Expert review of hematology
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Transfusion-related acute lung injury (TRALI) has been identified as the most common cause of transfusion-related death. Although extensive literature supports restrictions on female-donor plasma to reduce antibody-mediated TRALI, only a few outcome studies have assessed for effects of this change, and some, but not all, have endorsed the policy. A recent report even suggests poorer outcomes in cardiac surgery patients with a shift to male-donor-only plasma, raising concerns that TRALI alone, whether catastrophic or more survivable, is insufficient compared with broader measures, such as short-term mortality or long-term survival, as an end point to assess for overall improvements in patient care.
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Natural killer (NK)-cell malignancies are uncommon neoplasms, which have been referred to as polymorphic reticulosis or angiocentric T-cell lymphomas in the past. In the current WHO classification, they are categorized as extranodal NK/T-cell lymphoma, nasal type and aggressive NK-cell leukemia. NK-cell malignancies show a geographical predilection for Asian and South American populations and are rare in the west. ⋯ Recent regimens that incorporate the use of L-asparaginase have resulted in substantial improvements in outcome in high-risk, refractory or relapsed patients. High-dose chemotherapy and hematopoietic stem-cell transplantation with autologous or allogeneic hematopoietic stem cells may be beneficial to selected patients. Prognostication of patients with clinical prognostic models and presentation circulating Epstein-Barr DNA load may be useful in the stratification of patients for various treatment modalities.
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Recent insights from models of transfusion-related acute lung injury (TRALI), and from clinical reports, reveal that host factors are important in TRALI pathogenesis. Predisposing factors with lung neutrophil-priming capacity, such as sepsis and mechanical ventilation, increase susceptibility for a TRALI reaction, and can aggravate the course of disease. These findings may explain the higher incidence of TRALI in the critically ill compared with general hospital populations. ⋯ Suspected TRALI cases in which another acute lung injury risk factor is present (termed 'possible TRALI' in the consensus definition) should be reported to the blood bank, including patients suffering from an underlying condition. In reporting of TRALI cases, use of the international TRALI consensus definition should be used, rather then national TRALI scoring systems, to ensure a uniform approach, which may decrease variance in estimations of incidence. In terms of treatment of TRALI patients, there is a rationale to apply therapeutic strategies, which have proven to be beneficial in acute lung injury.
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Injured patients stress the transfusion service with frequent demands for uncrossmatched red cells and plasma, occasional requirements for large amounts of blood products and the need for new and better blood products. Transfusion services stress trauma centers with demands for strict accountability for individual blood component units and adherence to indications in a clinical field where research has been difficult, and guidance opinion-based. New data suggest that the most severely injured patients arrive at the trauma center already coagulopathic and that these patients benefit from prompt, specific, corrective treatment. This research is clarifying trauma system requirements for new blood products and blood-product usage patterns, but the inability to obtain informed consent from severely injured patients remains an obstacle to further research.