Transfusion of incompatible blood to a patient with alloanti-Sc1

Sc1 is a high-prevalence blood group antigen that is part of the Scianna blood group system. The clinical significance of Scianna antibodies is not well understood because of their rarity; there are only a handful of cases in the literature. This scarcity of information can make it difficult to decide on the best course of action when transfusing a patient with alloantibodies to Scianna blood group antigens. We describe a case of an 85-year-old woman presenting with melena and a hemoglobin of 66 g/L. Upon request for crossmatched blood, a panreactive antibody was found, later elucidated to be alloanti-Sc1. Because of the urgent nature of the transfusion, the patient was transfused with 2 incompatible, presumed Sc1+, red blood cell units with no evidence of an acute or delayed transfusion reaction. This case has been shared with the International Society of Blood Transfusion Rare Donor Working Party, via their Outcome of Incompatible Transfusion form, and adds to the body of evidence on clinical significance of antibodies to the antigens of the Scianna blood group system.

Ethics of Early Clinical Trials of Bio-Artificial Organs

Regenerative medicine is the new frontier in the field of organ transplantation. Research groups around the world are using regenerative medicine technologies to develop bio-artificial organs for transplantation into human patients. While most of this research is still at the preclinical stage, bio-artificial organ technologies are gearing up for first-in-human clinical trials in the not-too-distant future. What are the ethical conditions under which early-phase clinical research of bio-artificial organs can be conducted safely and responsibly? What lessons can be learned from prior experiences with early-phase clinical trials in adjacent fields of research? This is a Meeting Report of an online international workshop organised in the context of the Horizon 2020-funded VANGUARD project, which is developing a bio-artificial pancreas for the treatment of patients with type 1 diabetes.

Psychosocial Evaluation of Candidates for Solid Organ Transplantation

Transplant candidates should undergo an assessment of their mental health, social support, lifestyle, and behaviors. The primary aims of this "psychosocial evaluation" are to ensure that transplantation is of benefit to life expectancy and quality of life, and to allow optimization of the candidate and transplant outcomes. The content of psychosocial evaluations is informed by evidence regarding pretransplant psychosocial predictors of transplant outcomes. This review summarizes the current literature on pretransplant psychosocial predictors of transplant outcomes across differing solid organ transplants and discusses the limitations of existing research. Pretransplant depression, substance misuse, and nonadherence are associated with poorer posttransplant outcomes. Depression, smoking, and high levels of prescription opioid use are associated with reduced posttransplant survival. Pretransplant nonadherence is associated with posttransplant rejection, and nonadherence may mediate the effects of other psychosocial variables such as substance misuse. There is evidence to suggest that social support is associated with likelihood of substance misuse relapse after transplantation, but there is a lack of consistent evidence for an association between social support and posttransplant adherence, rejection, or survival across all organ transplant types. Psychosocial evaluations should be undertaken by a trained individual and should comprise multiple consultations with the transplant candidate, family members, and healthcare professionals. Tools exist that can be useful for guiding and standardizing assessment, but research is needed to determine how well scores predict posttransplant outcomes. Few studies have evaluated interventions designed to improve psychosocial functioning specifically pretransplant. We highlight the challenges of carrying out such research and make recommendations regarding future work.

Resistant hypertension improved after 3 months by measuring drug levels to identify non-adherence

Introduction

Identification of non-adherence to antihypertensive drugs is crucial to improve resistant hypertension (RH). For this therapeutic drug monitoring is the most reliable method.

Purpose

The primary objective of this analysis is to determine whether drug levels measured with a dried blood spot (DBS) method combined with personalized feedback leads to a decrease in prevalence of RH after 3 months due to an increase in adherence.

Methods

This is a multi-centre single-blinded randomized controlled trial (RHYME-RCT, NL6736). Patients went to an eligibility visit, where DBS sampling and a 24-hour ambulatory blood pressure measurement (ABPM) was performed simultaneously. Patients with a daytime systolic blood pressure (SBP) >135 and/or diastolic blood pressure (DBP) >85 mmHg were randomized to standard treatment (control) or intervention. The intervention was performed by the treating physician and included information on drug levels and a personalized feedback conversation based on a feedback tool. The follow-up period was one year and included visits at 3, 6 and 12 months after the eligibility visit. At each visit an ABPM and DBS were performed.

Results

A total of 53 patients (mean age of 59±11 years, 78.7% male) with at least three months of follow-up were included. The prevalence of RH decreased from 100% in both arms to 75.0% in the intervention arm (p=0.014, n=24) and 58.6% in the control arm (p=0.001, n=29). No improvements were seen in adherence rates over time. Furthermore, no significant differences were found after three months between the two groups in the degree of RH (p=0.214), SBP (p=0.551) or adherence (p=0.746).

Conclusion

Measuring blood pressure and drug levels led to a decrease in the prevalence of RH. However, this improvement could not be linked to the actual intervention or improvement of adherence.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): ZonMW

The emergence of regenerative medicine in organ transplantation: 1st European Cell Therapy and Organ Regeneration Section meeting

Regenerative medicine is emerging as a novel field in organ transplantation. In September 2019, the European Cell Therapy and Organ Regeneration Section (ECTORS) of the European Society for Organ Transplantation (ESOT) held its first meeting to discuss the state‐of‐the‐art of regenerative medicine in organ transplantation. The present article highlights the key areas of interest and major advances in this multidisciplinary field in organ regeneration and discusses its implications for the future of organ transplantation.

Cost-effectiveness of a home-based group educational programme on renal replacement therapies: a study protocol

INTRODUCTION

Living donor kidney transplantation (LDKT) is the optimal treatment for most patients with end-stage renal disease (ESRD). However, there are numerous patients who cannot find a living kidney donor. Randomised controlled trials have shown that home-based education for patients with ESRD and their family/friends leads to four times more LDKTs. This educational intervention is currently being implemented in eight hospitals in the Netherlands. Supervision and quality assessment are being employed to maintain the quality of the intervention. In this study, we aim to: (1) conduct a cost-effectiveness analysis of the educational programme and its quality assurance system; (2) investigate the relationship between the quality of the implementation of the intervention and the outcomes knowledge, communication and LDKT activities; and (3) investigate policy implications.

METHODS AND DESIGN

Patients with ESRD who do not have a living kidney donor are eligible to receive the home-based educational intervention. This is carried out by allied health transplantation professionals and psychologists across eight hospitals in the Netherlands. The cost-effectiveness analysis will be conducted with a Markov model. Cost data will be obtained from the literature. We will obtain the quality of life data from the patients who participate in the educational programme. Questionnaires on knowledge and communication will be used to measure the outcomes of the programme. Data on LDKT activities will be obtained from medical records up to 24 months after the education. A protocol adherence measure will be assessed by a third party by means of a telephone interview with the patients and the invitees.

ETHICS AND DISSEMINATION

Ethical approval was obtained through all participating hospitals. Results will be disseminated through peer-reviewed publications and scientific presentations. Results of the cost-effectiveness of the educational programme will also be disseminated to the Dutch National Health Care Institute.

TRIAL REGISTRATION NUMBER

NL6529.

A Nurse-Led Self-Management Support Intervention (ZENN) for Kidney Transplant Recipients Using Intervention Mapping: Protocol for a Mixed-Methods Feasibility Study

Background

Optimal self-management in kidney transplant recipients is essential for patient and graft survival, reducing comorbidity and health care costs while improving the quality of life. However, there are few effective interventions aimed at providing self-management support after kidney transplantation.

Objective

This study aims to systematically develop a nurse-led, self-management (support) intervention for kidney transplant recipients.

Methods

The Intervention Mapping protocol was used to develop an intervention that incorporates kidney transplant recipients’ and nurses’ needs, and theories as well as evidence-based methods. The needs of recipients and nurses were assessed by reviewing the literature, conducting focus groups, individual interviews, and observations (step 1). Based on the needs assessment, Self-Regulation Theory, and the “5A’s” model, change objectives were formulated (step 2). Evidence-based methods to achieve these objectives were selected and subsequently translated into practical implementation strategies (step 3). Then, program materials and protocols were developed accordingly (step 4). The implementation to test the feasibility and acceptability was scheduled for 2015-2017 (step 5). The last step of Intervention Mapping, evaluation of the intervention, falls outside the scope of this paper (step 6).

Results

The intervention was developed to optimize self-management (support) after kidney transplantation and targeted both kidney transplant recipients and nurse practitioners who delivered the intervention. The intervention was clustered into four 15-minute sessions that were combined with regular appointments at the outpatient clinic. Nurses received a training syllabus and were trained in communication techniques based on the principles of Solution-Focused Brief Therapy and Motivational Interviewing; this entailed guiding the patients to generate their own goals and solutions and focus on strengths and successes. Kidney transplant recipients were encouraged to assess self-management challenges using the Self-Management Web and subsequently develop specific goals, action plans, and pursuit skills to solve these challenges.

Conclusions

The Intervention Mapping protocol provided a rigorous framework to systematically develop a self-management intervention in which nurses and kidney transplant recipients’ needs, evidence-based methods, and theories were integrated.

International Registered Report Identifier (IRRID)

DERR1-10.2196/11856

Correction to: S11 Experiences with a nurse-led self-management support intervention for people with chronic conditions; a mixed-methods approach

[This corrects the article DOI: 10.1186/s12912-018-0301-3.].

Cyanoferrocenes as redox-active metalloligands for coordination-driven self-assembly

Ferrocene-based Lewis bases have found utility as metalloligands in a wide variety of applications. The coordination chemistry of cyanoferrocenes however, is underexplored. Herein, we describe a new synthetic protocol for the generation of cyanoferrocenes. The coordination chemistry of these metalloligands to [Cu(NCMe)4][PF6], [(PPh3)2Cu(NCMe)2][PF6] and [(dppf)Cu(NCMe)2][PF6] salts has been explored, providing crystallographic evidence of cluster and polymeric forms of 1,1'- and 1,2-dicyanoferrocene complexes. The stability of the complexes and ligand dissociation were found to be strongly solvent-dependent.

Health needs of older populations affected by humanitarian crises in low- and middle-income countries: a systematic review

BACKGROUND

The combination of global demographic changes and a growing number of humanitarian crises in middle-income countries that have a higher life expectancy has led to an increase in the number of older populations affected by humanitarian crises. The aim of this review was to systematically examine evidence on the health needs of older populations in humanitarian crises, including both armed conflicts and natural disasters, in low- and middle-income countries (LMICs).

METHODS

A systematic review methodology was used. The search strategy used terms related to older populations and humanitarian crises in LMICs. Five bibliographic databases were used, along with relevant grey literature sources. Descriptive analysis was used, and a quality assessment conducted using the Newcastle-Ottawa Scale and CASP instruments.

RESULTS

A total of 36 studies were eligible for review. The majority of the studies were cross-sectional, three were cohort studies, and four used qualitative methodologies. The main health outcomes were mental health, physical health, functioning, and nutrition. Vulnerability factors included older age, female gender, being widowed, increased exposure to traumatic events, prior mental health problems, low income and education, and rural residency. Ten studies addressed the responsiveness of health systems and access to such services. The quality of the included studies was generally low.

CONCLUSIONS

There is an urgent need to strengthen the evidence base on the health needs of older populations in humanitarian crises.

Thematic analysis of psychiatric patients' perceptions of nursing staff

Therapeutic and informal interactions with nurses are integral to the quality of care that psychiatric patients receive. How well these interactions are performed, and their impact on the experience and outcomes of inpatient care, have not been subject to systematic evaluation. The aim of the present study was to examine patients' perceptions of the personal and professional qualities of nursing staff and how these contribute to the ward environment. Patients (n = 119) from 16 acute psychiatric wards were interviewed using a schedule developed by a service-user researcher. Transcriptions of interviews were coded and organized into six themes: staff duties, staff disposition, control, communication and engagement, therapeutic ward environment, and consistency. Patients recognized that nurses have a difficult and stressful job, but frequently expressed feelings of anger, frustration, and hopelessness about their experience of the wards. Patients frequently felt that nursing staff did not understand issues from their perspective or attempt to empathize with them. The findings indicate poorly-communicated and inconsistent care. Initiatives to improve patients' experiences of acute psychiatric wards are urgently needed.

Rotterdam: main port for organ transplantation research in the Netherlands

This overview describes the full spectrum of current pre-clinical and clinical kidney-, liver-, heart- and lung transplantation research performed in Erasmus MC - University Medical Centre in Rotterdam, The Netherlands. An update is provided on the development of a large living donor kidney transplantation program and on optimization of kidney allocation, including the implementation of a domino kidney-donation program. Our current research efforts to optimize immunosuppressive regimens and find novel targets for immunosuppressive therapy, our recent studies on prevention of ischemia-reperfusion-induced graft injury, our newest findings on stimulation of tissue regeneration, our novel approaches to prevent rejection and viral infection, and our latest insights in the regulation of allograft rejection, are summarized.

Aspects of Love: The Effect of Mortality Salience and Attachment Style on Romantic Beliefs

Two studies are reported which explore romance as a means of terror management for participants with secure and insecure attachment styles. Mikulincer and Florian (2000) have shown that while mortality salience increases the desire for intimacy in securely attached individuals, the insecurely attached use cultural world views rather than close relationships to cope with fear of death. Study 1 used the romantic belief scale to compare the effects of attachment style and mortality salience on the cultural aspects of close relationships and showed that the only the insecurely attached were more romantic following mortality salience. Study 2 replicated this effect and demonstrated that this difference was not simply due to lower self-esteem in the insecurely attached. The additional inclusion of the Relationship assessment questionnaire failed to provide any evidence that the securely attached were affected by the mortality salience manipulation, even on a more interpersonal measure.

Oncoplastic surgery for breast cancer based on tumour location and a quadrant-per-quadrant atlas

BACKGROUND

The majority of published techniques for oncoplastic surgery rely on an inverted-T mammoplasty, independent of tumour location. These techniques, although useful, cannot be adapted to all situations. A quadrant-per-quadrant atlas of mammoplasty techniques for large breast cancers was developed in order to offer breast surgeons a technique dependent on tumour location, which reduces the risk of postoperative complications and delay to adjuvant therapy.

METHODS

From 2005 to 2010, a series of eligible women with breast cancer were treated by quadrant-specific oncoplastic techniques. All complications and any delay to adjuvant treatment were recorded prospectively, along with local and distant cancer recurrences. Cosmetic outcome was evaluated using a five-point scale.

RESULTS

A total of 175 patients were analysed. The median tumour size, after histological examination, was 25 (range 4-90) mm. Twenty-three patients (13.1 per cent) had involved margins. Seventeen of these patients were treated by mastectomy and three had a re-excision. Complications occurred in 13 patients (7.4 per cent), which led to a delay to adjuvant treatment in three (1.7 per cent). After a median follow-up of 49 (range 23-96) months, three patients had developed a local recurrence. The mean score after cosmetic evaluation was 4.6 of 5.

CONCLUSION

A quadrant-per-quadrant approach to oncoplastic techniques for breast cancer was developed that tailors the mammoplasty for each tumour location. This panel of techniques should be a useful guide for breast surgeons, and extends the possibilities for breast conservation for large or poorly limited cancers, with a low complication rate and good cosmetic results.

P3-07-23: Intraoperative Molecular Analysis of Sentinel Lymph Nodes in Breast Cancer Using One Step Nucleic Acid Amplification (OSNA)

Introduction: The OSNA method for the intra-operative analysis of sentinel lymph nodes (SLNs) in breast cancer has been introduced in 3 UK centres since 2007. The methodology uses a polymerase chain reaction to quantitate CK19, a cytokeratin specific to breast duct epithelial cells. OSNA provides “real-time” results on SLNs analysed as negative (−) or positive with either micro (+) or macrometastases (++).

Method: This is a single-centre prospective pilot study of all patients undergoing breast cancer surgery including sentinel node biopsy from February 2010 to May 2011. SLN identification was performed using a dual localization technique with peri-areolar Patente V blue dye and Tc99 radio-active isotope. SLNs were cut into 4 slices labeled as A, B, C and D, respectively after the removal of all perinodal fat. In all SLNs, slices A and C were processed in OSNA and slices B and D underwent histological assessment by H&E staining. Slices A and C were prepared for OSNA analysis with the required reagent (Lynorhag), followed by centrifugation and homogenization. Micro-pipetted samples were processed against control specimens, to produce normalized and quantitative curve results. The primary outcome measure was to correlate the results of OSNA with histopathology for each SLN. A negative SLN resulted in no further axillary surgery compared to a level I axillary sampling following the presence of micrometastases and a level II dissection following the detection of macrometastases. The total duration of OSNA for all SLNs was recorded in relation to delays in the completion of the intended breast surgery in each patient.

Results: 251 SLNs were analysed in 112 patients (mean age of 55 years). Comparisons between OSNA and histopathology were made in 116 nodes (34 SLNs analysed by OSNA only). SLN positivity was evident in 30 nodes (26%) comprising either macrometastases (n=13) or micrometastases (n=17). The OSNA sensitivity and specificity of was 93% and 89%, respectively. Accounting for a tissue allocation bias in the presence of micrometastases only, the specificity rose to 94% if these cases were excluded in the analysis. There was no correlation between SLN positivity and tumour grade, size or receptor status. The time to OSNA results were analysed in 75 patients undergoing 45 wide local excisions (WLE), of which 18 were wire localized; 23 mastectomies and 22 SLNB alone. The mean time for OSNA was 40.5, 51.8, 54 and 61.5 minutes for 1,2,3, and 4 sentinel lymph nodes respectively. Operation time was prolonged by a median of 20 minutes (range −48 to +65 minutes) WLEs were delayed by the greatest time Exclusions: Nodes that were not available for histological comparison i) nodes weighing <0.05g (n=34) were processed whole. ii) Departmental agreement from mid March 2011 to process nodes whole via OSNA (n=51); 6 had micro or macrometastases.

Conclusion: OSNA prevented staged axillary surgery in 24 (21%) of patients. A median time of 20 minutes for the OSNA procedure is comparable with acceptable operating times. Current experience supports the use of OSNA for each individual whole SLN analysis. The pilot data has resulted in a prescribed change in policy to analyse the whole SLN using this technique.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P3-07-23.

Who calls the breast care nurses – the rich, the poor or the poorly?

Abstract #6094

Introduction: Breast care nurses (BCNs) are valuable members of the team; they provide advice, counselling and act as patients' advocates. We have previously demonstrated the worth of BCNs in our UK centre1 and the high number of calls they receive from patients and family. In this study, we investigate factors that might influence call rates from individual patients. We have examined the effect of patient age, prognosis and social deprivation on demand for this service.
 Methods: Our BCNs collect prospectively daily call sheets. These sheets include hospital number, age, type of call (phone or face to face), duration of call, purpose of call and outcome. We have examined breast nurse call sheets over a six-month period. The patients' home zip codes were also collected and allocated to the correct electoral ward (small geographical areas with average population of 5500). Using data from the UK National Census in 2000, information on social status was derived from the patients' zip codes and given as the Index of Multiple Deprivation (ID2000). The ID2000 has both an ID2000 score and ID2000 ranking for different electoral wards across England. Low ID2000 scores and high ID2000 rankings correspond to areas of affluence. Prognostic information was derived using the Nottingham Prognostic Index (NPI). The data were analysed by Spearman rank correlation using Statview 5.0 (SAS Inc) software comparing call rate to age, NPI and ID2000 scores & rankings.
 Results: During a six-month period, 1188 patients contacted the breast cancer nurse specialists in the NHS and private setting. 204 (17.1%) patients contacted their BCN once; 228 (19.1%) twice; 264 (22.2%) three times and 492 (41.4%) of patients called four times or more.
 Analysis by Spearman rank correlation of number of calls against age (Rho = -0.009, p=0.90), NPI (Rho = 0.068, p=0.40), ID2000 scores (Rho = 0.058, p=0.41) & ID20000 rank (Rho = -0.060, p=0.40) show no evidence of a relationship between age, prognosis or deprivation and the need to access BCNs.
 Conclusions: The BCNs provide a valuable service to patients with breast cancer. This support continues throughout the individual patient's cancer journey. In Gloucestershire, the need for support appears to be independent of age, prognosis and social status.
 1 Counselling women with breast cancer - whose line is it anyway?
 F G Court, S Scarrott, M Cassidy-Gray, A Thomas, S Vestey, J Bristol, M Ghilchik, H Y Chan
 Abstract 6045 - SABCS 2007.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 6094.

Choosing breast reconstruction – for richer, for poorer?

Abstract #5094

OBJECTIVE
 To assess whether the age or socio-economic status of patients undergoing mastectomy play any part in influencing their decision to undergo breast reconstruction.
 METHODS
 Details were collated from all patients undergoing mastectomy with or without reconstruction under the care of a single surgeon at Cheltenham General Hospital over a 5 year period. All patients having a mastectomy were offered a reconstruction. Zip codes were used to assign government deprivation scores and the corresponding national rank for each patient's residential district, according to the 2000 UK national census. Affluent areas have low scores and high rank; deprived areas have high scores and low rank. The Mann-Whitney U test was used to determine whether there was a statistical difference in age or social status between those patients in the mastectomy only group and those who were reconstructed.
 RESULTS
 50 patients underwent mastectomy only (median age 63.5, IQR 52-72), 30 opted for reconstruction (median age 53.5, IQR 44.5-58). There was a statistically significant difference (at the 95% confidence interval) between the average age of the 2 groups (P=0.0002).
 Median deprivation score for the mastectomy group was 10.4 (6.28-17.84) and for the reconstruction group 9.67 (6.52-17.37). This was not significant (P=0.26).
 Median ranks were 6224 (4008-7525) and 6511 (2502-7213) respectively (P=0.29).
 CONCLUSIONS
 The socio-economic status of patients does not affect their decision on whether or not to undergo post-mastectomy reconstruction. However, younger patients are statistically more likely to opt for a reconstructive procedure.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 5094.

An acute haemolytic transfusion reaction caused by anti-Wr

The Wright (Wr(a)) antigen is found on the red blood cells of approximately 1 : 1000 Caucasians. Anti-Wr(a) has been reported to be present in 1 : 25 to 1 : 100 healthy blood donors and an even higher proportion of hospital patients. Incompatibility due to anti-Wr(a) might therefore be expected to occur in approximately 1 in 50,000 blood transfusions. Reports of haemolytic transfusion reactions (HTR) and haemolytic disease of the newborn due to anti-Wr(a) are, however, rare. We report an acute HTR due to anti-Wr(a) in a 58-year-old man with myelodysplastic syndrome associated with rigors, shortness of breath and a significant rise in serum bilirubin from 16 micromol L(-1) pretransfusion to 110 micromol L(-1) immediately afterwards. This was accompanied by the appearance of bilirubin and urobilinogen in his urine and a fall in haemoglobin of nearly 2 g dL(-1) following the transfusion. Anti-Wr(a) was the only antibody implicated. When tested against the recipients plasma, Wr(a+) panel cells and the transfused unit responsible for the reaction were 2-3+ by indirect antiglobulin test (IAT) and the donation typed as Wr(a+). The recipient had the common Wr(a-) phenotype. The reaction resulted in the patient being admitted to hospital for 2 days. The increasing use of electronic issue may result in more frequent reports of reactions due to anti-Wr(a) using current screening cells.

Granulocyte transfusions for treating infections in patients with neutropenia or neutrophil dysfunction

BACKGROUND

Transfusions of granulocytes have a long history of usage in clinical practice to support and treat severe infection in high risk groups of patients with neutropenia or neutrophil dysfunction. However, there is considerable current variability in therapeutic granulocyte transfusion practice, and uncertainty about the beneficial effect of transfusions given as an adjunct to antibiotics on mortality.

OBJECTIVES

To determine the effectiveness of granulocyte transfusions compared to no granulocyte transfusions for treating infections in patients with neutropenia or disorders of neutrophil function in reducing mortality.

SEARCH STRATEGY

Randomised controlled trials (RCTs) were searched for in the Cochrane Central Register of Controlled Trials (CENTRAL) in 2003. Searching was also undertaken on the OVID versions of Medline and Embase using an RCT search filter strategy.

SELECTION CRITERIA

RCTs involving transfusions of granulocytes, given therapeutically, to patients with neutropenia or disorders of neutrophil dysfunction.

DATA COLLECTION AND ANALYSIS

Two reviewers completed data extraction independently. Relative risk (RR) with 95% confidence intervals (CI) using the random effects model were reported for dichotomous outcomes. Pre-specified subgroup analyses were done and reported eg granulocyte dose.

MAIN RESULTS

Eight parallel RCTs were included with 310 total analysed patient episodes. Different policies were applied for the schedule of transfusion, method of granulocyte procurement and process of donor selection including leucocyte compatibility. Each study used different criteria for neutropenia (range < 0.1 to < 1.0 x 10(9)/L) and definition of infection requiring treatment. For mortality, which was extracted from six trials, the summary RR = 0.64 in favour of transfusion (95% CI 0.33, 1.26), but with evidence of significant statistical heterogeneity (Chi-square 11.3 and I(2) = 56%). The data for the combined RR for mortality for the four studies transfusing higher granulocyte doses greater than 1x10(10) indicated a significant summary RR= 0.37 (95% CI 0.17, 0.82); Chi-square 3.9, I(2) 23%. Data on rates of reversal of infection could be extracted from four studies, and the combined RR was 0.94 (95% CI 0.71, 1.26), again with evidence of heterogeneity. In addition to the observed clinical diversity between all studies, uncertainty about the quantitative and qualitative analyses for these studies is compounded by methodological deficiencies.

AUTHORS' CONCLUSIONS

Currently, there is inconclusive evidence from RCTs to support or refute the generalised use of granulocyte transfusion therapy in the most common neutropenic patient populations, that is caused by myeloablative chemotherapy with or without haematopoietic stem cell support. Contemporary well designed prospective trials are required to evaluate the efficacy of this intervention in these patient populations and to establish definitively whether it has clinical benefit. In such studies, average numbers of collected granulocytes for adults should be (at least) greater than 1x10(10).

Exposure of cardiac fibroblasts to the herbicide nitrofen causes altered interactions with the extracellular matrix

A large proportion of congenital heart defects result from dysmorphogenesis of valvuloseptal precursors, the endocardial cushions. Intrinsic to formation and maturation of these tissues are developmental changes in cell-cell and cell-extracellular matrix interactions. Interactions between cells and the extracellular matrix play critical roles in modulating cellular processes including proliferation, migration, differentiation and even survival. While significant progress is being made in the elucidation of the cellular events involved in valvuloseptal development, little is known regarding how environmental factors may affect this process. Embryonic exposure to the herbicide nitrofen has been shown to result in congenital heart defects associated with altered endocardial cushion formation or maturation. The present studies were performed to begin to address the cellular mechanisms of these nitrofen-induced effects. Heart fibroblasts were isolated and treated with varying doses of nitrofen in vitro. Experiments were performed to determine the effects of this herbicide on important cellular processes including migration, proliferation and apoptosis. These studies illustrated a dose-dependent decrease in collagen gel contraction and proliferation in response to nitrofen. Assays were also performed to determine the effects of nitrofen on fibroblast gene expression. Increased expression of collagen type I and specific integrins were seen following nitrofen exposure. These studies illustrate that nitrofen has direct effects on cardiac fibroblast proliferation and extracellular matrix remodeling, cellular events important in valvuloseptal development.

Diabetic thoracic radiculopathy: an unusual cause of post-thoracotomy pain

Persistent pain is common following thoracotomy. A 64-year-old retired electrician with Type 2 diabetes presented with chest wall and abdominal pain 3 months following video-assisted thoracoscopic surgery (VATS). Postoperatively the patient had suffered pain despite a functioning thoracic epidural catheter. Following investigation, his persistent pain was due to diabetic thoracic radiculopathy (DTR). The disorder is characterized by pain, sensory loss, abdominal and thoracic muscle weakness in patients with diabetes. As in this patient, the pain and sensory loss usually resolve within one year after onset. The disorder may be distinguished from intercostal neuralgia based upon clinical and electromyographic features.

Acute myeloblastic leukaemias of FAB types M6 and M4, with cryptic PML/RARalpha fusion gene formation, relapsing as acute promyelocytic leukaemia M3

Demonstration of either the translocation t(15;17)(q22;q21) or the fusion of PML and RARalpha genes is regarded as diagnostic for acute myeloid leukaemia (AML) of FAB type M3, but has occasionally been seen in other FAB types. We present two such cases. Case 1 presented with FAB type M6 and a complex karyotype involving chromosomes 1, 2, 11 and 17. Bone marrow relapse of FAB type M3 followed autologous bone marrow transplantation. Subsequent marrow dysplasia and an M6 relapse were accompanied by a new cytogenetic clone involving chromosomes X, 2, 4, 6, 7 and 16. Fluorescence in situ hybridization (FISH) of metaphase chromosomes at diagnosis showed insertion of material from chromosome 17 into a 'normal' 15 with juxtaposition of PML and RARalpha. Case 2 presented as AML M4 and relapsed as M3. Cytogenetic analysis at diagnosis and in relapse showed 46,XY,t(15;17)(q22;q11),del(16)(q22). FISH analysis showed this to be a three-way translocation involving chromosomes 15, 16 and 17 again with juxtaposition of PML and RARalpha. Reverse transcription-polymerase chain reaction (RT-PCR) revealed PML/RARalpha fusion at diagnosis, in remission and in first relapse. These examples strengthen the case for RT-PCR screening of all AML patients for these fusion genes.

Practicing physicians' assessments of the impact of their medical-school clinical hospice experience

BACKGROUND

The authors measured the impact of a clinical hospice experience in medical school on present medical practice by surveying former students after graduation.

METHODS AND RESULTS

Of the graduates who apparently received anonymous questionnaires, 46 (71%) completed and returned them. Most were still in residency, and about a third were in private practice. Using a Likert scale, most gave the highest possible rankings in response to questions about how the experience had affected their present day-to-day communication with patients and their working knowledge of pain control, and the general question that asked about understanding quality-of-life issues. Written responses noted positive effects of the experience on the physicians' present practices, including improved knowledge of and attitudes towards dying patients, assessment of the effects of disease on patients and families, and quality-of-life.

CONCLUSIONS

Although course work about death and dying is increasingly encountered in medical-school curricula, an intensive, focused clinical exposure is often lacking. This type of exposure has positive effects on physicians' self-assessments of their knowledge, attitudes, and skills in their present practices.

Micronucleus induction in V79 cells after direct exposure to whole cigarette smoke

Previous investigations on the effects of cigarette smoke on cultured cells have used mainly smoke condensate dissolved in culture medium. A system has been designed which allows direct exposure of cells to fresh cigarette smoke, without an intervening layer of growth medium between the cells and the smoke. Preliminary results have been obtained which demonstrate the viability of the system. V79 cells were cultured on porous membranes (Transwell; Costar). During smoke exposure only the lower surface of each Transwell is supplied with culture medium from the bottom of the culture chambers. In this way the cells had direct contact with the atmosphere at the upper surface and could be exposed directly to the test compound. The constructed exposure system consists of a smoke generator and an exposure unit containing six Transwells, the latter contained in an incubator. Cigarette smoke was generated using a standard 2 s, 35 ml puff once per min. The puff is diluted with conditioned air from the incubator and injected into the exposure unit. Following exposure of the cells to air only for 3 h there was no effect upon V79 cell viability. However, after exposure to smoke containing between 88 and 224 mg/m3 particulate matter, an inhibition of cell proliferation and induction of micronuclei was measured. When a Cambridge filter pad was placed between the cigarette and the cell exposure system to remove particulate matter cell proliferation was also reduced and an increased frequency of micronuclei above the control value was measured.

Covert poisoning with difenacoum: clinical and toxicological observations

1. The coumarin anticoagulant difenacoum was detected by high performance liquid chromatography (HPLC) with multi-wavelength UV detection in plasma from a 41 years old man who presented with a severe deficiency of vitamin K-dependent clotting factors of unknown aetiology. A longitudinal toxicological study of the consequent coagulopathy is described. 2. Plasma concentrations of difenacoum declined from 0.97 to 0.11 mgl-1 in 47 days with a terminal half life of 11.7 days. Rifampacin (300 mg bd) had no apparent effect on the terminal half life of the drug. Subsequently plasma concentrations of difenacoum and descarboxyprothrombin (DCP) unexpectedly increased. 3. Seven months after exposure clotting times were prolonged. The patient continued to have episodes of epistaxis, haematoma, purpurae and bruising and he required frequent treatment with Fresh Frozen Plasma in additional to oral phylloquinone (200 mg day-1). 4. Intermittent and unexpected increases in plasma concentrations of difenacoum and descarboxypro-thrombin suggested that covert, repeated ingestion of the anticoagulant was the most likely cause of the poisoning. The measurement of low concentrations of plasma phylloquinone except following supervised ingestion of the vitamin indicated that as an outpatient, the subject was not compliant with treatment despite his protestations to the contrary. He continued to deny this even when confronted by laboratory findings and at no time did he ever admit to self-poisoning.