Prophylactic platelet transfusion is performed in patients with acute leukemia receiving induction chemotherapy. We retrospectively analyzed platelet trigger (PT) values and transfused platelet concentrate numbers in acute myeloblastic leukemia (AML) and acute lymphoblastc leukemia (ALL) patients receiving induction chemotherapy in our hospital.
AML and ALL patients admitted between 1994 and 1999 were grouped as A1 and B1, respectively, while those admitted between 2004 and 2006 were grouped as A2 and B2, respectively. PT values, transfused platelet concentrate numbers, and factors associated with platelet transfusion were analyzed. The investigation period extended from the day of diagnosis to the day on which the neutrophil count reached more than 1,000/μl after induction. No significant differences were seen in blood cell count at admission, induction regimen, number of granulocyte colony-stimulating factor administrations, disseminated intravascular coagulation scores, number of patienst with infection, number of patients with fever, complete remission rate, and bleeding severity based on the WHO grading system between A1 and A2 and between B1 and B2. In AML, the mean PT value in A2 (1.7×10⁴/μl) was significantly lower than that in A1(2.7×10⁴/μl). The mean number of platelet concentrates in A2 (56 units) was significantly lower than that in A1. In ALL, the mean PT value in B2 (1.1×10⁴/μl) was significantly lower than that in B1 (2.1×10⁴/μl). However, the mean number of platelet concentrates was not significantly different between groups, i.e., 8.45 units in B1 and 7.3 units in B2.
These results indicate that PT values of between 1.0×10⁴ and 2.0×10⁴/μl for acute leukemia patients receiving induction chemotherapy in Japan permit a decrease in platelet concentrate number without increasing hemorrhagic risk.

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Background and objects: Although it is well known that the use of imported albumin products in Japan is high, the status of albumin usage in hospitals is not clear. In our hospital, albumin products are managed by the Transfusion Division, and indications for albumin use are evaluated according to the guidelines issued by the Ministry of Health, Labor and Welfare before administration. The amount of albumin used in our hospital is relatively lower than that in other hospitals. We therefore reviewed t albumin usage in our hospital in comparison with that at the seven other general hospitals to clarify the characteristics of use at our hospital.
Materials and methods: We investigated the status of usage of albumin products for all patients who received albumin products at our hospital and seven general hospitals for a month in April, 2005, and also investigated the background of usage.
Results: The number of participants at our hospital and the seven hospitals was 56 and 444 patients, and the number of albumin products used was 180 and 2,512 vials, respectively. The major purpose of albumin administration was the maintenance of circulation at our hospital, and hypoalbuminemia at the seven hospitals. Serum albumin level before albumin administration at our hospital and the seven hospitals was 2.3±0.5g/dl or 2.8±0.7g/dl(p<0.000001), usage amount of albumin per therapy was 23.5±15.3g or 44.7±59.3g(p<0.000001), and the mortality rate after albumin therapy was 16.1% or 14.6% (P=0.77), respectively. Mortality rate was t higher for patients with lower serum albumin before albumin administration.
Discussion: The amount of albumin used per therapy was much lower in our hospital than in the seven other hospitals. We consider that one main reason for this is our review of the indications for albumin before use. This study indicates that hypoalbuminemia may be a marker of bad prognosis, but that albumin administration may not improve the prognosis.

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Objective: Evaluate the clinical efficacy and safety of autologous fibrin glue (AFG) prepared by CryoSeal^®.
Background: Control of oozing during surgery remains an important task for surgeons. Although commercial adhesives and hospital made fibrin glue are often used to control oozing, the risk of pathogen transmission and allergic reaction cannot be completely avoided.
Methods: A multicenter, open-label, non-randomized study was conducted with 74 patients undergoing surgery with preoperative autologous blood transfusion. CryoSeal^® was used to prepare autologous cryoprecipitate and thrombin from patient blood. Hemostatic effects were assessed in 62 of 74 patients.
Results: On average, 263.8±26.7ml of plasma was collected, and 5.3±1.2ml of both cryoprecipitate and thrombin were prepared. Median in vitro clotting time for AFG was 4.1 seconds (range, 1.3-195.2 seconds). The hemostatic effect against oozing was effective in 54 of 62 patients (87%). The effective rate in patients with thrombin activity ≥20U/ml was 96% (46 of 48 patients), which was significantly higher than 54% (7 of 13) in patients with thrombin activity <20U/ml(p<0.001, Fisher's test). Complications attributable to the use of AFG were not observed.
Conclusions: AFG produced by CryoSeal^® was prepared in a short time and clinically effective in stopping oozing. Our results show that AFG could be used for adjunct hemostasis as well as commercial adhesives and hospital made fibrin glue.

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We describe a patient with myelodysplastic syndrome (MDS) whose thrombocytopenia was transiently improved by high-dose intravenous gammaglobulin before orthopedic surgery. A 79-year-old woman with MDS-refractory anemia (RA) and complications due to a fracture of the left femur underwent total hip replacement. Platelet (PLT) count, which had improved from 0.2×10⁴/μl to 4.4×10⁴/μl after administration of 30mg/day prednisolone (PSL), dramatically increased to 10.3×10⁴/μl after administration of gammaglobulin at 400mg/kg body weight/day for 3 days. Although the surgery was safely performed with a low volume of bleeding, the patient developed deep vein thrombosis (DVT) of the right popliteal vein. It is well known that patients with MDS occasionally show complications such as various immunological abnormalities and respond to immunosuppressive therapy. In particular, high-dose intravenous gammaglobulin is a potentially useful treatment when a prompt increase in PLT is required. However, prevention of DVT is necessary, particularly in cases with risk factors such as old age, confinement to bed, or orthopedic surgery.

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Background: Vascular injury, such as thrombotic complications, is known to occur as a side effect of high dose intravascular immunoglobulin therapy (IVIG therapy). Here, we report two cases of cerebral vessel disease.
Case 1: In September 2006, a 67-year old man, complicating of muscle insufficiency in the lower extremities, was diagnosed with sigmoid cancer and polymyositis with complicated aspiration pneumonia. Although antibiotic therapy for pneumonia, IVIG therapy for polymyositis, and surgical operative therapy for sigmoid cancer were performed, the patient died due to hemorrhage of the bilateral thalamus.
Case 2: In May 2006, a 62-year old man, who had previous history of pyoderma gangrenosum and myelodysplastic syndrome, suffered from fever and red blisters in the palm of his right hand. He was diagnosed with the recurrent pyoderma gangrenosum and necrotizing fasciitis. Although intensive therapy was performed using IVIG, antibiotics, mPSL pulse, and cyclosporine A, the patient died due to multiple cerebral infarction (right middle artery area, right posterior artery area, and cerebella area).
Discussion: Both cases show the possible difficulties of cerebral vessel complication in IVIG therapy. These observations suggest that further risk-value analysis is required to better assess cerebral vessel complications in IVIG therapy.

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Objective:
Hospital transfusion services receive blood components supplied by the Red Cross Blood Center and forward them to places where blood transfusions are conducted. Therefore, in case of an urgent and/or massive transfusion, the transfusion services are required to act with speed and precision to ensure that sufficient blood components are prepared for resuscitation. We performed a nationwide questionnaire survey of the current status of transfusion services in the management of critical hemorrhages.
Materials and methods:
In November 2007, we conducted the survey in 385 transfusion services of hospitals accredited by the Japan Society of Anesthesiologists.
Results:
1. Almost all the hospitals complied with the Japanese standard operating procedures for blood transfusion practice.
2. Procedures for urgent and massive transfusions were insufficiently documented.
3. The existence of newly published guidelines, entitled "Guidelines for Urgent Transfusion Practices for Life-Threatening Hemorrhages," was already known to staff members in transfusion services. Nevertheless, the guidelines were not well known to either surgeons or anesthesiologists at the hospitals.
4. Many reasons for avoiding ABO-mismatched compatible blood transfusion to patients in life-threatening situations were identified.
5. The time required for both blood-typing and crossmatching tests was longer outside office hours than during office hours. Consequently, the time required for emergency release was longer outside office hours.
6. Transportation time from the regional blood center to a hospital transfusion service did not differ during and outside office hours.
7. ABO-matched blood without crossmatching had been used for urgent transfusions at about 40% of the hospitals. Moreover, ABO-mismatched compatible blood components without crossmatching had been used at about 20%.
Conclusion:
It is necessary to establish documented institutional procedures for urgent transfusion practices according to the Guidelines for Urgent Transfusion Practices for Life-threatening Hemorrhages.
On the occurrence of a life-threatening hemorrhage, we recommend the use of ABO-matched blood components without crossmatching or ABO-mismatched compatible blood components within an appropriate time to save the patient's life.

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Background: Activation of the complement system induced by the formation of immune complex is assumed to be a possible developmental mechanism of nonhemolytic transfusion reactions.
Materials and methods: Serum C4 and C3 concentrations of 197 patients who experienced nonhemolytic transfusion reactions were measured before and after the transfusion reactions and compared. Serum tryptase concentrations were also measured as an indicator of the activation of the mast cells to examine its relation to the complement activation.
Results: Simultaneous decreases in serum C4 and C3 concentrations were observed in patients who experienced nonhemolytic transfusion reactions classified as anaphylactic shock, anaphylactoid reactions or urticaria according to their symptoms. Increases in serum tryptase levels were also observed in these patients. However, no significant correlations were observed between the decrease in complement concentration and the increase in tryptase levels.
Conclusions: Activation of the complement system via the classical pathway during transfusion reactions is suggested in patients with anaphylactic shock, anaphylactoid reactions and urticaria. However, a correlation between the activation of complement and mast cells was not observed. These findings suggest the possibility that nonhemolytic transfusion reactions develop via different mechanisms.

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A questionnaire regarding transfusion medicine containing identical questions was sent to 1,355 hospitals for each of the fiscal years from FY2004 to FY2007. Replies were received from 829 hospitals (FY2004), 857 hospitals (FY2005), 872 hospitals (FY2006) and 844 hospitals (FY2007). This paper reports the results of this survey that were related to adverse reactions during transfusion. Unified reporting systems for adverse reactions gradually spread, increasing to 78.9% in FY2007 from 59.1% in FY2004. Although adverse reactions were widely reported in paper form, reporting by internet did not appear to be in customary use, as only 91 hospitals (11.0%) mentioned doing so in FY2007. Transfusion bags suspected as the cause of adverse reactions were collected in most hospitals. 343 hospitals (41.7%) in FY2007 collected all bags responsible for adverse reactions regardless of criticality. Non-irradiated transfusion bags were still used in 63 hospitals (7.3%) in FY2006 and 58 hospitals (6.9%) in FY2007. Blood typing tests were had not double-checked in 219 hospitals (25.4%) reporting in FY2006 and 190 hospitals (22.7%) in FY2007. Double-checking is an indispensible process. In 70% of hospitals, it is customary to give type O red cell concentrated blood in extreme emergencies with no compatibility tests performed. In other hospitals, hospital transfusion committees should establish practical guidelines for extreme emergencies. Serious hazards stemming from transfusion were investigated in FY2007, and 32 cases demonstrated transfusion-related acute lung injury (TRALI). Severe allergic reactions were detected in 61 cases and graft versus host disease (GVHD) in 2 cases. No transfusion-transmitted bacterial infections were diagnosed. There were 10 deaths reported among hazards stemming from transfusion, in 4 of whom the cause of death is thought to be the transfusion. Survey of adverse reactions during transfusion is important in order to establish appropriate transfusion practices, including measures against the hazards of transfusion.

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