Monitoring for underutilization of RBC components and platelets

BACKGROUND: Monitoring blood transfusion for overutilization is standard practice at most institutions. STUDY DESIGN AND METHODS: This study monitored for underutilization of blood transfusion over a 14-month period, by evaluating patients who had Hb levels that were reported to be <5 g per dL or platelet counts <10 x 10(9) per L and who did not receive an RBC or platelet transfusion within 24 hours of the reported results. RESULTS: During the study period, 24,004 units of RBCs and 3,967 units of apheresis platelets were transfused. There were 148 patients who had a Hb level that was reported to be <5 g per dL or a platelet count reported to be <10 x 10(9) per L and who did not receive a transfusion during the 24 hours after the reporting of these results. In 5 cases, the patients died before the reporting of the low Hb or platelet counts, which precluded the low Hb or low platelet count reports from triggering transfusion therapy. In 8 cases, an underutilization review investigation could not be done, because of the unavailability of patient charts. Of the remaining 135 cases, investigation revealed justifiable reasons for withholding transfusion in 133. In 2 cases, the withholding of transfusion was deemed by peer review to be inappropriate, as the patients should have received a transfusion. Overall, there was one documented underutilization of RBC transfusion therapy during a period when 24,004 units were transfused and one underutilization of platelet transfusion therapy during a period when 3,967 units of apheresis platelets were transfused. CONCLUSION: Monitoring for underutilization of transfusion therapy fulfills the requirements of the Joint Commission on the Accreditation of Healthcare Organizations: While the underutilization of transfusion therapy did not appear to be a significant problem at this medical center, determining the reasons for withholding transfusions shed light on important patient care-related issues, including preexisting causes of falsely low platelet counts and Hb levels, delays in investigating critical laboratory values, and the need for policies for the treatment of patients who refuse transfusion for personal or religious reasons.     

Assay of ornithine carbamoyltransferase activity in human liver using carbon-labeled ornithine and thin-layer chromatography

Ornithine carbamoyltransferase (EC 2.1.3.3) activity in human liver homogenates has been measured using 14C-labeled ornithine and unlabeled carbamoyl phosphate. A thin-layer chromatographic (TLC) procedure is used to separate the radioactive substrate and product, ornithine and citrulline, respectively, and the regions of the chromatogram corresponding to ornithine and citrulline are cut out and counted in a liquid scintillation spectrophotometer. The method has the following advantages: (1) the radioactive substrate ornithine is more stable in solution than carbamoyl phosphate, (2) 14C-labeled ornithine is available in higher specific activity than carbamoyl phosphate, (3) all radioactivity may be accounted for by using the TLC system, (4) the developed thin-layer chromatogram is stable indefinitely, (5) in contrast to colorimetric assays, other compounds in the raction mixture do not interfere with the citrulline determination, and (6) most importantly, the rate of the enzyme reaction at various time intervals can be determined by taking aliquots from the same incubation tube.     

Emergency physician care of family members,friends, colleagues and self

Emergency Physicians are frequently called upon to treat family members, friends, colleagues, subordinates or others with whom they have a personal relationship; or they may elect to treat themselves. This may occur in the Emergency Department (ED), outside of the ED, as an informal, or “curbside” consultation, long distance by telecommunication or even at home at any hour. In surveys, the vast majority of physicians report that they have provided some level of care to family members, friends, colleagues or themselves, sometime during their professional career. Despite being common, this practice raises ethical concerns and concern for the welfare of both the patient and the physician. This article suggests ethical and practical guidance for the emergency physician as to how to approach these situations.     

Efficacy of rabeprazole in patients with reflux esophagitis: A single-center, open-label, practice-based, postmarketing surveillance investigation

Background: The efficacy of rabeprazole sodium 20 mg/d for the treatment of reflux esophagitis has been demonstrated in several studies in Japan. However, studies of rabeprazole sodium 10 mg/d are lacking.Objective: This study was conducted to assess the efficacy and tolerability of rabeprazole 10 mg/d for the treatment of reflux esophagitis.Methods: Patients diagnosed with reflux esophagitis in routine clinical practice were enrolled in this single-center, open-label, practice-based, post-marketing surveillance investigation. Patients were to receive 10 mg of rabeprazole once daily for 8 weeks. The efficacy of rabeprazole was assessed on the basis of symptoms and endoscopic findings in accordance with the modified Los Angeles classification. Tolerability was assessed using subjective symptoms recorded before, during, and after treatment.Results: Of a total of 61 patients enrolled in this study, 47 (77%; 29 men, 18 women; mean age, 63 years) were included in the efficacy and tolerability analyses. Fourteen (23%) patients, including 5 (8.2%) patients who were treated with rabeprazole 20 mg/d, were excluded from the analyses. Endoscopic examinations were performed before and after treatment in 32 of 47 (68.1%) patients; mucosal lesions were healed in 20 of 32 (62.5%) patients after rabeprazole treatment. In patients with mild mucosal lesions prior to treatment, complete remission was achieved in 17 of 24 (70.8%) patients after treatment. Rates of improvement of symptoms were as follows: epigastralgia, 76%; heartburn, 76.7%; dull pain in the esophagus, 86.7%; and belching, 72.2%. Rabeprazole was well tolerated throughout the study; no serious symptomatic adverse events were reported. Although 1 case each of elevated alkaline phosphatase and gamma-glutamyltranspeptidase levels were reported, these changes were mild and improved after continuous treatment with rabeprazole.Conclusion: In this study, rabeprazole 10 mg/d was well tolerated and was shown to have satisfactory efficacy in the healing of esophagitis and the relief of the symptoms of esophagitis.     

Reliability and validity of shoulder function outcome measures in people with a proximal humeral fracture

Abstract

Purpose: Investigate test--retest reliability and validity of five shoulder outcome measures in people during their active rehabilitation after a shoulder fracture. Method: This prospective longitudinal study assessed shoulder function in 20 people (16 women, mean age 68.1 years) with surgical or conservative management at 6, 12 and 13 weeks post proximal humeral fracture using three patient-reported (Disabilities of Arm, Shoulder and Hand; Oxford Shoulder Score; Subjective Shoulder Value) and two clinician-administered (Constant Score; UCLA Shoulder score) outcome measures. Results: Content analysis categorised items into multiple domains of functioning for each outcome measure. Construct validity testing between measures found moderate to strong correlations (r?=?0.43–0.92). Longitudinal validity (responsiveness), represented by correlations between change scores, was moderate to strong (r?=?0.44–0.83). Although ICCs_2,1 for test–retest reliability ranged from 0.75 to 0.93, Limits of Agreement between measurements were relatively wide (10–23% of available range of scores). Minimal clinically important difference estimates varied between anchor- and distribution-based methods. Conclusions: The five outcome measures assessing shoulder function provided values for reliability and validity that meet measurement requirements for use in groups of people after a proximal humeral fracture. However, the use of these outcome measures might be limited by low absolute agreement between measurements and their content covering multiple domains of functioning.

• Implications for Rehabilitation

• Linking the International Classification of Functioning, Disability and Health (ICF) to the content of common shoulder function outcome measures showed that multiple domains of functioning are combined into a single score. This might not be preferred for measurement of the single construct of “shoulder function”.

• Currently available shoulder function outcome measures may not be sufficiently reliable to monitor change in an individual after a proximal humeral fracture during the rehabilitation phase.

     

Plasma normetanephrine measurements for detection of pheochromocytoma in patients with hypertension

We describe a simple and specific radioenzymatic assay for measurement of total plasma normetanephrine (NMN), which is an extension of a previously developed procedure for measuring of urinary NMN. Plasma NMN is deconjugated by acid hydrolysis at pH 1.0 and boiled for 20 min. The assay is based on the conversion of NMN to its N-methylated, tritiated derivative metanephrine (3H-MN), utilizing phenylethanolamine N-methyltransferase and S-adenosyl-[3H]methionine. The assay is rapid, sensitive and results can be obtained in less than 4 h. Many antihypertensive drugs tested did not interfere with the assay. This assay could be used for detection of pheochromocytomas in patients with hypertension.     

3-Mercaptopyruvate sulfurtransferase (EC 2.8.1.2): a simple assay adapted to human blood cells

A product of cysteine catabolism, 3-mercaptopyruvate, is enzymatically degraded to sulfur and pyruvate by a sulfurtransferase (EC 2.8.1.2.) present in human red and white blood cells. A simple sulfurtransferase assay is reported which takes advantage of the fact that pyruvate is conveniently measured enzymatically by lactate dehydrogenase (LDH) after the elimination of 3-mercaptopyruvate, also a substrate of LDH, by addition of N-ethylmaleimide. Sulfite is employed as sulfur acceptor, and conditions for a reproducible assay including data for preparation and storage of reactants, their assay, and their optimal concentrations are given. The apparent K_m for sulfite is 6.5 · 10^?3 M and for 3-mercaptopyruvate is 1.9 · 10^?3 M. A reducing agent, in this assay dithiothreitol (Cleland's reagent), is essential for active transsulfuration. A normal metabolite, 3-mercaptopyruvate is reported elsewhere to have the capacity of producing polyploidy and chromosomal endoreduplication, a feature rendering it of interest in tumor metabolism.     

The change in the pH 4 and pH 6 forms of alpha-glucosidase in cultured amniotic fluid cells and its implication in prenatal diagnosis of Pompe's disease.

Activities of two major forms of alpha-glucosidase in cultured amniotic fluid cells have been measured by the 4-methylumbelliferyl-alpha-D-glucoside assay after 3, 6 and 9 weeks of culturing. Activity of the pH 4 forms of alpha-glucosidase, which is deficient in Pompe's disease, was low in early culture but increased rapidly as the culture time was increased. The cells harvested at 3 weeks had a low absolute activity of the pH 4 form as well as low ratio of the pH 4 to pH 6 enzyme. The pH 6 form is not affected in Pompe's disease. The results suggest cautions when attempting early diagnosis by use of microtechniques and re-emphasizes the need for differentiation of these two forms of alpha-glucosidases in prenatal diagnosis of Pompe's disease.     

Activity of some proteolytic enzymes in normal and dystrophic human muscle.

1. The following proteolytic enzymes were measured in muscles of control subjects and patients with muscular dystrophies and related neuromuscular diseases: an elastase-like enzyme, carboxypeptidase A, carboxypeptidase B and pyroglutamyl peptidase. 2. Elastase-like enzyme and carboxypeptidase B did not show significant alterations in various disease conditions that were examined. 3. Carboxypeptidase A was moderately elevated in dystrophic as well as other diseased muscles. 4. Pyroglutamyl peptidase was not markedly altered in any disease condition except that is was slightly lower in dystrophic muscles.     

Sensor Measures of Symmetry Quantify Upper Limb Movement in the Natural Environment Across the Lifespan

Knowledge of upper limb activity in the natural environment is critical for evaluating the effectiveness of rehabilitation services. Wearable sensors allow efficient collection of these data and have the potential to be less burdensome than self-report measures of activity. Sensors can capture many different variables of activity and daily performance, many of which could be useful in identifying deviation from typical movement behavior or measuring outcomes from rehabilitation interventions. Although it has potential, sensor measurement is just emerging, and there is a lack of consensus regarding which variables of daily performance are valid, sensitive, specific, and useful. We propose that symmetry of full-day upper limb movement is a key variable. We describe here that symmetry is valid, robustly observed within a narrow range across the lifespan in typical development, and shows evidence of being different in populations with neuromotor impairment. Key next steps include the determination of sensitivity, specificity, minimal detectable change, and minimal clinically important change/difference. This information is needed to determine whether an individual belongs to the typical or atypical group, whether change has occurred, and whether that change is beneficial.     

The care of VIPs in the emergency department: Triage,treatment and ethics

People identified as Very Important Persons (VIPs) often present or are referred to the Emergency Department (ED). Celebrities are a small subset of this group, but many others are included. Triage of these patients, including occasional prioritization, creates practical and ethical challenges. Treatment also provides challenges with the risks of over testing, overtreatment, over consultation, and over or under admission to the hospital. This article presents a practical and ethical framework for addressing the care of VIPs in the ED.