Further studies to evaluate methods of leucoreduction to prevent alloimmune platelet refractoriness and induce tolerance in a dog platelet transfusion model.

OBJECTIVES: Three leucoreduction filters were evaluated - when used alone or combined with centrifuge leucoreduction (C-LR) - to prevent alloimmune platelet refractoriness in a dog platelet transfusion model. MATERIALS AND METHODS: Donor platelet-rich plasma (PRP) or buffy coat (BC) platelets were either filter leucoreduced (F-LR) or F-LR/C-LR, (51) Cr radiolabelled and transfused. Weekly transfusions were given for up to 8 weeks or until platelet refractoriness. Recipients who accepted treated transfusions were then given non-leucoreduced (non-LR) platelets to determine whether donor-specific tolerance had been induced. RESULTS: Acceptance of F-LR PRP transfusions ranged from 29% to 66%. F-LR/C-LR transfusions prepared from PRP were accepted by 92%, from BC by 63% and from pooled PRP by 75% of recipients (p=NS); overall acceptance rate of F-LR/C-LR transfusions was 83%. Tolerance to subsequent non-LR transfusions occurred in 45% of the F-LR-/C-LR-accepting recipients unrelated to DR-B compatibility between donors and recipients (P = 0·18). CONCLUSION: In a dog platelet transfusion model, acceptance of donor platelets required combining F-LR with C-LR as apparently each process removes different immunizing WBCs.

Extended storage of autologous apheresis platelets in plasma.

BACKGROUND AND OBJECTIVES: The purpose of our studies was to determine the effects of extended platelet storage on poststorage platelet viability. MATERIALS AND METHODS: Normal subjects were recruited to donate platelets using two different apheresis systems: either the COBE Spectra (n = 58) or the Haemonetics MCS+ (n = 84). Platelet recovery and survival data from the two systems were compared with each other and with in vitro measurements of the stored platelets. RESULTS: There were no significant differences in either platelet recoveries or survivals between the two machines between 1 and 8 days of storage. Combining the data from both machines, platelet recoveries decreased by 2.6% and survivals by 0.3 days/storage day. In vitro assays did not predict either platelet recoveries or survivals during storage for 5-8 days. After 9 days of storage, pHs were unacceptable (≤ 6.1), suggesting that 8 days will be the longest possible storage time. CONCLUSIONS: These data suggest that, if stored platelet bacterial contamination issues are resolved, significant extension of platelet storage times is possible.

The misuse of law as a barrier to injury prevention.

Injury prevention relies heavily on law to require or prohibit particular behaviors (e.g., seatbelt use laws or drunk driving laws) and to establish specific standards (e.g., Federal Motor Vehicle Safety Standards). But opponents of such laws often make effective use of distortion and misunderstanding of the law to hinder preventive efforts. Injury prevention advocates must be prepared to counter such disinformation. They can do so by (I) focusing on prevention goals, not laws, (2) openly discussing the law, (3) refusing to be defensive in legal arguments, (4) daring opponents to test their assertions in court, and (5) taking the political offensive on issues of legal rights.

Developing a model law restricting the transporting of passengers in the cargo areas of pickup trucks.

Pickup trucks have become increasingly popular in the United States, accounting for about one in five vehicles involved in fatal motor-vehicle crashes. A critical factor in these deaths is the practice of carrying passengers in truck cargo areas, which are not designed for this purpose. Each year approximately 200 deaths occur to occupants riding in the back of pickup trucks. Over half the states have laws dealing with preventable injury problem, but these laws vary widely and most are too limited to be effective. We have reviewed existing laws, as well as crash injury data, and we have developed and recommend a model bill. The bill focuses on intended use, restricting passengers to only those portions of a vehicle designed for human transport. We have also conducted and report on a survey of legislative sponsors of pickup truck legislation.

Preparing and presenting an introductory course on motor vehicle injury.

Health professionals are key to any progress in reducing motor vehicle injury and death, yet they have been slow to recognize their role in this important area. One factor contributing to this problem has been the absence of courses on motor vehicle injury from the curriculums of the health professions schools. A comprehensive course on motor vehicle injury and death was developed, presented, and evaluated at the University of Illinois at Chicago School of Public Health. The major course objectives were for students to (a) comprehend that highway injury is a major public health problem, (b) understand that this problem can be mitigated by proven public health techniques, and (c) understand and be able to implement multidisciplinary solutions. It was hoped that students would champion the prevention of motor vehicle injuries as a high priority for public health agencies and other professional and community organizations. The course has now been presented twice. A teaching guide was prepared and was reviewed by faculty at 13 schools of public health. This guide discusses practical aspects of introducing and implementing this type of course, overall course objectives, specific learning objectives, a model curriculum (with suggested readings) for nine topic areas, materials from which transparencies or slides could be made, and a geographic listing of resource persons. The objectives for the guide were for it to be a practical model for a motor vehicle injury course and to acquaint health professions faculty with the resources available to them for course development, as well as with a network of professionals who are willing to aid them in their efforts. The guide is not a programmed learning text or a collection of canned lectures, but rather it is intended to provide a framework and encouragement to those at other institutions who seek to develop such a course.

Fluorides, facts and fanatics: public health advocacy shouldn't stop at the courthouse door.

KIE: One of the more controversial American public health issues is fluoridation of municipal water supplies. Opponents occasionally succeed in halting fluoridation through local referenda, but the courts usually uphold fluoridation laws. In 1982, however, an Illinois trial judge ruled that a state law authorizing fluoridation was unconstitutional. Although unimpressed by the plaintiff's evidence purporting to show fluoridation's risks, the judge was compelled to rule against the state because it had failed to counter with evidence on the safety of fluoridated water. Christoffel analyzes the trial court's decision and its subsequent reversal by the Illinois Supreme Court. He urges public health professionals to assume advocacy roles by ensuring that the scientific rationale behind public health regulations becomes part of the legislative record and by forcefully supporting public health policies in all forums, including the courts.^ieng

Medical care evaluation: an old new idea.

The recent implementation of medical care evaluation (medical audit) systems in the nation's hospitals is a phenomenon of major consequence. The systematic measurement of the quality of patient care based on outcome data is becoming a part of the delivery of that care. Sixty years ago Dr. E. A. Codman developed and crusaded for a similar idea that seemed at one point to be on the threshold of widespread acceptance in U. S. hospitals, but for reasons other than lack of conceptual soundness the effort failed. In this article the author reviews the history of this early approach to the evaluation of patient care quality and suggests some lessons this historical episode holds for today's health care professionals.

Evaluating the quality of ambulatory health care: a review of emerging methods.

While hospital quality evaluation activities have progressed dramatically in recent years, there has not been a comparable development and implementation of methods for the review and evaluation of ambulatory health care. Various technical problems regarding ambulatory records and the nature of ambulatory care itself have combined to retard the evolution of review methods. These problems are discussed, as are current efforts to overcome them. We have reviewed the relevant issues and literature and have attempted to provide a conceptual framework for better understanding the measurement of ambulatory health care quality. A selective bibliography of literature relating specifically to ambulatory care quality evaluation is presented as a guide to further study.

Handguns as a pediatric problem.

Handgun injury is a major cause of morbidity and mortality in American society, particularly among young people. Large numbers of children are affected by handgun violence through the loss of fathers, brothers, and other relatives. Young children are injured, and occasionally killed, in handgun "accidents." Some young children and many adolescents are murdered with handguns. Like infant mortality, handgun violence in the United States is a medical as well as a social problem. Because of the great lethality of handguns and their very limited ability to provide personal protection, handgun injury can best be reduced by making handguns less available. Handgun control cannot reduce rates of crime or interpersonal assault, but it can reduce the frequency and severity of injury arising from these situations toward the much lower levels found in other countries. The involvement of children in the United States handgun injury epidemic warrants effective pediatrician involvement in efforts toward handgun control.

Epidemiology and the law: courts and confidence intervals.

Beginning with the swine flu litigation of the early 1980s, epidemiological evidence has played an increasingly prominent role in helping the nation's courts deal with alleged causal connections between plaintiffs' diseases or other harm and exposure to specific noxious agents (such as asbestos, toxic waste, radiation, and pharmaceuticals). Judicial reliance on epidemiology has high-lighted the contrast between the nature of scientific proof and of legal proof. Epidemiologists need to recognize and understand the growing involvement of their profession in complex tort litigation.

Handguns as a pediatric problem. 1986.

Handgun injury is a major cause of morbidity and mortality in American society, particularly for young people. Large numbers of children are affected by handgun violence through the loss of fathers, brothers, and other relatives. Young children are injured and sometimes killed in handgun accidents. Some children and many adolescents are murdered with handguns. Because of their great lethality and very limited ability to provide personal protection, the great burden of handgun injury can best be reduced by making handguns less available. Handgun control cannot reduce rates of crime or interpersonal assault, but it can be expected to reduce the frequency and severity of injury which grows out of these situations, to levels closer to the much lower ones found in other countries. Pediatricians can contribute to this effort, as they have to the efforts to reduce the morbidity and mortality from poisonings and motor vehicle passenger injury.

A short course on motor vehicle injury for emergency medicine residents.

Despite growing interest and activity by emergency physicians in injury prevention, we found no reports of any attempts to include injury control concepts in emergency medicine residency training. An existing course for graduate level public health students on motor vehicle injury was modified for emergency medicine residents, presented as a one-day short course, and evaluated. The objective of the course was to provide information regarding the dynamics and prevention of motor vehicle crashes. An equally important second objective was to demonstrate to the residents the need for emergency physicians as part of the injury control research team. The content of the course was based on the conceptual model in which a motor vehicle crash is analyzed in terms of precrash, crash, and post-crash factors. The correlation between the mechanism of injury and the types of injuries experienced was of particular interest. A one-day format was found to be too concentrated. The incorporation of injury prevention concepts and research methods into the grand rounds, journal club, and conferences of the emergency medicine residency is recommended. Educational objectives and practical suggestions for implementation are provided. A comprehensive reading list is available on request.