Effect of the administration of recombinant activated factor VII (rFVIIa; NovoSeven) in the management of severe uncontrolled bleeding in patients undergoing heart valve replacement surgery.

Recombinant activated factor VII (rFVIIa; NovoSeven, Novo Nordisk A/S, Bagsvaerd, Denmark) is being increasingly used to secure haemostasis in difficult clinical situations. The role of rFVIIa in the treatment of patients undergoing open-heart surgery for valvular heart disease was evaluated in an open pilot study. Study objectives included evaluation of blood loss, haemostatic effect and safety and laboratory parameters following rFVIIa administration. To date, we have treated five patients (one child aged 2.5 years and four adults) undergoing surgical procedures including arterial switch, closure of atrial septal defect and De Vega's procedure (mitral valve replacement with tricuspid valve repair). Four patients received rFVIIa intraoperatively, while the fifth received it postoperatively. Satisfactory haemostasis was achieved with a single dose (30 microg/kg) of rFVIIa. Four hours after treatment mean blood loss was 262.5 ml for adults (220-334 ml) and 85 ml for the child. No significant adverse events were reported. Laboratory parameters indicated a mean 18.5-fold (range 3.7-42) increase in FVII levels at 30 min postinjection and a mean reduction of 12 s (range 3-39 s) in prothrombin time. In conclusion, rFVIIa represents an effective and well-tolerated treatment for serious bleeding episodes both during cardiac surgery and postoperatively.

Fulminant septicaemic syndrome of Bacillus cereus: three case reports.

Three patients with acute leukaemia, who were severely neutropenic and iatrogenically immunosuppressed post-chemotherapy, developed rapidly fatal septicaemic shock and coma caused by Bacillus cereus (B. cereus). The illness was marked by two phases: a mild febrile illness lasting 6-14 h and accompanied by subtle symptoms of autonomic sympathetic nervous system overactivity, and a second short fulminant one, marked by high fever of 40-41 degrees C accompanied by major central nervous system disturbances, and ending with deep coma and brain stem dysfunction. One patient developed the sepsis in spite of 4 days of coverage with amikacin. In the other two patients, amikacin was commenced at the earliest phase of the infection, but failed to influence the outcome. This form of B. cereus sepsis in neutropenic patients seems to be caused by strains capable of causing bacteraemia and meningitis and has the ability to produce a substance that causes leptomeningeal and neuronal necrosis. Lack of early clinical and laboratory markers inevitably leads to death. Use of antibiotics effective against B. cereus and capable of achieving high concentrations in the cerebrospinal fluid. and identification and neutralization of the necrotizing substance may hopefully help to reverse this fatal illness.

Severe aquired haemophilia A treated with recombinant factor VIIa.

Acquired haemophilia can be associated with various conditions including pregnancy, autoimmune diseases and lymphoproliferative disorders, though often no underlying cause is found. It often presents with a rapid onset of muscle bleeding and involves the IgG antibody. It may be treated with human or porcine factor VIII (FVIII), prothrombin complex concentrates, factor IX (FIX) complex concentrates, factor VIIa (FVIIa) or by immunosuppression. We report a case of acquired haemophilia in a 40-year-old woman diagnosed following laparotomy. She was treated unsuccessfully using human FVIII and cryoprecipitate, porcine FVIII and FIX complex concentrate, before being treated with recombinant FVIIa (NovoSeven, Novo Nordisk). On treatment with recombinant FVIIa, bleeding stopped rapidly with no side-effects and the abdominal haematoma was evacuated with minimal post-operative bleeding.

The experience of bone marrow transplantation at riyadh armed forces hospital.

This is a report about the program of bone marrow transplantation (BMT), which was established in 1989 at the Armed Forces Hospital in Riyadh, Saudi Arabia. We follow the strict international protocol of pre transplant assessment of the donor and the recipient, BMT conditioning by Cyclosphosphamide and Basulphan or body irradiation, BM harvest and processing, graft versus host disease prophylaxis by cyclosporin and methotrexate, and post-transplant care. Since the start of the BMT programme at the Armed Forces Hospitals in Riyadh in May 1989 and until the end of March 1996, fifty nine allogeneic and one autologous transplants have been performed. Chronic myelocytic and acute myeloid leukemia were the principal indications for BMT in our institute. The acturial five years survival of BMT in these two conditions was 67% and 47% respectively. Besides allografting, we finished the preparations for autologus BMT and peripheral blood stem cells transplantation, which may be used for treating patients with solid tumors and leukemias who are not suitable for allogenic transplantation due to older age or donor unavailability.