Iron overload disorders: Growth and gonadal dysfunction in childhood and adolescence

Hemochromatosis (HC) is characterized by the progressive accumulation of iron in the body, resulting in organ damage. Endocrine complications are particularly common, especially when the condition manifests in childhood or adolescence, when HC can adversely affect linear growth or pubertal development, with significant repercussions on quality of life even into adulthood. Therefore, a timely and accurate diagnosis of these disorders is mandatory, but sometimes complex for hematologists without endocrinological support. This is a narrative review focused on puberty and growth disorders during infancy and adolescence aiming to offer guidance for diagnosis, treatment, and proper follow-up. Additionally, it aims to highlight gaps in the existing literature and emphasizes the importance of collaboration among specialists, which is essential in the era of precision medicine.

Transfusions in autoimmune hemolytic anemias: Frequency and clinical significance of alloimmunization

BACKGROUND

Autoimmune hemolytic anemia (AIHA) may be associated with transfusion reactions and risk of alloimmunization.

OBJECTIVES

To evaluate the transfusion policy and rate of alloimmunization and its clinical significance in AIHA.

METHODS

Data from 305 AIHA patients followed at a reference hematologic Center in Milan, Italy from 1997 to 2022 were retrospectively/prospectively collected (NCT05931718).

RESULTS

Overall, 33% patients required transfusions with a response rate of 83% and eight transfusion reactions (7%), none hemolytic. Alloantibodies were detected in 19% of patients, being associated with higher transfusion burden (p = 0.01), lower Hb increase post-transfusion (p = 0.05), and transfusion reactions (p = 0.04). Along decades, the rate of RBC transfusions decreased from 53% to 20% and that of alloimmunization dropped from 30% to 6% likely due to the adoption of prestorage leukoreduction, the use of more restrictive Hb thresholds, and the implementation of molecular typing.

CONCLUSIONS

Severe symptomatic AIHA may be safely transfused provided appropriate matching of patients and donors.

Perspectives on Transfusions for Hospice Patients With Blood Cancers: A Survey of Hospice Providers

CONTEXT

Patients with blood cancers have low rates of hospice use. While lack of transfusion access in hospice is posited to substantially contribute to these low rates, little is known about the perspectives of hospice providers regarding transfusion access in hospice.

OBJECTIVES

To characterize hospice providers' perspectives regarding care for patients with blood cancers and transfusions in the hospice setting.

METHODS

In 2022, we conducted a cross-sectional survey of a sample of hospices in the United States regarding their experience caring for patients with blood cancers, perceived barriers to hospice use, and interventions to increase enrollment.

RESULTS

We received 113 completed surveys (response rate = 23.5%). Of the cohort, 2.7% reported that their agency always offers transfusions, 40.7% reported sometimes offering transfusions, and 54.9% reported never offering transfusions. In multivariable analyses, factors associated with offering transfusions included nonprofit ownership (OR 5.93, 95% CI, 2.2-15.2) and daily census >50 patients (OR 3.06, 95% CI, 1.19-7.87). Most respondents (76.6%) identified lack of transfusion access in hospice as a barrier to hospice enrollment for blood cancer patients. The top intervention considered as "very helpful" for increasing enrollment was additional reimbursement for transfusions (72.1%).

CONCLUSION

In this national sample of hospices, access to palliative transfusions was severely limited and was considered a significant barrier to hospice use for blood cancer patients. Moreover, hospices felt increased reimbursement for transfusions would be an important intervention. These data suggest that hospice providers are supportive of increasing transfusion access and highlight the critical need for innovative hospice payment models to improve end-of-life care for patients with blood cancers.

Cryopreservation affects platelet macromolecular composition over time after thawing and differently impacts on cancer cells behavior in vitro

Cryopreservation affects platelets' function, questioning their use for cancer patients. We aimed to investigate the biochemical events that occur over time after thawing to optimize transfusion timing and evaluate the effect of platelet supernatants on tumor cell behavior in vitro. We compared fresh (Fresh-PLT) with Cryopreserved platelets (Cryo-PLT) at 1 h, 3 h and 6 h after thawing. MCF-7 and HL-60 cells were cultured with Fresh- or 1 h Cryo-PLT supernatants to investigate cell proliferation, migration, and PLT-cell adhesion. We noticed a significant impairment of hemostatic activity accompanied by a post-thaw decrease of CD42b+ , which identifies the CD62P--population. FTIR spectroscopy revealed a decrease in the total protein content together with changes in their conformational structure, which identified two sub-groups: 1) Fresh and 1 h Cryo-PLT; 2) 3 h and 6 h cryo-PLT. Extracellular vesicle shedding and phosphatidylserine externalization (PS) increased after thawing. Cryo-PLT supernatants inhibited cell proliferation, impaired MCF-7 cell migration, and reduced ability to adhere to tumor cells. Within the first 3 hours after thawing, irreversible alterations of biomolecular structure occur in Cryo-PLT. Nevertheless, Cryo-PLT should be considered safe for the transfusion of cancer patients because of their insufficient capability to promote cancer cell proliferation, adhesion, or migration.

ABO Blood Group and Bleeding and Survival in VA-ECMO Patients

ABO blood group has been shown to be a major determinant of plasma von Willebrand factor (vWF) levels. O blood group is associated with the lowest vWF levels and confers an increased risk of hemorrhagic events, while AB blood group has the highest levels and is associated with thromboembolic events. We hypothesized in extracorporeal membrane oxygenation (ECMO) patients that O blood type would have the highest and AB blood type would have the lowest transfusions, with an inverse relationship to survival. A retrospective analysis of 307 VA-ECMO patients at a major quaternary referral hospital was performed. The distribution of blood groups included 124 group O (40%), 122 group A (40%), 44 group B (14%), and 17 group AB (6%) patients. Regarding usage of packed red blood cells, fresh frozen plasma, and platelets, there was a non-statistically significant difference in transfusions, with group O having the least and group AB having the most requirements. However, there was a statistically significant difference in cryoprecipitate usage when comparing to group O: group A (1.77, 95% CI: 1.05-2.97, P < .05), group B (2.05, 95% CI: 1.16-3.63, P < .05), and group AB (3.43, 95% CI: 1.71-6.90, P < .001). Furthermore, a 20% increase in length of days on ECMO was associated with a 2-12% increase in blood product usage. The cumulative 30-day mortality rate for groups O and A was 60%, group B was 50%, and group AB was 40%; the 1-year mortality rate for groups O and A was 65%, group B was 57%, and group AB was 41%; however, the mortality differences were not statistically significant.

Factors Associated with Perioperative Transfusions in Veterans

Background: Private sector literature demonstrates an association between perioperative transfusions and poor clinical outcomes. Hemostatic agents, surgeon training, and patient blood management programs (PBMPs) may mitigate perioperative bleeding. This study attempts to identify preoperative risk factors associated with perioperative transfusions in Veterans. Study Design and Methods: This study is a retrospective review of the prospectively maintained Veterans Affairs Surgical Quality Improvement Project database. Included patients were older than 18 years and underwent noncardiac surgery between April 1, 2016, and March 31, 2021. Data collected included demographics, surgery variables, preoperative clinical variables, postoperative outcomes, and perioperative transfusions. Cohorts were created based on transfusion status. Univariate and multivariate analyses were performed to characterize the similarities, differences, and potential predictors of perioperative transfusion. Results: Of 6108 patients included, 153 patients received perioperative transfusions. The risks for transfusion included older age, male sex, black race, smoking, and low body mass index (BMI). The highest percent of transfused patients underwent vascular (43.4%), orthopedic (22%), and general surgeries (20%). Transfusion increased risk for postoperative cerebral vascular accident (P = .041) and 30-day mortality (P < .001). Multivariate regression analysis revealed American Society of Anesthesiology class, chemotherapy within 30 days, increased age, tobacco smoking, and decreased BMI were predictive of perioperative transfusions. Discussion: Perioperative transfusions are associated with increased morbidity and mortality in the Veteran population. These retrospective data describe the complex relationships between perioperative transfusions and outcomes after noncardiac surgery. These results serve as a foundation to create predictive models and PBMP within the veteran population to decrease transfusion requirements and associated complications.

Implementation of a molecular genotyping protocol for patients with warm autoantibodies

BACKGROUND

Warm autoantibodies (WAAs) cause delays and additional expenses while determining suitable products when using a traditional protocol (TP). In 2013, Carter BloodCare Immunohematology Reference Laboratory (IRL) introduced a molecular protocol (MP) for patients with WAAs.

STUDY DESIGN AND METHODS

Retrospective review of records for samples referred to the IRL from November 2004 to September 2020, was performed. Referrals, alloantibody(ies), gender, and age were recorded. Additionally, the count of common clinically significant antigens needed for phenotypically matched red blood cells (RBCs) were recorded for patients in MP. To further analyze charges and time spent testing patients with WAAs, 300 patients were selected.

RESULTS

Analysis of average charges to the referring hospital and time spent testing in the IRL determined savings at two or more referrals. Overall, 219 of 300 (73%) of patients in the study met or exceeded the number of referrals. Further analysis shows that while the population of patients with WAA (n = 300) shared similar demographics, there was a statistically significant difference between the average time testing patients in TP (M = 264.18, SD = 15.06) and MP (M = 156.00, SD = 90.37), t(157) = 14.46, p < .001, 95% confidence interval [CI] (93.41-122.97). Additionally, the assumption that each patient received two RBCs per referral provided no statistically significant difference between average charges to the hospitals of patients in TP (M = 1222.58, SD = 165.69) and MP (M = 1269.78, SD = 433.52), t(192) = -1.25, p = .214, 95% CI (-121.95-27.54).

CONCLUSION

The MP has been effective in saving time spent testing patients with WAAs, which benefits referring hospitals, patients, and IRLs. Charges for prophylactic phenotypically matched blood were negligible and a MP would alleviate some of the current laboratory difficulties while providing safe products to patients.

The Implementation of a Prehospital Whole Blood Transfusion Program and Early Results

INTRODUCTION

In far-forward combat situations, the military challenged dogma by using whole blood transfusions (WBTs) rather than component-based therapy. More recently, some trauma centers have initiated WBT programs with reported success. There are a few Emergency Medical Service (EMS) systems that are using WBTs, but the vast majority are not. Given the increasing data supporting the use of WBTs in the prehospital setting, more EMS systems are likely to consider or begin WBT programs in the future.

OBJECTIVE

A prehospital WBT program was recently implemented in Palm Beach County, Florida (USA). This report will discuss how the program was implemented, the obstacles faced, and the initial results.

METHODS

This report describes the process by which a prehospital WBT program was implemented by Palm Beach County Fire Rescue and the outcomes of the initial case series of patients who received WBTs in this system. Efforts to initiate the prehospital WBT program for this system began in 2018. The program had several obstacles to overcome, with one of the major obstacles being the legal team's perception of potential liability that might occur with a new prehospital blood transfusion program. This obstacle was overcome through education of local elected officials regarding the latest scientific evidence in favor of prehospital WBTs with potential life-saving benefits to the community. After moving past this hurdle, the program went live on July 6, 2022. The initial indications for transfusion of cold-stored, low titer, leukoreduced O+ whole blood in the prehospital setting included traumatic injuries with systolic blood pressure (SBP) < 70mmHg or SBP < 90mmHg plus heart rate (HR) > 110 beats per minute.

FINDINGS

From the date of onset through December 31, 2022, Palm Beach County Fire Rescue transported a total of 881 trauma activation patients, with 20 (2.3%) receiving WBT. Overall, nine (45%) of the patients who had received WBTs so far remain alive. No adverse events related to transfusion were identified following WBT administration. A total of 18 units of whole blood reached expiration of the unit's shelf life prior to transfusion.

CONCLUSION

Despite a number of logistical and legal obstacles, Palm Beach County Fire Rescue successfully implemented a prehospital WBT program. Other EMS systems that are considering a prehospital WBT program should review the included protocol and the barriers to implementation that were faced.

Patient Blood Management after Hematopoietic Stem Cell Transplantation in a Pediatric Setting: Starting Low and Going Lower

Despite the substantial transfusion requirements, there are few studies on the optimal transfusion strategy in pediatric patients undergoing hematopoietic stem cell transplantation (HSCT). Our study aimed to retrospectively analyze red blood cell (RBC) and platelet (PLT) transfusion practices during the first 100 days after HSCT at the pediatric hematology/oncology unit of our hospital between 2016 and 2019, due to a more restrictive approach adopted after 2016. We also evaluated the impact on patient outcomes. A total of 146 consecutive HSCT patients were analyzed. In patients without hemorrhagic complications, the Hb threshold for RBC transfusions decreased significantly from 2016 to 2017 (from 7.8 g/dL to 7.3 g/dL; p = 0.010), whereas it remained the same in 2017, 2018, and 2019 (7.3, 7.2, and 7.2 g/dL, respectively). Similarly, the PLT threshold decreased significantly from 2016 to 2017 (from 18,000 to 16,000/μL; p = 0.026) and further decreased in 2019 (15,000/μL). In patients without severe hemorrhagic complications, the number of RBC and PLT transfusions remained very low over time. No increase in 100-day and 180-day non-relapse mortality or adverse events was observed during the study period. No patient died due to hemorrhagic complications. Our preliminary observations support robust studies enrolling HSCT patients in patient blood management programs.

Prophylactic uterine artery embolization during cesarean delivery for management of hemorrhage in complete placenta previa: An observational study

Complete placenta previa is a major cause of morbidity and mortality in pregnant women and fetuses. This study aimed to evaluate whether prophylactic uterine artery embolization (PUAE) could reduce bleeding in patients with complete placenta previa. We retrospectively analyzed patients with complete placenta previa admitted to Taixing People's Hospital for elective cesarean delivery between January 2019 and December 2020. The women were treated with PUAE (PUAE group, n = 20) or without (control group, control, n = 20). Risk factors for bleeding (age, gestational age, pregnancy times, delivery times, cesarean delivery times), intraoperative blood loss, hemoglobin difference before and after surgery, transfusions volume, hysterectomy cases, major maternal complication cases, neonatal birth weight, neonatal Apgar score in 1 minute, postoperative hospitalization time were compared between 2 groups. There were no significant differences on risk factors for bleeding, neonatal birth weight, neonatal Apgar score in 1 minute, postoperative hospitalization time between 2 groups. However, the intraoperative blood loss, hemoglobin before and after operation, transfusion volume in the PUAE group was significantly lower than the control. There was no case of hysterectomy or major maternal complications in both groups. PUAE during cesarean may be an effective and safe strategy to reduce intraoperative blood loss and transfusion volume for patients with complete placenta previa.

Plasma-Free Strategy for Cardiac Surgery with Cardiopulmonary Bypass in Infants < 10 kg: A Retrospective, Propensity-Matched Study

BACKGROUND

Infants < 10 kg undergoing cardiac surgery with cardiopulmonary bypass (CPB) may receive either fresh frozen plasma (FFP) or other solutions in the CPB priming volume. The existing comparative studies are controversial. No study addressed the possibility of total avoidance of FFP throughout the whole perioperative course in this patient population. This retrospective, non-inferiority, propensity-matched study investigates an FFP-free strategy compared to an FFP-based strategy.

METHODS

Among patients <10 kg with available viscoelastic measurements, 18 patients who received a total FFP-free strategy were compared to 27 patients (1:1.5 propensity matching) receiving an FFP-based strategy. The primary endpoint was chest drain blood loss in the first 24 postoperative hours. The level of non-inferiority was settled at a difference of 5 mL/kg.

RESULTS

The 24-h chest drain blood loss difference between groups was -7.7 mL (95% confidence interval -20.8 to 5.3) in favor of the FFP-based group, and the non-inferiority hypothesis was rejected. The main difference in coagulation profile was a lower level of fibrinogen concentration and FIBTEM maximum clot firmness in the FFP-free group immediately after protamine, at the admission in the ICU and for 48 postoperative hours. No differences in transfusion of red blood cells or platelet concentrate were observed; patients in the FFP-free group did not receive FFP but required a larger dose of fibrinogen concentrate and prothrombin complex concentrate.

CONCLUSIONS

An FFP-free strategy in infants < 10 kg operated with CPB is technically feasible but results in an early post-CPB coagulopathy that was not completely compensated with our bleeding management protocol.

Platelet and cryoprecipitate transfusions from female donors improve coagulopathy in vitro

BACKGROUND

Females are relatively hypercoagulable compared with males, with increased platelet aggregation and improved clot dynamics. However, sex differences in coagulation have not yet been considered in transfusion guidelines. Therefore, our objective was to evaluate hemostatic differences in sex concordant and sex discordant cryoprecipitate and platelet transfusions. We hypothesized that transfusion of blood products from female donors results in improved coagulopathy compared with male blood products.

METHODS

This was a cohort study evaluating sex dimorphisms in coagulation assays and clotting factors in healthy volunteer plasma and cryoprecipitate. Sex dimorphisms in transfusions were evaluated using an in vitro coagulopathy model. Female or male platelets or single-donor cryoprecipitate was added to "recipient" whole blood after dilution of recipient blood with citrated saline to provoke a coagulopathic profile. Citrated native thromboelastography was then performed. Liquid chromatography/mass spectroscopy was performed on single-donor cryoprecipitate to evaluate sex dimorphisms in the proteome of cryoprecipitate.

RESULTS

Females have an increased proportion of functional fibrinogen. Transfusion of female-donor platelets and cryoprecipitate induces a larger decrease in R time and greater increase in angle than male-donor platelets or cryoprecipitate. Female-donor cryoprecipitate has increased factor V and factor XIII compared with male cryoprecipitate, and comprehensive proteomics revealed sex differences in several proteins with potential immunological significance.

CONCLUSION

Platelets and cryoprecipitate from female donors improve coagulopathy more than male blood products in vitro. Increased factor V and factor XIII activity as well as increased fibrinogen activity in female donors appears to drive this disparity. Sex differences in the proteome of cryoprecipitate may influence how transfusions modulate the thromboinflammation of trauma. The differing hemostatic profiles of female and male blood products suggest the potential role of sex-specific transfusions guidelines in hemostatic resuscitation.

Updates and advances in pyruvate kinase deficiency

Mutations in the PKLR gene lead to pyruvate kinase (PK) deficiency, causing chronic hemolytic anemia secondary to reduced red cell energy, which is crucial for maintenance of the red cell membrane and function. Heterogeneous clinical manifestations can result in significant morbidity and reduced health-related quality of life. Treatment options have historically been limited to supportive care, including red cell transfusions and splenectomy. Current disease-modifying treatment considerations include an oral allosteric PK activator, mitapivat, which was recently approved for adults with PK deficiency, and gene therapy, which is currently undergoing clinical trials. Studies evaluating the role of PK activators in other congenital hemolytic anemias are ongoing. The long-term effect of treatment with disease-modifying therapy in PK deficiency will require continued evaluation.

Hip hemiarthroplasty for the treatment of femoral neck fractures in dialysis patients

OBJECTIVES

This study sought to delineate the postoperative outcomes in dialysis patients undergoing hip hemiarthroplasty (HHA) for the treatment of femoral neck fractures (FNF) in order to better optimise pre- and postoperative management and minimise short-term morbidity and mortality rates.

METHODS

16,955 patients who had undergone HHA for femoral neck fractures from 2005 to 2018 were isolated from a multi-institutional surgical registry, of which 343 (2.0%) were on dialysis and 16,612 (98.0%) were not. The cohorts were identified/analysed for differences in their comorbidities, demographic factors, and 30-day postoperative complications using Fischer's exact tests and Mann-Whitney U-tests. Coarsened exact matching (CEM) was implemented in order to control for baseline difference in demographics and comorbidities. Multivariate logistic regression analyses were used to assess the impact of dialysis as an independent risk factor for various complications, including reoperations, readmissions, and mortality.

RESULTS

Upon CEM-matching (L1-statistic <0.001), weighted multivariate logistic regression analyses demonstrated dialysis to be an independent risk factor for minor complications (OR 3.051, p < 0.001), pneumonia (OR 3.943, p < 0.001), urinary tract infections (UTIs) (OR 2.684, p < 0.001), major complications (OR 1.892, p < 0.001), unplanned intubation (OR 2.555, p = 0.047), cardiac arrest (OR 11.897, p < 0.001), deep vein thrombosis (DVT), (OR 2.610, p = 0.049), and mortality (OR 2.960, p < 0.001).

CONCLUSIONS

Dialysis independently increased the risk for unplanned intubation, cardiac arrest, blood transfusions, pneumonia, DVT, and mortality. In communicating postoperative expectations, surgeons should aim to clarify the patients' preferences and potential resuscitation designations prior to surgical intervention due to the increased risk of serious complications. A lower threshold of suspicion for DVT in this population is reasonable. Identifying high-risk patient populations that may experience increased rates of complications, with the ensuing financial expenditures, due to medical complexity rather than subpar management may help providers avoid penalties in caring for these patients.

Case report: Xenotransfusion of canine lyophilized platelets for hemostasis in a feline patient with post-operative abdominal hemorrhage

Objective

To describe the management of post-operative abdominal hemorrhage with a xenotransfusion of canine lyophilized platelets in a feline patient.

Case summary

A 9-year-old male castrated domestic shorthair presented for a spontaneous hemoabdomen secondary to hepatic amyloidosis. Clinically significant hemorrhage occurred in the perioperative and post-operative period and the patient received a massive transfusion and anti-fibrinolytic therapy in combination with a xenotransfusion of canine lyophilized platelets at 0.9 × 10⁹ particles/kg and recombinant human factor VIIa (rhFVIIa). The combination of these interventions decreased transfusion requirements in this patient and the xenotransfusion was well tolerated with no acute or immediate transfusion reactions noted.

New or unique information provided

This case report describes the xenotransfusion of canine lyophilized platelets in a feline patient with severe, non-compressible abdominal hemorrhage.

Neonatal Anemia

All neonates experience a downtrend in their hematocrit values immediately following the birth through normal falls in erythropoietin (Epo) production, transition to adult hemoglobin, and hemodilution with somatic growth. However, this drop is more pronounced in critically ill and preterm neonates and can lead to potentially pathologic anemia that impairs tissue oxygen delivery. In this review, we highlight the mechanisms underlying physiologic anemia and anemia of prematurity and briefly review the evidence for the treatment of anemia in the neonatal population, including the use of red blood cell transfusions, erythropoietic stimulating agents, and iron supplementation.

Real-World Evidence on Disease Burden and Economic Impact of Sickle Cell Disease in Italy

A real-world analysis was conducted in Italy among sickle cell disease (SCD) patients to evaluate the epidemiology of SCD, describe patients' characteristics and the therapeutic and economic burden. A retrospective analysis of administrative databases of various Italian entities was carried out. All patients with ≥1 hospitalization with SCD diagnosis were included from 01/2010-12/2017 (up to 12/2018 for epidemiologic analysis). The index date corresponded to the first SCD diagnosis. In 2018, SCD incidence rate was 0.93/100,000, the prevalence was estimated at 13.1/100,000. Overall, 1816 patients were included. During the 1st year of follow-up, 50.7% of patients had one all-cause hospitalization, 27.8% had 2, 10.4% had 3, and 11.1% had ≥4. Over follow-up, 6.1-7.2% of patients were treated with SCD-specific, 58.4-69.4% with SCD-related, 60.7-71.3% with SCD-complications-related drugs. Mean annual number per patient of overall treatments was 14.9 ± 13.9, hospitalizations 1.1 ± 1.1, and out-patient services 5.3 ± 7.6. The total mean direct cost per patient was EUR 7918/year (EUR 2201 drugs, EUR 3320 hospitalizations, and EUR 2397 out-patient services). The results from this real-world analysis showed a high disease burden for SCD patients with multiple hospitalizations during the follow-up. High healthcare resource utilization and costs were associated with patient' management and were most likely underestimated since indirect costs and Emergency Room admissions were not included.

Where Do We Stand on "Buddy Transfusion" During Military Operations?

Warm fresh whole-blood transfusion between comrades on the battlefield, also known as "buddy transfusion," has been thrust back into the limelight for several years now. It means drawing blood on the battlefield, once a bleeding soldier needs a transfusion, from one of their uninjured companions and immediately infusing it. It is a lifesaving procedure, effective and hardy. This work aims to answer the main questions that military caregivers might have about it: interest of this procedure, donor and recipient safety, and hemostatic capacity of the blood collected this way.

Association of platelet deficiency with severe retinopathy of prematurity: a review

AIM

The aim of this review was to compile existing evidence on the role of platelets in the development of severe retinopathy of prematurity (ROP), highlight the strengths and weaknesses of the available studies and critically discuss the reported data.

METHODS

A comprehensive literature search was conducted on PubMed from January 2000 to January 2022, and the reference lists of the included studies were screened manually.

RESULTS

There were 19 primary studies that fulfilled the eligibility criteria. Experimental research indicated lower platelet count in mice oxygen-induced retinopathy model compared with normoxia controls, while platelet transfusions suppressed neovascularisation. The latter finding was not consistently confirmed in clinical research, where a low platelet count, an increased number of thrombopenic episodes and of platelet transfusions have all been implicated in the development of ROP requiring treatment, either type I or aggressive posterior or both. However, existing studies exhibit significant clinical heterogeneity and present methodological limitations that imperil their reliability and validity.

CONCLUSION

Platelet deficiency has been associated with severe ROP. However, critical thresholds of platelet parameters are still unrecognised. Future research is required to determine whether platelet parameters can be predictive biomarkers for ROP requiring treatment and at what thresholds.

Sodium supply from administered blood products was associated with severe intraventricular haemorrhage in extremely preterm infants

Aim

The aim of this study was to investigate the associations between sodium supply, fluid volume, sodium imbalances and severe intraventricular haemorrhage (IVH) in extremely preterm (EPT) infants.

Methods

We used data from the EXtremely PREterm infants in Sweden Study (EXPRESS) cohort consisting of all infants born at 22 to 26 gestational weeks from 2004 to 2007 and conducted a nested case–control study. For every infant with severe IVH (grade 3 or peri‐ventricular haemorrhagic infarction), one IVH‐free control infant with the birthday closest to the case infant and matched for hospital, sex, gestational age and birth weight was selected (n = 70 case–control pairs).

Results

Total sodium supply and fluid volume were higher in infants with severe IVH compared with controls [daily total sodium supply until postnatal Day 2: mean ± SD (mmol/kg/day): 5.49 ± 2.53 vs. 3.95 ± 1.91, p = 0.009]. These differences were accounted for by sodium and fluid from transfused blood products. High plasma sodium concentrations or large sodium fluctuations were not associated with severe IVH.

Conclusion

Our results suggest a relationship between sodium‐rich transfusions of blood products and severe IVH in EPT infants. It is unclear whether this is an effect of sodium load, volume load or some other transfusion‐related factor.

[Topical use of tranexamic acid in total hip arthroplasties: retrospective analysis of its advantages]

INTRODUCTION

intravenous (IV) tranexamic acid (TXA) has shown its usefulness to prevent postsurgical anemia, but few studies have analyzed its topical administration. Seven years ago, we implemented a new topical administration (moistening three gauzes with 1.5 g of TXA) in our primary total hip arthroplasties (THA). The objective of this study was to compare blood loss, hospital stay and complications without the use of TXA, topical use or 10 mg/kg IV plus topical.

MATERIAL AND METHODS

consecutive retrospective series of 274 patients undergoing CTA (mean 70 years [59-76], 59% women) operated from 2014 to 2019. Loss of hemoglobin and hematocrit, blood transfusions, hospital stay, thromboembolic complications were compared and 30-day mortality among three groups: non-tranexamic (44.2%), topical (45.6%), topical + IV (9.9%).

RESULTS

after 24 and 48 hours, hemoglobin and hematocrit decreased less (p < 0.05) in patients treated with TXA (topical and/or IV). Blood transfusion was required in 32% of patients without TXA, 12% of those treated with topical TXA only (RR = 3.24 [95% CI: 1.69-6.20]), and 0% of patients who received IV TXA (p = 0.005) (RR = 4.07 [95% CI: 2.14-7.48]). Hospital stay was reduced three days with TXA (p < 0.001). We have not observed any adverse effects related to TXA.

CONCLUSIONS

the use of TXA in CTA significantly reduces anemia, transfusions and hospital stay without increasing complications. Isolated topical TXA (hemostatic pads) is less effective than topical IV + topical use, but both significantly improve anemia, transfusions, and hospital stay compared to no use.

Placebo and nocebo effects in transfusion medicine

BACKGROUND

Our own observations suggested that placebo and nocebo effects may occur with transfusions. However these effects seem to have been poorly studied.

OBJECTIVES

To examine published information on, and draw attention to the possibility of, placebo and nocebo effects with transfusion.

METHODS

Focused literature review.

RESULTS

There is some information on placebo effects with clotting factors and this effect appears modest at best. There is very little published information on this regarding other fresh blood components. Although unknown biologic effects cannot be ruled out, there are hints that placebo effects might operate - especially with red blood cell transfusions. There is practically no information on nocebo effects with transfusions.

CONCLUSIONS

There are ways of surmounting the practical and ethical difficulties involved, and obtaining better information on both types of effects. Individualised, contextualised, informed consenting of transfusion recipients may help to enhance placebo, and reduce nocebo, effects. This may be supportable ethically, and desirable clinically, and financially.

Transfusion double whammy? Adrenaline-takotsubo-anaphylaxis-Kounis complex post transfusion?

BACKGROUND AND OBJECTIVES

The adrenaline-takotsubo-anaphylaxis-Kounis, or the ATAK complex, where there are clinical and pathophysiological overlaps between takotsubo and Kounis syndromes, in which histaminergic, adrenergic and other mediators may play roles, was recently described. The objective of this report was to describe three cases where the ATAK complex was suspected to have occurred after transfusion.

MATERIALS AND METHODS

Three cases were recently reported to the New Zealand Blood Service haemovigilance programme that appeared to have features in common suggestive of the ATAK complex.

RESULTS

All three patients had had a blood component transfused, an initial severe allergic reaction, treatment with adrenaline or a congener, subsequent acute left ventricular failure or transfusion-associated circulatory overload, and features suggestive of takotsubo cardiomyopathy.

CONCLUSIONS

Although rarely described, transfusion-associated ATAK complex may be occurring more often than believed. Circumstances during a transfusion may predispose to it. It should be suspected if the sequence of events described above occur. Its characteristics need to be better understood. Risk factors for it may be modifiable.

Effects of dual chelation therapy with deferasirox and deferoxamine in patients with beta thalassaemia major

BACKGROUND AND OBJECTIVES

Patients with thalassaemia experience complications related to iron overload. In Australia currently, the two main options for iron chelation are deferasirox and deferoxamine. Optimal iron chelation using monotherapy can be limited due to toxicity or tolerability. Dual chelation therapy (DCT) may provide more aggressive iron chelation.

MATERIAL AND METHODS

A retrospective, observational study was performed on a state-wide referral centre for patients receiving red cell transfusions for haemoglobinopathies (Monash Health, Australia). All patients prescribed DCT were identified using a local pharmacy dispensing database and were included in the study. Pre-DCT initiation and post-DCT completion were correlated with serum ferritin, cardiac iron loading (based on MRI T2* measurements) and liver iron content (LIC) using Wilcoxon signed-rank test.

RESULTS

A total of 18 patients (12 adults, 6 children) were identified as receiving DCT. All patients received a combination of deferasirox and deferoxamine. The median duration of therapy was 23 months (range 2-73). Median serum ferritin reduced by 42% (p = 0.004) and there was a 76% reduction in LIC (p = 0.062). No significant changes were seen in cardiac iron loading.

CONCLUSION

DCT over a prolonged period is effective at reducing serum ferritin and may contribute to improvement in liver iron loading.

Clinical implications of anticoagulant oral therapy in elderly patients with hip fracture

BACKGROUND AND AIM

Proximal femur fractures (PFFs) are among the most common fractures, especially in the elderly population. A PFF often represents a life-changing event. Their dramatic effects are attributable not only to the massive hemorrhages caused by the fracture, but also to the high risk of dramatic complications. These risks are supposed to be even higher for patients under oral anticoagulant treatment. In this study we evaluated how oral anticoagulant therapy effected patient's prognosis.   Methods:Ours was a case-control review of over-65 patients treated surgically for proximal femur fractures between 2013 and 2019. Cases were divided in 2 groups depending if they were (Group A) or were not (Group B) under oral anticoagulant therapy at the moment of hospitalization.   Results:200 cases were included in our study: 100 in Group A and 100 in Group B. Surgical delay was significantly higher for cases under oral anticoagulant treatment compared to the other cases. Group A cases were transfused with a significantly higher frequency and with more blood units compared to Group B (p=0.0300; p=0.013). Combined cardiological and vascular complications occurred in 21 cases (10.5%), being significantly more common in Group A (16) than Group B (5), as testified by a chi-square test (P=0.011).   Conclusions:Cases under oral anticoagulant therapy are frail patients with a higher risk to develop massive hemorrhages after an hip fracture. For this reason, it is mandatory to achieve an early stabilization of patient's clinical conditions and then perform surgery as soon as possible.

An update on the US adult thalassaemia population: a report from the CDC thalassaemia treatment centres

Thalassaemia is caused by genetic globin defects leading to anaemia, transfusion-dependence and comorbidities. Reduced survival and systemic organ disease affect transfusion-dependent thalassaemia major and thalassaemia intermedia. Recent improvements in clinical management have reduced thalassaemia mortality. The therapeutic landscape of thalassaemia may soon include gene therapies as functional cures. An analysis of the adult US thalassaemia population has not been performed since the Thalassemia Clinical Research Network cohort study from 2000 to 2006. The Centers for Disease Control and Prevention supported US thalassaemia treatment centres (TTCs) to compile longitudinal information on individuals with thalassaemia. This dataset provided an opportunity to evaluate iron balance, chelation, comorbidities and demographics of adults with thalassaemia receiving care at TTCs. Two adult cohorts were compared: those over 40 years old (n = 75) and younger adults ages 18-39 (n = 201). The older adult cohort was characterized by higher numbers of iron-related comorbidities and transfusion-related complications. By contrast, younger adults had excess hepatic and cardiac iron and were receiving combination chelation therapy. The ethnic composition of the younger cohort was predominantly of Asian origin, reflecting the demographics of immigration. These findings demonstrate that comprehensive care and periodic surveys are needed to ensure optimal health and access to emerging therapies.

Luspatercept for β-thalassemia: beyond red blood cell transfusions

INTRODUCTION

Red blood cell transfusions and iron chelation therapy are the cornerstone of treatment for β-thalassemia, with allogeneic hematopoietic stem cell transplantation and gene therapy offering further disease-management options for eligible patients. With up to 90% of severe cases of β-thalassemia occurring in resource-constrained countries, and estimates indicating that 22,500 deaths occur annually as a direct consequence of undertransfusion, provision of adequate treatment remains a major issue.

AREAS COVERED

In this review, we provide an overview of luspatercept, a first-in-class erythroid maturation agent, and present the available clinical data related to the treatment of β-thalassemia.

EXPERT OPINION

The recent approval of luspatercept offers a new, long-term therapeutic option for adult patients with transfusion-dependent β-thalassemia to reduce red blood cell transfusion burden, anemia, and iron overload.

Impact of Exercise Training on Hematological Outcomes Following Hematopoietic Cell Transplantation: A Scoping Review

PURPOSE

Hematopoietic cell transplantation (HCT) is associated with significant risk prior to hematopoietic engraftment. Endurance exercise can modify the bone marrow microenvironment, alter hematopoiesis and accelerate hematopoietic regeneration in mouse models of transplantation.

METHODS

A systematic review was conducted to clarify the impact of exercise on clinically relevant hemato-logical outcomes in patients following HCT.

RESULTS

A systematic search of the literature identified 13 studies (total of 615 participants; 313 in study arms). Studies included exercise regimens that were primarily low-to-moderate intensity. A total of five studies re-ported on engraftment and length of stay, which were largely unchanged with intervention. Rates of graft-ver-sus host disease were reported in six studies whereas red cell and platelet transfusion needs were reported in four studies, neither of which was different with exercise. Survival was reported in four studies and was significantly improved by exercise in one study.

CONCLUSIONS

Exercise in patients receiving HCT appears feasible and safe. Heterogeneity in type and intensity of exercise was observed and few studies examined high intensity exercise. Outcome reporting was inconsis-tent regarding transplant-related outcomes. Standardized hematological outcome measures are needed to clarify the impact of higher intensity exercise on HCT.

Use of eltrombopag for the treatment of poor graft function after hematopoietic stem cell transplantation in children

The main objective of this study was to determine whether Eltrombopag, a synthetic thrombopoietin receptor agonist, could improve peripheral blood counts in the three hematopoietic lineages and achieve transfusion independence in children with poor graft function (PGF) after allogenic hematopoietic stem cell transplantation (HSCT). Retrospective study of patients under 18 years who developed PGF post-HSCT in a large tertiary institution between January 2013 and March 2019. Out of 198 allogeneic HSCT, five patients met PGF criteria and were treated with eltrombopag. Median time from HSCT to eltrombopag initiation was 120 days. The median starting dose was 50 mg/day and the maximum dose reached was 75 mg/day. Median treatment duration was 9 months. Three patients achieved complete response and one partial response. The median dose among responders was 75 mg/day and the median time to response 8 weeks. Responses were sustained in three patients and two required a booster dose of CD34⁺ -selected cells from the original donor. None of the patients had to stop treatment due to adverse effects. The use of eltrombopag in children with PGF achieved responses in 80% of cases and demonstrated to be an effective and safe therapeutic option in pediatric patients with PGF.

Deferasirox-associated Fanconi syndrome in adult patients with transfusional iron overload

BACKGROUND AND OBJECTIVES

Deferasirox is an oral chelator approved for iron overload, which has a potential side effect of renal Fanconi syndrome, with proximal tubular dysfunction and tubular acidosis. Monitoring of renal function is recommended, though no standard for monitoring exists. We aim to describe cases of deferasirox-associated Fanconi syndrome in adults and the renal monitoring required to detect these findings.

MATERIALS AND METHODS

We present a review of the literature and six cases from our institution of deferasirox-associated partial Fanconi syndrome in adult patients with transfusional iron overload secondary to β-thalassemia or Diamond Blackfan Anaemia.

RESULTS

While prior cases in the literature occurred at high doses of deferasirox, our series included patients on doses as low as deferasirox 10 mg/kg who had been aggressively chelated. All patients had resolution of laboratory abnormalities with drug interruption.

CONCLUSION

Rather than chelating to normal iron levels, this series supports prior suggestions that deferasirox dose be reduced if ferritin <500-1000 ng/ml, and also supports dose reduction if liver iron content <3 mg iron per g dry weight or for those undergoing aggressive chelation with rapid decrease in iron. Monitoring with metabolic panel and urinalysis were sufficient to detect clinically significant proximal tubular dysfunction, but should be followed up with additional studies to confirm the diagnosis while deferasirox dose is decreased or held.

Blood Transfusion: Knowledge, Perspectives, and Experience of Individuals With Sickle Cell Disease

Patient voice and perspective were needed to inform effective, comprehensive strategies for reducing preventable transfusion-associated complications. This report presents the results of interviews with sickle cell disease (SCD) patients and implications for strategies to reduce transfusion complications in this population. Twenty-two participants were recruited from 2 comprehensive SCD treatment centers in Georgia and interviewed regarding knowledge about transfusions and potential complications, attitudes about data storage and sharing, and the transfusion experience. Participants had general knowledge of physiology, blood products, and blood transfusions, including knowing the risk of complications, but varied in comprehension of complex health information and level of misinformation. Patients also varied in preferences for how they would like their transfusion information stored. They saw both advantages and disadvantages to wallet cards, smartphone applications, and registries. There is a need for a patient-centered approach that involves transfusion education and shared decision-making. Education should range from essential and simple to more in-depth to accommodate varying education and comprehension levels. Multiple tracking methods should be offered to store sensitive patient information.

Perioperative Blood Transfusions or Operative Time: Which Drives Post-Hepatectomy Outcomes?

BACKGROUND

Perioperative blood transfusions and operative time are surgical quality indicators. The aim of this analysis is to determine which of these variables drives post-hepatectomy outcomes.

METHODS

Patients undergoing major or partial hepatectomy were identified in the 2014-2018 American College of Surgeons National Surgical Quality Improvement Program hepatectomy targeted database. Prolonged operative time was defined as ≥ 240 minutes. Multivariable logistic regressions were performed for multiple postoperative outcomes.

RESULTS

Of 20 521 hepatectomies, 18% of patients received a perioperative transfusion, and the median operative time was 218 minutes. Patients receiving a transfusion had a significant (P < .001) increase in mortality (5.1% vs. .7%) and serious morbidity (43% vs. 16%). Prolonged operative time was associated with significantly (P < .001) increased mortality (2.4% vs. .8%) and serious morbidity (29% vs. 14%). Those with primary hepatobiliary cancer had the highest rates of postoperative morbidity and mortality compared to patients with metastatic and benign disease when a transfusion occurred. On multivariable regression analyses, perioperative transfusions conferred a higher risk (P < .001) than prolonged operative time for mortality (OR 5.02 vs. 1.47) and serious morbidity (OR 2.56 vs. 1.50).

CONCLUSIONS

Perioperative blood transfusions are a more robust predictor of post-hepatectomy outcomes than increased operative time, especially in patients with primary hepatobiliary cancer.

Improved stenosis outcome in stroke-free sickle cell anemia children after transplantation compared to chronic transfusion

We report here the 3-year stenosis outcome in 60 stroke-free children with sickle cell anaemia (SCA) and an abnormal transcranial Doppler history, enrolled in the DREPAGREFFE trial, which compared stem cell transplantation (SCT) with standard-care (chronic transfusion for 1-year minimum). Twenty-eight patients with matched sibling donors were transplanted, while 32 remained on standard-care. Stenosis scores were calculated after performing cerebral/cervical 3D time-of-flight magnetic resonance angiography. Fourteen patients had stenosis at enrollment, but only five SCT versus 10 standard-care patients still had stenosis at 3 years. Stenosis scores remained stable on standard-care, but significantly improved after SCT (P = 0·006). No patient developed stenosis after SCT, while two on standard-care did, indicating better stenosis prevention and improved outcome after SCT.

Delayed disseminated intravascular coagulopathy post thoracic endovascular aortic repair (TEVAR)

Disseminated intravascular coagulopathy (DIC) is a very rare outcome post endovascular repair of aortic aneurysm dissections. We present a case of a 70-year-old male who presented with DIC post a thoracic endovascular aortic repair (TEVAR) procedure due to a type 1A endoleak. Initially, the patient was treated with red blood cells and blood products; however, when failing to improve, he underwent a hybrid arch replacement. In this study, we will analyze the management of DIC post TEVAR and look at its presentation more extensively, as it is currently a topic that is poorly studied.

Evaluation of the WHO global database on blood safety

OBJECTIVE

While the Global Database on Blood Safety (GDBS) helps to monitor the status of adequate and safe blood availability, its presence alone does not serve as a solution to existing challenges. The objective of this evaluation was to determine the GDBS usefulness in improving the availability of adequate safe blood and its ability to function as a surveillance system.

METHODS

The GDBS was evaluated using methods set out by the Centers for Disease Control and Prevention (CDC) Guidelines for assessing surveillance systems. Six recommended tasks were used to evaluate if the GDBS met the requirements of a surveillance system in a public health context.

RESULTS

The majority of stakeholders engaged with GDBS found it was unique and useful. The GDBS answered all six questions essential for determining a blood safety surveillance system's usefulness. The GDBS fully met the needs to six of the eleven attributes used for evaluating the usefulness of a surveillance system.

CONCLUSION

The GDBS is a unique global activity that provides vital data on safety of blood transfusion services across countries and regions. However, aspects of the GDBS such as timeliness of reporting and improvement of WHO Member States national blood information systems could enhance its effectiveness and potential to serve as a global surveillance system for blood safety.

Rethinking strategies for blood transfusion in hip fracture patients

OBJECTIVES

Most patients can tolerate a hemoglobin (Hgb) > 8 g per deciliter. In some cases, however, transfusion will delay physical therapy and hospital discharge. This study aims to review Hgb and transfusion data for a large volume of recent hip fracture patients in order to identify new opportunities for decreasing the length of hospital stay. Our hypotheses are that in some cases, earlier transfusion of more blood will be associated with shorter hospital stays, and that Hgb levels consistently decrease for more than 3 days postoperatively.

DESIGN

Retrospective chart review.

SETTING

Two academic medical centers with Geriatric Fracture Programs.

PATIENTS

Data was collected from patients 50 years and older with hip fractures April 2015 and October 2017.

INTERVENTION

Operative stabilization of the hip fractures according to standard of care for the fracture type and patient characteristics. Transfusion according to established standards.

MAIN OUTCOME MEASUREMENTS

Electronic records were retrospectively reviewed for demographic information, Hgb levels, and transfusion events.

RESULTS

One thousand fifteen patients with femoral neck or intertrochanteric hip fractures were identified. Eight hundred sixty met the inclusion criteria. The average length of hospital stay was 6.7 days. The mean patient age was 82 years. The average American Society of Anesthesiologists score was 2.9. The average Hgb level consistently decreased for 5 days postoperatively before beginning to increase on day 6. There was poor consistency between intraoperative Hgb levels and preoperative or postoperative Hgb levels. Three hundred sixty-eight (42.8%) patients were transfused an average of 1.9 (range 1-6) units. One hundred five patients required a transfusion on postoperative day (POD) 1: 72 received only 1 unit of blood: 36 (50%) of the 72 required a second transfusion in the following days, compared to 9 of 33 (27%) who received 2 units on POD 1 (χ2 = 3.8898; P < .05). Patients who received transfusions on POD 3 or later had an average length of stay >2.5 days longer than those who received a transfusion earlier (P = 0.005).

CONCLUSIONS

Our findings do not support earlier transfusion of more blood. Although in some cases, there is an association between earlier transfusion of more blood and shorter hospital stay, routine transfusion of more blood would incur higher transfusion risks in some patients who would not otherwise meet criteria for transfusion. After hip fracture surgery, the Hgb usually decreases for 5 days and does not begin to increase until POD 6. This information will provide utility in the population health management of hip fracture patients.

LEVEL OF EVIDENCE

Level III, Retrospective Cohort Study.

Effect of intravenous ferric carboxymaltose supplementation in non-anaemic iron deficient patients undergoing hip and knee arthroplasty

Preoperative anaemia and non-anaemic iron deficiency are independent risk factors for perioperative blood transfusion, morbidity, and mortality. Although the efficacy to treat anaemia with iron infusion before elective surgery has been widely studied, the literature offers few data about the efficacy of treating iron deficient, non-anaemic patients before elective surgery. This retrospective study assessed the effect of preoperative ferric carboxymaltose (FC) administration on the concentration of Haemoglobin (Hb) in iron deficient, non-anaemic individuals following total knee or hip arthroplasty. A treatment group of 83 non-anaemic iron deficient individuals scheduled for arthroplasty were administered a 1000mg FC infusion over 15 minutes 4 weeks prior to surgery. In the control group (n=62) FC was not administered preoperatively. No individual from either group was given any iron supplement following the pre-operative visit. Blood tests were performed and analysed 4-weeks before surgery, on admission, and then 2-days, 4-days and 4-weeks postoperatively. Number of blood transfusions performed and adverse events were recorded. Hb concentration did not change substantially after iron supplementation prior to surgery. No difference in the number of blood transfusions was observed. In the treatment, group postoperative Hb concentration recovered significantly more quickly compared to control (p=0.0047). No adverse event was reported. The administration of FC in non-anaemic iron deficient individuals quickens the restoration of Hb concentration following THA or TKA procedures.

Results of the CB-TrIP study

Repeated red blood cell (RBC) transfusions in preterm neonates are associated with poor outcome and increased risk for prematurity-associated diseases. RBC transfusions cause the progressive replacement of fetal haemoglobin (HbF) by adult haemoglobin (HbA). We monitored HbF levels in 25 preterm neonates until 36 weeks of post-menstrual age (PMA); patients received RBC units from allogeneic cord blood (cord-RBCs) or from adult donors (adult-RBCs), depending on whether cord-RBCs were available. Primary outcome was HbF level at PMA of 32 weeks. Twenty-three neonates survived until this age: 14 received no transfusions, two only cord-RBCs, three only adult-RBCs and four both RBC types. HbF levels in neonates transfused with cord-RBCs were significantly higher than in neonates receiving adult-RBCs (P < 0·0001) or both RBC types (P < 0·0001). Superimposable results were obtained at PMA of 36 weeks. Every adult-RBCs transfusion increased the risk for an HbF in the lowest quartile by about 10-fold, whereas this effect was not evident if combined adult- and cord-RBCs were evaluated. Overall, these data show that transfusing cord-RBCs can limit the HbF depletion caused by conventional RBC transfusions. Transfusing cord blood warrants investigation in randomised trials as a strategy to mitigate the severity of retinopathy of prematurity (NCT03764813).

Perspectives Regarding Hospice Services and Transfusion Access: Focus Groups With Blood Cancer Patients and Bereaved Caregivers

CONTEXT

Patients with blood cancers have low rates of timely hospice use. Barriers to hospice use for this population are not well understood. Lack of transfusion access in most hospice settings is posited as a potential reason for low and late enrollment rates.

OBJECTIVES

We explored the perspectives of patients with blood cancers and their bereaved caregivers regarding the value of hospice services and transfusions.

METHODS

Between June 2018 and January 2019, we conducted three focus groups with blood cancer patients with an estimated life expectancy of six months or less and two focus groups with bereaved caregivers of patients with blood cancers. We asked participants their perspectives regarding quality of life (QOL) and about the potential association of traditional hospice services and transfusions with QOL. A hematologic oncologist, sociologist, and qualitatively trained research assistant conducted thematic analysis of the data.

RESULTS

Twenty-seven individuals (18 patients and nine bereaved caregivers) participated in the five focus groups. Participants identified various QOL domains that were important to them but focused largely on a desire for energy to maintain physical/functional well-being. Participants considered transfusions a high-priority service for their QOL. They also felt that standard hospice services were important for QOL. Bereaved caregivers reported overall positive experiences with hospice.

CONCLUSION

Our analysis suggests that although patients with blood cancers value hospice services, they also consider transfusions vital to their QOL. Innovative care delivery models that combine the elements of standard hospice services with other patient-valued services like transfusions are most likely to optimize end-of-life care for patients with blood cancers.

Clinical and economic effect of administration of red blood product transfusions in an outpatient supportive care cancer service

Patients with cancer may develop disease- or treatment-associated anemia, requiring red blood product transfusions. In Italy, transfusions are usually administered in a day hospital service or in inpatient wards. Since 2013, a dedicated supportive care service for outpatients has been implemented in Pisa, where red blood product transfusions are administered. The present study evaluated the patients that received red blood product transfusions at the dedicated supportive care service for outpatients in 2016. The clinical features of patients were analyzed, and the procedural cost was evaluated by comparing its administration with a hypothetical scenario in which transfusions were provided via day hospital services or inpatient wards. The results revealed that the dedicated supportive care service for outpatients avoided the hospitalization of patients, allowing them to receive prompt and timely transfusions, with a rapid resolution of symptoms. Avoiding hospitalization was also estimated to decrease transfusion-associated costs by €48,805-177,805.

Hydroxyurea can be used in children with sickle cell disease and cerebral vasculopathy for the prevention of chronic complications? A meta-analysis

We conducted a systematic review for evaluating the impact of hydroxyurea and chronic blood transfusion in children with sickle cell disease (SCD). A search was done in four databases from inception to 2017. Trials enrolling pediatric patients with SCD and cerebral vasculopathy with or without previous episode of stroke and that reported outcomes of occurrence of stroke and other events were included. Trained reviewers determined eligibility, risk of bias, and abstracted data. Random-effects meta-analysis was conducted. We found that the primary outcome was the occurrence of stroke. We found two trials that recruited 254 patients. No difference was found for confirmed stroke occurrence (risk difference 0.04 [95% CI: -0.03 to 0.03]) and for new-onset neurological deficit (risk difference 0.11 [95% CI: -0.00 to 0.21]). Transfusions provided a significant lower risk of vaso-occlussive crisis (risk difference 0.10 [95% CI: 0.001 to 0.20]). Finally, transfusions provided a lower risk of having high concentrations of abnormal hemoglobin S (mean difference 37.94 [95% CI: 27.55 to 48.32]). As a conclusion, transfusions plus chelation therapy might be used instead of hydroxyurea in children with SCD. There is a lack of high-quality research in the care of children with SCD, and therefore a call for action is needed.

Long-Term Sustainability of a Quality Initiative Program on Transfusion Rates in Total Joint Arthroplasty: A Follow-Up Study

BACKGROUND

There are significant variations in transfusion rates among institutions performing total joint arthroplasty. We previously demonstrated that implementation of an educational program to increase awareness of the American Association of Blood Banks' transfusion guidelines led to an immediate decrease in transfusion rates at our facilities. It remained unclear how this initiative would endure over time. We report the long-term success and sustainability of this quality program.

METHODS

We reviewed the Michigan Arthroplasty Collaborative Quality Initiative data from 2012 through 2017 of all patients undergoing primary hip and knee arthroplasty at our institutions for preoperative and postoperative hemoglobin level, transfusion status, and number of units transfused and transfusions outside of protocol to identify changes surrounding our blood transfusion educational initiative. We calculated the transfusions prevented and cost implications over the course of the study.

RESULTS

We identified 6645 primary hip and knee arthroplasty patients. There was a significant decrease in transfusion rate and overall transfusions in each group when compared to pre-education values. Subgroup analysis of TKA and THA independently showed significant decreases in both transfusion rate and overall transfusions. Over the final 3 years of the study, only 2 patients were transfused outside of the American Association of Blood Banks protocol. We estimate prevention of 519 transfusions over the study period.

CONCLUSION

Application of this quality initiative was an effective means of identifying opportunities for quality improvement. The program was easily initiated, had significant early impact, and has been shown to be sustainable.

Transfusion rates after 800 Aquablation procedures using various haemostasis methods

OBJECTIVE

To determine if athermal methods are as effective in preventing blood transfusions as the use of cautery across various prostate volumes following prostate tissue resection for benign prostatic hyperplasia using Aquablation.

PATIENTS AND METHODS

The current commercial AQUABEAM robot that performs Aquablation therapy was first used in 2014. Since then numerous clinical studies have been conducted in various countries; Australia, Canada, Germany, India, Lebanon, Spain, New Zealand, United Kingdom, and the United States. All of the clinical trial data since 2014 were pooled with the early commercial procedures from France, Germany, and Spain to determine the effectiveness of haemostatic techniques in reducing the transfusion rate in patients after Aquablation.

RESULTS

In all, 801 patients were treated with Aquablation therapy from 2014 to early 2019. The mean (SD, range) prostate volume was 67 (33, 20-280) mL and 31 (3.9%) transfusions were reported. The largest contributing factor to transfusion risk was prostate size and method of traction. There was an increasing risk of transfusions in larger prostates when robust traction using a catheter-tensioning device (CTD) without cautery was used, ranging from 0.8% to 7.8% in prostates ranging from 20 to 280 mL. However, when standard traction (taping the catheter to the leg, gauze knot synched up to the meatus, or no traction at all) was used and where the surgeon performed bladder neck cautery only when necessary, the risk of transfusion was 1.4-2.5% in prostates ranging from 20 to 280 mL.

CONCLUSIONS

While the athermal subgroup with robust traction with a CTD had comparable transfusion rates for smaller prostates, the risk increased significantly as prostate volume increased. With standard traction methods and selective bladder neck cautery, the risk of transfusion was reduced to 1.9% across all prostate sizes.

Minimizing Blood Loss in Spine Surgery

STUDY DESIGN

Broad narrative review.

OBJECTIVE

To review and summarize the current literature on guidelines, outcomes, techniques and indications surrounding multiple modalities of minimizing blood loss in spine surgery.

METHODS

A thorough review of peer-reviewed literature was performed on the guidelines, outcomes, techniques, and indications for multiple modalities of minimizing blood loss in spine surgery.

RESULTS

There is a large body of literature that provides a consensus on guidelines regarding the appropriate timing of discontinuation of anticoagulation, aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), and herbal supplements prior to surgery. Additionally, there is a more heterogenous discussion the utility of preoperative autologous blood donation facilitated by erythropoietin and iron supplementation for healthy patients slated for procedures with high anticipated blood loss and for whom allogeneic transfusion is likely. Intraoperative maneuvers available to minimize blood loss include positioning and maintaining normothermia. Tranexamic acid (TXA), bipolar sealer electrocautery, and topical hemostatic agents, and hypotensive anesthesia (mean arterial pressure (MAP) <65 mm Hg) should be strongly considered in cases with larger exposures and higher anticipated blood loss. There is strong level 1 evidence for the use of TXA in spine surgery as it reduces the overall blood loss and transfusion requirements.

CONCLUSION

As the volume and complexity of spinal procedures rise, intraoperative blood loss management has become a pivotal topic of research within the field. There are many tools for minimizing blood loss in patients undergoing spine surgery. The current literature supports combining techniques to use a cost- effective multimodal approach to minimize blood loss in the perioperative period.

Revision of the medicolegal assessment criteria in hypovolemic patients

Trauma scoring systems are often used for the determination of the severity level of the lesion and the clinical status in medico-legal assessment of the trauma patient. Trauma scoring systems are used also for the determination of the life-threatening conditions. Blood loss of more than 20% was reported as the only criterion for life-threatening conditions in the acute hypovolemia. The objective of this study was to revise the medico-legal assessment criteria in the patients with acute hypovolemia and to discuss other parameters, which might be used in the determination of the severity level of the clinical status.The medical reports of the patients with acute hypovolemia due to the trauma, which were sent by the judicial authorities and by other departments of our medical faculty to the department of the forensic medicine between 1999 and 2009, were evaluated. The characteristics such as age, gender, severity of the injury, type of the trauma, history of liquid replacement or blood transfusion, vital signs, type of the physical injury, injured region of the body, presence of any chronic disease were assessed and recorded.The mean age of the included 155 patients was 34.70 ± 16.08 years (3-87 years). 118 (76%) of patients were males and 37 females (24%). Regarding the event types, road accidents were the most common cause (60.0%) and it was followed by sharp object injuries (18.7%) and firearm injuries (11.6%). 27.7% of the subjects received 2 units blood and blood products transfusion and 21.3% only 1 unit transfusion. According to the results of the medico-legal assessment, 84.5% of the patients had life-threatening conditions.While evaluating the severity of the clinical conditions in the hypovolemic patients, to report only the losses in percentage causes problems and limitations. Therefore, in respect of the medico-legal assessment of the hypovolemic patients, we believe that it would be more appropriate to use the physiological trauma scoring systems (like Revised Trauma Score) instead of the anatomic scoring systems.

How we manage patients with pyruvate kinase deficiency

Novel therapies in development have brought a new focus on pyruvate kinase deficiency (PKD), the most common congenital haemolytic anaemia due to a glycolytic enzyme deficiency. With an improved recognition of its clinical presentation and understanding of the diagnostic pathway, more patients are likely to be identified with this anaemia. Complications, including gallstones and non-transfusion-related iron overload, require monitoring for early diagnosis and management. Current management remains supportive with red cell transfusions, chelation and splenectomy. Decisions to transfuse and/or splenectomise must be individualised. Haematopoietic stem cell transplant has been pursued in a small number of patients with mixed outcomes. Novel treatment approaches, which range from a small molecule pyruvate kinase activator to gene therapy, may transform the way in which PKD is managed in the future. In this review, we discuss the pathophysiology of PKD and present our approaches to diagnosis, monitoring and management of patients with this anaemia.

Decreased mortality, laparotomy, and embolization rates for liver injuries during a 13-year period in a major Scandinavian trauma center

Background

Although non-operative management (NOM) has become the treatment of choice in hemodynamically normal patients with liver injuries, the optimal management of Organ Injury Scale (OIS) grades 4 and 5 injuries is still controversial. Oslo University Hospital Ulleval (OUHU) has since 2008 performed angiography only with signs of bleeding. Simultaneously, damage control resuscitation was implemented. Would these changes result in a decreased laparotomy rate and need for angioembolization (AE), as well as decreased mortality?

Methods

We performed a retrospective study on all adult patients with liver injuries admitted at OUHU between 2002 and 2014. The total study population and patients with OIS grades 4 and 5 liver injuries underwent comparison between the periods before (P1) and after (P2) August 1, 2008.

Results

583 patients were included (P1: 237, P2: 346), with a median Injury Severity Score (ISS) of 29. The total population and the subgroup of OIS 4 and 5 injuries were comparable in age, gender, mechanism of injury, injury severity and physiology. Overall laparotomy rates decreased from P1 to P2 (35%–24%; p<0.01), as did the AE rate (11%–5%; p<0.01). The 30-day crude mortality decreased from 14% to 7% (p<0.05). A logistic regression model predicted an OR of 0.45 (95% CI 0.21 to 0.98) for dying when admitted in P2. In OIS grades 4 and 5 injuries (n=149, median ISS 34), similar reduction in AE rate was seen (30%–12%; p<0.05). The NOM rate for OIS grades 4 and 5 injuries was 70%, with 98% success rate. For the 30% requiring surgery, the mortality remained high (P1 52%; P2 40%), despite more balanced transfusion strategy.

Discussion

Changes in resuscitation and treatment protocols were associated with decreased laparotomy, and AE rates as well as overall mortality. NOM is safe in 70% of patients with OIS grades 4 and 5 injuries, in contrast to the critically ill 30% requiring surgery who still have poor outcome.

Level of evidence

IV.

Cost-consequence analysis of a hemostatic matrix alone or in combination for spine surgery patients

BACKGROUND

A five-year retrospective database analysis comparing the use of Floseal ¹ flowable topical hemostat alone (F) and in combination with gelatin/thrombin (F + G/T) to achieve hemostasis and control surgical bleeding showed higher resource utilization for F + G/T cases relative to F matched pairs during spinal surgery. Lower resource use in the F group was characterized by shorter hospital length of stay and surgical time as well as fewer blood transfusions and less hemostat agent used per surgery.

OBJECTIVE

To evaluate the cost-consequence of using F compared to F + G/T in minor, major and severe spinal surgery from the US hospital perspective.

METHODS

A cost-consequence model was developed using the US hospital perspective. Model inputs include clinical inputs from the literature, cost inputs (hemostatic matrices, blood product transfusion, hospital stay and operating room time) from the literature, and an analysis of annual spine surgery volume (minor, major and severe) using the 2012 National Inpatient Sample (NIS) database. Costs are reported in 2017 US dollars. One-way and probabilistic sensitivity analyses address sources of variability in the results.

RESULTS

A medium-volume hospital (130 spine surgeries per year) using F versus F + G/T for spine surgeries is expected to require 85 less hours of surgical time, 58 fewer hospital days and 7 fewer blood transfusions in addition to hemostat volume savings (F: 1 mL, thrombin: 1994 mL). The cost savings associated with the hospital resources for a medium-volume hospital are expected to be $317,959 (surgical hours = $154,746, hospital days = $125,237, blood transfusions = $19,023, hemostatic agents = $18,953) or $2445 per spine surgery.

CONCLUSIONS

The use of F versus F + G/T could lead to annual cost savings for US hospitals performing a low to high volume of spinal surgeries per year.

Economic Analysis of the Reduction of Blood Transfusions during Surgical Procedures While Continuous Hemoglobin Monitoring Is Used

Background: Two million transfusions are performed in Spain every year. These come at a high economic price for the health system, increasing the morbidity and mortality rates. The way of obtaining the hemoglobin concentration value is via invasive and intermittent methods, the results of which take time to obtain. The drawbacks of this method mean that some transfusions are unnecessary. New continuous noninvasive hemoglobin measurement technology can save unnecessary transfusions. Methods: A prospective study was carried out with a historical control of two homogeneous groups. The control group used the traditional hemoglobin measurement methodology. The experimental group used the new continuous hemoglobin measurement technology. The difference was analyzed by comparing the transfused units of the groups. The economic savings was calculated by multiplying the cost of a transfusion by the difference in units, taking into account measurement costs. Results: The percentage of patients needing a transfusion decreased by 7.4%, and the number of transfused units per patient by 12.56%. Economic savings per patient were €20.59. At the national level, savings were estimated to be 13,500 transfusions (€1.736 million). Conclusions: Constant monitoring of the hemoglobin level significantly reduces the need for blood transfusions. By using this new measurement technology, health care facilities can significantly reduce costs and improve care quality.

Damage Control Resuscitation

Damage control surgery is a combination of temporizing surgical interventions to arrest hemorrhage and control infectious source, with goal directed resuscitation to restore normal physiology. The convention of damage control surgery largely arose following the discovery of the lethal triad of hypothermia, acidosis, and coagulopathy, with the goal of Damage Control Surgery (DCS) is to avoid the initiation of this "bloody vicious cycle" or to reverse its progression. While hypothermia and acidosis are generally corrected with resuscitation, coagulopathy remains a challenging aspect of DCS, and is exacerbated by excessive crystalloid administration. This chapter focuses on resuscitative principles in the four settings of trauma care: the prehospital setting, emergency department, operating room, and intensive care unit including historical perspectives, resuscitative methods, controversies, and future directions. Each setting provides unique challenges with specific goals of care.