A pilot study to assess physician knowledge in transfusion medicine

INTRODUCTION

An assessment of transfusion medicine knowledge and practice in Canada was carried out over a 3-week period.

METHODS

Fifty-five questions were posed to evaluate both basic information on blood and blood products and on clinical use. The form was distributed through the Canadian Society for Transfusion Medicine with designated individuals asked to handle regional distribution. Some used provincial mailing lists, others distributed within each hospital. Approximately, 2000 forms were sent, including 500 in French.

RESULTS

A total of 294 forms were returned; answers were recorded as 'correct', 'incorrect', 'no answer' or with 'added comments'. Overall, 52% of the questions were answered correctly or were answered with qualifying comments. In clinical practice questions, 63% were answered correctly or with qualifying comments. Basic knowledge questions drew correct answers in 37% of the cases. Several issues were answered poorly. The volume of an apheresis plasma unit was correctly estimated by less than 10% of respondents with many understanding the volume (500-600 mL) by as much as 300-400 mL. Anaesthesiologists responded most often (21%); few haematologists participated (4%). Provincial response varied: most were received from Ontario (30%) and British Columbia (22%).

CONCLUSIONS

The answers show that clinical application of transfusion is generally accompanied by a questioning process - it is not entirely by rote. Basic knowledge about products needs improvement.

Effect of premedication guidelines and leukoreduction on the rate of febrile nonhaemolytic platelet transfusion reactions

Platelet transfusion reactions were prospectively studied in haematology/oncology patients at five university teaching hospitals over three consecutive summers. The initial summer study provided baseline information on the use of premedications and the rate of platelet transfusion reactions (fever, chills, rigors and hives). Most (73%) platelet recipients were premedicated and 30% (95% CI 28-33%) of transfusions were complicated by reactions. The second study followed implementation of guidelines for premedicating platelet transfusions. Despite a marked reduction in premedication (50%), there was little change in the platelet transfusion reaction rate, 26% (95% CI 24-29%), or the type of reactions. The third study followed implementation of prestorage platelet leukoreduction while maintaining the premedication guidelines. The reaction rate decreased to 19% (95% CI 17-22%). For nonleukoreduced platelets, there was a statistically significant association between the platelet age and reaction rate (P = 0.04). For leukoreduced platelets, there was no statistically significant association between platelet age and reaction rate (P = 0.5). Plasma reduction of nonleukoreduced platelet products also reduced the reaction rate. These prospective studies document a high rate of platelet transfusion reactions in haematology/oncology patients and indicate premedication use can be reduced without increasing the reaction rate. Prestorage leukoreduction and/or plasma reduction of platelet products reduces but does not eliminate febrile nonhemolytic platelet transfusion reactions.

Stem cell function and engraftment is not affected by "in vivo purging" with rituximab for autologous stem cell treatment for patients with low-grade non-Hodgkin's lymphoma

The chimeric anti-CD20 monoclonal antibody rituximab (Rituxan; IDEC Pharmaceuticals, San Diego, CA, and Genentech, Inc, San Francisco, CA) has recently been approved by the US Food and Drug Administration as single-agent treatment of relapsed/refractory low-grade or follicular non-Hodgkin's lymphoma. Initial results from the pivotal clinical trial revealed that response rates to rituximab were higher in patients who previously had high-dose therapy and autologous stem cell transplantation. We have initiated a clinical trial that combines the use of rituximab with high-dose chemotherapy followed by autologous stem cell transplantation for patients with chemosensitive relapsed follicular small cleaved or mantle cell lymphoma. A unique feature of this study is that in addition to eight maintenance infusions of rituximab after autologous stem cell transplantation, patients also received rituximab 375 mg/m2 2 days before a granulocyte colony-stimulating factor-mobilized stem cell collection as "in vivo purge." We report on preliminary results demonstrating the safety and efficacy of the in vivo purge on 10 patients undergoing stem cell mobilization, nine of whom have already undergone transplantation. The peripheral blood CD34+ counts were 14.92 and 20 x 10(6)/L on day 4 and day 5, respectively, of the stem cell mobilization with granulocyte colony-stimulating factor. This compares with 11.7 and 11.8 x 10(6)/L, respectively, for the control population. The median CD34 stem cell yield in the graft collection was 3.7 x 10(6)/kg in patients receiving rituximab in vivo purge compared with 3.1 x 10(6)/kg in the control population. The target stem cell collection was successfully collected in six of 10 patients in a 1-day single large-volume leukapheresis collection, while two patients required 2 days and the last two patients required 3 days. Functional assays revealed the stem cell colony-forming unit-granulocyte monocyte and burst-forming unit-erythrocyte to be 55 and 44 colonies per plate, respectively, for the patients receiving the in vivo rituximab purge. This compares favorably with 37 and 38.5 colonies per plate, respectively, for the control population. Neutrophil engraftment took a median of 11 days for both cohorts; platelet independence was achieved in 8 days compared with 10 days for the control population. The median number of platelet transfusions was two for patients receiving rituximab and 2.5 for the control group. Assessment of serum cytokines immediately before the rituximab infusion during the stem cell mobilization and immediately after revealed a twofold to sevenfold increase in interleukin-1beta, tumor necrosis factor-alpha, and interleukin-6. The polymerase chain reaction analysis for minimal residual disease in stem cell collections and in peripheral blood and bone marrow samples of these patients will help to determine the efficacy of rituximab in vivo purge on disease progression.

Review of autologous and allogeneic blood transfusion practices in patients undergoing radical hysterectomy

To review the practice and predictors of autologous (AUT) and allogeneic blood transfusion in patients undergoing radical hysterectomy (RH). All patients undergoing RH between April 1, 1991 and March 31, 1995 were identified by the hospital blood bank. Clinical and tumour characteristics were abstracted from the charts of endometrial cancer patients, and amalgamated with our cervical cancer RH database. Pre and post-operative hemoglobin (Hg), the number of units of AUT blood requested, obtained, and transfused, and the number of units of allogeneic blood transfused were obtained from the blood bank records. Forty eight of the 111 patients undergoing RH during the study period predeposited AUT blood. There were no differences in the median age, quetelet index, American Society of Anaesthesiologists classification of physical status, or blood loss between the AUT and non-donors. The tumour size was greater in the AUT donors, and the preoperative Hg was greater in the non donors (p = 0.001, p < 0.04 respectively). Operative time was less in the AUT donors (2.1 hrs vs 2.7 hrs, p < 0.001), and there was a significant difference in the use of the AUT program between the 3 surgeons (0.5%, 68%, p < 0.0001). Despite similar blood loss, 98% and 33% of AUT and non-donors were transfused intra/postop respectively (p < 0.0001). Regression analysis revealed surgeon (p < 0.0001) to be the only predictor of AUT donation. Blood loss was found to be the only predictor of intraoperative/postoperative blood transfusion in the non donor group (p = 0.0006). The utilization of an AUT blood program differs significantly between surgeons. Physicians are more liberal to transfuse AUT than allogeneic blood.

Location of breakpoints within the major breakpoint cluster region (bcr) in 33 patients with bcr rearrangement-positive chronic myeloid leukemia (CML) with complex or absent Philadelphia chromosomes

We report the sublocalization of the breakpoint in chromosome 22 in 33 patients with chronic myeloid leukemia (CML) who also had unusual marrow cytogenetics. In 23 patients, the leukemic clones were characterized by Philadelphia (Ph1) chromosomes that arose through complex translocations that involved three or more chromosomes. In the remaining ten patients, there were no detectable Ph1 chromosomes despite molecular evidence for the presence of rearrangements in the major breakpoint cluster region (bcr) of chromosome 22 in all cases. There was no significant difference between the two groups with respect to location of the breakpoints within the bcr. When these two groups of patients were combined, there was a significant excess of breakpoints in one segment of the bcr when compared to the distribution of breakpoints seen in 119 patients with simple 9;22 translocations. The difference in breakpoint distributions did not appear to be entirely attributable to differences between groups in disease duration at the time of study. These data support the notion that the unusual genetic recombinations that give rise to BCR/ABL fusion genes in CML involve specific DNA sequences of BCR (and possibly ABL) and additional, recombinogenic sequences, at least some of which are present in loci known to be nonrandomly involved in complex Ph1 translocations.

Acquisition of additional primary chromosome abnormalities in the course of karyotype evolution in a case of FAB-M2 acute leukemia

Cytogenetic studies of bone marrow metaphases from a 17-year-old woman with acute myeloid leukemia revealed a leukemic clone characterized by the t(8;21)(q22;q22) characteristic of FAB-M2. The patient was treated and achieved transient remissions. On relapse, her leukemic clone had acquired, in addition to the t(8;21), the inv(16)(p13q22) characteristic of FAB-M4Eo and a 5q- of the type seen in various acute myeloid leukemias and myelodysplastic syndromes. This cell line persisted throughout the remainder of the patient's clinical course. There were no other clonal chromosome abnormalities observed. The observation of multiple chromosome mutations, usually regarded separately as primary, in a single leukemic clone is most unusual and raises questions about our concepts of the nature of primary acquired chromosome mutations in cancer.

Some rare hemoglobin variants with altered oxygen affinities; Hb linkoping [beta 36(C2)Pro----Thr], Hb Caribbean [beta 91(F7)Leu----Arg], and Hb Sunnybrook [beta 36(C2)Pro----Arg]

A few rare hemoglobin variants with altered functional properties have been observed in Canadian subjects with either an erythrocytosis or mild anemia. These variants were Hb Alberta [beta 101(G3)Glu----Gly], Hb Linkoping [beta 36(C2)Pro----Thr], a new variant Hb Sunnybrook [beta 36(C2)Pro----Arg], and Hb Caribbean [beta 91(F7)Leu----Arg]. Short clinical descriptions of the subjects are given, the characterization of the variants is described in detail (except for Hb Alberta), while data from some functional analyses are provided. Comparisons with previously published data have been made and the unusual chromatographic property of two abnormal beta chains in a reversed phase high performance liquid chromatographic system is reviewed.

Cystic fibrosis in adult life: a study of coping patterns

Despite comparable degrees of physical disability, some patients with cystic fibrosis (CF) cope more successfully than others with the difficulties of competitive adult life. This study found substantial differences between a coping and non-coping sample of adult CF patients. Non-copers had twice as many hospital admissions as copers over a year, even though their ventilatory function was better. The non-coping sample compared unfavourably with the copers in four main spheres of psychosocial functioning--their vocational records; level of family support; awareness of anomalies in sexual function; and knowledge about CF.

Children with end-stage renal failure: psychological effects on patients, siblings and parents

Thirty-two children diagnosed as suffering from renal failure, their parents and siblings were the subjects of this study. Anxiety, depression and psychosomatic complaints were examined in the parents and behaviour problems in the child and siblings using standardised tests. The personality characteristics (EPQ) of the child and the child's view of the family (modified family relations test) were also ascertained. Parents showed greater levels of anxiety and depression than a normal sample and more psychosomatic problems than a control group consisting of parents of children with other chronic physical conditions. Siblings and the sick child did not have more behaviour problems at school than a normal control group. Positive correlations were found between age on diagnosis of renal failure and fathers' depression and anxiety scores. Mothers' anxiety and depression scores were also positively correlated with those of father. Negative correlations were found between age on diagnosis of renal failure and lie scores on the EPQ.

The psychosomatic approach in paediatrics

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