Severe anemia after gastrointestinal hemorrhage in a Jehovah's Witness: new treatment strategies

Tracking Research on Hemoglobin-Based Oxygen Carriers: A Scientometric Analysis and In-Depth Review

Numerous studies on the formulation and clinical applications of novel hemoglobin-based oxygen carriers (HBOCs) are reported in the scientific literature. However, there are fewer scientometric analysis related to HBOCs. Here, we illustrate recent studies on HBOCs using both a scientometric analysis approach and a scope review method. We used the former to investigate research on HBOCs from 1991 to 2022, exploring the current hotspots and research trends, and then we comprehensively analyzed the relationship between concepts based on the keyword analysis. The evolution of research fields, knowledge structures, and research topics in which HBOCs located are revealed by scientometric analysis. The elucidation of type, acting mechanism, potential clinical practice, and adverse effects of HBOCs helps to clarify the prospects of this biological agent. Scientometrics analyzed 1034 publications in this research field, and these findings provide a promising roadmap for further study.

New Applications of HBOC-201: A 25-Year Review of the Literature

If not cured promptly, tissue ischemia and hypoxia can cause serious consequences or even threaten the life of the patient. Hemoglobin-based oxygen carrier-201 (HBOC-201), bovine hemoglobin polymerized by glutaraldehyde and stored in a modified Ringer's lactic acid solution, has been investigated as a blood substitute for clinical use. HBOC-201 was approved in South Africa in 2001 to treat patients with low hemoglobin (Hb) levels when red blood cells (RBCs) are contraindicated, rejected, or unavailable. By promoting oxygen diffusion and convective oxygen delivery, HBOC-201 may act as a direct oxygen donor and increase oxygen transfer between RBCs and between RBCs and tissues. Therefore, HBOC-201 is gradually finding applications in treating various ischemic and hypoxic diseases including traumatic hemorrhagic shock, hemolysis, myocardial infarction, cardiopulmonary bypass, perioperative period, organ transplantation, etc. However, side effects such as vasoconstriction and elevated methemoglobin caused by HBOC-201 are major concerns in clinical applications because Hbs are not encapsulated by cell membranes. This study summarizes preclinical and clinical studies of HBOC-201 applied in various clinical scenarios, outlines the relevant mechanisms, highlights potential side effects and solutions, and discusses the application prospects. Randomized trials with large samples need to be further studied to better validate the efficacy, safety, and tolerability of HBOC-201 to the extent where patient-specific treatment strategies would be developed for various clinical scenarios to improve clinical outcomes.

Treating a Patient with Your Hands Tied: Acute Chest Syndrome in a Jehovah's Witness

Acute chest syndrome (ACS), a vaso-occlusive crisis in patients with sickle cell anemia, is a life-threatening condition and a leading cause of death in these patients. It is treated with analgesics, antibiotics, intravenous fluid, supplemental oxygen (or ventilatory support in severe cases) with simple or exchange transfusion, being the mainstay of therapy. We report a young Jehovah's Witness (JW) patient with sickle cell anemia who presented with ACS. Her religious beliefs precluded the use of blood products. Despite concomitant hemolytic and aplastic crisis and a hemoglobin nadir of 3.1 g/dL, the patient was treated successfully with supportive care - including mechanical ventilation, sedation, paralysis, and erythropoiesis stimulation - and survived. A maximal supportive strategy consisting of ventilatory support with a high fraction of inspired oxygen, sedation, paralysis, erythropoiesis stimulation, and limitation of blood draws can result in the successful treatment of JW patients who refuse blood products.

Bloodless Intensive Care: A Case Series and Review of Jehovah's Witnesses in ICU

The objective of this study was to assess the outcome of Jehovah's Witness (JW) patients admitted to a major Australasian ICU and to review the literature regarding the management of critically ill Jehovah's Witness patients.

All Jehovah's Witness patients admitted to the ICU between January 1999 and September 2003 were identified from a prospective database. Their ICU mortality, APACHE II scores, APACHE II risk of death and ICU length of stay were compared to the general ICU population. Twenty-one (0.24%) out of 8869 patients (excluding re-admissions) admitted to the ICU over this period were Jehovah's Witness patients. Their mean APACHE II score was 14.1 (±7.0), the mean APACHE II risk of death was 21.2% (±16.6), and the mean nadir haemoglobin (Hb) was 80.2 g/l (±36.4). Four out of 21 Jehovah's Witness patients died in ICU compared to 782 out of 8848 non- Jehovah's Witness patients (19.0% vs 8.8%, P=0.10, chi square). The median ICU length of stay in both groups was two days (P=0.64, Wilcoxon rank sum). The lowest Hb recorded in a survivor was 23 g/l.

Jehovah's Witness patients appear to be an uncommon patient population in a major Australasian ICU but are not over-represented when compared with their prevalence in the community. Despite similar severity of illness scores and predicted mortality to those in the general ICU population, there was a trend towards higher mortality in Jehovah's Witness patients.

Treatment of individuals who cannot receive blood products for religious or other reasons

By virtue of their religious principles, Jehovah's Witnesses (JWs) generally object to receiving blood products, raising numerous ethical, legal, and medical challenges for providers who care for these patients, especially in the emergent setting. In this review, we discuss several areas relevant to the care of JWs, including the current literature on "bloodless" medical care in the setting of perioperative and intraoperative management, acute blood loss, trauma, pregnancy, and malignancy. We have found that medical and administrative efforts in the form of bloodless medicine and surgery programs can be instrumental in helping to reduce risks of morbidity and mortality in these patients. Planning prior to an anticipated event associated with blood loss or anemia (such as elective surgery, pregnancy, and chemotherapy) is critical. Specifically, bloodless medicine programs should prioritize vigilant early screening and management of anemias, early establishment of patient wishes regarding transfusion, and the incorporation of those wishes into multidisciplinary medical and surgical care. Although there are now a variety of human-based and nonhuman-based products available as transfusion alternatives, the degree and quality of evidence to support their use varies significantly between products and is also largely dependent on the clinical setting.

Use of hyperbaric oxygen therapy and PEGylated carboxyhemoglobin bovine in a Jehovah's Witness with life-threatening anemia following postpartum hemorrhage

We present a case of a Jehovah's Witness patient who refused blood products, with the exception of albumin and clotting factors, and underwent cesarean section under spinal anesthesia complicated by postpartum hemorrhage. She was fluid resuscitated and treated with multiple uterotonics and internal iliac artery embolization. Because of agitation she required emergency tracheal intubation. Her hemoglobin concentration dropped from a preoperative value of 12mg/dL to 3mg/dL on postoperative day one. She was acidotic, requiring vasopressors for hemodynamic stability and remained ventilated and sedated. She was treated with daily erythropoietin, iron therapy and cyanocobalamin. Because of ongoing hemorrhage, continued acidemia and vasopressor requirements she was co-treated with PEGylated carboxyhemoglobin bovine and hyperbaric oxygen therapy to reverse her oxygen debt. On postoperative day eight her hemoglobin concentration was 7mg/dL, she was hemodynamically stable and vasopressors were discontinued. She was extubated and discharged from the intensive care unit on postoperative day eight. This report highlights the multiple modalities used in treating a severely anemic patient who refused blood, the use of an investigational new drug, the process of obtaining this drug via the United States Food and Drug Administration emergency expanded access regulation for single patient clinical treatment, and ethical dilemmas faced during treatment.

Failure to address African Americans' spiritual needs during hospitalization: identifying predictors of dissatisfaction across the arc of service provision

Using a national sample of recently hospitalized older African Americans (N = 2,227), this study identified predictors of dissatisfaction with the manner in which clients' spiritual needs were addressed during hospitalization. Of 8 major areas of service provision examined, 3 were significant predictors of dissatisfaction: nurses, physicians, and the discharge process. The findings underscore the importance of collaborative efforts to address elderly Black clients' spiritual needs. Social workers, who frequently oversee the discharge process, can play an important role in addressing African Americans' spiritual needs by developing discharge plans that incorporate clients' spiritual strengths and resources into the planning process.

Surgical management in treatment of Jehovah's witness in trauma surgery in Indian subcontinent

The Jehovah's Witness religion is a Christian movement, founded in the US in the 1870s, with 7 million followers worldwide with only 0.002% in India. There is minimal to complete absence of awareness about the existence of this community in our society. Astonishing is that fact that among medical professionals, there is almost no awareness about this unique population, regarding the fact that they completely refuse of blood transfusion even if it leads to their death. This is integral to their faith. Besides legal and ethical issues in treating these group of patients, the biggest challenge exist even in the western world is their management in trauma scenario where few options exist. We have discussed the issues and recommendations in management in trauma scenario in our Indian subcontinent.

Adenosine-5'-triphosphate-adenosine-glutathione cross-linked hemoglobin as erythropoiesis-stimulating agent

An effective hemoglobin (Hb)-based blood substitute that acts as a physiological oxygen carrier and volume expander ought to stimulate erythropoiesis. A speedy replacement of blood loss with endogenous red blood cells should be an essential feature of any blood substitute product because of its relatively short circulatory retention time and high autoxidation rate. Erythropoiesis is a complex process controlled by oxygen and redox-regulated transcription factors and their target genes that can be affected by Hb physicochemical properties. Using an in vitro cellular model, we investigated the molecular mechanisms of erythropoietic action of unmodified tetrameric Hb (UHb) and Hb cross-linked with adenosine-5'-triphosphate (ATP), adenosine, and reduced glutathione (GSH). These effects were studied under normoxic and hypoxic conditions. Results indicate that these Hb solutions have different effects on stabilization and nuclear translocation of hypoxia-inducible factor (HIF)-1 alpha, induction of the erythropoietin (EPO) gene, activation of nuclear factor (NF)-kappa B, and expression of the anti-erythropoietic agents-tumor necrosis factor-alpha and transforming growth factor-beta 1. UHb suppresses erythropoiesis by increasing the cytoplasmic degradation of HIF-1 alpha and decreasing binding to the EPO gene while inducing NF-kappa B-dependent anti-erythropoietic genes. Cross-linked Hb accelerates erythropoiesis by downregulating NF-kappa B, stabilizing and facilitating HIF-1 alpha binding to the EPO gene, under both oxygen conditions. ATP and adenosine contribute to normoxic stabilization of HIF-1 and, with GSH, inhibit the NF-kappa B pathway that is involved in the suppression of erythroid-specific genes. Proper chemical/pharmacological modification is required to consider acellular Hb as an erythropoiesis-stimulating agent.

When a patient refuses life-saving care: issues raised when treating a Jehovah's Witness

Patients who are Jehovah's Witnesses frequently cross the path of nephrologists when they are acutely ill in the intensive care unit and stable in the long-term setting. It is important that we as a group have a rudimentary understanding of their philosophy about blood transfusion so that we can be proactive in their management. We use a case as a launching point to discuss the origins of the faith and the decision to refuse blood, as well as potential therapeutic strategies that can be used to improve the care of these patients. Improvement in our understanding as physicians will facilitate a more productive conversation with our patients about a complex and emotional issue.

Resuscitation and monitoring in gastrointestinal bleeding

INTRODUCTION

Gastrointestinal bleeding is a common life-threatening problem, causing significant mortality, costs and resource allocation. Its management requires a dynamic multidisciplinary approach that directs diagnostic and therapeutic priorities appropriately.

MATERIALS AND METHODS

Articles published within the past 15 years, related to gastrointestinal bleeding, were reviewed through MEDLINE search, in addition to current guidelines and standards.

RESULTS

Decisions of ICU admission and blood transfusion must be individualized based on the extent of bleeding, hemodynamic profile and comorbidities of the patient and the risk of rebleeding. A secure airway may be required to optimize oxygenation and to prevent aspiration. Doses of induction agents must be reduced due to the changes in volume of distribution. Volume replacement is the cornerstone of resuscitation in profuse bleeding, but nontargeted aggressive fluid resuscitation must be avoided to allow clot formation and to prevent increased bleeding. Decision to give blood transfusion must be based on physiologic triggers rather than a fixed level of hemoglobin. Coagulopathy must be corrected and hypothermia avoided. Need for massive transfusion must be recognized as early as possible, and a 1:1:1 ratio of packed red blood cells, fresh frozen plasma and platelets is recommended to prevent dilutional coagulopathy. Tromboelastography can be used to direct hemostatic resuscitation. Transfusion related lung injury (TRALI) is a significant problem with a mortality rate approaching 40%. Prevention of TRALI is important in patients with gastrointestinal bleeding, especially among patients having end-stage liver disease. Preventive strategies include prestorage leukoreduction, use of male-only or never-pregnant donors and avoidance of long storage times. Management of gastrointestinal bleeding requires delicately tailoring resuscitation to patient needs to avoid nonspecific aggressive resuscitation. "Functional hemodynamic monitoring" requires recognition of indications and limitations of hemodynamic measurements. Dynamic indices like systolic pressure variation are more reliable predictors of volume responsiveness. Noninvasive methods of hemodynamic monitoring and cardiac output measurement need further verification in patients with gastrointestinal bleeding.

CONCLUSIONS

Management of gastrointestinal bleeding requires a dynamic multidisciplinary approach. The mentioned advances in management of hemorrhagic shock must be considered in resuscitation and monitoring of patients with GI bleeding.

Protective effects of hemoglobin-based oxygen carrier given to isolated heart during ischemia via attenuation of mitochondrial oxidative damage

Ischemia/reperfusion (I/R) injury is harmful to the cardiovascular system and responsible for mitochondrial oxidative stress, which will in turn aggravate cardiac dysfunction. This study was designed to investigate the protective effect of a hemoglobin-based oxygen carrier (HBOC) on I/R heart and to elucidate the potential mechanism. Isolated Sprague-Dawley rat hearts were perfused in Langendorff mode. After 30-min basal perfusion, warm ischemia (37 degrees C) or hypothermic storage (4 degrees C) was performed and followed by 2-h reperfusion. The results of our study reveal that HBOC provides a profound protection against cardiac I/R injury as evidenced by significantly improved cardiac function and decreased myocardial infarction, necrosis, and apoptosis. In addition to more oxygen supply to the myocardium, the cardioprotection of HBOC was closely related to well-preserved mitochondrial redox potential, significantly elevated mitochondrial superoxide dismutase activity, and decreased mitochondrial hydrogen peroxide and malondialdehyde formation, which indicated that the I/R-induced mitochondrial oxidative damage was remarkably attenuated. Furthermore, the elevated mitochondrial function and unchanged mitochondrial structure provide additional evidence of the prominent role of HBOC in mitochondrial preservation. In conclusion, our results demonstrate the cardioprotective effect of HBOC on I/R heart and reveal that this protection was mediated in large part by attenuation of mitochondrial oxidative damage.

Management of adult Jehovah's Witness patients with acute bleeding

Because of the firm refusal of transfusion of blood and blood components by Jehovah's Witnesses, the management of Jehovah's Witness patients with severe bleeding is often complicated by medical, ethical, and legal concerns. Because of a rapidly growing and worldwide membership, physicians working in hospitals should be prepared to manage these patients. Appropriate management of a Jehovah's Witness patient with severe bleeding entails understanding of the legal and ethical issues involved, and meticulous medical management, including treatment of hypovolemic shock, local hemostatic interventions, and administration of prohemostatic agents, when appropriate. In addition, high-dose recombinant erythropoietin in combination with supplemental iron may enhance the speed of hemoglobin synthesis.

Clinical strategies for supporting the untransfusable hemorrhaging patient

Hemorrhaging patients who cannot be transfused due to personal beliefs or the lack of compatible blood products provide a unique challenge for clinicians. Here we describe a 58-year-old African American man with a history of sickle cell-beta(+) thalassemia who had recently received a multiunit exchange transfusion and developed hematochezia followed by severe anemia. Due to the presence of multiple alloantibodies, no compatible packed red blood cell (pRBC) units could initially be located. The patient was managed with mechanical ventilation, colloid and crystalloid solutions, procoagulants, and recombinant erythropoietin. After an extensive search by our blood bank, enough compatible pRBC units were identified and the patient survived without significant clinical sequelae. Management of the untransfusable hemorrhaging patient requires a multidisciplined approach, with coordination between blood banks, hematologists, intensivists, and other specialists. Steps should be taken to avoid or limit blood loss, identify compatible pRBC units, control hypotension, maximize oxygen delivery, minimize metabolic demand, and stimulate erythropoiesis. In dire circumstances, use of experimental hemoglobin substitutes or transfusion of the least serologically incompatible pRBCs available may be considered.

Polymerized placenta hemoglobin attenuates ischemia/reperfusion injury and restores the nitroso-redox balance in isolated rat heart

Ischemia/reperfusion (I/R) injury mainly caused by oxidative stress plays a major role in cardiac damage. The extent of the I/R injury is also an important factor that determines the function of a transplanted heart. This study first examined whether hemoglobin-based oxygen carriers (HBOCs) could protect isolated rat heart from I/R injury and then elucidated the underlying mechanism. Using the Langendorff model, isolated Sprague-Dawley rat hearts were arrested and stored at 4 degrees C for 8 h and then reperfused for 2 h. Compared with St. Thomas' solution (STS) and rat self blood in STS, polymerized placenta hemoglobin (PolyPHb) in STS greatly improved heart contraction and decreased infarction size. The extent of myocardial apoptosis was also significantly decreased, which was related to reduced iNOS-derived nitric oxide production, increased protein ratio of Bcl-2/Bax, and reduced caspase-3 activity and cleavage level. Furthermore, PolyPHb in STS did not increase malondialdehyde, peroxynitrite, or mitochondrial hydrogen peroxide formation, but greatly elevated superoxide dismutase activity and preserved mitochondrial ATP synthesis, which served to maintain redox homeostasis in I/R heart. In conclusion, our results demonstrate that HBOCs protected isolated heart from I/R injury and this protection was associated with attenuation of NO-mediated myocardial apoptosis and restoration of the nitroso-redox balance.

Inhaled nitric oxide enables artificial blood transfusion without hypertension

BACKGROUND

One of the major obstacles hindering the clinical development of a cell-free, hemoglobin-based oxygen carrier (HBOC) is systemic vasoconstriction.

METHODS AND RESULTS

Experiments were performed in healthy mice and lambs by infusion of either murine tetrameric hemoglobin (0.48 g/kg) or glutaraldehyde-polymerized bovine hemoglobin (HBOC-201, 1.44 g/kg). We observed that intravenous infusion of either murine tetrameric hemoglobin or HBOC-201 induced prolonged systemic vasoconstriction in wild-type mice but not in mice congenitally deficient in endothelial nitric oxide (NO) synthase (NOS3). Treatment of wild-type mice by breathing NO at 80 ppm in air for 15 or 60 minutes or with 200 ppm NO for 7 minutes prevented the systemic hypertension induced by subsequent intravenous administration of murine tetrameric hemoglobin or HBOC-201 and did not result in conversion of plasma hemoglobin to methemoglobin. Intravenous administration of sodium nitrite (48 nmol) 5 minutes before infusion of murine tetrameric hemoglobin also prevented the development of systemic hypertension. In awake lambs, breathing NO at 80 ppm for 1 hour prevented the systemic hypertension caused by subsequent infusion of HBOC-201.

CONCLUSIONS

These findings demonstrate that HBOC can cause systemic vasoconstriction by scavenging NO produced by NOS3. Moreover, in 2 species, inhaled NO administered before the intravenous infusion of HBOC can prevent systemic vasoconstriction without causing methemoglobinemia.

Blood substitutes: hemoglobin-based oxygen carriers

Blood product substitutes, particularly the hemoglobin-based oxygen carriers, represent one of the most exciting fields of research and development in modern medicine. The concept has been several decades in the making, and with products in phase III clinical trials, the use of hemoglobin-based oxygen carriers may be close to reality. The potential applications are limitless with interest from the military and civilian sectors.

Use of hemoglobin raffimer for postoperative life-threatening anemia in a Jehovah’s Witness

PURPOSE

To describe the successful treatment of acute, life-threatening anemia with the oxygen therapeutic agent, hemoglobin (Hb) raffimer.

CLINICAL FEATURES

A 53-yr-old female Jehovah's Witness developed severe anemia following total hip replacement. Due to prior patient directive, red blood cells were not transfused. Tachycardia, hypotension, electrocardiographic abnormalities and mental status changes developed with a nadir Hb concentration of 3.2 g x dL(-1). Hb raffimer is a purified, cross-linked, human Hb solution developed as a substitute for red blood cell Hb. After obtaining informed consent as well as Food and Drug Administration and Institutional Review Board approval for compassionate use, 2 L of Hb raffimer (Hemolink, Hemosol, Inc., Toronto, ON, Canada) were administered along with ferrous sulfate and epoetin alfa therapy. The patient's Hb level rose to 5.5 g x dL(-1) with resolution of symptoms. To allow recovery of red blood cell mass while maintaining Hb level > 4.5 g x dL(-1), additional 1000 mL doses of Hb raffimer were administered on postoperative days three, five and seven (total dose = 500 g Hb). The patient developed no serious adverse events related to treatment with Hb raffimer. By postoperative day 14, the patient's Hb level increased to 6.5 g x dL(-1) with a hematocrit of 23%. The patient was discharged.

CONCLUSIONS

Use of Hb raffimer as a bridge to recovery of this patient's red blood cell mass may have prevented adverse clinical outcome. Because this product is a purified Hb solution devoid of other cellular components, it may be accepted as therapy by patients who, due to religious conviction, refuse allogeneic red blood cell transfusion.

Successful Use of a Polymerized Hemoglobin Blood Substitute in a Critically Anemic Jehovahʼs Witness

A stable, polymerized hemoglobin product has been formulated that overcomes the three traditional hurdles of hemoglobin-based blood substitutes: nephrotoxicity, osmotic diuresis, and blood-borne pathogens. We present a case of a patient with persistent colonic bleeding and a hemoglobin of 2.9 g/100 mL. Since her religious faith prevented her from accepting blood products, we offered a hemoglobin-based substitute and describe the use of this product.

Kidney and pancreas transplants in Jehovah's witnesses: ethical and practical implications

Jehovah's Witnesses refuse blood transfusions but accept solid organ transplants. Six Jehovah's Witnesses received a kidney and/or a pancreas transplant in our center. After a mean follow-up of 31.4 months (range: 18 to 39) all the recipients are alive and well with functioning grafts. However, 1 month after grafting, one recipient required blood transfusions. Hemorrhage was ruled out and the anemia was attributed to drug-related toxicity. Thus, Jehovah's Witnesses can receive a kidney and/or a pancreas transplant without blood transfusions at the time of surgery. However, lifesaving transfusions may be needed later on, which raises additional and unique medical and ethical issues.

Care of the injured Jehovah's Witness patient: Case report and review of the literature

Care for the Jehovah's Witness patient can be a challenge and often a dilemma to clinicians because of the patient's religious beliefs and teachings against receiving blood and blood products, especially in emergency or trauma settings. We present a case of a severely injured elderly Jehovah's Witness patient who survived. We also review the literature and offer an organized approach to care for such patients.

Use of a hemoglobin-based oxygen carrier in the treatment of severe anemia

BACKGROUND

Hemoglobin-based oxygen carriers hold promise for the treatment of acute anemia.

CASE

We report a patient with severe dysfunctional uterine bleeding. During her hospitalization, her lowest hemoglobin level was 3.1 g/dL, with a hematocrit of 9.3%. An investigational product, o-raffinose cross-linked human hemoglobin solution (hemoglobin raffimer), was infused along with ongoing high-dose recombinant human erythropoietin and estrogen. The time until the patient's own hematopoiesis provided sufficient red blood cell mass was successfully managed by reducing oxygen demand and providing multiple hemoglobin-based oxygen carrier infusions. After hemoglobin-based oxygen carrier administration, transient pulmonary hypertension and fever were noted. She was discharged after corrective surgery 7 days after hemoglobin-based oxygen carrier administration with a hemoglobin level of 7.8 g/dL.

CONCLUSION

The hemoglobin level-based oxygen carrier improved oxygen delivery and permitted uterine corrective surgery.

Does recombinant human erythropoietin accelerate correction of post-ulcer-bleeding anaemia A pilot study

AIM: Anaemia caused by acute upper gastrointestinal bleeding is treated with blood transfusion or iron, but patients usually face a two-month recovery period from post-haemorrhage anaemia. This prospective, randomised, open, pilot study was designed to investigate whether recombinant human erythropoietin (Epoetin) therapy accelerate haematocrit increase in the post-bleeding recovery period.

METHODS: We studied hospitalised patients admitted because of acute ulcer bleeding or haemorrhagic gastritis, who had a haematocrit of 27%-33% and did not receive blood transfusions. One day after the endoscopic confirmation of cessation of bleeding, they were randomised either to erythropoietin (20000 IU Epoetin alfa subcutaneously, on days 0, 4 and 6) plus iron (100 mg im, on days 1 - 6, (G₁) or iron only (G₂). Haematocrit was measured on days 0, 6, 14, 30, 45, and 60, respectively.

RESULTS: One patient from G₁ and two from G₂ were lost to follow-up. Therefore, 14 and 13 patients from G₁ and G₂ respectively were analysed. Demographic characteristics, serum iron, ferritin, total iron binding capacity, reticulocytes, and haematocrit were not significantly different at entry to the study. Median reticulocyte counts were significantly different between groups on day six (G₁: 4.0, 3.0-6.4 vs G₂: 3.5, 2.1%-4.4%, P = 0.03) and median haematocrit on day fourteen [G₁: 35.9, 30.7-41.0 vs G_2: 32.5, 29.5%-37.0% (median, range), P = 0.04].

CONCLUSION: Erythropoietin administration significantly accelerates correction of anemia after acute ulcer bleeding. The haematocrit gain is equivalent to one unit of transfused blood two weeks after the bleeding episode.

Red blood cell transfusion in autoimmune hemolytic anemia

PURPOSE OF REVIEW

Transfusion, in the setting of autoimmune hemolytic anemia, can be a complicated and potentially dangerous proposition.

RECENT FINDINGS

The selection and delivery of an appropriate red blood cell unit must focus on several areas: (1) the laboratory detection of the autoantibody, (2) the detection of clinically significant red blood cell alloantibodies potentially masked by the autoantibodies, and (3) the selection and delivery of appropriate, although potentially incompatible, units. In addition, alternatives to red blood cell transfusion, specifically red blood cell substitutes, may also play an important role in the clinical treatment of these patients in the future.

SUMMARY

In this article, we will review the most recent developments in the transfusion management of patients with autoimmune hemolytic anemia, specifically focusing on published articles between the period of May 2002 to April 2003.

The risk of death for Jehovah's Witnesses after major trauma

BACKGROUND

Trauma surgeons are faced with life-threatening blood loss in patients such as Jehovah's Witnesses. We assessed and compared the risks of death after major trauma for Jehovah's Witnesses and other religious groups.

METHODS

A retrospective cohort study was conducted between August 1992 and September 1999 in a Level I academic trauma center. Statistical methods included Tukey's one-way analysis of variance, chi2 analysis, and bivariate and multivariate logistic regression analyses.

RESULTS

The cohort consisted of 556 patients: 82 Jehovah's Witnesses (14.7%), 52 Baptists (9.4%), 101 Catholics (18.2%), and 321 patients belonging to other religious groups (57.7%). Mean Injury Severity Scores for 433 patients were 10.3 +/- 9, 8.9 +/- 10, 10.3 +/- 11, and 11.3 +/- 14, respectively. There were no significant differences in mean Injury Severity Scores between religious groups, and no statistically significant associations between religion and Injury Severity Scores were identified. Significant predictors of mortality were age, systolic blood pressure at admission, Glasgow Coma Scale score, and type of trauma. Jehovah's Witnesses were 6% more likely to die after major trauma than Baptists, 20% more likely than Catholics, and as likely as patients from any other religious groups.

CONCLUSION

After controlling for age, race, systolic blood pressure, Glasgow Coma Scale score, and type of trauma, Jehovah's Witnesses have a nonsignificant increased risk of death after major trauma compared with other religious groups.