Mass Transfusion Research Articles

Epidemiology of open tibia fractures in a population-based database: update on current risk factors and clinical implications.

Open tibia fractures usually occur in high-energy mechanisms and are commonly associated with multiple traumas. The purposes of this study were to define the epidemiology of open tibia fractures in severely injured patients and to evaluate risk factors for major complications. A cohort from a nationwide population-based prospective database was analyzed (TraumaRegister DGU®). Inclusion criteria were: (1) open or closed tibia fracture, (2) Injury Severity Score (ISS) ≥ 16 points, (3) age ≥ 16years, and (4) survival until primary admission. According to the soft tissue status, patients were divided either in the closed (CTF) or into the open fracture (OTF) group. The OTF group was subdivided according to the Gustilo/Anderson classification. Demographic data, injury mechanisms, injury severity, surgical fracture management, hospital and ICU length of stay and systemic complications (e.g., multiple organ failure (MOF), sepsis, mortality) were collected and analyzed by SPSS (Version 23, IBM Inc., NY, USA). Out of 148.498 registered patients between 1/2002 and 12/2013; a total of 4.940 met the inclusion criteria (mean age 46.2 ± 19.4 years, ISS 30.4 ± 12.6 points). The CTF group included 2000 patients (40.5%), whereas 2940 patients (59.5%) sustained open tibia fractures (I°: 49.3%, II°: 27.5%, III°: 23.2%). High-energy trauma was the leading mechanism in case of open fractures. Despite comparable ISS and NISS values in patients with closed and open tibia fractures, open fractures were significantly associated with higher volume resuscitation (p < 0.001), more blood (p < 0.001), and mass transfusions (p = 0.006). While the rate of external fixation increased with the severity of soft tissue injury (37.6 to 76.5%), no major effect on mortality and other major complications was observed. Open tibia fractures are common in multiple trauma patients and are therefore associated with increased resuscitation requirements, more surgical procedures and increased in-hospital length of stay. However, increased systemic complications are not observed if a soft tissue adapted surgical protocol is applied.

Non-trauma Emergency Pancreatoduodenectomies: A Single-Center Retrospective Analysis.

To retrospectively assess the frequency and indications for emergency pancreatoduodenctomies in a tertiary referral center. Pancreatoduodenectomies between January 2005 and January 2014 were retrospectively assessed for emergency indications defined as surgery following unplanned hospital admission in less than 24h. Data on indications and on the intraoperative as well as the post-operative course were collected. Out of 583 pancreatoduodenectomies during the interval, a total of 10 (1.7%) were performed as an emergency surgery. Indications included uncontrollable bleeding, duodenal and proximal jejunal perforations, and endoscopic retrograde cholangiopancreatography-related complications. Three of the 10 (30.0%) patients died during the hospital course. In one patient, an intraoperative mass transfusion was necessary. No intraoperative death occurred. All but one patient were American Society of Anesthesiologists class three or higher. In two cases, the pancreatic remnant was left without anastomosis for second-stage pancreatojejunostomy. Median operation time was 326.5min (SD 100.3min). Hospital stay of the surviving patients was prolonged (median 43.0days; SD 24.0days). Emergency pancreatoduodenectomies are non-frequent, have a diverse range of indications and serve as an ultima ratio to cope with severe injuries and complications around the pancreatic head area.

Short-term complications in hip fracture surgery using spinal versus general anaesthesia

BackgroundSpinal anaesthesia when compared to general anaesthesia has been shown to decrease postoperative morbidity in orthopaedic surgery. The aim of the present study was to assess the differences in thirty-day morbidity and mortality for patients undergoing hip fracture surgery with spinal versus general anaesthesia. MethodsThe American College of Surgeons National Surgical Quality and Improvement Program (NSQIP) database was used to identify patients who underwent hip fracture surgery with general or spinal anaesthesia between 2010 and 2012 using CPT codes 27245 and 27244. Patient characteristics, complications, and mortality rates were compared. Univariate analysis and multivariate logistic regression were used to identify predictors of thirty-day complications. Stratified propensity scores were employed to adjust for potential selection bias between cohorts. Results6133 patients underwent hip fracture surgery with spinal or general anaesthesia; 4318 (72.6%) patients underwent fracture repair with general anaesthesia and 1815 (27.4%) underwent fracture repair with spinal anaesthesia. The spinal anaesthesia group had a lower unadjusted frequency of blood transfusions (39.34% versus 45.49%; p<0.0001), deep vein thrombosis (0.72% versus 1.64%; p=0.004), urinary tract infection (8.87% versus 5.76%; p<0.0001), and overall complications (45.75% versus 48.97%; p=0.001). The length of surgery was shorter in the spinal anaesthesia group (55.81 versus 65.36min; p<0.0001). After multivariate logistic regression was used to adjust for confounders, general anaesthesia (odds ratio, 1.29; 95% confidence interval, 1.14–1.47; p=0.0002) was significantly associated with increased risk for complication after hip fracture surgery. Age, female sex, body mass index, hypertension, transfusion, emergency procedure, operation time, and ASA score were risk factors for complications after hip fracture repair (all p<0.05). ConclusionsPatients who underwent hip fracture surgery with general anaesthesia had a higher risk of thirty-day complications as compared to patients who underwent hip fracture repair with spinal anaesthesia. Surgeons should consider using spinal anaesthesia for hip fracture surgery.

Epidemiology and risk factors of multiple-organ failure after multiple trauma

In the severely injured who survive the early posttraumatic phase, multiple-organ failure (MOF) is the main cause of morbidity and mortality. An enhanced prediction of MOF might influence individual monitoring and therapy of severely injured patients. We performed a retrospective analysis of a nationwide prospective database, the TraumaRegister DGU of the German Trauma Society. Patients with complete data sets (2002-2011) and a relevant trauma load (Injury Severity Score [ISS] ≥ 16), who were admitted to an intensive care unit, were included. Of a total of 31,154 patients enclosed in this study, 10,201 (32.7%) developed an MOF according to the Sequential Organ Failure Assessment score. During the study period, mortality of all patients decreased from 18.1% in 2002 to 15.3% in 2011 (p < 0.001). Meanwhile, MOF occurred significantly more often (24.6% in 2002 vs. 31.5% in 2011, p < 0.001), but mortality of MOF patients decreased (42.6% vs. 33.3%, p < 0.001). MOF patients who died survived 2 days less (11 days in 2002 vs. 8.9 days in 2011, p < 0.001). Independent risk factors for the development of MOF following severe trauma were age, ISS, head Abbreviated Injury Scale (AIS) score of 3 or higher, thoracic AIS score of 3 or higher, male sex, Glasgow Coma Scale (GCS) score of 8 or less, mass transfusion, base excess of less than -3, systolic blood pressure less than 90 mm Hg at admission, and coagulopathy. Over one decade, we observed an ongoing decrease of mortality after multiple trauma, accompanied by decreasing mortality in the subgroup with MOF. However, incidence of MOF in the severely injured increased significantly. Thus, MOF after multiple trauma remains a challenge in intensive care. The risk factors from multivariate analysis could be instrumental in anticipating the early development of MOF. Furthermore, a reliable prediction model might be supportive for patient enrolment in trauma studies, in which MOF marks the primary end point. Epidemiologic study, level III.

Assessing the Efficiency of Scoring System for Predicting the Probability of Massive Transfusion in Trauma Patients

Background: Management of hemorrhage plays a critical role in acute trauma care, owing to its significant association with morbidity and mortality in severely injured patients. We aimed at comparing the accuracy of three prediction models Trauma Associated Severe Hemorrhage (TASH) score, Assessment of Blood Consumption (ABC) score and Emergency Transfusion Score (ETS) for early estimation of the probability of massive transfusion, and its prognostic significance following trauma. Methods and Materials: retrospective analysis all cases of trauma, who required transfusion of >3 units of packed red blood cells (PRBC) was conducted for the duration of six months. Massive transfusion was defined as transfusion of >10 units of packed red blood cells within 24 hours. Correlation of all scoring systems with the probability of mass transfusion, severity of injury and in hospital mortality was done. Area under receiver operating characteristic (AUROC) Curve used to compare the scoring systems. Sensitivity, specificity, positive and negative predictive values were calculated for different prediction models. Results: 13.7% of the patients included in the study received massive transfusion. The accuracy was the highest for TASH score (57.1%) followed by ETS score (22.8%) and ABC score (13.1%). Statistically significant association was observed between TASH score and PRBC units transfused (p 0.003). 87 patients died within the duration of this study, association of lower ETS score with in hospital mortality was fund to be statistically significant Conclusion: TASH score predicts the individual’s risk for massive transfusion at a very early stage following severe injury. The scoring system may indicate risk and impact trauma care management strategies to stop bleeding and stabilize coagulation.

Combined Hemorrhage/Trauma Models in Pigs—Current State and Future Perspectives

The majority of injury combinations in multiply injured patients entail the chest, abdomen, and extremities. Numerous pig models focus on the investigation of posttraumatic pathophysiology, organ performance monitoring and on potential treatment options. Depending on the experimental question, previous authors have included isolated insults (controlled or uncontrolled hemorrhage, chest trauma) or a combination of these injuries (hemorrhage with abdominal trauma, chest trauma, traumatic brain injury, and/or long-bone fractures). Combined trauma models in pigs can provide a high level of clinical relevance, when they are properly designed and mimicking the clinical situation. Most of these models focus on the first hours after trauma, to assess the acute sequel of traumatic hemorrhage. However, hemorrhagic shock and the associated mass transfusion are also major causes for organ failure and mortality in the later clinical course. Thus, most models lack information on the pathomechanisms during the late posttraumatic phase. Studying new therapies only during the early phase is also not reflective of the clinical situation. Therefore, a longer observation period is required to study the effects of therapeutic approaches during intensive care treatment when using animal models. These long-term studies of combined trauma models will allow the development of valuable therapeutic approaches relevant for the later posttraumatic course. This review summarizes the existing porcine models and outlines the need for long-term models to provide real effective novel therapeutics for multiply injured patients to improve organ function and clinical outcome.

Prenatal diagnosis of abnormally invasive placenta reduces maternal peripartum hemorrhage and morbidity

Abnormally invasive placenta (AIP) poses diagnostic and therapeutic challenges. We analyzed clinical cases with confirmed placenta increta or percreta. Retrospective case series. Multicenter study. Pregnant women with AIP. Chart review. Prenatal detection rates, treatment choices, morbidity, mortality and short-term outcome. Sixty-six cases were analyzed. All women and all but three fetuses survived; 57/64 women (89%) had previous uterine surgery. In 26 women (39%) the diagnosis was not known before delivery (Group 1), in the remaining 40 (61%) diagnosis had been made between 14 and 37 weeks of gestation (Group 2). Placenta previa was present in 36 women (54%). In Groups 1 and 2, 50% (13/26) and 62% (25/40) of the women required hysterectomy, respectively. In Group 1 (unknown at the time of delivery) 69% (9/13) required (emergency) hysterectomy for severe hemorrhage in the immediate peripartum period compared with only 12% (3/25) in Group 2 (p = 0.0004). Mass transfusions were more frequently required in Group 1 (46%, 12/26 vs. 20%, 8/40; p = 0.025). In 18/40 women (45%) from Group 2 the placenta was intentionally left in situ; secondary hysterectomies and infections were equally frequent (18%) among these differently treated women. Overall, postpartum infections occurred in 11% and 20% of women in Groups 1 and 2, respectively. AIP was known before delivery in more than half of the cases. Unknown AIP led to significantly more emergency hysterectomies and mass transfusions during or immediately after delivery. Prenatal diagnosis of AIP reduces morbidity. Future studies should also address the selection criteria for cases appropriate for leaving the placenta in situ.

Nuclear Detonation and Effect on Platelet

The problem of nuclear detonation due to the Fukushima nuclear accident in Japan is still a hot issue at present. Although there are many reports on the side effect of exposure to leak nuclides, there are very few reports on the effect on platelet. With references to the previous well-known nuclear crisis, the Chernobyl crisis, there are some reports on this topic. Indeed, hematologic changes, particularly in the oxidative enzymes of platelets, are reported in exposed populations. In addition, in case with acute radiation syndrome, severe thrombocytopenia can be observed and the early management by fresh donor platelet mass transfusions is recommended. This condition can be improved after a long-term follow-up. However, in some cases, persistent postradiation thrombocytopenia accompanied with bone marrow failure can be seen and the recommended treatment is hematopoietic cell infusion.

Sodium-reduced continuous venovenous hemodiafiltration (CVVHDF) for the prevention of central pontine myelinolysis (CPM) in hyponatremic patients scheduled for orthotopic liver transplantation

Two patients in end-stage hepatic failure presented for orthotopic liver transplantation with longstanding severe hyponatremia (121 and 122 mmol/L). Both patients underwent liver transplantation with the concomitant use of continuous venovenous hemodiafiltration. Replacement and dialysate solutions were prepared individually to contain a sodium level that was individually considered safe with regard to the development of central pontine myelinolysis. The sodium increase in both patients was within the expected and planned limits despite a situation of mass transfusion. Both patients did well postoperatively and neither patient suffered neurological deficits.

Mass Transfusion to Combat Trauma's Lethal Triad

Mass Transfusion to Combat Trauma's Lethal Triad

Application of blood salvaging technologies in cardiosurgical patients operated under cardiopulmonary bypass

Aim. To evaluate the effectiveness of blood salvaging technologies in cardiosurgical patients operated under cardiopulmonary circulation. Methods. Analysis of perfusion protocols and transfusion cards of cardiosurgical patients operated using cardiopulmonary bypass during the period 2010-2011. Two groups of patients were identified: the first group - with the application of blood salvaging technologies (906 patients), the second group - without the application of this technique (122 patients). Blood from the operative wound was collected during the operation, processed, filtered through the «Cell-saver» machine from «Fresenius» company and was then re-introduced into the patient’s bloodstream. After completion of cardiopulmonary bypass the blood remaining in the circuit of the cell-saver machine and blood that was discharged through the drainage tubes was returned to the patient after being processed. Results. In the first group at the end of the operation 314.6±28.6 ml of washed red blood cells were returned to the patient from the heart-lung machine, while during the first postoperative day, the amount of the returned autologous erythrocytes from the drainage tubes was 72.8±12.5 ml. In this group, only 45 (4.9%) patients required donor erythrocyte mass transfusion, its volume per patient amounted to 172.3±31.8 ml. In the first group 182 (20.1%) patients required transfusion of fresh frozen plasma with the aim of achieving hemostasis, its volume amounted to 425±51.3 ml. In the second group 51 (41.8%) patients received erythrocyte mass transfusion in the volume of 346.7±31.1 ml, and 86 (70.5%) - received fresh frozen plasma in the amount of 568.7±41.2 ml. Hemoglobin content and hematocrit at the end of the operation and on the first postoperative day were significantly higher in the first group compared to the second group (p 0.01). These changes were associated with both intraoperative bleeding and with the loss of blood through the drainage tubes on the first postoperative day in the second group of patients. Compensation for these losses required transfusion of blood components significantly more frequently (p 0.001) and in larger volumes (p 0.01) than in the first group. Conclusion. Blood salvaging technologies using the «Cell-saver» machine during cardiac surgery under cardiopulmonary bypass significantly reduce blood loss, reduce the number of postoperative hospital days and complications, and are less expensive.

Increased activation of the transcription factor c-Jun by MAP kinases in monocytes of multiple trauma patients is associated with adverse outcome and mass transfusion

BackgroundPost-traumatic dysfunction of the immune system is a major source of morbidity and mortality in patients with multiple trauma. The underlying intracellular mechanisms are still incompletely understood. Previous mRNA expression studies in monocytes suggested an involvement of the MAP kinases p38 and JNK and of the transcription factor c-Jun. Therefore, it was the aim of this study to elucidate whether alterations in the protein expression p38 MAPK, JNK, and c-Jun could be linked to PRBC substitution and survival. Materials and methodsThirty-seven patients with blunt multiple injuries and an ISS > 16 points were enrolled in our study. Blood was drawn on admission and 6, 12, 24, 48, and 72 h after the traumatic event. Monocytes were isolated immediately after sample collection and nuclear protein was extracted and phosphoprotein concentrations were measured. The resulting data were statistically analyzed. ResultsAn increased activation of MAP kinases and c-Jun could be shown in patients who died from their injuries. Additionally, patients who received PRBC substitution ≥10 units exhibited increased expression of activated MAP kinases and c-Jun. ConclusionsWe present a serial, sequential investigation in human monocytes of major trauma patients evaluating the activation of p38 MAPK, JNK and c-Jun in the post-traumatic period. We show that death after trauma and massive PRBC substitution are associated with activation of this pathway. The p38 MAPK, JNK, and c-Jun have well established proinflammatory properties. Therefore, it appears likely that this pathway is involved in the systemic hyperinflammatory states seen after massive PRBC transfusion and multiple trauma.

Epidemiology of in-hospital trauma deaths.

About half of all trauma-related deaths occur after hospital admission. The present study tries to characterize trauma deaths according to the time of death, and, thereby, contributes to the discussion about factors considered as the cause of death. Data from two large European trauma registries (Trauma Registry of the German Society of Trauma Surgery, TR-DGU, and the Trauma Audit and Research Network, TARN) were analyzed in parallel. All hospital deaths with Injury Severity Score (ISS)>9 documented between 2000 and 2010 were considered. Patients were categorized into five subgroups according to the time to death (0-6h; 7-24h; day 1-6; day 7-30; beyond day 30). Surviving patients from the same time period served as a control group. In total, 6,685 and 6,867 non-survivors were included from the TR-DGU and TARN, respectively. The hospital mortality rate was between 15 and 17%. About half of all deaths occurred within the first 24h after admission (TR-DGU: 54%; TARN: 45%). The earliest subgroup of trauma deaths showed the highest mean ISS and the highest rate of mass transfusions. Severe head injury was most frequently observed in the subgroup of day 1-6. Late deaths are associated with higher age and more complications (sepsis, multiple organ failure). The time to death after severe trauma does not follow a trimodal distribution but shows a constantly decreasing incidence.

Desmopressin-induced Moschcowitz-like syndrome after treatment of uterine atonic bleeding in a 28-year-old pregnant woman

Here we report of a patient who developed a Moschcowitz-like syndrome following a desmopressin treatment of severe postpartum hemorrhage. The patient got an anaphylactic reaction after cervical ripening with dinoproston, leading to an emergency cesarean. A postpartum uterine atony with a blood loss more than 1500 ml resulted in a disseminated intravascular coagulation that was treated with mass transfusion of blood products, including platelets and factor VII. Desmopressin is used as rescue medication in situations of severe bleeding. It was given in this life-threatening situation and presumably triggered a Moschcowitz-like syndrome. Desmopressin exerts its haemostatic effect by releasing von Willebrand factor, which is elevated in pregnancy per se. This results in an increased risk of developing microthrombi, leading to a Moschcowitz-like syndrome. In conclusion, desmopressin should not be administered in pregnant patients owing to its potential risk of triggering the development of thrombotic-thrombocytopenic purpura.

Pathogenesis of indirect (secondary) acute lung injury

At present, therapeutic interventions to treat acute lung injury (ALI) or acute respiratory distress syndrome (ARDS) remain largely limited to lung-protective strategies, as no real molecular–pathophysiologic-driven therapeutic intervention has yet become available. This is in part the result of the heterogeneous nature of the etiological processes that contribute to the state of ALI/ARDS. This article sets out to understand the development of ALI resulting from indirect pulmonary insults, such as extrapulmonary sepsis and trauma, shock, burn injury or mass transfusion, as opposed to direct pulmonary challenges, such as pneumonia, aspiration or lung contusion. Here, we consider not only the experimental and clinical data concerning the roles of various immune (neutrophil, macrophage, lymphocyte and dendritic) as well as nonimmune (epithelial and endothelial) cells in orchestrating the development of ALI resulting from indirect pulmonary stimuli, but also how these cell populations might be targeted therapeutically.

Does Stress-Induced Hyperglycemia Increase the Risk of Perioperative Infectious Complications in Orthopaedic Trauma Patients?

To determine if hyperglycemia in postoperative orthopaedic trauma patients with no known history of diabetes mellitus is associated with an increased rate of infectious complications. Retrospective review. University Level I trauma center. One hundred ten consecutive orthopaedic trauma patients, Perioperative pneumonia, urinary tract infection, sepsis, or wound infection. Patients were divided into two subgroups based on mean serum glucose greater than 220 mg/dL (hyperglycemic index [HGI] 3.0 or greater). The incidence of infections was calculated for the following factors: age, medical comorbidities, Injury Severity Score, body mass index, HGI, sex, transfusions, tobacco use, and presence of open fracture. Means were compared using two-sample t tests (with or without adjustment for unequal variances as necessary), and percentages were compared using either chi square or Fisher exact tests. If the data were not normally distributed or measured on the ordinal scale, then the Wilcoxon rank sum test was used. A multivariate analysis using logistic regression was performed with the presence or absence of an infection as the dependent variable. A two-tailed P value < 0.05 was considered significant. SAS, Version 9.1 (SAS Institute Inc, Cary, NC), was used for all analyses. Forty-six infections occurred in 28 patients, including 11 wound infections, 17 pneumonia, 11 urinary tract infections, and seven sepsis or bacteremia. The overall infection rate for the study cohort was 28 of 110 (25%). No significant associations were identified among age, comorbidities, transfusions, tobacco use, open fracture, sex, body mass index, Injury Severity Score, and the presence of any infection. Ninety nine patients had an HGI less than 3.0 and 21 (21%) of these had a perioperative infection. Eleven patients had an HGI 3.0 or greater and seven (64%) of these had a perioperative infection. This difference was significant (P = 0.0056). Mean perioperative glucose levels greater than 220 mg/dL (HGI greater than 3.0) were associated with a seven times higher risk of infection in orthopaedic trauma patients with no known history of diabetes mellitus. Further prospective studies are needed to study the effects of stress-induced hyperglycemia and to determine whether this physiological response is protective or detrimental to the postoperative trauma patient.

Feasibility of laparoscopic management of acute haemoperitoneum secondary to ruptured ovarian cysts in a haemodynamically unstable patient

Acute haemoperitoneum in patients with coagulation disorders or those under anticoagulation therapy is a diagnostic and therapeutic dilemma. Since radiological imaging is often insufficient for establishing the origin of the bleeding, a laparoscopic approach can be considered before a laparotomy is performed in haemodynamically unstable patients. A 32-year-old woman receiving coumadin therapy presented with acute lower abdominal complaints. Due to suspicion of a tubo-ovarian abscess after the initial ultrasound, a conservative treatment was administered. A routine blood count after 12 hours showed a significant reduction in haemoglobin. During the CT scan, the patient developed unstable haemodynamics. Based on deteriorating coagulation parameters, mass transfusion and stabilization of the coagulation were performed but were not successful. Therefore an interventional laparoscopy was performed and a ruptured ovarian cyst was found to be the cause of bleeding. A ruptured ovarian cyst might be the cause of an acute abdomen and haemoperitoneum in young women. Therefore cyclus anamnesis and the exclusion of other obvious reasons for acute mass bleeding, i.e. ectopic pregnancy, can justify the laparoscopic approach after stabilization of the coagulation parameters. Long-term combined oral contraceptive therapy is indispensable for the prevention of these sorts of bleeding complications.

Radiation-Related Predictors of Hematologic Toxicity After Concurrent Chemoradiation for Cervical Cancer and Implications for Bone Marrow–Sparing Pelvic IMRT

To determine factors predictive for hematologic toxicity (HT) associated with concurrent chemoradiation for Stage II through IV cervical cancer. The medical records of 40 women receiving concurrent chemoradiation for cervical cancer were reviewed. Hematologic toxicity was defined by use of Common Terminology Criteria for Adverse Events (version 3.0). Variables predicting for HT including age, body mass index, transfusions, and bone marrow volumes irradiated were included in the data analysis. Of the patients, 13 (32.5%) had Grade 0 or 1 HT and 27 (67.5%) had Grade 2 through 4 HT (HT2+). Multiple logistic regression analysis of potential predictors showed that only the volume of bone receiving 20 Gy (V20) for whole pelvic bone tended toward significance for predicting HT2+. A strong correlation was noted between HT2+ and V20 (r = 0.8, p < 0.0001). A partitioning analysis to predict HT2+ showed a cutoff value of 79.42% (approximately 80%) for V20 of whole pelvic bone. That is, if the V20 of the whole pelvis exceeds 80%, the risk of HT2+ developing increases by a factor (odds ratio) of 4.5 (95%, confidence interval, 1.08-18.69) (p < 0.05). We have shown a correlation between bone marrow volume radiated and development of HT. This has implications for use of pelvic intensity-modulated radiation therapy, which can potentially decrease the volume of bone marrow radiated.

Comparative efficiency and hemorheological consequences of hemotransfusion and epoetin therapy in anemic cancer patients

The aim of our study was to compare hemorheological consequences of hemotransfusion and recombinant human erythropoetin treatment in anemic cancer patients. Forty anemic patients with solid nonmyeloid malignancies were enrolled in this prospective, open-label study. Both prior to and following treatment (epoetin beta, 10,000 units subcutaneously thrice weekly, for four weeks and transfusion of 400 ml of erythrocyte mass) hemorheological measurements including blood and plasma viscosity, hematocrit (Hct), hemoglobin, red blood cell aggregation (RBCA) and deformability were completed. It was found an increase of Hb from 76.07+/-3.68 g/l to 87.86+/-4.26 g/l after the transfusion. It was accompanied by Hct rise by 25% (from 23.67+/-1.85 to 29.50+/-1.96%, p<0.05). Under these conditions the whole blood viscosity (BV) was increased by 19% (p<0.05). Plasma viscosity did not change markedly. Therefore the main cause of the whole blood viscosity rise was an increase of Hct. After erythrocyte mass transfusion there were some increases of red cell deformability and aggregation (by 7%, p>0.05). Under these conditions the Hct/BV ratio as an index of oxygen transport efficiency was changed after transfusion only slightly. While after four weeks of epoetin treatment the hematocrit/viscosity ratio was raised by 14% (p<0.05), in spite of the high blood viscosity. In addition RBCA decreased (p<0.01) and their deformability was increased by 14% (p<0.05). In vitro microrheological data permit to suggest that epoetin has a direct effect on the microrheological properties of red cells due to activation of the cellular signal transduction system including the tyrosine kinases and phosphatases. Thus, Epoetin beta administered s.c. thrice weekly, during four weeks, increased hemoglobin levels, improved hemorheological profile and especially its microrheological part as well as the blood transport capacity in anemic cancer patients who were receiving chemotherapy and its hemorheological effect was more positive than under hemotransfusion.

Acute gastrointestinal bleeding due to oesophageal varices: an unusual case of a thoracic spleen

Upper gastrointestinal bleeding is often seen in patients admitted to intensive care units. Ulcers are the most common cause of these haemorrhages, but other factors such as oesopageal varices or malignancy may also be sources [1]. We report a 36-year-old male patient (BMI 30 kg/m) admitted to hospital because of a first session of haematemesis and recurrent dyspnoea only days before. Patient’s history revealed only 15 years of nicotine abuse and an undefined infection episode 17 years ago. On admission, clinical examination, vital parameters, chest X-ray and ECG findings were unremarkable. Initial laboratory tests revealed no pathologic coagulation tests, but impaired hemoglobin levels (12.3 g/dl). An oesophagoscopy was performed and revealed varices grade 3 [2]. Nine consecutive ligatures were placed. Furthermore, since there was no history or ultrasonic findings of liver disease, a thoracic CT scan was performed, revealing a large retrocardial mass (12 9 12 9 6 cm, Fig. 1) between the main bronchi displacing the oesophagus. An endosonography excluded an infiltration of the oesophagus, and a pathological specimen taken by video-assisted thoracoscopy showed a vascularised tumor without malignancy. Meanwhile, an emergency oesophagoscopy was indicated due to another session of haematemesis with need for mass transfusion. In the following days, an anterolateral rightsided thoracotomy with tumor resection followed. The arterial delivery was provided by a number of bronchial arteries of both main bronchi. The cause of the paraoesophageal plexus varices was more likely the tumorous venous drainage than the compression by the tumour itself (Fig. 2). Histological examination and further immunohistochemical differentiation of the resected mass revealed an ectopic accessory spleen confirmed by a second, independent pathologist. A deep venous thrombosis occurred preoperatively promoted by lack of anticoagulation despite immobilization. Because postoperatively the thrombosis reached the pelvic vessels, a venous thrombectomy was also performed. The postoperative oesophagoscopy showed varices decreased to grade 2, and anticoagulation with coumadin was started.