Business continuity in blood services: two case studies from events with potentially catastrophic effect on the national provision of blood components.

BACKGROUND AND OBJECTIVES: NHS Blood and Transplant (NHSBT) and the Australian Red Cross Blood Service (ARCBS) are national blood establishments providing blood components to England and North Wales, and Australia, respectively. In 2012, both services experienced potentially catastrophic challenges to key assets. NHSBT suffered a flood that closed the largest blood-manufacturing centre in Europe, whilst ARCBS experienced the failure of a data centre network switch that rendered the national blood management system inaccessible for 42 h. This paper describes both crisis events, including the immediate actions, recovery procedures and lessons learned. MATERIALS AND METHODS: Both incidents triggered emergency response plans. These included hospital reprovisioning and recovery from the incident. Once normal services had been restored, both events were subjected to root cause analysis (RCA) and production of 'lessons learned' reports. RESULTS: In both scenarios, the key enablers of rapid recovery were established emergency plans, clear leadership and the support of a flexible workforce. Product issues to hospitals were unaffected, and there were no abnormal trends in hospital complaints. RCA identified the importance of risk mitigations that require co-operation with external organizations. Reviews of both events identified opportunities to enhance business resilience through prior identification of external risks and improvements to contingency plans, for example by implementing mass messaging to staff and other stakeholders. CONCLUSIONS: Blood establishment emergency plans tend to focus on responding to mass casualty events. However, consolidation of manufacturing to fewer sites combined with a reliance on national IT systems increases the impact of loss of function. Blood services should develop business continuity plans which include prevention of such losses, and the maintenance of services and disaster recovery.

Plasma concentrations of endotoxin and platelet activation in the developmental stage of oligofructose-induced laminitis.

The link between the fermentation of carbohydrate in the equine large intestine and the development of acute laminitis is poorly understood. Absorption of endotoxin (lipopolysaccharide; LPS) into the plasma has been observed in one experimental model of laminitis, but does not cause laminitis when administered alone. Thus, the potential role of endotoxin is unclear. Platelet activation has previously been demonstrated in the developmental stage of laminitis. Equine platelets are more sensitive than leukocytes to activation by endotoxin, and can be activated directly by LPS in the low pg/ml range, activating p38 MAP kinase and releasing serotonin (5-HT) and thromboxane. The objectives of this study were firstly to determine whether endotoxin and platelet activation could be measured in the plasma of horses in the developmental phase of laminitis induced with oligofructose. Secondly, the time course of events involving platelet activation and platelet-derived vasoactive mediator production was investigated. Laminitis was induced in six Standardbred horses by the administration of 10 g/kg bwt of oligofructose. Plasma samples were obtained every 4h, and platelet pellets were obtained by centrifugation. LPS was measured using a kinetic limulus amebocyte lysate assay, and platelet activation was assessed by Western blotting for the phosphorylated form of p38 MAP kinase. Plasma 5-HT was assayed by HPLC with electrochemical detection and thromboxane B(2) was measured by radioimmunoassay. Clinical signs of laminitis and histopathologic changes were observed in lamellar sections from five of the six horses. Onset of lameness was between 20 and 30 h after the administration of oligofructose. LPS increased above the limit of detection (0.6 pg/ml) to reach a peak of 2.4+/-1.0 pg/ml at 8 h. TNFalpha was also detectable in the plasma from 12 to 24 h. There was a time-dependent increase in platelet p38 MAPK phosphorylation, which peaked at approximately 12 h (3.8+/-1.3 fold increase); plasma 5-HT and thromboxane increased steadily after this time (2.9+/-0.6 and 11.3+/-5.0 fold increases, respectively). These data indicate that small quantities of endotoxin may move into the circulation from the large intestine after the sharp decrease in pH that occurs as a result of carbohydrate fermentation. Correlating these findings with in vitro studies suggests that LPS may primarily activate platelets, leading indirectly to the activation of leukocytes. Therefore, endotoxin may contribute in the initiation of the early inflammatory changes observed in experimental models of acute laminitis.

Bcl-2 family proteins are essential for platelet survival.

Platelets are relatively short-lived, anucleated cells that are essential for proper hemostasis. The regulation of platelet survival in the circulation remains poorly understood. The process of platelet activation and senescence in vivo is associated with processes similar to those observed during apoptosis in nucleated cells, including loss of mitochondrial membrane potential, caspase activation, phosphatidylserine (PS) externalization, and cell shrinkage. ABT-737, a potent antagonist of Bcl-2, Bcl-X(L), and Bcl-w, induces apoptosis in nucleated cells dependent on these proteins for survival. In vivo, ABT-737 induces a reduction of circulating platelets that is maintained during drug therapy, followed by recovery to normal levels within several days after treatment cessation. Whole body scintography utilizing ([111])Indium-labeled platelets in dogs shows that ABT-737-induced platelet clearance is primarily mediated by the liver. In vitro, ABT-737 treatment leads to activation of key apoptotic processes including cytochrome c release, caspase-3 activation, and PS externalization in isolated platelets. Despite these changes, ABT-737 is ineffective in promoting platelet activation as measured by granule release markers and platelet aggregation. Taken together, these data suggest that ABT-737 induces an apoptosis-like response in platelets that is distinct from platelet activation and results in enhanced clearance in vivo by the reticuloendothelial system.

Thin-film micro-electrode stimulation of the cochlea in rats exposed to aminoglycoside induced hearing loss.

The multi-channel cochlear implant (CI) provides sound and speech perception to thousands of individuals who would otherwise be deaf. Broad activation of auditory nerve fibres when using a CI results in poor frequency discrimination. The CI also provides users with poor amplitude perception due to elicitation of a narrow dynamic range. Provision of more discrete frequency perception and a greater control over amplitude may allow users to better distinguish speech in noise and to segregate sound sources. In this research, thin-film (TF) high density micro-electrode arrays and conventional platinum ring electrode arrays were used to stimulate the cochlea of rats administered sensorineural hearing loss (SNHL) via ototoxic insult, with neural responses taken at 434 multiunit clusters in the central nucleus of the inferior colliculus (CIC). Threshold, dynamic range and broadness of response were used to compare electrode arrays. A stronger current was required to elicit CIC threshold when using the TF array compared to the platinum ring electrode array. TF stimulation also elicited a narrower dynamic range than the PR counterpart. However, monopolar stimulation using the TF array produced more localised CIC responses than other stimulation strategies. These results suggest that individuals with SNHL could benefit from micro stimulation of the cochlea using a monopolar configuration which may provide discrete frequency perception when using TF electrode arrays.

Phytohaemagglutinin stimulation of human lymphocytes: effect of fatty acids on uridine uptake and phosphoglyceride fatty acid profile.

1. When added to cultures of human peripheral lymphocytes, saturated (palmitate, stearate, heptadecanoate) and unsaturated (oleate, linoleate, arachidonate) fatty acids bound to albumin at an acid-albumin ratio of 2:1, inhibited the phytohaemaegglutinin-stimulated uptake of [14C]-uridine. Uridine uptake in unstimulated cells was not affected by any of these fatty acids. 2. When saturated and unsaturated acids were present simultaneously in the incubation mixture the inhibit but relieved the inhibitory effects of both saturated and unsaturated fatty acids. 4. Stimulated and unstimulated cells incorporated exogenous fatty acids into membrane phosphoglycerides. Details of the fatty acid profiles are given. 5. Evidence is presented that the inhibition results, at least in part, from modification of phosphoglyceride fatty acid profile.

Contraception for teenagers and young adults with cancer.

Adolescence can be an extremely stressful time for all concerned. When this period is then compounded by the development of cancer, formidable and seemingly insurmountable problems may be perceived. Cancer in adolescence is relatively uncommon, with an annual incidence rate in western populations of approximately 150-200 per million. Five-year survival of patients diagnosed around 1990 exceeded 70% in the United Kingdom (UK) and United States of America (USA), and adolescents with cancer are likely to remain fertile. Further advances in therapeutic modalities are creating a generation of adolescents and young adults with cancer who can now aspire to the same sexual and reproductive activities as their healthy peers. This then raises the issue of avoidance of undesired pregnancy during and after treatment. This article aims to address the contraceptive needs of adolescents and young adults undergoing treatment for cancer.

The antinociception evoked by anterior pretectal nucleus stimulation is partially dependent upon ventrolateral medullary neurones.

Electrical stimulation (35 microA rms/15 s) of the anterior pretectal nucleus (APtN) inhibits the spinal reflex of the tail-flick (TF) to noxious heat in unanaesthetised rats. APtN stimulation also reduces the nociceptive response of spinal dorsal horn neurones in halothane-anaesthetised rats. This study determined if the antinociceptive effects of APtN stimulation depended on neurones in the ventral medulla. Bilateral electrolytic lesions of the ventrolateral medulla, but not the nucleus raphe magnus, reduced by 70% the antinociceptive effect of APtN stimulation in the TF test. In rats anaesthetised with halothane, electrical stimulation of the APtN (single square wave 0.1 msec pulses, 2-20 microA, 1 Hz) excited cells in the ventrolateral medulla. These data suggest a connection between both areas. This connection is further confirmed by neuroanatomical tract tracing studies in which the retrograde dye Fast Blue was injected into the ventrolateral medulla. Fluorescent cell bodies were found in the APtN. We therefore conclude that the ventrolateral medulla is part of a descending antinociceptive pathway from the APtN.

Antibody response to experimental Trypanosoma rangeli infection and its implications for immunodiagnosis of South American trypanosomiasis.

Differential immunodiagnosis of T. rangeli and T. cruzi infections in man poses a particular problem, not only because these parasites share antigenic determinants, as detected by immunofluorescence, but also because they have a similar geographical distribution, the same host range and often identical insect vectors. We show here that whereas mouse anti-T. rangeli sera have significant cross reactivity with T. cruzi by immunofluorescence, they are entirely specific when tested by ELISA, using apparently similar antigen preparations. Immunoprecipitation analysis detected relatively little cross-reactivity between heterologous antisera and parasite combinations. Intriguingly, immunization with T. rangeli epimastigotes was much more powerful than similar immunization with trypomastigotes, and the majority of the antibody was directed against a single polypeptide of apparent Mr 73kDa.

Improved methods for transplanting split-heart neonatal cardiac grafts into the ear pinna of mice and rats.

The rodent heterotopic ear-heart transplant method is a useful alternative to the more technically demanding vascularized graft technique. We modified the procedure to improve efficiency and used it in mice and rats to determine the survival times of both isologous and allogeneic grafts and compare reference immunosuppressants. Bisected rat and mouse cardiac (split-heart) isografts were uniformly viable up to 4 weeks postimplant; however, by 24 weeks only 90% of Lewis rat or C3H mouse split-heart isografts retained electrocardiographic activity, regressing to 81% by 60 weeks for the Lewis rat and to less than 50% for the C3H mouse by 43 weeks post-implant. The potency of tacrolimus, sirolimus, and cyclosporine for prevention of allograft rejection was comparable whether using split-hearts or whole hearts in the Balb/C to C3H mouse model. The maximally effective doses at 2 weeks postimplant for intraperitoneally administered tacrolimus, sirolimus, cyclosporine, and oral leflunomide with Brown-Norway (BN) to Lewis rat ear-split-heart allografts (0.3, 0.1, 3.0, 10, mg/kg/day, respectively) agreed extremely well with published data for the rat primary vascularized heterotopic heart model. This reproducible and efficient transplantation model was improved by using split-hearts to double available donor tissue, a gonadotropin-enhanced breeding strategy that enables routine use of low-fecundity inbred rats as donors, implantation devices that speed and simplify the procedure, and defined electrocardiographic evaluation criteria to maximize sensitivity and provide an objective endpoint for defining rejection.

Chemical burns of the eye: causes and management.

For the 14 months 1 January 1985 to 28 February 1986 all cases of chemical eye injury presenting to the Croydon Eye Unit were analysed. Of the 180 cases 19 were caused by assaults and 14 were admitted for treatment. The wide range of injurious substances is emphasised, and the circumstances of injury are listed. A discussion of the management of chemical eye injury is included.

Case of cerebrotendinous xanthomatosis. I: Unusual ophthalmic features.

A case of cerebrotendinous xanthomatosis is reported. In addition to the classical ophthalmic and systemic features the patient presented with unilateral proptosis. This feature has never previously been reported. The results of investigations are described and illustrated.

Radial keratotomy: a review of 300 cases.

Three hundred consecutive cases of radial keratotomy performed between 1985 and 1990 were reviewed. There were no sight threatening complications of surgery and no patient lost one or more lines of corrected Snellen acuity. Overall 78.7% saw 6/12 or better unaided postoperatively and 51.7% saw 6/6 or better. Refraction showed 61.3% to be within 1 dioptre of emmetropia and 86.7% were within 2 dioptres. Further analysis demonstrated that results of unaided acuity and proximity to emmetropia were much better for low (< -2.87 D) and moderate (-3.0 to -5.87 D) than for high (> -6.0 D) myopes.

A case of cerebrotendinous xanthomatosis. II: The sterol content of a cataractous lens.

The cholestanol content of a cataractous lens nucleus from a patient with cerebrotendinous xanthomatosis (CTX) was quantified by gas chromatography-mass spectrometry and found to be 0.27 micrograms per mg freeze-dried lens tissue. The cholestanol-cholesterol ratio of 1.7% in the lens nucleus was similar to that in the serum of the CTX patient. The cholestanol content and cholestanol-cholesterol ratio in the CTX lens were approximately four-fold and six-fold greater respectively than the mean levels found in three senile cataractous lens nuclei analysed simultaneously for comparative purposes.

A novel mutation in KRT12 associated with Meesmann's epithelial corneal dystrophy.

BACKGROUND: The molecular basis of Meesmann's epithelial corneal dystrophy (MECD) has recently been attributed to mutations in the cornea specific keratin genes KRT3 and KRT12. The mechanisms by which these mutations cause the Meesmann's phenotype are not clear. This study presents new data, examines clinical, histological, ultrastructural, and molecular aspects of MECD, and compares the features seen in this condition with those observed in other well studied keratin diseases such as epidermolysis bullosa simplex. METHODS: A two generation family with typical features of Meesmann's epithelial corneal dystrophy (MECD) was studied. All family members were examined under a slit lamp. Biopsy material from elective keratoplasty was studied by histopathological and ultrastructural analysis using standard techniques. Direct automated sequencing of genomic DNA was used for mutation detection, mutations were confirmed by restriction digest analysis. RESULTS: The abnormal corneal epithelium was acanthotic and contained numerous dyskeratotic cells and intraepithelial vesicles. By electron microscopy abnormally aggregated and clumped keratin filament bundles were detected in basal and suprabasal keratinocytes from the centre of the cornea. Direct sequencing of the patients' genomic DNA revealed a novel missense mutation (423T>G) in exon 1 of the cornea specific keratin 12 (KRT12) gene. This mutation predicts the amino acid change N133K within the helix initiation motif of the K12 polypeptide. Comparative studies with well established keratin disorders of other human epithelia underscore the pathogenic relevance of K3 and K12 gene mutations in Meesmann's epithelial corneal dystrophy. The morphological data presented here illustrate the disruptive effects of keratin gene mutations on the integrity of corneal keratinocytes. CONCLUSIONS: A clinical, histopathological, and ultrastructural study of a previously unreported family with MECD is presented. In this family the disease is ascribed to a novel mutation in KRT12. A molecular mechanism is proposed for MECD based on the comparison with other well characterised keratin diseases.

Development of a fixed-dose approach for the fluorescein leakage test.

To answer the question, "How toxic is this material?", rather than the question more usually asked in in vitro toxicology, "At what concentration does this material produce a given degree of toxicity?", a fixed-dose approach has been developed with the FRAME fluorescein leakage (FL) test. Recovery from the initial cytotoxic effect was also noted sometimes, after the cells had been maintained in fresh medium for a further 72 hr. Chemicals rated R41 or R36 in vivo gave a level of FL above 20% immediately, and 66% or more 72 hr later (i.e. there was further deterioration, rather than recovery). Acetaldehyde, when duplicated and tested either in Hanks' balanced salt solution or oil, showed greater toxicity in the oil because of its high volatility. The chemicals classified as no-label gave FL values below 12% immediately after exposure, except Brij-35, which showed no further deterioration during the 72-hr period in fresh medium.

Iliosacral screw fixation of the posterior pelvic ring using local anaesthesia and computerised tomography.

Various techniques have been used for the fixation of the posterior pelvis, each with disadvantages specific to the technique. In this study, a new protocol involving the placement of posterior pelvic screws in the CT suite is described and evaluated. A total of 66 patients with unstable pelvic ring injuries was stabilised under local anaesthesia with sedation. The mean length of time for the procedure was 26 minutes per screw. There were no technical difficulties or misplaced screws and no cases of infection or nonunion. All patients stated that they would choose to have the CT scan procedure again rather than a procedure requiring general anaesthesia. The charges for the procedure were approximately 1840 pounds sterling (2800 dollars) per operation. CT-guided placement of iliosacral screws is a safe, feasible, and cost-effective alternative to radiologically-guided placement in the operating theatre in selected patients.

A new fiber optic probe for cellular visualization.

Thrombus formation within artificial organs has been shown, at least in part, to be caused by retarded or stagnant blood flow. The goal of this work was to develop a magnifying fiber optic probe capable of visualizing particle flow and cellular deposition in a physiologically relevant cellular suspension (blood). The probe has minimal cross sectional area to allow for access to confined areas and to minimize flow disturbance. The probe consists of a germanium oxide fiber optic bundle and a gradient index imaging lens. Fluorescent microspheres of 48 microns, 7 microns, and 3 microns in diameter were imaged after deposition on to a cover slip. The flow (1.44 mm/sec) of 3 microns microspheres suspended in buffer alone and with red cell hematocrits of 10%, 25% and 45% were also visualized. To investigate the potential for this probe to detect ongoing thrombosis, fluorescently labeled human platelets were observed depositing on surfaces from a stagnant platelet rich buffer. These initial data suggest that this probe may offer a technique for the visualization of blood cell adhesion on the interior of artificial organs and the local quantification of flow in such devices.

Nonunion of a pediatric lateral condyle fracture without ulnar nerve palsy: sixty-year follow-up.

Displaced lateral condyle fractures in the pediatric population are usually treated with open reduction and internal fixation. Significant complications associated with the nonoperative management include nonunion, malunion, deformity, and tardy ulnar nerve palsy. However, few cases of nonunion of the lateral condyle and tardy ulnar nerve palsy with long-term follow-up have been reported. We present a radiographically documented case of a pediatric lateral condyle fracture and subsequent nonunion with significant cubitus valgus deformity without ulnar nerve palsy sixty years following injury.

Attitudes of orthopaedic trauma surgeons regarding current controversies in the management of pelvic and acetabular fractures.

A closed-ended questionnaire was mailed to all 363 active members of the Orthopaedic Trauma Association. It directed, toward practicing pelvic and acetabular surgeons, questions pertaining to practice demographics and preferred methods for detection and prevention of deep venous thrombosis (DVT), nerve injury, and heterotopic ossification (HO). Questionnaires were received from 226 surgeons (62 percent). Of the surgeons who responded, 181 (80 percent) perform pelvic-fracture and acetabular-fracture surgery; only questionnaires from this group were analyzed. Standard statistical methods were used to perform both univariate and multivariate analyses. Preoperative DVT screening was performed by 48 percent of the surgeons; ultrasound was the most commonly used modality (82 percent). Preoperative DVT prophylaxis was administered by 88 percent of those surveyed; the majority (78 percent) used sequential compression devices. Postoperative prophylaxis was used by 99 percent; the most commonly used modality was sequential compression devices. Analysis suggests that fellowship-trained surgeons and surgeons in practice for fewer than twenty years are more likely to use preoperative DVT prophylaxis. HO prophylaxis was administered by 88 percent; the most commonly used modality was indomethacin. Intraoperative nerve monitoring was performed by only 15 percent of the respondents. Most surgeons employed prophylactic measures to prevent DVT and HO. The wide variation in type of prophylaxis and reasons for use suggests that controversy will continue, and a standard of care for these conditions has yet to be defined. Very few surgeons use intraoperative nerve monitoring routinely.

Histology and morphometry of Strongylus vulgaris-mediated equine mesenteric arteritis.

Histological and morphometric evaluation of equine cranial mesenteric arteries was performed on 239 and 89 arteries, respectively. Histological examination revealed that thrombosis and the severity of inflammation varied on a seasonal basis and were directly associated with larval presence. Intimal and adventitial fibrosis were generally of greater severity than medial fibrosis. Fibrosis of the vasa vasorum was less frequent than fibrosis of the artery itself. Morphometry revealed a significant increase in intimal, adventitial and, to a lesser extent, medial area in affected as compared with normal arteries. This change was due to the accumulation of collagen and was considered to result in decreased arterial elasticity. The luminal area varied widely among affected arteries.