Self-healing juvenile cutaneous mucinosis in a patient with nephroblastoma

PURPOSE: Enhanced engraftment and reduced viral complications may be achieved in bone marrow transplantation (BMT) by limiting homologous transfusions. We report on limiting donor exposures before and after BMT in a newborn with severe combined immunodeficiency (SCID) using dedicated whole blood and plateletpheresis donors as well as a sterile connecting device (SCD). PATIENTS AND METHODS: A 1-day-old neonate was admitted for an allogeneic, human leukocyte antigen-disparate, T-cell-depleted BMT performed on day 43 of hospitalization. All transfused red blood cells (RBCs) and platelets were cytomegalovirus negative, and were irradiated and leukodepleted (via a Pall filter). Using the SCD, tubing above the filter was connected to the product bag, and the distal tubing was connected to a transfer pack for collection of the filtered product. Additional transfer packs were connected to the filtered product using the SCD to separate small aliquots as needed. RBC aliquots were irradiated individually before each transfusion. RESULTS: During a total of 134 days of hospitalization, only four donor exposures occurred. Eleven RBC transfusions (mean volume 46.4 +/- 12.6 ml) from three donors and five plateletpheresis transfusions (mean volume 74.2 +/- 7.5 ml) from one donor constituted all the patients' transfusion requirements. Evidence of engraftment was seen on day 18 post-BMT with an absolute neutrophil count sustained at > 500 cells/mm3. The last transfusion was received on day 35 post-BMT. CONCLUSIONS: Current blood transfusion technology enables patients undergoing bone marrow transplantation to have limited donor exposures. This practice should decrease viral complications without effecting bone marrow engraftment.     

Adenine metabolism during and after exchange transfusions in newborn infants with CPD-adenine blood

CPD-adenine blood (adenine in a final concentration of 0.25 mmol/1) was used in exchange transfusions in four newborn infants. The amount of adenine in one exchange transfusion ranged from 27 to 29 mumol per kg bodyweight. The maximum P-adenine concentration during the exchange transfusions ranged from 4 to 8 mumol/1 but decreased to pretransfusion levels 20 minutes after the exchange transfusions. During a 24-hour period following the exchange transfusions, the total urine excretion of adenine and 2,8-dihydroxyadenine corresponded to 0.5 to 1.3 per cent of the given adenine dose calculated on a molar basis. Accumulated data indicate that CPD-adenine blood can be used even in repeated exchange transfusions in newborn infants.     

Iron supplementation enhances response to high doses of recombinant human erythropoietin in preterm infants

AIMS: To determine whether iron supplementation would enhance erythropoiesis in preterm infants treated with high doses of human recombinant erythropoietin (r-HuEPO). METHODS: Sixty three preterm infants were randomly allocated at birth to one of three groups to receive: r-HuEPO alone, 1200 IU/kg/week (EPO); or r-HuEPO and iron, 1200 IU/kg/week of r-HuEPO plus 20 mg/kg/week of intravenous iron (EPO + iron); or to serve as controls. All three groups received blood transfusions according to uniform guidelines. RESULTS: Infants in the EPO + iron group needed fewer transfusions than controls--mean (95% CI) 1.0 (0.28-1.18) vs 2.9 (1.84-3.88) and received lower volumes of blood--mean (95% CI) 16.7 (4.9-28.6) vs 44.4 (29.0-59.7) ml/kg. The EPO group also needed lower volumes of blood than the controls--mean (95% CI) 20.1 (6.2-34.2) vs 44.4 (29.0-59.7) ml/kg, but the same number of transfusions, 1.3 (0.54-2.06) vs 2.9 (1.84-3.88). Reticulocyte and haematocrit values from postnatal weeks 5 to 8 were higher in the EPO + iron than in the EPO group, and both groups had higher values than the controls. Mean (SEM) plasma ferritin was lower in the EPO group-65 (55) micrograms/l than in the EPO + iron group 780 (182) micrograms/l, and 561 (228) micrograms/l in the control infants. CONCLUSIONS: Early administration of high doses of r-HuEPO with iron supplements significantly reduced the need for blood transfusion. Intravenous iron (20 mg/kg/week in conjunction with r-HuEPO yielded a higher reticulocyte count and haematocrit concentration after the forth week of life than r-HuEPO alone. Infants treated with r-HuEPO alone showed signs of reduced iron stores.     

Prevalence of IgG and IgM anti-Toxoplasma antibodies in patients with HIV and acquired immunodeficiency syndrome (AIDS)

OBJECTIVE/STUDY DESIGN: After blood loss, production of erythropoietin in adults increases, which accelerates erythropoiesis and restores the erythroid mass. It is unclear whether preterm infants with large phlebotomy losses have a similar response. We therefore measured serum erythropoietin concentrations in 11 ill preterm infants (1057 +/- 167 gm) as their phlebotomy losses accumulated. RESULTS: Before the first transfusion, erythropoietin concentrations were 68.9 +/- 36.2 mU/ml (range 0 to 205 mU/ml) at 5 ml/kg blood out, 17.4 +/- 8.9 mU/ml at 10 ml/kg, and 4.8 +/- 2.6 mU/ml at 15 ml/kg. Erythropoietin concentrations did not increase in any patients despite increasing phlebotomy losses. CONCLUSION: Serum erythropoietin concentrations in ill preterm infants do not increase in the face of significant blood loss. Although the mechanistic explanation for this failure is unclear, it likely contributes to the transfusion requirements of this population.     

Transfusion of newly stored blood

It is shown that freshly stored stabilized blood differs in its effect on a recipient only on account of addition of stabilizors to it. The replacement effect due to transfusion of freshly preserved citrated blood is analogous to that noted in direct blood transfusion, however the response of the cardiovascular system inadequate for the transfused blood volume would restrict the rate and volume of transfusion. Freshly heparinized blood differs from donor blood by impaired coagulation factors, but it is identical in hemodynamic effect. Freshly preserved sorbent blood is mostly close in its efficacy to direct transfusions, since its content differs from native donor blood only in calcium content.     

Acute normovolemic hemodilution can replace preoperative autologous blood donation as a standard of care for autologous blood procurement in radical prostatectomy

Predonation of autologous blood (PAD) is a standard of care for patients undergoing radical prostatectomy, but recent studies have shown that PAD is not cost-effective. Acute normovolemic hemodilution (ANH) is an alternative autologous blood procurement technique that is much less costly than PAD. We compared the efficacy and costs of ANH alone to ANH combined with PAD. Two hundred-fifty patients who predonated fewer than 3 units of autologous blood before radical prostatectomy underwent ANH to a target hematocrit of 28%. Perioperative hematocrit levels, transfusion outcomes and costs, and postoperative outcomes were compared for patients who predonated 0, 1, or 2 units of blood before surgery. A computer model was used to estimate the savings in red blood cells (RBC) associated with each autologous intervention. ANH alone resulted in a 21% allogeneic transfusion rate and contributed a mean net savings of 112 mL RBC in blood conservation (equivalent to 0.6 unit of blood). The addition of 1 or 2 units of PAD reduced allogeneic exposure rates to 6% or 0%, respectively. Overall, patients who predonated blood had a mean net loss of 198 mL of RBC (equivalent to 1 blood unit), due to both an absence in compensatory erythropoiesis and to the wastage of 60% of the blood units donated. Patients who underwent ANH alone had a 60% reduction in mean total transfusion costs ($103 +/- $102) compared with patients who predeposited 2 units of autologous blood in addition to ANH ($269 +/- $11, P < 0.05). We conclude that ANH can replace PAD as an autologous blood option because it is less costly and equally effective. A combination of ANH and PAD can further decrease allogeneic blood exposure, but it increases transfusion costs and wastage. IMPLICATIONS: A patient's own blood can be obtained for use in surgery by predonation or acute normovolemic hemodilution on the day of surgery. Both blood collection techniques decrease the need for blood bank transfusions, but acute normovolemic hemodilution is less expensive and more convenient for patients.     

The effect of epoetin beta (recombinant human erythropoietin) on the need for transfusion in very-low-birth-weight infants. European Multicentre Erythropoietin Study Group

BACKGROUND: Anemia of prematurity is characterized by low reticulocyte counts and inadequate erythropoietin response, for which many very-low-birth-weight infants receive multiple blood transfusions. We investigated whether early treatment of such infants with recombinant human erythropoietin would reduce their need for transfusions. METHODS: We performed a controlled, blinded trial in 241 infants with very low birth weights at 12 centers in six European countries. When three days old, the infants were randomly assigned either to the epoetin group or to the control group. Those in the epoetin group received 250 IU of epoetin beta per kilogram of body weight subcutaneously three times a week from day 3 to day 42 (for a total of 17 doses); those in the control group did not receive this drug. Infants in both groups received oral iron (2 mg per day) from day 14 onward. RESULTS: The control infants needed a mean of 1.25 transfusions each, as compared with 0.87 transfusion for epoetin-treated infants (P = 0.013). The median cumulative volume of blood transfused per kilogram per day was 0.41 ml in the control group (first quartile, 0 ml; third quartile, 0.8 ml) and 0.09 ml in the epoetin group (first quartile, 0 ml; third quartile, 0.8 ml) (P = 0.044). The rate of success, defined as an absence of need for transfusions and a hematocrit that never fell below 32 percent, was 4.1 percent in the control group and 27.5 percent in the epoetin group (P = 0.008). Epoetin was most beneficial in boys with birth weights of 1200 g or more and a base-line hematocrit of 48 percent or more. No toxic effects were observed in the epoetin group; as compared with the control group, the epoetin group had an increased incidence of septicemia (14 vs. 7 episodes, P not significant) and reduced weight gain (520 vs. 571 g, P = 0.02). CONCLUSIONS: Infants with very low birth weights have less need of transfusions if given epoetin beta during the first six weeks of life (250 IU per kilogram three times a week). We recommend early epoetin treatment for all such infants, but further studies of nutrition and iron supplementation during treatment are needed.     

Current red blood cell transfusion practices

The appropriate use of blood transfusions remains variable among health-care institutions and patient populations. Transfusion practices are discussed in this article in relation to medical practice guidelines and utilization review. Specific transfusion practices in the settings of intensive care, orthopedic surgery, and open heart surgery are reviewed. A new, promising approach to improving transfusion outcomes is the use of transfusion algorithms. Transfusion algorithms may prove especially useful if they incorporate point-of-care testing that is both physiologic and patient-specific for transfusion decisions. Transfusion algorithms are discussed and data presented for cardiac surgical adults.     

Cerebral edema, mass effects, and regional blood volume in man

The relation between directly measured arterial blood pressure and blood volume was studied in 61 sick preterm infants. Mean blood volume (derived from plasma volume [T1824 ten-minute albumin space] and hematocrit value) of 26 hypotensive infants (89.1 +/- 17.26 ml/kg) was not significantly different from that of 35 normotensive, but otherwise comparable, infants (91.4 +/- 14.57 ml/kg). There was no relation between arterial mean blood pressure and blood volume. Twenty-one infants with arterial mean blood pressure less than 30 mm Hg were given 1.0 g/kg of 10% salt-poor albumin. Significant increases in blood pressure occurred but were small in magnitude; more than one half of infants had arterial mean blood pressures persistently less than 30 mm Hg. Arterial/alveolar PO2 ratio decreased significantly with albumin infusion in six infants with hyaline membrane disease not receiving continuous distending-airway pressure, suggesting an association between infused albumin and impaired oxygen exchange.     

Collection and transfusion of blood and blood components in the United States, 1994

BACKGROUND: Collections and transfusions of blood in the United States in 1994 were measured and compared with those in 1992. STUDY DESIGN AND METHODS: Completed survey questionnaires were returned by all 147 regional blood centers, 1340 American Association of Blood Banks (AABB) member hospitals, and 523 non-AABB hospitals. Statistical tests verified the representativeness of the sample. RESULTS: The United States domestic blood supply in 1994 (13,340,000 units) was 3.3 percent less than in 1992. It included allogeneic blood (11,773,000 units), autologous blood (1,013,000 units), and directed donations (334,000 units). Of these, 432,000 units were rejected on testing, 11,107,000 units were transfused to 3,398,000 patients, and 1,801,000 units were discarded or unaccounted for. Platelet transfusions amounted to 7,866,000 units. Compared with the totals for 1992, transfusions of single-donor platelets (714,000 packs or 4,284,000 units) increased by 17.6 percent, while transfusions of platelet concentrates (3,582,000 units) fell by 23.6 percent. Fresh-frozen plasma transfusions (2,621,000 units) increased by 16.2 percent over the number for 1992. CONCLUSIONS: The US blood collection rate in 1994 was 74.6 units per 1000 population of donor age, the lowest recorded level since 1971. The US RBC transfusion rate in 1994 was 42.8 units per 1000 population, about the same as 1979. Transfusions of single-donor platelets, 16.5 units per 1000 population, exceeded transfusions of platelet concentrate (13.8/1000) for the first time. Plasma transfusions were 10.1 units per 1000 population. The US blood supply in 1994 was adequate to meet patient demands.     

Autologous blood transfusion for pulmonary and mediastinal surgery in 144 patients. The effectiveness of recombinant erythropoietin injection

Preserved autologous transfusions have been performed for elective pulmonary and mediastinal surgery to prevent the adverse effects of homologous transfusions. Autologous blood was collected preoperatively from 144 patients. The collected blood volume ranged from 400 to 1,600 ml with a mean volume of 544 ml. In four patients with benign diseases, 1,200 to 1,600 ml of blood was collected using 3,000 U of intravenous recombinant human erythropoietin (rh-EPO) administered every other day. One hundred twenty-three of these patients (85 percent) did not require a homologous transfusion. In the 84 patients undergoing either a pneumonectomy, lobectomy, or segmentectomy, 68 (81 percent) avoided homologous blood exposure. A patient with rh-EPO who bled 2,000 g during surgery received an autotransfusion of only 1,400 ml and his postoperative course was uneventful. Preserved autologous blood collected after rh-EPO injections is an effective method for minimizing homologous blood transfusions in pulmonary and mediastinal surgery.     

The natural course of nonreducing disk displacement of the temporomandibular joint: changes in condylar mobility and radiographic alterations at one-year follow up

OBJECTIVE: To evaluate the efficacy and safety of recombinant human erythropoietin (rHuEPO) in very low birth weight infants with anemia of prematurity. STUDY DESIGN: Thirty infants were randomly assigned to receive either rHuEPO (300 U/kg per dose) or placebo twice a week. Hematologic parameters, transfusion requirements, caloric intake, and growth were monitored. RESULTS: The number and volume of erythrocyte transfusions were significantly lower in infants treated with rHuEPO. Serum ferritin levels, similar in both groups at study entry, fell and were significantly lower in rHuEPO-group infants at the completion of the study. An inverse correlation was observed between reticulocyte count and absolute neutrophil count both at entry and at completion of the study. CONCLUSION: Twice-a-week administration of rHuEPO significantly reduces the need for erythrocyte transfusion in very low birth weight infants in stable condition. A significant decrease in serum ferritin levels in infants receiving rHuEPO suggests the need to determine the optimal dose of iron supplementation in these infants.     

Blood transfusion and non-Hodgkin lymphoma: lack of association

BACKGROUND: Non-Hodgkin lymphoma is the seventh most commonly diagnosed malignant condition worldwide, and its incidence has increased markedly in recent decades. Blood transfusions have been implicated as a possible risk factor for non-Hodgkin lymphoma. OBJECTIVE: To determine whether blood transfusions are associated with an elevated risk for non-Hodgkin lymphoma. DESIGN: Population-based, nested case-control study. SETTING: Nationwide cohort in Sweden. PATIENTS: 361 patients with non-Hodgkin lymphoma and 705 matched controls, nested within a population-based cohort of 96795 patients at risk for blood transfusion between 1970 and 1983. Prospectively collected information on exposure was retrieved from computerized transfusion registries. MEASUREMENTS: Odds ratios obtained from conditional logistic regression models were used as measures of relative risks. RESULTS: No association was found between blood transfusions and the risk for non-Hodgkin lymphoma when patients who had received transfusions were compared with patients who had not received transfusions (odds ratio, 0.93 [95% CI, 0.71 to 1.23]). A reduction in risk was seen among persons who received transfusion of blood without leukocyte depletion (odds ratio, 0.72 [CI, 0.53 to 0.97]). Risk was not related to number of transfusions, and no interaction was seen with latency after transfusion. CONCLUSION: The findings in this study do not support previous observations of an association between blood transfusions and the risk for non-Hodgkin lymphoma.     

Teaching language to mentally retarded deaf children: a review of the literature and a description of one classroom program

Premature infants with hyaline membrane disease and related disorders are frequently hypovolemic. Furthermore, they frequently require repeated phlebotomies for laboratory evaluation of electrolytes, pH, oxygen tension, and other parameters. Adequate care of such infants is aided by small transfusions of heparinized blood. The walking donor program at the Sacramento Medical Center premature nursery furnishes these transfusions without exposing the infants to the hazards of receiving blood from many different donors. The program is described in detail, and the shortcomings of some of the alternative programs are pointed out.     

Lower homologous blood requirement in autologous blood donors after treatment with recombinant human erythropoietin

The risk of blood-borne diseases has substantially increased the use of autologous blood transfusion. Many autologous donors, however, still need homologous transfusions. To find out whether recombinant erythropoietin (rhEPO) reduces requirements for homologous blood transfusion, we carried out a randomised, controlled trial, in which patients were stratified according to blood volume. We studied 95 autologous blood donors undergoing elective hip surgery. 50 patients were randomly assigned 500 U/kg rhEPO subcutaneously twice a week for 3 weeks, and 45 patients received no treatment (control group). The patients each donated two units of blood before surgery. Only 5 (10%) rhEPO-treated patients received homologous transfusions compared with 16 (36%) controls (p < 0.01). rhEPO was most useful in patients with a blood volume below 4 L and an estimated blood loss below 2 L or with a blood volume of 4-5 L and blood loss of 1-2 L. Continued administration of rhEPO caused no further increase in reticulocyte counts after the fourth injection, which was accompanied by a pronounced depletion of storage iron. rhEPO treatment had no effect on renal function, platelet count, or blood pressure. Subcutaneous rhEPO is an effective and safe way to reduce exposure to homologous blood in autologous donors. Its use can be restricted to a subpopulation of autologous blood donors, which improves the cost-effectiveness of this expensive approach.     

Erythropoietin in very preterm infants

Three neonates (a male and two females of gestational ages 27, 27 and 29 weeks with birthweight 985, 660 and 1130 g), born to parents who are Jehovah's Witnesses, were admitted to our neonatal intensive care unit over a 2 month period in 1992. Human recombinant erythropoietin (rHuEpo, 200 u/kg sc. on alternate days for 6-8 weeks) was started early in conjunction with strict control of blood sampling in an attempt to avoid the need for blood transfusion. The lowest haemoglobin recorded was 95 g/L at 35 days of age in the first infant. The amount of blood withdrawn for sampling was 21.4 mL, 20.7 mL and 5.5 mL, respectively. All were discharged near their expected birthdate, never having received a blood transfusion in the Nursery. It is possible to manage sick, very preterm, very low birthweight neonates in a neonatal intensive care setting without the use of blood transfusions by the early use of rHuEpo in conjunction with strict control of blood sampling.     

Nitrofurantoin prophylaxis for bacteriuria and urinary tract infection in children with neurogenic bladder on intermittent catheterization

OBJECT: This study was undertaken to determine the efficacy of preoperative erythropoietin administration in infants scheduled for craniofacial surgery and, in so doing, to minimize problems associated with blood transfusions. METHODS: Families were offered the option of having their children receive erythropoietin injections before undergoing craniofacial surgery. The children whose families accepted this option received daily iron and 300 U/kg erythropoietin three times per week for 3 weeks preoperatively. Weekly complete blood counts with reticulocyte counts were measured and transfusion requirements were noted. Blood transfusions were administered depending on the clinical condition of the child. A case-matched control population was also evaluated to compare initial hematocrit levels and transfusion requirements. Thirty patients in the erythropoietin treatment group and 30 control patients were evaluated. The dose of erythropoietin administered was shown to increase hematocrit levels from 35.4 +/- 0.9% to 43.3 +/- 0.9% during the course of therapy. The resulting hematocrit levels in patients treated with erythropoietin at the time of surgery were higher compared with baseline hematocrit levels obtained in control patients at the time of surgery (34.2 +/- 0.5%). Transfusion requirements also differed: all control patients received transfusions, whereas 64% (19 of 30) of erythropoietin-treated patients received transfusions. CONCLUSIONS: The authors conclude that treatment with erythropoietin in otherwise healthy young children will increase hematocrit levels and modify transfusion requirements. Erythropoietin therapy for elective surgery in children of this age must be individualized according to the clinical situation, family and physician beliefs, and cost effectiveness, as evaluated at the individual center.     

Perioperative blood transfusion does not prevent recurrence in Crohn's disease. A pooled analysis

The effect of perioperative blood transfusion on the recurrence of Crohn's disease is controversial. Various studies have suggested that perioperative blood transfusions reduce the risk of recurrence; others have failed to find a protective effect. Since all the studies are based on relatively small numbers, we performed a pooled analysis. We contacted the senior authors of seven previously published studies and asked for the original data. Four authors provided their data. The pooled database included 622 patients with a primary and complete resection of macroscopic disease. Recurrence was defined as the need for repeat surgery for disease control. Kaplan-Meier life table analysis was performed. Of the study sample, 366 cases (59%) were female. Disease distribution was as follows: small bowel (47%), small/large bowel (35%), and large bowel only (18%). Three hundred thirty-one patients (53%) received blood in the perioperative period. Mean follow-up was 72.8 months. For the overall sample, the 5-year recurrence rates were 26.9% for the transfused group and 25.2% for the nontransfused (p = 0.456). When the data were stratified by age, gender, disease location, and length of resection, no difference in 5-year recurrence rates between transfused and nontransfused cases could be detected. In this pooled analysis of four retrospective studies on the effect of blood transfusions on the risk of recurrence in Crohn's disease, we were unable to document a protective effect.     

Adverse effects due to unstable blood products

Most discussions of blood transfusion cover risks and side effects, while the daily benefits of donor systems and transfusion concepts for modern medicine are taken for granted. Even though in this report side effects are a major part of the content, we should be aware that today's component concept leads to a remarkable quality level of blood products. After a historical introduction we present a patient with transfusion transmitted anti-hepatitis A IgM antibodies and a delayed type hemolytic transfusion reaction induced by a boostered anti-Fyb alloantibody. This case demonstrates that the safety of transfusions depends on both the blood product and the patient's transfusion history. In the second part we summarize side effects from transfused blood products: (1) transmission of infectious diseases and the risk of blood products testing falsely negative, (2) immune mediated side effects, (3) immuno-modulations by blood transfusions, (4) side effects caused by human error. Minimizing transfusion risks is not only the task of the doctors specialized in transfusion medicine, but can only be achieved by close cooperation between all the persons associated with each step, from motivating unpaid blood donors, evaluation of donors, phlebotomy, viral testing, preparation of components, storage, and transportation conditions, to adequate indications and transfusions for the patients.     

Effect of plumbagin on the radiation induced cytogenetic and cell cycle changes in mouse Ehrlich ascites carcinoma in vivo

BACKGROUND: Controversy exists concerning whether the costs and potential risks outweigh the potential benefits of "crossover" use in the general blood supply of unutilized blood that was donated for autologous transfusion. STUDY DESIGN AND METHODS: Published articles and reports were identified through systematic search of MEDLINE and review of references cited in previously identified articles, textbooks, and reports. Consultation was made with experts in blood donation and transfusion. Additional peer review was received from the American Medical Association (AMA) Council on Scientific Affairs RESULTS: Concern over infectious disease transmission has led to increased interest in and support for autologous transfusion for individuals having planned surgeries. Different requirements exist for collection, labeling, and screening of blood to be used for autologous versus allogeneic transfusions; therefore, procedures for diverting autologous blood donations to the general blood supply involve considerable expense. Several cost-effectiveness studies of autologous blood donation and transfusion conclude that currently this "crossover" appears to be an expensive procedure yielding little increased benefit from a societal perspective. CONCLUSIONS: The recommendations in this report were adopted as AMA Policy at the AMA Annual Meeting in June 1997. The AMA does not encourage blood collection programs to "cross over" units donated for autologous use to the allogeneic blood supply. Practice guidelines are needed, and should be utilized to ensure parsimony in the use of autologous blood donations and transfusions.