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Biomedical subjects

C S Kitchens

Publications and source records attributed to C S Kitchens.

At least 19 recordsLinked to original sources
PubMed2005

To bleed or not to bleed? Is that the question for the PTT?

The activated partial thromboplastin time (PTT) is the grandchild of the Lee-White whole blood clot time (WBCT). Both tests were developed to assist the diagnostic process for patients who exhibited features consistent with hemophilia, i.e., the pretest probability was extremely high. Probably <0.1%-1.0% of PTTs ordered in current medical practice fit that indication with the most common indication now being routine admission order; i.e., a pretest probability that is extremely low. The question asked of the PTT has evolved from 'why does this patient bleed?' to 'will this patient bleed?' As the PTT was never intended to answer that question, one must be careful regarding interpretation of results of that test. As many situations not related to hemorrhage are associated with perturbations of the PTT, a prolonged PTT is not strongly predictive of hemorrhage nor does a normal PTT provide shelter against hemorrhagic risk.

Blood Loss, Surgical↗
PubMed2001

A randomized multicenter trial of crotalinae polyvalent immune Fab (ovine) antivenom for the treatment for crotaline snakebite in the United States.

BACKGROUND: Current therapy for crotaline snakebite includes antivenin (Crotalidae) polyvalent, an antivenom with numerous adverse effects. We compared the efficacy and safety of 2 dosing regimens with a new antivenom, Crotalinae polyvalent immune Fab (Fab AV). METHODS: A single dose of Fab AV alone (as-needed [PRN] group) was compared with an initial dose plus repeated treatments during 18 hours (scheduled group) in a multicenter randomized trial. The study included patients with minimal or moderate envenomation by a crotaline snake within the preceding 6 hours, aged 10 years or older, in whom worsening of the envenomation syndrome was observed before Fab AV treatment. After treatment with Fab AV to achieve initial control, patients were randomized to the scheduled or PRN treatment group. Scheduled group patients received additional doses of Fab AV every 6 hours for 3 doses. The PRN group received no planned additional doses of antivenom. RESULTS: The mean severity score of the 31 patients decreased from 4.35 to 2.39 points (P<.001); there was no difference between scheduled and PRN groups. No patient in the scheduled group received unplanned Fab AV doses, but 8 of 16 patients in the PRN group received unplanned doses (P =.002). Acute reactions occurred in 6 patients (19%), and serum sickness occurred in 6 (23%) of 26 patients who returned for follow-up. CONCLUSIONS: In the first randomized trial of antivenom in the United States, Fab AV effectively terminated venom effects. Since the unplanned use of Fab AV in the PRN group was common, the treatment regimen may require more than 1 initial dose.

Adolescent↗
PubMed2001

Autoantibody formation in the alloimmunized red blood cell recipient: clinical and laboratory implications.

Alloimmunization to erythrocyte antigens is a well-characterized complication in heavily transfused patients. Less well recognized, however, is the frequency of autoantibody formation in these previously alloimmunized patients. The autoantibodies are heterogeneous and of variable clinical significance. We describe the clinical history, laboratory evaluation, diagnosis, and treatment in 4 patients who developed autoantibodies in temporal association with alloantibody formation. In one case, the autoantibody found on routine screening had no clinical significance. In another case, the autoantibody made accurate blood typing and subsequent transfusion exceedingly difficult. Two patients experienced hemolysis as a consequence of the autoantibody. The management of both patients included supportive measures, while one patient required glucocorticosteroids and red blood cell transfusion. We review the published literature concerning autoimmunization in the transfused alloimmunized host. The spectrum of clinical consequences is important for the general practitioner to recognize, as these complications may occur during routine blood transfusions.

Adult↗
PubMed1998

Thrombotic storm: when thrombosis begets thrombosis.

Patients with hypercoagulability may present with a single thrombosis and subsequently develop progressive thromboses at other sites. With inadequate therapy, the thrombotic process may self-perpetuate, leading to multiple thromboses and even death. Six cases are presented demonstrating key features of what may be termed thrombotic storm: (1) an underlying hypercoagulable disorder; (2) a provocation to initiate thrombosis; (3) rapid development of new thromboses; (4) response to prompt use of thrombolytic agent or anticoagulant therapy; and (5) remarkable good long-term prognosis if the cycle of thrombosis is interrupted. Continued activation of coagulation by fresh thrombosis is hypothesized as the cause of the syndrome, which may explain its control by anticoagulants. Whereas these unusual patients' courses most likely represent only an extreme of hypercoagulability and not a new disorder, their characteristic behavior warrants attention.

Adult↗
PubMed1997

Affinity-purified, mixed monospecific crotalid antivenom ovine Fab for the treatment of crotalid venom poisoning.

SUBJECT OBJECTIVE: To test the efficacy and safety of a new antivenom, affinity-purified, mixed monospecific crotalid antivenom ovine Fab, in human subjects with minimal or moderate crotalid envenomation. METHODS: We conducted a prospective multicenter clinical trial of 11 patients 10 years or older with progressive manifestations after mild to moderate crotalid snakebite. After giving their consent, subjects received four to eight vials of study drug and were then repeatedly examined over 48 hours and at 7 and 14 days after discharge. Each patient's clinical condition was evaluated serially with the use of a validated severity score, as well as on the basis of the investigator's assessment. RESULTS: In all 11 subjects to the antivenom was judged by the investigator to have had a beneficial response. The severity score for each patient remained the same or decreased over the first 4 hours. However, two subjects demonstrated worsened condition 12 to 15 hours after antivenom administration. In no subject did an allergic reaction develop. CONCLUSION: In this patient group, affinity-purified, mixed monospecific crotalid antivenom ovine Fab was associated with a halt of progressive crotalid venom poisoning. Initial safety data are promising but must be addressed further in subsequent studies.

Adolescent↗
PubMed1997

Canebrake rattlesnake envenomation.

STUDY OBJECTIVE: To document the clinical presentation and course of consecutive cases of envenomation by the canebrake rattlesnake (Crotalus horridus atricaudatus). METHODS: The medical care provided all patients envenomated by canebrake rattlesnakes in two institutions was retrospectively reviewed. Particular attention was paid to coagulation abnormalities, serum enzymes, electrocardiographic findings, and treatment with antivenom. RESULTS: Of the 15 patients, envenomation was judged to be mild in 3, moderate in 6, and severe in 5. In one case envenomation caused death. The clinical course generally predicted the degree of increase in the serum creatinine kinase (CK) level, as well as the amount of antivenom used for treatment. Despite increases in serum CK concentration and frequent increases in the serum CK-MB fraction, we found no evidence of cardiac damage. CONCLUSION: In envenomation by North American pit vipers, rhabdomyolysis appears to be characteristic of envenomation by the canebrake rattlesnake. We speculate that toxins in the canebrake venom cause skeletal muscle rhabdomyolysis. Physicians caring for victims of canebrake bite should regard marked increases in CK concentration as coming from skeletal, not cardiac, muscle. Good general medical support and antivenom for victims with moderate to severe envenomation appears effective.

Adolescent↗
PubMed1995

Disseminated intravascular coagulation.

Disseminated intravascular coagulation is the result of a severe underlying disorder that initiates massive activation of the coagulation system. It is always a symptom of the underlying disorder. These disorders may be as varied as meningococcemia and abdominal aortic aneurysm. Disseminated intravascular coagulation is a clinical diagnosis. Once the clinical impression has been considered, a small number of readily available tests will substantiate the diagnosis. Further testing is probably not necessary and certainly not cost-effective. Therapy for disseminated intravascular coagulation requires 1) the correction of the underlying problem, either by drainage of an abscess for sepsis, evacuation of the uterus in an obstetric catastrophe, or treatment of septicemia with antibiotics; and 2) the concomitant restoration of the circulatory system, perfusion, blood pressure, and electrolyte balance. Other forms of therapy are available but are quite secondary to these two. Success depends on the ability to recognize and correct the cause.

Anticoagulants↗
PubMed1994

Zinc-induced sideroblastic anemia: report of a case, review of the literature, and description of the hematologic syndrome.

Zinc ingestion has become increasingly popular in the lay and food faddist population. Herein described by way of a case report and review of the 13 cases in the literature is the syndrome of severe anemia associated with excessive and prolonged intake of oral zinc. The syndrome is characterized by anemia, granulocytopenia, and bone marrow findings of vacuolated precursors and ringed sideroblasts. Serum analysis reveals increased zinc levels, decreased copper levels, and a decrease in ceruloplasmin. The mechanism appears to be zinc-induced copper deficiency, which is instrumental in producing the profound bone marrow abnormalities, as zinc itself is of low toxicity. Importantly, the syndrome is totally reversible with cessation of zinc intake. Hematologists should be aware of this form of reversible sideroblastic anemia.

Adult↗
PubMed1994

Case report: fatal Staphylococcus aureus sepsis from single-donor platelet transfusion.

Bacterial sepsis is a rare and potentially fatal complication of platelet transfusions. Bacterial contamination is estimated to occur in 2% to 6% of platelet concentrates, but clinically apparent septicemia occurs in less than 1% of multi-donor platelet transfusions. The incidence of bacterial sepsis from single-donor platelet transfusions is significantly lower, possibly because of shorter storage time of apheresis platelets. The authors report a case of fatal Staphylococcus aureus sepsis from a single-donor platelet transfusion obtained through a closed system. They conclude that as the demand for platelet transfusion increases, recognition of bacterial sepsis from transfusions and continued reassessment of procedures for collection and storage of platelet concentrates is warranted.

Aged↗
PubMed1993

Are transfusions overrated? Surgical outcome of Jehovah's Witnesses.

Physicians as well as their patients are quite familiar with the ever growing list of complications of transfusion. Blood is usually administered by physicians with the nearly unchallenged view that failure to transfuse would have dire consequences. Evidence supporting that view is very difficult to obtain. Although no controlled trial exists, data are collected from 16 reports of the surgical outcome of a series of patients of the Jehovah's Witness faith who were not given transfusion for operations during which transfusion is typically given. Analysis of these data supports the concept that approximately 0.5% to 1.5% of such operations are complicated by anemia resulting in death. This risk of not transfusing patients must be weighed against the cost, morbidity, and mortality that would be expected to accrue had these patients been transfused. These concepts should be employed whenever one is formulating a risk-benefit ratio for patients for whom transfusion is contemplated.

Blood Loss, Surgical↗
PubMed1992

Evolution of our understanding of the pathophysiology of primary mesenteric venous thrombosis.

Mesenteric venous thrombosis is a rare insidious event that is difficult to diagnose. Approximately half the cases in the past were deemed "primary" or "idiopathic." These cases were also frequently associated with a previous history of thromboembolism and a family history positive for thromboembolism. Inherited hypercoagulable disorders, such as deficiency of protein C, protein S, or antithrombin III, will probably explain many "primary" cases. Prompt diagnosis, especially with modern imaging techniques, and prompt anticoagulant therapy decrease mortality.

Humans↗
PubMed1992

Changes in coagulation and anticoagulation in women taking low-dose triphasic oral contraceptives: a controlled comparative 12-month clinical trial.

OBJECTIVE: The effects of two triphasic oral contraceptives on coagulation and anticoagulation factors were compared in a 12-month open-label study. STUDY DESIGN: Fifty-two women (mean age 26 years) were enrolled in and completed the study; 20 had been randomly assigned to receive levonorgestrel plus ethinyl estradiol, 24 had been randomly assigned to receive norethindrone plus ethinyl estradiol, and eight surgically sterile women acted as untreated controls. Coagulation and anticoagulation factors were measured at baseline and during the sixth and twelfth months. RESULTS: Both oral contraceptives produced significant decreases from baseline in prothrombin time and partial thromboplastin time; there were also significant changes in laboratory control times. Factor XII was significantly increased in both oral contraceptive groups after 6 and 12 months. Fibrinogen antigen was significantly increased for norethindrone plus ethinyl estradiol after 6 and 12 months and for levonorgestrel plus ethinyl estradiol after 12 months. Platelet counts were unchanged. There was a significant increase in antithrombin III activity with norethindrone plus ethinyl estradiol at 12 months. Antithrombin III antigen was unchanged with the oral contraceptives; however, significant increases existed for alpha 1-antitrypsin antigen and plasminogen antigen and activity after 6 and 12 months and for alpha 2-macroglobulin antigen after 12 months for both oral contraceptives. alpha 2-Antiplasmin antigen was significantly increased for norethindrone plus ethinyl estradiol at the 12-month evaluation. There were no significant differences between the oral contraceptives for any coagulation or anticoagulation factor, and mean values generally remained within reference ranges. CONCLUSIONS: Levonorgestrel plus ethinyl estradiol and norethindrone plus ethinyl estradiol had equivalent, minimal effects on hemostasis, and changes in coagulation factors appeared to be balanced by changes in anticoagulation factors.

Adult↗
PubMed1992

Hemostatic aspects of envenomation by North American snakes.

1. North American poisonous snakes have a wide spectrum of complex venoms. 2. Venom, especially that of the rattlesnakes, may cause a variety of hemostatic abnormalities by directly, yet only partially, cleaving fibrinogen, activating the fibrinolytic system, or activating and clearing platelets through the action of proteolytic enzymes. 3. Because these venoms do not result in the generation of thrombin, the syndrome is distinct from true DIC. Bleeding or thrombosis is rare. 4. As thrombin generation remains intact, hemostasis is largely preserved despite dramatic changes in hemostatic tests. 5. Therapy with heparin, blood, or blood products is rarely indicated. 6. Therapy with antivenin in selected cases is logical and efficacious.

Animals↗