Packed Cell Transfusion Research Articles

Pyogenic renal abscess masquerading as malignancy

Dear Editor, Renal abscess may arise from both an initial urinary tract infection and hematogenous spreading of bacteria from a primary focus of infection outside the kidney.[1] We present a case of pyogenic renal abscess which presented to us masquerading as renal malignancy. A 64-year old male farmer presented in the emergency unit of Medical College, Kolkata with history of painless hematuria for 1 month and severe loss of weight and appetite for 2 months. There was a history of single episode of fever for 1 day without chills and rigors, about 1 month ago. There was no history of tuberculosis. On examination the patient had severe pallor, tachycardia but no fever and no obvious swelling palpable per abdomen. The renal angle was nontender. His hemoglobin on admission was 5.7 g% and the total count of white blood cells was 4500. His erythrocyte sedimentation rate was 15 mm/h and C-reactive protein was 3.4 mg/l (normal < 10 mg/l). Ultrasonography showed a hypoechoic lesion 3.1 × 2.5 cm at the lower pole of the right kidney. The patient was nondiabetic and did not have any features suggestive of vescico-ureteral reflex, nephrolithiasis or urinary tract obstruction. The patient received 6 units packed cell transfusion and was put on intravenous ciprofloxacin 500 mg IV twice daily which the patient received for 5 days. Contrast-enhanced CT scan showed right kidney having irregular low-density lesion with perirenal fluid collection. Left kidney, ureters, urinary bladder, and prostate were normal [Figure 1]. Urine for culture sensitivity showed growth of Escherichia coli with colony count of 100,000/ml sensitive to norfloxacin. The patient was then put on oral norfloxacin 400 mg twice daily for 14 days. Figure 1 Contrast-enhanced CT of the patient showing the right kidney having irregular low density lesion with perirenal collection. Left kidney appears normal History and presentation were suggestive of renal malignancy, but CECT showed a low-density lesion and urine had no malignant cell. Pyogenic abscess was a possibility but the patient had no burning sensation of urine, single episode of fever without chills and rigor or back pain and total count of white blood cells was also normal. Tubercular abscess was another possibility as the patient presented with pallor and weight loss but his chest X-ray was normal, sputum and urine for acid fast bacilli was negative, and a Montaux test was also negative. Repeat hemoglobin was after 2 weeks of presentation was 9.8 g% and the total count of white blood cells was 4000. A CT-guided fine-needle aspiration biopsy was planned for the patient for a definite diagnosis, but a repeat ultasonography before the procedure showed both kidneys to be normal. A thin rim of perirenal collection was seen around the right kidney with minimal collection noted in hepatorenal pouch of Morrison. The lesion had vanished! The patient had been on oral norfloxacin for about 2 weeks. The patient was then asked to continue the antibiotic for 2 more weeks. On follow-up, after 6 months of discharge the patient was asymptomatic with normal kidneys on ultrasonography. Image-guided renal biopsy is safe, reliable, and accurate. It changes clinical management in many cases avoiding nephrectomy or other surgical options. It should be promoted as a potentially useful option for managing suspicious or indeterminate renal masses.[2,3] This case did not require image-guided biopsy but one should not hesitate in cases of suspicious renal lesions. Various conditions seem to predispose to renal abscesses urinary tract infection, urinary calculi, and diabetes mellitus being a common cause.[4,5] Treatment of renal abscess requires at least 4 weeks of antibiotic therapy according to etiological agent.[6] Larger abscess may require parenteral antibiotic or surgical intervention if fever or symptoms do not settle down.

Factors Affecting the Postoperative Mortality in the Ruptured Abdominal Aortic Aneurysm

BackgroundAlthough patients with a ruptured abdominal aortic aneurysm (RAAA) often reach the hospital alive, the perioperative mortality is still very high. We retrospectively reviewed thirty patients who underwent repair of RAAA to identify the factors affecting postoperative mortality in a single hospital.Materials and MethodsBetween September 2007 and May 2011, thirty patients with RAAA underwent emergent surgery (n=27) or endovascular aneurysm repair (n=3). Their medical records were retrospectively reviewed regarding three categories: 1) preoperative patient status: age, gender, vital signs, serum creatinine, blood urea nitrogen, hematocrit, and hemoglobin level: 2) aneurysmal status: size, type, and rupture status; and 3) operative factors: interval time to operating room, operative duration, and amount of perioperative transfusion.ResultsThe 30-day postoperative mortality rate was 13.3% (4/30); later mortality was 3.3% (1/30). On multivariate analysis, the initial diastolic blood pressure (BP), interval time to operating room and amount of preoperative packed cell transfusion were statistically significantly linked with postoperative mortality (p<0.05).ConclusionIn this study, preoperative diastolic BP, preoperative packed cell transfusion amount and interval time between arrival and entry to operating room were significantly associated with postoperative mortality. It is important to prevent hemorrhage as quickly as possible.

PTU-022 Preoperative neutrophil: lymphocyte ratio does not predict post-operative complications following hepatic resection

IntroductionNeutrophil:lymphocyte ratio (NLR) is a marker of systemic inflammation and, if high, has been shown in several studies to be correlated with adverse outcome following operative intervention in many conditions.1–3...

Myelofibrosis

A 10-year-old girl presented with gradually increasing pallor and abdominal distension for 1 year and fever for 6 months. She required 3 packed cell transfusions during this interval. Investigations done revealed that the child had thalassemia intermedia and parents were carrier of β-thalassemia gene. The increased transfusion requirement in this case prompted further investigations, which revealed the presence of myelofibrosis. Case reports of myelofibrosis and myelodysplastic syndromes with acquired hemoglobin disorders exist in literature, especially α-thalassemia. To the best of our knowledge, this is the first reported case of β-thalassemia intermedia in association with myelofibrosis.

Evaluation of hematological parameters in partial exchange and packed cell transfusion in treatment of severe anemia in pregnancy.

Objectives. Anemia is a major public health problem throughout the world which assumes prominence in pregnant mothers. Patients with severe anemia continue to present themselves at term or in labor. This study was conducted to compare the improvements in hematological parameters of patients receiving partial exchange blood transfusion and transfusion of packed cells without exchange. Methods. One hundred and twenty-five severely anemic antenatal mothers were admitted from outpatient service. Partial exchange transfusion was given to sixty-six patients while fifty-nine received transfusion of packed cells with frusemide cover. Results. The two groups were comparable in terms of age, height, weight, religion, diet, education, occupation of self and husband, and income. Hemoglobin level in Group 1 was comparatively less than Group 2 at prelevel (5.2 ± 1.5 versus 6.6 ± 2.3, P = 0.001) and postlevel (7.2 ± 1.5 versus 8.6 ± 1.8, P = 0.001), respectively, but there was no significant difference between the two modes of transfusion (2.09 ± 1.6 versus 2.01 ± 1.5, P = 0.78). Conclusion. The study produced an equally significant improvement in hematological parameters in partial exchange and packed cell transfusion. Platelet counts were significantly less in partial exchange as compared with packed cell transfusion.

Hemolytic Disease of the Newborn- Anti c Antibody Induced Hemolysis

Hemolytic disease in the newborn, as a cause of early jaundice, is not uncommon. This is mostly due to Rh (D), ABO incompatibility and rarely due to other minor blood group incompatibility. The authors report two cases of Rh anti c isoimmunization presenting as significant early neonatal jaundice within the 20 h of life. Both the babies were treated with intensive phototherapy. One baby underwent exchange transfusion and the other required packed cell transfusion for anemia.

Risk Factors for Severe Retinopathy of Prematurity in Preterm Low Birth Weight Neonates

To evaluate the risk factors predisposing to severe retinopathy of prematurity (ROP) in a level III neonatal unit. This retrospective study was conducted in a tertiary care neonatal and ophthalmic center. The authors retrospectively analyzed data of preterm infants who were born from January 2003 through December 2008 and were screened for ROP. Data were collected from prospectively filled ROP screening forms. All the neonates with gestation ≤ 32 wks or birth weight ≤ 1500 g were screened. In addition, infants with birth weight of 1501-1800 g or gestation of 33-34 wks were also screened in the presence of additional risk factors like need for oxygen or mechanical ventilation. Primary outcome was severe ROP defined as treatable ROP as per type I ETROP guidelines (after year 2005) or threshold disease (before 2005). A total of 704 neonates were screened during the study period, of whom 84 (11.9%) and 33 (4.7%) infants developed any ROP and severe ROP, respectively. The mean birth weight and gestation of infants with severe ROP were 1113 ± 438 g and 29 ± 3 wks, respectively. The following risk factors were found to be significant for severe ROP on univariate analysis: gestation ≤ 30 wks, birth weight < 1000 g, respiratory distress syndrome, use of surfactant, apnea, hypotension, patent ductus arteriosus (PDA), sepsis, necrotizing enterocolitis, pneumonia, meningitis, intraventricular hemorrhage, packed cell transfusion, and use of oxygen, continuous positive airway pressure and positive pressure ventilation. On multivariate analysis by stepwise logistic regression, respiratory distress syndrome (adjusted OR: 8.1 (95% CI 2.6-25.1); p < 0.001), PDA requiring medical or surgical management (adjusted OR: 3.2 (95% CI 1.1-8.9); p = 0.03), and meningitis (adjusted OR: 6.7 (95% CI 1.9-23.0); p = 0.002) were found to be independently associated with severe ROP. All infants with severe ROP had regression of the disease after laser therapy. Respiratory distress syndrome, PDA requiring medical or surgical management and meningitis were found to be associated with severe ROP. Outcomes were good after laser therapy with all followed-up infants having regression of the disease.

Average Absolute Neutrophil Count During Maintenance Chemotherapy In Latino Versus Non-Latino Caucasian Patients with Childhood Acute Lymphoblastic Leukemia

AbstractAbstract 3237Despite recent advances in the treatment of childhood acute lymphoblastic leukemia (ALL), Latino children consistently have survival rates approximately 10% lower than among Caucasians. The thiopurine, 6-mercaptopurine (6MP), is an essential component of ALL maintenance therapy; therefore differences in adherence, absorption, and/or the pharmacogenomics of 6MP metabolism may play a role in explaining their survival difference. The presence of one or more polymorphism of the enzyme thiopurine methyltransferase (TPMT) affects TPMT enzyme activity, and therefore sensitivity to 6MP. Genotype is commonly evaluated prior to initiating 6MP therapy, to identify patients at risk for significant myelosuppression who will require dose reductions, allowing patients to maintain targeted neutrophil counts while forming adequate concentrations of the metabolite thioguanine nucleotide (TGN). The TPMT phenotype reflects actual enzyme activity level, but it is less commonly measured prior to 6MP therapy, since results may be obscured by recent packed cell transfusions frequently given to patients at diagnosis. Most individuals (89%) inherit a normal TPMT genotype (wild type); however, there is significant heterogeneity of TPMT enzyme activity within this group. Recent data suggest that ALL patients who are genotypically normal, and have higher TPMT enzyme activity may have inferior survival compared to patients with lower TPMT enzyme activity. Higher activity may be associated clinically with a higher absolute neutrophil count (ANC) as higher TPMT enzyme activity is associated with the formation of more methylated metabolite and less TGN. Thus, we hypothesized that our Latino patients with wild type TPMT activity would have a skewed distribution of TPMT activity with higher activity than our non-Latino Caucasian population and that the absolute neutrophil count (ANC), which is used to dose adjust 6MP, would serve as a surrogate marker of TPMT enzyme activity.We conducted a retrospective analysis of all patients with ALL undergoing maintenance chemotherapy between 2005–2009 at Children's Medical Center of Dallas. All patients diagnosed with ALL between January 1, 2005 to August 1, 2009, who were self-described Latino and non-Latino Caucasian, and treated per a current COG treatment protocol, were included in this analysis. We recorded demographic information, diagnostic and risk stratification characteristics, all complete blood counts during maintenance therapy, 6MP and methotrexate dosing, and all coinciding infections and medications which could affect neutrophil counts. 134 patient records were analyzed. The nine patients known to have a heterozygous TPMT genotype were excluded; however, the 31 (25%) patients who had not been genotyped were included. Of those 125 patients, 68 (54%) were self-described Latino and 57 (46%) were non-Latino Caucasian. There was no significant difference in the average dose of 6-MP prescribed during maintenance therapy among Latino versus non-Latino Caucasians (445 mg/m2/week vs 426 mg/m2/week, p = 0.4), nor was there a significant difference in the average ANC for Latinos versus non-Latino Caucasians (2,199 vs 2,134, p = 0.6, by the Wilcoxon rank sum test). There was a wide range of enzyme activity in both Latino and non-Latinos Caucasian patients (17.4 - 60.6 EU/mL and 16.9 – 50.6 EU/mL, n = 32), with 3 Latino patients having activity levels > 50 EU/mL. In conclusion, this study did not demonstrate a difference in average ANC during maintenance therapy between Latino and non-Latino Caucasians in our Dallas population. Thus, if there were significant differences in either adherence or metabolism of 6MP secondary to a skew in TPMT activity, it was not detectable through an analysis of the average ANC during maintenance therapy. Enzyme activity was widely distributed in patients with wild type genetics, in both populations. Our study has many limitations, including small sample size, use of average ANC as a surrogate rather than direct measurements of TPMT enzyme activity, reliance on the medical record for definition of ethnicity, and possible inclusion of non-wild type patients who had not been genotyped. A larger prospective study is needed to directly evaluate TPMT enzyme activity in patients with known wild type genetics in order to elucidate the role of TPMT phenotypic variation in TPMT wild-type Latino patients. Disclosures:No relevant conflicts of interest to declare.

Severe iron deficiency anaemia in a 37-year-old with HBSC disease: a case report and review of literature.

Background: Iron deficiency anaemia (IDA) is not a recognised complication of sickle cell disease; it is uncommon in an adult patients. However, it could occur in children with the disease on the background of a significant nutritional deficiency. Method: Clinical note of the patient was retrieved for relevant information. The date of first contact with health facility, and subsequent follow-up clinical status was noted. The steady state blood counts, the clinical and laboratory findings at presentation of severe IDA was reviewed. Result: The patient runs a mild disease and was haemoglobin SC. The severe IDA was precipitated by ascaris lumbricoides infestation. This necessitated packed cell transfusion for the first time ever in this patient. Conclusion: There should be a high index of suspicion for worm infestations in previously untransfused SCD patients presenting with severe anaemia. The role of iron-deficient state in sickle cell disease amelioration needs further evaluation. Key words: sickle cell disease, iron deficiency, worm infestation.

Ocular masquerade syndrome as a herald of progression of acute myelogenous leukemia

Dear Editor, A 77-year-old Indian female presented with a 5-day history of left eye redness, pain, and intermittent blurring of vision. She had been diagnosed with acute myeloid leukemia (AML) 6 months ago and decided for conservative management, with dependence on monthly packed cell transfusions. Presenting Snellen acuity was 20/50 on the right and 20/40 on the left. Anterior segment examination revealed conjunctival injection with anterior chamber inflammation of 3+ cells, 2+ retrolental cells, and vitritis 1+ cells with normal fundus and intraocular pressure (IOP). Right eye was unremarkable. Flow cytometry of aqueous revealed 12% myeloblasts. No background monocytes or neutrophils were detected, and cultures were negative. Full blood count (FBC) revealed raised total white cells 22.2×10/L, comprising of 63% blasts (13.99×10/L), myelocytes (0.22×10/L), thrombocytopenia 9×10/L (170–420), and anemia 7.6 g/dL. Erythrocyte sedimentation rate was >140 mm/h. She was treated conservatively with topical prednisolone acetate 1%. Subsequent review showed no treatment response. IOP remained normal. She was admitted for palliation of severe bone pain and received multiple packed cell transfusions, but succumbed to pneumonia 30 days later.

Early outcome of preterm infants with birth weight of 1500 g or less and gestational age of 30 weeks or less in Isfahan city, Iran

The outcome of preterm neonates has been varied in different hospitals and regions in developing countries. This study aimed to determine the mortality, morbidity and survival of neonates weighing 1500 g or less and with gestational age of 30 weeks or less who were admitted to referral neonatal intensive care units (NICUs) of two hospitals in Isfahan city, Iran and to investigate the effect of birth weight, gestational age and Apgar score on infant mortality. We studied retrospectively the morbidity, mortality and survival of 194 newborns with a birth weight of </=1500 g and a gestational age of </=30 weeks who had been hospitalized during a 15-month period in NICUs of the two referral hospitals. The Kaplan-Meier method was used to estimate the survival of the neonates. The survival was defined as the discharge of live infant from the hospital within 75 days. Overall, 125 (64.4%; 95%CI 58%-71%) of the 194 infants died during their hospital stay. The morbidity in this study was as follows: respiratory distress syndrome 76% (95%CI 70%-82%), septicemia 30.9% (95%CI 24%-37%), bronchopulmonary dysplasia 10.3% (95%CI 6%-15%), necrotizing enterocolitis 6.7% (95%CI 3%-10%), patent ductus arteriosus 12.4% (95%CI 8%-17%), intraventricular hemorrhage 7.2% (95%CI 4%-11%), and apnea 16.5% (95%CI 11%-22%). Packed cell transfusion was required in 43.3% (95%CI 36%-50%) of the neonates. The Kaplan Meier survival analysis revealed that 75% of the infants would live past 2 days, 50% after 14 days, and 25% after 69 days. Even with modern perinatal technology and care, early deaths of very low birth weight infants are still common in our referral hospitals. The outcome of infants born at 24-28 weeks is unfavorable. The hospital level is an important factor affecting the mortality and morbidity of these infants.

Performance of MASCC score and other factors for identifying low-risk febrile-neutropenic cancer patients.

e19533 Background: The standard empirical broad-spectrum-intravenous-antibiotic (AB) treatment and hospitalisation though safe lead to over-treatment of substantial group of patients. Validation of parameters to identify low-risk febrile neutropenia (FN) that can be safely treated in an outpatient setting with minimal/no AB treatment needed. Methods: A retrospective analysis to validate risk assessment model in FN patients from January 2007 to December 2008 done. Inclusion criteria were histologic diagnosis of malignancy, FN secondary to chemotherapy, absolute neutrophil count of ≤500/μl, axillary temperature of ≥38° C and age ≥ 14years. Other clinical and lab parameters were explored for risk stratification during FN episodes .Receiver operating characteristic curves were used to find the thresholdvalue and Chisquare analysis was done to find association between outcome and the parameters. Results: A total of 178 FN episodes were documented; 22 in solid tumors while 156 in haematolymphoid malignancies. Cultures were positive in 59 episodes with Escherichia-coli being the commonest organism. Risk stratification was done by Multinational Association of Supportive Care in Cancer (MASCC) risk index score. The association between MSACC score and risk stratification could not be established (p = not significant).The total no of complications were 23 (Sepsis 22, Mortality 23). Other factors found to be significantly associated with high risk of complications were mucositis (p = 0.03), maximum temperature ≥ 103°F (p = 0.01), tachycardia (p<0.001),tachypnoea (p = <0.001), age (p = 0.006), high dose of steroid (p<0.001), total duration of fever (≥2.5 days (for which Sensitivity(S) and specificity (Sp) 87% and 81% respectively), serum creatinine (≥0.45mg%, S = 100%, Sp = 97%), bilirubin (≥0.5, S = 100%. Sp = 90%) requirement of second line antibiotics (p = 0.02), intensive care (p = <0.001), ventilatory support (p<0.001) and requirement of packed cell transfusion (p = 0.02). Conclusions: The MASCC risk index score could not be validated in this population while other clinical and lab parameters were found to have strong association in risk stratification of cancer patients during FN episodes. No significant financial relationships to disclose.

A rare presentation of a rare disease—congenital tuberculosis presenting as subdural haematoma

Congenital tuberculosis is a rare disease. Only 21 cases have been reported in English language journals since 2001. Subdural haematoma associated with congenital tuberculosis has never been reported. A 26-year-old cachectic looking, Asian lady presented acutely in labour at 33 weeks. She had an uneventful antenatal period and normal antenatal scans. Fetal distress and a suboptimal cardiotocogram led to emergency caesarean section. Abnormal caseating peritoneal material was noted during the Caesarean section raising suspicion of maternal tuberculosis. The preterm baby girl was born in poor condition and needed resuscitation including mechanical ventilation. Following admission to neonatal intensive care, she was noted to have deranged clotting, thrombocytopenia and anaemia. She received fresh frozen plasma, platelet and packed cell transfusions. Antituberculous treatment was added to the antibiotics, with a suspicion of congenital tuberculosis. Cerebrospinal fluid analysis was highly suggestive of tuberculous meningitis. Following an abnormal cranial ultrasound scan, CT brain confirmed a large left subdural parieto-temporal collection with a significant mass effect. The baby was immediately transferred to the nearest tertiary centre and the subdural collection was urgently evacuated by neurosurgeons. This lead to a dramatic improvement in clinical condition followed by extubation on day 6. Congenital tuberculosis was confirmed by microbiological evidence from baby9s gastric aspirate and mother9s peritoneal fluid. In this case, the presence of acid-fast bacilli on microscopic examination of the nasogastric aspirate suggests possible ingestion of infected amniotic fluid by the fetus. Secondly, the biochemical and microbiological analysis of cerebrospinal fluid is highly suggestive of tuberculosis meningitis which suggests haematogenous spread of infection from mother. Significant inflammation and disseminated intravascular coagulopathy in tuberculosis could cause subdural haematoma. Early imaging in conjunction to clinical suspicion is the key in managing this complication.

Risk Stratification without a Liver Biopsy of Patients with β Thalassemia Major Undergoing a Matched Related Allogeneic Bone Marrow Transplant.

Abstract 659An allogeneic stem cell transplant (SCT) remains the only curative option for patients with β thalassemia major (TM). Conventional risk stratification requires a liver biopsy to be done prior to transplant, has inadequate chelation therapy as a risk factor, which is poorly defined with currently available therapies and results in a large heterogeneous high risk group. We have previously shown that survival can be significantly different in subsets within this high risk group (BBMT 2007;13:889)From October 1991 to December 2008, 271 patients with TM underwent a SCT at our center. The median age was 7 years (range: 2-24) and there were 175 males (64.6%). 133 (49%) were conventional Class III patients. Myelo-ablative conditioning regimen in the majority was busulphan (oral) and cyclophosphamide with or without anti lymphocyte globulin. GVHD prophylaxis was cylcosporine and short course methotrexate. Two hundred and sixty six (98%) received a bone marrow graft. At a median follow up of 41 months (range: 0-209) the 5-year Kaplan-Meir estimate of overall survival (OS) and event free survival (EFS) was 70.79±2.9% and 63.75±3% respectively. On a univariate analysis, factors associated with an adverse impact on EFS were patients' age, donor age, liver size, serum AST level, serum ferritin level, number of packed cell transfusions received, spleen size and splenectomy. On a multivariate analysis only liver size (both 2-5 cm and >5 cm) retained its significant adverse impact. The remaining parameters that were significant on a univariate analysis as a continuous variable were further evaluated after dividing them into quartiles. On a cox-regression analysis of the quartiles only age retained significance in all quartiles while the rest were significant only in the highest quartile. For the latter, the cut offs of the highest quartile was used to dichotomize the cohort into two groups for each parameter and a score given proportional to relative risk (Table 1). The total score could therefore range form 0 to 13 for each patient. On a multivariate analysis none of these generated values, including age in the different quartiles, had an independent significant impact on EFS. They were still retained in the scoring system because of the established biological relevance of these parameters on transplant outcomes. Splenectomy was excluded in view of the small number of cases. Kaplan-Meir estimates of EFS were generated for each of these scores and clustered into groups. Three groups could be recognized; Group A with a score <3.5 (n=125 [46%], Group B 3.5-7.5 (n=87 [32%]) and Group C >7.5 (n=59 [22%]). Figure 1 illustrates the Kaplan-Meir estimates of EFS and cumulative risk of rejection between these groups which were significantly different. There were 133 (49%) patients in this cohort who belonged to the conventional Lucarelli Class III subset. Of these, using the current risk stratification 18(13%) would be in Group A, 58(44%) in Group B and 57(43%) in Group C.The proposed risk stratification does not require a liver biopsy, has a good distribution of cases in the defined groups and better identifies a high risk subset of patients, than the conventional risk stratification system. This high risk subset may need innovative strategies for improving outcomes following an allogeneic SCT. The proposed risk stratification system will need to be validated prospectively.Table 1Variables Score011.524Liver size (cm)<22-5>5Age (years)<55-77-11>11Packed cell transfusions (units)<90>90Serum AST (IU/Lt)<75>75Serum Ferritin (ng/ml)<3500>3500Spleen size (cm)<3.0>3.0 [Display omitted] Disclosures:No relevant conflicts of interest to declare.

Evaluation of postpartum blood loss after misoprostol‐induced labour

shown to increase maternal morbidity. It has been reported to be associated with increases in grade three perineal tears, cervical tears, postpartum haemorrhage, retained placenta and packed cell transfusions. It is also known to be strongly associated with placental abruption. Analysis of the study by Sheiner et al. showed that prostaglandin E2 induction is an independent risk factor for precipitate labour. These are significant findings for clinicians conducting induction of labour in practice. During the process of induction of labour, often the aim is to achieve a short induction to delivery interval. It has been reported that women might prefer obstetric interventions that lead to a shorter labour, even if operative outcomes are not altered. UK National Institute for Health and Clinical Excellence (NICE) Induction of Labour guideline did not review the induction to delivery interval and its implications, when recommending the methods of induction of labour. The finding of this paper and previous studies highlighted the potential risks of a short induction to delivery interval. When choosing the method of induction, consideration should include avoidance of precipitate labour; other risk factors of precipitate labour should also be taken into account. Awareness of the risks will allow adequate preparation, to avoid and manage complications, and ultimately decrease morbidity of precipitate labour.j

A neonate with fetal distress and anaemia

A baby girl was delivered by emergency caesarean section for fetal bradycardia at 37 weeks' gestation. The 20-week fetal anomaly antenatal scans had showed no obvious abnormalities. At birth the baby looked pale and floppy, needing resuscitation with bag and mask. The Apgar scores were 6 and 8 at 1 and 5 minutes respectively. The baby weighed 1.98 kg. On examination she was noted to be pale with an abdominal mass extending from the left hypochondrium to the right iliac fossa. The initial blood results showed a low haemoglobin of 9.9 g/dl with normal white cell and platelet count. The urea, creatinine, electrolytes, C-reactive protein and liver functions tests were in the normal neonatal range. The Coombs test was negative. There was no evidence of haemolytic anaemia. She received packed cell transfusion for correction of anaemia. An abdominal X-ray showed a paucity of gas in the lower abdomen (Figure 1). Ultrasound of the abdomen and pelvis showed a large pelvic mass with numerous irregular fluid-filled spaces. The liver, biliary tree and the kidneys were normal. A computed tomography scan of the abdomen and pelvis (Figure 2) with contrast showed a 7×5×5 cm low attenuation mass arising from the pelvis and extending into the abdomen, most likely to be right ovarian in origin. Laparotomy showed a large right-sided ovarian cyst with haemorrhagic areas. She underwent right oopherectomy which on macroscopic examination showed multiple blood-filled cysts. Histopathology of the mass suggested a luteinized follicular cyst with no malignant features. She made good postoperative recovery and on follow up at 5 months of age, she was growing and developing normally with no ongoing problems related to the ovarian cyst.

The Association of Hemodilution and Transfusion of Red Blood Cells with Biochemical Markers of Splanchnic and Renal Injury During Cardiopulmonary Bypass

Hemodilution is the main cause of a low hematocrit concentration during cardiopulmonary bypass. This low hematocrit may be insufficient for optimal tissue oxygen delivery and often results in packed cell transfusion. Our objective in this study was to find a relationship between intraoperative hematocrit and allogeneic blood transfusion on release of postoperative injury markers from the kidneys and the splanchnic area. Fifty consecutive patients undergoing coronary artery bypass grafting with cardiopulmonary bypass were included. Systemic tissue hypoxia was assessed by lactate concentrations. Kidney and splanchnic ischemia were assessed by the measurement of N-acetyl-beta-D-glucosaminidase (NAG) and intestinal fatty acid binding protein (IFABP) in urine. Patients were retrospectively placed into groups according to their lowest hematocrit concentration on bypass (<24% or >or=24%). The intraoperative lactate and the postoperative NAG and IFABP concentrations were higher in the low hematocrit group (<24%) than in the high hematocrit group (>or=24%; P < 0.05). Low hematocrit correlated with higher lactate concentrations (R(2) = 0.150, P < 0.01) and with higher NAG concentrations (R(2) = 0.138, P < 0.01) and IFABP concentrations (R(2) = 0.107, P < 0.01) postoperatively. Transfusion of packed cells during cardiopulmonary bypass correlated with higher lactate (R(2) = 0.089, P < 0.05), NAG (R(2) = 0.431, P < 0.01), and IFABP concentrations (R(2) = 0.189, P < 0.01). The results support the concept that hemodilution below an intraoperative hematocrit of 24% and consequently transfusion of red blood cells is related to release of injury markers of the kidneys and splanchnic area.

Terlipressin vs. Octreotide in Bleeding Esophageal Varices as an Adjuvant Therapy With Endoscopic Band Ligation: A Randomized Double-Blind Placebo-Controlled Trial

Data are scarce on the head-to-head efficacy of terlipressin and octreotide as an adjuvant therapy to endoscopic management of variceal bleed. The aim of this study was to compare the efficacy and safety of terlipressin with octreotide as an adjuvant therapy to endoscopic variceal band ligation in patients with esophageal variceal bleeding. Cirrhotic patients with esophageal variceal bleed were randomized on admission to receive terlipressin (group A) or octreotide (group B) along with the placebo in the other arm in a double-blind fashion. The two groups were compared for efficacy, safety, overall survival, and length of hospital stay. "Control of variceal bleed" was the measure of efficacy of terlipressin and octreotide. Factors predicting length of stay were also assessed. A total of 324 patients were enrolled; 163 in the terlipressin group (group A) and 161 in the octreotide group (group B). The baseline characteristics of the two groups were comparable for age, gender, etiology of cirrhosis, hemoglobin at presentation, and Child-Pugh class, except that active bleed was seen during upper gastrointestinal endoscopy at the time of enrollment in 26 (16%) and 41 (25.5%) patients in groups A and B, respectively (P=0.034). Overall sixteen patients died (three failure to control bleed and thirteen from causes other than variceal bleed); nine in group A (5.5%) and seven (4.3%) in group B (P=0.626). In the intention to treat analysis, "control of variceal bleed" was noted in 305 patients (94.13%); 151 (92.63%) patients in group A and 154 (95.6%) patients in group B (confidence interval: 0.219-1.492). Packed cell transfusions in group A were 3.7+/-2.3 units, whereas in group B there were 3.9+/-2.5 units (P=0.273). Length of hospital stay in groups A and B was 108.40+/-34.81 and 126.39+/-47.45 h, respectively (P< or =0.001). No cardiovascular side effects were observed in either group. High pulse, low hemoglobin, prothrombin time, blood in nasogastric aspirate, and portosystemic encephalopathy (PSE) were predictors of prolonged hospital stay. The efficacy of terlipressin was not inferior to octreotide as an adjuvant therapy for the control of esophageal variceal bleed and in-hospital survival. The length of hospital stay in the terlipressin group was significantly shorter but not of any clinical importance. The predictors of prolonged hospital stay were low hemoglobin, high pulse, prolonged prothrombin time, blood at nasogastric aspirate, and PSE.

Splenectomy reduces packed red cell transfusion requirement in children with sickle cell disease

Purpose The purpose of the study was to measure the effect of splenectomy on packed-cell transfusion requirement in children with sickle cell disease. Methods Thirty-seven sickle cell children who underwent splenectomies between January 2000 and May 2006 at a children's hospital were reviewed. Data were collected 6 months preoperatively to 12 months postsplenectomy. Paired t test, analysis of variance, and multivariable regression analyses were performed. Results Of 37 children with median age 11 years (range, 2-18 years), 34 (21 males) had data that allowed analyses. Twenty-six had Hgb-SS, 5 had Hgb-SC, and 3 had Hgb S-Thal. Laparoscopic splenectomy was attempted in 36 and completed successfully in 34 (94% success). The number of units transfused decreased by 38% for 0 to 6 months and by 45% for 6 to 12 months postsplenectomy. Postoperatively, hematocrit levels increased and reticulocytes concurrently decreased with a reduction in transfusion clinic visits. The decrease in transfusion was not influenced by spleen weight, age, or hemoglobin type. Two children had acute chest syndrome (6%), and 1 had severe pneumonia (3%). Conclusion Laparoscopic splenectomy can be successfully completed in sickle cell children. Splenectomy significantly reduces the packed red cell transfusion requirement and frequency of clinic visits, in sickle cell children for at least 12 months postoperatively.

Total Laparoscopic Hysterectomy with Earlier Uterine Artery Ligation

We compared the feasibility, blood loss, duration of surgery, and complications between patients in whom both uterine arteries were sutured at the beginning of total laparoscopic hysterectomy (TLH) and patients in whom suturing was done after cornual pedicles. Using a prospective study (Canadian Task Force classification II-2) at a dedicated high-volume gynecologic laparoscopy center, a total of 350 women who underwent TLH from January 2005 through January 2007 were assigned into 2 groups. The indications for TLH were predominantly myomas and menorrhagia. In group A, TLH was done by suturing both uterine arteries at the beginning of the procedure. In group B, the uterine arteries were sutured after the cornual pedicles as done conventionally. All the other pedicles were desiccated and cut either with harmonic ultracision or bipolar diathermy. The uterus with cervix was removed either vaginally or by morcellation. The median age of patients in group A was 46 years and in group B was 44 years. Mean uterine size, weight, estimated blood loss, total operating time, need for blood transfusion, and complications were analyzed. In group A the total duration of surgery was 60 minutes (range 20–210). In group B, the total duration of surgery was 70 minutes (range 30–190). In group A, the median total blood loss was 50 mL (range 10–2000). In group B the total blood loss was 60 mL (range 10–2500). The comparison between the 2 groups revealed a statistically significant difference (p <.05, Mann–Whitney test). Need for blood transfusion was less in group A. One patient in group A had secondary hemorrhage 3 weeks later and the vaginal vault was resutured. In group B, 2 patients had blood loss more than 1500 mL (uterus weight > 1000 g) and required 4 units of packed cell transfusion in each. One patient in group B with previous cesarean section had a bladder wall rent and this was sutured laparoscopically using 3-0 delayed absorbable sutures. Uterine artery ligation at the beginning of TLH as done in group A is a technically feasible procedure. It reduces the total blood loss and decreases the time taken for the procedure.