Computer assisted prospective review of blood product utilization: a large hospital experience.

In an effort to assess need to administer blood products, we developed a computer-assisted prospective blood utilization review system. Prior to transfusion, clinical information (from the blood requisition form) and pertinent laboratory data (from the laboratory information system) are checked against approved hospital transfusion guidelines (HTG). If request-review is outside HTG, the blood bank physician is called to review and consult with ordering physician. Of 27,840 requests received in a year period (1995-1996), 1.2% (327) were outside HTG and were physician reviewed. The great majority, 120/160 (88%) of requests for red blood cells (RBC) or whole blood were approved; about 65% of these were approved in patients with cardiorespiratory dysfunction and hemoglobin (Hb) > or = 90 g/L. Slightly more than two-thirds, 84/119 (71%) of platelet concentrate requests reviewed were approved; about 69% of them were approved in patients who were either bleeding or were undergoing an invasive procedure and had platelets > or = 20 x 9/L. Almost four-fifths, 38/48 (79%) of fresh frozen plasma or cryoprecipitate requests reviewed were approved; all in bleeding patients with sepsis and/or disseminated intravascular coagulation. Based on the frequent request for RBC transfusions in patients with cardiorespiratory dysfunction and Hb > or = 90 g/L, we have obtained approval to increase the Hb threshold to < 130 g/L as a means of facilitating measures to increase oxygen delivery.

A rationale for omitting two-hour postprandial glucose determinations in gestational diabetes.

OBJECTIVE: In making decisions regarding initiation of insulin therapy in gestational diabetes, most maternal-fetal obstetricians rely more on elevated fasting glucose values than on elevated 2-hour postprandial levels. We sought to determine whether the latter test is necessary. STUDY DESIGN: From the patients with gestational diabetes mellitus managed over a 17-month period at Grady Memorial Hospital, we retrospectively analyzed data to determine whether normal (< 105 mg/dl) fasting plasma glucose values predict elevated 2-hour postprandial values and whether the latter predict adverse outcome. RESULTS: From 194 patients with gestational diabetes mellitus, 546 paired fasting and 2-hour postprandial glucose values were recorded. Fasting levels were normal in 467 (85%); in those, 2-hour levels were < 120 mg/dl in 83% and < 140 in fully 96%. In 131 women with all fasting plasma glucose values normal, the birth weights and the rates of cesarean delivery, shoulder dystocia, and macrosomia were similar, regardless of whether 2-hour postprandial glucose values were > or = 120. The actual cost of the 546 2-hour postprandial glucose tests was nearly $10,000. CONCLUSION: For metabolic surveillance in gestational diabetes mellitus, the 2-hour postprandial glucose test seems unnecessary, provided fasting plasma glucose values remain normal.

The impact of a clinic for adults with HIV infection on the microbiology laboratory.

The Infectious Diseases Clinic (IDC) discussed serves adults who are seropositive for human immunodeficiency virus. The authors reviewed the outpatient and inpatient microbiology tests of a three-month period during 1989 for a systematic sample of IDC patients. The 249 patients in the sample had 682 microbiology tests performed during the period (mean 2.7 tests per patient). Tests most frequently requested were mycobacterial culture, routine blood culture, and cryptococcal antigen determination. Patients with acquired immunodeficiency syndrome (43% of IDC patients) accounted for 63% of the requested IDC tests. IDC patients comprised about 2.4% of patients served but accounted for 3.9% of the requested microbiology tests and 6.6% of the microbiology work load for reported tests. Using Centers for Disease Control case projections, the authors estimated that services to IDC patients in 1993 would comprise 6.6% of all microbiology tests and 10.6% of the microbiology work load. The implications of these data for microbiology probably also apply to other laboratory testing and emphasize the need for more efficient ways to use and perform diagnostic studies required by patients with HIV infection.

Fetal intestinal obstruction: necessity for percutaneous umbilical blood sampling to assess the severity of Rh sensitization.

Investigation into the severity of hemolytic disease due to Rh isoimmunization may be complicated by concurrent amniotic fluid contamination with bile. We have presented a case in which a prenatal sonogram showed evidence of fetal intestinal obstruction, which was subsequently confirmed postpartum by exploratory laparotomy. Since intrauterine regurgitation of bile occurs with intestinal obstruction distal to the papilla of Vater, percutaneous umbilical blood sampling is necessary to discern the presence and severity of hemolytic disease as indicated by an abnormal spectrophotometric absorption pattern.

Disproportionate outdating of group A blood.

The authors studied the factors responsible for the disproportionate outdating of group A blood compared with group O blood over a 6-month interval. Distribution, transfusion, and outdate data for 99,251 units of blood were collected from representative hospitals within the region served by the Atlanta Regional Red Cross Blood Center. Factors evaluated included: neonatal transfusion of type O blood to type A recipients; use of type O blood in emergencies or due to group-specific shortages; demographic donor and recipient differences; and blood importing practices. Of 43,757 group O units (44.1% of total) available for distribution, 2050 (4.7%) were outdated, compared with 3908 (10.7%) of 36,501 group A units (36.8% of total). One thousand two hundred and seventy-nine units of type O blood were transfused to recipients who were not type O, including 842 group A neonatal patients. A larger inner-city hospital, where 46.8 percent of recipients were group O and 29.2 percent were group A, accounted for 180 more group O and 509 fewer group A transfusions than would be expected if donor-recipient ABO distributions were the same. Three hundred and seventy-four more group A units were imported than were needed. ABO-mismatched transfusions due to shortage or emergency were insignificant. It was concluded that increased use of group O blood for neonatal transfusions, donor-recipient differences in blood group frequencies, and blood importing practices are the major factors that increase the rate of group A outdating.

Autotransfusion from experimental hemothorax: levels of coagulation factors.

The coagulation system was investigated in five dogs undergoing autotransfusion from experimental hemothorax. One fourth of the blood volume was bled into the pleural space, drained, and autotransfused. The hemothorax blood showed: very prolonged PT and PTT; very low platelets and fibrinogen; midly elevated FDP; very low coagulation factors VIII, and V; reduced XII, prothrombin, X, XI, and VII. Partial clotting, mild fibrinolysis, and fibrin deposition over the pulmonary pleura seemed to cause incoagulability of hemothorax blood. Post autotransfusion arterial blood showed: normal PT and PTT; 25% decrease in platelets, and 31% decrease in fibrinogen from baseline values. There was also an overall 20% reduction of fibrinogen from baseline values. There was also an overall 20% reduction of all clotting factors, but their levels remained above 50% activity. It was concluded that autotransfusion from a hemothorax of 25% the blood volume in dogs causes a mild loss of hemostatic components, but does not significantly compromise the clotting mechanism.

Hemoglobin H disease with hemoglobin Constant Spring in a child of Laotian extraction.

In alpha-thalassemia, deletion or inactivation of one, two, three, or all four alpha-genes causes, respectively, silent carrier state (-alpha/alpha alpha); alpha-thalassemia trait (--/alpha alpha in Orientals, and -alpha/-alpha in blacks); Hb H disease (--/-alpha); and Hb Bart's hydrops fetalis (--/--). We have described a case of Hb H disease with Hb Constant Spring (--/alpha alpha cs) in a Laotian child whose father had alpha-thalassemia trait and whose mother was a carrier of Hb CS, a mutant hemoglobin produced in minimal amounts. Since alpha-thalassemia is highly prevalent in Southeast Asia, physicians should become alert to the potential occurrence of Hb H disease and Hb Bart's hydrops fetalis in the new Oriental immigrants and their progeny.

Isolation of leukocyte-free platelets from standard platelet concentrates by centrifugation.

We evaluated centrifugation techniques to isolate leukocyte-free platelets from standard platelet concentrates. Among various settings of centrifugation force and time, we found the setting at 300 X g for 10 minutes or 370 X g for 5 minutes to be efficient and reproducible for recovering sufficient quantities of platelets free of leukocytes.

Physiological Changes in Elite Male Distance Runners Training for Olympic Competition.

In Brief: Nine elite male distance runners were evaluated by comprehensive periodic monitoring of selected blood chemistry variables, percent body fat and lean body mass, and cardiopulmonary performance as they prepared for the 1984 Olympic Summer Games in Los Angeles. The most consistent changes included a decrease in percent body fat (5.4% to 4.6%, p <.05) and an increase in anaerobic threshold. Compared with a healthy, untrained group matched for age, sex, and height, the runners showed measurable differences in resting pulmonary function, including elevated pulmonary diffusing capacity, maximum voluntary ventilation, and peak expiratory flow rate. Consistent deviations in indexes of iron stores and metabolism were also noted. The extent to which such altered iron status compromises training and competitive performance or may be restored by iron supplementation needs further investigation.

Fluorometric assay of antithrombin III. Diagnostic value in 112 patients with abnormal hemostasis.

The authors assessed the diagnostic value of the plasma anti-thrombin III (AT III) assay in 112 adult hospitalized patients with abnormal hemostatic parameters, using the Protopath procedure. In 100 patients tested only once, low AT III was observed in 25 of 29 cases of acute disseminated intravascular coagulation (DIC); 7 of 10 with infections; 8 of 11 with acute liver disease; 19 of 20 with chronic liver disease; and 16 of 30 with other illnesses. The authors conclude that the assay cannot distinguish among disease categories, although it is a sensitive index of DIC. AT III was also repeatedly measured at various time intervals in 12 additional patients. The results suggest enhancement of the diagnostic and prognostic value of the assay with serial testing.

Value of serum immunoglobulins in the diagnosis of liver disease.

Serum immunoglobulins were determined in 145 consecutive patients with biopsy-proven steatosis, alcoholic hepatitis, alcoholic hepatitis with fibrosis, alcoholic hepatitis with cirrhosis, inactive cirrhosis, chronic active alcoholic hepatitis, chronic active hepatitis, primary biliary cirrhosis and nonspecific hepatitis. IgM was both a sensitive (90.5%) and specific (86.2%) marker for primary biliary cirrhosis, and mean IgM levels were higher in primary biliary cirrhosis than in other diagnostic categories (p less than 0.05). IgA levels were most commonly elevated in alcoholic liver disease (p less than 0.005). IgA detected 95% of alcoholic disease, but was poorly specific (41.1%). A trend of rising IgA with increasing severity of alcoholic injury was observed, but the differences were not significant. IgG was most commonly elevated in chronic active hepatitis and alcoholic hepatitis with cirrhosis, but the IgG values did not differ significantly from those found in other diagnostic categories. Our results substantiate assertions of a diagnostic sensitivity for elevated IgA in alcoholic liver disease and IgM in primary biliary cirrhosis. With the exception of IgM in primary biliary cirrhosis, however, serum immunoglobulins are not specific markers of liver histology.

Immune responses in eight patients infected with Bacteroides fragilis.

Sera from eight patients with either septicemia or pyothorax caused by Bacteroides fragilis were assayed for specific antibody by the agglutination, immunofluorescence, and agar gel diffusion techniques. Antibodies were detected in the sera of all eight patients by all three serological tests employed; titers as high as 1:160 and 1:320 were detected by the agglutination test and the immunofluorescence technique, respectively, and all patients had precipitating antibody. Failure of B. fragilis sub-species thetaiotaomicron to react with any heterologous antisera from the other seven patients infected with B. fragilis subspecies fragilis thetaiotaomicron was not serologically related to any of the other strains studied. Demonstration of an immune response to anaerobic infection supported the pathogenesis of anaerobes in infectious disease processes and indicated the possible diagnostic role that serological tests may serve in the diagnosis of anaerobic infections in humans.