The reasons and physiological triggers for blood transfusion in critically ill patients are not well characterized. Beyond hemoglobin levels, hemodynamic instability is frequently cited, but its role across clinical contexts remains unclear. (1) To determine whether reasons and triggers for RBC transfusion differ across intensive care unit (ICU) days with varying transfusion intensity. (2) To describe reasons for non-RBC transfusions across these intensity groups. This sub-study of the prospective International Point Prevalence Study of Intensive Care Unit Transfusion Practices (InPUT) classified ICU days by transfusion intensity: nonmajor (1 RBC unit), major (≥2 units), and massive (≥6 units in a single event, ≥10 per day, or Massive Transfusion Protocol activation). ICU days without transfusion for active bleeding were classified as no bleeding. Significant differences in the multivariate composition of reasons for RBC transfusion were observed across intensity groups on permutational analysis of variance (PERMANOVA). Hypotension was the most frequently cited physiological trigger in nonmajor (54%, n = 80/148) and major transfusions (68%, n = 196/288), but less frequent in massive transfusions (30%, n = 14/64). Tachycardia was the second most common trigger in nonmajor (37%, n = 80/148), major (40%, n = 116/288), and massive transfusions (22%, n = 19/64). RBC transfusions are administered for distinct, intensity-dependent combinations of reasons and triggers. Transfusion intensity and clinical context are therefore key factors in evaluating transfusion practices. Among bleeding critically ill patients, hypotension and tachycardia are the most frequently cited physiological triggers.
Blue rubber bleb nevus syndrome (BRBNS) is a rare vascular disorder characterized by venous malformations involving the skin and gastrointestinal (GI) tract. GI involvement may lead to chronic bleeding and iron deficiency anemia, most commonly presenting in younger individuals. We report the case of an 83-year-old male presenting with progressive fatigue and severe anemia (hemoglobin 5 g/dL), requiring multiple blood transfusions. His medical history was significant for recurrent anemia and prior gastrointestinal bleeding. Upper endoscopy was unremarkable; however, colonoscopy revealed multiple bluish, compressible venous malformations scattered throughout the ascending and transverse colon, consistent with BRBNS. Capsule endoscopy excluded small bowel involvement. Given the diffuse distribution and number of lesions, endoscopic or surgical intervention was not feasible. The patient was managed conservatively with blood transfusions and close outpatient follow-up. BRBNS is typically diagnosed in childhood, and adult presentation, particularly in the elderly, is uncommon. Gastrointestinal lesions are more prone to bleeding than cutaneous lesions and may lead to chronic transfusion-dependent anemia. Diagnosis requires a high index of suspicion, especially in patients with recurrent unexplained anemia and negative initial investigations. Management remains challenging and depends on disease extent, ranging from conservative measures to endoscopic, surgical, or pharmacologic therapies. This case highlights an unusual late presentation of BRBNS with isolated colonic involvement and emphasizes the importance of considering vascular malformations in the differential diagnosis of obscure gastrointestinal bleeding in elderly patients.
Accurate prediction of blood product demand is essential for maintaining adequate supply while minimizing wastage. Artificial intelligence (AI) and machine learning (ML) approaches have emerged as promising tools for transfusion demand forecasting across multiple scales, ranging from individual patients to regional supply chains. This review provides a structured overview of AI applications in blood banking, organized by prediction scope and clinical objective. We conducted a systematic review following PRISMA 2020 guidelines, searching PubMed and Scopus for studies published between January 2015 and December 2025. Studies applying AI or ML to transfusion demand prediction were included. We organized findings into a four-tier framework based on prediction scope and clinical goal and systematically compared technical approaches. Out of 535 identified records, supplemented by a targeted search during peer review, 24 studies met inclusion criteria. The four-tier framework revealed distinct prediction challenges: (1) patient-individual prediction (goal: improve individual care quality) achieved areas under the curve (AUCs) of 0.45-0.97 across five studies for 24-h to 72-h prediction, (2) procedure-specific models (goal: optimize surgical blood ordering) achieved AUCs of 0.70-0.91 across six studies, (3) facility-level optimization (goal: reduce wastage and shortages) approximately halved platelet outdating rates and achieved mean absolute percentage errors as low as 4.18% across eight studies for daily to weekly forecasting, and (4) regional forecasting (goal: secure long-term supply) achieved R 2 values up to 0.85 across five studies for monthly forecasting. Deep learning excelled for temporal patterns in individual patients, while traditional statistical methods (ARIMA, SARIMA) proved effective for aggregated regional forecasting, where deep learning approaches showed no consistent advantage over simpler models. Prediction horizons varied by blood product: 3-7 days for platelets versus weekly to monthly for red blood cells. AI-driven demand prediction offers substantial potential to improve blood supply management across all tiers of the blood supply chain. The choice of modeling approach should be guided by the prediction scope, available data infrastructure, and specific clinical objectives. Standardized external validation remains critical for clinical deployment.
Immune platelet transfusion refractoriness (iPTR) is a major complication in transfusion medicine. Although anti-HLA antibodies are recognized contributors, the mechanisms by which they drive platelet clearance remain incompletely defined. We examined sera from 18 patients with iPTR and found that anti-HLA antibodies induced uptake of human platelets expressing the cognate HLA-A2 target antigen and platelet particles derived from these platelets. These sera also mediated clearance of transgenic mouse platelets expressing human HLA-A2. Using THP-1-CD16A macrophages, uptake of both platelets and platelet particles was mediated predominantly through FcγRIIIa, with a partial contribution from FcγRI and little to no role for FcγRII. To test this pathway in vivo, we used a reductionist humanized murine model of iPTR in which HLA-A2 transgenic mouse platelets sensitized with human iPTR sera were transfused into FcγR-humanized mice. In this model, FcγRIII blockade with 17C02-albumin prevented platelet clearance under the conditions tested. These findings extend previous FcγR studies in antibody-mediated platelet clearance to the alloimmune setting of iPTR and support further investigation of FcγRIII-dependent pathways in antibody-mediated PTR.
Pseudoamniotic band syndrome (PABS) is an iatrogenic amniotic disruption sequence that may occur after invasive fetal procedures, including fetoscopic laser therapy and amniocentesis. Fetoscopic release of the bands has been reported in singleton pregnancies, but it remains rare in twin pregnancies after intrauterine fetal surgery. This study aimed to report two rare cases of PABS occurring after invasive fetal interventions-one for twin-to-twin transfusion syndrome (TTTS) and one for twin reversed arterial perfusion (TRAP) sequence-both of which were successfully managed by fetoscopic band release, and to review the clinical characteristics of PABS in TTTS. We describe one rare case off fetal abdominal constriction caused by amniotic bands following TTTS fetoscopic surgery, and one case of PABS in TRAP sequence after microwave ablation and amniocentesis. Both cases were successfully treated in utero via subsequent fetoscopic band release later. A literature review was conducted on PABS cases after TTTS intervention, comparing cases managed expectantly versus those treated with fetoscopic release. We reported two cases of PABS with constriction of the fetal abdomen and ankle, respectively, treated by fetoscopic band release, and both cases achieved successful outcomes after fetoscopic band release. A literature review identified 50 reported PABS cases after TTTS treatment. PABS occurred predominantly in recipients (78.0%, 39/50 cases), primarily affecting fetal limbs (88.2%, 45/51 fetuses). Antenatal detection was low (20.0%, 10/50 cases), and without intervention, 9.5% (4/42 fetuses) developed fetal limb amputation. Including our case, only 8 PABS cases in TTTS have undergone fetoscopic release, with a median interval of 4.3 weeks post-TTTS fetoscopic laser. The median GA at fetoscopic release surgery was 23.5 (range, 21-27.4) weeks, with a median interval of 5.6 (range, 0.8-11.9) weeks between fetoscopic release and delivery (at 30.7 weeks; range, 24.7-34.9). Of these, 37.5% (3/8) of the newborns required further plastic surgery after birth, but all fully recovered functionally without amputation. Serial ultrasound surveillance after fetal interventions should include PABS assessment, particularly 4 weeks post-procedure. Although antenatal diagnosis remains challenging, fetoscopic band release appears technically feasible in twin pregnancies and potentially beneficial in carefully selected, antenatally diagnosed cases, but the evidence remains limited and vulnerable to publication bias.
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The optimal surgical approach for knee arthroplasty remains under debate regarding reducing systemic complications. Although unicompartmental knee arthroplasty (UKA) is generally considered less invasive than total knee arthroplasty (TKA), it remains unclear whether this advantage persists across age groups. This study aimed to compare the risk of major systemic complications between UKA and TKA across age categories using a large-scale nationwide database. Patients who underwent UKA or TKA between July 2010 and March 2022 were identified from the Diagnosis Procedure Combination database in Japan. The primary outcome was a composite of postoperative in-hospital death and major systemic complications requiring additional interventions. Rates of postoperative red blood cell (RBC) transfusion were also evaluated as a secondary outcome. Stabilized inverse probability of treatment weighting (IPTW) using propensity scores was applied to compare outcomes between the groups. The cohort included 36,235 UKA and 322,424 TKA cases. After stabilized IPTW adjustment, the composite outcome occurred less frequently after UKA than after TKA (risk ratio [RR] 0.65; 95% confidence interval [CI] 0.50-0.85; p = 0.001). The RBC transfusion rate was also reduced in the UKA group (RR, 0.09; 95% CI 0.08-0.11; p < 0.001). In subgroup analyses stratified by age (≤ 79 and ≥ 80 years), UKA was associated with a lower incidence of the composite outcome compared with TKA in patients aged ≤ 79 years (RR 0.48; 95% CI 0.34-0.68; p < 0.001), whereas no significant difference between UKA and TKA was observed among patients aged ≥ 80 years (RR 0.92; 95% CI 0.62-1.35; p = 0.670). The rate of RBC transfusion was lower in the UKA group across age groups (for ≤ 79 years, RR 0.07; 95% CI 0.05-0.09; p < 0.001; for ≥ 80 years, RR 0.12; 95% CI 0.10-0.14; p < 0.001). RBC transfusion rates were consistently lower following UKA across age groups. While UKA was associated with fewer major systemic complications than TKA in patients aged ≤ 79 years, no such difference was observed in patients aged ≥ 80 years. In very elderly patients, careful perioperative risk assessment remains essential when considering UKA, similar to that for TKA.
Children with β-thalassemia major are at risk for neurocognitive impairment due to chronic anemia, iron overload, and possible neurotoxicity from chelation therapy. Despite improved transfusion and chelation protocols, the impact on cognitive function remains unclear. This study evaluated cognitive performance in children with β-thalassemia major and explored selected clinical and biochemical factors associated with cognitive scores. Seventeen patients aged 6-16 years with β-thalassemia major receiving regular transfusions and 17 healthy age- and sex-comparable controls were included. Demographic, anthropometric, and laboratory data (hemoglobin, ferritin, vitamin B12, and vitamin D) were collected. Cognitive performance was evaluated using the Wechsler Intelligence Scale for Children-Revised (WISC-R). Associations between cognitive scores and selected clinical and biochemical variables were evaluated as exploratory analyses, and key associations involving BMI z-score and transfusion duration were additionally adjusted for age. Patients showed significantly lower verbal IQ (81.9 ± 21.9) and full-scale IQ (83.7 ± 21.0) scores compared with controls (109.1 ± 20.1 and 104.6 ± 19.6; p<0.05). All verbal and performance subtests, including picture arrangement and block design, were reduced. In exploratory analyses, age, BMI z-score, and transfusion duration were associated with selected cognitive scores; however, several of these associations were attenuated after adjustment for age. Vitamin D showed positive associations with selected verbal cognitive scores, while ferritin was not significantly associated with cognitive scores in the revised analysis. Children with β-thalassemia major exhibit lower cognitive performance, especially in verbal domains. Associations with clinical and biochemical variables should be interpreted cautiously. Routine cognitive evaluation and metabolic follow-up are recommended for early detection and multidisciplinary care.
Iron deficiency anemia (IDA) is a common cause of perioperative morbidity among women and individuals with a uterus undergoing gynecologic surgery, particularly those with abnormal uterine bleeding (AUB). Although intravenous (IV) iron is a safe and effective alternative to red blood cell (RBC) transfusion, IDA often remains underrecognized and undertreated. The Impact of Iron Supplementation on Transfusion in Women Undergoing Gynecologic Procedures (STRONG) pilot study evaluated the feasibility of implementing a multidisciplinary IV iron pathway for patients with IDA awaiting gynecologic surgery. This prospective, single-centre cohort study was conducted between June 2022 and March 2025. Eligible patients were adults with laboratory-confirmed IDA (ferritin <30 μg/L or transferrin saturation <20%; and hemoglobin <120 g/L) scheduled for elective gynecologic surgery at least 4 weeks after diagnosis who had failed or were intolerant of oral iron. A multidisciplinary pathway integrating patient blood management (PBM) principles was developed for identifying and managing preoperative IDA. Primary outcomes were recruitment feasibility and pathway implementation feasibility, assessed by protocol adherence and IV iron delivery. Exploratory clinical measures included patient demographics, laboratory values, surgical details, transfusion rates, and perioperative outcomes. Twenty patients consented to study participation. Protocol adherence and IV iron delivery were 100%. Median hemoglobin increased from 93 g/L to 121 g/L preoperatively. Six patients (30%) required perioperative transfusion. Implementation of a multidisciplinary IV iron pathway for the detection and management of preoperative IDA in gynecologic surgery was feasible, supporting the integration of PBM strategies into routine perioperative care.
The CAR-HEMATOTOX score has been associated with hematologic toxicity after chimeric antigen receptor T-cell therapy, but it is usually assessed shortly before lymphodepletion, when hematopoietic reserve may already be affected by bridging therapy. We investigated whether the CAR-HEMATOTOX score assessed at leukapheresis, before bridging therapy initiation (Pre-CAR-HEMATOTOX), could predict delayed platelet recovery after idecabtagene vicleucel (ide-cel) in relapsed/refractory multiple myeloma. We conducted a single-center retrospective cohort study of consecutive patients with relapsed/refractory multiple myeloma who underwent leukapheresis and subsequently received ide-cel between November 2022 and March 2026. The primary endpoint was time to platelet recovery to ≥ 100 × 109/L without platelet transfusion or thrombopoietin receptor agonist support. Secondary endpoints included time to platelet recovery to ≥ 75 × 109/L, time to neutrophil recovery to ≥ 1.0 × 109/L without granulocyte colony-stimulating factor support, and platelet transfusion burden. Among 96 patients, median time to platelet recovery to ≥ 100 × 109/L was significantly shorter in the Pre-CAR-HEMATOTOX low group than in the high group (1.8 vs. 15.8 months, P < .001). Similar findings were observed for recovery to ≥ 75 × 109/L (1.3 vs. 6.3 months, P = .005). High Pre-CAR-HEMATOTOX remained independently associated with delayed platelet recovery in both the primary and exploratory multivariable models. High Pre-CAR-HEMATOTOX was also associated with greater platelet transfusion burden. In contrast, intensive BT, rather than Pre-CAR-HEMATOTOX, was independently associated with delayed neutrophil recovery. Pre-CAR-HEMATOTOX assessed at leukapheresis predicted delayed platelet recovery after ide-cel and may support early risk stratification before BT selection.
Bone disease is well recognized in β-thalassemia, but bone microarchitecture in α-thalassemia remains poorly characterized. We prospectively studied 86 adults with thalassemia at a tertiary center in northeast Thailand: 16 with α-thalassemia and 70 with β-thalassemia. Lumbar spine (LS) and femoral neck bone mineral density (BMD) and trabecular bone score (TBS) were measured using the same DXA platform. A prespecified Marrow Expansion Phenotype Score (MEPS; 0-3), comprising thalassemic facies, scoliosis, and hepatomegaly, served as an exploratory marker of chronic ineffective erythropoiesis. Sequential linear regression assessed attenuation of genotype effects after adjustment for transfusion-dependent thalassemia status and MEPS. Compared with β-thalassemia, α-thalassemia was associated with higher LS BMD (0.822 ± 0.130 vs. 0.754 ± 0.117 g/cm²; p = 0.039), higher LS Z-score (-1.27 ± 0.65 vs. -1.99 ± 0.99; p = 0.009), and a trend toward higher TBS (1.318 ± 0.102 vs. 1.255 ± 0.128; p = 0.071). Low LS Z-score (<-2) was less frequent in α-thalassemia (12.5% vs. 45.7%; p = 0.021). Mean MEPS was lower (0.88 ± 0.62 vs. 1.84 ± 0.88; p < 0.001). Genotype associations with TBS, LS BMD, and LS Z-score persisted after adjustment for transfusion status but were attenuated and no longer significant after MEPS adjustment. Ferritin adjustment did not materially change the estimates but cannot exclude effects of total iron burden. Adults with α-thalassemia had better lumbar bone density and microarchitecture than those with β-thalassemia. Attenuation after MEPS adjustment is consistent with, but does not prove, a role for marrow-expansion phenotype. Formal mediation was not performed. Given the small α-thalassemia group, these findings are exploratory and require replication.
This study aims to compare the rates of medical complication and mortality following initial bipolar hemiarthroplasty (bHA) and reoperation procedures, as well as between different causes of reoperation (nonseptic vs. septic). The retrospective study included 118 patients undergoing reoperation after bHA for femoral neck fractures between January 2002 and December 2022. The primary outcomes included in-hospital complications, readmission, and mortality events, while secondary outcomes included length of hospital stay, transfusion rates, and estimated blood loss. These outcomes were compared between each patient's initial bHA and their subsequent reoperation procedure. The two cohorts were matched using propensity scores based on age, sex, and Charlson Comorbidity Index to compare outcomes between nonseptic and septic causes of reoperation. Of the 118 patients, 64 were male and 54 were female. The mean age was 77.8 ± 7.9 years, with a range of 61 to 98 years. The in-hospital complication rate was higher after reoperation than after initial bHA (15.3% vs. 1.7%, p < 0.001). Conversely, the readmission rate was higher after the initial procedure (60.2% vs. 23.7%, p < 0.001), mainly due to surgical complications. Patients undergoing reoperation had longer hospital stays, higher transfusion requirements, and more frequently received general anesthesia compared to the initial procedure (p < 0.05). In the matched cohort, septic group had higher in-hospital complication rates than the nonseptic group (23.5% vs. 3.9%, p = 0.004), while readmission and mortality rates were comparable. Reoperations after bHA carry a higher risk of medical complications. This risk is particularly pronounced in cases related to septic conditions, underscoring the greater impact of reoperation and careful clinical attention.
Autoimmune hemolytic anemia is a rare but potentially life-threatening complication of Plasmodium vivax malaria. Most reported cases required corticosteroid therapy in addition to antimalarial treatment. We report the case of a 28-year-old Ethiopian man who presented with fever, pallor, and fatigue. Laboratory evaluation revealed severe anemia (hemoglobin 6 g/dL), thrombocytopenia (88,000/µL), hyperbilirubinemia, and a positive direct antiglobulin test. Peripheral smear confirmed P vivax infection with 2% parasitemia. Comprehensive immunohematological testing, including direct antiglobulin test, elution, adsorption, and extended antigen typing, confirmed immune-mediated hemolysis and excluded alloantibody-related incompatibility. The patient received 3 compatible blood transfusions and was treated with intravenous artesunate followed by primaquine, without corticosteroids or platelet transfusion. By day 5, hemoglobin improved to 10.2 g/dL, platelets normalized, and malaria smears were negative. He was discharged in stable condition. This report highlights an unusual presentation of P vivax malaria complicated by severe autoimmune hemolytic anemia and thrombocytopenia, which resolved with antimalarial therapy alone, without immunosuppressive therapy, including corticosteroids. This finding suggests that corticosteroids may not always be necessary in certain cases and underscores the importance of early recognition and comprehensive immunohematological evaluation in malaria-related cytopenias.
Geriatric trauma patients are at increased risk of death or disability, and some have proposed trauma team activations based on advanced age alone. We sought to determine if there is a specific age at which a different approach to the trauma patient should be taken, based on their age-related risk for death, disability, or for needing acute resuscitative care. We conducted a retrospective review of one year of data (2022) abstracted from the National Trauma Data Bank, including 984,335 adult trauma patients. The primary outcome was in-hospital mortality. Secondary outcomes were non-functional status at discharge, and a composite outcome created to capture the need for acute trauma interventions that included death in the ED, admission to the ICU, or need for emergent surgery, intubation, angioembolization, blood transfusions or procedures. Analyses adjusted for covariates showed the risk of receiving any acute intervention, including transfusions, surgeries, intubations and bedside procedures, all fell steadily with advancing age, as did risk of immediate death in the emergency department. Risk of death later during hospitalization, or of discharge to a non-functional status, rose steadily with advancing age. Trauma patients have rising mortality with advancing age, and a rise in likelihood of being sent to the ICU for care, but a falling rate of immediate, up-front death in the trauma bay, and a falling rate of receiving the acute, life-saving interventions associated with a trauma team activation. Further investigation is needed to determine the extent to which these findings illustrate differences in injury mechanism and severity, or age-related bias and differences in care.
Variant histology (VH) bladder cancer is characterized by aggressive biology and adverse outcomes; however, evidence in the robot-assisted radical cystectomy (RARC) era remains limited. We evaluated oncologic outcomes following RARC for VH using propensity score matching (PSM) in a multi-institutional cohort. We retrospectively analyzed 280 patients who underwent RARC at 5 institutions (January 2018-November 2024); 60 had VH, and 220 had pure urothelial carcinoma (PUC). Using 11 pretreatment covariates (including institution, smoking status, and comorbidities), 1:1 nearest-neighbor matching (caliper 0.10) yielded 51 matched pairs. The primary endpoint was perioperative and pathologic outcomes. Adjuvant therapy use was recorded as a descriptive measure. Disease-free (DFS), cancer-specific (CSS), and overall survival (OS) were exploratory endpoints. Before matching, VH was associated with more advanced clinical stage and significantly worse unadjusted DFS, CSS, and OS. After expanded PSM, baseline characteristics were well balanced. The VH group retained significantly higher rates of ≥ pT3 disease (68.6% vs. 37.3%, P = .003) and transfusion (29.4% vs. 9.8%, P = .025); operative time, blood loss, complications, and hospital stay were comparable. Adjuvant therapy use was more frequent in the VH group (37.3% vs. 9.8%, P = .002). On exploratory Cox analysis, VH remained independently associated with significantly worse DFS, CSS, and OS (hazard ratios 2.3-2.8; all P < .05) after expanded adjustment. In this multi-institutional RARC cohort, after PSM for an expanded set of pretreatment clinical and comorbidity factors, perioperative outcomes other than transfusion rate were comparable between VH and PUC, supporting RARC as a feasible surgical approach for VH. However, VH retained significantly higher rates of ≥ pT3 disease, and exploratory survival analysis showed persistently worse DFS, CSS, and OS despite a greater use of adjuvant therapy, indicating that the adverse oncologic behavior of VH is not fully explained by pretreatment factors. Close postoperative surveillance and multimodal systemic therapy remain essential.
Orbital compression syndrome (OCS) is a rare, sight-threatening complication of sickle cell disease (SCD), caused by vaso-occlusive infarction of orbital bone marrow with subperiosteal hematoma formation. Its presentation overlaps with orbital cellulitis and severe malaria, creating diagnostic uncertainty in resource-limited humanitarian settings. A 9-year-old boy with homozygous SCD (HbSS) presented to a primary health facility in Palabek Kal refugee settlement, Lamwo District, northern Uganda, with a 1-day history of sudden severe bilateral frontal headache radiating to the eyes, high-grade fever, and rapidly progressive bilateral periorbital edema, epiphora, and photophobia, without altered consciousness, seizures, vomiting, or respiratory distress. He was febrile (39.3°C) and unwell, with bilateral periorbital swelling, mild scleral icterus, and hepatomegaly (approximately 6 cm below the right costal margin); visual acuity, pupillary responses, extraocular movements, and proptosis assessment were normal. Laboratory evaluation showed severe anemia (hemoglobin 6.5 g/dL), leukocytosis (14.81 × 103/µL), and 3+ malaria parasitemia. Orbital imaging and cultures were unavailable. The clinical picture was most consistent with OCS secondary to vaso-occlusive crisis, with severe malaria, orbital cellulitis, and septicemia considered as concurrent or alternative diagnoses. The child received intravenous artesunate, empirical broad-spectrum antibiotics, intravenous fluids, analgesics, and one unit of blood transfusion for severe anemia, with close ophthalmic monitoring. Fever resolved, periorbital swelling subsided, and visual function was preserved without surgical intervention. This case illustrates the diagnostic challenge of OCS in a child with SCD in a malaria-endemic humanitarian setting. OCS should be considered in any child with SCD presenting with acute bilateral periorbital swelling, headache, and fever, even when malaria is confirmed and orbital imaging is unavailable. Early recognition, parallel management of competing diagnoses, close clinical monitoring, and expanded access to orbital imaging in humanitarian settings are critical to prevent avoidable visual morbidity. This report describes a 9-year-old South Sudanese refugee boy living in northern Uganda who developed sudden, painful swelling around both eyes along with a high fever. He had sickle cell disease, a blood condition that can make the bone marrow in the eye socket break down and bleed, causing swelling. A blood test also showed malaria, so the doctors faced a difficult question: was sickle cell disease, malaria, an eye infection, or blood poisoning causing the eye swelling? The health center did not have advanced scanning equipment. The clinical team treated all the likely causes at the same time, giving anti-malaria medicine, antibiotics, a blood transfusion, and pain relief. The child recovered fully; the swelling went down and he kept his vision. This case shows that sickle cell-related eye complications can occur alongside malaria, and it highlights the importance of considering multiple diagnoses and closely monitoring eye health in settings that lack advanced testing.
Although immune checkpoint inhibitors (ICIs) have transformed cancer treatment, they are associated with immune-related adverse events, including gastrointestinal (GI) toxicity. While GI bleeding is a common cause of hospitalization among cancer patients, the relationship between ICI exposure and the outcomes of GI bleeding at the national level remains unclear. This retrospective cohort study utilized data from the National Inpatient Sample (NIS) between 2018 and 2022. Adult cancer patients hospitalized with GI bleeding were identified and stratified by ICI exposure. The primary outcome was in-hospital mortality. Secondary outcomes included colectomy, intensive care unit (ICU) admission, and blood transfusion. Survey-weighted logistic regression models, adjusted for demographics, insurance, income, admission type, and year, were employed. Sensitivity analyses included adjustments for Elixhauser comorbidities, inverse probability of treatment weighting (IPTW), propensity score matching, exclusion of records with inpatient antineoplastic chemotherapy codes, exclusion of records from pandemic years, and alternative ICU-proxy thresholds. Of the 130,557 hospitalizations, 33,130 (25.4%) involved ICI exposure. ICI exposure was associated with significantly lower in-hospital mortality (adjusted odds ratio [aOR] 0.57, 95% confidence interval [CI] 0.54-0.60, p < 0.001), colectomy (aOR 0.65, 95% CI 0.60-0.70, p < 0.001), and ICU admission (aOR 0.66, 95% CI 0.64-0.68, p < 0.001). Blood transfusion was modestly more frequent in the ICI group (aOR 1.04, 95% CI 1.00-1.08, p = 0.034); this association was small in magnitude and was no longer significant when the pandemic years were excluded. The results were consistent across cancer subtypes, GI bleeding locations, and all sensitivity analyses (mortality aOR range 0.57-0.66). ICI exposure was associated with significantly lower in-hospital mortality, colectomy, and ICU admission among cancer patients hospitalized with GI bleeding. These findings likely reflect selection bias, as ICI-treated patients may represent a healthier subpopulation of cancer patients. Further studies incorporating detailed clinical data are needed to elucidate the mechanisms underlying these associations.
ABO-incompatible living kidney transplantation (ABOi-LKT) has become an established procedure with long-term patient and graft survival comparable to ABO-compatible transplantation. However, intensified immunosuppression increases the risk of severe infectious complications, particularly in the early post-transplant period. This study investigated whether ABOi-LKT in patients with low baseline anti-ABO isoagglutinin titers can be performed safely without rituximab and thereby reduce infectious complications. In this multicenter retrospective cohort study, recipients of ABOi-LKT with low pretransplant anti-ABO titers (≤1:16) were compared according to rituximab use. Clinical outcomes, graft function, rejection episodes, surgical complications, and infectious events were analyzed. Eleven German transplant centers identified 46 patients who underwent ABOi-LKT without rituximab between 2016 and 2024 and 85 low-titer recipients who received rituximab (single dose 375 mg/m²). Baseline characteristics and median pretransplant anti-ABO titers (1:2) were comparable between groups. Patients underwent a median of two extracorporeal antibody eliminations and received comparable immunosuppression. Graft function at discharge and after 3 and 12 months, as well as proteinuria, did not differ between cohorts. One graft loss due to acute antibody-mediated rejection occurred in the rituximab-free group, whereas two graft losses (one rejection, one BK polyomavirus nephropathy) and one patient death occurred in the rituximab group. Rates of surgical complications (34.8% vs. 36.5%), blood transfusions (21.7% vs. 17.6%), and rejection episodes (15% vs. 20%; p=0.499) were similar. In contrast, infectious complications were significantly more frequent among rituximab-treated patients, with a 2.4-fold increased infection risk (p=0.018). Infection-related hospitalizations occurred significantly more often in the rituximab group (64.6% vs. 31.3%; p=0.003). ABOi-LKT without rituximab appears safe in recipients with low pretransplant anti-ABO titers. Short-term graft function, graft survival, patient survival, and immunological outcomes were comparable to rituximab-based desensitization. Importantly, omission of rituximab was associated with significantly fewer infectious complications and infection-related hospitalizations, supporting a tailored, lower-intensity immunosuppressive approach in selected low-risk patients.
Human leukocyte antigen incompatibility, particularly in broadly sensitized kidney transplant candidates with high calculated panel reactive antibody, poses a significant barrier to transplantation. Two strategies exist: (1 ) virtual crossmatch with a donor -specific antibody -free donor or (2 ) desensitization. We compared immunological risks and posttransplant complications between these 2 approaches. We retrospectively screened 50 kidney transplant candidates with calculated panel reactive antibody ≥95 %. Donor -specific antibody positivity was defined as mean fluorescence intensity >750. Of 25 participants (13 male; mean age 36.8 ± 14.3 years ), 12 had calculated panel reactive antibody ≥95 % and no donor -specific antibodies (group A ), whereas 13 showed positivity for donor -specific antibodies and underwent desensitization (plasmapheresis, intravenous immunoglobulin, and rituximab with or without bortezomib; group B ). All but 1 patient received living donor transplants. Sensitization included prior transplant (n = 22 ), transfusions (n = 23 ), and pregnancies (n = 7 ). Median follow -up was 18 months, with no significant difference in estimated glomerular filtration rate between groups at any time point (at day of discharge; at 1, 3, 6, 12, 18, and 24 months posttransplant, and at most recent follow -up ). One graft loss occurred in group A due to vascular complications at 5 months. Sixteen biopsies were performed. Four episodes of acute antibody -mediated rejection were observed (1 in group A, 3 in group B; P = .728 ). Posttransplant infections occurred in 7 patients (28 % ), all in group B (P = .005 ), including BK virus (n = 5; P = .039 ) and parvovirus B19 (n = 2 ). Four patients in group A remained on immunosuppression versus none in group B (P = .039 ). In highly sensitized kidney transplant recipients, both virtual crossmatch with donor -specific antibody -free donors and desensitization strategies resulted in comparable short -term graft function. However, desensitized patients showed significantly higher risk of posttransplant infections.
Hemolytic disease of the fetus and newborn, which normally presents with unconjugated hyperbilirubinemia, has been known to cause cholestatic jaundice, albeit in rare circumstances; seen especially in the setting of Rhesus (Rh) hemolytic disease or when the mother has received intrauterine transfusion(s). Infants presenting with cholestatic jaundice in the setting of hemolytic anemia pose a clinical dilemma with regard to investigative approach and management. There are no evidence-based guidelines as to whether such infants should be managed conservatively or investigated comprehensively for other causes of cholestasis. Furthermore, whether such babies should receive chelation therapy besides supportive treatment is not known. We describe one such case where a neonate with Rh hemolytic disease presented with cholestasis and acute liver failure.