Red blood cell transfusion in palliative care: what are we doing and why are we doing it?

Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/141052/1/trf14437.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/141052/2/trf14437_am.pd

Intravascular Talcosis due to Intravenous Drug Use Is an Underrecognized Cause of Pulmonary Hypertension

Intravenous injection of illegal drugs or medications meant for oral administration can cause granulomatous disease of the lung. This intravascular talcosis results in pulmonary fibrosis and pulmonary hypertension. Nine cases of histologically confirmed intravascular talcosis were reviewed with specific attention given to the clinical histories in these patients. Five autopsy cases were included in this series with detailed investigation in the anatomic features associated with intravascular talcosis and pulmonary hypertension. All nine patients showed perivascular and/or intravascular deposition of polarizable foreign material in their lungs. Intravascular talcosis as a result of previous intravenous drug use was not clinically suspected in any patient despite clinically diagnosed pulmonary hypertension in five. All patients showed dilatation of the right and left heart, but none had dilatation of the aortic valve. Congestive heart failure with hepatosplenomegaly was also common. We conclude that intravascular talcosis is an underdiagnosed cause of pulmonary hypertension in patients with known history of intravenous drug use

The top 10 things to know about transfusion medicine before intern year: an evidence-based course for graduating medical students.

Background: Transfusion medicine (TM) knowledge varies widely among physician trainees. In addition, there have been few instances in which curricular changes have been meaningfully assessed for TM education in medical school. Methods: We created and presented a novel lecture to improve TM knowledge for graduating medical students using eight objectives designed to reinforce critical information about blood management. Each objective was coded according to unique color schemes, fonts, and graphics to create visual associations while quickly and clearly presenting complex concepts. The validated BEST Collaborative exam was used to measure changes in student TM knowledge, while a survey was conducted to gauge changes in confidence for each objective. Students were asked to submit anonymous feedback about their experiences. Results: The mean student post-course exam score was 50.0%, while the pre-course baseline score was 27.5% (P\u3c0.0001). Mean confidence levels increased significantly for all objectives. Student feedback was universally positive. Conclusion: This study improved knowledge and confidence for graduating medical students by utilizing engaging and visually stimulating presentations to display high-impact TM material. However, further efforts are needed to optimize learning

Pregnancy outcome in patients with fibroid: a retrospective study

Background: Fibroids are benign smooth muscle cell tumour of the uterus. In some patients of pregnancy associated with fibroid, it does not affect the outcome of pregnancy. On the other hand, various complications have been reported. The aim of our study was to evaluate the outcome in antenatal women with fibroids.Methods: This retrospective study was conducted at tertiary care center, obstetrics & gynecology department over a period of eighteen months between June 2018 to November 2019. Total 26 pregnant patients with >3 cm fibroid was included in the study. They were followed during antenatal period. Maternal age, parity, size of fibroid, complications during pregnancy, labour, and delivery, mode of delivery and indications of cesarean section were noted.Results: Out of 26 patients, 15 (57.6%) were between 26-30 years of age group and 16 (61.53%) were multigravidas. Normal vaginal delivery occurred in 8 (33.33%), while 16 (66.66%) delivered by caesarean section. There were 9 (34.61%) patients who had no complication whereas 17 (65.38%) had some complication. Pain was present in 8 (30.76%). PROM and preterm labour were present in 3 (18.75%) and 5 (19.23%) respectively. PPH was present in 2 (7.69%).Conclusions: Pregnant patients who have fibroids are to be carefully screened in the antenatal period, so as to have a regular follow up. The widespread use of ultrasonography has facilitated diagnosis and management of fibroids in pregnancy. The site and size of fibroid is very important to predict its effect on pregnancy

Longitudinal Assessments Using Validated Instruments In Myasthenia Gravis Outpatients Receiving Long-Term Therapeutic Plasma Exchange

Purpose: In the most recent American Society for Apheresis Guidelines on the Use of Therapeutic Apheresis in Clinical Practice, employing therapeutic plasma exchange (TPE) for long-term treatment of myasthenia gravis (MG) patients is a new indication and carries a category II, grade 2B recommendation. As data for this indication is evolving and subjective assessments of these patients are often uninformative, we sought to better characterize the impacts of long-term TPE in these MG patients using validated instruments. Methods: In this prospective observational study, we used a combination of validated instruments and openended questions clarifying concerns that are routinely applied to MG patients. The two validated instruments were the MG Activities of Daily Living (MG-ADL) and MG Quality of Life 15 (MG-QoL15r) profiles. Based on previous literature, a 2-point change in the MG-ADL and a 10-point change in the MGQoL15r indicates significant improvement or worsening. Over a 3-month period, MG patients receiving long-term TPE were assessed using a single-form questionnaire that integrated all of the MG-ADL and MG-QoL15r elements and was completed at every visit. Patients unable to complete the survey due to their medical condition were exempted. Results: In total, 9 patients were eligible and received long-term TPE at frequencies from 3 times per week to 1 time per month. Five patients (56%) were female, 6 (67%) were white, and mean age was 54 years. Active pharmacotherapy included prednisone, azathioprine, mycophenolate, rituximab, and pyridostigmine. All patients reported that lengthening the interval between successive TPE treatments, even by a few days, resulted in noticeable MG changes. Five patients (56%) were clinically stable during the study period and had no significant changes in MG-ADL or MG-QoL15r profiles, though these patients still documented issues with sight, speech, muscular weakness, and fatigue. During the study period, 4 patients (44%) had significant changes identified by the MG-ADL, a mean of 5.5 times per patient (range 2-8) and 2 (22%) had significant changes identified by the MG-QoL15r, a mean of 2 times per patient (range 1-3). MG-ADL appeared to be more sensitive in correlating with patient-reported clinical changes, with clinical improvements identified a mean of 3.2 times per patient and clinical deteriorations identified a mean of 2.3 times per patient (compared to 1.5 and 1 times per patient, respectively, for the MG-QoL15r; p=0.03 for interaction effect). In the 4 patients with significant changes in profile scores, associated clinical changes in breathing, swallowing, sight, speech, muscular strength, and fatigue were reported. Importantly, for all of 4 of these patients, subjective clinical deteriorations in conjunction with objectively worsening MG-ADL scores were used as evidence to medically justify intensification of TPE therapy. Conclusions: Objective longitudinal assessments in MG patients receiving long-term TPE may be helpful for accurate disease monitoring. A subset of MG patients receiving long-term TPE still has dynamic changes in disease status as assessed by clinical history and two different validated instruments. In all patients with stable MG, both the MD-ADL and MG-QoL15r accurately indicated no significant changes. However, in those with fluctuating disease status, MG-ADL was more sensitive to both clinical improvement and worsening. These findings need to be validated in larger studies

Aged Human Stored Red Blood Cell Supernatant Inhibits Macrophage Phagocytosis in an HMGB1 Dependent Manner After Trauma in a Murine Model:

Red blood cell transfusions in the setting of trauma is a double edged sword, as it is a necessary component for life-sustaining treatment in massive hemorrhagic shock, but also associated with increased risk for nosocomial infections and immune suppression. The mechanisms surrounding this immune suppression are unclear. Using supernatant from human packed red blood cell (RBC), we demonstrate that clearance of E. coli by macrophages is inhibited both in vitro and in vivo using a murine model of trauma and hemorrhagic shock. We further explore the mechanism of this inhibition by demonstrating that human stored RBCs contain soluble high mobility group box 1 protein (HMGB1) which increases throughout storage. HMGB1 derived from the supernatant of human stored RBCs was shown to inhibit bacterial clearance, as neutralizing antibodies to HMGB1 restored the ability of macrophages to clear bacteria. These findings demonstrate that extracellular HMGB1 within stored RBCs could be one factor leading to immune suppression following transfusion in the trauma setting

Effectiveness of an Algorithm-Based Approach to the Utilization of Plerixafor in Patients Undergoing Chemotherapy-Based Stem Cell Mobilization

AbstractAutologous stem cell transplantation remains a mainstay of therapy for diseases such as multiple myeloma and relapsed lymphoma. The use of plerixafor has been shown to augment the ability to collect adequate stem cells, but the optimal use of this agent when used with chemotherapy is not yet clear. We utilized an algorithm-based approach with the addition of plerixafor to 54 patients undergoing chemomobilization with reduced-dose etoposide who had a less than optimal preapheresis CD34+ cell count. We used a CD34+ precount of 20 cells/μL as a threshold to initiate stem cell apheresis. Ninety-four percent of patients were successfully collected and proceeded to transplantation. Fourteen of 51 (28%) patients who successfully collected required plerixafor to augment stem cell yield. Of the patients who successfully collected, 94% (89% of the entire population) were able to collect in 2 or fewer days. Compared with previous data from our institution, the rate of patients collecting > 4 × 106 CD34+ cells/kg in a single collection was increased from 39% to 69%. The safety profile of this approach was acceptable. The use of this algorithm-based method to determine when and whether to add plerixafor to chemomobilization was shown to be a successful and cost-effective approach to stem cell collection

COVID-19 Convalescent Plasma Therapy Decreases Inflammatory Cytokines: A Randomized Controlled Trial

This study examined the role that cytokines may have played in the beneficial outcomes found when outpatient individuals infected with SARS-CoV-2 were transfused with COVID-19 convalescent plasma (CCP) early in their infection. We found that the pro-inflammatory cytokine IL-6 decreased significantly faster in patients treated early with CCP. Participants with COVID-19 treated with CCP later in the infection did not have the same effect. This decrease in IL-6 levels after early CCP treatment suggests a possible role of inflammation in COVID-19 progression. The evidence of IL-6 involvement brings insight into the possible mechanisms involved in CCP treatment mitigating SARS-CoV-2 severity