Experiences of developed management in the Cardiovascular Service at Royal Adelaide Hospital.

Devolved management structures are on trial at Royal Adelaide Hospital with assistance from the Clinical Devolution Project. The trial is to assess the suitability of devolved management structures to support clinical decision making, and to evaluate financial management reporting systems and information support systems. A nurse at Assistant Director of Nursing level and a doctor head each of the three trial Clinical services. Both have equal responsibilities and delegations of authority for day to day operations utilising an allocated budget. The impact of devolution of responsibility to clinical units is considerable. Such reorganisation presents opportunities and difficulties. Nurse/doctor collaboration is essential to manage high patient throughout effectively and efficiently as well as to prepare for the impact of casemix and output based funding. Clinical department size, budget allocation, roles and organisational infrastructure affect the success or failure of devolved management structures, even if a service works within an allocated budget and achieves high patent throughput and decreasing length of patient stay.

[Advantages and limits of programmed autologous transfusion in cardiovascular surgery. Apropos of 524 patients]. / Avantages et limites de la transfusion autologue programmée en chirurgie cardiovasculaire. A propos de 524 patients.

Between October 1987 and July 1989, 544 patients, candidates for cardiovascular surgery, were included in a trial of programmed autologous autotransfusion. Five hundred and twenty four patients underwent one or several (maximum 4) blood donation sessions in the 3 weeks before surgery with no complications. Overall, 57% of patients benefited from homologous blood transfusion, thereby avoiding all risk of contamination. It was in the group of patients able to undergo 3 or 4 preoperative blood donations that we observed the smallest number of homologous transfusions (30%). Programmed autologous transfusion would seem to be a very useful technique for cardiac surgery, allowing a reduction in health care costs without additional patient risk. In order to improve on this method, it may be useful to associate a peroperative technique of blood recuperation in patients in whom the transfusion needs are likely to exceed the possibilities of preoperative blood donation alone.

[Significance of alanine aminotransferase and reduction of post-transfusion non-A, non-B hepatitis]. / Valeur de l'alanine aminotransférase et réduction des hépatites non-A non-B post-transfusionnelles.

To appreciate the test based on the activity of sera alanine aminotransferase (ALT) in the reduction of non-A non-B post-transfusional hepatitis, a study of the variation of this enzyme's activity was done versus several parameters: sex, age and acquired diseases. The population which included 25,813 Parisian blood donors (41.2% of men and 58.8% of women) was divided into two groups: the first was constituted of 25,585 subjects (40.9% of men and 59.1% of women) without clinical etiology and biological diseases, it will be the reference population; the second group was composed of 173 subjects (68.2% of men and 31.8% of women) who had acquired biological markers or clinical diseases during the life. The study within the reference population showed a sexual dimorphism. The study by dispersion diagrams in the population with high seric activity of ALT could explain the causes of blood donors' elimination.

Partial reversal of low molecular weight heparin (PK 10169) anti-Xa activity by protamine sulfate: in vitro and in vivo study during cardiac surgery with extracorporeal circulation.

Neutralization of a low molecular weight (LMW) heparin fraction by protamine sulfate was evaluated in vitro and in vivo. Anti-Xa and anti-IIa activities were measured by amidolytic and coagulation methods (activated partial thromboplastin time, APTT). Fifteen patients (4 males and 11 females) underwent surgery with extracorporeal circulation. In vitro, anti-Xa and anti-IIa activities and APTT of unfractionated heparin were neutralized with a protamine/heparin (P/H) gravimetric ratio of 1.6, 1.33 and about 2, respectively. Anti-IIa activity and APTT induced by PK 10169 were completely corrected at a P/H ratio of 1 and 2, respectively, while anti-Xa activity was incompletely neutralized at a ratio of 5. In vivo, in 9 patients who did not receive intravenous protamine sulfate, a good correlation was found between doses of PK 10169 infused, anti-IIa plasma level and blood loss. In 3 patients who were treated prophylactically with protamine, bleeding was normal or only slightly increased. In 3 patients who received protamine because of hemorrhage, mean anti-Xa and anti-IIa were 2.3 and 0.54 U before and 1.32-0.06 U after neutralization. Bleeding was stopped by a second dose of protamine in 1 patient, but blood loss was abnormal in the other patients. However, a correlation between bleeding and anti-Xa or anti-IIa activities was not clearly evident.

Plasma beta-thromboglobulin in patients with valvular heart disease with or without valve replacement: relationship with thromboembolic accidents.

Plasma beta-thromboglobulin (BTG) was measured in 132 patients with valvular heart disease: 43 were studied before, 89 after surgery (78 mechanical valves and 11 bioprostheses). In this group of 89 selected patients, a history of thromboembolism was present in 53 (5 of them had bioprosthesis). Some abnormalities have been observed in patients with valvular heart disease as compared with controls: decreased platelet count and retention on glass column, and increased BTG. There is no statistically significant difference in BTG level between patients with (m +/- SD: 62.4 +/- 42.0 ng ml-1), or without (59.5 +/- 41.0 ng ml-1) a prosthesis; in the small series of 11 patients with a bioprosthesis, BTG was slightly lower than in other patients (44.5 +/- 14.1 ng ml-1), but still higher than in controls (26.8 +/- 13.3 ng ml-1). In the patients with a history of thromboembolism, BTG was significantly higher (66.7 +/- 47.9 ng ml-1 than in patients without this complication (49.9 +/- 21.0 ng ml-1). Thus, BTG evaluation may have some value in valvular heart disease but, at present, it should be confined to systematic research including prospective studies.

[Clinical study of prostacyclin in extracorporeal circulation. Effects on hemodynamics and coagulation]. / Etude clinique de la prostacycline dans les circulations extra-corporelles. Effets ssur l'hémodynamique et la coagulation.

The effects of prostacycline (PGI2), the most powerful known platelet antiaggregant on platelet count and function during cardiopulmonary bypass, were assessed in a double blind study. One group of 13 patients received 2,5 mg/Kg of Heparin with an infusion of 25 ng/Kg/min of prostacycline instituted 15 minutes before the Heparin, continued at the beginning of cardiopulmonary bypass at a dose of 50 ng/Kg/min and terminated at the end of bypass. A second group of 15 patients were studied by the same protocol with a placebo infusion. The platelet count was significantly higher at the end of cardiopulmonary bypass in the Prostacycline group. Platelet aggregation was reduced by comparison with the control group from the beginning of Prostacycline infusion. The active thrombin time was significantly longer in the Prostacycline group. However, blood loss did not differ significantly between the two groups although it was less in the study group. The platelet count and function during cardiopulmonary bypass with Prostacycline was therefore increased and resulted in a reduction in Heparin consumption.

[Changes in serum beta-thromboglobulin levels during oral contraception, cardiac valve disease and pulmonary embolism (author's transl)]. / Variations de la bêta thrombologlobuline au cours de la contraception orale, des valvulopathies appareillées ou non, et de l'embolie pulmonaire.

beta-thromboglobulin (beta TG), a platelet-specific protein, was measured in the plasma of 53 healthy subjects (20 men and 33 women), 53 women using estrogen-progestogen contraceptives, 31 patients with cardiac valve disease (including 19 with prosthesis) and 71 patients about to undergo scintigraphy for suspected pulmonary embolism. Compared with levels in healthy subjects, beta TG levels were significantly increased in oral contraceptive users and in cardiac patients with or without prosthesis. High beta TG levels were also found in 20 out of 28 patients with pulmonary embolism confirmed by scintigraphy, but also in some of the .9 lung patients with chronic bronchopulmonary disease. Cardiac patients treated with heparin had higher beta TG levels than non heparin-treated patients, which raises queries about a possible influence of heparin on this particular blood protein.

PIP: Beta-thromboglobulin (BTG), a platelet-specific protein, was measured in the plasma of 53 healthy subjects (20 men and 33 women), 53 women using estrogen progrestogen contraceptives, 31 patients with cardiac valve disease (including 19 with prosthesis) and 71 patients about to undergo scintigraphy for suspected pulmonary embolism. Compared with levels in healthy subjects, BTG levels were significantly increased in oral contraceptive users and in cardiac patients with or without prosthesis. High BTG levels were also found in 20 out of 28 patients with pulmonary embolism confirmed by scintigraphy, but also in some of the .9 lung patients treated with heparin had higher BTG levels than non heparin-treated patients, with chronic bronchopulmonary disease. Cardiac patients treated with heparin had higher BTG levels than non heparin-treated patients, which raises queries about a possible influence of heparin on this particular blood protein. (Author's modified)

Screening and use of high titered anti-HLA-DR sera in PHA-blast complement fixation and B-lymphocytotoxicity techniques.

Screening for anti-HLA-DR sera was performed by complement fixation on PHA stimulated peripheral blood lymphocytes (PHA-CF), or cultured B lymphoid cell lines. Out of 1,350 sera from multiparous women, multitransfused patients, and patients transfused during extra-corporal circulation (ECC), 219 contained anti-HLA-DR activity (16.2%). Anti-HLA-DR antibodies developed after ECC were often high titered (1:10 to 1:100). In half of these sera anti-HLA-A, B antibodies were weak or absent, making it possible to use then as anti-HLA-DR reagents without platelet absorption. Of the 219 positive sera 51 contained defined anti-DR antibodies (20 monospecific and 31 bi- or multispecific). The 13 best sera recognized DR1 and DR7 specificities with r values from 0.83 to 1. Twenty-four sera selected by CF were also studied by lymphocytotoxicity technique against peripheral blood B lymphocytes (B-LCT). Both PHA-CF and B-LCT techniques gave similar results, detecting the same specificities and showing comparable sensitivity. The advantages of CF are: easy storage of target cells at -80 degrees C or + 4 degrees C, and fast reading. For these reasons PHA-CF or CF on cultured B lymphoid cell lines can be proposed for large scale screening of anti-HLA-DR sera. The sera thus screened can be used for HLA-DR typing either by PHA-CF or B-LCT.

[Detection of lipid abnormalities in blood donors]. / Dépistage des anomalies lipidiques chez les donneurs de sang.

The high incidence of cardio- or cerebro-vascular diseases is positively correlated with hyperlipoproteinemia. A large-scale screening of blood donor's populations could be used for the prevention of the atherogenic disease. Therefore lipoproteins electrophoresis on cellogel was compared with serum levels of triglycerides, cholesterol and lipids in 1184 blood donors (792 men, 392 women). The electrophoretic pattern was found abnormal in 32 cases (25 men, 7 women). It was a type IIb hyperlipoproteinemia, according to the classification of the World Health Organization. In these 32 subjects, serum triglycerides, cholesterol and lipids concentrations were significantly higher (p less than 0,001) than in 41 other donors with a normal electrophoretic pattern. A good positive correlation was found between high blood pressure or obesity or blood group O and abnormal electrophoretic pattern. Lipoproteins electrophoresis on cellogel appears to be a suitable test (easy, fast and economical) in large-scale screening for dyslipidemia in subjects over 40, or at least in cases of mild hypertension or obesity.

Maintenance of 2,3-DPG and ATP levels in blood stored for 30 days at a constant pH obtained by variation of CO2.

A novel procedure for storing blood at a controlled pH consists in collecting blood in a pH 8.20, Tris-CPD solution and storing it in a special recipient including a gas permeable membrane under a CO2 atmosphere. The recipient is placed in an atmosphere of variable CO2 content, so that the initial alkalinity of the preservative is balanced by dissolved CO2, the proportion of which is diminished when lactate production increases with storage. 2,3-DPG and ATP were studied at three different pH levels of approximately 7.25, 7.45, and 7.65 at 4 degrees C. The best pH for the simultaneous maintenance of 2,3-DPG and ATP was 7.65. Under these conditions, 2,3-DPG is maintained at its initial level and ATP at 55% of its initial level at the 30th day. Lactate production is linear and hemolysis moderate.

[Comparative study of technics of screening of carriers of HBs antigen]. / Etude comparative des techniques de dépistage des porteurs d'antigène HBs

The purpose of this study was to compare the results of 3 reverse passive haemagglutination techniques currently used by blood centers for the HBS antigen screening in donors' blood. A comparison was also made with 3 other techniques: Radio-immuno-assay (RIA), Counter-electrophoresis (CEP), Complement fixation (CF). The sera from 2.028 blood donors were screened by all those techniques, as well as 105 known sera, used as references (87 HBS antigen positive sera with different titers, 18 HBS antigen negative sera) and coming from 4 origins: NIH-Bethesda, Centre National de Transfusion Sanguine, Paris; Hôpital de la Pitié-Salpêtrière, Paris; Hôpital Broussais, Paris. The reverse passive haemagglutination techniques were shown to be slightly less sensitive than RIA and definitely more sensitive than CEP and CF, since 18 sera were HBS antigen positive with RIA (0.88%), 10 or 12 with haemagglutination (0.40-0.59%), 8 with CF (0.39%) and 7 with CEP (0.34%). The frequency of false positive results changed with the haemagglutination technique used (0.84% for WH.HBS, to 2.3% for Hepanosticon) and involved confirmatory tests (absorption and/or neutralisation). In sum, the sensitivity, specificity and practicability of the 3 haemagglutination techniques were shown to be nearly identical, with a slight but sure advantage for the WH.HBS in our experiment. Thus reverse passive haemagglutination techniques seem, at the present time, to be the best ones for HBS antigen screening when RIA cannot be applied.

[Frequency of hepatitis after extra-corporeal circulation]. / Fréquence des hépatites après circulation extra-corporelle

In cardio-vascular surgery the risk that the hepatitis-B (H.B.) virus be transmitted was measured in 3 groups of patients (Professor Ch. Dubost), before and since systematic screening for HBS antigen in donors' blood. The same questionnaire was sent to each patient in each group 6 months after extra-corporeal-circulation (ECC), in order to determine the efficiency of HB virus screening tests. The present study gives the following results: --in the first group (no screening for HBS antigen in donors' blood), the frequency of icteric hepatitis was 6.7% (26 cases of jaundice, probably due to hepatitis viruses, out of 386 ECC); --in the second group (screening for HBS antigen in donors' blood by immuno-diffusion (often made after transfusion of fresh blood) the frequency of icteric hepatitis after transfusion of HBS antigen positive blood); --in the third groups, icteric hepatitis was less frequent (4.6%) since systematic screening for HBS antigen by counter-electrophoresis and complement fixation was performed (29 cas out of 629 ECC). Additionally, viral hepatitis appeared more frequently in men than in women, and among older patients than younger ones. Recovery was generally complete in 2 months; however, the evolution of the disease was severe in 3 cases and fatal in one case. In sum, after ECC, hepatitis still remains a frequent side-effect, compelling blood centers to use th most sensitive screening tests now available for HBS screening: radio-immuno-assay and reverse passive haemagglutination tests. As a consequence of the present study, these 2 techniques are being applied on a daily basis in our laboratory for HBS antigen screening tests are ineffective in preventing the transmission of other strains of viral hepatitis by blood transfusion.