Clinical Results of a Massive Blood Transfusion Protocol for Postpartum Hemorrhage in a University Hospital in Japan: A Retrospective Study.

Background and objectives: Massive postpartum hemorrhage (PPH) is the most common cause of maternal death worldwide. A massive transfusion protocol (MTP) may be used to provide significant benefits in the management of PPH; however, only a limited number of hospitals use MTP protocol to manage massive obstetric hemorrhages, especially in Japan. This study aimed to assess the clinical outcomes in patients in whom MTP was activated in our hospital. Materials and Methods: We retrospectively reviewed the etiology of PPH, transfusion outcomes, and laboratory findings among the patients treated with MTP after delivery in our hospital. Results: MTP was applied in 24 cases (0.7% of deliveries). Among them, MTP was activated within 2 h of delivery in 15 patients (62.5%). The median estimated blood loss was 5017 mL. Additional procedures to control bleeding were performed in 19 cases, including transarterial embolization (18 cases, 75%) and hysterectomy (1 case, 4.2%). The mean number of units of red blood cells, fresh frozen plasma, and platelets were 17.9, 20.2, and 20.4 units, respectively. The correlation coefficients of any two items among red blood cells, fresh frozen plasma, platelets, blood loss, and obstetrical disseminated intravascular coagulation score ranged from 0.757 to 0.892, indicating high levels of correlation coefficients. Although prothrombin time and activated partial thromboplastin time levels were significantly higher in the <150 mg/dL fibrinogen group than in the ≥150 mg/dL fibrinogen group at the onset of PPH, the amount of blood loss and blood transfusion were comparable between the two groups. Conclusions: Our MTP provides early access to blood products for patients experiencing severe PPH and could contribute to improving maternal outcomes after resuscitation in our hospital. Our study suggests the implementation of a hospital-specific MTP protocol to improve the supply and utilization of blood products to physicians managing major obstetric hemorrhage.

[Two serial events of delayed hemolytic transfusion reactions due to different primary immune response-induced irregular antibodies].

A 74-year-old woman with a history of pregnancies, but without previous transfusions, received a red blood cell transfusion for aplstic anemia. She lost consciousness due to severe anemia two weeks later and was transported by ambulance to our hospital. Delayed hemolytic transfusion reaction (DHTR) was diagnosed based on the detection of anti-E antibody and positive E antigen of the previously transfused product. A transfusion of E antigen-negative red cell products was performed. However, DHTR due to anti-c antibody developed 16 d after the transfusion of a c antigen-positive product. Based on the onset of ≥14 d after the transfusions and the detection of a causative IgM-type antibody, DHTR due to a primary immune response was diagnosed. Because the incidence of DHTR is low, physicians rarely experience it in clinical practice. However, in our case, DHTR due to a primary immune response, which is even rarer in DHTR cases, developed twice within a short period. A history of transfusion and pregnancy as well as preexisting irregular antibodies have been identified as risk factors for DHTR. Thus, more attention should be paid to the risk of DHTR redevelopment by repeated transfusions.

Production of anti-ABO blood group antibodies after minor ABO-incompatible bone marrow transplantation in NOD/SCID/gamma(c)(null) mice.

ABO incompatibility is a barrier for solid organ transplantation, but not for hematopoietic stem cell transplantation. To investigate tolerance induction, we enrolled patients who had undergone minor ABO-incompatible (O into A group, n = 6) and ABO-identical (O into O group, n = 4) bone marrow transplantation (BMT). None of the six O into A patients were positive for recipient-specific (anti-blood group A) isohemagglutinins, whereas all four O into O patients were. Peripheral blood mononuclear cells (PBMCs) were engrafted into NOD/SCID/gamma(c)(null) (NOG) mice, followed by sensitization of blood group A red blood cells. Anti-blood group A antibodies (Abs) in the sera of the patients and the human PBMC-engrafted NOG mice were measured by enzyme-linked immunosorbent assays. Anti-blood group A Abs in the patients' sera were significantly correlated with anti-A isohemagglutinin titers (p < 0.01). In the human PBMC-engrafted NOG mice, anti-blood group A Abs were significantly lower in the O into A group than in the O into O group (p < 0.05), despite ex vivo restimulation of B cells. The results of this study suggest that long after receiving minor ABO-incompatible BMT, B cells derived from newly engrafted donor precursor cells were induced tolerance to recipient-specific antigens.

gamma-Glutamyl PAMAM dendrimer as versatile precursor for dendrimer-based targeting devices.

Poly(amidoamine) (PAMAM) dendrimers are highly branched spherical polymers that have a unique surface of primary amine groups and provide a versatile design for targeted delivery of pharmaceuticals and imaging agents. Acetylation or succinylation of surface amine groups of PAMAM dendrimer derivatives is frequently performed to reduce nonspecific uptake. However, since targeting molecules, drugs/imaging agents, and acylating reagents react with the amine groups on dendrimer, such modification may limit the number of targeting molecules and/or drugs or may result in insufficient charge reduction. In this study, a gamma-glutamyl PAMAM dendrimer was designed and synthesized as a new precursor for targeting device. The relationship between surface electrical properties of the PAMAM dendrimer derivatives and pharmacokinetics was also determined. A PAMAM dendrimer (generation 4.0) was modified with a small number of Bolton-Hunter reagent to prepare Phe-P (pI 9.2). The amine residues of Phe-P were gamma-glutamylated to prepare Glu-P (pI 7.1). The alpha-amine residues of Glu-P were then acetylated or succinylated to prepare Ac-Glu-P (pI 5.3) or Suc-Glu-P (pI 3.6). For comparison, Phe-P was acetylated or succinylated to prepare Ac-P (pI 6.0) or Suc-P (pI 5.1). All the PAMAM dendrimer derivatives exhibited similar molecular size (7.2 to 7.8 nm) except for Ac-P (5.1 nm). The biodistribution studies were performed after radioiodination of each PAMAM dendrimer derivative with Na[(125)I]I. When injected intravenously to mice, both [(125)I]Ac-P and [(125)I]Suc-P exhibited prolonged radioactivity levels in the blood and significantly lower hepatic and renal radioactivity levels than those of [(125)I]Phe-P. Both [(125)I]Glu-P and [(125)I]Ac-Glu-P showed residence times in the blood similar to those of [(125)I]Ac-P and [(125)I]Suc-P. However, [(125)I]Glu-P also registered higher radioactivity levels in the kidney. High hepatic and renal radioactivity levels were observed with highly anionic [(125)I]Suc-Glu-P. These results indicate that, while the manipulation of pI between 5 to 6 would be appropriate to enhance blood retention and reduce renal and hepatic uptake, the amount of primary amine residues on dendrimer surface may also play a crucial role in their renal uptake. The findings in this study show that gamma-glutamyl PAMAM dendrimers would constitute versatile precursors to prepare PAMAM dendrimer-based targeting devices due to their neutral molecular charge (pI 7.1) and the presence of a large number of alpha-amine residues available for conjugation of targeting molecules and drugs/imaging agents.

[Present status of preparatory measures for massive hemorrhage and emergency blood transfusion in regional hospitals with an accredited department of anesthesiology in 2006].

BACKGROUND: Annual surveys conducted by the Japanese Society of Anesthesiologists repeatedly show that hemorrhage is the leading cause of life-threatening events in the operating room. METHODS: We performed a questionnaire survey regarding the present status of critical hemorrhage/ blood transfusion occurring in the operating room on an institutional scale and individual blood transfusion management in cases of massive hemorrhage (> or = 5,000 ml) in hospitals with > or = 500 beds and those with an accredited Department of Anesthesiology regarded as regional hospitals. RESULTS: Of 384 institutions, 247 responded to the questionnaire (response rate: 64%), and 692,241 cases managed by anesthesiologists in 2006 were registered. There were 2,657 cases of massive hemorrhage above the circulating blood volume in the operating room, and 404 of them were critical. Thus, the number of cases of massive hemorrhage was 6.6 times that of cases of critical events due to hemorrhage. In the survey of individual cases of massive hemorrhage (> or = 5,000 ml), 1,257 cases were registered in 2006, of whom 196 cases (15.6%) died within 30 post-operative days and 160 cases (12.7%) had some sequelae. The amount of transfused red blood cell concentrate was 25.2 +/- 24.2 units. The amount of red blood cell concentrates stocked for emergency was 12.7 +/- 10.1 units for blood group A, 9.7 +/- 7.3 units for group B, 11.9 +/- 9.6 group AB, and 11.3 +/- 11.0 for group O. Therefore, for those other than group O cases, 21-46 units of red blood cell concentrates seemed to be available in the hospital. The survey of individual cases showed uncross-matched, same blood group transfusion and compatible, different blood group transfusion were performed in only 8.2% and 4.3%, respectively. The lowest hemoglobin concentration was below 5 g x dl(-1) in 16.7% of the cases, but uncross-matched, same blood group transfusion was performed only in 19.0% and compatible, different blood group red cell concentrate transfusion in 5.2%. Even in cases who required cardiac massage, uncross-matched, same blood group transfusion was performed only in 17.1% and compatible, different blood group red cell concentrate transfusion in 8.5%. Intraoperative blood salvage was performed in only 5.7% in cases who underwent non-cardiac surgery. The "Guidelines for the Management of Critical Hemorrhage" proposed in 2007 or the manuals for in-hospital emergency blood transfusion were insufficiently recognized, even by anesthesiologists, and rarely known by surgeons. There were no such manuals in more than 60% of the institutions. CONCLUSIONS: Undertransfusion may occur in 16.7-28.3% of cases of massive hemorrhage in the operating room, and the rate of emergency blood transfusion was much lower than this percentage. To avoid operation-associated deaths from hemorrhage, the improvement of hospital systems for emergency blood transfusion, including the active use of intraoperative blood salvage, should be promoted.

Technetium-99m-labeled long chain fatty acid analogues metabolized by beta-oxidation in the heart.

The development of 99mTc-labeled fatty acid analogues metabolized by beta-oxidation in the myocardium constitutes an unsolved challenge. On the basis of our recent findings that [188Re]tricarbonyl(cyclopentadienylcarbonate)rhenium ([188Re]CpTR-COOH) was recognized as an aromatic compound and was metabolized as such in the body, [99mTc]cyclopentadienyltricarbonyltechnetium ([99mTc]CpTT) was conjugated at the omega-position of pentadecanoic acid to prepare [99mTc]CpTT-PA. When injected into rats, [99mTc]CpTT-PA exhibited the maximum myocardial accumulation and heart-to-blood ratio of 3.85 %ID/g at 1 min and 4.60 at 10 min postinjection, respectively. The metabolic study using isolated Langendorff perfused rat hearts demonstrated that approximately 67% of perfused [99mTc]CpTT-PA was incorporated and [99mTc]CpTT-propionic acid, the metabolite after six cycles of beta-oxidation of [99mTc]CpTT-PA, was detected as the major radiometabolite in the perfusate and myocardium. These findings indicate that [99mTc]CpTT-PA was recognized, transported, and metabolized as a long chain fatty acid analogue for energy production in the myocardium.