[Home blood transfusion in France: Benefits and development terms]. / Transfusion à domicile : intérêt et conditions de développement dans le contexte français.

OBJECTIVES: Patients with cancers or malignant homeopathies can suffer from chronic anemia and be regularly transfused in hospitals. Most of the time, their performance status is low. Few local structures currently provide blood transfusion services and patients have to go under difficult and costing transportation to the hospital. The objective of this work is to evaluate benefits and development terms of home blood transfusion for patients with chronic anemia and having to get transfused regularly. METHODS: A field investigation-mixing observations and interviews and a literature review were conducted. RESULTS: Home blood transfusion represented a little part of home health care activity. When it was practiced, its organization was heterogeneous: it was sometimes performed by a doctor, sometimes by a nurse. Home blood transfusion was benefic for patients: it was more comfortable and it allowed them to avoid harmful transportation to the hospital. Few adverse events occurred during various experiments, all were mild. Before its revaluation in March 2018, home blood transfusion was not enough funded by National health insurance. Home blood transfusion also suffered from a lack of framework until the publication of recommendations in April 2018. CONCLUSIONS: Lack of a framework and sufficient funding prevented home blood transfusion development until changes that occurred in 2018. Therefore, this activity should develop in years to come. Allowing reducing unnecessary hospitalizations, home blood transfusion fit into French health national strategy.

[Analysis of causes of destruction of labile blood products in health institutions: A multicentric study]. / Analyse des causes de destruction des produits sanguins labiles dans les établissements de santé : une étude multicentrique.

OBJECTIVE: One of the tasks of haemovigilance correspondents in Health Institutions (HI) is to reduce the destruction of labile blood components (LBC). The objective of this study was to analyse in depth, five years after a first multicentric study, the causes of LBC destruction in order to assess the impact of measures taken and to define new ways of improvement. METHODS: Prospective analysis was carried out throughout 2016. For every LBC destroyed, the following elements were reported: type of LBC, transfusion department, cause of destruction analysed according to a decision tree, subsequently classed as avoidable or unavoidable. RESULTS: The study included 15 HI. A total 3058 LBC were destroyed, representing an average 0.90% of issued LBC, and this analysis concerned 2576 LBC. Sixty-seven percent of LBC were issued for surgery, intensive care or emergencies. Forty percent of the causes of destruction were patient-related (death, clinical worsening, adverse effects or abnormal constants prior to delivery). Thirty percent were prescription-related, mainly cases of excessive prescription for different reasons. Eleven percent were linked to organisational issues. The rate of destruction judged avoidable, all causes combined, was 36%. CONCLUSION: Comparison with the precedent study shows improvement, thus revealing the efficacy of implemented measures (single-dose distribution, return procedures back to the site of distribution, training of participants). In order to further reduce this rate of destruction, we suggest to promote storage procedures and, above all, to continue to raise awareness within healthcare teams.

[Suitability of autologous blood donation before bone marrow donation]. / Pertinence du prélèvement sanguin autologue et de sa transfusion lors d'un don de moelle osseuse.

We assessed the benefit of predeposite autologous blood donation (PAD) before bone marrow (BM) donation on transfusion requirements, haemoglobin concentrations (Hb) and the occurrence of adverse events (AE). We collected data retrospectively from 50 donors of BM with PAD from 2010 to 2014. An autologous transfusion (AT) was given to 50% of the donors (group 1). In the group 2, the products from PAD were not used. The total volume median of marrow harvested was 17.7 mL/k (range 12.3-21.4) in the group 1 and 13.3 mL/k (8.6-22.6) in the group 2. The female ratio was higher in the group 1 (60%) than in the group 2 (16%). Bone marrow harvest led to a decline in Hb (from PAD to first day after BM donation) by 2.9 g/dL (1.5-5.5) in the group 1 and by 3.5 g/dL (1.2-5) in the group 2. The post-harvest Hb (D+1) median was identical in the two groups: 10.9 g/dL (7.6-13.5) in the group 1 versus 11.5 g/dL (9.3-13.4) in the group 2. Six AE were reported in each group. In the group with AE, the median weight was lower: 58 k (50-71) versus 75 k (52-110); and the median total volume of marrow harvested was higher: 20.1 mL/k (9.9-21.4) versus 14.3 mL/k (8.6-22.6). All post-harvest Hb were ≥ 7.6g/dL. This study shows the high loss of Hb after BM donation but not enough to prove a blood transfusion in BM donors with median age of 36 years (16-62) and without comorbidity. The occurrence of AE (25% of BM donors) justifies a careful surveillance after the BM donation. The PAD should not be routinely offered to bone marrow donors.

[Suitability of red blood cell transfusion: a multicenter study]. / Évaluation multicentrique de la pertinence des prescriptions de concentrés de globules rouges.

The purpose of this retrospective observational multicenter study was to assess appropriateness of red blood cell (RBC) transfusion, according to the French national guidelines (Agence française de sécurité sanitaire des produits de santé) published in 2002. Six hundred and thirty-nine RBC transfusions from nine institutions have been randomly selected and analysed. The data collected are issued from different specialities. Patients' characteristics, occurrences of transfusion, admission, pre-transfusion, post-transfusion and discharge haemoglobin concentrations have been collected. Two physicians (who are in charge) must evaluate the appropriateness of pre-transfusion, discharged haemoglobin concentrations, quantity and quality of transfused RBC. The mean pre-transfusion haemoglobin concentration was 7.89 ± 1.24, the median number of transfused RBC was two (extremes: 1-16), the mean discharge haemoglobin concentration was 10.14 ± 1.30 (-5 days after the end of transfusion). The pre-transfusion and discharge haemoglobin concentrations were higher if the patient presented a co-morbidity factor. Ninety-three percent of pre-transfusion and 79% of discharge haemoglobin concentrations are in accordance with the guidelines. According to the physicians, the RBC transfusions are too "precocious" when pre-transfusion haemoglobin concentration is above nine and the anaemia is asymptomatic. 50% of RBC transfusion with discharge haemoglobin concentration above 10 is not excessive. In case of acute anaemia, the pre-transfusion and discharge haemoglobin concentrations are higher and RBC transfusion excessive. In this study, the trigger haemoglobin concentration is "restrictive", but the target haemoglobin concentration is "liberal" with a high-discharge haemoglobin concentration. Inappropriate RBC transfusions are mainly due to over-transfusion.

An active haemovigilance programme characterizing the safety profile of 7437 platelet transfusions prepared with amotosalen photochemical treatment.

BACKGROUND: An active haemovigilance programme was implemented to survey adverse events (AE) associated with transfusion of platelets photochemically treated with amotosalen and ultraviolet A (PCT-PLT). The results of 5106 transfusions have already been reported. Here we report the results of an additional 7437 PCT-PLT transfusions. METHODS: The focus of this ongoing haemovigilance programme is to document all AEs associated with PCT-PLT transfusion. Data collected for AEs include: time of event after starting transfusion, clinical descriptions, vital signs, results from radiographs and bacterial cultures, event severity (Grade 0-4) and causal relationship to PCT-PLT transfusion. RESULTS: One thousand four hundred patients (mean 60 years, range 1-96) received PCT-PLT transfusions. The majority of the patients (53.4%) had haematology-oncology diseases and required conventional chemotherapy (44.8%) or stem cell transplantation (8.6%). Sixty-eight PCT-PLT transfusions were associated with AE. Acute transfusion reactions (ATR), classified as an AE possibly related, probably related, or related to PCT-PLT transfusions were infrequent (n = 55, 55/7437 = 0.7%) and most were of Grade 1 severity. Thirty-nine patients (39/1400 = 2.8%) experienced one or more ATRs. The most frequently reported signs/symptoms were chills, fever, urticaria, dyspnoea, nausea and vomiting. Five AEs were considered severe (> or = Grade 2); however, no causal relationship to PCT-PLT transfusion was found. Repeated exposure to PCT-PLT did not increase the likelihood of an ATR. No cases of transfusion-related acute lung injury and no deaths due to PCT-PLT transfusions were reported. CONCLUSIONS: Routine transfusion of PCT-PLT is well-tolerated in a wide range of patients. ATRs related to PCT-PLT transfusion were infrequent and most were of mild severity.

[Incidents of blood donation]. / Les incidents du prélèvement.

In France, more than two million blood donations are needed for transfusion each year. The rules and requirements for blood donors selection are strict and aim to protect the donors' health as well as the patients'security. However, the review of the literature shows that adverse effects of blood withdrawal occur quite frequently. They can be classified in immediate or delayed events, or local (hematoma, nerve injury, arterial puncture injury, allergy, veinitis, thrombosis) and general reactions (vasovagal reaction, citrate toxicity, cardiovascular failure, allergy to ethylene oxide, adverse effects of drugs used for some types of donation). This article reviews the principal adverse events described in the literature and concludes with the necessity to set up hemovigilance for donors, as defined in directive 2002/98/EC of the European parliament and of the council.

[Discovery of a chronic HVC infection without seroconversion in a blood donor in France during 28 months]. / Découverte d'une infection chronique par le VHC sans séroconversion chez un donneur de sang en France pendant 28 mois.

The HCV-RNA screening technique developed by the French Fractionation and Biotechnology Laboratory singled out in March 1998 a case of positive HCV-RNA viremia in a blood donor without any anti-HCV antibody. That donor was a 46-year-old woman who had made 54 donations of blood products from 1988 to 1997. She had no history of blood transfusion, no history of hepatitis and no life-style risk factor. Clinical examination was normal. Liver tests (serum alanine amino transferases, gamma glutamyl transpeptidase , alkaline phosphatase, bilirubin , prothrombin and albumin) were normal. Total blood count was normal. Lymphocyte count was normal as well as in vitro functional analysis of lymphocytes (stimulation with different antigens). All screening HCV Elisa tests and immunoblot System available on the French market were unable to detect anti-HCV antibodies. Quantification of serum HCV-RNA (Amplicor Monitor Roche) showed 294,000 copies/mL and HCV genotype 1b determination was performed using Innolipa assay. Further examination of the HCV genotype by direct sequencing of the PCR product showed a classical 1b genotype sequence. The hemovigilance inquiry identified 25 labile products distributed since 1988. Analyzing the records of the recipients that have so far been traced and identified revealed three periods: 1997 to 1995: three recipients were found to be positive for anti-HCV antibodies; two are now cured of hepatitis C. In one recipient, direct sequencing after specific PCR of the hypervariable region coding for the envelope domain showed 100% homology with the donor; 1993 to 1990: four recipients were identified and traced without contamination; in 1988: three of four blood product recipients were anti-HCV negative without HCV-RNA viremia. The forth carried anti-HCV antibodies and genotype 1b HCV-RNA but had a history of multiple surgery. Alter et al. [4] and Bush et al. [5] have previously suggested the possibility of a chronic, immunologically silent state of infection. The case described herein, is the first evidence for this hypothesis. Indeed, the donor has not yet seroconverted 28 months after viremia was discovered. This blood donor was identified by HCV-RNA screening of plasma products. The identification of the same sequence in a recipient of blood from this donor clearly establishes the transmission of the virus by transfusion. The prevalence of such cases of infectious silent chronic HCV carriers has to be determined and the mechanisms responsible for the absence of antibody production need to be clarified.

[Transfusion and Jehovah's witnesses. A review of medicosurgical attitudes in a University hospital in 1995]. / Transfusion et témoins de Jéhovah. Enquête sur les attitudes médicochirurgicales dans un CHU en 1995.

The aim of this study was to evaluate the attitudes of physicians (anaesthetists + other doctors + surgeons) towards Jehovah's witness patients refusing blood transfusion. Such a situation is not uncommon: 79% of respondents uncountered it. For scheduled surgery in adults, 75% of these physicians (54% of anaesthetists) would accept to lake care of these patients. In case of emergency or unforeseen indication for transfusion, 54% of these physicians (72% of anaesthetists) would administer blood, despite a written transfusion refusal. These figures would be 95 and 97% respectively in children.

[Postoperative autotransfusion and transfusion evaluation in cardiac surgery]. / Autotransfusion postopératoire et bilan transfusionnel en chirurgie cardiaque.

In cardiac surgery, blood retransfusion from the thoracic drainages, though already ancient, still remains controversial either for its quantitative or its qualitative interests. A retrospective study has been conducted, between the 1st january 1992 and the 30th june 1993, over 1.655 consecutive operations. Most of the patients suffered from coronary disease (937) or a valvular disease (605), others had been operated for a combined valvular and coronary revascularization surgery (113). The safety of this technique, guaranteed by strict rules, allowed a "transfusional strategy" which tends to reduce the homologous blood consumption. Twenty-nine percent of all the patients received homologous red cells units and only 23% of the patients operated for a coronary revascularization. This strategy aims to reduce both the risks of blood transfusion and the health cost.

[Oral contraception and surgery]. / Contraception orale et chirurgie.

PIP: Oral contraceptives (OCs) and surgery are both recognized risk factors for thromboembolism. Observation of a postoperative deep venous thrombosis and pulmonary embolism in a 21-year-old OC user prompted the authors to define the risk of OC use in surgical patients through a review of the literature. The patient had no other relevant risk factors except a moderate smoking habit. Surgery increases risk of thromboembolism because of the postoperative hypercoagulation state with declines in AT III, elevation of fibrinogen and products of degradation of fibrin, decline of plasminogen, and elevation of antiplasmin. The risks are greater in the immobile postsurgical phase and are increased as well by direct vascular lesions during surgery. Estimates of rates of deep venous thrombosis are very variable according to different authors because of the difficulties of diagnosis, heterogeneity of risk factors encountered, and variety of prophylactic methods employed. The most thrombogenic surgery is believed to be that on the legs; 1 literature review produced a range of estimates from 45-70% without prophylaxis and with 2% involving fatal pulmonary emboli. Another study estimated the risk of deep venous thrombosis at 2% for young subjects in good health undergoing minor surgery lasting less than 30 minutes and at 10-40% for subjects over 40 undergoing moderately serious general surgical procedures. No ideal method of prevention has been found that is well accepted by patients, nurses, and physicians. OC use entails multiple physiopathologic modifications including among others alterations of the vascular walls with endothelial proliferation and/or thickening of the media, increased blood viscosity, hyperaggregability of platelets, and increases in certain coagulation factors. Synthetic estrogens play the major role in modifications but progestins diminish venous tone and increase stasis. Large epidemiologic studies in the US and Great Britain found a significantly increased thromboembolic risk in OC users beginning in the 1st month of use and persisting until 3-4 weeks after termination of treatment. Most authors believe that OC use increases the postsurgical risk of thromboembolism by a factor of about 3. More selective choice of OC users, reduced estrogen doses, and better surveillance of users appear to have diminished the risk of thromboembolic disease with OC use. But unfortunately there are no sure predictors of thromboembolic disease. All authors recognize the reversibility of modifications caused by OCs on hemostasis by 4 weeks after termination. If therefore is recommended that OC use be interrupted 1 cycle before surgery.^ieng