Treatment policy of a psychogeriatric admission ward

Microaggregates begin to develop within a few hours of storage of blood in plastic or glass containers, but their numbers increase mainly towards the end of the first week. They include degenerated platelets, leucocytes, fibrin strands, denatured proteins and fragmented red cells, and range in size from 10 to 40 micrometer or more in diameter. The rate of formation is related to the platelet and leucocyte concentrations prior to storage and the anticoagulant used. While clinical and experimental evidence of deleterious pulmonary effects of these unwanted particles has been limited and contradictory, recent studies have demonstrated that significant increases in pulmonary arteriovenous shunting and alveolar-arterial oxygen differences occur in patients transfused more than 20% of their blood volume throught the standard 170 micrometer filters. These changes are not seen when the blood is passed through a 20 micrometer Dacron wool filter. Other methods of reducing the microaggregate content of transfused blood include the use of fresh blood (less than 2 days), glycerol-frozen fresh blood correctly thawed, or saline-washed packed red cells. Since none of these is feasible for routine use at present, removal by microfiltration prior to rransfusion is employed. Of the filters currently available, the 40 micrometer screen filters appear to offer important practical advantages over the alternative depth filters. Routine filtration of all stored blood transfused is advocated.     

Preparation of leukocyte-free blood by a method of sedimentation-filtration

After centrifugation of 450 ml-CPD-whole blood, 125 ml of packed red cells are diluted to 50 percent with saline (pH 7, 2). To remove leukocytes the diluted blood is filtered at room temperature through a newly devised column packed with cotton wool disks. 200 ml of red blood cells suspension are recovered and contain less than 5.10(6) leukocytes. Appropriate controls show that: 1. The filtered blood contains no pyrogen; 2. The red blood cells have a normal osmotic resistance; 3. The suspension can be maintained at 4 degrees C up to 5 days before transfusion without cellular damage.     

Primary biliary cirrhosis associated with mixed type autoimmune hemolytic anemia and sicca syndrome: a case report and review of literature

A case presenting with an unusual association of primary biliary cirrhosis and mixed type autoimmune hemolytic anemia plus sicca syndrome is described. The 49-yr-old female primary biliary cirrhosis patient had a confirmed sicca syndrome and presented with jaundice and life-threatening anemia. Laboratory tests revealed positive Coombs' test with coexisting cold and warm autoantibodies. She was successfully treated by blood transfusion with packed red cells lacking any red cell antigens corresponding to serum alloantibodies and pulse methylprednisolone therapy. The patient remained stable under maintenance treatment using oral steroids and ursodeoxycholic acid. This case is probably the first reported showing an association between primary biliary cirrhosis and mixed type autoimmune hemolytic anemia plus sicca syndrome and was probably induced by heterogenous and complicated autoimmune reactions.     

Hemolytic disease of the newborn due to anti-Di(a): report of one case

In the Diego blood group, the frequency of the Di(a + b +) or Di(a + b -) phenotype among Chinese in Taiwan is estimated to be 3.2%. Here we report a case of severe hemolytic disease caused by anti-Di(a). The baby's total bilirubin elevated to 23 mg/dl at the age of 72 hours. A blood exchange transfusion and phototherapy were performed. We suggest to include Diego positive cell panels in testing antibody specificities that are likely to be encountered in this population.     

Mechanics of avian fibrous periosteum: tensile and adhesion properties during growth

Aprotinin is a proteinase inhibitor that reduces blood loss in total hip arthroplasty when administered in large doses. Little is known about the capability of smaller doses of aprotinin in reducing blood loss and transfusion needs in this surgical setting. We reviewed the medical records of 372 patients who had undergone unilateral primary total hip arthroplasty under general anaesthesia during a 6-year period (1989 to 1994) at our institution. Successively, 193 patients had and 179 patients had not received aprotinin in a dose of 20,000 kallikrein inhibitor units per kilogram body weight intravenously before surgery. Neither the volume of red blood cells lost nor that of red blood cells transfused during hospitalization differed significantly between the patients who had and those who had not received aprotinin (520 +/- 406 vs. 549 +/- 394 mL and 463 +/- 379 vs. 475 +/- 367 mL; P = 0.49 and P = 0.76 respectively). These results suggest that small-dose aprotinin was not effective in reducing blood loss and transfusion needs in patients undergoing unilateral primary total hip replacement.     

The risk of acquiring Lyme disease or babesiosis from a blood transfusion

To determine the risk of acquiring Lyme disease or babesiosis from blood transfusion, serum was collected before and 6 weeks after patients received multiple transfusions during cardiothoracic surgery and antibodies to Borrelia burgdorferi and Babesia microti were measured. Of 155 subjects, 149 received 601 total units of packed red blood cells (PRBC) and 48 received 371 total units of platelets. No patient developed clinical or serologic evidence of Lyme disease; 1 (who received 5 units of PRBC) developed clinical and serologic evidence of babesiosis. The risk of acquiring Lyme disease from a transfused unit of PRBC was 0 (95% confidence interval [CI], 0-0.5%) and from a transfused unit of platelets was 0 (95% CI, 0-0.8%); the same risks for babesiosis were 0.17% (95% CI, 0.004%-0.9%) and 0 (95% CI, 0-0.8%), respectively. The risk of acquiring either Lyme disease or babesiosis from a blood transfusion in Connecticut is very low.     

Conjugated estrogen reduces transfusion and coagulation factor requirements in orthotopic liver transplantation

We conducted a prospective, randomized study to determine the efficacy of conjugated estrogen in reducing blood product transfusion during orthotopic liver transplantation (OLT). Patients undergoing OLT were included in the study. Only those having a reaction time of more than 30 mm or 15 min (19 -28 mm) on computed thromboelastography (CTEG) at the beginning of surgery were enrolled in the study. Patients were randomized to receive either conjugated estrogen (CE) or placebo. Every patient received a first dose of CE (100 mg i.v.) (20 mL) or placebo (20 mL of isotonic sodium chloride solution) at the beginning of the procedure and a second dose of CE (100 mg i.v.) or 20 mL of placebo (20 mL of isotonic sodium chloride solution) just after reperfusion of the new graft. The two groups were similar in age, weight, requirement for veno-veno bypass, time on veno-veno bypass, CTEG measurement, and preoperative hemoglobin and platelet values. Blood products were given in relation to hematocrit and coagulation (CTEG) variables, which were measured every hour during the surgery. The amount of transfused blood products did not differ in terms of units of cryoprecipitate, but the intraoperative requirements for red blood cells (6 +/- 3 vs 9 +/- 6 U; P = 0.05), platelets (12 +/- 8 U vs 18 +/- 10 U; P = 0.05) and fresh-frozen plasma (3 +/- 3 U vs 6 +/- 4 U; P = 0.001) was significantly less in the estrogen group than in the control group. We conclude that CE is associated with a significant decrease in use of fresh-frozen plasma, platelets, and red blood cells during OLT. Implications: In this study, we prospectively investigated whether i.v. conjugated estrogen could decrease blood product transfusion during orthotopic liver transplantation. Conjugated estrogen-treated patients received less fresh-frozen plasma, red blood cells, and platelets. In this population of patients, conjugated estrogen can be a useful addition in coagulation management during orthotopic liver transplantation.     

Retropubic and perineal approach: plea for perineal radical prostatectomy

OBJECTIVES: Two surgical approaches are proposed for radical prostatectomy: the retropubic route and the perineal route. We compared the surgical, oncological and functional aspects of these two approaches and present arguments suggesting that the perineal approach is the preferred approach for radical prostatectomy. MATERIAL AND METHODS: 55 retropubic radical prostatectomies were retrospectively compared to 55 perineal radical prostatectomies and performed between March 1992 to December 1995. The clinical TNM, preoperative PSA, results of 6 systematized intrarectal biopsies, operating time, intraoperative bleeding, number of patients transfused and number of packed cell units per patient transfused, medical and surgical complications, catheterization time and length of hospital stay, incidence of urethrovesical anastomosis leak and stenosis, analysis of the prostatectomy specimen, course of PSA, continence and erection were studied. RESULTS: Statistically significant differences were observed for the retropubic and perineal approaches, respectively: preoperative PSA (24 vs 15 ng/mL), intraoperative bleeding (2664 vs 1071 mL), number of patients transfused (91% vs 28%), number of packed cell units per patient transfused (3.9 vs 2.7), medical and surgical complications (56.9 vs 29.1%), anastomotic leak (24.1 vs 7.2%), anastomotic stenosis (31.5 vs 1.8%), duration of catheterization (18 vs 13 days) and length of hospital stay (14 vs 8 days). At 2 years, PSA remained less than 0.5 ng/mL in both groups. CONCLUSION: Even taking the learning period into account, the perineal approach provides the same results as the retropubic approach in terms of functional and oncological parameters, with a simpler postoperative course for patient.     

Intraoperative and postoperative autologous transfusion in orthopedic surgery

Information was collected retrospectively on three comparable groups, 25 patients in each, who had been operated on for thoracic scoliosis. Group 1 received homologous transfusions only. Group 2 and group 3 were transfused postoperatively with drained whole blood (Solcotrans orthopaedics). Group 3 received in addition peroperatively washed packed red blood cells (Haemolite 2 Cell Saver) recirculated. The need for homologous transfusions was reduced from 119 units to 23 patients in group 1, to 36 units to 14 patients in group 2 and 34 units to 13 patients in group 3. Three of the first 15 patients in group 2 experienced chills and fever reactions in connection with the autologous transfusion. No reactions were seen after infusion when we scrapped the last 50 to 100 ml of drained blood.     

Multiple birth defects in a newborn exposed to Mycoplasma pneumoniae in utero

A newborn baby girl with progressive hydrocephalus and congenital defects of the skin and eyes was born to a mother who experienced bilateral bronchopneumonia in her first trimester. At the time of her infection, the mother's serum cold agglutinin titer was 1:128 and at delivery the mother's and baby's serum samples had complement-fixation titers to Mycoplasma pneumoniae of 1:1,024 and 1:256, respectively. At 1 week of age the baby's serum IgM value was 44 mg/100 ml (98% of cord IgM values in normal newborns range from 0 to 20 mg/100 ml). The baby died of progressive hydrocephalus, which may have had an inflammatory basis in view of the cerebrospinal fluid (CSF) protein level of 192 mg/100 ml. We realize that the significance of this association is questionable, but we believe that it is worthwhile to call the coincidence of events to the attention of others.     

Indirect bonding

A case is reported of hemolytic anemia following rifampicin administration and complicated by acute renal failure. Furthermore clotting analyses suggested a slight disseminated intravascular coagulation, very likely activated by hemolysis products. Both hemolysis and renal function impairment subsided spontaneously, after the sole withdrawal of rifampin. Direct antiglobulin test became negative within a few days, while an indirect Coomb's test was demonstrated persistently with the patient's serum using red blood cells sensitized in vitro with the drug. Otherwise from all reports in the literature, the patient developed an acute hemolytic anemia while on daily therapy and as many as twenty years after a previous treatment with rifampicin. Mechanisms of drug-induced immune hemolytic anemia and acute nephropathy are discussed (formation of drug-antibody complexes, which adhere on the red blood cells surface and are able to fix complement and induce intravascular hemolysis; tubular necrosis due to hemoglobinuria or immuno-mediated interstitial nephritis).     

Changes of serum hemolytic activity and the number of reticulocytes in canine Babesia gibsoni-infection

When the serum hemolytic activity in Babesia gibsoni-infected dogs was determined with self red blood cells from the infected animals, the decrease in the activity is paralleled with the increase in the number of reticulocytes. The activity determined with red blood cells from phenylhydrazine-induced anemia also decreased parallel with the increase in the number of reticulocytes. These results suggest that the rapid decrease in the serum hemolytic activity after reaching the peak is due to the increase in reticulocytes, which are probably unsusceptible to the hemolytic factor(s).     

Sulindac-induced immune hemolytic anemia

BACKGROUND: Sulindac, a nonsteroidal, anti-inflammatory, indene-derived drug, caused life-threatening immune hemolytic anemia in an individual with back pain. CASE REPORT: A patient was admitted to the hospital with immune hemolytic anemia and kidney and liver failure after several days ingestion of sulindac. The direct antiglobulin test was positive with polyspecific and monospecific anti-IgG but not with anti-C3. The eluate did not react in routine tests but reacted strongly after the addition of sulindac. The serum contained a sulindac-dependent antibody reacting to a titer of 32. The sulindac-dependent antibody was of both IgG and IgM classes and had no apparent blood group specificity. The antibody agglutinated red cells from humans and chimpanzees but not from chickens, rabbits, or sheep, which implied that a specific component on human and chimpanzee red cells was needed for reactivity. The antibody reacted with red cells treated with trypsin, papain, pronase, dithiothreitol, and sialidase. With aggressive medical care, the patient's condition improved. CONCLUSION: These findings appear compatible with the so-called immune complex mechanism for drug-induced immune hemolytic anemia. Physicians are alerted to the severe nature of this syndrome.     

Hemolytic uremic syndrome as a clinical manifestation of oxidative stress

An examination was made of seventeen children having various stages of the hemolytic uremic syndrome: Stage 1 is the period of an expanded clinical picture of the disease, the patients' condition is grave (anuria, azotemia, severe hemolytic anemia and thrombocytopenia); Stage 2 is the period of recovery. The plasma levels of malonic dialdehyde, dienic conjugates, alpha-tocopherol at the first stage of the disease were considerably higher than the control ones, on recovery there were their reductions though their levels remained higher than the normal levels. The levels of malonic dialdehyde in the red blood cell membranes in ill children were also much higher than those in healthy donors, but at the second stage they decreased, but remained high. The activity of superoxide dismutase in the red blood cells of ill children in the acute period of the disease did not significantly differ from that of donors. At the second stage of the disease there was a significant fall in the activity of red blood cell superoxide dismutase. The activity of catalase in the red blood cells of ill children was thrice higher than in the controls; however, this index decreased during treatment and at the second stage it did not differ from that in the controls. There were no significant differences in the activity of red blood cell superoxide dismutase in donors and ill children. Mechanisms responsible for abnormal plasma and red blood cell peroxidation are considered in the hemolytic uremic syndrome. It is concluded that free radical reactions play a substantial role in the pathogenesis of this abnormality.     

Guidelines for the use of blood transfusions

Over 11 million units of red blood cells are transfused each year in the United States at a cost of over $2 billion. This paper reviews the indications for and the risks of red blood cell transfusions, and provides guidelines for transfusions in both surgical and non-surgical settings.     

The presurgical management with erythrocytapheresis of a patient with a high-oxygen-affinity, unstable Hb variant (Hb Bryn Mawr)

BACKGROUND: Hemoglobin (Hb) Bryn Mawr is an unstable Hb variant resulting in congenital hemolytic anemia. This variant Hb also has an increased affinity for oxygen. The perioperative transfusion management of this disorder is described, and the first genomic analysis of this Hb variant is given. CASE REPORT: An 11-year-old boy, heterozygous for Hb Bryn Mawr, was referred for cholecystectomy. Sequence analysis of genomic DNA confirmed that the patients was heterozygous for a T-->C transition in the codon for amino acid 85, causing a substitution of serine for phenylalanine in the beta-globin chain. On the basis of whole-blood O2 dissociation studies, projected tissue O2 delivery would have been suboptimal during general anesthesia; therefore, a partial red cell exchange transfusion was performed to lower variant Hb and prevent tissue hypoxia during surgery. The red cell mass to be exchanged (50%) was determined from the calculated increase in O2 delivery capacity required to maintain an O2 extraction of 4 to 5 mL of O2 per dL of whole blood. The p50 of whole blood from the patients immediately after the exchange transfusion was 16.0 torr. At the time of surgery, the p50 was normal (25.9 torr). The patient's whole blood 2,3 DPG levels were 4.70 mmol per mL of red cells (before transfusion) (normal range = 4.8 +/- 0.3 mmol/mL red cells), 4.07 mmol per mL of red cells (immediately after transfusion), and 4.55 mmol per mL of red cells (48 hours after transfusion). CONCLUSION: This patient with Hb Bryn Mawr was prepared for surgery with a partial exchange transfusion to prevent tissue hypoxia during anesthesia. Decreased 2,3 DPG levels immediately after transfusion resulted in increased O2 affinity of whole blood; however, 48 hours after exchange transfusion, a normal p50 (due to both removal of variant Hb and regeneration of 2,3, DPG) was observed. Partial exchange transfusion is useful in the preoperative management of patients with Hb variants characterized by increased O2 affinity.     

Predictive value of contact investigation for identifying recent transmission of Mycobacterium tuberculosis

BACKGROUND: Abciximab (ReoPro; Eli Lilly and Co, Indianapolis, IN) is a monoclonal antibody that binds to the platelet glycoprotein IIb/IIIa receptor and produces powerful inhibition of platelet function. Clinical trials of abciximab in patients undergoing coronary angioplasty have demonstrated a reduction in thrombotic complications and have encouraged the widespread use of this agent. We have observed a substantial incidence of excessive bleeding among patients who receive abciximab and subsequently require emergency cardiac operations. METHODS: The records of 11 consecutive patients who required emergency cardiac operations after administration of abciximab and failed angioplasty or stent placement were reviewed. RESULTS: The interval from the cessation of abciximab administration to operation was critical in determining the degree of coagulopathy after cardiopulmonary bypass. The median values for postoperative chest drainage (1,300 versus 400 mL; p < 0.01), packed red blood cells transfused (6 versus 0 U; p = 0.02), platelets transfused (20 versus 0 packs; p = 0.02), and maximum activated clotting time (800 versus 528 seconds; p = 0.01) all were significantly greater in the early group (cardiac operation < 12 hours after abciximab administration; n = 6) compared with the late (cardiac operation >12 hours after abciximab administration; n = 5) group. CONCLUSIONS: This report suggests that the antiplatelet agent abciximab is associated with substantial bleeding when it is administered within 12 hours of operation.     

The problem of post-partum fistulas in developing countries

Transfusional iron overload leading to cardiopathy and other severe complications continues to be a major problem in chronically transfused homozygous beta-thalassaemia patients. It is well known that young red cells (neocytes) survive longer after transfusion and therefore may contribute to the extension of the intervals between transfusions. We evaluated the impact of neocytes in the total annual blood requirements and consequently the transfusional iron load in 18 thalassaemia patients. A two-period study comparing transfusions of standard red cells versus neocytes in the same group of patients was performed. Neocytes were harvested by density separation using the Neocel System. The method of preparation was simple with relatively low costs and required no special equipment. There was a significant difference (p < 0.005) in PK and MCV values of the neocyte and older red cell (gerocyte) fractions indicating that a good separation of the two populations was achieved. All patients had a reduction in blood requirements during the neocyte period. The total annually transfused red blood cells and concomitant iron blood load were significantly reduced (p < 0.001) by 20.2 +/- 9.1%. However, the response was variable. Seven of the 18 patients had a large reduction in blood consumption (24.8-34.8%), 9 others ranged between 10.7 and 21.6%, and in 2 the reduction was less than 10%. This reduction in blood requirements and in the transfused iron may change the chelation index resulting in more efficient iron chelation therapy and perhaps reduce the cost of the haemochromatosis therapy on a long-term basis. We conclude that the use of neocyte therapy using this system can benefit the majority of chronically transfused patients by reducing transfusional iron overload and related complications and may lead to a much better quality of life.     

Serological investigation and clinical significance of high-titer, low-avidity (HTLA) antibodies

High-titer, low-avidity (HTLA) antibodies are frequently described as "reactive weakly by the antiglobulin test." These antibodies include: anti-Chido (Cha) and anti-Rodgers (Rga), and anti-Cost-Stirling (Csa) and anti-York (Yka), anti-Knops (Kna) and anti-McCoy (McCa), and anti-John Milton Hagen (JMH), the majority of which are directed at high-incidence red cell antigens. The classic HTLA antibodies are thought to be incapable of fixing complement or causing in vitro hemolysis. Present data indicate that these antibodies do not cause either increased red cell destruction when incompatible blood is transfused or hemolytic disease of the newborn. Special serological techniques can be used to differentiate the antibodies within the HTLA classification from antibodies not of an HTLA nature.     

Time-dependent loss of surface complement regulatory activity during storage of donor blood

The survival of transfused red cells (RBCs) diminishes with time of in vitro storage in blood banks, but the molecular mechanisms underlying the slow but incessant deterioration are incompletely understood. To investigate the possibility that impaired resistance to autologous complement attack could play a role in this phenomenon, packed RBCs stored for variable periods were assayed for decay-accelerating factor (DAF) and CD59, two glycoinositol-phospholipid (GPI)-anchored, membrane-associated complement regulatory proteins that function physiologically to protect blood cells from autologous complement activation on their surfaces. Immunoradiometric and flow cytometric assays employing DAF and CD59 monoclonal antibodies showed that levels of both surface proteins gradually declined over 6 weeks. Digestion analyses with phosphatidylinositol-specific phospholipase C, an enzyme that releases GPI-anchored proteins from cell surfaces, showed that DAF and CD59 molecules with GPI anchors containing unacylated inositol were preferentially lost. These findings suggest: 1) that DAF and CD59 molecules with acylated GPI anchors are more stable in RBC membranes than are molecules with unacylated GPI anchors, and 2) that DAF and CD59 loss may participate with other membrane alterations that occur during in vitro storage in compromising the survival of transfused cells.