Prophylactic versus reactive transfusion of thawed plasma in patients undergoing surgical repair of craniosynostosis: a randomized clinical trial.

BACKGROUND: Surgical repair of craniosynostosis in young children is associated with copious bleeding and often coagulopathy. Typically, a reactive transfusion strategy is used to treat coagulopathy whereby fresh frozen plasma (FFP) is given only after clinical manifestation of clotting abnormality. This prospective, randomized clinical trial was designed to test the hypothesis that prophylactic FFP during craniofacial surgery reduces blood loss and blood transfusion requirements compared to a reactive FFP transfusion strategy. METHODS: Eighty-one patients less than 2 years of age requiring primary repair of craniosynostosis were randomized to receive FFP using either a prophylactic or reactive strategy. Laboratory values were measured at four standardized time points. The volume of blood products transfused, length of stay in the pediatric intensive care unit (PICU), hospital length of stay, and number of donor exposures were recorded for each patient. RESULTS: The prophylactic FFP group received a significantly greater average volume of FFP compared to the reactive group (29.7 ml·kg(-1) vs 16.1 ml·kg(-1) ; P < 0.001), which was associated with improvement in coagulation values at multiple time points. However, there was no difference in blood transfusion requirements or blood loss between the two groups. The two transfusion strategies resulted in similar median donor exposures. There was no difference in PICU or hospital length of stay. CONCLUSION: A reactive FFP transfusion strategy required less plasma transfusion and was associated with similar rates of blood loss and PRBC transfusion as prophylactic FFP despite improvement in coagulation values in the prophylactic FFP group.

Evidence-based practice guidelines for plasma transfusion.

BACKGROUND: There is little systematically derived evidence-based guidance to inform plasma transfusion decisions. To address this issue, the AABB commissioned the development of clinical practice guidelines to help direct appropriate transfusion of plasma. STUDY DESIGN AND METHODS: A systematic review (SR) and meta-analysis of randomized and observational studies was performed to quantify known benefits and harms of plasma transfusion in common clinical scenarios (see accompanying article). A multidisciplinary guidelines panel then used the SR and the GRADE methodology to develop evidence-based plasma transfusion guidelines as well as identify areas for future investigation. RESULTS: Based on evidence ranging primarily from moderate to very low in quality, the panel developed the following guidelines: 1) The panel suggested that plasma be transfused to patients requiring massive transfusion. However, 2) the panel could not recommend for or against transfusion of plasma at a plasma : red blood cell ratio of 1:3 or more during massive transfusion, 3) nor could the panel recommend for or against transfusion of plasma to patients undergoing surgery in the absence of massive transfusion. 4) The panel suggested that plasma be transfused in patients with warfarin therapy-related intracranial hemorrhage, 5) but could not recommend for or against transfusion of plasma to reverse warfarin anticoagulation in patients without intracranial hemorrhage. 6) The panel suggested against plasma transfusion for other selected groups of patients. CONCLUSION: We have systematically developed evidence-based guidance to inform plasma transfusion decisions in common clinical scenarios. Data from additional randomized studies will be required to establish more comprehensive and definitive guidelines for plasma transfusion.

Objective and subjective indicators of happiness in Brazil: the mediating role of social class.

The authors tested the proposition that monetary household income affects subjective well-being (E. Deiner, E. M. Suh, R. E. Lucas, & H. L. Smith, 1999) through the mediating mechanisms of objective and subjective social classes. The present authors drew a representative sample in a door-to-door survey format from a Brazilian urban center. Using a back-translated version of E. Diener, R. A. Emmons, R. J. Larson, and S. Griffin's (1985) Satisfaction With Life Scale, the present authors demonstrated a significant relation with income. However, this effect was mediated by objectively and subjectively measured social classes. These effects reinforce, extend, and internationally generalize the Person x Situation perspective elaborated by E. Diener et al. (1999).

Comparison of BD Directigen EZ RSV and Binax NOW RSV tests for rapid detection of respiratory syncytial virus from nasopharyngeal aspirates in a pediatric population.

The BD Directigen EZ RSV (BD) assay and the Binax NOW RSV (BN) assays are lateral flow immunochromatographic assays used in the rapid diagnosis of respiratory syncytial virus (RSV) infection. A prospective study was undertaken to compare the performance characteristics of the BD and BN assays using 99 fresh nasopharyngeal aspirate specimens from children. All specimens were cultured by tube cultures and R-mix shell vials. Culture-negative specimens that tested positive by 1 or both antigen tests were analyzed by reverse transcriptase polymerase chain reaction (RT-PCR) for the presence of RSV nucleic acids. Specimens positive by culture and/or RT-PCR were considered true positives. The sensitivity, specificity, positive predictive value, and negative predictive value for BD were 90%, 94%, 94%, and 90%, respectively, and those for BN were 90%, 100%, 100%, and 90% respectively. The overall agreement between the 2 assays was 93% (confidence interval, 86.3-96.6%). Three specimens negative by both assays were positive by viral culture. The rapid lateral flow immunochromatographic assays were easy to perform and easy to interpret, and the results are available in less than 30 min. The reduced turnaround time offered by these assays is particularly useful in the rapid detection of RSV infections in children from outpatient settings.

Pediatric laboratory medicine: current challenges and future opportunities.

The practice of pediatric laboratory medicine involves unique challenges related to development, nutrition, growth, and diseases during different periods of infancy, childhood, and adolescence. This article discusses key aspects of pediatric laboratory medicine faced by clinical pathologists, clinical laboratory scientists, and clinicians, including point-of-care testing, preanalytic variables, analytic factors, age-specific reference intervals, esoteric laboratory tests, clinical impact, andfuture opportunities. Although challenging, pediatric laboratory testing offers many opportunities for improved patient care, clinical- and laboratory-based research, and education.

QuantiFERON-TB Gold in-tube testing for tuberculosis in healthcare professionals.

OBJECTIVE: To assess the performance of the QuantiFERON-TB Gold in-tube (QFT-GIT) assay for tuberculosis (TB) screening using a convenience sample from among a population of healthcare provider (HCP) employees of a hospital. METHODS: For the individuals in our cohort, we reviewed occupational health records, including TB risk factors, and the results of QFT-GIT testing. We considered a QFT-GIT result of greater than 0.35 IU/mL to be positive; when we obtained a positive result from a specimen from a particular individual, we repeated testing on a fresh specimen from that individual. RESULTS: Of the 758 HCP employees whose specimens we screened, 439 had negative QFT-GIT results with negative TB risk factors and 268 had a negative QFT-GIT result but had positive TB risk factors. QFT-GIT results were positive in 47 subjects. Of the positive participants, 12 had a mean TB antigen value (antigen minus nil stimulated concentrations [Ag-Nil]) of 0.61 on initial testing and had a negative result on repeat testing, 22 had a TB Ag-Nil of 1.19 on initial testing and had a positive result on repeat testing (P = .01). CONCLUSIONS: The QFT-GIT assay is useful for screening HCPs. However, false-positive results occur, particularly in a borderline zone of less than 1 IU/ml. Re-evaluation by repeat testing of fresh specimens from the same individual should be considered in subjects whose specimens test within the low-level positive cutoff.

Plasma cell-rich acute cellular rejection of a transplanted kidney associated with antibody to the red cell Kidd antigen.

Plasma cell-rich acute cellular rejection of a transplanted kidney is described in association with the identification of serum antibody to the red cell Kidd antigen, Jk-b, which is also found in the kidney. This antibody was formed without a history of a recent blood transfusion or exposure to intravenous immunoglobulin. The role this antibody could have in the rejection of the transplant is discussed.

Teaching pediatric laboratory medicine to pathology residents.

CONTEXT: Laboratory data are essential to the medical care of fetuses, infants, children, and adolescents. However, the performance and interpretation of laboratory tests on specimens from these patients, which may constitute a significant component of the workload in general hospitals and integrated health care systems as well as specialized perinatal or pediatric centers, present unique challenges to the clinical pathologist and the laboratory. Therefore, pathology residents should receive training in pediatric laboratory medicine. OBJECTIVE: Children's Health Improvement through Laboratory Diagnostics, a group of pathologists and laboratory scientists with interest and expertise in pediatric laboratory medicine, convened a task force to develop a list of curriculum topics, key resources, and training experiences in pediatric laboratory medicine for trainees in anatomic and clinical pathology or straight clinical pathology residency programs and in pediatric pathology fellowship programs. DATA SOURCES: Based on the experiences of 11 training programs, we have compiled a comprehensive list of pediatric topics in the areas of clinical chemistry, endocrinology, hematology, urinalysis, coagulation medicine, transfusion medicine, immunology, microbiology and virology, biochemical genetics, cytogenetics and molecular diagnostics, point of care testing, and laboratory management. This report also includes recommendations for training experiences and a list of key texts and other resources in pediatric laboratory medicine. CONCLUSIONS: Clinical pathologists should be trained to meet the laboratory medicine needs of pediatric patients and to assist the clinicians caring for these patients with the selection and interpretation of laboratory studies. This review helps program directors tailor their curricula to more effectively provide this training.

Clinical evaluation of the ZstatFlu-II test: a chemiluminescent rapid diagnostic test for influenza virus.

Exploiting the high sensitivity of the chemiluminescence phenomenon, an accurate and sensitive point-of-care test, called the ZstatFlu-II test (ZymeTx, Inc., Oklahoma City, Okla.), was developed to detect influenza virus infections. The ZstatFlu-II test takes 20 min and requires approximately 2 min of "hands-on" time for operational steps. The ZstatFlu-II test does not distinguish between infections with influenza virus types A and B. ZstatFlu-II test results are printed on Polaroid High-Speed Detector Film, allowing test results to be archived. A prototype version of the ZstatFlu-II test was evaluated during the 2000-to-2001 flu season with 300 nasal aspirate specimens from children at a pediatric hospital. Compared to culture, the ZstatFlu-II test had 88% sensitivity and 92% specificity. The Directigen test had a sensitivity of 75% and a specificity of 93%. The sensitivity of the ZstatFlu-II test was significantly higher than that of the Directigen test (P < 0.0574).