Anti-Vel alloimmunization and severe hemolytic disease of the fetus and newborn.

Only rare cases of anti-Vel-associated mild-to-moderate hemolytic disease of the fetus and newborn have been previously reported. No case of fetal anemia requiring prenatal therapy has been noted to date. We report such a case recently encountered at our Fetal Center. Strategies are discussed for managing pregnancy complicated with alloimmunization to an antibody to a high-prevalence antigen, including sources of red blood cells for intrauterine transfusions.Only rare cases of anti-Vel­associated mild-to-moderate hemolytic disease of the fetus and newborn have been previously reported. No case of fetal anemia requiring prenatal therapy has been noted to date. We report such a case recently encountered at our Fetal Center. Strategies are discussed for managing pregnancy complicated with alloimmunization to an antibody to a high-prevalence antigen, including sources of red blood cells for intrauterine transfusions.

The Collaborative Hospital Transfusion Study: variations in use of autologous blood account for hospital differences in red cell use during primary hip and knee surgery.

BACKGROUND: Red cell use in patients undergoing Diagnosis Related Group (DRG) 209 procedures (major joint and limb reconstruction procedures of the lower extremities) has been shown to have large, unexplained interhospital variations. STUDY DESIGN AND METHODS: Abstracted records of 2590 consecutive DRG 209 patients at five university hospitals from January 1992 to December 1993 were stratified by procedure and preoperative blood deposit status. Patient characteristics and transfusion and in-hospital outcomes were compared across hospitals. RESULTS: Blood use among patients who did not preoperatively deposit blood was similar across hospitals. Significant differences were found across hospitals for total hip replacement patients in the percentage of patients preoperatively depositing blood (59-80%), percentage of patients receiving transfusion(s) (51 to > 99%), the mean number of units collected per patient (1.6-2.9), and the mean number of unused autologous units per 100 patients (1-185). No significant differences were found in the percentage of those who deposited blood and then required allogeneic units. There was little variability in length of hospital stay or in last hematocrits. Findings were similar for total knee replacement patients. CONCLUSIONS: Interhospital variations in red cell use for primary total hip and knee reconstruction are primarily due to hospital-specific differences in autologous blood collection and transfusion.

Determinants of red cell, platelet, plasma, and cryoprecipitate transfusions during coronary artery bypass graft surgery: the Collaborative Hospital Transfusion Study.

BACKGROUND: Very little is known about the determinants of blood transfusions in patients undergoing coronary artery bypass graft surgery. STUDY DESIGN AND METHODS: To identify factors that influenced the transfusion of red cells, platelets, plasma, and cryoprecipitate, statistical methods were used to study 2476 consecutive diagnosis-related group 106 and 107 patients in five teaching hospitals who underwent coronary artery bypass surgery between January 1, 1992, and June 30, 1993. RESULTS: The likelihood of red cell transfusion was significantly associated with 10 preoperative factors: 1) admission hematocrit, 2) the patient's age, 3) the patient's gender, 4) previous coronary artery bypass surgery, 5) active tobacco use, 6) catheterization during the same admission, 7) coagulation defects, 8) insulin-dependent diabetes with renal or circulatory manifestations, 9) first treatment of new episode of transmural myocardial infarction, and 10) severe clinical complications. Platelet and/or plasma transfusions were strongly associated with the dose of red cells transfused. Transfusion requirements and other in-hospital outcomes were associated with patient characteristics, surgical procedure (reoperation vs. primary procedure), and the conduits used for revascularization (venous graft only, venous and internal mammary artery graft, or internal mammary artery graft only). Blood resource use and donor exposures were evaluated with respect to the risk to patients of contracting hepatitis C virus and human immunodeficiency virus infections. CONCLUSION: The classification of coronary artery bypass graft patients on the basis of attributes known preoperatively and by conduits used yields subsets of patients with distinctly different transfusion requirements and in-hospital outcomes.

Ionized calcium buffering in the transfused anhepatic patient: Ab initio calculations of calcium ion concentrations.

Homeostatic control of ionized calcium can be volatile during liver transplantation, particularly during the anhepatic stage. Recently, an opportunity arose to evaluate an 11-year-old girl who developed persistent ionic hypocalcemia during a prolonged anhepatic period subsequent to the failure and removal of the graft. The patient was remarkable for having survived a 34-hour anhepatic interval before a second and successful orthotopic liver transplant. Ionic hypocalcemia (ionized calcium less than 1 mmol per L) coexisted with significant hypercalcemia (total calcium greater than 5 mmol per L) during this anhepatic interval. The discrepancy was due to high concentrations of citrate, which accumulated from the multiple transfusions of citrated blood, and the inability to metabolize citrate in the anhepatic state. Using a mathematical model to solve for free calcium ion concentration in the presence of multiple ligands, it is demonstrated that prolonged hypercitricemia markedly alters the calcium ion buffering properties of blood, and these changes must be recognized in order to prevent adverse clinical consequences of ionic hypocalcemia.

Vascular adrenal cysts. A clinicopathologic and immunohistochemical study of endothelial and hemorrhagic (pseudocystic) variants.

Three endothelial cysts and five hemorrhagic cysts (pseudocysts) arose in the adrenal glands of seven patients aged 23-73 years. Four patients were male and three were female. Five were symptomatic and gave abdominal pain as their chief complaint. Endothelial cysts were collapsed or filled with serous fluid, multiloculated, had an endothelial lining, and often contained adrenal cortex in their outer walls. The endothelial lining reacted only weakly for Factor VIII-related antigen (FVII-RAg), but it stained strongly for collagen type IV (C-IV). The lack of hemorrhage and the FVIII-RAg/C-IV staining pattern in endothelial cysts suggest lymphatic differentiation. Hemorrhagic cysts were spherical, firm masses containing clotted blood and hyalinized thrombus with attenuated adrenal cortex in the outer fibrous wall. Islands of intact cortical cells were present deep within the thrombi of four hemorrhagic cysts. Three of five hemorrhagic cysts stained strongly for FVIII-RAg and C-IV in irregular vascular channels of the attenuated cortex and within the cyst contents. These channels suggest that at least some hemorrhagic cysts arise when hemorrhage occurs in a preexisting blood vascular anomaly. Entrapment of cortical islands by extravasated blood in hemorrhagic cysts may be misdiagnosed as necrotic cortical neoplasm. To avoid confusion, one must recognize the normality of the entrapped cortical cells, identify an intrinsic vascular anomaly, and distinguish thrombus from necrotic tumor.

Comparison of plateletpheresis using two cell separators and identical donors.

For prospective comparison of product yield and volume, collection efficiency, white cell (WBC) and red cell (RBC) contamination, donor acceptability, and staff acceptance, each of 31 donors underwent plateletpheresis on two different cell separators (the Fenwal CS-3000 and the COBE Spectra). The same operator performed the paired procedures and collected all study data. The instruments provided equivalent high-yield platelet products (CS-3000: 5.3 x 10(11); Spectra: 5.7 x 10(11]. Platelet collection efficiency was greater with the Spectra (81%) than with the CS-3000 (57%) (p less than 0.0005). All products contained less than 1 mL of RBCs, but the Spectra products were more likely to contain less than 10(6) WBCs (14/31) than those of the CS-3000 (1/31) (p less than 0.001). In the remaining products, the mean WBC contamination was 1.0 x 10(8) for the CS-3000 and 0.03 x 10(8) for the Spectra (p less than 0.001). More ACD-A anticoagulant was infused with Spectra (463 mL) than with CS-3000 procedures (400 mL) (p = 0.002). Although postdonation ionized calcium (Ca2+) levels and the percentage of decrease in Ca2+ were not significantly different between groups, more Spectra donors experienced symptoms of hypocalcemia (20/31 vs 9/31; p = 0.015). CS-3000 products had lower mean volumes (217 mL) than Spectra collections (300 mL) (p less than 0.0005). Both instruments were accepted well by volunteer donors and the technical staff.

Fine-needle aspiration cytology of an adult rhabdomyoma of the head and neck.

The cytologic features of a multifocal adult rhabdomyoma of the head and neck, as observed in a fine-needle aspiration specimen, are described. Cross-striations and characteristic cytoplasmic "crystals" were conspicuous in the cytologic preparations and also during ultrastructural examination. The cytologic features of adult rhabdomyoma are distinctive, allowing a rapid specific diagnosis.

Promyelocyte morphology. Differentiation of acute promyelocytic leukemia from benign myeloid proliferations.

Bone marrow aspirates from patients with acute agranulocytosis or a marked left shift in myeloid maturation can mimic acute leukemia, particularly acute hypergranular promyelocytic leukemia. Bone marrow aspirates from 16 cases of apparent acute promyelocytic leukemia, 4 cases of acute agranulocytosis, and 1 case of a marked myeloid left shift were studied for the presence or absence of differentiating features. Normal or reactive promyelocytes were characterized by prominent paranuclear clear Golgi zones, whereas promyelocytes from true leukemic cases all had heavy azurophilic granules dispersed diffusely throughout the cytoplasm. Prominent Golgi zones in promyelocytes were associated only with benign myeloid conditions and were not observed in acute promyelocytic leukemia. The presence of prominent clear Golgi zones in promyelocytes is an important feature assisting in the distinction between leukemic and benign promyelocytes.