Palliative treatment at home for patients with haematological disorders.

Supportive treatment of patients with haematological disorders mainly takes the form of transfusions of blood and platelets, and sometimes palliative chemotherapy is given. Most patients are treated in hospital or at the outpatient clinic. However, it is often difficult for the patients to arrange to come to the hospital, as they need transport by ambulance or taxi and sometimes a relative to help them. Throughout 1996 we offered such patients supportive treatment at home. A nurse was employed on the project, who was supplied with a car and a mobile telephone. Treatment was given at home. In all, 17 patients were treated, with a total of 90 blood and 40 platelet transfusions. At three visits chemotherapy was administered. No complications were seen, and the patients felt safe and content. We conclude that supportive treatment at home is safe and well accepted by patients and their relatives. In addition, the costs for transportation and hospital care of this patient group were reduced.

[Trends and traditions in Scandinavian general medicine]. / Trender och traditioner i nordisk allmänmedicin.

Recent decades have witnessed radical changes both in the workload and in the job description of general practitioners (GPs) in the Nordic countries, and the trend continues. Owing to social changes, particularly the deterioration in health care economy, the GPs will in the future be required to deal with increasing numbers of patients as well as increasingly severe categories of diseases, previously treated at hospital departments and clinics. This will entail increased demands in terms both of the further education of GPs and of the equipment available to them. It will also entail improved and extended cooperation between GPs and consultants, both in matters of overall policy and in the management of individual cases.

Respiratory distress following major trauma. Predictive value of blood coagulation tests.

We have evaluated the use of laboratory parameters to predict the risk of adult respiratory distress syndrome (ARDS) at an early stage after major trauma. Patients with lung contusion were excluded. Five of 29 patients fulfilled our criteria of ARDS, i.e. PaO2/FiO2 less than or equal to 38. They showed lower platelet counts and antiplasmin as well as a tendency to lower antithrombin III, fibrinogen, and plasminogen. These changes indicated activation of the coagulation and fibrinolytic systems by trauma. The most sensitive indicator of ARDS seemed to be the platelet count, although it was also related to blood loss and amount of blood transfused. Hence the platelet count should be considered in relation to blood replacement in the patient with major trauma. Tentative laboratory values are suggested to indicate risk levels of developing ARDS.

Value of blood coagulation tests in ischemic cerebral disease.

80 patients with transitory ischemic attacks (TIA) and 30 patients with cerebral infarction (CI) were investigated regarding hemostatic disturbances to evaluate selected coagulation test methods for routine laboratory use. The patients were studied a few days after the first appearance of symptoms and at defined times subsequently. The study included measurements of circulating platelet aggregates; platelet adhesiveness, factor-VIII-related antigen (VIIIR:Ag), fibrinolytic activity after venous stasis, alpha-2-antiplasmin activity, and antithrombin III activity. Platelet aggregates and/or adhesiveness were increased in the acute stage in most patients as well as in patients with recurrent attacks. Increased platelet adhesiveness was also found in some patients with nonvascular neurologic diseases. Factor VIIIR:Ag was increased especially in the acute stage and more in patients with recurrent attacks. Diminished fibrinolytic response after venous stasis was found in about 40% of the TIA and in 50% of the CI patients as well as in all patients who died from vascular disease. Antiplasmin activity was increased especially in women. Antithrombin activity was increased during warfarin treatment. The effect of acetylsalicylic acid (ASA) treatment on platelet function was registered only in women but ASA seemed to influence mechanisms other than platelet function, e.g. normalization of factor VIIIR:Ag. Our findings indicate that with methods available for the routine laboratory the measurement of fibrinolytic response to venous stasis, factor VIIIR:Ag and platelet reactivity would be of value in selecting risk patients and following the effect of treatment.

Effects of heparin and a semi-synthetic heparin analogue on platelet aggregation, lipoprotein lipase and other laboratory tests in surgical patients.

Platelet aggregation, lipoprotein lipase activity, coagulation parameters and routine blood chemistry were measured in a randomised study of 21 surgical patients before, immediately after and 3 months after operation. Sodium heparin 5000 IU was given subcutaneously to 11 patients every 12 hours for 7 days, the first injection 2 hours preoperatively; 10 patients received a semi-synthetic heparin analogue (SSHA 75 mg) in the same manner. The groups were sex and age matched. No conclusive changes were found in platelet aggregation. The increase in lipoprotein lipase activity in SSHA patients 2 hours after injection was significantly greater than in heparin patients. Neither of the two drugs induced significant changes in coagulation parameters or routine blood chemistry. The results indicate a difference in the effect on lipoprotein lipase release between heparin and SSHA at the used dosage schedules.

Use of a lyophilized reference plasma to compare coagulation test procedures: Normotest, Simplastin-A and Thrombotest.

In 4 collaborative trials, involving a varying number of hospital laboratories in the Stockholm area, the coagulation activity of different test materials was estimated with the one-stage prothrombin tests routinely used in the laboratories, viz. Normotest, Simplastin-A and Thrombotest. The test materials included different batches of a lyophilized reference plasma, deep-frozen specimens of diluted and undiluted normal plasmas, and fresh and deep-frozen specimens from patients on long-term oral anticoagulant therapy. Although a close relationship was found between different methods, Simplastin-A gave consistently lower values than Normotest, the difference being proportional to the estimated activity. The discrepancy was of about the same magnitude on all the test materials, and was probably due to a divergence between the manufacturers' procedures used to set "normal percentage activity", as well as to a varying ratio of measured activity to plasma concentration. The extent of discrepancy may vary with the batch-to-batch variation of thromboplastin reagents. The close agreement between results obtained on different test materials suggests that the investigated reference plasma could be used to calibrate the examined thromboplastin reagents, and to compare the degree of hypocoagulability estimated by the examined PIVKA-insensitive thromboplastin reagents. The assigned coagulation activity of batches of the reference plasma agreed closely with experimentally obtained values. The stability of supplied batches was satisfactory as judged from the reproducibility of repeated measurements. The variability of test procedures was approximately the same on different test materials.

Assessment of different mathematical models for calculating and expressing the results of coagulation test procedures.

Coagulation activity, expressed as percentage of normal and as clotting time ratio, was estimated in 220 specimens from patients on long-term anticoagulant treatment by 3 different coagulation test procedures, i.e. Thrombotest, Simplastin-A and Normotest. The estimates were calculated from the same determinations. The distribution of percentage values showed a fairly pronounced deviation from normality. After logarithmic transformation, the distribution was normalized, the regression lines between Thrombotest and other tests became parallel, and that between PIVKA-insensitive systems was shifted to a 45 degree line. Logarithmic transformation also stabilized the residual variance. These features make percentage values accessible for treatment according to the standard methods of bioassay statistics. Attempts to normalize the distribution of ratio values by various transformations were unsuccessful. Formal analysis of data revealed a variation in the proportionality of ratio values with the level of estimated coagulation defect. This may restrict the usefulness of the ratio approach. Logarithmic transformation partly reduced the discrepancy.

Fibrin plate method with reagents purified by affinity chromatography and its use for determination of fibrinolytic and other proteolytic activity in saliva, bile and plasma.

A modification of the fibrin plate method is presented. Plasminogen-free human fibrinogen and plasminogen purified by affinity chromatography have been used. Fibrin plates without and with a constant amount of plasminogen and with agarose as stabilizing medium were used for the estimation of plasmin and plasminogen activator activity. Activator activity could be demonstrated in sterile bile and saliva. When plasmin activity was present, estimations of plasminogen activator were approximate. The method is sensitive, small volumes of reagents and samples are needed. The error of the method is comparatively low and the reproducibility is good.