Ward treatment milieu and posthospital functioning.

Two units of seven and 14 state hospital wards were used in a study to explore possible relationships between some socio-cultural aspects of ward environments and outcome of treatment as assessed by time out of the hospital after discharge. Confounding variables such as pretreatment characteristics, length of hospitalization, and community of discharge make conclusions from many such studies tenuous. Methods were derived and are here described in detail that reduce the influence of some of these variables. Within unit 2 (14 wards), a vector of social structure that differentiated the wards and consisted of two highly correlated factors on the Ward Atmosphere Scale was found to be significantly associated with outcome. Those wards seen by both patients and staff as lower in the allowance of expression of anger and aggression and higher in order and organization (only staff's perception) had better outcomes. The wards of unit 1 were homogeneous both in outcome and in staff and patients' assessments of order and organization and freedom to express anger and aggression.

Effect of the factor V Leiden mutation on the clinical expression of severe hemophilia A.

To determine whether the factor V Leiden mutation is associated with decreased bleeding in individuals with severe hemophilia A, factor concentrate utilization, maximum annual number of bleeding episodes, and the prevalence of hemophilic arthropathy between carriers and non-carriers of the factor V Leiden mutation were compared. Heterozygosity for the factor V Leiden mutation was found in 6 of 137 subjects (4.4%). Carriers of the factor V Leiden mutation utilized less factor concentrate (geometric mean: 310 vs. 1185 units/kg/year) and had fewer bleeding episodes than non-carriers (proportion with 10 or fewer bleeding episodes in their worst year: 50 vs. 11%). However, the factor V Leiden mutation was not associated with the absence of arthropathy. The intron 22 inversion mutation of the factor VIII gene was tested for in a subgroup of 80 subjects, but it was not found to be a significant variable for any of the bleeding endpoints. The results of this small study are consistent with the hypothesis that the factor V Leiden mutation imparts a protective effect; however, a larger confirmatory study in which the factor VIII molecular defects can be controlled for is needed. Furthermore, most severe hemophiliacs who used fewer than 200 units/kg/year of factor concentrate or who had experienced 10 or fewer bleeding episodes per year did not carry the factor V Leiden mutation, suggesting that the proportion of severe hemophiliacs whose mild clinical course can be attributed to the factor V Leiden mutation is small.

Effect of splenectomy on slowing human immunodeficiency virus disease progression.

BACKGROUND: Lymphoreticular tissue is the most important site for human immunodeficiency virus (HIV) replication in HIV-infected individuals. OBJECTIVE: To compare the long-term effect of splenectomy on survival and time to development of acquired immunodeficiency syndrome in subjects who had undergone splenectomy with subjects who had not undergone splenectomy. DESIGN: A cohort study with a follow-up of up to 13.4 years. SETTING: Subjects were recruited from a hospital outpatient clinic population and a multicenter study of patients with hemophilia. PARTICIPANTS: Forty-five HIV-infected individuals were observed prospectively for up to 13.4 years (17 had undergone splenectomy and 28 had not undergone splenectomy). Five subjects underwent splenectomy before acquiring HIV infection and 12 underwent splenectomy during the asymptomatic phase of HIV infection. The group who did not undergo splenectomy consisted of HIV-infected individuals who were asymptomatic at study enrollment. MAIN OUTCOME MEASURES: A Cox proportional hazards model was used to test the effects of splenectomy on survival and time to development of acquired immunodeficiency syndrome when adjusting for potential confounders (age, initial CD4+ cell count, and treatment with antiretroviral drugs). Splenectomy was treated as a time-dependent covariate to account for the variation in its timing. RESULTS: During the average follow-up of 8.6 years, 9 (53%) of the 17 subjects who underwent splenectomy and 23 (82%) of the 28 subjects who did not undergo splenectomy died; acquired immunodeficiency syndrome developed in 6 (35%) of the subjects who underwent splenectomy and 23 (82%) of the subjects who did not undergo splenectomy. Splenectomy was associated with a significant reduction of risk of developing acquired immunodeficiency syndrome (adjusted relative risk [RR] <0.4, P<.05), whereas the effect on risk of mortality approached, although it did not reach, significance (adjusted RR approximately 0.5, P approximately .10). CONCLUSION: The absence of a spleen during the asymptomatic phase of HIV infection seems to have a beneficial effect on HIV disease progression.

Aprotinin reduces the need for blood products during liver transplantation.

BACKGROUND: Bleeding complications and blood product consumption have been a major concern during liver transplantation. Prevention of plasminogen activation and fibrinolysis by aprotinin administration has been shown to reduce perioperative bleeding during operations associated with high blood-product consumption. PATIENTS AND METHODS: Use of blood-products (packed red cells, frozen plasma, platelets, and cryoprecipitate) was analyzed both during the three stages of orthotopic liver transplantation and during total hospitalization of the 26 patients transplanted without aprotinin and the subsequent 40 patients with aprotinin. A similar analysis was performed for 15 patients immediately before and after the introduction of aprotinin to eliminate the "learning curve" effect for liver transplantation. The effect of epsilon-amino-caproic acid was analyzed as 13 patients received neither epsilon-aminocaproic acid nor aprotinin and 13 patients received epsilon-aminocaproic acid but not aprotinin. RESULTS: There was a significant reduction in total hospital use of cryoprecipitate, frozen plasma, platelets, and red cells in the aprotinin-treated patients. This reduction was seen during the anhepatic and reperfusion stages of liver transplantation. There was no difference in blood product consumption between the groups who were or were not treated with epsilon-aminocaproic acid. CONCLUSION: Aprotinin significantly reduces the need for red cell, frozen plasma, platelet, and cryoprecipitate transfusion use during orthotopic liver transplantation, and appears to be more efficacious than epsilon-aminocaproic acid.

A reexamination of the validity of the Children's Personality Questionnaire.

Scores on the Children's Personality Questionnaire (CPO) were correlated with ratings on the Devereux Elementary School Behavior Rating Scale (DESB). Three judges matched scales from the two instruments that appeared to measure the same behavior. For about one-third of these matches significant correlations in the predicted direction were found. Of the 156 possible correlations between CPQ factors and DESB scales 50 reaches significance. The results contradict those of a similar investigation (Willis & Sevmour, 1978), whose methodology is questioned. The correlations found in the present study provide limited support for the validity of CPQ factors.

Effects of lead poisoning on cognitive test performance.

47 lead-poisoned children, treated and without encephalopathy, are compared with sibling controls on perceptual-verbal pattern comparisons of subtests of the Wechsler Intelligence Scale for Children to determine whether there has been brain damage. Both groups of children do not differ significantly from each other on comparisons of these patterns, and they appear to be similar to each other in WISC functioning. The conclusion is that lead-poisoning, treated, and without encephalopathy, does not result in detectable brain damage by means of these pattern analyses.

The approach taken to reducing the risk of transfusion related acute lung injury in Canada.

Transfusion related acute lung injury (TRALI) has become a major reported cause of severe transfusion reactions and mortality. Over the past four years significant changes have been taken in Canada in order both to improve the recognition of the risk and to decrease its incidence. An international meeting was held in April of 2004 entitled "Towards an Understanding of TRALI". As a result of the analysis and recommendations from this meeting, the Canadian Blood Services established an ongoing review committee and established a laboratory diagnostic facility to identify at risk donors and recipients. A system has been developed to identify implicated donors and exclude them from the blood donor pool. Other steps have been taken to exclude potentially high risk donors, such as previously pregnant females, from the plasma and platelet donor pool. A considerable amount of education also has been offered to clinical services in the country. This paper summarizes the definitions, categorizations of implicated donors, and the ongoing precautionary activities related to plasma products. Noted within the article are the methods used for locating and selecting data. These were primarily based on the international TRALI conference in 2004, and from ongoing discussions and information provided by the Canadian Blood Services TRALI Review Committee. No ethics referral or approval was requested, and a summary is included in the article.

Blood product utilization and management in Canada.

The utilization of blood for transfusion in Canada has remained at 900,000-950,000 units p.a. for the past six years. Donation has decreased slightly from a peak of 1,200,000 units p.a. in 1989. The use of fresh plasma and cryo-precipitate has decreased while the use of platelets has doubled in the past six years. The increased use of albumen cannot be explained. In Vancouver, all anaesthesia residents take a compulsory transfusion medicine rotation which appears to be successful in rationalizing transfusion practice.

Recombinant blood components: clinical administration today and tomorrow.

Improvements in the technology of whole blood fractionation have resulted in the development of many subfractions that allow more specific management of clotting deficiencies, such as the hemophilias. Infective disasters have occurred in recent years, which has led to concern regarding the use of human blood components. There has been great interest in the search for alternatives, such as synthetic volume expanders, antifibrinolytic drugs, and hormones to stimulate bone marrow production. Recombinant technology has developed rapidly over the past 15 years, and several products are now available for use, including recombinant factor VIII and recombinant factor VIIa for the treatment of hemophilia and recombinant erythropoietin to stimulate red blood cell production. As these recombinant proteins are complex, they require mammalian cell lines as their substrate. Recombinant processes have the potential to produce sufficient quantities of these products for the treatment of patients around the world independent of a human plasma source. The introduction of all of the new recombinant products has been done in an orderly fashion through clinical trials. Erythropoietin was extensively reviewed initially for its effect in chronic renal failure patients and appears to have other applications. Recombinant factor VIII has now become a mainstay of treatment for many patients with hemophilia A, and recombinant factor VIIa has a major role to play in the management of patients with inhibitors to factors VIII and IX. We anticipate the availability of other recombinant blood proteins soon.

The introduction of high-purity products in Canada.

In October 1993, the Canadian Blood Agency, the agent for the provinces/territories in Canada, agreed to the introduction of high-purity coagulation products, either recombinant or highly purified factor concentrates, for the management of coagulation deficiencies. This represented a cost increase of approximately $30 million (40%) for the national coagulation product inventory. Representatives of the relevant recipients of the products, some of the treaters, the distributor and the funders met on a regular basis in order to monitor the impact of these new products. The Association of Hemophilia Clinic Directors of Canada also agreed to include some specific outcome studies over a longer period of time to include evaluation of inhibitor formation, prophylaxis regimens, immune status and the incidence of thrombosis. The 'Hemophilia and Von Willebrand's Disease' clinical practice guidelines were also developed under their auspices. A usage monitoring system has been implemented and has been continuously managed by the Canadian Blood Agency. This resulted in trends of practice and rationales for unexpected use being identified early for planning and funding purposes. The Working Group set up under the auspices of the Canadian Blood Agency was an effective vehicle to evaluate the conversion and the impact of these new products in the country and can serve as a model for future endeavours.