Abstract Background Use of antifibrinolytic agents in total hip arthroplasty (THA) is well supported; however, most studies used tranexamic acid (TXA), whereas few used ε-aminocaproic acid (EACA), a ...similar antifibrinolytic. This study compares the efficacy and cost per surgery of intraoperative infusion of EACA and TXA in reducing postoperative blood transfusion rates in THA. Methods Retrospective chart review of 1799 primary unilateral THA cases from April 2012 through December 2014 at 5 hospitals within our health care network. Results In our cohort, 711 received EACA, 445 received TXA, and 643 (control group) received no antifibrinolytic. Both antifibrinolytic groups had significantly fewer patients receiving red blood cell (RBC) transfusions when compared with control group (EACA 6.8% P < .0001, TXA 9.7% P < .0001 vs control group 24.7%). Average number of RBC units per patient were similar for EACA and TXA (0.11 units/patient and 0.15 units/patient, respectively), and both were significantly lower than the control group (0.48 units/patient, P < .0001). No significant difference was noted in mean RBC units per patient and percentage of patients transfused between EACA and TXA groups ( P = .144, P = .074). Logistic regression showed no difference between EACA and TXA when adjusting for age, gender, higher severity of illness levels, admission hemoglobin, performing surgeon, and hospital. Medication acquisition cost for EACA averaged $2.70 per surgery compared with TXA at $39.58 per surgery. Conclusion Intraoperative antifibrinolytic use significantly decreases need for postoperative blood transfusions. At our institution, EACA is comparable to TXA in THA for reducing transfusion rates while at a lower cost per surgery.
The serologic evaluation of autoimmune hemolytic anemia (AIHA) confirms the clinical diagnosis, helps distinguish the type of AIHA, and identifies whether any underlying alloantibodies are present ...that might complicate the selection of the safest blood for any needed transfusion. The spectrum of testing is generally dependent on the amount and class (immunoglobulin G or M) of autoantibody as well as the resources and methodologies where testing is performed. The approach may range from routine pretransfusion testing, including the direct antiglobulin test, to advanced techniques such as adsorptions, elution, and red cell genotyping. When transfusion is needed, the selection of the optimal unit of red blood cells is based on urgency and whether time allows for the completion of sophisticated serologic and molecular testing methods. From the start of when AIHA is suspected until the completion of testing, communication among the clinical team and medical laboratory scientists in the transfusion service and immunohematology reference laboratory is critical as testing can take several hours and the need for transfusion may be urgent. The frequent exchange of information including the patient's transfusion history and clinical status, the progress of testing, and any available results is invaluable for timely diagnosis, ongoing management of the patient, and the safety of transfusion if required before testing is complete.
BackgroundAlthough anthrax is a rare zoonotic infection, it still causes significant mortality and morbidity. In this multicenter study, which is the largest anthrax case series ever reported, we ...aimed to describe the factors leading to dissemination of cutaneous anthrax. MethodsAdult patients with cutaneous anthrax from 16 referral centers were pooled. The study had a retrospective design, and included patients treated between January 1, 1990 and December 1, 2019. Probable, and confirmed cases based upon CDC anthrax 2018 case definition were included in the study. A descriptive statistical analysis was performed for all variables. ResultsA total of 141 cutaneous anthrax patients were included. Of these, 105 (74%) patients had probable and 36 (26%) had confirmed diagnosis. Anthrax meningitis and bacteremia occurred in three and six patients, respectively. Sequelae were observed in three patients: cicatricial ectropion followed by ocular anthrax (n = 2) and movement restriction on the left hand after surgical intervention (n = 1). One patient had gastrointestinal anthrax. The parameters related to poor outcome (p < 0.05) were fever, anorexia, hypoxia, malaise/fatigue, cellulitis, fasciitis, lymphadenopathy, leukocytosis, high CRP and creatinine levels, longer duration of antimicrobial therapy, and combined therapy. The last two were seemingly the consequences of dissemination rather than being the reasons. The fatality rate was 1.4%. ConclusionsRapid identification of anthrax is crucial for prompt and effective treatment. Systemic symptoms, disseminated local infection, and high inflammatory markers should alert the treating physicians for the dissemination of the disease.
Tetanus is an acute, severe infection caused by a neurotoxin secreting bacterium. Various prognostic factors affecting mortality in tetanus patients have been described in the literature. In this ...study, we aimed to analyze the factors affecting mortality in hospitalized tetanus patients in a large case series. This retrospective multicenter study pooled data of tetanus patients from 25 medical centers. The hospitals participating in this study were the collaborating centers of the Infectious Diseases International Research Initiative (ID-IRI). Only adult patients over the age of 15 years with tetanus were included. The diagnosis of tetanus was made by the clinicians at the participant centers. Izmir Bozyaka Education and Research Hospital’s Review Board approved the study. Prognostic factors were analyzed by using the multivariate regression analysis method. In this study, 117 adult patients with tetanus were included. Of these, 79 (67.5%) patients survived and 38 (32.5%) patients died. Most of the deaths were observed in patients >60 years of age (60.5%). Generalized type of tetanus, presence of pain at the wound area, presence of generalized spasms, leukocytosis, high alanine aminotransferase (ALT) and C-reactive protein (CRP) values on admission, and the use of equine immunoglobulins in the treatment were found to be statistically associated with mortality (
p
< 0.05 for all). Here, we describe the prognostic factors for mortality in tetanus. Immunization seems to be the most critical point, considering the advanced age of our patients. A combination of laboratory and clinical parameters indicates mortality. Moreover, human immunoglobulins should be preferred over equine sera to increase survival.
Multiple studies have shown tranexamic acid (TXA) to reduce blood loss and transfusion rates in patients undergoing total knee arthroplasty (TKA). Accordingly, TXA has become a routine blood ...conservation agent for TKA. In contrast, ε-aminocaproic acid (EACA), a similar acting antifibrinolytic to TXA, has been less frequently used. This study evaluated whether EACA is as efficacious as TXA in reducing postoperative blood transfusion rates and compared the cost per surgery between agents. A multicenter retrospective chart review of elective unilateral TKA from April 2012 through December 2014 was performed. Five hospitals within a health care system participated. Data collected included age, gender, severity of illness score, use of antifibrinolytic and dose, red blood cell (RBC) transfusions and the number of units, and preadmission and discharge hemoglobin (Hb). Dosing of the antifibrinolytic differed based on the agent used, 5 or 10 g (based on weight) for EACA versus 1 g for TXA. The institutional acquisition cost of each antifibrinolytic was obtained and averaged over the study period. Of 2,922 primary unilateral TKA cases, 820 patients received EACA, 610 patients received TXA, and 1,492 patients received no antifibrinolytic (control group). Compared with the control group both EACA and TXA groups had significantly fewer patients transfused (EACA 2.8%
< 0.0001, TXA 3.2%
< 0.0001 vs. control 10.8%) and lower mean RBC units transfused per patient (EACA 0.05 units/patient pt
< 0.0001, TXA 0.05 units/pt
< 0.0001 vs. control 0.19 units/pt. There was no difference in mean RBC units transfused per patient, percentage of patients transfused, and discharge Hb levels between the EACA and TXA groups (
= 0.822, 0.236, and 0.322, respectively). Medication acquisition cost for EACA averaged $2.23 per surgery compared with TXA at $39.58 per surgery. Administration of EACA or TXA significantly decreased postoperative transfusion rates compared with no antifibrinolytic therapy. Utilization of EACA for unilateral TKA proved to be comparable to TXA in all studied aspects at a lower cost. The level of evidence for the study is Level 3.
BACKGROUND: The von Willebrand factor (VWF)‐cleaving protease, ADAMTS13, is often deficient in cases of thrombotic thrombocytopenic purpura (TTP). The primary treatment of TTP is therapeutic plasma ...exchange (TPE) utilizing a variety of plasma products that help restore ADAMTS13 activity. However, multiple replacement products are available to choose from. Thawed plasma products have a variable refrigerated shelf life depending on the product type; stability of ADAMTS13 in thawed products stored at 1 to 6°C has not been determined.
STUDY DESIGN AND METHODS: ADAMTS13 activity was measured in three types of plasma products and cryoprecipitate. Fresh‐frozen plasma (FFP) aliquots and cryoprecipitate‐poor plasma (CPP) products were produced from 10 whole‐blood (WB) donations. Twenty‐four‐hour plasma products were manufactured from 10 additional WB donations. ADAMTS13 activity in these products at time of thaw and after 5 days of storage at 1 to 6°C was measured with a modified version of the FRETS‐VWF73 fluorogenic assay. ADAMTS13 activity at time of thaw was measured in 10 units of cryoprecipitate and five related CPP products.
RESULTS: ADAMTS13 is present in similar amounts in FFP, CPP, and 24‐hour plasma products. Storage at 1 to 6°C for up to 5 days did not significantly diminish ADAMTS13 activity. The concentration of ADAMTS13 in cryoprecipitate was significantly higher than that observed in plasma products.
CONCLUSION: FFP, CPP, and 24‐hour plasma products should be equally effective for ADAMTS13 restoration through TPE and should remain so for the duration of the shelf life of the thawed products.
Carotid-jugular fistula is an abnormal connection between the carotid artery and/or its branches and jugular vein. It can develop either because of trauma or spontaneous causes. Traumatic fistula may ...occur after head injuries and can range from minor falls to severe penetrating wounds. Traumatic fistula may also result from endovascular therapy; however, these fistulas may be congenital arteriovenous connections that open spontaneously in the setting of collagen vascular disease, atherosclerotic disease, hypertension, or childbirth. Spontaneous fistulas between internal carotid artery and internal jugular vein are very exceptional diseases; therefore, this case is presented for its rare incidence in literature.
BACKGROUND
Adjunctive automated whole blood or red blood cell exchange (RBCEx) can rapidly decrease malarial hyperparasitemia. Several case reports and series suggest improvement in clinical ...symptomatology; however, recent Centers of Disease Control and Prevention (CDC) recommendations concluded that RBCEx has no efficacy as an adjunctive therapy. We present a case of mental status changes secondary to cerebral malaria treated with automated RBCEx resulting in rapid and dramatic neurologic improvement.
CASE REPORT
An 84‐year‐old Somali woman presented with a 3‐day history of altered mental status, spiking fevers, chills, bilateral leg pain and weakness, and intermittent diarrhea. Her travel history included a recent trip to Kenya for 1 month without antimalarial chemoprophylaxis. During the hospital stay, her health declined, and she became obtunded. Physical examination revealed fever, tachypnea, hypertension, hypoxia, and no response to verbal or physical stimuli. Her hemoglobin decreased from 12.6 to 6.5 g/dL with 12% intraerythrocytic parasitemia by thin smear. Intraerythrocytic trophozoites and banana‐shaped gametocytes were present consistent with Plasmodium falciparum. An emergent 1.5‐volume RBC mass automated RBCEx and quinidine infusion decreased her parasitemia to 2%. The patient's mental status improved throughout the procedure, and after the 2½‐hour procedure, the patient was alert, oriented, and speaking coherently. The patient continued to receive quinidine and artesunate 1 day later from CDC.
CONCLUSION
Automated RBCEx transfusion reduced the parasite burden and restored neurologic functioning in a patient with cerebral malaria while awaiting definitive treatment with artesunate.
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