1986 update of HIV seroprevalence, seroconversion, AIDS incidence, and immunologic correlates of HIV infection in patients with hemophilia A and B

A cohort of 181 patients with hemophilia A (149) and hemophilia B (32) cared for at the Hemophilia Center of Western Pennsylvania was followed to determine human immunodeficiency virus (HIV) seroprevalence, seroconversion rate, and clinical and immunologic correlates of HIV infection. By December 1986, 82 (45%) were HIV seropositive, and of these, ten (12%) had developed AIDS, 28 (34%) had symptomatic HIV infection (CDC class III, IV), of whom 14 (17%) had AIDS-related complex (ARC), and 44 (54%) had asymptomatic HIV infection (CDC class II). The HIV seropositive group included 82% of those treated with factor VIII concentrate (97% severe, 5% moderate), 48% of those treated with factor IX concentrate (92% severe, 8% moderate), 10% of those treated with cryoprecipitate (67% severe, 33% moderate), and none of those treated with fresh frozen plasma. Based on 77 serially sampled HIV seropositive hemophiliacs (1977 to 1986), peak seroconversion occurred in 1982, with 14% (11 of 77) occurring since 1984. With increasing time from seroconversion, both T4 lymphocyte number and function (the latter measured by growth in soft agar [T colony assay]) progressively declined; T4 number declined to 135 +/- 26/mm3 (SEM), and colony count declined 1193 +/- 537 (control 3851 +/- 387) by 5 years after seroconversion. In those developing AIDS, total T4 fell below 100/mm3 (33 +/- 8/mm3) at diagnosis. In this cohort, the overall AIDS incidence is 5.5% (12% among the HIV seropositive) and in those seropositive 5 or more years, the AIDS incidence approaches 32%.     

Central venous catheter infection in haemophiliacs undergoing prophylaxis or immune tolerance with clotting factor concentrate

The risk of infection in individuals with haemophilia using central vascular access devices for administration of clotting factor concentrates for prophylaxis or immune tolerance is unknown. We conducted a survey of US haemophilia treatment centres to determine the incidence and clinical characteristics of infection associated with the use of central venous catheters. Seventy (38.3%) of 183 patients using central lines developed device-associated infection, including 30 (28.0%) on prophylaxis and 40 (52.6%) on immune tolerance, P < 0.005. Over half (54.8%) the infections occurred in those 3 years of age. Implanted/tunnelled devices (port catheters) were more likely to become infected in the first 30 days after insertion, 11 of 41 (26.8%), than external catheters (broviac/hickman), none of 29 (0%), P = 0.00003. The median time to infection from initial device placement, 124 days, varied with age, 57 days in those 2 years of age vs. 161 days in those > 2 years of age, P = 0.0008, but not with type of device or treatment. Staphylococcal infections were more common with implanted devices (ports), 30 (73.2%), than external catheters, 12 (41.4%), P < 0.01, and Gram-negative infections were more common with external catheters, 17 (58.6%), than tunnelled devices, 7 (17.1%), P < 0.005. In summary, the rate of infection with central venous access devices in haemophiliacs is high, and alternative approaches to venous access should be explored.     

Analyse d’un incident de la chaîne transfusionnelle et gestion du retour d’expérience

Analysing adverse events is part of the medical practice in so far as the part it plays is outstanding in terms of feedback and improved healthcare safety. The integrated implementation of this practice is based on a four-dimensional system: strategic (corporate policies), cultural (safety-oriented cultural mindset), structural (dedicated organization and resources) and technical (methodologies and utilities). Two case studies illustrate the sequencing process from selecting the to-be-analyzed event down to figuring out the appropriate action plan. Beyond the visible and obvious origin, thanks to the implemented methods such as causal tree or ALARM method, far-fetched analysis elements and identified factors likely to explain events can be discovered. Comments on the role and terms of feedback are also hereto expressed.