Large Volumes Of Blood Research Articles

Management of PEG Site Gastric Ulcer in a Patient with Large Hiatus Hernia and Massive Hematemesis

We describe the management dilemmas in a 72 year old lady who presented with massive haemetemesis after reinsertion of a dislodged Percutaneous Endoscopic Gastrostomy (PEG) tube. She had a history of nasopharyngeal carcinoma with multiple recurrences, and underwent wide field radiation therapy, left radical neck dissection and a left nasopharyngectomy. The patient was on long term feeding via a 20-Fr PEG tube. A new PEG tube was inserted over the existing tract after initial dislodgement. The patient presented 2 days later with large volume hematemesis and blood clots. Both a therapeutic gastroscope and a standard gastroscope could not cross the tight upper esophageal sphincter (UES). A Paediatric gastroscope was eventually used. A large Forrest IIb gastric ulcer at the antrum opposite the tip of the PEG tube, where it abutted the gastric mucosa (Image 1). Therapeutic options were limited given the smaller working channel, and removal of the adherent blood clot and hemoclip application could not be performed. A total of 7ml of adrenaline was injected into the ulcer edges with haemostasis achieved. Subsequent imaging revealed a large hiatus hernia with the gastric corpus and fundus located in the thorax. This resulted in a very limited space in the antrum and pylorus for new PEG tube insertion. Nasogastric tube could not be passed for feeding due to the prior instrumentation of nasopharynx and tight UES. A suitable anatomical space for new PEG tube insertion could not be found even with fluoroscopic guidance. Moreover, re-insertion of another PEG tube via the same tract would re-expose the patient to bleeding and perforation risks as the tip could erode the same ulcer. The decision was made to insert a 20-Fr low profile PEG tube via existing tract with the tip placed in the duodenum to reduce risk of further ulceration in the tight antrum. This PEG tube was used for insufflation of the stomach for insertion of a new 20-Fr definitive PEG tube at a different anatomical site 3 weeks later when the patient was more stable. Our case describes the successful usage of low profile PEG reinsertion for both interim feeding and as an aid for definitive PEG tube re-siting in the presence of hostile anatomy and limited treatment options.Figure 1

Dynamic platelet function on von Willebrand factor is different in preterm neonates and full‐term neonates: changes in neonatal platelet function

Background Very low birth weight (VLBW) preterm neonates have an increased risk of hemorrhage-related morbidity and mortality as compared with their full-term counterparts. It is unclear whether platelet function differs between preterm and full-term neonates. This is partly because of the large volumes of blood required to perform standard platelet function tests, and the difficulty in obtaining such samples in neonates. Objectives This study was designed to characterize platelet behavior in neonates with a physiologic flow-based assay that quantifies platelet function in microliter volumes of blood under arterial shear. Methods Blood from VLBW preterm neonates of ≤ 32 weeks' gestation (n = 15) and full-term neonates (n = 13) was perfused under arterial shear over surface-immobilized von Willebrand factor (VWF). Platelet behavior was recorded by digital-image microscopy and analyzed. Surface expression of platelet glycoprotein (GP) Ibα and GPIIIa of VLBW preterm and full-term neonates was also measured. Results VLBW preterm neonates had increased numbers of platelets interacting with VWF, and increased GPIbα expression on the platelet surface. Despite the increased numbers of VWF interactions as reflected by flow-driven platelet translocation along the protein surface, no significant differences were observed in the numbers of platelets that adhered in a stationary fashion to VWF. Platelets from VLBW preterm neonates and those from full-term neonates behaved differently on VWF. Conclusions These differences in platelet function may contribute to the higher incidence of bleeding observed in VLBW preterm neonatal populations, or may represent a compensatory mechanism to counteract this risk of bleeding.

Impact of Operational Theater on Combat and Noncombat Trauma-Related Infections.

The Trauma Infectious Disease Outcomes Study began in June 2009 as combat operations were decreasing in Iraq and increasing in Afghanistan. Our analysis examines the rate of infections of wounded U.S. military personnel from operational theaters in Iraq and Afghanistan admitted to Landstuhl Regional Medical Center between June 2009 and December 2013 and transferred to a participating U.S. hospital. Infection risk factors were examined in a multivariate logistic regression analysis (expressed as odds ratios [OR]; 95% confidence intervals [CI]). The study population includes 524 wounded military personnel from Iraq and 4,766 from Afghanistan. The proportion of patients with at least one infection was 28% and 34% from the Iraq and Afghanistan theaters, respectively. The incidence density rate was 2.0 (per 100 person-days) for Iraq and 2.7 infections for Afghanistan. Independent risk factors included large-volume blood product transfusions (OR: 10.68; CI: 6.73-16.95), high Injury Severity Score (OR: 2.48; CI: 1.81-3.41), and improvised explosive device injury mechanism (OR: 1.84; CI: 1.35-2.49). Operational theater (OR: 1.32; CI: 0.87-1.99) was not a risk factor. The difference in infection rates between operational theaters is primarily a result of increased injury severity in Afghanistan from a higher proportion of blast-related trauma during the study period.

Faster rate of blood volume change in pediatric hemodialysis patients impairs cardiac index.

Intradialytic hypotension and myocardial stunning are proposed as contributing to the pathogenesis of increased cardiovascular disease burden and death in patients receiving maintenance hemodialysis (HD). Noninvasive cardiac output measurements provide a dynamic, real-time assessment of hemodynamic parameters. We investigated intradialytic changes in hemodynamic parameters in pediatric outpatients receiving chronic HD and determined patient and treatment risk factors associated with such intradialytic changes. Hemodialysis was performed using linear fluid removal over 4h with polysulfone dialyzers. Continuous wave Doppler ultrasound was used to measure hemodynamic parameters prior, 2h into, and after the mid-week HD treatment session. Pulse wave tonometry was performed at the same time. The percentage change in blood volume was measured by noninvasive hematocrit monitoring during HD. Twenty-two patients fit the inclusion criteria, of whom 16 (73%) were male. The mean age of the patients was 17 ± 3.8years, and the dialysis vintage was 47.8 ± 33.7months. The cardiac index decreased significantly midway through the HD treatment session and remained low until the end of treatment. A significant decline in cardiac index without hypotension occurred in 12 (54 %) patients. Expected increase in systemic vascular resistance index to preserve the cardiac index was not observed. Weight, percentage fluid overload, dialysis vintage, and adequacy did not correlate with the observed decline in the cardiac index. The decrease in blood volume at the 2h (R = 0.43, p = 0.045) and 4h (R = 0.56, p = 0.007) time points was the only factor associated with cardiac index decline. The cardiac index and stroke volume decreased significantly during the HD session. Patients with larger blood volume changes during the first 2h of HD and at 4 h showed a significant decrease in cardiac index that did not recover at the completion of the HD treatment. Rate of fluid removal was the only significant risk factor for compromised cardiac index during HD. Conventional methods currently used for assisting fluid removal in HD are inadequate to assess hemodynamic changes.

Abstract 3966: Effect of anticoagulant and sample storage conditions on circulating tumor cells enrichment by vortex

Abstract Background Circulating tumor cells (CTC) have recently emerged as powerful biomarkers for non-invasive diagnosis and prognosis of cancer [1]. The rarity and fragility of these cells has proven to be a significant impediment to their clinical use. Delay between phlebotomy and sample processing, together with blood sample storage, can impact the integrity of these cells and hamper their subsequent isolation. Addressing these issues could allow shipping between clinical facilities and significantly increase the use of CTCs. Here, we assessed the effects of various blood anticoagulants on the isolation of CTCs using Vortex technology. Vortex is a label-free, size-based technology that relies on the generation of laminar flow microvortices where CTCs can be trapped [2], and released off-chip, into a small volume compatible with various downstream assays. Methods To evaluate the effects of delayed processing on capture performances, samples from healthy donors were drawn into 4 different blood collection tubes (BCT): K3EDTA, ACD-B, CellSave and cell-free DNA Streck. Each BCT was spiked with MCF7 breast cancer cells and stored at room temperature for up to 3 days (72H). On days 0, 1, 2 and 3, aliquots of blood (0.5 ml; n = 3) from each BCT were diluted 10X and processed through Vortex chip. Captured cells were stained (CK, CD45, DAPI) and enumerated. Capture efficiency and purity were determined for each time point and BCT. To simulate over-sea shipping and processing of patient samples, larger blood volumes (6mL in EDTA, CellSave and Streck BCT) were also tested after 48H. Capture performances and device clogging were evaluated. Results Significant differences were observed for capture performances between the BCTs. Best results were obtained for CellSave tube, with an efficiency of 19.8 ± 2.5%, stable for up to 3 days, and a purity ranging from 40.6 to 52.8%. In comparison, performances for standard K3EDTA were maximal at 24H, with 19.1% efficiency decreasing to 10% at 72H. ACD-B and Streck showed lower efficiencies, reaching 4.6 and 9.7% respectively. Purity for EDTA, CellSave and Streck BCT was in a similar range (48.4, 46.5 and 34.9% respectively). No significant device clogging was observed between EDTA, CellSave and Streck BCT when larger blood volumes were processed. Conclusion Here we demonstrate the ability to isolate cancer cells spiked in blood for up to 48H post-phlebotomy, with higher overall performances obtained with CellSave tube. Standard EDTA BCT gives optimal performances up to 24H and would be the option to select whenever viable cells are required. This suggests that Vortex technology is compatible with various anticoagulants and preservatives containing blood collection tube; the election would depend on the assay performed downstream. Future work will include shipping blood samples from remote sites and effect on CTC enrichment by Vortex technology. [1] Ignatiadis et al. Clin Cancer Res 2015. [2] Sollier et al. Lab Chip 2014. Citation Format: Charles L. Wilkerson, Corinne M. Renier, Violet R. Hanft, Stefanie S. Jeffrey, Elodie Sollier. Effect of anticoagulant and sample storage conditions on circulating tumor cells enrichment by vortex. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr 3966.

A study of CT perfusion imaging before and after radiotherapy for solid lung cancer

Objective To analyze the perfusion status of lung cancer before radiotherapy and the relationship between changes in CT perfusion parameters after radiotherapy and the efficacy of radiotherapy. Methods Twenty-eight patients clinically and pathologically diagnosed with lung cancer were enrolled as subjects. Those patients received CT perfusion imaging scan and perfusion parameters including blood flow (BF), blood volume (BV), mean transit time (MTT), and permeability surface (PS) were calculated. We use linear correlation analysis for relation between value of CT perfusion imaging and the target volume of lung cancer before radiotherapy, t-test for difference between the remission groups and non-remission groups, compared paired sample t-test for value of CT perfusion imaging before and after radiotherapy. Results According to the efficacy of radiotherapy, 28 patients with lung cancer were divided into response group (n=16) and non-response group (n=12). The response group had significantly smaller tumor sizes before and after radiotherapy than the non-response group (58.72±22.95 cm3vs.24.53±13.79 cm3, P=0.000). However, there was no significant correlation of target volume before radiotherapy with any perfusion parameter (P=0.628). The response group had significantly larger BF and BV than the non-response group before radiotherapy (1.23±1.36 vs.6.42±2.57, P=0.024 and 1.23±0.31 vs.0.59±0.18, =0.041), suggesting a low perfusion state of tumor tissue in the non-response group. However, there were no significant differences in MTT and PS between the two groups (0.93±0.58 vs.0.93±0.66, P=0.851 and 1.46±0.83 vs.1.17±0.56, P=0.141). All the 28 patients had significantly smaller BF, BV, MTT, and PS after radiotherapy (9.81±3.56 vs.7.48±3.31, P=0.006; 0.96±0.41 vs.0.64±0.38, P=0.003; 0.93±0.60 vs.0.53±0.30, P=0.007; 1.34±0.73 vs.0.74±0.44, P=0.001). Conclusions CT perfusion imaging can predict the efficacy of radiotherapy for lung cancer, which may guide the planning and implementation of precise radiotherapy for lung cancer. Key words: Perfusion imaging; Blood flow; Lung neoplasms/radiotherapy

Abstract 369: Automating recovery of spiked tumor cells from blood

Abstract The isolation and study of circulating tumor cells (CTC) enables personalized medicine solutions, monitoring of therapeutics (theragnostics), and monitoring of minimal residual disease (MRD); culturing these rare cells is a frequent goal in cancer research, however the common methods for their isolation (gradient centrifugation, lysis buffer) are damaging to these cells, and many emerging technologies leave the cells bound in a consumable, bound to a biomarker or in a state that is difficult to use in cell culture. Further, the anuclear cells in blood greatly outnumber nucleated cells and present significant challenges to the study of the nucleated cells, for example, erythrocytes can absorb excitation or emission wavelengths in fluorescence studies, and their shape promotes rouleaux formation which can sequester the cells of interest; platelets also have a tendency to be activated by physical handling and cause aggregation that can also sequester and damage the cells of interest, and these all contain the greatest content of RNA and other markers that increase background noise in many assays. We demonstrate a new technology that automates the depletion of erythrocytes, thrombocytes, and plasma markers from, initially, small volumes of blood, using a micromachined membrane filter. We spiked small counts (10 to 1000 estimated from dilution) of tumor cell lines BT474 (breast cancer), DLD1 (colorectal cancer), and K562 (myelogenous leukemia) and other cell types into aliquots of blood. Using calcein-AM-loading to distinguish the spiked cells from blood cells, the recovery rates were determined in a flow cytometer, indicating an average of 80% ±4% (SE, N = 27) recovery of the rare cells after depletion of anuclear cells and plasma. The technology is amenable to use of beads for initial negative depletion of common nucleated cells by magnetic beads and has a recovery capacity of a few to as much as 3 million cells per specimen. Tumor cell lines alone that were run through this automation process then seeded for cell culture demonstrated growth rates indistinguishable from those seeded in similar counts in a regular cell passage. In further studies we demonstrate depletion of leukocytes with magnetic beads and of anuclear cells by filtration to handle larger blood volumes. The filtration system may be used for automated recovery of nucleated cells or cell clusters from blood or other fluid samples (liquid biopsies) without use of harsh chemicals or centrifugation, removing a common barrier for emerging analytical approaches. Citation Format: Mark Sarinana, Ky Truong, Keith Cannon, Antonio Guia. Automating recovery of spiked tumor cells from blood. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr 369.

Recommendations for Releasing the Pelvic Binder After a Non-Invasive Pelvic Stabilisation Procedure Under Emergency Room Conditions

Severe brain, thoracic and intrapelvic injuries, as well as heavy bleeding, are the main causes of death in patients with major trauma. Unstable pelvic ring fractures can cause this bleeding and the so-called "C problem". This is usually due to haemorrhagic shock caused by the loss of large volumes of blood from the presacral venous plexus, iliac vessels and the fracture surfaces. Many clinical studies have shown that, in the preclinical setting, unstable pelvic ring injuries are often underestimated. The application of a non-invasive external pelvic ring stabilisation (pelvic binder) is therefore recommended if a pelvic fracture is possible. Several circumferential pelvic binders have been developed and their prehospital use is increasing. Clinical and biomechanical studies have demonstrated that there is a favourable haemodynamic effect in unstable fractures, due to rapid closure of the pelvic ring. It is unclear whether the pelvic binder can be safely removed in a presumably haemodynamically stable patient. A correctly placed pelvic binder leads to anatomical closure of the pelvic ring. Therefore unstable pelvic ring fractures may be clinically and radiologically overlooked. This is a particular problem in unconscious patients. Furthermore, the real severity of the injury may then be underestimated in the diagnostic evaluation. Unconsidered opening of the pelvic binder can thus provoke renewed deterioration of the circulatory situation, especially if the injury was adequately treated by the binder and the C problem was controlled. The aim of this article is to describe procedures for handling pelvic binders, particularly as to how to deal with an already applied pelvic binder and how to "clear the pelvic region" while reducing the risk of haemodynamic instability. A detailed analysis of the literature and a Delphi-like discussion among several experts were performed. The following points were raised: 1) Assessment of the clinical situation, including trauma kinematics. 2) Assessment of the haemodynamic status. 3) Check of the need to open the pelvic binder for diagnostic/therapeutic measures before completing all diagnostic tests. 4) Assessment of the radiology diagnostic testing and release of the pelvic region. The result is a so-called "clear the pelvis algorithm" which describes a structured approach according to specific criteria and which specifies the circumstances under which the pelvic binder can be opened. Additional studies are necessary to analyse the applicability and safety of this algorithm in a clinical context. Our advice is not to "clear" the pelvis if no X-rays or CT scans of the pelvis have been carried out without (or with an opened) pelvic binder.

A Single Bout Of Exercise Enhances The Ex Vivo Manufacture Of Viral-specific T-cells

Cytomegalovirus (CMV) and Epstein-Barr virus (EBV) infections remain a major cause of morbidity and mortality after allogeneic hematopoietic stem cell transplantation (HSCT). The adoptive transfer of donor-derived viral-specific cytotoxic T-cells (CTLs) is an effective treatment for controlling CMV and EBV infections during HSCT. However, in many instances, the time taken to manufacture adequate numbers of CTLs from healthy donors is too long and requires the collection of large and impractical blood volumes. PURPOSE: To determine if a single exercise bout can augment the ex vivo manufacture of viral-specific T-cells from healthy donors. METHODS: Nine healthy CMV and EBV seropositive participants (mean ± SD age: 31.3 ± 3.3 years) completed a 30-min continuous cycling protocol at a workload corresponding to +15% of the individual blood lactate threshold. PBMCs (10x106) isolated before and immediately after exercise were stimulated with CMV (pp65 and IE1) and EBV (lmp2 and BMLF1) peptides and expanded over 8 days. At Day 8, viral-specific T-cells were enumerated using IFN-γ ELIPOST assays and the phenotypes of the expanded CTLs and viral-specific T-cells were determined by flow cytometry. RESULTS: Compared to CTLs expanded before exercise, the number of T-cells specific to CMV pp65, EBV lmp2, and EBV BMLF1 was markedly greater among the post-exercise expanded CTLs (fold-difference: CMVpp65: 2.6, EBV lmp-2: 2.5 and EBV BMLF-1: 4.4). Expanded CTLs predominantly consisted of effector memory (CD45RA-/CD62L-) and CD45RA+ effector memory (CD45RA+/CD62L-) T-cells, but no phenotypic differences were observed between CTLs expanded before and after exercise. Moreover, CTLs expanded before and after exercise were equally capable of killing viral-peptide pulsed autologous target cells in an MHC restricted manner. Viral-specific CTLs could not be expanded from a CMV/EBV seronegative participant, indicating that the augmenting effects of exercise are due to the priming and expansion of pre-existing memory T-cells. CONCLUSION: This is the first study to show that a single bout of exercise enhances the ex vivo manufacture of CMV and EBV-specific T-cells from healthy donors without altering their phenotype or function. Exercise may therefore serve as a safe adjuvant to improve viral-specific T-cell generation for HSCT.

Monitoring the Cytomegalovirus-specific cellular immunity in lung transplant recipients: A comparative analysis of two assay systems

Abstract Objective Monitoring the cellular immunity for Cytomegalovirus (CMV) in organ transplant recipients is a promising tool to support prevention strategies for posttransplant CMV infection or reactivation. Commercially available in vitro test systems differ substantially in their capacity to stimulate subpopulations of T-lymphocytes. We compared two assays for CMV immune monitoring in respect of their clinical practicability and significance. Methods Blood samples of 30 lung transplant recipients (LuTRs) were examined before transplantation and over a period of six months afterwards with T-Track® CMV (Lophius Biosciences GmbH, Regensburg) and QuantiFERON®-CMV (Cellestis GmbH, Darmstadt). The T-Track® CMV is based on ELISpot-technology, allowing quantification of interferon-gamma (IFNγ) secreting CD4+ and CD8+ T-cells after specific stimulation. Contrarily, the QuantiFERON®-CMV assay is restricted to detection of IFNγ secreted by CD8+ T-lymphocytes with ELISA. The data are evaluated in the context of transplant outcome and determination of viral load in plasma by qPCR. Results and Conclusion Both approaches provide similar results while exhibiting certain advantages and limitations. Early during immune suppressive therapy, QuantiFERON®-CMV generates often indeterminate results as depletion of T-cells is not taken into account. Although a comparatively large volume of blood is required, T-Track® CMV circumvents this drawback. In addition, T-Track® CMV reaches a higher sensitivity prior to LuTx and after onset of immunosuppression.

Double Superior Vena Cava: A Case Report

During routine dissection, a double superior vena cava, which is commonly known as persistent left superior vena cava (PLSVC) was observed in a 75‐ year‐old female cadaver. PLSVC drained into the right atrium through the coronary sinus. Coronary sinus was abnormally dilated to accommodate the large volume of venous blood reaching it through the PLSVC. Three sets of veins; common cardinal, anterior cardinal and posterior cardinal veins are involved in the normal development of the vena cavae. Embryological basis of PLSVC and its clinical significance in heart diseases will be discussed.

Application of Cytotoxic T-Lymphocytes for the Treatment of Cytomegalovirus Infection in Hematopoietic Stem Cell Transplantation

Human cytomegalovirus (HCMV) infection, a common complication, remains a major risk factor related with patient death after hematopoietic stem cell transplantation (HSCT). Cytotoxic T lymphocytes (CTL) which is crucial to control HCMV infection, can prevent or treat HCMV infection safely and effectively after adoptive infusion. Many studies have been focussed on exploring different methods for preparation of CTL. The method of using antigen presenting cells to stimulate peripheral blood mononuclear cells is simple to operate, easy to conduct large-scale clinical trials. Isolation of CTL from donor-derived PBMC by peptide-tetramer or INF-γ antibody requires a large volume of peripheral blood and high cost for preparation. Third-party CTL can provide an "off-the-shelf" product, but the problem of HLA-mismatch still would be solved. In addition, the clinical efficacy and safety of different methods also vary. This article reviews and compares the current methods to generate CTL and efficacy of the cells after infusions.

Risk Scores to Facilitate Preoperative Prediction of Transfusion and Large Volume Blood Transfusion Associated With Adult Cardiac Surgery

Background The aim of this study was to develop two novel risk prediction scores for transfusion and bleeding that would be used to inform treatment decisions, quality assurance, and clinical trial design in cardiac surgery. Methods Clinical data prospectively collected from 26 UK cardiac surgical centres and a single European centre were used to develop two risk prediction models: one for any red blood cell (RBC) transfusion, and the other for large volume blood transfusion (≥4 RBC units; LVBT), an index of severe blood loss. ‘Complete case' data were available for 24 749 patients. Multiple imputation was used for missing covariate data (typically Results The area under the receiver operating characteristic curve (AUC) was 0.77 (95% confidence interval 0.77–0.77) for the any RBC transfusion score and AUC 0.80 (0.79–0.80) for the LVBT score in the imputed data set. The LVBT model also showed excellent discrimination (Hosmer–Lemeshow P=0.32). In the imputed data set, the AUCs for the TRACK and TRUST scores for any RBC transfusion were 0.71 and 0.71, respectively, and for LVBT the AUC for the BRiSc score was 0.69. Conclusions Two new risk scores for any RBC transfusion or LVBT among cardiac surgery patients have excellent discrimination, and could inform clinical decision making.

An Autopsy Case of Asphyxia Caused by Uncontrolled Hemorrhage Following Transbronchial Lung Biopsy

Bronchoscopy is an important technique and flexible bronchoscopy procedures are considered comparatively safe. Notwithstanding, we here describe a woman who died of asphyxia caused uncontrolled hemorrhage following transbronchial lung biopsy. A medico-legal autopsy disclosed a small wound with clotted blood at the point of the transbronchial lung biopsy. The right lung was filled with a large volume of blood. Other organs showed no significant findings. Thus, this woman died from asphyxia associated with uncontrolled hemorrhage from the site of a transbronchial lung biopsy. We believe that our case is very instructive for safety bronchoscopy procedures.

STATA- Strategy of Transfusion in Trauma Patients: A Randomized Trial

Background: Trauma is a leading cause of death worldwide and massive bleeding is the main cause of death in the first 24 hours after injury. Patients with large blood volume loss should undergo the massive transfusion protocol to quickly restore the blood volume and the clotting factors that were lost during bleeding. There are two common strategies regarding transfusion therapy for multiple trauma patients with severe bleeding. The fixed ratio strategy is based on the proportional transfusion of packed red blood cells, fresh frozen plasma and platelets (fixed ratio 1:1:1). The thromboelastometry guide approach is based on the physiopathology of the trauma coagulopathy is a phenomenon that occurs in the early stages of trauma, with hyperfibrinolysis and fibrinogen consumption. Blood products are given based on viscoelastic tests. Methods/design: This study is a prospective, single-center, open-label, randomized trial. Males and females between 18 and 80 years old, with severe trauma and a high Injury Severity Score (ISS- greater or equal than 15) admitted to trauma emergency room are included. To be included, patients require is bleeding actively, with inclusion criteria’s to massive transfusion protocol. Patients are randomly allocated to one of the two strategies for massive transfusion (Group A- fixed ratio 1:1:1 or group B- thromboelastometry guided). The primary outcome is the incidence of organ dysfunction on the first, 5th, and 7th day until 28 days post. The secondary outcome are the consumption of blood products within 48 hours, the length of stay in the hospital, days without mechanical ventilation and the financial costs in both groups. Discussion: This trial was proposed to answer questions about the outcomes related to these two strategies of transfusion. This study is important because there is a lack of prospective studies with the subject proposed. Trial registration: Clinical Trial NCT02416817

Haematocrit influences insulin concentration measurements in dried blood spots

Introduction: A major barrier to conducting pharmacokinetic studies in neonates is the relatively large blood volume required by most assays. The use of dried blood spots (DBS) has potential to enable the use of smaller volumes and simplify sample processing and handling.Aim: The aim of this study is to determine the effect of haematocrit on insulin concentrations from DBS.Methods: DBS of varying haematocrit (0.25–0.65) were prepared at three insulin plasma concentrations (10, 25, and 50 mU/L). DBS were analysed for insulin using the method developed by Butter et al. (2001). DBS and paired plasma samples were obtained from neonates at Dunedin Hospital NICU.Results: Insulin chemiluminescence responses were significantly lower at higher haematocrit values (p < 0.05). All results showed high variability (CV% = 9–61%). Calculated whole blood concentrations were plotted against chemiluminescence and an exponential function fitted. Plasma insulin concentrations from neonatal DBS were typically higher than paired plasma samples.Conclusions: Haematocrit has a significant effect on insulin measurement by chemiluminescence when using DBS. Plasma insulin concentration could be determined when haematocrit was known. DBS insulin concentrations higher than plasma indicate that insulin may be present in red blood cells. However, measuring plasma insulin concentrations with DBS in neonates is not ideal due to high variability.

Ultra-fast, label-free isolation of circulating tumor cells from blood using spiral microfluidics.

Circulating tumor cells (CTCs) are rare cancer cells that are shed from primary or metastatic tumors into the peripheral blood circulation. Phenotypic and genetic characterization of these rare cells can provide important information to guide cancer staging and treatment, and thus further research into their characteristics and properties is an area of considerable interest. In this protocol, we describe detailed procedures for the production and use of a label-free spiral microfluidic device to allow size-based isolation of viable CTCs using hydrodynamic forces that are present in curvilinear microchannels. This spiral system enables us to achieve ≥ 85% recovery of spiked cells across multiple cancer cell lines and 99.99% depletion of white blood cells in whole blood. The described spiral microfluidic devices can be produced at an extremely low cost using standard microfabrication and soft lithography techniques (2-3 d), and they can be operated using two syringe pumps for lysed blood samples (7.5 ml in 12.5 min for a three-layered multiplexed chip). The fast processing time and the ability to collect CTCs from a large patient blood volume allows this technique to be used experimentally in a broad range of potential genomic and transcriptomic applications.

Risk Scores to Facilitate Preoperative Prediction of Transfusion and Large Volume Blood Transfusion Associated With Adult Cardiac Surgery

Risk Scores to Facilitate Preoperative Prediction of Transfusion and Large Volume Blood Transfusion Associated With Adult Cardiac Surgery

Trauma, Critical Care, and Emergency Care Anesthesiology: A New Paradigm for the "Acute Care" Anesthesiologist?

Trauma, Critical Care, and Emergency Care Anesthesiology: A New Paradigm for the "Acute Care" Anesthesiologist?

High efficiency vortex trapping of circulating tumor cells.

Circulating tumor cells (CTCs) are important biomarkers for monitoring tumor dynamics and efficacy of cancer therapy. Several technologies have been demonstrated to isolate CTCs with high efficiency but achieve a low purity from a large background of blood cells. We have previously shown the ability to enrich CTCs with high purity from large volumes of blood through selective capture in microvortices using the Vortex Chip. The device consists of a narrow channel followed by a series of expansion regions called reservoirs. Fast flow in the narrow entry channel gives rise to inertial forces, which direct larger cells into trapping vortices in the reservoirs where they remain circulating in orbits. By studying the entry and stability of particles following entry into reservoirs, we discover that channel cross sectional area plays an important role in controlling the size of trapped particles, not just the orbital trajectories. Using these design modifications, we demonstrate a new device that is able to capture a wider size range of CTCs from clinical samples, uncovering further heterogeneity. This simple biophysical method opens doors for a range of downstream interventions, including genetic analysis, cell culture, and ultimately personalized cancer therapy.