Croatian physicians' and nurses' experience with ethical issues in clinical practice.

AIM: To assess ethical issues in everyday clinical practice among physicians and nurses of the University Hospital Rijeka, Rijeka, Croatia. SUBJECTS AND METHODS: We surveyed the entire population of internal medicine, oncology and intensive care specialists and associated nurses employed at the University Hospital Rijeka, Rijeka, Croatia (n = 532). An anonymous questionnaire was used to explore the type and frequency of ethical dilemmas, rank of their difficulty, access to and use of ethics support services, training in ethics and confidence about knowledge in ethics. Physicians (n = 113, 55% of them female) ranged in age from 27 to 61 years, and nurses (n = 251, 95% female), from 20 to 52. RESULTS: The most frequent ethical dilemmas concerned uncertain or impaired decision-making capacity (66% of physicians, 47% of nurses, p = 0.008), limitation of treatment at the end of life (60% of physicians, 31% of nurses, p<0.001) and disagreements among family members (47% of physicians, 31% of nurses, p = 0.025). The most difficult dilemmas concerned euthanasia and physician-assisted suicide (49% of physicians, 52% of nurses) and limitation of treatment at the end of life (14% of physicians, 18% of nurses). Only a minority reported ever using any kind of ethics support services (12% of physicians, 3% of nurses, p = 0.001) or being very confident about knowledge in ethics (5% of physicians, 6% of nurses). CONCLUSIONS: Similar ethical difficulties are present in the clinical practice of both physicians and nurses, with important differences in access and use of ethics support services. A need for systematic ethics educational activities was identified. Inclusion of individual ethics consultants in Croatian healthcare ethics support services is strongly advised.

Nurse practitioner geropsychiatric consultation service to nursing homes.

A nurse practitioner (NP) psychiatric consultation service was established to provide the residents of five nursing homes with on-site assessment and follow-up treatment for behavioral and psychiatric problems under OBRA and Medicare guidelines. During the 1-year project, 175 residents were referred by the nursing home (NH) staff for agitation, disruptive behavior, depressive symptoms, or decline in activities of daily living. An outcome evaluation documented that the NP recommendations resulted in positive behavioral changes in 62% of residents. Primary physicians, NH staff, and administrators validated that close monitoring of psychotropic medications and staff education in behavioral management strategies provided an effective, collaborative service. The practical aspects of establishing this consult service are addressed.

Electrokinetic properties of human cryopreserved platelets.

A method for the cryopreservation of human platelets with glycerol/glucose is described which was a simplified modification of the method of Dayian and Pert (1979). The effect of cryoinjury of the platelet surface membrane was investigated by studying the surface electrokinetic properties of the platelet. A significant increase in platelet electrophoretic mobility was found after cryopreservation. The fresh platelets had a mean electrophoretic mobility of 1.04 +/- 0.05 microns s-1 V-1 cm-1 and cryopreserved platelets 1.18 +/- 0.05 microns s-1 V-1 cm-1, P < 0.05. However, the total platelet sialic acid of fresh platelets was 62.5 +/- 5.6 nmol 10(-9) platelets compared to 47.2 +/- 4.6 nmol 10(-9) platelets after cryopreservation, P < 0.001. Similarly, the neuraminidase-labile sialic acid was 26.4 +/- 4.3 nmol 10(-9) platelets for fresh platelets and 17.6 +/- 4.0 nmol 10(-9) platelets after cryopreservation, P < 0.001. Using polyacrylamide gel electrophoresis with Western blotting, we showed a reduction in the platelet glycoprotein Gp Ib after cryopreservation, this was confirmed by using crossed immunoelectrophoresis. Electron microscopy revealed a significant change in platelet morphology after the cryopreservation procedure with disruption of the platelet membrane and also platelet shape change. These features may explain the changes in platelet electrokinetic properties.

Impact of aprotinin on blood transfusion requirements in liver transplantation.

A retrospective study was carried out to ascertain the blood bank provision required to support a liver transplant programme and to assess the effect of intraoperative aprotinin on blood product requirements in liver transplant recipients with cirrhosis. Sixty patients with end-stage liver disease underwent 62 consecutive orthotopic liver transplants between October 1988 and January 1991. The total and intraoperative requirements of red cells, platelets and fresh frozen plasma (FFP) were analysed for three groups of liver transplant recipients, those without cirrhosis (n = 15), those with cirrhosis (n = 25) and those with cirrhosis who received intraoperative aprotinin (n = 20). Fifteen without cirrhosis had mean total requirements of 15 units of red cells, 18 units of platelets and 16 units of FFP. Twenty patients with cirrhosis who received intraoperative aprotinin had broadly similar requirements. However, blood product requirements for 25 patients with cirrhosis were significantly greater (46 units of red cells, 41 units of platelets, 43 units of FFP, excluding the seven patients with primary biliary cirrhosis). We conclude that a liver transplant programme can be supported by a teaching hospital blood bank. The use of intraoperative aprotinin significantly reduces blood product requirements.

The Use of Fresh Plasma and a Plasma-free Medium to Enhance the Aggregation Response of Stored Platelets.

Platelet aggregation in response to ADP (10 µM) and collagen (4 µg/ml) in fresh and stored platelet concentrates (PC) and the enhancement of aggregation of the stored platelets after resuspension in fresh plasma and plasma-free medium were measured. The ability of platelets in autologous plasma to respond to the two agonists decreased significantly on days 2 and 5 of storage to 18 and 4% (p < 0.001) respectively of that seen in platelet-rich plasma on day 0 (100%). A 2-fold or greater improvement (p < 0.01) in the aggregation response was achieved when the autologous plasma in stored PC was replaced by fresh allogeneic plasma just before testing. The effect was even greater (three-fold or more, p < 0.001) when the autologous plasma was first replaced by plasma-free medium followed by suitable dilution for the test in fresh allogeneic plasma. These observations indicate another way to rejuvenate stored platelets and enhance their residual capacity to aggregate ex vivo. They could provide a basis for a suitable test for use within a quality assurance programme for stored PC.

Guidelines for platelet transfusions. British Committee for Standards in Haematology, Working Party of the Blood Transfusion Task Force.

Recommendations for the optimal transfusion support of patients likely to receive repeated platelet transfusions. 1. Determine policy for prophylactic platelet support, and select the platelet count below which platelet transfusions will be used. 2. Consider using leucocyte depletion of red cell and platelet concentrates to prevent HLA alloimmunization from the outset. 3. Type patients for HLA-A and B antigens at an early stage. 4. Use random donor platelet concentrates for initial platelet support (either single or multiple donor, depending on availability). 5. If refractoriness occurs, determine whether clinical factors, which may be associated with non-immune consumption of platelets, are present and test the patient's serum for HLA antibodies. 6. Use HLA-matched platelet transfusions if HLA alloimmunization is the most likely cause of refractoriness. 7. If there is no improvement with HLA-matched transfusions, platelet crossmatching may identify the cause of the problem and help with the selection of compatible donors. 8. Discontinue prophylactic platelet support if a compatible donor cannot be found. Use platelet transfusions from random donors to control bleeding and increase the dose, if necessary.

An overview of current trends in platelet preparation, storage and transfusion.

We present an overview of issues relating to preparation, storage and transfusion of platelet concentrates. The concepts of quality are described and potential benefits from leucodepletion, UVB irradiation and the use of additive solutions discussed. Emphasis is placed on laboratory evaluation of the storage lesion and in particular morphological changes of platelets during storage.

The use of mean platelet volume for evaluation of quality of platelet concentrates.

Mean platelet volume (MPV) was determined on whole blood and platelet concentrates (PC) prepared from units of the same blood, as well as on samples of venous blood taken from donors before plateletpheresis and on PC collected by Spectra (COBE Laboratories Ltd) and CS-3000 (Baxter Healthcare Ltd) cell separators. The mean (+/- SD) MPV for PC prepared from blood (7.18 +/- 0.76 fl, n = 12) was significantly lower than that for whole blood (8.32 +/- 0.72 fl, P < 0.02) suggesting significant separation of young, large and dense platelets together with the red cells. In contrast, the mean MPV for PC collected with Spectra and CS-3000 cell separators was 8.48 +/- 0.52 fl (n = 20) and 8.94 +/- 0.60 fl (n = 12), respectively, and was significantly higher (P < 0.01) than that determined in venous blood samples of donors taken before plateletpheresis (7.76 +/- 0.74 fl and 8.12 +/- 0.62 fl respectively). This indicates preferential separation of large platelets, which are by inference, of better quality, into PC.

Blood product support in patients undergoing chemotherapy and autologous or allogeneic bone marrow transplantation for haematological malignancies.

Three groups of patients with leukaemia and myelodysplasia were assessed with regard to the blood product support they required during their period of bone marrow hypoplasia following treatment. One group received myelo-ablative remission-induction chemotherapy followed by appropriate consolidation therapy (two courses in patients with acute myeloid leukaemia and one or two intensification courses in patients with acute lymphoblastic leukaemia); whilst the other two had 'conditioning' with chemotherapy and radiotherapy prior to autologous bone marrow transplantation (auto-BMT) or T cell depleted allogeneic bone marrow transplantation (allo-BMT). There was no statistically significant difference in blood product requirements between the three groups. However, platelet requirements during remission-induction chemotherapy alone were significantly less than for allo-BMT or auto-BMT. Platelet requirements for patients undergoing auto-BMT were also significantly higher than for patients receiving consolidation chemotherapy; and were required for a longer period than for patients receiving allogeneic-BMT. There was no difference in blood product support between ABO matched and mismatched transplants within the allogeneic group, but the presence of graft versus host disease and/or cytomegalovirus infection did significantly increase the requirements for blood product support.

Effect of EDTA on platelet count and other platelet parameters in blood and blood components collected with CPDA-1.

We have shown in this study that addition of dried K2EDTA (1.5 mg/ml) to blood samples anticoagulated with CPDA-1 increases significantly the platelet count and mean platelet volume (MPV) of whole blood, red cell concentrate (RCC) and platelet concentrate (PC), but not of platelet-rich plasma (PRP) or of platelet-poor plasma (PPP). Transmission and scanning electron microscopy illustrated that platelet aggregates which are present in some components are dispersed on mixing of the sample with EDTA and that this is accompanied by a change in platelet morphology. Determination of the platelet distribution width (PDW) indicated that the platelet populations in whole blood and RCC seem to be more uniform in size than the populations in PRP, PPP and PC. The determination of MPV and PDW changes after addition of EDTA may provide a new approach to quality control of PC.

Differences between the effects of EDTA and citrate anticoagulants on platelet count and mean platelet volume.

Platelet counts on whole blood samples collected into tripotassium salt of EDTA, trisodium citrate (Na3 citr), citrate phosphate dextrose adenine formula 1 (CPDA-1) and acid citrate dextrose formula A (ACD-A), all showed a statistically significant drop (P less than 0.01) after 1 h standing at room temperature (RT) as compared with the immediate (within 30 min) counts. After 1 h the enumeration became stable in the EDTA samples but the drop continued up to 4-6 h in those samples taken into citrate. The decreases in citrate were significant (18-30%, P less than 0.001). The addition of EDTA (1.5 mg/ml) to the citrated samples after the sixth hour count created a significant rise (6-22%, P less than 0.01) in the counts between the sixth and the seventh hour. Our observations show that platelet counts in citrated blood samples are lower than those in EDTA and highlight the necessity to present citrated samples mixed wtih dried EDTA when characterization or quality control of blood and blood components is required. Analysis of the mean platelet volume (MPV) showed significantly lower values (6-13%, P less than 0.05) in the citrated samples as compared to the same samples in EDTA, and a significant increase (4-6%, P less than 0.01) on the addition of EDTA to the citrated samples after the sixth hour analysis.

Lymphocytopenia in donors undergoing regular platelet apheresis with cell separators.

The effect of regular platelet apheresis on lymphocyte count was investigated in 142 platelet donors who donated up to 113 times on Haemonetics Model 30 and Fenwal Model CS-3000 cell separators. Lymphocytopenia (lymphocyte count less than 0.9 X 10(9)/l) was found in 21 out of 113 (18.6%) donors who donated solely on the Haemonetics Model 30 compared with 2 out of 100 (2%) whole blood donors and none of 100 plasmapheresis donors (P less than 0.002). Lymphocyte count was inversely related to the total number of platelet donations (r = 0.51, P less than 0.001) and total estimated lymphocyte loss (r = 0.49, P less than 0.001) suggesting a cumulative effect. T4 and T8 lymphocyte subsets were found to be reduced in each of 13 lymphocytopenic platelet donors tested but T4/T8 ratios were similar to those of controls (2.51 +/- 0.79 and 2.33 +/- 0.58 respectively). No adverse effects on platelet donor health were observed but it is suggested that platelet apheresis protocols should be designed to minimize lymphocyte loss.

Preservation of platelet function in cryopreserved platelet concentrates with prostacyclin.

Prostacyclin (Epoprostenol) or a stable prostacyclin analogue (ZK 36,374) were added to platelet concentrates prior to cryopreservation. This resulted in significantly better preserved function of the thawed platelet concentrate, assessed by platelet aggregation to various concentrations of ADP, collagen and ristocetin, compared to control cryopreserved platelet concentrates. The use of prostacyclin or one of its stable analogues should be considered to reduce platelet activation and subsequent loss of function during the various manipulative procedures when preparing standard and cryopreserved platelet concentrates.

Leukocyte-depleted blood. A comparison of filtration techniques.

Febrile transfusion reactions due to leukoagglutinins are commonly seen in multitransfused patients. It has been suggested that reduction of the number of leukocytes per transfusion to 0.5 x 10(9) or less would prevent nonhemolytic febrile transfusion reactions in the majority of patients. Therefore, we have compared the ability of several filters to reduce the leukocyte content of stored whole blood drawn into citrate-phosphate-dextrose. The leukocyte absorption filters, Imugard IG500 and Erypur, produced 98.3 +/- 2.4 and 98.3 +/- 1.7 percent leukocyte depletion, respectively. The leukocyte adherence filter, Leuko-Pak, produced a depletion of 54.6 +/- 14.7 percent. The microaggregate filters, Biotest MF10B Microfiltration set, Ultipor Blood Transfusion Filter SQ40S, and Travenol 20 micron High Capacity Transfusion Filter, produced 37.5 +/- 10.8, 13.3 +/- 11.2, and 44.5 +/- 11.3 percent leukocyte depletion, respectively. It would appear that of the filters tested, the Imugard IG500 and the Erypur are the only filters which can invariably reduce the absolute number of leukocytes in a unit of stored whole blood to below 0.5 x 10(9).