Improved removal of white cells with minimal platelet loss by filtration of apheresis platelets during collection.

BACKGROUND: Filtration of apheresis platelets to remove white cells (WBCs) requires operator intervention after the collection procedure (postcollection filtration), which may cause variable and unsatisfactory filter performance (WBC removal and platelet loss). The MCS+ LN9000 apheresis system filters platelets through a WBC-reduction filter during each collection cycle (continuous filtration) at a flow rate of 15 to 25 mL per minute. Apheresis platelets obtained by continuous filtration were evaluated in terms of platelet loss, WBC removal, and platelet storage properties and then were compared to unfiltered apheresis platelets and to apheresis platelets that underwent postcollection filtration. Two WBC-reduction filters were tested (LRF6 and LRFXL). STUDY DESIGN AND METHODS: In 70 apheresis platelets, postcollection filtration was performed by using the LRF6 at flow rates of 80 mL per minute (n = 30) and 50 mL per minute (n = 30) and the LRFXL at 50 mL per minute (n = 10). One hundred fifty-eight apheresis platelets underwent continuous filtration through the LRF6 (n = 58) or the LRFXL (n = 100). Unfiltered apheresis platelets (controls) (n = 30) were obtained by the same collection protocol. RESULTS: Estimated platelet loss with continuous filtration was 7 percent for the LRFXL and 3 percent for the LRF6. A reduction in the filtration flow rate from 80 to 50 mL per minute with postcollection filtration through the LRF6 resulted in markedly lower WBC levels, with 10 percent versus 57 percent of the apheresis platelets having WBC counts <1 x 10(5), respectively. Additional improvements in WBC removal were found with continuous filtration; 85 percent of the apheresis platelets filtered with the LRF6 and 100 percent of the apheresis platelets filtered with the LRFXL had WBC counts <1 x 10(5). CONCLUSIONS: Continuous or postcollection filtration of freshly collected apheresis platelets resulted in minimal platelet loss. Better WBC removal from apheresis platelets was obtained with continuous filtration than with postcollection filtration, likely because of the slower flow rate. Platelet storage quality was not affected by filtration.

[Choledochal calculosis due to a suture thread]. / Calcolosi coledocica da filo di sutura.

The authors recently observed a patient suffering from recurrent choledochal, postcholecystectomy calculosis caused by suture thread. Given the relative rarity of this pathology, the difficulty of preoperative diagnosis and the possible confusion with other anatomoclinical syndromes, they take this opportunity to make a number of diagnostic and therapeutic comments in the light of the latest literature on this subject.

[Treatment of large bowel obstruction. Experience with intra-operative wash-out of the colon]. / Il trattamento delle ostruzioni del grosso intestino. Nostra esperienza sul wash-out intraoperatorio del colon.

The treatment of colorectal obstructions is a surgical problem. The surgeon can choose between primary resection with anastomosis and the staged operations. The one stage procedures need colon decompression or intraoperative colonic lavage. In our experience between 1990 and 1993, 23 patients required an emergency intervention for colon obstruction; between them 13 patients were affected by a left colonic obstruction and were treated with a staged procedure (like Hartman operation) in 9 cases and with intraoperative colonic wash-out with primary anastomosis in 4 cases. The last group had a good postoperative course without an increased incidence of anastomotic leakage (no one in our limited experience). Compared with staged surgery, immediate resection and anastomosis had significant advantages for the patients because: 1) the quality of the life is better (absence of colonstomy); 2) the cumulative hospitalization is reduced (15 days vs 32 days); 3) there is a reduction in operative risk and in the cumulative intra- and postoperative immunodepression. The correct evaluation of the effect on the long-term survival of these factors needs larger series and of longer follow-up.

An analysis of 9,918 consecutive perioperative autotransfusions.

The efficacy of perioperative autotransfusion (PAT) can be evaluated by the reduction in homologous transfusion accompanying its use. An alternative approach is to evaluate the amount of blood salvaged and retransfused. An analysis of 9,918 consecutive PAT procedures in various surgical specialties revealed that the average return of autologous blood salvaged was equivalent to 2.61 units of erythrocytes ("packed cells"). Cardiac operation had the greatest average number of units recovered (4.65), while orthopedic operation had the least (1.05). This method of analysis demonstrates that significant quantities of blood can be salvaged during PAT procedures.

Postoperative blood salvage in total hip and knee arthroplasty. A randomised controlled trial.

We undertook a prospective controlled clinical trial of 109 patients to determine whether postoperative blood salvage in patients undergoing total hip or knee arthroplasty decreased the need for transfusion with banked blood. The average amount of blood collected in our series was 493 ml, most of which was collected in the first four postoperative hours. In patients undergoing bilateral total knee arthroplasty, there was a 54% reduction in banked blood utilisation. None of our patients developed adverse effects from the reinfused material. The cost of collecting and processing wound drainage using the Haemolite cell washer was $175 per patient, regardless of the volume processed, compared to $125 for a unit of banked blood. By reducing the requirement for homologous transfusion, blood salvage diminishes the risks of transmission of HIV and hepatitis viruses. In those cases where the equivalent of two units of blood are reinfused, blood salvage saves money. However, due to the small amounts of blood collected in unilateral hip or knee arthroplasty, we do not recommend its routine application in these cases.

An autologous blood program coordinated by a regional blood center: a 5-year experience.

The Southern Arizona Regional Red Cross blood program offers preoperative autologous blood deposit to all patients and intraoperative autotransfusion services to all hospitals in the region. During a 5-year period, the amount of preoperatively deposited autologous blood and intraoperatively salvaged red cells available increased from 0.3 to 19.6 percent of the community's total collections. Further increases in the availability and use of autologous blood may be achieved by community-wide integration of services.

Intraoperative autotransfusion: a community program.

The Southern Arizona Regional Blood Program of the American Red Cross in cooperation with Tucson hospitals conducted a pilot program of the provision of intraoperative autologous transfusion services. The service provided instruments, staff, and disposables to salvage and wash red cells shed during scheduled and emergency surgical procedures. The lower cost and other efficiencies of providing this service through a regional blood center suggest that it may be more appropriate to offer this service on a regional basis than exclusively within a hospital. Hospitals and regional blood centers should consider offering this advanced form of hemotherapy to their communities.

Determinants of homologous blood usage utilizing autologous platelet-rich plasma in cardiac operations.

The present study evaluated (1) the influence of the collection of autologous platelet-rich plasma intraoperatively in addition to intraoperative autotransfusion on homologous blood usage and bleeding in cardiac operations; (2) the influence of age, sex, body surface area, type of operation, and reoperations on homologous blood usage and bleeding in cardiac operations utilizing intraoperative autotransfusion and autologous platelet-rich plasma collected intraoperatively; and (3) the influence of the preoperative administration of aspirin, Persantine (dipyridamole), heparin sodium, thrombolytic agents, Coumadin (crystalline warfarin sodium), and nonsteroid, antiinflammatory drugs on homologous blood usage and bleeding in cardiac operations utilizing intraoperative autotransfusion and autologous platelet-rich plasma collected intraoperatively. The results demonstrated a decrease in homologous blood use and bleeding when autologous platelet-rich plasma is collected in addition to the use of intraoperative autotransfusion. All of the patient and procedural variables influenced homologous blood usage and bleeding to some extent. Only the thrombolytic agents affected blood usage by increasing homologous plasma usage. All other drugs evaluated did not influence blood utilization or the amount of bleeding intraoperatively or postoperatively.

Autologous platelet-rich plasma in cardiac surgery: effect on intraoperative and postoperative transfusion requirements.

The Southern Arizona Red Cross Blood program, in conjunction with participating hospitals and cardiac surgeons, evaluated the effect of a program to harvest autologous platelet-rich plasma (PRP) from patients immediately prior to undergoing cardiopulmonary bypass surgery. The PRP was transfused back to the patient after heparin neutralization was achieved at the completion of cardiopulmonary bypass. The effect of this autologous PRP product on homologous plasma and platelet usage was examined. The study demonstrates a significant decrease in homologous plasma and platelet usage when autologous PRP is used in cardiac surgery.

Intraoperative autotransfusion in cardiac operations. Effect on intraoperative and postoperative transfusion requirements.

The Southern Arizona Regional Red Cross Blood Program, in cooperation with two cardiac surgery groups, examined the effect of intraoperative autotransfusion on red cell, plasma, and platelet usage during and after cardiac operations. The study evaluated whether intraoperative autotransfusion influenced intraoperative or postoperative blood usage and whether regular use was more effective than selective use. The study demonstrated that intraoperative autotransfusion reduces intraoperative and postoperative blood use and that regular use of intraoperative autotransfusion is more effective than selective use.

Adjuvant chemotherapy of axillary node-negative carcinoma of the breast using doxorubicin and cyclophosphamide.

One hundred fifty-six women with axillary node-negative breast cancer and primary tumors less than or equal to 5 cm in diameter (T1N0 or T2N0) were treated with a brief course of postoperative adjuvant chemotherapy consisting of doxorubicin and cyclophosphamide. Treatment was well tolerated and toxicity was minimal. With a median follow-up time of 58 months, there has been 1 relapse among 58 patients with T1 primary lesions and 15 relapses among 98 patients with T2 primary tumors. When compared with a matched historical control group receiving surgery alone, significant improvement was apparent in disease-free survival among the patients who received adjuvant chemotherapy. Prospective controlled trials are needed if we are to confirm this favorable experience with adjuvant chemotherapy in the treatment of women with node-negative breast cancer.

Spur cell anemia associated with extrahepatic biliary tract obstruction.

Two patients with extrahepatic biliary obstruction developed spur cell hemolytic anemia. Hemolysis and erythrocyte morphology reverted to normal when the obstruction was relieved. During the hemolytic phase, one patient's plasma converted normal erythrocytes to spur cells and normal plasma converted the patient's spur cells to normal morphology. The spur cells were discovered only when the patients' blood was examined under phase microscopy. We suggest that spur cells may occur in association with biliary obstruction more frequently than previously suspected and that their presence may be uncovered using phase microscopy.

Adjuvant treatment of node-positive breast cancer with adriamycin-cyclophosphamide with or without radiation therapy: interim results of an ongoing clinical trial.

During 1974-1980, 138 women with node-positive stage II breast cancer were treated with either eight courses of adriamycin-cyclophosphamide (AC) chemotherapy (82 patients) or AC chemotherapy plus comprehensive regional radiotherapy (56 patients). The overall relapse-free survival of the treated patients was significantly superior (P less than 0.001) to a comparable group of women who underwent surgery alone. This effect of adjuvant therapy was clearly manifest in all groups of patients irrespective of nodal involvement or menopausal status. To date, relapse-free survival for patients receiving AC compared to AC plus radiotherapy is not different (P = 0.7). In summary, wer have demonstrated that a brief 6-month course of adjuvant chemotherapy with AC can significantly reduce the recurrence rate in women with stage II breast cancer.

Marrow cell egress. The central interaction of barrier pore size and cell maturation.

Release of marrow cells may be determined primarily by the restrictive barrier that separates marrow hematopoietic cords from sinusoids, and by the ability of the cell to negotiate the barrier pores which are of smaller diameter than the cell. This critical interrelationship may be further modulated by humoral agents (releasing factors). To test this hypothesis, we placed human marrow cells in a chamber between millipore or nucleopore filters with pore diameters of 1-8 mum. Fixed, stained, cross sections of the filters allowed histological examination of the penetration of cells and quantification of egress of age-specific cell types. The rate of marrow granulocyte egress was highly correlated with (a) barrier pore diameter. (b) morphological age of cells, and (c) the presence of chemical attractant. Immature granulocytes would not exit through a restrictive barrier even after protracted periods and were not responsive to chemoattractants. Intermediate-aged granulocytes showed a slight ability to respond to attractants and to exit if pore diameters were large. Mature granulocytes exited through the restrictive barrier at all pore diameters studied, however, this egress was accelerated by increasing pore diameter and by the presence of an attractant. Leukemia blast cells were incapable of traversing pore diameters of 1-8 mum.These studies support the hypothesis that the development of deformability, motility, and surface receptors for chemoattractants at the later stages of granulocyte development allow the egress of cells through the marrow sinusoid wall which appears by electron microscopy to be a porous barrier with aperture diameters smaller than cell diameters; and that this process can be modulated by humoral agents which enhance directed movement of cells and may also increase pore size. Moreover, on the basis of our observations, the egress of leukemia cells is best explained by destruction of the normal sinusoid barrier of marrow indicating that manifestations of the disease are dependent on alteration in stromal as well as parenchymal marrow cells.