Prevention of D sensitization after mismatched transfusion of blood components: toward optimal use of RhIG

Transfusion of D+ red blood cells (RBCs) into D- recipients, whether through whole blood, RBC, or platelet (PLT) transfusion, can lead to alloimmunization with associated risks of hemolytic reactions from subsequent mismatched transfusion. The incidence of D alloimmunization in various transfused patient populations may be different from that reported in normal subjects or in pregnancy, but prevention of D alloimmunization after mismatched transfusion can be achieved using RhIG. An optimal approach to the use of RhIG, however, has not been identified for the United States. Case histories and studies of volunteers reported over the past 40 years have established that alloimmunization to mismatched RBC transfusion can be successfully prevented with a dose of 20 microg of RhIG per 1 mL of D+ RBCs (per 2 mL of whole blood) when given within a window of opportunity that extends to at least 72 hours. Evidence from prospective studies of RhIG as a therapy for immune thrombocytopenic purpura suggests that such doses can be tolerably given by intravenous injections over short periods, with adverse event rates minimized when pretransfusion medication is given. For mismatched PLT transfusions, the lowest dose of standard preparations of RhIG (e.g., 125 or 300 microg) should be sufficient to prevent alloimmunization given the small D+ RBC volumes involved. This article reviews how our understanding of prevention of alloimmunization in mismatched transfusion has progressed over the years and outlines some practical considerations based on the currently available evidence.     

Finanzierungsproblematik von Investitionsgütern

The provision of financial support of hospitals by States for buying capital goods is becoming increasingly more limited. In order to still make investments, alternative forms of financing such as leasing must be considered in hospitals. However, the change from the classical form of dual financing and the decision to opt for a leasing model involves much more than just a question of costs. Leasing results in easily manageable expenditure, flexibility and adaptability for the choice of model but the leasing installments must be directly financed by the turnover from diagnosis-related groups and so lead to a reduction in the annual profit. In this article the authors try to give the reader an overview of the complex and sometimes counter-productive effect of financial instruments for investments in hospitals using leasing financing as an example. In the follow-up article the decision-making procedure using dynamic investment calculations will be demonstrated using a concrete example.     

Dipeptidyl peptidase IV (DDP IV) in NASH patients

Objective(s): Non-alcoholic steatohepatitis (NASH) is a chronic liver disease with unknown etiology. The insulin resistance, immune mechanisms and oxidative stress are the main factors in its pathogenesis. Dipeptidyl peptidase IV (DPPIV) or CD26 is a protein with endocrine and immune functions. This study aimed to elicudate the changes related to DPPIV in NASH patients. Methods: Serum and urinary DPPIV activities were measured in 31 NASH patients and 17 healthy controls. The liver biopsies of 29 patients were immunolabeled for CD26. Results: The mean age of patients were 46 ± 11 years and 14 (45%) of them were female. The serum DPPIV activity was higher in patients (57.3 ± 7.8 U/L) than controls (43.6 ± 10.6 U/L) (p < 0.0001), and correlated with the histopathological grade (p = 0.038, r = 0.373) and hepatosteatosis (p = 0.018, r = 0.423) but not with stage (p = 0.286), class (p = 0.286) or CD26 staining (p = 0.743). The urinary DPPIV activity was similar in patients (1.52 ± 0.94 U/mmol creatinine) and controls (1.37 ± 0.68 U/mmol creatinine) (p = 0.861). Three acinar zones of liver had equal CD26 expression (p = 0.076). The intensity of CD26 immunostaining was correlated with histopathological grade (p = 0.001) and hepatosteatosis (p = 0.003) but no correlation with stage or class could be detected (p = 0.610 and 0.956, respectively). In Conclusions: The serum DPPIV activity and the staining intensity of CD26 in liver are correlated with histopathologic grade of NASH and hepatosteatosis. DPPIV can be proposed as a novel candidate with several potential functions in NASH pathogenesis.     

Fatal hepatitis C associated fibrosing cholestatic hepatitis as a complication of cyclophosphamide and corticosteroid treatment of active glomerulonephritis

Fibrosing cholestatic hepatitis (FCH) is an aggressive and usually fatal form of viral hepatitis in immunocompromised patients. It is characterized by progressive cholestasis leading to hepatic failure, and a characteristic histopathological features including: periportal fibrosis, ballooning degeneration of hepatocytes, cholestasis, with minimal inflammation. FCH has been reported almost exclusively in heavily immunosuppressed organ transplant recipients or patients with AIDS. This case report describes a previously immunocompetent patient with previously stable chronic hepatitis C who developed fibrosing cholestatic hepatitis after receiving cyclophosphamide and corticosteroids for active glomerulonephritis.     

High-resolution chest tomography in idiopathic pulmonary fibrosis and nonspecific interstitial pneumonia: utility and challenges

PURPOSE OF REVIEW: High-resolution computed tomography (HRCT) scan is regarded as the imaging modality of choice to evaluate patients with known or suspected interstitial lung disease. With current technology, HRCT allows for detailed assessment of interstitial compartments. We examine recent data on its role in the diagnostic evaluation, clinical decision-making, and prognosis of patients with interstitial lung disease, and we highlight the challenges related to its application in this field. RECENT FINDINGS: HRCT findings are either diagnostic or strongly suggestive of underlying pathologic patterns. By identifying the presence of certain characteristics, radiologists have developed a clearer understanding of HRCT patterns that coincide with underlying pathology. Challenges and controversies still remain, however. For example, recent studies indicate that the diagnostic accuracy and performance characteristics of HRCT depend predominantly on the study setting; intra-observer and inter-observer variability are less between academic radiologists than between community radiologists. Despite this, clinicians tend to rely primarily on HRCT when a radiologic pattern characteristic for histologic usual interstitial pneumonia is identified. SUMMARY: Specific HRCT patterns help to differentiate and prognosticate different interstitial lung diseases. It is important for clinicians to understand the utility and limitations of HRCT in managing their patients. A multidisciplinary approach remains the gold standard.