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Coller BS. Foreword: A Brief History of Ideas About Platelets in Health and Disease. Platelets 2019. [DOI: 10.1016/b978-0-12-813456-6.09988-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Cid J. Prevention of transfusion-associated graft-versus-host disease with pathogen-reduced platelets with amotosalen and ultraviolet A light: a review. Vox Sang 2017; 112:607-613. [DOI: 10.1111/vox.12558] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Revised: 06/13/2017] [Accepted: 07/04/2017] [Indexed: 01/28/2023]
Affiliation(s)
- J. Cid
- Department of Hemotherapy and Hemostasis; ICMHO; IDIBAPS; Hospital Clínic; University of Barcelona; Barcelona Spain
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Jawan B, Wang CH, Chen CL, Huang CJ, Cheng KW, Wu SC, Shih TH, Yang SC. Review of anesthesia in liver transplantation. ACTA ACUST UNITED AC 2014; 52:185-96. [PMID: 25477262 DOI: 10.1016/j.aat.2014.09.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2014] [Accepted: 09/26/2014] [Indexed: 01/10/2023]
Abstract
Liver transplantation (LT) is a well-accepted treatment modality of many end-stage liver diseases. The main issue in LT is the shortage of deceased donors to accommodate the needs of patients waiting for such transplants. Live donors have tremendously increased the pool of available liver grafts, especially in countries where deceased donors are not common. The main ethical concern of this procedure is the safety of healthy donors, who undergo a major abdominal surgery not for their own health, but to help cure others. The first part of the review concentrates on live donor selection, preanesthetic evaluation, and intraoperative anesthetic care for living liver donors. The second part reviews patient evaluation, intraoperative anesthesia monitoring, and fluid management of the recipient. This review provides up-to-date information to help improve the quality of anesthesia, and contribute to the success of LT and increase the long-term survival of the recipients.
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Affiliation(s)
- Bruno Jawan
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan.
| | - Chih-Hsien Wang
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chao-Long Chen
- Liver Transplant Program, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chia-Jung Huang
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Kwok-Wai Cheng
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Shao-Chun Wu
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Tsung-Hsiao Shih
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Sheng-Chun Yang
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
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Flatt JF, Bawazir WM, Bruce LJ. The involvement of cation leaks in the storage lesion of red blood cells. Front Physiol 2014; 5:214. [PMID: 24987374 PMCID: PMC4060409 DOI: 10.3389/fphys.2014.00214] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2014] [Accepted: 05/19/2014] [Indexed: 12/12/2022] Open
Abstract
Stored blood components are a critical life-saving tool provided to patients by health services worldwide. Red cells may be stored for up to 42 days, allowing for efficient blood bank inventory management, but with prolonged storage comes an unwanted side-effect known as the "storage lesion", which has been implicated in poorer patient outcomes. This lesion is comprised of a number of processes that are inter-dependent. Metabolic changes include a reduction in glycolysis and ATP production after the first week of storage. This leads to an accumulation of lactate and drop in pH. Longer term damage may be done by the consequent reduction in anti-oxidant enzymes, which contributes to protein and lipid oxidation via reactive oxygen species. The oxidative damage to the cytoskeleton and membrane is involved in increased vesiculation and loss of cation gradients across the membrane. The irreversible damage caused by extensive membrane loss via vesiculation alongside dehydration is likely to result in immediate splenic sequestration of these dense, spherocytic cells. Although often overlooked in the literature, the loss of the cation gradient in stored cells will be considered in more depth in this review as well as the possible effects it may have on other elements of the storage lesion. It has now become clear that blood donors can exhibit quite large variations in the properties of their red cells, including microvesicle production and the rate of cation leak. The implications for the quality of stored red cells from such donors is discussed.
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Affiliation(s)
- Joanna F Flatt
- Bristol Institute for Transfusion Sciences, NHS Blood and Transplant Bristol, UK
| | - Waleed M Bawazir
- Bristol Institute for Transfusion Sciences, NHS Blood and Transplant Bristol, UK ; School of Biochemistry, University of Bristol Bristol, UK
| | - Lesley J Bruce
- Bristol Institute for Transfusion Sciences, NHS Blood and Transplant Bristol, UK
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Ozkardesler S, Avkan-Oguz V, Akan M, Unek T, Ozbilgin M, Meseri R, Cimen M, Karademir S. Effects of blood products on nosocomial infections in liver transplant recipients. EXP CLIN TRANSPLANT 2013; 11:530-6. [PMID: 23901878 DOI: 10.6002/ect.2012.0286] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
OBJECTIVES Infection is the most severe complication after an organ transplant. Blood cell transfusion is an independent risk factor for adverse events, including infection in the recipient. This study sought to evaluate the effect of blood product transfusions on nosocomial infections in liver transplant patients. MATERIALS AND METHODS Patients who underwent a liver transplant at our hospital between 2003 and 2010 were recruited for this study. Exclusion criteria were incomplete records, patients who were hospitalized for more than 48 hours during the 4 weeks before transplant, and pediatric transplants. Incidence of nosocomial infections, which were defined as infections occurring within 30 days after transplant was the primary endpoint. RESULTS The incidence of nosocomial infections was 28.7%. The number of transfusions of packed red blood cells and fresh frozen plasma was significantly higher in patients with nosocomial infection compared with patients without nosocomial infection (P = .018 and P = .039). Blood products dose-dependently contributed to nosocomial infections. Transfusions of ≥ 7.5 units of red blood cells (odds ratio: 2.8) or ≥ 12.5 units of fresh frozen plasma (odds ratio: 3.27) were associated with nosocomial infections (P = .042 and P = .015). The infection-related mortality rate was 10.3%. CONCLUSIONS Blood product transfusions are associated with an increased rate of nosocomial infections, which contributes to higher morbidity and mortality.
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Affiliation(s)
- Sevda Ozkardesler
- Department of Anesthesiology, School of Medicine, Dokuz Eylul University, Izmir, Turkey
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Abstract
Platelets are a remarkable mammalian adaptation that are required for human survival by virtue of their ability to prevent and arrest bleeding. Ironically, however, in the past century, the platelets' hemostatic activity became maladaptive for the increasingly large percentage of individuals who develop age-dependent progressive atherosclerosis. As a result, platelets also make a major contribution to ischemic thrombotic vascular disease, the leading cause of death worldwide. In this brief review, I provide historical descriptions of a highly selected group of topics to provide a framework for understanding our current knowledge and the trends that are likely to continue into the future of platelet research. For convenience, I separate the eras of platelet research into the "Descriptive Period" extending from ~1880-1960 and the "Mechanistic Period" encompassing the past ~50 years since 1960. We currently are reaching yet another inflection point, as there is a major shift from a focus on traditional biochemistry and cell and molecular biology to an era of single molecule biophysics, single cell biology, single cell molecular biology, structural biology, computational simulations, and the high-throughput, data-dense techniques collectively named with the "omics postfix". Given the progress made in understanding, diagnosing, and treating many rare and common platelet disorders during the past 50 years, I think it appropriate to consider it a Golden Age of Platelet Research and to recognize all of the investigators who have made important contributions to this remarkable achievement..
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Affiliation(s)
- Barry S. Coller
- Laboratory of Blood and Vascular Biology, Rockefeller University, 1230 York Avenue, New York, NY 10065, Tel: 212-327-7490, Fax: 212-327-7493
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Englehart MS, Cho SD, Morris MS, Gee AC, Riha G, Underwood SJ, Differding JA, Luem ND, Wiesberg TT, Boshkov LK, Schreiber MA. Use of leukoreduced blood does not reduce infection, organ failure, or mortality following trauma. World J Surg 2009; 33:1626-32. [PMID: 19452207 PMCID: PMC7101844 DOI: 10.1007/s00268-009-0076-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Background Leukoreduced (LR) blood has been demonstrated to reduce morbidity and mortality in high-risk surgical patients, but not in trauma patients. The objective of the present study was to determine the effect of LR blood on morbidity and mortality. We hypothesized that the use of LR blood does not improve outcome in trauma patients. Methods This study was a retrospective cohort analysis of trauma patients transfused at a level 1 Trauma Center from 2001 to 2004. Between 2002 and 2003, LR blood was transfused. Prior to that time and subsequent to it, non-leukoreduced (NLR) blood was transfused. This created two historical comparison groups. Data collected included patient demographics, units of blood transfused, intensive care unit (ICU) and hospital days, ventilator days, injury severity score (ISS), mortality, presence of acute respiratory distress syndrome (ARDS), and infectious complications. A multiple organ dysfunction syndrome (MODS) score was calculated. Results The distribution of patients was as follows: 284 patients received only NLR blood, 153 received only LR blood, and 58 received at least one unit of each. The mean ISS was similar (NLR: 26, LR: 24; P > 0.1). No differences were seen between groups in units transfused (6.2 vs. 5.5), number of ICU days (8.2 vs. 9.0), number of hospital days (16.9 vs. 18.6), number of ventilator days (6.1 vs. 5.7), incidence of ARDS (8.3% vs. 8.5%), MODS score (5.5 vs. 5.9), mortality rate (15.1% vs. 15.7%), or infection rate (36% vs. 30%) (P > 0.1). Conclusions This study represents the largest series comparing trauma patients who received either LR or standard blood transfusions. The use of LR blood does not improve outcome in trauma patients.
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Affiliation(s)
- Michael S Englehart
- Department of Surgery, Oregon Health & Science University, 3181 SW Sam Jackson Road-L223A, Portland, OR 97239, USA
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Shander A, Hofmann A, Gombotz H, Theusinger OM, Spahn DR. Estimating the cost of blood: past, present, and future directions. Best Pract Res Clin Anaesthesiol 2007; 21:271-89. [PMID: 17650777 DOI: 10.1016/j.bpa.2007.01.002] [Citation(s) in RCA: 145] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Understanding the costs associated with blood products requires sophisticated knowledge about transfusion medicine and is attracting the attention of clinical and administrative healthcare sectors worldwide. To improve outcomes, blood usage must be optimized and expenditures controlled so that resources may be channeled toward other diagnostic, therapeutic, and technological initiatives. Estimating blood costs, however, is a complex undertaking, surpassing simple supply versus demand economics. Shrinking donor availability and application of a precautionary principle to minimize transfusion risks are factors that continue to drive the cost of blood products upward. Recognizing that historical accounting attempts to determine blood costs have varied in scope, perspective, and methodology, new approaches have been initiated to identify all potential cost elements related to blood and blood product administration. Activities are also under way to tie these elements together in a comprehensive and practical model that will be applicable to all single-donor blood products without regard to practice type (e.g., academic, private, multi- or single-center clinic). These initiatives, their rationale, importance, and future directions are described.
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Affiliation(s)
- Aryeh Shander
- Department of Anesthesiology and Critical Care, New Jersey Institute for the Advancement of Bloodless Medicine and Surgery Englewood Hospital and Medical Center, 350 Engle Street, Englewood, NJ 07631, USA.
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Coller BS. Foreword: A Brief History of Ideas about Platelets in Health and Disease. Platelets 2007. [DOI: 10.1016/b978-012369367-9/50762-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Ludlam CA, Turner ML. Managing the risk of transmission of variant Creutzfeldt Jakob disease by blood products. Br J Haematol 2006; 132:13-24. [PMID: 16371015 DOI: 10.1111/j.1365-2141.2005.05796.x] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Whereas plasma-derived clotting factor concentrates now have a very good safety record for not being infectious for lipid enveloped viruses, concern has arisen about the possibility that prion diseases might be transmitted by blood products. There is epidemiological evidence that classical sporadic Creutzfeld Jakob disease (CJD) is not transmitted by blood transfusion. There is now good evidence that the abnormal prion associated with variant CJD can be transmitted by transfusion of fresh blood components and infect recipients. To reduce the risk of the pathological prion in the UK infecting recipients of clotting factor concentrates, these are now only manufactured from imported plasma collected from countries where there has not been bovine spongiform encephalopathy (BSE) in cattle and the risk of variant CJD in the population is, therefore, considered negligible. The safety of these concentrates is also enhanced because prion protein is, to an appreciable extent, excluded by the manufacturing process from the final product. To help reduce the chance of prion transmission by fresh blood products, donations are leucodepleted, there is increasing use of imported fresh frozen plasma (especially for treating children) and potential donors, who have been recipients of blood since 1980 (the beginning of the BSE epidemic in cattle) are deferred.
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Da Ponte A, Bidoli E, Talamini R, Steffan A, Abbruzzese L, Toffola RT, De Marco L. Pre-storage leucocyte depletion and transfusion reaction rates in cancer patients. Transfus Med 2005; 15:37-43. [PMID: 15713127 DOI: 10.1111/j.1365-3148.2005.00546.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Passenger leucocytes transfused with allogenic blood are responsible for potential adverse effects. The impact of pre-storage leucodepletion (in-line filtration) of all whole blood units on transfusion reaction rate among patients suffering from cancer was retrospectively studied, comparing all reactions following red blood cell (RBC) transfusions during 2 years of pre-storage vs. 2 years of selective (bedside) leucodepletion. During selective leucodepletion, 5165 RBC units - of which 2745 were bedside filtered units- were transfused to 866 patients. Twenty-eight reactions were recorded: 22 (15 in the bedside group) febrile non-haemolytic transfusion reactions (FNHTR) and six allergic reactions (five in the bedside group). The overall percentage of reactions was 0.54 (0.76 for bedside) and 0.42 for FNHTR (0.54 for bedside). During pre-storage leucodepletion, 4116 RBC units were transfused to 841 patients. Eleven reactions were recorded: four FNHTR and seven allergic reactions (urticaria). The percentage of reactions for transfused RBC units was 0.26 (0.09 for FNHTR). Comparison between pre-storage filtration and bedside filtration with regard to FNHTR showed an odds ratio of 2.80 (95% confidence interval = 0.83-14.87) for bedside filtration. The study suggests that, for transfused patients affected by cancer, pre-storage leucodepletion is more effective than selective (bedside) filtration in reducing the incidence of transfusion reactions (FNHTR).
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Affiliation(s)
- A Da Ponte
- Blood Bank and Department of Clinical Pathology and Immunohaematology, National Cancer Institute, Aviano, Italy.
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Trannoy LL, Lagerberg JWM, Dubbelman TMAR, Schuitmaker HJ, Brand A. Positively charged porphyrins: a new series of photosensitizers for sterilization of RBCs. Transfusion 2004; 44:1186-96. [PMID: 15265123 DOI: 10.1111/j.1537-2995.2004.03275.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Photodynamic treatment could be a way to inactivate pathogens in RBCs. The objective of this study was to characterize the virucidal activity and RBC-damaging activity of a series of cationic porphyrins. Using the most efficacious photosensitizer, various in-vitro human RBC quality variables and in-vivo RBC survival in Rhesus monkeys were evaluated. STUDY DESIGN AND METHODS RBCs, spiked with 5 log of extracellular VSV, were treated with porphyrins (25 micro mol/L) and red light (100 W/m2) and essayed for virucidal activity. In-vitro RBC quality variables were assessed during 5 weeks of storage in various ASs. In-vivo survival was investigated with autologous RBCs in Rhesus monkeys. RESULTS Tri-P(4) was by far the best sensitizer of a series tested, giving the least hemolysis under conditions that resulted in 5 log-kill of extracellular VSV. Under our experimental conditions, the percentage hemolysis in treated cells was 5.1 +/- 1.1 percent after 5 weeks of storage in SAG-M compared to 1.9 +/- 1.1 percent in the untreated control. Storage in AS-3 resulted hemolysis of 2.3 +/- 1.9 percent. With the exception of IgG binding and potassium leakage, RBC quality variables remained unchanged after photodynamic treatment. Addition of reduced glutathione (GSH) during treatment reduced IgG binding. The 24-hour recovery and T50 of treated RBCs in Rhesus monkeys were satisfactory. CONCLUSION Porphyrin Tri-P(4) may be a suitable photosensitizer for sterilization of RBCs. However, further exploration to optimize the method is necessary to reach clinically acceptable goals.
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Affiliation(s)
- Laurence L Trannoy
- Department of Research and Development, Sanquin Blood Supply Foundation, Blood bank South-west, Leiden, the Netherlands.
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Hedin G, Eriksson I, Kumlin U, Boman J. A lack of serologic evidence of transmission of Chlamydia pneumoniae by transfusion of buffy coat-depleted RBCs. Transfusion 2003; 43:646-50. [PMID: 12702188 DOI: 10.1046/j.1537-2995.2003.00379.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Recent studies have shown that a high percentage of blood donors harbor Chlamydia pneumoniae DNA and antigens within their PBMNCs. The aim of the present study was to investigate whether recipients of RBC transfusions who were seronegative for C. pneumoniae before transfusion showed any evidence of seroconversion after transfusion. STUDY DESIGN AND METHODS Patients who were possible recipients of RBC transfusion and negative in a screen test for IgG antibodies against C. pneumoniae at the time of blood group determination were candidates to be included in the study. The patients were contacted 3.0 to 3.5 months after the blood group determination, and those who accepted to participate agreed that another venous blood sample could be taken. RESULTS Among the patients who participated, 53 had become recipients of RBC transfusion (transfused group), and 51 later did not receive any RBC transfusion (control group). No significant change was found in IgG titer against C. pneumoniae between the first and the second sample from the same patient, in either the transfused group or the control group. CONCLUSION In our study, which was limited to 53 seronegative recipients of RBC units from seropositive donors, we found no serologic evidence that C. pneumoniae could be transmitted by RBC transfusion.
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Affiliation(s)
- Göran Hedin
- Department of Clinical Bacteriology, Huddinge University Hospital, F71, SE-141 86 Stockholm, Sweden.
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Pasqualetti D, Ghirardini A, Cafolla A, Biffoni M, Coluzzi S, Vaglio S, Girelli G. Lymphocyte T subsets and natural killer cells in Italian and Philippino blood donors. Vox Sang 2003; 84:68-72. [PMID: 12542736 DOI: 10.1046/j.1423-0410.2003.00243.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND AND OBJECTIVES The characterization of lymphocyte subsets in blood donors has been utilized to determine the normal ranges that can be related to race. A study was performed in blood donors from two racial groups - Caucasian (Italians) and Asian (Philippinos) - to define respective T-lymphocyte subsets and levels of cytokines. MATERIALS AND METHODS Ninety-two blood donors (46 Italians and 46 Philippinos) were enrolled. Blood count and immunophenotyping of lymphocytes by flow cytometry were carried out, and cytokine production was tested in six blood donors of each group. RESULTS Philippino blood donors showed a significantly higher mean value of leucocytes (P = 0.01) and lymphocytes (P < 0.001) than Italians. The mean absolute count of lymphocyte subsets CD3- CD16+ CD56+ and CD3+ CD8+ were both significantly higher in Philippino than in Italian subjects, respectively, P < 0.01 and P < 0.0001. Philippinos showed a statistically significant higher frequency of lymphocytes producing interferon-gamma (IFN-gamma) compared to Italians (P = 0.02). CONCLUSIONS T-lymphocyte subsets in Italian and Philippino blood donors seem to be correlated to ethnic background. The higher levels of CD3+ CD8+ T cells, natural killer (NK) cells and IFN-gamma-producing cells found in Philippinos suggest leucoreduction in Asian blood donors.
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Affiliation(s)
- D Pasqualetti
- Blood Bank, Department of Biotecnologie Cellulari ed Ematologia, University La Sapienza, Rome, Italy.
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Williamson LM, Murphy MF, Llewelyn C, Todd A, Taylor R, Stevens W. Leucocyte-depleted blood in prevention of post-operative infections following elective orthopaedic and cardiac procedures. Vox Sang 2002; 83 Suppl 1:457-60. [PMID: 12617186 DOI: 10.1111/j.1423-0410.2002.tb05352.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Abstract
Variant Creutzfeldt-Jakob disease (vCJD) was first described in the United Kingdom in 1996 and is thought to have been transmitted from cattle infected with bovine spongiform encephalopathy probably via the food chain. Thus far just over 100 definite or probable clinical cases have been described, though the number of people currently infected and the eventual size and geographic distribution of any future clinical epidemic remain uncertain. There is little evidence that sporadic CJD is transmitted by blood transfusion. However, the same cannot necessarily be assumed to apply to the new variant strain of disease in which involvement of peripheral lymphoid tissues has been demonstrated. In the face of uncertainty surrounding the risk of transmission of vCJD by blood products, blood transfusion services in a number of countries have implemented precautionary policies, though whether in the long term these will prove to have been necessary or sufficient remains to be seen.
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Affiliation(s)
- M L Turner
- Department of Oncology, University of Edinburgh and Scottish National Blood Transfusion Service, Edinburgh, Scotland, UK.
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