Jk3 alloantibodies during pregnancy-blood bank management and hemolytic disease of the fetus and newborn risk.

BACKGROUND: The Kidd-null phenotype, Jk(a-b-), occurs in individuals who do not express the JK glycoprotein. Jk(a-b-) individuals can make an antibody against the Jk3 antigen, a high-incidence antigen present in more than 99.9% of most populations. This presents many challenges to the blood bank including identification of the antibody, masking of other antibodies, and how to provide transfusion support given the rarity of Jk3-negative blood products. Kidd antibodies may cause acute and delayed hemolytic reactions as well as hemolytic disease of the fetus and newborn (HDFN). In this article, we present a series of four practical cases of pregnant women with the anti-Jk3 alloantibody that demonstrate a range of clinical presentations of Kidd-related HDFN. STUDY DESIGN AND METHODS: We retrospectively reviewed the clinical and blood bank records for four patients and their newborns encountered at institutions in Tennessee, Missouri, Hawaii, and Guam with an anti-Jk3 identified during pregnancy. RESULTS: Two cases showed no significant evidence for HDFN, while two cases were of mild-to-moderate severity requiring early delivery due to elevated middle cerebral artery (MCA) flow velocities but requiring only phototherapy for hyperbilirubinemia. No intrauterine or neonatal transfusions were necessary. Anti-Jk3 alloantibody titers ranged from 2 to 128. CONCLUSION: Clinical manifestations of anti-Jk3 HDFN are generally mild to moderate. Anti-Jk3 titers were not found to correlate directly with HDFN severity. We suggest a titer of 16 to 32 as a cutoff for implementing enhanced monitoring of fetal MCA flow velocities, as such titers may be indicative of elevated HDFN risk.

Thinking about thinking and emotion: the metacognitive approach to the medical humanities that integrates the humanities with the basic and clinical sciences.

Medical knowledge in recent decades has grown prodigiously and has outstripped the capacity of the human brain to absorb and understand it all. This burgeoning of knowledge has created a dilemma for medical educators. We can no longer expect students to continue memorizing this large body of increasingly complex knowledge. Instead, our efforts should be redirected at developing in students a competency as flexible thinkers and agile learners so they can adeptly deal with new knowledge, complexity, and uncertainty in a rapidly changing world. Such a competency would entail not only cognitive but also emotional skills essential for the holistic development of their professional identity. This article will argue that metacognition--"thinking about thinking (and emotion)"--offers the most viable path toward developing this competency. The overwhelming volume of medical knowledge has driven some medical schools to reduce the time allocated in their curricula to the "soft-option" humanities as they tend to consider them an expendable "luxury." Vanderbilt University School of Medicine, Nashville, TN, has moved away from the traditional conception of the medical humanities as "the arts," composed of art, music, and literature, toward an approach that integrates the humanities with the basic and clinical sciences, based on metacognition. This metacognitive approach to the humanities, described in this article, has three goals: 1) to develop students as flexible thinkers and agile learners and to provide them with essential cognitive and emotional skills for navigating medical complexity and uncertainty; 2) to elicit in students empathy and tolerance by making them aware of the immense diversity in human cognition (and emotion); and 3) to integrate the humanities with the basic and clinical sciences. Through this metacognitive approach, students come to understand their patterns of cognition and emotions, and in the group setting, they learn to mindfully calibrate their thinking and emotions. They gain a humbling appreciation of the fallibility of the human mind/brain and how cognitive biases and misperception can lead to medical error. They come to appreciate the complex interplay between cognition and emotion, and the importance of cognitive monitoring and emotional regulation. In the group setting, students also gain a sense of perspective of their thinking patterns and emotions in relation to those of their peers. Perspective taking and mindfulness engender tolerance and empathy, which ultimately serves as a platform for working collaboratively in teams as medical professionals. Students become aware of the social context in which thinking and learning occur, and this further shapes their professional identity. Thinking, learning, and interacting in the group setting ultimately induces a shift from self-preoccupation and an individualistic approach to knowledge toward an appreciation of collective cognition and empathy towards others. In this article, I describe the metacognitive approach to the medical humanities at Vanderbilt University School of Medicine and how it is designed to develop students as agile learners and flexible thinkers with the mindful capacity for cognitive and emotional monitoring and regulation. Thinking and learning in the group setting of the colloquium ultimately also fosters the student's professional identity.