Optimizing platelet transfusions.

PURPOSE OF REVIEW: Platelet transfusion remains a challenging procedure. Concerns about bacterial contamination and other complications, and the interest in improving the evidence base for criteria for platelet transfusion thresholds and policies have provided impetus for studies that challenge the status quo. The current review highlights recent studies and reviews which address these questions in innovative and thoughtful ways. RECENT FINDINGS: Randomized controlled trials have determined that prophylactic platelet transfusions for the prevention of bleeding in chemotherapy and hematopoietic stem cell transplant patients are superior to a therapeutic approach. For the treatment of immune refractoriness, an observational study identified that of the two main ways to treat, the provision of human leukocyte antigen-matched or cross-matched platelets, neither appears to be as effective as previously believed. When emergent reversal of antiplatelet medications is desired, platelet transfusion is common, however the evidence as to the benefit of this practice is indeterminate. ABO plasma-incompatible platelet transfusion remains a challenge as this product may pose an increased risk for hemolysis. Low-anti-A, anti-B titered products are encouraged, but are not routinely available. SUMMARY: Platelet transfusion practices are being questioned more than ever before. As we develop better therapies and guidelines, the practice of platelet therapy can be expected to change in the near future.

Parathyroidectomy for primary hyperparathyroidism in octogenarians and nonagenarians: a risk-benefit analysis.

BACKGROUND: The only cure for primary hyperparathyroidism (1 degrees HPT) is parathyroidectomy. However, many elderly patients are not referred for surgery due to medical comorbidities and/or advanced age. The purpose of this study was to evaluate benefits against risks of parathyroidectomy in this patient population. MATERIALS AND METHODS: From March 2001 to June 2006, 50 patients aged 80 years or older with 1 degrees HPT underwent parathyroidectomy by a single surgeon. Clinical presentation and surgical outcomes of all patients were evaluated. The standard form of the SF-36 Health Survey, designed to measure patient quality of life (QOL), was completed by a subset of patients. RESULTS: There were 45 females and 5 males with a mean age of 83 +/- 2 y. Patient comorbidities included hypertension (72%), coronary artery disease (22%), diabetes mellitus (16%), chronic obstructive pulmonary disease (10%), and congestive heart failure (10%). Bone pain was the most common primary presenting symptom (44%), followed by fatigue (12%), confusion (6%), and joint pain (6%). Eleven patients (22%) had ectopic glands. The cure rate postsurgery was 98% (49/50). There were 2 postoperative complications (4%): one patient with transient hypocalcemia and another with cellulitus at an i.v. site. Of patients who completed QOL surveys, greater than 60% reported improved physical functioning, social functioning, and/or mental health, and reduction of bodily pain. CONCLUSION: Parathyroidectomy is safe and curative for octogenarians and nonagenarians with 1 degrees HPT, and maintains or improves quality of life. The surgical benefits outweigh operative risks, making parathyroid surgery an excellent option for patients over 80 years of age.

A prospective evaluation of novel methods to intraoperatively distinguish parathyroid tissue utilizing a parathyroid hormone assay.

BACKGROUND: Frozen section analysis has traditionally been used to confirm the identity of parathyroid tissue intraoperatively; however, it is time-consuming and costly and requires the excision of a significant portion of tissue. An intraoperative biopsy and analysis with a parathyroid hormone (PTH) assay is a possible alternative; however, this technique has not been perfected. METHODS: Two hundred twenty-three tissue specimens were collected prospectively from patients undergoing neck exploration. Each specimen was sampled intraoperatively using three different biopsy techniques: a fine-needle aspiration (FNA) with 10 passes of a needle (FNA10), a FNA with 20 passes of a needle (FNA20), and a tissue biopsy of approximately 1.0 mm3 (BIOPSY). The PTH concentration of each sample was determined via the Elecsys 1010 PTH immunoassay. The final tissue diagnosis was determined by histology or operative data. RESULTS: Parathyroid samples from all techniques had higher median PTH concentrations than nonparathyroid samples. However, the accuracies for the detection of parathyroid tissue varied markedly (PTH cutoff of 1000 pg/ml): the accuracies of the FNA10 and FNA20 were 71 and 80%, respectively, while the BIOPSY was 99% accurate. CONCLUSIONS: This is the first prospective study evaluating multiple methods to diagnose parathyroid tissue intraoperatively using a rapid PTH assay. We conclusively show that the BIOPSY technique is 99% accurate for the diagnosis of parathyroid tissue, and therefore, should be the method of choice when the intraoperative confirmation of parathyroid tissue is needed.