stakeholders to think seriously and innovatively about how best to attract and retain new donors as well as sourcing for alternatives to allogeneic red cell transfusion. A successful and sustainable future demands exemplary stewardship from all players in the careful management of both red cell supply and demand issues. We have a significant challenge to reduce unnecessary demand through world class management of this precious product by applying the best available evidenced-based medical practices. To improve outcomes, red cell usage must be optimized and expenditures controlled so that resources may be channelled toward other diagnostic, therapeutic, and technological initiatives. Health professionals involved in the care of anaemic patients has a real and pressing obligation to fulfil their responsibilities, in terms of accountability for the human, financial, clinical and other resources associated with managing blood donations. There is need to reduce the growth in demand for allogeneic red cell transfusion. We must accept the challenge that growth cannot continue at the present rate and take real steps to ensure that any growth reflects real evidence-based clinical need and is not driven by historical practice. Wastage of this precious gift is an unacceptable failure in the stewardship of blood products.

Anemia is a frequent finding during routine assessment of patients prior to elective surgery. In this setting, anemia has been demonstrated to be a risk factor for negative post-operative outcomes as well as increased intra- and postoperative transfusion requirements. Historically, blood products were given in abundance to surgical patients, based on liberal “transfusion triggers”, i.e. mildly decreased hemoglobin or hematocrit levels prompted the transfusion of blood. Current guidelines propose a more restrictive approach for surgical patients, reflecting the increased recognition of complications of blood products beyond hemolytic transfusion reactions and disease transmission. Transfusionrelated acute lung injury, immunosuppression, alloimmunization, and even increased recurrence of malignancies have been associated with the administration of blood transfusions, and are of particular concern in the surgical population. Restoration of homeostasis and augmentation of oxygen delivery to tissues are the most common indications to administer blood products in surgical patients; their capability to achieve these goals, however, is rather limited. A stronger focus on preoperative optimization of elective surgical patients, including earlier detection and treatment of anemia, along with increased efforts to minimize intraoperative blood loss may be the most promising strategies to avoid the complications associated with both anemia and blood products.

Primary central nervous system lymphoma (PCNSL) is an intracranial tumorous lesion that develops in acquired immunodeficiency syndrome (AIDS) patients. PCNSL is very rare, but its prevalence has increased with the expansion of human immunodeficiency virus (HIV) infections. It is diagnosed by imaging or biopsy. Serum and cerebrospinal fluid (CSF) have been analyzed for the presence of diagnostic biomarkers for PCNSL. The presence of Epstein-Barr virus in the CSF is a widely used biomarker, but it has a low positive predictive value. B-cell activation-related cytokines, tumor-specific DNA methylation, and microRNAs have been reported as new candidate biomarkers. Previously, the prognosis of AIDS-related PCNSL was very poor. However, highly active antiretroviral therapy emerged in the late 1990s, which continuously inhibits viral replication and facilitates the recovery of immunity in HIV-infected persons, improving the prognosis of PCNSL patients in combination with whole-brain irradiation. In this review, we focus on the diagnosis of and biomarkers for AIDS-related PCNSL and advancements in its treatment.

Sickle Cell Trait (SCT) -the awareness of this problem is non-existent in middle and high school students, especially the African-Americans and those having malaria impacted regions as their descent. Sickle Cell trait is found in 8% of African-Americans. There is no comprehensive program across the country to make school students aware of SCT. The students are not aware that the sickle cell trait can lead to health complications if they are doing strenuous exercise or swimming to build stamina or to compete. The students volunteering in Civil Air Patrol, an United States Air Force Auxili ary, who do air sorties in unpressurised planes are unaware of sudden death risk due to hypoexemia. Incorporating the education material in biology, science and physical education text books and lectures has been proposed as a viable solution. As the student progresses through various grades so does the chapter advances each year with enhanced education material. It ties up with evolution, natural selection, vector diseases, geographical distribution, blood composition, advanced biology and environmental science. Chapters in mathematics, probability and computer science adopt simulations for natural selection based upon recessive and dominant genes as in Sickle Cell. Geographical Information Systems depict the geographical distribution and immigration of people. Social science students learn about historical perspectives and social implications of marriage between two persons having similar genetic traits. Before any pain management techniques or medications are adopted, the students should be made aware of the problem and the clinical symptoms. A comprehensive education strategy to create awareness and enhance knowledge especially in context with SCT amongst school students is proposed.

Recurrent hemarthroses in childhhood before the initiation of primary prophylaxis will result in joint damage after a decade or later. The best way that we have today to protecting against hemophilic arthropathy is primary prophylaxis. The decision to institute early full prophylaxis by means of a port (central venous access device) has to be balanced against the child’s bleeding tendency, the family’s social situation and the experience of the specific hemophilia center. The reported complication rates for infection and thrombosis have varied considerably from center to center. Risk of infection can be reduced by repeated education of patients and staff, effective surveillance routines and limitations on the number of individuals allowed to use the device. In discussing options for early therapy, the risks and benefits should be thoroughly discussed with the parents. From a practical point of view, primary prophylaxis together with synovectomy (radioactive, chemical, arthroscopic, or open) to avoid joint bleeding, can help halt hemophilic synovitis. Radiosynovectomy is a relatively simple, virtually painless and inexpensive treatment for chronic hemophilic synovitis, even in patients with inhibitors and must be the best choice for patients with persistent synovitis (which must be confirmed by US and/or MRI). Arthroscopic joint debridement may be indicated in younger hemophiliacs when there is relative preservation of the joint architecture and congruity, after the failure of three radiosynovectomies with a 6-month interval, and when joint replacement is not considered to be a viable alternative. Total joint arthroplasty should be indicated in hemophiliacs with severe joint pain and disability, including those who are HIV-positive. Hemophilia is a risk factor for infection after total joint arthroplasty. An extended period (2-3 weeks) of adequate hemostatic function is necessary to achieve normal healing after orthopedic procedures in hemophilia.