Project S.T.O.P (Stop the Over-ordering of Platelets): An initiative to reduce platelet wastages for pediatric open-heart surgeries.

INTRODUCTION: Due to a national policy change in the management of unused platelet units from September 2018, there was a drastic increase in the number of platelet units wasted in our institution. METHODS: Using Quality Improvement (QI) tools, platelet wastages from pediatric heart surgeries was identified as a priority area to work on. An intervention based on the creation of 'Order Sets' for pediatric open-heart surgeries was implemented, standardizing standby platelet orders based on type of surgery and patient weight. RESULTS: This intervention led to a dramatic improvement in the number of platelets ordered on standby, and consequently a decrease in platelet wastage from 47.6% to 16.9% for pediatric open-heart surgeries, without any reported adverse events. CONCLUSION: With the creation of Order Sets and continuous education, it was possible to eradicate the practice of requesting unnecessary standby platelets for surgeries. This is an effective patient blood management (PBM) strategy resulting in a significant decrease in platelet wastage rate and substantial cost savings.

[Analysis of magnetic resonance imaging characteristics in Chinese patients with myelin oligodendrocyte glycoprotein antibody associated disorders].

Objective: To investigate the magnetic resonance imaging (MRI) characteristics in the brain and spinal cord of Chinese patients with myelin oligodendrocyte glycoprotein antibodies associated diseases (MOGAD). Methods: Forty nine MOGAD patients with seropositive MOG-IgG and 58 AQP4-IgG positive patients were enrolled in this study. The characteristics of brain and spinal cord MRI were retrospectively analyzed. Results: There was no significant difference in the proportion of abnormal brain MRI of the two groups (69.4% vs 65.5%, P=0.177) , while the proportion of abnormal spinal cord MRI of the AQP4-IgG positive group was significantly higher than that in the MOG-IgG positive group (84.5% vs 36.7%, P=0.001) . The proportion of MOG-IgG positive patients with subcortical white matter lesions and large lesions in the brain MRI was significantly higher than that in AQP4-IgG positive group (48.9% vs 13.8%, P=0.003, 46.9% vs 12.1%, P=0.000) . The longitudinally extensive transverse myelitis in spinal cord MRI of AQP4-IgG positive group was significantly higher than that in the MOG-IgG group (70.7% vs 24.5%, P=0.002) . In addition, the proportion of MOG-IgG positive child patients with large lesions in the brain was significantly higher than that in AQP4-IgG positive child patients (76.9% vs 20.0%, P=0.047) . Conclusion: Demyelinating MRI lesions caused by MOG-IgG are heterogeneous, and could lead to a wide range of clinical phenotypes which is significantly different from those with AQP4-IgG.

[Expression of HLA-DP in patients with neuromyelitis optica spectrum disorders].

Objective: To investigate the effect of HLA-DP gene expression on the susceptibility and disease status of neuromyelitis optica spectrum disorders (NMOSD). Methods: A total of 86 NMOSD patients (52 in acute phase and 34 in remission phase), 52 multiple sclerosis (MS) patients (20 in acute phase and 32 in remission phase) diagnosed in Department of Neurology, the Third Affiliated Hospital of Sun Yat-sen University and 29 healthy controls were enrolled prospectively. Genotyping of HLA-DP was performed. The expression levels of HLA-DP molecules in peripheral blood B cells and monocytes were measured by flow cytometry. The transcription levels of HLA-DPB1 mRNA in peripheral blood mononuclear cells (PBMC) were measured by real time-PCR. The results were compared among different groups Results: There was no statistically significant difference of the distributions of HLA-DPB1*0501/HLA-DPB1*0501, HLA-DPB1*0501/X and X/X genotypes and the frequencies of allele of HLA-DPB1*0501 among NMOSD, MS patients and healthy controls (P=0.96 and 0.71, respectively). The expression levels of HLA-DP on the surface of B cells in NMOSD patients, especially in remission phase patients, were significantly higher than those in healthy controls(212±328 and 374±394 vs 55±57, P=0.049 and 0.002, respectively). The expression levels of HLA-DP on the surface of monocytes in NMOSD patients in acute phase were significantly higher than those in healthy controls(158±175 vs 65±90, P=0.025). The transcription levels of PMBC HLA-DPB1 mRNA in acute phase and remission phase of NMOSD patients were significantly higher than those in healthy controls (3.0±1.4 and 2.9±1.3 vs 1.5±1.4, P=0.000 and 0.003, respectively). The expression levels of HLA-DP molecules on the surface of peripheral blood B cells and monocytes and the transcription levels of PMBC HLA-DPB1 mRNA in MS patients at the acute and remission stages were not significantly different from those in healthy controls. The expression levels of HLA-DP molecules on the surface of B cells in patients with HLA-DPB1*0501/HLA-DPB1*0501, HLA-DPB1*0501/X and X/X genotypes were statistically different (P=0.017). Conclusion: HLA-DP gene transcription and molecular expression levels in antigen presenting cells may affect the susceptibility and disease status of NMOSD patients, while HLA-DPB1*0501 allele may affect the transcription and molecular expression levels of HLA-DP gene in antigen presenting cells.

[Clinical analysis of acute disseminated encephalomyelitis in 44 cases].

Objective: To investigate the clinical features in 44 patients with acute disseminated encephalomyelitis (ADEM). Methods: Consecutive ADEM patients admitted to Neurology Department of the Third Affiliated Hospital of Sun yat-sen University during August 2009 to July 2014 were enrolled.Clinical and laboratory data of the patients were reviewed and analyzed. Results: Forty-four patients with ADEM based on the 2012 criteria were recruited, including 23 male and 21 female; 9 children, 11 teenagers and 24 adults.There were 23 monophasic ADEM (23/44, 52%) and 21 multiphasic ADEM (21/44, 48%). Fourteen patients (31.8%) had definite incentive factors within 2 weeks preceding the disease onset.The commonest presenting symptoms were fever (20/44, 45%), mental disorder (18/44, 41%), disturbance of consciousness (17/44, 39%) and seizure (12/44, 27%). The average EDSS score was (4.3±1.3), and the average mRS score was (2.7±0.9). Abnormal autoimmune antibodies were detected in 10 patients.Two patients were positive for NMO-IgG, and three patients were positive for oligoclonal bands.On MRI scanning, small lesions were observed in 18 of 44 patients (18/44, 41%); large confluent white matter lesions in 10 patients (10/44, 23%); symmetric bithalamic involvement in 12 patients (12/44, 27%). Patients were mainly treated with intravenous corticosteroids (40/44, 90.9%) and immunoglobulin G ( 13/44, 29.5%) in acute phase.Regular follow-up performed in 29 patients (65.9%), and the average follow-up time was (4.2±2.3) year.A monophasic course was found in 10 patients, and multiphasic course in 19 patients.After (2.5±2.3) years, patients with multiphasic ADEM experienced their first clinical relapse, and the relapse frequency was (3.3±1.4). The average EDSS score was (3.9±2.2), and the mRS score was (2.2±1.3) in their latest relapse.In follow-up MRI for (5.3±1.9) years, lesions in 18 patients (62.1%) were partially ameliorated, while 6 patients (20.7%) persisted, and new lesions appeared in 5 patients (17.2%). For the 13 multiphasic patients with regular treatment, intravenous corticosteroids (13/13, 100.0%) and immunoglobulin G (7/13, 53.8%) were still important treatments in the acute phase, while oral steroids (12/13, 92.3%) plus immunosuppressants including azathioprine, tacrolimus, cyclosporine and rituximab were chosen in the remission phase. Conclusions: ADEM is not uncommon in adults, presenting with multiphasic course, encephalopathy features and disseminated lesions on MRI.As it shows very heterogeneous characteristics, ADEM is best viewed as a "syndrome" rather than a specific disorder.

[Effect of CD40 knock out on cytotoxic effector function in CD8(+) T cell of mice with cigarette smoke-induced emphysema].

OBJECTIVE: To explore the effect of CD40 knock out on the cytotoxic function of CD8(+) T cell of mice with cigarette smoke-induced emphysema. METHODS: A total of 40 male C57 mice were divided into four groups according to the random number table, including CD40(+ /+) control group, CD40(+ /+) smoke-exposure group, CD40(-/-)control group, CD40(-/-)smoke-exposure group. The smoke-exposure groups were exposed to cigarette smoke for 24 weeks to establish emphysema model. Morphological changes were evaluated by linear intercepts. The percentages of CD8, perforin, granzyme B positive cells were evaluated by immunohistochemistry. The mRNA expressions of perforin, granzyme B, interleukin (IL) -27 were measured by fluorescent real time quantitative polymerase chain reaction (RT-PCR). The IL-27 cytokine level was tested by enzyme-linked immunosorbent assay (ELISA). RESULTS: The mean linear intercepts in CD40(+ /+) smoke-exposure group was significantly higher than CD40(+ /+) control group, CD40(-/-)control group, and CD40(-/-)smoke-exposure group [(37.2±3.6) vs (24.0±3.4), (22.5±2.4), (29.9±1.7) µm] (all P<0.05). CD40(-/-)smoke-exposure group was higher than CD40(+ /+) control group, CD40(-/-)control group (all P<0.05). The percentages of CD8 positive, perforin positive and granzyme B positive cells in CD40(+ /+) smoke-exposure group [(16.3±2.3)%, (11.4±2.1)%, (10.7±1.9)%] were significantly higher than CD40(+ /+) control group [(8.3±1.6)%, (5.1±1.2)%, (4.6±1.0)%], CD40(-/-)control group [ (6.4±1.5)%, (4.3±1.0)%, (4.2±1.0)%] and CD40(-/-)smoke-exposure group [(8.6±1.7)%, (5.6±1.3)%, (5.5±1.3)%] (all P<0.05). RT-PCR results showed that the mRNA expressions of perforin, granzyme B and IL-27 in CD40(+ /+) smoke-exposure group [(20.3±7.3), (18.3±12.3), (2.2±0.7)] were significantly higher than CD40(+ /+) control group [(9.4±4.8), (10.6±3.8), (1.3±0.6)], CD40(-/-)control group [ (8.1±3.1), (7.7±3.5), (1.1±0.5)] and CD40(-/-)smoke-exposure group [(12.9±6.2), (10.4±4.6), (1.5±0.4)] (all P<0.05). ELISA results showed that the level of IL-27 in CD40(+ /+) smoke-exposure group was significantly higher than CD40(+ /+) control group, CD40(-/-)control group and CD40(-/-)smoke-exposure group [(3 242±754) vs (1 627±710), (1 600±680), (1 850±583) ng/L] (all P<0.05). CONCLUSION: Knockout the CD40 gene can inhibit the cytotoxic effector function in CD8(+) T cells of mice with cigarette smoke-induced emphysema, and alleviate the degree of emphysema.

[Effect of CD40 on Foxp3(+) Treg cell in the lung of cigarette smoke exposure mice].

OBJECTIVE: To evaluate the effect of CD40 on Foxp3(+) Treg cell in the lung of cigarette smoke exposure mice. METHODS: According to the random number table, 20 wild type (WT) C57 BL/6 mice and 20 CD40(-/-)C57 BL/6 mice were randomly divided into two groups: WT control group, WT smoke-exposure group (24 weeks) and CD40(-/-) control group, CD40(-/-) smoke-exposure group (24 weeks) (n=10 each). Alveolar airspace enlargement was observed by HE staining. Morphological change was evaluated by mean linear intercepts (MLI). Immunohistochemical method was used to detect the quantity of Foxp3(+) cell in the lung. The mRNA expression of Foxp3 was measured by fluorescence quantitative real-time polymerase chain reaction (qRT-PCR). The protein level of Foxp3 was measured by Western blot. Interleukin (IL)-10 and IL-35 levels in the lung were tested by enzyme-linked immunosorbent assay (ELISA). RESULTS: The MLI in CD40(-/-) smoke-exposure group was significantly lower than the WT smoke-exposure group[(30.0±1.7) vs (37.3±3.7) µm], but higher than the CD40(-/-) control group[(23.2±2.5) µm], WT smoke-exposure group was significantly higher than the WT control group[(22.2±1.7) µm](all P<0.05). The percentage of Foxp3(+) cell in the lungs of CD40(-/-) smoke-exposure group was significantly higher than the WT smoke-exposure group and CD40(-/-) control group[(16.89±0.75)% vs (9.65±0.74)% and (13.58±0.51)%], WT smoke-exposure group was significantly lower than WT control group[(12.13±0.81)%](all P<0.05). In the lungs, Foxp3 mRNA and protein expression in CD40(-/-) smoke-exposure group were increased compared to WT-smoke-exposure group and CD40(-/-) control group, WT smoke-exposure group were decreased compared to WT control group (all P<0.05). In the lungs, the level of IL-10 in CD40(-/-) smoke-exposure group was higher than the WT smoke-exposure group and CD40(-/-) control group[(231±25) vs (80±31) and (183±29) ng/L], WT smoke-exposure group was lower than the WT control group[(192±37) ng/L](all P<0.05). The level of IL-35 in CD40(-/-) smoke-exposure group was higher than the CD40(-/-) control group, WT control group and WT smoke-exposure group[(208±29) vs (118±29) , (148±36), (137±37) ng/L, all P<0.05]. CONCLUSION: Knockout the CD40 gene can promote the differentiation of Foxp3(+) Treg cell in the lung of cigarette smoke exposure mice, indicating that blocking the CD40-CD40 ligand pathway may contribute to alleviate the smoking-induced pulmonary emphysema.

Two case reports of Castleman disease with pulmonary involvement.

Castleman disease (CD) is a rare reactive lymphoproliferative disorder, first identified in 1954. We recently had the opportunity to analyse the characteristics of two variations of CD with pulmonary involvement. Case 1 had localised retroperitoneal hyaline vascular type CD, while Case 2 was diagnosed as multicentric plasma cell type CD. Both patients had pulmonary symptoms and signs, including cough, dyspnoea, hypoxaemia and ventilatory dysfunction; however, they had different physiological manifestations of their pulmonary abnormalities.

Significance of white blood cell count and its subtypes in patients with acute coronary syndrome.

BACKGROUND: Inflammation plays a role in the pathogenesis of coronary atherosclerosis. MATERIALS AND METHODS: Six hundred twenty-three patients with acute coronary syndrome (ACS) referred for coronary angiography for the first time in our hospital were enrolled in this study. White blood cell and its subtypes were measured on admission. The study population was divided into three groups based on total white blood cell count and followed up. Clinical end points were major adverse cardiac events (MACEs), including cardiogenic death, stroke, heart failure, non-fatal myocardial infarction, rehospitalization for angina pectoris. RESULTS: The median age was 68 years (range 31-92) and 64.2% of the patients were men. The median white blood cell count was 6.48 x 10(9 )L(-1) (range 2.34-27.10 x 10(9 )L(-1)). The median follow-up duration was 21 months (range 1-116) and MACEs occurred in 167 patients. The multivariable Cox proportional hazards regression model revealed that neutrophil count [Relative risk = 1.098, 95% Confidence interval (CI): 1.010-1.193, P = 0.029) was a risk factor for MACEs. The logistic regression model revealed that lymphocyte count [Odds ratio (OR) = 1.075, 95% CI: 1.012-1.142, P = 0.018] and monocyte count (OR = 8.578, 95% CI: 2.687-27.381, P < 0.001) were predictive of stenosis >or= 75%; Neutrophil proportion (OR = 1.060, 95% CI: 1.007-1.115, P = 0.026), monocyte count (OR = 12.370, 95% CI: 1.298-118.761, P = 0.029) were predictive of the presence of multivessel disease. Kaplan-Meier analysis of short-term and long-term cumulative survival showed no significant statistical differences among three groups. CONCLUSIONS: Neutrophil count adds prognostic information to MACEs in ACS. Monocyte count and lymphocyte count are predictive of severity of coronary atherosclerosis.

Effects of allergen inhalation and oral glucocorticoid on serum soluble CTLA-4 in allergic asthmatics.

BACKGROUND: The serum soluble cytotoxic T lymphocyte associated antigen-4 (sCTLA-4) concentration is significantly elevated in patients with asthma, and sCTLA-4 concentration correlate with the severity of asthma. The aim of the present study was to investigate effects of allergen inhalation and oral glucocorticoid on concentration of serum sCTLA-4 in patients with allergic asthma. METHODS: Allergen inhalation challenge was conducted in allergic asthmatics with isolated early asthma response and those with dual asthma response. In a randomized, double-blind, placebo-controlled, parallel group fashion, prednisolone or placebo was give orally once a day for 2 weeks. Venous blood samples were collected before and after allergen inhalation or prednisolone administration for obtaining sera. The serum sCTLA-4 concentrations were determined using enzyme-linked immunosorbent assay. RESULTS: The serum sCTLA-4 concentrations in the dual responder group increased from 29.0 (14.5-43.7) microg/l [median (25-75 percentiles)] before allergen inhalation to 44.0 (24.3-61.3) microg/l 24 h after allergen inhalation. In the isolated early responders, there were no significant increase in serum sCTLA-4 concentrations after allergen inhalation compared with baseline levels. There was a significant decrease in serum sCTLA-4 concentrations after 2 weeks of glucocorticoid therapy [22.0 (15.5-31.0) microg/l] compared with baseline values [37.0 (19.5-53.0) microg/l], whereas there was no significant difference in the placebo group. CONCLUSION: This study has demonstrated that serum sCTLA-4 concentrations increased after allergen inhalation in sensitized asthmatic subjects, and that serum sCTLA-4 concentrations were downregulated by prednisolone therapy.

Myrsinionosides A-E: megastigmane glycosides from the leaves of Myrsine seguinii Lev.

Eight megastigmane glycosides were isolated from the leaves of Myrsine seguinii collected in Okinawa. Three of them were found to be known compounds, i.e., ampelopsisionoside, alangionoside J, and linarionoside A. The structures of the new megastigmane glycosides were elucidated from the spectroscopic data and their absolute stereochemistries were determined in detail using a modified Mosher's method.

Determination of germanium in some plants and animals.

The Ge contents of plants and animals were investigated by a wet ashing procedure by hydride generation and inductively coupled plasma atomic emission spectrometry with flow injection. The analytical results obtained indicated that Ge contents widely vary in plant and animal kingdoms in the range of 8-302 ppb.