Journal of Blood & Lymph

Patient Blood Management (PBM) programs are a growing need in healthcare to stem overutilization of blood products. Aside from the fact that blood transfusions are associated with infectious and noninfectious risks, there are further pressures driving key reasons to control overutilization, including a narrowing gap between blood donor collections and transfusions, an association of reduced transfusions with improved patient outcomes, and the need to reduce healthcare costs associated with blood product transfusions. Implementation of a PBM program involves different stages of development that can lead to a successful program, eligible for certification. Maintenance of the program requires active oversight and surveillance to ensure peak performance.

Acute Promyelocytic Leukemia (APL) has become the most curable subtype of acute myeloid leukemia in adults with the advent of the differentiating agents, all-trans retinoic acid and arsenic trioxide. However, Early Death (ED) remains a challenge and represents the last major obstacle to the cure of almost every patient. An overwhelming majority of ED in APL is attributable to life-threatening bleeding, a phenomenon driven by complex alterations in the coagulation system. Therefore, prompt recognition of APL and immediate initiation of All-Trans Retinoic Acid (ATRA) in emergency departments–prior to confirmation of the diagnosis–is essential. All-trans retinoic acid must be immediately available, which is often problematic since most institutions will see very few APL patients in a year and will not find it cost-effective to maintain a supply. Aggressive management of the coagulopathy and less common causes of ED, such as the differentiation syndrome and infections, is required. Since emergency departments and immediate care healthcare professionals are often the first to encounter a patient with APL, their training should include comprehensive diagnostic and initial management details. Recent data suggest that early consultation with a colleague with expertise in APL for initial hour-by-hour management is very helpful in reducing the ED rate. Tackling this last major obstacle in the cure of all patients requires providers to astutely recognize the disease and manage patients according to recommended guidelines.

Background: Thrombotic Thrombocytopenic Purpura (TTP) is a rare, potentially fatal disease with multisystem involvement. ADAMTS13 assays are often used for supporting the diagnosis, here we present a rare case of TTP with normal ADAMTS13 levels.

Case presentation: A 39-year-old female presents with syncopal episodes, blurred vision in both eyes during a patch test, headaches, and tenderness over the abdomen, all against a backdrop of hypertensive emergency. She had a history of chronic hypertension managed on medications, iron deficiency secondary to fibroid and an episode of provoked deep vein thrombosis and pulmonary embolism with negative work-up of thrombophilia. Labs revealed low hemoglobin of 9.8 mg/dl, platelet in the range of 52,000/ ml, 3 mEq/L potassium, with high levels of Creatinine (Cr) 6.7 mg/dl and Blood Urea Nitrogen (BUN) levels of 59 mg/ dl. Due to the clinical triad of thrombocytopenia, hemolysis pattern and neurological manifestation, ADAMTS13 essay was ordered. Thrombophilia work-up showed haptoglobin was less than 20 mg/dl, LDH of 752 U/L, and a normal ADAMTS13 level. PLASMIC score was 5, suggestive of moderate risk. With high levels of abnormal creatinine levels and BUN, renal biopsy was done to look for the cause of acute kidney injury in the setting of suspected TTP which revealed diffuse thrombotic microangiopathy, along with moderate to chronic changes with greater than 50% tubular atrophy and interstitial fibrosis. CT scan of the brain was negative for detecting any cause of syncope; MRI showed lacunar infarcts secondary to thromboembolism. A provisional diagnosis of TTP with normal ADAMTS13 level was made and she was started on plasma exchange. Drastic symptom improvement was noted with FFP and 8 units of plasma exchange.

The blood flow through w-shaped tapered artery in the presence of catheter is discussed. The equations governing the fluid flow have been solved analytically under the assumption of the mild stenosis. The blood flow behavior through the w-shaped stenosed artery is considered using the Prandlt fluid model and the flow of blood is considered as suspension of nano-particles. The analysis with respect to various parameters arising out of fluid and geometry considered, on temperature distribution of the w-shaped stenosis as well as across the entire length of the stenosis has been reported. Heat transfer phenomena have been examined for the physical features of the flow of blood through a stenosed artery, which is tapered in shape and with the presence of a clot. The temperature profile has been discussed with graphs for several different parameters of clot size, stenosis height, heat source, and sink parameter. It is observed that in converging tapering the temperature provides greater values as estimated together with the non-tapered arteries and diverging tapering arteries