Blood Exchange Research Articles

FAT EMBOLISM SYNDROME AS THE PRESENTING SYNDROME OF UNDIAGNOSED SICKLE CELL DISEASE IN A MIDDLE-AGED ADULT

SESSION TITLE: Medical Student/Resident Critical Care Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Fat embolism syndrome (FES) represents a myriad of clinical signs and symptoms that occur following the release of fat emboli into systemic circulation including hypoxemia, neurologic changes, petechial rash, and multi-organ dysfunction. FES often occurs post-orthopedic trauma but can be a complication of sickle cell disease (SS) [1]. CASE PRESENTATION: An otherwise healthy 44-year-old female presented to our emergency department (ED) with worsening, atraumatic back and knee pain after an ED visit three days prior where x-rays and blood-work were unremarkable. She was short of breath, hypoxic, tachycardic and hypotensive. Her mental and respiratory status deteriorated requiring intubation. Laboratory work was significant for hemoglobin 8.5 g/dL, hematocrit 24.0%, WBC 14.8x10⁹/L, and platelets 59x10⁹/L including 11% bands and 15% nRBCs (baseline CBC had no abnormalities). A chest x-ray revealed bilateral, patchy infiltrates consistent with pulmonary edema. Further blood-work revealed acute renal and liver failure, lactic acidosis, and troponinemia. CT imaging revealed patchy, widespread pulmonary disease/edema and splenomegaly. She underwent resuscitation with fluid, blood products, vasopressor support, and broad spectrum antibiotics. All infectious disease workups were negative. The patient was ultimately transferred elsewhere for whole blood exchange but expired. Autopsy revealed vertebral and long-bone marrow infarction and evidence of FES. She was discovered to be hemoglobin SS post-mortem, and no trigger for this episode, including infectious disease, was identified. DISCUSSION: Sickle cell disease screening is routine in the United States but less standardized in other nations [2]. Most sickle cell disease patients exhibit disease signs by age 4-5 months making her middle-aged presentation uncommon. Our patient, a Haitian immigrant, as well as her husband, adamantly denied prior SS symptoms or crisis. Moreover, according to a recent systematic review, FES is a rare complication of sickle cell disease with a predilection for heterozygous patients [2]. Of all FES cases, only 15% of patients were homozygous SS (n = 13) [3]. It is rare for FES to be the presenting syndrome of a previously undiagnosed, middle-aged, homozygous SS disease patient. CONCLUSIONS: We present a rare case of FES as the presenting syndrome of a previously undiagnosed, middle-aged, SS disease patient. Prompt consideration and treatment of FES should be initiated to avoid complications. Reference #1: Akhtar S. Fat embolism. Anesthesiol. Clin. 2009; 27 (3):533–550. Reference #2: Center for Disease Control Sickle Cell Disease. Oct 2019. Retrieved from https://www.cdc.gov/ncbddd/sicklecell Reference #3: Tsitsikas DA, May JE, Gangaraju R, Abukar J, Amos RJ, Marques MB. Revisiting Fat Embolism in Sickle Syndrome: Diagnostic and Emergency Therapeutic Measures. British Journal of Haematology. 2019 Aug; 186(4), 112-115. DISCLOSURES: No relevant relationships by Osman Abbasi, source=Web Response No relevant relationships by Jamie Allen, source=Web Response No relevant relationships by Jeffrey Gesell, source=Web Response No relevant relationships by Benjamin Lin, source=Web Response No relevant relationships by Louis Morolla, source=Web Response No relevant relationships by Andres Zirlinger, source=Web Response

Kidney Single-Cell Atlas Reveals Myeloid Heterogeneity in Progression and Regression of Kidney Disease.

Little is known about the roles of myeloid cell subsets in kidney injury and in the limited ability of the organ to repair itself. Characterizing these cells based only on surface markers using flow cytometry might not provide a full phenotypic picture. Defining these cells at the single-cell, transcriptomic level could reveal myeloid heterogeneity in the progression and regression of kidney disease. Integrated droplet- and plate-based single-cell RNA sequencing were used in the murine, reversible, unilateral ureteric obstruction model to dissect the transcriptomic landscape at the single-cell level during renal injury and the resolution of fibrosis. Paired blood exchange tracked the fate of monocytes recruited to the injured kidney. A single-cell atlas of the kidney generated using transcriptomics revealed marked changes in the proportion and gene expression of renal cell types during injury and repair. Conventional flow cytometry markers would not have identified the 12 myeloid cell subsets. Monocytes recruited to the kidney early after injury rapidly adopt a proinflammatory, profibrotic phenotype that expresses Arg1, before transitioning to become Ccr2+ macrophages that accumulate in late injury. Conversely, a novel Mmp12+ macrophage subset acts during repair. Complementary technologies identified novel myeloid subtypes, based on transcriptomics in single cells, that represent therapeutic targets to inhibit progression or promote regression of kidney disease.

Automated RBC Exchange has a greater effect on whole blood viscosity than manual whole blood exchange in adult patients with sickle cell disease.

Blood transfusion is the cornerstone treatment to reduce the clinical severity of sickle cell disease (SCD), but we need to maintain the haematocrit (Hct) within an acceptable range to avoid a deleterious increase in blood viscosity. The aim of this study was to compare the effects of manual versus automated red blood cell (RBC) Exchange on haematological parameters and blood viscosity. This prospective, single-centre, open nonrandomized observational study included forty-three sickle cell patients: 12 had automated RBC Exchange and 31 manual RBC Exchange. Samples were collected in EDTA tubes just before and within one hour after the end of the RBC Exchange to measure the haematological parameters and blood viscosity. Both automated and manual RBC Exchange decreased haemoglobin S levels and leucocyte and platelet counts, but the decrease was greater for automated RBC Exchange. Manual RBC Exchange caused a significant rise in haematocrit and haemoglobin levels and did not change blood viscosity. In contrast, automated RBC Exchange decreased blood viscosity without any significant change in haematocrit and only a very slight increase in haemoglobin levels. The change in blood viscosity correlated with the modifications of haematocrit and haemoglobin levels, irrespective of the RBC Exchange procedure. When adjusted for the volume of RBC Exchange, the magnitude of change in each biological parameter was not different between the two procedures. Our study demonstrates that the automated RBC Exchange provided greater haematological and haemorheological benefits than manual RBC Exchange, mainly because of the higher volume exchanged, suggesting that automated RBC Exchange should be favoured over manual RBC Exchange when possible and indicated.

Biomaterials for Bioprinting Microvasculature.

Microvasculature functions at the tissue and cell level, regulating local mass exchange of oxygen and nutrient-rich blood. While there has been considerable success in the biofabrication of large- and small-vessel replacements, functional microvasculature has been particularly challenging to engineer due to its size and complexity. Recently, three-dimensional bioprinting has expanded the possibilities of fabricating sophisticated microvascular systems by enabling precise spatiotemporal placement of cells and biomaterials based on computer-aided design. However, there are still significant challenges facing the development of printable biomaterials that promote robust formation and controlled 3D organization of microvascular networks. This review provides a thorough examination and critical evaluation of contemporary biomaterials and their specific roles in bioprinting microvasculature. We first provide an overview of bioprinting methods and techniques that enable the fabrication of microvessels. We then offer an in-depth critical analysis on the use of hydrogel bioinks for printing microvascularized constructs within the framework of current bioprinting modalities. We end with a review of recent applications of bioprinted microvasculature for disease modeling, drug testing, and tissue engineering, and conclude with an outlook on the challenges facing the evolution of biomaterials design for bioprinting microvasculature with physiological complexity.

The Duration of Breastfeeding and Attention-Deficit Hyperactivity Disorder in School-Aged Children

ABSTRACT Attention-deficit hyperactivity disorder (ADHD) is one of the most common childhood-onset neurodevelopmental disorders. In some recent studies breastfeeding had positive effects on physical health and mental development of children and these studies have recommended further studies in this issue. This study evaluated the relationship between duration of breastfeeding and ADHD. This case-control study was carried out in 2017 on 404 children aged 7–12 (196 children with ADHD and 208 children without ADHD). The questionnaire included items on the risk factors such as the child’s sex, age, delivery method, birth weight, birth rank, gestational age, age of mother, duration of breastfeeding, history of neonatal hospitalization, history of drug use in neonatal period, history of drug use in pregnancy, history of hypothyroidism and hyperthyroidism in pregnancy, history of neonatal icter, history of neonatal blood exchange. Data were analyzed using t-test, chi-square and logistic regression. The mean of breastfeeding duration in children with ADHD was 17.05 ± 7.52 months compared with 18.59 ± 6.74 months in control group (p = .03). A stepwise logistic regression that included the variables was found to be significant in univariate analysis, demonstrating a significant association between ADHD and breastfeeding duration (p = .01), male gender (OR = 2.8), mother hypothyroidism(OR = 4.5) and history of drug use in neonatal period (OR = 1.9). Long-term duration of breastfeeding (more than 12 months) could be a protective factor in ADHD. However, further studies are required.

Blood exchange transfusion in viral hepatitis in a small infant: a case report

We report a case of blood exchange transfusion to treat acute liver failure following hepatitis B infection at the Infectious Disease Department of Children's Hospital No.2 in Ho Chi Minh City, Vietnam. A 3.5-month old baby boy was admitted to the hospital with a presentation of progressively worsening jaundice for the past one month. The patient was diagnosed with hepatitis B infection with a positive HBV DNA quantitative assay. Plasma exchange was indicated in view of progressive liver failure and gradually increasing hepatic coma. However, it was impossible to perform plasmapheresis in this case because the patient was small (in terms of age and weight) and there was no suitable plasma exchange filter. Accordingly, the patient was treated with 3 times of blood exchange transfusion in combination with an antiviral drug, lamivudine. After each blood exchange transfusion, the biochemical values (bilirubin, liver enzymes, and coagulation profile) gradually improved and he was discharged after 1 month of treatment. Blood exchange transfusion is an effective procedure for managing acute liver failure, where plasma exchange is not possible while waiting for the recovery of liver functions or liver transplantation.

Rejuvenation of three germ layers tissues by exchanging old blood plasma with saline-albumin.

Heterochronic blood sharing rejuvenates old tissues, and most of the studies on how this works focus on young plasma, its fractions, and a few youthful systemic candidates. However, it was not formally established that young blood is necessary for this multi-tissue rejuvenation. Here, using our recently developed small animal blood exchange process, we replaced half of the plasma in mice with saline containing 5% albumin (terming it a “neutral” age blood exchange, NBE) thus diluting the plasma factors and replenishing the albumin that would be diminished if only saline was used. Our data demonstrate that a single NBE suffices to meet or exceed the rejuvenative effects of enhancing muscle repair, reducing liver adiposity and fibrosis, and increasing hippocampal neurogenesis in old mice, all the key outcomes seen after blood heterochronicity. Comparative proteomic analysis on serum from NBE, and from a similar human clinical procedure of therapeutic plasma exchange (TPE), revealed a molecular re-setting of the systemic signaling milieu, interestingly, elevating the levels of some proteins, which broadly coordinate tissue maintenance and repair and promote immune responses. Moreover, a single TPE yielded functional blood rejuvenation, abrogating the typical old serum inhibition of progenitor cell proliferation. Ectopically added albumin does not seem to be the sole determinant of such rejuvenation, and levels of albumin do not decrease with age nor are increased by NBE/TPE. A model of action (supported by a large body of published data) is that significant dilution of autoregulatory proteins that crosstalk to multiple signaling pathways (with their own feedback loops) would, through changes in gene expression, have long-lasting molecular and functional effects that are consistent with our observations. This work improves our understanding of the systemic paradigms of multi-tissue rejuvenation and suggest a novel and immediate use of the FDA approved TPE for improving the health and resilience of older people.

PMD2 HEALTH OUTCOMES ASSOCIATED WITH DIFFERENT TRANSFUSION MODALITIES IN SICKLE CELL DISEASE

To avoid and overcome significant sickle cell disease (SCD) complications, treating physicians have different therapeutic options including several chronic transfusion modalities such as simple blood transfusion (ST), manual blood exchange procedure (MBE) or automated red blood cell exchange procedure (RBCX). The objective of this study was to determine the impact of different blood transfusion modalities and their ability to avoid and overcome SCD patient complications. The main study method was physician reported patient health outcomes. The study relied on a double blinded cross-sectional survey amongst 53 treating physicians based in the US. Together, these physicians yearly routinely treat 5,989 SCD patients out of an estimated total population of 100,000 SCD patients in the US. The impact of chronic blood transfusion modalities on SCD complications was measured on 14 disease complications. Chronic automated RBCX largely outperformed simple blood transfusion and manual blood exchange in terms of SCD patient complication reduction. Complication reduction for RBCX was found to be 56% higher versus manual exchange and 46% higher vs simple blood transfusion. Compared to the next best transfusion alternative (simple transfusion or manual exchange) RBCX was reported to have a significantly (p < 0.01) positive impact (% reduction) on the following disease complications: acute chest syndrome (-24%), stroke (-45%), silent infarction (-54%), renal failure (-38%), priapism (-62%), iron overload (-50%) and severe infection (-32%). Automated RBCX is likely to reduce the incidence of multiple SCD complications. Physicians access to multiple transfusion modalities at their facility will decrease the patient burden of disease and potential long-term consequences of SCD most by utilizing automated RBCX whenever possible.

Monochorionic diamniotic twins: What do I tell the prospective parents?

Monochorionic diamniotic twins occur in about 1 in 300 pregnancies. Compared with dichorionic twins, they face increased risks because of the shared circulation. In about 15%, an imbalance in blood exchange occurs, such as twin-twin transfusion syndrome and twin anemia polycythemia sequence. In this review, we summarize the latest evidence on the management of monochorionic diamniotic twin pregnancies and their specific complications, with a focus on information that is relevant for prospective parents.

Vascular anastomoses in intrauterine growth in monochorionic twins.

Objectives To evaluate the impact of placental anastomoses on the intrauterine growth of monochorionic (MC) twins. Methods A prospective study was conducted in a group of 53 MC twins. Intrapartally umbilical cords were clamped to identify placental sides corresponding to each twin. The postnatal dye injection technique was administered to evaluate vascular anastomoses, their number and type and visualize placental territory sharing patterns. Data from digital analysis were correlated with obstetrical follow-up. Results Vascular anastomoses were revealed in 88.7% of cases. Arteriovenous (AV) anastomoses occurred in 75.4% and arterioarterial (AA) in 71.1% while venovenous (VV) in 26.4%. In the subgroup of MC twins without placental anastomoses, significantly higher birthweight difference and discordance were revealed when compared to MC twins without anastomoses (382.0 vs. 22 g; P = 0.03 and 49.14% vs. 16.02%; P = 0.03). On the other hand, in subgroups of MC twins with at least one AA anastomosis, twins' birthweights were similar (p = ns) despite significantly higher placental territory sharing discordance (30.44% vs. 15.81%; P = 0.31). Conclusions Vascular anastomoses have a major impact on the intrauterine growth of MC twins. In certain cases, they may cause specific complications; however, in general, they regulate intertwin blood exchange and may compensate unequal placental territory.

Pilot Study: The role of chronic stress on brain microvessel density in male and female mice

The cerebrovasculature, an intricate configuration of blood vessels, is responsible for the exchange of blood to and from the brain. Reduction of cerebrovascular vessels can reduce or prevent the flow of nutrients &amp; oxygen that is necessary for proper brain function and increase risk of cerebrovascular diseases. Chronic stress is also a risk factor to various cerebrovascular diseases.In this pilot study, brain microvessel density in both female and male chronically stressed mice were analyzed. Beginning at the age of 18 weeks, mice were subjected to the unpredictable chronic mild stress (UCMS) paradigm for 5 days a week/seven hours a day for 8 weeks. Upon euthanization brain samples were flash frozen and sectioned at 8um using a cryostat. Immunofluorescence was utilized to observe endothelial cells via a CD31 antibody. Images were taken using a Nikon Eclipse 800 at a 40X objective and analyzed and quantified for density using ImageJ.Preliminary data (n=3/group) suggest that the male mice have a 26% higher microvessel density compared to females (p&lt;0.05). When stressed, males exhibit a 17% lower microvessel density whereas stressed females did not display a loss in microvessel density (p&lt;0.05).Here we showed that the brain of male and female mice can be physiologically diverse in microvessel density and that males and females display a different response when exposed to chronic stress.Support or Funding InformationNIH Cobra Grant 5P20GM109098; NIH INBRE P20GM103434

A rare encounter in nonsuspecting circumstances: First congenital visceral leishmaniasis (kala-azar) in Libya

Congenital transmission of Leishmaniasis is very rare. It occurs through blood exchange from the mother to the child during pregnancy or delivery. We report the first confirmed congenital leishmaniasis in a 4-month-old Libyan boy with prolonged jaundice and hepatosplenomegaly. This was a congenital transmission from his mother who was asymptomatic and not known to have leishmaniasis, which was confirmed after the diagnosis of the infant. Despite treatment, the infant died. The diagnostic approach is illustrated by the case report. Poor obstetric history in the mother may be related to her own undiagnosed kala azar.

The question of the use of trainer of MOTO - med is examined in the article in complex physical therapy

As one of technologies of restoration treatment of children with a cerebral palsy, that is sent to normalization of muscular tonus, decline of spasticity of muscular groups and neuromuscular or musculoskeletal disorders, improvements of blood supply and exchange processes in cerebral fabric, improvement of motive possibilities and walking. MOTO- med motor mechanotherapy has been developed for people with physical disabilities and complements physical therapy, ergotherapy and sports therapy. Users can exercise while wheelchair or chair. In the supine position, patients can use MOTO-med from the bed or from the treatment couch. To ensure safety during classes, MOTOmed devices have special software installed: motion protection" function stops the rotation of the simulator pedals. It doesn’t matter how the overall muscular tension changes, the level of "movement protection" does not always remain constant, but adapts to changes and therefore always remains optimally sensitive. This function is used on all MOTOmed models using sensitive sensors. "Spasm control" program with automatic change of direction of pedal rotation reduces muscle spasticity in accordance with the following therapeutic principle: flexor spasticity is reduced due to slow straightening, and extensor spasticity is due to limb flexion. During the operation of this program, the electric motor smoothly stops the rotation of the pedals. the muscles of the legs / arms relax, and after a short pause, a smooth change in the direction of rotation of the pedals occurs. This process is repeated until the cramping stops. Sessions of mechanotherapy on the trainer of MOTO - med help children with physical limitations to realize their natural necessity to motion.

Blood transfusions for treating acute chest syndrome in people with sickle cell disease.

Sickle cell disease is an inherited autosomal recessive blood condition and is one of the most prevalent genetic blood diseases worldwide. Acute chest syndrome is a frequent complication of sickle cell disease, as well as a major cause of morbidity and the greatest single cause of mortality in children with sickle cell disease. Standard treatment may include intravenous hydration, oxygen as treatment for hypoxia, antibiotics to treat the infectious cause and blood transfusions may be given. This is an update of a Cochrane Review first published in 2010 and updated in 2016. To assess the effectiveness of blood transfusions, simple and exchange, for treating acute chest syndrome by comparing improvement in symptoms and clinical outcomes against standard care. We searched The Cochrane Cystic Fibrosis and Genetic Disorders Group's Haemoglobinopathies Trials Register, which comprises references identified from comprehensive electronic database searches and handsearching of relevant journals and abstract books of conference proceedings. Date of the most recent search: 30 May 2019. Randomised controlled trials and quasi-randomised controlled trials comparing either simple or exchange transfusion versus standard care (no transfusion) in people with sickle cell disease suffering from acute chest syndrome. Both authors independently selected trials and assessed the risk of bias, no data could be extracted. One trial was eligible for inclusion in the review. While in the multicentre trial 237 people were enrolled (169 SCC, 42 SC, 15 Sβ⁰-thalassaemia, 11Sβ+-thalassaemia); the majority were recruited to an observational arm and only ten participants met the inclusion criteria for randomisation. Of these, four were randomised to the transfusion arm and received a single transfusion of 7 to 13 mL/kg packed red blood cells, and six were randomised to standard care. None of the four participants who received packed red blood cells developed acute chest syndrome, while 33% (two participants) developed acute chest syndrome in standard care arm. No data for any pre-defined outcomes were available. We found only one very small randomised controlled trial; this is not enough to make any reliable conclusion to support the use of blood transfusion. Whilst there appears to be some indication that chronic blood transfusion may play a roll in reducing the incidence of acute chest syndrome in people with sickle cell disease and albeit offering transfusions may be a widely accepted clinical practice, there is currently no reliable evidence to support or refute the perceived benefits of these as treatment options; very limited information about any of the potential harms associated with these interventions or indeed guidance that can be used to aid clinical decision making. Clinicians should therefore base any treatment decisions on a combination of; their clinical experience, individual circumstances and the unique characteristics and preferences of adequately informed people with sickle cell disease who are suffering with acute chest syndrome. This review highlights the need of further high quality research to provide reliable evidence for the effectiveness of these interventions for the relief of the symptoms of acute chest syndrome in people with sickle cell disease.

How do I perform whole blood exchange?

How do I perform whole blood exchange?

Hemodilution causes glycocalyx shedding without affecting vascular endothelial barrier permeability in rats

The consequences of acute normovolemic hemodilution (ANH) following different types of fluids on the different components of the glycocalyx and on vascular barrier permeability (VBP) remain unknown. The aim of the study was to investigate whether the microcirculatory disruption and glycocalyx shedding induced by ANH alters VBP and whether this is affected by the composition and volume of the resuscitation fluid. Anesthetized Wistar albino rats (n=24) underwent stepwise ANH at hematocrit levels of 35%, 25%, 20%, and 15% induced by the exchange of blood with 6% balanced hydroxyethyl starch (1:1), balanced crystalloid (1:3), and normal saline (NS) (1:3). Glycocalyx-shed products were measured at each level of hemodilution. VBP was reflected in the decay of fluorescence dyes of different molecular size and their plasma retention ratios. Edema was assessed by measuring organ water content and muscle microcirculation by hand-held videomicroscopy. NS caused increased degradation of heparan sulfate and hyaluronan compared with the control group (P=0.003, P=0.004, respectively). Neither VBP nor tissue edema was affected by the fluid used. The total and perfused vessel densities within the microcirculation of muscle tissue decreased at hematocrit 15% in the balanced crystalloid (P=0.02) and NS groups only (P<0.0001, P=0.0003, respectively) compared with baseline. Balanced colloid solution preserved the glycocalyx layer better than balanced and unbalanced crystalloid solutions while maintaining the microcirculatory function associated with an improved total intravascular volume. Among the fluids tested, NS caused the most microcirculatory alterations. While ANH caused the degradation of glycocalyx components regardless of fluid, it did not disrupt the vascular barrier as indicated by macromolecular leakage. The results of this study provide insight into the choice of fluid for optimal perioperative fluid management and the consequences of fluid type on the vascular barrier, glycocalyx, and microcirculation.

The clinical characteristics and prognosis of pertussis among unvaccinated infants in pediatric intensive care unit

Aim:To evaluate the clinical characteristics, risk factors, and prognosis of pertussis in the pediatric intensive care unit.Material and Methods:Patients who were hospitalized in pediatric intensive care unit between January 2017 and January 2019 and diagnosed as having pertussis were retrospectively evaluated. Samples were taken from tracheal aspirate material in intubated patients and nasopharyngeal swabs in the other patients. Samples for Bordetella pertussis were studied using multiplex real-time polymerase chain reaction.Results:Eighteen patients were admitted to our pediatric intensive care unit with a diagnosis of pertussis. Ten patients were female (55.5%), and all patients were unvaccinated. The median age was 40 (range, 38–47.5) days and the median intensive care unit stay was 9 (range, 5–14) days. All patients had respiratory distress, 14 patients had cough (77.7%), four patients had fever (22.2%), and three patients had convulsions (16.6%). Seven patients were intubated. Three patients died of multiple organ failure and cardiogenic shock despite extracorporeal treatment. Respiratory syncytial virus was found in two patients and rhinovirus was found in one patient. The median leukocyte count was significantly higher in non-survivors than in survivors. Blood exchange was performed in three patients due to hyperleukocytosis. Pulmonary hypertension was the most common cardiac pathology detected in echocardiographic examinations.Conclusion:We found that high leukocyte count, viral co-infection, and severe pulmonary hypertension were associated with mortality and morbidity in pertussis.

Serial Arterial Lactate Clearance and Outcome in Patients with Cardio-respiratory Insufficiency Presenting in Emergency Ward at Tertiary Level Hospital

Introduction: Acute cardio-respiratory failure is one of the acute common problems encountered in emergency and which required immediately intervention. It creates an imbalance between energy supply, demand, and consumption. Earlier lactate clearance should be useful to identify patient able to reverse the metabolic derangement and failure to rapidly resolve the oxygen debt, indicated by poor lactate clearance, would be correlated with negative outcome. For this purpose lactate clearance at 2 hour is more useful. Methods: This was a prospective study conducted at B. P. Koirala Institute of Health Sciences, Dharan, Nepal. Preliminary diagnosis was made according to clinical history, physical examination, arterial blood gas and chest radio graph. A national emergency warning system was used for patient evaluation. Gas exchange and lactate blood concentration was assessed at Emergency ward at arrival, 2 & 6 hr. Two-hour lactate clearance was calculated as (Lactate start − lactate 2 hour)/lactate start (%). Blood gas-analysis and arterial lactate was performed by intermittent blood sampling and co-oximetry. Results: Out of 74 patients the COPD was the most common co-morbidity condition (25.7%), followed by congestive heart failure (18.9%). Comprising of lactate clearance at two hours and the lactate clearance at six hours, the lactate clearance at two hours and its outcomes was more significant (P=0.001, OR=10.133) than lactate clearance at six hours (P=0.213). Conclusions: Early lactate clearance was associated with positive outcome rather than late clearance.

Bulk transfer of blood and its component: A single-center experience after 2 years of its implementation

Background and Objectives: BTS in India is highly decentralized and lack many vital resources. National blood policy also depicted safe and adequate blood supply. An Important initiative that can lead to increased efficiency of blood transfusion services (BTS) in our country namely bulk transfer of blood permitting the exchange of blood among licensed blood bank was taken by NACO in the year 2015. In this study we tried to understand the impact of bulk transfer policy in bridging the gap between demand and supply and also prevent the wastages of precious blood resources. Material and Methods: Retrospective analysis of demand-supply of PCV and PC was done for the year 2016-2017. The same done again after implementation of bulk transfer policy for the year 2017-2018 just starting phase (few blood banks adopted) and for the year 2018-2019 after many blood banks taken up bulk transfer. Results: Before implementation of bulk transfer policy only 54.63% patients got red cell concentrate for transfusion and 38.35% patients got platelet concentrate. Supply increases to 68.31% and 69.41% respectively and hence reduces the wastage. Conclusion: Bulk transfer amendment is of great help to prevent wastages of precious blood resources, and hence can win the trust of society and increase voluntary blood donation.

Clinical and laboratory parameters, risk factors predisposing to the development of priapism in sickle cell patients.

Although sickle cell disease is very common in Oman, priapism is a relatively rare complication of this disease. This study was aimed to identify the clinical and laboratory risk factors that predispose sickle cell disease patients to priapism. In a retrospective, case-control study, data on 21 male sickle cell disease patients, with priapism, were compared to 20 age and sex-matched sickle cell disease patients without priapism from the hospital medical records. Specifically, the demographical, hematological, biochemical, and clinical parameters including complications attributable to priapism were studied. Means for continuous measures and independent t-test were used to evaluate the association between the parameter studied and the occurrence of priapism. Priapism occurrence was associated with low basal hemoglobin (Hb), along with an increase in other parameters such as white blood cell count (WBC) ( P = 0.010), platelet count ( P = 0.001), reticulocyte count ( P &lt; 0.001), mean corpuscular volume (MCV) ( P &lt; 0.001), and mean corpuscular hemoglobin (MCH) ( P &lt; 0.001). Biochemical laboratory parameters revealed an association with an increased total bilirubin ( P &lt; 0.001). Patients with priapism were more likely to have acute chest syndrome, stroke, pulmonary hypertension, asplenia ( P = 0.006), gallbladder stones, and consequently cholecystectomy. Blood exchange and Penile aspiration were the most frequent medical therapies ( P = 0.010 and P &lt; 0.001 respectively). Patients with sickle cell disease who presented with priapism were young adults with low Hb, high WBC’s, platelets, reticulocytes, MCV, MCH, bilirubin, and LDH. These findings suggest an association of priapism with increased hemolysis. Impact statement Sickle cell disease is prevalent throughout the world with a 5.8% incidence of sickle cell trait among the Omani population, yet priapism was a relatively rare complication. Penile erection and detumescence are complex physiological processes, which require a delicate neurohormonal and cardiovascular response. In this cohort, young SCD patients developed priapism with a low incidence of complications. These patients had high WBCs, platelets, bilirubin, LDH, and reticulocytes with low hemoglobin as compared to controls, suggesting an increased hemolytic process. Favorable outcome was dependent on early intervention, with almost half of these patients needing surgical intervention.