Recommendations for the transfusion of red blood cells

A 42-year-old woman with abnormal uterine bleeding-leiomyoma (AUB-L) reporting a hemoglobin of 1.6 g/dL: a case report

BACKGROUND

Abnormal uterine bleeding, formerly known as menometrorrhagia, is estimated to occur in up to one-third of women, commonly at menarche or perimenopause. Among many other causes, abnormal uterine bleeding is known to be caused by leiomyomas, and is itself a leading cause of severe iron deficiency and iron deficiency anemia in women. Rarely, abnormal uterine bleeding can lead to critically low hemoglobin values of less than 2 g/dL. We report here a case of a woman with abnormal uterine bleeding caused by leiomyomas presenting with severely low hemoglobin.

CASE PRESENTATION

We report the case of a 42-year-old Asian American woman who presented to the emergency department with chronic abnormal uterine bleeding and symptoms of anemia, including multiple syncopal episodes and abnormally pale skin but otherwise alert and oriented. Laboratory tests found a record-low hemoglobin of 1.6 g/dL and hematocrit of 6%. Transabdominal pelvic ultrasound revealed a lower uterine segment/cervical fibroid measuring 7.5 × 5 × 7.8 cm (length × depth × width). Patient was diagnosed with abnormal uterine bleeding-leiomyoma and received five units of packed red blood cells, one unit of fresh frozen plasma, Venofer infusions, tranexamic acid, and medroxyprogesterone. She was discharged from the hospital after 4 days.

CONCLUSION

To date, only a handful of cases have been reported of female patient survival following severely low hemoglobin caused by abnormal uterine bleeding. This case adds to this literature, highlighting the remarkable degree of compensation that can lead to an alert, ambulatory, and oriented patient with abnormal uterine bleeding caused by leiomyoma.

Prediction of post-delivery hemoglobin levels with machine learning algorithms

Predicting postpartum hemorrhage (PPH) before delivery is crucial for enhancing patient outcomes, enabling timely transfer and implementation of prophylactic therapies. We attempted to utilize machine learning (ML) using basic pre-labor clinical data and laboratory measurements to predict postpartum Hemoglobin (Hb) in non-complicated singleton pregnancies. The local databases of two academic care centers on patient delivery were incorporated into the current study. Patients with preexisting coagulopathy, traumatic cases, and allogenic blood transfusion were excluded from all analyses. The association of pre-delivery variables with 24-h post-delivery hemoglobin level was evaluated using feature selection with Elastic Net regression and Random Forest algorithms. A suite of ML algorithms was employed to predict post-delivery Hb levels. Out of 2051 pregnant women, 1974 were included in the final analysis. After data pre-processing and redundant variable removal, the top predictors selected via feature selection for predicting post-delivery Hb were parity (B: 0.09 [0.05-0.12]), gestational age, pre-delivery hemoglobin (B:0.83 [0.80-0.85]) and fibrinogen levels (B:0.01 [0.01-0.01]), and pre-labor platelet count (B*1000: 0.77 [0.30-1.23]). Among the trained algorithms, artificial neural network provided the most accurate model (Root mean squared error: 0.62), which was subsequently deployed as a web-based calculator: https://predictivecalculators.shinyapps.io/ANN-HB . The current study shows that ML models could be utilized as accurate predictors of indirect measures of PPH and can be readily incorporated into healthcare systems. Further studies with heterogenous population-based samples may further improve the generalizability of these models.

Abnormalities in C-type lectin-like receptor 2 in a patient with Gorham-Stout disease: the first case report

Background

Gorham-Stout disease (GSD) is a form of lymphangiomatosis of unknown etiology, characterized by abnormal distribution of lymphatic vessels. Platelets and lymphangiogenesis are closely related via C-type lectin-like receptor 2 (CLEC-2)/podoplanin.

Key Clinical Question

Despite similarities between abnormal lymphatic vessels in CLEC-2-deficient mice and patients with GSD, whether CLEC-2 on platelets is involved in GSD pathogenesis is unknown.

Clinical Approach

We examined CLEC-2 expression in platelets of a patient with lethal GSD. Most of the patient's platelets expressed aberrant CLEC-2 that was not detectable by certain monoclonal antibodies for human CLEC-2. Further, this population was not activated by a CLEC-2-activating snake venom, rhodocytin. Possible causes of abnormal CLEC-2 including anti-CLEC-2 autoantibodies, podoplanin binding to CLEC-2, and pathogenic CLEC1B gene alteration were excluded.

Conclusions

We believe that this is the first report of a patient with structurally and functionally abnormal CLEC-2. CLEC-2 abnormality may be associated with dysregulated lymphangiogenesis in GSD.

Effect of recombinant human erythropoietin combined with iron sucrose on postoperative hemoglobin in patients undergoing artificial joint replacement

With the aging of the population, an increasing number of elderly patients are opting for artificial joint replacement, leading to the exploration of various rapid rehabilitation programs in the perioperative period. In this study, we aimed to investigate the effectiveness of combining recombinant human erythropoietin and iron sucrose in altering the range and trend of postoperative hemoglobin in patients undergoing arthroplasty. Specifically, we will examine whether this combination can effectively alter the rise and fall of postoperative haemoglobin, identify the inflection point of haemoglobin change or recovery after arthroplasty, and assess the effect of treatment on serum iron in postoperative blood. We conducted a retrospective study of 138 patients who underwent unilateral total joint arthroplasty by the same surgeon in the same hospital before July 2022. The results of this study may provide valuable insights for the development of effective rehabilitation programs for patients undergoing arthroplasty.

Efficacy of immediate postoperative intravenous iron supplementation after staged bilateral total knee arthroplasty

BACKGROUND

Approximately 26% of patients undergoing major orthopedic elective procedures have preoperative anemia. This study aimed to investigate the effect of intravenous (IV) iron supplementation on the hemoglobin (Hb) level after staged bilateral total knee arthroplasty (TKA) in patients with or without preoperative anemia.

METHODS

We retrospectively analyzed 418 patients who underwent staged bilateral TKA (1 week interval). The iron group (n = 220) received IV iron isomaltoside immediately after each TKA. The no-iron group (n = 198) was recommended to receive transfusion if postoperative anemia was diagnosed between the first and second TKA. Preoperative anemia was present in 42 (21.2%) and 50 (22.7%) patients in the no-iron and iron groups, respectively. Demographic data, preoperative and postoperative Hb levels, Hb level change (preoperative minus postoperative 6-week Hb level), and blood drainage amount were compared between groups.

RESULTS

The transfusion rate was lower in the iron group than in the no-iron group (96.5% vs. 58.6%, P < 0.001). Overall, the demographic data, preoperative and postoperative 6-week Hb levels, Hb level change, and blood drainage amount were not significantly different between the two groups. Among patients with preoperative anemia, the iron group showed lower Hb level change (0.6 ± 0.9 vs. 0.1 ± 1.1, P = 0.016).

CONCLUSION

Patients with preoperative anemia treated with IV iron showed lower Hb level change than did those without IV iron treatment. Despite the lower transfusion rate, the iron group showed similar postoperative 6-week Hb level and Hb level change to the no-iron group.

Strategies to capitalize on cell spheroid therapeutic potential for tissue repair and disease modeling

Cell therapies offer a tailorable, personalized treatment for use in tissue engineering to address defects arising from trauma, inefficient wound repair, or congenital malformation. However, most cell therapies have achieved limited success to date. Typically injected in solution as monodispersed cells, transplanted cells exhibit rapid cell death or insufficient retention at the site, thereby limiting their intended effects to only a few days. Spheroids, which are dense, three-dimensional (3D) aggregates of cells, enhance the beneficial effects of cell therapies by increasing and prolonging cell-cell and cell-matrix signaling. The use of spheroids is currently under investigation for many cell types. Among cells under evaluation, spheroids formed of mesenchymal stromal cells (MSCs) are particularly promising. MSC spheroids not only exhibit increased cell survival and retained differentiation, but they also secrete a potent secretome that promotes angiogenesis, reduces inflammation, and attracts endogenous host cells to promote tissue regeneration and repair. However, the clinical translation of spheroids has lagged behind promising preclinical outcomes due to hurdles in their formation, instruction, and use that have yet to be overcome. This review will describe the current state of preclinical spheroid research and highlight two key examples of spheroid use in clinically relevant disease modeling. It will highlight techniques used to instruct the phenotype and function of spheroids, describe current limitations to their use, and offer suggestions for the effective translation of cell spheroids for therapeutic treatments.

Study on the Physical, Thermal and Mechanical Properties of SEBS/PP (Styrene-Ethylene-Butylene-Styrene/Polypropylene) Blend as a Medical Fluid Bag

The presence of DEHP in PVC-based medical bags poses a significant health risk to patients undergoing blood transfusion. In order to fabricate safer medical fluid bag materials, the use of SEBS/PP polymer blend as a potential material was investigated. Polymeric blends with varying weight percentages of styrene-ethylene-butylene-styrene/polypropylene (SEBS/PP) were fabricated by melt mixing using an internal Haake mixer. The physical properties of the SEBS/PP polymer blends were investigated using differential scanning calorimetry (DSC), X-ray diffraction (XRD), and inductively coupled plasma–mass spectrometry (ICP-MS). In addition, measurements of the mechanical strength (tensile strength and Young’s modulus) as per ASTM 638, polymer hardness was tested using a durometer and swelling was analysed through water absorption and compared with commercial PVC-based blood bags. The results indicate that the SEBS/PP 50/50 blend has approximately similar characteristics as PVC-based blood bags. The SEBS/PP polymer blend possesses approximate tensile strength and Young’s modulus with values of 23.28 MPa and 14.42 MPa, respectively, to that of the conventional PVC blood bags. The results show that the SEBS/PP polymer blends have negligible zinc and aluminium migration with values of 1.6 and 2.1 mg/kg, respectively, and do not elute any harmful leachates, while the thermal studies indicate that the studied SEBS/PP materials are capable of withstanding steam sterilisation at 120 °C and cold storage below −40 °C. The investigated material can be utilized for medical fluid bags and contributes towards sustainable development goals, such as SDG 3 to ensure healthy lives and promote well-being, as well as SDG 12 to ensure sustainable consumption and production patterns.

Response Assessment to Erythropoietin-Zeta (Epo-Alpha Biosimilar) Therapy in Low-Risk Myelodysplastic Syndromes

Background. This prospective observational study aimed to verify the efficacy of erythropoietin zeta in the treatment of patients with low-risk myelodysplastic syndrome. Methods. Patients with low/int-1 IPSS risk and serum erythropoietin level below 500 U/L were enrolled. Treatment consisted of erythropoietin zeta 40,000 U subcutaneously once a week. The primary endpoint was the erythroid response. According to Simon’s two-stage statistical design, 36 patients were recruited. The median age was 75 years (range 56–83 years), male/female ratio was 1.1/1, median baseline serum erythropoietin was 57.9 U/L (range 9.4–475 U/L). 53% of patients had low-risk disease, while the remaining had Int-1 risk. Results. After 8 weeks, a significant response (rise in Hb levels of at least 1.5 g/dL) was achieved in 18 patients (50%) out of 36. However, 17 patients did not improve; 8/17 patients pursued the 40,000 U weekly schedule of erythropoietin zeta, and 4/8 (50%) of them reached the erythroid response after 16 weeks. Nine patients underwent dosage doubling (40,000 U twice per week), and 5/9 (55%) of them achieved the erythroid response. Conclusion. Compared with data from the literature, this prospective study revealed that EPO-zeta is a safe and effective therapeutic option in low-risk MDS patients.

Radiographic Features of the Maxillofacial Anomalies in Beta-Thalassemia Major: With New View

BACKGROUND

Beta- thalassemia major causes the basic skeletal changes due to ineffective erythropoiesis in suffering patients. The aim of the study was to determine the frequency of maxillo-facial anomalies and the hemoglobin and ferritin levels in patients with beta-thalassemia major compared to the healthy control group.

METHODS

The present study was performed on 72 beta- thalassemia major patients and 70 healthy control group in Ahvaz, Southwest Iran, from Jan 2014 to Mar 2015. Panoramic radiographs were taken using a standard procedure. The frequency of abnormalities including enlargement of bone marrow spaces, small maxillary sinuses, thickness of inferior mandibular cortex, prominent antegonial notch, absence of inferior alveolar canal and thin lamina dura, were determined by two Oral and Maxillofacial Radiologist. We also paid to identification of the relationship between abnormalities frequency and hemoglobin and ferritin levels during previous 6 months in thalassemia patients.

RESULTS

The mean age of case and control groups was 18.6±7.25 and 17 ± 6. 55 yr, respectively. The frequency of abnormalities in the case and control groups was as follows, enlargement of bone marrow spaces [69 (95.8%) vs 3 (4.3%)], small maxillary sinuses [45 (62.5%) vs 1(1.4%)], reduced thickness of inferior mandibular cortex [21(29.2%) vs 6 (8.6%)], prominent antegonial notch [10 (13.9%) vs 2 (2.9%)], absence of inferior alveolar canal [68(94.4%) vs 41(58.6%)] and thin lamina dura [40 (55.6%) vs 5 (7.1%)].

CONCLUSION

The all above mentioned abnormalities in patients with beta-thalassemia major was higher than the control group. Moreover, the frequency of maxillo-facial abnormalities decreased by increasing hemoglobin and decreasing ferritin.

Prospective cohort study of induction of labor: Indications, outcome and postpartum hemorrhage

INTRODUCTION

This study was undertaken because of the increasing rate of induction of labor (IOL) in our hospital and its associated higher caesarean section (CS) rates. The objective was to ascertain the incidence, indications, methods, outcome, and complications of IOL, in particular postpartum hemorrhage.

METHODS

This was a prospective observational cohort study of women who underwent IOL in a medium-sized district general hospital. Blood loss was measured by the gravimetric method and correlated to postpartum hemoglobin level within 48 hours of birth.

RESULTS

A total of 445 women needed IOL (incidence 33%). Common indications were: small for gestational age (SGA) or fetal growth restriction (FGR) (18%), spontaneous rupture of membrane (17%), reduced fetal movement (16%), prolonged pregnancy (15%), and diabetes (13%). In all, 67% women achieved spontaneous vaginal delivery and 18% underwent caesarean section. With regard to blood loss, 62 women (14%) had postpartum hemorrhage (PPH) of >1000 mL and 22 women (4.9%) had a blood loss >1500 mL. The caesarean section rate was higher than the overall emergency caesarean section rate in that year. Incidence of PPH in this cohort was higher than the normal incidence.

CONCLUSIONS

Increasing trend of induction of labor (IOL) is due to the changing clinical policy on management of small for gestational age babies, spontaneous rupture of membrane, reduced fetal movement and other complications of pregnancy. There is conflicting evidence on the effect of IOL on caesarean section rates. IOL is a risk factor for PPH. Accurate measurement of blood loss is essential in detecting a fall in hemoglobin which in turn helps in the appropriate management of PPH.

Impact of tourniquet during knee arthroplasty: a bayesian network meta-analysis of peri-operative outcomes

INTRODUCTION

The role of tourniquet during knee arthroplasty is controversial. The present study compares various tourniquet protocols using a Bayesian network meta-analysis of peri-operative data.

MATERIAL AND METHODS

The present study was conducted in accordance with the PRISMA extension statement for reporting systematic reviews incorporating network meta-analyses of health interventions. The literature search was conducted in September 2020. All clinical trials investigating the role of tourniquet in knee arthroplasty were considered for inclusion. Methodological quality was assessed using Review Manager 5.3. A Bayesian hierarchical random-effects model analysis was used in all comparisons.

RESULTS

Ultimately, pooled data from 68 studies (7413 procedures) were analysed. Significant inconsistency was found in the data relating to total estimated blood lost; no assumption could be made on this outcome. Full-time tourniquet resulted in the shortest surgical duration and lowest intra-operative blood lost, in both cases followed by incision-to-suture. The incision-to-suture protocol achieved the smallest drop in haemoglobin during the first 72 h post-operatively and the lowest rate of blood transfusion, both followed by full-time tourniquet. Hospitalisation was shortest in the absence (no-tourniquet) group, followed by the cementation-to-end group.

CONCLUSION

For knee arthroplasty, longer tourniquet use is associated with the shorter duration of surgery, lower intra-operative blood lost, lower drops in haemoglobin and fewer transfusion units. The shortest average hospitalisation was associated with no tourniquet use.

Role of Emergency Automated Red Cell Exchange in Sickle Cell Crisis: A Case Report

For many years main stay of treatment for sickle cell anaemia was transfusion therapy. But repeated transfusions put the patient at risk of iron overload. Automated red cell exchange is an evolving and newer technique which rapidly removes the sickle cells and has benefit in decreasing sickle cell load and related complications. Red cell exchange is a therapeutic procedure in which the patient’s whole blood is processed centrifugally in cell separator. Patient’s red cells are separated from other blood components and removed and replaced with donor red cells and colloids. We report our first experience of automated red cell exchange in 24-year-old female diagnosed case of sickle cell anaemia presented to us with acute chest syndrome with septic shock. Red cell exchange was planned to tide over the acute sickle cell crisis and provide symptomatic improvement. We also highlight that compound heterozygous thalassaemia could be associated with sickle cell disease which could make the diagnosis difficult. New generation automated Apheresis equipment’s provides better monitoring of the procedure that can be useful in severely ill patients also.

Optimizing Nitrogen Balance Is Associated with Better Outcomes in Neurocritically Ill Patients

Marked protein catabolism is common in critically ill patients. We hypothesized that optimal protein supplementation using nitrogen balance might be associated with better outcomes in the neurointensive care unit (NICU) patients. A total of 175 patients admitted to the NICU between July 2017 and December 2018 were included. Nitrogen balance was measured after NICU admission and measurements were repeated in 77 patients. The outcomes were compared according to initial nitrogen balance results and improvement of nitrogen balance on follow-up measurements. A total of 140 (80.0%) patients had a negative nitrogen balance on initial assessments. The negative balance group had more events of in-hospital mortality and poor functional outcome at three months. In follow-up measurement patients, 39 (50.6%) showed an improvement in nitrogen balance. The improvement group had fewer events of in-hospital mortality (p = 0.047) and poor functional outcomes (p = 0.046). Moreover, improvement of nitrogen balance was associated with a lower risk of poor functional outcomes (Odds ratio, 0.247; 95% confidence interval, 0.066–0.925, p = 0.038). This study demonstrated that a significant proportion of patients in the NICU were under protein hypercatabolism. Moreover, an improvement in protein balance was related to improved outcomes in neurocritically ill patients. Further studies are needed to confirm the relationship between protein balance and outcomes.

Association between blood transfusions and complications in head and neck reconstruction: a systematic review and meta-analysis

PURPOSE

The aim of this meta-analysis is to assess the correlation between blood transfusions and the medical/surgical complications after head and neck reconstructive surgery.

METHODS

The PRISMA protocol was used and the literature search was performed on Pubmed, Scopus, Cochrane Library and Web of Science up to March 13, 2020. The risk of bias in individual studies was assessed through the Newcastle Ottawa Scale.

RESULTS

A total of 1219 records were screened after the electronic search, 22 of which were included in the qualitative analysis. Of there 22 scores, 18 articles were included in the meta-analysis. The OR for medical and surgical complications of transfused patients was 1,64 (95% CI 1.23-2.21); while, the OR for hospital readmission was 1.53 (95% CI 1.29-1.81).

CONCLUSIONS

The results of this meta-analysis suggested that blood transfusions are associated with both an increased risk of surgical and medical complications of head and neck flaps and with the hospital readmission.

Relationship between splenomegaly and transfusion requirements in patients with cirrhosis

Patients with cirrhosis and splenomegaly commonly develop cytopenias and require the transfusion of blood products. In this study, we evaluated spleen size as a clinical indicator for red blood cell transfusion effectiveness and hypothesized that transfusion would be less effective in patients with splenomegaly. Our retrospective cohort study compared 215 cirrhotic patients with splenomegaly and 114 cirrhotic patients without splenomegaly and measured their respective change in hemoglobin concentration after a unit of transfused red blood cells. The primary endpoint was the percent difference between the measured rise in hemoglobin after transfusion in these cohorts. Patient sex (P < 0.0035), body mass index (P < 0.0001), and the change in hemoglobin concentration after a leukocyte-reduced red blood transfusion (P < 0.0001) were found to be significantly related to spleen size. When compared to the nonsplenomegaly cohort, it was found that the splenomegaly cohort experienced 79.70% (95% CI 71.26%-89.14%) of the change in hemoglobin concentration after red blood cell transfusion when adjusted for patient sex and body mass index. In conclusion, in patients with cirrhosis, increased spleen size was correlated with a decreased responsiveness to red blood cell transfusion when adjusted for patient sex and body mass index.

Multifaceted role of glycosylation in transfusion medicine, platelets, and red blood cells

Glycosylation is highly prevalent, and also one of the most complex and varied posttranslational modifications. This large glycan diversity results in a wide range of biological functions. Functional diversity includes protein degradation, protein clearance, cell trafficking, cell signaling, host-pathogen interactions, and immune defense, including both innate and acquired immunity. Glycan-based ABO(H) antigens are critical in providing compatible products in the setting of transfusion and organ transplantation. However, evidence also suggests that ABO expression may influence cardiovascular disease, thrombosis, and hemostasis disorders, including alterations in platelet function and von Willebrand factor blood levels. Glycans also regulate immune and hemostasis function beyond ABO(H) antigens. Mutations in glycogenes (PIGA, COSMC) lead to serious blood disorders, including Tn syndrome associated with hyperagglutination, hemolysis, and thrombocytopenia. Alterations in genes responsible for sialic acids (Sia) synthesis (GNE) and UDP-galactose (GALE) and lactosamine (LacNAc) (B4GALT1) profoundly affect circulating platelet counts. Desialylation (removal of Sia) is affected by human and pathogenic neuraminidases. This review addresses the role of glycans in transfusion medicine, hemostasis and thrombosis, and red blood cell and platelet survival.

Predictors and Outcomes of Cardiac Events following Thoracic Endovascular Aortic Repair in Descending Thoracic Aortic Aneurysm and Dissection

BACKGROUND

 Cardiac events following thoracic endovascular aortic repair (TEVAR) have been associated with significant morbidity and mortality. However, predictors of post-TEVAR cardiac events in descending thoracic aortic aneurysm or dissection are poorly understood.

METHODS

 A retrospective analysis of completed TEVAR procedures performed from 2010 to 2016 was conducted using the ACS-NSQIP (American College of Surgeons National Surgical Quality Improvement Program) participant user file database. Adult patients (≥18 years) who underwent TEVAR for descending thoracic aortic aneurysm or dissection were identified and 30-day outcomes were examined. An initial univariate analysis was performed to determine associations between all patient variables and cardiac events, defined as myocardial infarction or cardiac arrest that occurred ≤30 days of surgery. Multivariate logistic regression was subsequently performed to identify independent risk factors for cardiac events following TEVAR.

RESULTS

 The study identified 150 out of 2,905 (5.2%) patients who underwent TEVAR for descending thoracic aortic aneurysm or dissection who developed cardiac events. No significant difference in incidence of cardiac events was noted among patients presenting with aortic aneurysm or dissection (p = 0.339). The overall 30-day mortality rate for all patients was 9.1%. Independent preoperative predictors of post-TEVAR cardiac events included emergency procedure (odds ratio [OR] 2.80, 95% confidence interval [CI] 1.9-4.1, p < 0.01); American Society of Anesthesiologists score >3 (OR 1.71, 95% CI 1.1-2.6, p = 0.01), ventilator dependence (OR 2.33, 95% CI 1.3-4.2, p < 0.01), renal failure (OR 2.53, 95% CI 1.50-4.3, p < 0.01), blood transfusion (OR 1.84, 95% CI 1.1-3.2, p = 0.03), and preoperative leukocytosis (OR 2.45, 1.6-3.8, p < 0.01). After TEVAR, unplanned reintubation (OR 5.52, 95% CI 3.5-8.8, p < 0.01), prolonged mechanical ventilation (OR 1.94, 95% CI 1.2-3.2, p = 0.011), and postoperative blood transfusion (OR 4.02, 95% CI 2.70-6.0, p < 0.01) were independent predictors of cardiac events. Cardiac events greatly increased mortality (60.7 vs. 5.5%), total length of hospital stay (13.2 ± 14.7 days vs. 8.3 ± 9.3 days), and readmission rates (19.3 vs. 8.2%, p < 0.01).

CONCLUSIONS

 Cardiac events following TEVAR are associated with significant mortality. Patients with these risk factors should be appropriately monitored to improve outcomes.

Enhanced Recovery After Surgery-Based Perioperative Protocol for Head and Neck Free Flap Reconstruction

Objectives

Evaluate an enhanced recovery after surgery (ERAS)–based free flap management protocol implemented at our center.

Study Design

Prospective cohort study of patients after implementation of an ERAS-based perioperative care protocol for patients undergoing free flap reconstruction of the head and neck as compared with a historical control group.

Setting

Tertiary care academic medical center.

Participants and Methods

All patients undergoing free flap reconstruction were prospectively enrolled in the ERAS protocol group. A retrospective control group was identified by randomly selecting an equivalent number of patients from a records search of those undergoing free flap surgery between 2009 and 2015. Blood transfusion, complications, 30-day readmission rates, intensive care unit (ICU) and hospital length of stay, and costs of hospitalization were compared.

Results

Sixty-one patients were included in each group. Patients in the ERAS group underwent less frequent flap monitoring by physicians and had lower rates of intraoperative (70.5% vs 86.8%, P = .04) and postoperative (49.2% vs 27.2%, P = .026) blood transfusion, were more likely to be off vasopressors (98.3% vs 50.8%, P < .01) and ventilator support (63.9% vs 9.8%, P < .01) at the conclusion of surgery, and had shorter ICU stays (2.11 vs 3.39 days, P = .017). Length of stay, readmissions, and complication rates did not significantly differ between groups.

Conclusion

ERAS-based perioperative practices for head and neck free flap reconstruction can reduce time on the ventilator and in the ICU and the need for vasopressors, blood transfusions, and labor-intensive flap monitoring, without adverse effects on outcomes.

Early intravenous iron administration in the Emergency Department reduces red blood cell unit transfusion, hospitalisation, re-transfusion, length of stay and costs

BACKGROUND

Moderate to severe iron deficiency anaemia is a common finding in patients admitted to the Emergency Department (ED). According to Patient Blood Management principles, intravenous iron should be the therapy of choice instead of blood transfusion for selected cases affected by chronic iron deficiency anaemia. However, this option is only rarely taken into account by physicians in the ED. As a result, in many circumstances, treatment of iron deficiency anaemia in the ED can differ from that of the Anaemia Clinic. With the aim of reducing inappropriate transfusions, and to implement intravenous iron usage, we shared a specific protocol with the ED.

MATERIAL AND METHODS

We reviewed the medical records of all subjects admitted to the ED (n=267, Post-protocol group) with hemoglobin ≤9.0 g/dL and mean corpuscular volume <80 fL in a 13-month period, except if the massive transfusion protocol was activated, and results were compared with an equivalent Pre-protocol historical cohort (n=226).

RESULTS

In comparison with the Pre-protocol series, the number of patients transfused did not change, but the appropriateness in terms of transfusion and red blood cell volume transfused improved sharply (87.0 vs 13.3%; p<0.001) with a significant increase in intravenous iron administration (50.2 vs 4.4% of cases; p<0.001). As a positive consequence, both the time spent in the ED by patients who were then directly discharged and costs per subject treated dropped by 37.9% and 59.0%, respectively. Treatment with infusion only in comparison with transfusion only led to a statistically significant Relative Risk reduction in transfusion on the ward and post-discharge transfusion of 55.6% and 44.4%, respectively.

DISCUSSION

The implementation of Patient Blood Management principles and early intravenous iron therapy in the Emergency Department have proved to be effective tools to optimise resources both in terms of units transfused and costs.

Photodynamic Inactivation of Candida albicans in Blood Plasma and Whole Blood

The few approved disinfection techniques for blood derivatives promote damage in the blood components, representing risks for the transfusion receptor. Antimicrobial photodynamic therapy (aPDT) seems to be a promising approach for the photoinactivation of pathogens in blood, but only three photosensitizers (PSs) have been approved, methylene blue (MB) for plasma and riboflavin and amotosalen for plasma and platelets. In this study, the efficiency of the porphyrinic photosensitizer Tri-Py(+)-Me and of the porphyrinic formulation FORM was studied in the photoinactivation of Candida albicans in plasma and in whole blood and the results were compared to the ones obtained with the already approved PS MB. The results show that FORM and Tri-Py(+)-Me are promising PSs to inactivate C. albicans in plasma. Although in whole blood the inactivation rates obtained were higher than the ones obtained with MB, further improvements are required. None of these PSs had promoted hemolysis at the isotonic conditions when hemolysis was evaluated in whole blood and after the addition of treated plasma with these PSs to concentrates of red blood cells.

Joint effect of pre-operative anemia and perioperative blood transfusion on outcomes of colon-cancer patients undergoing colectomy

Background

Both pre-operative anemia and perioperative (intra- and/or post-operative) blood transfusion have been reported to increase post-operative complications in patients with colon cancer undergoing colectomy. However, their joint effect has not been investigated. The purpose of this study was to evaluate the joint effect of pre-operative anemia and perioperative blood transfusion on the post-operative outcome of colon-cancer patients after colectomy.

Methods

We identified patients from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database 2006-2016 who underwent colectomy for colon cancer. Multivariate logistic regression analysis was employed to assess the independent and joint effects of anemia and blood transfusion on patient outcomes.

Results

A total of 35,863 patients-18,936 (52.8%) with left-side colon cancer (LCC) and 16,927 (47.2%) with right-side colon cancer (RCC)-were identified. RCC patients were more likely to have mild anemia (62.7%) and severe anemia (2.9%) than LCC patients (40.2% mild anemia and 1.4% severe anemia). A total of 2,661 (7.4%) of all patients (1,079 [5.7%] with LCC and 1,582 [9.3%] with RCC) received a perioperative blood transfusion. Overall, the occurrence rates of complications were comparable between LCC and RCC patients (odds ratio [OR] = 1.01; 95% confidence interval [CI] = 0.95-1.07; P = 0.750). There were significant joint effects of anemia and transfusion on complications and the 30-day death rate (P for interaction: 0.010). Patients without anemia who received a transfusion had a higher risk of any complications (LCC, OR = 3.51; 95% CI = 2.55-4.85; P < 0.001; RCC, OR = 3.74; 95% CI = 2.50-5.59; P < 0.001), minor complications (LCC, OR = 2.54; 95% CI = 1.63-3.97; P < 0.001; RCC, OR = 2.27; 95% CI = 1.24-4.15; P = 0.008), and major complications (LCC, OR = 5.31; 95% CI = 3.68-7.64; P < 0.001; RCC, OR = 5.64; 95% CI = 3.61-8.79; P < 0.001), and had an increased 30-day death rate (LCC, OR = 6.97; 95% CI = 3.07-15.80; P < 0.001; RCC, OR = 4.91; 95% CI = 1.88-12.85; P = 0.001) than patients without anemia who did not receive a transfusion.

Conclusions

Pre-operative anemia and perioperative transfusion are associated with an increased risk of post-operative complications and increased death rate in colon-cancer patients undergoing colectomy.

Does packed red cell transfusion provide symptomatic benefits to cancer palliative patients?: a longitudinal study from a single private oncology center in Nepal

Background

Palliative patients generally present with symptoms of dyspnea, easy fatigability, lethargy and feeling of being unwell which can broadly be attributed to one root cause: cancer-related anemia. So, packed red cell transfusion is often carried out aiming to improve patients’ functional status. Different cut off hemoglobin values have been suggested, with Hb < 9 g/dL the most commonly accepted. The present study aims at evaluating and comparing the benefits in subjective symptoms of fatigue and breathlessness among transfused and non-transfused palliative patients on Day 0 and Day 7.

Methods

Hemoglobin values, anemia related subjective symptoms of fatigue and breathlessness were recorded from 122 patients. The patients were re-evaluated on day-7 post-transfusion. The pre and post-transfusion symptomatic benefit was compared in both transfused and non-transfused palliative care patients.

Results

The currently practiced hemoglobin trigger for packed red cell transfusion is 10 g/dL. The units of packed red cell to be transfused was decided according to the hemoglobin values targeting the rise to > 10 g/dL. A mean 1.36 units were transfused. Statistically significant improvement was observed in patient reported symptoms of fatigue and breathlessness among both transfused and non-transfused palliative patients.

Conclusion

Anemic cancer palliative patients were found to benefit following packed red cell transfusion, suggesting a favorable association between the transfusion and patient-reported fatigue and dyspnea.

Spontaneous Heterotopic Pregnancy Associated with Massive Intraperitoneal Haemorrhage and a Normal Heart Rate, Illustrating the Concept of Relative Bradycardia

A 28-year-old, 9 and a half weeks pregnant (spontaneous conception) multigravida presented with abdominal pain and vaginal bleeding. On examination, her abdomen was diffusely tender, particularly in the right iliac fossa, though guarding was absent. Transabdominal and transvaginal ultrasonography demonstrated a viable intrauterine pregnancy and large-volume intraperitoneal haemoperitoneum; the right ovary could not be identified. The patient became hypotensive with decreased responsiveness, yet her heart rate remained normal. She proceeded to surgery where a ruptured right tubal ectopic pregnancy was identified and right salpingectomy was performed. Estimated blood loss was 3900ml. Postoperative recovery was uneventful. Ultrasound 3 days after surgery demonstrated a viable intrauterine pregnancy of gestational age 9 weeks + 1 day. The patient remains well. Her anomaly scan at 20 weeks and 6 days showed normal growth, amniotic fluid, and Dopplers with no obvious structural defects. She is currently 27 weeks pregnant and will be rescanned at 36 weeks.

Concordance between glucose-6-phosphate dehydrogenase (G6PD) genotype and phenotype and rasburicase use in patients with hematologic malignancies

Phenotypic rather than genotypic tests remain the gold standard for diagnosing glucose-6-phosphate dehydrogenase (G6PD) deficiency. However, with increasing use of genomic arrays and whole exome or genome sequencing, G6PD genetic data are increasingly available. We examined the utility of G6PD genetic data in patients with hematologic malignancies and the association of G6PD genotype and phenotype with rasburicase-induced methemoglobinemia. We analyzed G6PD activity for 990 patients. Genotype data were available from the Affymetrix DMET array (n=379), whole exome sequencing (n=374), and/or the Illumina exome array (n=634) for 645 patients. Medical records of 341 patients with methemoglobin measures were assessed for the administration of rasburicase. We observed 5 non-synonymous SNPs, 4 of which were known to be associated with deficient G6PD activity (WHO Class I-III). Genotyping 367 males resulted in a positive predictive value of 81.8% (47.8–96.8%), and two males with a Class I-III allele having normal activity both received a red blood cell transfusion prior to the activity assay. However, genotyping males had only 39.1% (20.5–61.2%) sensitivity. Two of the 12 heterozygous females had deficient G6PD activity. Rasburicase-induced methemoglobinemia occurred in 6 patients, 5 of whom had at least one Class I-III allele, despite 2 of these having normal G6PD activity. We conclude that although an apparent nondeficient genotype does not necessarily imply a normal phenotype, a deficient genotype result indicates a deficient phenotype in those without transfusions, and may be a useful adjuct to phenotype to prevent adverse drug reactions.

Is It Possible to Reverse the Storage-Induced Lesion of Red Blood Cells?

Cold-storage of packed red blood cells (PRBCs) in the blood bank is reportedly associated with alteration in a wide range of RBC features, which change cell storage each on its own timescale. Thus, some of the changes take place at an early stage of storage (during the first 7 days), while others occur later. We still do not have a clear understanding what happens to the damaged PRBC following their transfusion. We know that some portion (from a few to 10%) of transfused cells with a high degree of damage are removed from the bloodstream immediately or in the first hour(s) after the transfusion. The remaining cells partially restore their functionality and remain in the recipient’s blood for a longer time. Thus, the ability of transfused cells to recover is a significant factor in PRBC transfusion effectiveness. In the present review, we discuss publications that examined RBC lesions induced by the cold storage, aiming to offer a better understanding of the time frame in which these lesions occur, with particular emphasis on the question of their reversibility. We argue that transfused RBCs are capable (in a matter of a few hours) of restoring their pre-storage levels of ATP and 2,3-DPG, with subsequent restoration of cell functionality, especially of those properties having a more pronounced ATP-dependence. The extent of reversal is inversely proportional to the extent of damage, and some of the changes cannot be reversed.

Changes in the microRNA expression profile during blood storage

Objectives

For several decades, autologous blood doping (ABD) in sports has been a major problem, and even today there is still no reliable method for satisfactorily detecting ABD. For this kind of doping, stored individual erythrocytes are used to increase stamina and endurance caused by a higher erythrocyte level in the athlete's body. Since there is growing evidence that these cells are enriched with microRNAs (miRNAs), this study has been carried out to discover and validate all miRNAs occurring in fresh blood as well as in stored blood.

Methods

Therefore, small RNA Next Generation Sequencing has been performed, which allows untargeted detection of all miRNAs in a blood sample. The focus of this investigation has been to find miRNA alterations in blood bags after erythrocyte processing and during storage, as compared with fresh blood directly withdrawn from subjects. Blood samples were obtained from 12 healthy, recreationally active male subjects three times before blood donation and from blood bags at several time points after blood processing.

Results

189 miRNAs have been considered stable over two consecutive weeks. A further analysis revealed a complex biomarker signature of 28 miRNAs, consisting of 6 miRNAs that altered during 6 weeks of storage and 22 miRNAs that altered due to processing.

Conclusion

These results suggest that the identified miRNA biomarker signature may be used for the detection of ABD. These 28 miRNA candidates are tested and verified currently in a follow-up study, a human transfusion clinical trial in healthy sportsmen.

Transfusion practice in anemic, non-bleeding patients: Cross-sectional survey of physicians working in general internal medicine teaching hospitals in Switzerland

Background

Transfusion practice might significantly influence patient morbidity and mortality. Between European countries, transfusion practice of red blood cells (RBC) greatly differs. Only sparse data are available on transfusion practice of general internal medicine physicians in Switzerland.

Methods

In this cross-sectional survey, physicians working in general medicine teaching hospitals in Switzerland were investigated regarding their self-reported transfusion practice in anemic patients without acute bleeding. The definition of anemia, transfusion triggers, knowledge on RBC transfusion, and implementation of guidelines were assessed.

Results

560 physicians of 71 hospitals (64%) responded to the survey. Anemia was defined at very diverging hemoglobin values (by 38% at a hemoglobin <130 g/L for men and by 57% at <120 g/L in non-pregnant women). 62% and 43% respectively, did not define anemia in men and in women according to the World Health Organization. Fifty percent reported not to transfuse RBC according to international guidelines. Following factors were indicated to influence the decision to transfuse: educational background of the physicians, geographical region of employment, severity of anemia, and presence of known coronary artery disease. 60% indicated that their knowledge on Transfusion-related Acute Lung Injury (TRALI) did not influence transfusion practice. 50% of physicians stated that no local transfusion guidelines exist and 84% supported the development of national recommendations on transfusion in non-acutely bleeding, anemic patients.

Conclusion

This study highlights the lack of adherence to current transfusion guidelines in Switzerland. Identifying and subsequently correcting this deficit in knowledge translation may have a significant impact on patient care.

Acute respiratory distress syndrome in traumatic brain injury: how do we manage it?

Traumatic brain injury (TBI) is an important cause of morbidity and mortality worldwide. TBI patients frequently suffer from lung complications and acute respiratory distress syndrome (ARDS), which is associated with poor clinical outcomes. Moreover, the association between TBI and ARDS in trauma patients is well recognized. Mechanical ventilation of patients with a concomitance of acute brain injury and lung injury can present significant challenges. Frequently, guidelines recommending management strategies for patients with traumatic brain injuries come into conflict with what is now considered best ventilator practice. In this review, we will explore the strategies of the best practice in the ventilatory management of patients with ARDS and TBI, concentrating on those areas in which a conflict exists. We will discuss the use of ventilator strategies such as protective ventilation, high positive end expiratory pressure (PEEP), prone position, recruitment maneuvers (RMs), as well as techniques which at present are used for 'rescue' in ARDS (including extracorporeal membrane oxygenation) in patients with TBI. Furthermore, general principles of fluid, haemodynamic and hemoglobin management will be discussed. Currently, there are inadequate data addressing the safety or efficacy of ventilator strategies used in ARDS in adult patients with TBI. At present, choice of ventilator rescue strategies is best decided on a case-by-case basis in conjunction with local expertise.

Morphology, membrane nanostructure and stiffness for quality assessment of packed red blood cells

Transfusion of packed red blood cells (PRBC) to patients in critical states is often accompanied by post-transfusion complications. This may be related with disturbance of properties of PRBC and their membranes during long-term storage in the hemopreservative solution. The purpose of our work is the study of transformation of morphology, membranes stiffness and nanostructure for assessment of PRBC quality, in vitro. By atomic force microscopy we studied the transformation of cell morphology, the appearance of topological nanodefects of membranes and by atomic force spectroscopy studied the change of membrane stiffness during 40 days of storage of PRBC. It was shown that there is a transition period (20–26 days), in which we observed an increase in the Young’s modulus of the membranes 1.6–2 times and transition of cells into irreversible forms. This process was preceded by the appearance of topological nanodefects of membranes. These parameters can be used for quality assessment of PRBC and for improvement of transfusion rules.

Red blood cell storage time and transfusion: current practice, concerns and future perspectives

Red blood cells (RBCs) units are the most requested transfusion product worldwide. Indications for transfusion include symptomatic anaemia, acute sickle cell crisis, and acute blood loss of more than 30% of the blood volume, with the aim of restoring tissue oxygen delivery. However, stored RBCs from donors are not a qualitative equal product, and, in many ways, this is a matter of concern in the transfusion practice. Besides donor-to-donor variation, the storage time influences the RBC unit at the qualitative level, as RBCs age in the storage bag and are exposed to the so-called storage lesion. Several studies have shown that the storage lesion leads to post-transfusion enhanced clearance, plasma transferrin saturation, nitric oxide scavenging and/or immunomodulation with potential unwanted transfusion-related clinical outcomes, such as acute lung injury or higher mortality rate. While, to date, several studies have claimed the risk or deleterious effects of "old" vs "young" RBC transfusion regimes, it is still a matter of debate, and consideration should be taken of the clinical context. Transfusion-dependent patients may benefit from transfusion with "young" RBC units, as it assures longer inter-transfusion periods, while transfusion with "old" RBC units is not itself harmful. Unbiased Omics approaches are being applied to the characterisation of RBC through storage, to better understand the (patho)physiological role of microparticles (MPs) that are found naturally, and also on stored RBC units. Perhaps RBC storage time is not an accurate surrogate for RBC quality and there is a need to establish which parameters do indeed reflect optimal efficacy and safety. A better Omics characterisation of components of "young" and "old" RBC units, including MPs, donor and recipient, might lead to the development of new therapies, including the use of engineered RBCs or MPs as cell-based drug delivering tools, or cost-effective personalised transfusion strategies.

Comparative serological investigation between cat and tiger blood for transfusion

Evidence suggests that non-domesticated felids inherited the same AB-erythrocyte antigens as domestic cats. To study the possible compatibility of tiger blood with that of other endangered felidae, blood samples from captive tigers and domestic cats were subjected to an in vitro study. The objectives of this study were to (1) identify whether the captive tigers had blood type AB and (2) determine the compatibility between the blood of captive tigers and that of domestic cats with a similar blood type. The anti-coagulated blood with ethylenediaminetetraacetic acid of 30 tigers was examined to determine blood type, and a crossmatching test was performed between tiger and cat blood. All 30 tigers had blood type A. Tube agglutination tests using tiger plasma with cat erythrocytes resulted in 100% agglutination (n=30) with type B cat erythrocytes and 76.7% agglutination (n=23) with type A cat erythrocytes. The 80% of major and 60% of minor compatibilities between blood from 10 tigers and 10 domestic cats with blood type A were found to pass compatibility tests. Interestingly, 3/10 of the tigers’ red blood cell samples were fully compatible with all cat plasmas, and 1/10 of the tiger plasma samples were fully compatible with the type A red cells of domestic cats. Although the result of present findings revealed type-A blood group in the surveyed tigers, the reaction of tiger plasma with Type-A red cell from cats suggested a possibility of other blood type in tigers.

A fast-track anaemia clinic in the Emergency Department: cost-analysis of intravenous iron administration for treating iron-deficiency anaemia

BACKGROUND

A fast-track anaemia clinic (FTAC) for the management of moderate-to-severe iron-deficiency anaemia (IDA) was established in our Emergency Department in 2010. In this FTAC, the replacement of packed red cell transfusion by ferric carboxymaltose administration was proven to be safe and effective. The aim of this study was a cost-analysis of IDA management in the FTAC, comparing this management with the previous standard care pathway consisting of packed red cell transfusion, if needed, and referral to outpatient specialised care.

MATERIALS AND METHODS

A cost study was performed for patients with IDA who were at risk of requiring transfusion (haemoglobin <9 g/dL) but did not require hospitalisation. Total IDA treatment costs in the FTAC were compared to those theoretically incurred if these patients had been managed using the standard care pathway. In addition, a sensitivity analysis considering variations of up to ±30% in ferric carboxymaltose and packed red cell acquisition costs was performed (49 possible scenarios).

RESULTS

Between 2012 and 2015, 238 IDA patients were treated in the FTAC. The average treatment cost was € 594±337/patient in the FTAC group and € 672±301/patient in the standard care pathway group, with a saving of € 78±28/patient (95% CI, 22-133; p<0.001). The sensitivity analysis showed that IDA treatment costs in the FTAC (€ 480-722/patient), compared with those of the standard care pathway (€ 550-794/patient), resulted in significant cost-savings for all studied scenarios (€ 51-104/patient; p<0.005).

DISCUSSION

The administration of ferric carboxymaltose for IDA management in a FTAC may be cost-saving compared with the standard care pathway.

Percutaneous nephrolithotomy; alarming variables for postoperative bleeding

OBJECTIVES

To evaluate factors contributing to bleeding after percutaneous nephrolithotomy (PCNL) and ways of managing this complication, as bleeding is a serious sequela that requires prompt management.

PATIENTS AND METHODS

The demographic and procedural data of 200 patients, who underwent unilateral PCNL during a 20-month period, were prospectively collected. Preoperative, operative, and postoperative details were recorded. The preoperative variables analysed included: age, sex, body mass index (BMI), the presence of hypertension, diabetes mellitus, serum creatinine, degree of hydronephrosis, previous ipsilateral open renal surgery, stone size and complexity. The operative variables analysed included: number of tracts, operative time, size of Amplatz sheath, type of anaesthesia, and complications such as calyceal and pelvic perforation.

RESULTS

The variables of age, sex, BMI, diabetes, hypertension, and a preoperative creatinine level of >1.4 mg/dL had no significant effect on blood loss (all P > 0.05). However, the rate of bleeding was significantly higher (P ⩽ 0.05) in patients who had a history of previous open renal surgery, intraoperative pelvicalyceal perforations, and Guy's Stone Score (GSS) grade 3 and 4 complex stones; however, absence of hydronephrosis, larger stone size, operative time (>83 min), more than one puncture, and size of the Amplatz sheath (26-30 F) did not maintain their significance in multivariate analysis.

CONCLUSION

According to our present results stone complexity (GSS grade 3 and 4), history of ipsilateral renal stone surgery, and occurrence of intraoperative pelvicalyceal perforation are alarming variables for post-PCNL bleeding.

Evaluation of capillary haemoglobin determination for anaemia screening in blood donation settings

BACKGROUND

An accurate assessment of hemoglobin (Hb) values before donation is unavoidable for safeguarding donors' safety and fulfilling the current specifications of Hb content in blood bags. This study was hence aimed to compare a finger-prick method for Hb measurement in capillary blood with Hb assessment in venous blood using a hematological analyser.

MATERIALS AND METHODS

The study populations consisted in 1,014 consecutive blood donors, who had paired measurement of Hb values with HemoCue on capillary blood and UniCel DxH800 in venous blood.

RESULTS

A significant overestimation was found with HemoCue compared to UniCel DxH800, but the correlation between methods was significant (comprised between 0.600 and 0.759; all p<0.01) and the bias always lower than the quality specifications. The prevalence of Hb values below the gender-specific thresholds for blood donation was also not significantly different (p=0.186).

DISCUSSION

It can hence be concluded that the finger-prick method evaluated is a safe and reliable means for screening blood donors.

Leucoreduction of blood components: an effective way to increase blood safety?

Over the past 30 years, it has been demonstrated that removal of white blood cells from blood components is effective in preventing some adverse reactions such as febrile non-haemolytic transfusion reactions, immunisation against human leucocyte antigens and human platelet antigens, and transmission of cytomegalovirus. In this review we discuss indications for leucoreduction and classify them into three categories: evidence-based indications for which the clinical efficacy is proven, indications based on the analysis of observational clinical studies with very consistent results and indications for which the clinical efficacy is partial or unproven.

Clinical factors influencing the decision to transfuse after percutaneous native kidney biopsy

Background

Transfusion of erythrocytes is the most common intervention after a complicated percutaneous renal biopsy (PRB). Anemia is considered to be a leading risk factor for bleeding following a PRB, and based on recent studies of transfusions in hospitalized patients, many institutions are restricting the threshold for erythrocyte transfusion to a lower hemoglobin concentration (Hgb). The purpose of this study is to analyze factors that influence the transfusion decision after a PRB, and to determine whether anemia is truly a risk factor for bleeding or anemic patients are simply more likely to receive a transfusion because of their already lower pre-PRB Hgb.

Methods

PRB of native kidneys was performed using real-time ultrasound with automated biopsy needles from January 1990 to April 2014. All patients were prospectively followed for bleeding with a 24-h inpatient observation. An intervention for a bleeding complication (BL-I) was defined by undergoing a procedure (cystoscopy, embolization), receiving a blood transfusion (BL-T), death and/or readmission related to the biopsy. To further define the effect of anemia, patients were divided into three pre-PRB Hgb groups: <9.0 g/dL (n = 79), 9.0–11.0 g/dL (n = 266) and >11.0 g/dL (n = 565).

Results

BL-I occurred in 71/910 (7.8%) of PRBs. The majority of these were BL-T (57/71, 80%; 57/910, 6.3% overall). Patients with BL-I had lower pre-PRB Hgb than those without BL-I (mean ± SD; 10.3 ± 2.0 versus 12.0 ± 2.1 g/dL, P < 0.0001) and a greater change (Δ) in Hgb (2.1 ± 1.6 versus 1.0 ± 0.8 g/dL, P < 0.0001). When compared with higher Hgb, patients with Hgb <9.0 g/dL had more traditional risk factors for bleeding (older age: 49 ± 18 versus 48 ± 18 versus 45 ± 16 years, P = 0.02; female: 72 versus 70 versus 56%, P < 0.0001; higher serum creatinine: 4.0 ± 2.9 versus 2.9 ± 2.6 versus 1.7 ± 1.4 mg/dL, P < 0.0001; higher systolic blood pressure: 138 ± 18 versus 133 ± 19 versus 133 ± 18 mmHg, P = 0.06; higher bleeding time: 7.6 ± 1.8 versus 7.4 ± 2.0 versus 6.7 ± 1.8 min, P < 0.0001). When BL-T was stratified by pre-PRB Hgb, there were more transfusions in those with lower pre-PRB Hgb (24 versus 9 versus 3%, P < 0.0001). However, these patients not only had fewer hematomas (58 versus 83 versus 87%, P = 0.04) but also demonstrated a smaller ΔHgb post-PRB (1.3 ± 1.0 versus 1.8 ± 0.8 versus 3.2 ± 1.6, P < 0.0001) compared with patients with higher pre-PRB Hgb, yet still received a transfusion.

Conclusions

While patients with lower pre-PRB Hgb have more of the traditional risk factors for a complication after PRB, there was actually less clinically evident bleeding in these patients who were transfused. Although anemia itself has been considered to be a risk factor for a complication in the past, it more accurately represents only a predictor of receiving an erythrocyte transfusion. In the setting of the PRB, the decision for transfusion is influenced more by the severity of anemia at baseline as opposed to clinically evident bleeding.

Neonatal transfusion models to determine the impact of using fresh red blood cells on inventory and exposure

BACKGROUND

Data on age of blood and its impact on donor exposure and inventory in the paediatric setting are lacking. The standard of practice of reserving a specific red blood cell (RBC) unit for neonates who may require repeat transfusions is unique to the paediatric setting. Requiring transfusion of fresher RBC units may increase the exposure of neonates to multiple units and negatively affect the supply of fresh RBC. We constructed a transfusion model based on a 6 months of retrospective neonatal transfusion data at our institution.

MATERIALS AND METHODS

All neonates (≤4 months old) at Texas Children's Hospital who received a RBC transfusion from June to November 2011 were included and RBC transfusion data were compiled. The age of blood at the time of each RBC transfusion was recorded. These data were reviewed to calculate exposure and inventory impact if each transfusion had been restricted to RBC either ≤7 or ≤14 days old at transfusion.

RESULTS

A total of 216 neonates received 938 RBC transfusions. Of these, 393 (42%) were fresh RBC (≤14 days old), even without a required age guideline. Requiring fresh (≤14 days) RBC for all transfusions in this period would have resulted in 70 additional fresh units and one or more additional exposures in 44 patients. Requiring fresher (≤7 days old) RBC would have resulted in an additional 147 units and. one or more additional exposures in 54 patients.

DISCUSSION

The more conservative model of fresh (≤7 days old) RBC would greatly increase fresh RBC inventory requirements, and 25% of transfused neonates would require additional RBC exposure. Based on retrospective data and the two transfusion models, it can be concluded that requiring RBC ≤14 days old for neonatal transfusion would best balance the use of fresher RBC with the smallest increase in patient exposure (20%) and minimum impact on the RBC inventory.

Hypertransfusion therapy in sickle cell disease in Nigeria

Introduction. Hypertransfusion refers to chronic blood transfusion therapy aimed at ameliorating disease complications in various haemopathies particularly the haemoglobinopathies. In sickle cell disease, hypertransfusion is aimed at maintaining patient's haemoglobin level at 10 to 11 g/dL using haemoglobin AA blood and its resultant dilutional effect on sickle haemoglobin is sustained by intermittent long-term transfusions. Aim and Objective. This paper highlights hypertransfusion and its privileged position as a secondary measure in prevention and treatment of sickle cell disease, especially in the Nigerian context. Materials and Methods. Relevant literatures were searched on PubMed, Google Scholar and standard texts in haematology and transfusion medicine. Keywords used in the search are hypertransfusion, sickle cell disease, chronic transfusion, and Nigeria. Literatures gathered were reviewed, summarized, and presented in this paper. Result. Immense clinical benefit is associated with hypertransfusion therapy including prevention of stroke and amelioration of severe sickle cell disease especially in transplant ineligible patients. Careful patient selections, appropriate blood component, and prevention of transfusion hazards as well as oversight function of an experienced haematologist are pertinent to a successful hypertransfusion therapy. Conclusion. Improved knowledge of the benefits and practice of hypertransfusion will effectively translate into improved health status even among Nigerian sickle cell disease patients.

Theoretical modelling of fibrinogen supplementation with therapeutic plasma, cryoprecipitate, or fibrinogen concentrate

Background

We aimed to create a theoretical tool to model the effect of three haemostatic agents containing fibrinogen (therapeutic plasma, cryoprecipitate, and fibrinogen concentrate) on the patient's plasma fibrinogen level.

Methods

A mathematical model was developed step-wise. The relationship between the amount of haemostatic agent and plasma fibrinogen level was plotted for each agent. A fibrinogen concentration simulator (FCS_amount) was developed, where the amount of haemostatic agent was calculated from patient characteristics, agent characteristics, and target plasma fibrinogen level. Refinements were introduced so that (i) FCS_amount would account for in vivo fibrinogen recovery, (ii) circulatory volume would not increase ad infinitum with increasing amounts, and (iii) red blood cells would be included in the simulation if haematocrit decreased below a certain level. A second FCS (FCS_level) was created to calculate fibrinogen levels resulting from specified amounts of haemostatic agents.

Results

Fibrinogen concentration in haemostatic agents has a critical impact on their ability to increase patients' fibrinogen levels. If the target plasma fibrinogen level approaches the concentration of the fibrinogen source, the required amounts increase exponentially; it is impossible to achieve a target above the concentration of the fibrinogen source.

Conclusions

We successfully developed two theoretical tools answering the questions: ‘How much therapeutic plasma, cryoprecipitate, or fibrinogen concentrate would be needed to achieve a specified target fibrinogen level?’ and ‘What would be the resultant fibrinogen level for a specified amount of haemostatic agent?’ The current tools are not intended for clinical application, but they are potentially useful for educational purposes.

A primary care approach to myelodysplastic syndromes

Myelodysplastic syndromes (MDS) are probably the most common hematologic malignancies in adults over the age of 60 and are a major source of morbidity and mortality among older age groups. Diagnosis and management of this chronic blood cancer has evolved significantly in recent years and there are Food and Drug Administration-approved therapies that can extend patients' life expectancy and improve quality of life. Primary care physicians (PCPs) are often involved in the process of diagnosis and follow-up of MDS patients, especially those in low-risk groups. They can therefore play an important role in improving patient care and quality of life by ensuring early referral and participating in supportive management. There is also a shortage of oncologists which increases the importance of the role of PCPs in management of MDS patients. In the face of limited resources, PCPs can improve access and quality of care in MDS patients. This article provides an overview of the common manifestations, diagnostic approaches, and therapeutic modalities of MDS for PCPs, with a focus on when to suspect MDS, when a referral is appropriate, and how to provide appropriate supportive care for patients diagnosed with MDS.

Cost of post-operative intravenous iron therapy in total lower limb arthroplasty: a retrospective, matched cohort study

BACKGROUND

Requirements for allogeneic red cell transfusion after total lower limb arthroplasty are still high (20-50%), and post-operative intravenous iron has been shown to reduce transfusion requirements for this surgery. We performed a cost analysis to ascertain whether this alternative is also likely to be cost-effective.

MATERIALS AND METHODS

Data from 182 matched-pairs of total lower limb arthroplasty patients, managed with a restrictive transfusion protocol and without (control group) or with post-operative intravenous iron (iron group), were retrospectively reviewed. Acquisition and administration costs of iron (iron sucrose or ferric carboxymaltose) and allogeneic red cell concentrates, haemoglobin measurements, and prolonged stay in hospital were used for blood management cost analysis.

RESULTS

Patients in the iron group received 600 mg intravenous iron, without clinically relevant incidents, and had a lower allogeneic transfusion rate (11.5% vs 26.4% for the iron and control groups, respectively; p=0.001). The reduction in transfusion rate was more pronounced in anaemic patients (17% vs 40%; p=0.015) than in non-anaemic ones (9.6% vs 21.2%; p=0.011). There were no differences with respect to post-operative infection rate. Patients receiving allogeneic transfusion stayed in hospital longer (+1.9 days [95% CI: 1.2-2.6]). As intravenous iron reduces the allogeneic transfusion rate, both iron formulations were cost-neutral in the different cost scenarios (-25.5 to 62.1 €/patient for iron sucrose, and -51.1 to 64.4 €/patient for ferric carboxymaltose).

DISCUSSION

In patients presenting with or without pre-operative anaemia, post-operative intravenous iron after total lower limb arthroplasty seems to be safe and is associated with reduced transfusion rates, without incremental costs. For anaemic patients, its efficacy could be increased by associating some other blood-saving method.

Hemoglobin levels and transfusions in neurocritically ill patients: a systematic review of comparative studies

Introduction

Accumulating evidence suggests that, in critically ill patients, a lower hemoglobin transfusion threshold is safe. However, the optimal hemoglobin level and associated transfusion threshold remain unknown in neurocritically ill patients.

Methods

We conducted a systematic review of comparative studies (randomized and nonrandomized) to evaluate the effect of hemoglobin levels on mortality, neurologic function, intensive care unit (ICU) and hospital length of stay, duration of mechanical ventilation, and multiple organ failure in adult and pediatric neurocritically ill patients. We searched MEDLINE, The Cochrane Central Register of Controlled Trials, Embase, Web of Knowledge, and Google Scholar. Studies focusing on any neurocritical care conditions were included. Data are presented by using odds ratios for dichotomous outcomes and mean differences for continuous outcomes.

Results

Among 4,310 retrieved records, six studies met inclusion criteria (n = 537). Four studies were conducted in traumatic brain injury (TBI), one in subarachnoid hemorrhage (SAH), and one in a mixed population of neurocritically ill patients. The minimal hemoglobin levels or transfusion thresholds ranged from 7 to 10 g/dl in the lower-Hb groups and from 9.3 to 11.5 g/dl in the higher-Hb groups. Three studies had a low risk of bias, and three had a high risk of bias. No effect was observed on mortality, duration of mechanical ventilation, or multiple organ failure. In studies reporting on length of stay (n = 4), one reported a significant shorter ICU stay (mean, -11.4 days (95% confidence interval, -16.1 to -6.7)), and one, a shorter hospital stay (mean, -5.7 days (-10.3 to -1.1)) in the lower-Hb groups, whereas the other two found no significant association.

Conclusions

We found insufficient evidence to confirm or refute a difference in effect between lower- and higher-Hb groups in neurocritically ill patients. Considering the lack of evidence regarding long-term neurologic functional outcomes and the high risk of bias of half the studies, no recommendation can be made regarding which hemoglobin level to target and which associated transfusion strategy (restrictive or liberal) to favor in neurocritically ill patients.

Study of damage to red blood cells exposed to different doses of γ-ray irradiation

BACKGROUND

The aims of this research were to study alterations in the ultrastructure of red blood cells, the changes in concentrations of plasma electrolytes and the killing effect of lymphocytes in samples of blood exposed to different doses of γ-ray irradiation.

MATERIALS AND METHODS

Blood samples were treated with different doses of γ-ray irradiation and then preserved for different periods. Specimens were prepared for standard electron microscopy and transmission electron microscopy. At the same time, changes in the concentrations of Na(+), K(+) and Cl(-) and pH values in the plasma as well as Fas and FasL expression of lymphocytes before and after irradiation were determined.

RESULTS

The proportions of reversibly and irreversibly transformed cells, for example, echinocytes, sphero-echinocytes, and degenerated forms, increased with increasing doses of irradiation and storage period, while the number of discocyte shaped red blood cells decreased. The change in K(+) concentration was greater than that of Na+ or Cl(-) after irradiation and was dosage-dependent. Plasma pH was influenced by different doses of radiation and storage time. After exposure to (137)Cs γ-irradiation, the expression of both Fas and FasL in lymphocytes differed significantly from that in the control group: the expression was positively correlated with irradiation dose (r=0.95, 0.96), but no significant difference in the Fas/FasL ratio was observed (P>0.05).

DISCUSSION

We conclude that the ultrastructure of red blood cells is not changed obviously by irradiation with some doses of γ-rays and various periods of storage. However, irradiation does have some dose-dependent and time-dependent adverse effects on the erythrocytes.