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Jalink M, Yan MTS, Cohn CS, Eichbaum QG, Fung MK, Lu W, Murphy MF, Pagano MB, Stanworth SJ, Shih AW. Systematic review for the serological testing for cold agglutinins: The BEST collaborative study. Transfusion 2024. [PMID: 38642020 DOI: 10.1111/trf.17842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Revised: 03/16/2024] [Accepted: 04/08/2024] [Indexed: 04/22/2024]
Affiliation(s)
- Marit Jalink
- Center for Clinical Transfusion Research, Sanquin Research, Amsterdam, The Netherlands
- Department of Hematology, Leiden University Medical Center, Leiden, The Netherlands
| | - Matthew T S Yan
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Medical Affairs and Innovation, Canadian Blood Services, Ottawa, Ontario, Canada
| | - Claudia S Cohn
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Quentin G Eichbaum
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Mark K Fung
- Department of Pathology and Laboratory Medicine, University of Vermont Medical Center, Burlington, Vermont, USA
| | - Wen Lu
- Department of Laboratory Medicine and Pathology, Center for Regenerative Biotherapeutics, Mayo Clinic, Rochester, Minnesota, USA
| | - Michael F Murphy
- NHS Blood and Transplant, Oxford University Hospitals NHS Foundation Trust, and the University of Oxford, Oxford, UK
| | - Monica B Pagano
- Department of Laboratory Medicine and Pathology, University of Washington, Washington, USA
| | - Simon J Stanworth
- NHS Blood and Transplant, Oxford University Hospitals NHS Foundation Trust, and the University of Oxford, Oxford, UK
| | - Andrew W Shih
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
- Centre for Innovation, Canadian Blood Services, Ottawa, Ontario, Canada
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Apelseth TO, Raza S, Callum J, Ipe T, Blackwood B, Akhtar A, Hess JR, Marks DC, Brown B, Delaney M, Wendel S, Stanworth SJ. A review and analysis of outcomes in randomized clinical trials of plasma transfusion in patients with bleeding or for the prevention of bleeding: The BEST collaborative study. Transfusion 2024. [PMID: 38623793 DOI: 10.1111/trf.17835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 03/26/2024] [Accepted: 03/28/2024] [Indexed: 04/17/2024]
Abstract
BACKGROUND Previous systematic reviews have revealed an inconsistency of outcome definitions as a major barrier in providing evidence-based guidance for the use of plasma transfusion to prevent or treat bleeding. We reviewed and analyzed outcomes in randomized controlled trials (RCTs) to provide a methodology for describing and classifying outcomes. STUDY DESIGN AND METHODS RCTs involving transfusion of plasma published after 2000 were identified from a prior review (Yang 2012) and combined with an updated systematic literature search of multiple databases (July 1, 2011 to January 17, 2023). Inclusion of publications, data extraction, and risk of bias assessments were performed in duplicate. (PROSPERO registration number is: CRD42020158581). RESULTS In total, 5579 citations were identified in the new systematic search and 22 were included. Six additional trials were identified from the previous review, resulting in a total of 28 trials: 23 therapeutic and five prophylactic studies. An increasing number of studies in the setting of major bleeding such as in cardiovascular surgery and trauma were identified. Eighty-seven outcomes were reported with a mean of 11 (min-max. 4-32) per study. There was substantial variation in outcomes used with a preponderance of surrogate measures for clinical effect such as laboratory parameters and blood usage. CONCLUSION There is an expanding literature on plasma transfusion to inform guidelines. However, considerable heterogeneity of reported outcomes constrains comparisons. A core outcome set should be developed for plasma transfusion studies. Standardization of outcomes will motivate better study design, facilitate comparison, and improve clinical relevance for future trials of plasma transfusion.
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Affiliation(s)
- Torunn O Apelseth
- Department of Immunology and Transfusion Medicine, Haukeland University Hospital, Bergen, Norway
- Faculty of Medicine, University of Bergen, Bergen, Norway
- Norwegian Armed Forces Joint Medical Services, Oslo, Norway
| | - Sheharyar Raza
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Canada
| | - Jeannie Callum
- Department of Pathology and Molecular Medicine, Kingston Health Sciences Centre and Queen's University, Kingston, Canada
| | - Tina Ipe
- Our Blood Institute, Oklahoma City, Oklahoma, USA
- Department of Pathology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Bronagh Blackwood
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University, Belfast, UK
| | | | - John R Hess
- Department of Laboratory Medicine and Pathology, University of Washington School of Medicine, Seattle, Washington, USA
| | - Denese C Marks
- Research and Development, Australian Red Cross Lifeblood, Sydney, Australia
| | - Bethany Brown
- American Red Cross, Medical and Scientific Office, Washington, DC, USA
| | | | | | - Simon J Stanworth
- NHSBT, Oxford University Hospitals NHS Trust; Blood Transfusion Research Unit (BTRU), University of Oxford, Oxford, UK
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3
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Du Pont-Thibodeau G, Li SYH, Ducharme-Crevier L, Jutras C, Pantopoulos K, Farrell C, Roumeliotis N, Harrington K, Thibault C, Roy N, Shah A, Lacroix J, Stanworth SJ. Iron Deficiency in Anemic Children Surviving Critical Illness: Post Hoc Analysis of a Single-Center Prospective Cohort in Canada, 2019-2022. Pediatr Crit Care Med 2024; 25:344-353. [PMID: 38358779 DOI: 10.1097/pcc.0000000000003442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/16/2024]
Abstract
OBJECTIVES Many children leave the PICU with anemia. The mechanisms of post-PICU anemia are poorly investigated, and treatment of anemia, other than blood, is rarely started during PICU. We aimed to characterize the contributions of iron depletion (ID) and/or inflammation in the development of post-PICU anemia and to explore the utility of hepcidin (a novel iron marker) at detecting ID during inflammation. DESIGN Post hoc analysis of a single-center prospective study (November 2019 to September 2022). SETTING PICU, quaternary center, Canada. PATIENTS Children admitted to PICU with greater than or equal to 48 hours of invasive or greater than or equal to 96 hours of noninvasive ventilation. We excluded patients with preexisting conditions causing anemia or those admitted after cardiac surgery. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Hematological and iron profiles were performed at PICU discharge on 56 participants of which 37 (37/56) were diagnosed with anemia. Thirty-three children (33/56; 59%) were younger than 2 years. Median Pediatric Logistic Organ Dysfunction score was 11 (interquartile range, 6-16). Twenty-four of the 37 anemic patients had repeat bloodwork 2 months post-PICU. Of those, four (4/24; 16%) remained anemic. Hematologic profiles were categorized as: anemia of inflammation (AI), iron deficiency anemia (IDA), IDA with inflammation, and ID (low iron stores without anemia). Seven (7/47; 15%) had AI at discharge, and one had persistent AI post-PICU. Three patients (3/47; 6%) had IDA at discharge; of which one was lost to follow-up and the other two were no longer anemic but had ID post-PICU. Eleven additional patients developed ID post-PICU. In the exploratory analysis, we identified a diagnostic cutoff value for ID during inflammation from the receiver operating characteristic curve for hepcidin of 31.9 pg/mL. This cutoff would increase the detection of ID at discharge from 6% to 34%. CONCLUSIONS The burden of ID in children post-PICU is high and better management strategies are required. Hepcidin may increase the diagnostic yield of ID in patients with inflammation.
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Affiliation(s)
| | - Shu Yin Han Li
- Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montréal, QC, Canada
| | | | - Camille Jutras
- Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montréal, QC, Canada
| | - Kostas Pantopoulos
- Lady Davis Institute for Medical Research, Jewish General Hospital, McGill University, Montréal, QC, Canada
| | - Catherine Farrell
- Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montréal, QC, Canada
| | - Nadia Roumeliotis
- Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montréal, QC, Canada
| | - Karen Harrington
- Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montréal, QC, Canada
| | - Céline Thibault
- Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montréal, QC, Canada
| | - Noémi Roy
- Department of Hematology, John Radcliffe Hospital, Oxford University Hospitals NHS Trust, Oxford, United Kingdom
| | - Akshay Shah
- Nuffield Department of Clinical Neuroscience, University of Oxford, Oxford, United Kingdom
| | - Jacques Lacroix
- Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montréal, QC, Canada
| | - Simon J Stanworth
- Department of Hematology, John Radcliffe Hospital, Oxford University Hospitals NHS Trust, Oxford, United Kingdom
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4
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Pagano MB, Stanworth SJ, Valentine S, Metcalf R, Wood EM, Pavenski K, Cholette J, So-Osman C, Carson JL. The 2023 AABB international guidelines for red blood cell transfusions: What is new? Transfusion 2024; 64:727-732. [PMID: 38380850 DOI: 10.1111/trf.17764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Accepted: 02/06/2024] [Indexed: 02/22/2024]
Affiliation(s)
- Monica B Pagano
- Transfusion Medicine, Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington, USA
- AABB Clinical Transfusion Practice Committee, Bethesda, Maryland, USA
| | - Simon J Stanworth
- Department of Haematology, Oxford University Hospitals NHS Trust; NHSBT, Oxford, UK
- Radcliffe Department of Medicine, Department of Transfusion Medicine, NHS Blood and Transplant, Oxford, UK
| | - Stacey Valentine
- Department of Pediatrics, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Ryan Metcalf
- AABB Clinical Transfusion Practice Committee, Bethesda, Maryland, USA
- Department of Pathology, University of Utah, Salt Lake City, Utah, USA
| | - Erica M Wood
- Department of Haematology, Monash Health, Melbourne, Victoria, Australia
- Monash University School of Public Health and Preventive Medicine, Melbourne, Victoria, Australia
- International Society of Blood Transfusion, Amsterdam, Netherlands
| | - Katerina Pavenski
- Department of Laboratory Medicine and Pathobiology, University of Toronto and St Michael's Hospital-Unity Health Toronto, Toronto, Ontario, Canada
- International Collaboration for Transfusion Medicine Guidelines, British Columbia, Canada
| | - Jill Cholette
- Department of Pediatrics, University of Rochester, Golisano Children's Hospital, Rochester, New York, USA
| | - Cynthia So-Osman
- Department of Unit Transfusion Medicine (UTG), Sanquin Blood Bank, Amsterdam, the Netherlands
- Department Hematology, Erasmus Medical Center, Rotterdam, the Netherlands
- European Haematology Association, Transfusion-Specialized Working Group
| | - Jeffrey L Carson
- Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
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5
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Buckstein R, Callum J, Prica A, Bowen D, Wells RA, Leber B, Heddle N, Chodirker L, Cheung M, Mozessohn L, Yee K, Gallagher J, Parmentier A, Jamula E, McQuilten Z, Wood EM, Weinkov R, Zhang L, Mamedov A, Stanworth SJ, Lin Y. Red cell transfusion thresholds in outpatients with myelodysplastic syndromes: Combined results from two randomized controlled feasibility studies. Am J Hematol 2024; 99:473-476. [PMID: 38126081 DOI: 10.1002/ajh.27181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 11/21/2023] [Accepted: 11/30/2023] [Indexed: 12/23/2023]
Affiliation(s)
- Rena Buckstein
- Department of Medicine, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Jeannie Callum
- Department of Pathology and Molecular Medicine, Kingston Health Sciences Center, Kingston, Ontario, Canada
| | - Anca Prica
- Department of Medicine, Princess Margaret Hospital, United Health Network, Toronto, Ontario, Canada
| | - David Bowen
- Department of Medicine, University of York, York, UK
| | - Richard A Wells
- Department of Medicine, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Brian Leber
- Department of Medicine, Mcmaster University, Hamilton, Ontario, Canada
| | - Nancy Heddle
- Mcmaster Centre for Transfusion Research, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Lisa Chodirker
- Department of Medicine, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Matthew Cheung
- Department of Medicine, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Lee Mozessohn
- Department of Medicine, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Karen Yee
- Department of Medicine, Princess Margaret Hospital, United Health Network, Toronto, Ontario, Canada
| | - Jennifer Gallagher
- Department of Medicine, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Anne Parmentier
- Department of Medicine, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Erin Jamula
- Department of Medicine, Mcmaster University, Hamilton, Ontario, Canada
| | - Zoe McQuilten
- Transfusion Research Unit, Division of Acute and Critical Care, Monash University, Melbourne, Victoria, Australia
| | - Erica M Wood
- Transfusion Research Unit, Division of Acute and Critical Care, Monash University, Melbourne, Victoria, Australia
| | - Robert Weinkov
- Malaghan Institute of Medical Research Newton, Wellington, New Zealand
| | | | - Alex Mamedov
- Department of Medicine, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Simon J Stanworth
- NHS Blood and Transplant, Oxford, UK
- Oxford University NHS Trust, The John Radcliffe Hospital, Oxford, UK
- Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Yulia Lin
- Precision Diagnostics and Therapeutics Program, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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6
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Buckstein R, Callum J, Prica A, Bowen D, Wells RA, Leber B, Heddle N, Chodirker L, Cheung M, Mozessohn L, Yee K, Gallagher J, Parmentier A, Jamula E, Zhang L, Mamedov A, Stanworth SJ, Lin Y. Red cell transfusion thresholds in outpatients with myelodysplastic syndromes: Results of a pilot randomized trial RBC-ENHANCE. Transfusion 2024; 64:223-235. [PMID: 38323704 DOI: 10.1111/trf.17721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 11/16/2023] [Accepted: 11/18/2023] [Indexed: 02/08/2024]
Abstract
BACKGROUND The optimal hemoglobin (Hb) threshold for red blood cell transfusions in adult patients with myelodysplastic syndromes (MDS) has not been defined. STUDY DESIGN AND METHODS We conducted a pilot randomized multi-center study of two transfusion algorithms (liberal, to maintain Hb 110-120 g/L, transfuse 2 units if Hb < 105 g/L and 1 unit if Hb 105-110 g/L vs. restrictive, 85-105 g/L, transfuse 2 units when Hgb < 85 g/L). Primary objectives were 70% compliance in maintaining the q2 week hemoglobin within the targeted range and the achievement of a 15 g/L difference in pre-transfusion Hb. Secondary outcomes included measures of quality of life (QOL), iron studies and safety. RESULTS Twenty-eight patients were randomized between February 2015-2020, 13 to the restrictive arm and 15 to the liberal arm in three tertiary care centers. The compliance was 66% and 45% and the mean pre-transfusion Hb thresholds were 86 (standard deviation [SD] 8) and 98 g/L (SD 10) in the restrictive and liberal arms, (mean difference 11.8 g/L, p < .0001), respectively. Patients in the liberal arm experienced a mean of 3.4 (SD 2.6) more transfusion visits and received a mean of 5.3 (SD 5.5) more units of blood during the 12-week study. Ferritin increased by 1043 (SD 1516) IU/L and 148 (SD 1319) IU/L in the liberal and restrictive arms, respectively. Selected QOL scores were superior pre-transfusion and more patients achieved clinically important improvements in the liberal arm compared with the restrictive arm for selected symptoms and function domains. CONCLUSION The results establish that policies for transfusion support can be delivered in practice at multiple hospitals, but further research is required to understand the full clinical effects and safety of liberal transfusion policies in MDS outpatients.
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Affiliation(s)
- Rena Buckstein
- Department of Medicine, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Jeannie Callum
- Department of Pathology and Molecular Medicine, Kingston Health Sciences Centre and Queen's University, Kingston, Ontario, Canada
| | - Anca Prica
- Department of Medicine, Princess Margaret Hospital, United Health Network, Toronto, Ontario, Canada
| | - David Bowen
- Department of Medicine, University of York, York, UK
| | - Richard A Wells
- Department of Medicine, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Brian Leber
- Department of Medicine, Mcmaster University, Hamilton, Ontario, Canada
| | - Nancy Heddle
- Mcmaster Centre for Transfusion Research, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Lisa Chodirker
- Department of Medicine, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Matthew Cheung
- Department of Medicine, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Lee Mozessohn
- Department of Medicine, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Karen Yee
- Department of Medicine, Princess Margaret Hospital, United Health Network, Toronto, Ontario, Canada
| | - Jennifer Gallagher
- Department of Medicine, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Anne Parmentier
- Department of Medicine, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Erin Jamula
- Department of Medicine, Mcmaster University, Hamilton, Ontario, Canada
| | | | - Alex Mamedov
- Department of Medicine, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Simon J Stanworth
- NHS Blood and Transplant, Oxford, UK
- Oxford University NHS Trust, The John Radcliffe Hospital, Oxford, UK
- Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Yulia Lin
- Precision Diagnostics and Therapeutics Program, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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7
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Mo A, Wood E, Shortt J, Charlton A, Evers D, Hoeks M, Pritchard E, Daly J, Hodgson C, Opat S, Bowen D, Reynolds J, Thi Phung Thao L, Stanworth SJ, McQuilten Z. Rethinking the transfusion pathway in myelodysplastic syndromes: Study protocol for a novel randomized feasibility n-of-1 trial of weekly-interval red cell transfusion in myelodysplastic syndromes. Transfusion 2024; 64:236-247. [PMID: 38214417 DOI: 10.1111/trf.17706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Revised: 11/30/2023] [Accepted: 12/07/2023] [Indexed: 01/13/2024]
Abstract
BACKGROUND Anemia in myelodysplastic syndromes (MDS) is associated with poorer health-related quality of life (HRQoL) and physical function, and is frequently treated with transfusions. The current common practice of transfusing multiple red blood cells (RBC) units every 2-4 weeks may result in peaks/troughs in hemoglobin (Hb) level, yet maintaining a stable Hb may better improve HRQoL. We describe a study protocol aiming to investigate the feasibility of weekly low-dose RBC transfusion in MDS patients, including assessing HRQoL and physical function outcomes. STUDY DESIGN AND METHODS In this n-of-1 pilot study, patients receive two treatment arms, with randomly allocated treatment sequence: arm A (patient's usual transfusion schedule) and arm B (weekly transfusion, individualized per patient). To facilitate timely delivery of weekly transfusion, extended-matched RBCs are provided, with transfusion based upon the previous week's Hb/pre-transfusion testing results to eliminate delays of awaiting contemporaneous cross-matching. Primary outcome is the feasibility of delivering weekly transfusion. Secondary outcomes include HRQoL, functional activity measurements, RBC usage, and alloimmunization rates. A qualitative substudy explores patient and staff experiences. RESULTS The trial is open in Australia, Netherlands, and UK. The first patient was recruited in 2020. Inter-country differences in providing RBCs are observed, including patient genotyping versus serological phenotyping to select compatible units. DISCUSSION This pilot trial evaluates a novel personalized transfusion approach of weekly matched RBC transfusion and challenges the dogma of current routine pre-transfusion matching practice. Findings on study feasibility, HRQoL, and physical functional outcomes and the qualitative substudy will inform the design of a larger definitive trial powered for clinical outcomes.
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Affiliation(s)
- Allison Mo
- Transfusion Research Unit, School of Public Health & Preventive Medicine, Monash University, Australia
- Department of Haematology, Monash Health, Clayton, Australia
- Austin Pathology & Department of Haematology, Austin Health, Heidelberg, Australia
| | - Erica Wood
- Transfusion Research Unit, School of Public Health & Preventive Medicine, Monash University, Australia
- Department of Haematology, Monash Health, Clayton, Australia
| | - Jake Shortt
- Department of Haematology, Monash Health, Clayton, Australia
- Department of Medicine, School of Clinical Sciences, Faculty of Medicine, Nursing & Health Sciences, Monash University, Melbourne, Australia
| | - Andrew Charlton
- Department of Haematology, The Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK
- Transfusion Medicine, NHS Blood and Transplant, Oxford, UK
| | - Dorothea Evers
- Department of Haematology, Radboudumc, Nijmegen, The Netherlands
| | - Marlijn Hoeks
- Department of Haematology, Radboudumc, Nijmegen, The Netherlands
| | - Elizabeth Pritchard
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - James Daly
- Australian Red Cross Lifeblood, Melbourne, Australia
| | - Carol Hodgson
- The Australian and New Zealand Intensive Care-Research Centre, Monash University, Melbourne, Australia
- The Alfred, Melbourne, Australia
- The George Institute for Global Health, Sydney, Australia
- Department of Critical Care, The University of Melbourne, Melbourne, Australia
| | - Stephen Opat
- Department of Haematology, Monash Health, Clayton, Australia
| | - David Bowen
- Department of Health Sciences, University of York, York, UK
| | - John Reynolds
- Department of Clinical Haematology, The Alfred, Melbourne, Australia
- Australian Centre for Blood Diseases, Central Clinical School, Monash University, Melbourne, Australia
| | - Le Thi Phung Thao
- Transfusion Research Unit, School of Public Health & Preventive Medicine, Monash University, Australia
| | - Simon J Stanworth
- Transfusion Medicine, NHS Blood and Transplant, Oxford, UK
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Zoe McQuilten
- Transfusion Research Unit, School of Public Health & Preventive Medicine, Monash University, Australia
- Department of Haematology, Monash Health, Clayton, Australia
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8
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Evans HG, Murphy MF, Foy R, Dhiman P, Green L, Kotze A, von Neree L, Palmer AJ, Robinson SE, Shah A, Tomini F, Trompeter S, Warnakulasuriya S, Wong WK, Stanworth SJ. Harnessing the potential of data-driven strategies to optimise transfusion practice. Br J Haematol 2024; 204:74-85. [PMID: 37964471 DOI: 10.1111/bjh.19158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Revised: 09/24/2023] [Accepted: 10/03/2023] [Indexed: 11/16/2023]
Abstract
No one doubts the significant variation in the practice of transfusion medicine. Common examples are the variability in transfusion thresholds and the use of tranexamic acid for surgery with likely high blood loss despite evidence-based standards. There is a long history of applying different strategies to address this variation, including education, clinical guidelines, audit and feedback, but the effectiveness and cost-effectiveness of these initiatives remains unclear. Advances in computerised decision support systems and the application of novel electronic capabilities offer alternative approaches to improving transfusion practice. In England, the National Institute for Health and Care Research funded a Blood and Transplant Research Unit (BTRU) programme focussing on 'A data-enabled programme of research to improve transfusion practices'. The overarching aim of the BTRU is to accelerate the development of data-driven methods to optimise the use of blood and transfusion alternatives, and to integrate them within routine practice to improve patient outcomes. One particular area of focus is implementation science to address variation in practice.
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Affiliation(s)
- H G Evans
- NIHR Blood and Transplant Research Unit in Data Driven Transfusion Practice, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - M F Murphy
- NIHR Blood and Transplant Research Unit in Data Driven Transfusion Practice, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
- Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK
- NHS Blood and Transplant, John Radcliffe Hospital, Oxford, UK
| | - R Foy
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - P Dhiman
- Centre for Statistics in Medicine, Botnar Research Centre, Oxford, UK
| | - L Green
- Blizard Institute, Queen Mary University of London, London, UK
- Barts Health NHS Trust, London, UK
- NHS Blood and Transplant, London, UK
| | - A Kotze
- Leeds Teaching Hospitals, Leeds, UK
| | - L von Neree
- University College London Hospitals NHS Foundation Trust, London, UK
| | - A J Palmer
- Nuffield Orthopaedic Centre, Oxford University NHS Foundation Trust, Oxford, UK
| | - S E Robinson
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - A Shah
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - F Tomini
- Queen Mary University of London, London, UK
| | - S Trompeter
- University College London Hospitals NHS Foundation Trust, London, UK
- University College London, London, UK
| | - S Warnakulasuriya
- University College London Hospitals NHS Foundation Trust, London, UK
- University College London, London, UK
| | - W K Wong
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - S J Stanworth
- NIHR Blood and Transplant Research Unit in Data Driven Transfusion Practice, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
- Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK
- NHS Blood and Transplant, John Radcliffe Hospital, Oxford, UK
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9
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Maynard S, Farrington J, Alimam S, Evans H, Li K, Wong WK, Stanworth SJ. Machine learning in transfusion medicine: A scoping review. Transfusion 2024; 64:162-184. [PMID: 37950535 DOI: 10.1111/trf.17582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 09/25/2023] [Accepted: 09/27/2023] [Indexed: 11/12/2023]
Affiliation(s)
- Suzanne Maynard
- Medical Sciences Division, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
- NIHR Blood and Transplant Research Unit in Data Driven Transfusion Practice, Nuffield Division of Clinical Laboratory Sciences, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
- NHSBT and Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Joseph Farrington
- Institute of Health Informatics, University College London, London, UK
| | - Samah Alimam
- Haematology Department, University College London Hospitals NHS Foundation Trust, London, UK
| | - Hayley Evans
- NIHR Blood and Transplant Research Unit in Data Driven Transfusion Practice, Nuffield Division of Clinical Laboratory Sciences, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Kezhi Li
- Institute of Health Informatics, University College London, London, UK
| | - Wai Keong Wong
- Director of Digital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Simon J Stanworth
- Medical Sciences Division, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
- NIHR Blood and Transplant Research Unit in Data Driven Transfusion Practice, Nuffield Division of Clinical Laboratory Sciences, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
- NHSBT and Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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10
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Al-Riyami AZ, Vanden Broeck J, Rahimi-Levene N, Das S, Saxon B, Lin Y, Stanworth SJ. E-learning in transfusion medicine: A scoping review. Transfusion 2023; 63:2362-2376. [PMID: 37876263 DOI: 10.1111/trf.17564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 09/06/2023] [Accepted: 09/08/2023] [Indexed: 10/26/2023]
Affiliation(s)
- Arwa Z Al-Riyami
- Department of Haematology, Sultan Qaboos University Hospital, Sultan Qaboos University, Muscat, Oman
| | - Jana Vanden Broeck
- Department of Hematology, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel (VUB), Brussels, Belgium
- Federal Public Service Health, Food Chain Safety and Environment, Brussels, Belgium
| | - Naomi Rahimi-Levene
- Blood Bank, Shamir Medical Center, Zerifin, Israel
- Adelson School of Medicine, Ariel University, Ariel, Israel
| | - Soumya Das
- Department of Transfusion Medicine, All India Institute of Medical Sciences (AIIMS), Nagpur, Maharashtra, India
| | - Ben Saxon
- Department of Haematology/Oncology, Women's and Children's Hospital, Adelaide, Australia
| | - Yulia Lin
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
- University of Toronto Quality in Utilization, Education and Safety in Transfusion (QUEST) Research Program, Toronto, Ontario, Canada
| | - Simon J Stanworth
- Transfusion Medicine, NHS Blood and Transplant, Oxford, Oxford, UK
- Oxford University Hospitals NHS Trust, University of Oxford, Oxford, UK
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11
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van der Staaij H, Stanworth SJ, Fustolo-Gunnink SF. Prophylactic Platelet Transfusions: Why Less Is More. Clin Perinatol 2023; 50:775-792. [PMID: 37866847 DOI: 10.1016/j.clp.2023.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2023]
Abstract
Preterm neonates are a highly transfused patient group, with platelet transfusions being the second most transfused cellular blood component. Historically, however, evidence to inform optimal platelet transfusion practice has been limited. In pediatrics, much of the evidence has been inferred from studies in adult patients, although neonatologists have generally applied more cautious and liberal platelet transfusion thresholds to mitigate the complications of intraventricular hemorrhage. A total of three randomized controlled trials have now been published comparing different platelet transfusion strategies in neonates.
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Affiliation(s)
- Hilde van der Staaij
- Department of Pediatrics, Division of Neonatology, Willem-Alexander Children's Hospital, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, the Netherlands; Sanquin Research & Lab Services, Sanquin Blood Supply Foundation, Amsterdam, Plesmanlaan 125, 1066 CX, the Netherlands; Department of Pediatric Hematology, Emma Children's Hospital, Amsterdam University Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands.
| | - Simon J Stanworth
- NHSBT, Oxford University Hospitals, NHS Foundation Trust, Radcliffe Department of Medicine, University of Oxford, Headley Way, Headington, Oxford OX3 9DU, United Kingdom
| | - Susanna F Fustolo-Gunnink
- Department of Pediatrics, Division of Neonatology, Willem-Alexander Children's Hospital, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, the Netherlands; Sanquin Research & Lab Services, Sanquin Blood Supply Foundation, Amsterdam, Plesmanlaan 125, 1066 CX, the Netherlands; Department of Pediatric Hematology, Emma Children's Hospital, Amsterdam University Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands
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12
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Davenport R, Curry N, Fox EE, Thomas H, Lucas J, Evans A, Shanmugaranjan S, Sharma R, Deary A, Edwards A, Green L, Wade CE, Benger JR, Cotton BA, Stanworth SJ, Brohi K. Early and Empirical High-Dose Cryoprecipitate for Hemorrhage After Traumatic Injury: The CRYOSTAT-2 Randomized Clinical Trial. JAMA 2023; 330:1882-1891. [PMID: 37824155 PMCID: PMC10570921 DOI: 10.1001/jama.2023.21019] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 09/26/2023] [Indexed: 10/13/2023]
Abstract
Importance Critical bleeding is associated with a high mortality rate in patients with trauma. Hemorrhage is exacerbated by a complex derangement of coagulation, including an acute fibrinogen deficiency. Management is fibrinogen replacement with cryoprecipitate transfusions or fibrinogen concentrate, usually administered relatively late during hemorrhage. Objective To assess whether survival could be improved by administering an early and empirical high dose of cryoprecipitate to all patients with trauma and bleeding that required activation of a major hemorrhage protocol. Design, Setting, and Participants CRYOSTAT-2 was an interventional, randomized, open-label, parallel-group controlled, international, multicenter study. Patients were enrolled at 26 UK and US major trauma centers from August 2017 to November 2021. Eligible patients were injured adults requiring activation of the hospital's major hemorrhage protocol with evidence of active hemorrhage, systolic blood pressure less than 90 mm Hg at any time, and receiving at least 1 U of a blood component transfusion. Intervention Patients were randomly assigned (in a 1:1 ratio) to receive standard care, which was the local major hemorrhage protocol (reviewed for guideline adherence), or cryoprecipitate, in which 3 pools of cryoprecipitate (6-g fibrinogen equivalent) were to be administered in addition to standard care within 90 minutes of randomization and 3 hours of injury. Main Outcomes and Measures The primary outcome was all-cause mortality at 28 days in the intention-to-treat population. Results Among 1604 eligible patients, 799 were randomized to the cryoprecipitate group and 805 to the standard care group. Missing primary outcome data occurred in 73 patients (principally due to withdrawal of consent) and 1531 (95%) were included in the primary analysis population. The median (IQR) age of participants was 39 (26-55) years, 1251 (79%) were men, median (IQR) Injury Severity Score was 29 (18-43), 36% had penetrating injury, and 33% had systolic blood pressure less than 90 mm Hg at hospital arrival. All-cause 28-day mortality in the intention-to-treat population was 26.1% in the standard care group vs 25.3% in the cryoprecipitate group (odds ratio, 0.96 [95% CI, 0.75-1.23]; P = .74). There was no difference in safety outcomes or incidence of thrombotic events in the standard care vs cryoprecipitate group (12.9% vs 12.7%). Conclusions and Relevance Among patients with trauma and bleeding who required activation of a major hemorrhage protocol, the addition of early and empirical high-dose cryoprecipitate to standard care did not improve all cause 28-day mortality. Trial Registration ClinicalTrials.gov Identifier: NCT04704869; ISRCTN Identifier: ISRCTN14998314.
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Affiliation(s)
- Ross Davenport
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, United Kingdom
| | - Nicola Curry
- Nuffield Orthopedic Hospital, Oxford University Hospitals NHS Foundation Trust, Headington, Oxford, United Kingdom
| | - Erin E. Fox
- Center for Translational Injury Research, The University of Texas Health Science Center, Houston
| | - Helen Thomas
- NHS Blood and Transplant Clinical Trials Unit, Stoke Gifford, Bristol, United Kingdom
| | - Joanne Lucas
- NHS Blood and Transplant Clinical Trials Unit, Cambridge, United Kingdom
| | - Amy Evans
- NHS Blood and Transplant Clinical Trials Unit, Cambridge, United Kingdom
| | | | - Rupa Sharma
- NHS Blood and Transplant Clinical Trials Unit, Cambridge, United Kingdom
| | - Alison Deary
- NHS Blood and Transplant Clinical Trials Unit, Cambridge, United Kingdom
| | - Antoinette Edwards
- The Trauma Audit & Research Network, University of Manchester, Salford Royal NHS Foundation Trust, Salford, United Kingdom
| | - Laura Green
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, United Kingdom
| | - Charles E. Wade
- Center for Translational Injury Research, The University of Texas Health Science Center, Houston
| | - Jonathan R. Benger
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, United Kingdom
| | - Bryan A. Cotton
- Center for Translational Injury Research, The University of Texas Health Science Center, Houston
| | - Simon J. Stanworth
- Radcliffe Department of Medicine, John Radcliffe Hospital, NHS Blood and Transplant and Oxford University Hospitals NHS Foundation Trust, University of Oxford, Headington, Oxford, United Kingdom
| | - Karim Brohi
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, United Kingdom
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13
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Carson JL, Stanworth SJ, Guyatt G, Valentine S, Dennis J, Bakhtary S, Cohn CS, Dubon A, Grossman BJ, Gupta GK, Hess AS, Jacobson JL, Kaplan LJ, Lin Y, Metcalf RA, Murphy CH, Pavenski K, Prochaska MT, Raval JS, Salazar E, Saifee NH, Tobian AAR, So-Osman C, Waters J, Wood EM, Zantek ND, Pagano MB. Red Blood Cell Transfusion: 2023 AABB International Guidelines. JAMA 2023; 330:1892-1902. [PMID: 37824153 DOI: 10.1001/jama.2023.12914] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/13/2023]
Abstract
Importance Red blood cell transfusion is a common medical intervention with benefits and harms. Objective To provide recommendations for use of red blood cell transfusion in adults and children. Evidence Review Standards for trustworthy guidelines were followed, including using Grading of Recommendations Assessment, Development and Evaluation methods, managing conflicts of interest, and making values and preferences explicit. Evidence from systematic reviews of randomized controlled trials was reviewed. Findings For adults, 45 randomized controlled trials with 20 599 participants compared restrictive hemoglobin-based transfusion thresholds, typically 7 to 8 g/dL, with liberal transfusion thresholds of 9 to 10 g/dL. For pediatric patients, 7 randomized controlled trials with 2730 participants compared a variety of restrictive and liberal transfusion thresholds. For most patient populations, results provided moderate quality evidence that restrictive transfusion thresholds did not adversely affect patient-important outcomes. Recommendation 1: for hospitalized adult patients who are hemodynamically stable, the international panel recommends a restrictive transfusion strategy considering transfusion when the hemoglobin concentration is less than 7 g/dL (strong recommendation, moderate certainty evidence). In accordance with the restrictive strategy threshold used in most trials, clinicians may choose a threshold of 7.5 g/dL for patients undergoing cardiac surgery and 8 g/dL for those undergoing orthopedic surgery or those with preexisting cardiovascular disease. Recommendation 2: for hospitalized adult patients with hematologic and oncologic disorders, the panel suggests a restrictive transfusion strategy considering transfusion when the hemoglobin concentration is less than 7 g/dL (conditional recommendations, low certainty evidence). Recommendation 3: for critically ill children and those at risk of critical illness who are hemodynamically stable and without a hemoglobinopathy, cyanotic cardiac condition, or severe hypoxemia, the international panel recommends a restrictive transfusion strategy considering transfusion when the hemoglobin concentration is less than 7 g/dL (strong recommendation, moderate certainty evidence). Recommendation 4: for hemodynamically stable children with congenital heart disease, the international panel suggests a transfusion threshold that is based on the cardiac abnormality and stage of surgical repair: 7 g/dL (biventricular repair), 9 g/dL (single-ventricle palliation), or 7 to 9 g/dL (uncorrected congenital heart disease) (conditional recommendation, low certainty evidence). Conclusions and Relevance It is good practice to consider overall clinical context and alternative therapies to transfusion when making transfusion decisions about an individual patient.
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Affiliation(s)
- Jeffrey L Carson
- Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Simon J Stanworth
- Department of Haematology, Oxford University Hospitals NHS Trust, Oxford, United Kingdom
- NHSBT, Oxford, United Kingdom
- Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
- Department of Transfusion Medicine, NHS Blood and Transplant, Oxford, United Kingdom
| | - Gordon Guyatt
- Departments of Clinical Epidemiology and Biostatistics and Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Stacey Valentine
- Department of Pediatrics, University of Massachusetts Chan Medical School, Worcester
| | - Jane Dennis
- Cochrane Injuries Group, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Sara Bakhtary
- Department of Laboratory Medicine, University of California, San Francisco
| | - Claudia S Cohn
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis
| | | | - Brenda J Grossman
- Department of Pathology and Immunology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Gaurav K Gupta
- Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Aaron S Hess
- Departments of Anesthesiology and Pathology and Laboratory Medicine, University of Wisconsin-Madison, Madison
| | - Jessica L Jacobson
- Department of Pathology, New York University Grossman School of Medicine, New York
- NYC Health + Hospitals/Bellevue, New York, New York
| | - Lewis J Kaplan
- Department of Surgery, Division of Trauma, Surgical Critical Care and Surgical Emergencies, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Yulia Lin
- Precision Diagnostics and Therapeutics Program, Sunnybrook Health Sciences Centre, Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Ryan A Metcalf
- Department of Pathology, University of Utah, Salt Lake City
| | - Colin H Murphy
- Pathology Associates of Albuquerque, Albuquerque, New Mexico
| | - Katerina Pavenski
- Department of Laboratory Medicine and Pathobiology, University of Toronto and St Michael's Hospital-Unity Health Toronto, Toronto, Ontario, Canada
| | | | - Jay S Raval
- Department of Pathology, University of New Mexico, Albuquerque
| | - Eric Salazar
- Department of Pathology and Laboratory Medicine, UT Health San Antonio, San Antonio, Texas
| | - Nabiha H Saifee
- Department of Laboratory Medicine and Pathology, Seattle Children's Hospital, Seattle, Washington
| | - Aaron A R Tobian
- Department of Pathology, Johns Hopkins University, Baltimore, Maryland
| | - Cynthia So-Osman
- Department of Unit Transfusion Medicine (UTG), Sanquin Blood Bank, Amsterdam, the Netherlands
- Department Hematology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Jonathan Waters
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Erica M Wood
- Department of Haematology, Monash Health, Monash University School of Public Health and Preventive Medicine, Melbourne, Victoria, Australia
| | - Nicole D Zantek
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis
| | - Monica B Pagano
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle
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14
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Smith JE, Barnard EBG, Brown-O'Sullivan C, Cardigan R, Davies J, Hawton A, Laing E, Lucas J, Lyon R, Perkins GD, Smith L, Stanworth SJ, Weaver A, Woolley T, Green L. The SWiFT trial (Study of Whole Blood in Frontline Trauma)-the clinical and cost effectiveness of pre-hospital whole blood versus standard care in patients with life-threatening traumatic haemorrhage: study protocol for a multi-centre randomised controlled trial. Trials 2023; 24:725. [PMID: 37964393 PMCID: PMC10644622 DOI: 10.1186/s13063-023-07711-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 10/06/2023] [Indexed: 11/16/2023] Open
Abstract
BACKGROUND Early blood transfusion improves survival in patients with life-threatening bleeding, but the optimal transfusion strategy in the pre-hospital setting has yet to be established. Although there is some evidence of benefit with the use of whole blood, there have been no randomised controlled trials exploring the clinical and cost effectiveness of pre-hospital administration of whole blood versus component therapy for trauma patients with life-threatening bleeding. The aim of this trial is to determine whether pre-hospital leukocyte-depleted whole blood transfusion is better than standard care (blood component transfusion) in reducing the proportion of participants who experience death or massive transfusion at 24 h. METHODS This is a multi-centre, superiority, open-label, randomised controlled trial with internal pilot and within-trial cost-effectiveness analysis. Patients of any age will be eligible if they have suffered major traumatic haemorrhage and are attended by a participating air ambulance service. The primary outcome is the proportion of participants with traumatic haemorrhage who have died (all-cause mortality) or received massive transfusion in the first 24 h from randomisation. A number of secondary clinical, process, and safety endpoints will be collected and analysed. Cost (provision of whole blood, hospital, health, and wider care resource use) and outcome data will be synthesised to present incremental cost-effectiveness ratios for the trial primary outcome and cost per quality-adjusted life year at 90 days after injury. We plan to recruit 848 participants (a two-sided test with 85% power, 5% type I error, 1-1 allocation, and one interim analysis would require 602 participants-after allowing for 25% of participants in traumatic cardiac arrest and an additional 5% drop out, the sample size is 848). DISCUSSION The SWiFT trial will recruit 848 participants across at least ten air ambulances services in the UK. It will investigate the clinical and cost-effectiveness of whole blood transfusion versus component therapy in the management of patients with life-threatening bleeding in the pre-hospital setting. TRIAL REGISTRATION ISRCTN: 23657907; EudraCT: 2021-006876-18; IRAS Number: 300414; REC: 22/SC/0072, 21 Dec 2021.
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Affiliation(s)
- Jason E Smith
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine, Birmingham, UK.
- University Hospitals Plymouth NHS Trust, Plymouth, UK.
| | - Ed B G Barnard
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine, Birmingham, UK
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | | | - Rebecca Cardigan
- NHS Blood & Transplant, Bristol, UK
- Department of Haematology, University of Cambridge, Cambridge, UK
| | | | - Annie Hawton
- Health Economics Group, University of Exeter, Exeter, UK
| | - Emma Laing
- Intensive Care National Audit and Research Centre (ICNARC), London, UK
| | - Joanne Lucas
- NHS Blood and Transplant Clinical Trials Unit, Cambridge, UK
| | - Richard Lyon
- Air Ambulance Kent Surrey Sussex, Rochester, UK
- Department of Health Sciences, University of Surrey, Guildford, UK
| | - Gavin D Perkins
- Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK
| | - Laura Smith
- NHS Blood and Transplant Clinical Trials Unit, Cambridge, UK
| | - Simon J Stanworth
- NHS Blood & Transplant, Bristol, UK
- Oxford University Hospitals, Oxford, UK
- University of Oxford, Oxford, UK
| | - Anne Weaver
- London's Air Ambulance and Royal London Hospital, London, UK
| | - Tom Woolley
- Academic Department of Military Anaesthesia and Critical Care, Royal Centre for Defence Medicine, Birmingham, UK
| | - Laura Green
- NHS Blood & Transplant, Bristol, UK
- Barts Health NHS Trust, London, UK
- Queen Mary University of London, London, UK
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15
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Pagano MB, Dennis JA, Idemudia OM, Stanworth SJ, Carson JL. An analysis of quality of life and functional outcomes as reported in randomized trials for red cell transfusions. Transfusion 2023; 63:2032-2039. [PMID: 37723866 DOI: 10.1111/trf.17540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 07/21/2023] [Accepted: 08/15/2023] [Indexed: 09/20/2023]
Abstract
BACKGROUND Meta-analyses of randomized controlled trials (RCTs) evaluating thresholds for red blood cell (RBC) transfusion typically focus on mortality; however, other outcomes are highly relevant. The aim of this study is to summarize the effects of different transfusion thresholds on the outcomes of quality of life (QoL) and function. STUDY DESIGN We extracted data from RCTs identified in a recently published Cochrane systematic review. Primary analysis was descriptive. RESULTS A total of 23 RCTs with 13,743 adult participants were included. Fifteen RCTs included patients in the postoperative period, of which 9 RCTs were conducted in hip (n = 3024) and 6 (n = 8672) in cardiac surgeries; 5 RCTs (n = 489) were in patients with hematological malignancies; 2 in the setting of bleeding (gastrointestinal bleed [n = 936] and postpartum [n = 521]); and one RCT (n = 936) included critically ill patients. QoL and function were reported using a variety of questionnaires and tools. The timing of assessments varied between trials. No clear clinical differences in QoL outcomes were identified in comparisons between restrictive and liberal transfusion thresholds. DISCUSSION There is no evidence that a liberal transfusion strategy improves QoL and functional outcomes. However, the substantial limitations of many included studies indicate the need for further well-designed and adequately powered trials.
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Affiliation(s)
- Monica B Pagano
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington, USA
| | - Jane A Dennis
- Cochrane Injuries Group, London School of Hygiene & Tropical Medicine, London, UK
| | - Osaumwense M Idemudia
- Department of Medicine, Rutgers Robert Wood Johnson Medical School, Piscataway, New Jersey, USA
| | - Simon J Stanworth
- NHS Blood and Transplant, Oxford, UK
- Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK
- Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Jeffrey L Carson
- Department of Medicine, Rutgers Robert Wood Johnson Medical School, Piscataway, New Jersey, USA
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16
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Maier CL, Stanworth SJ, Sola-Visner M, Kor D, Mast AE, Fasano R, Josephson CD, Triulzi DJ, Nellis ME. Prophylactic Platelet Transfusion: Is There Evidence of Benefit, Harm, or No Effect? Transfus Med Rev 2023; 37:150751. [PMID: 37599188 DOI: 10.1016/j.tmrv.2023.150751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 06/12/2023] [Accepted: 06/12/2023] [Indexed: 08/22/2023]
Abstract
The optimal use of prophylactic platelet transfusion remains uncertain in a number of clinical scenarios. Platelet count thresholds have been established in patients with hematologic malignancies, yet thresholds backed by scientific data are limited or do not exist for many patient populations. Clinical scenarios involving transfusion thresholds for thrombocytopenic patients with critical illness, need for surgery or invasive procedures, or those involving specials populations like children and neonates, lack clear evidence for discerning favorable outcomes without undue risk related to platelet transfusion. In addition, while prophylactic platelet transfusions are administered with the goal of enhancing hemostasis, increasing evidence supports critical nonhemostatic roles for platelets related to innate and adaptive immunity, inflammation, and angiogenesis, which may impact patient responses and outcomes. Here we review several recent studies conducted in adult or pediatric patients that highlight the limitations in our current understanding of prophylactic platelet transfusion. Together, these studies underscore the need for additional research, especially in the form of robust randomized clinical trials and integrating additional parameters beyond the platelet count. Future research at the basic, translational, and clinical levels will best define the optimal role for prophylactic transfusion across the lifespan and its broader impact on health and disease.
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Affiliation(s)
- Cheryl L Maier
- Center for Transfusion Medicine and Cellular Therapies, Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, GA, USA.
| | - Simon J Stanworth
- NHSBT; Oxford University Hospitals NHS Foundation Trust; Radcliffe Department of Medicine, University of Oxford; Oxford, United Kingdom
| | | | - Daryl Kor
- Department of Anesthesia and Perioperative Medicine, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Allan E Mast
- Department of Cell Biology, Neurobiology and Anatomy, Versiti Blood Center of Wisconsin, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Ross Fasano
- Center for Transfusion Medicine and Cellular Therapies, Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Cassandra D Josephson
- Department of Oncology, Cancer and Blood Disorders Institute, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
| | - Darrell J Triulzi
- Department of Pathology, Division of Transfusion Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Marianne E Nellis
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Weill Cornell Medicine, New York, NY, USA
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17
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Stanworth SJ, Shah A, Doidge J, Watkinson P. The ongoing dilemma of prophylactic platelet transfusions pre-procedure and the development of evidence-based recommendations. Transfus Med 2023; 33:428-430. [PMID: 37712550 DOI: 10.1111/tme.12994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 08/18/2023] [Indexed: 09/16/2023]
Affiliation(s)
- Simon J Stanworth
- Radcliffe Department of Medicine, University of Oxford, Oxford, UK
- NHS Blood and Transplant, Oxford, UK
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Akshay Shah
- Intensive Care National Audit and Research Centre, and London School of Hygiene & Tropical Medicine, London, UK
| | - James Doidge
- Oxford University Hospitals NHS Trust, Oxford, UK
| | - Peter Watkinson
- Intensive Care National Audit and Research Centre, and London School of Hygiene & Tropical Medicine, London, UK
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18
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Mo A, Poynton M, Wood E, Shortt J, Brunskill SJ, Doree C, Sandercock J, Saadah N, Luk E, Stanworth SJ, McQuilten Z. Do anemia treatments improve quality of life and physical function in patients with myelodysplastic syndromes (MDS)? A systematic review. Blood Rev 2023; 61:101114. [PMID: 37479599 DOI: 10.1016/j.blre.2023.101114] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 07/10/2023] [Accepted: 07/10/2023] [Indexed: 07/23/2023]
Abstract
Anemia is common in Myelodysplastic Syndromes (MDS). Different anemia treatments have been tested in clinical studies, but the full impact on patients' health-related quality of life (HRQoL) and physical function is unknown. The main aim of this review was to assess whether improvements in anemia are associated with changes in HRQoL/physical function. Twenty-six full-text publications were identified, enrolling 2211 patients: nine randomized trials (RCTs), fourteen non-randomized studies of interventions and three cross-sectional studies. Interventions included: growth factors/erythropoiesis-stimulating agents (n = 14), red cell transfusion (n = 9), erythroid maturation agents (n = 1), or a combination (n = 2). Five RCTs reported no changes in HRQoL despite erythroid response to the intervention, raising the question of whether anemia treatment alone can effectively improve HRQoL. Many studies were considered at high risk of bias for assessing HRQoL. There is a pressing need for future clinical trials to better define the nature of the relationship between anemia and HRQoL/functional outcomes.
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Affiliation(s)
- Allison Mo
- Transfusion Research Unit, School of Public Health & Preventive Medicine, Monash University, Australia; Department of Haematology, Monash Health, Clayton, Australia; Austin Pathology & Department of Haematology, Heidelberg, Australia
| | - Matthew Poynton
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Erica Wood
- Transfusion Research Unit, School of Public Health & Preventive Medicine, Monash University, Australia; Department of Haematology, Monash Health, Clayton, Australia
| | - Jake Shortt
- Department of Haematology, Monash Health, Clayton, Australia; School of Clinical Sciences, Monash University, Australia
| | - Susan J Brunskill
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, United Kingdom
| | - Carolyn Doree
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, United Kingdom
| | - Josie Sandercock
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, United Kingdom
| | - Nicholas Saadah
- Transfusion Research Unit, School of Public Health & Preventive Medicine, Monash University, Australia
| | - Edwin Luk
- Department of Medicine (Royal Melbourne Hospital), University of Melbourne, Melbourne, Australia
| | - Simon J Stanworth
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom; NHS Blood and Transplant, John Radcliffe Hospital, Oxford, United Kingdom; Radcliffe Department of Medicine, University of Oxford, United Kingdom
| | - Zoe McQuilten
- Transfusion Research Unit, School of Public Health & Preventive Medicine, Monash University, Australia; Department of Haematology, Monash Health, Clayton, Australia.
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Lisman T, Carlin S, Gatt A, Hernández-Gea V, Luyendyk JP, Roberts LN, Stanworth SJ. The ISTH SSC subcommittee on Hemostatic Management of Patients with Liver Disease: goals, ambitions, and call for collaboration: reply. J Thromb Haemost 2023; 21:2632-2633. [PMID: 37597901 DOI: 10.1016/j.jtha.2023.05.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 05/19/2023] [Indexed: 08/21/2023]
Affiliation(s)
- Ton Lisman
- Surgical Research Laboratory and Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands.
| | - Stephanie Carlin
- Thrombosis Service, Hamilton General Hospital, Hamilton, Ontario, Canada
| | - Alex Gatt
- Department of Pathology, Faculty of Medicine and Surgery, University of Malta, Msida, Malta
| | - Virginia Hernández-Gea
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, IDIBAPS, Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Health Care Provider of the European Reference Network on Rare Liver Disorders, University of Barcelona, Barcelona, Spain
| | - James P Luyendyk
- Department of Pathobiology and Diagnostic Investigation, Michigan State University, East Lansing, Michigan, USA
| | - Lara N Roberts
- King's Thrombosis Centre, Department of Haematological Medicine, King's College Hospital, London, UK
| | - Simon J Stanworth
- Transfusion Medicine, NHS Blood and Transplant, Department of Haematology, Oxford University Hospitals, NHS Foundation Trust, Radcliffe Department of Medicine, University of Oxford and NIHR Oxford Biomedical Research Centre (Haematology), Oxford, UK
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20
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Laermans J, Van Remoortel H, Scheers H, Avau B, Georgsen J, Nahirniak S, Shehata N, Stanworth SJ, De Buck E, Compernolle V, Vandekerckhove P. Cost Effectiveness of Different Platelet Preparation, Storage, Selection and Dosing Methods in Platelet Transfusion: A Systematic Review. Pharmacoecon Open 2023; 7:679-708. [PMID: 37365482 PMCID: PMC10471540 DOI: 10.1007/s41669-023-00427-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/24/2023] [Indexed: 06/28/2023]
Abstract
BACKGROUND AND OBJECTIVE Evidence-based guidelines on platelet transfusion therapy assist clinicians to optimize patient care, but currently do not take into account costs associated with different methods used during the preparation, storage, selection and dosing of platelets for transfusion. This systematic review aimed to summarize the available literature regarding the cost effectiveness (CE) of these methods. METHODS Eight databases and registries, as well as 58 grey literature sources, were searched up to 29 October 2021 for full economic evaluations comparing the CE of methods for preparation, storage, selection and dosing of allogeneic platelets intended for transfusion in adults. Incremental CE ratios, expressed as standardized cost (in 2022 EUR) per quality-adjusted life-year (QALY) or per health outcome, were synthesized narratively. Studies were critically appraised using the Philips checklist. RESULTS Fifteen full economic evaluations were identified. Eight investigated the costs and health consequences (transfusion-related events, bacterial and viral infections or illnesses) of pathogen reduction. The estimated incremental cost per QALY varied widely from EUR 259,614 to EUR 36,688,323. For other methods, such as pathogen testing/culturing, use of apheresis instead of whole blood-derived platelets, and storage in platelet additive solution, evidence was sparse. Overall, the quality and applicability of the included studies was limited. CONCLUSIONS Our findings are of interest to decision makers who consider implementing pathogen reduction. For other preparation, storage, selection and dosing methods in platelet transfusion, CE remains unclear due to insufficient and outdated evaluations. Future high-quality research is needed to expand the evidence base and increase our confidence in the findings.
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Affiliation(s)
- Jorien Laermans
- Centre for Evidence-Based Practice (CEBaP), Belgian Red Cross, Motstraat 42, 2800, Mechelen, Belgium.
- Department of Public Health and Primary Care, Leuven Institute for Healthcare Policy, KU Leuven, Leuven, Belgium.
| | - Hans Van Remoortel
- Centre for Evidence-Based Practice (CEBaP), Belgian Red Cross, Motstraat 42, 2800, Mechelen, Belgium
- Department of Public Health and Primary Care, Leuven Institute for Healthcare Policy, KU Leuven, Leuven, Belgium
| | - Hans Scheers
- Centre for Evidence-Based Practice (CEBaP), Belgian Red Cross, Motstraat 42, 2800, Mechelen, Belgium
- Department of Public Health and Primary Care, Leuven Institute for Healthcare Policy, KU Leuven, Leuven, Belgium
| | - Bert Avau
- Centre for Evidence-Based Practice (CEBaP), Belgian Red Cross, Motstraat 42, 2800, Mechelen, Belgium
| | - Jørgen Georgsen
- Department of Clinical Immunology, South Danish Transfusion Service & Tissue Center, Odense University Hospital, Odense, Denmark
| | - Susan Nahirniak
- Faculty of Medicine, University of Alberta, Edmonton, Canada
- Transfusion and Transplantation Medicine, Alberta Precision Laboratories, Alberta, Canada
| | - Nadine Shehata
- Laboratory Medicine and Pathobiology, Department of Medicine, Institute of Health Policy Management and Evaluation, Mount Sinai Hospital, University of Toronto, Toronto, Canada
| | - Simon J Stanworth
- Transfusion Medicine, NHS Blood and Transplant, Oxford, UK
- Radcliffe Department of Medicine, NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Emmy De Buck
- Centre for Evidence-Based Practice (CEBaP), Belgian Red Cross, Motstraat 42, 2800, Mechelen, Belgium
- Department of Public Health and Primary Care, Leuven Institute for Healthcare Policy, KU Leuven, Leuven, Belgium
| | - Veerle Compernolle
- Blood Services, Belgian Red Cross, Mechelen, Belgium
- Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Philippe Vandekerckhove
- Department of Public Health and Primary Care, Leuven Institute for Healthcare Policy, KU Leuven, Leuven, Belgium
- Belgian Red Cross, Mechelen, Belgium
- Division of Epidemiology and Biostatistics, Department of Global health, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
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21
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Loke J, Upasani V, Gaskell C, Fox S, Fletcher R, Thomas C, Hopkins L, Kumari A, Tang T, Yafai E, Boucher R, Homer V, Toth A, Chan YLT, Randall K, Rider T, O'Nions J, Drew V, Pillai A, Dungarwalla M, Murray D, Khan A, Wandroo F, Moore S, Krishnamurthy P, Huang YWJ, Knapper S, Byrne J, Zhao R, Craddock C, Parry H, Moss P, Stanworth SJ, Lowe DM. Defective T-cell response to COVID-19 vaccination in acute myeloid leukaemia and myelodysplastic syndromes. Br J Haematol 2023; 202:498-503. [PMID: 37303189 DOI: 10.1111/bjh.18894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Revised: 05/18/2023] [Accepted: 05/19/2023] [Indexed: 06/13/2023]
Abstract
Limited data exist on COVID-19 vaccination efficacy in patients with acute myeloid leukemia and myelodysplasia with excess blasts (AML/MDS-EB2). We report results from a prospective study, PACE (Patients with AML and COVID-19 Epidemiology). 93 patients provided samples post-vaccine 2 or 3 (PV2, PV3). Antibodies against SARS-COV-2 spike antigen were detectable in all samples. Neutralization of the omicron variant was poorer than ancestral variants but improved PV3. In contrast, adequate T-cell reactivity to SARS-COV-2 spike protein was seen in only 16/47 (34%) patients PV2 and 23/52 (44%) PV3. Using regression models, disease response (not in CR/Cri), and increasing age predicted poor T cell response.
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Affiliation(s)
- Justin Loke
- Centre for Clinical Haematology, Queen Elizabeth Hospital, Birmingham, UK
- CRUK Clinical Trials Unit, University of Birmingham, Birmingham, UK
- Dana Farber Cancer Institute, Boston, Massachusetts, USA
| | | | | | - Sonia Fox
- CRUK Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Rachel Fletcher
- CRUK Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Catherine Thomas
- CRUK Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Louise Hopkins
- CRUK Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Anita Kumari
- CRUK Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Tina Tang
- CRUK Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Emily Yafai
- CRUK Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Rebecca Boucher
- CRUK Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Victoria Homer
- CRUK Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Arpad Toth
- Clatterbridge Cancer Hospital, Liverpool, UK
| | | | - Katie Randall
- South Warwickshire University NHS Foundation Trust, Warwick, UK
| | - Tom Rider
- Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | | | | | | | | | | | | | - Farooq Wandroo
- Sandwell and West Birmingham Hospitals NHS Trust, West Bromwich, UK
| | - Sally Moore
- Royal United Hospital Bath NHS Foundation Trust, Bath, UK
| | | | | | | | - Jenny Byrne
- Nottingham University Hospitals Trust, Nottingham, UK
| | | | - Charles Craddock
- Centre for Clinical Haematology, Queen Elizabeth Hospital, Birmingham, UK
- CRUK Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Helen Parry
- Centre for Clinical Haematology, Queen Elizabeth Hospital, Birmingham, UK
- University of Birmingham, Birmingham, UK
| | - Paul Moss
- Centre for Clinical Haematology, Queen Elizabeth Hospital, Birmingham, UK
- University of Birmingham, Birmingham, UK
| | - Simon J Stanworth
- Oxford University Hospitals, Oxford, UK
- University of Oxford, Oxford, UK
- NHS Blood and Transplant, Oxford, UK
| | - David M Lowe
- University College London, London, UK
- Royal Free London NHS Foundation Trust, London, UK
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22
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Lin VS, Sun E, Yau S, Abeyakoon C, Seamer G, Bhopal S, Tucker H, Doree C, Brunskill SJ, McQuilten ZK, Stanworth SJ, Wood EM, Green L. Definitions of massive transfusion in adults with critical bleeding: a systematic review. Crit Care 2023; 27:265. [PMID: 37407998 DOI: 10.1186/s13054-023-04537-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 06/19/2023] [Indexed: 07/07/2023] Open
Abstract
BACKGROUND Definitions for massive transfusion (MT) vary widely between studies, contributing to challenges in interpretation of research findings and practice evaluation. In this first systematic review, we aimed to identify all MT definitions used in randomised controlled trials (RCTs) to date to inform the development of consensus definitions for MT. METHODS We systematically searched the following databases for RCTs from inception until 11 August 2022: MEDLINE, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, Cumulative Index to Nursing and Allied Health Literature, and Transfusion Evidence Library. Ongoing trials were sought from CENTRAL, ClinicalTrials.gov, and World Health Organisation International Clinical Trials Registry Platform. To be eligible for inclusion, studies had to fulfil all the following three criteria: (1) be an RCT; (2) include an adult patient population with major bleeding who had received, or were anticipated to receive, an MT in any clinical setting; and (3) specify a definition for MT as an inclusion criterion or outcome measure. RESULTS Of the 8,458 distinct references identified, 30 trials were included for analysis (19 published, 11 ongoing). Trauma was the most common clinical setting in published trials, while for ongoing trials, it was obstetrics. A total of 15 different definitions of MT were identified across published and ongoing trials, varying greatly in cut-offs for volume transfused and time period. Almost all definitions specified the number of red blood cells (RBCs) within a set time period, with none including plasma, platelets or other haemostatic agents that are part of contemporary transfusion resuscitation. For completed trials, the most commonly used definition was transfusion of ≥ 10 RBC units in 24 h (9/19, all in trauma), while for ongoing trials it was 3-5 RBC units (n = 7), with the timing for transfusion being poorly defined, or in some trials not provided at all (n = 5). CONCLUSIONS Transfusion of ≥ 10 RBC units within 24 h was the most commonly used definition in published RCTs, while lower RBC volumes are being used in ongoing RCTs. Any consensus definitions should reflect the need to incorporate different blood components/products for MT and agree on whether a 'one-size-fits-all' approach should be used across different clinical settings.
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Affiliation(s)
- Victor S Lin
- Transfusion Research Unit, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Emily Sun
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Parkville, Australia
| | - Serine Yau
- Faculty of Medicine, Nursing, and Health Sciences, Monash University, Clayton, Australia
| | | | - Georgia Seamer
- Faculty of Medicine, Nursing, and Health Sciences, Monash University, Clayton, Australia
| | - Simran Bhopal
- Faculty of Medicine, Nursing, and Health Sciences, Monash University, Clayton, Australia
| | - Harriet Tucker
- Blizard Institute, Queen Mary University of London, London, UK
| | - Carolyn Doree
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
| | | | - Zoe K McQuilten
- Transfusion Research Unit, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Department of Clinical Haematology, Monash Health, Clayton, Australia
| | - Simon J Stanworth
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
- Radcliffe Department of Medicine, University of Oxford, Oxford, UK
- National Institute for Health Research Biomedical Research Centre Haematology Theme, Oxford, UK
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Erica M Wood
- Transfusion Research Unit, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Department of Clinical Haematology, Monash Health, Clayton, Australia
| | - Laura Green
- Blizard Institute, Queen Mary University of London, London, UK.
- NHS Blood and Transplant, London, UK.
- Barts Health NHS Trust, London, UK.
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23
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Desborough MJR, Al-Shahi Salman R, Stanworth SJ, Havard D, Woodhouse LJ, Craig J, Krishnan K, Brennan PM, Dineen RA, Coats TJ, Hepburn T, Bath PM, Sprigg N. Desmopressin for patients with spontaneous intracerebral haemorrhage taking antiplatelet drugs (DASH): a UK-based, phase 2, randomised, placebo-controlled, multicentre feasibility trial. Lancet Neurol 2023; 22:557-567. [PMID: 37353276 PMCID: PMC10284719 DOI: 10.1016/s1474-4422(23)00157-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 04/13/2023] [Accepted: 04/14/2023] [Indexed: 06/25/2023]
Abstract
BACKGROUND The risk of death from spontaneous intracerebral haemorrhage is increased for people taking antiplatelet drugs. We aimed to assess the feasibility of randomising patients on antiplatelet drug therapy with spontaneous intracerebral haemorrhage to desmopressin or placebo to reduce the antiplatelet drug effect. METHODS DASH was a phase 2, randomised, placebo-controlled, multicentre feasibility trial. Patients were recruited from ten acute stroke centres in the UK and were eligible if they had an intracerebral haemorrhage with stroke symptom onset within 24 h of randomisation, were aged 18 years or older, and were taking an antiplatelet drug. Participants were randomly assigned (1:1) to a single dose of intravenous desmopressin 20 μg or matching placebo. Treatment allocation was concealed from all staff and patients involved in the trial. The primary outcome was feasibility, which was measured as the number of eligible patients randomised and the proportion of eligible patients approached, and analysis was by intention to treat. The trial was prospectively registered with ISRCTN (reference ISRCTN67038373), and it is closed to recruitment. FINDINGS Between April 1, 2019, and March 31, 2022, 1380 potential participants were screened for eligibility. 176 (13%) participants were potentially eligible, of whom 57 (32%) were approached, and 54 (31%) consented and were subsequently recruited and randomly assigned to receive desmopressin (n=27) or placebo (n=27). The main reason for eligible patients not being recruited was the patient arriving out of hours (74 [61%] of 122 participants). The recruitment rate increased after the enrolment period was extended from 12 h to 24 h, but it was then impaired due to the COVID-19 pandemic. Of the 54 participants included in the analysis (mean age 76·4 years [SD 11·3]), most were male (36 [67%]) and White (50 [93%]). 53 (98%) of 54 participants received all of their allocated treatment (one participant assigned desmopressin only received part of the infusion). No participants were lost to follow-up or withdrew from the trial. Death or dependency on others for daily activities at day 90 (modified Rankin Scale score >4) occurred in six (22%) of 27 participants in the desmopressin group and ten (37%) of 27 participants in the placebo group. Serious adverse events occurred in 12 (44%) participants in the desmopressin group and 13 (48%) participants in the placebo group. The most common adverse events were expansion of the haemorrhagic stroke (four [15%] of 27 participants in the desmopressin group and six [22%] of 27 participants in the placebo group) and pneumonia (one [4%] of 27 participants in the desmopressin group and six [22%] of 27 participants in the placebo group). INTERPRETATION Our results show it is feasible to randomise patients with spontaneous intracerebral haemorrhage who are taking antiplatelet drugs to desmopressin or placebo. Our findings support the need for a definitive trial to determine if desmopressin improves outcomes in patients with intracerebral haemorrhage on antiplatelet drug therapy. FUNDING National Institute for Health Research.
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Affiliation(s)
- Michael J R Desborough
- Department of Clinical Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK; Radcliffe Department of Medicine, University of Oxford, Oxford, UK.
| | | | - Simon J Stanworth
- Department of Clinical Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK; Radcliffe Department of Medicine, University of Oxford, Oxford, UK; Transfusion Medicine, NHS Blood and Transplant, Oxford, UK
| | - Diane Havard
- Stroke Trials Unit, University of Nottingham, Nottingham, UK
| | | | - Jennifer Craig
- Stroke Trials Unit, University of Nottingham, Nottingham, UK
| | - Kailash Krishnan
- Stroke, Medicine Division, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Paul M Brennan
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Robert A Dineen
- Radiological Sciences, University of Nottingham, Nottingham, UK; NIHR Nottingham Biomedical Research Centre, Nottingham, UK
| | - Tim J Coats
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Trish Hepburn
- Mental Health and Clinical Neurosciences, and Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Philip M Bath
- Stroke Trials Unit, University of Nottingham, Nottingham, UK; Stroke, Medicine Division, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Nikola Sprigg
- Stroke Trials Unit, University of Nottingham, Nottingham, UK; Stroke, Medicine Division, Nottingham University Hospitals NHS Trust, Nottingham, UK
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24
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Lewis SR, Pritchard MW, Estcourt LJ, Stanworth SJ, Griffin XL. Interventions for reducing red blood cell transfusion in adults undergoing hip fracture surgery: an overview of systematic reviews. Cochrane Database Syst Rev 2023; 6:CD013737. [PMID: 37294864 PMCID: PMC10249061 DOI: 10.1002/14651858.cd013737.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
BACKGROUND Following hip fracture, people sustain an acute blood loss caused by the injury and subsequent surgery. Because the majority of hip fractures occur in older adults, blood loss may be compounded by pre-existing anaemia. Allogenic blood transfusions (ABT) may be given before, during, and after surgery to correct chronic anaemia or acute blood loss. However, there is uncertainty about the benefit-risk ratio for ABT. This is a potentially scarce resource, with availability of blood products sometimes uncertain. Other strategies from Patient Blood Management may prevent or minimise blood loss and avoid administration of ABT. OBJECTIVES To summarise the evidence from Cochrane Reviews and other systematic reviews of randomised or quasi-randomised trials evaluating the effects of pharmacological and non-pharmacological interventions, administered perioperatively, on reducing blood loss, anaemia, and the need for ABT in adults undergoing hip fracture surgery. METHODS In January 2022, we searched the Cochrane Library, MEDLINE, Embase, and five other databases for systematic reviews of randomised controlled trials (RCTs) of interventions given to prevent or minimise blood loss, treat the effects of anaemia, and reduce the need for ABT, in adults undergoing hip fracture surgery. We searched for pharmacological interventions (fibrinogen, factor VIIa and factor XIII, desmopressin, antifibrinolytics, fibrin and non-fibrin sealants and glue, agents to reverse the effects of anticoagulants, erythropoiesis agents, iron, vitamin B12, and folate replacement therapy) and non-pharmacological interventions (surgical approaches to reduce or manage blood loss, intraoperative cell salvage and autologous blood transfusion, temperature management, and oxygen therapy). We used Cochrane methodology, and assessed the methodological quality of included reviews using AMSTAR 2. We assessed the degree of overlap of RCTs between reviews. Because overlap was very high, we used a hierarchical approach to select reviews from which to report data; we compared the findings of selected reviews with findings from the other reviews. Outcomes were: number of people requiring ABT, volume of transfused blood (measured as units of packed red blood cells (PRC)), postoperative delirium, adverse events, activities of daily living (ADL), health-related quality of life (HRQoL), and mortality. MAIN RESULTS We found 26 systematic reviews including 36 RCTs (3923 participants), which only evaluated tranexamic acid and iron. We found no reviews of other pharmacological interventions or any non-pharmacological interventions. Tranexamic acid (17 reviews, 29 eligible RCTs) We selected reviews with the most recent search date, and which included data for the most outcomes. The methodological quality of these reviews was low. However, the findings were largely consistent across reviews. One review included 24 RCTs, with participants who had internal fixation or arthroplasty for different types of hip fracture. Tranexamic acid was given intravenously or topically during the perioperative period. In this review, based on a control group risk of 451 people per 1000, 194 fewer people per 1000 probably require ABT after receiving tranexamic acid (risk ratio (RR) 0.56, 95% confidence interval (CI) 0.46 to 0.68; 21 studies, 2148 participants; moderate-certainty evidence). We downgraded the certainty for possible publication bias. Review authors found that there was probably little or no difference in the risks of adverse events, reported as deep vein thrombosis (RR 1.16, 95% CI 0.74 to 1.81; 22 studies), pulmonary embolism (RR 1.01, 95% CI 0.36 to 2.86; 9 studies), myocardial infarction (RR 1.00, 95% CI 0.23 to 4.33; 8 studies), cerebrovascular accident (RR 1.45, 95% CI 0.56 to 3.70; 8 studies), or death (RR 1.01, 95% CI 0.70 to 1.46; 10 studies). We judged evidence from these outcomes to be moderate certainty, downgraded for imprecision. Another review, with a similarly broad inclusion criteria, included 10 studies, and found that tranexamic acid probably reduces the volume of transfused PRC (0.53 fewer units, 95% CI 0.27 to 0.80; 7 studies, 813 participants; moderate-certainty evidence). We downgraded the certainty because of unexplained high levels of statistical heterogeneity. No reviews reported outcomes of postoperative delirium, ADL, or HRQoL. Iron (9 reviews, 7 eligible RCTs) Whilst all reviews included studies in hip fracture populations, most also included other surgical populations. The most current, direct evidence was reported in two RCTs, with 403 participants with hip fracture; iron was given intravenously, starting preoperatively. This review did not include evidence for iron with erythropoietin. The methodological quality of this review was low. In this review, there was low-certainty evidence from two studies (403 participants) that there may be little or no difference according to whether intravenous iron was given in: the number of people who required ABT (RR 0.90, 95% CI 0.73 to 1.11), the volume of transfused blood (MD -0.07 units of PRC, 95% CI -0.31 to 0.17), infection (RR 0.99, 95% CI 0.55 to 1.80), or mortality within 30 days (RR 1.06, 95% CI 0.53 to 2.13). There may be little or no difference in delirium (25 events in the iron group compared to 26 events in control group; 1 study, 303 participants; low-certainty evidence). We are very unsure whether there was any difference in HRQoL, since it was reported without an effect estimate. The findings were largely consistent across reviews. We downgraded the evidence for imprecision, because studies included few participants, and the wide CIs indicated possible benefit and harm. No reviews reported outcomes of cognitive dysfunction, ADL, or HRQoL. AUTHORS' CONCLUSIONS Tranexamic acid probably reduces the need for ABT in adults undergoing hip fracture surgery, and there is probably little or no difference in adverse events. For iron, there may be little or no difference in overall clinical effects, but this finding is limited by evidence from only a few small studies. Reviews of these treatments did not adequately include patient-reported outcome measures (PROMS), and evidence for their effectiveness remains incomplete. We were unable to effectively explore the impact of timing and route of administration between reviews. A lack of systematic reviews for other types of pharmacological or any non-pharmacological interventions to reduce the need for ABT indicates a need for further evidence syntheses to explore this. Methodologically sound evidence syntheses should include PROMS within four months of surgery.
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Affiliation(s)
- Sharon R Lewis
- Bone and Joint Health, Blizard Institute, Queen Mary University of London, London, UK
| | - Michael W Pritchard
- Bone and Joint Health, Blizard Institute, Queen Mary University of London, London, UK
| | - Lise J Estcourt
- Haematology/Transfusion Medicine, NHS Blood and Transplant, Oxford, UK
| | - Simon J Stanworth
- National Institute for Health Research (NIHR) Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust and University of Oxford, Oxford, UK
| | - Xavier L Griffin
- Trauma & Orthopaedics Surgery Group, Blizard Institute, Queen Mary University of London, London, UK
- The Royal London Hospital Barts Health NHS Trust, London, UK
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25
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Stanworth SJ, Mumford AD. How I diagnose and treat neonatal thrombocytopenia. Blood 2023; 141:2685-2697. [PMID: 36787503 DOI: 10.1182/blood.2022018017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 02/02/2023] [Accepted: 02/03/2023] [Indexed: 02/16/2023] Open
Abstract
Neonatal thrombocytopenia, defined as the presence of a circulating platelet count <150 × 109/L, is a common abnormality in babies admitted to neonatal intensive care units. Thrombocytopenia that is typically mild and self-limiting often accompanies neonatal stress in scenarios such as premature delivery or intrauterine growth restriction. However, the differential diagnosis of neonatal thrombocytopenia is wide and includes potentially life-threatening disorders, such as bacterial sepsis, viral infection, and necrotizing enterocolitis. Distinguishing these causes of thrombocytopenia from entities such as genetic thrombocytopenia and fetal and neonatal alloimmune thrombocytopenia is critical for the accurate quantitation of significant adverse events, such as intracranial bleeding, and for the selection of treatments, such as platelet transfusion. In this review, we focus on common differential diagnoses of neonatal thrombocytopenia and highlight how the landscape of diagnosis and management is changing with recent advances in genomic technology and the completion of pivotal clinical trials of platelet transfusion practice. Increasing evidence highlights the need for judicious and restrictive use of platelet transfusions in neonates.
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Affiliation(s)
- Simon J Stanworth
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
- Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
- Department of Transfusion Medicine, NHS Blood & Transplant, Oxford, United Kingdom
| | - Andrew D Mumford
- School of Cellular and Molecular Medicine, University of Bristol, Bristol, United Kingdom
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26
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Van Remoortel H, Scheers H, Avau B, Georgsen J, Nahirniak S, Shehata N, Stanworth SJ, De Buck E, Compernolle V, Vandekerckhove P. Cost-Effectiveness of Thrombopoietin Mimetics in Patients with Thrombocytopenia: A Systematic Review. Pharmacoeconomics 2023:10.1007/s40273-023-01271-w. [PMID: 37145291 DOI: 10.1007/s40273-023-01271-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/23/2023] [Indexed: 05/06/2023]
Abstract
OBJECTIVES Thrombopoietin (TPO) mimetics are a potential alternative to platelet transfusion to minimize blood loss in patients with thrombocytopenia. This systematic review aimed to evaluate the cost-effectiveness of TPO mimetics, compared with not using TPO mimetics, in adult patients with thrombocytopenia. METHODS Eight databases and registries were searched for full economic evaluations (EEs) and randomized controlled trials (RCTs). Incremental cost-effectiveness ratios (ICERs) were synthesized as cost per quality-adjusted life year gained (QALY) or as cost per health outcome (e.g. bleeding event avoided). Included studies were critically appraised using the Philips reporting checklist. RESULTS Eighteen evaluations from nine different countries were included, evaluating the cost-effectiveness of TPO mimetics compared with no TPO, watch-and-rescue therapy, the standard of care, rituximab, splenectomy or platelet transfusion. ICERs varied from a dominant strategy (i.e. cost-saving and more effective), to an incremental cost per QALY/health outcome of EUR 25,000-50,000, EUR 75,000-750,000 and EUR > 1 million, to a dominated strategy (cost-increasing and less effective). Few evaluations (n = 2, 10%) addressed the four principal types of uncertainty (methodological, structural, heterogeneity and parameter). Parameter uncertainty was most frequently reported (80%), followed by heterogeneity (45%), structural uncertainty (43%) and methodological uncertainty (28%). CONCLUSIONS Cost-effectiveness of TPO mimetics in adult patients with thrombocytopenia ranged from a dominant strategy to a significant incremental cost per QALY/health outcome or a strategy that is clinically inferior and has increased costs. Future validation and tackling the uncertainty of these models with country-specific cost data and up-to-date efficacy and safety data are needed to increase the generalizability.
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Affiliation(s)
- Hans Van Remoortel
- Centre for Evidence-Based Practice, Belgian Red Cross, Mechelen, Belgium.
- Department of Public Health and Primary Care, Leuven Institute for Healthcare Policy, KU Leuven, Leuven, Belgium.
| | - Hans Scheers
- Centre for Evidence-Based Practice, Belgian Red Cross, Mechelen, Belgium
- Department of Public Health and Primary Care, Leuven Institute for Healthcare Policy, KU Leuven, Leuven, Belgium
| | - Bert Avau
- Centre for Evidence-Based Practice, Belgian Red Cross, Mechelen, Belgium
| | - Jørgen Georgsen
- Department of Clinical Immunology, South Danish Transfusion Service and Tissue Center, Odense University Hospital, Odense, Denmark
| | - Susan Nahirniak
- Faculty of Medicine, University of Alberta, Edmonton, Canada
- Transfusion and Transplantation Medicine, Alberta Precision Laboratories, Alberta, Canada
| | - Nadine Shehata
- Departments of Medicine, Laboratory Medicine and Pathobiology, Institute of Health Policy Management and Evaluation, University of Toronto, Mount Sinai Hospital, Toronto, Canada
| | - Simon J Stanworth
- Transfusion Medicine, NHS Blood and Transplant, Oxford, UK
- Radcliffe Department of Medicine, University of Oxford, NIHR Oxford Biomedical Research Centre, Oxford, UK
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Emmy De Buck
- Centre for Evidence-Based Practice, Belgian Red Cross, Mechelen, Belgium
- Department of Public Health and Primary Care, Leuven Institute for Healthcare Policy, KU Leuven, Leuven, Belgium
| | - Veerle Compernolle
- Blood Services, Belgian Red Cross, Mechelen, Belgium
- Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Philippe Vandekerckhove
- Department of Public Health and Primary Care, Leuven Institute for Healthcare Policy, KU Leuven, Leuven, Belgium
- Belgian Red Cross, Mechelen, Belgium
- Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
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Lisman T, Carlin S, Gatt A, Hernandez-Gea V, Luyendyk JP, Roberts LN, Stanworth SJ. The ISTH SSC Subcommittee on Hemostatic Management of Patients with Liver Disease: goals, ambitions, and call for collaboration. J Thromb Haemost 2023; 21:1073-1074. [PMID: 37121615 DOI: 10.1016/j.jtha.2023.02.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 02/08/2023] [Indexed: 05/02/2023]
Affiliation(s)
- Ton Lisman
- Department of Surgery, Surgical Research Laboratory and Section of Hepatobiliary Surgery and Liver Transplantation, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
| | - Stephanie Carlin
- Thrombosis Service, Hamilton General Hospital, Hamilton, Ontario, Canada
| | - Alex Gatt
- Department of Pathology, Faculty of Medicine and Surgery, University of Malta, Msida, Malta
| | - Virginia Hernandez-Gea
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, IDIBAPS, Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver), University of Barcelona, Barcelona, Spain
| | - James P Luyendyk
- Department of Pathobiology and Diagnostic Investigation, Michigan State University, East Lansing, Michigan, USA
| | - Lara N Roberts
- Department of Haematological Medicine, King's Thrombosis Centre, King's College Hospital, London, United Kingdom
| | - Simon J Stanworth
- Department of Haematology, Transfusion Medicine, NHS Blood and Transplant, Oxford University Hospitals, NHS Foundation Trust, Radcliffe Department of Medicine, University of Oxford and NIHR Oxford Biomedical Research Centre (Haematology), Oxford, United Kingdom
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28
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Curry N, Davenport R, Lucas J, Deary A, Benger J, Edwards A, Evans A, Foley C, Green L, Morris S, Thomas H, Brohi K, Stanworth SJ. The CRYOSTAT2 trial: The rationale and study protocol for a multi-Centre, randomised, controlled trial evaluating the effects of early high-dose cryoprecipitate in adult patients with major trauma haemorrhage requiring major haemorrhage protocol activation. Transfus Med 2023; 33:123-131. [PMID: 36321753 DOI: 10.1111/tme.12932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 09/05/2022] [Accepted: 10/03/2022] [Indexed: 11/05/2022]
Abstract
OBJECTIVES To describe the protocol for a multinational randomised, parallel, superiority trial, in which patients were randomised to receive early high-dose cryoprecipitate in addition to standard major haemorrhage protocol (MHP), or Standard MHP alone. BACKGROUND Blood transfusion support for trauma-related major bleeding includes red cells, plasma and platelets. The role of concentrated sources of fibrinogen is less clear and has not been evaluated in large clinical trials. Fibrinogen is a key pro-coagulant factor that is essential for stable clot formation. A pilot trial had demonstrated that it was feasible to deliver cryoprecipitate as a source of fibrinogen within 90 min of admission. METHODS Randomisation was via opaque sealed envelopes held securely in participating Emergency Departments or transfusion laboratories. Early cryoprecipitate, provided as 3 pools (equivalent to 15 single units of cryoprecipitate or 6 g fibrinogen supplementation), was transfused as rapidly as possible, and started within 90 min of admission. Participants in both arms received standard treatment defined in the receiving hospital MHP. The primary outcome measure was all-cause mortality at 28 days. Symptomatic thrombotic events including venous thromboembolism and arterial thrombotic events (myocardial infarction, stroke) were collected from randomisation up to day 28 or discharge from hospital. EQ5D-5Land Glasgow Outcome Score were completed at discharge and 6 months. All analyses will be performed on an intention to treat basis, with per protocol sensitivity analysis. RESULTS The trial opened for recruitment in June 2017 and the final patient completed follow-up in May 2022. DISCUSSION This trial will provide firmer evidence to evaluate the effectiveness and cost-effectiveness of early high-dose cryoprecipitate alongside the standard MHP in major traumatic haemorrhage.
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Affiliation(s)
- Nicola Curry
- Oxford UniversityHospitals NHS Foundation Trust, Nuffield Orthopaedic Hospital, Oxford, UK
| | - Ross Davenport
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK
| | - Joanne Lucas
- NHS Blood and Transplant Clinical Trials Unit, Cambridge, UK
| | - Alison Deary
- NHS Blood and Transplant Clinical Trials Unit, Cambridge, UK
| | - Jonathan Benger
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK
| | - Antoinette Edwards
- Trauma Audit and Research Network, Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Salford, UK
| | - Amy Evans
- NHS Blood and Transplant Clinical Trials Unit, Cambridge, UK
| | - Claire Foley
- NHS Blood and Transplant Clinical Trials Unit, Cambridge, UK
| | - Laura Green
- Blizard Institute, Queen Mary University of London, London, UK
- NHS Blood and Transplant and Bart's Health NHS Trust, London, UK
| | - Stephen Morris
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Helen Thomas
- NHS Blood and Transplant Clinical Trials Unit, Bristol, UK
| | - Karim Brohi
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK
| | - Simon J Stanworth
- NHS Blood and Transplant and Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK
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Morton S, Fleming K, Stanworth SJ. How are granulocytes for transfusion best used? The past, the present and the future. Br J Haematol 2023; 200:420-428. [PMID: 36114720 DOI: 10.1111/bjh.18445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 08/17/2022] [Accepted: 08/22/2022] [Indexed: 02/04/2023]
Abstract
Granulocyte transfusions continue to be used in clinical practice, predominantly for treatment of refractory infection in the setting of severe neutropenia. There is biological plausibility for effectiveness in these patients with deficiencies of neutrophils, either as a consequence of disease or treatment. However, there is a chequered history of conducting and completing interventional trials to define optimal use, and many uncertainties remain regarding schedule and dose. Practice and clinical studies are severely limited by the short shelf life and viability of current products, which often restricts the timely access to granulocyte transfusions. In the future, methods are needed to optimise donor-derived granulocyte products. Options include use of manufactured neutrophils, expanded and engineered from stem cells. Further possibilities include manipulation of neutrophils to enhance their function and/or longevity. Granulocyte transfusions contain a heterogeneous mix of cells, and there is additional interest in how these transfusions may have immunomodulatory effects, including for potential uses as adjuncts for anti-cancer effects.
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Affiliation(s)
- Suzy Morton
- Transfusion Medicine, NHS Blood and Transplant, Birmingham, UK.,University Hospitals Birmingham, Birmingham, UK
| | - Katy Fleming
- Bristol Haematology and Oncology Centre, Bristol, UK.,School of Cellular and Molecular Medicine, University of Bristol, Bristol, UK
| | - Simon J Stanworth
- Transfusion Medicine, NHS Blood and Transplant, Oxford, UK.,Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Radcliffe Department of Medicine, University of Oxford, and NIHR Oxford Biomedical Research Centre, Oxford, UK
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30
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Curry NS, Davenport R, Wong H, Gaarder C, Johansson P, Juffermans NP, Maegele M, Stensballe J, Brohi K, Laffan M, Stanworth SJ. Traumatic coagulopathy in the older patient: analysis of coagulation profiles from the Activation of Coagulation and Inflammation in Trauma-2 (ACIT-2) observational, multicenter study. J Thromb Haemost 2023; 21:215-226. [PMID: 36700506 DOI: 10.1016/j.jtha.2022.11.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 10/19/2022] [Accepted: 11/04/2022] [Indexed: 01/26/2023]
Abstract
BACKGROUND Most studies describing traumatic coagulopathy have used data from patient cohorts with an average age of between 35 and 45 years. The last 10 years has seen a steep increase in the number of patients admitted with significant injury and bleeding who are older than the age of 65 years. Many coagulation protein levels alter significantly with normal aging, and it is possible that traumatic coagulopathy has a different signature with age. OBJECTIVES The aim of this study was to report the coagulation profiles, including standard and extended laboratory, as well as viscoelastic hemostatic assays, stratified according to age to explore age-related differences in hemostatic capability. METHODS In total, 1576 patients were analyzed from 6 European level 1 trauma centers. RESULTS As age increased, there was evidence of higher fibrinogen, greater thrombin generation, greater clotting factor consumption, and greater activation of fibrinolysis. Despite this, shock and severe injury led to the same pattern of changes within age groups: lower procoagulant factors (including fibrinogen), increased fibrinolysis, and higher levels of activated protein C. Thromboelastography and rotational thromboelastometry tests detected traumatic coagulopathy with prolongation of R/clotting time and reductions in clot amplitudes in each age cohort. Advancing age strongly correlated with higher fibrinogen levels and greater fibrinolysis. CONCLUSION Age-related coagulation changes are evident in injured patients. Broadly, similar patterns of coagulation abnormalities are seen across age groups following severe injury/shock, but thresholds for single clotting factors differ. Age-related differences may need to be considered when clinical treatments (eg, transfusion therapy) are indicated.
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Affiliation(s)
- Nicola S Curry
- Oxford Haemophilia and Thrombosis Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom; Radcliffe Department of Medicine, Oxford University, Oxford, United Kingdom.
| | - Ross Davenport
- Trauma Sciences, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Henna Wong
- Radcliffe Department of Medicine, Oxford University, Oxford, United Kingdom
| | | | - Pär Johansson
- Department of Anesthesiology and Trauma Center, and Section for Transfusion Medicine, Capital Region Blood Bank, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Nicole P Juffermans
- Department of Intensive Care Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Marc Maegele
- Department of Traumatology and Orthopaedic Surgery, Cologne-Merheim Medical Center, University of Witten/Herdecke, Cologne, Germany
| | - Jakob Stensballe
- Department of Anesthesiology and Trauma Center, and Section for Transfusion Medicine, Capital Region Blood Bank, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Karim Brohi
- Trauma Sciences, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Mike Laffan
- Imperial College and Hammersmith Hospital, London, United Kingdom
| | - Simon J Stanworth
- Radcliffe Department of Medicine, Oxford University, Oxford, United Kingdom; NHS Blood and Transplant, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
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31
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Abstract
Major haemorrhage is a leading cause of morbidity and mortality worldwide. Successful treatment requires early recognition, planned responses, readily available resources (such as blood products) and rapid access to surgery or interventional radiology. Major haemorrhage is often accompanied by volume loss, haemodilution, acidaemia, hypothermia and coagulopathy (factor consumption and fibrinolysis). Management of major haemorrhage over the past decade has evolved to now deliver a 'package' of haemostatic resuscitation including: surgical or radiological control of bleeding; regular monitoring of haemostasis; advanced critical care support; and avoidance of the lethal triad of hypothermia, acidaemia and coagulopathy. Recent trial data advocate for a more personalised approach depending on the clinical scenario. Fresh frozen plasma should be given as early as possible in major trauma in a 1:1 ratio with red blood cells until the results of coagulation tests are available. Tranexamic acid is a cheap, life-saving drug and is advocated in major trauma, postpartum haemorrhage and surgery, but not in patients with gastrointestinal bleeding. Fibrinogen levels should be maintained > 2 g.l-1 in postpartum haemorrhage and > 1.5 g.l-1 in other haemorrhage. Improving outcomes after major traumatic haemorrhage is now driving research to include extending blood-product resuscitation into prehospital care.
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Affiliation(s)
- A Shah
- Nuffield Department of Clinical Neurosciences, University of Oxford, UK
| | - V Kerner
- Nuffield Department of Anaesthesia, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - S J Stanworth
- Radcliffe Department of Medicine, University of Oxford, UK
| | - S Agarwal
- Department of Anaesthesia, Manchester University NHS Foundation Trust, Manchester, UK
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32
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Avau B, O D, Veys K, Georgsen J, Nahirniak S, Shehata N, Stanworth SJ, Van Remoortel H, De Buck E, Compernolle V, Vandekerckhove P. Systematic reviews on platelet transfusions: Is there unnecessary duplication of effort? A scoping review. Vox Sang 2023; 118:16-23. [PMID: 36454598 PMCID: PMC10107266 DOI: 10.1111/vox.13387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 11/03/2022] [Accepted: 11/18/2022] [Indexed: 12/05/2022]
Abstract
BACKGROUND AND OBJECTIVES Platelet transfusions are used across multiple patient populations to prevent and correct bleeding. This scoping review aimed to map the currently available systematic reviews (SRs) and evidence-based guidelines in the field of platelet transfusion. MATERIALS AND METHODS A systematic literature search was conducted in seven databases for SRs on effectiveness (including dose and timing, transfusion trigger and ratio to other blood products), production modalities and decision support related to platelet transfusion. The following data were charted: methodological features of the SR, population, concept and context features, outcomes reported, study design and number of studies included. Results were synthesized in interactive evidence maps. RESULTS We identified 110 SRs. The majority focused on clinical effectiveness, including prophylactic or therapeutic transfusions compared to no platelet transfusion (34 SRs), prophylactic compared to therapeutic-only transfusion (8 SRs), dose, timing (11 SRs) and threshold for platelet transfusion (15 SRs) and the ratio of platelet transfusion to other blood products in massive transfusion (14 SRs). Furthermore, we included 34 SRs on decision support, of which 26 evaluated viscoelastic testing. Finally, we identified 22 SRs on platelet production modalities, including derivation (4 SRs), pathogen inactivation (6 SRs), leucodepletion (4 SRs) and ABO/human leucocyte antigen matching (5 SRs). The SRs were mapped according to concept and clinical context. CONCLUSION An interactive evidence map of SRs and evidence-based guidelines in the field of platelet transfusion has been developed and identified multiple reviews. This work serves as a tool for researchers looking for evidence gaps, thereby both supporting research and avoiding unnecessary duplication.
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Affiliation(s)
- Bert Avau
- Centre for Evidence-Based Practice, Belgian Red Cross, Mechelen, Belgium
| | - Dorien O
- Centre for Evidence-Based Practice, Belgian Red Cross, Mechelen, Belgium
| | - Koen Veys
- Centre for Evidence-Based Practice, Belgian Red Cross, Mechelen, Belgium
| | - Jørgen Georgsen
- South Danish Transfusion Service & Tissue Center, Department of Clinical Immunology, Odense University Hospital, Odense, Denmark
| | - Susan Nahirniak
- Faculty of Medicine, University of Alberta, Edmonton, Canada.,Transfusion and Transplantation Medicine, Alberta Precision Laboratories, Calgary, Alberta, Canada
| | - Nadine Shehata
- Departments of Medicine, Laboratory Medicine and Pathobiology, Institute of Health Policy Management and Evaluation, University of Toronto, Mount Sinai Hospital, Toronto, Canada
| | - Simon J Stanworth
- Transfusion Medicine, NHS Blood and Transplant, Oxford, UK.,Radcliffe Department of Medicine, University of Oxford, and NIHR Oxford Biomedical Research Centre, Oxford, UK.,Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Hans Van Remoortel
- Centre for Evidence-Based Practice, Belgian Red Cross, Mechelen, Belgium.,Department of Public Health and Primary Care, Leuven Institute for Healthcare Policy, KU Leuven, Leuven, Belgium
| | - Emmy De Buck
- Centre for Evidence-Based Practice, Belgian Red Cross, Mechelen, Belgium.,Department of Public Health and Primary Care, Leuven Institute for Healthcare Policy, KU Leuven, Leuven, Belgium
| | - Veerle Compernolle
- Blood Services, Belgian Red Cross, Mechelen, Belgium.,Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Philippe Vandekerckhove
- Department of Public Health and Primary Care, Leuven Institute for Healthcare Policy, KU Leuven, Leuven, Belgium.,Belgian Red Cross, Mechelen, Belgium.,Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
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Volkmer B, Lorencatto F, Stanworth SJ, Hirani SP, Francis JJ. Blood transfusion in haematology: A qualitative exploration of patients' and healthcare professionals' perceptions. Br J Health Psychol 2022; 27:1241-1274. [PMID: 35543198 PMCID: PMC9790503 DOI: 10.1111/bjhp.12597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 03/30/2022] [Indexed: 01/19/2023]
Abstract
OBJECTIVES Repeated blood transfusions are indicated for the management of patients with cancer or blood disorders. Patients' perceptions about transfusions may be associated with decision-making and coping, which has been under-explored in the haematology context. This study therefore aimed to explore haematology transfusion patients' and HCPs' perceptions of blood transfusion, drawing on theory and previously identified themes of transfusion perceptions. DESIGN Semi-structured interview study with 14 adult blood transfusion patients and 14 HCPs (consultants, registrars, nurses) at two UK haematology units. METHODS Patient- and HCP-tailored topic guides were developed based on themes of blood transfusion perceptions identified in a systematic review: 'Health benefits', 'Safety/risk', 'Negative emotions', 'Alternatives' 'Decision making' and 'Necessity'. Transcripts were analysed using deductive and thematic analysis. Patient and HCP themes were compared using triangulation methods. Conceptual models (one for patients, one for HCPs) specific to haematology portraying the association between themes were developed. RESULTS Findings for patients and HCPs converged with transfusion reported as beneficial for patients, who were largely involved in the decision-making. Both groups also reported concerns about transfusion, including iron-overload, allergic reactions and challenges to deliver transfusions in time-pressurized services. Themes in the conceptual models included patient 'Burden' of receiving repeated transfusions and 'Supportive relationships', reflective of patients' positive interactions with other patients and HCPs in the haematology unit. CONCLUSION Despite the challenges for patients receiving repeated transfusions, convergent perceptions suggest a shared understanding of patients' transfusion experiences. Identified challenges could inform ways to improve transfusion services and patients' experiences.
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Affiliation(s)
- Brittannia Volkmer
- Centre for Health Services ResearchSchool of Health SciencesCity, University of LondonLondonUK
| | | | - Simon J. Stanworth
- NHS Blood and Transplant/ Oxford University Hospitals NHS Foundation TrustJohn Radcliffe HospitalOxfordUK,Oxford Clinical Research in Transfusion MedicineUniversity of OxfordOxfordUK
| | - Shashivadan P. Hirani
- Centre for Health Services ResearchSchool of Health SciencesCity, University of LondonLondonUK
| | - Jill J. Francis
- School of Health SciencesUniversity of MelbourneMelbourneVictoriaAustralia,Clinical Epidemiology ProgramOttawa Hospital Research InstituteOttawaOntarioCanada
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34
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Churchill D, Ali H, Moussa M, Donohue C, Pavord S, Robinson SE, Cheshire K, Wilson P, Grant-Casey J, Stanworth SJ. Maternal iron deficiency anaemia in pregnancy: Lessons from a national audit. Br J Haematol 2022; 199:277-284. [PMID: 35922080 DOI: 10.1111/bjh.18391] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 07/04/2022] [Accepted: 07/19/2022] [Indexed: 11/28/2022]
Abstract
We describe the management and the prevalence of iron deficiency anaemia (IDA) during pregnancy by comparison to standards. A cross-sectional national cohort study of women who had given birth six weeks prior to data collection was conducted at maternity units in the UK and Ireland. Participating centres collected data from 10 consecutive pregnant women. Analysis was descriptive to define the prevalence of IDA in pregnancy and the puerperium, and to compare the outcomes in women who had IDA with women who did not have anaemia anytime during pregnancy. Eighty-six maternity units contributed data on 860 pregnancies and births. The overall prevalence of IDA during pregnancy was 30.4% and in the puerperium 20%. Anaemic women were more likely to be from ethnic minorities, odds ratio 2.23 (1.50, 3.32). Adherence to national guidance was suboptimal, and the prevalence of anaemia in pregnancy remains very high. There is pressing need to explore barriers to early identification and effective management of iron deficiency. IDA should be considered a major public health problem in the UK.
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Affiliation(s)
- David Churchill
- The Royal Wolverhampton Hospital NHS Trust, New Cross Hospital, Wolverhampton, UK.,Research Institute in Healthcare Science, University of Wolverhampton, Wolverhampton, UK
| | - Hind Ali
- The Royal Wolverhampton Hospital NHS Trust, New Cross Hospital, Wolverhampton, UK
| | - Mahmoud Moussa
- Great Western Hospitals NHS Foundation Trust, Swindon, UK
| | - Ciara Donohue
- The Royal Free Hospital NHS Foundation Trust, London, UK
| | - Sue Pavord
- Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK
| | | | - Katherine Cheshire
- The Royal Wolverhampton Hospital NHS Trust, New Cross Hospital, Wolverhampton, UK
| | - Paul Wilson
- Faculty of Science and Engineering, School of Mathematics and Computer Science, University of Wolverhampton, Wolverhampton, UK
| | - John Grant-Casey
- NHS Blood and Transplant Service, John Radcliffe Hospital, Oxford, UK
| | - Simon J Stanworth
- Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK.,NHS Blood and Transplant Service, John Radcliffe Hospital, Oxford, UK.,Radcliffe Department of Medicine, University of Oxford, Oxford, UK
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35
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Stanworth SJ, Dowling K, Curry N, Doughty H, Hunt BJ, Fraser L, Narayan S, Smith J, Sullivan I, Green L. A guideline for the haematological management of major haemorrhage: a British Society for Haematology Guideline. Br J Haematol 2022; 198:654-667. [PMID: 35687716 DOI: 10.1111/bjh.18275] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 05/07/2022] [Accepted: 05/09/2022] [Indexed: 12/17/2022]
Affiliation(s)
- Simon J Stanworth
- Transfusion Medicine, NHS Blood and Transplant, Oxford, UK.,Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Radcliffe Department of Medicine, University of Oxford, and NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Kerry Dowling
- Transfusion Laboratory Manager, Southampton University Hospitals NHS Foundation Trust, Southampton, UK
| | - Nikki Curry
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Radcliffe Department of Medicine, University of Oxford, and NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Heidi Doughty
- Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK.,NIHR Surgical Reconstruction and Microbiology Research Centre, Birmingham, UK
| | - Beverley J Hunt
- Department of Haematology, Guy's and St Thomas's Hospital, London, UK
| | - Laura Fraser
- Transfusion Practitioner, NHS Lanarkshire, University Hospital Wishaw, Wishaw, UK.,National Services Scotland/Scottish National Blood Transfusion, Edinburgh, UK
| | - Shruthi Narayan
- Medical director, Serious Hazards of Transfusion, Manchester, UK
| | - Juliet Smith
- Lead Transfusion Practitioner, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Ian Sullivan
- Transfusion Laboratory Manager, Royal Cornwall Hospitals NHS Trust, Truro, UK
| | - Laura Green
- Transfusion Medicine, NHS Blood and Transplant, London, UK.,Barts Health NHS Trust, London, UK.,Blizzard Institute, Queen Mary University of London, London, UK
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36
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Vijenthira A, Starkman R, Lin Y, Stanworth SJ, Bowen D, Harrison L, Wintrich S, Callum J, Buckstein R. Multi-national survey of transfusion experiences and preferences of patients with myelodysplastic syndrome. Transfusion 2022; 62:1355-1364. [PMID: 35686926 DOI: 10.1111/trf.16946] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 04/04/2022] [Accepted: 04/06/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Transfusion dependence on red blood cells (RBCs) is common for patients with myelodysplastic syndromes (MDS) but transfusion practice and experience for outpatients with MDS are largely unknown. METHODS We conducted a web-based cross-sectional multi-national survey to audit real-world transfusion practices and understand the experiences and preferences of patients with MDS requiring RBC transfusion. The survey comprised 57 questions and was distributed to patients in the United States of America, Canada, and the United Kingdom. RESULTS 447 respondents (45% female) with a median age of 72 years (IQR 66-77) were eligible on the basis of receiving an RBC transfusion in the last 8 weeks. There was wide variability in the hemoglobin thresholds for transfusion with the most common being <80 g/L. 40% of patients were transfused at a lower threshold (<70-75 g/L), with the largest proportion of these patients from the United States. Patients experienced significant symptoms prior to receiving a transfusion with fatigue and dyspnea having the most negative impacts on quality of life. Finally, patients endorsed two potential alterations to transfusion care that could improve their quality of life, including self-administered point of care testing of hemoglobin and higher hemoglobin transfusion thresholds. Of these patients, 62% preferred a threshold of at least 85 g/L, and 20% preferred a threshold of at least 100 g/L. DISCUSSION In summary, this multi-national survey of patients with MDS requiring RBC transfusions demonstrated substantial variation in patients' experiences and preferences that differed also by country, supporting the need for further comparative clinical trials of transfusion practice interventions.
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Affiliation(s)
- Abi Vijenthira
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | | | - Yulia Lin
- Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Simon J Stanworth
- Transfusion Medicine, NHS Blood and Transplant, Oxford, UK.,Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Radcliffe Department of Medicine, University of Oxford, Oxford, UK.,NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - David Bowen
- Department of Hematology, Leeds Teaching Hospitals, Leeds, United Kingdom
| | | | | | - Jeannie Callum
- Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Rena Buckstein
- MDS Research Program, Sunnybrook Odette Cancer Center, Toronto, Ontario, Canada
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Wright-Hughes A, Willis TA, Wilson S, Weller A, Lorencatto F, Althaf M, Seymour V, Farrin AJ, Francis J, Brehaut J, Ivers N, Alderson SL, Brown BC, Feltbower RG, Gale CP, Stanworth SJ, Hartley S, Colquhoun H, Presseau J, Walwyn R, Foy R. A randomised fractional factorial screening experiment to predict effective features of audit and feedback. Implement Sci 2022; 17:34. [PMID: 35619097 PMCID: PMC9137082 DOI: 10.1186/s13012-022-01208-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Accepted: 04/29/2022] [Indexed: 11/11/2022] Open
Abstract
Background Audit and feedback aims to improve patient care by comparing healthcare performance against explicit standards. It is used to monitor and improve patient care, including through National Clinical Audit (NCA) programmes in the UK. Variability in effectiveness of audit and feedback is attributed to intervention design; separate randomised trials to address multiple questions about how to optimise effectiveness would be inefficient. We evaluated different feedback modifications to identify leading candidates for further “real-world” evaluation. Methods Using an online fractional factorial screening experiment, we randomised recipients of feedback from five UK NCAs to different combinations of six feedback modifications applied within an audit report excerpt: use effective comparators, provide multimodal feedback, recommend specific actions, provide optional detail, incorporate the patient voice, and minimise cognitive load. Outcomes, assessed immediately after exposure to the online modifications, included intention to enact audit standards (primary outcome, ranked on a scale of −3 to +3, tailored to the NCA), comprehension, user experience, and engagement. Results We randomised 1241 participants (clinicians, managers, and audit staff) between April and October 2019. Inappropriate repeated participant completion occurred; we conservatively excluded participant entries during the relevant period, leaving a primary analysis population of 638 (51.4%) participants. None of the six feedback modifications had an independent effect on intention across the five NCAs. We observed both synergistic and antagonistic effects across outcomes when modifications were combined; the specific NCA and whether recipients had a clinical role had dominant influences on outcome, and there was an antagonistic interaction between multimodal feedback and optional detail. Among clinical participants, predicted intention ranged from 1.22 (95% confidence interval 0.72, 1.72) for the least effective combination in which multimodal feedback, optional detail, and reduced cognitive load were applied within the audit report, up to 2.40 (95% CI 1.88, 2.93) for the most effective combination including multimodal feedback, specific actions, patient voice, and reduced cognitive load. Conclusion Potentially important synergistic and antagonistic effects were identified across combinations of feedback modifications, audit programmes, and recipients, suggesting that feedback designers must explicitly consider how different features of feedback may interact to achieve (or undermine) the desired effects. Trial registration International Standard Randomised Controlled Trial Number: ISRCTN41584028 Supplementary Information The online version contains supplementary material available at 10.1186/s13012-022-01208-5.
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Affiliation(s)
| | - Thomas A Willis
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Stephanie Wilson
- Centre for Human-Computer Interaction Design, City, University of London, London, UK
| | - Ana Weller
- Centre for Human-Computer Interaction Design, City, University of London, London, UK
| | | | - Mohamed Althaf
- Centre for Human-Computer Interaction Design, City, University of London, London, UK
| | - Valentine Seymour
- Centre for Human-Computer Interaction Design, City, University of London, London, UK
| | - Amanda J Farrin
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Jillian Francis
- School of Health Sciences, University of Melbourne, Melbourne, Australia.,Ottawa Hospital Research Institute, Ottawa, Canada
| | - Jamie Brehaut
- Ottawa Hospital Research Institute, Ottawa, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - Noah Ivers
- Department of Family and Community Medicine, Womens College Hospital, University of Toronto, Toronto, Canada
| | - Sarah L Alderson
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Benjamin C Brown
- Centre for Health Informatics, University of Manchester, Manchester, UK.,Centre for Primary Care, University of Manchester, Manchester, UK
| | - Richard G Feltbower
- Leeds Institute for Data Analytics, School of Medicine, University of Leeds, Leeds, UK
| | - Chris P Gale
- Leeds Institute for Data Analytics, School of Medicine, University of Leeds, Leeds, UK.,Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK.,Department of Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Simon J Stanworth
- Transfusion Medicine, NHS Blood and Transplant (NHSBT), Oxford, UK.,Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Radcliffe Department of Medicine, University of Oxford, Oxford, UK.,NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Suzanne Hartley
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Heather Colquhoun
- Department of Occupational Science and Occupational Therapy, University of Toronto, Toronto, Canada
| | - Justin Presseau
- Ottawa Hospital Research Institute, Ottawa, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - Rebecca Walwyn
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Robbie Foy
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
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38
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Bradbury CA, Lawler PR, Stanworth SJ, McVerry BJ, McQuilten Z, Higgins AM, Mouncey PR, Al-Beidh F, Rowan KM, Berry LR, Lorenzi E, Zarychanski R, Arabi YM, Annane D, Beane A, van Bentum-Puijk W, Bhimani Z, Bihari S, Bonten MJM, Brunkhorst FM, Buzgau A, Buxton M, Carrier M, Cheng AC, Cove M, Detry MA, Estcourt LJ, Fitzgerald M, Girard TD, Goligher EC, Goossens H, Haniffa R, Hills T, Huang DT, Horvat CM, Hunt BJ, Ichihara N, Lamontagne F, Leavis HL, Linstrum KM, Litton E, Marshall JC, McAuley DF, McGlothlin A, McGuinness SP, Middeldorp S, Montgomery SK, Morpeth SC, Murthy S, Neal MD, Nichol AD, Parke RL, Parker JC, Reyes LF, Saito H, Santos MS, Saunders CT, Serpa-Neto A, Seymour CW, Shankar-Hari M, Singh V, Tolppa T, Turgeon AF, Turner AM, van de Veerdonk FL, Green C, Lewis RJ, Angus DC, McArthur CJ, Berry S, Derde LPG, Webb SA, Gordon AC. Effect of Antiplatelet Therapy on Survival and Organ Support-Free Days in Critically Ill Patients With COVID-19: A Randomized Clinical Trial. JAMA 2022; 327:1247-1259. [PMID: 35315874 PMCID: PMC8941448 DOI: 10.1001/jama.2022.2910] [Citation(s) in RCA: 68] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Importance The efficacy of antiplatelet therapy in critically ill patients with COVID-19 is uncertain. Objective To determine whether antiplatelet therapy improves outcomes for critically ill adults with COVID-19. Design, Setting, and Participants In an ongoing adaptive platform trial (REMAP-CAP) testing multiple interventions within multiple therapeutic domains, 1557 critically ill adult patients with COVID-19 were enrolled between October 30, 2020, and June 23, 2021, from 105 sites in 8 countries and followed up for 90 days (final follow-up date: July 26, 2021). Interventions Patients were randomized to receive either open-label aspirin (n = 565), a P2Y12 inhibitor (n = 455), or no antiplatelet therapy (control; n = 529). Interventions were continued in the hospital for a maximum of 14 days and were in addition to anticoagulation thromboprophylaxis. Main Outcomes and Measures The primary end point was organ support-free days (days alive and free of intensive care unit-based respiratory or cardiovascular organ support) within 21 days, ranging from -1 for any death in hospital (censored at 90 days) to 22 for survivors with no organ support. There were 13 secondary outcomes, including survival to discharge and major bleeding to 14 days. The primary analysis was a bayesian cumulative logistic model. An odds ratio (OR) greater than 1 represented improved survival, more organ support-free days, or both. Efficacy was defined as greater than 99% posterior probability of an OR greater than 1. Futility was defined as greater than 95% posterior probability of an OR less than 1.2 vs control. Intervention equivalence was defined as greater than 90% probability that the OR (compared with each other) was between 1/1.2 and 1.2 for 2 noncontrol interventions. Results The aspirin and P2Y12 inhibitor groups met the predefined criteria for equivalence at an adaptive analysis and were statistically pooled for further analysis. Enrollment was discontinued after the prespecified criterion for futility was met for the pooled antiplatelet group compared with control. Among the 1557 critically ill patients randomized, 8 patients withdrew consent and 1549 completed the trial (median age, 57 years; 521 [33.6%] female). The median for organ support-free days was 7 (IQR, -1 to 16) in both the antiplatelet and control groups (median-adjusted OR, 1.02 [95% credible interval {CrI}, 0.86-1.23]; 95.7% posterior probability of futility). The proportions of patients surviving to hospital discharge were 71.5% (723/1011) and 67.9% (354/521) in the antiplatelet and control groups, respectively (median-adjusted OR, 1.27 [95% CrI, 0.99-1.62]; adjusted absolute difference, 5% [95% CrI, -0.2% to 9.5%]; 97% posterior probability of efficacy). Among survivors, the median for organ support-free days was 14 in both groups. Major bleeding occurred in 2.1% and 0.4% of patients in the antiplatelet and control groups (adjusted OR, 2.97 [95% CrI, 1.23-8.28]; adjusted absolute risk increase, 0.8% [95% CrI, 0.1%-2.7%]; 99.4% probability of harm). Conclusions and Relevance Among critically ill patients with COVID-19, treatment with an antiplatelet agent, compared with no antiplatelet agent, had a low likelihood of providing improvement in the number of organ support-free days within 21 days. Trial Registration ClinicalTrials.gov Identifier: NCT02735707.
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Affiliation(s)
| | - Patrick R Lawler
- Peter Munk Cardiac Centre at University Health Network, Toronto, Ontario, Canada
- University of Toronto, Toronto, Ontario, Canada
| | - Simon J Stanworth
- University of Oxford, Oxford, England
- NHS Blood and Transplant, Oxford, England
| | | | - Zoe McQuilten
- Monash University, Melbourne, Victoria, Australia
- Monash Health, Melbourne, Victoria, Australia
| | | | - Paul R Mouncey
- Intensive Care National Audit and Research Centre (ICNARC), London, England
| | | | - Kathryn M Rowan
- Intensive Care National Audit and Research Centre (ICNARC), London, England
| | | | | | | | - Yaseen M Arabi
- King Saud bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Djillali Annane
- Hospital Raymond Poincaré (Assistance Publique Hôpitaux de Paris), Garches, France
- Université Versailles SQY-Université Paris Saclay, Montigny-le-Bretonneux, France
| | - Abi Beane
- University of Oxford, Oxford, England
| | | | - Zahra Bhimani
- St Michael's Hospital Unity Health, Toronto, Ontario, Canada
| | - Shailesh Bihari
- Flinders University, Bedford Park, South Australia, Australia
| | | | | | | | - Meredith Buxton
- Global Coalition for Adaptive Research, Los Angeles, California
| | - Marc Carrier
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Institut du Savoir Montfort, Ottawa, Ontario, Canada
| | - Allen C Cheng
- Monash University, Melbourne, Victoria, Australia
- Alfred Health, Melbourne, Victoria, Australia
| | - Matthew Cove
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | | | | | | | | | - Ewan C Goligher
- Peter Munk Cardiac Centre at University Health Network, Toronto, Ontario, Canada
- University of Toronto, Toronto, Ontario, Canada
| | | | - Rashan Haniffa
- University of Oxford, Bangkok, Thailand
- National Intensive Care Surveillance (NICST), Colombo, Sri Lanka
| | - Thomas Hills
- Medical Research Institute of New Zealand (MRINZ), Wellington, New Zealand
| | | | | | | | | | | | - Helen L Leavis
- University Medical Center Utrecht, Utrecht, the Netherlands
| | | | - Edward Litton
- Fiona Stanley Hospital, Perth, Western Australia, Australia
- University of Western Australia, Perth, Australia
| | - John C Marshall
- St Michael's Hospital Unity Health, Toronto, Ontario, Canada
| | - Daniel F McAuley
- Queen's University Belfast, Belfast, Northern Ireland
- Royal Victoria Hospital, Belfast, Northern Ireland
| | | | - Shay P McGuinness
- Monash University, Melbourne, Victoria, Australia
- Auckland City Hospital, Auckland, New Zealand
| | | | | | | | | | | | - Alistair D Nichol
- Monash University, Melbourne, Victoria, Australia
- University College Dublin, Dublin, Ireland
| | - Rachael L Parke
- Auckland City Hospital, Auckland, New Zealand
- University of Auckland, Auckland, New Zealand
| | | | - Luis F Reyes
- Universidad de La Sabana, Chia, Colombia
- Clinica Universidad de La Sabana, Chia, Colombia
| | - Hiroki Saito
- St Marianna University School of Medicine, Yokohama City Seibu Hospital, Yokohama, Japan
| | | | | | - Ary Serpa-Neto
- Monash University, Melbourne, Victoria, Australia
- Hospital Israelita Albert Einstein, Sao Paulo, Brazil
| | | | - Manu Shankar-Hari
- King's College London, London, England
- Guy's and St Thomas' NHS Foundation Trust, London, England
| | | | - Timo Tolppa
- National Intensive Care Surveillance (NICST), Colombo, Sri Lanka
| | - Alexis F Turgeon
- Université Laval, Québec City, Québec, Canada
- CHU de Québec-Université Laval Research Center, Québec City, Québec, Canada
| | - Anne M Turner
- Medical Research Institute of New Zealand (MRINZ), Wellington, New Zealand
| | | | | | - Roger J Lewis
- Berry Consultants, Austin, Texas
- Harbor-UCLA Medical Center, Torrance, California
| | | | | | | | | | - Steve A Webb
- Monash University, Melbourne, Victoria, Australia
- St John of God Hospital, Subiaco, Western Australia, Australia
| | - Anthony C Gordon
- Imperial College London, London, England
- Imperial College Healthcare NHS Trust, St Mary's Hospital, London, England
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39
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Sola-Visner M, Leeman KT, Stanworth SJ. Neonatal platelet transfusions: New evidence and the challenges of translating evidence-based recommendations into clinical practice. J Thromb Haemost 2022; 20:556-564. [PMID: 35112471 DOI: 10.1111/jth.15664] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 01/28/2022] [Indexed: 01/19/2023]
Abstract
Platelet transfusions are a common intervention for thrombocytopenia. Although the main reason for transfusing platelets is to improve hemostasis, platelets have many additional physiological roles, including interactions with immune pathways. Much of the evidence base for safe and effective transfusions has been informed by randomized trials in adult patients with hematological malignancies. Only three randomized trials have been conducted in sick neonates. These trials have indicated evidence of harm, including a significantly higher rate of death or major bleeding within 28 days after randomization for the largest trial, which enrolled 660 infants. The overall research indicates limited effectiveness of platelet transfusions to reduce bleeding risk. It is important that the results of trials are implemented into practice, but uptake of research findings into neonatal medicine remains inconsistent, as for many areas of health care. There is a need to establish which potential implementation strategies (cost-) efficiently enact change, such as audit and feedback, automated reminder systems for ordering transfusions, and use of opinion leaders. Research is exploring potential mechanisms underlying the lack of effectiveness of platelet transfusions and the increased bleeding and mortality observed in neonatal randomized trials. One potential mechanism concerns the roles of platelets to promote excessive angiogenic signals during a vulnerable period of brain development. A further hypothesis explores the effects of transfusing "adult" platelets into "neonatal" thrombocytopenic blood on primary hemostasis and immune responses.
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Affiliation(s)
- Martha Sola-Visner
- Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Kristen T Leeman
- Pediatrics, Boston Children's Hospital, Harvard Neonatal-Perinatal Fellowship Program, Harvard Medical School, Boston, Massachusetts, USA
| | - Simon J Stanworth
- Haematology and Transfusion Medicine, Department of Haematology, NHS Blood and Transplant, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Radcliffe Department of Medicine, University of Oxford, Oxford, UK
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40
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Foy R, Lorencatto F, Walwyn R, Farrin A, Francis J, Gould N, McIntyre S, Patel R, Smith J, During C, Hartley S, Cicero R, Glidewell L, Grant-Casey J, Rowley M, Deary A, Swart N, Morris S, Collinson M, Moreau L, Bird J, Michie S, Grimshaw JM, Stanworth SJ. Enhanced feedback interventions to promote evidence-based blood transfusion guidance and reduce unnecessary use of blood components: the AFFINITIE research programme including two cluster factorial RCTs. Programme Grants Appl Res 2022. [DOI: 10.3310/rehp1241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background
Blood transfusion is a common but costly treatment. Repeated national audits in the UK suggest that up to one-fifth of transfusions are unnecessary when judged against recommendations for good clinical practice. Audit and feedback seeks to improve patient care and outcomes by comparing clinical care against explicit standards. It is widely used internationally in quality improvement. Audit and feedback generally has modest but variable effects on patient care. A considerable scope exists to improve the impact that audit and feedback has, particularly through head-to-head trials comparing different ways of delivering feedback.
Objectives
The AFFINITIE (Development & Evaluation of Audit and Feedback INterventions to Increase evidence-based Transfusion practIcE) programme aimed to design and evaluate enhanced feedback interventions, within a national blood transfusion audit programme, to promote evidence-based guidance and reduce the unnecessary use of blood components. We developed, piloted and refined two feedback interventions, ‘enhanced content’ and ‘enhanced follow-on’ (workstream 1), evaluated the effectiveness and cost-effectiveness of the two feedback interventions compared with standard feedback practice (workstream 2), examined intervention fidelity and contextual influences (workstream 3) and developed general implementation recommendations and tools for other audit and feedback programmes (workstream 4).
Design
Interviews, observations and documentary analysis in four purposively sampled hospitals explored contemporary practice and opportunities for strengthening feedback. We developed two interventions: ‘enhanced content’, to improve the clarity and utility of feedback reports, and ‘enhanced follow-on’, to help hospital staff with action-planning (workstream 1). We conducted two linked 2 × 2 factorial cross-sectional cluster-randomised trials within transfusion audits for major surgery and haematological oncology, respectively (workstream 2). We randomised hospital clusters (the organisational level at which hospital transfusion teams operate) to enhanced or standard content or enhanced or standard follow-on. Outcome assessment was masked to assignment. Decision-analytic modelling evaluated the costs, benefits and cost-effectiveness of the feedback interventions in both trials from the perspective of the NHS. A parallel process evaluation used semistructured interviews, documentary analyses and web analytics to assess the fidelity of delivery, receipt and enactment and to identify contextual influences (workstream 3). We explored ways of improving the impact of national audits with their representatives (workstream 4).
Setting and participants
All NHS hospital trusts and health boards participating in the National Comparative Audit of Blood Transfusions were invited to take part. Among 189 hospital trusts and health boards screened, 152 hospital clusters participated in the surgical audit. Among 187 hospital trusts and health boards screened, 141 hospital clusters participated in the haematology audit.
Interventions
‘Enhanced content’ aimed to ensure that the content and format of feedback reports were consistent with behaviour change theory and evidence. ‘Enhanced follow-on’ comprised a web-based toolkit and telephone support to facilitate local dissemination, planning and response to feedback.
Main outcome measures
Proportions of acceptable transfusions, based on existing evidence and guidance and algorithmically derived from national audit data.
Data sources
Trial primary outcomes were derived from manually collected, patient-level audit data. Secondary outcomes included routinely collected data for blood transfusion.
Results
With regard to the transfusions in the major surgery audit, 135 (89%) hospital clusters participated from 152 invited. We randomised 69 and 66 clusters to enhanced and standard content, respectively, and 68 and 67 clusters to enhanced and standard follow-on, respectively. We analysed a total of 2222 patient outcomes at 12 months in 54 and 58 (enhanced and standard content, respectively) and 54 and 58 (enhanced and standard follow-on, respectively) hospital clusters. With regard to the haematology audit, 134 hospital clusters (95%) participated from 141 invited. We randomised 66 and 68 clusters to enhanced and standard content, respectively, and 67 clusters to both enhanced and standard follow-on. We analysed a total of 3859 patient outcomes at 12 months in 61 and 61 (enhanced and standard content, respectively) and 63 and 59 (enhanced and standard follow-on) hospital clusters. We found no effect of either of the enhanced feedback interventions in either trial across all outcomes. Incremental enhanced intervention costs ranged from £18 to £248 per site. The enhanced feedback interventions were dominated by the standard intervention in cost-effectiveness analyses. The interventions were delivered as designed and intended, but subsequent local engagement was low. Although the enhancements were generally acceptable, doubts about the credibility of the blood transfusion audits undermined the case for change.
Limitations
Limitations included the number of participating clusters; loss to follow-up of trial clusters, reducing statistical power and validity; incomplete audit and cost data contributing to outcome measures; participant self-selection; reporting; missing data related to additional staff activity generated in response to receiving feedback; and recall biases in the process evaluation interviews.
Conclusions
The enhanced feedback interventions were acceptable to recipients but were more costly and no more effective than standard feedback in reducing unnecessary use of blood components, and, therefore, should not be recommended on economic grounds.
Future work
We have demonstrated the feasibility of embedding ambitious large-scale rigorous research within national audit programmes. Further head-to-head comparisons of different feedback interventions are needed in these programmes to identify cost-effective ways of increasing the impact of the interventions.
Trial registration
This trial is registered as ISRCTN15490813.
Funding
This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 10, No. 2. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Robbie Foy
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Fabiana Lorencatto
- Division of Psychology and Language Sciences, University College London, London, UK
| | - Rebecca Walwyn
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Amanda Farrin
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Jill Francis
- School of Health Sciences, University of Melbourne, Melbourne, VIC, Australia
- Centre of Implementation Research, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Natalie Gould
- School of Humanities and Social Science, University of Brighton, Brighton, UK
| | - Stephen McIntyre
- School of Humanities and Social Science, University of Brighton, Brighton, UK
| | - Riya Patel
- Centre for Intelligent Healthcare, Coventry University, Coventry, UK
| | - James Smith
- School of Humanities and Social Science, University of Brighton, Brighton, UK
| | - Camilla During
- School of Humanities and Social Science, University of Brighton, Brighton, UK
| | - Suzanne Hartley
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Robert Cicero
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Liz Glidewell
- Hull York Medical School and Health Sciences, University of York, York, UK
| | - John Grant-Casey
- Department of Transfusion Medicine, John Radcliffe Hospital, NHS Blood and Transplant, Oxford, UK
| | - Megan Rowley
- Scottish National Blood Transfusion Service, Edinburgh, UK
| | - Alison Deary
- Department of Transfusion Medicine, John Radcliffe Hospital, NHS Blood and Transplant, Oxford, UK
| | - Nicholas Swart
- Department of Applied Health Research, University College London, London, UK
| | - Stephen Morris
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Michelle Collinson
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Lauren Moreau
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Jon Bird
- School of Humanities and Social Science, University of Brighton, Brighton, UK
- Faculty of Engineering, University of Bristol, Bristol, UK
| | - Susan Michie
- Division of Psychology and Language Sciences, University College London, London, UK
| | - Jeremy M Grimshaw
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Simon J Stanworth
- Department of Transfusion Medicine, John Radcliffe Hospital, NHS Blood and Transplant, Oxford, UK
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Radcliffe Department of Medicine and Oxford BRC Haematology Theme, University of Oxford, Oxford, UK
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41
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Morton S, Sekhar M, Smethurst H, Mora A, Hodge RL, Hudson CL, Parsons J, Hopkins V, Stanworth SJ. Do liberal thresholds for red cell transfusion result in improved quality of life for patients undergoing intensive chemotherapy for acute myeloid leukemia? A randomized cross over feasibility study. Haematologica 2022; 107:1474-1478. [PMID: 35199504 PMCID: PMC9152957 DOI: 10.3324/haematol.2021.279867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Indexed: 11/20/2022] Open
Affiliation(s)
- Suzy Morton
- Department of Clinical Haematology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom. B15 2WB; Medical Department, NHS Blood and Transplant, Birmingham, United Kingdom. B15 2SG.
| | - Mallika Sekhar
- Department of Haematology, University College London Hospitals NHS Foundation Trust, London, United Kingdom. NW1 2BU; Royal Free London NHS Foundation Trust, Department of Haematology, London, United Kingdom. NW3 2QG
| | - Heather Smethurst
- Clinical Trials Unit, NHS Blood and Transplant, Cambridge, United Kingdom. CB2 0PT
| | - Ana Mora
- Clinical Trials Unit, NHS Blood and Transplant, Cambridge, United Kingdom. CB2 0PT
| | - Renate L Hodge
- Clinical Trials Unit, NHS Blood and Transplant, Cambridge, United Kingdom. CB2 0PT
| | - Cara L Hudson
- Clinical Trials Unit, NHS Blood and Transplant, Bristol, United Kingdom. BS34 8RR
| | - Joseph Parsons
- Clinical Trials Unit, NHS Blood and Transplant, Bristol, United Kingdom. BS34 8RR
| | - Valerie Hopkins
- Clinical Trials Unit, NHS Blood and Transplant, Cambridge, United Kingdom. CB2 0PT
| | - Simon J Stanworth
- Department of Clinical Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom. OX3 9BQ; Clinical Department, NHS Blood and Transplant, Oxford, United Kingdom. OX3 9BQ; Radcliffe Department of Medicine, University of Oxford, and NIHR Oxford Biomedical Research Centre
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Stanworth SJ, Walwyn R, Grant-Casey J, Hartley S, Moreau L, Lorencatto F, Francis J, Gould N, Swart N, Rowley M, Morris S, Grimshaw J, Farrin A, Foy R. Effectiveness of Enhanced Performance Feedback on Appropriate Use of Blood Transfusions: A Comparison of 2 Cluster Randomized Trials. JAMA Netw Open 2022; 5:e220364. [PMID: 35201305 PMCID: PMC8874348 DOI: 10.1001/jamanetworkopen.2022.0364] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
IMPORTANCE Auditing and feedback are frequently used to improve patient care. However, it remains unclear how to optimize feedback effectiveness for the appropriate use of treatments such as blood transfusion, a common but costly procedure that is more often overused than underused. OBJECTIVE To evaluate 2 theoretically informed feedback interventions to improve the appropriate use of blood transfusions. DESIGN, SETTING, AND PARTICIPANTS Two sequential, linked 2 × 2 cluster randomized trials were performed in hospitals in the UK participating in national audits of transfusion for perioperative anemia and management of hematological disorders. Data were collected for a surgical trial from October 1, 2014, to October 31, 2016, with follow-up completed on October 31, 2016. Data were collected for a hematological trial through follow-up from July 1, 2015, to June 30, 2017. Trial data were analyzed from November 1, 2016, to June 1, 2019. INTERVENTIONS Hospitals were randomized to standard content or enhanced content to improve feedback clarity and usability and to standard support or enhanced support for staff to act on feedback. MAIN OUTCOMES AND MEASURES The primary end point was appropriateness of transfusions audited at 12 months. Secondary end points included volume of transfusions (aiming for reductions at patient and cluster levels) and transfusion-related adverse events and reactions. RESULTS One hundred thirty-five of 152 eligible clusters participated in the surgical audit (2714 patients; mean [SD] age, 74.9 [14.0] years; 1809 women [66.7%]), and 134 of 141 participated in the hematological audit (4439 patients; median age, 72.0 [IQR, 64.0-80.0] years; 2641 men [59.5%]). Fifty-seven of 69 clusters (82.6%) in the surgical audit randomized to enhanced content downloaded reports compared with 52 of 66 clusters (78.8%) randomized to standard reports. Fifty-nine of 68 clusters (86.8%) randomized to enhanced support logged onto the toolkit. The proportion of patients with appropriate transfusions was 0.184 for standard content and 0.176 for enhanced content (adjusted odds ratio [OR], 0.91 [97.5% CI, 0.61-1.36]) and 0.181 for standard support and 0.180 for enhanced support (adjusted OR, 1.05 [97.5% CI, 0.68-1.61]). For the hematological audit, 53 of 66 clusters (80.3%) randomized to enhanced content downloaded the reports compared with 53 of 68 clusters (77.9%) randomized to standard content. Forty-nine of 67 clusters sites (73.1%) assigned to enhanced support logged into the toolkit at least once. The proportion of patients with appropriate transfusions was 0.744 for standard content and 0.714 for enhanced content (adjusted OR, 0.81 [97.5% CI, 0.56-1.12]), and 0.739 for standard support and 0.721 for enhanced support (adjusted OR, 0.96 [97.5% CI, 0.67-1.38]). CONCLUSIONS AND RELEVANCE This comparison of cluster randomized trials found that interventions to improve feedback usability and guide local action were no more effective than standard feedback in increasing the appropriate use of blood transfusions. Auditing and feedback delivered at scale is a complex and costly program; therefore, effective responses may depend on developing robust local quality improvement arrangements, which can be evaluated using rigorous experimental designs embedded within national programs. TRIAL REGISTRATION isrctn.org Identifier: ISRCTN15490813.
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Affiliation(s)
- Simon J. Stanworth
- NHS Blood and Transplant, John Radcliffe Hospital, Oxford, United Kingdom
- Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
- Radcliffe Department of Medicine and Oxford Biomedical Research Center Haematology Theme, University of Oxford, Oxford, United Kingdom
| | - Rebecca Walwyn
- Clinical Trials Research Unit, Leeds Institute for Clinical Trials Research, University of Leeds, Leeds, United Kingdom
| | - John Grant-Casey
- NHS Blood and Transplant, John Radcliffe Hospital, Oxford, United Kingdom
| | - Suzanne Hartley
- Clinical Trials Research Unit, Leeds Institute for Clinical Trials Research, University of Leeds, Leeds, United Kingdom
| | - Lauren Moreau
- Clinical Trials Research Unit, Leeds Institute for Clinical Trials Research, University of Leeds, Leeds, United Kingdom
| | - Fabiana Lorencatto
- Division of Psychology and Language Sciences, University College London, London, United Kingdom
| | - Jill Francis
- School of Health Sciences City, University of London, London, United Kingdom
- School of Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Natalie Gould
- School of Health Sciences City, University of London, London, United Kingdom
| | - Nick Swart
- Department of Applied Health Research, University College London, London, United Kingdom
| | - Megan Rowley
- Scottish National Blood Transfusion Service, Edinburgh, Edinburgh, United Kingdom
| | - Steve Morris
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
| | - Jeremy Grimshaw
- Faculty of Medicine, University of Ottawa, Ontario, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Amanda Farrin
- Clinical Trials Research Unit, Leeds Institute for Clinical Trials Research, University of Leeds, Leeds, United Kingdom
| | - Robbie Foy
- Leeds Institute of Health Sciences, University of Leeds, Leeds, United Kingdom
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Nellis ME, Karam O, Valentine SL, Bateman ST, Remy KE, Lacroix J, Cholette JM, Bembea MM, Russell RT, Steiner ME, Goobie SM, Tucci M, Stricker PA, Stanworth SJ, Delaney M, Lieberman L, Muszynski JA, Bauer DF, Steffen K, Nishijima D, Ibla J, Emani S, Vogel AM, Haas T, Goel R, Crighton G, Delgado D, Demetres M, Parker RI. Executive Summary of Recommendations and Expert Consensus for Plasma and Platelet Transfusion Practice in Critically Ill Children: From the Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding (TAXI-CAB). Pediatr Crit Care Med 2022; 23:34-51. [PMID: 34989711 PMCID: PMC8820267 DOI: 10.1097/pcc.0000000000002851] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVES Critically ill children frequently receive plasma and platelet transfusions. We sought to determine evidence-based recommendations, and when evidence was insufficient, we developed expert-based consensus statements about decision-making for plasma and platelet transfusions in critically ill pediatric patients. DESIGN Systematic review and consensus conference series involving multidisciplinary international experts in hemostasis, and plasma/platelet transfusion in critically ill infants and children (Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding [TAXI-CAB]). SETTING Not applicable. PATIENTS Children admitted to a PICU at risk of bleeding and receipt of plasma and/or platelet transfusions. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A panel of 29 experts in methodology, transfusion, and implementation science from five countries and nine pediatric subspecialties completed a systematic review and participated in a virtual consensus conference series to develop recommendations. The search included MEDLINE, EMBASE, and Cochrane Library databases, from inception to December 2020, using a combination of subject heading terms and text words for concepts of plasma and platelet transfusion in critically ill children. Four graded recommendations and 49 consensus expert statements were developed using modified Research and Development/UCLA and Grading of Recommendations, Assessment, Development, and Evaluation methodology. We focused on eight subpopulations of critical illness (1, severe trauma, intracranial hemorrhage, or traumatic brain injury; 2, cardiopulmonary bypass surgery; 3, extracorporeal membrane oxygenation; 4, oncologic diagnosis or hematopoietic stem cell transplantation; 5, acute liver failure or liver transplantation; 6, noncardiac surgery; 7, invasive procedures outside the operating room; 8, sepsis and/or disseminated intravascular coagulation) as well as laboratory assays and selection/processing of plasma and platelet components. In total, we came to consensus on four recommendations, five good practice statements, and 44 consensus-based statements. These results were further developed into consensus-based clinical decision trees for plasma and platelet transfusion in critically ill pediatric patients. CONCLUSIONS The TAXI-CAB program provides expert-based consensus for pediatric intensivists for the administration of plasma and/or platelet transfusions in critically ill pediatric patients. There is a pressing need for primary research to provide more evidence to guide practitioners.
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Affiliation(s)
- Marianne E Nellis
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, NY Presbyterian Hospital-Weill Cornell Medicine, New York, NY
| | - Oliver Karam
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Children's Hospital of Richmond at VCU, Richmond, VA
| | - Stacey L Valentine
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Massachusetts Medical School, Worcester, MA
| | - Scot T Bateman
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Massachusetts Medical School, Worcester, MA
| | - Kenneth E Remy
- Division of Pediatric Critical Care Medicine and Pulmonary/Critical Care Medicine, Departments of Pediatrics and Internal Medicine, Washington University of St. Louis, St. Louis, MO
| | - Jacques Lacroix
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montreal, QC, Canada
| | - Jill M Cholette
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Rochester Golisano Children's Hospital, Rochester, NY
| | - Melania M Bembea
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Robert T Russell
- Department of Surgery, University of Alabama Birmingham, Birmingham, AL
| | - Marie E Steiner
- Department of Pediatrics, University of Minnesota, Minneapolis, MN
| | - Susan M Goobie
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Marisa Tucci
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montreal, QC, Canada
| | - Paul A Stricker
- Department of Anesthesiology and Critical Care, The Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, PA
| | - Simon J Stanworth
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, NY Presbyterian Hospital-Weill Cornell Medicine, New York, NY
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Children's Hospital of Richmond at VCU, Richmond, VA
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Massachusetts Medical School, Worcester, MA
- Division of Pediatric Critical Care Medicine and Pulmonary/Critical Care Medicine, Departments of Pediatrics and Internal Medicine, Washington University of St. Louis, St. Louis, MO
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montreal, QC, Canada
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Rochester Golisano Children's Hospital, Rochester, NY
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Surgery, University of Alabama Birmingham, Birmingham, AL
- Department of Pediatrics, University of Minnesota, Minneapolis, MN
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA
- Department of Anesthesiology and Critical Care, The Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, PA
- NHS Blood and Transplant, Oxford, United Kingdom
- Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
- Radcliffe Department of Medicine and Oxford BRC Haematology Theme, University of Oxford, Oxford, United Kingdom
- Division of Pathology & Laboratory Medicine, Children's National Hospital, Washington, DC
- Department of Pathology & Pediatrics, The George Washington University Health Sciences, Washington, DC
- Department of Clinical Pathology, University Health Network Hospitals, Toronto, ON, Canada
- Department of Laboratory Medicine & Pathobiology, University of Toronto, Toronto, ON, Canada
- Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH
- Division of Pediatric Neurosurgery Texas Children's Hospital, Department of Neurosurgery, Baylor College of Medicine, Houston, TX
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Stanford University, Palo Alto, CA
- Department of Emergency Medicine, University of California, Davis School of Medicine, Davis, CA
- Department of Cardiovascular Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA
- Division of Pediatric Surgery Texas Children's Hospital, Department of Surgery, Baylor College of Medicine, Houston, TX
- Department of Pediatric Anesthesia, University Children's Hospital Zurich, Zurich, Switzerland
- Division of Transfusion Medicine, Department of Pathology, Johns Hopkins University, Baltimore, MD
- Department of Haematology, Royal Children's Hospital, Melbourne, VIC, Australia
- Samuel J. Wood Library & C.V. Starr Biomedical Information Center, Weill Cornell Medicine, New York, NY
- Department of Pediatric Hematology/Oncology, Renaissance School of Medicine, State University of New York at Stony Brook, Stony Brook, NY
| | - Meghan Delaney
- Division of Pathology & Laboratory Medicine, Children's National Hospital, Washington, DC
- Department of Pathology & Pediatrics, The George Washington University Health Sciences, Washington, DC
| | - Lani Lieberman
- Department of Clinical Pathology, University Health Network Hospitals, Toronto, ON, Canada
- Department of Laboratory Medicine & Pathobiology, University of Toronto, Toronto, ON, Canada
| | - Jennifer A Muszynski
- Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH
| | - David F Bauer
- Division of Pediatric Neurosurgery Texas Children's Hospital, Department of Neurosurgery, Baylor College of Medicine, Houston, TX
| | - Katherine Steffen
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Stanford University, Palo Alto, CA
| | - Daniel Nishijima
- Department of Emergency Medicine, University of California, Davis School of Medicine, Davis, CA
| | - Juan Ibla
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Sitaram Emani
- Department of Cardiovascular Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Adam M Vogel
- Division of Pediatric Surgery Texas Children's Hospital, Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Thorsten Haas
- Department of Pediatric Anesthesia, University Children's Hospital Zurich, Zurich, Switzerland
| | - Ruchika Goel
- Division of Transfusion Medicine, Department of Pathology, Johns Hopkins University, Baltimore, MD
| | - Gemma Crighton
- Department of Haematology, Royal Children's Hospital, Melbourne, VIC, Australia
| | - Diana Delgado
- Samuel J. Wood Library & C.V. Starr Biomedical Information Center, Weill Cornell Medicine, New York, NY
| | - Michelle Demetres
- Samuel J. Wood Library & C.V. Starr Biomedical Information Center, Weill Cornell Medicine, New York, NY
| | - Robert I Parker
- Department of Pediatric Hematology/Oncology, Renaissance School of Medicine, State University of New York at Stony Brook, Stony Brook, NY
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Lieberman L, Karam O, Stanworth SJ, Goobie SM, Crighton G, Goel R, Lacroix J, Nellis ME, Parker RI, Steffen K, Stricker P, Valentine SL, Steiner ME. Plasma and Platelet Transfusion Strategies in Critically Ill Children With Malignancy, Acute Liver Failure and/or Liver Transplantation, or Sepsis: From the Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding. Pediatr Crit Care Med 2022; 23:e37-e49. [PMID: 34989704 PMCID: PMC8769367 DOI: 10.1097/pcc.0000000000002857] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVES To present the consensus statements with supporting literature for plasma and platelet transfusions in critically ill neonates and children with malignancy, acute liver disease and/or following liver transplantation, and sepsis and/or disseminated intravascular coagulation from the Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding. DESIGN Systematic review and consensus conference of international, multidisciplinary experts in platelet and plasma transfusion management of critically ill children. SETTING Not applicable. PATIENTS Critically ill neonates and children with malignancy, acute liver disease and/or following liver transplantation, and sepsis and/or disseminated intravascular coagulation. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A panel of 13 experts developed evidence-based and, when evidence was insufficient, expert-based statements for plasma and platelet transfusions in critically ill neonates and children with malignancy, acute liver disease and/or following liver transplantation, and sepsis and/or disseminated intravascular coagulation. These statements were reviewed and ratified by the 29 Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding experts. A systematic review was conducted using MEDLINE, EMBASE, and Cochrane Library databases, from inception to December 2020. Consensus was obtained using the Research and Development/University of California, Los Angeles Appropriateness Method. Results were summarized using the Grading of Recommendations Assessment, Development, and Evaluation method. We developed 12 expert consensus statements. CONCLUSIONS In the Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding program, the current absence of evidence for use of plasma and/or platelet transfusion in critically ill children with malignancy, acute liver disease and/or following liver transplantation, and sepsis means that only expert consensus statements are possible for these areas of practice.
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Affiliation(s)
- Lani Lieberman
- Department of Clinical Pathology, University Health Network Hospitals. Department of Laboratory Medicine & Pathobiology; University of Toronto, Toronto, Canada
| | - Oliver Karam
- Division of Pediatric Critical Care Medicine, Children’s Hospital of Richmond at VCU, Richmond, VA, USA
| | - Simon J. Stanworth
- NHS Blood and Transplant; Oxford University Hospitals NHS Foundation Trust; Radcliffe Department of Medicine and Oxford BRC Haematology Theme, University of Oxford, UK
| | - Susan M. Goobie
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Gemma Crighton
- Department of Haematology, Royal Children’s Hospital, Melbourne, Australia
| | - Ruchika Goel
- Division of Transfusion Medicine, Department of Pathology, Johns Hopkins University, Baltimore, MD and Simmons Cancer Institute, Division of Hematology Oncology at SIU School of Medicine, Springfield, IL, USA
| | - Jacques Lacroix
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, QC, Canada
| | - Marianne E. Nellis
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, NY Presbyterian Hospital – Weill Cornell Medicine, New York, NY, USA
| | - Robert I. Parker
- Department of Pediatric Hematology/Oncology, Renaissance School of Medicine, State University of New York at Stony Brook, Stony Brook, NY, USA
| | - Katherine Steffen
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Stanford University, Palo Alto, CA, USA
| | - Paul Stricker
- Department of Anesthesiology and Critical Care, The Children’s Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, PA, USA
| | - Stacey L. Valentine
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Massachusetts Medical School, Worcester, MA, USA
| | - Marie E. Steiner
- Divisions of Hematology and Critical Care, Department of Pediatrics, University of Minnesota, Minneapolis, MN, USA
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Carson JL, Stanworth SJ, Dennis JA, Trivella M, Roubinian N, Fergusson DA, Triulzi D, Dorée C, Hébert PC. Transfusion thresholds for guiding red blood cell transfusion. Cochrane Database Syst Rev 2021; 12:CD002042. [PMID: 34932836 PMCID: PMC8691808 DOI: 10.1002/14651858.cd002042.pub5] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND The optimal haemoglobin threshold for use of red blood cell (RBC) transfusions in anaemic patients remains an active field of research. Blood is a scarce resource, and in some countries, transfusions are less safe than in others because of inadequate testing for viral pathogens. If a liberal transfusion policy does not improve clinical outcomes, or if it is equivalent, then adopting a more restrictive approach could be recognised as the standard of care. OBJECTIVES: The aim of this review update was to compare 30-day mortality and other clinical outcomes for participants randomised to restrictive versus liberal red blood cell (RBC) transfusion thresholds (triggers) for all clinical conditions. The restrictive transfusion threshold uses a lower haemoglobin concentration as a threshold for transfusion (most commonly, 7.0 g/dL to 8.0 g/dL), and the liberal transfusion threshold uses a higher haemoglobin concentration as a threshold for transfusion (most commonly, 9.0 g/dL to 10.0 g/dL). SEARCH METHODS We identified trials through updated searches: CENTRAL (2020, Issue 11), MEDLINE (1946 to November 2020), Embase (1974 to November 2020), Transfusion Evidence Library (1950 to November 2020), Web of Science Conference Proceedings Citation Index (1990 to November 2020), and trial registries (November 2020). We checked the reference lists of other published reviews and relevant papers to identify additional trials. We were aware of one trial identified in earlier searching that was in the process of being published (in February 2021), and we were able to include it before this review was finalised. SELECTION CRITERIA We included randomised trials of surgical or medical participants that recruited adults or children, or both. We excluded studies that focused on neonates. Eligible trials assigned intervention groups on the basis of different transfusion schedules or thresholds or 'triggers'. These thresholds would be defined by a haemoglobin (Hb) or haematocrit (Hct) concentration below which an RBC transfusion would be administered; the haemoglobin concentration remains the most commonly applied marker of the need for RBC transfusion in clinical practice. We included trials in which investigators had allocated participants to higher thresholds or more liberal transfusion strategies compared to more restrictive ones, which might include no transfusion. As in previous versions of this review, we did not exclude unregistered trials published after 2010 (as per the policy of the Cochrane Injuries Group, 2015), however, we did conduct analyses to consider the differential impact of results of trials for which prospective registration could not be confirmed. DATA COLLECTION AND ANALYSIS: We identified trials for inclusion and extracted data using Cochrane methods. We pooled risk ratios of clinical outcomes across trials using a random-effects model. Two review authors independently extracted data and assessed risk of bias. We conducted predefined analyses by clinical subgroups. We defined participants randomly allocated to the lower transfusion threshold as being in the 'restrictive transfusion' group and those randomly allocated to the higher transfusion threshold as being in the 'liberal transfusion' group. MAIN RESULTS A total of 48 trials, involving data from 21,433 participants (at baseline), across a range of clinical contexts (e.g. orthopaedic, cardiac, or vascular surgery; critical care; acute blood loss (including gastrointestinal bleeding); acute coronary syndrome; cancer; leukaemia; haematological malignancies), met the eligibility criteria. The haemoglobin concentration used to define the restrictive transfusion group in most trials (36) was between 7.0 g/dL and 8.0 g/dL. Most trials included only adults; three trials focused on children. The included studies were generally at low risk of bias for key domains including allocation concealment and incomplete outcome data. Restrictive transfusion strategies reduced the risk of receiving at least one RBC transfusion by 41% across a broad range of clinical contexts (risk ratio (RR) 0.59, 95% confidence interval (CI) 0.53 to 0.66; 42 studies, 20,057 participants; high-quality evidence), with a large amount of heterogeneity between trials (I² = 96%). Overall, restrictive transfusion strategies did not increase or decrease the risk of 30-day mortality compared with liberal transfusion strategies (RR 0.99, 95% CI 0.86 to 1.15; 31 studies, 16,729 participants; I² = 30%; moderate-quality evidence) or any of the other outcomes assessed (i.e. cardiac events (low-quality evidence), myocardial infarction, stroke, thromboembolism (all high-quality evidence)). High-quality evidence shows that the liberal transfusion threshold did not affect the risk of infection (pneumonia, wound infection, or bacteraemia). Transfusion-specific reactions are uncommon and were inconsistently reported within trials. We noted less certainty in the strength of evidence to support the safety of restrictive transfusion thresholds for the following predefined clinical subgroups: myocardial infarction, vascular surgery, haematological malignancies, and chronic bone-marrow disorders. AUTHORS' CONCLUSIONS Transfusion at a restrictive haemoglobin concentration decreased the proportion of people exposed to RBC transfusion by 41% across a broad range of clinical contexts. Across all trials, no evidence suggests that a restrictive transfusion strategy impacted 30-day mortality, mortality at other time points, or morbidity (i.e. cardiac events, myocardial infarction, stroke, pneumonia, thromboembolism, infection) compared with a liberal transfusion strategy. Despite including 17 more randomised trials (and 8846 participants), data remain insufficient to inform the safety of transfusion policies in important and selected clinical contexts, such as myocardial infarction, chronic cardiovascular disease, neurological injury or traumatic brain injury, stroke, thrombocytopenia, and cancer or haematological malignancies, including chronic bone marrow failure. Further work is needed to improve our understanding of outcomes other than mortality. Most trials compared only two separate thresholds for haemoglobin concentration, which may not identify the actual optimal threshold for transfusion in a particular patient. Haemoglobin concentration may not be the most informative marker of the need for transfusion in individual patients with different degrees of physiological adaptation to anaemia. Notwithstanding these issues, overall findings provide good evidence that transfusions with allogeneic RBCs can be avoided in most patients with haemoglobin thresholds between the range of 7.0 g/dL and 8.0 g/dL. Some patient subgroups might benefit from RBCs to maintain higher haemoglobin concentrations; research efforts should focus on these clinical contexts.
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Affiliation(s)
- Jeffrey L Carson
- Division of General Internal Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Simon J Stanworth
- John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Radcliffe Department of Medicine, NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
| | - Jane A Dennis
- Cochrane Injuries Group, London School of Hygiene & Tropical Medicine, London, UK
| | | | - Nareg Roubinian
- Kaiser Permanente Division of Research Northern California, Oakland, California, USA
| | - Dean A Fergusson
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Darrell Triulzi
- The Institute for Transfusion Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Carolyn Dorée
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
| | - Paul C Hébert
- Centre for Research, University of Montreal Hospital Research Centre, Montreal, Canada
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Pham TM, White IR, Kahan BC, Morris TP, Stanworth SJ, Forbes G. A comparison of methods for analyzing a binary composite endpoint with partially observed components in randomized controlled trials. Stat Med 2021; 40:6634-6650. [PMID: 34590333 DOI: 10.1002/sim.9203] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 06/21/2021] [Accepted: 09/02/2021] [Indexed: 11/05/2022]
Abstract
Composite endpoints are commonly used to define primary outcomes in randomized controlled trials. A participant may be classified as meeting the endpoint if they experience an event in one or several components (eg, a favorable outcome based on a composite of being alive and attaining negative culture results in trials assessing tuberculosis treatments). Partially observed components that are not missing simultaneously complicate the analysis of the composite endpoint. An intuitive strategy frequently used in practice for handling missing values in the components is to derive the values of the composite endpoint from observed components when possible, and exclude from analysis participants whose composite endpoint cannot be derived. Alternatively, complete record analysis (CRA) (excluding participants with any missing components) or multiple imputation (MI) can be used. We compare a set of methods for analyzing a composite endpoint with partially observed components mathematically and by simulation, and apply these methods in a reanalysis of a published trial (TOPPS). We show that the derived composite endpoint can be missing not at random even when the components are missing completely at random. Consequently, the treatment effect estimated from the derived endpoint is biased while CRA results without the derived endpoint are valid. Missing at random mechanisms require MI of the components. We conclude that, although superficially attractive, deriving the composite endpoint from observed components should generally be avoided. Despite the potential risk of imputation model mis-specification, MI of missing components is the preferred approach in this study setting.
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Affiliation(s)
- Tra My Pham
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, London, UK
| | - Ian R White
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, London, UK
| | - Brennan C Kahan
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, London, UK
| | - Tim P Morris
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, London, UK
| | - Simon J Stanworth
- NHS Blood & Transplant, Oxford University Hospitals and the University of Oxford, Oxford, UK
| | - Gordon Forbes
- Biostatistics & Health Informatics Department, King's College London, London, UK
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Shah A, Chester-Jones M, Dutton SJ, Marian IR, Barber VS, Griffith DM, Singleton J, Wray K, James T, Drakesmith H, Robbins PA, Frise MC, Young JD, Walsh TS, McKechnie SR, Stanworth SJ. Intravenous iron to treat anaemia following critical care: a multicentre feasibility randomised trial. Br J Anaesth 2021; 128:272-282. [PMID: 34872717 DOI: 10.1016/j.bja.2021.11.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 10/12/2021] [Accepted: 11/01/2021] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Anaemia is common and associated with poor outcomes in survivors of critical illness. However, the optimal treatment strategy is unclear. METHODS We conducted a multicentre, feasibility RCT to compare either a single dose of ferric carboxymaltose 1000 mg i.v. or usual care in patients being discharged from the ICU with moderate or severe anaemia (haemoglobin ≤100 g L-1). We collected data on feasibility (recruitment, randomisation, follow-up), biological efficacy, and clinical outcomes. RESULTS Ninety-eight participants were randomly allocated (49 in each arm). The overall recruitment rate was 34% with 6.5 participants recruited on average per month. Forty-seven of 49 (96%) participants received the intervention. Patient-reported outcome measures were available for 79/93 (85%) survivors at 90 days. Intravenous iron resulted in a higher mean (standard deviation [sd]) haemoglobin at 28 days (119.8 [13.3] vs 106.7 [14.9] g L-1) and 90 days (130.5 [15.1] vs 122.7 [17.3] g L-1), adjusted mean difference (10.98 g L-1; 95% confidence interval [CI], 4.96-17.01; P<0.001) over 90 days after randomisation. Infection rates were similar in both groups. Hospital readmissions at 90 days post-ICU discharge were lower in the i.v. iron group (7/40 vs 15/39; risk ratio=0.46; 95% CI, 0.21-0.99; P=0.037). The median (inter-quartile range) post-ICU hospital stay was shorter in the i.v. iron group but did not reach statistical significance (5.0 [3.0-13.0] vs 9.0 [5.0-16.0] days, P=0.15). CONCLUSION A large, multicentre RCT of i.v. iron to treat anaemia in survivors of critical illness appears feasible and is necessary to determine the effects on patient-centred outcomes. CLINICAL TRIAL REGISTRATION ISRCTN13721808 (www.isrctn.com).
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Affiliation(s)
- Akshay Shah
- Radcliffe Department of Medicine, University of Oxford, Oxford, UK; Adult Intensive Care Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.
| | - Mae Chester-Jones
- Oxford Clinical Trials Research Unit (OCTRU), Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Susan J Dutton
- Oxford Clinical Trials Research Unit (OCTRU), Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Ioana R Marian
- Oxford Clinical Trials Research Unit (OCTRU), Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Vicki S Barber
- Oxford Clinical Trials Research Unit (OCTRU), Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - David M Griffith
- Anaesthesia, Critical Care and Pain Medicine, University of Edinburgh, Edinburgh, UK; Deanery of Molecular, Genetic and Population Health Sciences and University of Edinburgh, Edinburgh, UK
| | - Jo Singleton
- Anaesthesia, Critical Care and Pain Medicine, University of Edinburgh, Edinburgh, UK
| | - Katherine Wray
- MRC Human Immunology Unit, MRC Weatherall Institute of Molecular Medicine, Oxford, UK
| | - Tim James
- Department of Clinical Biochemistry, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Hal Drakesmith
- MRC Human Immunology Unit, MRC Weatherall Institute of Molecular Medicine, Oxford, UK; Haematology Theme, NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Peter A Robbins
- Department of Physiology, Anatomy and Genetics, University of Oxford, Oxford, UK
| | - Matthew C Frise
- Department of Physiology, Anatomy and Genetics, University of Oxford, Oxford, UK; Intensive Care Unit, Royal Berkshire Hospitals NHS Foundation Trust, Reading, UK
| | - J Duncan Young
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Timothy S Walsh
- Anaesthesia, Critical Care and Pain Medicine, University of Edinburgh, Edinburgh, UK; Usher Institute for Population Health Sciences, University of Edinburgh, Edinburgh, UK
| | - Stuart R McKechnie
- Adult Intensive Care Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK; Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Simon J Stanworth
- Radcliffe Department of Medicine, University of Oxford, Oxford, UK; Haematology Theme, NIHR Oxford Biomedical Research Centre, Oxford, UK; Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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48
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Smethurst PA, McAndrew M, Proffitt S, Procter S, Davies J, New HV, Stanworth SJ, Doughty H, Cardigan R. Evaluating apheresis platelets at reduced dose as a contingency measure for extreme shortages. Transfusion 2021; 62:173-182. [PMID: 34757639 DOI: 10.1111/trf.16723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 10/13/2021] [Accepted: 10/19/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND The COVID19 pandemic highlights the need for contingency planning in the event of blood shortages. To increase platelet supply, we assessed the operational impact and effect on platelet quality of splitting units prior to storage. STUDY DESIGN AND METHODS Using production figures, we modeled the impact on unit numbers, platelet counts, and volumes of splitting only apheresis double donations into three units (yielding ⅔ doses), or all standard dose units in half. To assess quality, eight pools of three ABO/Rh-matched apheresis (Trima Accel) double donations in plasma were split to ⅔ and ½ volumes in both Terumo and Fresenius storage bags. These were irradiated and subject to maximal permitted periods of nonagitation (3 × 8 h) before comparing platelet quality markers (including pH, CD62P expression) to Day 9 of storage. RESULTS Splitting all double donations into three predicted inventory expansion of 23% overall whereas halving all standard dose units clearly doubles stock. In our study, ⅔ and ½ doses contained 153 ± 15 × 109 (~138 ml) and 113 ± 11 × 109 (~102 ml) platelets respectively. Following storage, higher pH was observed in ⅔ than in ½ doses and in Terumo compared to Fresenius bags. The higher pH was reflected in better quality markers, including lower CD62P expression. Despite the differences, on Day 8 (of pH monitoring at expiry) all ⅔ doses and most ½ doses were ≥pH 6.4. CONCLUSION A strategy to split apheresis platelets in plasma to lower doses is feasible, maintains acceptable platelet quality, and should be considered by blood services in response to extreme shortages.
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Affiliation(s)
- Peter A Smethurst
- Component Development Laboratory, NHS Blood and Transplant, Cambridge, UK
| | - Margaret McAndrew
- Component Development Laboratory, NHS Blood and Transplant, Cambridge, UK
| | - Susan Proffitt
- Component Development Laboratory, NHS Blood and Transplant, Cambridge, UK
| | - Simon Procter
- Quality Monitoring, NHS Blood and Transplant, London, UK
| | - Jane Davies
- Technical & Scientific Development, NHS Blood and Transplant, London, UK
| | - Helen V New
- Centre for Haematology, Imperial College London, London, UK.,Clinical Services Directorate, NHS Blood and Transplant, London, UK
| | - Simon J Stanworth
- Clinical Services Directorate, NHS Blood and Transplant, London, UK.,Radcliffe Department of Medicine, University of Oxford, and NIHR Oxford Biomedical Research Centre, Oxford, UK.,Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Heidi Doughty
- Clinical Services Directorate, NHS Blood and Transplant, London, UK
| | - Rebecca Cardigan
- Component Development Laboratory, NHS Blood and Transplant, Cambridge, UK.,Department of Haematology, University of Cambridge, Cambridge, UK
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49
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Shah AA, Donovan K, Seeley C, Dickson EA, Palmer AJR, Doree C, Brunskill S, Reid J, Acheson AG, Sugavanam A, Litton E, Stanworth SJ. Risk of Infection Associated With Administration of Intravenous Iron: A Systematic Review and Meta-analysis. JAMA Netw Open 2021; 4:e2133935. [PMID: 34767026 PMCID: PMC8590171 DOI: 10.1001/jamanetworkopen.2021.33935] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
IMPORTANCE Intravenous iron is recommended by many clinical guidelines based largely on its effectiveness in reducing anemia. However, the association with important safety outcomes, such as infection, remains uncertain. OBJECTIVE To examine the risk of infection associated with intravenous iron compared with oral iron or no iron. DATA SOURCES Medline, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL) were searched for randomized clinical trials (RCTs) from 1966 to January 31, 2021. Ongoing trials were sought from ClinicalTrials.gov, CENTRAL, and the World Health Organization International Clinical Trials Search Registry Platform. STUDY SELECTION Pairs of reviewers identified RCTs that compared intravenous iron with oral iron or no iron across all patient populations, excluding healthy volunteers. Nonrandomized studies published since January 1, 2007, were also included. A total of 312 full-text articles were assessed for eligibility. DATA EXTRACTION AND SYNTHESIS Data extraction and risk of bias assessments were performed according to the Preferred Reporting Items of Systematic Reviews and Meta-analyses (PRISMA) and Cochrane recommendations, and the quality of evidence was assessed using the GRADE (Grades of Recommendation, Assessment, Development, and Evaluation) approach. Two reviewers extracted data independently. A random-effects model was used to synthesize data from RCTs. A narrative synthesis was performed to characterize the reporting of infection. MAIN OUTCOMES AND MEASURES The primary outcome was risk of infection. Secondary outcomes included mortality, hospital length of stay, and changes in hemoglobin and red blood cell transfusion requirements. Measures of association were reported as risk ratios (RRs) or mean differences. RESULTS A total of 154 RCTs (32 920 participants) were included in the main analysis. Intravenous iron was associated with an increased risk of infection when compared with oral iron or no iron (RR, 1.17; 95% CI, 1.04-1.31; I2 = 37%; moderate certainty of evidence). Intravenous iron also was associated with an increase in hemoglobin (mean difference, 0.57 g/dL; 95% CI, 0.50-0.64 g/dL; I2 = 94%) and a reduction in the risk of requiring a red blood cell transfusion (RR, 0.93; 95% CI, 0.76-0.89; I2 = 15%) when compared with oral iron or no iron. There was no evidence of an effect on mortality or hospital length of stay. CONCLUSIONS AND RELEVANCE In this large systematic review and meta-analysis, intravenous iron was associated with an increased risk of infection. Well-designed studies, using standardized definitions of infection, are required to understand the balance between this risk and the potential benefits.
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Affiliation(s)
- Akshay A. Shah
- Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
- National Institute for Health Research Biomedical Research Centre Haematology Theme, Oxford, United Kingdom
- Adult Intensive Care Unit, Oxford University Hospitals National Health Service (NHS) Foundation Trust, Oxford, United Kingdom
| | - Killian Donovan
- Adult Intensive Care Unit, Oxford University Hospitals National Health Service (NHS) Foundation Trust, Oxford, United Kingdom
| | - Claire Seeley
- Department of Anaesthesia, Royal Berkshire Hospitals NHS Foundation Trust, Reading, United Kingdom
| | - Edward A. Dickson
- National Institute for Health Research Biomedical Research Centre in Gastrointestinal and Liver Diseases, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
- Department of Colorectal Surgery, Nottingham University Hospitals NHS Trust, University of Nottingham, Nottingham, United Kingdom
| | - Antony J. R. Palmer
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Carolyn Doree
- Systematic Review Initiative, NHS Blood & Transplant, Oxford, United Kingdom
| | - Susan Brunskill
- Systematic Review Initiative, NHS Blood & Transplant, Oxford, United Kingdom
| | - Jack Reid
- Department of Anaesthesia, Brighton and Sussex University Hospitals NHS Trust, Brighton, United Kingdom
| | - Austin G. Acheson
- National Institute for Health Research Biomedical Research Centre in Gastrointestinal and Liver Diseases, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
- Department of Colorectal Surgery, Nottingham University Hospitals NHS Trust, University of Nottingham, Nottingham, United Kingdom
| | - Anita Sugavanam
- Department of Anaesthesia, Brighton and Sussex University Hospitals NHS Trust, Brighton, United Kingdom
| | - Edward Litton
- Intensive Care Unit, Fiona Stanley Hospital, Perth, Australia
| | - Simon J. Stanworth
- Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
- National Institute for Health Research Biomedical Research Centre Haematology Theme, Oxford, United Kingdom
- Systematic Review Initiative, NHS Blood & Transplant, Oxford, United Kingdom
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
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50
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Cornelissen LL, Caram‐Deelder C, Fustolo‐Gunnink SF, Groenwold RHH, Stanworth SJ, Zwaginga JJ, van der Bom JG. Expected individual benefit of prophylactic platelet transfusions in hemato-oncology patients based on bleeding risks. Transfusion 2021; 61:2578-2587. [PMID: 34263930 PMCID: PMC8518514 DOI: 10.1111/trf.16587] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Revised: 06/15/2021] [Accepted: 06/23/2021] [Indexed: 01/01/2023]
Abstract
BACKGROUND Prophylactic platelet transfusions prevent bleeding in hemato-oncology patients, but it is unclear how any benefit varies between patients. Our aim was to assess if patients with different baseline risks for bleeding benefit differently from a prophylactic platelet transfusion strategy. STUDY DESIGN AND METHODS Using the data from the randomized controlled TOPPS trial (Trial of Platelet Prophylaxis), we developed a prediction model for World Health Organization grades 2, 3, and 4 bleeding risk (defined as at least one bleeding episode in a 30 days period) and grouped patients in four risk-quartiles based on this predicted baseline risk. Predictors in the model were baseline platelet count, age, diagnosis, disease modifying treatment, disease status, previous stem cell transplantation, and the randomization arm. RESULTS The model had a c-statistic of 0.58 (95% confidence interval [CI] 0.54-0.64). There was little variation in predicted risks (quartiles 46%, 47%, and 51%), but prophylactic platelet transfusions gave a risk reduction in all risk quartiles. The absolute risk difference (ARD) was 3.4% (CI -12.2 to 18.9) in the lowest risk quartile (quartile 1), 7.4% (95% CI -8.4 to 23.3) in quartile 2, 6.8% (95% CI -9.1 to 22.9) in quartile 3, and 12.8% (CI -3.1 to 28.7) in the highest risk quartile (quartile 4). CONCLUSION In our study, generally accepted bleeding risk predictors had limited predictive power (expressed by the low c-statistic), and, given the wide confidence intervals of predicted ARD, could not aid in identifying subgroups of patients who might benefit more (or less) from prophylactic platelet transfusion.
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Affiliation(s)
- Loes L. Cornelissen
- Jon J van Rood Center for Clinical Transfusion Research, Sanquin/LUMCLeidenThe Netherlands
- Department of HematologyLeiden University medical CenterLeidenThe Netherlands
- Department of Clinical EpidemiologyLeiden University Medical CenterLeidenThe Netherlands
| | - Camila Caram‐Deelder
- Jon J van Rood Center for Clinical Transfusion Research, Sanquin/LUMCLeidenThe Netherlands
- Department of Clinical EpidemiologyLeiden University Medical CenterLeidenThe Netherlands
| | - Susanna F. Fustolo‐Gunnink
- Jon J van Rood Center for Clinical Transfusion Research, Sanquin/LUMCLeidenThe Netherlands
- Department of Clinical EpidemiologyLeiden University Medical CenterLeidenThe Netherlands
- Department of Pediatric Hematology, Emma Children's Hospital, Amsterdam University Medical Center (UMC)University of AmsterdamAmsterdamThe Netherlands
| | - Rolf H. H. Groenwold
- Department of Clinical EpidemiologyLeiden University Medical CenterLeidenThe Netherlands
| | - Simon J. Stanworth
- Transfusion Medicine, NHS Blood and Transplant (NHSBT)OxfordUK
- Department of HaematologyOxford University Hospitals NHS Foundation TrustOxfordUK
- Radcliffe Department of MedicineUniversity of OxfordOxfordUK
- NIHR Oxford Biomedical Research CentreOxfordUK
| | - Jaap Jan Zwaginga
- Jon J van Rood Center for Clinical Transfusion Research, Sanquin/LUMCLeidenThe Netherlands
- Department of HematologyLeiden University medical CenterLeidenThe Netherlands
| | - Johanna G. van der Bom
- Jon J van Rood Center for Clinical Transfusion Research, Sanquin/LUMCLeidenThe Netherlands
- Department of Clinical EpidemiologyLeiden University Medical CenterLeidenThe Netherlands
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