Improving the efficacy of preoperative autologous blood donation in patients with low hematocrit: a randomized, double-blind, controlled trial of recombinant human erythropoietin.

The effects of therapy with recombinant human erythropoietin (Epoetin alfa) on erythropoiesis, preoperative autologous blood donation, and risk of exposure to allogeneic blood were evaluated in 204 patients scheduled to undergo elective orthopedic surgery. Study protocol required patients to have a baseline hematocrit < or = 39% and surgery scheduled 25-35 days in advance. Patients were randomized to two equal groups and were seen at study centers every 3-4 days within the 21-day trial period. At each visit, phlebotomy(< or = 450 mL) was performed if the hematocrit was > or = 33%, and Epoetin alfa (600 U/kg) or placebo was administered intravenously. A total of 173 patients were assessable; 31% of placebo recipients and 20% of Epoetin alfa recipients required allogeneic transfusion (p = 0.09). Logistic regression modeling showed that the risk of allogeneic transfusion was reduced by Epoetin alfa (p = 0.025). When patients receiving > 6 units of blood (necessitating allogeneic units) were excluded from analysis, 29% of placebo recipients and 14% of Epoetin alfa recipients were exposed to allogeneic blood (p = 0.015). Epoetin alfa recipients predonated more autologous units than did placebo recipients (4.5 vs 3.0 units, respectively; p < 0.001), and their production of red blood cells increased significantly more over baseline production values (668 vs 353 mL, respectively; p < 0.05). These results demonstrate that administration of Epoetin alfa stimulates erythropoiesis, allows predonation of more units of autologous blood, and reduces the risk of exposure to allogeneic blood. Optimal dosing regimens and surgical patients most likely to benefit fro Epoetin alfa therapy must be established.

The effect of recombinant human erythropoietin on the efficacy of autologous blood donation in patients with low hematocrits: a multicenter, randomized, double-blind, controlled trial.

BACKGROUND: This randomized controlled study was undertaken to determine the effect of recombinant human erythropoietin (rHuEPO) on erythropoiesis, autologous blood collection, and allogeneic transfusion risk in elective surgery patients with low baseline hematocrits. STUDY DESIGN AND METHODS: Patients (n = 204) with low baseline hematocrits ( < or = 39%), scheduled for orthopedic surgery within 25 to 35 days, were seen every 3 to 4 days for 21 days. At each visit, 450 mL of blood was collected if the hematocrit was > or = 33 percent, and rHuEPO (600 U/kg) or placebo was administered intravenously. RESULTS: One hundred seventy-three patients were evaluable. The number of autologous units collected from the rHuEPO and control groups, respectively, was 4.5 +/- 1.0 and 3.0 +/- 1.1 (p < 0.001), and marrow production of red cells increased by 668 +/- 222 and 353 +/- 155 mL over and above baseline production (p < 0.05). Allogeneic blood transfusion was required by 31 percent of control and 20 percent of rHuEPO patients (p = 0.09). Excluding 8 patients who received > 6 units, 29 percent of control and 14 percent of rHuEPO patients required allogeneic blood (p = 0.015). Logistic regression modeling determined that the risk of allogeneic transfusion was reduced by rHuEPO (p = 0.025). CONCLUSION: The use of rHuEPO stimulates erythropoiesis, permits the storage of more autologous blood, and reduces allogeneic transfusion risk in patients with low hematocrits who are undergoing elective orthopedic surgery. Additional studies are necessary to determine the optimal schedules of rHuEPO administration and autologous blood collection as well as the cost-effectiveness of this strategy.

Venous thromboembolism and high grade gliomas.

A retrospective study was done to determine the incidence of and the risk factors predisposing to clinical venous thromboembolism (VTE) in patients treated for high grade gliomas. Medical records of 68 consecutive patients diagnosed and treated at Saint Francis Hospital and Medical Center from January 1986 to June 1991 were reviewed. The follow up was to time of death or at least 6 months (up to December 1991). All clinically suspected episodes of VTE were confirmed by objective tests. Sixteen episodes of VTE were detected in 13 patients for an overall episode rate of 23.5%. Administration of chemotherapy (p = 0.027, two tailed Fisher exact test) and presence of paresis (p = 0.031, two tailed Fisher exact test) were statistically significant risk factors for the development of VTE. Thrombotic events were more likely to occur in the paretic limb and this difference was statistically significant (p = 0.00049, chi square test, with Yates correction). No major bleeding complications were seen in the nine episodes treated with long term anticoagulation. We conclude that venous thromboembolic complications are frequently encountered in patients being treated for high grade gliomas and the presence of paresis and the administration of chemotherapy increases the risk of such complications.

Non-Hodgkin's lymphoma presenting with cardiac tamponade.

Large-cell lymphoma presented with pericardial effusion and acute tamponade in a previously healthy 76-year-old woman. Initial therapy with percutaneous pericardiocentesis was diagnostic. Our review of the literature underscores the unique nature of this presentation and emphasizes the value of cytologic examination in new-onset pericardial effusion.

VP-16, vincristine and procarbazine with radiation therapy for treatment of malignant brain tumors.

Twelve patients aged 34 to 65 with malignant gliomas were treated with VP-16, Procarbazine, Vincristine and concurrent radiation therapy. There were 9 patients with glioblastoma multiforme and 3 with anaplastic astrocytoma. All patients had a subtotal resection or biopsy as the initial procedure. Six patients (1 anaplastic astrocytoma) have developed progressive disease. Mean time to tumor progression was 46 weeks. This combined modality treatment program was associated with reversible hematologic toxicity which was severe in 2 patients. These data compare favorably to data obtained from similar patients treated with radiation therapy and BCNU.

Preleukemia following large dose radioiodide therapy for metastatic thyroid carcinoma.

A 67-yr-old woman had follicular thyroid carcinoma metastatic to several osseous sites. There was also evidence of functioning pulmonary metastases. She was treated by total thyroidectomy and multiple doses of radioiodide (131I). Approximately 2.5 yr after the initial ablative dose, and a total dose of 820 mCi of sodium iodide 131I, preleukemic changes were noted in the bone marrow. This appears to be the second case of preleukemia that bears a temporal relationship to radioiodide therapy of thyroid carcinoma, and the first in which radioiodide alone has been used in therapy (without additional external radiation).

Thrombotic thrombocytopenic purpura and hemolytic-uremic syndrome in HLA-identical siblings.

Thrombotic thrombocytopenic purpura and hemolytic-uremic syndrome occurred 6 1/2 years apart in HLA-identical brothers. This unique occurrence supports the concept that the two disorders may be varieties of a basic disease process and suggests the possibility of an inherited predisposition for them.

Left ventricular aneurysms caused by blunt chest trauma.

This report describes the case of a 25-year-old man who suffered blunt chest trauma with resultant development of an asymptomatic left ventricular aneurysm which was successfully resected. A review of the literature reveals 25 reported cases of left ventricular aneurysm due to blunt trauma since 1892. The clinical findings and complications are similar to those of left ventricular aneurysm from other causes. The prognosis is not clear, but it is not necessarily benign even in asymptomatic cases. Aneurysmectomy has been generally successful and may be the treatment of choice. The surgical risk and prognosis is expected to be better than in left ventricular aneurysm due to myocardial infarction because of the relative infrequency of coexisting coronary artery disease.