bluuebunny/crossref_metadata_2025 huggingface dataset:
PL02 Obtaining a Suitable Analyte from Deceased Tissue Donors for a Potential vCJD Test
Authors: Poniatowski S.
Published: September 2006

There is much current interest in the development and validation of a suitable blood test that could be used to screen all donors to avoid potential vCJD transmissions. In the interim there are other ‘tissues’ where abnormal prion could be assayed including those of the central nervous and lymphatic systems. Tonsil and spleen biopsies assessed for abnormal PrP are thought to be possible early indicators of infectivity. Although it is not reasonable to routinely obtain these biopsies from living blood donors, clearly there is a potential to obtain these tissues from donors who are deceased with appropriate consent. There are however problems associated with obtaining this tissue including the impact of the post‐mortem investigation into cause of death, expertise in locating the tissue and the effects of rigor mortis. Also, given the assay result turnaround time, there are further complications associated with managing a positive test result including where organs or tissues from the donor have already been transplanted. These issues limit the suitable donor pool. The result is that only 25–50% of deceased tissue donors are indeed suitable. This population is being tested as a pilot within the NBS as a potential risk reduction measure.
SI19 NAT or Not to NAT – This is the Dilemma?
Authors: Reeves I.
Published: September 2006

The National Blood Service has undertaken a strategic review of Nucleic acid Amplification Technology (NAT) Testing used to screen blood for Hepatitis C Virus (HCV) at the request of the Department of Health.

Three strategic options have been considered and are presented within this review:

Continue testing (which in practice also includes developing this technology further as new automated platforms and multiplex tests become available).

Substitute HCV antigen testing for NAT testing

Stop NAT HCV testing

In essence, this review concludes that NAT HCV testing is an extremely expensive intervention. Now that NAT testing is well developed by Blood Services world‐wide and has been in use to screen the UK population for some time, the consequences of pursuing each of the options presented can be predicted with accuracy.
SI23 Assessment of Bleeding in Patients with Haematological Malignancies and the Association between Platelet Count and Bleeding
Authors: Dyer C. , Casbard A. , Murphy M. , Stanworth S.
Published: September 2006

Aim  To evaluate methods to collect bleeding outcomes in thrombocytopenic patients, including by patient self‐assessment, and to investigate the association between platelet count and bleeding.

Methods  Consecutive patients with haematological malignancies were enrolled in a study of bleeding data collection, platelet counts and transfusions during the period of thrombocytopenia. An educational session and information sheet was designed for patient self‐assessment.

Results  A total of 19 patients were included in the study. 410 days of thrombocytopenia were eligible for assessment of bleeds. Self‐assessment was deemed feasible, as self‐assessment was successfully completed on 288/410 (70%) of thrombocytopenic days. There was 86% agreement between bleeding data collected by both self‐assessment and medical examination, using a structured assessment form. Examples of discrepancies included the duration of petechiae/bruises and the reporting of minor bleeding. There was no evidence for an association between patients’ morning platelet count and daily WHO bleeding grade. Bleeding events were compared for platelet counts of ≤10 × 109 L−1, 11–20 × 109 L−1, and >20 × 109 L−1. The incidence of WHO Grade one and two bleeds were similar and did not reveal higher rates of bleeding at lower counts1.

Conclusion  Patient self‐assessment can help support comprehensive daily prospective monitoring of bleeding, specifically facilitating data collection following hospital discharge. Exact definitions for bleeding events remains problematic. The association between platelet count, risk of bleeding and role of prophylactic platelet transfusions needs further evaluating in larger prospective trials.

Reference  1Stanworth S.J., Dyer C, Casbard A & Murphy M. (2006) Vox Sang. 91 63–9
SI24 Quality Improvements on Transfusion Practice. The Role of a National Blood Use Reporting System
Authors: Stewart A. , McClelland D. B. L.
Published: September 2006

Introduction and Background  The development of a sustainable system that would provide information about the clinical use of blood was a requirement of the Better Blood Transfusion Programme (BBTP). The system was to be designed to identify variations in practice, encourage clinical review of blood used and contribute to the goal of reducing avoidable transfusions. The system would assist with achieving the target of reducing the population exposure to Red Blood Cells (RBCs) by 10%, this translates to the achievement of a target of 41 RBC units transfused per 1000 population.

Study Design  The sustainable system has been developed and named STED (Scottish Transfusion Epidemiology Database). Hospital Blood Bank records are regularly extracted from the majority of hospital blood banks in Scotland. The records are then linked to hospital inpatient and day case records (SMR1) records by probability matching based on patient details (name, address, postcode, date of birth). The linked datasets are available for analysis in an Oracle data warehouse and the Business Objects reporting suite enables NHSS wide access to the datasets.

Results  The initial development of STED has been to provide access to a surgical view of RBCs. Surgical blood use reports at a National, Divisional, Hospital and Consultant level has enabled clinical review of blood use across Scotland. The project is in its early stages and evaluation must take account of other initiatives for better transfusion as well as environmental factors over recent years. The programme and results, mainly related to surgical interventions has so far been presented to 21 groups of practitioners (totalling 380 individuals), in 15 hospitals. For most this was the opportunity to view local practice data in the context of other centres in the NHSS. 49 groups of operations likely to be transfused have been identified based on OPCS groups and from 2002/03 to 2004/05 the probability of transfusion for patients in these groups has reduced from 14.3% to 11.2% and the average RBC per operation has reduced from 0.6 to 0.4 during the same time period. New actions and projects can be directly attributable to STED development including a project to explore relationships between transfusion and mortality data in cardiac surgery patients. The reports are supporting business case development for support of cell salvage in Cardiac Surgery and to evaluate the effectiveness of salvage in revision hip surgery. The reports are also being used as a resource for Transfusion Practitioners of the BBTP to support local audit work.

Conclusion  The results reflect the combined effect of BBTP interventions and other influences. Further data will be presented on changes in blood use for surgical and nonsurgical patient groups, in addition to current developments in the programme.
SI26 Interactive Modelling of the Impact a Flu Pandemic may have on Blood Supplies (on behalf of the NHSBT Emergency Planning Group)
Authors: Jelly M. , Harris C. , Bedford R.
Published: September 2006

Introduction  The NHS Blood and Transplant (NHSBT) has developed emergency plans based on a few scenarios including a potential Human Flu Pandemic. A model has been created illustrating the impact on the national red cell and platelet stocks using current assumptions made by the NHSBT Emergency Planning Group, NHS and the Department of Health (DH).

Methodology  As no suitable model was available a model was created in Microsoft Excel, which is widely available within the National Blood Service (NBS) and NHSBT. This allows the user to change planning assumptions which will automatically recalculate the impact on the total NBS stock of red cells and platelets. The model can be used to view different scenarios, e.g.

Changes to demand (–10%)

Clinical attack rate–the % of total population contracting Flu (25%)

Possible duration and profile of pandemic wave as per NHS Flu Contingency Plan

% of population caring for victims (5%)

Deferral period for donors contracting flu (2 weeks ill and 2 weeks deferred)

Whole Blood and component donation supply (increased pre‐pandemic only)

Buffy Coat (BC) production (49%)

Starting stock (Red Cells 56 k, Platelets 958 doses)

% of population self deferring (based on NHSBT figures).

Results  The activities modelled in this particular scenario would increase red cell stock from 56 k to 62 k before the virus is isolated in the UK. Once there was widespread activity across the UK, red cell stock would fall to 40 k before recovering after the pandemic ends. Platelet stocks could be maintained if buffy coat production was increased to 49% (normally 29%). If a more extreme scenario is modelled e.g. the clinical attack rate is increased to 50%, red cell stock would fall to 4 k (without further demand reduction) and platelet stock could only be maintained if buffy coat production is increased to 85%.

Conclusion  This model is useful in illustrating the impact of flu planning assumptions on the ability of the NBS to maintain supply of red cells and platelets and could model other scenarios e.g. severe weather conditions or terrorist activity. As more information becomes available, the NBS and other Blood Services can use the model to illustrate the impact of revised assumptions and take appropriate action to mitigate problems. The model can be used to assess potential policy decisions e.g. donor deferral periods and it could be used in real time as a potential pandemic emerges to help inform decision‐making by predicting future stock levels. The model is being further developed to assist NBS and NHSBT in predicting impact on staffing resource levels. While the model is dynamic and easily manipulated the eventual output is determined by the accuracy of the assumptions. The ultimate accuracy of the model and the assumptions will only be fully understood if and when a Flu Pandemic develops.
SI30 The Naughties–Recruiting Donors in the Decade of Donor Deferrals
Authors: Wilson J.
Published: September 2006

Since the millennium, there have been large cohorts of donors affected by blood donor selection criteria in Scotland: Previously Transfused Donors (implemented 2004, 4.9% of donor base affected)

Blood Safety and Quality Regulations (implemented 2005, increased medical deferrals from 11.55% to 13.1%, contributing to the increase in total deferral rate – including Hb donor deferrals – from 16% to 20.5%)

This means there is now a 26.3% increase in the deferral rate for new donors since 2003/04, and 38.5% increase in deferral rates for regular donors since 2003/04. UK blood services continue to prepare for a vCJD test, which is likely to further erode the donor base. This means the decade poses severe challenges in terms of donor recruitment. At the beginning of 2000, 5.8% of Scots were giving blood. By 2006, this figure has reduced to 5.2%. As we try and recruit further into the ‘nondonor’ population, segmentation analysis has identified increased barriers to giving blood. Further socio‐demographic analysis provides insight into characteristics blood donors, nondonors and lapsed donors may share. To stabilise the donor base after these deferrals, a through the line donor recruitment strategy has been implemented in Scotland, impacting on all these groups. Particularly effective methods include the expansion of a blood group specific and geographically specific direct mail campaign. A variety of traditional advertising techniques have merged with innovative new tactics. The performance of the donor recruitment strategy, and it's continued ability to cope with such massive donor base losses for the remainder of the decade will be evaluated.
SI01 Evidence Base for Transfusion
Authors: Hyde C. , Brunskill S. J.
Published: September 2006

The exponential growth of innovations in health care and research on them has made it essential that we improve systems to get succinct, accurate summaries of evidence on effectiveness to health care workers, patients, carers and donors when they need it. This is one driving force behind JPAC now. However this simple aspiration requires a number of challenges to be overcome:

What evidence should we communicate?

How should we bring it together?

How do we convert the accumulated evidence it into usable messages that will help?

How do we make sure the messages reach the people who need them?

This presentation will discuss approaches to each of these questions in turn, focusing particularly on explaining what a systematic review is for those who may not have come across it before. An issue of particular concern is the difference between evidence of ineffectiveness and absence of evidence. The latter is often mistakenly considered identical to the former, and we will explain the nature of this problem. Test yourself: is a research study showing an odds ratio of transfusion related adverse events associated with a new process of 1.2 (95% CI 0.5–11) evidence of ineffectiveness or absence of evidence? The importance of identifying uncertainty about the effectiveness of new approaches, and communicating this clearly, is a further issue we will explore. The goal of bringing together evidence on transfusion is a long term goal. As our guided tour of the JPAC site will demonstrate we have made a good start. However, there is still much work to do and we need everyone's help at many different levels to achieve the ultimate goal.
SI38 Characterisation of Membrane Proteins on Vesicles from Normal Red Cells and on Red Cells of Patients with Membranopathy
Authors: King M. J. , Jepson M. A. , Kumpel B. , Mushens R. , Guest A.
Published: September 2006

Background  Red cell vesicles are formed either after prolonged blood storage at 4°C or during incubation in calcium‐loaded medium. Unlike mature red cells, these vesicles are depleted in spectrin but carry band 3, glycophorins, acetylcholinesterase and CD47. Absorption of human anti‐D by vesicles indicated the presence of Rh proteins.

Study Design  The aims were to identify the membrane components present on red cell vesicles, and to investigate whether red cells after vesiculation in vitro were similar to those from patients with inherited haemolytic anaemias: hereditary spherocytosis (HS) and pyropoikilocytosis (HPP). Vesicles released from fresh normal red cells in Ca2+ loaded medium were purified by filtration through 0.8 μm filters. Specific monoclonal antibodies (Mabs) were used to identify integral membrane components. The analytical techniques used were SDS‐PAGE, Western blotting, confocal microscropy, and rosette formation with magnetic beads (Dynabeads) conjugated with anti‐mouse immunoglobulins. Flow cytometry quantified antibody bound to red cells after vesiculation and from patients with HS and HPP.

Results  We confirmed depletion of spectrin and the presence of band 3, CD47 and glycophorins in vesicles released from normal red cells. Confocal microscopy demonstrated the coating of Rh(D+) vesicles with human Mab anti‐D. Other membrane molecules detected on the vesicles were Duffy glycoprotein, Kell glycoprotein, glucose transporter, protein 4.2, Rh glycoprotein (RhAG), CD59, and blood group A antigen. Flow cytometry detected reductions in binding of Mabs to band 3, Rh proteins and RhAG on vesiculated red cells as well as on HS red cells. CD47 content was lower on HS than on vesiculated red cells. Greater losses of these membrane components occurred on HPP red cells with a concomitant reduction in CD59, and glycophorins A and C. Confocal microscopy of dual labelled HS and HPP red cells showed that the loss of membrane proteins was not a uniform process but ranged from strong, moderate to dim (or no) fluorescence.

Conclusion  Shedding a large number of membrane proteins in red cell vesicles is probably a physiological process of cell ageing. The greater loss of band 3, CD47, Rh protein and RhAG on HS and HPP red cells probably reflects an accelerated vesiculation process secondary to their underlying cytoskeletal defect.
SI02 Standing Advisory Committee on Blood Components (SACBC)
Authors: MacLennan S.
Published: September 2006

The remit of the SACBC is to provide advice on the safety and quality of blood components to the UK Transfusion Services/NIBSC Joint Professional Advisory Committee. More specifically this includes setting specifications for blood components (evidence‐based where possible), developing and reviewing validation of novel components, setting and assessing requirements for storage and transport systems, developing protocols for evaluating methods for the collection and processing of blood components, liasing with other SACs as required and ‘horizon scanning’ for any new component developments. Work completed in the last 2 years has included revision of chapters related to components for the 7th edition of the UKBTS Guidelines for Transfusion Services (‘Red Book’), feedback into the revision of 12th edition of the Council of Europe Guide to the Preparation, Use and Quality Assurance of Blood Components, and response to consultation on the EU Directive on Blood as it relates to component issues. Other specific projects completed have addressed the requirement for RhD labelling of leucodepleted fresh frozen plasma (FFP), the requirement for continuous agitation of platelets, the frozen and post‐thaw shelf life of FFP, the shelf life of red cells in additive solution, quality of red cells filtered by a novel prion removal filter and in vitro validation of a novel pooled buffy coat component for granulocyte transfusion. In 2006/7 SACBC will continue to review and provide recommendations on new component developments, which at present includes other prion filters, extension of platelet shelf life and use of platelet suspension medium. Aspects of quality monitoring will be reviewed, including leucodepletion performance, quality monitoring requirements for new processes and review of the application of Statistical Process Control for monitoring quality and conformance of blood components. Data on component quality related to changes in processing of blood will be assessed, e.g. with use of new processing technology and overnight hold of whole blood at ambient temperature prior to processing.
P11 A Trial of Preoperative IV Iron Sucrose (Venofer) Supplementation in Patients with Iron Deficiency Anaemia Undergoing Hip Arthroplasty at the Royal Bournemouth Hospital
Authors: Burt T. , Lim S. , Hall R. , Locke K. , Brannan L. , Johnson J. , Clark M.
Published: September 2006

We present the protocol and initial results for a trial of preoperative IV iron in anaemic patients presenting for hip arthroplasty at The Royal Bournemouth Hospital (RBH). A review of audit data at RBH has revealed 30% of primary hip replacements receive blood transfusion of at least 2 units of red cells. These patients often present to preoperative assessment clinic with a low haemoglobin (Hb). A proportion of patients with a low Hb are iron deficient. In patients with iron deficiency anaemia, oral iron therapy is frequently poorly tolerated and a rise in Hb following oral iron is slow making it unsuitable to use in the preoperative setting. IV Iron Sucrose (Venofer, Synermed Pharmaceutical Products Limited) provides predictable bioavailable iron and has an low allergenic potential. It is safe and quick to give in an outpatient setting. In addition it is a cheap alternative to allogeneic blood. At RBH approximately 20 anaemic patients present monthly to orthopaedic pre‐assessment clinic for hip arthroplasty. These patients have a Hb <120 g dL−1 (female) or Hb <130 g dL−1 (male) and currently proceed to surgery with no further investigation unless Hb <10 g dL−1. A proportion of these patients will have iron deficiency anaemia and are therefore amenable to preoperative treatment with IV iron therapy. Study protocol flags up anaemic patients for further investigation to the Haematology Specialist Registrar (SpR) who sends a further blood form and patient information about the IV iron replacement trial. Blood tests include FBC and blood film, iron studies (ferritin, serum Fe, TIBC, transferrin saturation), coagulation screen, ESR, renal and liver function tests. Patients found to have iron deficiency anaemia are consented for the trial at an appointment with the SpR and are randomised to receive IV Iron (Venofer) or ‘standard treatment’ (no therapy). Venofer patients receive 2–3 doses (formula calculated) of IV iron (Venofer bolus over 10 min) at weekly intervals. The FBC is checked after an initial two doses and a third dose given only if the patient is still anaemic. The hospital transfusion practitioner (HTP) gives the 1st dose at the time of consent. The subsequent doses are given at weekly intervals by the HTP. Patients who have iron deficiency anaemia are also referred to the iron deficiency clinic for further investigations. Primary end points are number of patients receiving blood transfusion and number of units of blood transfused. Secondary end points are discharge times from hospital and postoperative infection rates. We present our full protocol and data collection form. We also hope to present the results from the first patients recruited.
P20 Surgical Performance Benchmarking ‐ Results from the Pilot Study
Authors: Chapman J. F. , Hick R.
Published: September 2006

Surgical performance benchmarking (SPB) was included in the Integrated Blood Shortage Plan benchmarking framework document circulated to hospitals in January 2005. The aim of the benchmarking was to ensure that hospitals that have implemented actions on appropriate use would be treated fairly in the event of a blood shortage. The SPB covered five surgical procedures; total hip replacement, total knee replacement, trans urethral resection of prostate (TURP), anterior resection (AR) and coronary artery bypass grafting (CAVBG). A scoring system was proposed taking into account mean blood usage and the percentage of patients transfused for each operation. The Blood Stocks Management Scheme (BSMS) were asked to develop a tool to enable implementation of this area of benchmarking. A web‐based system, the surgical information database (SID), was developed in conjunction with the National Blood Service IT department. It had similar characteristics to VANESA, the BSMS inventory management database. 10 of the 12 hospitals invited agreed to participate, ranging from a large multi site teaching hospital to a small private hospital. They were asked to submit data on 40 consecutive patients for each surgical procedure in a three month period. Data was collected up to 7 days pre‐operation and 30 days postoperation. Nine hospitals submitted data in the allocated time period. Some hospitals found it difficult to achieve the 40 operations target particularly for AR. The results showed that for mean blood usage, AR gave the greatest range (0.3–2 units per operation), the most consistent usage was for CAVBG (1.3–1.7 units per operations). The largest range for the percentage of patients transfused was for AR (13%–60%). Only 4/225 patients undergoing TURP were transfused. Of eight hospitals contacted in a post pilot telephone survey, all found SID easy to use, and 6/8 felt that the exercise had been beneficial for their hospital. The results were reported to the Regional Transfusion Committee chairs committee. After discussion they decided that SPB was not robust enough for their requirements and therefore would not proceed with this part of the benchmarking framework. They will look for an alternative tool. The BSMS plan to make alternative use of SID in the future.
P23 Recurrent Hyperhaemolysis
Authors: Win N. , Rao L. , Trumpeter S. , New H. , DelaFuente J.
Published: September 2006

Hyperhaemolysis is a rare complication of blood transfusion in patients with SCD. An 8 year‐old boy with SCD was on a regular transfusion programme because of right frontal lobe ischaemia. He was admitted to hospital 5 days after receiving transfusion with Hb 6.5 g dL−1, reticulocyte count 330 × 109 L−1 and total bilirubin 84 μmol L−1. Haemoglobinuria was demonstrated. He was treated with oral hydration, ibuprofen and morphine for a vaso‐occlusive crisis. His Hb continued to drop to 4.1 g dL−1, reticulocyte count to 170 × 109 L−1.The DAT was negative and no red cell alloantibodies were identified. A diagnosis of hyperhaemolysis syndrome was made and he was commenced on IVIg 1 g kg−1 for 2 days and prednisolone 1 mg kg−1 for 1 week. His Hb gradually improved over a week to 6.2 g dL−1 and he did not receive transfusions. Six months later he was re‐started on a transfusion programme because of nocturnal hypoxaemia. A week after the first transfusion he was admitted with a history of lower limb and abdominal pain.Hb 7.8 g dL−1, reticulocyte count 297 × 109 L−1 and total bilirubin 106 μmol L−1 and LDH 6000 IU L−1. The Hb dropped to 3.2 g dL−1, reticulocyte count further dropped to 168 × 109 L−1 with evidence of haemoglobinuria. He developed cardiorespiratory failure requiring transfer to intensive care unit. He was given IVIg 0.5 g kg−1 for four days and three doses of methylprednisolone 4 mg kg−1 and received two RBCs units. DAT and red cell alloantibody screen were negative. He also received Erythropoietin 500 units subcutaneously three times a week. He improved over 10 days and at discharge had Hb 7.1 g dL−1, reticulocyte count 220, LDH 2033 ΙU L−1 and total bilirrubin 20 μmol L−1. He is currently on hydroxycarbamide with a stable Hb and no evidence of red cell alloantibodies. We report a case of recurrent hyperhaemolysis which is extremely rare as there were only two cases reported in the literature. The first was an adult SCD patient who had a recurrent hyperhaemolysis 27 months after the initial episode. The second was a paediatric SCD patient who had three separate episodes of hyperhaemolysis. Second and third episodes occured when additional transfusion were given 6 and 12 months after the original episode. Hyperhaemolysis may recur. It is not possible to predict which patient may recur after receiving blood. In life threatening recurrent hyperhaemolysis, use of IVIg and steroids may be life saving.
P32 Column Agglutination DAT ‐ the Top and Bottom of it.
Authors: Maley M. , Pearson A. , Stamps R.
Published: September 2006

Background  There are no published data or recommendations regarding where red cells should be sampled from within a blood sample when performing a direct antiglobulin test (DAT) using concentrated cells. It is postulated that heavily antibody‐coated red cells accumulate at the bottom of the concentrated red cells during centrifugation. To investigate this possibility, we performed DAT's on patient samples and experimental sample mixtures after centrifugation, by aspirating cells from both the top and bottom of the red cells.

Methods  Direct antiglobulin testing was carried out using DiaMed DC‐Screening1 monospecific direct antiglobulin cards, which contain anti‐IgG, IgA, IgM, C3c and C3d. The cards also have a negative control well. DAT testing was performed in accordance with manufacturer's instructions. Agglutination strength was interpreted by eye and reaction grades scored on a scale of 0–5. Experimental samples were prepared by mixing aliquots of 100 uL, 250 μL, and 1 μL of IgG coated reagent red cells with 1 mL of uncoated reagent red cells. Red cell sample mixtures were then centrifuged at RCF 3500 for 5 min and DAT testing performed as above.

Results  Twelve of 24 patient samples gave results that differed by at least one reaction grade. Of these samples, eight gave reactions that were 1–2 grades stronger with anti‐IgG with cells from the bottom of the concentrated red cells. Three samples gave reactions that were positive in tests from the bottom and negative from the top (1x IgG, 1x IgM, 1x C3d). All three experimental samples gave markedly different reaction grades (reaction grades with cells from the top ranging from 0–1 and from the bottom ranging from 3–4).

Conclusions  These results show that performing a DAT using DiaMed monospecific cards with cells from the top of the concentrated red cells of a centrifuged sample may give misleading results. This may be due to heavily coated, denser cells being displaced to the bottom of the red cells during centrifugation. This could have implications when performing autoimmune haemolytic anaemia and possible haemolytic transfusion reaction investigations. Our findings support the view that further in‐depth study of this phenomenon is warranted.
P34 Management of Pregnancy Complicated by Anti‐hrB and/or Anti‐HrB.
Authors: Win N. , Needs M. , Tillyer L.
Published: September 2006

Anti‐hrB and anti‐HrB are rare alloantibodies, so far found exclusively in people of Black African descent. There is no data available regarding haemolytic transfusion reactions in association with anti‐hrB, and precise information is limited. Anti‐HrB may cause transfusion reactions, but no data is available. Selection of blood for transfusion support for patients with these alloantibodies imposes a special challenge in the UK, as, in the case of anti‐hrB (if accompanied with anti‐D) it is difficult to locate suitable antigen negative blood, whilst HrB‐ blood is almost unknown amongst the UK donor population. Two antenatal cases are reported, one with anti‐hrB, and one with anti‐HrB. Weak anti‐D was also identified in the serum in both cases. For the former case, r“r” ( dcE/dcE) units were provided to cover the delivery. The baby was delivered by vaginal route. Cord sample DAT was negative, with no evidence of haemolytic disease of the newborn (HDN). The patient did not require transfusion. The patient was known to have anti‐hrB in her previous pregnancy, and there was no evidence of HDN in that pregnancy. Anti‐HrB may cause haemolytic transfusion reaction. In the latter case, there are two options: either to import extremely rare D‐, HrB blood from South Africa or to provide rare Rhnull units. The patient received two Rhnull units to cover for Caesarean Section and transfusion was uneventful. Although the cord sample DAT was positive (Anti‐IgG 2+, ‐C3d1+) the infant's delivery Hb level was 15.2 g dL‐1 and bilirubin was within the normal range. No therapy was required. A literature search confirms that there is not much data available regarding the clinical significance of anti‐hrB and anti‐HrB. The few previous reports indicate that both anti‐hrB and anti‐HrB appear not to cause HDN. Our cases supported that HDN is not associated with both anti‐hrB and anti‐HrB. The cases reported here illustrate the complexity in providing transfusion support for these patients. Further case reports are warranted to establish the clinical relevance of these rare antibodies.
P62 Processing of Whole Femoral Head Allografts: Efficacy and Biological Compatability of a New Procesing Technique
Authors: Board T. N. , Mann J. , Rooney P. , Eagle M. , Hogg P. , Kay P. , Kearney J.
Published: September 2006

Introduction  Due to the possibility of disease transmission, removal of marrow components from banked, allograft bone is desirable. The majority of bone supplied by Tissue Banks to surgeons in the UK is whole fresh‐frozen femoral heads, which still contain donor bone marrow. Some surgeons wash the bone in‐theatre whilst others do not and actually incorporate the donor marrow with the graft. Little is known about the efficacy of theatre washing to remove marrow components even though evidence suggests that marrow removal results in improved stability and enhanced incorporation of washed bone. We have recently developed a tissue bank‐based bone washing protocol for whole femoral heads and in this study we compare the efficacy of tissue bank‐washed bone and theatre‐washed bone to remove marrow components and assess the biocompatability of the products.

Methods  A 12‐step tissue bank protocol has been devised which involves sonication, centrifugation and washes in hydrogen peroxide, ethanol and warm water. Twenty‐four femoral heads were put through this protocol and amounts of soluble protein, DNA and haemoglobin removed at each stage were evaluated. Residual values were obtained by pulverising the final product into a fine powder. Similarly, 24 femoral heads were milled in a bone mill and subjected to four sequential rinses in warm saline, amounts of marrow components removed were evaluated with respect to residual content of pulverised product. Contact and extract cytotoxicity assays were performed on tissue bank‐washed bone, theatre‐washed bone and unwashed bone using a human osteoblastic cell line (MG63) and human skin fibroblasts.

Results  The tissue bank‐washing protocol removed a minimum of 99% of soluble protein, DNA and haemoglobin from bone, the washed bone product was not cytotoxic. Theatre‐washed bone removed 41% haemoglobin, 72% DNA and 92% soluble protein, the washed bone product was not cytotoxic, however, unwashed bone was found to be cytotoxic against both cell lines.

Conclusion  Tissue bank‐washed bone and theatre‐washed bone both produce a product which is not cytotoxic and more biocompatible than frozen‐thawed unwashed bone. The tissue bank washing protocol is more efficacious and consistant at removing bone marrow components than currently used techniques of in‐theatre washing after milling. We would suggest that tissue bank‐washed bone would allow for safer and more biocompatible allograft usage.
The effect of tillage system and use of a paraplow on weed flora in a semiarid soil from central Spain
Authors: DORADO J , LÓPEZ‐FANDO C
Published: September 2006

Field experiments were conducted to study weed population shifts in long‐term conservation tillage systems. The objectives of this study were to determine weed community abundance, diversity and composition on conventional tillage (CT), minimum tillage (MT), no‐tillage with paraplow (ZT) and no‐tillage (NT) systems, and to identify species that are associated with specific tillage systems. The paraplow is a subsoiling technique that results in a deep loosening of the soil, in order to alleviate compaction in certain soils where NT is practiced. The results showed significant differences in both the composition and the abundance of weeds, depending on the tillage systems. Weed diversity, species richness and Shannon's diversity and evenness indices were higher under the conservation tillage systems than in the CT system. In addition, various weed species were associated with reduced tillage systems. For instance, Anthemis arvensis, Hirschfeldia incana and Lolium rigidum became more prevalent in the NT system, whereas Chenopodium album and Filago pyramidata dominated in the ZT system. Therefore, the application of a paraplow treatment changed the weed community in the NT system. Other weed species, such as Capsella bursa‐pastoris and Torilis nodosa, dominated in all three conservation tillage systems, whereas soil disturbance by mouldboard ploughing favoured species such as Polygonum aviculare and Phalaris paradoxa.
Feeding with speed: prey capture evolution in cichilds
Authors: HIGHAM T. E. , HULSEY C. D. , ŘÍČAN O. , CARROLL A. M.
Published: September 2006

The diversity of both the locomotor and feeding systems in fish is extensive, although little is known about the integrated evolution of the two systems. Virtually, all fish swim to ingest prey and all open their buccal cavity during prey capture, but the relationship between these two ubiquitous components of fish feeding strikes is unknown. We predicted that there should be a positive correlation between ram speed (RS) and maximum gape (MG) because the accuracy of a predatory strike goes down with an increase in RS and fish with larger mouths eat larger, more evasive prey. For 18 species of neotropical cichlids, we used phylogenetic‐independent contrasts to study the relationship between the predator closing speed (RS) and mouth size (MG) during prey capture. To provide a robust comparative framework, we augmented existing phylogenetic information available from the mitochondrial cytochrome b gene with sequences from the S7 nuclear ribosomal intron for these species. Then, we captured high‐speed (500 images per second), lateral view feeding sequences of each species by using a digital video camera and measured both RS and MG. Uncorrected species values of MG and RS were positively and significantly correlated. When accounting for any of the set of phylogenetic relationships recovered, the independent contrasts of RS and MG remained significantly, and positively, correlated. This tight evolutionary coupling highlights what is likely a common relationship between locomotor behaviour and feeding kinematics in many organisms.
A comparison between multivariate Slash, Student'stand probit threshold models for analysis of clinical mastitis in first lactation cows
Authors: Chang Y‐M. , Gianola D. , Heringstad B. , Klemetsdal G.
Published: September 2006

Robust threshold models with multivariate Student'stor multivariate Slash link functions were employed to infer genetic parameters of clinical mastitis at different stages of lactation, with each cow defining a cluster of records. The robust fits were compared with that from a multivariate probit model via a pseudo‐Bayes factor and an analysis of residuals. Clinical mastitis records on 36 178 first‐lactation Norwegian Red cows from 5286 herds, daughters of 245 sires, were analysed. The opportunity for infection interval, going from 30 days pre‐calving to 300 days postpartum, was divided into four periods: (i) −30 to 0 days pre‐calving; (ii) 1–30 days; (iii) 31–120 days; and (iv) 121–300 days of lactation. Within each period, absence or presence of clinical mastitis was scored as 0 or 1 respectively. Markov chain Monte Carlo methods were used to draw samples from posterior distributions of interest. Pseudo‐Bayes factors strongly favoured the multivariate Slash and Student'stmodels over the probit model. The posterior mean of the degrees of freedom parameter for the Slash model was 2.2, indicating heavy tails of the liability distribution. The posterior mean of the degrees of freedom for the Student'stmodel was 8.5, also pointing away from a normal liability for clinical mastitis. A residual was the observed phenotype (0 or 1) minus the posterior mean of the probability of mastitis. The Slash and Student'stmodels tended to have smaller residuals than the probit model in cows that contracted mastitis. Heritability of liability to clinical mastitis was 0.13–0.14 before calving, and ranged from 0.05 to 0.08 after calving in the robust models. Genetic correlations were between 0.50 and 0.73, suggesting that clinical mastitis resistance is not the same trait across periods, corroborating earlier findings with probit models.
Age and distal colonic findings determine the yield of advanced proximal neoplasia in Chinese patients with rectal bleeding
Authors: Liou Jyh‐Ming , Lin Jaw‐Town , Wang Hsiu‐Po , Huang Shih‐Pei , Lin Jou‐Wei , Wu Ming‐Shiang
Published: September 2006

Background and Aims:  Few data were available on the optimal diagnostic strategy for Chinese patients with hematochezia. We aimed to evaluate the impact of age and distal colonic findings on the yield of diagnostic strategies in young Chinese patients with hematochezia.

Methods:  Consecutive outpatients aged less than 50 years were analyzed using a hypothesized mixed diagnostic strategy to determine the optimal cut‐off age for the use of sigmoidoscopy and colonoscopy. The efficacy and cost of the diagnostic strategy and the number of colonoscopies needed to detect one advanced proximal neoplasm (APN) using different cut‐off ages were assessed.

Results:  In the hypothesized mixed diagnostic strategy for young patients, the sensitivities for the detection of APN were 100%, 92% and 75% if the cut‐off ages were 30, 35 and 40 years, respectively. The cost needed to detect one APN would be $US 3155, $US 3179 and $US 3497 if the cut‐off ages were 30, 35 and 40 years, respectively. Colonoscopy would be performed in 84%, 69% and 51% of patients if the cut‐off ages were 30, 35 and 40 years, respectively.

Conclusion:  Colonoscopy should be considered for Chinese patients with rectal bleeding who are aged ≥35 years or those aged <35 years who have adenoma in the distal colon.
High prevalence of hepatitis B virus infection and inferior vena cava obstruction among patients with liver cirrhosis or hepatocellular carcinoma in Nepal
Authors: Shrestha Santosh Man , Shrestha Shobhana , Shrestha Ananta , Tsuda Fumio , Endo Kazunori , Takahashi Masaharu , Okamoto Hiroaki
Published: September 2006

Background: Little is known about the prevalence of hepatitis B virus (HBV) DNA and the genotype distribution among patients with liver diseases in Nepal, where obstruction of the hepatic portion of the inferior vena cava (IVCO) is common. The aim of the present paper was to assess the roles of HBV infection and IVCO in liver cirrhosis (LC) and hepatocellular carcinoma (HCC) in Nepal.

Methods: Serum samples from 121 patients (89 male, 32 female; age, 55.0 ± 13.6 years) with or without IVCO consisting of 70 LC patients and 51 HCC patients in Nepal, were tested for HBV‐DNA.

Results: The HBV‐DNA was detected in 68 patients (56%) including 20 hepatitis B surface antigen (HBsAg)‐negative patients: 33 LC patients (47%) and 35 HCC patients (69%) had detectable HBV‐DNA (P = 0.0303). Among the 89 patients with IVCO, HBV‐DNA was detected in HCC patients significantly more frequently than in LC patients (80%vs43%,P = 0.0005). The frequency of HBV viremia was significantly higher among HCC patients with IVCO than those without (80%vs44%,P = 0.0236), and that of HBV viremia with IVCO was significantly higher among HCC patients than among LC patients (55%vs27%,P = 0.0153). The HBV genotypes A and D were predominant, and genotype A was significantly more frequent among HCC patients than among LC patients (22%vs6%,P = 0.0090). Among HCC patients, those with genotype A HBV were significantly younger than those with genotype D (43 ± 13vs57 ± 12 years,P = 0.0252).

Conclusion: Hepatitis B virus alone (especially genotype A) or in concert with IVCO may be responsible for development of HCC in Nepal.
Role of interleukin‐18 in the development of acute pulmonary injury induced by intestinal ischemia/reperfusion and its possible mechanism
Authors: Yang Yong‐jie , Chen Song‐hua , Ge Xi‐rui
Published: September 2006

Background and Aims: Lung injury is an important target for the systemic inflammatory response associated with intestinal ischemia/reperfusion (I/R). In the present study, the role of interleukin (IL)‐18 in the development of acute pulmonary injury induced by intestinal I/R and its possible mechanism in relation to the increased activity of inducible nitric oxide synthase and tumor necrosis factor (TNF)‐α were investigated.

Methods: Mice were randomly divided into three groups: normal control group without operation; sham group with sham operation; and I/R group in which mice underwent superior mesenteric artery occlusion for 30 min followed by reperfusion for 3 h. Each group received pretreatment with exogenous IL‐18, anti‐IL‐18 neutralizing antibody or L‐NIL, the selective inhibitor of inducible nitric oxide synthase, 30 min before ischemia. The expression of TNF‐α was detected by reverse transcription‐polymerase chain reaction (RT‐PCR) and enzyme‐linked immunosorbent assay (ELISA). Lung injury was evaluated by means of Evans blue dye (EBD) concentration, myeloperoxidase (MPO) activity and morphological analysis.

Results: The experimental results showed that both in the sham‐operated and I/R groups of animals, pretreatment with exogenous IL‐18 clearly enhanced pulmonary MPO activity, microvascular leakage and the expression of TNF‐α mRNA and protein. In contrast, IL‐18 did not increase the TNF‐α level and degree of lung injury, although it clearly enhanced the pulmonary MPO activity in normal animals. Meanwhile, IL‐18 antibody given prior to ischemia led to a reduction in the sequestration of neutrophils, extravasation of EBD and downregulation of the serum level of TNF‐α in the I/R group of animals. In addition, selective inhibition of inducible nitric oxide synthase (iNOS) that inhibited plasma extravasation and pulmonary injury without affecting the MPO activity could be demonstrated in all treated animals.

Conclusions: These data suggested a role of IL‐18 in the activation and sequestration of neutrophils in lungs. Our results were consistent with the hypothesis that increased sequestration of neutrophils and microvascular leakage might, respectively, relate to the increased IL‐18 level and the elevation of TNF‐α/iNOS activity, and these two aspects might synergically contribute to intestinal I/R‐induced pulmonary dysfunction.
11β‐hydroxylase deficiency masked by alternative medicines
Authors: Greaves Ronda , Poomthavorn Preamrudee , Zacharin Margaret
Published: September 2006

Abstract:  A 3.5‐year‐old Vietnamese boy presented with precocious pseudopuberty, hypertension and a skin rash that was treated with Vietnamese medications for 6 weeks, with resolution. Serum androgen levels were prepubertal, adrenal ultrasound was normal but a large unknown abnormal peak was detected in the urine steroid profile. Cessation of medications disclosed elevation of plasma androgen and 11‐deoxycortisol levels. The unidentified urine steroid profile peak disappeared and a tetrahydro‐11‐deoxycortisol peak was detected. This patient represents a difficult and challenging diagnosis of 11β‐hydroxylase deficiency. Careful evaluation of history and physical finding in the presence of apparent biochemistry discrepancy resulted in a correct diagnosis.
Critical appraisal of the management of severe malnutrition: 1. Epidemiology and treatment guidelines
Authors: Brewster David R
Published: September 2006

Abstract:  Hospital case‐fatality rates for severe malnutrition in the developing world remain high, particularly in Africa where they have not changed much over recent decades. In an effort to improve case management, WHO has developed treatment guidelines. The aim of this review is to critically appraise the evidence for the guidelines and review important recent advances in the management of severe malnutrition. We conclude that not only is the evidence base deficient, but also the external generalisability of even good‐quality studies is seriously compromised by the great variability in clinical practice between regions and types of health facilities in the developing world, which is much greater than between developed countries. The diagnosis of severe wasting is complicated by the dramatic change in reference standards (from CDC/WHO 1978 to CDC 2000 in EpiNut) and also by difficulties in accurate measurement of length. Although following treatment guidelines has resulted in improved outcomes, there is evidence against the statement that case‐fatality rates (particularly in African hospitals) can be reduced below 5% and that higher rates are proof of poor practice, because there is wide variation in severity of illness factors. The practice of prolonged hospital treatment of severe malnutrition until wasting and/or oedema has resolved is being replaced by shorter hospital stays combined with outpatient or community follow‐up because of advances in dietary management outside of hospital.