TRALI risk reduction: Donor and component management strategies

Transfusion‐related lung injury (TRALI) occurs in ～1 in 5,000 transfusions and may cause considerably more morbidity and mortality that is not recognized in clinical practice. Based on the current understanding of the etiology of TRALI, blood centers have implemented or are evaluating various donor and component management strategies in an effort to mitigate the risk of TRALI. Many cases of TRALI are likely caused by antibodies to leukocyte antigens (HLA or HNA) in blood components. Approximately 10 to 20% of female blood donors with a history of pregnancy and 1 to 5% of male blood donors harbor these antibodies. Alternatively, TRALI may be mediated by other bioactive lipids or substances that accumulate during storage and cause a reaction when transfused to susceptible patients. The complex interplay among various donor‐, component‐, and patient‐related factors underlying TRALI guarantees that effective prevention will not be a single or simple intervention but rather will require a multifaceted approach. Perhaps, the most important risk reduction strategy is the effort to ensure appropriate use of blood products and eliminate unnecessary transfusions. Blood collection agencies, however, have more proximate control over donor selection and component management than transfusion practice. AABB has provided some guidance on deferring donors implicated in TRALI and minimizing the preparation of high plasma volume components from donors who have anti‐leukocyte antibodies or are at increased risk of leukocyte alloimmunization. Blood centers have taken various approaches to mitigate the risk of TRALI, and the possible benefit and the inherent limitations of the current strategies will be reviewed. J. Clin. Apheresis 2009. © 2009 Wiley‐Liss, Inc.     

Infection control: reducing the risk to medical patients

Patients on medical wards are at risk of infections, both from their conditions and invasive procedures carried out on them. Scrupulous infection control by nurses can do much to reduce this risk.     

Venous thromboembolism: reducing the risk

This article demonstrates how services provided in minor injury units (MIUs) and emergency departments (EDs) can be improved by the implementation of routine thromboprophylaxis by subcutaneous injections of low molecular weight heparin for patients whose lower limbs are immobilised by plaster casts. The author offers evidence of the need for such a change in practice from a literature review and a case study, and describes how it can be achieved in five steps. She also outlines a protocol for routine thromboprophylaxis in MIUs and EDs.     

Prevention: the key to reducing cardiovascular disease risk in women

More than 500,000 US women die of cardiovascular disease (CVD) annually, exceeding deaths for cancer, accidents, and diabetes combined. Yet women are largely unaware of this and fear breast cancer more. One way of changing this number is to change the way we approach CVD, that is, to practice preventive healthcare. Until recently, guidelines for women with CVD were derived largely from research conducted primarily on white middle-aged men. Although evidence-based medicine is still lacking, guidelines and recommendations specifically for women are now available and include aggressive management of the risk factors of smoking, hypertension, dyslipidemia, diabetes mellitus, and obesity. Unless women are educated regarding these risk factors and are enabled to make lifestyle changes, their chances of modifying and reducing their risks are severely impaired.     

Burns: causes and risk factors

In a retrospective study of 277 adult patients consecutively hospitalized for burns over a five-year period (1975-1979) patients' characteristics, circumstances of burn injury and prevalence of established predisposing factors were determined. The average age was 44.5 years, 78% were black and 62% were men. Average extent of burn was 19.7% body surface area. Major causes included flames in 44.8%, scalds in 28.5%, and chemicals in 9.7%. Seventy-four percent of all burns occurred at home. Burns resulting from assault accounted for 20.9%. Fifty-six percent of the patients had one or more of the established predisposing factors. Judged to be predisposed to burn injury were all of those who attempted suicide, all who were using self-treatment for some preexisting conditions, 85% of the elderly, 83% of those who died, 81% of those burned in the bathtub and 80% of those assaulted. Other described groups were also at high risk. Living alone increased risk of injury in persons prone to burn. The most common predisposing factors were alcohol and drug abuse, physical and mental illness and advanced age. Mortality rate was 12.6%. This study emphasizes the urgent need for effective burn prevention programs in which all health professionals should play an important role.     

Maintaining instrument quality while reducing items: application of Rasch analysis to a self-report of visual function

While efficiency has been of concern in the measurement of health care outcomes, little attention has been devoted to methods that achieve efficient, shortened instruments that have good psychometric properties. The purpose of this study was to show how Rasch analysis could be used to reduce the number of items in an instrument while maintaining credible psychometric properties. This approach was applied to the Visual Function-14 (VF-14), a self-report of 14 vision-dependent activities, designed to measure the need for and outcomes of cataract surgery. An instrument which contained the VF-14 plus an additional 10 items that were developed for the study (VF-24) was administered to sixty-one patients (73.7+/-9.5 years) about to undergo extracapsular cataract removal at one of two surgical centers. Rasch analysis (BIGSTEPS) of the VF-14 showed a number of limitations to the original instrument, including: 1) unequal use of the five rating categories, 2) ceiling effect, 3) several other gaps where patient abilities did not match with item difficulties, and 4) sets of items that appeared redundant, (i.e., having the same calibration level). To resolve the first three of these problems, the rating scale was converted to a three-point scale and BIGSTEPS was run with all 24 items. (10 additional items added to the VF-14 designed to "fill in" the gaps). The conversion to a three-point scale and the increase in items resulted in some improvement in the matching of item difficulty to patient ability, as evidenced by a slight decrease in gaps. The addition of items resulted in improvements in person separation (2.55 to 2.99) and Cronbach's alpha (.83 to .91) but did not substantially reduce the ceiling effect and furthermore resulted in an increase in item redundancy. The final practical improvement undertaken was to reduce the number of items while attempting to maintain the psychometric qualities of the instrument as a whole. Three criteria were used in deciding to remove items: 1) high mean square, 2) low mean square and 3) items having similar calibrations. In addition, if an analysis showed that the removal of an item substantially decrease person separation, that item was retained for further analyses. Relative to the original VF-14, the resulting VF-10 showed less redundancy of items while person separation (2.20) and Cronbach's alpha (.89) remained relatively intact. The study demonstrates that Rasch analysis, while effective in elucidating the metrics of an original instrument, can also be useful in designing modifications of instruments that are both efficient and psychometrically sound.     

Adolescent care: reducing risk and promoting resilience

In summary adolescence is a crucial period in the chronology of health. Most lifelong health choices are decided at this stage and clinicians can help adolescents make healthy choices to ensure a safe, secure future. They also develop skills for the rest of their lives to cope with stress, take care of their bodies, and decide whom to spend time with in meaningful relationships. Preventive health for adolescence stems from the relationship the provider cultivates with the patient and the power that comes from that dynamic relationship to respond to patient needs and promote health throughout the life cycle.     

Skin cancer: causes and groups at risk

This second in a two-part series focuses on the causes and risk factors of skin cancer, highlighting risk factors among the general population as well as in high-risk groups. Part 1, published last week, outlined the main types of skin cancer and the treatment options available for each type; this article stresses the importance of early identification and patient education to prevent skin cancer.