Post-transfusion hepatitis--effect of modified gamma globulin added to blood in vitro

Post-transfusion hepatitis in a London hospital: results of a two-year prospective study

Seven hundred and sixty-eight patients were seen and tested at frequent intervals after transfusion of whole blood. Eight patients were judged to have developed icteric or anicteric post-transfusion viral hepatitis, an incidence of 1%. Five were icteric and four of these were hepatitis B antigen (HB Ag) positive; two of these four died. One of the fatal cases and one non-fatal HB Ag positive case had received HB Ag positive blood. Two other antigen-positive patients had received blood or plasma or both which had not been tested for antigen.

Thirty-five patients showed conspicuous or sustained elevations of alanine transaminase without clinical features of hepatitis.

Four were positive for HB Ag but had not received antigen positive blood.

Two who had received antigen positive blood remained antigen negative, but one developed hepatitis B antibody (HB Ab).

Two other patients were also transfused with plasma.

Five had serological evidence of cytomegalovirus (CMV) infection accompanying the enzyme changes.

One patient who had received HB Ag positive blood remained antigen-negative and showed no abnormalities.

Five patients who became HB Ag positive, although they had been given antigen-negative blood, remained clinically and biochemically well.

Cytomegalovirus primary infection or reactivation occurred in another 32 patients; five had isolated, transient enzyme rises, one other was associated with a drug-induced focal liver necrosis and 26 showed no enzyme changes. Epstein–Barr virus infections, one of which was associated with a transient upset of enzyme activity, were detected in five patients. There were no cases of post-perfusion syndrome.

Management guidelines for health care workers exposed to blood and body fluids

The purpose of this article is to propose specific management guidelines for the immediate emergency department and subsequent occupational health treatment of health care workers (HCWs) following accidental exposures to blood or body fluids. These guidelines are based on a collective review of the literature and the recommendations of the Advisory Committee on Immunization Practices (ACIP) and authorities expert in this knowledge domain. Guidelines are needed to assure appropriate treatment and coordinated efforts by ED and occupational health providers. Although numerous infections can potentially be transmitted by exposure to blood and body fluids, these guidelines are intended only for evaluation and postexposure prophylaxis of hepatitis B, hepatitis C, and infection with HIV.

Complexity and contradiction in clinical trial research

Randomized clinical trials have become the accepted scientific standard for evaluating therapeutic efficacy. Contradictory results from multiple randomized clinical trials on the same topic have been attributed either to methodologic deficiencies in the design of one of the trials or to small sample sizes that did not provide assurance that a meaningful therapeutic difference would be detected. When 36 topics with conflicting results that included over 200 randomized clinical trials in cardiology and gastroenterology were reviewed, it was discovered that results of randomized clinical trials often disagree because the complexity of the randomized clinical trial design and the clinical setting creates inconsistencies and variation in the therapeutic evaluation. Nine methodologic sources of this variation were identified, including six items concerned with the design of the trials, and three items concerned with interpretation. The design issues include eligibility criteria and the selection of study groups, baseline differences in the available population, variability in indications for the principal and concomitant therapies, protocol requirements of the randomized clinical trial, and management of intermediate outcomes. The issues in interpreting the trials include the regulatory effects of treatments, the frailty of double-blinding, and the occurrence of unexpected trial outcomes. The results of this review suggest that pooled analyses of conflicting results of randomized clinical trials (meta-analyses) may be misleading by obscuring important distinctions among trials, and that enhanced flexibility in strategies for data analysis will be needed to ensure the clinical applicability of randomized clinical trial results.

[Problems of intravenous gammaglobulin therapy (author's transl)]

The presently available i.v. gammaglobulines (GG) can be classified into two groups. Degraded GG are produced by pepsin or plasmin digestion. Intact GG are obtained by beta-propiolactone treatment, acidification at pH or precipitation with polyethylenglycol-hydroxyethylstarch (PEG/HES). The various products have different characteristics with regard to their biological activity (certain functions of complement activation and opsonization are connected with the Fc structure) as well as their elimination (intact GG have longer intra- and extravasal half-life times). While their is no doubt about an effect of GG in animal experiments, little controlled studies have been done for most of the clinical indications. One controlled prospective study showed that in surgical high risk patients the frequency of septic complications can be reduced by prophylactic application of high doses of 7 S-GG. For the future, the development of a broad spectrum of hyperimmunoglobulines seems desirable.

Efficacy of prophylactic gamma-globulin in preventing non-A, non-B post-transfusion hepatitis

Of 279 cardiac-surgery patients receiving a mean of twelve transfusions, 47 had significantly increased transaminase concentrations 14 to 180 days postoperatively and 10 were icteric. Preoperatively, each patient randomly received high-titre HbsAb gamma-globulin, normal gamma-globulin, or placebo and was followed at intervals for 9 months. Only 3 patients had serological evidence of hepatitis-B infection. 3 additional patients had serological evidence of cytomegalovirus infection, while none had evidence of hepatitis-A or Epstein-Barr infection. Less icteric hepatitis occurred in patients receiving the gamma-globulin preparations (P = 0-003), and the overall frequency of hepatitis was significantly reduced when compared with recipients of placebo. The protective effects of the two gamma-globulin preparations were not significantly different. Most post-transfusion hepatitis tody is neither viral hepatitis type B nor type A, and its severity and transmission are reduced by pre-transfusion gamma-globulin.