Sacrococcygeal teratomas (SCT), although rare, are the most common teratomas found in neonates. Anesthetic management of neonates undergoing SCT resection surgery is challenging, given the risk of massive hemorrhage and high mortality rate. The primary aim of this single center retrospective study was to analyze neonates undergoing SCT resection over the last decade and report on perioperative outcomes, including blood product transfusion practices. The secondary aim was to describe patient and tumor characteristics that might place neonates undergoing SCT resection surgery at elevated risk for morbidity and mortality. Retrospective chart review of neonates who underwent sacrococcygeal teratoma resection at Boston Children's Hospital between January 2012 and April 2024. Demographic data, tumor characteristics, transfusion data, perioperative respiratory and hemodynamic data, and 30-day outcomes were collected. Descriptive statistics for patient and tumor characteristics are reported. Univariate analyses using Fisher's exact test and the Wilcoxon rank sum test were used for analysis of transfusion data and clinically significant postoperative events. Seventeen patients were identified. The median age at the time of surgery was day of life 4 with a median weight of 3.3 kg. Thirty-nine percent of neonates experienced a clinically significant postoperative event within 30 days of surgery, defined as a composite outcome event. One patient died within 30 days of surgery. Fifty-nine percent of neonates received an intraoperative blood transfusion. The median transfusion volume of RBCs was 24.8 mL/kg (0, 43). Those transfused had a larger median tumor volume [947.3 cm3 (interquartile range: 354.2, 2048)] and tumor volume-to-weight ratio [0.31 (0.10, 0.77)] compared to those who were not transfused [48.6 cm3 (24.2, 367.5)] and [0.02 (0.01, 0.07)] respectively. The median duration of anesthesia in transfused patients was 7.8 h (6.4, 9.2) versus 5.8 h (3.7, 6.7) in patients not transfused. Although more neonates with non-cystic tumors got transfused (70% vs. 30%), there was no statistically significant difference in median volume of red blood cells transfused intraoperatively for cystic [28.1 mL/kg (0, 40)] versus non-cystic tumors [24.8 mL/kg (0, 60)]. Neonates undergoing SCT surgery had a high rate of blood transfusion (59%), replacing on average over a quarter of their blood volume, and a high composite adverse outcome rate (39%). Predictors of blood product transfusion include immature tumors, gestational age less than 37 weeks, larger median tumor volume, greater tumor volume-to-weight ratio, higher intraoperative estimated blood loss, and longer time under anesthesia. Predictors of clinically significant postoperative events within 30 days of surgery include Altman type 2 tumors, gestational age less than 37 weeks, and longer anesthesia times.

This study identifies and characterizes the novel compound heterozygous mutations in the KNG1 gene responsible for severe high molecular weight kininogen (HMWK) deficiency in a 3-year-old Chinese boy. The proband was identified during preoperative screening due to an isolated, prolonged activated partial thromboplastin time (APTT) without bleeding symptoms. Coagulation profiles, including thromboelastography (TEG), were analyzed. HMWK antigen (HMWK:Ag) levels were quantified by ELISA. Genetic analysis was performed using whole-exome and Sanger sequencing of the KNG1 gene in the proband and his parents. The pathogenicity of the novel variant was assessed according to ACMG/AMP guidelines. Coagulation tests revealed a significantly prolonged APTT and a delayed R time on TEG, which was not corrected with extended incubation. HMWK:Ag levels were severely reduced (1.7 μg/ml) in the proband. Genetic analysis identified compound heterozygous mutations in KNG1: a novel missense variant in exon 5 (c.611C>T, p.Thr204Met) and a known nonsense variant in exon 6 (c.718C>T, p.Arg240*). Bioinformatic tools predicted the p.Thr204Met variant to be deleterious, and it was classified as "Likely Pathogenic." The mutations were inherited in trans, confirming the genetic basis of the HMWK deficiency. We report a novel compound heterozygous mutation (c.611C>T and c.718C>T) in the KNG1 gene causing severe HMWK deficiency. This case expands the mutational spectrum of this ultra-rare disorder and highlights that its primary clinical significance is an isolated APTT prolongation without a bleeding diathesis. Genetic diagnosis is crucial to avoid unnecessary treatments, surgical delays, and exposure to blood products in such patients.

Development of an optimal maximum surgical blood ordering schedule to achieve a prespecified crossmatch-to-transfusion ratio.

The safety and efficacy of peripartum transfusion support depends on a comprehensive risk analysis, the provision of substantiated criteria for ordering blood products, and surveillance of outcomes over time. We aimed to determine bleeding frequencies and volumes of blood loss, associated patient risk factors, and the effectiveness of our transfusion support scheme. Birth records of 12,255 pregnant women who gave birth at our hospital were screened for haemorrhage volumes, mode of delivery, bleeding aetiology, accompanying risk factors as well as outcome. Transfusion related data was extracted from the electronic blood product database. A total of 204 (1.6 %) women who gave birth within the 5-year study period received at least one RBC transfusion within 48 h after delivery. Differences in haemorrhage volumes in all women compared to those receiving RBC transfusion confirmed an increased probability of RBC transfusion with larger haemorrhage volumes. Uterus atony bleeding (UAB) was the most common cause associated with transfusions. Six risk factors for RBC transfusion among transfused patients were identified that showed a probability of >10 %: Adherent placenta (31.4 %), preterm rupture of membranes (PROM) (25.5 %), age over 35 (25.0 %), a previous caesarean section (19.6 %), gestational diabetes mellitus (15.2 %), and a twin pregnancy (11.8 %). An overall crossmatch-to-transfusion (C/T) ratio of 2.75:1 was reached and no patient with major haemorrhage-related morbidity or mortality was recorded. Evaluation of peripartum haemorrhage and associated RBC transfusion using the described methodology revealed RBC transfusions in 1.6 % of all women who gave birth within the study period. The described blood ordering scheme demonstrates a safe and efficient utilisation of blood products.

By age three, 5%-75% of children have a documented antibiotic allergy (AL). Despite this prevalence, recognition remains low because of limited clinician knowledge and time. Our study evaluates a novel approach to identifying AL using electronic medical record (EMR) prescription patterns. An EMR report was developed to identify paediatric encounters where adrenaline and/or an antihistamine was administered within 48 h of the last antibiotic dose. The first 100 cases were reviewed to refine exclusion criteria. Exclusions included diagnoses of eczema, or rash; antihistamine/adrenaline given before antibiotic initiation; adrenaline infusion; and antihistamines given after opioids or before blood products or monoclonal antibodies. Case notes from the cohort (2016-2023) were reviewed for suspected AL. The EMR report identified 342 children, with 67 (20%) assessed as having a possible/probable AL. Of these, 38 (57%) had a documented allergy, whereas 29 (43%) were newly identified. Implicated antimicrobials were ceftriaxone (34%), flucloxacillin (19%) and amoxicillin ± clavulanic acid (18%). Immediate-severe reactions accounted for eight cases (12%), including anaphylaxis (9%), angioedema (1%) and respiratory distress (1%). Most reactions (82%) were nonimmediate, nonsevere reactions. One case (1%) was a nonimmediate, severe, serum-sickness-like reaction. Of the 29 newly identified cases, six (21%) were considered too high of a risk to undergo antibiotic challenge, and three (13%) had a positive challenge result. This is the first study using EMR prescription patterns to identify AL in children. One in five children had a potential AL. This method could complement existing allergy identification practices.

The survival rate of extremely preterm infants (< 28weeks of gestation) has substantially improved over the past decades. The earlier an infant is born, the more likely anesthesiological care becomes necessary (62% < 28weeks gestation vs.6% in term infants). Anesthesiologists are therefore increasingly involved in the management of this highly vulnerable population of neonates and preterm infants. Intraoperative events requiring intervention, such as hypotension, hypoxemia and anemia, are frequently found, occurring in up to 70% of infants younger than 32weeks postmenstrual age and markedly increase morbidity and mortality, particularly when they occur in combination. This article reviews the current literature on three outcome-relevant domains in the anesthesiological management of neonates and preterm infants: hemodynamic management, ventilation strategies and transfusion of cellular blood products and outlines approaches by which clinical outcomes can be improved.

Intensive treatment regimens for hematologic malignancies often lead to prolonged hospitalizations, strained inpatient resources, and reduced quality of life. Standard outpatient clinic models are frequently unable to support early discharge for these high-acuity patients. To address this local care-delivery gap, Northwell Health established New York State's first Early Discharge Clinic (EDC). We herein describe EDC operationalization and initial outcomes and compare the average hospital length of stay (ALOS) with historical Northwell Health's EDC for Hematologic Malignancies controls. This quality improvement initiative proposed a structured EDC for patients with hematologic malignancies enrolled in 2023 and 2024. Eligible patients were identified during inpatient admissions and selected for early discharge based on clinical stability, supportive care needs, and logistical readiness for frequent outpatient follow-up. The EDC incorporated nine operational pillars supporting high-acuity outpatient care. Performance measures were selected to assess utilization (visit frequency, blood product utilization), timeliness of supportive care (time to antibiotic administration), safety (nonscheduled readmissions within 48 hours and 7 days after discharge, mortality), and efficiency (ALOS). The program accrued 191 enrollments from 112 unique individuals. Patients received a median of five structured evaluations, and most required blood product support. Neutropenic fever occurred in 36 of 191 enrollments; the median time to antimicrobial administration was 46 minutes (range, 6-131 minutes). There were no unplanned readmissions within 48 hours of discharge, and 11 within 7 days. No outpatient mortality occurred. EDC implementation reduced ALOS by 10.2 days, corresponding to a 39.7% reduction (P = .00025). The EDC demonstrated a safe and effective model for early outpatient management of selected patients undergoing therapy for hematologic malignancies. These findings support the EDC as a practical framework for improving efficiency and reducing hospitalization while maintaining timely high-acuity care.

Blood transfusion before arrival at a hospital reduces mortality from traumatic hemorrhage and shock. Whether transfusion with whole blood is more beneficial than transfusion with blood components is uncertain, as are the effects of the length of time that blood products are in storage between donation and transfusion. In this pragmatic, multicenter, phase 3, cluster-randomized trial, we assigned 44 air medical bases in a 2:1 ratio to the use of up to 2 units of whole blood or as-indicated blood components (plasma, red cells, or both) for prehospital transfusion in trauma patients during 1-month blocks. The primary outcome was death from any cause within 30 days after randomization. An observational substudy assessed outcomes according to the storage age of whole blood. Of 1020 eligible patients transported to hospitals by the air bases, 715 were assigned to receive whole blood and 305 to receive blood components; 695 and 298, respectively, were included in the primary analysis. Mortality at 30 days was 25.9% in the whole-blood group and 20.5% in the component group (adjusted odds ratio, 1.24; 95% confidence interval [CI], 0.87 to 1.76; P = 0.24). No substantial between-group differences in adverse events were observed. In the observational substudy, 30-day mortality was 27.1% among 210 patients who received whole blood with a storage age of 15 to 21 days and 26.4% among 443 patients who received whole blood with a storage age of 1 to 14 days (adjusted odds ratio, 0.99; 95% CI, 0.74 to 1.32). In injured patients with hemorrhagic shock, the use of whole blood for prehospital transfusion did not result in lower 30-day mortality than the use of blood components. (Funded by the Congressionally Directed Medical Research Programs and the U.S. Army Medical Research Acquisition Activity; TOWAR ClinicalTrials.gov number, NCT04684719.).

BackgroundMassive transfusion (MT) protocols improve survival in trauma patients. Elderly trauma patients requiring MT represent a high-risk population, yet outcome data remain limited. Understanding age-related differences is critical to guide resuscitation and resource allocation.ObjectiveTo characterize the association between MT and mortality in elderly vs younger trauma patients.ParticipantsTrauma patients at a Level I trauma center (1/2013-09/2024) who required MT (≥10 units of whole blood (WB) and/or packed red blood cells (pRBC) within 24h) were included. Patients ≥65 (elderly) were compared to <65 (non-elderly). The primary outcome was 30-day mortality. Secondary outcomes included ICU and hospital length of stay (LOS), and ventilator days.ResultsOf 368 patients meeting inclusion criteria, 30 (8%) were elderly. Elderly patients were equally likely to be male (70% vs 83%, P = 0.06), but were significantly less likely to present with GCS ≤8 (20% vs 45%, P < 0.01) despite a significantly higher incidence of severe head trauma (AIS head >3 [53% vs 32%, P = 0.02]). There was no difference in median blood products transfused within the first 24 hours (23 vs 22 units, P = 0.95). Overall mortality was 51%, higher in elderly patients (73% vs 49%, P < 0.01), with shorter time to death (median 14 vs 34days, P < 0.01). Adjusted Cox regression confirmed significantly higher adjusted mortality in the elderly (HR 1.25, P = 0.04).ConclusionElderly trauma patients requiring MT experience earlier and significantly higher mortality than younger patients, highlighting the need for improved risk stratification and tailored resuscitation strategies.

BackgroundRepeated blood product ordering is associated with order entry errors and potential patient harm. Traditional electronic health record order sets require repeated re-entry for recurrent transfusions, creating inefficiencies and opportunities for error, and contributing to physician burnout. Historically, we have used order sets to order blood products, which must be re-entered each time a transfusion is needed. Reusable transfusion therapy plans may address these challenges by standardizing and streamlining transfusion workflows. We conducted a pre-post study at a single pediatric academic center, evaluating the implementation of reusable transfusion therapy plans for packed red blood cells and platelets in oncology patients and those undergoing hematopoietic stem cell transplantation.ObjectiveThe primary outcome was to evaluate the proportion of transfusions originating from the transfusion therapy plans during the postimplementation period. Secondary outcomes included evaluating (1) the proportion of eligible patients with applied transfusion therapy plans, (2) changes in transfusion efficiency (time from laboratory result to transfusion release and administration, premedication timing, and estimated overnight pages), and (3) the impact on safety (guideline-concordant dosing, irradiated product ordering, and transfusion thresholds). We also assessed health care practitioner experience using an adaptation of the technology acceptance model survey.MethodsThe prestudy period consisted of the 1-year preimplementation, and the postperiod consisted of the 1-year post implementation. We used our institution’s enterprise data warehouse (SickKids Enterprise-Wide Data in Azure Repository) to obtain demographic and transfusion details for all eligible patients. The adapted technology acceptance model survey was administered to eligible oncology clinicians.ResultsThe preimplementation cohort had 558 unique patients who received a total of 2678 transfusions. The postimplementation cohort had 521 unique patients who received 2777 transfusions. During the postimplementation period, 59% of transfusion orders originated from a therapy plan, increasing to 71% in the final month. Compared with order sets, therapy plan–derived transfusions were released and administered significantly faster following laboratory results (P<.001). Guideline-concordant transfusion volumes increased significantly postimplementation for both packed red blood cells and platelets (P<.001), as did the ordering of irradiated blood products (P<.001). No differences were observed in pretransfusion hemoglobin or platelet thresholds between study periods. Use of therapy plans was associated with an average avoidance of 4 overnight blood product entries per night. Survey responses from nurses and providers demonstrated high perceived usefulness and ease of use, with 95% endorsing continued use.ConclusionsReusable transfusion therapy plans improved efficiency, standardized safe ordering practices, and were highly acceptable to clinicians. This longitudinal, noninterruptive electronic health record intervention represents a scalable approach to supporting high-risk transfusion workflows in pediatric oncology.

Inaccurate blood product ordering can have a negative impact on patient care by leading to delays in transfusion initiation and inadequate use of hospital resources. The pediatric hematology/oncology patient population is at an increased risk of blood product ordering errors due to the numerous modifications, weight-based dosing, and special processing that are often required to keep transfusions safe. Our SMART Aim was to decrease the percentage of incorrectly ordered blood products at our center by 50% over a 9-month time period. At baseline, we found that there was a 60% median error rate in blood product ordering. The most common error in blood product ordering at our institution was the utilization of cytomegalovirus-negative blood products when it was not required institutionally due to our standardized leukoreduction process. Educating providers on the blood product ordering process, appropriate modifications required for a given clinical scenario, and weight-based dosing was associated with a reduction in the median percentage of incorrectly ordered blood products to 30% over the course of the project. In the future, we plan to implement improvements in blood product ordering across the entirety of the children's hospital at our institution.

Rotational thromboelastometry (ROTEM) provides rapid, point-of-care coagulation data. However, the specific effect of its use for coagulopathy management on blood component transfusions during severe postpartum hemorrhage remains undetermined. We aimed to assess whether the use of ROTEM was associated with reduced administration of hemostatic blood products and blood transfusions in women with postpartum hemorrhage ≥1000 mL. In this single-center retrospective pre-post matched study, administration of hemostatic blood products and packed red blood cells was compared in two groups of adult patients with postpartum hemorrhage ≥1000 mL. The Control group consisted of patients managed empirically or based on laboratory results between 2016 and 2018. The ROTEM group consisted of patients managed using a ROTEM-guided coagulopathy protocol between 2021 and 2023. Exact matching was applied for qualitative variables, and propensity score matching was used for quantitative variables. A 1:1 matching procedure was performed using 14 confounders. Odds ratios were estimated using conditional logistic regression. After matching, 102 patients were included in each group. ROTEM use was associated with significantly lower transfusion rates of any hemostatic blood product (25% vs. 38%; OR: 0.46 [95% CI: 0.22 to 0.94]), fibrinogen concentrates (25% vs. 37%; OR: 0.48 [95% CI: 0.23-0.98]), fresh frozen plasma (3% vs. 17%; OR: 0.13 [95% CI: 0.03-0.54], and packed red blood cells (29% vs. 49%; OR: 0.38 [95% CI: 0.19-0.73]). The use of ROTEM to manage hemostatic impairment in postpartum hemorrhage ≥1000 mL was associated with a significant reduction in the transfusion of hemostatic blood products and red blood cells.

Infants with early drug-resistant epilepsy caused by hemimegalencephaly (HME) and hemispheric cortical dysplasia (HCD) pose substantial surgical and critical care challenges and have poor seizure outcome prognosis. This study evaluated the safety, complications, and seizure outcomes of hemispheric surgeries in infants younger than 12 months with HME and HCD. A retrospective analysis included patients younger than 12 months who underwent functional hemispherectomy or hemispherotomy, between 2005 and 2024, at a national epilepsy surgery referral center. Data included demographics, medical history, age at seizure onset and surgery, duration of surgery, intubation and intensive care unit stay duration, blood product requirements, and perioperative and long-term complications. Seizure outcomes were assessed by Engel classification. Fifteen infants (7 male, 8 female) with HME (13) or HCD (2) were analyzed. Median seizure onset was 3 days (interquartile range [IQR] 1.5-8.5), with all experiencing multiple daily seizures. Patients underwent surgery at a median age of 6.4 months (IQR 4.7-9.1) and with a median body weight of 7200 g (IQR 6900-8560; minimum 6400 g; percentiles 2-91). All infants received intraoperative blood transfusions (median 44.8 mL/kg, IQR 23.8-71.5); total blood requirement was 57.3 mL/kg (range 17.5-239.1). One-third (5/15) required more than one circulating volume. No mortalities occurred. Major complications included intracerebral bleeding (2/15, 13.3%) and intraoperative cardiac arrest (1/15, 6.7%). Frequent adverse events included prolonged postoperative intensive care stay of more than 5 days (6/15, 40%) and shunt placement for postoperative hydrocephalus (4/15, 26.7%). Engel class I outcome at 12-month follow-up was achieved in 8 of 15 (53.3%) overall and in 6 of 13 (46%) of HME cases. Hemispheric surgery within the first year of life in patients with HME and HCD is feasible but demanding, with substantial perioperative risk. Seizure-freedom rates in HME are favorable, but lower than in other etiologies. Multidisciplinary management remains crucial for optimal outcomes.

Adequate blood supply remains a challenge in sub-Saharan Africa (SSA). Malawi has a 13% shortfall in required blood supplies. Innovative recruitment and retention strategies are crucial to ensuring a sufficient number of donors and blood supply. We explored alternative approaches to enhance blood donation in Malawi to bridge the gap. A qualitative exploratory design was utilised with a sample of 135 participants purposively selected in eight districts, in the Northern, Central, Southern and Eastern regions of Malawi. Data were collected using in-depth interviews with 20 participants (first-time and repeat donors, lapsed and non-donors), 20 key informant interviews with community, policy-level stakeholders, Malawi Blood Transfusion Service (MBTS) staff and 16 focus group discussions (involving 95 participants). Thematic content analysis was used to categorise the strategies, and a qualitative software data package (NVivo version 12) was used to organise the qualitative data. Donor education emerged as a key strategy for donor recruitment and retention. Other strategies included the formation of blood donor clubs in secondary schools and for post-secondary students, accountability mechanisms related to blood: its collection and management of blood and blood products, the provision of incentives and youth-friendly motivation strategies, including school competitions (quizzes and sports) and entertainment. The study emphasised the significance of blood donor education in encouraging blood donation. Participants' views suggest that developing innovative approaches for education to increase awareness and understanding of blood-donation processes may help motivate more individuals to donate. In addition, participants suggested other youth-friendly approaches to support blood donor recruitment, including providing incentives preferred by young people, introducing intra-school competitions and incorporating entertainment activities. These insights point to the potential value of developing innovative strategies to support blood donor recruitment efforts.

Existing evidence on transfusion requirements in oral and maxillofacial surgery (OMFS) is limited to selected indications. This study aimed to provide an overview of transfusion rates across the full diagnostic spectrum and to identify factors influencing transfusion rates with relevance for patient blood management (PBM). All operated OMFS patients from a five-year period (n = 13,239) were retrospectively analyzed. Diagnosis-specific transfusion rates were determined, followed by a subgroup analysis of free flap surgeries. Logistic regressions identified factors influencing transfusion rates. ROC analysis in the free flap subgroup determined preoperative hemoglobin cut-off values for increased transfusion risk. Differences in treatment course associated with preoperative anemia were assessed. Overall transfusion rate was 5.1%. Microvascular free flap surgery was the primary driver of transfusion with a rate of 58.8%, independent of underlying pathologies. Non-oncologic indications requiring free flap reconstruction showed high transfusion rates similar to oncologic indications, whereas the same diagnoses without free flaps had rates < 5%. Free flap reconstruction (OR 5.21) and preoperative anemia (OR 6.25) were the strongest factors influencing transfusion rates. ROC analysis identified preoperative hemoglobin of 12.25g/dl as risk threshold for intraoperative transfusion. Preoperative anemia was associated with a less favorable course regarding intensive care unit treatment, in-hospital mortality and hospital length of stay. Transfusion rates in OMFS are generally low but increased in reconstructive free flap surgery. These findings offer an evidence base for targeted PBM strategies, including early identification and treatment of preoperative anemia, like intravenous iron therapy in free flap patients, and transfusion rate-adapted blood product preparation to improve perioperative management.

Kawasaki disease (KD) is an acute febrile systemic vasculitis of unknown etiology and the leading cause of acquired heart disease among children. Complement activation has long been observed in patients with acute KD, however, its contribution to disease development remains unknown. Here, using publicly available datasets, we showed that patients with acute KD exhibited higher expression of complement products in whole blood, consistent with the activation of the complement pathway. Similarly, in the Lactobacillus casei cell wall extract (LCWE) murine model of KD, LCWE injection induced increased expression of complement products in cardiovascular tissues, suggestive of activation of the complement pathways. C3-deficient mice or WT mice treated with the complement C5a Receptor 1 (C5ar1) antagonist developed significantly more severe LCWE-induced cardiovascular lesions and vasculitis. Furthermore, we observed that LCWE binds to serum C3, an opsonizing factor that labels microbial targets for clearance, and LCWE deposition in the liver was significantly higher in C3-deficient mice compared to WT mice. Overall, our data indicate that blocking the complement system significantly exacerbates LCWE-induced KD vasculitis, likely by impairing C3-mediated clearance of LCWE. These data suggest that the complement pathway may play a protective role in KD pathogenesis by promoting clearance of potential bacterial or viral trigger of KD.

Post-transfusion purpura is a rare complication characterised by paradoxical destruction of autologous platelets 5-10 days after transfusion of cellular blood products. A middle-aged multiparous woman presented with mucocutaneous bleeding and severe thrombocytopenia seven days after aorta graft surgery and platelet transfusion. Initial treatment with steroids and intravenous immunoglobulin was ineffective. Platelet antibody testing showed anti-HPA-1a at a very high level of >600 IU/mL, weak anti-HPA-3a and platelet auto-reactivity. Weakly reactive anti-HLA class I antibodies were also observed. The patient's platelet type was HPA-1bb/HPA-3bb. A diagnosis of post-transfusion purpura was therefore made. Additional treatment with plasma exchange was initiated, resulting in rapidly rising platelet counts, resolution of bleeding symptoms and decreasing antibody levels. Sustained normal platelet counts were achieved on day 50 after the initiating event. This case represents a classic presentation of post-transfusion purpura, with high levels of anti-HPA-1a and severe thrombocytopenia with bleeding one week after transfusion, successfully treated with a combination of plasma exchange and intravenous immunoglobulin. Direct platelet antibody testing was positive during the thrombocytopenic phase and became negative following normalisation of the platelet count. This correlation between autoreactivity and thrombocytopenia supports the hypothesis of a secondary autoreactive process trigged by an HPA-incompatible transfusion.

To investigate the value of applying preoperative magnetic resonance imaging (MRI)-based arterial enhancement ratio (AER) map to habitat analysis for predicting transarterial chemoembolization (TACE) refractoriness in patients with unresectable hepatocellular carcinoma (HCC). 176 patients with unresectable HCC who underwent preoperative contrast-enhanced MRI and received consecutive TACE treatments were randomly allocated to a training cohort (n = 124) and a validation cohort (n = 52). A dual-mode encoding strategy (mode 1: based on T1-pre; mode 2: based on T1-pre with the AER map) was employed to define tumor habitats. Signal intensity, entropy, and volume fraction were quantified for each habitat. Combined with laboratory findings and imaging features, logistic regression analyses were performed to identify independent risk factors for TACE refractoriness and a predictive model was constructed. The performance of the model was evaluated using the area under the receiver operating characteristic curve (AUC). Each tumor lesion was segmented into 5 habitats using mode 1 and 3 habitats using mode 2. Regression analysis identified Barcelona Clinic Liver Cancer stage (OR = 2.099, P = 0.027), blood products in mass (OR = 11.063, P = 0.028), and AER entropy value of habitat 2 derived from mode 2 (OR = 4.586, P = 0.033) as independent factors for predicting TACE refractoriness. AUC value of the nomogram on validation cohort was 0.721 (95% CI = 0.577-0.866). Calibration curve demonstrated favorable clinical applicability of the model. Incorporation of the AER map into habitat analysis enables preoperative prediction of TACE refractoriness risk in patients with unresectable HCC. Not applicable.

Background and objectives Sepsis remains a leading cause of mortality among children worldwide. This study aimed to describe clinical profile, intensive care needs, outcome, and predictors of mortality among children with severe sepsis. Methods This secondary analysis of FerriPedS study was conducted in a tertiary pediatric intensive care units (PICU) in North India involving 115 children (3 months-12 yr) with severe sepsis. Data were collected regarding clinical details, laboratory investigations, organ dysfunction, intensive care needs, and outcome. Univariate and multinomial logistic regression analyses were used to determine predictors of mortality among severity score, organ dysfunction, serum ferritin, and PICU needs. Results The median (IQR) age was 3 (1-7) years, and common diagnoses were community acquired pneumonia (CAP) (n=45 39.1%), scrub typhus (n=16, 13.9%), and CNS infections (n=12,10.4%). Mortality was 27.8% (n=32). Non-survivors had significantly higher Pediatric Risk of Mortality-III (PRISM III) score, serum ferritin, and daily Pediatric logistic organ dysfunction-2 (PeLOD-2) score. Higher proportion of non-survivors had positive blood culture at admission, coagulopathy, hepatic dysfunction, shock, acute respiratory distress (ARDS), acute kidney injury (AKI), and multiple organ dysfunction score (MODS); and required invasive mechanical ventilation, vasoactive drugs, blood products, and RRT. On multinomial logistic regression analysis, PRISM-III, ARDS, and AKI were independent predictors of mortality. Interpretation and conclusions In children with severe sepsis, the common etiologies included CAP, scrub typhus, and CNS infections, and characterised by high mortality (27.8%). PRISM-III score, ARDS, and AKI were independent predictors of mortality.

Postpartum hemorrhage (PPH) remains a leading cause of maternal morbidity and mortality. Little is known about transfusion practices in patients requiring blood tansfusions following cesarean delivery. The objective of this study is to describe the use of blood products, clotting factors, colloids, and antifibrinolytics in a contemporary cohort of patients with hemorrhage during cesarean and compare blood product use with a historic cohort of patients with a similar diagnosis. Secondary analysis of a multicenter trial of tranexamic acid versus placebo to prevent PPH during cesarean delivery. Patients with qualitative estimated intraoperative blood loss (EBL) of more than 1 L were included in this analysis. Variables analyzed included transfusion of blood products, ratio of transfused packed red blood cell (PRBC) to fresh frozen plasma (FFP) and platelets, and use of clotting factors, anti-fibrinolytics, and colloids. Transfusion strategies were also compared with a historic cohort from the APEX study. Of the 707 (7.7%) who had EBL of greater than 1 liter, packed red cells were transfused in 21.1%, FFP in 5.4%, platelets in 2.4%, and cryoprecipitate in 2.3%. Among patients who received both PRBC and FFP, three quarters had a PRBC:FFP ratio between 1:1 and 2:1. Patients receiving both PRBC and platelets had a 1:1 ratio or less in 76.5% of cases. Clotting factor concentrates were not used in any case. Albumin was administered in 10.2% of cases. When compared with the historic cohort with an EBL > 1 L during cesarean, no differences in the use of blood products was noted. 1 in 5 patients with intraoperative EBL > 1 L received PRBC transfusion. The use of other blood products was rare. There was no difference in transfusion strategies overtime when compared with a similar historic cohort. Obstetrical hemorrhage in patients undergoing cesarean delivery rarely involves intensive transfusion therapy. · A total of 21% of patients with hemorrhage during cesarean received packed red cells.. · Use of other blood products was rare.. · Pathological activation of the clotting cascade is unlikely.. · No difference in transfusion strategies was noted overtime..