Systems Science for Caribbean Health: the development and piloting of a model for guiding policy on diabetes in the Caribbean.

BACKGROUND: Diabetes is highly prevalent in the Caribbean, associated with a high morbidity and mortality and is a recognised threat to economic and social development. Heads of Government in the Caribbean Community came together in 2007 and declared their commitment to reducing the burden of non-communicable diseases (NCDs), including diabetes, by calling for a multi-sectoral, systemic response. To facilitate the development of effective policies, policymakers are being engaged in the development and use of a system dynamics (SD) model of diabetes for Caribbean countries. METHODS: Previous work on a diabetes SD model from the United States of America (USA) is being adapted to a local context for three countries in the region using input from stakeholders, a review of existing qualitative and quantitative data, and collection of new qualitative data. Three country models will be developed using one-on-one stakeholder engagement and iterative revision. An inter-country model will also be developed following a model-building workshop. Models will be compared to each other and to the USA model. The inter-country model will be used to simulate policies identified as priorities by stakeholders and to develop targets for prevention and control. The model and model-building process will be evaluated by stakeholders and a manual developed for use in other high-burden developing regions. DISCUSSION: SD has been applied with success for health policy development in high-income country settings. The utility of SD in developing countries as an aid to policy decision-making related to NCDs has not been tested. This study represents the first of its kind.

A preliminary examination of the effects of genetic variants of redox enzymes on susceptibility to oedematous malnutrition and on percentage cytotoxicity in response to oxidative stress in vitro.

BACKGROUND: The causes of oedematous vs non-oedematous childhood malnutrition (OM vs NOM) remain elusive. It is possible that inherited differences in handling oxidant stressors are a contributing factor. AIMS: To test for associations between polymorphisms in five genes and (i) risk of OM, a case-control study, and (ii) percentage cytotoxicity in peripheral blood mononuclear cells (PBMCs) exposed to hydrogen peroxide (H(2)O(2)), an in vitro cell challenge study. METHODS: Participants had been admitted previously for treatment of OM (cases, n = 74) or NOM (controls, n = 50), or were an independent set of healthy pregnant women (n = 47) who donated peripheral blood mononuclear cells. We tested for associations between genetic variation and outcome using single markers or a bivariate score constructed by counting numbers of deleterious alleles for each of 15 possible pairs of markers. RESULTS: In the case-control study there were no significant single-marker associations with OM. We did find that higher bivariate scores were associated with OM for the pair of NAD(P)H:quinone oxidoreductase 1 and catalase (odds ratio 2·00, 95% CI 1·05-3·82). In the cell challenge experiments, there were no significant associations with percentage cytotoxicity. CONCLUSIONS: Variation in this small set of genes seems unlikely to have a large impact on either risk of OM or cytotoxicity after H(2)O(2) exposure. The use of larger sample sizes to test the effects of a much larger set of genetic variants will be required in order to determine whether genetic variation contributes to the risk of OM. Such studies have potential for improving our understanding of causal pathways in OM.

Anaesthetic morbidity at the University Hospital of the West Indies.

OBJECTIVE: There is little information on adverse anaesthetic outcomes from the Caribbean. The aim of this study was to investigate the occurrence of anaesthetic morbidity and mortality at the University Hospital of the West Indies (UHWI) and to identify possible risk factors. METHODS: All anaesthetic procedures at the UHWI were monitored for adverse events and patient outcomes for the 12-month period from March 2004 to February 2005. Possible risk factors for these adverse events were assessed using logistic regression. RESULTS: Of 3185 anaesthetic procedures, the incidence of intra-operative events was 201 per 1000 (95% CI 187, 215); 151 per 1000 being cardiovascular and 26 per 1000 respiratory. Others included excess blood loss and equipment failure, hyperglycaemia, nausea and vomiting. Patients with intraoperative complications were three times more likely to have complications during recovery (OR = 3.35; 95% CI 2.59, 4.33, p < 0.001). The incidence of complications among paediatric patients was 139 per 1000 (95% CI 104, 174) intra-operatively and 58 per 1000 (95% CI 34, 81) during recovery. Risk factors for developing complications (p < 0.05) included age > 50 years, ASA status > or = II, prolonged anaesthesia, high surgical risk, general or combined anaesthetic techniques, senior anaesthetist, intubated patients and co-morbidities. There were 14 operative mortalities, none of which was anaesthesia-related CONCLUSION: Anaesthetic complication rates at the UHWI are comparable to those in developed countries, except for higher paediatric complication rates and ICU admissions and lower rates of postoperative nausea and vomiting.

Voices of the women: feedback from women of child-bearing age who are living with HIV can help improve efficacy of psychosocial interventions.

BACKGROUND: We hypothesized that voluntary counselling and testing during pregnancy are necessary but not sufficient to provide the holistic psychosocial support needed by Jamaican women living with HIV and/or AIDS. Based on this hypothesis, we investigated a range of coping methods and support systems used by HIV-infected women and a group of their HIV-negative counterparts before, during and immediately after their pregnancies. METHODS: Women attending obstetric clinics in urban Jamaica completed a quantitative survey aimed at discovering coping behaviours, social and spiritual support systems. Pre-survey focus group studies and key informant interviews contributed to the design of the questionnaire while post-survey focus groups were used to probe the validity of the data gleaned from the questionnaire survey Survey data were analyzed using non-parametric tests for trend with independent univariate tests. RESULTS: Fifty-five HIV-infected women and 51 HIV-negative women completed the survey Compared with HIV-negative women, more HIV-infected women reported both feeling depressed (p = 0.07) and having difficulty concentrating (p = 0.05) during the month immediately prior to the study. Other statistically significant differences included: HIV-infected women were more likely to pray, to sleep and to change eating habits in response to worry and stress (p = 0.001 in each instance). Although several women declared religious faith, significantly fewer HIV-infected women were willing to talk to a religious leader about their problems compared to their HIV-negative counterparts (p < 0.001). CONCLUSIONS: Participation of HIV-infected women in post-survey focus groups augmented the survey findings. Many of the women reported negative emotions and some indicated serious challenges in accessing social support. The results point to the need for systematic documentation of psychosocial profiles as part of the approach to caring for these women. In addition, in the Jamaican sociocultural context, we recommend improved training of religious leaders and healthcare providers in psychosocial issues.

Medical paediatric admission patterns at the University Hospital of the West Indies: issues for future planning.

An understanding of the epidemiological trend in hospital admissions, including morbidity and mortality patterns and the economic impact, is critical for healthcare planning and appropriate resource allocation. Data were collected on all admissions to the paediatric unit of the University Hospital of the West Indies during the period 1999. Each observation included demographic data, admission and discharge data and billed cost of care. There were 1350 admissions (570 female and 715 male, p < 0.001). Admissions "lows" were observed in February, April and July; minor peaks in March and June and the major peaks between October and January coincided with admissions due primarily to respiratory conditions. The evening shift was generally the busiest, with the night shift having the lowest average number of admissions in any one-week period Occupancy was uniformly high between November and April, with minor lows in May and August/September. The total cost for a typical patient was J$9708 per admission and the total daily cost for a typical patient was J$1823 (US$1 = J$39 in 1999). The findings could assist with resource allocation and rationalization of health services.

The prevalence of marijuana smoking in young adults with sickle cell disease: a longitudinal study.

BACKGROUND: The active ingredients of marijuana may have beneficial properties in the treatment of chronic pain and inflammation and is being used by sufferers of chronic pain and arthritis in some settings. Anecdotally, marijuana is believed by some sickle cell disease (SCD) patients to improve their health. This study aimed to determine the prevalence of marijuana smoking in the Jamaica Sickle Cell Cohort Study (JSCCS) in the years 2000 and 2004. The perception that marijuana use ameliorated the complications of SCD was also investigated. METHODS: All patients in the JSCCS were invited to attend an annual review, and during the 2000 and 2004 reviews, participants with homozygous sickle cell (SS) disease and sickle cell haemoglobin-C (SC) disease were asked whether they smoked marijuana, and if they smoked, whether it was used for medicinal purposes related to SCD. The authors compared smoking prevalence by gender, disease, and year of review. The association of smoking with a measure of pain frequency was also examined. RESULTS: The prevalence of marijuana smoking was higher among men and among SC participants. The proportion of either gender reporting smoking of marijuana increased in 2004 compared to 2000, and this use was not related to a simple measure of clinical severity of SCD. CONCLUSIONS: Marijuana smoking is common in adults with SCD but its usage is unrelated to clinical severity of the disease.

Skin test reactivity to aeroallergens in Jamaicans: relationship to asthma.

BACKGROUND: Asthma causes significant morbidity and mortality in the developing world. It is thus important to identify modifiable risk factors. OBJECTIVES: To undertake a cross-sectional study to determine the prevalence of skin test reactivity to aeroallergens in Jamaican children and adults and the relationship of the diagnosis of asthma to the pattern of skin test positivity. METHODS: One hundred and sixty subjects without the sickle cell gene (genotype AA), eighty adults and eighty children, were recruited. Skin testing to seven aeroallergens was undertaken (atopy being diagnosed if there were at least one positive reaction). Asthma status was determined by a questionnaire and/or medical records. RESULTS: Twenty-seven (34%) of the children and forty-one (51%) of the adults were skin test positive to at least one aeroallergen. The most common positive responses in both age groups were to Dermatophagoides farinae, Dermatophagoides pteronyssinus and cockroach mix-(German and American). All adult asthmatics with current symptoms reacted to cockroach allergen. CONCLUSIONS: Appropriate steps to reduce cockroaches and cockroach sensitization might positively impact on asthma morbidity in Jamaica.

Growth curves for normal Jamaican neonates.

The aim of this study was to provide standards for the assessment of birthweight, head circumference and crown-heel length for normal, singleton newborns of predominantly West African descent. Data were collected for 10 482 or 94% of all recorded births in Jamaica during the two-month period September 1 to October 31, 1986. After editing procedures, data were available for 6178 (birthweight), 5975 (head circumference), and 5990 (crown-heel length). The data presented in tables and growth curves include birthweight, head circumference and crown-heel length for males and females separately, for gestational ages 30-43 weeks. Data sets from the University Hospital of the West Indies in 1990 and 1999 were used to explore the possibility of secular change over the period 1986-1999. In conclusion, these ethnic and gender-specific growth curves are based on the most extensive dataset currently available in Jamaica for babies of West African descent.

Triage decisions and outcome among the critically ill at the University Hospital of the West Indies.

The worldwide scarcity of intensive care therapy leads to the rationing of this expensive resource. This prospective study investigates the rationing of intensive therapy at the University Hospital of the West Indies (UHWI) by recording triage decisions for intensive care unit (ICU) admission and the impact of these decisions on patient outcome. Between June 2001 and May 2002, all patients triaged for admission to a multidisciplinary ICU were studied For each patient, data were collected including APACHE II score, ICU resource availability and patient survival. There were 356 eligible requests, and 285 (80%) were admitted to the ICU, with 73 (26%) of these admitted patients receiving intensive care outside of the ICU due to space limitations. The APACHE II score was the strongest predictor of ICU admission, with admission more likely as the score decreased (odds ratio = 0.94, 95% confidence interval 0.91, 0.98, p = 0.001). Of 311 requests considered suitable for admission, 26 (8%) were refused admission due to resource limitations. Mortality among these eligible refusals was 81%, compared to 34% among admitted patients (p < 0.001). Although triage decisions are based predominantly on a patient's disease severity, the demand for ICU space exceeds supply, and patient care is negatively impacted by this imbalance.

Anaesthesia for operative deliveries at the University Hospital of the West Indies: a change of practice.

There has been an increasing trend worldwide to use regional anaesthesia for operative deliveries. The Confidential Enquiry into Maternal Deaths in the United Kingdom has demonstrated a steady decline in the anaesthesia-related deaths since the introduction of regional anaesthesia. There are lower morbidity profiles in mothers delivering under regional anaesthesia as well as better infant Apgar scores. In 1997, a decision was taken to have at least 60% of all elective Caesarean sections done at the University Hospital of the West Indies (UHWI) performed under spinal anaesthesia. This is a review of the anaesthetic technique for Caesarean sections at the UHWI since 1996. The Deliveries and Anaesthetic Books on the labour ward were reviewed and the type of anaesthesia for elective and emergency Caesarean sections recorded for the period January 1996 to December 2001. At the beginning of the period under study, more than 90% of the Caesarean sections were being done under general anaesthesia. By the middle of 1998, spinal anaesthesia was more commonly employed than general anaesthesia for Caesarean sections and by December 2001, more than eight out of every ten Caesarean sections were being done under spinal anaesthesia. The main reasons for the successful change of practice were that it was consultant-led, there was good communication between relevant departments, the junior staff were properly trained, there was a consistent supply of appropriate drugs and there was a high level of patient satisfaction.

The Chhattisgarh state screening programme for the sickle cell gene: a cost-effective approach to a public health problem.

In India, the Chhattisgarh State screening programme for sickle haemoglobin focuses on children aged 3-15 years and has screened over 1,050,440 subjects over the last 6 years. Commencing in the District around the capital Raipur, this programme has now completed screening in 7 of the 27 Districts of Chhattisgarh State. Screening is initially performed by solubility tests on fingerprick samples in the field and those with positive tests have venipunctures for haemoglobin electrophoresis. The frequency of the sickle cell trait was 9.64 % and of the SS phenotype 0.29 % with only two Districts in Hardy-Weinberg equilibrium, most Districts showing an excess of the SS 'phenotype' most readily explained by symptomatic selection. The estimated costs were US$0.28 (solubility tests alone) and US$0.60 (haemoglobin electrophoresis). Of the social groupings commonly used in India, the OBC's (other backward classes) had the highest frequencies of the sickle cell gene mutations, followed by the Scheduled Tribes and the Scheduled Castes. The objectives of the programme were the detection of sickle cell disease for prospective clinical management and of the sickle cell trait for purposes of genetic counselling. The former objective is being met for diagnosis although the success of referral to clinic services requires audit. The objective of genetic counselling is compromised by the failure of the screening test to detect other genes of potential clinical significance such as HbD Punjab and the beta thalassaemia trait. Despite these exceptions, the detection of HbS appears relatively robust and could be another condition factored into the traditions of partner selection amongst the underprivileged communities of this state. Overall, the Chhattisgarh programme seeks to address the daunting challenges of large populations carrying the sickle cell gene and maybe a useful model for elsewhere.

Identifying homozygous sickle cell disease when neonatal screening is not available: a clinic-based observational study.

OBJECTIVES: Life-threatening clinical complications can occur in the first years of life in people with homozygous sickle cell disease. There is consensus that a clinical care programme comanaged by a specialist clinic should follow early-life disease identification. In a setting without widespread neonatal screening for this disease, we predict the percentage of affected births that enrol in specialist clinics during childhood, and the percentage that enrol early enough to benefit from penicillin prophylaxis (which is offered until five years of age). SETTING: A retrospective study of enrolment between 1973 and 1999 at three clinics in Jamaica, the country's only referral centres for sickle cell disease. RESULTS: Among enrolees not screened at birth, observed enrolment by age five was 10.1% (95% confidence interval [CI] 5.7-16.7%) among 1974 births, which is predicted to rise to 35.7% (95% CI 35.0-36.4%) among 1999 births. Observed enrolment by 18 years of age was 45.9% (95% CI 35.7-58.2%) among 1974 births, which is predicted to peak at 61.9% (95% CI 60.5-63.2%) among 1984 births, and fall to 48.9% (95% CI 40.9-56.9%) among 1999 births. Median age at enrolment was 10.5 years (95% CI 10.0-11.3). CONCLUSIONS: Based on 1999 estimates, almost 65% of children affected by homozygous sickle cell disease not identified at birth will not benefit from important early-life clinical intervention, and half will not enrol for specialised care by their 18th birthday. Among patients that enrol, half do so in adolescence when management is less focused on preventive care.

Inhaled bronchodilators for acute chest syndrome in people with sickle cell disease.

BACKGROUND: Bronchodilators are used to treat bronchial hyper-responsiveness in asthma. Bronchial hyper-responsiveness may be a component of the acute chest syndrome in people with sickle cell disease. Therefore, bronchodilators may be useful in the treatment of acute chest syndrome. OBJECTIVES: To assess the benefits and risks associated with the use of bronchodilators in people with acute chest syndrome. SEARCH STRATEGY: We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group trials register which comprises references identified from comprehensive electronic database searches, handsearching relevant journals and abstract books of conference proceedings. Additional searches were carried out on MEDLINE (1966 to 2002) and EMBASE (1981 to 2002).Date of the most recent search of the Group's haemoglobinopathies register: May 2002. SELECTION CRITERIA: Randomised or quasi-randomised controlled trials. Trials using quasi-randomisation methods will be included in future updates of this review if there is sufficient evidence that the treatment and control groups are similar at baseline. DATA COLLECTION AND ANALYSIS: We found no trials investigating the use of bronchodilators for acute chest syndrome in people with sickle cell disease. MAIN RESULTS: We found no trials investigating the use of bronchodilators for acute chest syndrome in people with sickle cell disease. REVIEWER'S CONCLUSIONS: If bronchial hyper-responsiveness is an important component of some episodes of acute chest syndrome in people with sickle cell disease, the use of inhaled bronchodilators may be indicated. There is need for a well-designed, adequately powered randomised controlled trial to assess the benefits and risks of the addition of inhaled bronchodilators to established therapies for acute chest syndrome in people with sickle cell disease.

Patients' desire for peri-operative information: Jamaican attitudes.

The desire for peri-operative information has been examined in patients from other countries. This study was undertaken to assess the peri-operative information needs in Jamaican patients and to compare them to those from other populations. A questionnaire examining the desire for information about impending anaesthesia was administered to 93 patients awaiting elective surgery at the University Hospital of the West Indies. Responses were assessed across age and gender, and were compared to results from five industrialized countries. Although Jamaican patients expressed a desire for information concerning anaesthesia and surgery, they did not regard it as their right to get information, and this was the most important factor in the Jamaican sample providing a significantly less positive response than patients from other nations (p < 0.01 versus each country). Information priority was given to practical aspects of anaesthesia and post-operative outcome-mobility, pain, and the consumption of food and drink. Meeting the anesthetist was high on the list of desires. Female patients were 1.9 (Confidence Interval 1.4, 2.5) times more likely to express a positive desire for information. There were no age-related differences.

Psychological distress among younger siblings of patients with homozygous sickle cell disease in the Jamaican cohort study.

The presence of a chronically ill family member may adversely affect the psychological health of siblings. This study used the General Health Questionnaire and the Modified Social Adjustment Scale to assess psychological distress in 20 younger siblings (4 AA, 16 AS genotypes), aged 16-19 years, of patients with homozygous sickle cell (SS) disease. The results were compared with those previously obtained in the 20 older siblings with SS disease and in 89 controls with a normal haemoglobin (AA) genotype. High levels of psychological distress occurred among all three groups. Greater psychological distress and poorer social adjustment occurred among siblings compared to AA controls but these differences disappeared after adjusting for the reduced age of siblings. The two measures were similar in SS patients and AA controls. The level of psychological distress among siblings of SS patients did not differ from that in SS patients or AA controls.

Paravertebral anaesthesia for breast surgery an initial experience at the University Hospital of the West Indies.

Paravertebral blockade (PVB) is a regional anaesthetic technique that allows the injection of local anaesthetic agents into the paravertebral space. It has been used for acute and chronic pain relief and as an anaesthetic technique for unilateral surgery of the chest, breast, shoulder, kidney, and inguinal region. Paravertebral blockade has been performed on a limited basis for breast surgery at the University Hospital of the West Indies (UHWI) since 1998. This retrospective review was undertaken to report the initial experience with this block. We reviewed the notes of all patients who were given a PVB alone, or in combination with general anaesthesia (GA). Twenty-one patients had P VB: twenty females and one male, with age range of 24 to 90 years. Six were attempted with PVB alone, but two of these needed supplementation with a GA. Fifteen were done in combination with GA. No complications were recorded The initial experience shows that the performance of PVB is both possible and safe; it may offer an alternative to GA for breast surgery. A randomized prospective study is underway to allow a detailed comparison between the two methods.

Antiretroviral drug therapy in HIV-infected Jamaican children.

BACKGROUND: The study describes a cohort of HIV-infected Jamaican children receiving antiretroviral therapy (ART) and reports the outcome. METHOD: An observational prospective study was conducted on HIV-infected Jamaican children receiving anti retroviral drug therapy (ART). The outcome measures, weight, height, hospital admissions and length of stay were compared at initiation and within six months of commencing ART. RESULTS: There were 37 (33.6%) of 110 HIV-infected children receiving ART during 2001 to 2003. The median age at commencement was six years (age range 1-16 years) with 54.1% (20) males and 48% AIDS orphans. Care was home-based for 68 % of all cases with the University Hospital of the West Indies managing 27 (73%) and the Bustamante Hospital for Children 10 (27%). The distribution by Centers for Disease Control and Prevention (CDC) clinical class was C (severely symptomatic), 22 (59.5%); B (moderately symptomatic), 8 (21.6%); A (mildly symptomatic), 6 (16.2%) and N (asymptomatic), one (2.7%). Among 14 (36%) children with CD4 counts, 8 (57%) were CDC immune class 2 (moderate immunodeficiency) and 6 (43%) were class 3 (severe immunodeficiency). After commencing ART the mean difference in admissions was--1.5+/-2.55 admissions (95% CI -2.3, -0.6; p < 0.001) and in length of stay was -12.9+/-21 day (95% CI -19.9, -0.5.9; p < 0.001). Antiretroviral therapy resulted in a mean weight gain of 2.8 kg+/-4.9 kg (95% CI 1.0, 4.5; p < 0.003) and a mean gain in height of 1.7 cm+/-2.6 cm (95% CI 0.6, 2.8; p < 0.003). Five children required second line therapy. CONCLUSION: The introduction of antiretroviral therapy has resulted in improved outcomes and is being initiated in older children cared for mainly at home. Limitations in accessing affordable second line agents underscore the need for compliance with first line therapy.

The changing face of homozygous sickle cell disease: 102 patients over 60 years.

Earlier reports on homozygous sickle cell (SS) disease have been biased by severely affected cases. The Jamaican clinic which seeks to avoid such bias has 102 patients surviving beyond 60 years. The objective of this study was to examine the features of elderly cases and assess factors determining survival and the behaviour of this disease with advancing age. A retrospective review of all cases and prospective assessment in survivors was conducted at The Sickle Cell Clinic at the University of the West Indies, Kingston, Jamaica previously operated by the MRC Laboratories. All patients with SS disease born prior to December 31, 1943 who would, by January 2004, have passed their 60th birthday were traced and their current status ascertained. The molecular and clinical features were assessed and observations on the clinical behaviour of the disease and of haematology and biochemistry are presented. Of the 102 patients, 58 had died, four had emigrated and 40 were alive, resident in Jamaica and aged 60-87 years. Survival was associated with female gender and higher foetal haemoglobin but not with alpha-thalassaemia or beta-globin haplotype. A tendency to familial clustering among elderly survivors did not reach statistical significance. Painful crises ameliorated with age and there was a benign course in pregnancy. Mean haemoglobin levels fell with age and were generally associated with rising creatinine levels indicating the importance of renal failure. Elderly survivors present some features of intrinsic mildness but also manifest age-related amelioration of painful crises and falling haemoglobin levels from progressive renal damage.

The inflammatory effect of cardiopulmonary bypass on leukocyte extravasation in vivo.

OBJECTIVE: Extravascular trafficking of leukocytes into organs is thought to play a major role in the pathophysiologic mechanisms of the inflammatory response to cardiopulmonary bypass, yet leukocyte extravasation is difficult to study clinically. Here we have tested the hypothesis that leukocyte emigration into skin blisters can provide a way to monitor the inflammatory effect of cardiopulmonary bypass that allows testing of anti-inflammatory interventions (exemplified by aprotinin). METHODS: Patients undergoing primary elective coronary artery bypass grafting (n = 14) were randomized into 2 equal groups to receive saline infusion during cardiopulmonary bypass (control group) or high-dose aprotinin. Experimental skin blisters (in duplicate) were induced on the forearm by means of topical application of the vesicant cantharidin, and blister fluid was sampled at 5 hours postoperatively. Inflammatory leukocyte subsets in blister fluid were analyzed by means of flow cytometry by using expression of CD11b and CD62L as a phenotypic marker of activation. RESULTS: In the control group of patients, cardiopulmonary bypass surgery triggered a 381% increase in leukocyte extravasation into the skin compared with reference blisters carried out before surgical intervention, with neutrophil (P = .014), monocyte (P = .014), and eosinophil (P = .009) levels all statistically significantly increased. In the aprotinin group there was no statistically significant increase during cardiopulmonary bypass surgery in any inflammatory leukocyte subset. The activation phenotype of extravascular leukocytes was not significantly altered between surgical groups. CONCLUSIONS: This study introduces the cantharidin blister technique as a powerful new research tool for analyzing the inflammatory effect of cardiopulmonary bypass in vivo. It has provided detailed molecular insight into the extravascular leukocyte population during cardiopulmonary bypass. Although aprotinin blocked cardiopulmonary bypass-dependent extravasation of leukocytes, there was no change in their CD11b/CD62L activation status. The cantharidin skin test thus represents a novel research tool for evaluating future anti-inflammatory interventions in cardiothoracic surgery.