Patient blood management, what does this actually mean for neonates and infants?

Patient blood management (PBM) refers to an evidence-based package of care that aims to improve patient outcomes by optimal use of transfusion therapy, including managing anaemia, preventing blood loss and improving anaemia tolerance in surgical and other patients who may need transfusion. In adults, PBM programmes are well established, yet the definition and implementation of PBM in neonates and children lags behind. Neonates and infants are frequently transfused, yet they are often under-represented in transfusion trials. Adult PBM programmes may not be directly applicable to these populations. We review the literature in neonatal (and applicable paediatric) transfusion medicine and propose specific neonatal PBM definitions and elements.

Paediatric transfusion.

The requirements of children undergoing transfusion should be considered as a distinct entity from those of adults. Neonates are particularly vulnerable and there have been concerns over infective or toxic risks to this group. Neonates may also have more acute side-effects as a result of their small blood volume. Most children who are transfused will have a good life expectancy, so long-term side-effects will be more significant than for adults. In Britain, there are a number of transfusion components with neonatal specifications, but there appears to be some confusion, among both medical and laboratory staff, as to the appropriate use of these. Although there are many paediatric guidelines on the use of blood, there is a lack of evidence underlying these. However, there are trends to decreased blood usage in neonates and ongoing studies to investigate the appropriate use of blood for children.

Differential effects on Xenopus development of interference with type IIA and type IIB activin receptors.

One candidate for a mesoderm-inducing factor in early amphibian development is activin, a member of the TGF beta family. Overexpression of a truncated form of an activin receptor Type IIB abolishes activin responsiveness and mesoderm formation in vivo. The Xenopus Type IIA activin receptor XSTK9 differs from the Type IIB receptor by 43 and 25% in extracellular and intracellular domains respectively, suggesting the possibility of different functions in vivo. In this paper, we compare the Type IIA receptor with the Type IIB to test such a possibility. Simple overexpression of the wild-type receptors reveals minimal differences, but experiments with dominant negative mutants of each receptor show qualitatively distinct effects. We show that while truncated (kinase domain-deleted) Type IIB receptors cause axial defects as previously described, truncated type IIA receptors cause formation of secondary axes, similar to those seen by overexpression of truncated receptors for BMP-4, another TGF beta family member. Furthermore, in animal cap assays, truncated type IIB receptors inhibit induction of all mesodermal markers tested, while truncated type IIA receptors suppress induction only of ventral markers; the anterior/dorsal marker goosecoid is virtually unaffected. The suppression of ventral development by the type IIA truncated receptor suggests either that the truncated Type IIA receptor interferes with ventral BMP pathways, or that activin signaling through the Type IIA receptor is necessary for ventral patterning.

Intercellular signalling in mesoderm formation during amphibian development.

The mesoderm of amphibian embryos arises through an inductive interaction in which a signal from the vegetal hemisphere of the blastula-stage embryo acts on overlying equatorial cells. Strong candidates for endogenous mesoderm-inducing signals include members of the fibroblast growth factor (FGF) and activin families. In this paper we show that cells form different mesodermal cell types in response to different concentrations of these factors, and that graded distributions of activin and FGF can, in principle, provide sufficient positional information to generate the body plan of the Xenopus embryo.

Responses of embryonic Xenopus cells to activin and FGF are separated by multiple dose thresholds and correspond to distinct axes of the mesoderm.

The potent mesoderm-inducing factors activin and FGF are present as maternally synthesized proteins in embryos of X. laevis. We show that activin can act on explanted blastomeres to induce at least five different cell states ranging from posterolateral mesoderm to dorsoanterior organizer mesoderm. Each state is induced in a narrow dose range bounded by sharp thresholds. By contrast, FGF induces only posterolateral markers and does so over relatively broad dose ranges. FGF can modulate the actions of activin, potentiating them and broadening the threshold-bounded dose windows. Our results indicate that orthogonal gradients of activin and FGF would be sufficient to specify the main elements of the body plan.

Inductive interactions in early embryonic development.

This is an update of a previous review (Current Opinion in Cell Biology 2:969-974) in which we discussed recent work attempting to understand the sequence of inductive interactions responsible for establishing the body plan of the early embryo. As before, we concentrate on inductive interactions in amphibian embryos, where significant progress has been made in the past two years. In this update, however, we also consider recent embryological data obtained with amniote embryos such as the chick, together with complementary data provided by genetic analyses of mouse and Drosophila development.

Calcitonin gene-related peptide regulates muscle acetylcholine receptor synthesis.

Innervation of muscle by motoneurones induces the development of a characteristic, high density cluster of acetylcholine receptors (AChRs) at the neuromuscular junction. Studies in vitro show that the accumulation of AChRs at nerve-muscle contacts results from both increased insertion of new AChRs into the muscle plasma membrane beneath nerve terminals and redistribution of preexisting AChRs; these two modes of AChR accumulation may be separately controlled since factors have been identified that influence AChR redistribution but not synthesis. Although many aspects of muscle development are regulated by nerve-dependent muscle activity, junctional AChR clusters still develop when neuromuscular transmission is blocked by either curare or alpha-bungarotoxin, suggesting that their formation is mediated by nerve-derived trophic factors other than activity. A molecule immunologically related to calcitonin gene-related peptide (CGRP-I) has been found in motoneurones in a variety of mammals including man. Here we provide indirect evidence that CGRP-I may be a motoneurone-derived trophic factor that increases AChR synthesis at vertebrate neuromuscular junctions.

Distribution and ontogeny of SP, CGRP, SOM, and VIP in chick sensory and sympathetic ganglia.

The distribution and ontogeny of four neuropeptides in developing chick lumbosacral sensory and sympathetic ganglia were studied using immunohistochemical techniques. Antibodies to two of these peptides, substance P (SP) and calcitonin gene-related peptide (CGRP), stained small neurons in the medial part of the dorsal root ganglia from embryonic Day 5 and Day 10, respectively, whereas neurons in the lateral part of the ganglia were negative; this distribution persisted throughout development. Both sets of neurons apparently send fibers to the dorsal horn of the spinal cord: SP to laminae I and II, and CGRP to lamina I, suggesting that the SP- and CGRP-positive sensory neurons are nociceptive or thermoreceptive. This correlation between the presence of SP or CGRP in a neuron and a particular functional modality thus provides evidence for a functional distinction between the mediodorsal and ventrolateral zones that are apparent during the development of chick dorsal root ganglia. Moreover, this study suggests that the type of neuron that develops within the dorsal root ganglion correlates with its position within the ganglion. In contrast to SP and CGRP, somatostatin (SOM) and vasoactive intestinal polypeptide (VIP) immunoreactivities were not seen in the lumbosacral sensory ganglia at any stage during development. However, both were present in sympathetic ganglia: SOM from embryonic Day 4.5 and VIP from embryonic Day 10. VIP immunoreactivity persisted throughout development in a large number of sympathetic neurons, but the number of cells with SOM immunoreactivity decreased from embryonic Day 10 onward. SOM therefore appears to be present only transiently in most chick lumbosacral sympathetic cells.