Red coral keratitis

PURPOSE

We describe a 39-year-old woman who was seen for pain and blurred vision in the right eye that presented immediately after scuba diving several inches from a red coral reef.

METHODS

The patient was found to have multiple superficial corneal foreign bodies with adjacent infiltrates on slit-lamp examination. She was treated with long-term topical corticosteroids.

RESULTS

The infiltrates and symptoms gradually resolved after nearly 3 months of treatment.

CONCLUSION

This case represents a form of keratitis caused by exposure to red coral. Possible mechanisms for the keratitis include type I and 4 hypersensitivities, resulting from the release of vasoactive substances. This is triggered by the red coral's nematocysts, or toxin-releasing organelles. Long-term corticosteroid treatment was effective in resolving the lesions.

The cost-effectiveness of postoperative recovery of RBCs in preventing transfusion-associated virus transmission after joint arthroplasty

BACKGROUND

The return of joint drainage after hip and knee arthroplasty is a widely used but expensive blood-conservation technique.

STUDY DESIGN AND METHODS

A Markov decision analysis model was used to evaluate the cost-effectiveness of postoperative RBC recovery in preventing viral complications of allogeneic transfusion.

RESULTS

In the baseline analysis, using an RBC-recovery device saves 5 quality-adjusted minutes of longevity at an average incremental cost of $53. This corresponds to $5.7 million per quality-adjusted life year. This figure was most sensitive to the direct cost differences of allogeneic versus recovered RBCs and to the volume of RBCs recovered per device. Such devices would save health care resources if they cost less than $73 or if they were applied only in cases where joint drainage was between 600 and 1100 mL.

CONCLUSION

For most clinical situations, postarthroplasty RBC recovery does not appear to be as cost-effective as most other medical interventions. Clinical attention should be directed toward developing protocols for the preferential use of postoperative RBC-recovery devices in situations where they provide the greatest benefit.

Gynecomastia-like lesions in the female breast

CONTEXT

Gynecomastia is an abnormal enlargement of the male breast, but the histopathologic abnormalities could theoretically be present in female breasts as well. To my knowledge, however, there have been no reports in the literature to date that have attributed a clinically or radiologically detectable mass in a female breast exclusively to the histopathologic findings seen in gynecomastia.

OBJECTIVE

The clinical, radiologic, and histopathologic findings of 4 patients with lesions composed exclusively of the findings of gynecomastia, herein termed gynecomastia-like lesions, are presented and compared with those of 3 patients with lesser degrees of these changes, herein termed gynecomastia-like areas, which were incidental accompaniments to other lesions.

SETTING

During a 26-month interval, 1242 breast excisions (excluding needle biopsies or aspirates) were examined in a 170-bed, acute-care, community-medical school teaching hospital.

RESULTS

Four patients had gynecomastia-like lesions varying from 1 to 3 cm in greatest dimension with histopathologic features showing the changes of gynecomastia exclusively. Two patients had clinically palpable masses. Two other patients had masses detected only by mammography. One postmenopausal patient was taking estrogen/progesterone replacement medication. Two of the 3 others were not taking birth control pills, and none had a clinical endocrinopathy. Thus far, none of the lesions have recurred. The 3 patients with gynecomastia-like areas were diagnosed separately with infiltrating ductal carcinoma, fibroadenoma, and lipoma.

CONCLUSIONS

Pathologists should be aware that clinically palpable or radiologically detected masses in female breasts may be composed exclusively of the histopathologic findings of gynecomastia.

Squamous carcinoma in situ of the skin containing premelanosomes, with melanocytic colonization of the tumor

Premelanosomes in nonmelanocytic epithelial neoplasms and "colonization" of nonmelanocytic tumors by melanocytes are two phenomena rarely documented in the literature. We report a squamous carcinoma-in-situ of skin displaying both phenomena. Light microscopy showed clusters of tumor cells in the epidermis, some of which contained melanin. Dendritic melanocytes were admixed with the tumor cells. No ulceration was present. Immunoperoxidase stains for keratin showed no staining of tumor cells. Some nondendritic cells stained for HMB-45, consistent with a melanocytic lesion. Electron microscopy showed two cell types, one with desmosomes, tonofilaments, and premelanosomes and a second dendritic type with only premelanosomes. Premelanosomes were also present free in the intercellular space. These findings suggest that premelanosomes may first be discharged by melanocytes into the intercellular space and are then phagocytosed by the neoplastic cells. Thus the presence of premelanosomes in a tumor cell is not pathognomonic for melanoma or other neural crest tumors.

Metanephric adenoma-like tumors of the kidney: report of 3 malignancies with emphasis on discriminating features

BACKGROUND

Metanephric adenoma is a very rare benign renal tumor; only 80 well-documented cases have been reported to date. We have seen several renal tumors that were originally incorrectly diagnosed as metanephric adenoma.

DESIGN

We present 3 unusual renal tumors (2 primary and 1 metastatic), each of which illustrates important pathologic features useful in discriminating metanephric adenoma from malignant mimics.

RESULTS

Case 1 involved a 46-year-old man with multiple small, cortical, solid, papillary (chromophil) renal cell carcinomas in his right kidney; the patient developed multiple, histologically identical, solid, papillary (chromophil) carcinomas in the opposite kidney 17 months later. Case 2 involved a 32-year-old woman with a 14-cm right renal tumor who developed soft tissue and bone metastases over a 17-year period. Case 3 involved a 52-year-old woman who presented with a 1.8-cm corticomedullary renal nodule, which eventually proved to represent a metastasis from a poorly differentiated (insular) carcinoma of the thyroid. All 3 tumors superficially resembled metanephric adenoma and consisted of primitive, dark-staining cells arranged in tubules or sheets. Each tumor, however, also had features inconsistent with the diagnosis of metanephric adenoma, including multifocal lesions with a variable nuclear-cytoplasmic ratio and diffuse cytokeratin 7 and epithelial membrane antigen immunopositivity in case 1, a 14-cm-diameter tumor with occasional mitoses in case 2, and a distinct fibrous capsule with capsular and vascular invasion in case 3. In addition, all 3 tumors lacked the cytologic features of bland overlapping nuclei with imperceptible cytoplasm consistently seen in metanephric adenoma.

CONCLUSION

Adherence to strict histopathologic criteria will discourage misdiagnosis of a malignant or potentially malignant renal neoplasm as the rare and always benign metanephric adenoma.

Comparison of transillumination and histologic slide measurements of choroidal melanoma

OBJECTIVE

To compare transillumination and histologic slide measurements of choroidal melanomas in 479 eyes randomized to enucleation in the Collaborative Ocular Melanoma Study.

DESIGN

Transillumination defects were measured during gross examination of enucleated eyes. Tumor basal diameter and height were measured on histologic slides and each tumor was assigned to 1 of 8 distinct shape categories. Comparison of the transillumination and histologic slide measurements revealed 3 categories of difference: underestimation (transillumination measurement more than 4 mm smaller than the histologic slide measurement), overestimation (transillumination measurement more than 4 mm larger than the histologic slide measurement), and agreement within 4 mm.

RESULTS

There was good correlation between transillumination and histologic slide estimates of largest basal diameter, particularly when the basal diameter was 16 mm or less. Measurement discrepancies were related to the shape of the tumors but not to the presence of subretinal fluid or fixation.

CONCLUSION

Agreement was high between measurements of transillumination defect and histologic sections.

Orbital lesions in the blue rubber bleb nevus syndrome

PURPOSE

To identify ophthalmologic manifestations of the blue rubber bleb nevus syndrome, a rare cutaneovisceral hemangiomatosis.

METHODS

The authors report two patients with a diagnosis of blue rubber bleb nevus syndrome with orbital hemangiomas.

RESULTS

In one patient, the orbital lesion presented with signs and symptoms similar to an orbital varix and in the other with lid ecchymosis from an eyelid lesion.

CONCLUSION

Patients with the blue rubber bleb nevus syndrome may have vascular orbital lesions associated with intermittent proptosis. Ophthalmologists should be familiar with the syndrome and its life-threatening complication of gastrointestinal hemorrhage.

Red cell loss following orthopedic surgery: the case against postoperative blood salvage

BACKGROUND

Expensive devices have been developed for the collection and transfusion of blood salvaged after hip or knee arthroplasty.

STUDY DESIGN AND METHODS

The volume of salvaged red cells was measured for the first 6 hours after operation. This volume was compared to total red cell loss during hospitalization and to the volume of allogeneic red cells transfused.

RESULTS

Mean postoperative red cell loss in 31 patients following hip replacement was 55 +/- 29 mL and that in 20 patients following knee replacement was 121 +/- 50 mL. The 6-hour wound drainage represented 8.7 and 16.8 percent of overall red cell loss during hospitalization for hip and knee replacement, respectively. The transfusion of postoperatively salvaged red cells would have supplanted transfusion of less than one-third of a unit of allogenic blood after hip replacement and two-thirds of a unit after knee replacement. Only three patients (5.9%) lost red cell volume in the drainage equivalent to or in excess of 1 unit of red cells (180 mL). The volume of red cells salvaged postoperatively bore no relationship to perioperative red cell losses as a whole.

CONCLUSION

The relatively small red cell loss in the postoperative period in most arthroplasty patients does not appear to justify the routine use of this technique for the recovery of autologous blood.

Antibodies to hydrocortisone in reagent red cells causing positive antibody screening tests

When a patient's serum contains a temperature-independent antibody reacting with all antibody screening and antibody identification panel cells but with few or no units of blood used for crossmatching, one should suspect an antibody against a constituent of the suspension medium of the reagent blood cells. This observation is confirmed by negative reactions with a) washed reagent cells or b) another manufacturer's cells that do not contain the same additives. Two patients are described with antibodies to hydrocortisone that are present in one manufacturer's antibody screening cells and identification panels. The hydrocortisone was added by the manufacturer to prevent hemolysis of the reagent red cells. The patient's antibodies were IgM, complement independent, and nonneutralizable by prior incubation with hydrocortisone. The addition of hydrocortisone to other manufacturers' reagents converted previously negative reactions to the same level of positivity as was seen with the reagent from the index manufacturer. Antibodies to reagent constituents can cause delays in finding compatible blood. It is suggested that manufacturers delete irrelevant additives or those of questionable necessity from their reagents.

Survival and half-life of red cells salvaged after hip and knee replacement surgery

The survival of autologous red cells collected intraoperatively has been reported previously. This study measures the survival and half-life of red cells collected 3 hours after hip and knee arthroplasty. For six patients, four having knee replacements and two having hip replacements, the salvaged red cells were labeled with radioactive 51Cr. Peripheral blood was simultaneously labeled with nonradioactive 52Cr. There was no significant difference in the survival or half-life of the salvaged and the venous blood.

Spindle cell pseudotumor due to Mycobacterium avium-intracellulare in patients with acquired immunodeficiency syndrome (AIDS). Positive staining of mycobacteria for cytoskeleton filaments

A rare spindle-cell pseudotumor caused by Mycobacterium avium-intracellulare (MAI) that mimics a mesenchymal tumor, was recently reported (7,14). We report on three such pseudotumors in patients with the acquired immunodeficiency syndrome (AIDS), two involving lymph nodes and one involving the bone marrow. In the course of investigating the first-encountered example of this tumor for evidence of smooth-muscle origin of the spindle cells, it was noted that these cells stained positively for desmin by immunoperoxidase techniques (IPX), as did a variety of other cytoskeleton filaments of all sizes. Electron microscopic examination of one of these lesions revealed spindle cells containing lysosomes and large numbers of microorganisms compatible with MAI but no filaments or organelles suggestive of smooth-muscle cells. Further studies revealed that the typical lesions produced by MAI in patients with AIDS, namely aggregates of histiocytes or individual histiocytes laden with organisms, rather than the expansile spindle-cell pseudotumor, also strain strongly for cytoskeleton filaments, as do M. tuberculosis and Mycobacterium leprae. Awareness of the existence of this unusual manifestation of MAI infection in AIDS patients and its desmin positivity can avoid misdiagnosis of a primary or metastatic smooth-muscle neoplasm. The cell of origin appears to be the histiocyte.

Suitable survival and half-life of red cells after frozen storage in excess of 10 years

To examine the appropriateness of the Food and Drug Administration's 10-year storage time for previously frozen red cells, 24-hour posttransfusion survival studies were performed, and the half-life of 3 units of autologous red cells that had been stored for 13.5, 14, and 17 years, respectively, was measured. The units had acceptable freeze-thaw-wash recovery (83.3-91.4%). When a 51Cr label was used for the previously frozen red cells and a simultaneous 52Cr label for freshly drawn autologous red cells was used as a comparison, it was seen that the previously frozen cells had normal 24-hour posttransfusion survival (75.1-88.4%) as well as normal half-life (23-33.7 days). These findings support further extension of the maximum allowable storage time for previously frozen red cells.

A cryoglobulin with cold agglutinin and erythroid stem cell suppressant properties

A 93-year-old woman presented with profound anemia (hematocrit 23% [0.23]); there was clumping of her red cells in test tubes and on peripheral blood smears. There was also a marked decrease in erythroid precursors in the bone marrow and reticulocytopenia in the peripheral blood. An IgM kappa monoclonal gammopathy was found in low concentration (approximately 1%) in her serum, and the cold agglutinins had a titer of 2560. However, the cold agglutinin titer of the supernatant after cryoglobulin precipitation was 40. Redissolving the cryoglobulin in the supernatant resulted in a cold agglutinin titer of 1280. Moreover, the addition of the patient's whole serum inhibited erythroid colony formation in culture. The inhibition was removed by cryoprecipitation of the cryoglobulin. The patient was given steroid therapy, to which she responded with reticulocytosis and an elevation of hematocrit. By 3 months, the cold agglutinin titer had fallen to 10. She remained well 4 years later. Whereas reports of cryoprecipitable cold agglutinins are rare, this case is unique because there have been no previous reports that these cold active proteins also have erythroid stem cell-suppressant properties.

Heterotopic pancreas: gastric outlet obstruction secondary to pancreatitis and pancreatic pseudocyst

Heterotopic pancreas, usually a silent gastrointestinal anomaly, may become clinically evident when complicated by a pathologic process. We report a unique case in which pancreatitis and pseudocyst formation in an antral lesion produced gastric outlet obstruction. The nature of heterotopic pancreas, its diagnosis, and management are discussed.

Warfarin-induced alopecia

Earlier reports of the association between oral anticoagulation and alopecia describe a high incidence of this complication (42 to 78 percent). However, judged by its extreme rarity in a survey of eight experienced, busy academic dermatologists in Boston, this association is not common, nor is the assumption that the alopecia tends to occur soon after the administration of warfarin necessarily true. Nevertheless, alopecia persists in the face of continued warfarin administration; the time required for hair to regrow after discontinuation of the drug may be too long to be practical if continued anticoagulation is necessary; the effect of oral substitutes for warfarin is unknown; and alopecia may recur if the patient is rechallenged with warfarin.

The ultrastructure of fiber cells in primate lenses: a model for studying membrane senescence

We have compared the surface morphology of the youngest (cortical) fiber cells with that of the most senescent (nuclear) fiber cells in monkey and baboon crystalline lenses by stereo scanning electron microscopy (SEM) and thick-section stereo transmission electron microscopy (TEM). Both the broad and the narrow faces of the most senescent fiber cells featured distinctive, polygonal areas (domains) of furrowed cell membrane. The domains ranged in size from 2.42 to 8.78 microns2. Stereopair SEM and TEM micrographs demonstrated precisely oriented microvilli measuring approximately 0.14 micron in diameter and ranging in length from 1.27 to 4.65 microns overlying each ridge in the domains. Formation of microvilli on senescent cells has been noted in other types of aging cells but they are imprecisely arranged and their function is unknown. Since every fiber cell remains in a fixed location (relative to other fiber cells) throughout life, the lens provides a unique model to study structure-function relationships of senescent microvilli in situ. The discovery of an age-related elaboration of numerous microvilli on senescent fiber cells of noncataractous lenses invalidates the currently accepted theory that close, parallel apposition of the broad faces of lens fiber cells is necessary for the lens to be transparent.

Acquired immunodeficiency syndrome and directed blood donations. A dilemma for American medicine

The devastating consequences of transfusion-associated acquired immunodeficiency syndrome have led some patients and physicians to propose recipient-orchestrated (directed) donations as a method of improving the safety of blood transfusions. This method is not safer than volunteer blood donation and introduces several legal, ethical, and administrative problems. Blood banks should discourage the use of directed blood donations, and physicians should work to educate the public about the lack of benefit of directed donations and their potential risks.

Heparin monitoring and neutralization during cardiopulmonary bypass using a rapid plasma separator and a fluorometric assay

Avoidance of over- or underheparinization during cardiopulmonary bypass (CPB) is crucial in preventing bleeding or clotting. Currently no completely satisfactory method is available for measuring heparin levels--a method that would be rapid, inexpensive, specific, and reproducible. We combined the use of two devices, a rapid plasma separator and a fluorometric heparin assay system, in an attempt to satisfy these requirements in 15 patients having CPB during cardiac surgical procedures. The first instrument separates plasma from whole blood using a pneumatic filtration principle, while the heparin assay system measures the effect of heparin on thrombin conversion of a synthetic fluorogenic substrate. Accurate plasma heparin levels can be generated in less than five minutes, and the assays are inexpensive and easy to perform. Performing heparin assays at critical intervals during CPB allowed desired heparin levels to be maintained and the protamine dose for heparin neutralization to be reduced to a minimum. In addition, studies for heparin rebound revealed negligible rebound up to six hours postoperatively despite the reduced doses of protamine. There were no hemorrhagic or clotting complications in the series.

Anticoagulant monitoring and neutralization during open heart surgery--a rapid method for measuring heparin and calculating safe reduced protamine doses

Confident monitoring of heparin during cardiopulmonary bypass and subsequent neutralization by protamine has been hampered by the absence of an accurate, reproducible, rapid, simple, and specific assay for heparin. By using two new instruments in tandem, one of which produced 0.5 ml of plasma in 1 min and one which specifically measures heparin in 3-4 min, heparin levels are available in approximately 5 min. By performing heparin assays at a variety of intervals, it was demonstrated that 76% of patients receiving common doses of heparin during cardiopulmonary bypass may have plasma levels that are potentially too low. Minimum neutralizing doses of protamine may be calculated using the formula: (estimated blood volume + pump prime volume) X (plasma heparin level/100) X 1.1 + 50. These doses were nearly two-thirds of previous doses and were unassociated with increased bleeding, clotting, or clinically significant heparin rebound.

Nonfamilial Turcot's syndrome associated with Crohn's disease and duodenal ulcer in one kindred

We report a case of Turcot's syndrome in a 56-year-old man with nonfamilial polyposis coli and Dukes C adenocarcinoma of the colon who later manifested a grade 3 astrocytoma of the brain. His daughter has well-documented Crohn's disease of the small and large bowel and his son suffered from a duodenal ulcer since the age of 7.

A device for rapid plasma separation

The STATSEP Plasma Separator (Instrumentation Laboratory, Inc, Lexington, MA), a device for rapidly separating plasma from whole blood, generates plasma at the rate of 0.5 ml/min by filtration rather than centrifugation. When plasma was separated by conventional centrifugation or by the plasma separator, there were no clinically significant differences in concentrations of a variety of important analytes in duplicate specimens. In addition, there were no clinically significant differences in measurements of prothrombin times (PT) and partial thromboplastin times (PTT) on plasmas generated by the 2 techniques. This device, therefore, reduces the analytic time of these frequent coagulation tests by 9 min. The above tests were performed on patients with leukemia and with benign and neoplastic elevations of platelet counts, with no differences seen between plasma specimens separated by either technique. Elevated hematocrits, however, require as much as 2 min to produce 0.5 ml of plasma. Both the machine and disposables are inexpensive and easy to operate.

Transfusion of patients undergoing cardiopulmonary bypass

Although certain hematologic changes that occur as a consequence of cardiopulmonary bypass are unique, their influence on the transfusion requirements of open-heart surgical patients is not different from that on other bleeding patients. While knowledge of the peculiarities of open-heart surgery is important for the blood bank medical director, this clinical situation can be managed using the basic principles of component therapy as they apply to other clinical situations.

Measurement of plasma heparin levels using a fluorometric assay

The performance of a fluorometric heparin assay system was evaluated. The system indirectly measures heparin by its inhibition of thrombin protease action on a synthetic substrate. Our results confirm that within the range of heparin concentrations recommended by the manufacturer, i.e., 0.1-0.8 units/ml, there is an excellent correlation between expected and observed values. Within-day coefficients of variation range from 1% to 2.6%; the between-day coefficient of variation is 6.5. The accuracy of the assay diminishes under 0.1 units/ml. The assay is not influenced by bilirubin, hemolysis, fibrin split products, or lipemia. Results can be generated in less than 5 min. Possible drawbacks are the wide range of acceptability for the supplied heparin standard, and the frequency of pipetting involved.

Comparison of filtration leukapheresis and centrifugation leukapheresis in treatment of lymphosarcoma cell leukemia

A patient with lymphosarcoma cell leukemia resistant to chemotherapy was treated with filtration leukapheresis and centrifugation leukapheresis. Filtration leukapheresis removed only 10(11) leukemia cells per 8.5 liters of blood processed, while centrifugation leukapheresis removed approximately six times as many leukemia cells from the same amount of blood. Lymph nodes and spleen diminished in size and the WBC count decreased after nine treatments. However, the patient remained markedly thrombocytopenic, and his bone marrow remained infiltrated with lymphosarcoma cells on repeat biopsy. This study shows that centrifugation leukapheresis is superior to filtration leukapheresis in removing significant numbers of circulating lymphosarcoma cells, though the clinical benefit of leukapheresis in this situation remains to be determined.

A simplified method for quality control of deglycerolized erythrocytes

Quality control to detect inadequately deglycerolized red blood cells can be easily and inexpensively accomplished by suspending the deglycerolized cells in either recipient serum or normal saline in the same way in which the routine crossmatch is performed. In vitro hemolysis is readily and consistently apparent when the residual glycerol exceeds either 2.4% (in saline) or 2.5% (in serum). In contrast to generally held beliefs, the in vivo 24-hour survival of red blood cells with a residual glycerol concentration of up to 2.7% was demonstrated to be 76% of greater, a level which is well above what is usually accepted as adequate.

Heparin removal in an autotransfusor device

In order to determine the residual heparin in the supernatant fluid recovered from blood washed with increasing amounts of solution in the Haemonetics Cell Saver, various modifications of Grann's polybrene neutralization test applied. It is suggested that each 450 to 500 ml of recovered heparinized blood be washed with a minimum of 500 ml of saline, although 700 ml is advisable. The red color from hemolyzed erythrocytes may clear while unacceptably high levels of heparin remain.

Use of the refractive index to measure the adequacy of glycerol removal from previously frozen erythrocytes

A common method for measuring deglycerolization of previously frozen erythrocytes is to determine the osmolality of the supernatant fluid after completion of the wash cycle. We attempted to compare this type of examination with the simpler, faster, and cheaper determination of refractive index (RI) using the Goldberg refractometer. One hundred twenty units of deglycerolized red blood cells, some with glycerol added so as to exceed an acceptable 1% glycerol content, had measurements made of the post-wash supernatant fluid by refractive index and osmometry. The responsiveness of refractive index to residual glycerol was essentially the same as osmolality. Although there is more interference from supernatant hemoglobin, this did not preclude the use of RI to measure glycerol removal. Readings up to 28 had glycerol levels of less than 1%. Readings between 29 and 31 should be checked by osmometry, and readings over 31 should cause the unit of blood to be rejected.

Rapid reduction of platelet count in essential hemorrhagic thrombocythemia by discontinuous flow plateletpheresis

Dramatic reduction of the platelet count by discontinuous flow plateletpheresis was achieved safely and swiftly in a patient with essential hemorrhagic thrombocythemia. The patient had a history of thrombo-occlusive arterial disease and on admission had gastrointestinal bleeding. This technic is recommended as an effective means of rapidly controlling marked increase in the platelet count and its consequences in the interval before chemotherapy becomes effective.

Polybrene neutralization as a means of monitoring heparin therapy for extracoporeal cirulation

Dose-response effects of heparin and protamine in 34 adult patients undergoing cardiac operations were monitored by an in vitro analysis utilizing hexadimetharine bromide (Polybrene) neutralization. Heparin administered prior to cannulation for cardiopulmonary bypass in a dose of 3.0 mg (300 units) per kilogram of body weight, and 1.5 mg (150 units) per kilogram for each subsequent hour of bypass, routinely produced circulating heparin concentrations greater than 1.0 units per milliliter of plasma. A protamine dose equal to 80% of the total number of milligrams of heparin given resulted in no detectable plasma heparin in 23 of the 34 patients one-half hour after administration. No patient required protamine in an amount greater than the total number of milligrams in the heparin dose to achieve heparin neutralization. Modest postoperative chest tube drainage (mean, 784 ml in 48 hours) in these patients provides clinical support for low-dose protamine administration for heparin neutralization at the conclusion of cardiopulmonary bypass.

The use of frozen blood in neonatal exchange transfusion

Because of inability to quickly locate donors to provide fresh heparinized blood, seven exchange transfusions were performed on four newborns with hemolytic disease due to Rhesus incompatibility using previously frozen erythrocytes suspended in albumin or heparinized, decitrated fresh frozen plasma. Platellets were added to one unit of previously frozen erythrocytes because of severe thrombocytopenia in one patient following an earlier exchange transfusion. The hematologic and bilirubin removing responses were comparable to those seen with fresh heparinized whole blood. Using this method, the safest red blood cells available, namely the mother's, can be drawn and frozen early in gestation for subsequent exchange transfusion.

Fibrinolysis and disseminated intravascular coagulation in open heart sergery

Fibrinolysis and disseminated intravascular coagulation (DIC) have been implicated as the cause or contributing mechanisms for hemorrhage during and after cardiopulmonary bypass. Even when unassociated with hemorrhage, both processes have been thought to be common occurences during open heart surgery. In order to measure the degree to which these mechanisms occur, fibrin split products (FSP) were measured simultaneously in blood and chest tube drainage of open heart surgical patients. In addition, serial measurements of platelets and fibrinogen were also measured in the blood of these patients. It is concluded that fibrinolysis invariably occurs to a high degree in the chest postoperatively but with few systemic manifestations and that fibrinolysis and/or DIC are rare causes of a hemorrhagic diathesis after cardiopulmonary bypass.

The pathology of esophageal intramural pseudodiverticulosis

The gross and microscopic findings of an atuopsied case of esophageal intramural pseudodiverticulosis are presented. The source of the pseudodiverticula is shown to be pathologically dilated pre-existing excretory ducts of the submucosal glands, with which the pseudodiverticula often remained in continuity. Unlike what has been previously reported but poorly documented, the submucosal glands themselves did not contribute to the structure of the pseudodiverticula, the number of duct-gland units was not increased, and the thickening of the wall of the esophagus was the result of submucosal fibrosis, not hypertrophy of the muscularis propria. The etiology of this entity remains unidentified.

In vivo platelet function following cardiopulmonary bypass

In order to test the in vivo hemostatic function of platelets exposed to cardiopulmonary bypass, template bleeding times (TBT) were performed prebypass, three hours postbypass and 18 to 20 hours postoperatively in 22 patients undergoing open-heart surgery. The Harker-Slichter formula was applied to platelet counts below 100,000/cu mm to determine the expected TBT if the platelets function normally but were associated with a prolonged bleeding time merely from thrombocytopenia. Half of the patients received only frozen erythrocyte transfusions. Twenty of the 22 patients (91%) had normal or shorter than the expected TBT. Eight of the ten patients with platelet counts under 100,000/cu mm had shorter than predicted TBTs. All of the patients receiving only frozen erythrocytes had normal or shorter than predicted TBTs. It is concluded that in vivo platelet hemostatic function is usually normal postbypass, that routine platelet transfusions are therefore not necessary, and that most open-heart surgical procedures can be performed using frozen erythrocyte transfusions exclusively.

The effect on blood coagulation of the exclusive use of transfusions of frozen red cells during and after cardiopulmonary bypass

The essentially indefinite storage life of previously frozen erythrocytes (PFE), combined with the virtual freedom from hepatitis, high 2,3-diphosphoglycerate (2,3-DPG) content, and low level of HL-A antigens, should make its use in open-heart surgery attractive. However, since the suspension medium for PFE is usually saline, the potential exists for creating a hemorrhagic diathesis by accentuating the dilution of plasma procoagulants by the pump prime. To test this possibility, we used PFE exclusively in transfusing a group of 13 open-heart surgery patients; they were given no plasma or platelets. A control group of 12 open-heart surgery patients were transfused with only shelf blood. Determination of prothrombin times (PT), partial thromboplastin times (PTT), platelets, and fibrinogen were done at various intervals. No clinically significant differences between the two groups were seen in any of these parameters at any interval, and there was no significant difference between the groups in amount of chest tube drainage or transfusions in the first 24 hours. It is concluded that most open-heart surgery can be safely performed exclusively with frozen blood.

Washed hyperpacked frozen and shelf red blood cells

In order to determine the maximum degree to which blood units could be packed and still be effective, shelf stored blood and previously frozen red blood cells were washed and hyperpacked to hematocrits of 90 to 98 per cent. These products had average volumes of 180 and 162 ml, respectively. When transfused into a group of patients with stable nonhemolytic anemias or with slow or intermittent blood loss, the hyperpacked shelf stored blood resulted in average hematocrit increments of 4.4 per cent; the hyperpacked frozen red blood cells resulted in average hematocrit increments of 3.4 per cent. Conventionally packed unwashed red blood cells had approximately 10 per cent more hemoglobin and volumes of 270 to 330 ml, but resulted in average hematocrit elevations of only 2.8 per cent. Unwashed blood hyperpacked to hematocrits of 90 per cent with removal of the visible buffy coat took much longer to administer. Thus, by washing and hyperpacking shelf stored blood or previously forzen red blood cells, transfusions with the minimal amount of extraneous material can be given.