Educational interventions encouraging appropriate use of blood transfusions.

BACKGROUND AND OBJECTIVES: The integration of a restrictive packed red blood cells (PRBC) transfusion strategy into daily clinical practice presents a challenge. This study describes the effect of an intervention including educational presentations and computerized alerts on PRBC utilization at a tertiary hospital. MATERIALS AND METHODS: During December 2014, lectures describing recommended PRBC transfusion indications were presented to all non-intensive care departments. Starting from January 2015, an alert was added to the electronic drug ordering system recommending transfusions at a haemoglobin (Hb) level <7 g/dl or Hb < 8 g/dl in symptomatic patients. The physician was not required to acknowledge the alert. Data regarding measured Hb preceding transfusions were collected. The primary end-point was defined as the percentage of PRBC administered at Hb ≥ 8 g/dl in 2015 compared with 2014. Secondary end-points were the percentage of PRBC administered to patients with Hb < 7 g/dl and the absolute number of PRBC transfused in 2015 compared with 2014. RESULTS: Compared to 2014, in 2015, the percentage of PRBC transfused when the Hb ≥ 8 g/dl was reduced by 18·8% (P < 0·001) and made up 29% of the total PRBC transfused. The absolute number of PRBC transfused decreased by 7·7%. The percentage of PRBC transfused when the Hb < 7 g/dl increased by 25·9% (P < 0·001). CONCLUSIONS: Following the described intervention, there was a significant improvement in the appropriateness of PRBC transfusions in our medical centre. These changes occurred despite the lack of interruption of the physician's workflow from the computerized alert. This simple strategy might be of use in implementing a restrictive PRBC transfusion strategy.

[18F]FDG-PET/CT for the diagnosis of patients with fever of unknown origin.

BACKGROUND AND AIMS: The diagnosis of patients with fever of unknown origin (FUO) remains a challenging medical problem. We aimed to assess the diagnostic contribution of 18-fluoro-2-deoxy-d-glucose positron emission tomography (FDG-PET)/computed tomography (CT) for the evaluation of FUO. METHODS: We performed a 4-year retrospective single-center study of all hospitalized patients that underwent FDG-PET/CT for evaluation of FUO. The final diagnosis of the febrile disease was based on clinical, microbiological, radiological and pathological data available at the final follow-up. Predictors for a contributory exam were sought. RESULTS: One hundred and twelve patients underwent FDG-PET/CT for the investigation of FUO in the years 2008-2012 and were included in the study. A final diagnosis was determined in 83 patients (74%) and included: infectious disease in 49 patients (43%), non-infectious inflammatory disease in 17 patients (16%), malignancies in 15 patients (14%), other diagnoses in 2 patients (1.7%), FUO resolved with no diagnosis and no evidence of disease during a 6-month follow-up in 23 patients (20%), and death with fever and with no diagnosis in 6 patients (5%). Seventy-four FDG-PET/CT studies (66%) were considered clinically helpful and contributory to diagnosis (46% positive contributory value and 20.5% contributory to exclusion of diagnosis). PET/CT had a sensitivity of 72.2%, a specificity of 57.5%, a positive predictive value (PPV) of 74.2% and a negative predictive value (NPV) of 53.5%. On multivariable analysis, significant predictors of a positive PET/CT contributory to diagnosis were a short duration of fever and male gender. CONCLUSIONS: PET/CT is an important diagnostic tool for patients with FUO.

Pharmacometrics: opportunity for reducing disease burden in the developing world: the case of Africa.

Pharmacometricians are virtually nonexistent in Africa and the developing world. The unrelenting burden of infectious diseases, which are often treated using medicines with narrow effectiveness and safety dose ranges, and the growing prevalence and recognition of non-communicable diseases represent significant threats for the patients, although affording an opportunity for advancing science. This article outlines the case for pharmacometricians to redirect their expertise to focus on the disease burden affecting the developing world.CPT: Pharmacometrics & Systems Pharmacology (2013) 2, e69; doi:10.1038/psp.2013.45; published online 28 August 2013.

[Organophosphate poisoning in inexperienced workers].

Organophosphates are frequently used as insecticides in agricultural areas, therefore they may pose a risk for accidental exposure by dermal contact or through inhalation. We present the cases of eight young men, who worked unprotected and inexperienced with organophosphates. They were exposed dermally and developed mainly gastrointestinal symptoms and also diaphoresis, hypersalivation, blurred vision and miosis. One patient developed severe weakness, fasciculations, disorientation and sleepiness. All had low levels of plasma acetylcholinesterase. All were admitted to the hospital and received antidotal treatment of atropine and toxogonin. They were released after 48 hours in good physical condition. The hospital staff rapidly diagnosed the organophosphate intoxication; additional doctors and nurses were called to the emergency department. The patients were decontaminated in showers within the hospital. This case emphasizes the need for workers handling pesticides, to be supervised by an experienced person and the advantages of hospital drills in rapid diagnosis and preparedness to provide treatment to many patients.

Down-regulation of surface antigens recognized by systemic lupus erythematosus antibodies on embryonal cells following differentiation and exposure to corticosteroids.

We have previously suggested that anti-DNA antibodies present in systemic lupus erythematosus patients can bind directly to tissues as a result of cross-reactivity with embryonal tissue-based antigens. Here we have analyzed the interaction between polyclonal and monoclonal mouse and human lupus autoantibodies and an embryonal cell line. We report that a murine embryonal stem cell line (ES) expresses a surface antigen which is recognized by mouse and human lupus autoantibodies. This surface antigen is down-regulated following maturation of the cells or incubation with corticosteroids. Adhesion molecules may serve as the target membrane antigen in ES cells since preincubation with these antibodies decreases the ability of ES cells to adhere to the plate.

The urine of SLE patients contains antibodies that bind to the laminin component of the extracellular matrix.

Direct immunofluorescence of tissues derived from patients affected with SLE demonstrates antibodies bound to the extracellular matrix (ECM). In the present work we have tested whether such antibodies are found in the serum and urine of lupus patients and mice. We found that the urine of patients with active SLE and of MRL/lpr/lpr mice contains antibodies that bind ECM and that a major target for these antibodies is the 200 kDa light chain of laminin which is one of the matrix components. The level of the anti-ECM, anti-laminin antibodies correlates with disease activity.

[Delayed pressure urticaria: therapeutic response to cetirizine].

We describe a 39-year-old man who suffered from delayed pressure urticaria for 2 years. His severe symptoms did not respond to antihistamine (H1 and H2) treatment and corticosteroid therapy was given despite severe side-effects. A new, nonsedating antihistamine drug, cetirizine, relieved most of his symptoms, enabled him to be weaned from corticosteroid therapy, and restored his former quality of life.