Plasma-first resuscitation to treat haemorrhagic shock during emergency ground transportation in an urban area: a randomised trial

BACKGROUND

Plasma is integral to haemostatic resuscitation after injury, but the timing of administration remains controversial. Anticipating approval of lyophilised plasma by the US Food and Drug Administration, the US Department of Defense funded trials of prehospital plasma resuscitation. We investigated use of prehospital plasma during rapid ground rescue of patients with haemorrhagic shock before arrival at an urban level 1 trauma centre.

METHODS

The Control of Major Bleeding After Trauma Trial was a pragmatic, randomised, single-centre trial done at the Denver Health Medical Center (DHMC), which houses the paramedic division for Denver city. Consecutive trauma patients in haemorrhagic shock (defined as systolic blood pressure [SBP] ≤70 mm Hg or 71-90 mm Hg plus heart rate ≥108 beats per min) were assessed for eligibility at the scene of the injury by trained paramedics. Eligible patients were randomly assigned to receive plasma or normal saline (control). Randomisation was achieved by preloading all ambulances with sealed coolers at the start of each shift. Coolers were randomly assigned to groups 1:1 in blocks of 20 according to a schedule generated by the research coordinators. If the coolers contained two units of frozen plasma, they were defrosted in the ambulance and the infusion started. If the coolers contained a dummy load of frozen water, this indicated allocation to the control group and saline was infused. The primary endpoint was mortality within 28 days of injury. Analyses were done in the as-treated population and by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT01838863.

FINDINGS

From April 1, 2014, to March 31, 2017, paramedics randomly assigned 144 patients to study groups. The as-treated analysis included 125 eligible patients, 65 received plasma and 60 received saline. Median age was 33 years (IQR 25-47) and median New Injury Severity Score was 27 (10-38). 70 (56%) patients required blood transfusions within 6 h of injury. The groups were similar at baseline and had similar transport times (plasma group median 19 min [IQR 16-23] vs control 16 min [14-22]). The groups did not differ in mortality at 28 days (15% in the plasma group vs 10% in the control group, p=0·37). In the intention-to-treat analysis, we saw no significant differences between the groups in safety outcomes and adverse events. Due to the consistent lack of differences in the analyses, the study was stopped for futility after 144 of 150 planned enrolments.

INTERPRETATION

During rapid ground rescue to an urban level 1 trauma centre, use of prehospital plasma was not associated with survival benefit. Blood products might be beneficial in settings with longer transport times, but the financial burden would not be justified in an urban environment with short distances to mature trauma centres.

FUNDING

US Department of Defense.

Routine storage of red blood cell (RBC) units in additive solution-3: a comprehensive investigation of the RBC metabolome

BACKGROUND

In most countries, red blood cells (RBCs) can be stored up to 42 days before transfusion. However, observational studies have suggested that storage duration might be associated with increased morbidity and mortality. While clinical trials are under way, impaired metabolism has been documented in RBCs stored in several additive solutions (ASs). Here we hypothesize that, despite reported beneficial effects, storage in AS-3 results in metabolic impairment weeks before the end of the unit shelf life.

STUDY DESIGN AND METHODS

Five leukofiltered AS-3 RBC units were sampled before, during, and after leukoreduction Day 0 and then assayed on a weekly basis from storage Day 1 through Day 42. RBC extracts and supernatants were assayed using a ultra-high-performance liquid chromatography separations coupled online with mass spectrometry detection metabolomics workflow.

RESULTS

Blood bank storage significantly affects metabolic profiles of RBC extracts and supernatants by Day 14. In addition to energy and redox metabolism impairment, intra- and extracellular accumulation of amino acids was observed proportionally to storage duration, suggesting a role for glutamine and serine metabolism in aging RBCs.

CONCLUSION

Metabolomics of stored RBCs could drive the introduction of alternative ASs to address some of the storage-dependent metabolic lesions herein reported, thereby increasing the quality of transfused RBCs and minimizing potential links to patient morbidity.

Sepsis Attributed to Bacterial Contamination of Platelets Associated with a Potential Common Source - Multiple States, 2018

During May-October 2018, four patients from three states experienced sepsis after transfusion of apheresis platelets contaminated with Acinetobacter calcoaceticus-baumannii complex (ACBC) and Staphylococcus saprophyticus; one patient died. ACBC isolates from patients' blood, transfused platelet residuals, and two environmental samples were closely related by whole genome sequencing. S. saprophyticus isolates from two patients' blood, three transfused platelet residuals, and one hospital environmental sample formed two whole genome sequencing clusters. This whole genome sequencing analysis indicated a potential common source of bacterial contamination; investigation into the contamination source continues. All platelet donations were collected using apheresis cell separator machines and collection sets from the same manufacturer; two of three collection sets were from the same lot. One implicated platelet unit had been treated with pathogen-inactivation technology, and two had tested negative with a rapid bacterial detection device after negative primary culture. Because platelets are usually stored at room temperature, bacteria in contaminated platelet units can proliferate to clinically relevant levels by the time of transfusion. Clinicians should monitor for sepsis after platelet transfusions even after implementation of bacterial contamination mitigation strategies. Recognizing adverse transfusion reactions and reporting to the platelet supplier and hemovigilance systems is crucial for public health practitioners to detect and prevent sepsis associated with contaminated platelets.

Conjoint analysis: a novel, rigorous tool for determining patient preferences for topical antibiotic treatment for acne. A randomised controlled trial

BACKGROUND

Acne vulgaris is an extremely common skin disorder that can be treated effectively with drugs that are currently available. Poor compliance, however, is a major factor in the high failure rates seen in acne treatment. Compliance might be enhanced by considering patient preferences for acne medications. Conjoint analysis is well suited for the study of patient preferences in healthcare, but is novel to the field of dermatology.

OBJECTIVES

The study aimed to determine and compare patient preferences for four topical antibiotics used for 1 week, once or twice daily, to treat acne vulgaris.

METHODS

A randomised, phase IV, single-centre, cross-over study was performed using conjoint analysis and a traditional patient questionnaire. Over 4 weeks, the patients used each of four topical antibiotics for 1 week: erythromycin/zinc solution, clindamycin phosphate lotion, benzoyl peroxide (BP)/erythromycin gel (each applied twice daily) and clindamycin phosphate gel (applied once daily). The conjoint analysis examined five different attributes of acne medications: form, storage, product life once opened, method of application and regimen (each with two or three possible options). From 108 possible permutations of the five attributes, 16 hypothetical medications were selected at random and described on printed cards. Pre- and post-treatment, the patients ranked the cards in order of preference and rated each hypothetical product based on their likelihood to use it. For each patient, product 'utilities' were then calculated by multiple regression. The patients also completed a patient acceptability questionnaire, by which they rated the product acceptability after 1 week of treatment with each of the four topical antibiotics. The patients later ranked the medications in order of preference after using all four treatments. Adverse events were recorded in diary cards to assess tolerability.

RESULTS

Of 67 patients recruited, 64 used all four medications and completed the study. The conjoint analysis found that a gel formulation, room temperature storage, product life of up to 18 months once opened, application with fingers and once-daily regimen were the options ranked first for the five product attributes. According to the ranking order (out of 108) for the combination of attributes representing the four study medications, clindamycin phosphate gel had the highest rankings (6 and 1 pre- and post-treatment, respectively) and BP/erythromycin gel had the lowest rankings (93 and 70 pre- and post-treatment). The rankings of clindamycin phosphate lotion and erythromycin/zinc solution worsened from pre- to post-treatment, indicating a shift in patient preference after they experienced products 'in-use' during the study. Based on the questionnaire, clindamycin phosphate gel was liked best by the highest proportion of patients (33%). In terms of overall satisfaction, the order of preference was: (i) clindamycin phosphate gel, (ii) clindamycin phosphate lotion, (iii) BP/erythromycin gel and (iv) erythromycin/zinc solution. Adverse events related to medication occurred most frequently with erythromycin/zinc solution and BP/erythromycin gel. Clindamycin phosphate gel was the only product not associated with any episodes resulting in a change of medication or dose.

CONCLUSIONS

Conjoint analysis provided a convenient, reliable tool for assessing patient preferences for topical antibiotics used to treat acne. The patients clearly preferred a gel formulation that could be applied with the fingers once daily and stored at room temperature for as long as 18 months. One product (clindamycin phosphate gel) combined all five of the preferred attributes, a preference confirmed by the simulated product rankings. These findings of the conjoint analysis are consistent with the safety profiles and the results of the traditional questionnaire.

The pro-inflammatory potential of microparticles in red blood cell units

BACKGROUND

Microparticles (MPs) are submicron size cell fragments that are released from cells.

OBJECTIVES

We hypothesise that MPs increase during red blood cell (RBC) storage and are part of the pro-inflammatory activity, which accumulates in the RBC supernatant.

METHODS/MATERIALS

RBC units were separated from whole blood of eight healthy donors: 5 U were split, with 50% undergoing leucoreduction (LR) and the remaining left as unmodified controls. The remaining 3 U were leucoreduced. Samples were obtained at days (D) 1 and 42 and cell-free supernatants separated and stored. The supernatants were centrifuged at 17 000 × g (60 min) or 100 000 × g (120 min) into microparticle-rich (MPR) and microparticle-poor (MPP) portions, resuspended in albumin, incubated with antibodies to CD235 (RBCs), CD45 [white blood cells (WBCs)] and CD41a [platelets (Plts)], and analysed by flow cytometry. Isolated neutrophils were incubated with these samples, and priming activity measured.

RESULTS

Total MPs increased during storage; however, MPs that marked for precursor cell types did not. Significant priming accumulated in the MPP fraction during storage with some activity present in the MPR fraction from D1 and D42 LR-RBCs.

CONCLUSION

Most of the pro-inflammatory priming activity from stored RBCs resides in the MPP supernatant, although the MPR fraction from D42 LR-RBCs does contain some priming activity.

Proteomic analysis of the supernatant of red blood cell units: the effects of storage and leucoreduction

BACKGROUND

Red blood cell (RBC) transfusion is a life-saving intervention for critically ill patients; however, it has been linked to increased morbidity and mortality. We hypothesize that a number of important proteins accumulate during routine storage of RBCs, which may explain some of the adverse effects seen in transfused patients.

STUDY DESIGN

Five RBC units were drawn and divided (half prestorage leucoreduced (LR-RBC) and half left as an unmodified control (RBC). The supernatant was separated on days 1 and 42 of storage and proteomic analyses completed with in-gel tryptic digestion and nano-liquid chromatography tandem mass spectrometry.

RESULTS

In RBC supernatants, 401 proteins were identified: 203 increased with storage, 114 decreased, and 84 were unchanged. In LR-RBC supernatant, 231 proteins were identified: 84 increased with storage, 30 decreased, and 117 were unchanged. Prestorage leucoreduction removed many platelet- and leucocyte-derived structural proteins; however, a number of intracellular proteins accumulated including peroxiredoxins (Prdx) 6 and latexin. The increases were confirmed by immunoblotting, including the T-phosphorylation of Prdx-6, indicating that it may be functioning as an active phospholipase. Active matrix metalloproteinase-9 also increased with a coinciding decrease in the metalloproteinase inhibitor 1 and cystatin C.

CONCLUSION

We conclude that a number of proteins increase with RBC storage, which is partially ameliorated with leucoreduction, and transfusion of stored RBCs may introduce mediators that result in adverse events in the transfused host.

Acute effects of dietary protein on calcium metabolism in patients with osteoporosis

Five untreated osteoporotic patients were studied in a metabolic unit for 30 days while receiving control (0.8 gm/kg) and high (2.0 gm/kg) protein diets of purified proteins. The high protein diet increased urinary calcium and produced a negative calcium balance without causing significant change in calcium absorption, serum chemical values, or urinary sodium and potassium. Variable effects of calcium and/or estrogens were found on the negative balance. Hence, increased dietary protein acutely causes a negative calcium balance in osteoporotic patients and may contribute to bone loss in this disease.

Optimizing nitrogen management in food and energy production and environmental protection: summary statement from the Second International Nitrogen Conference

Human efforts to produce food and energy are changing the nitrogen (N) cycle of the Earth. Many of these changes are highly beneficial for humans, while others are detrimental to people and the environment. These changes transcend scientific disciplines, geographical boundaries, and political structures. They challenge the creative minds of natural and social scientists, economists, engineers, business leaders, and decision makers. The Second International Nitrogen Conference was designed to facilitate communications among all stakeholders in the "nitrogen community" of the world. The Conference participants" goal in the years and decades ahead is to encourage every country to make optimal choices about N management in food production and consumption, energy production and use, and environmental protection. Scientific findings and recommendations for decision makers that emerged from the Conference are presented.

Transfusion-related acute lung injury: advances in understanding the role of proinflammatory mediators in its genesis

Transfusion-related acute lung injury (TRALI) is the most common cause of serious morbidity and mortality due to hemotherapy. The pathogenesis is the result of two events: the first related to the recipient's clinical condition, predisposing to acute lung injury (ALI) through neutrophil or polymorphonuclear leukocyte sequestration, and the second being the infusion of antibodies or mediators that activate these adherent polymorphonuclear neutrophils, resulting in endothelial damage, capillary leak and ALI. TRALI is most prevalent in the critically ill, although many of these cases are termed ALI. Although mitigation strategies, such as the use of male-only plasma, have decreased the number of TRALI cases and deaths, TRALI still occurs. This review will detail the pathophysiology of TRALI, provide insight into newer areas of research and critically assess current practices to mitigate TRALI and improve transfusion safety.

The Lifestyle Behaviour Checklist: evaluation of the factor structure

OBJECTIVE

Childhood overweight and obesity have been identified as a significant global health problem, and have multiple health and socio-emotional sequelae. The family context and parenting behaviours in particular play an important role in childhood overweight and obesity; however, limited research has explored the relationship between parenting and child obesity. The aim of this research was to refine the content of a tool designed to assess child lifestyle behaviour problems and parents' confidence in managing these behaviours.

DESIGN

Content revisions of the Lifestyle Behaviour Checklist (LBC) were undertaken, and the psychometric properties were examined.

SUBJECTS

One hundred and fifty-six parents of an overweight or obese child completed the LBC, as well as questionnaires regarding child behaviour in general and parenting practices.

RESULTS

The results of this study support the validity of the revised LBC as a measure of parental concerns about weight-related problem behaviour, and provide evidence for a four-factor structure and strong internal consistency.

Antiviral antibodies in the sera of homosexual men: correlation with their lifestyle and drug usage

Healthy homosexual men between the ages of 21 and 65 years, from the Washington, DC (n = 162), and New York City (n = 89) areas, were studied for antibodies in the serum against cytomegalovirus (CMV), herpes simplex virus (HSV) types 1 and 2, and Epstein Barr virus (EBV) viral capsid antigen (VCA). CMV-specific antibodies were assayed by enzyme-linked immunosorbent assay (ELISA), anti-HSV-1 and -2 antibodies were measured by indirect hemagglutination (IHA), and antibodies to EBV VCA were measured by the immunofluorescence assay. Antibodies to human T lymphotrophic virus III (HTLV-III) were detected by ELISA and Western blot procedures. T lymphocytes were enumerated using OKT4 monoclonal antibody. Healthy male volunteer blood donors (n = 90) matched for age range and race proportions were used as controls. The percentage of seropositive individuals in the homosexual group was higher (90-98%) for all the viruses tested than in the control group (47-87%). Comparisons of the geometric mean titers, expressed as reciprocal serum dilutions, of seropositive individuals in homosexual (H) vs control (C) group were as follows: CMV-IgG (ELISA) H = 1:794, C = 1:68; HSV-1 (IHA) H = 1:248, C = 1:14; HSV-2 (IHA) H = 1:56, C = 1:17; EBV-VCA (IFA) H = 1:385, C = 1:131. The homosexual group also showed a higher frequency of individuals with elevated titers than the control group. The CMV IgM antibody was prevalent in 17.7% of the homosexual group and 5% of the control group; arithmetic means for ELISA values for CMV IgM were 0.207 for the homosexual group and 0.05 for the control group. In the homosexual group, the anti-CMV antibody titers increased with age (P = 0.01) and with numbers of sex partners (P = 0.06). Both anti-HSV-1 and anti-HSV-2 antibodies correlated with the number of sex partners (P = 0.04 and P = 0.05, respectively). Neither age nor partner number correlated with response to EBV, and no particular sex act was related to the EBV VCA titer level. HTLV-III seropositivity was associated with higher herpes virus group antibody titers, probably because of life style cofactors. Among the HTLV-III-seropositive subjects, those with less than or equal to 400 T-helper lymphocytes/mm3 had lower antibody titers than those with greater than 400 T-helper lymphocytes/mm3 counts, suggesting an impaired immune response secondary to immunosuppression.

An observer‐blind, parallel‐group, randomized, multicentre clinical and microbiological study of a topical clindamycin/zinc gel and a topical clindamycin lotion in patients with mild/moderate acne

INTRODUCTION

A topical acne treatment in which clindamycin phosphate equivalent to 1% clindamycin is presented in a gel formulation has received marketing authorizations in a number of EU and non-EU countries. Clindamycin/zinc gel contains zinc acetate in a formulation that reduces systemic absorption of clindamycin through the skin.

OBJECTIVES

To compare the efficacy and safety of a 1% clindamycin/zinc gel when applied to the face once daily or twice daily with a 1% clindamycin lotion applied twice daily for 16 weeks in patients with mild to moderate acne vulgaris.

METHODS

This was a randomized, comparative, observer-blind, parallel-group, multicentre study involving 246 acne patients.

RESULTS

The study demonstrated therapeutic similarity between clindamycin/zinc gel applied once and twice daily with clindamycin lotion applied twice daily. All three regimens produced a gradual and time-dependent reduction in inflamed lesions, non-inflamed lesions and overall grade. Side effects were similar and minimal, consisting predominantly of mild irritant dermatitis. All regimes produced a time-related significant reduction in skin surface and follicular Propionibacterium spp. and Micrococcaceae. The emergence of resistant strains was less than 5% and was similar with all three regimes.

CONCLUSION

The equivalent efficacy and safety of clindamycin/zinc gel either once or twice daily to clindamycin lotion twice daily has been demonstrated. It is suggested that a treatment regime of one application per day may significantly enhance compliance and thus treatment success in acne patients.

Fatal acute hemolytic transfusion reaction due to anti-B from a platelet apheresis unit stored in platelet additive solution

BACKGROUND

Hemolytic transfusion reactions from out-of-group plasma in platelet (PLT) transfusions are uncommon, with most involving passive transfer of anti-A. Only rare reactions have ever been reported due to anti-B.

STUDY DESIGN AND METHODS

An apheresis PLT product was donated by a blood group O male, processed using PLT additive solution, and pathogen reduced. Postreaction recipient testing included an antibody screen using gel technology, a direct antiglobulin test (DAT) using immunoglobulin G and C3, and an eluate against group O and B cells. Postreaction donor testing included measuring anti-B titers in saline, with and without anti-human globulin.

RESULTS

A 60-year-old blood group B patient with relapsed acute myeloid leukemia developed confusion, fever, and hypotension within hours after a blood group O PLT transfusion. The posttransfusion reaction evaluation was remarkable for a positive DAT 3+ for C3; the eluate showed anti-B. Rapid extravascular hemolysis occurred, with a 50% decline in hemoglobin, a high lactate dehydrogenase, and a high bilirubin. She was resuscitated with fluids, blood products, pressors, and oxygen and died of asystole 60 hours later. The donor's anti-B titers were 128 by tube testing at immediate spin and 512 at the anti-human globulin phase. Notably, a group B patient at a different hospital received a split of the same apheresis unit, with no reaction.

CONCLUSION

To our knowledge, this is the first fatality reported from passively transfused anti-B. The fact that one transfusion recipient died whereas another did not have any reported reaction highlights the potential importance of recipient variables in isohemagglutinin-mediated hemolysis.

pH monitoring in patients with benign voice disorders

The aim of this study was to compare oesophageal pH-metry with laryngeal signs and symptoms in patients suspected of laryngeal reflux disease. A total of 60 patients with voice disorders, who were suspected of laryngeal reflux, were tested by single probe oesophageal pH monitoring. Thirty-two suffered from reflux laryngitis. A comparison of symptoms in patients with proven reflux to patients with no reflux was made. The symptoms were more frequent in the patients in the reflux group than in the non-reflux group. There was a significant difference between the groups with regard to dysphonia, sore throat, thick mucus and heartburn. Clinical signs appeared more frequently in the reflux group than in the non-reflux group. A significant difference was found between the groups regarding oedema of the vocal cords and hyperaemia and oedema of the posterior commisure, contact granuloma, posterior wall granulation and increased muscle tension. The patients in the reflux group were given medical treatment using omeprazole, and 76% logopedic voice training program. More than 50% of the laryngeal reflux patients were treated for more than 4 months before their voice problems had resolved. It is important to realize that signs of reflux laryngitis are not confined to the posterior commisure.

A laboratory investigation of the role of guide planes in the retention of cast cobalt-chromium alloy partial denture frameworks

OBJECTIVES

This in vitro study examined the resistance to displacement offered by guide planes and the displacement mechanics of a bilateral bounded saddle cast cobalt chrome alloy removable partial denture framework under conditions simulating an average initial fit.

METHODS

A specially designed model mouth jig fitted with strain gauges to monitor the forces across the guiding plane/guiding surface interfaces was used. Guiding planes of enamel, silver tin amalgam and dental composite with seven combinations of guide planes and three angles of withdrawal were examined. Guiding plane size was also examined for dental enamel.

RESULTS

A statistically significant difference in retention was found for all factors examined. Retention increased with increasing angle of withdrawal. Size effects were found but considered unreliable.

CONCLUSIONS

It was concluded that with a tight fit guiding plane retention may be readily predicted for any given material, combination of mesial, distal and lingual guiding planes and angulation conditions by the application of mechanical principles providing the basic parameters are known. Attention is drawn to the reasons for further work to fully understand the clinical situation.

Supernatants and lipids from stored red blood cells activate pulmonary microvascular endothelium through the BLT2 receptor and protein kinase C activation

BACKGROUND

Although transfusion is a lifesaving intervention, it may be associated with significant morbidity in injured patients. We hypothesize that stored red blood cells (RBCs) induce proinflammatory activation of human pulmonary microvascular endothelial cells (HMVECs) resulting in neutrophil (PMN) adhesion and predisposition to acute lung injury (ALI).

STUDY DESIGN AND METHODS

Ten units of RBCs were collected; 50% (by weight) were leukoreduced (LR-RBCs) and the remainder was unmodified and stored in additive solution-5 (AS-5). An additional 10 units of RBCs were collected, leukoreduced, and stored in AS-3. HMVECs were incubated with [10%-40%]_FINAL of the supernatants on Day (D)1 to D42 of storage, lipid extracts, and purified lipids. Endothelial surface expression of intercellular adhesion molecule-1 (ICAM-1), interleukin (IL)-8 release, and PMN adhesion to HMVECs were measured. HMVEC signaling via the BLT2 receptor was evaluated. Supernatants and lipids were also employed as the first event in a two-event model of ALI.

RESULTS

The supernatants [10%-40%]_FINAL from D21 LR-RBCs and D42 RBCs and LR-RBCs and the lipids from D42 stored in AS-5 induced increased ICAM-1 surface expression on endothelium, IL-8 release, and PMN adhesion. In addition, the supernatants [20%-40%]_FINAL from D21 and D42 RBCs in AS-5 also increased endothelial surface expression of ICAM-1. D42 supernatants and lipids also caused coprecipitation of β-arrestin-1 with BLT2, protein kinase C (PKC)β_I , and PKCδ and served as the first event in a two-event rodent model of ALI.

CONCLUSION

Lipids that accumulate during RBC storage activate endothelium and predispose to ALI, which may explain some of the adverse events associated with the transfusion of critically injured patients.

Rapid washing of filter paper discs in a solid-phase radioimmunoassay with a constant flow washing device

A machine has been developed for the rapid washing of the cellulose filter paper discs that are used in a number of radioimmunoassays. The machine is simple in design, easy to use, and is capable of washing 96 filter paper discs simultaneously. The efficiency of the machine is demonstrated by a RAST assay for measuring IgE antibodies to the venom. Time taken to wash the discs was reduced 3-fold without loss of sensitivity or reproducibility.

A comparison of different methods of red blood cell leukoreduction and additive solutions on the accumulation of neutrophil-priming activity during storage

BACKGROUND

Three methods of leukoreduction (LR) are used worldwide: filtration, buffy coat removal (BCR), and a combination of the previous two methods. Additionally, there are a number of additive solutions (ASs) used to preserve red blood cell (RBC) function throughout storage. During RBC storage, proinflammatory activity accumulates; thus, we hypothesize that both the method of LR and the AS affect the accumulation of proinflammatory activity.

STUDY DESIGN AND METHODS

Ten units of whole blood were drawn from healthy donors, the RBC units were isolated, divided in half by weight, and leukoreduced by: 1) BCR, 2) filtration, or 3) BCR and filtration (combination-LR); stored in bags containing AS-3 per AABB criteria; and sampled weekly. The supernatants were isolated and frozen (-80°C). RBC units drawn from healthy donors into AS-1-, AS-3-, or AS-5-containing bags were also stored and sampled weekly, and the supernatants were isolated and frozen. The supernatants were assayed for neutrophil (PMN)-priming activity and underwent proteomic analyses.

RESULTS

Filtration and combination LR decreased priming activity accumulation versus buffy coat LR, although the accumulation of priming activity was not different during storage. Combination LR increased hemolysis versus filtration via proteomic analysis. Priming activity from AS-3 units was significant later in storage versus AS-1- or AS-5-stored units.

CONCLUSIONS

Although both filtration and combination LR decrease the accumulation of proinflammatory activity versus buffy coat LR, combination LR is not more advantageous over filtration, has increased costs, and may cause increased hemolysis. In addition, AS-3 decreases the early accumulation of PMN-priming activity during storage versus AS-1 or AS-5.

Survival of herpes simplex virus in water specimens collected from hot tubs in spa facilities and on plastic surfaces

Several health spas were closed temporarily because of possible nonvenereal spread of herpes simplex virus (HSV) in spa water at these facilities. We collected water specimens from two health spas and studied them for (1) the presence of HSV; (2) bromine (Br2), chlorine (Cl2), and pH levels; and (3) the ability of HSV to survive in water. No HSV could be isolated from the spa water specimens. Spa water had high levels of Cl2 and Br2, tap water specimens had low levels of Cl2, and distilled water had no detectable Cl2 or Br2. The addition of spa water to laboratory stock virus immediately inactivated the virus. The HSV survived four hours in the tap water and 24 hours in distilled water. The survival of HSV appeared to be related to the free halogen content of water. To approximate the conditions of survival of HSV on plastic-coated benches and seats in spa facilities, HSV was placed on plastic surfaces in a humid atmosphere at 37 to 40 degrees C. The virus was found to survive up to 4.5 hours under these conditions. The survival of HSV from human lesions may be different due to the presence of tissue secretions and proteins. Furthermore, transmission may require other factors, such as rubbing of skin or penetration through abrasions. However, survival of significant amounts of virus for 4.5 hours on plastic surfaces suggests that fomites such as these may be nonvenereal routes of HSV transmission.

Endoscopic placement of self-expanding metal stents for treatment of colorectal obstruction with long-term follow-up

INTRODUCTION

Relief of colorectal obstruction by means of self-expandable metal mesh stents (SEMS) has been suggested for palliation and acute decompression followed by optimization of the patients' general condition prior to definitive surgery.

METHODOLOGY

Twelve patients with high operative risk and/or metastatic disease were selected for stenting with a dedicated colorectal partly covered SEMS (Choo Colo-Rectal Stent, Solco Intermed Co., Seoul, Korea).

RESULTS

Stent deployment was successful in nine, two of whom had total obstruction. In one a guidewire perforation was treated conservatively. In two patients (one benign stricture, and one rectal cancer) the stents migrated within three weeks. One re-obstructed. In the remaining six patients colonic decompression was achieved, and the stents have been patent until death after median 116 days (33-292 days).

CONCLUSION

These results are promising, but data from several centres should be compiled prospectively in a standardized fashion in order to allow for assessment of the method's safety and success rates before randomised trials can be initiated.

Red Blood Cell Transfusion

Blood is classified as a drug and transfusion is one of the most commonly performed procedures in the USA. General knowledge of blood manufacturing, shelf life and storage media, common component modifications, blood types, and product compatibility allows the clinician to better communicate their needs and to understand what options may be available when ordering blood products. All transfusions offer benefits, and the clinician must comprehend the possible adverse events, especially those related to TRALI, which continues to be the most common cause of transfusion-related death reported to FDA, with TACO as the second most-commonly reported event. Transfusing in the setting of hemorrhagic blood loss adds additional challenges regarding volume overload, coagulopathy, and optimum transfusion ratios of red cells, plasma, platelets, and cryoprecipitate. The information imparted in this chapter will help equip the clinician with the knowledge needed to make the best decisions for patients requiring blood products, especially injured patients.

Dysplasia in gastric mucosa: prognostic significance

Forty-seven patients having dysplasia in biopsies from the gastric mucosa were subjected to re-investigation. Twenty-three patients were alive at follow-up and 14 underwent gastroscopy with removal of random biopsies. The median duration of observation was 39 months, range 10-63 months. Regression of the dysplasia was found in all patients; in nine there was normal mucosa without dysplastic alterations in the control biopsies, mild dysplasia was still present in five of the patients. Our results suggest that the incidental finding of mild or moderate dysplasia does not, per se, indicate the necessity of further control, whereas severe dysplasia indicates repeat gastroscopies with biopsies, as such epithelial changes can occur together with gastric carcinoma.