Water security in one blue planet: twenty-first century policy challenges for science.

Water-related risks threaten society at the local, national and global scales in our inter-connected and rapidly changing world. Most of the world's poor are deeply water insecure and face intolerable water-related risks associated with complex hydrology. Most of the world's wealthy face lower water-related risks and less complex hydrology. This inverse relationship between hydrological complexity and wealth contributes to a divided world. This must be addressed if global water security is to be achieved. Using a risk-based framework provides the potential to link the current policy-oriented discourse on water security to a new and rigorous science-based approach to the description, measurement, analysis and management of water security. To provide the basis for this science-based approach, we propose an encompassing definition rooted in risk science: water security is a tolerable level of water-related risk to society. Water security policy questions need to be framed so that science can marshal interdisciplinary data and evidence to identify solutions. We join a growing group of scientists in asserting a bold vision for science leadership, calling for a new and comprehensive understanding of the planet's water system and society's water needs.

Evaluation of a new rapid anti-HbF FITC assay, Trillium QuikQuant, for detection and quantitation of foetomaternal haemorrhage.

INTRODUCTION: This study evaluated a new product for flow cytometric foetomaternal haemorrhage (FMH) quantitation, Trillium QuikQuant anti-HbF FITC kit (Trillium Diagnostics, USA), in comparison with the Millipore anti-HbF FITC method. METHODS: Blood from 67 antenatal or postpartum RhD-negative women together with 108 samples spiked with 0.2%, 0.4%, 0.6%, 2%, 4%, 5%, 6%, 8% and 10% of foetal red cells were analysed by both methods. RESULTS: Results for both methods were linear to 10% foetal red cells. Analysis using the Wilcoxon test found that there was no difference between the paired results of Trillium QuikQuant and the expected values of the spiked samples (P = 0.48). In contrast, Millipore anti-HbF FITC gave statistically higher results compared with both the expected values and Trillium QuikQuant anti-HbF FITC (P = 0.0003 and P < 0.0001, respectively). The Bland-Altman plot for Trillium QuikQuant showed a mean difference of only 0.06% below the expected values, whilst Millipore was 0.13% above. The analysis time with Trillium QuikQuant was approximately 40 min, requiring significantly less hands-on time than the Millipore method that required an additional four wash steps. CONCLUSION: Trillium QuikQuant is a new precise, accurate and rapid flow cytometric kit method for the quantitation of FMH in both the antenatal and postpartum period.

Iron studies and red cell transfusion in cardiothoracic and orthopaedic surgical patients: a retrospective audit at a tertiary hospital.

BACKGROUND AND OBJECTIVES: Preoperative diagnosis and treatment of anaemia are important to minimize adverse postoperative outcomes. This audit reviewed red cell transfusion practice, degree of anaemia, iron deficiency anaemia (IDA) and chronic disease or anaemia of inflammation (AI) in cardiothoracic and orthopaedic surgical patients who had available iron studies. MATERIALS AND METHODS: A total of 178 consecutive cardiothoracic and orthopaedic surgical patients with available iron studies were retrospectively reviewed. RESULTS: Of patients, 36·5% had preoperative iron studies. However, 63·2% males and 45·3% females with postoperative iron studies presented with anaemia; 38·5% patients with preoperative iron studies had AI; 21·5% IDA; 23·1% normal. For patients with iron studies requested within the first two postoperative intervals (≤ 5 days and 6 ≤ 10 days) 73·8% and 63·6%, respectively, had AI; few had classical IDA or were normal, and 51·5% patients transfused postsurgery had a discharge Hb ≥ 110 g/l. Restricting the discharge Hb to 90 or 100 g/l may have eliminated postsurgical transfusion in 14·8-42·6% patients. CONCLUSION: Iron studies were more commonly requested postoperatively despite many being anaemic at admission. A higher proportion of patients with postoperative iron studies had AI, and few had classical IDA or normal iron parameters, suggesting a transient inflammatory effect of surgery. This may mask underlying IDA or normal iron parameters and affect treatment. Preadmission assessment, including iron status, should be emphasized allowing diagnosis and correction of presurgical anaemia with treatment modalities other than red cell transfusion. In the postsurgical setting, consideration of a restrictive transfusion regimen sufficient to alleviate a patient's clinical symptoms would ensure that this valuable resource is appropriately used.

Transfusion-related acute lung injury in a neutropenic patient.

Transfusion-related acute lung injury (TRALI) is a leading cause of transfusion related morbidity and mortality. Current concepts regarding the pathogenesis of this disorder imply a "two-hit" model in which neutrophils are sequestered in the pulmonary capillary bed, and subsequently activated by substances in the transfused blood product. We report a case of TRALI in a patient with neutropenia and discuss the possible factors contributing to the respiratory symptoms in this patient. We also emphasise the importance of recognising mild cases of TRALI in order to investigate the implicated donor/s appropriately, and to minimise the risk for more severe episodes in other patients.

Red cell transfusion for iron-deficiency anaemia: a retrospective audit at a tertiary hospital.

BACKGROUND AND OBJECTIVES: The role of red cell transfusion in the management of iron-deficiency anaemia is controversial. This audit was undertaken to monitor the overall transfusion practices of patients admitted to a 600-bed acute tertiary hospital with confirmed severe iron deficiency. MATERIALS AND METHODS: Data from 615 consecutive patients with iron deficiency and no evidence of iron therapy during the period from 1 March 2001 to 30 September 2005 were retrospectively reviewed. RESULTS: Of the 615 iron-deficient patients, 39.2% were transfused. Overall transfused patients were significantly older (mean 73 years old vs. 53 years old; P < 0.0001) with more comorbidities than those not transfused. The pretransfusion haemoglobin (Hb) was < 90 g/l in 92.5% compared to 15.4% of patients not transfused. The post-transfusion Hb was > or = 100 g/l in 75.0% of patients and > or = 110 g/l in 44.2%. Although currently rare (2.5% patients) our speculative data suggest that single red cell transfusions may be appropriate in < or = 29% of patients if restrictive thresholds were adopted. CONCLUSION: Red cell transfusions are commonly administered to elderly patients with severe iron-deficiency anaemia. They may be necessary to alleviate severe morbidity until the time at which iron therapy becomes clinically effective. However, greater emphasis should be given to restrictive transfusion strategies and dosing. Transfusion of single red cell units followed by clinical assessment will determine the need for subsequent units and ensure that this valuable resource is appropriately used.

The utility of an automated electronic system to monitor and audit transfusion practice.

BACKGROUND AND OBJECTIVES: Transfusion laboratories with transfusion committees have a responsibility to monitor transfusion practice and generate improvements in clinical decision-making and red cell usage. However, this can be problematic and expensive because data cannot be readily extracted from most laboratory information systems. To overcome this problem, we developed and introduced a system to electronically extract and collate extensive amounts of data from two laboratory information systems and to link it with ICD10 clinical codes in a new database using standard information technology. MATERIALS AND METHODS: Three data files were generated from two laboratory information systems, ULTRA (version 3.2) and TM, using standard information technology scripts. These were patient pre- and post-transfusion haemoglobin, blood group and antibody screen, and cross match and transfusion data. These data together with ICD10 codes for surgical cases were imported into an MS ACCESS database and linked by means of a unique laboratory number. Queries were then run to extract the relevant information and processed in Microsoft Excel for graphical presentation. We assessed the utility of this data extraction system to audit transfusion practice in a 600-bed adult tertiary hospital over an 18-month period. RESULTS: A total of 52 MB of data were extracted from the two laboratory information systems for the 18-month period and together with 2.0 MB theatre ICD10 data enabled case-specific transfusion information to be generated. The audit evaluated 15,992 blood group and antibody screens, 25,344 cross-matched red cell units and 15,455 transfused red cell units. Data evaluated included cross-matched to transfusion ratios and pre- and post-transfusion haemoglobin levels for a range of clinical diagnoses. Data showed significant differences between clinical units and by ICD10 code. CONCLUSION: This method to electronically extract large amounts of data and linkage with clinical databases has provided a powerful and sustainable tool for monitoring transfusion practice. It has been successfully used to identify areas requiring education, training and clinical guidance and allows for comparison with national haemoglobin-based transfusion guidelines.

Effects of treated and untreated depressive symptoms on highly active antiretroviral therapy use in a US multi-site cohort of HIV-positive women.

This study examines the effects of treated and untreated depressive symptoms on the likelihood of utilization of highly active antiretroviral therapy (HAART) among a multi-site cohort of HIV-infected women who screened positive for probable depression. Data were collected biannually from 1996 through 2001 in a prospective cohort study. Random-effects regression analysis was used to estimate the longitudinal effects of mental health treatment on the probability of HAART utilization, controlling for clinical indicators (CD4 count, viral load), demographic features (race/ethnicity, income), and behavioural factors (recent crack, cocaine, or heroin use). Use of antidepressants plus mental health therapy, or use of mental health therapy alone significantly increased the probability of HAART utilization, compared to receiving no depression treatment. Use of antidepressants alone did not differ significantly from receiving no depression treatment. African American women and those who used crack, cocaine, or heroin also were less likely to use HAART. These findings suggest that efforts to enhance depressed women's access to psychopharmacologic treatment and therapy may increase their use of the most effective HIV therapies.

The role of RhD agglutination for the detection of weak D red cells by anti-D flow cytometry.

Anti-D flow cytometry is an accurate method for quantifying feto-maternal haemorrhage (FMH). However, weak D red cells with <1000 RhD sites are not detectable using this methodology but are immunogenic. As quantitation of RhD sites is not practical, an alternative approach is required to identify those weak D fetal red cells where anti-D flow cytometry is inappropriate. We describe a simple algorithm based on RhD agglutination and flow cytometry peak separation. All weak D (n = 34) gave weak agglutination with RUM-1 on immediate spin (grading

Case report: immune anti-D stimulated by transfusion of fresh frozen plasma.

FFP has occasionally been reported to generate an immune response to RBC antigens (e.g., anti-D and anti-Fya). The Council of Europe requires that each unit of FFP have less than 6 x 10(9)/L RBCs. However, there is considerable variation internationally in the method of production and the level and assessment of RBC contamination of FFP. This study reports the case of a 63-year-old group B, D- man who received multiple transfusions of D- blood products over a 4-month period. Seven months later the patient's antibody screen remained negative and he was transfused with seven units of D- RBCs and six units of FFP, four of which were D+. Two months later anti-D, -E, and -K were detected in his plasma. Although the anti-E and anti-K could have resulted from transfusion of antigen-positive RBCs, the anti-D could have resulted only from transfusion of the D+ FFP. The D status of FFP is currently not considered when selecting products for transfusion even though the D antigen is highly immunogenic and the level of RBC contamination of FFP is not always known. This case highlights that transfusion of FFP is a stimulus for RBC antibodies and that when a patient has had a recent transfusion of FFP, consideration should be given to obtaining a sample for pretransfusion testing within 3 days before a scheduled RBC transfusion. In addition, the D status of FFP should be considered before administering FFP to premenopausal D- women.

Bioartificial organ grafts: a view at the beginning of the third millennium.

An immunoisolated collection of cells, which communicate and exchange essential factors, co-stimulatory hormones, as well as providing immunoprotection and immunomodulation, can be prepared, given existing scientific and medical know-how, within two decades. These "Bioartificial Organ Grafts" have advantages relative to isolated cell therapies, including beta-cell encapsulation for diabetes treatment, and xenotransplantation, which has a de facto moratorium. This paper documents that the majority of the research for the bioartificial organ grafts has been concluded, with the remaining hurdles minimum in comparison. The use of co-encapsulation and the induction of local immune-privilege will provide a more sensitive humoral hormonal response and graft survival, without systemic immunosuppression. A call for the staged implementation of bioartificial organ grafts, based on the best available medical practice, materials, tissue and technology available, is advocated. The implementation of bioartificial organ grafts can begin within the next two years, based on allografts succeeded by genetically modified human tissue, without the need to pass through a xenograft stage.

Beyond the river: the benefits of cooperation on international rivers.

Management of international rivers can be a cause of conflict or cooperation between states. Benefits of cooperation include benefits to the ecological river, the economic river, the political river and the catalytic river. The challenges are in balancing the trade-offs between states.

Wettable phosphorylcholine-containing polymers useful in blood filtration.

The use of phosphorylcholine (PC)-containing polymers has long been acknowledged as a method to improve the haemocompatibility of blood contacting devices. Such polymers were investigated for coating leukocyte filters, as a means of preserving precious platelet numbers and function. It was demonstrated that by use of such coated filters, the platelet recovery could be significantly increased by some 30%. This was however, balanced by a decrease in the leukocyte removal efficiency of the filter. More problematic however, was the poor critical wetting surface tension (CWST) of the filter (45 mNm(-1)). This was due to the surface expression of the hydrophobic groups of the polymer in air. In order to obtain a filter that could be immediately wetted by the blood and hence remove the need for any detrimental priming of the filter, the PC polymer was modified in order to reduce its hydrophobic content. A series of new cross-linkable polymers was developed that contained other hydrophilic monomers, yet could film-form to produce a coating stable to fluid contact. These materials demonstrated the required wetting characteristics (a CWST of >78 mNm(-1)), whilst retaining the excellent blood-contacting properties.

Comparison of low ionic diluents for use with the Diamed antiglobulin gel test.

Microtube column systems, although widely used in transfusion serology for the detection of red cell antibodies, may not detect weak Fy(a), Jk(a), S and K antibodies. A number of low ionic diluents are used to shorten the incubation time required for red cell antibody detection in the antiglobulin test. However, there are no published reports to show whether these low ionic diluents vary in their ability to detect red cell antibodies using microcolumn detection systems. Three low ionic diluents, Diamed ID-CellStab, Diamed ID-Diluent2 and an in-house produced low ionic strength solution (LISS), were assessed using the Diamed-ID LISS/Coombs microtube column system (in accordance with the manufacturer's instructions), to ascertain whether the choice of diluent influences red cell antibody detection. Two hundred and seventy patient samples were screened for red cell antibodies. The reaction strength was increased in 50% of the samples with detectable red cell antibodies using LISS as the diluent compared with ID-CellStab. Of the 51 red cell antibodies directed against Rhesus, Duffy, Kidd or Kell antigens, 21% reacted more strongly in LISS compared with Diamed ID-CellStab with a difference in grading of > or =1. Minimal disparity was found between ID-Diluent2 and LISS. Biochemical analysis of pH, osmolality, sodium, potassium and phosphate were comparable for ID-CellStab, ID-Diluent2 and LISS. Measurement of conductivity in each low ionic diluent was performed as a measure of ionic strength in the final reactant mix, as the same amount of low ionic diluent was used for each test. The conductivity was 3 x 5 mS cm for LISS and ID-Diluent2, and 5 x 8 mS cm for ID-CellStab; the acceptable range being 3 x 7 +/- 0 x 3 mS cm as cited in the Guidelines for the Blood Transfusion Services in the United Kingdom. This evaluation suggests that ID-CellStab is a suboptimal low ionic diluent for red cell antibody detection using Diamed-ID LISS/Coombs gel cards. The poorer performance of ID-CellStab compared with LISS may be explained by its higher ionic strength.

Vocational outcomes among formerly homeless persons with severe mental illness in the access program.

OBJECTIVE: This study examined the vocational outcomes of 4,778 formerly homeless individuals with severe mental illness who were enrolled in the Access to Community Care and Effective Services and Support (ACCESS) program, a multisite demonstration project designed to provide services to this population. METHODS: Participants were interviewed at the time of enrollment and again three months and 12 months later by trained researchers who were not part of the treatment team to determine their employment status. At 12 months, participants were also asked about the types of services they had received during the past 60 days. Multiple logistic regression analysis was used to predict employment at 12 months. RESULTS: ACCESS participants reported receiving relatively few job-related services. Nonetheless, modest but significant increases occurred between baseline and three months and between three months and 12 months in the total proportion of participants who were employed and who were employed full-time and in hourly earnings and estimated monthly earnings. The number of hours worked per week increased significantly between three months and 12 months. When the analysis controlled for site, study condition (whether the ACCESS site received or did not receive extra funds to improve service integration), minority status, addiction treatment, and mental health treatment, participants who were employed at 12 months were more likely to have received job training and job placement services. CONCLUSIONS: Programs that work with homeless mentally ill persons may better serve their clients by placing as great an emphasis on providing employment services as on providing housing and clinical treatment.

HPA-1, 3, 5 genotyping to establish a typed platelet donor panel.

Platelet antigen typing of blood donors is not routinely performed. Usually, ABO-matched platelets are transfused. In situations where the recipient has a human platelet-associated (HPA) antibody resulting in refractoriness to platelet transfusions, post-transfusion purpura or neonatal alloimmune thrombocytopenia, HPA-typed platelets may be required. Having a panel of HPA-typed donors would be helpful. This study utilised PCR-RFLP and PCR-SSP methods to determine the HPA-1, 3, 5 genotypes of 1,000 blood donors to establish a panel of HPA homozygous donors who could donate platelets for patients with anti-HPA-antibodies. The study demonstrates the HPA genotype frequencies in a Western Australian blood donor population and has identified donors who are homozygous for the "aa" and "bb" genotypes for HPA-1, 3 and 5. The Australian Red Cross Blood Service-NW Region can now use these data to develop a panel of HPA-1, 3 and 5 "aa" and "bb" homozygous platelet donors, which can be accessed for patients with HPA antibodies requiring platelet transfusion.

Detection of massive transplacental haemorrhage by flow cytometry.

Flow cytometry has been shown to be a more accurate and sensitive method than the Kleihauer-Betke test for the measurement of feto-maternal haemorrhage in Rh(D) incompatibility. This report describes the successful use of flow cytometry to detect and monitor the management of a massive transplacental haemorrhage (105 ml) of fetal Rh(D) positive cells in a Rh(D) negative woman. The report highlights the accuracy and reproducibility of the test and the stability of a blood sample when transferred 596 kilometres to a central testing facility.

Monocyte activation in platelet concentrates.

BACKGROUND AND OBJECTIVES: Cytokines in platelet concentrates contribute to febrile transfusion reactions. Activated monocytes are a major source of inflammatory cytokines, however the role of monocytes in cytokine production in platelet concentrates has not been clarified. This study undertook to quantitate monocytes, determine whether monocyte activation occurs and identify an association with IL-6 and IL-1beta concentrations in platelet concentrates. MATERIALS AND METHODS: 17 platelet concentrates were analysed for total leucocyte and monocyte counts, CD14 and CD16 monocyte-associated antigen expression and IL-1beta and IL-6 measurements on days 1, 2, 3, 4 and 5. RESULTS: Monocytes in all platelet concentrates expressed increased levels of CD14 and CD16 from day 1 of storage. 10/17 platelet concentrates had elevated IL-6 levels by day 3. Platelet concentrates with IL-6 levels above 15 pg/ml on day 5 had monocyte counts between 0.14 and 15.6 x 10(6)/unit on day 1, while those with IL-6 levels below 15 pg/ml had low monocyte counts of < 0.01 to 1.2 x 10(6)/unit on day 1. CONCLUSION: Monocytes present in platelet concentrates exhibit features of activation. Monocyte activation is present following the preparation of platelet concentrates, implicating the manufacturing process in its development. Increased IL-6 and IL-1beta levels during platelet concentrate storage are commonly associated with a higher monocyte count. However, no direct association could be identified between the extent of monocyte activation and the level of cytokine release.