Advancing Malaria Prevention and Control in Africa Through the Peace Corps-US President’s Malaria Initiative Partnership

Background

Peace Corps is a US government volunteer service agency which provides trained Volunteers to assist host countries in addressing critical development challenges at the community level. The US President’s Malaria Initiative provides technical expertise and financial resources to reduce malaria morbidity and mortality in focus countries in sub-Saharan Africa.

Objective

We aim to describe the nature of the collaboration between Peace Corps and President’s Malaria Initiative (PMI) and highlight examples of the partnership in select countries.

Methods

We conducted an analysis of retrospective data obtained from Peace Corps and PMI for the years 2014–2019.

Results

Volunteers were able to learn about and work on malaria prevention and control with PMI in three key ways: a malaria-specific training program for staff and Volunteers; malaria-focused small grants; and extension of Volunteer assignments for a third year to support malaria projects. Successful Peace Corps projects supported by PMI, at the community level, were highlighted, with a focus on Rwanda, Benin, Zambia, Madagascar, and Senegal. In Fiscal Year 2019, 1408 Volunteers contributed to malaria prevention activities in 18 Peace Corps programs across Africa, of which 15 were PMI focus countries. While the majority of documented work by Volunteers has involved social and behavior change, there were many other ways to partner with PMI staff.

Conclusion

Each of the proven interventions that PMI supports for malaria prevention and control may have a role for Volunteer involvement. Combined with the technical expertise and the relationships that PMI staff have with national-level counterparts in PMI focus countries, the continued collaboration between Peace Corps and PMI can accelerate the fight against malaria.

Fibrinolysis: strategies to enhance the treatment of acute ischemic stroke

Stroke is a major cause of disability worldwide, and is the second leading cause of death after ischemic heart disease. Until recently, tissue-type plasminogen activator (t-PA) was the only treatment for acute ischemic stroke. If administered within 4.5 h of symptom onset, t-PA improves the outcome in stroke patients. Mechanical thrombectomy is now the preferred treatment for patients with acute ischemic stroke resulting from a large-artery occlusion in the anterior circulation. However, the widespread use of mechanical thrombectomy is limited by two factors. First, only ⁓ 10% of patients with acute ischemic stroke have a proximal large-artery occlusion in the anterior circulation and present early enough to undergo mechanical thrombectomy within 6 h; an additional 9-10% of patients presenting within the 6-24-h time window may also qualify for the procedure. Second, not all stroke centers have the resources or expertise to perform mechanical thrombectomy. Nonetheless, patients who present to hospitals where thrombectomy is not an option can receive intravenous t-PA, and those with qualifying anterior circulation strokes can then be transferred to tertiary stroke centers where thrombectomy is available. Therefore, despite the advances afforded by mechanical thrombectomy, there remains a need for treatments that improve the efficacy and safety of thrombolytic therapy. In this review, we discuss: (i) current treatment options for acute ischemic stroke; (ii) the mechanism of action of fibrinolytic agents; and (iii) potential strategies to manipulate the fibrinolytic system to promote endogenous fibrinolysis or to enhance the efficacy of fibrinolytic therapy.

Long term health outcomes among Returned Peace Corps Volunteers after malaria prophylaxis, 1995-2014

BACKGROUND

A primary reason for non-adherence to malaria chemoprophylaxis is fear of latent side effects. We examined latent effects of malaria chemoprophylaxis among Returned Peace Corps Volunteers (RPCVs).

METHODS

During July 18-September 16, 2016, RPCVs who served during 1995-2014 with an e-mail address in Peace Corps' RPCV database were invited to take an internet-based survey on malaria prophylaxis and medical diagnoses. "Good adherence" meant taking prophylaxis "as prescribed" or "most of the time." Prevalence of diseases diagnosed after Peace Corps service was compared between users and nonusers of each antimalarial using log-binomial regression.

RESULTS

Of 8931 participants (11% response rate), 5055 (57%) took chemoprophylaxis. Initial chemoprophylaxis was mefloquine 59%, chloroquine 13%, doxycycline 16%, atovaquone-proguanil 4%, and "other" 8%. Sixty percent reported good adherence. Mefloquine users had the best adherence (67% good adherence). Prevalences of most diseases were similar between exposed and unexposed groups. Certain psychiatric diagnoses were slightly more likely among mefloquine users (PR 1.14, 95% CI [1.04-1.25], P = 0.0048). When excluding those with prior psychiatric illness, there were no differences in psychiatric diagnosis rates.

CONCLUSION

Malaria chemoprophylaxis use by Peace Corps Volunteers is safe. Avoiding mefloquine use in those with prior psychiatric illness can reduce psychiatric side effects.

Road traffic injuries in Peace Corps Volunteers, 1996-2014

INTRODUCTION

Road traffic injuries are a leading cause of mortality and morbidity worldwide. Travellers are at risk given unfamiliarity with local road conditions and traffic rules. Peace Corps Volunteers are a unique population of long-term travellers who live and work in-country, often in remote settings, over a period of 27 months and use a range of transportation modes.

METHODS

Data from Peace Corps' Epidemiologic Surveillance System (ESS) and Death In-Service (DIS) database were analysed in 2015 for non-fatal and fatal road traffic injuries among in-service Volunteers from 1996 to 2014. Volunteer-months were used to calculate incidence rates, and rates were compared among countries and regions.

RESULTS

A total of 5047 non-fatal and 15 fatal road crash injuries were reported during 1 616 252 Volunteer-months for an overall rate of 3.12 non-fatal injuries and 0.01 fatalities per 1000 Volunteer-months. The total combined rate of nonfatal road traffic injuries among Volunteers generally declined from 4.01 per 1000 Volunteer-months in 1996 to 2.84 in 2014. Pedestrian and bicycle injuries emerged as the most frequent mechanisms of injury during this timeframe. Differences in rates of observed road traffic-related fatalities among Volunteers compared with expected age-matched cohort rates in the US were not statistically significant.

CONCLUSIONS

Peace Corps transportation policies and training, and changes to road environments worldwide, may have led to a decrease in the rate of road traffic injuries among Peace Corps Volunteers. Pedestrians and bicyclists remain at risk of road traffic injuries.

Dengue in Peace Corps Volunteers, 2000-14

BACKGROUND

Dengue is an arboviral disease estimated to cause 50-100 million infections each year in >100 tropical and subtropical countries. Urbanization, human population growth and expanded global travel have resulted in an increase in the incidence of dengue worldwide. International travellers to areas with endemic dengue are at risk of contracting dengue and US Peace Corps Volunteers are one specific group of long-term travellers who are exposed to environments where dengue can be contracted.

METHODS

Cases of dengue among Peace Corps Volunteers, defined as clinically apparent infections with laboratory-confirmation by a positive NS1 antigen test, demonstration of IgM antibodies or by a 4-fold increase in IgG antibodies, between 1 January 2000 and 31 December 2014, reported to the Peace Corps’ Epidemiologic Surveillance System were analyzed.

RESULTS

Overall there were 1448 cases of dengue reported among Volunteers, with an incidence rate of 1.12 cases per 1000 Volunteer-months (95% CI 1.06-1.17). The highest rate of dengue among Volunteers was reported in the Caribbean region, with a rate of 5.51 cases per 1000 Volunteer-months (95% CI 4.97-6.10), followed by the East Asia/South Asia region (3.34, 95% CI 2.96-3.75) and Central America (2.55, 95% CI 2.32-2.79). The rate of dengue peaked in 2007, 2010 and 2013. Each peak year was followed by a trough year.

CONCLUSIONS

Globally, there appears to be a 3-year cyclical pattern of dengue incidence among Volunteers, with differences by region. Dengue continues to be a priority health issue for travellers to endemic areas, and enhanced surveillance of dengue among international travellers may result in improved patient education and prevention efforts.

Revisiting tuberculosis risk in Peace Corps Volunteers, 2006-13

BACKGROUND

Risk of tuberculosis (TB) is generally considered to be low for long-term travellers, though risk varies with travel destination, duration and purpose. Peace Corps Volunteers (PCVs) serve for 27 months as community-level development workers in various countries around the world and may be exposed to TB in the course of their service. This study examines recent trends in TB in PCVs and compares rates with a previous analysis published by Jung and Banks.

METHODS

Tuberculosis case data submitted to the Peace Corps' Epidemiologic Surveillance System by Peace Corps Medical Officers and gathered from Federal Employees Compensation Act claims for latent TB infection (LTBI) and active TB between 2006 and 2013 were aggregated and analysed for trends and significance.

RESULTS

Overall, there were 689 cases of LTBI and 13 cases of active TB, for a rate of 0.95 cases of LTBI [95% confidence interval (CI) 0.88-1.02] and 0.02 cases of active TB (95% CI 0.01-0.03) per 1000 Volunteer-months. Both are significantly lower than rates presented in the initial study (P < 0.001). Per-country incidence rates for LTBI ranged from 0.00 to 4.52 cases per 1000 Volunteer-months. Per-country active TB rates ranged from 0.00 to 0.78 cases per 1000 Volunteer-months. Among the 13 cases of active TB, there was one successfully treated case of extensively drug-resistant TB.

CONCLUSIONS

Overall rates of both active and latent TB in PCVs were significantly lower compared with the previous study period. PCVs continue to have statistically significantly higher rates of active TB compared with the general US population but lower rates compared with other long-term travellers.

Neonatal screening for haemoglobin variants using filter paper-dried blood specimens

Neonatal screening for haemoglobinopathies utilizing cord blood samples is well established, although it has a high miss rate and has the inherent problem of possible misdiagnosis from maternal contamination of the sample. The use of dried Guthrie card samples which are taken at six days of age avoids these problems and has the advantage of using an established system of sample collection. Controversy exists as to the method of choice for analysis of dried samples, this study of 2406 samples found that Iso-electric focusing (IEF) analysis of dried specimens gives excellent correlation when compared with cellulose acetate/citrate agar electrophoresis of liquid cord blood samples. The IEF results were clear and relatively simple to interpret even when the samples had been stored at room temperature for 4 weeks. The commercial enzyme linked immunosorbent assay (ELISA) screening test JOSHUA reliably determines the presence or absence of haemoglobin S in dried specimens. It could therefore be used as a relatively cheap and simple method for the confirmation of sickle cell trait in neonatal screening programmes based on dried specimens.

Self-report of quality of medical student health care

OBJECTIVES

To summarise survey results for the quality of medical students' personal health care, characterise the results according to the demographics and career orientations of the students, and evaluate the relationship between the perceived quality of health care received and the degree of emphasis on prevention in the health care provided.

METHODS

We carried out a cross-sectional study with 2316 medical students in the class of 2003 from 16 medical schools, surveyed at 3 points during their training. We used a self-administered questionnaire designed to assess personal health care and related variables in medical students.

RESULTS

The majority (92%) reported receiving health care that was at least good, but only a minority (23%) said they received excellent health care. Half had a regular doctor. Health care quality was rated more highly at Year 1 orientation than at later timepoints by students who had a regular personal doctor, and especially by those with personal doctors who emphasised prevention.

CONCLUSIONS

The majority of medical students perceived that they had received health care that was good or better, but most did not believe it was excellent. As the provision of preventive care is important to students, increasing the amount of preventive care provided to students may both increase their personal satisfaction with their health care and model good clinical preventive practices for them.

Older women and HIV: how much do they know and where are they getting their information?

OBJECTIVES

To assess older urban women's knowledge about sexual transmission of human immunodeficiency virus (HIV)/acquired immune deficiency syndrome (AIDS) and to evaluate the relationship between their HIV/AIDS knowledge level and sources of information.

DESIGN

Cross-sectional survey conducted between June 2001 and July 2002. Trained research assistants administered a questionnaire in a face-to-face interview.

SETTING

General medicine clinic in a large public hospital in a high HIV/AIDS incidence area.

PARTICIPANTS

Five hundred fourteen women aged 50 and older.

MEASUREMENTS

Nine questions assessing knowledge of risk of HIV sexual transmission with potential scores ranging from 0 to 9 correct answers. Participants identified all sources of HIV information.

RESULTS

The mean knowledge score was 3.7 out of a possible 9 correct responses (range 0 (3%) to 8 (1%)). Younger age, employment, and higher educational level were associated with higher knowledge scores, whereas marital status was unrelated. No respondent correctly answered all of the nine questions. The most commonly identified sources of HIV/AIDS information were television (85%), friends (54%), and newspapers (51%). Only 38% of respondents identified health professionals as a source of information about HIV/AIDS. Health professionals, newspapers, and family members were each independently associated with higher knowledge scores (P<.05).

CONCLUSION

Older women in a general medicine clinic had limited knowledge of sexual transmission of HIV. HIV/AIDS education specifically targeted to this subpopulation is warranted, and health professionals may have an important role in disseminating such messages.

Mg2+-dependent compaction and folding of yeast tRNAPhe and the catalytic domain of the B. subtilis RNase P RNA determined by small-angle X-ray scattering

We apply synchrotron-based small-angle X-ray scattering to investigate the relationship between compaction, metal binding, and structure formation of two RNAs at 37 degrees C: the 76 nucleotide yeast tRNA(Phe) and the 255 nucleotide catalytic domain of the Bacillus subtilis RNase P RNA. For both RNAs, this method provides direct evidence for the population of a distinct folding intermediate. The relative compaction between the intermediate and the native state does not correlate with the size of the RNA but does correlate well with the amount of surface burial as quantified previously by the urea-dependent m-value. The total compaction process can be described in two major stages. Starting from a completely unfolded state (4-8 M urea, no Mg(2+)), the major amount of compaction occurs upon the dilution of the denaturant and the addition of micromolar amounts of Mg(2+) to form the intermediate. The native state forms in a single transition from the intermediate state upon cooperative binding of three to four Mg(2+) ions. The characterization of this intermediate by small-angle X-ray scattering lends strong support for the cooperative Mg(2+)-binding model to describe the stability of a tertiary RNA.

A cross-sectional survey of pain and pharmacological analgesia in Canadian neonatal intensive care units

OBJECTIVE

To determine current practices for the use of analgesia term and preterm neonates cared for in Neonatal Intensive Care Units (NICUs).

DESIGN

One-week survey of medical charts of current patients.

SETTING

NICUs in Canada.

PARTICIPANTS

A total of 14 of 38 invited NICUs participated. These units were not different on number of beds, admissions per year, or university affiliation from the nonparticipating units.

MAIN OUTCOME MEASURES

Daily logs were kept of the frequency and type of procedures and analgesia administration for all ill neonates in each NICU during the study period.

RESULTS

The sample consisted of 239 patients. A total of 2,134 invasive procedures were performed. Medication was given specifically 18 times for 17 invasive procedures (0.8%). For another 129 invasive procedures, the patient was receiving analgesia for reasons other than the procedure. Sixteen patients had surgery during the survey period, and another 14 had surgery prior to but within 4 days of the survey. Fifty-one patients received anaesthesia or analgesia specifically related to surgery (39 times), procedures (35 times), or other reasons (34 times), a total of 108 courses. Opioids were the most frequently used medications and were given for all reasons, by continuous infusion, intermittent bolus, or sometimes both methods for the same patient.

CONCLUSIONS

Postoperative pain in neonates in Canadian NICUs appears to be consistently treated, primarily with opioid analgesics, but analgesia, opioid or nonopioid is rarely given for nonsurgical invasive procedures.

Monte Carlo modeling of small-angle scattering data from non-interacting homogeneous and heterogeneous particles in solution

A Monte Carlo algorithm that rapidly generates the scattered intensity function for complex heterogeneous particles is described. The heterogeneous particles are built from any number and orientation of simple building blocks, which include ellipsoidal shells, hollow ellipsoidal cylinders, ellipsoidal helices, triangular prisms, rectangular prisms, and semi-ellipsoidal shells. Applications are discussed such as real proteins and their complexes, polysaccharides, void effects on I(q), Guinier range estimation, and calculation of Stuhrmann plots.

Solution structures of GroEL and its complex with rhodanese from small-angle neutron scattering

BACKGROUND

Molecular chaperonins 60 are cylindrical oligomeric complexes which bind to unfolded proteins and assist in their folding. Studies to identify the location of the protein substrate have produced contradictory results: some suggest that the substrate-binding site is buried within the interior of the complex, whereas others indicate an external (polar) location.

RESULTS

Small-angle neutron scattering (SANS) measurements were made on GroEL chaperonin and on a complex of GroEL with rhodanese. The radius of gyration and the molecular weight determined from SANS measurements of GroEL agree well with those from its crystal structure. The positions of residues which were unresolved in the crystal structure have been confirmed. In addition, through model fitting of the SANS data, conformational changes in solution have been assessed and the location of bound rhodanese has been determined.

CONCLUSIONS

The overall structure of GroEL in solution is similar to the crystal structure. In GroEL the N-terminal and C-terminal residues are organized compactly near the equator of the cylinder and the apical domains are flared by about 5 degrees. The best fit of SANS data suggests the existence of an equilibrium between the complex and single rings and monomers. SANS data for the GroEL-rhodanese complex are consistent with a model wherein one rhodanese molecule binds across the opening to the chaperonin cavity, rather than within it.

Conformational changes in yeast phosphoglycerate kinase upon substrate binding

Small-angle neutron scattering (SANS) was used to measure the radius of gyration (Rg) of solutions of phosphoglycerate kinase (PGK) in a variety of substrate environments in D2O. The Rg of 24.0 A was measured for native PGK. A decrease in Rg was observed for the following: 23.7 A for PGK+sulphate; 23.5 A for PGK+ beta, gamma-bidentate Cr(H2O)4ATP (CrATP); 23.3 A for PGK + 3-phospho-D-glycerate (PGA)+CrATP; 22.9 A for PGK+CrATP+sulphate; 22.6 A for PGK+PGA+CrATP+sulphate. The statistical error was about +/- 0.3 A, which is less than systematic effects in this system. These results are consistent with catalysis by a hinge-bending motion of the enzyme. Since CrATP is not hydrolyzed, these results represent the conformational states of the bound substrates in the catalytically relevant ternary complex in the absence of product formation. The second virial coefficient is also measured for this system and this is consistent with that calculated from the protein volume only.

A heat and moisture exchanging filter in long-term ventilation

We report our experience of using the Pall BB50T heat and moisture exchanging filter (HMEF) in critically ill patients undergoing long-term ventilation. Three hundred and sixty-four ventilated patients humidified with the Pall HMEF were studied prospectively. Thirty-five patients (mean APACHE II score 24.6, mean predicted mortality 50.9%) were ventilated for more than 10 days (mean 18.9), accounting for 661 patient-ventilated days. During this period two patients suffered tracheal tube occlusion. No other complications could be attributed to the filter. We conclude that the Pall BB50T heat and moisture exchanging filter is safe in patients undergoing long-term ventilation. However, its use demands a high degree of respiratory care.

Renal organic acid transport: uptake by rat kidney slices of a furan dicarboxylic acid which inhibits plasma protein binding of acidic ligands in uremia

The furan dicarboxylic acid, 3-carboxy-4-methyl-5-propyl-2-furanpropanoic acid (5-propyl FPA), accumulates in uremic plasma and inhibits the binding of various drugs and marker ligands that are organic acids. 5-Propyl FPA is excreted unchanged in human urine and active tubular secretion is likely to be involved because of its high affinity for albumin. The uptake of 5-propyl FPA by rat kidney slices has been measured and compared with that of p-aminohippurate (PAH). The mean (+/- S.D.) slice/medium ratio for uptake of 5-propyl FPA (76 microM) was 22.7 +/- 2.6 (n = 11) and for PAH (75 microM) was 15.9 +/- 3.2 (n = 9) after incubation for 90 min at 25 degrees C. 5-Propyl FPA (149-829 microM) inhibited the uptake of PAH (77 microM) in a concentration-dependent manner, and likewise, PAH (150-830 microM) inhibited the uptake of 5-propyl FPA (77 microM). The mean apparent Km and Vmax values for the uptake of 5-propyl FPA were 194 +/- 125 microM and 55 +/- 28 nmol/g kidney/min, respectively, and 487 +/- 179 and 99 +/- 46 nmol/g kidney/min, respectively, for PAH. The kinetics of inhibition of uptake of PAH by 5-propyl FPA were mainly competitive. 5-Propyl FPA is thus likely to undergo active tubular secretion in a similar way to PAH, and this furan dicarboxylic acid, therefore, has the potential to inhibit the renal excretion of various drugs, drug conjugates and other endogenous organic acids.

Solution structure of phosphorylase kinase studied using small-angle X-ray and neutron scattering

Small-angle X-ray and neutron scattering have been used to characterize the solution structure of rabbit skeletal phosphorylase kinase. The radius of gyration of the unactivated holoenzyme determined from neutron scattering is 94 A, and its maximum dimension is approximately 275-295 A. A planar model has been constructed that is in general agreement with the dimensions of the transmission electron microscope images of negatively stained phosphorylase kinase and that gives values for the radius of gyration, maximum linear dimension, and a pair distribution function for the structure that are consistent with the scattering data.

Interaction of 3-carboxy-4-methyl-5-propyl-2-furanpropanoic acid, an inhibitor of plasma protein binding in uraemia, with human albumin

The furan dicarboxylic acid 3-carboxy-4-methyl-5-propyl-2-furanpropanoic acid (5-propyl FPA) accumulates in uraemic plasma and is a potent inhibitor of the binding of other anionic ligands to albumin. The interaction of 5-propyl FPA with human albumin has been investigated by equilibrium dialysis at 37 degrees and pH 7.4. Analysis of the binding data on the basis of a two-site model gave binding parameters of n1 = 0.6 and K1 = 4.8 x 10(6) M-1 for the primary binding site. 5-Propyl FPA binding was observed to decrease as the pH was raised from 6.4 to 8.3 which emphasizes the need for pH control of whole plasma or serum. Temperature, however, had little effect on binding as assessed by equilibrium dialysis at 10 degrees, 25 degrees and 37 degrees. The high affinity of 5-propyl FPA for albumin explains its retention in uraemic plasma, its potency as a binding inhibitor and points to active tubular secretion as the mechanism by which it is normally excreted by the kidney.

Low mortality associated with low volume pressure limited ventilation with permissive hypercapnia in severe adult respiratory distress syndrome

Many animal studies have shown that high peak inspiratory pressures (PIP) during mechanical ventilation can induce acute lung injury with hyaline membranes. Since 1984 we have limited PIP in patients with ARDS by reducing tidal volume, allowing spontaneous breathing with SIMV and disregarding hypercapnia. Since 1987 50 patients with severe ARDS with a "lung injury score" greater than or equal to 2.5 and a mean PaO2/FiO2 ratio of 94 were managed in this manner. The mean maximum PaCO2 was 62 mmHg, the highest being 129 mmHg. The hospital mortality was significantly lower than that predicted by Apache II (16% vs. 39.6%, chi 2 = 11.64, p less than 0.001). Only one death was due to respiratory failure, caused by pneumocystis pneumonia. 10 patients had a "ventilator score" greater than 80, which has previously predicted 100% mortality from respiratory failure. Only 2 died, neither from respiratory failure. There was no significant difference in lung injury score, ventilator score, PaO2/FiO2 or maximum PaCO2 between survivors and non-survivors. We suggest that this ventilatory management may substantially reduce mortality in ARDS, particularly from respiratory failure.

Antibody-mediated pure neutrophil aplasia, recurrent myasthenia gravis and previous thymoma: case report and literature review

We describe a case of neutrophil aplasia in a woman with recurrent myasthenia gravis and a past history of thymoma. Bone marrow showed virtually absent granulopoiesis but normal erythropoiesis and megakaryopoiesis. Bone marrow cultures showed no growth of granulocyte/mononuclear cell progenitors (CFU-GM). She was treated with immunosuppression including azathioprine, and her neutrophil count returned to normal. Serum before treatment, and also an IgG fraction thereof, inhibited CFU-GM growth both in autologous 'remission' marrow and in allogeneic marrow. She remains in complete remission 36 months after starting azathioprine. This association is extremely rare, and was formerly associated with a grim prognosis.

Structural relationships between the isoenzymes of human placental alkaline phosphatase: a serum factor converts M-PLAP to A- and B-PLAP

A protein factor has been found in serum which converts the M form of placental alkaline phosphatase (PLAP) to the A and B forms. The identity of the conversion products has been confirmed by analysis of their dimers and polypeptides. Proteolysis is not implicated in this phenomenon. This report establishes microvillous M-PLAP as the precursor of the A and B forms.

Factors producing error in the total leucocyte count as measured on the Coulter Counter S Plus IVD

Whole blood specimens, anticoagulated with potassium EDTA, which were seen to have particles interfering with the total leucocyte count were collected. This interference was detected, when the samples were processed through a Coulter Counter S Plus IVD, by R1 regional flags or backlighting of the leucocyte count. These specimens then had visual leucocyte counts performed using a counting chamber method and were examined microscopically, to ascertain possible causes of the interference. It was shown that the degree of error in the leucocyte count produced varies considerably but can be very high. Particles causing the error were found to include fibrin strands, platelet clumps, nucleated red cells and giant platelets.