The death of a neonatal infant following cardiac surgery and the transfusion of packed red cells (RBCs) with high plasma potassium levels is reported. The patient had been diagnosed at 2 weeks of age as having multiple cardiac malformations. During cardiopulmonary bypass surgery, multiple units of packed RBCs less than 5 days old were transfused. In response to a "stat" order and after depletion of stock units prepared for neonatal usage, a 32-day-old unit of packed RBCs was issued for transfusion. After approximately 60 mL was rapidly transfused from this unit, the patient experienced cardiac arrest. Serum potassium concentration after transfusion and before death was 8.9 mmol per L. Plasma potassium concentration in the remainder of the transfused packed RBC unit was approximately 60 mmol per L. A model was created to calculate the posttransfusion plasma potassium concentration, and close correlation was found between the model and the observed potassium concentration, which assumes that the potassium load had not yet been distributed to the extravascular and intracellular fluid compartments. It is concluded that the transfusion of relatively large volumes of RBCs be limited to fresh packed RBCs or to packed RBCs that have been saline washed, to minimize the complications of electrolyte disturbances.
HbA(1c) trimester-specific reference intervals are required to better inform the management of pregnancies complicated by diabetes.
Nonmelanoma skin cancers (NMSC), mainly basal cell carcinoma (BCC) and squamous cell carcinoma (SCC), are the most common cancers in white populations. 1 We discuss the randomized controlled trial of nicotinamide in the chemoprevention of such cancers, published by Chen et al. in 2015. 1 The study [(Oral Nicotinamide to Reduce Actinic Cancer (ONTRAC;)] was carried out in Sydney with a cohort of 386 patients, who were randomized in a 1 : 1 ratio to receive either nicotinamide 500 mg twice daily or matched placebo. Eligible participants were ≥ 18 years of age, and had been diagnosed with at least two histologically confirmed NMSCs in the previous 5 years. The primary endpoint was the number of new histologically confirmed cancers (including BCCs and both invasive and in situ SCCs); secondary endpoints included the number of new actinic keratoses (AK) during the 12-month intervention period, the number of new NMSCs in the 6-month post-intervention period, and assessment of the safety profile of nicotinamide. The mean number of new NMSCs per person throughout the 12month intervention period was more significantly reduced (by 23%) in the nicotinamide group than in the placebo group (95% CI 4-38; P = 0.02). As early as the first 3month visit, there were significantly lower numbers of AK in patients taking nicotinamide over placebo, and the overall number of AK alone was 13% lower at 12 months (P = 0.001). The adjusted rate of new SCCs was lower by 30% with nicotinamide (95% CI 0-51, P = 0.05), with the rate of BCCs being reduced by 20% with nicotinamide over placebo, (95% CI À6 to 39, P = 0.12). Patients receiving nicotinamide had a reduced incidence of superficial BCC over other subtypes of BCC. It is important to note, however, that the effect of nicotinamide on NMSCs was not maintained into the 6-month follow-up period after the drug was discontinued.The results of this paper indicate a potential financial saving; as stated by Chen et al., the annual total cost of treating NMSC in the USA is estimated to be $4.8 billion. 1 Similarly, in the UK, Vallejo-Torres et al. estimated that treatment of skin cancer will cost the NHS £180 million by the year 2020, with NMSC costing approximately £1000 per case on average. 2 That particular study was carried out by cost of illness analysis, and showed that prevention of NMSC would not only reduce the significant burden of disease to the patient but would also save the NHS considerable resources. Chen et al. 1 make a valid point that despite the preventative benefits of sunscreen with regard to development of SCC, BCC and melanoma, compliance is poor and there is a need for additional preventative measures. 1 Nicotinamide is an amide form of vitamin B3, and is naturally present in small quantities in lean meats, nuts, fish and legumes. It is the primary precursor of nicotinamide adenine dinucleotide (NAD+), an essential coenzyme in ATP production and the sole substrate of the nuclear enzyme poly-ADP-ribose polymerase (PARP)-1. 3 It therefore works by preventing ATP depletion an...
A man aged 78 years presented with a 3-week history of tender mouth ulceration associated with arthralgia and weight loss. He had ulcerative colitis that was diagnosed 10 years previously which was well controlled on adalimumab 40 mg fortnightly. Biochemical and haematological investigations showed raised inflammatory markers (CRP 105) and a marked neutrophilia (10). On examination, the patient had severe oral ulceration involving the anterior tongue and lips. In addition, on cutaneous examination had tender erythematous nodules involving the forehead. Histology from a diagnostic punch biopsy showed marked dermal oedema with an inflammatory infiltrate consisting of neutrophils. Our working diagnosis was therefore oral Sweet's syndrome. The patient was then started on oral prednisolone and later received colchicine which led to a complete resolution of symptoms.
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