A prospective, randomized clinical trial of universal WBC reduction

BACKGROUND

Recipient exposure to allogeneic donor WBCs results in transfusion complications for selected populations of recipients. Whether or not WBC reduction should be universally applied is highly controversial.

STUDY DESIGN AND METHODS

In a general hospital, a randomized, controlled clinical trial of conversion to universal WBC reduction was conducted. Patients (11%) with established medical indications for WBC-reduced blood were not eligible. All other patients who required transfusion were assigned at random to receive either unmodified blood components or stored WBC-reduced RBCs and platelets. Analysis for each patient was restricted to the first hospitalization.

RESULTS

All eligible patients (n = 2780) were enrolled. Three specified primary outcome measures were not different between the two groups: 1) in-hospital mortality (8.5% control; 9.0% WBC-reduced; OR, 0.94 [95% CI, 0.72-1.22]; p = 0.64); 2) hospital length of stay (LOS) after transfusion (median number of days, 6.4 for control and 6.3 for WBC-reduced; p = 0.21); and 3) total hospital costs (median, $19,500 for control and $19,200 for WBC-reduced, p = 0.24). Secondary outcomes (intensive care LOS, postoperative LOS, antibiotic usage, and readmission rate) were not different between the two groups. Subgroup analysis based on patient age, sex, amount of blood transfused, or category of surgical procedure showed no effect of WBC reduction. Patients who received WBC-reduced blood had a lower incidence of febrile reactions (p = 0.06).

CONCLUSION

A beneficial effect of conversion from selective to universal WBC reduction was not demonstrated.

Autologous platelet-rich plasma isolated using the Haemonetics Cell Saver 5 and Haemonetics MCS+ for the preparation of platelet gel

BACKGROUND AND OBJECTIVES

We compared three methods of isolating platelet-rich plasma (PRP) using the Haemonetics Cell Saver 5 and one method of isolating PRP by plateletpheresis using the Haemonetics MCS+. PRP contains both platelets and fibrinogen, which are used in the preparation of haemostatic agents.

MATERIALS AND METHODS

When the Haemonetics Cell Saver 5 was used, 500 ml of blood from each of 30 normal volunteer donors was collected into 70 ml of citrate-phosphate-dextrose (CPD) anticoagulant. In a further 14 normal volunteers, the Haemonetics MCS+ was used to isolate PRP by plateletpheresis using an acid citrate dextrose (ACD) to blood ratio of 1 : 9. In a separate study, CPD-anticoagulated whole blood from another 30 volunteers was used for measurement of fibrinogen levels in the plasma and cryoprecipitate.

RESULTS

A larger volume of PRP can be collected using the Haemonetics Cell Saver 5 than by using the Haemonetics MCS+. The platelet concentration and the total number of platelets were higher in the PRP isolated using the Haemonetics MCS+ than in the PRP isolated by the three methods used with the Haemonetics Cell Saver 5, with differences in platelet concentration and PRP volume among the four methods. The mean fibrinogen level in the plasma was 253 mg % +/- 47 (SD) and in the cryoprecipitate was 1085 mg % +/- 304 (SD).

CONCLUSIONS

The most appropriate method of PRP isolation for preparation of platelet gel is dependent upon the specific surgical procedure to be undertaken and the patient's needs.

A multicenter study of in vitro and in vivo values in human RBCs frozen with 40-percent (wt/vol) glycerol and stored after deglycerolization for 15 days at 4 degrees C in AS-3: assessment of RBC processing in the ACP 215

BACKGROUND

The FDA has approved the storage of frozen RBCs at -80 degrees C for 10 years. After deglycerolization, the RBCs can be stored at 4 degrees C for no more than 24 hours, because open systems are currently being used. Five laboratories have been evaluating an automated, functionally closed system (ACP 215, Haemonetics) for both the glycerolization and deglycerolization processes.

STUDY DESIGN AND METHODS

Studies were performed at three military sites and two civilian sites. Each site performed in vitro testing of 20 units of RBCs. In addition, one military site and two civilian sites conducted autologous transfusion studies on ten units of previously frozen, deglycerolized RBCs that had been stored at 4 degrees C in AS-3 for 15 days. At one of the civilian sites, 10 volunteers received autologous transfusions on two occasions in a randomized manner, once with previously frozen RBCs that had been stored at 4 degrees C in AS-3 for 15 days after deglycerolization and once with liquid-preserved RBCs that had been stored at 4 degrees C in AS-1 for 42 days.

RESULTS

The mean +/- SD in vitro freeze-thaw-wash recovery value was 87 +/- 5 percent; the mean +/- SD supernatant osmolality on the day of deglycerolization was 297 +/- 5 mOsm per kg of H(2)O, and the mean +/- SD percentage of hemolysis after storage at 4 degrees C in AS-3 for 15 days was 0.60 +/- 0.2 percent. The paired data from the study of 10 persons at the civilian site showed a mean +/- SD 24-hour posttransfusion survival of 76 +/- 6 percent for RBCs that had been stored at 4 degrees C for 15 days after deglycerolization and 72 +/- 5 percent for RBCs stored at 4 degrees C in AS-1 for 42 days. At the three sites at which 24-hour posttransfusion survival values were measured by three double-label procedures, a mean +/- SD 24-hour posttransfusion survival of 77 +/- 9 percent was observed for 36 autologous transfusions to 12 females and 24 males of previously frozen RBCs that had been stored at 4 degrees C in AS-3 for 15 days after deglycerolization.

CONCLUSION

The multicenter study showed the acceptable quality of RBCs that were glycerolized and deglycerolized in the automated ACP 215 instrument and stored in AS-3 at 4 degrees C for 15 days.

In vivo survival of apheresis RBCs, frozen with 40-percent (wt/vol) glycerol, deglycerolized in the ACP 215, and stored at 4 degrees C in AS-3 for up to 21 days

BACKGROUND

The FDA has approved the storage of frozen RBCs at -80 degrees C for 10 years and the postwash storage at 4 degrees C for no more than 24 hours. The 4 degrees C postwash storage period is limited to 24 hours, because the current deglycerolization systems are functionally open systems.

STUDY DESIGN AND METHODS

Two units of RBCs were collected from each of 13 healthy male volunteers. The RBCs were collected in CP2D by the FDA-approved protocol for an automated apheresis device (MCS, LN8150, Haemonetics) and were stored at 4 degrees C in AS-3 for 6 days. Using a single disposable glycerolization set in an automated, functionally closed system (ACP 215, Haemonetics) each unit was transferred to a 1000-mL PVC plastic bag and glycerolized to a concentration of 40-percent (wt/vol) glycerol and frozen at -80 degrees C. A single disposable deglycerolization set in the ACP 215 was used to deglycerolize the 2 units from the same donor. The deglycerolized RBCs were stored at 4 degrees C in AS-3 for as long as 21 days.

RESULTS

The mean +/- SD freeze-thaw-wash recovery value was 89.4 +/- 3 percent. The residual hemolysis in the RBCs stored at 4 degrees C in AS-3 for 21 days after deglycerolization was 0.9 +/- 0.2 percent, and the units were negative for both aerobic and anaerobic bacteria. The mean Nageotte WBC count was 9 x 10(6) per unit. When the deglycerolized RBCs were given as an autologous transfusion after storage at 4 degrees C in AS-3 for the 7- to 18-day period, the mean +/- SD 24-hour posttransfusion survival was 77 +/- 7 percent, and the index of therapeutic effectiveness was 69 +/- 8 percent.

CONCLUSION

Two units of human RBCs collected from a single donor by apheresis in the MCS using an LN8150 set can be glycerolized sequentially with a single disposable set and deglycerolized sequentially with another single disposable set in the ACP 215. The previously frozen RBCs stored in AS-3 for 7 to 18 days at 4 degrees C had acceptable hemolysis and an acceptable mean 24-hour posttransfusion survival value and index of therapeutic effectiveness.

Effect of 24-hour whole-blood storage on plasma clotting factors

BACKGROUND

The current requirements for the preparation of fresh-frozen plasma within 8 hours of whole-blood collection were designed to maintain clotting factor activities. These requirements, however, limit the production of fresh-frozen plasma in a large blood center. There are few data on the effect of the extension of CPD whole-blood storage to 24 hours on clotting factor activity.

STUDY DESIGN AND METHODS

A 500-mL unit of whole blood was collected from 10 volunteer donors. At 1 hour after collection, a plasma sample was separated by centrifugation, and each unit was equally divided into 2 half-units, with 1 half-unit stored at 4 degrees C (range, 1-6 degrees C) and 1 half-unit stored at 22 degrees C (range, 20-24 degrees C) for 8 hours after collection. Each half-unit was then placed at 4 degrees C for further storage for 16 hours. At 8 and 24 hours after collection, plasma samples were separated from each half-unit. All plasma samples were frozen at -18 degrees C. Factors V, VII, VIII, and X; fibrinogen; antithrombin III; protein C; and protein S were measured.

RESULTS

No significant changes were noted in factors V, VII, and X; fibrinogen; antithrombin III; protein C; and protein S over the 24-hour storage period. Factor VIII in both half-units was significantly reduced, by 13 percent, from the baseline sample as compared to the level in the 8-hour storage sample (p<0.05). Factor VIII was further reduced by 15 to 20 percent after the 24-hour storage period (p<0.05).

CONCLUSION

The coagulation factor activity for all factors measured, with the exception of factor VIII, showed no significant change over the 24-hour storage period. Factor VIII was significantly decreased by 13 percent in 8-hour storage and by an additional 15 to 20 percent in 24-hour storage. For clinical situations not requiring the replacement of factor VIII only, 24-hour frozen plasma has properties comparable to those of fresh-frozen plasma.

The receptor Msn5 exports the phosphorylated transcription factor Pho4 out of the nucleus

The movement of many transcription factors, kinases and replication factors between the nucleus and cytoplasm is important in regulating their activity. In some cases, phosphorylation of a protein regulates its entry into the nucleus; in others, it causes the protein to be exported to the cytoplasm. The mechanism by which phosphorylation promotes protein export from the nucleus is poorly understood. Here we investigate how the export of the yeast transcription factor Pho4 is regulated in response to changes in phosphate availability. We show that phosphorylation of Pho4 by a nuclear complex of a cyclin with a cyclin-dependent kinase, Pho80-Pho85, triggers its export from the nucleus. We also find that the shuttling receptor used by Pho4 for nuclear export is the importin-beta-family member Msn5, which is required for nuclear export of Pho4 in vivo and binds only to phosphorylated Pho4 in the presence of the GTP-bound form of yeast Ran in vitro. Our results reveal a simple mechanism by which phosphorylation can control the nuclear export of a protein.

Pointed, an ETS domain transcription factor, negatively regulates the EGF receptor pathway in Drosophila oogenesis

Spatially regulated activation of the Drosophila epidermal growth factor (EGF) receptor by its ligand, Gurken, is required for establishment of the dorsal/ventral axis of the oocyte and embryo. During mid-oogenesis, Gurken is concentrated at the dorsal-anterior of the oocyte and is thought to activate the EGF receptor pathway in adjacent follicle cells. In response to this signal, dorsal follicle cell fate is determined. These cells further differentiate into either appendage-producing or midline cells, resulting in patterning in the dorsal follicle cell layer. We show here that Pointed, an ETS transcription factor, is required in dorsal follicle cells for this patterning. Loss of pointed results in the loss of midline cells and an excess of appendage-forming cells, a phenotype associated with overactivation of the EGF receptor pathway in the dorsal region. Overexpression of pointed leads to a phenotype similar to that generated by loss of the EGF receptor pathway. This suggests that Pointed normally down-regulates EGF receptor signaling in the midline to generate patterning in the dorsal region. Interestingly, pointed expression is induced by the EGF receptor pathway. These data indicate a novel antagonistic function for Pointed in oogenesis; in response to activation of the EGF receptor, pointed is expressed and negatively regulates the EGF receptor pathway, possibly by integrating information from a second pathway.

Regulation of PHO4 nuclear localization by the PHO80-PHO85 cyclin-CDK complex

PHO4, a transcription factor required for induction of the PHO5 gene in response to phosphate starvation, is phosphorylated by the PHO80-PHO85 cyclin-CDK (cyclin-dependent kinase) complex when yeast are grown in phosphate-rich medium. PHO4 was shown to be concentrated in the nucleus when yeast were starved for phosphate and was predominantly cytoplasmic when yeast were grown in phosphate-rich medium. The sites of phosphorylation on PHO4 were identified, and phosphorylation was shown to be required for full repression of PHO5 transcription when yeast were grown in high phosphate. Thus, phosphorylation of PHO4 by PHO80-PHO85 turns off PHO5 transcription by regulating the nuclear localization of PHO4.

Functional domain analysis of glass, a zinc-finger-containing transcription factor in Drosophila

The glass gene is required for proper photo-receptor differentiation during development of the Drosophila eye glass codes for a DNA-binding protein containing five zinc fingers that we show is a transcriptional activator. A comparison of the sequences of the glass genes from two species of Drosophila and a detailed functional domain analysis of the Drosophila melanogaster glass gene reveal that both the DNA-binding domain and the transcriptional-activation domain are highly conserved between the two species. Analysis of the DNA-binding domain of glass indicates that the three carboxyl-terminal zinc fingers alone are necessary and sufficient for DNA binding. We also show that a deletion mutant of glass containing only the DNA-binding domain can behave in a dominant-negative manner both in vivo and in a cell culture assay that measures transcriptional activation.

The activities of two Ets-related transcription factors required for Drosophila eye development are modulated by the Ras/MAPK pathway

We show that the activities of two Ets-related transcription factors required for normal eye development in Drosophila, pointed and yan, are regulated by the Ras1/MAPK pathway. The pointed gene codes for two related proteins, and we show that one form is a constitutive activator of transcription, while the activity of the other form is stimulated by the Ras1/MAPK pathway. Mutation of the single consensus MAPK phosphorylation site in the second form abrogates this responsiveness. yan is a negative regulator of photoreceptor determination, and genetic data suggest that it acts as an antagonist of Ras1. We demonstrate that yan can repress transcription and that this repression activity is negatively regulated by the Ras1/MAPK signal, most likely through direct phosphorylation of yan by MAPK.

Expression of Drosophila glass protein and evidence for negative regulation of its activity in non-neuronal cells by another DNA-binding protein

The glass gene encodes a DNA-binding zinc-finger protein required for the development of Drosophila photoreceptor cells and which appears to regulate a number of genes specifically expressed in photoreceptors. We have generated monoclonal antibodies to Glass and used them to examine Glass distribution during development. Glass is expressed in all cell types of the developing eye and in all other organs that contain photoreceptor cells in Drosophila, including a small number of cells in the brain. We altered the normal pattern of glass expression by placing the gene under the control of the hsp70 promoter. Our results suggest that nonphotoreceptor cells are restricted in their response to Glass expression. In an effort to discover the mechanism of this restriction, we examined the expression of a number of reporter gene constructs. Our results suggest that nonsensory cells are unable to express certain reporter constructs in response to Glass expression because another DNA-binding factor represses Glass activity in nonsensory cells.

Formation of lentivirus particles by mammalian cells infected with recombinant fowlpox virus

Recombinant fowlpox viruses (FPV) containing the env or gag-pol genes of simian immunodeficiency virus from macaques (SIVmac) were constructed. The env, gag, and pol-encoded polypeptides were efficiently expressed and processed in avian cells productively infected with FPV as well as in mammalian cells, in which FPV infection is abortive. In addition, the recombinant FPV expressing the gag-pol genes directed the formation of defective, lentivirus-like particles which were released into the culture medium of infected cells. Coinfection of cells with the env and gag-pol recombinant viruses resulted in the generation of particles containing SIVmac envelope glycoprotein. The applications of this system to vaccine development are discussed.

Family screening for duplex kidneys

Family screening was offered to the relatives of 57 patients with duplex renal systems and this resulted in the detection of another 37 cases. A further 5 first degree relatives had abnormal intravenous urography, so that 25% of the screened relatives had significant renal abnormalities. It is suggested that there may be a place for screening the whole family if renal tract duplex is detected.

Physiology of "mutans-like" Streptococcus ferus from wild rats

Strains of Streptococcus ferus isolated from the oral cavities of wild rodents inhabiting sucrose-rich and sucrose-poor environments have many traits in common with the "mutans" streptococci. Thus, S. ferus HD3 and 8S1, like cariogenic S. sobrinus 6715-13, from adherent, alpha (1 leads to 3) glucopyranosyl-glucose linkage-rich, plaquelike deposits in vitro and in vivo through the action of constitutive glucosyltransferase(s) enzymes on sucrose, produce and degrade intracellular polysaccharide, produce short-chain fatty acids from the catabolism of mono- and disaccharides, carry the c antigen of S. mutans, and penetrate, persist, and proliferate in a sucrose-augmented fashion in the oral cavities of specific-pathogen-free rodent caries models. However, unlike infection with common S. mutans, infection with tested S. ferus strains does not cause caries. This avirulence appeared to result more from the reduced aciduricity of S. ferus than from differences in glucosyltransferase complements. Studies showed that despite generally similar growth rates and extracellular glucan syntheses, the acidogenic metabolism of S. ferus was more inhibited by declining environmental pH than was cariogenic S. sobrinus 6715-13 and that, in vitro, less hydroxyapatite was solubilized by S. ferus metabolic end products. The physiology of these S. ferus strains demonstrated that, in addition to plaque formation and acid production, acid tolerance was crucial to the carious process.

Alpha-aminoadipic aciduria: chemical and enzymatic studies

A new case of alpha-aminoadipic aciduria had an apparent immunodeficiency and died at the age of 4 months. The urine contained large amounts of alpha-aminoadipate and smaller quantities of alpha-keto- and alpha-hydroxyadipate. Post mortem, the highest concentrations of alpha-aminoadipate were found in liver and kidney. Enzymatic studies on liver and cultured fibroblasts failed to demonstrate the expected deficiency of alpha-amino-adipate aminotransferase, a result perhaps explicable by the presence of cytoplasmic aminotransferase activity.

An electrophysiological investigation of skeletal muscle in human chronic Chagas' disease

An electrophysiological study has been made of the thenar, hypothenar, soleus and extensor digitorum brevis muscles and their inervation in 90 patients with chronic Chagas' disease. Some of them showed a reduced number of functional motor units with increased size of many of the surviving units. No decremental muscle response was found to repetitive nerve stimulation. Motor and sensory conduction velocities as well as motor terminal latencies were on the normal range. These findings suggested that the muscle changes resulted from a primary defect of the alpha spinal motoneurone soma.

Turner's infantile phenotype

Turner's infantile phenotype is a term used to describe infants with stigmata suggestive of Turner's syndrome. These include brawny oedema of the feet, loose neck folds, and a characteristic facies. Ten cases are described in this report. Four of these had a similar facial appearance and three had serous effusions. Two of the latter died and at necropsy no cardiac, vascular, or renal cause for the effusions was found, but the gonads in each were macroscopically reduced in size and microscopically were grossly abnormal.