Kendall P. Crookston

A randomized, controlled Phase III trial of therapeutic plasma exchange with fresh-frozen plasma (FFP) prepared with amotosalen and ultraviolet A light compared to untreated FFP in thrombotic thrombocytopenic purpura

BACKGROUND: Photochemical treatment of fresh‐frozen plasma (FFP) with amotosalen and ultraviolet (UV) A light (PCT FFP) results in inactivation of a broad spectrum of pathogens while retaining coagulation factor activity, antithrombotic proteins, and von Willebrand factor–cleaving protease (VWF‐CP) activity.

Evidence-based recommendations for the use of WBC-reduced cellular blood components

In the United States, approximately 12 million to 14 million units of blood are donated annually.1 These units typically are fractionated into some 20 million blood components, mainly RBCs, platelets, and FFP.2 Alternatively, plasma, RBCs, and platelets may be obtained by apheresis. On average, 3 million to 4 million patients receive Evidence-based recommendations for the use of WBC-reduced cellular blood components

Recombinant factor VIIa in management of spontaneous subcapsular liver hematoma associated with pregnancy.

BACKGROUND: Spontaneous subcapsular liver hemorrhage is a rare but life-threatening complication of pregnancy. Optimal management of an expanding hematoma or ruptured capsule has not been established. CASES: We report 3 patients with preeclampsia and hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome with spontaneous subcapsular liver hematomas. The first 2 patients with ruptured liver hematomas experienced life-threatening hemorrhage. The third patient experienced uncontrollable vaginal bleeding, liver hemorrhage, and was in imminent danger of capsule rupture. Despite aggressive surgical intervention and traditional blood component therapy, adequate hemostasis could not be achieved in any of these patients. Recombinant factor VIIa was used to achieve hemostasis in all three patients. CONCLUSION: Recombinant factor VIIa is an effective adjunct in the treatment of preeclamptic patients with expanding or ruptured subcapsular liver hematoma.

Educating medical students in laboratory medicine: a proposed curriculum.

As the 100th anniversary of the Flexner report nears, medical student education is being reviewed at many levels. One area of concern, expressed in recent reports from some national health care organizations, is the adequacy of training in the discipline of laboratory medicine (also termed clinical pathology). The Academy of Clinical Laboratory Physicians and Scientists appointed an ad hoc committee to review this topic and to develop a suggested curriculum, which was subsequently forwarded to the entire membership for review. The proposed medical student laboratory medicine curriculum defines goals and objectives for training, provides guidelines for instructional methods, and gives examples of how outcomes can be assessed. This curriculum is presented as a potentially helpful outline for use by medical school faculty and curriculum committees.

The approach to the patient who refuses blood transfusion

From the Department of Pathology, University of New Mexico, United Blood Services of New Mexico, and TriCore Reference Laboratories, Albuquerque, New Mexico. Address reprint requests to: Kendall P. Crookston, MD, PhD, Department of Pathology, University of New Mexico, MSC084640, University of New Mexico, Albuquerque, NM 87131; e-mail: kcrookston@bigfoot.com. Disclaimer/note: Neither author is affiliated with Jehovah’s Witnesses. Received for publication April 7, 2006; revision received April 18, 2006, and accepted April 18, 2006. doi: 10.1111/j.1537-2995.2006.00947.x TRANSFUSION 2006;46:1471-1477. H O W D O I . . . ?

Libman-Sacks Endocarditis and Embolic Cerebrovascular Disease

OBJECTIVES The aim of this study was to determine whether Libman-Sacks endocarditis is a pathogenic factor for cerebrovascular disease (CVD) in systemic lupus erythematosus (SLE). BACKGROUND A cardioembolic pathogenesis of SLE CVD manifested as: 1) neuropsychiatric systemic lupus erythematosus (NPSLE), including stroke and transient ischemic attacks (TIA); 2) neurocognitive dysfunction; and 3) magnetic resonance imaging of focal brain lesions has not been established. METHODS A 6-year study of 30 patients with acute NPSLE (27 women, 38 ± 12 years of age), 46 age- and sex-matched SLE controls without NPSLE (42 women, 36 ± 12 years of age), and 26 age- and sex-matched healthy controls (22 women, 34 ± 11 years of age) who underwent clinical and laboratory evaluations, transesophageal echocardiography, carotid duplex ultrasound, transcranial Doppler ultrasound, neurocognitive testing, and brain magnetic resonance imaging/magnetic resonance angiography. Patients with NPSLE were re-evaluated after 4.5 months of therapy. All patients were followed clinically for a median of 52 months. RESULTS Libman-Sacks vegetations (87%), cerebromicroembolism (27% with 2.5 times more events per hour), neurocognitive dysfunction (60%), and cerebral infarcts (47%) were more common in NPSLE than in SLE (28%, 20%, 33%, and 0%) and healthy controls (8%, 0%, 4%, and 0%, respectively) (all p ≤ 0.009). Patients with vegetations had 3 times more cerebromicroemboli per hour, lower cerebral blood flow, more strokes/TIA and overall NPSLE events, neurocognitive dysfunction, cerebral infarcts, and brain lesion load than those without (all p ≤ 0.01). Libman-Sacks vegetations were independent risk factors of NPSLE (odds ratio [OR]: 13.4; p < 0.001), neurocognitive dysfunction (OR: 8.0; p = 0.01), brain lesions (OR: 5.6; p = 0.004), and all 3 outcomes combined (OR: 7.5; p < 0.001). Follow-up re-evaluations in 18 of 23 (78%) surviving patients with NPSLE demonstrated improvement of vegetations, microembolism, brain perfusion, neurocognitive dysfunction, and lesion load (all p ≤ 0.04). Finally, patients with vegetations had reduced event-free survival time to stroke/TIA, cognitive disability, or death (p = 0.007). CONCLUSIONS The presence of Libman-Sacks endocarditis in patients with SLE was associated with a higher risk for embolic CVD. This suggests that Libman-Sacks endocarditis may be a source of cerebral emboli.

A proposal for curriculum content in transfusion medicine and blood banking education in pathology residency programs

T he fields of blood banking (BB) and transfusion medicine (TM), like other areas of medicine, have evolved into specialties with a diverse array of areas of knowledge. These areas include advances in the detection of pathogens in donated blood, advances in methods to collect and manipulate progenitor cells, advances in blood conservation techniques, and advances in treatments for both the acutely and the chronically ill patient, among many others. As a consequence, the knowledge base that a resident trainee in pathology is expected to master has expanded well beyond the mere understanding of compatibility testing and inventory management. In the past several years, guidance regarding pathology residency training has been published for clinical pathology and anatomic pathology, as well as in some subspecialty areas. Although intended for medical students, an NIH-funded transfusion medicine curriculum initiative also provided a comprehensive overview of areas of knowledge relevant to pathology resident training. A survey of TM fellowships was also performed with implications for residency training, as have recent commentaries regarding the role of physicians in blood centers and hospital transfusion services. There is no document that specifically addresses pathology residency training in BB and/or TM, however, and the current requirements of the Accreditation Council for Graduate Medical Education (ACGME) on general competencies in residency training. Recently, the Academy of Clinical Laboratory Physicians and Scientists (ACLPS) and the members of the Children’s Health Initiative through Laboratory Diagnostics (CHILDx) separately produced comprehensive clinical pathology residency training documents of which BB and/or TM was a subsection. As a follow-up to the activities of ACLPS and the new requirements of the ACGME regarding general competencies, a task force was created by the AABB to address the needs for a residency curriculum on this subject. The rotation objectives outlined below for BB and TM were adapted from the subsection on BB and/or TM from the ACLPS document and further expanded. The task force further elaborated on these objectives by including additional guidance on the different needs of the general anatomic pathology– and clinical pathology–trained pathologist, who has either minimal or infrequent supervision of a transfusion service, compared with the specialist whose responsibilities might include directing a blood collection center, a cell therapeutics laboratory, or a high-complexity transfusion service. The task force further designated what each specific rotation ABBREVIATIONS: ACGME = Accreditation Council for Graduate Medical Education; BB = blood banking; CAP = College of American Pathologists; FACT = Foundation for the Accreditation of Cellular Therapy; IC = interpersonal and communication skills; JCAHO = Joint Commission on Accreditation of Healthcare Organizations; MK = medical knowledge; PC = patient care; PL = practice-based learning and improvement; PR = professionalism; SP = systems-based practice; TM = transfusion medicine.

Circulating microparticles in neuropsychiatric systemic lupus erythematosus.

Phosphatidylserine‐rich microparticles derived from endothelial cells, platelets and leukocytes have been implicated as surrogate markers of cellular activation in systemic lupus erythematosus (SLE). Because microparticles have also been associated with many primary neurologic diseases, this study investigated whether cellular‐derived microparticles are also implicated in neuropsychiatric SLE (NPSLE).

HBOC-201 use in traumatic brain injury: case report and review of literature

BACKGROUND: The first use of HBOC‐201 in severe traumatic brain injury (TBI) is presented. The use of noninvasive cerebral oximetric devices to follow clinical progress in a patient infused with HBOC‐201 is reported and the literature of hemoglobin‐based oxygen carriers (HBOCs) in brain injury is reported.

How we manage requests for recombinant factor VIIa (NovoSeven)

From the Departments of Pathology and Pediatrics, University of New Mexico, United Blood Services of New Mexico, and TriCore Reference Laboratories, Albuquerque, New Mexico. Address reprint requests to: Toby L. Simon, MD, 5201 Congress Avenue, Suite 220, Boca Raton, FL 33487; e-mail: toby.simon@zlbplasma.com. Received for publication March 31, 2006; revision received August 17, 2006, and accepted August 30, 2006. doi: 10.1111/j.1537-2995.2007.01058.x TRANSFUSION 2007;47:8-14. H O W D O I . . . ?