Transfusion medicine. First of two parts--blood transfusion

[Impact of hemoglobin level on lung cancer survival]

BACKGROUND AND OBJECTIVE

Anemia is commonly observed in lung cancer (LC). Hemoglobin levels at the time of diagnosis could be considered a prognostic indicator in patients with LC. The aim of this trial was to analyze hemoglobin levels at the time of diagnosis as a prognostic factor in patients with LC.

PATIENTS AND METHOD

We retrospectively examined all patients with LC (cytologically or histologically confirmed) diagnosed in our health area for a period of 3 years. Correlation between hemoglobin levels and survival was assessed. All patients were divided into 2 groups: patients with low hemoglobin levels (lower than percentile 25 of the distribution), and patients who exceeded that figure. By means of Cox's regression, the influence of hemoglobin levels in survival was calculated and adjusted to other factors.

RESULTS

421 patients were included, 52.2% of them presented anemia at the time of diagnosis. Mean age was 65.8 years and 92.7% were male. The group of patients with hemoglobin levels lower than percentile 25 had a survival rate that was 41% inferior.

CONCLUSIONS

Low hemoglobin levels are associated with decreased survival in patients with LC. The evaluation of this parameter could be used for a more accurate prognosis in LC and a better adequacy of therapeutic indications.

Reducing blood transfusion requirements in preterm infants by a new device: a pilot study

OBJECTIVE

To test a new device designed to salvage red blood cells (RBCs) from blood samples drawn from preterm infants, with the intent of decreasing blood loss and lowering the requirements for RBC transfusions.

DESIGN

A case-controlled pilot study was conducted in two Israeli neonatal intensive care units in large municipal hospitals. Twenty low-birthweight preterm infants were randomly and equally divided into the ErythroSave group or a control group. All blood tests in the study group (except for complete blood count and coagulation parameters) were obtained during the first week of life by the new device in the study group and by ordinary syringes in the control group. The main outcome measure was the total number of units of blood needed.

RESULTS

The average volume of blood obtained for laboratory analyses from each infant was 27 mL in the ErythroSave group and 24 mL in controls (not significant). The average volume of transfused packed cells was 6.4 mL for the ErythroSave group and 21.3 mL for the controls (p = 0.008).

CONCLUSION

The use of ErythroSave for sampling blood significantly reduced blood transfusion requirements in premature infants compared to sampling by conventional syringes.

Hemoglobin targets and blood transfusions in hemodialysis patients without symptomatic cardiac disease receiving erythropoietin therapy

BACKGROUND AND OBJECTIVES

Optimal hemoglobin targets for chronic kidney disease patients receiving erythropoiesis-stimulating agents remain controversial. The effects of different hemoglobin targets on blood transfusion requirements have not been well characterized, despite their relevance to clinical decision-making.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Five hundred ninety-six incident hemodialysis patients without symptomatic cardiac disease were randomly assigned to hemoglobin targets of 9.5 to 11.5 g/dl or 13.5 to 14.5 g/dl for 96 wk using epoetin alfa as primary therapy and changes in left ventricular structure as the primary outcome (previously reported). Patients were masked to treatment assignment. Blood transfusion data were prospectively collected at 4-wk intervals.

RESULTS

The mean age and prior duration of dialysis therapy of the study population were 50.8 and 0.8 yr, respectively. Previously reported mortality was similar in low and high-target subjects, at 4.7 (95% confidence interval 3.0, 7.3) and 3.1 (1.8, 5.4) per hundred patient years, respectively. Transfusion rates were 0.66 (0.59, 0.74) units of blood per year in low and 0.26 (0.22, 0.32) in high-target subjects (P < 0.0001). Hemoglobin level at transfusion (7.7 [7.5, 7.9]) versus 8.1 [7.6, 8.5] g/dl) were similar with both groups. High hemoglobin target was a significant predictor of time to first transfusion independent of baseline associations (hazard ratio = 0.42; 95% confidence interval = 0.26-0.67).

CONCLUSIONS

In hemodialysis patients with comparatively low mortality risks, normal hemoglobin targets may reduce the need for transfusions.

Incidence and mortality from non-Hodgkin lymphoma in Europe: the end of an epidemic?

Non-Hodgkin lymphomas (NHL) are among the few neoplasms whose incidence and mortality have been rising in Europe and North America over the last few decades. To update trends from NHL, we considered mortality data up to 2004 in several European countries, and for comparative purpose in the USA and Japan. We also analyzed patterns in incidence for selected European countries providing national data. In most European countries, NHL mortality rose up to the mid 1990s, and started to level off or decline in the following decade. The rates were, however, still increasing in eastern Europe. Overall, in the European Union, mortality from NHL declined from 4.3/100,000 to 4.1 in men and from 2.7 to 2.5 in women between the late 1990s and the early 2000s. Similarly, NHL mortality rates declined from 6.5/100,000 to 5.5 in US men and from 4.2 to 3.5 in US women. In most countries considered, NHL incidence rates rose up to 1995-99, while they tended to level off or decline thereafter, with particular favorable patterns in countries from northern Europe. Thus, the epidemic of NHL observed during the second half of the 20th century has now started to level off in Europe as in other developed areas of the world.

Continuing reassessment of the risks of erythropoiesis-stimulating agents in patients with cancer

PURPOSE

Erythropoiesis-stimulating agents (ESA) are approved for the treatment of anemia in patients with nonmyeloid malignancies whose anemia is due to the effect of concomitantly administered chemotherapy. Since the 1993 approval of epoetin alfa in patients with cancer, the risk of thrombovascular events, decreased survival, and poorer tumor control have been increasingly recognized. The risks of ESAs in patients with cancer and the design of trials to assess these risks have been the topic of discussion at two Oncologic Drugs Advisory Committees in 2004 and 2007.

EXPERIMENTAL DESIGN

Evaluation of randomized clinical trials comparing use of ESAs to transfusion support alone in patients with active cancer.

RESULTS

Six studies (Breast Cancer Erythropoeitin Survival Trial, Evaluation of NeoRecormon on outcome in Head And Neck Cancer in Europe, Danish Head and Neck Cancer, Lymphoid Malignancy, CAN-20, and Anemia of Cancer) investigating ESAs in oncology patients showed decreased survival, decreased duration of locoregional tumor control, and/or increased risk of thrombovascular events. In these six studies, ESA dosing was targeted to achieve and maintain hemoglobin values in excess of current recommendations, and in three of the six studies, ESAs were administered to patients not receiving chemotherapy.

CONCLUSIONS

ESAs increase the risk of thrombovascular events and result in decreased survival and poorer tumor control when administered to achieve hemoglobin levels of > or =12 g/dL in patients with nonmyeloid malignancies. No completed or ongoing randomized, controlled trial has addressed safety issues of ESAs in patients with chemotherapy-associated anemia using currently approved dosing regimens in an epidermal tumor type. Additional studies are needed to better characterize these risks.

The contemporary approach to the care of Jehovah's witnesses

BACKGROUND

Jehovah's Witnesses are widely known for their prohibition on the acceptance of blood transfusion. Such refusal serves as a potential obstacle to optimal therapeutic intervention among critically injured Jehovah's Witnesses. As such, care of these patients requires an aggressive and multidisciplinary approach to therapy.

METHODS

A review of the pertinent English language literature.

RESULTS

Jehovah's Witnesses exercise the right of any adult with capacity to refuse medical treatment and often carry advance directive cards indicating their incontrovertible refusal of blood. Despite their belief regarding transfusion, Jehovah's Witnesses do not have a higher mortality rate after traumatic injury or surgery. Transfusion requirements are often overestimated. Increased morbidity and mortality is rarely observed in patients with a hemoglobin concentration >7 g/dL, and the acute hemoglobin threshold for cardiovascular collapse may be as low as 3 g/dL to 5 g/dL. There are many modalities to treat the Jehovah's Witness patient with acute blood loss. Treatment with recombinant human erythropoietin, albumin, and recombinant activated Factor VIIa have all been used with success. Autologous autotransfusion and isovolemic hemodilution can also be used to treat patients who refuse transfusion. Hemoglobin-based oxygen carriers may play a future role as intravascular volume expanders in lieu of transfusion of red blood cell concentrates.

CONCLUSION

There are many treatment modalities available to assist in the care of Jehovah's Witness patients, especially since their beliefs on the intricacies of the Blood Ban appear to be in flux.

HBOC-201 as an alternative to blood transfusion: efficacy and safety evaluation in a multicenter phase III trial in elective orthopedic surgery

BACKGROUND

The ability of hemoglobin based oxygen carrier-201 (HBOC-201) to safely reduce and/or eliminate perioperative transfusion was studied in orthopedic surgery patients.

METHODS

A randomized, single-blind, packed red blood cell (PRBC)-controlled, parallel-group multicenter study was conducted. Six hundred eighty-eight patients were randomized to treatment with HBOC-201 (H, n = 350) or PRBC (R, n = 338) at the first transfusion decision. Primary endpoints were transfusion avoidance and blinded assessment [Mann-Whitney estimator (MW)] of safety noninferiority. Groups were compared directly and by paired/matching group analyses predicated on a prospectively defined dichotomy [treatment success (HH) vs. failure (HR)] in the H arm and an equivalently defined dichotomy [</=3 (R3-) vs. >3 (R3+) units PRBC] in the R arm, based on need (moderate vs. high) for additional oxygen carrying capacity.

RESULTS

A total of 59.4% of patients in the H arm avoided PRBC transfusion. Adverse events (8.47 vs. 5.88), and serious adverse events (SAEs) (0.35 vs. 0.25) per patient were higher in the H versus R arms (p < 0.001 and p < 0.01) with MW = 0.561 (95 CI 0.528-0.594). HH versus R3- had identical (0.14) serious adverse events/patient and a MW = 0.519 (95% confidence limit 0.481-0.558), whereas the incidence was higher (0.63 vs. 0.47) for HR versus R3+ with a MW = 0.605 (95% confidence limit 0.550-0.662). Age (>80 years), volume overload and undertreatment contributed to this imbalance.

CONCLUSION

HBOC-201 eliminated transfusion in the majority of subjects. The between arms (H vs. R) safety analysis was unfavorable and likely related to patient age, volume overload, and undertreatment and was isolated to patients that could not be managed by HBOC-201 alone. However, patients <80 years old with moderate clinical need may safely avoid transfusion when treated with up to 10 units of HBOC-201.

Cell salvage in obstetrics

The safety of cell salvage in obstetrics has been questioned because of the presumed risk of precipitating amniotic fluid embolism and, to a lesser extent, maternal alloimmunisation. For these reasons, experience in this field is limited and has lagged far behind that in other surgical specialties. There has, however, been renewed interest in its use over recent years, mainly as a result of problems associated with allogeneic blood transfusion. Our aim was to review the medical literature to ascertain the principles of cell salvage, the ability of the process to remove contaminants, and its safety profile in the obstetric setting. The search engines PubMed and Google Scholar were used and relevant articles and websites hand searched for further references. Existing cell salvage systems differ in their ability to clear contaminants and all require the addition of a leucocyte depletion filter. Although large prospective trials of cell salvage with autotransfusion in obstetrics are lacking, to date, no single serious complication leading to poor maternal outcome has been directly attributed to its use. Cell salvage in obstetrics has been endorsed by several bodies based on current evidence. Current evidence supports the use of cell salvage in obstetrics, which is likely to become increasingly commonplace, but more data are required concerning its clinical use.

Improving outcomes of percutaneous coronary intervention through the application of guidelines and benchmarking: reduction of major bleeding and blood transfusion as a model

Blood transfusions are a relatively common occurrence after performing any percutaneous coronary intervention (PCI). Although guidelines for blood transfusion have been previously specified, retrospective analysis of transfusion practices have suggested that these guidelines are rarely applied. We describe a model for the application of a continuous quality improvement program including benchmarking and available guidelines for blood transfusion, aimed toward reducing transfusion rates among patients undergoing PCI.

Analysis of blood transfusion predictors in patients undergoing elective oesophagectomy for cancer

BACKGROUND

Oesophagectomy for cancers is a major operation with significant blood loss and usage. Concerns exist about the side effects of blood transfusion, cost and availability of donated blood. We are not aware of any previous study that has evaluated predictive factors for perioperative blood transfusion in patients undergoing elective oesophagectomy for cancer. This study aimed to audit the pattern of blood crossmatch and to evaluate factors predictive of transfusion requirements in oesophagectomy patients.

METHODS

Data was collected from the database of all patients who underwent oesophagectomy for cancer over a 2-year period. Clinico-pathological data collected included patients demographics, clinical factors, tumour histopathological data, preoperative and discharge haemoglobin levels, total blood loss, number of units of blood crossmatched pre-, intra- and postoperatively, number of blood units transfused, crossmatched units reused for another patient and number of blood units wasted.Clinico-pathological variables were evaluated and logistic regression analysis was performed to determine which factors were predictive of blood transfusion.

RESULTS

A total of 145 patients with a male to female ratio of 2.5:1 and median age of 68 (40-85) years were audited. The mean preoperative haemoglobin (Hb) was 13.0 g/dl. 37% of males (Hb < 13.0 g/dl) and 29% of females (Hb < 11.5 g/dl) were anaemic preoperatively. A total of 1241 blood units were crossmatched and 316 units were transfused to 71 patients. Seventy four patients (51%) did not require blood transfusion during their hospital episode. 846 blood units not used for oesophagectomy patients were reused for other patients and 79 units were wasted. The overall crossmatch to transfusion ratio was 4:1 and reuse and wastage rates were 65.2% and 6.3% respectively. The independent predictors of blood transfusion include age >70 years, Hb level <11.0 g/dl, T-stage, presence of postoperative complications and anastomotic leak.

CONCLUSION

The cohort of patients audited was over-crossmatched. The identified independent predictors of blood transfusion should be considered in preoperative blood ordering for oesophagectomy patients. This study has directly led to a reduction in the maximum surgical blood-ordering schedule for oesophagectomy to 2 units and a reaudit is underway.

Career activities of physicians taking the subspecialty board examination in blood banking/transfusion medicine

BACKGROUND

Changes in blood banking and transfusion medicine (BB/TM) in the past 15 years may have made BB/TM a less attractive career choice than previously for physicians.

STUDY DESIGN AND METHODS

To evaluate this, we developed a survey of professional activities and sent it to all physicians who took the BB/TM specialty examination offered by the American Board of Pathology (ABP) between 1995 and 2004.

RESULTS

The examination was taken by 390 physicians (range, 25-68/year). Responses to the survey were received by 151 (39%). The number of candidates did not appear to be declining during the 10 years. All physicians who responded had practiced BB/TM and 94 percent were still doing so. Forty-three percent were engaged in BB/TM full-time and another 10 percent for at least 75 percent of the time. Most of the remaining time was devoted to pathology. Forty-three percent practiced in a university hospital, 22 percent in a community hospital, and 21 percent in a blood center. Examples of practice activities included transfusion service (85%), therapeutic apheresis (63%), stem cell collection (46%), stem cell laboratory (32%), and coagulation laboratory (29%). Sixty-six percent are involved in research.

DISCUSSION

Interest in BB/TM careers is not decreasing as evidenced by the number of physicians taking the ABP specialty examination. Most currently practice BB/TM, many in an academic environment. Their activities are diverse. Many are involved in research and have presented abstracts at professional meetings. Approximately 60 percent combine the practice of BB/TM with pathology, but only a few (6%) practice hematology.

Blood component therapy in obstetrics

Hemorrhage is the leading cause of intensive care unit admission and one of the leading causes of death in the obstetric population. This emphasizes the importance of a working knowledge of the indications for and complications associated with blood product replacement in obstetric practice. This article provides current information regarding preparation for and administration of blood products, discusses alternatives to banked blood in the obstetric population, and introduces pharmacological strategies for treatment of hemorrhage.

Complications related to blood donation: a population-based study

BACKGROUND

Population-based data on the rate and outcome of complications related to blood donation are sparse.

STUDY DESIGN AND METHODS

Data from a survey conducted in 2003 in Aarhus County, Denmark, were used to assess the overall rate of donor complications. Additional nationwide data on moderate and severe donor complications were obtained from the Danish Register of Complications Related to Blood Donation, with records of all moderate and severe donor complications in Denmark occurring during the period 1997-2003.

RESULTS

In the regional survey, we identified 340 complications of any type among 41 274 donations, corresponding to a rate of 824/100,000 donations [95% confidence interval (CI): 741-916]. All complications were either needle injuries or vasovagal reactions. In the nationwide register, a total of 752 moderate and severe complications were recorded among 2,575,264 donations, corresponding to a rate of 29/100,000 donations (95% CI: 27-31). The rates of complications leading to long-term morbidity or disablement (> 5% loss of working capacity) were 5/100,000 donations (95% CI: 4.2-5.9) and 2.3/100,000 donations (95% CI: 1.8-2.9), respectively.

CONCLUSION

The risk of complications related to blood donation is low. However, attention towards donor complications is warranted, given the non-negligible rate of complications resulting in long-term morbidity and disablement.

Short-term benefits and risks of intravenous iron: a systematic review and meta-analysis

BACKGROUND

Intravenous (IV) iron may correct anemia more efficiently than oral iron, but it has been associated with allergic and hemodynamic reactions, and it may increase the risks of infectious complications. The objective of this systematic review and meta-analysis was to clarify these controversial issues.

STUDY DESIGN AND METHODS

Studies evaluating the use of IV iron compared to enteral or no iron with outcomes within 2 months of treatment initiation were identified. Only randomized controlled trials were included. When a meta-analysis was possible, studies were combined with the Review Manager of the Cochrane Collaboration Group 2003. Statistics were calculated as standardized mean differences (SMDs), with a random-effect model.

RESULTS

Thirteen studies met inclusion criteria. Meta-analysis revealed a significant increase in the reticulocyte count (SMD, 0.70; 95% confidence interval [CI], 0.10-1.29; p = 0.02) and in ferritin levels (SMD, 1.18; 95% CI, 0.69-1.68; p = 0.00001), but it also showed that in such a short period of time, IV iron does not correct hemoglobin (Hb)-hematocrit (Hct) better than enteral or no iron. In a sensitivity analysis, however, the increase in Hb-Hct became significant in the nondextran group (SMD, 0.27; 95% CI, 0.04-0.51; p = 0.02). No increase in transferrin saturation was observed. Meta-analysis of the allergic and hemodynamic reactions was not possible as most studies did not clearly describe these outcomes.

CONCLUSION

Our results suggest that treatment with nondextran IV iron may benefit a wide variety of patients. Randomized controlled studies are definitively needed to further evaluate the usefulness and safety of IV iron.

Comparison between spinal surgery blood transfusion services costs and associated treatment practices in the United States and Belgium

OBJECTIVE

This study assessed utilization and cost of allogeneic blood transfusion (ABT) associated with spinal surgery in the United States (US) and Belgium.

METHODS

A retrospective cohort of 292,864 spinal surgery inpatients in US hospitals was pooled with a cohort of 27,952 inpatients who had similar procedures in Belgian hospitals. Utilization and cost data were derived from hospital accounting systems. Costs were converted to US dollars. Descriptive and multivariate statistics were used to describe the factors associated with the use and cost of ABT. Missing data, confounding, and variable measurement error were addressed using standard approaches for observational studies.

RESULTS

US hospitalizations cost $12,044 (SD = 15,920) over 3.6 days compared to $4010 (SD = 3586) over 10.3 days in Belgium. Low molecular weight heparin was used by 78% of Belgian patients and 4% of US patients. Red blood cell utilization occurred in approximately 7% of patients from both countries; however US patients received 6 units compared to 3 units by Belgian patients. US patients spent 3.5 (p < 0.0001) less days in hospital, 1.0 (p < 0.0001) more days in an intensive care unit, used 64% more allogeneic blood (OR = 1.64, 95% CI 1.53-1.75), and incurred $13,647 (p < 0.0001) more per hospitalization than Belgian patients.

CONCLUSIONS

US patients used more blood products, had shorter hospital stays, and incurred greater costs than Belgian patients. Specialists as attending physicians were associated with lower utilization of ABT; this may be an administrative change that hospitals can implement to reduce utilization and costs.

Anemia and transfusions in patients undergoing surgery for cancer

Preoperative, operative, and postoperative factors may all contribute to high rates of anemia in patients undergoing surgery for cancer. Allogeneic blood transfusion is associated with both infectious risks and noninfectious risks such as human errors, hemolytic reactions, transfusion-related acute lung injury, transfusion-associated graft-versus-host disease, and transfusion-related immune modulation. Blood transfusion may also be associated with increased risk of cancer recurrence. Blood-conservation measures such as preoperative autologous donation, acute normovolemic hemodilution, perioperative blood salvage, recombinant human erythropoietin (epoetin alfa), electrosurgical dissection, and minimally invasive surgical procedures may reduce the need for allogeneic blood transfusion in elective surgery. This review summarizes published evidence of the consequences of anemia and blood transfusion, the effects of blood storage, the infectious and noninfectious risks of blood transfusion, and the role of blood-conservation strategies for cancer patients who undergo surgery. The optimal blood-management strategy remains to be defined by additional clinical studies. Until that evidence becomes available, the clinical utility of blood conservation should be assessed for each patient individually as a component of preoperative planning in surgical oncology.

Transfusion strategy for primary knee and hip arthroplasty: impact of an algorithm to lower transfusion rates and hospital costs

BACKGROUND

Blood transfusion strategies should reduce both blood transfusion and costs. Possible solutions include autologous donation for selected patients and the prescription of erythropoietin (EPO).

METHODS

We conducted a quality improvement program to examine the effect of a transfusion strategy algorithm in primary knee (TKA) and hip arthroplasty (THA). Our algorithm is presented as a diagram and is based on tolerated and expected blood losses. Patient characteristics, blood loss, transfusions given, autologous blood wastage, and costs were examined during an initial evaluation and after implementation of the algorithm.

RESULTS

Analysis of 302 (initial evaluation) and 173 (post-implementation) arthroplasties demonstrated a 55% reduction in the prescription of autologous blood donation. The proportion of EPO prescriptions increased from 6.6% to 17.3% (P<0.05). There was a 56% overall reduction in transfusions to fewer autologous (32% vs 12%, P<0.0001) and allogeneic transfusions (21% vs 13%, NS). There were 50% fewer wasted autologous blood units (P=0.002) and a 50% reduction in hospital costs (euro345 vs 169) with no significant change in overall costs (euro439 vs 407). Anaesthetists applied the algorithm in 97% of patients, and it is still in use 1 yr after evaluation.

CONCLUSIONS

In this study, the implementation of an algorithm for transfusion strategy changed practice and improved quality of care. The costs for EPO, its administration, and monitoring outside hospital were offset by the reduction in hospital transfusion costs.

Evaluation of bacterial inactivation in prestorage pooled, leukoreduced, whole blood?derived platelet concentrates suspended in plasma prepared with photochemical treatment

BACKGROUND

Photochemical treatment (PCT) with amotosalen and ultraviolet light was developed to inactivate pathogens in platelet (PLT) components suspended in 35 percent plasma and 65 percent additive solution (AS). Because PLT additive solutions (ASs) are not used in the United States, this study evaluated the ability of the PCT process to inactivate low levels of bacteria in pooled whole blood-derived PLTs (RDP) suspended in 100 percent plasma.

STUDY DESIGN AND METHODS

Four replicate experiments were performed with two Gram-positive organisms, Staphylococcus epidermidis and Staphylococcus aureus, and two Gram-negative organisms, Klebsiella pneumoniae and Escherichia coli. For each experiment, 6 ABO-identical RDP units were pooled, leukoreduced before or after pooling, inoculated to approximately 1 to 10 colony-forming units per mL with plasma-resistant bacteria, and treated with the PCT process. Residual viable bacterial levels were measured before and after each step and 4 and 6 days after inoculation. For each bacterium studied, a fifth RDP pool was prepared and contaminated, but not treated. These units served as controls for bacterial growth.

RESULTS

Growth of S. epidermidis, S. aureus, and K. pneumoniae was eliminated in all four treated pools while growth continued in the control pools. There was no growth of E. coli in the treated pools and the control pool.

CONCLUSION

These pilot experiments demonstrate inactivation of bacteria in PLTs suspended in plasma, suggesting that the PCT process may address contamination in conventional RDPs. Additional experiments with a wider range of bacteria and evaluation of PLT function in 100 percent plasma will be needed before implementation.

Blood transfusion and in-hospital outcomes in anemic patients with myocardial infarction undergoing percutaneous coronary intervention

Studies have shown poor prognostic implications of anemia in patients with myocardial infarction (MI) and in patients undergoing percutaneous coronary intervention (PCI). The impact of blood transfusion in these populations remains controversial. The objective of this study was to examine the effect of transfusion on in-hospital mortality in anemic patients undergoing PCI for MI. Data from 67,051 PCIs (June 1, 1997 to January 31, 2004) were prospectively collected in a multicenter registry (Blue Cross Blue Shield of Michigan Cardiovascular Consortium). Of these, 4,623 patients who were classified as anemic according to the World Health Organization criteria underwent PCI within 7 days of presentation with acute MI. A propensity score for being transfused was estimated for each patient, and propensity matching and a prediction model for in-hospital death were developed. The average age was 67.8 years, 57.7% of patients were men, and 22.3% of patients received a transfusion during hospitalization. Transfused patients, compared to nontransfused patients, were more likely to be older, female, have lower preprocedure hemoglobin levels, more comorbidities, and a higher unadjusted in-hospital mortality rate (14.52% vs. 3.01%, p < 0.0001). After adjustment for comorbidities and propensity for transfusion, blood transfusion was associated with a higher risk of in-hospital mortality (adjusted odds ratio = 2.02, 95% confidence interval 1.47-2.79, p < 0.0001). In anemic patients undergoing PCI for MI, transfusion was associated with an increased crude and adjusted rate of in-hospital mortality. A randomized controlled trial is needed to determine the value of transfusion and the ideal transfusion criteria.

Umbilical cord blood transfusions for prevention of progressive brain injury and induction of neural recovery: an immunological perspective

One of the most promising treatments for neurodegenerative diseases appears to be human umbilical cord blood cell transplantation. A variety of studies demonstrate some benefit of this method of treatment in a number of different animal models and case studies. However, before the methodologies and results of these animal studies and case studies can be translated into successful widespread treatments, aspects relating to the immunological properties of the transplanted cells must be considered. In this perspective, we discuss the benefit of the cellular immaturity of these cells with respect to the immune response, and compare cord blood transplantation to blood transfusions, as well as discussing what future studies should entail.

The background and methodology of the Anaemia Cancer Treatment (A.C.T.) study: a global retrospective study of practice patterns and outcomes in the management of anaemia in cancer patients and their congruence with evidence-based guidelines

GOAL

The benefit of supportive care with erythropoiesis-stimulating agents (ESAs) for patients with cancer-related anaemia is well known. However, the European Cancer Anaemia Survey (ECAS, data from 2001) showed that about 60% of cancer patients with anaemia do not receive any treatment. Since ECAS, evidence-based guidelines have provided recommendations for ESA use, but it is not known to what extent current treatment patterns follow these guidelines. To address this issue, the Anaemia Cancer Treatment (A.C.T.) study was initiated. The background to the development of the A.C.T. study and study methodology are described.

MATERIALS AND METHODS

The A.C.T. study is a global, retrospective, pharmacoepidemiologic study of at least 2,560 medical records of anaemic patients with cancer who were previously treated with an ESA from a minimum of 186 centres. Records from patients aged greater than or equal to 18 years with a diagnosis of solid tumour or myeloma or lymphoma and who were started on ESAs 3-12 months before inclusion and followed for 8-10 weeks will be eligible. Factors associated with ESA non-responsiveness will also be evaluated.

MAIN RESULTS

Completion of the European phase of the study is anticipated in late 2007 with the rest of the world closing in late 2007 or early 2008. Publication of findings is anticipated in 2008.

CONCLUSIONS

By examining the extent to which anaemia management in clinical practice is congruent with best practice guidelines, the A.C.T. study will provide a further foundation for the development of evidence-based supportive cancer care.

Estimating the cost of blood: past, present, and future directions

Understanding the costs associated with blood products requires sophisticated knowledge about transfusion medicine and is attracting the attention of clinical and administrative healthcare sectors worldwide. To improve outcomes, blood usage must be optimized and expenditures controlled so that resources may be channeled toward other diagnostic, therapeutic, and technological initiatives. Estimating blood costs, however, is a complex undertaking, surpassing simple supply versus demand economics. Shrinking donor availability and application of a precautionary principle to minimize transfusion risks are factors that continue to drive the cost of blood products upward. Recognizing that historical accounting attempts to determine blood costs have varied in scope, perspective, and methodology, new approaches have been initiated to identify all potential cost elements related to blood and blood product administration. Activities are also under way to tie these elements together in a comprehensive and practical model that will be applicable to all single-donor blood products without regard to practice type (e.g., academic, private, multi- or single-center clinic). These initiatives, their rationale, importance, and future directions are described.

Update on Transfusion Medicine

Clinical pharmacists often participate on critical care teams that manage patients with bleeding emergencies. Although blood products are usually dispensed from the blood bank and not the pharmacy, pharmacists should be conversant in the language and trends of transfusion medicine, much like they are with other therapeutic agents. Toward that goal, this review provides a concise transfusion medicine tutorial, covering all commonly used blood products, including red blood cells, platelets, fresh frozen plasma, and plasma derivatives such as cryoprecipitate, prothrombin complex concentrates, and albumin. Usage patterns, the rationale for administering the various blood products, and studies that have attempted to determine appropriate criteria for ordering transfusions (transfusion triggers) are discussed. The benefits, risks, and several ongoing controversies that relate to the appropriateness and safety of blood product use are also summarized.

NovaSil clay intervention in Ghanaians at high risk for aflatoxicosis. I. Study design and clinical outcomes

A 3-month double-blind and placebo-controlled, phase IIa clinical trial was conducted in Ghana to investigate the safety, tolerance and aflatoxin-sorption efficacy of dietary NovaSil (NS). Volunteers (507 subjects) were clinically screened to evaluate their general health, pregnancy status and blood AFB(1)-albumin adduct levels. Of these subjects, 177 were randomly assigned to three groups: high-dose (HD), low-dose (LD) and placebo-control (PL) groups receiving 3.0, 1.5 and 0 g NS day(-1) in capsules. Trained study-monitors supervised NS capsule administration to participants and recorded side-effects daily. Physical examinations were performed monthly. Blood and urine samples were collected for laboratory analysis. Approximately 92% of the participants (162 of 177) completed the study and compliance rate was over 97%. Overall, 99.5% of person x time reported no side-effects throughout the study. Mild to moderate health events ( approximately 0.5% of person x time) were recorded in some participants. Symptoms included nausea, diarrhea, heartburn and dizziness. These side-effects were statistically similar among all three groups. No significant differences were shown in hematology, liver and kidney function or electrolytes in the three groups. These findings demonstrate that NS clay is apparently safe and practical for the protection of humans against aflatoxins in populations at high risk for aflatoxicosis.

Treatment of acquired haemophilia with recombinant activated FVII: a critical appraisal

Acquired haemophilia is a rare bleeding disorder usually caused by the spontaneous formation of inhibitory antibodies to coagulation FVIII. The disease occurs most commonly in the elderly, and although acquired haemophilia may be associated with a variety of underlying conditions, up to 50% of reported cases are idiopathic. Treatment options have traditionally involved human FVIII or FIX replacement therapy (if the inhibitor titre allows), porcine FVIII or the use of activated pro-thrombin complex concentrates. Recombinant activated coagulation FVII (rFVIIa) was available on an emergency and compassionate use basis from 1988 to 1999 at sites in Europe and North America. It has been registered in Europe for use in treating acquired haemophilia since 1996 and has recently been licensed for this indication in the United States. By directly activating FX on the surface of activated platelets at the site of injury (thereby bypassing FVIII and FIX), rFVIIa can circumvent the actions of inhibitory antibodies present in acquired haemophilia patients. This paper provides an overview of experiences with rFVIIa for the treatment of acquired haemophilia from the NovoSeven compassionate and emergency use programmes (1989-1999), the Hemophilia and Thrombosis Research Society Registry, and independent published reports from January 1999 to September 2005. rFVIIa has been reported to provide safe and effective haemostasis as a first line therapy in patients of all ages for a variety of surgical and non-surgical bleeding situations.

Hemolytic Transfusion Reaction After Preoperative Prophylactic Blood Transfusion for Sickle Cell Disease in Pregnancy

BACKGROUND

Preoperative transfusions are frequently given to prevent morbidity in nonpregnant patients with sickle cell disease. We describe a case of a life-threatening delayed hemolytic transfusion reaction with hyperhemolysis syndrome in pregnancy.

CASE

A multigravida with sickle cell disease underwent prophylactic blood transfusion before repeat cesarean delivery. Her immediate postpartum course was uneventful, but on postoperative day number 6 she presented in grave condition with what was thought initially to be an infection versus crisis. Delayed hemolytic transfusion reaction with hyperhemolysis was ultimately diagnosed.

CONCLUSION

In the gravida with sickle cell disease and known multiple red cell antibodies, blood transfusion may incur a higher risk for delayed transfusion reaction, hyperhemolysis syndrome, and possible death. Blood transfusion should be used cautiously in these patients.

Blood tranfusion in critically ill patients: state of the art

Anemia is one of the most common abnormal findings in critically ill patients, and many of these patients will receive a blood transfusion during their intensive care unit stay. However, the determinants of exactly which patients do receive transfusions remains to be defined and have been the subject of considerable debate in recent years. Concerns and doubts have emerged regarding the benefits and safety of blood transfusion, in part due to the lack of evidence of better outcomes resulting from randomized studies and in part related to the observations that transfusion may increase the risk of infection. As a result of these concerns and of several studies suggesting better or similar outcomes with a lower transfusion trigger, there has been a general tendency to decrease the transfusion threshold from the classic 10 g/dL to lower values. In this review, we focus on some of the key studies providing insight into current transfusion practices and fueling the current debate on the ideal transfusion trigger.

Pathogen inactivation: the definitive safeguard for the blood supply

CONTEXT

Pathogen inactivation provides a proactive approach to cleansing the blood supply. In the plasma fractionation and manufacturing industry, pathogen inactivation technologies have been successfully implemented resulting in no transmission of human immunodeficiency, hepatitis C, or hepatitis B viruses by US-licensed plasma derivatives since 1985. However, these technologies cannot be used to pathogen inactivate cellular blood components. Although current blood donor screening and disease testing has drastically reduced the incidence of transfusion-transmitted diseases, there still looms the threat to the blood supply of a new or reemerging pathogen. Of particular concern is the silent emergence of a new agent with a prolonged latent period in which asymptomatic infected carriers would donate and spread infection.

OBJECTIVE

To review and summarize the principles, challenges, achievements, prospective technologies, and future goals of pathogen inactivation of the blood supply.

DATA SOURCES

The current published English-language literature from 1968 through 2006 and a historical landmark article from 1943 are integrated into a review of this subject.

CONCLUSIONS

The ultimate goal of pathogen inactivation is to maximally reduce the transmission of potential pathogens without significantly compromising the therapeutic efficacy of the cellular and protein constituents of blood. This must be accomplished without introducing toxicities into the blood supply and without causing neoantigen formation and subsequent antibody production. Several promising pathogen inactivation technologies are being developed and clinically tested, and others are currently in use. Pathogen inactivation offers additional layers of protection from infectious agents that threaten the blood supply and has the potential to impact the safety of blood transfusions worldwide.

Intraoperative cell salvage during radical cystectomy does not affect long-term survival

OBJECTIVES

To evaluate the risk of long-term recurrence for patients who received cell-salvaged blood during radical cystectomy (RC).

METHODS

We retrospectively analyzed an RC database and compared those who did and did not receive cell-salvaged blood according to baseline parameters, pathologic outcomes, and recurrence.

RESULTS

A total of 378 patients underwent RC between 1992 and 2005 by one surgeon. Of these, 65 (17.2%) received cell-salvaged blood and 313 (82.8%) did not. The two groups had similar baseline characteristics. There were no differences between the two groups when compared by pathologic stage. The median follow-up for patients who did and did not receive cell-salvaged blood was 19.1 and 20.7 months, respectively (P = 0.464). The 3-year disease-specific survival rate for the two groups was 72.2% and 73.0%, respectively (P = 0.90).

CONCLUSIONS

Intraoperative cell salvage is a safe blood management strategy for patients undergoing RC. There is no increased risk of metastatic disease or death for those who receive cell-salvaged blood. Concerns about spreading tumors cells by IOCS during RC would seem unwarranted. However, only a prospective, multicenter, randomized trial would provide the most valid assessment of the safety of IOCS.

Anemia and heart failure: a cause of progression or only a consequence?

Anemia is one of the most frequent co-morbidities in the patients with heart failure. Its prevalence increases from 4-7% in the subjects with asymptomatic left ventricular dysfunction to >30% in the patients with severe heart failure. Renal insufficiency, activation of inflammatory mediators, and treatment with renin-angiotensin antagonists seem to be its main determinants. The results of many studies agree in showing that anemia is a powerful independent determinant of survival in patients with heart failure. However, the mechanisms of this relation are still incompletely understood. Moreover a favourable effect on prognosis of the correction of anemia has not been shown, yet, and also controlled studies assessing its effects on exercise tolerance have yielded controversial results.

Anemia in critical care patients: incidence, etiology, impact, management, and use of treatment guidelines and protocols

PURPOSE

The incidence, etiology, impact, and management of anemia in critical care patients and the development of treatment guidelines and protocols for the management of anemia in this patient population are discussed.

SUMMARY

Most patients in intensive care units develop anemia as a result of blood losses, nutritional deficiencies, hemolysis, myelosuppression, renal insufficiency, inflammation, infection, or another disease process. Anemia can have an adverse impact on critically ill patients with severe ischemic heart disease or cerebrovascular disease and patients undergoing surgery. The use of blood conservation measures and restrictive blood transfusion strategies can circumvent problems associated with transfusion. Epoetin alfa increases hemoglobin concentrations and reduces the need for transfusion in critical care patients, including surgical patients with large anticipated blood losses. Epoetin alfa also appears to be effective for managing anemia in patients with multiple organ dysfunction syndrome. Iron supplementation is needed by most patients receiving erythropoietic therapy. Iron supplementation without erythropoietic therapy is inadequate to correct anemia unrelated to iron deficiency. Concerns have been raised about a possible increased risk for infection when parenteral iron therapy is used in critical care patients. Developing treatment guidelines or protocols for managing anemia in critical care patients can minimize the need for transfusions and improve prescribing of erythropoietic therapy.

CONCLUSION

Epoetin alfa can play an important role in managing anemia in critical care patients, thereby minimizing patient exposure to transfusion-related risks and optimizing the use of the limited blood supply. There is currently no data available for use of darbepoetin in this manner.

Legal, financial, and public health consequences of transfusion-transmitted hepatitis C virus in persons with haemophilia

BACKGROUND

Since the first cases of acquired immunodeficiency syndrome in persons with haemophilia were reported in 1982, much has been written about the consequences of human immunodeficiency virus (HIV) contamination of the blood supply. Relatively little attention has been paid to similar hepatitis C virus (HCV) concerns since the first cases of HCV-infected persons with haemophilia were identified in 1989.

METHODS

We review the history, public health, policy, and financial consequences of blood supply policy decisions made for persons with haemophilia who received HCV-contaminated blood products in eight countries that were severely impacted by viral contamination of the blood supply during the 1980s, contrasting these findings with those reported previously for HIV contamination of the blood supply during the same time-period. A Medline search and a hand search of retrieved bibliographies of English-language articles on HCV concerns in haemophilia patients published from 1989 to 2006 were performed.

RESULTS

Our review identified that two- to eightfold more persons with haemophilia in the eight countries contracted HCV vs. HIV from contaminated blood products during the 1980s. Opportunistic infections and immunosuppression-related complications among persons with haemophilia developed shortly after these patients received HIV-infected blood products whereas hepatic complications among HCV-infected persons with haemophilia are just now being diagnosed two decades after these individuals received HCV-contaminated blood products. Policy makers in four countries conducted official public inquiries into blood safety decisions related to HIV- and/or HCV-contamination of the blood supply. More than 20 countries allocated compensation funds for HIV-infected persons with haemophilia (mean award ranging from $37 000 to 400 000) whereas only the UK, Canada, and Ireland allocated compensation funds for HCV-infected persons with haemophilia (mean award ranging from $37 000 to 50 000).

CONCLUSION

While the clinical impact among persons with haemophilia of HCV contamination of the blood supply in the 1980s was larger than the impact of HIV contamination of the blood supply during this time-period, the policy response was smaller. Consideration should be given to adopting support programmes for HCV-infected persons with haemophilia in countries that do not have these programs.

Evaluating the impact of public health notification of suspected transfusion-transmissible hepatitis C virus infection and effectiveness of lookback and traceback investigations by Canadian Blood Services in British Columbia, Canada, August 2002 through F

BACKGROUND

Suspected transfusion-transmissible infections (TTIs) have been reported to public health (PH) in British Columbia (BC) since August 2002. The impact of PH notification of suspected transfusion-transmissible hepatitis C virus (TT-HCV) infection over the first 2.5 years and the effectiveness of HCV lookback (LB) and traceback (TB) investigations conducted by Canadian Blood Services (CBS) in BC were evaluated.

STUDY DESIGN AND METHODS

Suspected TT-HCV cases reported to CBS in BC between August 28, 2002, and February 28, 2005, were analyzed. The incremental yield of plausible TTIs from PH-reported suspected TTIs was calculated. The effectiveness of LB and TB investigations was assessed with respect to the impact of improved anti-HCV donor screening, the number of newly recognized HCV infections, and the timeliness of initiating investigations.

RESULTS

Nine of 553 (1.6%) investigations were initiated after PH reporting, yielding an additional 2 of 237 (i.e., 0.8%) plausible TTIs. Ninety-two percent of investigations with transfused units involved transfusions before implementing second-generation anti-HCV enzyme immunoassay (EIA) donor screening. Almost one-third of HCV-infected persons in linked investigations (i.e., LB triggered by a TB and vice versa) were newly identified. Recently tested, PH-reported cases incurred a mean delay exceeding 6 months until initiating a LB or TB investigation.

CONCLUSION

PH reporting of TTIs and investigating transfusions after second-generation anti-HCV EIA donor screening identified few plausible TT-HCV infections. Many HCV-infected recipients or lapsed donors first became aware of their infection status as a result of CBS investigations. The current process of reporting suspected TTIs incurs significant time delay.

Effect of blood transfusion on outcome after pancreaticoduodenectomy for exocrine tumour of the pancreas

BACKGROUND

Blood transfusion is thought to have an immunosuppressive effect. The aims of this study were to examine survival in patients with pancreatic cancer receiving blood transfusion in association with pancreaticoduodenectomy, and to define preoperative risk factors for subsequent transfusion.

METHODS

A retrospective review was performed of a prospective database of patients with exocrine tumours of the head of the pancreas who had undergone pancreaticoduodenectomy between 1998 and 2003. Clinical data, transfusion records and preoperative laboratory values were recorded.

RESULTS

A total of 294 patients underwent pancreaticoduodenectomy for exocrine tumours in the pancreatic head. Of these, 140 (47.6 per cent) received a blood transfusion. Their median survival was 18 months, compared with 24 months for those who did not have a transfusion (P = 0.036). Postoperative transfusion, margin status and node stage were independent predictors of survival. Age and preoperative total bilirubin and haemoglobin levels were the only preoperative factors that correlated with transfusion.

CONCLUSION

In patients with exocrine tumours of the pancreas, blood transfusion should be avoided when possible. Preoperative risk factors can identify patients who are likely to require transfusion and would therefore benefit most from blood conservation methods.

Preoperative use of recombinant human erythropoietin in pediatric orthopedics: a decision model for long-term outcomes

BACKGROUND CONTEXT

Spine surgery for scoliosis is associated with significant blood loss and may require blood transfusion. The risks inherent in blood transfusion have inspired interventions, including human recombinant erythropoietin (rHuEPO), which has emerged as a safe and effective adjunct in minimizing exposure to allogenic blood in children undergoing scoliosis surgery. However, there is little information in the literature on their economic impact on the health-care system.

PURPOSE

The purpose of this study was to evaluate the cost-effectiveness of rHuEPO in adolescent idiopathic scoliosis.

STUDY DESIGN/SETTING

We designed a decision analytic model capturing costs and potential long-term outcomes of transfusion-related complications to compare the cost-effectiveness of preoperative rHuEPO with a control group and a common alternative, preoperative autologous donation (PAD).

PATIENT SAMPLE

This is a decision analytic model. Decision modeling relies on a summation of the probability of different clinical studies; no patients were specifically studied.

OUTCOME MEASURES

The standard cost-effectiveness ratio (C/E) of $50,000 per quality-adjusted life year (QALY) was used as the threshold value for determining the cost-effectiveness of these two preoperative intervention strategies.

METHODS

From the model we calculated the probability that a patient would experience transfusion-related complications based on the mean number of allogenic units transferred as a result of scoliosis surgery. The standard C/E of $50,000 per QALY was used as the threshold value for determining the cost-effectiveness. Some aspects of the model were derived from retrospective data from the literature. Sensitivity analyses were also conducted to discover which variables, when changed within the accepted range, caused the final result of the model to change significantly.

RESULTS

Results indicated a cost per year-of-life-saved exceeding $1 million for the PAD arm and over $1.5 million for the rHuEPO arm. The low rates of transfusion in adolescent idiopathic scoliosis surgery and the relative safety of the blood supply create a scenario where even inexpensive interventions are not cost-effective. However, rHuEPO would become cost-effective if decreased transfusion rates or higher postoperative hematocrit resulted in decreased length of stay.

CONCLUSION

The use of rHuEPO preoperatively and the use of PAD are not cost-effective although both techniques remain clinically effective tools.

Assessment of education and computerized decision support interventions for improving transfusion practice

BACKGROUND

Overuse of blood products is common, but prior efforts to improve transfusion decisions have met with limited success.

STUDY DESIGN AND METHODS

This study examines transfusion practices before and after a conventional educational intervention followed by a randomized controlled trial of a decision support (DS) intervention with computerized physician order entry (CPOE) for red blood cell, platelet, and fresh-frozen plasma orders. The study was conducted in an academic medical center between April 2003 and June 2004. Orders originating from units not using CPOE with DS (e.g., the emergency department) were excluded. Junior housestaff were randomly assigned into a control group and an intervention group who received DS for transfusion orders. Transfusion orders were initially classified according to guideline rules as DS-agree or DS-disagree. Chart reviews assessed inappropriateness for all DS-disagree orders and a sample of DS-agree orders. The total of inappropriate transfusion orders included chart review confirmed DS-disagree orders and DS-agree orders reclassified as inappropriate.

RESULTS

The percentages of inappropriate nonemergent transfusion orders during the baseline phase for the entire staff and randomly assigned junior housestaff were 72.6 percent (2154/2967) and 71.9 percent (1259/1752) and improved after conventional education to 63.8 percent (1699/2663; p < 0.0001) and 63.3 percent (1263/1996; p < 0.0001), respectively. The percentage of inappropriate orders in the DS intervention group continued to improve (59.6%, 804/1350; p < 0.0001). Physicians accepted 14 percent (133/939) of new DS-recommended orders, especially recommendations to increase transfusion doses (73%).

CONCLUSIONS

Education and computerized DS both decreased the percentage of inappropriate transfusions, although the residual amount of inappropriate transfusions remained high.

Transfusion risks and transfusion-related pro-inflammatory responses

Despite improvements in blood screening and administration techniques, serious adverse events related to transfusion continue to occur, albeit at a much lower incidence. In addition to the development and implementation of new screening and blood purification/modification techniques and implementation of an optimal blood management program, the incidence and consequences of transfusion reactions can be reduced by a basic understanding of transfusion-related complications. Although acute hemolytic transfusion reactions, transfusion-associated anaphylaxis and sepsis, and transfusion-associated acute lung injury occur infrequently, diligence in administration of blood and monitoring for development of respective signs/symptoms can minimize the severity of these potentially life-threatening complications. In addition, emerging blood-banking techniques such as psoralen-UV inactivation of pathogens and use of patient identification systems may attenuate the incidence of adverse events related to transfusion. With respect to optimizing blood management by means of an effective blood management program involving pharmacologic and nonpharmacologic strategies, the ability to reduce use of blood products and to decrease operative time or re-exploration rates has important implications for disease prevention, blood inventory and costs, and overall health care costs.