Frequency Of Blood Transfusion Research Articles

Obesity deleteriously affects anesthetic and surgical outcome in body mass index-dependent fashion

ObjectivesTo evaluate obesity effect on anesthetic and surgical outcome of patients of varying BMI assigned for open abdominal surgery.Patients and methodsSixty patients were categorized according to WHO classification of obesity into three classes: class I (n = 30), class II (n = 18) and class III (n = 12). All patients underwent open laparotomy under combined anesthesia using continuous remifentanil infusion and balanced sevoflurane anesthesia. Hemodynamic variables, duration of surgery, intraoperative bleeding, frequency of blood transfusion, recovery times and intraoperative anesthetic or surgical problems were recorded. The occurrence of postoperative complications, admission to ICU, duration till 1st ambulation, 1st oral intake, hospital stay period and rates of morbidity and mortality were recorded.ResultsInduction of anesthesia significantly decreased arterial pressures and heart rate compared both to preoperative and pre-induction measures. After extubation all parameters returned to preoperative levels. Mean operative time was significantly longer and mean intraoperative blood loss was significantly more in patients of class III compared to those of class I and II. All recovery times showed BMI dependence as all were significantly prolonged in class II and III patients compared to class I patients with significantly shorter awakening and extubation times in class II patients than class III patients. Mean time till 1st walk was significantly longer in class III patients than class I and II patients, but time till 1st oral intake was non-significantly different. Sixteen patients developed PO complications. Mean PO hospital stay was significantly longer in class III patients compared to class I and II patients with significantly shorter duration in class II patients than those of class III.ConclusionObesity caused deleterious anesthetic and surgical effects with prolonged operative and recovery times and more need for blood transfusion, ICU admission and prolonged hospital stay duration. The used anesthetic regimen allowed controlled hypotension without compromising patients’ general condition.

VASCULAR ENDOTHELIAL GROWTH FACTOR IN CHILDREN WITH THALASSEMIA MAJOR PDF

BackgroundThe β-Thalassemia syndromes are the most common hereditary chronic hemolytic anemia due to impaired globin chain synthesis. Vascular endothelial growth factor (VEGF) plays several roles in angiogenesis which is a crucial process in the pathogenesis of several inflammatory, autoimmune and malignant diseases. Endothelial damage and inflammation make a significant contribution to the pathophysiology of β-thalassemia.Purpose: The aim of the study was to assess serum VEGF level in children with beta-thalassemia major as a marker of angiogenesis.MethodsA total of 50 children entered the study, 40 patients with thalassemia major and 10 healthy controls. We used enzyme-linked immunosorbent assay for quantitative evaluation of VEGF.ResultsVEGF level was significantly higher in patients with β-thalassemia major than healthy controls (p=0.001). VEGF level was also higher in splenectomised thalassemic patients than non splenectomised ones (p=0.001). There were a positive correlation between VEGF and chelation starting age (p=0.008), and a negative correlation between VEGF and frequency of blood transfusion (p=0.002).ConclusionThalassemia patients, especially splenectomized, have elevated serum levels of VEGF. Early chelation and regular blood transfusion help to decrease serum VEGF and the risk of angiogenesis.

Frequency and Risk Factors of Endocrine Complications in Turkish Children and Adolescents with Sickle Cell Anemia

Objective: To define frequency and risk factors of abnormalities in growth, puberty, thyroid function, and bone and carbohydrate metabolisms in children and adolescents with sickle cell disease (SCD).Materials and Methods: Endocrine problems including short stature, puberty and thyroid disorders, and carbohydrate and bone metabolisms in 50 Turkish children and adolescents with SCD were evaluated. Relationships among sex, disease type, blood transfusions, exchange and exacerbation frequency, ferritin levels, and endocrine pathologies were investigated.Results: The mean age of the study group was 13.1±2.9 years. Weights and heights of 12 participants (24%) were below -2 standard deviations and 4 participants (8%) had malnutrition. Mean difference (±standard deviation) between bone and chronological age of patients was -1.73±1.86 years. Fifty percent of patients had at least one endocrine abnormality other than vitamin D deficiency and insufficiency. Hypergonadotropic hypogonadism in 3 patients (6%), hypogonadotropic hypogonadism in 1 female patient (2%), and small testicular volume in respect to age in 3 male patients (8.5%) were seen. Growth hormone deficiency was detected in 1 (2%) female patient, and hypothyroidism was diagnosed in 3 patients (6%; 1 central case, 2 cases of primary hypothyroidism). At vertebral level, 5 patients (11.1%) had osteopenia and 1 patient (2.2%) had osteoporosis, while 5 patients (11.1%) had osteopenia at femur neck level. The most common endocrine abnormality was vitamin D deficiency. 25-Hydroxyvitamin D was deficient in 63.2% and insufficient in 18.4% of patients. Sex, disease type, blood transfusion frequency, exacerbation frequency, and ferritin levels were not related to endocrine pathologies. As the age was increased, standard deviation scores of femur neck bone mineral density was decreased (r =-0.56; p<0.05). Vitamin D was lower in patients whose weights and/or heights were below -2 standard deviations from the mean (p<0.05).Conclusion: Endocrine organ dysfunctions are commonly detected in children and adolescents with SCD, and vitamin D deficiency is the most commonly encountered endocrine disorder. Regular follow- ups of patients for endocrine complications, starting from early ages of patients, and initiation of appropriate treatments will elongate expectancy and quality of life.Conflict of interest:None declared.

Differences in Short-Term Complications Between Spinal and General Anesthesia for Primary Total Knee Arthroplasty

Spinal anesthesia has been associated with lower postoperative rates of deep-vein thrombosis, a shorter operative time, and less blood loss when compared with general anesthesia. The purpose of the present study was to identify differences in thirty-day perioperative morbidity and mortality between anesthesia choices among patients undergoing total knee arthroplasty. The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database was searched to identify patients who underwent primary total knee arthroplasty between 2005 and 2010. Complications that occurred within thirty days after the procedure in patients who had been managed with either general or spinal anesthesia were identified. Patient characteristics, thirty-day complication rates, and mortality were compared. Multivariate logistic regression identified predictors of thirty-day morbidity, and stratified propensity scores were used to adjust for selection bias. The database search identified 14,052 cases of primary total knee arthroplasty; 6030 (42.9%) were performed with the patient under spinal anesthesia and 8022 (57.1%) were performed with the patient under general anesthesia. The spinal anesthesia group had a lower unadjusted frequency of superficial wound infections (0.68% versus 0.92%; p = 0.0003), blood transfusions (5.02% versus 6.07%; p = 0.0086), and overall complications (10.72% versus 12.34%; p = 0.0032). The length of surgery (ninety-six versus 100 minutes; p < 0.0001) and the length of hospital stay (3.45 versus 3.77 days; p < 0.0001) were shorter in the spinal anesthesia group. After adjustment for potential confounders, the overall likelihood of complications was significantly higher in association with general anesthesia (odds ratio, 1.129; 95% confidence interval, 1.004 to 1.269). Patients with the highest number of preoperative comorbidities, as defined by propensity score-matched quintiles, demonstrated a significant difference between the groups with regard to the short-term complication rate (11.63% versus 15.28%; p = 0.0152). Age, female sex, black race, elevated creatinine, American Society of Anesthesiologists class, operative time, and anesthetic choice were all independent risk factors of short-term complication after total knee arthroplasty. Patients undergoing total knee arthroplasty who were managed with general anesthesia had a small but significant increase in the risk of complications as compared with patients who were managed with spinal anesthesia; the difference was greatest for patients with multiple comorbidities. Surgeons who perform knee arthroplasty may consider spinal anesthesia for patients with comorbidities.

Challenges of providing maintenance hemodialysis in a resource poor country: Experience from a single teaching hospital in Lagos, Southwest Nigeria

Providing maintenance hemodialysis is associated with high costs and poor outcomes. In Nigeria, more than 90% of the population lives below the poverty line, and patients with end-stage renal disease (ESRD) pay out-of-pocket for maintenance hemodialysis. To highlight the challenges of providing maintenance hemodialysis for patients with ESRD in Nigeria, we reviewed records of all patients who joined the maintenance hemodialysis program of our dialysis unit over a 21-month period. Information regarding frequency of hemodialysis, types of vascular access for dialysis, mode of anemia treatment and frequency of blood transfusion received were retrieved. One hundred and twenty patients joined the maintenance hemodialysis program of our unit during the period under review. Seventy-two (60%) were males and the mean age of the study population was 47 + 14 years. The mean hemoglobin concentration at commencement of dialysis was 7.3 g/dL + 1.6 g/dL. The initial vascular access was femoral vein cannulation in all the patients. A total of 73.5% of the patients required blood transfusion at some point with 33% receiving five or more pints of blood. Only 3.3% of the patients had thrice weekly dialysis, 21.7% dialyzed twice weekly, 23.3% once weekly, 16.7% once in two weeks, 2.5% once in three weeks and 11.7% once monthly. At the time of review, 8.3% of the patients had died while 38.3% were lost to follow-up. Majority of patients with ESRD on maintenance hemodialysis in our unit were poorly prepared for dialysis, were under-dialyzed, and were frequently transfused with blood with resultant poor outcomes.

Curative effect of decitabine combined with cytokine-induced killer cells in two elderly patients with acute myeloid leukemia

This study was aimed to evaluate the effectiveness and safety of low methylation drug decitabine combined with autologous cytokine induced killer cells (CIK) to treat the elderly patients with acute myeloid leukemia (AML). Two AML patients aged over 80 years old were diagnosed and treated in our department from 2006 to 2012; both company with MDS history, and one case was M4-type, another case was M6-type according to FAB classification. The changes in lymphocyte subsets, hematologic response, transfusion frequency, leukemic gene expression, obtaining CR or PR, quality of life and survival time of the patients with different treatment regimen (decitabine alone; CIK alone; decitabine combined with CIK) were systematically observed. The results showed that therapy of decitabine combined with CIK cells could reduce bone marrow suppression extent, decrease the frequency and volume of blood transfusion, and prolong the duration of partial remission, compared with the single use of CIK cell infusion and single use of decitabine treatment. Meanwhile, the kinds of expressed genes associated with leukemia decreased and the survival time was prolonged obviously. The patients' life quality significantly improved. It is concluded that decitabine combined with CIK for treatment of elderly patients with AML is safe and effective.

Effects of perioperative blood transfusion on the severity of postoperative infection

This study was purposed to explore whether the blood transfusion of surgical patients can increase the severity of postoperative infection by a retrospective analysis of patients with postoperative infection in Chinese PLA General Hospital. By using a software "clinical transfusion database" developed by our department, 150 infected surgical cases were retrieved and divided into deep infection group and superficial infection group according to the infected location. These two groups were compared in term of the patient's age, duration of hospitalization, red blood cell transfusion volume, none-red cell transfusion volume, transfusion frequency and average transfusion volume. The results showed that red blood cell transfusion volume or none-red cells transfusion volume of patients with superficial infection was 4.50 (0 - 59) U or 2.95 (0 - 119.6) U, and that of deep infection was 9.00 (0 - 153) U and 8.05 (0 - 136.6) U, the differences was significant (P < 0.05). Between two groups, the transfusion frequency showed the most significant difference, median in the patients with superficial infection was about 2 (1 - 31) times, less than the deep infection group about 4 (1 - 49) times (P < 0.001). There was no significant difference between two groups in the average transfusion volume. It is concluded that perioperative blood transfusion volume and frequency of surgical patients seems to display a positive correlation with the degree of postoperative infection.

Changes in Care Associated with the Introduction of a Postpartum Hemorrhage Patient Safety Program

To determine whether the introduction of a postpartum hemorrhage (PPH) patient safety program was associated with changes in patient care or outcomes. A multipronged patient safety program regarding PPH was instituted at a tertiary care maternity hospital. Patient care and outcomes were assessed for 6 months prior to (period A) and 6 months after (period B) program institution. In all, 278 and 341 women were diagnosed with PPH during periods A and B, respectively. Women who had a PPH after the program were more likely to receive more than one dose of prostaglandin F2 α (24% versus 9%, p = 0.01) and more than one type of uterotonic (34% versus 25%, p = 0.02) and to have a B-lynch suture placed (9.4% versus 4.7%, p = 0.03). The frequency of blood transfusion, hysterectomy, and intensive care unit admission were similar between periods. Introduction of a PPH safety program resulted in several indications of a more quickly escalated response.

Cinétique du saignement en chirurgie orthopédique majeure : implications pour la prise en charge périopératoire

IntroductionManagement of the perioperative hemorrhagic risk is of major interest in patients undergoing total arthroplasty of the lower limb. Anemia in the postoperative period of that increasingly performed surgery carries its own morbidity and mortality. Better anticipation of its occurrence could be done with a refined knowledge of bleeding kinetics. Patients and methodsWe conducted a retrospective study in a single centre on 451 consecutive patients undergoing elective unilateral primary total hip or knee arthroplasty for osteoarthritis. Volume of total blood loss according to Mercuriali's formula and variations of haemoglobin levels were calculated between day 0 (D0) and postoperative day 8 (D8), and during subdivided periods between D0–D1, D1–D3 and D3–D8. Frequency and volume of autologous and homologous blood transfusions were also analyzed. Comparisons were done taking into account the use of intraoperative tranexemic acid (TA). ResultsSeventy to 75% of blood loss occurred between D0 and D1. Bleeding occurred mostly between the end of surgery and morning of D1, and tended to stop at D3. TA significantly reduced blood loss in the first 3days, mostly after knee prosthesis surgery. However, the bleeding kinetics were the same with or without TA. ConclusionLoss of haemoglobin occurred mostly in the early postoperative period. To avoid transfusion delays, haemoglobin levels should be monitored regularly until the third postoperative day after total arthroplasty, especially when D1 haemoglobin is close to the transfusion threshold. Furthermore, our results support the routine use of TA.

Morbidities and Mortality in Transfusion-Dependent Beta-Thalassemia Patients (Single-Center Experience)

Background: The improvement of quality and duration of life of transfusion-dependent B thalassemia patients over the last years discloses several complications due to the underling disorder, iron overload and the treatment with iron chelators. Our Aim was to assess the morbidity patterns and mortality rate of transfusion-dependent thalassemia patients, and compare the outcomes in relation to age of onset, type, duration, and compliance to iron chelation therapy and frequency of blood transfusion. Procedure: This retrospective study included 447 transfusion-dependent β-thalassemia patients who attended the Thalassemia Center, Ain Shams University Children's Hospital over the last 10 years in the period between January 2000 and January 2010. Data were collected from the patients or their caregivers, as well as by reviewing follow up sheets for examinations and investigations done to detect morbidities as well as iron chelation therapies given. Determination of mortality rate and the causes of death were also done. Results: Results revealed that the most common morbidities were endocrinologic (44.7%) followed by cardiovascular (41.3%) and hepatic (40.5%), then renal (4%). The different iron chelation therapy groups showed a comparable prevalence of different morbidities. The mortality rate was 1.5% and infection was the most common cause of death. The 5, 10, 20 years' survival rate among the studied patients was 80%, 50%, 20%, respectively. Conclusion: In the past 10 years, the survival and morbidity rates in our center have markedly improved as a result of regular blood transfusion, new iron chelators, and better compliance of the patients.

Study of Serum Hepcidin in Hereditary Hemolytic Anemias

AbstractAbstract 5168 Background:Thalassemia is the most common genetic disorder in Egypt composes a major health problem with an estimated carrier rate of 5. 3%-9%. Registered cases in large centers in Egypt September 2007 were 9912 cases, and in Cairo University hematology clinic were alone 2597 cases. Patients with thalassemia major requiring regular blood transfusions accumulate iron that is toxic to the heart, liver, and endocrine systems.Hepcidin, is a 25 amino-acid peptide hormone synthesized in the liver is a key regulator of iron homeostasis. Recently, hepcidin was reported to bind to the trans-membrane iron exporter “ferroportin” which is present on macrophages, the basolateral site of entrecotes, and in hepatocytes. Hepcidin induces the internalization and degradation of ferroportin. liver hepcidin controls reduction of iron uptake and release. There is also evidence for local production of hepcidin by macrophages, fat cells and cardiomyocytes. Thus, hepcidin is involved in different regulatory mechanisms that control iron imbalance. Objective:The aim of this study is to assess the level of serum hepcidin in hereditary chronic hemolytic anemias and correlate its level to the need for blood transfusion (frequency of blood transfusion) and the serum ferritin level. Study design:Seventy pediatric patients with hereditary chronic hemolytic anemias were the subjects of this study; 53 thalassemia major (TM), 10 thalassemia intermedia (TI), 4 congenital spherocytosis(CS) and 3 sickle cell disease(SCD) patients, mean age 7. 8+3. 9 years (range 1–14). Seventy normal children age and sex matched were studied as controls. Serum hepcidin was measured in all patients and controls by ELISA technique. Serum Hepcidin was measured in all patients one day pre transfusion and in 20 TM patients 3–4 days post transfusion. Results:Significant decrease in serum hepcidin levels in all patients compared to controls (mean 22. 9 ±6 vs 132. 4±16. 7 ng/ml, P <0. 001). Hepcidin levels were higher in TM (mean 23. 7±6. 2 ng/ml) than in TI patients (mean =21. 8±4 ng/ml) (Fig 1). The median number of blood transfusions in TM was 70/year (range18–120), in TI the median was 7/year (range 6–17). A 280% increase of serum hepcidin levels of pre transfusion levels was found post transfusion in TM patients (n=20). A significant positive correlation was found between serum hepcidin and frequency of blood transfusion (r=0. 4, p<0. 001), serum ferritin (r=0. 28, p <0. 05) and CRP (r=0. 4, p<0. 05). The hepcidin to ferritin ratio a marker of the hepcidin expression relative to the degree of iron burden was significantly less than one in TM and TI patients (0. 03± 0. 004 and 0. 025± 0. 002 respectively) and far from the level in normal controls (mean 2. 3±0. 7, P<0. 001). Hepcidin and hepcidin/ferritin ratio as markers of iron overload in our patients showed high sensitivity and specificity (99% and 98%, 97% respectively) (table 1, fig 2). Discussion and Conclusion:This study examined serum hepcidin and hepcidin/ferritin ratio in hereditary chronic hemolytic anemias, significant low levels were detected. The increase in serum hepcidin level in TM than TI and its marked increase post transfusion in TM patients can be explained by the positive correlation between frequency of blood transfusion and serum hepcidin level in this study. Hepcidin and hepcidin/ferritin ratio can be used as valid markers of iron overload in hereditary chronic hemolytic anemias. Evidence from laboratories around the world have converged on hepcidin as a rational therapeutic agent for treatment of B-thalassemia. Treatment with a hepcidin agonist, at a carefully defined dose, has the potential to ameliorate several aspects of TI due to the specific reduction of iron overload and splenomegaly. Testing this approach provides an exciting opportunity to improve the current management strategies for these diseases, and our study agrees with this approach. [Display omitted] Table (1)Validity of hepcidin (pretransfusion) in case of iron overloadHepcidin/ferritin ratioHepcidinVariables0.670Best cut off0.980.99Area under the curve99%99%Sensitivity97%98%Specificity96%99%PPV97%98%NPV [Display omitted] Disclosures:No relevant conflicts of interest to declare.

Deferasirox Treatment for up to 3 Years in Iron-Overloaded Pediatric Patients Reduces Serum Ferritin with a Manageable Safety Profile

AbstractAbstract 1028 Background:To prevent complications associated with iron overload in patients with transfusion-dependent anemias, iron chelation therapy is required throughout life starting from early childhood. Long-term studies of iron chelation therapy are therefore required, particularly in pediatric patients. The 1-year open-label, single-arm, multicenter EPIC (Evaluation of Patients’ Iron Chelation with Exjade®) trial evaluating the efficacy and safety of deferasirox in patients with transfusion-dependent iron overload enrolled 577 pediatric patients across 23 countries. In an extension period of up to 18 months, or until deferasirox was available locally, patients completing the core study could continue to receive deferasirox, thus providing long-term efficacy and safety data of deferasirox in iron-overloaded pediatric patients. Methods:At enrolment, transfusion-dependent pediatric patients (defined as ≥2–<16 years at enrollment) had serum ferritin ≥1000 ng/mL OR <1000 ng/mL with a history of multiple transfusions (>20 transfusions or >100 mL/kg red blood cells transfused) and liver iron concentration >2 mg Fe/g dw confirmed by R2 magnetic resonance imaging. Deferasirox starting dose was 10–30 mg/kg/day depending on frequency of blood transfusions, with protocol-specified adjustments of 5–10 mg/kg/day (range 0–40 mg/kg/day) based on 3-monthly serum ferritin trends and safety. Biochemistry analysis including serum ferritin was performed on a monthly basis, and growth was monitored every 12 weeks, with continuous assessment of safety parameters. Creatinine clearance was calculated using the Schwarz formula for pediatric patients. Changes from the start of deferasirox treatment (core baseline) are presented. Results:267 pediatric patients aged 2–<6 (n=68), 6–<12 (n=114) and 12–<16 (n=85) years entered the extension period (n=141 [52.8%] male; n=248 [92.9%] with underlying thalassemia; n=33 [12.4%] with a history of hepatitis B and/or C). Median duration of deferasirox exposure was 101.3 weeks (range 55.6–159.9) with mean ± SD deferasirox dose 25.7 ± 5.8 mg/kg/day (13.4–40.0). Median serum ferritin decreased from a baseline of 3222 ng/mL (951–16,944) to 2431 ng/mL (238–29,681) at the end of the extension (absolute change from baseline –528 ng/mL [–6354 to 25,127]; P<0.0001; last observation carried forward).Overall, 257/267 (96.3%) patients completed the extension; main reasons (more than two patients) for discontinuation were unsatisfactory therapeutic effect (n=4, 1.5%) and consent withdrawal (n=3; 1.1%). The most common (>5%) investigator-assessed drug-related AEs were increased alanine aminotransferase (ALT; n=47, 17.6%), increased aspartate aminotransferase (AST; n=44, 16.5%), increased blood creatinine (n=24, 9.0%) and rash (n=23, 8.6%). ALT and AST increases were mostly mild in severity, transient, non-progressive and managed with dose adjustments. There were no reported drug-related serious AEs and no deaths occurred.45/267 (16.9%) patients had two consecutive ALT values >5 × upper limit of normal (ULN). Of these 45 patients, 40 had high ALT levels at baseline and 30 had ALT or AST >2.5 × ULN at baseline; 13/45 had a history of hepatitis B and/or C. 6/267 (2.2%) patients had two consecutive serum creatinine values >33% above baseline and >ULN; all had normal values at baseline. The relative change in creatinine clearance from baseline to end of the extension was between –10 and –20% for the majority of patients (n=52, 19.5%), although changes in both directions were variable.Stature, growth and weight assessments indicated positive growth velocity. For all patients combined, mean ± SD growth velocity at end of extension was 5.9 ± 43.3 cm/year (median 2.6 cm/year). Conclusions:Deferasirox therapy for up to 3 years in pediatric patients significantly decreased serum ferritin, similar to previous reports. The majority of patients with elevated liver enzymes during the study also had elevated levels at baseline; renal safety was consistent with previous reports. While patient age and gender will influence individual growth rates, positive growth velocity was nonetheless maintained during treatment. Disclosures:Lin:Novartis: Honoraria. Aydinok:Novartis: Honoraria, Research Funding, Speakers Bureau; Ferrokin: Research Funding. Galanello:Novartis: Research Funding, Speakers Bureau; Apopharma: Research Funding, Speakers Bureau; Ferrokin: Research Funding. El-Ali:Novartis: Employment. Martin:Novartis: Employment. Cappellini:Novartis: Speakers Bureau.

Renal anaemia treatment in haemodialysis patients in the Central and Eastern European countries in everyday clinical practice follow-up

BackgroundChronic kidney disease is almost always accompanied by anaemia. Erythropoietin-stimulating agents (ESA) can increase haemoglobin concentration and thus reduce the frequency of anaemia-related complications including the cardiovascular events.AimThe aim of the study was to collect prospective data on 12-month standard ESA therapy used in haemodialyzed patients in selected CEE countries as well as on cardiovascular complications, iron status and anaemia treatment.Patients and methodsFifty centres in 3 countries participated in the study. A group of 398 haemodialysed stable patients (M-231, F-167) aged 19–90 years (57.5 ± 14.7) on standard ESA therapy for chronic renal anaemia were recruited. Twelve-month prospective data on iron parameters, ESA therapy and cardiovascular events were collected. The use of iron, folic acid and blood transfusions were also assessed. Patient were divided into three groups according to ESA therapy start: group A—patients who received ESA after start of haemodialysis, group B—patients who received ESA within 3 months from the day of first haemodialysis and group C—patients who had received ESA more than 3 months before haemodialysis. Chi2 test for qualitative data and Kruskall–Wallis test for quantitative data with p < 0.05 were used in statistical analysis.ResultsAt prestudy period, the mean weekly dose of ESA in group C was statistically lower than in the remaining two groups (3,823 ± 3,169 vs. 5,276 ± 2,915 and 6,427 ± 3,441 units/week, p < 0.001), but during prospective phase of the study the doses did not differ among groups A, B and C. No major fluctuation of ESA administration schedule was observed during the study in the groups; however, at majority of visits, the mean frequency of ESA administration in group C was statistically higher than in groups A and B. At baseline visit, the haemoglobin concentration in group A patients (10.86 ± 1.34 g/dL) was slightly lower than in group B (11.26 ± 1.43 g/dL) and group C (10.98 ± 1.35 g/dL) (p = 0.025), but at subsequent visits these differences disappeared and mean haemoglobin concentration was stable around 11 g/dL. Ferritin concentration increased from 280 ± 241 at baseline to 506 ± 405 at month 12, and no important differences in the groups were observed. The other haematological parameters (haematocrit, iron concentration) remained stable during the entire study. The frequency of blood transfusion and total volume of blood in group C were lower than in groups A and B. During the prospective 12-month follow-up, 23 (5.8 %) of the patients died and 35 (8.8 %) were transplanted. No differences in death or transplantation rate were observed among groups A, B and C. The number of patients with adverse events, serious adverse events or drug-related adverse events in all groups was similar. In conclusion, ESA therapy increased haemoglobin concentration and no major differences in haematological parameters among the groups were observed during the entire study irrespective of early versus late start. Mortality, cardiovascular events or other adverse events were similar among the groups during the observation period; however, the limitation of the study is the sample size.

Efficacy and safety of deferasirox at low and high iron burdens: results from the EPIC magnetic resonance imaging substudy

The effect of deferasirox dosing tailored for iron burden and iron loading based on liver iron concentration (LIC) was assessed over 1 year in less versus more heavily iron-overloaded patients in a substudy of the Evaluation of Patients’ Iron Chelation with Exjade®. Deferasirox starting dose was 10–30 mg/kg/day, depending on blood transfusion frequency, with recommended dose adjustments every 3 months. Therapeutic goals were LIC maintenance or reduction in patients with baseline LIC <7 or ≥7 mg Fe/g dry weight (dw), respectively. Changes in LIC (R2-magnetic resonance imaging) and serum ferritin after 1 year were assessed. Adverse events (AEs) and laboratory parameters were monitored throughout. Of 374 patients, 71 and 303 had baseline LIC <7 and ≥7 mg Fe/g dw, respectively; mean deferasirox doses were 20.7 and 27.1 mg/kg/day (overall average time to dose increase, 24 weeks). At 1 year, mean LIC and median serum ferritin levels were maintained in the low-iron cohort (−0.02 ± 2.4 mg Fe/g dw, −57 ng/mL; P = not significant) and significantly decreased in the high-iron cohort (−6.1 ± 9.1 mg Fe/g dw, −830 ng/mL; P < 0.0001). Drug-related gastrointestinal AEs, mostly mild to moderate, were more frequently reported in the <7 versus ≥7 mg Fe/g dw cohort (39.4 versus 20.8 %; P = 0.001) and were not confounded by diagnosis, dosing, ethnicity, or hepatitis B and/or C history. Reported serum creatinine increases did not increase in low- versus high-iron cohort patients. Deferasirox doses of 20 mg/kg/day maintained LIC <7 mg Fe/g dw and doses of 30 mg/kg/day were required for net iron reduction in the high-iron cohort, with clinically manageable safety profiles. The higher incidence of gastrointestinal AEs at lower iron burdens requires further investigation.

Effect of Hospital Culture on Blood Transfusion in Cardiac Procedures

In our effort to reduce the use of blood products in cardiac operations in a health care system, we noted variations in transfusion practices among facilities. Interestingly, surgeons practicing at the same hospital had similar transfusion rates. We sought to quantitate the contribution of hospital influence on individual surgeons' transfusion practices. Blood transfusion data for coronary artery bypass graft operations at 12 Providence Health & Services facilities between January 2008 and June 2011 were reviewed. Frequency of perioperative blood transfusion, amount of transfusion, components transfused, and timing of transfusions were compared. Variation among surgeons at the same institution vs between institutions was computed based on multilevel mixed-effect logistic and linear regression models. Intraclass correlation coefficients were calculated. A total of 5,744 nonemergency first-time coronary artery bypass graft procedures were performed by 42 not-low volume (n>30 in 2.5 years) surgeons at 12 Providence Health & Services hospitals during the 3.5-year study period. Frequency, amount, timing, and blood component usage were different among facilities but relatively similar for surgeons within a facility. The variance of red blood cell transfusion rate among hospitals (.82) is more than two times that among surgeons practicing within the same hospital (.35). Thus, surgeons contribute 30% to the variation, and 70% of the total variation can be explained by the hospital effect. In our multihospital system, the hospital that a surgeon practices at plays a larger role in determining blood utilization than the individual surgeon's preference.

Limit allogeneic blood use with routine re-use of patient's own blood: a prospective, randomized, controlled trial in total hip surgery.

BackgroundThere are risks related to blood incompatibility and blood-borne diseases when using allogeneic blood transfusion. Several alternatives exist today, one of which, used for autologous blood salvage perioperatively, is the Sangvia Blood Management System. This study was designed to investigate the efficacy of the system and to add data to previously reported safety results.Methodology/Principal FindingsTwo hundred sixteen patients undergoing primary or revision total hip arthroplasty (THA) were enrolled in this randomized, controlled, assessor-blinded multicenter study. Randomization was either autologous blood transfusion (Sangvia group) or no use of autologous blood (Control group), both in combination with a transfusion protocol for allogeneic transfusion. Patients were followed during hospital stay and at two months after discharge. The primary outcome was allogeneic blood transfusion frequency. Data on blood loss, postoperative hemoglobin/hematocrit, safety and quality of life were also collected. The effectiveness analysis including all patients showed an allogeneic blood transfusion rate of 14% in both groups. The efficacy analysis included 197 patients and showed a transfusion rate of 9% in the Sangvia group as compared to 13% in the Control group (95%CI −0.05–0.12, p = 0.5016). A mean of 522 mL autologous blood was returned in the Sangvia group and lower calculated blood loss was seen. 1095 mL vs 1285 mL in the Control group (95%CI 31–346, p = 0.0175). No differences in postoperative hemoglobin was detected but a lower hematocrit reduction after surgery was seen among patients receiving autologous blood. No relevant differences were found for safety parameters or quality of life.Conclusions/SignificanceGeneral low use of allogeneic blood in THA is seen in the current study of the Sangvia system used together with a transfusion protocol. The trial setting is under-powered due to premature termination and therefore not able to verify efficacy for the system itself but contributes with descriptive data on safety.Trial RegistrationClinicaltrials.gov NCT00822588

The impact of early do not resuscitate (DNR) orders on patient care and outcomes following resuscitation from out of hospital cardiac arrest

ObjectivesAmong patients successfully resuscitated from out-of-hospital cardiac arrest (OHCA) and admitted to California hospitals, we examined how the placement of a do not resuscitate (DNR) order in the first 24h after admission was associated with patient care, procedures and inhospital survival. We further analyzed hospital and patient demographic factors associated with early DNR placement among patients admitted following OHCA. MethodsWe identified post-OHCA patients from a statewide California database of hospital admissions from 2002 to 2010. Documentation of patient and hospital demographics, hospital interventions, and patient outcome were analyzed by descriptive statistics and multiple regression models to calculate odds ratios and 95% confidence intervals. ResultsOf 5212 patients admitted to California hospitals after resuscitation from OHCA, 1692 (32.5%) had a DNR order placed in the first 24h after admission. These patients had decreased frequency of cardiac catheterization (1.1% vs. 4.3%), blood transfusion (7.6% vs. 11.2%), ICD placement (0.1% vs. 1.1%), and survival to discharge (5.2% vs. 21.6%, all p-values<0.0001). There was wide intrahospital variability and significant racial differences in the adjusted odds of early DNR orders (Asian, OR 0.67, 95% CI 0.48–0.95; Black, OR 0.49, 95% CI 0.35–0.69). ConclusionsEarly DNR placement is associated with a decrease in potentially critical hospital interventions, procedures, and survival to discharge, and wide variability in practice patterns between hospitals. In the absence of prior patient wishes, DNR placement within 24h may be premature given the lack of early prognostic indicators after OHCA.

Study of Serum Hepcidin in Hereditary Hemolytic Anemias

The aim of this study was to assess the level of hepcidin in hereditary chronic hemolytic anemias and to correlate the serum hepcidin levels to the need for blood transfusions (frequency of blood transfusions and the serum ferritin level). Seventy pediatric patients with hereditary chronic hemolytic anemias, attending to hematology clinics of Cairo University and Misr University for Science and Technology (MUST) hospitals were the subjects of this study [53 patients with β-thalassemia major (β-TM), 10 patients with β-thalassemia intermedia (β-TI), four patients with congenital spherocytosis and three patients with sickle cell disease) (38 males and 32 females)]; their ages ranged from 1-14 years. Seventy normal children, age- and sex-matched, served as the control group. The results of this study revealed decreased hepcidin levels in patients (all types of congenital chronic hemolytic anemias) [mean ± SD (standard deviation) = 22.9 ± 6.0] compared to controls (mean ± SD = 132.4 ± 16.7) with highly significant statistical difference in between. Hepcidin levels were higher in β-TM patients (mean ± SD = 23.7 ± 6.2) than in β-TI patients (mean ± SD = 21.8 ± 4.0), the hepcidin to ferritin ratio was significantly less than one. In β-TM patients, the mean ± SD was 0.03 ± 0.004, and in β-TI patients the mean ± SD = 0.025 ± 0.002, with highly significant statistical difference with hepcidin-to-ferritin ratios in controls being mean ± SD = 2.3 ± 0.7. Hepcidin and hepcidin/ferritin ratios can be used as good markers of hemolytic anemia and iron overload as they have very high sensitivity (99.0 and 99.0%, respectively) and very high specificity (98.0 and 97.0%, respectively). Our findings highlight the potential usefulness of hepcidin measurement as a diagnostic tool. The use of hepcidin as an adjuvant therapy with iron chelators is important as it has a vital role in combating hemosidrosis.

Considerations for Evaluating the Accuracy of Hemoglobin Monitoring

Considerations for Evaluating the Accuracy of Hemoglobin Monitoring

The comparative efficacies of intra-articular and IV tranexamic acid for reducing blood loss during total knee arthroplasty

Reduction in blood loss during surgery stabilizes hemodynamic status and aids in recovery after total knee arthroplasty (TKA). In this study, the authors examined whether different administration routes of tranexamic acid (TNA) might affect the amount of blood loss after TKA. A total of 150 patients were prospectively allocated to each of the three groups (intravenous, intra-articular, and placebo group) and underwent unilateral TKA. During closing the operative wound, TNA (1.5g mixed in 100cc of saline) was administered intravenously or intra-articularly according to the enrolled group, and an equivalent volume of normal saline was administered into the knee joint cavity and intravenously in the placebo group, respectively. The amount of blood loss and transfusion, and changes in haemoglobin levels were documented accordingly. The mean blood loss in the intravenous, intra-articular, and placebo groups were 528±227, 426±197, and 833±412ml, respectively. About 66% (intravenous), 80% (intra-articular), and 6% (placebo) of each group did not require transfusion for any reason, and the mean amount of transfusion was 273.6, 129.6, and 920.8ml, respectively. Preoperative haemoglobin values decreased by 1.6±0.8, 1.8±0.8, and 2.0±0.9mg/dl, respectively. Compared to intravenous administration, intra-articular administration of TNA seems to be more effective in terms of reducing blood loss and transfusion frequency. TNA may improve the general conditions of patients given TKA by maintaining a hemodynamically stable state, aiding in recovery, and reducing the chance of transfusion-associated side effects and complications. II.