An epitope-based approach of HLA-matched platelets for transfusion: a noninferiority crossover randomized trial.

Platelet transfusion refractoriness results in adverse outcomes and increased health care costs. Managing refractoriness resulting from HLA alloimmunization necessitates the use of HLA antigen-matched platelets but requires a large platelet donor pool and does not guarantee full matching. We report the first randomized, double-blind, noninferiority, crossover trial comparing HLA epitope-matched (HEM) platelets with HLA standard antigen-matched (HSM) platelet transfusions. Alloimmunized, platelet-refractory, thrombocytopenic patients with aplastic anemia, myelodysplastic syndrome, or acute myeloid leukemia were eligible. HEM platelets were selected using HLAMatchMaker epitope (specifically eplet) matching. Patients received up to 8 prophylactic HEM and HSM transfusions provided in random order. The primary outcome was 1-hour posttransfusion platelet count increment (PCI). Forty-nine patients were randomized at 14 UK hospitals. For intention to treat, numbers of evaluable transfusions were 107 and 112 for HEM and HSM methods, respectively. Unadjusted mean PCIs for HEM and HSM methods were 23.9 (standard deviation [SD], 15) and 23.5 (SD, 14.1), respectively (adjusted mean difference, -0.1; 95% confidence interval [CI], -2.9 to 2.8). Because the lower limit of the 95% CI was not greater than the predefined noninferiority limit, the HEM approach was declared noninferior to the HSM approach. There were no differences in secondary outcomes of platelet counts, transfusion requirements, and bleeding events. Adequate 1-hour PCI was more frequently observed, with a mean number of 3.2 epitope mismatches, compared with 5.5 epitope mismatches for inadequate 1-hour increments. For every additional epitope mismatch, the likelihood of an adequate PCI decreased by 15%. Epitope-matched platelets should be considered to support HLA alloimmunized patients. This trial was registered at www.isrctn.com as #ISRCTN23996532.

Las dificultades en los modos de vinculación entre jóvenes y unidades sanitarias, como obstáculos en la accesibilidad de la atención de la salud / Difficulties in the relationship between young people and health facilities as obstacles to the access to health care

INTRODUCCIÓN Los modos de vinculación entre los jóvenes y las instituciones condicionan el acceso a la salud. OBJETIVOS Conocer las barreras de acceso a partir de las dificultades existentes en los modos de vinculación de la Unidad Sanitaria n° 35 con los jóvenes del Barrio El Carmen de Berisso. MÉTODOS La investigación desarrollada se enmarcó en el área de las ciencias sociales y fue desarrollada con técnicas propias de los enfoques cualitativos, mediante la realización de entrevistas en profundidad y observaciones participantes. RESULTADOS Se identificaron dos modalidades de vinculación con los pacientes en general y con los jóvenes en particular por un lado, el abordaje de los pacientes "no convencionales", es decir, aquellos que no se ajustaban a las normas institucionales; por el otro, una tendencia profesional que ensayaba diferentes alternativas de atención y acercamiento a la comunidad. DISCUSIÓN Es necesario indagar acerca de las representaciones institucionales que actúan como barreras de acceso, para promover acciones tendientes a revertir la situación de desvinculación existente entre la unidad sanitaria y los jóvenes.