Safety of the blood supply.
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Bacterial Infections↗
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[Blood transmission and infections].
A blood transfusion can never become a completely risk free event. Almost all kinds of infectious agents; viruses, bacteria and parasites, can be transmitted by blood. So far, hepatitis and HIV-infections have been focused. The state of readiness to meet these infections must be kept while we prepare for "new" agents, like parvovirus B19. Extensive international travelling will increase the possibility of blood-borne parasitic infections, like malaria and Chagas' disease, even with the very high quality demands imposed for Norwegian blood donors. We can keep a better eye on the infectivity of the blood products by strictly realizing our objective of national self-sufficiency. Recent research results indicate transfusion-mediated effects to the immune system, particularly of allogeneic transfusions containing leucocytes. This immunomodulation seems to enhance the risk of secondary infections. So far, it is impossible to tell whether this immunomodulation has any impact on the long-term outcome of malignant diseases. A blood transfusion will always represent a risk, although small, to the patient. This recognition makes it essential to carefully consider whether to give a patient a transfusion, and to document this decision properly.
Blood Transfusion↗
[Hepatitis B and occupational risk groups].
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Blood-Borne Pathogens↗
[Costs of safety of blood and blood products].
The safety of blood and blood components in transfusion medicine has become a very important factor. While diagnostic and therapeutic medical procedures need an increasing amount of special blood products, increasing demands on safety result in a reduction of blood donations. Considerable costs are caused by the requirement of self-sufficiency, additional assays to detect virus infections such as HIV, HCV and others, virus inactivation of blood and plasma, storing of plasma in quarantine, increase of autologous blood donation, and a great many of further steps to improve the safety in transfusion medicine. To obtain absolute safety, efforts are required that necessarily exceed the financial capacity of our health system. Because of budget limitations increasing costs of blood products will interfere with progress of other areas of health care. In addition ethical aspects of the use of funds have to be taken into consideration.
Blood Component Transfusion↗
[Factor VIII preparation produced by recombinant DNA-technology is approved in Norway].
Recombinant factor VIII (Baxter) is approved by the Norwegian Medicines Control Authority. The product represents an alternative to plasma-derived factor VIII in the treatment of patients with haemophilia A. Its use should be guided by clinical experts in care of haemophilia. Characterization studies of this and another recombinant factor VIII preparation have revealed no significant differences from plasma-derived factor VIII as regards biochemical and functional properties. Clinical studies have demonstrated similar in vivo recovery, plasma half-life and haemostatic activity as for plasma-derived factor VIII. Recombinant factor VIII should carry a low, if any, risk of transmitting blood-borne viruses pathogenic to man. The product includes pasteurized human albumin added as stabilizer, which has a well-documented safety record. There is no clear evidence of increased incidence of factor VIII inhibitors than with plasma-derived factor VIII. Further long-term surveillance studies are needed, however, to elucidate these matters.
DNA, Recombinant↗
[GPT limit values in blood donors: lower, higher or eliminate completely?].
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Alanine Transaminase↗
[Alanine aminotransferase (ALAT, GPT): a reevaluation of exclusion limits for blood donors].
BACKGROUND: The screening policy of alanine aminotransferase (ALT) testing in blood donors was reassessed. The cutoff value for ALT levels according to German guidelines has always been controversial. In this study the activity and distribution of ALT in a blood donor population were reevaluated and new exclusion levels were defined. METHODS: 5,706 blood donors were tested for ALT activities with the Reflotron system at 37 degrees C. Donors with ALT levels > 51 IU/l were deferred, a detailed physical examination and additional serologic and biochemical testing were done. RESULTS: ALT values of blood donors were transformed in logarithmic values in order to get a Gaussian distribution. The mean transformed value +/- SD was calculated with 1.24 +/- 0.14 for females and with 1.35 +/- 0.16 for males, corresponding to mean values of ALT activity of 17.6 and 22.5 IU/l, respectively. Exclusion levels of > 33.4 IU/l for female and > 46.7 IU/l for male blood donors (geometric mean +2.0 SD) predict a loss of donations of 2.8 and 2.7%, respectively, cutoff values of > 39.1 or > 56.1 IU/l (geometric mean +2.5 SD) a loss of 1.8 and 1.4%, respectively. The most likely causes of elevated ALT levels in 166 of our donors included daily alcohol use (82), infections with/without antibiotic medication (29), therapy with hepatotoxic drugs (8), strenuous exercises (5), bodybuilding complemented by anabolic steroids (2), acute infections with HCV (1), HBV (1) and CMV (1), alcohol/drug abuse and detection of HCV antibodies (1). CONCLUSIONS: ALT screening is still considered a useful indicator of risk donors despite its nonspecificity and limited predictive value. The selection of the appropriate cutoff value has always been disputed. The present exclusion level of > 45 IU/l (25 degrees C), analogous to > 81.8 IU/l (37 degrees C), does not even take into account such a variable as sex. The cutoff value above 4.5 SD of the geometric mean for females and above 3.5 SD for males seems to be of limited medical and practical value.
Alanine Transaminase↗
[The legally required guidelines for reporting risks or side-effects caused by blood components].
OBJECTIVE: To prevent dangers to health resulting from the application of drugs, the legislator requires the central registration and evaluation of all drug risks, especially of side effects and reciprocal effects. Since 1988 pharmaceutical enterprises have had to denominate a qualified person ('Stufenplanbeauftragter') who is responsible for the fulfilment of obligatory reporting. In case of complaints or side effects he has to take suitable measures according to a special plan ('Stufenplan'). DATA SOURCES: The basis of this survey are the legal requirements for drugs ('Arzneimittelgesetz') and supplementary regulations which define the duties of the 'Stufenplanbeauftragter'. RESULTS: Blood components are subject to the legal requirements ('Arzneimittelgesetz') without reservations. Therefore the corresponding regulations have to be applied without modification in institutes for transfusion medicine. In this article the tasks of the 'Stufenplanbeauftragter' are summarized and practical experience of a university institute for transfusion medicine is presented. CONCLUSIONS: In connection with the transmission of viral infectious diseases it became evident that the 'Stufenplanbeauftragter' is very important for the initiation of effective measures in case of serious side effects. The security of blood components could be improved by the realization of the corresponding legal requirements in the institutes for transfusion medicine.
Adverse Drug Reaction Reporting Systems↗
Success, failures and costs of implementing standards in the USA--lessons for infection control.
In the US, extensive standards for performance and 'guidelines for practice' have been instituted by a number of governmental and non-governmental agencies. New governmental plans for health care depend heavily on practice guidelines, and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has been especially enthusiastic about continuous quality improvement. Monitoring the appropriateness of care and altering physician practice appeals to insurance carriers and health care management organizations. Some initial data exist to show that the quality of health care has been enhanced by these regulations. The total cost for health care administration in 1990 in the USA was 24.8% of each hospital's spending for health care. Much of this was associated with spending for new initiatives in practice guidelines, physician profiling, quality assurance, and the like. Few data exist to show that the quality of health care or hospital infection control has been enhanced by these expenditures. Regulations and guidelines also have proliferated in infection control. Guides from the JCAHO have been expanded, and recent mandates from the Occupational Health and Safety Administration (OSHA) for protecting employees from blood-borne and respiratory pathogens promise to be especially costly for health care organizations to implement. Little data exist to show that the quality of infection control has been enhanced by these regulations. Standards are difficult to develop, because the science to back them up often is lacking, interpretation of validating data is imprecise, and inherent biological variation makes exceptions common. Seven lessons are important for those developing standards today. These include focusing on objective measures of the impact of the standard, clearly indicating the degree of scientific validity, making the development process inclusive, allowing for local variation, making sure that funding is provided for mandated standards, considering non-scientific implications of standards, and remaining involved in the process after the guideline is developed. Infection control workers should make sure that standards developed take the lessons above into account before they are promulgated.
Financial Support↗
Immunological characterization of pulmonary intravascular macrophages.
Pulmonary intravascular macrophages (PIMs) are lung macrophages found apposed to the endothelium of pulmonary capillaries. In many species, they are responsible for the clearance of blood-borne particulates and pathogens; however, little else is known about their roles as immunologic effector cells. We compared PIMs with pulmonary alveolar macrophages (PAMs) to determine the relative immunological activities of these two cell populations. Our results suggested that both populations possess similar phagocytic and bactericidal activities. In assays measuring cytotoxicity, PIMs were more cytotoxic than PAMs against virally infected target cells; however, differences between these macrophage populations were not as marked when noninfected targets were used. LPS-stimulated PIMs produced more T-cell proliferative cytokines than PAMs, and both populations of nonstimulated macrophages produced similar amounts of the cytokines. In contrast, PAMs produced more TNF alpha and NO2- than PIMs when both populations were stimulated with LPS; however, nonstimulated PAMs and PIMs produced similar amounts of TNF alpha and NO2. These data suggest that bovine PIMs are immunologically active. Differences between the degrees of activity of PIMs and PAMs indicate that these macrophage populations may have different roles in lung surveillance.
Animals↗
[Acute hematogenous osteomyelitis due to ordinary germs in children with closed injuries. Study of a series of 44 cases].
The retrospective study of a series of 44 cases of acute hematogenous osteomyelitis in infants and children has shown that 16 out of the 44 patients (36%) have a history of previous trauma at the site of bone infection. Seven infants were less than one year of age. For the remaining 37 children the incidence of previous local trauma rose to 43% (16/37). This incidence is similar to that in previous studies. Acute hematogenous osteomyelitis follows blood-borne spread of a pathogen from a portal of entry. Why hematogenous infection selects a particular bone is an enigma. Trauma has been said to predispose to the localization of infection but the association between trauma and hematogenous osteomyelitis is only found in one-third of the cases in both this study and in previous series. However these cases with a history of local trauma raise questions regarding the concept of "locus minoris resistentiae" and its medicolegal consequences.
Acute Disease↗
Neisserial surface variation: how and why?
Neisseria gonorrhoeae exhibits striking variability in several of its surface components (pili, Opa proteins and lipooligosaccharide) in vivo and in vitro. Such flagrant variation of this mucosal pathogen's surface components contrasts sharply with changes in single surface components of blood-borne trypanosomes and borreliae. Despite these differences, similar molecular events are sometimes involved.
Animals↗
[Therapy and prognosis of bacterial arthritis: a retrospective analysis].
Antibiotic therapy and immediate drainage of the infected joint are established practice in the treatment of septic arthritis. The best method of drainage (repeated puncture, arthroscopy or surgical discharge) remains controversial. We analyze 34 patients with septic arthritis admitted to our hospital from 1984 to 1988. The pathogen was Staphylococcus aureus in 19 cases (56%), streptococcus in 6 (18%), pneumococcus in 2 (6%), other bacteria in (9%) and unknown in 4 (12%). In 62% the infection was blood-borne. The knee was affected in 12 cases (35%) and the shoulder in 10 (30%). A preceding joint puncture was the main source of infection. In 24 patients (70%) the initial joint drainage was by repeated puncture, while in 10 cases (30%) surgical drainage was the initial treatment. In 11 of the 24 patients initially treated by repeated puncture, surgical drainage was needed in the course of treatment because of persistent local infection of the joint. In only 13 (39%) was "medical" treatment alone effective. 5 patients died (14.7), 3 (8.8%) due to the infection. All deaths occurred in the "medical" group. 21 patients were asked about symptoms in the affected joint. In 71% there were no problems or only minimal ones, while in 29% there were distinct problems. 5 of the 6 patients with severe symptoms had been treated by repeated puncture. We conclude that surgical drainage of an infected joint is prescribed too rarely in departments of rheumatology and internal medicine. Arthroscopic or surgical drainage is indicated in cases of coxarthritis, omarthritis, in cases where symptoms last longer than 7 days and in patients with severe sepsis.
Adult↗
Epidemiology and pathogenicity of human retroviruses.
The human retroviruses can be divided into oncovirus (HTLV-I and HTLV-II) and lentivirus strains (HIV-1 and -2). The HTLVs are endemic in Central Africa, the Caribbean Islands and in southwest Japan, but now tend to spread through the i.v.-drug user population in the USA and in some countries in Western Europe. HTLV infection is associated with a malignant form of adult T-cell leukemia, tropical spastic paraparesis (TSP) and an associated myelopathy (HAM). The pathogenic mechanisms of HTLV are as yet poorly understood. HIV infection is spreading rapidly almost world-wide and has reached epidemic proportions in Central Africa, parts of South America and in certain populations in industrialized countries that have risk behaviour for contracting venereal or blood-borne infections. The mechanisms of HIV-induced immune suppression are still not entirely clear, as direct T-lymphocyte destruction after viral infection cannot account for the almost complete loss of CD4 T-cells in the final stages of disease. Various indirect mechanisms of HIV-induced immune cell destruction are outlined below.
Biological Products↗
Epididymitis, orchitis, and related conditions.
Epididymitis is the most common intrascrotal inflammation. Retrograde ascent of pathogens is the usual route of infection. Nonspecific bacterial epididymitis is caused by various aerobic bacteria, is frequently associated with anatomic abnormalities, and represents the most common type of epididymitis in older men. Sexually transmitted epididymitis is usually caused by Chlamydia trachomatis or Neisseria gonorrhoeae and represents the most frequent cause of acute scrotal swelling in men younger than 35 years of age. Underlying urologic abnormalities are uncommon in patients with sexually transmitted epididymitis. Systemic infections and trauma are unusual causes of epididymitis. Orchitis is less common than epididymitis. Blood-borne dissemination is the major route of testicular infection. With the exception of viral diseases, genitourinary tract infections seldom involve the testis primarily. Mumps is the most frequent cause of viral orchitis. Pyogenic orchitis usually results from an inflammatory process in the epididymis. Systemic dissemination of granulomatous infections may occasionally cause orchitis.
Adult↗
Observations on blood-borne parasites of domestic livestock in the lower Juba region of Somalia.
The commonest parasite to be found in blood of cattle in the Lower Juba Region is Theileria mutans. Antibodies against Trypanosoma spp. and Anaplasma marginale could be detected serologically whereas no antibodies against T. parva and T. annulata were present. A list of ticks collected between 1980 and 1982 in the above mentioned area shows that vectors of T. mutans are common. As the cattle throughout the region are indigenous Somali Boran it seems that endemic stability is maintained and mortality from T. mutans infection is negligible. It is not yet clear whether pathogenic strains of T. mutans similar to those isolated in East Africa occur.
Animals↗
Occurrence of interleukin-1 in cerebrospinal fluid of the conscious cat.
Interleukin-1 (IL-1) is synthesized and released in response to various pathogens, including bacterial endotoxin, and is assigned an intermediary function in the genesis of fever. Its site of action in the central nervous system (CNS), however, is uncertain because the polypeptide is seemingly unable to cross the blood-brain barrier. Since several cell types, including astroglial, microglial, and vascular cells, can generate IL-1 upon appropriate stimulation, we examined whether IL-1 is formed in the CNS and may therefore serve as a messenger for systemic noxae. Experiments were conducted in the conscious cat and IL-1 was assayed in cerebrospinal fluid (CSF) from the third ventricle using a highly sensitive murine helper T cell line, D10.G4.1. In general, IL-1 levels were barely detectable in the absence of fever and did not increase at any stage of the sustained fever following intravenous injection of endotoxin (bolus) or crude monocyte supernate containing IL-1 (bolus plus infusion). In contrast, intracerebroventricular injection of a pyrogenic dose of endotoxin led to the appearance of IL-1 in the CSF. IL-1 levels reached maximal elevation during the uprise phase of the fever and declined thereafter. By the same route, natural or recombinant human IL-1 had no effect on CSF-IL-1 levels, though both preparations were as effective as endotoxin in eliciting fever. These findings confirm earlier data with radiolabelled pyrogens and indicate that the blood-brain barrier is impermeable to IL-1. We conclude that blood-borne IL-1 is likely to act at a discrete site outside the blood-brain barrier, possibly the organum vasculosum laminae terminalis. Centrally formed IL-1 may instead act diffusely in promoting fever and fever-related events (e.g. sleep).
Animals↗