Fungal retinitis: a case of Torulopsis glabrata infection treated with miconazole.

Presumptive embolic chorioretinal Torulopsis glabrata infection is described in a patient who had received prolonged intravenous antibiotic therapy. The ocular findings are compared and contrasted with embolic lesions due to Candida albicans. The patient was treated for 6 weeks with intravenous miconazole. During this time there was shrinkage of the ocular lesions, some improvement in vision and abolition of fungaemia. Improvement in tests of immune function during treatment suggests that an early immunological deficit was secondary to the infection. Intravenous miconazole is a relatively nontoxic alternative to amphotericin and deserves further evaluation in the treatment of ocular mycosis.

Transfusion: morbidity and mortality.

Homologous, and to a significantly lesser extent, autologous blood transfusion is associated with definable and potentially serious risk. The increasing professional and public awareness has led to a critical evaluation of transfusion practices and a change in transfusion philosophy towards optimising transfusion therapy for individual patients. This involves the provision of the safest blood and the minimisation of homologous blood exposure. Autologous blood transfusion is not without risk as misidentification of patient or unit, bacterial contamination and volume overload can occur; consequently, the indications for the transfusion of autologous blood, as per homologous units, must be appropriate to the clinical circumstances. Appropriate transfusion criteria are being developed and lower haemoglobin levels are becoming accepted. Transfusion-related mortality and morbidity data is infrequently reported. Ongoing transfusion surveillance programs have reported adverse reactions in 3.5% of transfusion episodes and fatalities have resulted from ABO-incompatible acute haemolytic transfusion reactions, most commonly with group O recipients of group A or B red cells. A significant number of such deaths are attributable to misidentification of patient or units and are preventable by obsessional attention to clerical details. The risks should be considered in the evaluation of the risk-benefit equation and in the resultant decision to administer blood.

Red cell, plasma and albumin transfusion decision triggers.

Hypothetical clinical cases were used to investigate transfusion-related decision-making. Three red cell, three fresh frozen plasma (FFP) and three albumin transfusion decision cases were administered by questionnaire to 228 medical staff. The transfusion decision triggers were identified and comparisons made between resident and specialist groups and between Melbourne and Sydney participants. Factors important in red cell transfusion decisions included haemoglobin, symptoms of anaemia, presence of co-morbidities or surgery, gender, period of hospitalisation and the degree of documented blood loss. FFP administration was influenced by an abnormal coagulation test, the presence of co-morbidities and by the number of red cell units transfused. The administration of albumin, concentrated or 5% SPPS, was influenced by the period of hospitalisation and clinical circumstances such as a falling urine output postoperatively, and by the presence of hypotensive complications. Different transfusion responses were noted: resident staff transfused red cells and FFP earlier than specialists; Sydney specialists were more conservative of red cell transfusion; Melbourne specialists more conservative of FFP administration and surgeons were four times more likely to transfuse patients than physicians or anesthetists at certain haemoglobin values.

Fresh frozen plasma use in a tertiary referral hospital.

Hospital transfusion practice is directed towards the optimization of transfusion therapy. A fresh frozen plasma (FFP) usage audit was performed on 316 consecutive FFP units, transfused in 119 transfusion episodes to 75 patients (January-April 1992). All patients had coagulation tests before and after FFP administration; 76% of the coagulation tests were abnormal and of the 24% patients with normal coagulation tests 83% required a massive blood transfusion. Prophylactic to therapeutic and surgical (pre, intra, post) to medical use was 48%:52% and 56%:44%, respectively. From 1988 to 1992 there has been a 42% fall in the hospital's usage of FFP and the FFP to red cell usage is 1:10. In this audit four groups of patients received FFP appropriately for the following indications: coagulation factor deficiency (40%); acute reversal of anticoagulation therapy (19%); massive blood transfusion (27%) and complex medical problems including intensive plasmapheresis (12%). Only 2 patients received FFP (4 units) inappropriately. A total of 98.7% of the FFP units were considered appropriately transfused.

Late onset pyridoxine-responsive sideroblastic anaemia after allogeneic bone marrow transplantation.

We report the late development of transfusion-dependent sideroblastic anaemia in two patients who received a bone marrow transplant for chronic granulocytic leukaemia in blast crisis and T-cell acute lymphoblastic leukaemia respectively. Treatment with pyridoxine has either stopped or reduced these transfusion requirements. Red cell transfusion dependence later after marrow transplantation is rare and sideroblastic anaemia must be excluded.

Autologous blood transfusion for elective surgery.

Between September 1983 and June 1985, 336 patients were assessed by the Autologous Blood Transfusion Service; 267 men, mean age, 65 (range, 16-75) years, and 40 women, mean age, 63 (range, 40-70) years, participated in the programme (29 patients were excluded as unsuitable). Orthopaedic and vascular surgery accounted for 80% of the cases. Complications were minor even in this elderly group. Surgical and transfusion details for a one-month period were studied retrospectively. Of the surgical cases that required crossmatched blood, 50% were for "emergency" and "burn" surgery, and 50% for elective surgery. Forty-five per cent of this latter group were unsuitable as autologous donors, 21% had participated in the autologous blood transfusion programme, and an additional 34% were deemed to be suitable donors. The realistic upper limits of our autologous blood transfusion programme were determined as being 55% of elective cases that require crossmatched blood. To be efficient an autologous blood transfusion service must be incorporated into an existing homologous blood transfusion service and must complement, rather than replace, homologous blood transfusion.

Haemolysis induced by intravenously-administered immunoglobulin.

Two concurrent cases of haemolysis that was induced by intravenously-administered gamma-globulin are reported. Haemolysis, predominantly as a result of passively-acquired anti-A antibodies, occurred twice in one patient; anti-D antibodies also were incriminated in the first haemolytic episode. Passively-acquired anti-D antibodies that were found in the same batch of gamma-globulin contributed to the haemolytic episode in the second patient. These adverse reactions could have been prevented if a minor crossmatch procedure had been performed before the commencement of intravenous gamma-globulin therapy. It is considered important that manufacturers of intravenously-administered gamma-globulin preparations decide safe titres of these alloantibodies, and that suitable volumes be dispatched with each batch to enable a minor crossmatch procedure to be performed.

Transfusion of frozen thawed blood stored at -20 degrees C to -25 degrees C.

OBJECTIVE: To determine the clinical efficacy of transfusion of frozen-thawed (FT) red cells using a 5-bag system for freezing (at -20 degrees C to -25 degrees C), storage and reconstitution. DESIGN: A prospective, controlled, non-randomised clinical trial was undertaken with two groups of orthopaedic surgical patients. Nine patients received FT homologous blood and a control group of 10 patients received homologous blood stored in liquid form at 4 degrees C. Five transfusion-dependent patients with medical conditions were also studied. OUTCOME: Thirty-three FT units were transfused without incident to 14 patients. In addition to clinical assessment, haematological and biochemical parameters were monitored after transfusion. There were no clinical side effects and laboratory data were consistent with those after recent surgery or for pre-existing medical conditions and subsequent blood transfusion. On the practical side certain technical difficulties were encountered which improved with experience. CONCLUSIONS: One of the major advantages of the system is the 35-day shelf-life at 4 degrees C after reconstitution. This system has potential for pre-deposit autologous collection, especially where large volume replacement may be required.

The myelodysplastic syndromes: an analysis of prognostic factors in 226 cases from a single institution.

Two hundred and twenty-six patients were diagnosed with myelodysplastic syndrome (MDS), according to the French-American-British (FAB) criteria, over a 13-year period, and studied retrospectively in a single institution in order to study indicators which were prognostically significant. Analysis of clinical and laboratory data indicated that the FAB classification, the Bournemouth, Dusseldorf, Goasguen, Sanz and FAB Scoring Systems were all good predictors of survival. We found advancing age, haemoglobin (Hb) < or = 9 g/dl, platelet count < or = 50 x 10(9)/l, increased peripheral total white cell count (WCC) and monocytosis, increased bone marrow blasts, dysgranulopoiesis, and bone marrow fibrosis were significant adverse prognostic variables. The commonest complication and cause of death was infection; however, infective episodes were not significantly associated with low neutrophil counts (either < or = 1.5 x 10(9)/l or < or = 0.8 x 10(9)/l) and there was also no significant association between neutropenia and survival. These findings indicate that neutrophil dysfunction plays an important role in the clinical progression of patients with MDS. The effect of new therapeutic modalities, such as the haemopoietic growth factors, on reducing infective episodes may be as significant as their effect on increasing neutrophil counts.