HLA class I depletion by citric acid, and irradiation of apheresis platelets for transfusion of refractory patients.

BACKGROUND: Patients can form antibodies to foreign human leukocyte antigen (HLA) Class I antigens after exposure to allogeneic cells. These anti-HLA class I antibodies can bind transfused platelets (PLTs) and mediate their destruction, thus leading to PLT refractoriness. Patients with PLT refractoriness need HLA-matched PLTs, which require expensive HLA typing of donors, antibody analyses of patient sera and/or crossmatching. An alternative approach is to reduce PLT HLA Class I expression using a brief incubation in citric acid on ice at low pH. METHODS AND MATERIALS: Apheresis PLT concentrates were depleted of HLA Class I complexes by 5 minutes incubation in ice-cold citric acid, at pH 3.0. Surface expression of HLA Class I complexes, CD62P, CD63, phosphatidylserine, and complement factor C3c was analyzed by flow cytometry. PLT functionality was tested by thromboelastography (TEG). RESULTS: Acid treatment reduced the expression of HLA Class I complexes by 71% and potential for C3c binding by 11.5-fold compared to untreated PLTs. Acid-treated PLTs were significantly more activated than untreated PLTs, but irrespective of this increase in steady-state activation, CD62P and CD63 were strongly upregulated on both acid-treated and untreated PLTs after stimulation with thrombin receptor agonist peptide. Acid treatment did not induce apoptosis over time. X-ray irradiation did not significantly influence the expression of HLA Class I complexes, CD62P, CD63, and TEG variables on acid treated PLTs. CONCLUSION: The relatively simple acid stripping method can be used with irradiated apheresis PLTs and may prevent transfusion-associated HLA sensitization and overcome PLT refractoriness.

What matters to patients? A systematic review of preferences for medication-associated outcomes in mental disorders.

OBJECTIVE: To investigate patients' preferences for outcomes associated with psychoactive medications. SETTING/DESIGN: Systematic review of stated preference studies. No settings restrictions were applied. PARTICIPANTS/ELIGIBILITY CRITERIA: We included studies containing quantitative data regarding the relative value adults with mental disorders place on treatment outcomes. Studies with high risk of bias were excluded. PRIMARY AND SECONDARY OUTCOME MEASURES: We restricted the scope of our review to preferences for outcomes, including the consequences from, attributes of, and health states associated with particular medications or medication classes, and process outcomes. RESULTS: After reviewing 11 215 citations, 16 studies were included in the systematic review. These studies reported the stated preferences from patients with schizophrenia (n=9), depression (n=4), bipolar disorder (n=2) and attention deficit hyperactive disorder (n=1). The median sample size was 81. Side effects and symptom outcomes outnumbered functioning and process outcomes. Severe disease and hospitalisation were reported to be least desirable. Patients with schizophrenia tended to value disease states as higher and side effects as lower, compared to other stakeholder groups. In depression, the ability to cope with activities was found to be more important than a depressed mood, per se. Patient preferences could not consistently be predicted from demographic or disease variables. Only a limited number of potentially important outcomes had been investigated. Benefits to patients were not part of the purpose in 9 of the 16 studies, and in 10 studies patients were not involved when the outcomes to present were selected. CONCLUSIONS: Insufficient evidence exists on the relative value patients with mental disorders place on medication-associated outcomes. To increase patient-centredness in decisions involving psychoactive drugs, further research-with outcomes elicited from patients, and for a larger number of conditions-should be undertaken. TRIAL REGISTRATION NUMBER: PROSPERO CRD42013005685.

Measuring interpersonal continuity in high-frequency home healthcare services.

AIM: To provide a method for assessing the degree of interpersonal continuity adapted to context and to measure and assess the degree of interpersonal continuity for long-term recipients dependent on daily home health care. BACKGROUND: Interpersonal continuity is important to the quality of care for long-term dependents. In high-frequency home healthcare services where patients receive daily care from many nurses or other health personnel over time, interpersonal continuity may be difficult to attain. DESIGN: A cross-sectional study with a descriptive design. METHODS: Information concerning 79 patients receiving long-term frequent care was collected during four weeks in a maximum variation sample of Norwegian municipalities, from January 2009-May 2010. We measured interpersonal continuity objectively using indices of dispersion and the next-day sequence of health personnel. For each measure, we computed the highest feasible level of continuity that could be attained in this home healthcare context given a standard shift plan. This level was then used as benchmark against which the actual level of continuity was assessed. RESULTS: Patients received on average 51 visits from a mean of 17 different carers during four weeks. The results revealed a low degree of interpersonal continuity in practice, far below what was feasible according to the benchmarks. CONCLUSION: High-frequency home health care was characterized by interpersonal discontinuity, but with potential for improvement. Objective measures of interpersonal continuity, when the benchmark is adapted to the context, are useful tools for planning and surveying continuity of care.