What is the optimal pretransfusion testing interval for multi-transfused patients? The University Hospital of Brest experience.

The red cell allo-antibodies research is mandatory before transfusion. In France, pretransfusion testing intervals that are prescribed by regulatory and accrediting agencies are commonly 72hours. In the University hospital of Brest, the interval for multi-transfused patients has been 24hours. In this study we aim to analyse these practice and argue the delay. METHODS: This is a retrospective study of post-transfusional allo-immunizations from 2015 to 2020. For each patient, the time interval between the last negative research and the allo-immunization was investigated. RESULTS: 189 patients developed allo-antibodies. In 16 patients (8,5%), the interval for allo-immunization was 24hours, 48hours and 72hours in 4, 8 and 4 patients respectively. 12 patients were transfused after the discovery of the allo-antibodies. That means if we have chosen a delay of validity of 72hours, then 9 patients would have been transfused with a negative result. CONCLUSION: Checking for allo-antibodies before RBC transfusion with an interval of 24hours (and not 72hours) is pertinent in order to assure an optimal transfusion safety and to limit the risk of hemolytic transfusion reactions. A pretransfusion testing interval of 24hours for multi-transfused patients should be considered.

Study on the transfusion representation by nurses and midwives at the university hospital of Brest.

INTRODUCTION: Every day, large numbers of patients benefit from effective transfusion substitution therapy, through transfusion procedures that are generally safe and reliable. This care practice is complex, due to its history through the ages, ethical aspects linked to the donation of blood from one human to another, and the procedures and protocols linked to it. Nurses are a key link in the transfusion chain and are directly affected by the procedures implemented to limit transfusion risks. In this research study, we studied the nurses' and midwives' representations of transfusion, to evaluate their possible effects on transfusion practices. METHODOLOGY: With the aid of the various actors involved in transfusion, we developed and tested a questionnaire, which was then sent to 690 professionals in 69 care units. RESULTS: In total, 491 questionnaires were analyzed, corresponding to a response rate of 71%. The data collected revealed a strong feeling of responsibility among the healthcare staff questioned, with great attention paid to transfusion safety. The risk to the patient is very much taken into account by these professionals, who consider transfusion to be a healthcare practice unlike any other, generating a certain stress that affected all those questioned, regardless of the number of years they had been in practice, but was tempered by knowledge. CONCLUSION: This survey shows that nurses and midwives are very aware of the risks of transfusion to the patient, and that they take these risks into account with the same diligence throughout their careers. It would be useful to carry out semi-directed interviews to refine some of these results further.

[Appropriate use of red blood cell transfusion in the emergency department before and after a specific protocol]. / Pertinence des prescriptions de concentrés de globules rouges par le médecin urgentiste avant et après la mise en place d'un protocole.

The purpose of this study was to assess appropriateness of red blood cell (RBC) transfusion in the emergency department before and after a specific protocol. METHODS: A retrospective monocenter study was realized during two six-month periods at the emergency unit. A protocol based on the French national guidelines (HAS) in 2014 was set up between the two periods. All the adult patients, except in a context of massive transfusion, were included in the study. The principal criteria analysed was the rate of appropriate transfusion. RESULTS: Ninety-five patients were included during the first period (group 1) and 98 during the second one (group 2). The rate of appropriateness was the same in the two groups (81% for the group 1 and 81.6% for the group 2). The inappropriate indications were more frequent with older patients (74.6 ± 15.2 years in the group 1 and 79.5 ± 8.5 in the group 2, P=0.01) and patients suffering from a stable coronary artery disease (18.5% in the group 1 and 38.9% in the group 2, P=0.008). CONCLUSION: The rate of appropriate red blood cells transfusion, already high at the beginning of the study, could not be significantly improved with the institution of a specific protocol. It is necessary to continue medical training.

Compliance with the European trauma guidelines: An observational single centre study.

OBJECTIVES: The European trauma guidelines were developed to assist clinicians in the early phase of trauma management to diagnose and treat coagulopathy and bleeding. This study aimed to determine compliance with these European trauma guidelines in a French referral trauma centre. METHODS: Medical charts of trauma patients with an injury severity score≥16 admitted between January 2013 and December 2014 were reviewed. Compliance with 21 recommendations in the first 24-hours of patient management was assessed. RESULTS: There were 145 patients with median ISS of 34 [IQR 25-41]. A good level of compliance (i.e. applied in≥80% of patients) was identified for nine recommendations, inconsistent compliance (i.e. applied in 50 to 79% of patients) for six recommendations, including fibrinogen levels at hospital admission and achievement of a target mean arterial blood pressure (MAP)>80mmHg in patients with major bleeding and TBI (55.5%), and poor compliance (i.e. applied in<50% of patients) for another six recommendations. Poorly applied recommendations included early measurement of lactate or base deficit (32%), early administration of tranexamic acid (18%), and achievement of normocapnia in patients with TBI undergoing invasive ventilation (3%). CONCLUSIONS: In a referral trauma centre, nine of the 21 evaluable recommendations in the European trauma guidelines were applied in≥80% of patients. Early diagnosis and treatment of trauma-related coagulopathy was identified as an area for significant practice improvement. In patients with TBI, efforts should be made to achieve the targeted MAP and to maintain normocapnia.

Implementation and evaluation of a major haemorrhage protocol in the Emergency Department Resuscitation Area in the University-affiliated Hospital of Brest (France).

Haemorrhagic shock is a rare occurrence in emergency medicine but it can be associated with significant mortality. The purpose of this study was to evaluate the impact of a major haemorrhage protocol on patient management in Emergency Department Resuscitation Area. METHODS: A single-centre study was conducted to compare two periods, before and after institution of a massive haemorrhage protocol including the use of massive transfusion orders and the availability of packed red blood cell concentrates prior to patient's admission. Two groups of patients (in both trauma and non-trauma settings) were defined: "before protocol" and "after protocol". The primary outcome was the median transfusion time for a unit of red blood cell concentrate. RESULTS: Forty patients were included: 22 for the "pre-protocol" group and 18 for the "post-protocol" group. The two groups were balanced with baseline characteristics. This study showed a significantly reduced median transfusion time for a unit of red blood cell concentrate from 20min pre-protocol to 9min post-protocol. The time between patient's admission and transfusion of the first red blood cell concentrate was reduced but non-significantly from 71min to 36min. CONCLUSION: The major haemorrhage protocol optimised patient management by reducing the median transfusion time for red blood cell concentrates.

How clinicians can minimize transfusion-related adverse events?

OBJECTIVES: Transfusion-related adverse events (TRAE) can contribute to patient morbidity and mortality. In this brief narrative review, the strategies that clinicians can apply at the bedside to avoid TRAE are discussed. METHODS: Strategies to avoid the following five types of TRAE were reviewed: transfusion-associated circulatory overload (TACO), transfusion-related acute lung injury (TRALI), transfusion-associated hypothermia (TAH), transfusion-related allergic reactions (TRAR) and acute haemolytic transfusion reactions (AHTR). RESULTS: Minimizing exposure to blood components is fundamental to TRAE avoidance. Pre-transfusion assessment can identify patients at risk of TACO, TRAR and TAH, and avoidance steps implemented. Preventive strategies for TACO include lower transfusion rate, 'one unit at a time' transfusion policy and possibly diuretic medication. Patients with past history of TRAR should preferably be given plasma-free blood components; anti-histamine medication prior to transfusion could be considered. TAH is common in the massive transfusion setting, particularly trauma patients. Warming of patients are key strategies to avoid TAH. Identification of patients at risk of TRALI is more opaque; however, any measures that limit pulmonary inflammation prior to transfusion may decrease the risk of TRALI. Causes of AHTR are commonly due to human error and failure to apply rigorous cross-checks of patient and issued RBC component blood groups. CONCLUSIONS: Beneficial strategies to avoid TRAE include judicious use of blood components, identification of high-risk patients, adherence to recommended clinical processes and awareness of TRAE pathophysiology. More evidence is warranted to better guide clinicians in the prevention of TRAE.

[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.

[Is the research of posttransfusional alloantibodies still relevant?] / Est-ce que la réalisation de la recherche d'anticorps antiérythrocytaires post­transfusionnelle est toujours pertinente ?

The decision of November 6th, 2006 defining the principles of best practices recommends that posttransfusional red cell alloantibodies research is performed after one to three months after. In the University hospital of Brest, the haemovigilance unit takes charge of sending the medical prescription within the required time and centralizing the results. We wished to estimate if the realization of this research still remains relevant. METHODS: A prospective analysis was performed in 2015. We evaluated the realization rate, the red cell alloantibodies rate and the recipient adverse reactions with the diagnostic category: alloimmunization (delayed serological transfusion reaction, DSTR). RESULTS: In 2015, 2162 prescriptions were sent to the 3271 transfused patients. One thousand and eighteen red cell alloantibodies research were done, i.e. a return rate of 61%. Among them, 12 alloantibodies appeared (0.9%) within an average of 56 days. Thirty-three other alloantibodies appeared and were discovered most frequently before a new transfusion. In 10 cases, a posttransfusional research was done that was negative. A survey was conducted among GHCOH members to describe the practices in these health institutions. Twelve questionnaires were analysed. Ten institutions performed a posttransfusional alloantibodies research by issuing a prescription at the patient's exit with a return rate between 0.14 and 16%; 1 institution has a centralized organization with a return rate of 68.3%; 1566 red cell alloantibodies research were performed and among them, 24 alloantibodies appeared (1.53%). CONCLUSION: These results indicate that to be effective, the management of this biological test must be centralized. Despite this, the red cell alloantibodies rate remains very low (0.9 and 1.53%) and raises the question of the relevance of this systematic testing after transfusion, which is in any case mandatory before a new transfusion of red blood cells.

[Transfusion practices in elderly patients: A descriptive study about 241 patients at the university hospital of Brest]. / Transfusion sanguine chez les personnes âgées : étude descriptive à propos de 241 patients au CHRU de Brest.

Red blood cell transfusion is commonly required for elderly patients with little specific guidelines for this population. We wished to study the transfusion practices for patients aged≥75 years transfused with red blood cells in all units of our institution. The aim of this work is to describe this population of patients and to compare the transfusion practices to the HAS and ANSM guidelines published in 2014. METHODS: An observational study was performed including patients≥75 years, transfused with red blood cells between 27th January to 27th March 2014. Analysis of data included the patients' typology, the characteristics of anemia, the indications and transfusion practices, and the adequation with the guidelines. RESULTS: Two hundred and forty-one patients were transfused during the period with 422 transfusion episodes (mean age 83±5.2 years, sex-ratio women/men 1.4 with 4.4±2 pathologies and 6.7±3.2 treatments). Only 4.5% of the patients were transfused in geriatric wards. In 61% of the cases, the anemia is acute and chronic in 39%. Fatigue was reported in 50.6% of the cases and dyspnee in 31.7%. A percentage of 31.1 of the patients were prescribed furosemide for transfusion. The mean transfusion recovery was 1.2±0.5g/dL. Two adverse events were reported. Overall, only 10.4% of the prescriptions were not compliant with the guidelines of 2014. CONCLUSION: In this study, we describe transfusion practices for patients aged≥75 years. Although the non-compliance with the guidelines is weak, it is possible to improve the transfusion practices taking care of the geriatric characteristics. Prospective studies on a larger scale have to be done to converge on a more consensual management.

[Evaluation of midwives transfusion knowledge in Brittany public and private maternities, 2014]. / Évaluation des connaissances transfusionnelles des sages-femmes dans les maternités publiques et privées de la région Bretagne en 2014.

OBJECTIVES: This regional study aims to evaluate the transfusion knowledge of midwives in 22 Brittany maternity hospitals. MATERIALS AND METHODS: A multicentre, descriptive and comparative study used a questionnaire consisting in 16 theoretical questions about transfusion and questions being carried out. The analysis used the rate of correct answers and a pondered coefficient has been assigned to the different questions to evaluate the level of midwife knowledge. RESULTS: Twenty-two maternity hospitals participated in the study and 238 returned questionnaires could be analysed, a return rate of 36%. The rate of correct answers was between 5 and 98% depending on the questions; for example, the rate of correct answers of the ultimate control's reading varied between 64 and 98% and revealed that 5 to 7% of midwives would validate an incompatible transfusion. The average score was 31/50 with a minimum of 7/50 and a maximum of 44/50. Three statically significant links have been found according to the last year of training specific to blood transfusion, the graduation year and the level of maternity. CONCLUSION: This study revealed an insufficient knowledge of the transfusion among midwives and raised prospects, which could lead to an improvement of training courses offered to midwives.

[Transfusion-transmitted bacterial infection of a apheresis platelet concentrate with Streptococcus gallolyticus: Analysis of one case]. / Infection bactérienne à Streptococcus gallolyticus transmise par transfusion d'un concentré de plaquettes : à propos d'un cas.

Bacterial infections are uncommon complications of the blood products transfusion but they are potentially serious. Many advances have been done over the past few years to guarantee the microbiological security of blood products as the donors selection with a medical talk, the derivation of the first 30 millilitres blood during the donation, the deleucocytation of blood products… But in spite of these advances, cases of bacterial infection always remain. The purpose of this study was to point out the platelet concentrate's transfusion-transmitted bacterial infection with Streptococcus gallolyticus and the unusual consequence for the donor by uncovering an asymptomatic rectal neoplastic tumor. This study as raised as to whether the usefulness of systematic bacterial inactivation in the platelets concentrates.

[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.

[Who are the recipients of labile blood products? A multicenter nation-wide study--a "donation day." Blood banks, health facilities]. / Qui sont les receveurs de produits sanguins labiles (PSL)? Une étude nationale multicentrique - un jour donné. Etablissement de transfusion sanguine (ETS) - établissements de santé (ES).

During the years 1994-2001, a progressive decrease of the number of blood units transfused has been reported in France. In contrast, since 2002, there is an increasing number of blood units issuing (+7.6% between 2001 and 2006) and this must be investigated. On behalf of the French Society of Blood Transfusion, the "Recipients" working group promoted a nation wide survey with the support of the regional blood transfusion centres. This survey was aimed at describing the profiles of the transfused patients: socio-demographical patterns, and reasons of the blood transfusion (main and associated diagnoses). A cross-sectional survey was designed. All the patients who received a blood unit during a specific day were considered as the population of the study. They were identified by the regional transfusion centres by means of the "individual issuing form". Survey forms were fully filled for 90% of the patients. It has been considered as a good answer rate. Seven thousand four hundred and twenty-two blood units, delivered to 3450 patients were analyzed. Three groups of pathologies were found as a reason of transfusion: haematology-oncology (52.70% of the prescriptions) with 892 patients (27.8%) for haematological malignancies; surgical procedures (23.99%); intensive care and medicine procedures (21.92%). More than 50% of the recipients are 70 years old and more. This result is explained by the age distribution of inpatients. In a context of lack of donors and consequently difficulties to provide patients with optimal number of blood units, this study is helpful. Variability of blood unit issuings must be detected, analyzed and monitored in real time by the actors of the transfusion process, using computerized dashboards: the blood units provider (in order to adjust the strategy of blood units provision) and the health care establishment as well as care blood components prescribers (reasons of blood transfusion and evaluation of practices).

[Assessment of knowledge in blood transfusion of medical staff in 14 state-run hospitals]. / Evaluation des connaissances médicales transfusionnelles dans 14 établissements publics de santé

UNLABELLED: This multi-centre study aimed to assess the knowledge in blood transfusion of medical staff in 14 state-run hospitals. MATERIALS AND METHODS: A questionnaire was distributed to all potential prescribers of blood products. It contained 35 questions concerning various subjects: blood products, immuno-haematology, prescription of blood products, transfusion practice, interpretation of the final bedside controls. The rate of correct answers (RCA) was obtained for each question, for each subject, and for nine questions defined as essential for patient safety. A weighted score was also calculated by ranking each question between one and six according to its importance. RESULTS: Six hundred and ninety four questionnaires were analysed (rate of return 15%). The RCA ranged from 14 to 89%, according to the questions. The RCA ranged from 47 to 78% for seven of the nine essential safety questions, and 82% and 83% for the two questions concerning the interpretation of incompatible final bedside controls: there were 9% of wrong answers, which validated an incompatible blood transfusion. The mean weighted score was 62%. Both the RCA and the weighted score were higher for those that regularly prescribe blood products than for that only prescribe them occasionally. There were no significant differences between hospitals. CONCLUSION: This study has confirmed that medical staff have deficiencies in their knowledge of blood transfusion, deficiencies which are acknowledged by medical staff. These first results will help the members of the study group to develop and prioritize various actions to improve this state of affairs, and to follow the effects of the training given.

[Professional-practice evaluation of the medical and nursing dysfunctions observed during the transfusion chain at the University Hospital of Brest]. / Evaluation des pratiques professionnelles sur les dysfonctionnements médicaux et paramédicaux repérés au cours du processus transfusionnel au CHU de Brest.

The haemovigilance unit decided to set up since 2003 an evaluation of professional practices of blood transfusion chain from the prescription of blood products to the transfusion act and follow-up of receivers in several health care services. We have founded that the medical and nurse dysfunctions are the same in all cases. We have decided to analyze the causes of these dysfunctions and to propose actions to perform practices using a "problem-solving system model". We followed the next stages: (1) characterization of the problem in "QQOQCCP" form (What? Who? Where? When? How? How many? Why?), (2) analysis of the causes presented in Ishikawa's cause-and-effect diagram form and (3) search and selection of solutions of improvements.

[Evaluation of post transfusion hypertransaminasemia]. / Evaluation des hypertransaminasémies lors du bilan post-transfusionnel.

UNLABELLED: Dosage of post transfusion ALT has been performed since a government recommendation was issued in 1996. Yet, the advantage of this analysis during the post transfusion tests has not been determined. The aims of this study were to estimate: a) the incidence of hypertransaminasemia, b) the causes of hypertransaminasemia and c) the advantage of an etiologic investigation. PATIENTS AND METHODS: At the University Hospital of Brest, follow-up of the labile blood products recipients was initiated in June 1993. Since 1997, a visit in the hepatogastroenterology unit was systematically proposed to patients having post transfusion hypertransaminasemia. RESULTS: Since November 1997 to July 2003, ALT increase was detected in 235 patients (4%). Among them, 108 patients consulted a hepatologist. Diagnosis was certain for 46 patients (46%). A drug reaction or alcoholic disease was the cause of ALT elevation in the majority of cases (80%). The diagnosis was probable for 42 patients (39%) due to medications in 81% of cases. The diagnosis remained undetermined in 20 patients (18%). CONCLUSION: Our study shows that alcohol or drug hepatotoxicity explained the majority of post transfusion hypertransaminasemia. We could not demonstrate a viral cause. We have decided to continue the follow-up of post transfusion hypertransaminasemia during two more years and to reevaluate the usefulness of the etiologic investigation.

[A quality program in haemovigilance: evaluation of the blood transfusion chain]. / Démarche qualité en hémovigilance: analyse du processus transfusionnel.

Blood transfusion, like any effective therapy, involves an element of risk. In order to reduce such risks to a maximum, a legislative and statutory framework has been set up. A reliable evaluation of this system is necessary together with an efficient evaluation method whose aim is to guarantee quality service. Favouring the development of the evaluation of professional practices is one of the priorities of the National Agency of Accreditation and Evaluation in Health (ANAES) created in April 1996. Following the recommendations from ANAES, the University Hospital of Brest decided to set up an evaluation of blood transfusion chain from the prescription of blood products to the transfusion act and follow-up of receivers in two health care services. The method used for this evaluation was a clinical audit. It is a method of evaluation, which allows with the help of certain criteria, care practices to be compared to accepted references, in order to measure the quality of these practices and the results of hospital care, so that improvements may be added. We present here the method and results of this evaluation, as well as the improvements we have put in place.

The use of recombinant factor VIIa (NovoSeven) in a patient with a factor XI deficiency and a circulating anticoagulant.

A 75-year-old female known to have a chronic myelomonocytic leukaemia and an acquired FXI deficiency (FXI level, 5%) related to a FXI inhibitor (38 Bethesda units) was admitted to the hospital for acute pneumonia associated with a bulky pleural effusion. A therapeutic puncture was found to be essential for the patient. But, such a procedure is a haemostatic challenge which requires adequate preparation. A first treatment composed of intravenous immunoglobulins and immunosuppressive therapy failed to eradicate the inhibitor and to restore a normal FXI level. In this context, steroids or FXI concentrates were not recommended. Thus, small doses of recombinant activated factor VII were used to achieve haemostasis. The procedure was successful, the tolerance was good and no adverse events occurred.

[Evaluation of the immediate transfusion reaction incident reporting system at the Brest University Hospital Center]. / Evaluation du système de notification des incidents transfusionnels immédiats au CHU de Brest.

The Haemovigilance Unit of Brest University Hospital has had a reporting system of transfusion reactions since october 1994. Reporting "any unexpected or undesirable effect due or likely to be due to the administering of blood cell components" must be done on an answering machine immediately or in the next eight hours. The main goal of the evaluation of this epidemiological surveillance system was to assess its sensitivity, its positive predictive value, its acceptability, its timeliness and its simplicity, according to the Centers for Disease Control criteria. An exhaustive monitoring of the immediate transfusion reactions (ITR) occurring within the 24 hours following the procedure was conducted from April 1, to June 30, 1998. Two sources of information were used, the spontaneous notification to the Haemovigilance Unit using the answering machine, and a telephone survey of the nurse responsible for the transfusion or post-transfusion follow-up. During the survey, 19 ITR, among which 12 were reported to the Haemovigilance Unit on the answering machine, were recorded. The incidence rate of the I.T.R. was estimated at 5@1000 transfused blood cell components. The sensitivity of the notification system was estimated at 63% (95% confidence interval: 41-85) and the positive predictive value at 70% (95% confidence interval: 48-92). This notification system is operational. The function of sanitary alert is ensured at the primary level of the system surveillance. The undernotification of the ITR (37% of false negative) must be corrected by specific recommendations.

A case of chronic myelomonocytic leukaemia and factor XI deficiency with a circulating anticoagulant.

Inhibitors against factor XI (FXI) have been frequently described in patients who acquired inhibitors (due to auto-immune disorders, malignancies or infections), but less often in those with a congenital deficiency of this factor, who had received plasma infusions. The present report concerns one such inhibitor found in the plasma of a patient with chronic myelomonocytic leukaemia and infected by B19 parvovirus, who was neither a heterozygote nor a homozygote for FXI deficiency, and who had no bleeding tendency despite a very low FXI level. Taking this case into account, we discuss and present the clinical and biological features of acquired FXI deficiency caused by an inhibitor.