Randomized trial comparing packed red cell blood transfusion with and without leukocyte depletion for gastrointestinal surgery.

BACKGROUND: Allogeneic transfusion is associated with postoperative infections that significantly prolong hospital stays and increase costs. Recent studies suggest that filtering leukocytes from blood prior to transfusion reduces the risk of postoperative infection associated with blood transfusion. We compared the incidence of postoperative infections, hospital stays, and hospital charges of gastrointestinal surgery patients transfused with packed red cells or leukocyte-depleted cells. METHODS: Consecutive patients admitted for elective gastrointestinal surgery without previous blood transfusion were randomized to receive routine packed red cells or packed red cells filtered to remove leukocytes if transfusion was required. Multivariate analysis was used to assess the significance of the relationship between leukocyte-depleted blood and postoperative infectious complications, postoperative stay, and hospital charges. RESULTS: Fifty-nine (27%) of the 221 patients were transfused. The most significant variable related to transfusion was intraoperative blood loss (P <0.0001), followed by admission hematocrit (P <0.0001) and age (P = 0.0022). Infections were noted in 16% of the patients: 11% of untransfused patients, 16% of leukocyte-depleted blood recipients, and 44% of patients transfused with packed red cells. Both operative site and nosocomial infections were significantly (P <0.001) more frequent in patients transfused with packed red cells compared with patients transfused with leukocyte-depleted red cells. Postoperative stays averaged 9 days for untransfused patients, 12 days for leukocyte-depleted recipients, and 18 days for recipients of packed red cells. Hospital charges were $19,132, $33,954, and $41,002, respectively. Both transfusion and infection were significantly (P <0.001) related to postoperative stay in multivariate analysis. Hospital charges were significantly related to postoperative stay (P <0.001), blood loss (P <0.001), age (P <0.001), infection (P = 0.007), and randomization to packed red cells (P = 0.032). CONCLUSIONS: Filtering blood of leukocytes prior to transfusion for elective gastrointestinal surgery is associated with lower risk of postoperative infection, shorter postoperative stays, and lower hospital charges.

Increased incidence of HLA antigen B35 in patients with chronic lymphocytic leukemia.

We and others have reported an increased incidence of chronic lymphocytic leukemia (CLL) among Ashkenazi (ASH) Jews of European origin. We performed HLA Class I typing on all 50 CLL patients seen by us and compared them with 3886 controls consisting of healthy blood donors from the New York Blood Center. Thirty of our CLL patients were ASH Jews, 17 of whom (57%) expressed the B35 antigen compared with 462 ASH controls (26%). Seven (39%) of the CLL Caucasian patients expressed the B35 antigen compared with 305 (14.5%) of the Caucasian controls. Combining the information from the ASH Jews and the Caucasians the difference is highly significant, (p = 0.0001). The summary odds ratio was 3.7. These results indicate an increased incidence of the antigen B35 amongst ASH and Caucasian patients with CLL.

Experience with autologous bone marrow harvesting and transfusion of marrow-derived red cells.

Marrow red cells (MRBCs) from 56 autologous bone marrow harvests were rescued after processing and transfused as the sole transfusion support after surgery. There was no correlation between volume of harvest and total mononuclear cell (MNC) count. The marrow collection induced a significant decrease in hematocrit values (mean, 6.1; range, -0.3-12.3; p less than 0.001) unrelated to the patient's diagnosis, age, or gender. Processing of the marrows resulted in a mean transfused MRBC mass of 258 mL (range, 101-494 mL), representing 78 percent (range, 43-100%) of the MRBC mass collected. The amount of MRBCs transfused correlated with total MNC count (p less than 0.01). All autologous MRBC transfusions were well tolerated. It can be concluded that autologous MRBC transfusions are safe and may eliminate the need for homologous blood transfusions after marrow harvest.

Zidovudine and other reverse transcriptase inhibitors in the management of human immunodeficiency virus-related disease.

Licensed in 1987, zidovudine remains the only medication with proved efficacy for the treatment of disease caused by the human immunodeficiency virus (HIV). New information on the pharmacology (adults and children), effects of kidney and liver dysfunction on the disposition of the drug, and drug-drug interactions have improved the way we use and monitor this agent. The serious toxicity associated with zidovudine has led researchers to develop safer dosage regimens. Also, recognition that zidovudine slows but does not halt progression of disease has increased the search for effective alternatives. The best-studied agents are didanosine (2',3'-dideoxyinosine, ddl), zalcitabine (2',3'-dideoxycytidine, ddC), and foscarnet.

Porphyria cutanea tarda in a patient with acute leukemia.

A 20-year-old woman with acute nonlymphocytic leukemia in remission was treated postremission with intermittent courses of intensive chemotherapy. She required blood and platelet transfusions following therapy, and oral contraceptives were used to suppress her menses while she was thrombocytopenic. One and one-half years after treatment began, she developed blisters on her hands, hypertrichosis, and dark urine. The diagnosis of porphyria cutanea tarda was made. This report discusses the possible precipitating cause(s) and the subsequent treatment of both her porphyria and her leukemia.

Management of patients with anti-Cartwright (Yta).

Five patients with anti-Cartwright (Yta) in their serum were observed during a 14-month period. One of the patients in whom a 51Cr-labeled donor red cell survival study was done showed increased destruction of infused Yta-positive red cells while three other patients tested showed a survival of greater than 85 percent at 1 hour. None of the antibodies potentiated interaction between sensitized red cells and heterologous activated mononuclear cells. The fifth patient received many transfusions of Yta-positive red cells without any adverse reaction. Performance of a 1-hour red cell survival with 51Cr-labeled Yta-positive cells is recommended when time permits to determine whether patients with anti-Yta can receive Yta-positive red cells or, alternatively, whether they must receive Yta-negative red cells. This approach not only is the safest for the patient, but allows conservation of Yta-negative blood. Such an approach also should be used in patients with antibodies against other high-incidence antigens.

Thermophilic sporeforming bacilli that mimic fastidious growth characteristics and colonial morphology of legionella.

Gram-negative bacilli resembling legionellae were isolated from contaminated culture media. These bacilli are distinguishable from legionellae by their thermophilic characteristic.

Two epidemics of pseudobacteremia due to Staphylococcus aureus and Aerococcus viridans.

Two epidemics of pseudobacteremia are reported. The first, due to Staphyloccus aureus, was caused by a physician who had active staphylococcal skin infection and nasal colonization. Because the blood culture system in use at the time was open, and used screw cap bottles, we assume that the physician contaminated the bottles at the time of inoculation. The second outbreak, caused by Aerococcus viridans, was traced to contamination of the blood culture bottle tops as they were received from the manufacturer. We assume that there was inadequate disinfection of the bottle tops by the physicians prior to their use.

Administration of microaggregate filtered blood using a manual infusion pump.

Administration sets containing in-line plastic blood pumps are commonly used to transfuse blood. Flow rates were measured while six units of whole blood and red blood cells were infused through a blood pump administration set coupled to either a large pore 260-micron filter or a 20-micron microaggregate blood filter. Using the same type of blood pump administration system and three units of whole blood, the flow rates achieved by the currently available microaggregate blood filters were compared. Results showed that despite a smaller pore size the 20-micron microaggregate blood filter achieved flow rates that were faster than or equal to those recorded for the larger pore (260-micron) filter. This was attributed to the larger filtration surface area possessed by the smaller pore filter, 140 cm2 versus only 30 cm2 for the 260-micron filter. All of the microaggregate filters studied were able to filter three units of whole blood at flow rates in excess of 80 ml/minute. There was no evidence of blood pump induced hemolysis. We concluded that a manual infusion pump can be used to transfuse microaggregate filtered blood rapidly enough to be acceptable for routine clinical or intraoperative use.

Presumed immune thrombocytopenia and carcinoma: report of three cases and review of the literature.

Three patients presenting in a one-year period with coexisting carcinoma and presumed immune thrombocytopenia are the subject of this report. Review of the literature disclosed a paucity of previous reports of this association. Possible pathogenic mechanisms resulting in this association are discussed. All three patients responded to corticosteroids in usual doses used in treatment of chronic idiopathic thrombocytopenic purpura. The association of carcinoma with immune thrombocytopenia may be more common than has been previously appreciated.

An in vivo evaluation of microaggregate blood filtration during total hip replacement.

In order to evaluate the effect of microaggregate blood filtration on pulmonary status, hemostatic status, and incidence of infection, a prospective study was performed on patients undergoing elective total hip replacement for osteoarthritis. Forty patients were randomized to either a 260 micron standard filter group or a 20 micron microaggregate filter group. Patients were monitored pre- and postoperatively for changes in arterial blood gases and in vitro test of hemostasis. Postoperative measurements were also made of the total volume of blood collected from the operative wound drain and of the number of infections incurred by patients in the two filter groups. Average transfusion was 4.0 units for the standard filter group and 4.6 units for the microaggregate filter group. Results showed that postoperatively, either immediately or after 48 hours, there were no statistically significant differences (p greater than 0.05) between either filter group for any of the tests of pulmonary or hemostatic function evaluated. For infection no trends were found to suggest that microaggregate filters conveyed any protective effect. These data suggest that routine microaggregate blood filtration of up to 5 units of blood is not required.

Clinical and serologic management of patients with methyldopa-induced positive antiglobulin tests.

Methyldopa can produce both a positive direct antiglobulin test and less commonly a positive indirect antiglobulin test. When the drug-induced antibody is present in the serum, it acts as a panagglutinin and reacts with all normal red blood cells; consequently crossmatch-compatible blood cannot be prepared. Although the methyldopa-induced antibody itself rarely produces hemolysis, difficulties can arise in previously unscreened patients in whom the panagglutinin may mask an unknown, pre-existing, and potentially hemolytic alloantibody. We report on our clinical and serologic management of 14 such patients for whom transfusions were requested.

Hemolytic anti-hr" (e) detectable solely by an automated polybrene technique.

An example of a hemolytic anti-hr" (e) detectable solely by an AutoAnalyzer-Polybrene (AAP) system is reported. The antibody was undetectable by routine indirect antiglobulin and enzyme tests, and produced a delayed intravascular hemolytic transfusion reaction. The anti-hr" (e) was no longer AAP detectable five months after the transfusion reaction. This paper points out the potential usefulness of the AAP technique in detecting alloantibodies in cases of transfusion reactions where no antibody specificity can be demonstrated by standard manual techniques.

Folic acid deficiency in the United States: folate assays in a prenatal clinic.

Tissue deficiency of folic acid, as measured by a red cell folate level below 150 ng. per milliliter, was present in 16 per cent of 110 sequential pregnant women at the time of their first prenatal visit to a municipal clinic. A further 14 per cent of subjects had red cell folate levels in the range "suggestive but not conclusive for tissue folate depletion" (150 to 199 ng. per milliliter). All of the subjects were from low-income families in New York City and most were black or of Puerto Rican origin. Serum folate levels showed good general correlation with red cell folate but were of less value as a diagnostic test, since they were below the lower limit of normal in 64 per cent of subjects, including many subjects who did not yet have low tissue folate. In contrast to their value in other folate deficiency states, neutrophil lobe counts showed no correlation with serum or red cell folate levels in pregnancy and thus appeared of little diagnostic value in pregnancy. It is suggested that surveys of folate deficiency in other pregnant population groups in the United States be carried out. These results support the recommendations of the Committee on Maternal Nutrition and the Committee on Dietary Allowances of the Food and Nutrition Board, National Research Council (U.S.A.) that folic acid supplements (200 to 400 mug per day) should be taken throughout pregnancy.

Fever and pneumonia after flexible fiberoptic bronchoscopy.

The frequencies of fever, parenchymal infiltration, and bacteremia were studied prospectively after 100 flexible fiberoptic bronchoscopies performed transnasally under topical anesthesia. Fever occurred after 16 per cent, and parenchymal infiltration, after 6 per cent of the procedures. Most complications were mild and transient; however, one patient developed rapidly progressive pneumonia and died. No organisms were isolated from cultures of blood drawn at the time of the procedure or during complications. The organisms most commonly isolated from the sputum of the patients who developed pneumonia were the aerobic and anaerobic bacteria normally found in the mouth. Isolation of a significant pathogen before the procedure did not predispose to development of a complication. Advanced age (greater than 60 years) and the endoscopic findings of abnormalities were significant predisposing factors. Bronchial brushing, but not bronchial biopsy or bronchial washing, was associated with significantly higher complication rates in patients with bronchial carcinomas than in those without a neoplasm. The mechanism of the fever and parenchymal infiltration is thought to be related to obstructive atelectasis and infection produced by organisms present in the airways at the time of the procedures.

Subacute consumption coagulopathy--an unusual complication of angiography.

A 20-year-old female with congenital venous malformations in her left lower extremity had a self-limited, moderate consumption coagulopathy following angiographic studies. This episode was documented by both conventional coagulation studies and by 125l fibrinogen survival studies. It seems likely that venography triggered a local inflammation in the vascular malformations, which resulted in a localized consumption coagulopathy which abated as did the phlebitis in three weeks. We are aware of no prior reports of this complication of venography. Patients with venous malformations who undergo venography should have appropriate coagulation screening performed before and after the procedure so that any similar episode can be promptly diagnosed and treated, if treatment is deemed necessary.