Transmission of human immunodeficiency virus (HIV) by blood transfusions screened as negative for HIV antibody

A dual-mode RNA-splitting aptamer biosensor for sensitive HIV Tat peptide detection via colorimetry and fluorescence

Early diagnosis of human immunodeficiency virus (HIV) is critical for effective treatment; however, traditional antibody methods encounter challenges during the infection window, and nucleic acid tests require specialized equipment. In this study, a dual-mode ribonucleic acid (RNA)-splitting aptamer biosensor was developed to target the HIV trans-activator of transcription (Tat) protein, a key HIV biomarker for viral replication throughout the infection cycle. The biosensor integrates colorimetric and fluorescent detection techniques by utilizing gold nanoparticles (AuNPs) and two types of aptamers, one labeled with carboxyfluorescein (FAM). In the presence of Tat, RNA-splitting aptamers adsorb onto AuNPs, protecting them from recombination, while the fluorescence of FAM is quenched via fluorescence resonance energy transfer (FRET). Aptamers form a ternary complex with Tat, preventing adsorption and leading to thioflavin T-induced aggregation of AuNPs, accompanied by a visible color change and fluorescence signal restoration. The biosensor demonstrated excellent sensing performance, with a linear range of 0.5-60 nM and a detection limit of 0.28 nM, successfully detecting Tat in human serum. Therefore, this low-cost dual-mode detection platform offers a promising tool for early HIV diagnosis and potential applications in clinical and point-of-care fields.

Establishment of a keratinocyte and fibroblast bank for clinical applications in Japan

Regenerative medicine products using allogeneic cells, such as allogeneic cultured epidermis (allo-CE), have become a more critical therapeutic method for the treatment of burns. However, there are no clinically available allo-CE products in Japan. Therefore, establishing a quality-controlled cell bank is mandatory to create regenerative medical products using allogeneic cells. In this study, we selected ten patients from the Department of Plastic Surgery of Kyoto University Hospital to become cell donors. We performed medical interviews and blood sampling for the donor to ensure virus safety. We examined the tissues and isolated cells by performing a nucleic acid test (NAT). To establish a master cell bank, quality evaluation was performed according to the International Conference of Harmonization (ICH) Q5A. Serological tests of the blood samples from the ten donors showed that two of them were ineligible. The cells registered in the cell bank were found to be compatible after virus testing was performed, and a master cell bank was constructed. Hence, we established a keratinocyte and fibroblast bank of clinically usable human cultured cells in Japan for the first time.

Transfusion-Acquired HIV: History, Evolution of Screening Tests, and Current Challenges of Unreported Antiretroviral Drug Use in Brazil

Prevention of HIV acquisition by blood transfusion from its emergence to the present day is reviewed, and current challenges are delineated. The experience of Fundação Pró-Sangue/Hemocentro de São Paulo, Brazil, is highlighted in the quest for improvements in blood safety and the evolution of increasingly sensitive and specific screening tests. Concerns and establishing stringent criteria in the screening of potential blood donors are emphasized, and the current criteria for identifying and deferring candidates at high risk of acquiring sexually transmitted diseases are summarized. Future challenges relate to the identification of donors with unreported use of antiretroviral drugs for prophylaxis against possible HIV exposure or for treatment of an HIV infection whose viral expression is undetectable by current analyses. There is a need to better understand the motivation of HIV-exposed donors and to educate them about the risk of transfusion-mediated HIV transmission despite having low or undetectable viral loads. In situations in which traditional HIV RNA or antibody detection assays remain negative, more sensitive analyses are needed to identify potential donors at risk for HIV transmission.

A materials-science perspective on tackling COVID-19

The ongoing SARS-CoV-2 pandemic highlights the importance of materials science in providing tools and technologies for antiviral research and treatment development. In this Review, we discuss previous efforts in materials science in developing imaging systems and microfluidic devices for the in-depth and real-time investigation of viral structures and transmission, as well as material platforms for the detection of viruses and the delivery of antiviral drugs and vaccines. We highlight the contribution of materials science to the manufacturing of personal protective equipment and to the design of simple, accurate and low-cost virus-detection devices. We then investigate future possibilities of materials science in antiviral research and treatment development, examining the role of materials in antiviral-drug design, including the importance of synthetic material platforms for organoids and organs-on-a-chip, in drug delivery and vaccination, and for the production of medical equipment. Materials-science-based technologies not only contribute to the ongoing SARS-CoV-2 research efforts but can also provide platforms and tools for the understanding, protection, detection and treatment of future viral diseases.

Comparative changes of pre-operative autologous transfusions and peri-operative cell salvage in the United States

BACKGROUND

With improved safety of allogeneic blood supply, the use of preoperative autologous donations (PADs) and perioperative autologous cell salvage (PACS) has evolved. This study evaluated temporal trends in PAD and PACS use in the United States.

METHODS

The National Inpatient Sample database, a stratified probability sample of 20% of hospitalizations in the United States, was used to compare temporal trends in hospitalizations reporting use of PADs and PACS from 1995 to 2015. Factors associated with their use were examined between 2012 and 2015 with use of multivariable Poisson regression. Sampling weights were applied to generate nationally representative estimates.

RESULTS

There was a steady decrease in hospitalizations reporting PAD transfusions from 27.90 per 100 000 in 1995 to 1.48 per 100 000 hospitalizations in 2015 (P-trend <.001). In contrast, PACS increased from a rate of 1.16 per 100 000 in 1995 to peak of 20.51 per 100 000 hospitalizations in 2008 and then steadily declined (P-trend<.001). Higher odds of PACS and PADs were observed in older patients, elective procedures (vs urgent), and urban teaching/nonteaching hospitals (vs rural hospitals) (P < .001). PACS was more common in hospitalizations in patients with higher levels of severity of illness as compared to those with minor severity (adjusted prevalence ratio [adjPR], 2.39; 95% confidence interval [CI], 2.08-2.73; P<.001), while PADs were performed less often in patients with higher underlying severity of illness (All Patient Refined Diagnosis Related Groups, 4 vs 1, adjPR, 0.61; 95% CI, [0.39-0.95]; P = .028).

CONCLUSIONS

There was a significant decrease in PAD red blood cell transfusions, while PACS has increased and subsequently decreased; PACS plays an important role in surgical blood conservation. The subsequent decline in PACS likely reflects further optimization of transfusion practice through patient blood management programs and improvement of surgical interventions.

Analytic Reviews : Red Cell Transfusion in a Critical Care Unit

The acquired immunodeficiency syndrome epidemic and recognition of human immunodeficiency virus transmission by blood products have increased concern over the risks of blood transfusion and generated discus sion on proper indications. To assess current practice with respect to red blood cell transfusion, we examined transfusion practices in a medical-surgical intensive care unit. The extensive clinical and physiological moni toring in this setting allowed us to examine indices of oxygen carrying capacity, oxygen delivery, tissue oxy genation, and their associations with subsequent trans fusion. We were unable to detect changes in hemody namic or tissue oxygenation measurements associated with transfusions. Tissue oxygenation measures were in frequently documented even in the presence of an in dwelling pulmonary artery catheter. Hemoglobin and hematocrit levels showed statistically significant de creases prior to initial and subsequent transfusions. He modynamic and tissue oxygenation indices available in intensive care settings merit further evaluation for use in the assessment of transfusion need.

Massive Transfusion in the Intensive Care Unit

The transfusion of blood components is a frequent oc currence in intensive care units. Transfusion therapy demands not only a greater ability to meet the needs of acutely ill patients with an enlarging variety of blood components, but also an increasing awareness of previ ously recognized and newly discovered hazards of blood transfusion. Use of the more commonly adminis tered blood components is reviewed, and problems per tinent to the large-volume massively or multiply trans fused patient are discussed.

Public awareness of blood donation in Central Saudi Arabia

INTRODUCTION

In Saudi Arabia, voluntary donors are the only source of blood donation. The aim of this study was to assess the level of public knowledge and attitude toward blood donation in Saudi Arabia.

METHODS

Using a previously validated questionnaire that comprises 38 questions to assess the levels of knowledge, attitudes, and motivations towards blood donation, 469 Saudi adults who attended different shopping malls in Riyadh, Saudi Arabia were surveyed. Multiple regression analyses were used to identify the significant predictors of blood donation, with the significance set at P<0.05.

RESULTS

Approximately half of all subjects (53.3%) reported that they had previously donated blood, 39% of whom had donated more than once. The knowledge percentage mean score was 58.07%, denoting a poor level of knowledge, with only 11.9% reporting a good level of knowledge. The attitude percentage mean score towards donation was 75.45%, reflecting a neutral attitude towards donating blood, with 31.6% reporting a positive attitude. Donation was significantly more prevalent among males than females (66% versus 13.3%; P<0.001). After adjustment for confounders, a higher knowledge score (t=2.59; P=0.01), a higher attitude score (t=3.26; P=0.001), and male sex (t=10.45; P<0.001) were significant predictors of blood donation. An inability to reach the blood donation centers and a fear of anemia were the main reasons for females not donating blood (49.9% and 35.7%, respectively), whereas a lack of time was the main reason for males (59.5%).

CONCLUSION

Prevalence of blood donation was less than satisfactory among the Saudi public, probably due to misconceptions, poor knowledge, and unfavorable attitude to donation. Educational programs are necessary to increase the level of knowledge and improve the attitude of the Saudi public toward blood donation. Providing mobile blood collection units nearer to individuals' places of work to reduce their time costs of donating is a necessity.

Logistic model for determining factors associated with HIV infection among blood donor candidates at the Fundação HEMOPE

Objective

To determine factors associated with HIV infection in blood donor candidates in Recife, Brazil.

Methods

A transversal study was performed of 106,203 blood donor candidates found eligible by the routine clinical screening process in the blood bank in Recife of the Fundação de Hematologia e Hemoterapia de Pernambuco (HEMOPE) in the period from January 1998 to November 2003. Additional indirect immune and western blot confirmation tests for HIV infection were performed and the candidates were classified as HIV positive or negative. The Chi-squared test and stepwise multiple logistic regression were conducted to examine any association between HIV infection and age, gender, place of residence, schooling, number of donations and serological tests for core hepatitis B antigen virus (anti-HBc), the hepatitis C antivirus (anti-HCV), human T-type antivirus lymph cells (anti-HTLV 1 and 2), serological tests for syphilis (VDRL) and the hepatitis B virus surface antigen (HBsAg).

Results

In the observed sample, 0.204% of blood donor candidates were found to be HIV positive. Among the studied variables, the age, education level, residency, donation type, and serologic status for anti-HBc and VDRL tests were found to be associated with HIV infection.

Conclusions

The younger, spontaneous donor candidates living in the Recife metropolitan area with a low level of education and positive for anti-HBc and VDRL have an higher risk of HIV infection than the other candidates. Data such as these are useful to understand the dynamics of infection and to guide healthcare policies.

Antiretroviral therapy initiated soon after HIV diagnosis as standard care: potential to save lives?

In 2008, an estimated 33.4 million people were infected with human immunodeficiency virus (HIV) and ~4 million people were receiving antiretroviral therapy (ART). However, in 2007, an estimated 6.7 million people were in need of ART under the current World Health Organization guidelines, and 2.7 million more people became infected with HIV. Most of those not currently eligible for ART will become eligible within the next decade, making the current treatment strategy unsustainable. The development of cheaper, less toxic, and more potent antiretrovirals over the past decade has made it possible to consider novel strategies of arresting the HIV/AIDS epidemic. Evidence is growing that ART can be used to prevent HIV transmission and that earlier initiation of treatment is beneficial for those infected with HIV. A mathematical model predicts that by testing whole communities annually and treating all who are infected immediately, up to 7.2 million AIDS-related deaths could be prevented in the next 40 years, long-term funding required to fight the HIV epidemic could be reduced, and, most importantly, control of the HIV/ AIDS epidemic could be regained within 1–2 years of full-scale implementation of the strategy. We discuss the development of the concept of ART for the prevention of HIV transmission and the modeled impact that a test-and-treat strategy could have on the HIV epidemic, and consequently argue that a field trial should be carried out to confirm model parameters, highlight any practical problems, and test the model’s predictions.

The effect of acute normovolaemic haemodilution on blood gas parameters: a case report

INTRODUCTION

Increased awareness of the risks related to homologous blood transfusions such as immunological reactions, transmission of infections, and immunosuppression, has necessitated exploration of alternative techniques to deal with the needs of intra-operative blood transfusion. Strategies that reduce or remove the risks associated with allogeneic transfusion include pre-operative autologous donation, peri-operative cell-salvage techniques, deliberate hypotension, and pharmacological interventions. Acute normovolaemic haemodilution is another such technique.

METHODS

The effect of acute normovolaemic haemodilution on haemodynamics and blood gas parameters was studied in a male patient (58 y, 94 kg, American Society of Anesthesiologists physical status I) undergoing an orthopaedic surgical procedure for joint arthroplasty. After induction of general anaesthesia, 1600 ml of blood was collected and replaced with an equal volume of 6% hexaethyl starch.

RESULTS

Haemoglobin and haematocrit concentrations were significantly lower following haemodilution (14.9 and 9.2 g/dl for haemoglobin versus 45.0% and 31.7% for haematocrit). There was no significant change in the heart rate, blood pressure or end-tidal carbon dioxide tension throughout the operation period. Central venous pressure increased marginally from 5 to 90 min, but was within normal limits. There was no significant change in blood gas parameters following haemodilution. Platelet count decreased following haemodilution but the values were within normal limits.

CONCLUSION

Acute normovolaemic haemodilution with 6% hexaethyl starch is a safe procedure for blood conservation in selected operations. It did not cause any haemodynamic or blood gas parameters to change. It did not have any adverse effect on haemostatic mechanisms that could enhance the risk of bleeding at surgery.

Comparative study of autograft or allograft in primary anterior cruciate ligament reconstruction

Between December 1996 and December 2002, we treated 79 patients with arthroscopy-assisted anterior cruciate ligament (ACL) reconstructions. In 53 patients we used autografts and in 26 patients allografts. Patients were followed up for 38 (12-72) months. The two groups did not differ in preoperative sport activity level. The postoperative Lysholm score was 89.9+/-8.1 in the autograft group and 84.1+/-18.6 in the allograft group. Comparing the patients' Lysholm score according to whether they had a low (1-5) or a high (6-10) postoperative Tegner score, we found no statistically significant difference between the groups. On one occasion, the allograft ruptured during the implantation procedure just prior to the fixation. Postoperatively, we performed three revisions-two in the allograft group and one in the autograft group-and three second-look arthroscopies. There were no bacterial infections and no cases of viral transmission. No immune rejection, resorption, or immunsynovitis occurred during the follow-up.

Watering down the clots, or are we?

Fluid resuscitation is an essential part of managing patients with major trauma, as well as in the perioperative setting. Common misconceptions exist regarding the role of fluid therapy in maintaining, enhancing or inhibiting normal coagulation and haemostasis. This review provides an overview of the basic coagulation processes, as well as the influence of intravenous crystalloid and colloid preparations on haemostasis and coagulation. The use of point-of-care devices is encouraged as a feasible way of monitoring these effects in the acute setting.

Detection of an early HIV-1 infection by HIV RNA testing in an Italian blood donor during the preseroconversion window period

BACKGROUND

The implementation of NAT technologies for HIV screening has further reduced the diagnostic window in recent HIV infection. There is still a debate regarding the cost effectiveness of genomic screening of blood donations for transfusion-transmitted viruses (HBV, HCV, HIV).

STUDY DESIGN AND METHODS

Since October 2001, at the Transfusion Service of Verona, single-donation NAT testing for HCV and HIV-1 (Procleix TMA HIV-1/HCV Assay) of all blood donations has been performed.

CASE REPORT

A case of acute HIV-1 infection detected by HIV NAT in a repeat blood donor who donated during the preseroconversion window period is reported. All blood components donated were discarded, and the donor started antiretroviral therapy 2 weeks after blood donation. HIV-1 p24 antigen was still negative 10 days after the HIV-1 RNA-positive blood donation. Seroconversion was documented by Day 41 after donation.

CONCLUSION

This case report testifies that HIV NAT screening of blood donation is effective in preventing the transmission of HIV infection through blood components.

Human immunodeficiency virus infection in end-stage renal disease patients

Human immunodeficiency virus (HIV) infection in patients with end-stage renal disease (ESRD) offers many diagnostic and therapeutic challenges to nephrologists. Renal failure may be a direct consequence of viral infection (HIV-associated nephropathy), or intrinsic renal diseases may occur in previously infected individuals. Patients receiving renal replacement therapy (RRT) may acquire HIV infection from blood transfusions, renal allografts, sexual contacts, or needle sharing by drug addicts. In the early 1980s, the overall prognosis of patients with the acquired immunodeficiency syndrome (AIDS) was very poor, and survival of those with ESRD was dismal. Consequently many even questioned the value of providing maintenance dialysis to patients with AIDS. With advances in diagnostic techniques in serologic and viral markers of disease, and deployment of highly effective antiretroviral agents, the prognosis of HIV-infected patients has dramatically improved. Over the past two decades, experiences in the management of HIV patients with ESRD is accumulating. Both peritoneal dialysis and hemodialysis are effective modes of therapy and many centers are now beginning to perform renal transplantation in HIV-infected patients. This article deals with various aspects of HIV infection in patients with ESRD.

Perioperative hemodilution

Acute normovolemic hemodilution (ANH) entails the removal of blood from a patient either immediately before or shortly after induction of anesthesia and the simultaneous replacement with cell-free fluid, preferably synthetic colloids with a predictable volume effect (6% dextran 60/70, 6% hydroxyethyl starch 200,000 and 130.000, respectively). Hemodilution is part of the concept for avoiding or limiting the use of allogeneic blood and should be considered for patients undergoing elective surgery free of contraindications and presenting with an initial hemoglobin concentration > or = 12 g/dl and an anticipated blood loss of > or = 1500 ml. The efficacy of ANH, judged by the necessity to transfuse homologous blood, depends on the preoperative (initial) hematocrit, the target hematocrit (to which hemodilution is performed), and the preset intra- and postoperative transfusion trigger. In the past data from clinical trials have shown that in healthy subjects a target hematocrit of 20-25% (7.0-8.0 g/dl hemoglobin concentration) is feasible and safe for the patient. The lower the target hemoglobin concentration, the more extensive monitoring is required: intraoperative target hemoglobin concentrations of 5.0 g/dl and less have been tolerated by young surgical patients without adverse effects. The safety as well as efficacy of acute normovolemic hemodilution in terms of reducing homologous blood transfusion requirements have been demonstrated in various clinical studies. ANH therefore is regarded an integral part of programs aimed at reducing the need for homologous blood, and can thus be successfully combined with preoperative autologous blood deposition, intraoperative blood salvage and carefully adjusted surgical techniques.

TaqMan 5'-nuclease human immunodeficiency virus type 1 PCR assay with phage-packaged competitive internal control for high-throughput blood donor screening

Screening of blood donors for human immunodeficiency virus type 1 (HIV-1) infection by PCR permits the earlier diagnosis of HIV-1 infection compared with that by serologic assays. We have established a high-throughput reverse transcription (RT)-PCR assay based on 5'-nuclease PCR. By in-tube detection of HIV-1 RNA with a fluorogenic probe, the 5'-nuclease PCR technology (TaqMan PCR) eliminates the risk of carryover contamination, a major problem in PCR testing. We outline the development and evaluation of the PCR assay from a technical point of view. A one-step RT-PCR that targets the gag genes of all known HIV-1 group M isolates was developed. An internal control RNA detectable with a heterologous 5'-nuclease probe was derived from the viral target cDNA and was packaged into MS2 coliphages (Armored RNA). Because the RNA was protected against digestion with RNase, it could be spiked into patient plasma to control the complete sample preparation and amplification process. The assay detected 831 HIV-1 type B genome equivalents per ml of native plasma (95% confidence interval [CI], 759 to 936 HIV-1 B genome equivalents per ml) with a >or=95% probability of a positive result, as determined by probit regression analysis. A detection limit of 1,195 genome equivalents per ml of (individual) donor plasma (95% CI, 1,014 to 1,470 genome equivalents per ml of plasma pooled from individuals) was achieved when 96 samples were pooled and enriched by centrifugation. Up to 4,000 plasma samples per PCR run were tested in a 3-month trial period. Although data from the present pilot feasibility study will have to be complemented by a large clinical validation study, the assay is a promising approach to the high-throughput screening of blood donors and is the first noncommercial test for high-throughput screening for HIV-1.

Recombinant human erythropoietin administration in cardiac surgery

OBJECTIVE

Postoperative anemia and multiple blood transfusions are still important problems in cardiac surgery. During the past few years, there have been some reports indicating that multiple recombinant human erythropoietin infusions starting at least 2 weeks before the operation induced erythropoiesis. We aimed to reduce the risk of adverse reactions of high doses of recombinant human erythropoietin and reduce the period of hospitalization by using it only once, 4 days before the operation.

METHODS

Twenty-five patients received recombinant human erythropoietin 4 days before the operation, and 28 patients comprised the control group. All the hematologic parameters of the patients are measured on the day of admission, the day before the operation (fourth day), the first day after the operation, and 1 week later.

RESULTS

In the recombinant human erythropoietin group the mean hemoglobin concentration increased on the morning of the operation (14.5 +/- 0.52 g/dL in the recombinant human erythropoietin group and 12.4 +/- 0.65 in the control group, P <.05). To maintain hemoglobin levels at greater than 8.5 g/dL, 330 +/- 33 mL of homologous transfusion was required in the recombinant human erythropoietin group, whereas 680 +/- 75 mL was required in the control group (P <.01).

CONCLUSION

Recombinant human erythropoietin induces erythropoiesis rapidly, even when it is used with a low single dose just 4 days before the operation. No adverse reactions were seen with this kind of recombinant human erythropoietin treatment.

Radiology interventions in patients receiving low molecular weight heparin: timing is critical

Recent advances in diagnosis and treatment of venous thromboembolism have been associated with increasing use of low molecular weight heparins (LMWH) for treatment and prophylaxis of this disease. Despite this trend for more widespread use of LMWH, little is known of their safety in patients undergoing radiology interventions. Differences between LMWH and unfractionated heparin and the implications of these differences on use of LMWH in the setting of radiological interventions are outlined.

Sexually transmitted diseases in homosexual and bisexual males from a cohort of human immunodeficiency virus negative volunteers (Project Horizonte), Belo Horizonte, Brazil

Sexually transmitted diseases (STD) are very frequent in the whole world. Males who do not use a condom during their sexual relations are at great risk. We report cases of STD during six months of observation, among homosexual/bisexual males who participate in the Project Horizonte. There were 16 cases of genital warts, 6 cases of human immunodeficiency virus infection, 24 cases of unspecific urethritis, 28 cases of herpes simplex virus infection, 30 cases of syphilis, 58 cases of gonorrhea and 84 cases of pediculosis. We concluded that a condom must be used in all sexual relations and new counseling techniques are needed, to avoid this situation.

Current viral risks of blood and blood products

A number of viruses may be transmitted by blood transfusion, the most important of these are HIV, human T-cell lymphotrophic retrovirus (HTLV), hepatitis B virus (HBV), and hepatitis C virus (HCV). A series of overlapping safety measures are in place and are being improved and supplemented continuously. As a result, the risk of transmission of these viruses in the USA has been reduced to between one and four per million blood components transfused.

Transfusion Medicine: An Overview and Update

The discovery of AIDS in the 1980s and its rapid evolution as a major concern for physicians and their patients have led to many questions about the safety of the blood supply. The attention placed on AIDS has led to new discoveries and technologies to reduce the risk of other transfusion complications such as hepatitis, bacterial contamination, and transfusion-associated graft-vs-host disease. Concerns about blood safety have focused much attention on alternative blood transfusion strategies such as autologous blood, viral inactivation, and artificial blood substitutes. This review describes the transfusion medicine delivery system in the United States, with special emphasis on evolving developments and their implications for the discipline of chemical pathology.

Quantitative and Qualitative Evaluation of Blood Salvaged after Extracorporeal Circulation (ECC) in Paediatric Heart Surgery

The salvaging of ECC circuit priming blood is essential for reducing the morbidity related to homologous blood transfusions and the importance of this technique is inversely proportionate to the age and weight of the child. In infants, the washing and centrifugation of blood not only drastically reduce the risk of contracting blood-transmitted diseases and cut management costs, but are also of considerable hemodynamic importance, producing a rapid normalization of the patient's hematocrit and hemoglobin and balancing the O2consumption/demand ratio. The marketing of miniaturized salvaging devices with 55 ml bowls by Dideco has made possible the recovery of small quantities of blood, so as to normalise the hematic crisis and permit the application of total hemodilution in low-weight patients. The salvaged blood shows an average hematocrit of 52.7±9.7% (max 68.1%) and an average hemoglobin of 17.6±2.9 g/dl (max 20.7 g/dl), and maintains its structural components, osmotic resistance, concentration of intraerythrocytic hemoglobin and mean corpuscular hemoglobin all intact. Washing with isoosmotic and isoionic hydroelectrolytic solutions normalizes the ionic situation in the post-operative period and activated blood salvaging after Extracorporeal Circulation. The use of solutions without nutritional substances results however in a considerable fall in the number of enzymes in the intraerythrocytic metabolic glucide chain (G6PDH: −40.7±14.3% p<0.001), (PK: −23.8±20.5% p<0.03). This drop may be responsible for erythrocytic morphological alterations (echinocytic change) and probably for the release of hemoglobin from the red blood cells.

Washing with isoionic, isoosmotic solutions containing G5% and adenine could, at least in theory, improve the quality of the salvaged blood, by normalizing the morphology and the volume of the RBC and by increasing the hematocrit.

Cardiac surgery and the human immunodeficiency virus

Since the first deliberate open heart operation was performed on a patient known to be carrying HIV, much has been learned. The fear that cardiopulmonary bypass might cause acceleration of the disease has not been borne out. Patients infected with HIV have shown considerable tolerance to major cardiac and pulmonary surgery. Indeed, the extraordinary fruits of a massive research effort have made it reasonable to perform elective surgery and to offer major surgery to patients with the full-blown syndrome of AIDS. The concern that the operators would be exposed to significant risk of acquiring the infection during surgery has proved to be unfounded. This has been in part due to the widespread adoption of universal precautions against the passage of microorganisms from patient to operator. However, there remain surgeons who ignore these precautions. The price they pay is the risk of acquiring hepatitis, which is far more easily transmitted than AIDS and may be fatal.

How can autologous blood transfusions help our patients?

In modern day clinical nursing practice, respecting and encouraging patient autonomy, together with acting as advocate for the patient, is an integral part of holistic patient care. We have a 'duty of care' to our patients. So why, in the early days of the 21st century, are we still transfusing our patients with homologous blood products when there is a safer alternative which has been recognised for almost 200 years?

Performance of a multiplex qualitative PCR LCx assay for detection of human immunodeficiency virus type 1 (HIV-1) group M subtypes, group O, and HIV-2

Early detection of human immunodeficiency virus (HIV) in blood and blood products can be achieved by a sensitive nucleic acid amplification-based assay. We report on the performance of a PCR-based qualitative assay that detects both HIV type 1 (HIV-1) and HIV-2 with a sensitivity of 20 to 50 copies/ml. The assay has a specificity of 99.6% and an inhibition rate of 1.7%. One milliliter of sample is processed with a manifold system and Qiagen columns, and one-third of the extracted sample is used for PCR amplification. An internal control sequence, which is processed and amplified with each sample, monitors for amplification inhibition. Samples are reverse transcribed and are then amplified by reverse transcription-coupled PCR, after which HIV-1- and HIV-2-specific probes are hybridized to the amplified products. Following hybridization, samples are detected in the LCx instrument by microparticle enzyme immunoassay techniques. The detection system has an automated inactivation step that controls for PCR contamination. The HIV-1/2 qualitative RNA assay detects HIV-1 group M subtypes A, B, C, D, E, F, and G and group O. Testing of several HIV-1 seroconversion panels has demonstrated that the HIV-1/2 qualitative RNA assay detects HIV infection on the average of 6 days before p24 antigen can be detected and 11 days before antibodies can be detected.

Avoiding transfusion in head and neck surgery: feasibility study of erythropoietin

OBJECTIVE

To determine the feasibility of perioperative erythropoietin to avoid blood transfusion in head and neck cancer surgery.

STUDY DESIGN

Retrospective chart review.

METHODS

Ninety-nine patients undergoing surgical resection of head and neck tumors at our institution were assessed for demographic data, nutritional parameters, tumor/surgical information, hematological/transfusion data, and contraindications to erythropoietin. Each transfusion was classified as to its appropriateness, and the potential benefit of erythropoietin was assessed in each patient. A cost analysis was also performed.

RESULTS

Most transfused patients (63%) received too many units. A subgroup at high risk of transfusion was identified who would benefit most from perioperative erythropoietin. Assuming that perioperative erythropoietin therapy is equivalent to the transfusion of 4 units, we estimate that the majority (741%) of transfused patients would not have required a transfusion if more stringent transfusion criteria were followed and those at high risk were given perioperative erythropoietin. Although the cost for transfusing 4 units is equivalent to that of a perioperative course of erythropoietin, the overall direct cost of erythropoietin treatment would actually have been more expensive.

CONCLUSIONS

Perioperative erythropoietin therapy may be appropriate for a subgroup of head and neck cancer patients, but a prospective randomized controlled study in such a subgroup is needed to better define those most likely to benefit from it and to assess actual cost/benefit ratios.

Multicenter evaluation of a new rapid automated human immunodeficiency virus antigen detection assay

Although human immunodeficiency virus (HIV) antigen assays are of limited value for monitoring antiretroviral therapy, they play an important role for confirmatory testing of fourth generation HIV screening enzyme immunoassay (EIA) reactive samples. In a multicenter study, a new automated rapid p24 antigen assay, Elecsys HIV Ag (Roche Diagnostics Boehringer Mannheim GmbH, Penzberg, Germany), was compared to FDA licensed tests (Abbott HIV-1 Ag monoclonal and Coulter HIV-1 p24 antigen assay). In the evaluation 27 seroconversion panels were included, sera from the acute phase of infection, single and follow-up samples from HIV antibody positive patients, dilution series of HIV antigen positive standards, sera and cell culture supernatants infected with different HIV-1 subtypes (A-H, and O) HIV-2 and recombinant HIV-1 (gag/env) isolates. To challenge the specificity of the new assay, 2565 unselected blood donors, sera from pregnant women, dialysis and hospitalized patients and 407 potentially cross-reactive samples were investigated. Acute HIV infection was detected in three to eight seroconversion panels earlier with Elecsys HIV Ag than with the alternative assays. Higher numbers of serum samples from HIV infected patients tested positive by Elecsys HIV Ag than with the comparative assays. All HIV-1 subtypes and HIV-2 isolates were recognized with Elecsys HIV Ag. Abbott HIV-1 Ag monoclonal and Coulter HIV-1 p24 antigen assay showed a variable sensitivity for the different HIV-1 subtypes. The specificity of Elecsys HIV Ag and Coulter HIV-1 p24 antigen assay were 99.8 and 99.93%, respectively. All the eight sera that were false reactive by Elecsys HIV Ag were tested negative with the Elecsys HIV Ag Neutralization Test. In conclusion, Elecsys HIV Ag was more sensitive than the alternative assays and showed a high specificity in combination with the neutralization assay. The very short incubation time of 18 min and the fully automated procedure of Elecsys HIV Ag which permits direct testing from the primary patient blood collection tube, represent a major improvement for routine laboratory diagnosis in comparison to the alternative assays.

Reduction of the diagnostic window with a new combined p24 antigen and human immunodeficiency virus antibody screening assay

In order to reduce the window phase between time of human immunodeficiency virus (HIV) infection and laboratory diagnosis, new fourth generation screening assays which permit a simultaneous detection of HIV antigen and antibody have been developed. In a multicenter study, a new automated fourth generation assay, Enzymun-Test HIV Combi (Boehringer Mannheim GmbH) was compared to third generation assay, p24 antigen tests and Western blot. A total of 37 seroconversion panels, samples of the early infection (n = 42), HIV-1 antibody positive sera, including subtypes A E, and O (n = 1118), HIV-2 positive samples (n = 252) and cell culture supernatants infected with different HIV-1 subtypes and HIV-2 (n = 50), blood donors (n = 6649), hospitalized patients (n = 475), HIV neg. sera with indeterminate Western blot (n = 32), potentially cross reactive serum samples (n = 435) and HIV negative specimens from Cameroon (n = 68) were tested. A total of 16 of 29 seroconversions were detected on average 8.5 days earlier with Enzymun-Test HIV Combi than HIV-1/HIV-2 3rd generation EIA (Abbott Laboratories). Overall, in the 29 panels investigated comparatively with the two assays, the mean time delay between Enzymun-Test HIV Combi and HIV-1/HIV-2 3rd generation EIA was 4.7 days. HIV antigen was detected in three out of 35 seroconversions one bleed earlier with HIV-1 Ag Monoclonal than with Enzymun-Test HIV Combi. Enzymun-Test HIV Combi showed a sensitivity of 100% for HIV antibody detection for HIV-1 group M and O and HIV-2 positive specimens. While p24 antigen of different HIV-1 subtypes was detected with Enzymun-Test HIV Combi in all the 49 cell culture supernatants, HIV Ag was not detected in an HIV-2 virus lysate. A total of 66 false positive results out of 7659 HIV negative samples were obtained with the Enzymun-Test HIV Combi. The specificity for unselected blood donors was 99.6%. The Enzymun-Test HIV Combi permits an earlier diagnosis of HIV infection than third generation assays through the detection of p24 antigen, which may be present in serum samples from individuals with recent HIV infection prior to seroconversion and it shows an excellent sensitivity for antibodies to all known HIV-1 subtypes and HIV-2. The specificity in blood donors and hospitalized patients is comparable to that of other assays.

The use of polymerase chain reaction in plasma pools for the concomitant detection of hepatitis C virus and HIV type 1 RNA

BACKGROUND

Detection of viral nucleic acids might increase blood transfusion safety through the detection of recently infected blood donors during the preseroconversion window period. Individual screening is difficult to apply, because of technical and financial constraints.

STUDY DESIGN AND METHODS

A polymerase chain reaction (PCR)-based assay including a polyethylene glycol precipitation step was developed for the concomitant detection of hepatitis C virus (HCV) and HIV type 1 (HIV-1) RNA in plasma pools corresponding to 50 blood donations by the use of commercial assays.

RESULTS

The assay had a sensitivity of less than 33 copies per mL for HCV RNA and 1000 copies per mL for HIV-1 RNA for each individual sample included in the pool. The eight preseroconversion samples with HCV RNA between 1,250 and 762,000 copies per mL were all detected when 100-microL aliquots from the samples were introduced into 5-mL pools of 50 blood donations.

CONCLUSIONS

A PCR-based pooling assay associating a prepurification step with polyethylene glycol allows for the screening of blood donations for HCV and HIV-1 RNA without marked loss of sensitivity from that seen with commercially available assays. This procedure might increase blood safety through systematic screening of blood donations at relatively low cost.

A prospective study of the risk of transfusion-acquired viral infections

The risk of transfusion-transmitted viral infections may be estimated by several methods, but only prospective studies of transfusion recipients can directly measure the incidence, with associated 95% upper confidence bound, of these infections. From 1989 through 1995, 764 recipients of allogeneic or autologous red blood cell transfusions were enrolled; 486 (64%) provided both pretransfusion and 6-month follow-up specimens. Both specimens were tested for anti-HBc, anti-HCV, anti-HTLV-I and anti-HIV, with appropriate confirmatory testing. Thirty-nine (8.0%) subjects had seroprevalent anti-HBc, 19 (3.9%) subjects had seroprevalent anti-HCV, three (0.6%) subjects had seroprevalent anti-HTLV-I/II, and one (0.2%) subject had seroprevalent anti-HIV. There were no seroconversions for any agent among the 34 patients who received only autologous blood, and no confirmed seroconversions for anti-HTLV-I or anti-HIV among all subjects. There were three seroconversions for anti-HBc (incidence 1.04 x 10(-3); 95% confidence interval (CI) 2.15 x 10(-4), 3.05 x 10(-3) per allogeneic unit transfused), and two confirmed seroconversions for HCV (incidence 6.94 x 10(-4); 95% CI 8.34 x 10(-5), 2.51 x 10(-3) per allogeneic unit transfused). One of the two anti-HCV seroconversions occurred in March 1994, after the institution of HCV EIA 2.0 screening of donated blood. Transfusion-associated seroconversions to hepatitis B and C markers were observed at low rates in the early 1990s despite testing donors for markers of both viruses, whereas seroconversions to HTLV-I or HIV were less than 1.04 x 10(3) per allogeneic unit transfused, based upon the upper 95% confidence interval of the zero incidence in this study.

Detection of human immunodeficiency virus type 1 (HIV-1) RNA in pools of sera negative for antibodies to HIV-1 and HIV-2

A total of 234 pools were prepared from 10,692 consecutive serum samples negative for antibodies to human immunodeficiency virus type 1 (HIV-1) and HIV-2 collected at five virological laboratories (average pool size, 45 serum samples). Pools were screened for the presence of HIV-1 RNA by a modified commercial assay (Amplicor HIV-1 Monitor test) which included an additional polyethylene glycol (PEG) precipitation step prior to purification of viral RNA (PEG Amplicor assay). The sensitivity of this assay for HIV-1 RNA detection in individual serum samples within pools matches that of standard commercial assays for individual serum samples, i.e., 500 HIV-1 RNA copies per ml. Five pools were identified as positive, and each one contained one antibody-negative, HIV-1 RNA-positive serum sample, corresponding to an average of 1 infected sample per 2,138 serum samples. Retrospective analysis revealed that the five HIV-1 RNA-positive specimens originated from individuals who had symptomatic primary HIV-1 infection at the time of sample collection and who were also positive for p24 antigenemia. We next assessed the possibility of performing the prepurification step by high-speed centrifugation (50,000 x g for 80 min) of 1.5-ml pools containing 25 microl of 60 individual serum samples, of which only 1 contained HIV-1 RNA (centrifugation Amplicor assay). The sensitivity of this assay also matches the sensitivities of standard commercial assays for HIV-1 RNA detection in individual serum samples. The results demonstrate that both assays with pooled sera can be applied to the screening of large numbers of serum samples in a time- and cost-efficient manner.

Changes in red cell transfusion practice among adult trauma victims

BACKGROUND

Recent attention concerning the adverse outcomes of blood transfusion has resulted in decreased blood product usage for nonemergency care. We hypothesized that there has also been a decrease in blood product use in the management of seriously injured adults.

METHODS

A retrospective review of institutional database records was conducted at a regional trauma center for adults admitted during 1991, 1993, and 1995. Data was analyzed for trends in amount, type, and timing of blood product use.

RESULTS

A total of 1,738 patients were assessed, with 1,605 meeting inclusion. The three patient groups were similar, including injury severity (overall mean Injury Severity Score of 23.6), mechanism (88% blunt), and survival (87%). In 1991, 54% of the patients were transfused a total of 2,341 units of packed red blood cells (mean 4.67 units/pt treated) versus 42% of patients in 1995 (p < 0.0001) who received 2,018 packed red blood cells (mean 3.57 units/patient treated, p = 0.05). A significantly higher proportion of units was transfused in the first 24 hours of care in 1995 (64%) compared with 1991 (21%, p < 0.0001). A reduction in the use of universal donor type-O blood use was also found (1.21 vs. 0.65 units/patient transfused, p < 0.0001). Despite similar admission hemoglobin concentrations (124.1 vs. 125.3, not significant), significant reductions were found in the average 24-hour (109.2 vs. 103.8, p < 0.001), lowest (96.5 vs 92.1, p < 0.01) and discharge (115.8 vs. 110.5, p < 0.001) concentrations.

CONCLUSIONS

Between 1991 and 1995 there have been significant reductions in both the number of trauma patients receiving blood products and the total number of units transfused. These findings may reflect lower or abandoned hemoglobin transfusion triggers and increased awareness of complications related to transfusion.

Presence of human immunodeficiency virus (HIV) and T-lymphotropic virus type I and II (HTLV-I/II) in a haemophiliac population in Belo Horizonte, Brazil, and correlation with additional serological results

The aim of this study was to determine the prevalence of human immunodeficiency virus type 1 (HIV-1) and human T lymphotropic virus types I and II (HTLV-I/II) infections in 226 haemophiliac patients treated at Fundação Hemominas in Belo Horizonte, Minas Gerais State, Brazil, and to verify association with other serological results. Patients positive for HTLV-I/II had also a neurological, haematological and ophthalmological evaluation. Fundação Hemominas offers comprehensive care for all haemophiliac patients in Minas Gerais. Thirty-six (15.9%) of the 226 patients showed reactive results to HIV-1 [ELISA, Abbott, USA, confirmed by Western blot (WB), Cambridge Biotech, USA, and/or immunofluorescence, Fiocruz, Brazil] and 16 (7.1%) had reactive sera to HTLV-I/II (ELISA, Ortho). Eleven of these 16 (4.9%) were positive, 3/16 (1.3%) were indeterminate and 2/16 (0.9%) were negative in the HTLV WB (Cambridge Biotech). Neurological, haematological and ophthalmological examination of 9/16 patients revealed no abnormality suggestive of HTLV disease. Of the 16 patients reactive to HTLV-I/II ELISA test, six (37.5%) were also positive to HIV-1 (chi 2 = 5.92; P = 0.01). Seropositivity for HTLV-I/II and HIV-1 was associated with advancing age and positive results for hepatitis C virus (HCV), Chagas' disease (T. cruzi infection) and syphilis. No association between the presence of HTLV with type and severity of haemophilia and hepatitis B results was detected. The prevalence of antibodies against HIV-1 is approximately three times that of HTLV-I/II and a patient positive for HTLV-I/II had a significantly increased risk of being positive for HIV-1, HCV and T. cruzi.