Trends and regional variations in provision of contraception methods in a commercially insured population in the United States based on nationally proposed measures.

OBJECTIVES: Three measures to assess the provision of effective contraception methods among reproductive-aged women have recently been endorsed for national public reporting. Based on these measures, this study examined real-world trends and regional variations of contraceptive provision in a commercially insured population in the United States. STUDY DESIGN: Women 15-44years old with continuous enrollment in each year from 2005 to 2014 were identified from a commercial claims database. In accordance with the proposed measures, percentages of women (a) provided most effective or moderately effective (MEME) methods of contraception and (b) provided a long-acting reversible contraceptive (LARC) method were calculated in two populations: women at risk for unintended pregnancy and women who had a live birth within 3 and 60days of delivery. RESULTS: During the 10-year period, the percentages of women at risk for unintended pregnancy provided MEME contraceptive methods increased among 15-20-year-olds (24.5%-35.9%) and 21-44-year-olds (26.2%-31.5%), and those provided a LARC method also increased among 15-20-year-olds (0.1%-2.4%) and 21-44-year-olds (0.8%-3.9%). Provision of LARC methods increased most in the North Central and West among both age groups of women. Provision of MEME contraceptives and LARC methods to women who had a live birth within 60days postpartum also increased across age groups and regions. CONCLUSIONS: This assessment indicates an overall trend of increasing provision of MEME contraceptive methods in the commercial sector, albeit with age group and regional variations. If implemented, these proposed measures may have impacts on health plan contraceptive access policy.

Bleeding pattern and cycle control of a low-dose transdermal contraceptive patch compared with a combined oral contraceptive: a randomized study.

OBJECTIVE(S): The aim of this study was to investigate the bleeding pattern and cycle control of a contraceptive patch containing 0.55 mg ethinyl estradiol (EE) and 2.1 mg gestodene (GSD) compared with a combined oral contraceptive (COC) containing 0.02 mg EE and 0.1 mg levonorgestrel (LNG). STUDY DESIGN: In this phase III, randomized, controlled, double-blind, double-dummy, multicenter trial, healthy women aged 18-45 years (smokers aged 18-35 years) received either the EE/GSD patch and a placebo tablet (n=171), or a placebo patch and the COC (n=175) for seven 28-day cycles. Bleeding control was assessed in two 90-day reference periods. RESULTS: Mean number of bleeding/spotting days was comparable across treatment groups in both reference periods (p>.05). Mean number of bleeding/spotting episodes was also comparable in reference period 1; however, there were fewer bleeding/spotting episodes for COC in reference period 2 (3.4 versus 3.1; p=.01). Mean length of bleeding/spotting episodes was comparable across treatment groups for both reference periods (p>.05). Withdrawal bleeding occurred consistently in both groups over the entire treatment period, but its absence was more common in the COC group in cycles 4 and 6 of reference period 2 (p<.01). Intracyclic bleeding was comparable between groups. CONCLUSION(S): Bleeding pattern and cycle control with the EE/GSD patch was comparable to an EE/LNG-containing COC. IMPLICATIONS STATEMENT: The findings suggest that bleeding patterns with the EE/GSD patch are similar to an EE/LNG-containing COC, except for absence of withdrawal bleeding, which was less common in patch users. The EE/GSD patch may constitute an additional contraceptive option for women.

Purification and some properties of factor D of the human properdin system.

Factor D has been purified by gel and ion exchange chromatographies, and by ultrafiltration through different membranes. The final preparation appeared pure in various analytical tests. The molecular weight of human D is 21,500 according to gel chromatography, the isoelectric point was found at pH 7.8. Factor D is an active esterolytic enzyme, it cleaves N-alpha-acetyl-L-lysine methyl ester and N-alpha-acetyl-L-glycyl-L-lysine methyl ester. Both peptide esters inhibit the hydrolytic activation of factor B by D in the presence of cobra venom factor. D is also inhibited by diisopropyl-fluorophosphate and by penylmethyl-sulfonyl-flouride.

Stages of anti-N-like immunization: a further contribution to problems arising from anti-N-like antibodies in hemodialysis patients.

In the past years, the discussion around problems arising from anti-N-like antibodies has waned in spite of their continuing existence. Even highly sophisticated rinsing procedures of dialysers after sterilisation with Formalin are not capable of preventing an anti-N-like immunization. Therefore, formalin sterilisation should no longer be employed. Three stages of the formalin-dependent anti-N-like immunization are described. Hematological and immunohematological problems in this patient group are documented.

Characterization of formaldehyde-related antibodies encountered in hemodialysis patients at different stages of immunization.

In hemodialysis patients who reuse formaldehyde-sterilized dialysers we found that antibodies agglutinating native NN red cells belonged exclusively to the IgM fraction of immunoglobulins. In the same patients antibodies directed against formaldehyde-altered NN red cells proved to be mainly IgG in addition to IgM. Three stages of formaldehyde-dependent RBC immunization could be distinguished serologically. The production of these antibodies was dependent on the time of hemodialysis treatment. We found antibodies which could bind complement in the presence of soluble antigen. These antibodies are supposed to damage the patient's red cells immediately after contact to minute amounts of formaldehyde during hemodialysis.

Purification of a human serum protein ("factor E") which enhances cobra venom factor-induced indirect lysis. Identification with the fifth component of complement.

Complexes formed of Cobra venom factor (CVF) and activated factor B (B) by interaction of CVF and B with trypsin or factor D are capable of activating the third and fifth complement component. When incubated with sheep or guinea pig red cells and guinea pig serum in the presence of EDTA, these CVFB complexes produce "indirect lysis". Addition of a human serum factor, earlier designated as factor E (6), greatly enhances the efficiency of this lytic system. The component with this activity has been purified to homogeneity (disc and immunoelectrophoresis). In chromatographic fractionations it was inseparable from the fifth complement component, it was inactivated by and reacted with several anti-C5 antisera, and kinetics of inactivation by heat (56 degrees C) and trypsin were the same for factor E and hemolytic C5 activities. It is concluded that factor E is the fifth component of human complement. Guinea pig C5 is not capable of supporting indirect lysis in a comparable manner, for as yet unknown reasons. Some possible explanations are discussed.

Cleavage of the third complement component (C3) and generation of the spasmogenic peptide, C3a, in human serum via the properdin pathway: demonstration of inhibitory as well as enhancing effects of epsilon-amino-caproic acid.

Human and guinea pig serum loses hemolytic activity of the third complement component (C3) during incubation at 37 degrees C. The loss is due to specific C3 cleavage involving the properdin system. This is concluded from the finding that C3 inactivation is prevented by EDTA, by elimination of properdin factor B, and unimpaired in C4 deficient guinea pig serum. In the presence of 1 M epsilon-amino-caproic acid (EACA) spontaneous C3 cleavage is considerably enhanced and accompanied by the appearance of biologically active C3a. Lower concentrations of EACA inhibit rather than enhance C3 cleavage in serum. The inhibitory effect of EACA is due to interference with the interaction of the properdin factors and their action on C3 as demonstrated in various systems: the assembly of an active C3-cleaving complex on zymosan, its regeneration after decay by factor D and factor B (GBG), cleavage of GBG by C3b and factor D in systems of purified components, and cleavage of C3 by preformed properdin complexes. Reactions involving the cobra venom factor were likewise depressed. In all these systems EACA was inhibitory even at 1M concentration. No single step in the development or action of an active properdin system was found to be enhanced by 1 M EACA. The enhancing effect of high concentrations of EACA on C3 cleavage in serum may be explained by its observed inhibition of C3b inactivator (C3bINA). This factor controls the properdin system by destroying C3b. In serum the inhibitory effect of 1 M EACA on C3bINA appears to allow escape of the properdin system from its control and thus to increase its net activity toward C3 despite inhibition of the enzymic reactions proper. At lower concentrations the effect of EACA on C3bINA is apparently less significant; therefore, at low concentrations of EACA, its inhibitory effects on C3 cleavage by the properdin system in serum prediominate.

Characterization and quantification of anti-T in human serum using a reliable hemolysis test.

The need of fresh-frozen donor plasma with a low level of anti-T has been emphasized recently. Anti-T, as administered by transfusion of fresh-frozen plasma, has been accused repeatedly of enhancing hemolysis in septic children with T transformation of red cells. Therefore, a new hemolysis test for the quantification of anti-T in human serum has been developed. With our test, anti-T-poor plasma donors can be found. Additional results raise substantial doubt as to the pathogenetic role of anti-T in the development of the hemolytic-uremic syndrome, found in septic children with red-cell T transformation. It is impossible to predict in vivo hemolysis induced by anti-T knowing the temperature characteristics and the ionic conditions causing this antibody to mediate hemolysis in vitro. Obviously, T transformation itself plays the major pathogenetic role in these patients, and not the presence of anti-T. In the case of disseminated intravascular coagulation, a content of anti-T cannot be construed as prohibiting transfusion of fresh-frozen plasma to such patients.

Formation and composition of the C3 activating enzyme complex of the properdin system. Sequential assembly of its components on solid-phase trypsin-agarose.

An active C3 cleaving enzyme is generated when properdin factor B (glycine-rich beta-glycoprotein, GBG) is activated (GBG is cleaved) by factor D in the presence of C3b and Mg++. Factor D can be replaced by trypsin in this reaction but even then C3b and Mg++ are required. In the absence of C3b and/or Mg++ trypsin does not generate C3 cleaving activity from GBG although it cleaves GBG and releases its GGG fragment (B) under these conditions as well. Addition of C3b to GGG immediately after its release does not yield a C3 cleaving enzyme. These findings indicate that C3b, GBG and Mg++ interact, and that only in association with C3b can GBG be cleaved in a way that its enzyme activity, residing in a C3b, GGG complex, is expressed. The complex is labile (half-life at 20 degrees C: 9 minutes); Mg++ does not affect its stability nor is it essential for the activity. It was possible to sequentially fix on agarose the essential components of the C3 cleaving enzyme and thus to elucidate the single steps and the order of its formation. C3 was activated and the resulting C3b fragment fixed on agarose by incubating C3 with trypsin covalently bound to the agarose. The agarose-C3b intermediate was capable of binding GBG provided Mg++ was present. GBG could then be cleaved by factor D or trypsin added in solution; the solid-phase-fixed complex obtained had C3 cleaving activity, in the presence as well as absence of Mg++. Omission of any of these steps or components, or changes in the sequence did not give rise to an active enzyme. Mixtures of C3b, GBG and Mg++ have weak C3 cleaving activity by themselves. C3 cleavage in such incubation mixtures proceeds slowly for hours and is not accompanied by cleavage of GBG. There is thus complete analogy between the CVF-dependent and C3b-dependent C3 cleaving systems. C3b and CVF act in the same way, they form a reversible, weakly active C3 cleaving complex with GBG and Mg++, the activity of which is markedly enhanced but becomes subject to decay when GBG is cleaved by trypsin-like enzymes while bound to CVF or C3b.

Patients with anti-Vel--immunohematological characterization and transfusion management.

As reported by other authors we can confirm that the frequency of the blood group Vel negative in Lower Saxony is 1:4000. We report on a patient whose serological characteristics (IgM- and IgA-anti-Vel) made the transfusion of Vel positive blood impossible. Since it was not possible to obtain sufficient Vel negative red cell units in time, the patient was convinced to donate blood for autologous transfusions. This should be the procedure of first choice in the transfusion management of such patients.

T and Tk transformation in hemolytic uremic syndromes.

In two cases of hemolytic uremic syndrome (HUS) the bacterial pathogenesis of the disease could be elucidated by lectin red cell agglutination tests. The possible role of anti-T and anti-Tk antibodies is discussed. Transfusions of fresh plasma had no adverse effects. The fatal outcome in one case was caused by disseminated intravascular coagulation (DIC).

[Flow cytometry analysis of IGG subclasses of auto- and alloantibodies in autoimmune hemolytic anemia and hemolytic disease of the newborn]. / Durchflusszytometrische Analysen der IgG-Subklassen von Auto- und Alloantikörpern bei autoimmunhämolytischen Anämien und Morbus haemolyticus neonatorum.

Red cell IgG antibodies capable of causing hemolytic disease of the newborn (HDN) or autoimmune hemolytic anemia (AIHA) have been analyzed concerning their IgG subclasses using flow cytometry. The results were always in agreement with those of the direct Coombs test. Anti-A and/or anti-B able to cause HDN belonged to the IgG1 subclass (4/8 cases) or to the subclasses IgG1 and IgG2 (4/8 cases). In 3 out of 4 cases of HDN caused by Rh antibodies the antibodies belonged to the subclasses IgG1 and IgG3. In patients with lymphoma but without AIHA, red cell autoantibodies were often found to be IgG1 only (n = 10), in low concentrations. In cases of acute AIHA in adults caused by IgG autoantibodies the subclass IgG3 was found in addition to IgG1 in 4/5 cases. In our opinion flow cytometry should become substantial for immunohematological diagnostics.

[Rh-D genotyping for exon 2, 5 and 7 of German and Japanese blood donors with sequence specific polymerase chain reaction]. / Rh-D-Genotypisierung auf Exon 2, 5 und 7 von deutschen und japanischen Blutspendern mit sequenzspezifischer Polymerasekettenreaktion.

RHD genotyping from fetal cells was applied for the detection of the RHD gene in the fetus of immunized Rh-D-negative women. Additionally, RHD genotyping was applied for the characterization of Rh-D variants. Although 44 nucleotide substitutions are known to code for 35 amino acid differences between the RHCE and the RHD gene, only a few polymorphisms have been investigated yet. We investigated 7 RHD-specific nucleotides on exons 2, 5, and 7 with sequence-specific primers and 1 nucleotide with ligation-based typing. All RHD genotyping results were correlated with serological results and established genotyping methods in 116 German and 98 Japanese blood donors, because different genetic sequences coding for Rh-D polypeptides have been described in different ethnic groups. Sequence-specific amplification of D-specific sequences was concordant with the serological result in all blood donors tested. However, ligation-based typing on exon 5 gave false-negative results in 7 donors. In summary, 5 new sequence-specific PCRs have been evaluated for further characterization of Rh-D variants. Furthermore, the methods described allow nested PCR and thus may help in determination of the fetal RhD status from maternal peripheral blood during pregnancy.

[Hemolytic-uremic syndrome in an adult with T-cryptantigen liberation]. / Hämolytisch-urämisches Syndrom des Erwachsenen mit T-Kryptantigen-Freilegung.

Haemolytic uraemic syndrome was diagnosed in a 36-year-old woman with acute renal failure (creatinine 10.5 mg/dl), haemolytic anaemia (haemoglobin 9.7 g/dl, lactate dehydrogenase 1926 U/l) and thrombopenia (98,000/microliters). After initial plasmaphereses and high doses of furosemide all symptoms disappeared within three weeks. The lectin tests demonstrated that the illness was connected with the liberation of T-crypt-antigen (Thomsen-Friedenreich antigen) on the erythrocytes. This special form of the haemolytic uraemic syndrome (neuraminidase-induced haemolytic uraemic syndrome) has previously been observed almost exclusively in children. However, for diagnosis and differentiation of haemolytic uraemic syndromes the presence of liberated T-antigen on erythrocytes should also be tested for in adults.

[Initial results of a prospective study with automated solid phase and column/agglutination techniques in screening for transfusion relevant IgG antibodies]. / Erste Ergebnisse einer prospektiven Studie mit automatisations-fähigen Festphasen- und Säulen-/Agglutinationstechniken beim Screening auf transfusions-relevante IgG-Antikörper.

We report the first results of a prospective study concerning antibody screening in transfusion recipients. We compared the standard tube test (Liss Coombs) with two commercial tests for the detection of red cell IgG antibodies: (1) a column/agglutination test and (2) a microplate/solid-phase system. The results of the study demonstrate several significant advantages of the two methods as compared with the standard tube test. The new methods, especially the microplate test, are superior in determining red cell antibodies which are relevant to transfusion. The two methods are more sensitive and, when automated, more efficient and safer as compared with the standard tube test.

HFE genotype and parameters of iron metabolism in German first-time blood donors - evidence for an increased transferrin saturation in C282Y heterozygotes.

BACKGROUND: Hemochromatosis is usually inherited in an autosomal recessive mode and associated with missense mutations in the hemochromatosis gene (HFE), an HLA class 1 related gene. However the degree of penetrance is presently matter of debate. METHODS: To elucidate the frequency of HFE mutations in a German population and the relationship between genotype and phenotype, we determined the HFE C282Y and H63D genotypes in 500 first-time blood donors using an allele-specific ligase chain reaction (LCR). Ferritin and transferrin saturation (TS) of all donors found to have at least one mutation were compared to gender- and age-matched controls. RESULTS: The C282Y allele frequency was 46 in 1000 chromosomes (4.6 %). The allele frequency of H63D was 108 in 1000 (10.8 %) chromosomes. We found three persons homozygous for H63D, nine compound heterozygotes and none homozygous for C282Y. TS was elevated in C282Y heterozygotes (p = 0.002) and C282Y/H63D compound heterozygotes (p = 0.04) compared to wild-type controls. Serum ferritin tended to be elevated in compound heterozygotes (p = 0.053). Mean corpuscular volume (MCV) and hemoglobin (MCH) were not different from controls. CONCLUSION: The frequency of HFE mutations in the tested population was comparable to those of other northern European populations. The elevated TS in subjects carrying a single copy of the C282Y mutation suggests that C282Y heterozygosity is associated with an increased intestinal iron absorption and might therefore offer a selection advantage in conditions of iron depletion.

[Hemolytic-uremic syndrome in pneumococcal meningitis and infection. Importance of T-transformation]. / Hämolytisch-urämisches Syndrom bei Pneumokokken-meningitis und -sepsis. Bedeutung der T-Transformation.

A 4 month old girl developed a severe hemolytic uremic syndrome (HUS) following pneumococcal sepsis and meningitis. As a result of the hemolytic anemia and thrombocytopenia with associated gastrointestinal bleeding several red blood cell and thrombocyte transfusions became necessary. No plasma was transfused to the patient and all cellular blood components to be transfused were washed thoroughly in order to avoid the administration of eventually dangerous donor anti-T antibodies. Continuous peritoneal dialysis was performed for 23 days until sufficient spontaneous urine production was resumed. From the start of increased hemolysis T-transformation of the patient's red blood cells could be shown; bacterial neuraminidase was proven in the patient's serum, which could be neutralized in vitro by a commercial intravenous IgG preparation. The direct Coombs-Test was negative and no significant amounts of anti-T antibodies were detectable in the patient's serum at any stage of the disease. Our observation suggest that the T-transformation itself has caused the increased hemolysis and not an antigen-antibody (T-anti-T) reaction. In cases of HUS und proven T-transformation, intravenous IgG preparations should be tried therapeutically to inhibit the bacterial neuraminidase.

Flow cytometric analyses of the subclasses of red cell IgG antibodies.

We report on flow cytometric IgG subclass determinations of red cell antibodies using polyclonal FITC-labeled antibodies. The limit of detection of this method was 1 ng anti-D per 1 x 10(7) red cells. The inter- and intra-assay coefficients of variance were 8.2 and 2.3%, respectively. In 8 newborns with a positive direct antiglobulin test (DAT) in the gel centrifugation test (GCT), due to ABO antibodies, IgG1 was detected in all and IgG2 additionally in 4 of these cases. In 5 severe cases of hemolytic disease of the newborn (HDN) due to anti-D, large amounts of IgG1 were found, and in 3 of these 5, IgG3 in combination with IgG1. In 8 mild or moderate HDN cases (4 anti-D, 2 anti-E, 1 anti-Fya, 1 anti-Jka), phototherapy sufficed, and IgG1 was the only antibody. In 7 adult patients with malignant lymphoma and a positive DAT (GCT), only small amounts of IgG1 red cell autoantibodies could be demonstrated by flow cytometry. In 5 further patients with malignant lymphoma, a positive DAT, and severe hemolytic anemia, large amounts of IgG1 autoantibodies were found and IgG3 was also present in 3 of these cases. Flow-cytometric determination of IgG subclasses may be a useful tool in immunohematology, since subclass determinations were possible in all of these cases. This method is suited for clinical routine and offers the possibility of sufficient standardization.

Frequency and causes of refractoriness in multiply transfused patients.

The use of leukocyte-depleted blood components has become the standard therapy for multiply transfused patients during the past few years, as a measure to reduce the frequency of alloimmunization and refractoriness. We assessed frequency and causes of refractoriness, defined as a repeated 24-h post-transfusion platelet count below 20,000/microliters, in 145 consecutive patients who received three or more single-donor platelet concentrates during a 1-year period. Flow-cytometric detection of anti-platelet antibodies and a glycoprotein-specific ELISA were applied for the diagnosis of alloimmunization. Forty patients (27.6%) had at least one episode of refractoriness. In 25 of these 40 patients (62.5%), nonimmune factors (fever, sepsis, coagulopathy, splenomegaly) alone were the cause. In 15 refractory patients alloantibodies were detected. In seven patients (17.5%), alloimmunization alone caused an inadequate transfusion response, while in eight refractory patients (20.0%) alloimmunization and fever or sepsis were present. HLA antibodies were detected in 17 patients (11.7%); three patients (2%) had platelet-specific antibodies in addition to HLA antibodies; in two patients panreactive platelet antibodies were detectable. All 17 patients had a history of previous transfusions or pregnancy. We did not observe primary immunization in patients transfused exclusively with filtered (leukodepleted) blood products. Our data suggest that alloimmunization in patients with a negative risk history can be prevented by the exclusive use of leukodepleted blood components.

Flow cytometric detection of platelet-reactive antibodies and application in platelet crossmatching.

BACKGROUND: Alloimmunization against HLA or platelet antigens can cause refractoriness to platelet transfusions in multiply transfused patients. Crossmatching of platelet concentrates is effective in overcoming this problem. STUDY DESIGN AND METHODS: A flow cytometric assay was used for simultaneous detection of lymphocyte-reactive and platelet-reactive antibodies in a single sample using fluorescein isothiocyanate-labeled anti-IgG. This assay was compared with the monoclonal antibody-specific immobilization of platelet antigens (MAIPA) assay in selected sera containing HLA and platelet antibodies. In a further study, this assay was compared with lymphocytotoxicity test results from thrombocytopenic patients, for whom platelet concentrates were ordered. The results of both assays were then correlated with the 1-hour corrected count increment, with a corrected count increment greater then 7500 considered as an adequate transfusion response. RESULTS: The results of the MAIPA and flow cytometric assay in detecting platelet-reactive antibodies correlated well (p<0.0001, r = 0.84). The sensitivity and specificity of the flow cytometric assay in detecting platelet-reactive antibodies were 94.7 and 96.3 percent, when the MAIPA assay was taken as a reference. In unselected sera from patients, the sensitivity and specificity of the flow cytometric assays were, respectively, 72.7 and 91.7 percent in detecting lymphocyte-reactive antibodies and 70.6 and 77.7 percent in detecting platelet-reactive antibodies, when the lymphocytotoxicity test was used as a reference. With regard to an adequate transfusion response, the sensitivities and efficiencies were 20.0 and 82.1 percent, 33.3 and 84.3 percent, and 70.0 and 88.6 percent for the lymphocytotoxicity test and the lymphocyte-reactive and platelet-reactive flow cytometric assays, respectively. CONCLUSION: Flow cytometric crossmatching appears to be an effective method of detecting platelet-reactive antibodies that may affect the success of platelet transfusions. This procedure is well-suited for routine conditions and can be performed within 2 hours.