Case report: Eastern equine encephalitis virus imported to the UK.

Eastern equine encephalitis (EEE) is rare, but the most severe of the mosquito-borne encephalitides in the United States with a high case fatality rate of 30%. Here, we present a patient with EEE. EEE virus causes sporadic human disease in the Eastern parts of the United States, but the case we describe was a Scottish tourist who acquired the disease from mosquito bites while in holiday in the United States. This is a first report of an imported case to Europe.

Red blood cell 2,3-diphosphoglycerate concentration and in vivo P50 during early critical illness.

OBJECTIVE: To measure red blood cell 2,3-diphosphoglycerate (RBC 2,3-DPG) concentrations in early critical illness; to investigate factors associated with high or low RBC 2,3-DPG levels; to calculate in vivo P50 in patients with early critical illness; and to explore the relationship between RBC 2,3-DPG and intensive care mortality. DESIGN: Prospective cohort study. SETTING: General medical-surgical intensive care unit (ICU) of a major Scottish teaching hospital. PATIENTS: One-hundred eleven critically ill patients during the first 24 hrs in the ICU with no history of chronic hematologic disorders or RBC transfusion within 24 hrs and 34 age- and sex-matched healthy reference subjects. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We measured RBC 2,3-DPG concentration, plasma biochemistry values, and arterial blood gas parameters. On average, RBC 2,3-DPG was lower among critically ill patients than controls (mean [sd], 14.1 [6.3] vs. 16.7 [3.7] mumol/g hemoglobin; p = .004) and had a wider range of values (patients, 3.2-32.5 mumol/g hemoglobin; reference group, 9.1-24.3). Regression analysis indicated a strong independent association between plasma pH and RBC 2,3-DPG (B, 32.15 [95% confidence interval, 19.07-46.22], p < .001) and a weak association with plasma chloride (B, -0.196 [95% confidence interval, -0.39 to -0.01], p = .044) but not with hemoglobin or other measured biochemical parameters. The mean calculated in vivo P50 level was normal (3.8 kPa) but varied widely among patients (range, 2.0-5.5 kPa). RBC 2,3-DPG concentration was similar for ICU survivors and nonsurvivors. CONCLUSIONS: RBC 2,3-DPG concentrations vary widely among critically ill patients. Acidosis is associated with lower RBC 2,3-DPG concentrations, but anemia is not associated with a compensatory increase in RBC 2,3-DPG early in critical illness. Lower RBC 2,3-DPG concentrations during the first 24 hrs of intensive care are not associated with higher ICU mortality.

Does the storage time of transfused red blood cells influence regional or global indexes of tissue oxygenation in anemic critically ill patients?

OBJECTIVE: To determine whether transfusion of red cells either < or =5 days or > or =20 days from donation alters tonometric indexes of gastric mucosal oxygenation or global oxygenation parameters in euvolemic anemic critically ill patients without ongoing hemorrhage. The a priori hypothesis was that stored red cells worsen gastric oxygenation. DESIGN: Prospective, double-blind, randomized study. SETTING: A 12-bed general medical/surgical intensive care unit in a Scottish teaching hospital. PATIENTS: Ventilated euvolemic anemic (mean +/- sd hemoglobin, 85.8 +/- 8.4 g/L) critically ill patients with significant organ failure, but no evidence of hemorrhage. INTERVENTIONS: After baseline measurements, patients were randomized to receive two units of leukodepleted red cells that were either < or =5 days (ten patients) or > or =20 days (12 patients) after donation according to a standardized protocol. MEASUREMENTS AND MAIN RESULTS: Changes in gastric to arterial Pco2 gap (Pg-Paco2 gap), gastric intramucosal pH, arterial pH, arterial base excess, and arterial lactate concentrations were measured during baseline (2.5 hrs), during transfusion (3 hrs), and for 5 hrs after transfusion. Mean age of red cells stored < or =5 days was 2 days (first and third quartile, 2, 2.25; range, 2-3); red cells stored >/=20 days had a mean age of 28 days (first and third quartile, 27, 31; range, 22-32). Hemoglobin concentration increased by 15.0 g/L and 16.6 g/L, respectively, in the fresh and stored groups (p =.62). There were no significant differences between the groups either using treatment-by-time analysis or comparing the pre- and posttransfusion periods either for Pg-Paco2 gap (mean difference, 0.03 kPa; 95% confidence limits, -1.66, 1.72) or gastric intramucosal pH (mean difference, 0.015 pH units; 95% confidence limits, -0.054, 0.084). The mean change within each group from the pre- to posttransfusion period for Pg-Paco2 gap and gastric intramucosal pH, respectively, was 0.56 kPa (95% confidence limits, -0.68, 1.79) and -0.018 pH units (95% confidence limits, -0.069, 0.032) for "fresh" red cells and 0.52 kPa (95% confidence limits, -0.6, 1.64) and -0.033 pH units (95% confidence limits, -0.080, 0.129) for "stored" red cells. There was no statistically or clinically significant improvement in any other oxygenation index during the measurement period for either group compared to baseline values. CONCLUSIONS: Transfusion of stored leukodepleted red cells to euvolemic, anemic, critically ill patients has no clinically significant adverse effects on gastric tonometry or global indexes of tissue oxygenation. These findings do not support the use of fresh red cells in critically ill patients.