Jeffrey A Brinker, M.D.
- Professor of Medicine
- Joint Appointment in Radiology and Radiological Science
Data will be collected in a number of ways: • Background information completed by yourself in the attached questionnaire • Playground observations discount super p-force oral jelly 160mg online erectile dysfunction cures, occurring on four occasions throughout the research project and lasting 20 minutes each buy super p-force oral jelly overnight protocol for erectile dysfunction. Please note generic super p-force oral jelly 160mg erectile dysfunction natural treatment reviews, 10% of all observations will be conducted by an additional researcher alongside the researcher named above. The additional researcher will also be an employee of Cambridgeshire Community Educational Psychology Service. Interviews will be recorded and the copies of the recordings and any transcriptions will be securely stored by the researchers All data collected will be securely held only by the researchers and personal details will be securely destroyed once the data has been analysed. Participation is entirely voluntary and the child and/or their data can be withdrawn from the research at any time. All participants and their parents/carers will receive a letter at the end of the project explaining the overall findings. If have any questions or concerns throughout the research process please do not hesitate to contact the researcher directly. Your personal data will be treated in the strictest confidence and will not be disclosed to any unauthorised third parties. I understand that: My child’s participation in this research project is entirely voluntary, and, if I do choose to consent to their participation, I may withdraw their participation at any stage in the research Any information which is gathered by the researcher(s) will be used solely for the purposes of this research project, which may include academic publications Any information gathered by the researcher(s) may be shared between any of the other researcher(s) participating in this project in an anonymised form All information gathered will be treated as strictly confidential, and will be stored securely throughout the research process At the end of the research process all data gathered will be destroyed securely the researcher(s) will make every effort to preserve the anonymity of participants If I have any concerns about my child’s well-being which relate to their participation in the research I will share them with the researcher and the school. Data will be collected in a number of ways: • Background information completed by parent/guardian • Playground observations, occurring on four occasions throughout the research project and lasting 20 minutes each. Please note, 10% of all observations will be conducted by an additional researcher alongside the researcher named above. Interviews will be recorded and the copies of the recordings and any transcriptions will be securely stored by the researchers. All data collected will be securely held only by the researchers and personal details will be securely destroyed once the data has been analysed. Participation is entirely voluntary and the child and/or their data can be withdrawn from the research at any time. All participants, their parents/carers and schools will receive a letter at the end of the project explaining the overall findings. If have any questions or concerns throughout the research process please do not hesitate to contact the researcher directly. Your personal data will be treated in the strictest confidence and will not be disclosed to any unauthorised third parties. I understand that: the child’s participation in this research project is entirely voluntary, and, if I do choose to consent to their participation, I may withdraw their participation at any stage in the research Any information which is gathered by the researcher(s) will be used solely for the purposes of this research project, which may include academic publications Any information gathered by the researcher(s) may be shared between any of the other researcher(s) participating in this project in an anonymised form All information gathered will be treated as strictly confidential, and will be stored securely throughout the research process At the end of the research process all data gathered will be destroyed securely the researcher(s) will make every effort to preserve the anonymity of participants I will share any concerns about a child’s well-being which relates to their participation in the research with the researcher Child’s name: School: Signed: Print name: (Head teacher of school) (Head teacher of school) Signed: (Class teacher of above named Print name:(Class teacher of above child) named child) Page | 190 Appendix 10 Lego Therapy training booklet Lego Therapy training Outline of training • Introduction to Lego therapy • Theory and previous research • Session structure and implementation • Building with instructions • Freestyle building • the role of the activity leader • Lego club rewards • Monitoring and behaviour 1. Social skills are taught and modelled through collaborative, small group Lego play. Children are given roles to play in the group, and social skills and social problem solving are facilitated by an adult. Group members are expected to follow group rules, and can collectively work towards certificates. Aims of Lego Therapy • To promote the development of social, communication & play skills • Uses children’s strengths to develop these areas of weakness • To improve social competence enabling children to sustain lasting friendships and reach their potential Background Theory and Research Lego is based on the theory of Systemizing (Baron-Cohen). Improvements were seen in measures of social ability • LeGoff (2006): Measured long term outcomes. Lego therapy is a weekly intervention, min 45 mins per session – 30 mins building a Lego set. Children play roles of builder, engineer and supplier, and are required to follow instructions for set – 15 minutes collaborative ‘freestyle’ building in group • 8 weeks of intervention • Same room each week Rules It is important that children are aware of the rules of Lego Club so that the session can be beneficial for all group members. Rules should be on display each session so they can be referred to if rules are broken. The children can also add their own rules if there are extra things they consider to be important. Naming the bricks activity to develop the language of Lego Running the group: structure of sessions 1. Roles: • Engineer reads instructions • Supplier sorts and finds bricks (possibly take photographs through session) • Builder builds the model Page | 193 Building with Instructions Once roles have been allocated the building can begin. Building with instructions aims to develop: • Joint attention • Collaboration • Communicating ideas • Compromise • Joint problem solving • Turn taking • Sharing • Enjoyment • Good listening Tips: 1. The supplier may also like to take photographs of the building (up to 4 photos per session) 4. Build small sets in the first few sessions so that children can see the completed model and experience success 6. Monitor group dynamics and highlight problems early on in the programme Group activity: In groups of three, allocate roles within the group and begin to build a Lego model. The role of the Activity Leader Facilitate rather than direct: prompt children to come up with their own ideas and solutions as a group Reinforcing rules I think a rule has just been broken, what rule do you think has been broken Rewards: Encourage children to work towards rewards (see later section on Lego certificates) Noticing and commenting I noticed how nicely you asked Toby for the brick then” You just said something really positive to Toby then, well done” I’ve noticed how well you’ve all got on today. You’ve spoken politely to each other and you’ve built a really lovely model” Additionally: -Completing the attendance register There is a section on the attendance register that give you space to comment upon: – Any Behaviour issues It is important that the sessions are carried out consistently across weeks, and across schools that are participating in the research. Part 2: Freestyle building Children may need suggestions about things that they can build…. Freestyle building aims to develop: • Communicating ideas • Taking into account other’s ideas • Compromise • Explaining opinions/views Page | 195 • Dealing with competition • Thinking about the good points in others’ designs Freestyle building: • 15 minutes • No instructions, no set • Working in pairs or three • Children may prefer to play alone initially-encourage to play together but allow individual play in first sessions • Give reminders of time Lego Club rewards Lego club rewards can be given to the group when the activity leader thinks is appropriate. Certificates aim to motivate children to work together, and can be given to individuals or whole group. Helper-give after 1 or 2 sessions • Can pre-sort pieces, helps tidy up and clean room, sorts freestyle pieces, checks set against instructions Builder-give when they can construct moderate sets together (100+ pieces) Creator-give when they can create a freestyle creation with help from other children Master-Given when a child can lead a group project • Child to co-ordinate construction of a freestyle project, assign roles of builder and supplier and direct project Genius-Given rarely • Child shows leadership skills in directing a Lego film. To achieve certificate child must write a movie script, presenting idea to group, translate script into film and direct filming.
Page 137 • Voice output devices Ontario’s Preschool Speech and Language Program • Tablet computers A child’s frst years of life are very • apps”133 important for their learning of speech and language order super p-force oral jelly cheap doctor's guide to erectile dysfunction. The Learn More section has a list of speech Picture Exchange and language development Communication System milestones discount 160mg super p-force oral jelly erectile dysfunction drug approved to treat bph symptoms. Using visual aids • this program can help to identify generic 160 mg super p-force oral jelly with mastercard erectile dysfunction age, assess and treat Visual aids are an effective way language disorders and to to both communicate with your support language development. Visual Choice Boards have • There is no cost for pictures and labels of locations, this program. You can build on language skills by repeating the • You do not need to get a word associated with the image or referral from your doctor to asking your child to say it out loud, discuss your child’s needs with depending on their abilities. They may desire friendship and inclusion, but fnd it diffcult to make and Speech-Language Pathologists keep friends. It’s very troubling for parents when they know their child would like to Common signs that your child may have friends but is socially isolated. Speak to your health care With your help, your child’s teacher can:137 professional for additional information and/or to help you locate Speech-Language • Provide information about Pathologists in your area. While this may often be true behaviour, which could be in some cases, children and teens off-putting to other children; Page 139 • Find opportunities for your child Play Skills to demonstrate their skills and abilities in the class (such as in math or computers) or join a Why are play skills important So, bonds with classmates and siblings attending social events should not who may otherwise isolate or be treated as an end in itself. How to teach play skills Many Autism Ontario Chapters offer play skills groups, which provide an opportunity for children and their families to connect socially and practice play skills. Page 140 Kerry’s Place and the Geneva Bullying Centre for Autism also provide programs to promote social Bullying in Ontario schools is and play skills. When at home, there are a few things you can do to help your child develop play skills. Teaching eye Because they can stand out in their contact also helps promote social interactions they may be attention, which is important for seen as easy targets. Dealing with bullying is diffcult for parents as it usually occurs at Specifc examples of how to school and away from the home. Speak to your child about bullying Children with disabilities can also bully other children. Some do is describe the differences signs that your child may be between friendly behaviour and bullying others include: bullying behaviour. Often children think of bullying as being physically • Bruises, scrapes, and hurt. You may want to consider torn clothing explaining that bullying includes any behaviour that hurts them or • New possessions such as makes them feel upset physically toys, clothing, or anything or emotionally. The Learn More section also contains a link to a summary of More on Cyberbullying the Accepting Schools Act (Bill 13) which is designed to help schools What is it Cyberbullying is a relatively new form of bullying with which some parents may not be familiar. It Work with the school to has emerged with the increasing popularity of mobile technology fnd a solution and social networking. Two other helpful resources, also listed in the Learn More section: Resource Description Bullying & Proactive A pamphlet that is available to teachers. Inclusion of Youth with You may want to suggest that your child’s Autism Spectrum Disorder teacher request a copy of this for the school. Page 144 these developmental milestones Tools: show some of the skills that mark the progress of young children as Developmental they learn to communicate. There are also some tips on how you can Milestones help your child develop speech and language skills. If your child is not meeting one or more of these milestones, please contact your local Preschool Speech and Language Program. By 6 months: • turns to source of sounds • watches your face as you talk • startles in response to • smiles and laughs in response sudden, loud noises to your smiles and laughs • makes different cries for different • imitates coughs or other needs – I’m hungry, I’m tired sounds – ah, eh, buh By 9 months: • responds to his/her name • plays social games with you. Remember to interested in what they’re talk to your baby throughout doing and saying. Babies enjoy making • Tell them the names of the noises, and like it when you objects they are looking at imitate them over and over. Babies are interested in exploring and learning about new things, and like to hear what things are called. Page 147 Toddlers like it when you: • Let them touch and hold books • Give them simple directions to while you point to and name follow – Go fnd your red boots. Source: Ministry of Children and Youth Services ‘Your baby’s speech and language skills from birth to 30 months’ Resource type: Book Resource type: Book Social Matters: Improving social skills interventions for Ontarians with Autism Spectrum Disorder Autism Ontario Resource type: Article Emotional and Mental Health Introduction Mental or emotional health communicating. Because of this, problems can affect any child of some parents may worry that their any age. The tips more vulnerable to mental health and recommendations provided in problems such as low self-esteem, this section focus on helping you anxiety and depression, and it can identify signs that your child may be even more diffcult to identify be experiencing an emotional or and address these concerns, mental health issue. In this section you or pointing to degrees of a will see useful information on how specifc feeling on a feeling to identify symptoms of anxiety thermometer” a template for and depression and learn where a feeling thermometer has you can turn to for help if you think been provided in the Tools something is not right. In emotions your child is dealing with young children, routines sometimes can be a relief for parents. But it include stacking or lining up can also lead to the next question: items such as toys or cutlery.
If an emergency/acute care clinician has access to a palliative or pain service a consultation can provide additional options for patients with chronic pain purchase super p-force oral jelly us impotence with diabetes. Request medical and prescription records from other hospitals purchase super p-force oral jelly 160 mg fast delivery erectile dysfunction causes prescription drugs, provider’s offices effective 160mg super p-force oral jelly erectile dysfunction causes anxiety, etc. Sharing patient visit information between urgent care centers and emergency departments is also encouraged. These treatment communications may occur orally or in writing, by phone, fax, e mail, or otherwise. This includes sharing the information to consult with other providers to treat a different patient, or to refer the patient. The agreement typically identifies patient responsibilities and explains the potential for and consequences of misuse and addiction. Emergency/acute care facilities should use available electronic medical resources to coordinate the care of patients who frequently visit the facility, allowing information exchange between emergency/acute care facilities and other community care providers. Information sharing regarding visits to emergency/acute care facilities can identify patients with multiple emergency/acute care facility visits. This allows the emergency clinician to appropriately treat the patient and work to prevent drug-seeking behavior. Most conditions seen in the emergency/acute care facility should resolve or improve within a few days. Continued pain needs referral to the primary care provider or specialist for re-evaluation. Large prescriptions promote a longer period of time to elapse before the patient’s pain control and function can be evaluated by a physician. Opioid prescriptions for exacerbations of chronic pain from the emergency/acute care facility are discouraged. Chronic pain patients should obtain opioid prescriptions from a single opioid prescriber that monitors the patient’s pain relief and functioning. No opioids should be prescribed if the patient misrepresents the opioid prescriptions. Providing false information in an effort to obtain prescription opioids is an aberrant medication taking behavior that can signal an addiction problem. Opioid medications should be prescribed only after determining that alternative therapies do not deliver adequate pain relief. In exceptional circumstances, the emergency medical provider may prescribe opioid medication for acute exacerbations of chronic pain, when the following safeguards are followed: a. Only prescribe enough opioid pain medication to last until the patient can contact their primary prescriber, with a maximum of a three day supply of opioid (rather than a quantity sufficient to last until the patient’s next scheduled appointment). The emergency medical clinician should attempt to contact the primary opioid prescriber prior to prescribing any opioids. If the patient’s primary opioid provider feels further opioid pain medicine is appropriate, it can be prescribed by that provider, during office hours. The patient’s primary opioid prescriber is contacted first to approve further opioids for the patient. If approved, a limited prescription can be prescribed from the emergency/acute care facility to last until the patient is able to see their primary opioid prescriber. This reinforces the idea that patients should obtain pain medicine only from the primary opioid provider. Urine drug testing for illicit and prescribed substances requires a working knowledge of the potential for false positive and false negative results and the need for confirmatory testing. A discussion on the limitations of urine testing is beyond the scope of this guideline. Urine drug testing has the potential to identify patients using illicit drugs or not taking medications they report being prescribed. Clinicians knowledgeable at interpreting the results of the urine drug testing are encouraged to perform urine drug testing before prescribing opioids for exacerbations of chronic pain. This information may be included in the Discharge or Follow-Up Care Instructions or another handout. Discharge/Follow-Up Care instructions can serve both as guidance and as a warning to patients regarding the addictive nature of these medications and the importance of proper use. These instructions should include information about the dangers of sharing medications, combining medications and combining medications with alcohol. A statement should also be included about the proper storage and disposal of narcotics and other controlled medications. Emergency/acute care facilities should provide a patient handout that reflects the above guidelines and clearly states the facility position regarding the prescribing of opioids and other controlled substances. No legal proceeding, including medical malpractice proceedings or disciplinary hearings, should reference a deviation from any part of this document as constituting a breach of professional conduct. Clinicians should use their own clinical judgment and not base clinical decisions solely on this document. Vital Signs: Overdoses of Prescription Opioid Pain Relievers - United States, 1999—2008. Vital Signs: Overdoses of Prescription Opioid Pain Relievers - United States, 1999—2008. They are not intended to take the place of clinical judgment, which should always be utilized to provide the most appropriate care to meet the unique needs of each patient. Contact the patient’s routine provider who usually examination and risk for addiction. Perform case review or case management for provided if the patient has either previously patients who frequently visit the emergency/ presented with the same problem or received an acute care facilities with painrelated complaints. Replacement doses of Suboxone, Subutex or electronic medical resources to coordinate the care of Methadone for patients in a treatment program. Longacting or controlledrelease opioids (such as information exchange between emergency/acute care OxyContin, fentanyl patches, and methadone).
Advanced imaging based on nonspecifc signs or symptoms is subject to a high level of clinical review cheap 160mg super p-force oral jelly otc impotence in men symptoms and average age. At a minimum purchase discount super p-force oral jelly line impotence injections medications, this includes a differential diagnosis and temporal component buy super p-force oral jelly 160mg on line erectile dysfunction pump how do they work, along with documented fndings on physical exam. Additional considerations which may be relevant include comorbidities, risk factors, and likelihood of disease based on age and gender. The following indications include specifc considerations and requirements which help to determine appropriateness of advanced imaging for these symptoms. Visual disturbance Evaluation for central nervous system pathology when suggested by the ophthalmologic exam Vascular indications this section contains indications for aneurysm, cerebrovascular accident, congenital/developmental vascular anomalies, hemorrhage/hematoma, vasculitis, and venous thrombosis. Magnetic resonance imaging contribution for diagnosing symptomatic neurovascular contact in classical trigeminal neuralgia: a blinded case-control study and meta-analysis. Sentinel headache and the risk of rebleeding after aneurysmal subarachnoid hemorrhage. Clinical warning criteria in evaluation by computed tomography the secondary neurological headaches in adults. Screening for brain aneurysm in the Familial Intracranial Aneurysm study: frequency and predictors of lesion detection. Hippocampal abnormalities and seizure recurrence after antiepileptic drug withdrawal. Headache as the only neurological sign of cerebral venous thrombosis: A series of 17 cases Commentary. Comparison of magnetic resonance imaging sequences with computed tomography to detect low-grade subarachnoid hemorrhage: Role of fuid-attenuated inversion recovery sequence. Diagnostic yield of computed tomography angiography and magnetic resonance angiography in patients with catheter angiography-negative subarachnoid hemorrhage. A systematic review of causes of sudden and severe headache (Thunderclap Headache): should lists be evidence based Donington J, Ferguson M,Thoracic Oncology Network of American College of Chest Physicians; Workforce on Evidence-Based Surgery of Society of Thoracic Surgeons, et al. American College of Chest Physicians and Society of Thoracic Surgeons consensus statement for evaluation and management for high-risk patients with stage I non-small cell lung cancer. Clinical policy: Critical issues in the evaluation and management of adult patients presenting to the emergency department with acute headache. The incidence and prevalence of cluster headache: A meta-analysis of population-based studies. Transient Neurologic Defcits: Can Transient Ischemic Attacks Be Discrimated from Migraine Aura without Headache Evidence-based guidelines in the primary care setting: neuroimaging in patients with nonacute headache. Screening for intracranial aneurysms in autosomal dominant polycystic kidney disease. Does headache represent a clinical marker in early diagnosis of cerebral venous thrombosis Computed tomography angiography or magnetic resonance angiography for detection of intracranial vascular malformations in patients with intracerebral haemorrhage. Diagnostic imaging in paraneoplastic autoimmune multiorgan syndrome: retrospective single site study and literature review of 225 patients [published online 2014 Jul 29]. Choosing wisely in headache medicine: the american headache society’s list of fve things physicians and patients should question. Headaches that kill: A retrospective study of incidence, etiology and clinical features in cases of sudden death. Incidental fndings on brain magnetic resonance imaging: systematic review and meta-analysis. Sentinel headaches in aneurysmal subarachnoid haemorrhage: What is the true incidence Should patients with autosomal dominant polycystic kidney disease be screened for cerebral aneurysms Cost-effectiveness of magnetic resonance angiography versus intra-arterial digital subtraction angiography to follow-up patients with coiled intracranial aneurysms. Suchowersky O, Reich S, Quality Standards Subcommittee of the American Academy of Neurology, et al. Practice Parameter: diagnosis and prognosis of new onset Parkinson disease (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Headache as the sole presentation of cerebral venous thrombosis: a prospective study. Unruptured intracranial aneurysms: natural history, clinical outcome, and risks of surgical and endovascular treatment. Computed tomographic angiography, head, with contrast material(s), including noncontrast images, if performed, and image postprocessing 70544. Separate requests for concurrent imaging of the arteries and the veins in the head are inappropriate. Therefore, it is prudent to begin with the optimal study for the indication requested. Screening for brain aneurysm in the Familial Intracranial Aneurysm study: frequency and predictors of lesion detection. Headache as the only neurological sign of cerebral venous thrombosis: A series of 17 cases Commentary. Comparison of magnetic resonance imaging sequences with computed tomography to detect low-grade subarachnoid hemorrhage: Role of fuid-attenuated inversion recovery sequence. Diagnostic yield of computed tomography angiography and magnetic resonance angiography in patients with catheter angiography-negative subarachnoid hemorrhage.
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Deferasirox is recommended if the patient does not tolerate either of these iron chelators purchase super p-force oral jelly online from canada impotence psychological, or in the case of poor therapy compliance resulting in insufficient iron chelation purchase super p-force oral jelly 160mg otc erectile dysfunction drugs prostate cancer. As the number of leukocytes in blood components is now extremely low due to the routine use of leukocyte reduction order super p-force oral jelly with paypal impotence drugs over counter, this mainly relates to the secondary immune response in female recipients who have become immunised by pregnancy, transplantation and/or the transfusion of blood components. The frequency of this secondary immunisation was found to be approximately 40% in patients with acute leukaemia (Sintnicolaas 1995). The frequency of primary immunisation in these patients is approximately 7%, despite leukocyte reduction of erythrocyte and platelet concentrates. Although these studies demonstrate that blood transfusions can (permanently) affect the recipient’s immune system, more research is necessary to determine the clinical significance of many of these findings. A brief overview of the immunological effects of blood transfusion: Blood transfusion and immune suppression Studies of patients with long term use of blood components (haemophilia patients, poly transfusion patients and patients with renal insufficiency) show that the mononuclear cells in the peripheral blood of these patients react with a lower antigen-specific and non-specific lectin response. Blood transfusions and post-operative infections Meta-analyses of observational studies show that peri-operative transfusions are associated with a higher incidence of post-operative infections, even after correction for other risk factors (Houbiers 1994). Various blood components were compared in a randomised study and this revealed great variation in the number of infections, particularly with abdominal surgery (see table 7. A meta-analysis of these studies was not possible due to the heterogeneity of the data (Vamvakas 2007). The randomised studies in these patients are less heterogeneous, with meta-analyses showing significantly fewer post operative infections when filtered components are used (Vamvakas 2007, van de Watering 1998, Wallis 2002, Bracey 2002, Boshkov 2004, Bilgin 2004, Blumberg 2007). Blood transfusions and mortality in cardiovascular surgery Prospective randomised research performed in the Netherlands found a significant reduction in post-operative mortality if transfusions with leukocyte-reduced erythrocytes were given instead of standard erythrocytes from which only the ‘buffy coat’ was removed (van de Watering 1998, Bilgin 2004). Meta-analyses show improved survival with the use of filtered erythrocytes only for cardiovascular procedures (Vamvakas 2007). Blood transfusions and negative effects on cancer the proposed negative effect of blood transfusions on recurrence of a cancer that was cured is based on the hypothesis (Gantt 1981, Blumberg 1989) that the growth of metastases or local recurrence is partly under immunological control. Evaluating only those studies in which multi-variant analysis for known risk factors was applied, most studies did not anymore appear to show a negative effect of peri-operative transfusions. The renewed Cochrane analysis of studies on patients with colorectal cancer also failed to demonstrate a link (Amato 2008). A large observational Scandinavian study found no increased incidence of cancer in recipients of a blood transfusion (Hjalgrim 2007). A retrospective study showed a favourable effect of blood transfusions on the prevention of relapse of leukaemia after chemotherapy in patients with acute myeloid leukaemia (graft versus-leukaemia effect, Bilgin 2004). Various large case-control studies show that it is likely that particularly low grade and intermediate non-Hodgkin’s lymphomas occur at a frequency of up to two times higher after an interval of approximately 10 years after the transfusion of full blood or erythrocytes with leukocytes (Cerhan 2008, Erber 2009), but not after transfusion of ‘buffy coat’-depleted components (Blumberg 2007, Vamvakas 2007). Blood transfusions and transplantation tolerance There are many factors that play a role in transplantation survival. A number of studies have demonstrated that pre-transplantation blood transfusion is an important favourable factor for transplantation survival, not only for kidney transplantation (Opelz 1972, Vincenti 1978, Blood Transfusion Guideline, 2011 301 301 Opelz 1997), but also for heart (van der Mast 1997, Katz 1987), liver and combined kidney pancreas (Waanders 2008) transplantation. The larger studies still demonstrate a favourable effect of transfusions (Terasaki 1995). Level 1 A2 Bilgin 2004, A1 Vamvakas 2007 There are no indications that the immuno-suppressive effect of blood transfusions forms a risk for the recurrence of cancer following curative Level 2 surgery for colon cancer. A2 Amato 2008 Blood transfusions using full blood or leukocyte-containing erythrocyte concentrate are associated with a maximum two-fold higher incidence of low grade and intermediate non-Hodgkin’s lymphoma in particular than Level 2 after transfusion of ‘buffy coat’-reduced components. B Blumberg 2007, Vamvakas 2007 Other considerations the clinical significance of the changes in cellular immunity caused by blood transfusions is unknown. Thanks to the current immuno-suppressants, the transplantation results are so good that immune-modulating transfusions – with the accompanying disadvantages (10 – 30% antibodies) – are no longer worth the slight gain in transplant survival (Koneru 1997, Alexander 1999). Research on the mechanisms and causal factors of immune suppression by blood components is recommended. Immune-modulating pre-transplantation blood transfusions should only take place as part of a clinical protocol. This figure can increase to 2% 302 Blood Transfusion Guideline, 2011 for pooled platelet concentrates that are prepared from several donor units. Dutch research (Sanquin Blood Supply Foundation 2001) confirms that – in particular – platelet suspensions, which are stored at room temperature, are components at risk of bacterial contamination. The risk has been decreased by changing the method of disinfection and by using the first millilitres of blood donations to fill the test tubes (de Korte 2006). All platelet components are cultured by Sanquin Blood Supply and only released if the culture has remained negative until the time of release. Blood components that have been contaminated with bacteria can result in transient bacteraemia in the recipient, but also in sepsis. Sometimes the symptoms cannot be distinguished from a haemolytic transfusion reaction, namely fever, cold shivers, tachycardia, changes in systolic blood pressure (both increase and decrease), nausea and/or vomiting, shortness of breath, lower back pain, shock (Sanquin Blood Supply Foundation 2001). Both the symptoms themselves and the time at which the bacterial contamination manifests itself can vary greatly, which hampers the formation of a protocol. In the Netherlands, approximately three transfusion reactions per year are probably or definitely the result of a blood component contaminated by bacteria (de Korte 2006). Blood cultures must be collected from the patient and from the (remainder of the already) transfused blood component, the bag being sealed and stored in the correct manner, for a reliable diagnosis of a bacterial infection caused by blood components. Instead of or in addition to – blood cultures may also be taken from other blood components prepared from the same donation. Level 3 C Blajchman 1998, Schrezenmeier 2007 Infected components should be traced by means of a good haemovigilance system and a report should be sent back to Sanquin Blood Supply immediately. Two independent collections are performed as standard procedure, in order to increase the chance of a positive blood culture. In order to reduce the risk of contamination to a minimum, instructions for the collection of a blood culture, the disconnection, transport and storage conditions and method of sampling of a blood component must be present in the hospital and these instructions must be followed. One bacterial culture from the component and two blood cultures from the patient must be performed in case of a febrile reaction 2 °C and/or cold shivers.