Retrospective analysis of community hospital red blood cell recovery procedures: improved utilization needed for effectiveness.

BACKGROUND: Perioperative blood recovery (PBR) is an important component of patient blood management. We analyzed our experience providing PBR for community hospitals to determine procedure types and clinical variables associated with efficacy and cost-effectiveness. STUDY DESIGN AND METHODS: PBR cases (>25,000) from January 2008 through December 2012 were analyzed. For each procedure type, the median number of returned red blood cell units (rRBCs) and ratio of cases with at least 1 to less than 1 rRBC unit were calculated. Clinical predictors of rRBC were identified by linear and logistic regression. RESULTS: The overall median rRBC was 0.29 units despite median estimated blood loss (EBL) of 350 mL. Only three of 31 common procedure types had ≥1:<1 rRBC ratios near to or higher than 1. In nine of 31 common procedure types, at least 50% of cases had no rRBC return. Linear regression demonstrated significant association of rRBCs with increased EBL, longer operative duration, surgeon, PBR device type (autoLog vs. CS5), and decreasing age. EBL, autoLog use, high surgeon case volume, vascular procedures, and emergent versus elective procedures associated with higher odds of at least 1 rRBC. CONCLUSION: Discrepancy between rRBC and EBL and high percentages of cases with no rRBC suggests that PBR technique and case selection need optimization. Identification of procedure types and variables associated with PBR efficacy (≥1 rRBC) should improve utilization of PBR. Association of autoLog use with higher rRBC warrants further investigation.

IGH amplification in patients with B cell lymphoma unclassifiable, with features intermediate between diffuse large B cell lymphoma and Burkitt's lymphoma.

B cell lymphoma, unclassifiable, with features intermediate between diffuse large B-cell lymphoma (DLBCL) and Burkitt's lymphoma (BL) (B-UNC/BL/DLBCL) is a new category of tumors that have features resembling both DLBCL and BL. These tumors have large and medium sized cells with greater irregularity of nuclei and more prominent nucleoli than BL. Approximately 35% to 50% have C-MYC rearrangements, although half are non-immunoglobulin variants. We identified six cases of B-UNC/BL/DLBCL with low-level IGH amplification. Four patients died with a median survival of 7 months (range, 6-20). In conclusion, to our knowledge low-level IGH amplification has not been previously described and should be evaluated for in this patient population.

Therapeutic plasma exchange and intravenous immunoglobulin as primary therapy for D alloimmunization in pregnancy precludes the need for intrauterine transfusion.

BACKGROUND: Maternal D alloimmunization detected in early gestation requires aggressive intervention to prevent severe fetal anemia. An intrauterine transfusion (IUT) is indicated to prevent fetal death once severe fetal anemia has been detected, but is not without risk. Protocols combining therapeutic plasma exchange (TPE) and intravenous immunoglobulin (IVIG) have been described, but they usually bridge to IUT. STUDY DESIGN AND METHODS: We describe a 27-year-old G4, P0-1-2-0 Caucasian female with a history of ruptured ectopic pregnancy presented at 12 weeks' gestation with a very high anti-D titer (2048). TPE was performed on that week and twice more in the following week, with a fourth final exchange during Week 14. A loading dose of IVIG (2 g/kg) was administered over 2 days after the third TPE and then 1 g/kg per week until Week 28 (total, 14 doses). RESULTS: The antibody titer decreased to 256 by the beginning of 15 weeks' gestation and remained stable at that level for the remainder of the pregnancy. Doppler ultrasonographic measurements of the fetal middle cerebral artery peak flow velocity performed throughout gestation showed no evidence of fetal anemia. A healthy male infant was delivered at 37 weeks' gestation with mild immune-mediated hemolysis. The infant underwent successful treatment with an IVIG dose of 750 mg/kg and a red blood cell exchange. CONCLUSION: Our unique TPE-IVIG protocol was successful at preventing the onset of severe fetal anemia in a patient with high titer anti-D. Since IUT may be fatal, our approach offers a safer and less-invasive treatment regime that can adequately sustain a fetus until term.

Pediatric T-cell prolymphocytic leukemia with an isolated 12(p13) deletion and aberrant CD117 expression.

T-cell Prolymphocytic leukemia (T-PLL) is a rare post-thymic T-cell malignancy that follows an aggressive clinical course. The classical presentation includes an elevated white blood cell (WBC) count with anemia and thrombocytopenia, hepatosplenomegaly, and lymphadenopathy. T-PLL is a disease of the elderly and to our knowledge it has never been described in the pediatric age group. We report a case of T-PLL in a 9 year old male who was initially diagnosed with T-cell acute lymphoblastic lymphoma (ALL), the diagnosis was later refined to T-PLL following additional analysis of bone marrow morphology and immunophenotype. Two unusual findings in our patient included CD117 expression and an isolated chromosomal 12(p13) deletion. The patient failed to respond to standard ALL induction chemotherapy, but achieved complete remission following treatment with a fludarabine and alemtuzumab-based regimen.

Thrombotic thrombocytopenic purpura and its look-alikes: a single institution experience.

At presentation, variant or "look-alike" conditions can resemble TTP. We reviewed charts of 26 consecutive patients treated for presumed TTP. Of 15 classic TTP patients, 11 were tested for ADAMTS13; all showed severe deficiency, and inhibitor levels correlated with probability of relapse. The variant TMA group consisted of 8 patients who had active clinical disorders which overlapped with TTP. Variant TMA patients had higher creatinine and worse prognosis than classic TTP patients. "Look-alike" disorders included ITP with intravascular hemolysis following administration of WinRho™, and human granulocytic anaplasmosis. These conditions had not been previously described as TTP look-alikes.