Preoperative Autologous Blood Donation

The Health Technology and Advisory Committee (HTAC) has published a report on preoperative autologous blood donation (PABD). The HTAC was established in 1992 by the Minnesota state legislature. It is an independent, nonpartisan advisory body that evaluates new and emerging health care technologies based on existing scientific research and technology assessments.

The HTAC reports that PABD has been used since the mid-1980s in patients undergoing elective surgery for which blood transfusion was anticipated. However, the risk of acquiring blood-borne disease from allogeneic transfusion has been minimized in recent years by thorough screening of blood donors and extensive testing of all allogeneic blood.

According to the HTAC report, PABD decreases, but does not completely eliminate, the need for allogeneic transfusion during elective surgery. PABD increases the likelihood of any transfusion and is not without medical risks, such as vasovagal reactions, cardiac complications, anemia, possible administration of the wrong blood, and bacterial and viral infection. Only about two thirds of the autologous blood units collected are actually used, and the cost per life-year-saved is higher than the cost of accepted medical and surgical interventions. Therefore, in light of the safety of the current U.S. blood supply, PABD has not been shown to be cost-effective.

Based on the above information, the HTAC makes the following recommendations:

• PABD should be discontinued as a routine medical practice because of the high degree of safety of the U.S. blood bank supply, as well as the inherent associated medical risks.

• Blood transfusion requires the informed consent of patients, and the medical risks and benefits of blood transfusion should be discussed in detail before elective surgery.

• Allogeneic blood units should be transfused whenever clinically appropriate.

• Physicians should discuss the medical risks and costs associated with PABD in detail with their patients before encouraging its use.

This report (document 000801) and others published by the HTAC may be obtained by calling 651-282-6374 or by e-mail (htac@health.state.mn.us). There is no charge for the reports. All reports are also available on the HTAC Web site athttp://www.health.state.mn.us/htac.

Warning Against Concomitant Use of Heparin Products

The Institute for Safe Medication Practices (ISMP) recently issued a warning to health care professionals against the concomitant use of lowmolecular-weight heparin and unfractionated heparin. The warning was issued in response to three deaths reported in the past year that were caused by errors from concomitant use of heparin products. The current ISMP warning, which appears in the February 21, 2001 issue of ISMP Medication Safety Alert!, includes safe practice recommendations. The report is also available on the ISMP Web site athttp://www.ismp.org.

The ISMP safe practice recommendations include the following:

• Physicians, pharmacists and nurses must thoroughly review the patient's total drug regimen and consider current and recent drug therapy before ordering, dispensing or administering any heparin product.

• Low-molecular-weight heparin is often prescribed and administered outside the pharmacy department. Therefore, protocols, guidelines and standard order forms should prominently remind physicians to assess all drug therapy, including medications administered in emergency treatment areas, and avoid concomitant use when indicated (e.g., a heparin infusion should not be started if lowmolecular-weight heparin has just been administered).

• A summary of current and discontinued medications (including one-time doses) should be generated from the pharmacy computer system for all inpatients and placed on patients' charts daily for easy reference.

• A system must be in place to communicate all orders for heparin products to the pharmacy (including those prescribed in emergency treatment areas if patients are admitted) so that screening can occur for unsafe duplication of products and contraindications.

• Access to heparin products (except flushing solutions) should be restricted, when feasible, and this medication should be dispensed from the pharmacy as needed.

• Heparin products should be stored in automated dispensing cabinets outside emergency treatment areas that prohibit removal via the “override” system before the pharmacy has screened the order.

• An independent check by two persons should be required before heparin products are administered. An independent review of the patient's entire drug therapy profile and recent laboratory results should be considered.

• Nurses should be educated about the inherent risks of borrowing highalert medications from other patients' supplies. If some of these medications must be stored in patient care areas (e.g., emergency department), alerts should be displayed on automated dispensing cabinet screens or affixed to other storage areas.

AAP Statement on Molecular Genetic Testing in Children

The Committee on Genetics of the American Academy of Pediatrics (AAP) has issued a position statement on molecular genetic testing in pediatric patients. The AAP statement appears in the December 2000 issue of Pediatrics.

For decades, many types of diagnostic and carrier testing for genetic disorders have been available, but the use of molecular methods is a relatively recent phenomenon. According to the AAP committee, genetic research has accelerated the discovery of individual genes and enhanced our understanding of how gene abnormalities can lead to disease. Molecular diagnostic testing can provide the following: (1) diagnostic confirmation of a symptomatic patient, including genotype-phenotype correlation in some disorders; (2) carrier testing; and (3) presymptomatic testing for lateonset disorders. These tests also can be used for population-based screening to predict future genetic disease or assess the risk of complex conditions such as cancer, cardiovascular diseases and neurodegenerative disorders in persons who are otherwise healthy.

The AAP statement provides background information; discusses the various types of molecular testing, including indirect analysis, direct mutation analysis and molecular cytogenetic analysis; weighs the benefits and risks of molecular diagnosis; and addresses special concerns for children and adolescents.

While the AAP position statement focuses on molecular genetic testing that can be used to diagnose many genetic disorders, the committee stresses that this type of technology may not be appropriate for diagnosis of all, or even most, genetic conditions. Expert interpretation and explanation of test results to patients and their families are essential. Physicians should remember that predictive genetic testing in children and adolescents can lead to complicated medical, psychologic, ethical and legal issues. Physicians must understand these issues and adequately prepare families before ordering molecular genetic testing.

ASHA Web Site on Communication Disorders

The American Speech-Language-Hearing Association (ASHA) has launched an enhanced version of its consumer Web site (http://www.asha.org) to better serve persons seeking information about communication disorders. The ASHA Web site includes resources on the prevention, treatment and diagnosis of speech, language and hearing disorders.

The ASHA Web site provides information on stuttering, hearing loss, voice disorders, aphasia, tinnitus, delayed language development and dysphagia. The site also includes information on newborn hearing screening, augmentative and alternative communication, languagebased learning disabilities and bilingual children. A separate Web site for health care professionals is available athttp://www.asha.org/slp/practice-issues.

Coexisting Diseases in Hospitalized Patients

According to the Agency for Healthcare Research and Quality (AHRQ), more than one half of all hospitalized patients have coexisting diseases that are not the main reason for hospitalization but that can complicate treatment and lengthen their stay. This information is included in a report from the AHRQ, titled “Hospitalization in the United States, 1997.”

The AHRQ report states that one in three hospitalized patients has two or more comorbidities. In addition to their main diagnosis, one fifth have hypertension, which can complicate treatment of the primary diagnosis. The second most common comorbidity is fluid and electrolyte disorders, which may indicate that a patient is significantly dehydrated. About 11 percent of hospitalized patients have emphysema or chronic bronchitis, nearly 10 percent have diabetes mellitus and almost 7 percent have an irregular heartbeat.

For a free copy of “Hospitalization in the United States, 1997,” write to the AHRQ Publications Clearinghouse, P.O. Box 8547, Silver Spring, MD 20907, or call 800-358-9295. To view a chart of the five most common comorbidities among hospital patients, visit the AHRQ Web site athttp://www.ahrq.gov/news/press/pr2000/hospchart2.pdf.

Antiretroviral Approved for Use in Infants

The U.S. Food and Drug Administration has granted accelerated approval to market lopinavir-ritonavir (Kaletra) for the treatment of human immunodeficiency virus (HIV) infection in adults and children six months and older in combination with other antiretroviral medications. The accelerated approval was based on the response of viral load measurements and CD4 cell counts from a 24-week controlled, Phase III clinical trial. Lopinavir-ritonavir was formerly known as ABT-378/r.

Lopinavir-ritonavir is the only protease inhibitor approved for use in children as young as six months of age. The antiretroviral medication is available in capsule and liquid formulations. Lopinavir-ritonavir can cause serious side effects if used in combination with certain medications. It should not be taken if a patient has had an allergic reaction to any of the medication's ingredients.

The manufacturer stresses that lopinavir-ritonavir is not a cure for HIV infection. The most common side effects related to lopinavir/ritonavir are abdominal pain, abnormal stools, diarrhea, weakness/tiredness, headache, nausea and vomiting.

Overtraining with Resistance Exercise Programs

The American College of Sports Medicine (ACSM) has released an official statement on overtraining with resistance exercise. The statement appears in the ACSM's Current Comments, January 2001.

According to the ACSM, resistance exercise is currently one of the most popular types of exercise. Each resistance training session is a combination of five acute training variables: choice of exercise, order of exercise, exercise volume, load or intensity, and rest between sets. Variety of exercise in a long-term program helps to ensure that the body is continually being presented with stress that allows both progress and adequate recovery. It is important to note that training volume and intensity must be inversely related.

Many signs and symptoms of overtraining have been suggested. Not all of these symptoms will be present, and these symptoms do not always represent overtraining, reports the ACSM. Frequent signs of overtraining include the following: decreased performance and training tolerance; increased recovery requirements; decreased motor coordination; altered patterns of resting heart rate, blood pressure and respiration; increased basal metabolic rate; chronic fatigue; sleep and eating disorders; menstrual disruptions; headaches; gastrointestinal distress; muscle soreness and damage; joint aches and pains; depression and apathy; decreased selfesteem and concentration; increased occurrence of illness; and impaired immune function. Most of these symptoms are derived from research on endurance exercise overtraining.

Recommendations on the treatment of overtraining from resistance exercise include the following: addition of one or more recovery days per training week; avoidance of monotonous training; inverse relationship between training volume and intensity; avoidance of excessive intensity or training volume for extended periods; and avoidance of performing every set of every exercise of every session to absolute failure, with no variation.

Current Comments are official statements by the ACSM concerning topics of interest to the public at large. More information may be obtained by calling 317-637-9200 or by writing to the ACSM Public Information Department, P.O. Box 1440, Indianapolis, IN 46206-1440.