Receipt Of Blood Transfusion Research Articles

Impact of age on antimicrobial prescriptions in hospitalized children at three academic centres in South Africa: a point prevalence survey.

Antimicrobial resistance is a global threat in children, and the emergence of multi-drug-resistant organisms is of concern. This secondary analysis of an antimicrobial point prevalence survey (PPS) in children evaluates the impact of age on antimicrobial use. The mean antimicrobial prescriptions were assessed in neonates, infants, young children (1-5 years), school-going children (6-12 years), and adolescents (13-15 years) from a cross-sectional PPS at three academic hospitals between September 2021 and January 2022. Primary and secondary diagnoses, antibiotic type (World Health Organization AWaRe and Anatomical Therapeutic Chemical classifications), and the incidence of healthcare-associated infections (HAI) were evaluated per age category. Multiple regression models were used to analyse age-related risk factors for HAI. The number of antimicrobials per child (1.7-1.9 per patient) was higher in neonates and infants compared to children 6-12 years old (1.4 per patient). Watch antibiotics, especially carbapenems, were commonly prescribed in neonates (32.5%) and infants (42.2%). Reserve antimicrobial use was notable in neonates (4.7%) and infants (4.1%). The incidence risk ratio (IRR) of HAI was higher in neonates and infants (IRR 2.13; 95% CI 1.23-3.70, IRR 2.20; 95% CI 1.40-3.45, respectively) compared to 6- to 12-year-olds. On multivariate analysis of participants according to age, being HIV infected, length of stay >6 days, high McCabe severity score, having surgery and receipt of blood transfusion were associated with an increased risk of HAI (P < .001 for all) while on univariate analysis only, being premature and/or underweight was associated with an increased risk of HAI in infants (P < .001 for both). Infants with risk factors for HAI significantly influenced antimicrobial prescribing, underscoring the necessity for tailored antimicrobial stewardship and enhanced surveillance. The increased use of Watch antibiotics, particularly carbapenems, in infants warrants closer scrutiny. Further research is required to identify inappropriate antimicrobial use in high-risk hospitalized young children.

A joinpoint analysis examining trends in firearm injuries at six us trauma centers from 2016 to 2022

BackgroundThere is an epidemic of firearm injuries in the United States since the mid-2000s. Thus, we sought to examine whether hospitalization from firearm injuries have increased over time, and to examine temporal changes in patient demographics, firearm injury intent, and injury severity.MethodsThis was a multicenter, retrospective, observational cohort study of patients hospitalized with a traumatic injury to six US level I trauma centers between 1/1/2016 and 6/30/2022. ICD-10-CM cause codes were used to identify and describe firearm injuries. Temporal trends were compared for demographics (age, sex, race, insured status), intent (assault, unintentional, self-harm, legal intervention, and undetermined), and severity (death, ICU admission, severe injury (injury severity score ≥ 16), receipt of blood transfusion, mechanical ventilation, and hospital and ICU LOS (days). Temporal trends were examined over 13 six-month intervals (H1, January–June; H2, July–December) using joinpoint regression and reported as semi-annual percent change (SPC); significance was p < 0.05.ResultsFirearm injuries accounted for 2.6% (1908 of 72,474) of trauma hospitalizations. The rate of firearm injuries initially declined from 2016-H1 to 2018-H2 (SPC = − 4.0%, p = 0.002), followed by increased rates from 2018-H2 to 2020-H1 (SPC = 9.0%, p = 0.005), before stabilizing from 2020-H1 to 2022-H1 (0.5%, p = 0.73). NH black patients had the greatest hospitalization rate from firearm injuries (14.0%) and were the only group to demonstrate a temporal increase (SPC = 6.3%, p < 0.001). The proportion of uninsured patients increased (SPC = 2.3%, p = 0.02) but there were no temporal changes by age or sex. ICU admission rates declined (SPC = − 2.2%, p < 0.001), but ICU LOS increased (SPC = 2.8%, p = 0.04). There were no significant changes over time in rates of death (SPC = 0.3%), severe injury (SPC = 1.6%), blood transfusion (SPC = 0.6%), and mechanical ventilation (SPC = 0.6%). When examined by intent, self-harm injuries declined over time (SPC = − 4.1%, p < 0.001), assaults declined through 2019-H2 (SPC = − 5.6%, p = 0.01) before increasing through 2022-H1 (SPC = 6.5%, p = 0.01), while undetermined injuries increased through 2019-H1 (SPC = 24.1%, p = 0.01) then stabilized (SPC = − 4.5%, p = 0.39); there were no temporal changes in unintentional injuries or legal intervention.ConclusionsHospitalizations from firearm injuries are increasing following a period of declines, driven by increases among NH Black patients. Trauma systems need to consider these changing trends to best address the needs of the injured population.

The impact of anticoagulant medications on fragility femur fracture care: The hip and femoral fracture anticoagulation surgical timing evaluation (HASTE) study

IntroductionDue to their hypocoagulable state on presentation, anticoagulated patients with femoral fragility fractures typically experience delays to surgery. There are no large, multicentre studies previously carried out within the United Kingdom (UK) evaluating the impact of anticoagulant use in this patient population. This study aimed to evaluate the current epidemiology and compare the perioperative management of anticoagulated and non-anticoagulated femoral fragility fracture patients. MethodsData was prospectively collected through a collaborative, multicentre approach involving hospitals across the United Kingdom. Femoral fragility fracture patients aged ≥60 years and admitted to hospital between 1st May to 31st July 2023 were included. Main outcomes under investigation included time to surgery, receipt of blood transfusion between admission and 48 h following surgery, length of stay, and 30-day mortality. These were assessed using multivariable linear and logistic regression, and Cox proportional hazards models. Only data from hospitals ≥90 % case ascertainment with reference to figures from the National Hip Fracture Database (NHFD) were analysed. ResultsData on 10,197 patients from 78 hospitals were analysed. 18.5 % of patients were taking anticoagulants. Compared to non-anticoagulated patients, time to surgery was longer by 7.59 h (95 %CI 4.83–10.36; p < 0.001). 42.41 % of anticoagulated patients received surgery within 36 h (OR 0.54, 95 %CI 0.48–0.60, p < 0.001). Differences in time to surgery were similar between countries however there was some variation across units. There were no differences in blood transfusion and length of stay between groups (OR 1.03, 95 %CI 0.88–1.22, p = 0.646 and 0.22 days, 95 %CI -0.45–0.89; p = 0.887 respectively). Mortality within 30 days of admission was higher in anticoagulated patients (HR 1.27, 95 %CI 1.03–1.57, p = 0.026). ConclusionsAnticoagulated femoral fragility fracture patients comprise a substantial number of patients, and experience relatively longer delays to surgery with less than half receiving surgery within 36 h of admission. This may have resulted in their comparatively higher mortality rate. Inclusion of anticoagulation status in the minimum data set for the NHFD to enable routine auditing of performance, and development of a national guideline on the management of this growing and emerging patient group is likely to help standardise practice in this area and improve outcomes.

Early hip fracture surgery is safe for patients on direct oral anticoagulants.

To determine how preoperative direct oral anticoagulant (DOAC) use affects rates of blood transfusion, clinically important blood loss, and 30-day mortality in patients with hip fracture undergoing surgery within 48 hours of presentation to the emergency department. Retrospective cohort study. Academic trauma center. A total of 535 patients with hip fracture who underwent open cephalomedullary nail fixation or arthroplasty either taking a direct oral anticoagulant or no form of chemical anticoagulant/antiplatelet agent before presentation (control). Demographics, time to surgery, type of surgery, blood transfusion requirement, clinically important blood loss, and 30-day mortality. Forty-one patients (7.7%) were taking DOACs. DOAC patients were older (81.7 vs. 77 years, P = 0.02) and had higher BMI (26.9 vs. 24.2 kg/m2, P = 0.01). Time from admission to surgery was similar between DOAC users (20.1 hours) and the control (18.7 hours, P > 0.4). There was no difference in receipt of blood transfusion (P = 0.4), major bleeding diagnosis (P = 0.2), acute blood loss anemia diagnosis (P = 0.5), and 30-day mortality (P = 1) between the DOAC and control group. This was true when stratifying by type of surgery as well. Our results suggest that early surgery may be safe in patients with hip fracture taking DOACs despite theoretical risk of increased bleeding. Because early surgery has previously been associated with decreased morbidity and mortality, we suggest that hip fracture surgery should not be delayed because a patient is taking direct oral anticoagulants. Prognostic Level III.

Tranexamic acid versus placebo to reduce perioperative blood transfusion in patients undergoing liver resection: protocol for the haemorrhage during liver resection tranexamic acid (HeLiX) randomised controlled trial

IntroductionDespite use of operative and non-operative interventions to reduce blood loss during liver resection, 20%–40% of patients receive a perioperative blood transfusion. Extensive intraoperative blood loss is a major risk...

739 Maternal transfusion may overestimate severe maternal morbidity when used as an indicator

Although blood transfusion (TF) has been classified as an indicator of severe maternal morbidity (SMM), some patients receive blood without experiencing other morbid events possibly inflating rates of SMM. As many scientific bodies consider ≥ 4 units RBC to be significant for SMM, we sought to compare rates of SMM by this cutoff. This retrospective analysis included all women who delivered in a four-hospital system from January 2016 through January 2020. Demographic and clinical data were extracted using an automated query from the hospital system's electronic data warehouse, which aggregates data from the EHR, billing system, and other sources. Our primary analysis was to examine the rate of non-transfusion related SMM indicators (ntSMM) stratified by the number of units of RBCs (uRBC) transfused. ntSMM were identified using billing codes and receipt of blood TF was identified based on electronic orders. We then examined rates of specific ntSMM by units transfused. The cohort included 60,034 deliveries of which 1,452 (2%) received at least 1uRBC and of these 254 (17.5%) received ≥4uRBC. Patients who received ≥4uRBC tended to be older and have lower hematocrits prior to delivery with similar race, ethnicity and payer status. The average number of ntSMM increased when ≥ 4uRBC were transfused with 98% having at least one ntSMM (figure 1). Of those who received ≥ 4uRBC, the most prevalent ntSMM were hysterectomy (22.8%), disseminated intravascular coagulation (16.9%), sepsis (14.6%), shock (13.8%), acute kidney injury (11.8%) and acute respiratory distress syndrome (4.3%) (table 1). Among those who received <4uRBC, all individual ntSMM indicators were detected at rates ≤ 3%. An overwhelming majority of patients transfused ≥4uRBC have an associated ntSMM, making its use as a trigger for case review appropriate but use as a separate indicator of SMM unnecessary. Also, as a minority of patients with <4uRBC transfused have an associated ntSMM, the use of transfusion as an indicator may overestimate morbidity.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Assessing the appropriateness of blood transfusion among injured patients at a Ghanaian tertiary hospital: Time for clarity on the use of a scarce resource.

Hemorrhage is an important cause of preventable injury-related death. Many low- and middle-income country (LMIC) patients do not have timely access to safe blood. We sought to determine the degree of appropriateness of blood transfusion among patients with injuries requiring surgical intervention at presentation to a tertiary hospital in Ghana. We performed a retrospective review of such patients presenting to Komfo Anokye Teaching Hospital (KATH), from January 2015 to December 2016. Patients' hemoglobin levels at presentation were determined as the first record of hemoglobin after presentation and their receipt of blood transfusion was determined by explicit documentation in the chart. We defined appropriate blood transfusion practice as patients receiving transfusion when hemoglobin was equal or below a threshold, or patients not being transfused when hemoglobin was above the threshold. We considered both restrictive (hemoglobin ≤7 g/dL) and liberal (hemoglobin ≤10 g/dL) transfusion thresholds. There were 1,408 patients who presented to KATH with injuries that met inclusion criteria. Two hundred and ninety two (292) patients were excluded because of missing hemoglobin information. Four hundred and fifty eight (458;41%) patients received blood transfusion. Transfused patients had a higher mean age (38 vs 35 years) and were less likely to be male (62% vs 71%). Transfused patients underwent more external fixation procedures (28% vs 19%), trauma amputations (5% vs 1%) and trauma laparotomies (3% vs 1%). At a restrictive transfusion threshold (hemoglobin ≤7 g/dL), 20% of patients who needed a transfusion did not receive one and 39% of patients who did not need a transfusion received one. At a liberal threshold (hemoglobin ≤10 g/dL), 33% of patients who needed a transfusion did not receive one and 30% of patients who did not need a transfusion received one. Blood transfusion practice was inappropriate in 31%-39% of all patients. Our data suggest that clearer guidelines for blood transfusion among emergency surgery patients are needed in Ghana and similar LMICs to avoid inappropriate use of blood as a scarce resource.

Current Pattern of Use and Impact of Pringle Maneuver in Liver Resections in the United States

BackgroundPringle maneuver (PM) is used for inflow vascular control during hepatectomy, but its use remains controversial. We aimed to report its pattern of use and association with postoperative outcomes. MethodsWe identified hepatectomy patients using the liver-targeted National Surgical Quality Improvement Program database (2014-2016). Associations between PM and posthepatectomy liver failure (PHLF), receipt of blood transfusion, and total hospital length of stay (LOS) were evaluated. ResultsWe identified 7870 patients (74.9%) with no Pringle maneuver and 2632 (25.1%) with PM. PM patients were older (median age 61 versus 60 y, P = 0.002) and had higher ASA scores (76.1% versus 71.4% were ASA 3-4, P < 0.001). PM had more malignancy (83.0% versus 73.0%, P < 0.001), neoadjuvant therapy (37.7% versus 28.8%, P < 0.001), total lobectomy (30.6% versus 23.2%, P < 0.001), open resection (90.8% versus 74.9%, P < 0.001), and longer operations (246 min versus 212 min, P < 0.001). PM was associated with longer LOS (0.36 d, 95% confidence interval [CI] 0.11-0.60) and increased risk of PHLF (odds ratio [OR] 1.36, 95% CI 1.11-1.66), although not clinically significant grade B/C PHLF (OR 0.82, 95% CI 0.57-1.19), but was not associated with receipt of perioperative blood transfusions (OR 1.00, 95% CI 0.69-1.64). ConclusionsPM is associated with similar clinically significant PHLF and transfusion requirements but longer LOS compared with no Pringle maneuver.

Trends in Anemia, Iron Therapy and Transfusion in Pediatric Inflammatory Bowel Disease

Background:Inflammatory bowel disease (IBD) is a group of chronic inflammatory disorders of the gastrointestinal tract that affect approximately 70,000 children in the U.S. Anemia is the most common extra-intestinal symptom in children with IBD and is present in up to three-quarters of patients, most commonly due to iron deficiency.Despite its prevalence and impact, iron deficiency remains undertreated in children with IBD. Oral iron supplementation is often considered inefficient for such patients due to intolerance, sub-optimal absorption, and the potential to worsen local disease inflammation within the gastrointestinal tract. In adults with IBD, intravenous (IV) iron is commonly used and capable of improving iron status even in the setting of persistent inflammation. Newer IV iron formulations with decreased dosing requirements and improved safety profiles have reduced barriers to its use in pediatric patients. However, minimal published data exist on the use of IV iron in pediatric IBD.Objective:To evaluate trends in diagnosis of iron deficiency and its management utilizing a large national children's hospital database in pediatric patients with IBD over a 5 year period. We hypothesized that the use of IV iron to treat iron deficiency anemia (IDA) would increase and receipt of blood transfusion would subsequently decrease over time.Methods:In this retrospective multicenter cohort study, we used the Pediatric Health Information System (PHIS) de-identified administrative database containing data from 48 not-for-profit tertiary care pediatric hospitals in the U.S. ICD-9 and ICD-10 codes for Crohn's disease and ulcerative colitis identified all inpatient admissions for IBD from January 2012 through December 2017. Diagnostic codes were also used to identify those patients with anemia or iron deficiency during their admission. Procedure codes were assessed for receipt of transfusions, and pharmaceutical billing codes were assessed for iron (intravenous and oral preparations). Data were analyzed descriptively.Results:We identified 17,836 unique patients (9,308 male, 52.2%) with IBD diagnosis codes admitted between 2012 and 2017 for a total of 35,770 admissions. Median age at admission was 15.6 years (range 0 to 70 years; 733 (4.1%) > 21 years). There were 7,509 (42.1%) patients who also had a diagnosis of IDA during admission. Of the 35,770 admissions, iron therapy (oral or IV) was given in 7,918 admissions (22.1%). IV iron was given in 2,118 admissions (5.9%) and blood transfusions were given in 2,895 admissions (8.1%). Between 2012 and 2017, the prevalence of the diagnosis of IDA among IBD admissions increased from 24.3% in 2012 to 33.7% in 2017 (p<0.0001). Similarly, there was a steady increase in the proportion of IBD admissions that utilized IV iron, from 3.4% in 2012 to 8.4% in 2017 (p<0.0001). There was no difference in the use of oral iron over time (p=0.32). The proportion of admissions for IBD with red cell transfusions decreased over time from 9.5% to 5.7% (p<0.0001, Figure 1).Discussion:Iron deficiency anemia is highly prevalent among pediatric patients with IBD admitted to U.S. children's hospitals. The upward trend during this 5 year study period may potentially be due to increased recognition of this complication. Regarding management, we identified an increase in the use of IV iron for the treatment of IDA over time, and a decrease in admitted patients receiving transfusions. Further research is needed to further optimize detection of iron deficiency in pediatric IBD patients as well as evaluate the best approach for management of this common complication. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Large Outbreaks of Fungal and Bacterial Bloodstream Infections in a Neonatal Unit, South Africa, 2012–2016

Candidemia is a major cause of healthcare-associated infections. We describe a large outbreak of Candida krusei bloodstream infections among infants in Gauteng Province, South Africa, during a 4-month period; a series of candidemia and bacteremia outbreaks in the neonatal unit followed. We detected cases by using enhanced laboratory surveillance and audited hospital wards by environmental sampling and epidemiologic studies. During July–October 2014, among 589 patients, 48 unique cases of C. krusei candidemia occurred (8.2% incidence). Risk factors for candidemia on multivariable analyses were necrotizing enterocolitis, birthweight <1,500 g, receipt of parenteral nutrition, and receipt of blood transfusion. Despite initial interventions, outbreaks of bloodstream infection caused by C. krusei, rarer fungal species, and bacterial pathogens continued in the neonatal unit through July 29, 2016. Multiple factors contributed to these outbreaks; the most functional response is to fortify infection prevention and control.

Provision of respiratory support compared to no respiratory support before cord clamping for preterm infants.

Placental transfusion (by means of delayed cord clamping (DCC), cord milking, or cord stripping) confers benefits for preterm infants. It is not known if providing respiratory support to preterm infants before cord clamping improves outcomes. To assess the efficacy and safety of respiratory support provided during DCC compared with no respiratory support during placental transfusion (in the form of DCC, milking, or stripping) in preterm infants immediately after delivery. We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL, 2017, Issue 5), MEDLINE via PubMed (1966 to 19 June 2017), Embase (1980 to 19 June 2017), and CINAHL (1982 to 19 June 2017). We also searched clinical trials databases, conference proceedings, and the reference lists of retrieved articles for randomized controlled trials and quasi-randomized trials. Randomized, cluster randomized, or quasi-randomized controlled trials enrolling preterm infants undergoing DCC, where one of the groups received respiratory support before cord clamping and the control group received no respiratory support before cord clamping. All review authors assisted with data collection, assessment, and extraction. Two review authors assessed the quality of evidence using the GRADE approach. We contacted study authors to request missing information. One study fulfilled the review criteria. In this study, 150 preterm infants of less than 32 weeks' gestation undergoing 60 second DCC were randomized to a group who received respiratory support in the form of continuous positive airway pressure (CPAP) or positive pressure ventilation during DCC and a group that did not receive respiratory support during the procedure. Mortality during hospital admission was not significantly different between groups with wide confidence intervals (CI) for magnitude of effect (risk ratio (RR) 1.67, 95% CI 0.41 to 6.73). The study did not report neurodevelopmental disability and death or disability at two to three years of age. There were no significant differences between groups in condition at birth (Apgar scores or intubation in the delivery room), use of inotropic agents (RR 1.25, CI 0.63 to 2.49), and receipt of blood transfusion (RR 1.03, 95% CI 0.70 to 1.54). In addition, there were no significant differences in the incidences of any intraventricular haemorrhage (RR 1.50, 95% CI 0.65 to 3.46) and severe intraventricular haemorrhage (RR 1.33, 95% CI 0.31 to 5.75). Several continuous variables were reported in subgroups depending on method of delivery. Unpublished data for each group as a whole was made available and showed peak haematocrit in the first 24 hours and duration of phototherapy did not differ significantly. Overall, the quality of evidence for several key neonatal outcomes (e.g. mortality and intraventricular haemorrhage) was low because of lack of precision with wide CIs. The results from one study with wide CIs for magnitude of effect do not provide evidence either for or against the use of respiratory support before clamping the umbilical cord. A greater body of evidence is required as many of the outcomes of interest to the review occurred infrequently. Similarly, the one included study cannot answer the question of whether the intervention is or is not harmful.

Impact of Anemia and Transfusion on Readmission and Length of Stay After Spinal Surgery: A Single-center Study of 1187 Operations.

Retrospective cohort study. To determine whether receipt of blood transfusion and preoperative anemia are associated with increased rates of 30-day all-cause readmission, and secondarily with a prolonged hospital stay after spinal surgery. Increased focus on health care quality has led to efforts to determine postsurgical readmission rates and predictors of length of postoperative hospital stay. Although there are still no defined outcome measures specific to spinal surgery to which providers are held accountable, efforts to identify appropriate measures and to determine modifiable risk factors to optimize quality are ongoing. Records from 1187 consecutive spinal surgeries at Northwestern Memorial Hospital in 2010 were retrospectively reviewed and data were collected that described the patient, surgical procedure, hospital course, complications, and readmissions. Presence or absence of transfusion during the surgery and associated hospital course was treated as a binary variable. Multivariate negative binomial regression and logistic regression were used to model length of stay and readmission, respectively. Nearly one fifth (17.8%) of surgeries received transfusions, and the overall readmission rate was 6.1%. After controlling for potential confounders, we found that the presence of a transfusion was associated with a 60% longer hospital stay [adjusted incidence rate ratio=1.60 (1.34-1.91), P<0.001], but was not significantly associated with an increased rate of readmission [adjusted odds ratio=0.81 (0.39-1.70), P=0.582]. Any degree of preoperative anemia was associated with increased length of stay, but only severe anemia was associated with an increased rate of readmission. Both receipt of blood transfusion and any degree of preoperative anemia were associated with increased length of hospital stay after controlling for other variables. Severe anemia, but not receipt of blood transfusion, was associated with increased rate of readmission. Our findings may help define actions to reduce length of stay and decrease rates of readmission.

Clinical Performance of Prediction Rules and Nasogastric Lavage for the Evaluation of Upper Gastrointestinal Bleeding: A Retrospective Observational Study.

Introduction. The majority of patients with acute upper gastrointestinal bleeding (UGIB) are admitted for urgent endoscopy as it can be difficult to determine who can be safely managed as an outpatient. Our objective was to compare four clinical prediction scoring systems: Glasgow Blatchford Score (GBS) and Clinical Rockall, Adamopoulos, and Tammaro scores in a sample of patients presenting to the emergency department of a large US academic center. Methods. We performed a retrospective cohort study of patients during 2008–2010. Our outcome was significant UGIB defined as high-risk stigmata on endoscopy, or receipt of blood transfusion or surgery, or death. Results. A total of 393 patients met inclusion criteria. The GBS was the most sensitive for detecting significant UGIB at 98.30% and had the highest negative predictive value (90.00%). Adding nasogastric lavage data to the GBS increased the sensitivity to 99.57%. Conclusions. Of all four scoring systems compared, the GBS demonstrated the highest sensitivity and negative predictive value for identifying a patient with a significant UGIB. Therefore, patients with a 0 score can be safely managed as an outpatient. Our results also suggest that performing a nasogastric lavage adds little to the diagnosis UGIB.

Anemia, Blood Transfusion Requirements and Mortality Risk in Human Immunodeficiency Virus-Infected Adults Requiring Acute Medical Admission to Hospital in South Africa.

Background. Morbidity and mortality remain high among hospitalized patients infected with human immunodeficiency virus (HIV) in sub-Saharan Africa despite widespread availability of antiretroviral therapy. Severe anemia is likely one important driver, and some evidence suggests that blood transfusions may accelerate HIV progression and paradoxically increase short-term mortality. We investigated the relationship between anemia, blood transfusions, and mortality in a South African district hospital.Methods. Unselected consecutive HIV-infected adults requiring acute medical admission to a Cape Town township district hospital were recruited. Admission hemoglobin concentrations were used to classify anemia severity according to World Health Organization/AIDS Clinical Trials Group criteria. Vital status was determined at 90 days, and Cox regression analyses were used to determine independent predictors of mortality.Results. Of 585 HIV-infected patients enrolled, 578 (98.8%) were included in the analysis. Anemia was detected in 84.8% of patients and was severe (hemoglobin, 6.5–7.9 g/dL) or life-threatening (hemoglobin, <6.5 g/dL) in 17.3% and 13.3%, respectively. Within 90 days of the date of admission, 13.5% (n = 78) patients received at least 1 blood transfusion with red cell concentrate and 77 (13.3%) patients died. In univariable analysis, baseline hemoglobin and receipt of blood transfusion were associated with increased mortality risk. However, in multivariable analysis, neither hemoglobin nor receipt of a blood transfusion were independently associated with greater mortality risk. Acquired immune deficiency syndrome-defining illnesses other than tuberculosis and impaired renal function independently predicted mortality.Conclusions. Newly admitted HIV-infected adults had a high prevalence of severe or life-threatening anemia and blood transfusions were frequently required. However, after adjustment for confounders, blood transfusions did not confer an increased mortality risk.

Antifibrinolytic drugs for acute traumatic injury.

Uncontrolled bleeding is an important cause of death in trauma victims. Antifibrinolytic treatment has been shown to reduce blood loss following surgery and may also be effective in reducing blood loss following trauma. To assess the effect of antifibrinolytic drugs in patients with acute traumatic injury. We ran the most recent search in January 2015. We searched the Cochrane Injuries Group's Specialised Register, The Cochrane Library, Ovid MEDLINE(R), Ovid MEDLINE(R) In-Process & Other Non-Indexed Citations, Ovid MEDLINE(R) Daily and Ovid OLDMEDLINE(R), Embase Classic+Embase (OvidSP), PubMed and clinical trials registries. Randomised controlled trials of antifibrinolytic agents (aprotinin, tranexamic acid [TXA], epsilon-aminocaproic acid and aminomethylbenzoic acid) following acute traumatic injury. From the results of the screened electronic searches, bibliographic searches, and contacts with experts, two authors independently selected trials meeting the inclusion criteria, and extracted data. One review author assessed the risk of bias for key domains.Outcome measures included: mortality at end of follow-up (all-cause); adverse events (specifically vascular occlusive events [myocardial infarction, stroke, deep vein thrombosis or pulmonary embolism] and renal failure); number of patients undergoing surgical intervention or receiving blood transfusion; volume of blood transfused; volume of intracranial bleeding; brain ischaemic lesions; death or disability.We rated the quality of the evidence as 'high', 'moderate', 'low' or 'very low' according to the GRADE approach. Three trials met the inclusion criteria.Two trials (n = 20,451) assessed the effect of TXA. The larger of these (CRASH-2, n = 20,211) was conducted in 40 countries and included patients with a variety of types of trauma; the other (n = 240) restricted itself to those with traumatic brain injury (TBI) only.One trial (n = 77) assessed aprotinin in participants with major bony trauma and shock.The pooled data show that antifibrinolytic drugs reduce the risk of death from any cause by 10% (RR 0.90, 95% CI 0.85 to 0.96; P = 0.002) (quality of evidence: high).This estimate is based primarily on data from the CRASH-2 trial of TXA, which contributed 99% of the data.There is no evidence that antifibrinolytics have an effect on the risk of vascular occlusive events (quality of evidence: moderate), need for surgical intervention or receipt of blood transfusion (quality of evidence: high). There is no evidence for a difference in the effect by type of antifibrinolytic (TXA versus aprotinin) however, as the pooled analyses were based predominantly on trial data concerning the effects of TXA, the results can only be confidently applied to the effects of TXA. The effects of aprotinin in this patient group remain uncertain.There is some evidence from pooling data from one study (n = 240) and a subset of data from CRASH-2 (n = 270) in patients with TBI which suggest that TXA may reduce mortality although the estimates are imprecise, the quality of evidence is low, and uncertainty remains. Stronger evidence exists for the possibility of TXA reducing intracranial bleeding in this population. TXA safely reduces mortality in trauma patients with bleeding without increasing the risk of adverse events. TXA should be given as early as possible and within three hours of injury, as further analysis of the CRASH-2 trial showed that treatment later than this is unlikely to be effective and may be harmful. Although there is some promising evidence for the effect of TXA in patients with TBI, substantial uncertainty remains.Two ongoing trials being conducted in patients with isolated TBI should resolve these remaining uncertainties.

PD16-04 CURATIVE SURGERY IN RCC WITH THROMBUS; A COMPREHENSIVE RISK MODEL FROM A MODERN MULTICENTER ANALYSIS

You have accessJournal of UrologyKidney Cancer: Localized I1 Apr 2014PD16-04 CURATIVE SURGERY IN RCC WITH THROMBUS; A COMPREHENSIVE RISK MODEL FROM A MODERN MULTICENTER ANALYSIS Tyler M. Bauman, Vitaly Margulis, Christopher G. Wood, William P. Christensen, Vishnukamal Golla, Ramy F. Youssef, Laura-Maria Krabbe, David F. Jarrard, Tracy M. Downs, and E. Jason Abel Tyler M. BaumanTyler M. Bauman More articles by this author , Vitaly MargulisVitaly Margulis More articles by this author , Christopher G. WoodChristopher G. Wood More articles by this author , William P. ChristensenWilliam P. Christensen More articles by this author , Vishnukamal GollaVishnukamal Golla More articles by this author , Ramy F. YoussefRamy F. Youssef More articles by this author , Laura-Maria KrabbeLaura-Maria Krabbe More articles by this author , David F. JarrardDavid F. Jarrard More articles by this author , Tracy M. DownsTracy M. Downs More articles by this author , and E. Jason AbelE. Jason Abel More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.02.1149AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail Introduction and Objectives Recurrence is common in N0M0 patients with renal cell carcinoma (RCC) with venous thrombus after surgery. High risk patients may benefit from increased surveillance or enrollment in adjuvant clinical trials, but quality predictive models for recurrence are lacking for this patient population. The purpose of this study is to identify prognostic factors for disease recurrence in N0M0 RCC with venous thrombus using a multicenter contemporary dataset Methods Comprehensive patient data was collected for N0M0 RCC patients undergoing attempted curative surgery from 2000-2012 at the University of Wisconsin, UT Southwestern, and MD Anderson Cancer Center. Univariate and multivariate (MV) analysis was used to identify variables associated with risk of recurrence. Factors considered in analysis included: age, BMI, gender, smoking status, presence of local or systemic symptoms, year of surgery, laterality, preoperative labs (hemoglobin, creatinine, albumin, neutrophil count, lymphocyte count, ABO blood type), OR blood loss, receipt of blood transfusion, thrombus level, pT stage, tumor diameter, perinephric fat invasion, histologic subtype, and sarcomatoid de-differentiation. Results Of 470 patients identified, 191 (40.7%) progressed to metastatic disease during the study period. Thrombus extended into renal vein in 259 (55.1%), IVC below diaphragm 167 (35.5%) and IVC above diaphragm 44 (9.4%). Median CSS was 136.6 months (IQR 43.8-NR) and median follow-up was 28.4 months (IQR 12.2-54.9). After MV analysis, independent predictors of disease recurrence included: BMI ≤(HR 2.64, p=0.009), hemoglobin <LLN (HR 1.60, p=0.01), perinephric fat invasion (1.58, p=0.006), non-clear cell histology (2.02, p=0.008), and grade 4 (1.80; p=0.04). Independent predictors were used to create a risk factor model (figure). 5 year recurrence free survival (RFS) was 77% in patients with 0 risk factors compared to 19% in patients with more than 2 risk factors. Conclusions Independent predictors of disease recurrence in RCC with thrombus include: BMI ≤20, hemoglobin <LLN, perinephric fat invasion, non-clear cell histology, and grade 4. Patients with multiple risk factors should be considered for increased surveillance or adjuvant therapy clinical trials. © 2014FiguresReferencesRelatedDetails Volume 191Issue 4SApril 2014Page: e487-e488 Advertisement Copyright & Permissions© 2014MetricsAuthor Information Tyler M. Bauman More articles by this author Vitaly Margulis More articles by this author Christopher G. Wood More articles by this author William P. Christensen More articles by this author Vishnukamal Golla More articles by this author Ramy F. Youssef More articles by this author Laura-Maria Krabbe More articles by this author David F. Jarrard More articles by this author Tracy M. Downs More articles by this author E. Jason Abel More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Clinical Evaluation of Chronic Hepatitis C and Indications for HCV Treatment

Hepatitis C virus (HCV) is the most common cause of liver cirrhosis in the United States. If untreated, HCV can lead to death from complications of liver failure or hepatocellular carcinoma, making screening imperative in high-risk patients. Established risk factors for HCV infection include injection drug use, receipt of blood transfusion or organ transplantation prior to 1992, and hemodialysis. Recent evidence has demonstrated that those born between 1945-1965 are additionally at high risk for HCV acquisition and should undergo one time screening. Once diagnosed, consideration for treatment should be based on patient motivation, concurrent medical co-morbidities, degree of liver injury, and risk of progression to cirrhosis. Therapy may also be indicated in patients with extra-hepatic manifestations of HCV.

Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial

The article is reprinted after 'Lancet 2010; 376: 23-32' by the above collaborators with written permission from Lancet Authority.Background: Tranexamic acid can reduce bleeding in patients undergoing elective surgery. We assessed the effects of early administration of a short course of tranexamic acid on death, vascular ocdusive events, and the receipt of blood transfusion in trauma patients. Methods: This randomised controlled trial was undertaken in 274 hospitals in 40 countries. In Bangladesh we have taken 12 patients for this study. 20211 adult trauma patients with, or at risk of, significant bleeding were randomly assigned within 8 h of in jury to either tranexamic acid (loading dose 1 g over 10 mm then infusion of 1 g over 8 h) or matching placebo. Randomisation was balanced by centre, with an allocation sequence based on a block size of eight, generated with a computer random number generator. Both participants and study staff (site investigators and trial coordinating centre staft) were masked to treatment allocation. The primary outcome was death in hospital within 4 weeks of injury and was described with the following categories: bleeding, vascular ocdusion (myocardial infarction, stroke and pulmonary embolism), multiorgan failure, head injury, and other. All analyses were by intention to treat. This study is registered as ISRCTN867SO1O2, Clinicaltrials.gov NCT00375258, and South African Clinical Trial Register DOH-27-0607.1919. Findings: 10096 patients were allocated to tranexamic acid and 10115 to placebo, of whom 10060 and 10067, respectively, were analysed. All-cause mortality was significantly reduced with tranexamic add (1463(14.5%] tranexamic add group vs 1613 [16.0%] placebo group; relative risk 0.91, 95% Cl 0.85-0.97; p=0.0035). The risk of death due to bleeding was significantly reduced (489 [4.9%] vs 574 [5.7%]; relative risk 0.85, 95% CI 0.76 -0.96; p=O .0077). Interpretation: Tranexamic acid safely reduced the risk of death in bleeding trauma patients in this study. On the basis of these results, tranexamic acid should be considered for use in bleeding trauma patients. Funding: UK NIHR Health Technology Assessment programme, Pfizer, BUPA Foundation, and J P Moulton Charitable Foundation. DOI: http://dx.doi.org/10.3329/bccj.v1i2.17198 Bangladesh Crit Care J September 2013; 1 (2): 71-79

The CRASH-2 trial: a randomised controlled trial and economic evaluation of the effects of tranexamic acid on death, vascular occlusive events and transfusion requirement in bleeding trauma patients

Among trauma patients who survive to reach hospital, exsanguination is a common cause of death. A widely practicable treatment that reduces blood loss after trauma could prevent thousands of premature deaths each year. The CRASH-2 trial aimed to determine the effect of the early administration of tranexamic acid on death and transfusion requirement in bleeding trauma patients. In addition, the effort of tranexamic acid on the risk of vascular occlusive events was assessed. Tranexamic acid (TXA) reduces bleeding in patients undergoing elective surgery. We assessed the effects and cost-effectiveness of the early administration of a short course of TXA on death, vascular occlusive events and the receipt of blood transfusion in trauma patients. Randomised placebo-controlled trial and economic evaluation. Randomisation was balanced by centre, with an allocation sequence based on a block size of eight, generated with a computer random number generator. Both participants and study staff (site investigators and trial co-ordinating centre staff) were masked to treatment allocation. All analyses were by intention to treat. A Markov model was used to assess cost-effectiveness. The health outcome was the number of life-years (LYs) gained. Cost data were obtained from hospitals, the World Health Organization database and UK reference costs. Cost-effectiveness was measured in international dollars ($) per LY. Deterministic and probabilistic sensitivity analyses were performed to test the robustness of the results to model assumptions. Two hundred and seventy-four hospitals in 40 countries. Adult trauma patients (n = 20,211) with, or at risk of, significant bleeding who were within 8 hours of injury. Tranexamic acid (loading dose 1 g over 10 minutes then infusion of 1 g over 8 hours) or matching placebo. The primary outcome was death in hospital within 4 weeks of injury, and was described with the following categories: bleeding, vascular occlusion (myocardial infarction, stroke and pulmonary embolism), multiorgan failure, head injury and other. Patients were allocated to TXA (n = 10,096) and to placebo (n = 10,115), of whom 10,060 and 10,067 patients, respectively, were analysed. All-cause mortality at 28 days was significantly reduced by TXA [1463 patients (14.5%) in the TXA group vs 1613 patients (16.0%) in the placebo group; relative risk (RR) 0.91; 95% confidence interval (CI) 0.85 to 0.97; p = 0.0035]. The risk of death due to bleeding was significantly reduced [489 patients (4.9%) died in the TXA group vs 574 patients (5.7%) in the placebo group; RR 0.85; 95% CI 0.76 to 0.96; p = 0.0077]. We recorded strong evidence that the effect of TXA on death due to bleeding varied according to the time from injury to treatment (test for interaction p < 0.0001). Early treatment (≤ 1 hour from injury) significantly reduced the risk of death due to bleeding [198 out of 3747 patients (5.3%) died in the TXA group vs 286 out of 3704 patients (7.7%) in the placebo group; RR 0.68; 95% CI 0.57 to 0.82; p < 0.0001]. Treatment given between 1 and 3 hours also reduced the risk of death due to bleeding [147 out of 3037 patients (4.8%) died in the TXA group vs 184 out of 2996 patients (6.1%) in the placebo group; RR 0.79; 95% CI 0.64 to 0.97; p = 0.03]. Treatment given after 3 hours seemed to increase the risk of death due to bleeding [144 out of 3272 patients (4.4%) died in the TXA group vs 103 out of 3362 patients (3.1%) in the placebo group; RR 1.44; 95% CI1.12 to 1.84; p = 0.004]. We recorded no evidence that the effect of TXA on death due to bleeding varied by systolic blood pressure, Glasgow Coma Scale score or type of injury. Administering TXA to bleeding trauma patients within 3 hours of injury saved an estimated 755 LYs per 1000 trauma patients in the UK. The cost of giving TXA to 1000 patients was estimated at $30,830. The incremental cost of giving TXA compared with not giving TXA was $48,002. The incremental cost per LY gained of administering TXA was $64. Early administration of TXA safely reduced the risk of death in bleeding trauma patients and is highly cost-effective. Treatment beyond 3 hours of injury is unlikely to be effective. Future work [the Clinical Randomisation of an Antifibrinolytic in Significant Head injury-3 (CRASH-3) trial] will evaluate the effectiveness and safety of TXA in the treatments of isolated traumatic brain injury (http://crash3.lshtm.ac.uk/). Current Controlled Trials ISRCTN86750102, ClinicalTrials.gov NCT00375258 and South African Clinical Trial Register DOH-27-0607-1919. The project was funded by the Bupa Foundation, the J P Moulton Charitable Foundation and the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 17, No. 10. See HTA programme website for further project information.

Complications After Robot-assisted Radical Cystectomy: Results from the International Robotic Cystectomy Consortium

BackgroundComplication reporting is highly variable and nonstandardized. Therefore, it is imperative to determine the surgical outcomes of major oncologic procedures. ObjectiveTo describe the complications after robot-assisted radical cystectomy (RARC) using a standardized and validated reporting methodology. Design, setting, and participantsUsing the International Robotic Cystectomy Consortium (IRCC) database, we identified 939 patients who underwent RARC, had available complication data, and had at least 90 d of follow-up. Outcome measurements and statistical analysisComplications were analyzed and graded according to the Memorial Sloan-Kettering Cancer Center (MSKCC) system and were defined and stratified by organ system. Secondary outcomes included identification of preoperative and intraoperative variables predicting complications. Logistic regression models were used to define predictors of complications and readmission. Results and limitationsForty-one percent (n=387) and 48% (n=448) of patients experienced a complication within 30 and 90 d of surgery, respectively. The highest grade of complication was grade 0 in 52%, grade 1–2 in 29%, and grade 3–5 in 19% patients. Gastrointestinal, infectious, and genitourinary complications were most common (27%, 23%, and 17%, respectively). On multivariable analysis, increasing age group, neoadjuvant chemotherapy, and receipt of blood transfusion were independent predictors of any and high-grade complications, respectively. Thirty and 90-d mortality was 1.3% and 4.2%, respectively. As a multi-institutional database, a disparity in patient selection, operating standards, postoperative management, and reporting of complications can be considered a major limitation of the study. ConclusionsSurgical morbidity after RARC is significant when reported using a standardized reporting methodology. The majority of complications are low grade. Strict reporting of complications is necessary to advocate for radical cystectomy (RC) and helps in patient counseling.