An analysis of unscheduled return visits to an urban emergency department.

AIM: This study was undertaken to identify the reasons for unscheduled return visits to an urban emergency department, particularly those relating to physician errors in diagnosis and management, and, where possible, to identify strategies to reduce unscheduled return visits. METHOD: All patients returning to the Emergency Department, Christchurch Hospital, within seven calendar days of initial visit were identified. These cases were reviewed to identify reasons for return visit. RESULTS: Unscheduled return visits accounted for 2% of patient encounters. Sixty one per cent were due to illness related factors, 27% to patient related factors, 11% to physician related factors and 1% to system related factors. Significant management errors occurred in nine patients (4.4% of unscheduled return visits), three of whom were admitted. There were no ICU or CCU admissions and no deaths. CONCLUSIONS: Significant physician errors were a minor reason for reattendance at the emergency department and no specific areas of deficiency were identified. These might be further reduced by increasing the seniority and experience of staff and by the introduction of regular audit, continuing medical education and vocational training programmes. Interventions to reduce patient related unscheduled return visits might include better explanation of the role of the emergency department and better communication with patients about their illness and treatment.

Stability of murine monoclonal anti-A, anti-B and anti-A,B ABO grouping reagents and a multi-centre evaluation of their performance in routine use.

We have previously reported the production of 3 murine monoclonal reagents for ABO typing (designated ES-9, ES-4 and ES-15). This study presents results of tests of stability of these 3 reagents, together with a fourth murine monoclonal antibody (LM103/107). In addition, data are also presented from a multi-centre evaluation of the performance of the murine monoclonal reagents in routine ABO typing of both donors and patients using a wide variety of techniques, both manual and automated. The potency and stability of the 4 monoclonal antibody based reagents is compared with a broad selection of monoclonal and polyclonal ABO typing reagents. The reagents used for comparison were produced by European and United States manufacturers in both the public and private sector and are widely used in routine ABO typing. The Scottish monoclonal reagents have been used successfully to ABO type over 500,000 blood samples in 7 centres within the UK, with no discrepant results.

The management of reflux oesophagitis and oesophageal stricture.

In a five year period, 140 patients with hiatal hernia were admitted to the cardiothoracic surgery department for investigation and treatment of their condition. Seventy-three of these patients had oesophageal strictures and of these 35 were treated by oesophageal dilatation and Nissen fundoplication. One patient with an intractable stricture was treated by oesophagogastrectomy. The results of surgery were found to be identical with 47 patients without strictures who underwent Nissen fundoplication. Eighty-three percent of patients were symptom free with normal barium meals five to nine years postoperatively, 11% had only minor reflux or dysphagia and were greatly improved as compared with their preoperative state and 6% suffered significant recurrence of symptoms. Postoperative morbidity was slight and there was no mortality. Thirty-six patients with strictures were treated as outpatients by intermittent bouginage. Eleven patients still attend the department at approximately three monthly intervals.

Evaluation of monoclonal antibodies to blood group A.

Balb/c mice were immunized with human blood-group A2 active cyst fluid glycoprotein. Fusion of spleen cells with NS-1 myeloma cell line produced a total of 11 blood group antibody secreting hybridomas of which seven were apparently specific for blood-group A and were subjected to further evaluation. Of these 2 were IgM class and 5 IgG class. Two anti-A supernatants showed a significant decrease in avidity time against A2B cells when ionic strength was increased to 0.25. Tube titres of all anti-A supernatants were unaffected by ionic strength. pH had no effect on the avidity time or tube titre of any of the antibodies tested. The supernatant from one hybrid (ES-9) was selected for further evaluation as a blood grouping reagent. This supernatant had a tube titre of 1:128 and was used without concentration for comparison of its serological reactivity with two examples of commercial monoclonal anti-A and one example of human anti-A. Monoclonal anti-A (ES-9) was found to be a potentially useful red cell grouping reagent.

A mouse monoclonal antibody with anti-A,(B) specificity which agglutinates Ax cells.

A hybridoma (ES-15) was obtained by fusing the NS-1 cell line with spleen cells from a mouse immunised with soluble blood group A2 substance. The cloned hybridoma culture supernatant was shown to contain an IgM class antibody which strongly agglutinates group A cells and weakly agglutinates group B cells. The serological specificity of this antibody is described as anti-A,(B) in this report. The abilities of unconcentrated monoclonal anti-A,(B), a commercial human polyclonal anti-A,B (group O serum) and a commercial monoclonal anti-A reagent to detect 15 examples of Ax cells were compared by both slide and tube techniques. Using a slide technique monoclonal anti-A,(B) agglutinated 14 examples of Ax cells, human anti-A,B 2 examples, while monoclonal anti-A failed to detect any of the Ax cells tested. Similar differences in the reactivity of the three antibodies were observed using a tube technique. Data are also presented which show that a 1:1 (v/v) mixture of monoclonal anti-A,(B) with a monoclonal anti-B reagent is an effective replacement for human anti-A,B in ABO grouping procedures.

Pulmonary sequestration: a review of 12 cases.

A review of patients over a twenty-three year period with a diagnosis of pulmonary sequestration was undertaken. Of the twelve patients with this diagnosis, ten had intralobar sequestrations, and two had the extralobar variety. The most common presenting complaint, in six of the patients, was an unresolving localised chest infection. All had abnormal plain chest radiographs. There was a high incidence of an anomalous vascular supply, and aortography was useful in investigation. Operative management consisted of segmentectomy or lobectomy for the intralobar form and simple excision for the extralobar form with good results.

Coagulation abnormalities following intensive plasma exchange on the cell separator. II. Effects on factors I, II, V, VII, VIII, IX, X and antithrombin III.

The effects of intensive plasma exchange on the circulating levels of coagulation factors I, II, V, VII, VIII, IX, X and antithrombin III were determined. During courses of daily exchange marked cumulative reductions of coagulation factors may occur, particularly in the case of factors I, II and X, although usually remaining above the levels considered adequate for haemostasis. The extent of cumulative reduction and subsequent recovery differed for patients with different diseases. While antithrombin III levels were reduced during plasma exchange the results suggest that this may be partly due to consumption as well as physical removal. The very low incidence of haemorrhagic sequelae and absence of thrombotic events following plasma exchange at this Centre is explained by the maintenance of adequate levels of coagulation factors and of antithrombin III even during courses of daily plasma exchange.

In vitro thrombogenicity tests of factor IX concentrates. I. A survey of available assays.

Various factor IX concentrates have been examined in a number of in vitro tests of thrombogenicity. The results suggest that some tests are superfluous as in concentrates with activity in any of these tests activation is revealed by a combination of the non-activated partial thromboplastin time, the thrombin (or Xa) generation time and factor VIII inhibitor bypassing activity tests. Assay of individual coagulant enzymes revealed that most concentrates contained more factor IXa than Xa. However only a small number of concentrates, chiefly those that had been purposefully activated, contained appreciable amounts of either enzyme.

Coagulation abnormalities produced by plasma exchange on the cell separator with special reference to fibrinogen and platelet levels.

Five patients with immunopathologic renal disease, 12 with malignant paraproteinaemia and one with myasthenia gravis underwent a total of 179 plasma exchanges on a continuous flow cell separator. Replacement fluids devoid of coagulation factors were used in 160 exchanges while 19 exchanges were replaced with Fresh Frozen Plasma. Coagulation screening was done immediately before and 30 min after each plasma exchange. Plasma fibrinogen concentrations fell to a mean of 25% of initial levels during individual exchanges. Sequential reduction to 10.7% was observed after five consecutive daily exchanges and in one patient fell to 1.2% after 10 daily exchanges. Low levels of fibrinogen could be maintained with daily or alternate daily exchanges. Platelet counts fell to a mean of 50% of pre-exchange levels during individual exchanges. Consecutive daily exchanges resulted in mean reductions to 20.7% after 5 d, but further reductions were not observed with longer periods of exchange. Platelet counts recovered to pre-exchange values during exchange intervals of 2 or more days. Mild clinical bleeding episodes, probably related to low platelet counts, occurred in one exchange in each of three patients. Haemostasis was rapidly achieved in these patients by infusions of platelet concentrates. Coagulation screening, including prothrombin ratio, thrombin time, reptilase time and partial thromboplastin time with kaolin showed progressively greater abnormalities as the intervals between exchanges shortened. The low incidence of clinical haemorrhagic episodes, three of 179 exchanges (2.2%), despite markedly abnormal coagulation parameters, emphasize the safety of the procedure even in moribund patients. We conclude that the use of FFP in intensive exchange programmes solely for the prevention of spontaneous haemorrhagic phenoma is unjustified.