Fatal Parastrongylus dujardini infection in captive callitrichids.

Intravascular nematodes were considered the cause of death of 14 captive callitrichids. All animals were captive born at zoos in France and died with little or no premonitory signs of disease. No consistent gross lesions were observed at necropsy, although in certain cases intracardiac adult parasites were noted. The most significant histologic findings were verminous pneumonia and pulmonary endarteritis. In all cases except one, intravascular adult nematodes were observed with eggs and larvae in the lungs. Adult nematodes were obtained from 8 animals and in all cases were identified as Parastrongylus dujardini. To the authors' knowledge, this is the first report of intravascular angiostrongylosis with primary cardiopulmonary location in callitrichids in France.

[Ejaculation capacity in spinal cord injured patients carrying an endo-urethral stent for incontinentation: Descriptive study]. / Capacité éjaculatoire chez les sujets blessés médullaires porteurs d'une prothèse endo-urétrale d'incontinentation : étude descriptive.

OBJECTIVES: To assess the impact of endo-urethral stent (EUP) of incontinentation in spinal cord injured (SCI) men on ejaculation capacity. FIRST CRITERIA: Presence of ejaculation after EUP. SECONDARY CRITERIA: Modification on ejaculation type, stimulation mode, possibility of sperm conservation in the same population. POPULATION AND METHODS: A descriptive monocentric study including SCI subjects which underwent placement or change of temporary (Mémokath™ or Allium™) or definitive (Mémotherm™) EUP between January 2004 and January 2014 with at least one ejaculatory test. Are identified for each patient: the presence of ejaculation, type of ejaculation, stimulation mode used, number of frozen specimen and results from semen analysis. RESULTS: Over 11 men with tetraplegia, complete for motricity, there were 8 (72%) for whom ejaculation was possible after laying EUP. Of these, 6 (55%) had an antegrade or antero-retrograde ejaculation. It was not possible to make a freezing straw in four of them due to infection of semen (2) or terato-oligo-astenospermia (1) or absence of reproductive project (1). CONCLUSION: In this small sample, it was found that over 70% ejaculation have been preserved after laying EUP and more than 50% with antegrade or antero-retrograde ejaculation. A larger study would identify how EUP may alter the ejaculatory capacity or quality of the ejaculate. LEVEL OF EVIDENCE: 4.

[Antibioprophylaxy and urological management of women with spinal cord injury during pregnancy]. / Intérêt de l'antibioprophylaxie et manifestations urologiques des femmes blessées médullaires au cours de la grossesse.

OBJECTIVE: More and more women with spinal cord injury (SCI) can have a pregnancy. Few data have been published on these pregnancies and their urological impact. We report a series of these cases illustrating the urological experience of specialized centers. METHODS: This is a retrospective study that identified pregnancies in women with SCI followed-up between 2000 and 2014. Data covering all urological and obstetric events during pregnancies, before and after implementation of weekly oral cyclic antibiotics (WOCA) program, were collected from medical records. RESULTS: Fifteen women with SCI who gave birth to 20 children were included. Three of them were quadriplegics and 12 were paraplegics. All of them performed themselves intermittent catheterization: 11 by urethral way and 4 by high way because carrying a continent cystostomy. Mean follow-up period before pregnancy was 14.6 years [3-27 years IC 95%] and the mean follow-up for the study was 8.5 months [6.5-9 IC 95%]. We observed a reduction of symptomatic urinary tract infections after WOCA onset (13/13 before vs. 0/7 after, P=0.001), a reduction of recurrent urinary infections (6/13 vs. 0/7, P=0.03), a reduction of threats to premature births (8/13 vs. 0/7, P=0.001). Multi-resistant bacteria appeared to increase (0/13 vs. 3/7, P=0.01). We also observed a trend to significant reduction of premature births number (4/13 vs. 0/13, P=0.1) and that of low birth weight (3/13 versus 0/7, P=0.1). The overall neonatal survival rate was 100%. CONCLUSION: Our study before/after introduction of a weekly oral cycle antibiotic prophylaxis during pregnancy for women with spinal cord injury showed a significant reduction in symptomatic urinary tract infections and a tendency to improve pregnancy outcomes. LEVEL OF EVIDENCE: 4.

Premature ejaculation associated with lumbosacral lesions.

STUDY DESIGN: Retrospective study. OBJECTIVES: Spinal cord injuries are usually associated with anejaculation, but few premature ejaculations (PE) are described in lumbosacral lesions. The objective of the study is to analyze the retrospective files of patients with lumbosacral lesions to explore whether PE is systematic, and which type of lesions (conus teminalis, epiconal, cauda equina) is associated with these PE. METHODS: Standard sexological consultations from 34 men with L5-S4 lesions were analyzed including questions on psychogenic and reflexogenic erection, and ejaculation. Medical assessment included bulbocavernosus, anal, and cremasteric reflexes and urodynamics. RESULTS: Thirty one (31/33) patients maintained natural ejaculations, but 18 complained of PE and five of spontaneous ejaculations. Fourteen patients complained of dribbling ejaculation, and 27 of non-climactic ejaculation (13 no sensation, 10 some sensation, 4 painful sensation). Medical assessments showed absent or diminished anal sensation in 28 patients, absent or diminished anal reflexes in 21, absent or diminished bulbocavernosus reflexes in 20, but 12/13 positive cremasteric reflex. Urodynamics showed 12/20 areflex and 2/20 hyperactive bladders. CONCLUSIONS: Most men with lower lumbosacral lesions maintain natural ejaculation, but often complain of PE following injury. The PE is such that a mere sexual thought can trigger the response, or appear spontaneously as daytime ('sticky paints') or nighttime ('sticky sheets') emissions. PE appears to be a direct consequence of the lesion as it is reported from the very first ejaculation post injury, in men who otherwise controlled their ejaculation prior to injury. Underlying mechanisms may involve sacral inhibition on ejaculation, or simultaneous activation of psychogenic erection and emission. Clinical implications are discussed.

[Sexuality of women with neurologic disorders]. / Sexualité de la patiente neurologique.

INTRODUCTION: The prevalence of sexual dysfunction in spinal cord injured (SCI) women is high. METHODS: Medical literature on sexuality in women with SCI was reviewed and combined with expert opinion of the authors. RESULTS: The physiology of the female sexual response including vasocongestion and muscular contractions occurring during sexual arousal and orgasm, and their innervation through somatosensory and autonomic pathways (pudendal, pelvic, hypogastric, vagus nerves) is described. Studies on women with SCI demonstrate the presence of a sacral reflex vasocongestion and/or thoracolumbar psychogenic vasocongestion. Fifty percent of women with SCI report orgasm, most often with genital stimulation, suggesting that an autonomic reflex response, but which can be perceived by vagus nerve transmission. Studies on sexual experience show that the frequency of sexual activities decreases, but interest for intercourse remains. More emphasis is placed on oral-genital stimulation, kisses, cuddling, caresses, fantasies, and erogenous stimulation above the lesion level. Sixty-nine percent of women with SCI report sexual satisfaction. Limitations concern positions during intercourse, spasticity, incontinence and autonomic dysreflexia. Alteration of the sexual sense of self and body image are also reported. Facilitating factors include education level, having a stable partner, occurrence of the lesion in adulthood, and increased posttraumatic delay. Treatment should emphasize neurological assessment of thoracolumbar sensitivity and presence of sacral reflexes. Sexual education should be encouraged during rehabilitation and cover the female sexual response, procreation and pregnancy (risks, prevention), along with precautions concerning various contraceptives. Treatment should include a refined assessment of perineal sensitivity to allow a mental image of the vulva, and trials with vibrostimulation and medication (PDEI5, midodrine) to maximize sexual responses and facilitate perception of sexual pleasure and orgasm. CONCLUSION: Management of sexual dysfunction in SCI women must be holistic and biopsychosocial.

[Transsexualism]. / Le transsexualisme.

UNLABELLED: Transsexual conditions need to be assessed for a psychological, hormonal and surgical evaluation. A multidisciplinary consent is required to perform hormonal and surgical treatment. METHOD: A critical overview has been performed (PubMed) and the main guidelines have been summarised. RESULTS: Hormonal treatments include suppression of the naturally secreted hormone and the administration of hormone of the desired sex. The main comorbidity is thrombo-embolic complications for patients under oestogene therapy. The main surgical treatment for female to male (FtM) surgery are: periareolar mastectomy if possible, hysterectomy, ovariectomy and vaginectomy and phallic reconstruction including metaidioplasty and forearm or suprapubic phalloplasty dependant of patient's wishes. The main treatments for male to female (MtF) surgery are: prosthesis mammoplasty and vaginoplasty and for some facial feminisation. The results in term of global satisfaction are high despite a relatively high rate of complications as well. CONCLUSION: Results in terms of well-being and psychological improvement justify this treatment despite its relatively high morbidity.

Sexual function and autonomic dysreflexia in men with spinal cord injuries: how should we treat?

STUDY DESIGN: Systematic review. OBJECTIVES: Review the literature on the acute or prophylactic treatment of autonomic dysreflexia in the context of sexual activities. SETTING: International. METHODS: Medline search using AD and spinal cord injury and all years of publication. RESULTS: Thirty-seven papers on the specific treatment of AD showed that nifedipine, prazosin, captopril and clonidine are candidates in the context of sexual activities. Prazosin, however, has an initial hypotensive effect requiring to begin treatment 12 h before intercourse, which makes it less ideal for spontaneous sexual activities. Captopril has an initial hypotensive effect and was only studied in acute AD. Its usefulness in prophylaxis remains to be demonstrated. Clonidine has successfully been used clinically for decades, but never studied in randomized control trials. Nifedipine remains the most widely studied and significant treatment of AD whether in acute or prophylactic conditions. Recent concerns suggest increased cardiovascular risks with sublingual nifedipine in non-SCI populations, but negative long-term effects have not been reported in the SCI population. CONCLUSION: Sexual function is a priority for men with SCI. As sexual activities, in particular ejaculation, can be a source of AD, adequate treatments and prophylaxis must be considered in the context of sexual activities. Experts must meet and conclude on the thresholds, parameters and treatments that should be considered in the long-term management of AD in the context of sexual function in men with SCI.

[Who are the recipients of labile blood products? A multicenter nation-wide study--a "donation day." Blood banks, health facilities]. / Qui sont les receveurs de produits sanguins labiles (PSL)? Une étude nationale multicentrique - un jour donné. Etablissement de transfusion sanguine (ETS) - établissements de santé (ES).

During the years 1994-2001, a progressive decrease of the number of blood units transfused has been reported in France. In contrast, since 2002, there is an increasing number of blood units issuing (+7.6% between 2001 and 2006) and this must be investigated. On behalf of the French Society of Blood Transfusion, the "Recipients" working group promoted a nation wide survey with the support of the regional blood transfusion centres. This survey was aimed at describing the profiles of the transfused patients: socio-demographical patterns, and reasons of the blood transfusion (main and associated diagnoses). A cross-sectional survey was designed. All the patients who received a blood unit during a specific day were considered as the population of the study. They were identified by the regional transfusion centres by means of the "individual issuing form". Survey forms were fully filled for 90% of the patients. It has been considered as a good answer rate. Seven thousand four hundred and twenty-two blood units, delivered to 3450 patients were analyzed. Three groups of pathologies were found as a reason of transfusion: haematology-oncology (52.70% of the prescriptions) with 892 patients (27.8%) for haematological malignancies; surgical procedures (23.99%); intensive care and medicine procedures (21.92%). More than 50% of the recipients are 70 years old and more. This result is explained by the age distribution of inpatients. In a context of lack of donors and consequently difficulties to provide patients with optimal number of blood units, this study is helpful. Variability of blood unit issuings must be detected, analyzed and monitored in real time by the actors of the transfusion process, using computerized dashboards: the blood units provider (in order to adjust the strategy of blood units provision) and the health care establishment as well as care blood components prescribers (reasons of blood transfusion and evaluation of practices).

[Health care units in the French blood banks, why?]. / Les structures de soins dans les établissements de transfusion sanguine, pourquoi faire ?

In France for several years, many patients have been treated in Blood Transfusion Centers belonging to the EFS. This partnership between public hospitals and EFS is appreciated by the patients who find a competent staff in transfusion and apheresis process, in a more pleasant environment than in hospital. There is a total of 93 Health Care Units in Blood Transfusion Centers. Sixty-three of these Health Care Units perform only transfusions and bleeding. In the remaining 30 Health Care Units apheresis, peripheral blood hematopoietic stem, cell harvesting, plasmatic exchanges and extracorporeal photopheresis are also performed. Despite the perfect fit between hospital needs, comfort and easiness for patients, an economical problem remains. At the present time, the reimbursement rate by national health insurance is below the real cost. If unsolved, this discrepancy could force an end to this beneficial partnership.

Prediction of sexual function following spinal cord injury: a case series.

INTRODUCTION: Spinal Cord Injury (SCI) affects sexual response based on the level and degree of completeness of injury. By using the International Standards for the Neurologic Classification of SCI in conjunction with lumbo-sacral reflexes these effects can be predicted. The International Standards for the Assessment of Autonomic Function after SCI (ISAFSCI) document the impact of SCI on sexual responses including psychogenic and reflex arousal (erection or lubrication), orgasm, ejaculation, and sensation of menses. Responses are described based upon a 0 to 2 scale with 0 being absent, 1 altered, and 2 normal response. Additionally, the lesion is described as supraconal, conal or infraconal. CASE PRESENTATION: We present 4 representative cases of the impact of SCI on sexual responses and course of treatment. Case 1 describes a complete supraconal lesion above T6 with upper motor neuron syndrome. Case 2 describes a supraconal complete lesion including the T11-L2 segment. Case 3 describes an infraconal (cauda equina) lesion with lower motor neuron syndrome. Case 4 is theoretical and describes a supraconal lesion above T6 with upper motor neuron syndrome, partial sensation in T11-L2 dermatomes, and other medical comorbidities. DISCUSSION: Neurologic examination combined with reflex testing allows prediction of sexual responses after SCI. It would be useful for version 2.0 of the ISAFSCI to assist clinicians in determining the anticipated changes, whether their patients are functioning as anticipated sexually after SCI or whether other concerns also require treatment.

Stimulation of the medial preoptic area of the hypothalamus in the rat elicits increases in intracavernous pressure.

Penile erection can be elicited by various stimuli integrated in the spinal cord and/or higher central nervous structures. The medial preoptic area (MPOA) of the hypothalamus is known to play a key role in the regulation of the male sexual behavior. In anesthetized male rats we performed MPOA stimulation via stereotaxically implanted electrodes or canulae delivering L-glutamate. An erectile response, assessed by an increase of intracavernous pressure (ICP), was recorded during electrical stimulation of the MPOA. Stimulating the posterior region of the MPOA elicited a greater erectile response than stimulation applied to the anterior region. Microinjections of L-glutamate also elicited an ICP increase. Stimulation of MPOA neurons therefore elicits activation of neural pathways controlling penile erection.

Higher CNS control of penile responses in rats: the effect of hypothalamic stimulation.

The effect of electrical stimulation of the medial preoptic area (MPOA) of the hypothalamus on penile responses in rats was investigated. No females were present and penile responses were observed through the use of an inclined mirror. MPOA stimulation was found to elicit two types of penile responses: penile movement within the sheath and protrusion of the penis outside the penile sheath. While these responses also occurred spontaneously during the nonstimulation control sessions, they occurred in significantly higher frequencies following MPOA stimulation. The results also produced an unexpected finding. While studies on the effect of hypothalamic stimulation on copulation show stimulation-bound effects, MPOA stimulation in the absence of a receptive female consistently triggered penile responses as a poststimulation effect.

Erectile mechanism in paraplegia.

Erection is generally viewed as a reflex mechanism that can receive higher CNS influences. Paraplegic men who have lost reflex activity from the genital area are, therefore, treated as irreversibly impotent. However, the innervation of the male reproductive system suggests that two neural pathways innervate the genitals. In theory, the second (thoracic-lumbar) pathway should compensate for the loss of the first (sacral) pathway in cases of low spinal lesions. Clinical practice, however, ignores the TL pathway as a basis for treatment of spinal cord-injured men. This study used an animal model to demonstrate that the TL pathway could mediate penile responses in paraplegic rats. Eighty-five percent (85%) of spinal animals showed penile responses following hypothalamic (MPOA) stimulation despite a complete loss of peripheral erectile reflexes. These results not only have important implications from a clinical perspective, they further document the physiology of erection and support the view that erection is not a primary parasympathetic activity, but probably results from a sequence of sympathetic processes.

Molecular characterisation and ovine live vaccine 1B evaluation toward a Chlamydophila abortus strain isolated from springbok antelope abortion.

Chlamydiosis is a zoonosis with a worldwide distribution. The reservoir of susceptible hosts is large and includes birds and both domestic and wild mammals. Chlamydial infection, determined serologically, seems to be widespread among wild ruminants in the Paris zoo (France). In February 2003, an abortion case was reported within the springbok (Antidorcas marsupialis) herd of the zoo. PCR assay using primers targeting the polymorph membrane protein gene (pmp) family was performed on both vaginal swab and placenta samples revealing the presence of Chlamydophila. The inoculation into chicken embryos of an infected placenta extract led to the successful isolation of a C. abortus strain referred to as ASb1. The omp1 gene coding the major outer membrane protein (momp) and the 16S-23S rRNA spacer region of ASb1 were compared to those of various strains by restriction fragment length polymorphism (RFLP). The RFLP analysis showed that this isolate belonged to Chlamydophila abortus species and is highly related to known domestic ruminant's strains causing abortion. The efficacy of a live vaccine 1B, based on a temperature-sensitive mutant of the ovine abortion reference strain AB7, was tested. Protection-challenge experiments in a mouse model show that the ASb1 strain led to mice abortions and that vaccination with 1B vaccine provided them with effective protection.

Reappraisal of the association between the DRD2 gene, alcoholism and addiction.

We analysed the impact of the TaqI A1 allele of the D2 dopamine receptor gene on the risk for alcoholism, trying to depict three explanations frequently proposed to explain discrepancies in association and linkage studies: that the A1 allele may act as a marker rather than as a vulnerability factor, that stratification biases and unevaluated controls may explain positive results, and that the A1 allele is modifying the phenotype rather than increasing the risk for alcoholism. We thus tested another (dinucleotide STRP) marker within the DRD2 gene, selected a new homogenous sample of 113 alcoholic patients and 49 unaffected controls strictly matched for ethnic origins, and systematically assessed both samples with a semi-structured interview to detect (in both samples) alcohol dependence, but also such related traits as specificities of complications. The frequency of the A1 allele was not significantly different between alcoholics and controls but when comparing different subgroups of alcoholics, the A1 allele was significantly more frequent in alcoholic patients with somatic complications (OR = 3.00, CI[1.37-6.62]), social and professional complications (OR = 2. 72, CI[1.25-5.90]), or with co-morbid dependence (OR = 2.88, 95% IC [1.16-7.15]). The association for co-morbid dependence and somatic complications was also positive when taking into consideration both STRP and TaqIA polymorphisms. The A1 allele does not increase the risk for alcoholism per se in our sample, but may be involved in a related trait which is partially dependent on the diagnosis of alcoholism, through a disequilibrium with another close mutation.

[Normovolemic hemodilution: application to the treatment of refractory cutaneous ulcers. Transfusion Techniques and Therapeutics Group]. / L'Hémodilution Normovolémique: application au traitement des ulcères cutanés rebelles. Groupe Techniques Transfusionnelles et Thérapeutiques.

Resistant cutaneous leg ulcers have a long evolution and are not easily cured by traditional therapeutics. Normovolemic haemodilution was proposed in 1984 by Guenneguez and Ouvry, who studied a small number of patients with good results, by using a local protocol, and a manual procedure. Recent data about physiopathology of cutaneous leg ulcers seem to confirm the benefit that Normovolemic Haemodilution should bring to the treatment of this pathology. Therefore a multidisciplinary group was created to lead a multicentric study about the treatment of resistant cutaneous leg ulcers by long term Normovolemic Haemodilution.

[Transfusion at home? An alternative to the day hospital]. / La transfusion à domicile? Une alternative à l'hôpital de jour.

In response to the needs of the Home Medical Services a project was set up in the Hemobiology Transfusion Service of Beaujon Hospital. The objective of this project was to avoid the difficult transfer of patients who were receiving for the most part palliative treatment. This required strict organization between consultants, haemobiologist physicians and healthcare personnel. The exclusion criteria have been respected (geographical distance, state of the non-compensated clinic, absence of family/patient cooperation). During the last 4 years of activity, 1,662 transfusions have been carried out on 757 patients, of which 80% had hematological affections, 10% solid tumours and 10% AIDS affections. 5,548 blood components have been transfused (2,104 red cell concentrates, 3,152 pooled platelet concentrates and 292 apheresis platelet concentrates). Thirty-one minor incidents were observed representing a prevalence of 0.56%. The poor codification of cases has slowed down the development of this project. The centralization of requests with coordination by the haemobiologist physicians within the Paris region should allow a guaranteed response to the numerous requests.

[Insisting on intravenous polyvalent immunoglobulin therapy in polymyositis in spite of the occurrence of sever hemolytic anemia]. / Poursuite du traitement d'une polymyosite par les immunoglobulines intraveineuses polyvalentes malgré la survenue d'une anémie hémolytique sévère.

A 23-year-old female with polymyositis received high dose intravenous immunoglobulin (IVIg) therapy. The patient suffered severe hemolytic anemia after receiving first course of IVIg infusion. This adverse reaction was likely due to allohemaglutinin A and B and from or high molecular weight IgG complexes contained in the preparation. Though this effect was observed, the treatment was repeated six times. A mild hemolysis occurred following each IVIg, with no clinical consequence. Involvement of the saturation of macrophagic receptors might explain this partial destruction of erythrocytes.

[Risk behavior among blood donors: efficacy of a new questionnaire]. / Comportements à risque chez les donneurs de sang: efficacité d'un nouveau questionnaire.

The clinical selection of volunteers for blood donation is essential to reduce the risk of viral transmission by blood transfusion. The aim of this study was to evaluate a new questionnaire for a pre-donation medical interview. This questionnaire was developed by transfusion practitioners, epidemiologists and professional investigators, and focused on risk behaviors of blood donors and their partners. Five blood banks in the French Ile-de-France region (around Paris), participated in the study from May 1995 to January 1996. All participating doctors were specifically trained by professional investigators. The sex and the age of donors, the type of collection, the duration of interviews and the reasons for exclusion from donation were recorded. The results were compared to those of a prior study dealing with a sample of 15,000 donors presenting the same characteristics, whose blood was taken of at the same collection sites in 1993. Of the 1,527 volunteers donating blood, 14% were interviewed in fixed centers and 86% by moving teams (38% in firms, 22% in towns, 13% in civil service facilities, 13% in school or academic centers). For 15.9% of the volunteers, this was the first donation (range: 7.3% in fixed centers to 41.5% in school and academic centers). The mean duration of the interview was 11 min (10 min for volunteers included, 14 min for donors excluded from donation). It decreased from 14 min at the beginning of the study to 10 min by the end of the study. The percentage of donors excluded for risk behavior (3.7% in 1995-96 vs 1.5% in 1993, P < 0.001), or medical reasons (12.2% in 1995-96 vs 8.4%, in 1993, P < 0.001) was significantly greater in 1995-96 than in 1993 (15.9% vs 9.9%, P < 0.001). In 1995-96, 35.0% of exclusions for risk behavior were related to male homosexuality, multiple partners or the risk behavior of the partner vs 12% in 1993 (P < 0.001). The risk of exclusion was 5.5 times higher for donors not living in a couple. The results obtained demonstrated the value of this new approach to the medical interview.

[Feasibility of following up transfused patients]. / Faisabilité d'un suivi de patients transfusés.

The aim of this study was to assess the natural history of patients after transfusion and the acceptability of a standardized biological follow-up. In 1995, during 1 month, in 13 French hospitals, a follow-up at 3 and 6 months after blood transfusion was proposed to all blood recipients who had not received any blood transfusion within the past 6 months (eligible patients): screening for red cell antibodies, alanine aminotransferase (ALT) activity and specific viral markers of hepatitis B (hepatitis B surface antigen and antibody to hepatitis virus core antigen), of hepatitis C (antibodies) and of Human Immunodeficiency Virus (antibodies). At the beginning of the study, 296 patients were followed for 6 months. A complete follow-up was available at 3 months for 183 patients (62%), at 6 months for 168 (57%) and after 6 months, 198 patients (67%) have been once followed. Of eligible patients, 76% were alive at six months. After transfusion, the incidence of red cell alloantibodies and elevated ALT concentration were respectively 4% and 17%. At 6 months, one patient had Hepatitis B surface antigen; the responsibility of blood transfusion was excluded. Within the first 24 hours, 68 patients (23%) required another blood transfusion and 42% of units were transfused to patients with malignant disease. Our study quantifies in real conditions the difficulty of a biological follow-up in a transfused population, mostly composed of patients that could not be followed in the hospital where they were transfused.