Cryoprecipitate transfusion: assessing appropriateness and dosing in trauma

BACKGROUND

Originally developed for patients with congenital factor VIII deficiency, cryoprecipitate is currently largely used for acquired hypofibrinogenemia in the context of bleeding. However, scant evidence supports this indication and cryoprecipitate is commonly used outside guidelines. In trauma, the appropriate cryoprecipitate dose and its impact on plasma fibrinogen levels are unclear.

OBJECTIVES

The aims were to evaluate (i) the appropriateness of cryoprecipitate transfusion in trauma and (ii) the plasma fibrinogen response to cryoprecipitate transfusion during massive transfusion in trauma.

METHODS

Retrospective review (January 1998-June 2008) of indications, dose and plasma fibrinogen response to cryoprecipitate transfusion at a large teaching hospital. A fibrinogen of <1.0 g L(-1) within 2 and 6 h of transfusion was used for evaluating appropriateness.

RESULTS

Ten thousand five hundred and forty cryoprecipitate units were transfused in 1004 patients. Thirty-seven percent and 31% were used in cardiac surgery and trauma, respectively. In 394 events in trauma, 238 (60%) and 259 (66%) were considered appropriate using the 2- and 6-h cut-off criteria, respectively. In patients who did not receive plasma components 2 h prior to cryoprecipitate, a dose of 8.7 (± 1.7) units caused a mean increase in fibrinogen levels of 0.55 (± 0.24) g L(-1), or 0.06 g L(-1) per unit.

CONCLUSIONS

In our hospital, where transfusion guidelines are overseen by transfusion medicine specialists and technologists, and policies for rapid blood component and laboratory turnaround times exist, it is possible to achieve high rates of appropriateness for cryoprecipitate transfusion in trauma. The current recommended dose causes a modest increase in fibrinogen levels (0.55 g L(-1) ).

Helicobacter pylori in Dyspepsia - Antibiotic Sensitivity and Virulence Patterns

BACKGROUND

Helicobacter pylori is implicated in acute superficial gastritis, chronic atrophic gastritis, gastric carcinoma and MALT associated lymphoma. Though colonization can occur in normal individuals, treatment is given if the organism is associated with virulence factors like vacuolating toxin and cytopathic toxin as coded by vacA and cagA genes respectively. No causal relationship between non-ulcer dyspepsia (NUD) and H pylori has been established. This study was carried out to delineate colonizers from pathogens so that appropriate treatment can be planned.

METHOD

100 patients were recruited, 62 with NUD and 38 age and sex matched controls. 4 gastric biopsies and a serum samples were taken from each patient. The biopsies were examined for H pylori by culture, histopathology, rapid urease test, PCR and serum for IgG, IgM and IgA.

RESULTS

Culture showed 22.6% positivity and urease 19% among the test group. Histopathology showed 53.2% superficial gastritis and 30.6% chronic gastritis among the test group (P<0.001), PCR for H pylori was positive in 48.3% and vacA and cagA were 29% and 22.6% respectively (P=0.001) among the tests. IgG, IgM and IgA were 41.9%, 46.8% and 43.5% respectively.

CONCLUSION

The culture and rapid urease tests were highly specific with high positive predictive value but if negative, infection cannot be ruled out. Similarly IgA and IgM positivity has high positive predictive value for on-going infection where as IgG may be positive in old healed infections also. PCR assay in biopsy specimens is a valuable technique for detection of H pylori with high specificity and sensitivity. The presence of vacA and cagA genes can differentiate innocuous bystanders and potentially invasive organisms.

Sezary syndrome

Sezary syndrome is a rare form of primary cutaneous T cell lymphoma. A male patient of 37 years old was reported with multiple subcutaneous swelling at different parts of the body which were asymptomatic for the last 2 years. But he had persistent generalized itching, induration in skin surface and erythema for months. The disease was diagnosed by the presence of Sezary cells in the skin biopsy, peripheral blood smears and epidermotrophism of lymphocytes. The patient was treated by CHOP (Cyclophosphamide, Doxorubicin, Vincristine and Prednisolone) therapy.

An improved record system for tracing outcome of "transferred-out" DOTS patients

This study in Pakistan aimed to develop an improved record-keeping mechanism for the DOTS programme to establish the final treatment status of patients recorded as "transferred-out". In an intervention study in 40 DOTS diagnostics centres in Punjab province, a modification was made to the existing TB03 register. DOTS facilitators were trained to keep proper records of patients who transferred-out and transferred-in. Among 4442 registered cases, 104 patients (2.3%) transferred out of reporting centres. Correct matching of "-out and -in" patients was achieved for 74 (71.2%) patients; the remaining 30 (28.8%) were untraced. By tracing transferred-out cases, the adjusted outcome success rate increased in the intervention period from 89.6% to 90.9%.

Postoperatve pain relief in children after subumbilical surgeries-a comparison between caudal bupivacaine and bupivacaine-clonidine

In a randomised case control study in children undergoing elective subumbilical surgery, we have assessed the clinical value of bupivacaine and bupivacaine-clonidine mixture for caudal analgesia. Sixty children aged 2-10 years, were allocated randomly to two equal groups (n=30) to receive 0.25% bupivacaine 1ml/kg (Group I) and 0.25% bupivacaine 1ml/kg with clonidine 2μg/kg (Group II). The baseline haemodynamic parameters, heart rate and blood pressure were recorded. Intraoperatively children in both groups maintained haemodynamic stability and required less amount of muscle relaxant. Duration of analgesia in minutes was assessed by the time interval between the caudal extradural injection and the first analgesic demand by the patient. It was significantly longer (p=0.000) in Group II (712 ± 15.30 minutes) as compared with Group I (246 ± 8.74 minutes). Group II required significantly less supplementary analgesia after operation. There was no significant difference in the incidence of side effects between the two groups. Group I received more doses of diclofenac suppository in first 24 postoperative hours. We conclude that, when added to bupivacaine, clonidine improves the duration of caudal analgesia in children undergoing subumbilical surgery.

Superficial extraconal blockade for vitreoretinal surgery

Context:

Needle length plays an important role for the success of ophthalmic block. The standard practice is to use 25 mm needles length; however, unnecessarily long needles may increase the risk of complications especially in the presence of staphyloma or previous scleral buckle.

Aims:

This work was designed to compare the efficacy of using 15 and 25 mm needle in performing extraconal block for patients undergoing vitreoretinal surgery.

Settings and Design:

Prospective randomized double blinded study.

Materials and Methods:

A total of 120 patients were enrolled in this study and were divided in two groups. In group (1) extraconal block was performed using 25 mm needle, while in group (2) 15 mm needle was used. After primary injection, assessment of the block was done by an anesthesiologist who was unaware of the needle used. If satisfactory akinesia was not achieved a supplementation was provided. At the end of the procedures, patients and surgeons were asked to assess their pain and satisfaction with the anesthetic technique.

Statistical Analysis used:

The sample size calculation using N-Quary version 4. Numerical and categorical data were analyzed using an independent sample, a two-tailed t-test, and chi-square test, respectively.

Results:

The volume of primary injectable was significantly higher in group 2. The two groups were comparable as regards total volume of local anesthetic, supplementation rate, akinesia, pain score, and surgeon satisfaction.

Conclusions:

Using 15 mm needle length to perform extraconal blockade for posterior segment procedures is equally effective to 25 mm needle.

Scintimammography in conjunction with ultrasonography for local breast cancer recurrence in post-mastectomy breast

The aim of this study was to compare the usefulness of (99)Tc(m)-methoxy-isobutyl-isonitrile (MIBI) scintimammography and ultrasonography, alone and in combination, for the detection of chest wall recurrence in the post-mastectomy breast. A total of 41 consecutive post-mastectomy patients (mean age 46.6 years; median age 45 years) with clinical suspicion of breast cancer recurrence were evaluated. For scintimammography all patients received a 740-900 MBq iv injection of (99)Tc(m)-MIBI; planar images were taken 5-10 min post-injection followed by supine single photon emission CT. Breast ultrasonography was performed in each patient using a 7.5 MHz transducer. Both MIBI uptake and ultrasound findings were documented using standard protocols. All patients had fine needle aspiration cytology biopsy (FNAC), core biopsy or excision biopsy for final tissue diagnosis. Of the 41 patients, 24 had true positive signs of local breast cancer recurrence upon ultrasonography, 10 were diagnosed as true negatives, a sensitivity of 86%, specificity 77%, positive predictive value (PPV) 89%, negative predictive value (NPV) 71% and accuracy 83% (p = 0.001). By comparison, scintimammography findings were found to be true positive in 25 patients and true negative in 12 patients - sensitivity 89%, specificity 92%, PPV 96%, NPV 80% and accuracy 90% (p = 0.001). Using a combination of these two modalities, the combined sensitivity was 100%, specificity 77%, PPV 90%, NPV 100% and accuracy 93%. The high NPV of the two studies in combination implies a potential use of this approach to exclude recurrent disease in patients with a low initial index of suspicion and/or when histology is indeterminate.

Influence of microfiltration and adjunct culture on quality of Domiati cheese

The effects of microfiltration and pasteurization processes on proteolysis, lipolysis, and flavor development in Domiati cheese during 2 mo of pickling were studied. Cultures of starter lactic acid bacteria isolated from Egyptian dairy products were evaluated in experimental Domiati cheese for flavor development capabilities. In the first trial, raw skim milk was microfiltered and then the protein:fat ratio was standardized using pasteurized cream. Pasteurized milk with same protein:fat ratio was also used in the second trial. The chemical composition of cheeses seemed to be affected by milk treatment-microfiltration or pasteurization-rather than by the culture types. The moisture content was higher and the pH was lower in pasteurized milk cheeses than in microfiltered milk cheeses at d 1 of manufacture. Chemical composition of experimental cheeses was within the legal limits for Domiati cheese in Egypt. Proteolysis and lipolysis during cheese pickling were lower in microfiltered milk cheeses compared with pasteurized milk cheeses. Highly significant variations in free amino acids, free fatty acids, and sensory evaluation were found among the cultures used in Domiati cheesemaking. The cheese made using adjunct culture containing Lactobacillus delbrueckii ssp. lactis, Lactobacillus paracasei ssp. paracasei, Lactobacillus casei, Lactobacillus plantarum, and Enterococcus faecium received high scores in flavor acceptability. Cheeses made from microfiltered milk received a higher score in body and texture compared with cheeses made from pasteurized milk.

Complete nucleotide sequence of cherry virus A (CVA) infecting sweet cherry in India

Cherry virus A (CVA) is a graft-transmissible member of the genus Capillovirus that infects different stone fruits. Sweet cherry (Prunus avium L; family Rosaceae) is an important deciduous temperate fruit crop in the Western Himalayan region of India. In order to determine the health status of cherry plantations and the incidence of the virus in India, cherry orchards in the states of Jammu and Kashmir (J&K) and Himachal Pradesh (H.P.) were surveyed during the months of May and September 2009. The incidence of CVA was found to be 28 and 13% from J&K and H.P., respectively, by RT-PCR. In order to characterize the virus at the molecular level, the complete genome was amplified by RT-PCR using specific primers. The amplicon of about 7.4 kb was sequenced and was found to be 7,379 bp long, with sequence specificity to CVA. The genome organization was similar to that of isolates characterized earlier, coding for two ORFs, in which ORF 2 is nested in ORF1. The complete sequence was 81 and 84% similar to that of the type isolate at the nucleotide and amino acid level, respectively, with 5' and 3' UTRs of 54 and 299 nucleotides, respectively. This is the first report of the complete nucleotide sequence of cherry virus A infecting sweet cherry in India.

Intravenous recombinant tissue plasminogen activator for acute stroke in Poland: an analysis based on the Safe Implementation of Thrombolysis in Stroke (SITS) Registry

OBJECTIVES

Intravenous thrombolysis was conditionally approved in the European Union (EU) in 2002, under the requirement of entering all patients into Safe Implementation of Thrombolysis in Stroke - Monitoring Study (SITS-MOST). Countries not belonging to the EU by 2002, i.e. Poland were invited to enter data into the SITS International Stroke Thrombolysis Registry (SITS-ISTR). The aim of this study is to compare the safety and efficacy of thrombolysis in the Polish SITS-ISTR stroke patient population with patients registered in SITS-MOST.

METHODS

481 patients in Poland were reported between 2003 and 2007. Baseline and outcome data of Polish patients were compared with SITS-MOST.

RESULTS

Most of the baseline characteristics did not differ between the groups. The most important was the onset-to-needle and door-to-needle times were significantly longer in Polish patients, 150 vs 136 min and 82 vs 68 min, respectively (P < 0.001). The symptomatic intracranial haemorrhage and independence rates at 3 months were similar in both populations. Polish patients had a significantly higher 3-month mortality rate, 18.6% vs 11.3% (P < 0.001).

CONCLUSIONS

Because of higher mortality the study implies the need to improve the organization of thrombolysis services and provides the rationale to continue the monitoring of treatment in Poland.

Outcome of hematopoietic stem cell transplant as salvage therapy for Hodgkin's lymphoma in adolescents and young adults at a single institution

For patients with relapsed Hodgkin's lymphoma (HL), high dose chemotherapy with stem cell rescue (HDCT-SCT) may improve survival over chemotherapy alone. We assessed the outcomes of HDCT-SCT in 37 consecutive adolescent and young adult patients with relapsed HL whose malignancy was categorized based on sensitivity to chemotherapy. We determined whether current outcomes supported the use of HDCT-SCT in all of our patients or just those patients with lower-risk characteristics such as chemosensitivity. With a median follow-up of 6.5 years, the 2-year overall survival (OS) was 89% (95% CI: 62-97%) for the chemosensitive patients (n = 21), whereas for patients with resistant disease (n = 16), OS was 53% (95% CI: 25-74%). Both autologous and allogeneic transplants were well tolerated, with 100-day treatment-related mortality under 10%. Our data show encouraging outcomes for patients with chemosensitive relapsed HL who receive hematopoietic stem cell transplant (HSCT) and support the value of the procedure even when the disease is chemoresistant.