Effect of a Patient Blood Management system on perioperative transfusion practice and short-term outcomes of colorectal cancer surgery

BackgroundPatients undergoing colorectal cancer surgery may require a blood transfusion. However, blood transfusions are associated with postoperative complications and long-term oncologic outcomes. Patient blood management (PBM) is an evidence-based multimodal approach for blood transfusion optimisation. We sought to investigate the effects of PBM implementation in blood transfusion practice and on short-term postoperative outcomes.Materials and methodsThis study retrospectively reviewed data from 2,080 patients who had undergone colorectal cancer surgery at a single centre from 2015 to 2020. PBM was implemented in 2018, and outcomes were compared between the pre-PBM (2015–2017) and the post-PBM (2018–2020) periods.ResultsA total of 951 patients in the pre-PBM group and 1,129 in the post-PBM group were included. The transfusion rate of the total number of packed red blood cells (PRBCs) used decreased after PBM implementation (16.3 vs 8.3%; p<0.001). The rate of appropriately transfused PRBCs increased from the pre-PBM period to the post-PBM period (42 vs 67%; p<0.001). There was no significant difference in rates of complications between the two groups (23.0 vs 21.5%; p=0.412); however, a reduction in both anastomosis leakage (5.8 vs 3.7%; p=0.026) and the length of stay after surgery (LOS) (10.3±11.2 vs 8.2±5.7 days; p<0.001) was reported after PBM implementation.DiscussionThe PBM programme optimised the transfusion rate in patients undergoing colorectal cancer surgery. Implementation of the PBM programme had a positive effect on postoperative length of stay and anastomosis leakage while no increase in the risk of other complications was reported.     

The impact of timing of intravenous iron supplementation on preoperative haemoglobin in patients scheduled for major surgery

BackgroundAnaemia is frequent and an independent risk factor for morbidity and mortality in patients undergoing surgery. Iron deficiency (ID) is the main cause for anaemia and can be corrected by intravenous (IV) iron. The aim of this study was to investigate the timing of preoperative IV iron supplementation on preoperative haemoglobin (Hb) level.Materials and methodsSurgical patients were screened for the presence of anaemia and ID from November 2015 to January 2020. In case of ID or iron deficiency anaemia (IDA), patients received IV iron supplementation. The timing of IV iron supplementation on preoperative Hb level was analysed by days and time frames clustered by 5 days before surgery.ResultsIn total, 404 patients with IV iron supplementation were analysed. In all patients, IV iron was administered with a median (interquartile range [IQR]) of 3.0 (1.0; 9.0) days before surgery. Preoperative Hb level increased steadily starting from 6 days (0.13 [±1.2] g/dL) until 16 days before surgery (1.75 [±1.1] g/dL). Group comparison revealed a median preoperative Hb change of −0.2 (−0.5; 0.2) g/dL for days 1–5, 0.2 (0.0; 0.7) g/dL for days 6–10, 0.7 (0.2; 1.1) g/dL for days 11–15, 0.7 (0.2; 1.8) g/dL for days 16–20, 0.9 (0.3; 1.7) g/dL for days 21–25, 1.5 (0.4; 2.6) g/dL for days 26–30, and 0.6 (0.0; 1.7) g/dL for >31 days. Three patients received multiple administrations of IV iron which resulted in an increase in Hb of >4 g/dL.DiscussionSupplementation of IV iron to increase Hb concentration preoperatively may be most effective if administered at least ten days before surgery.     

Maturity Assessment model for Patient Blood Management to assist hospitals in improving patients’ safety and outcomes. The MAPBM project

BackgroundPatient blood management (PBM) is an evidence-based care bundle with proven ability to improve patients’ outcomes by managing and preserving the patient’s own blood. Since 2010, the World Health Organisation has urged member states to implement PBM. However, there has been limited progress in developing PBM programmes in hospitals due to the implicit challenges of implementing them. To address these challenges, we developed a Maturity Assessment Model (MAPBM) to assist healthcare organisations to measure, benchmark, assess in PBM, and communicate the results of their PBM programmes. We describe the MAPBM model, its benchmarking programme, and the feasibility of implementing it nationwide in Spain.Materials and methodsThe MAPBM considers the three dimensions of a transformation effort (structure, process and outcomes) and grades these within a maturity scale matrix. Each dimension includes the various drivers of a PBM programme, and their corresponding measures and key performance indicators. The structure measures are qualitative, and obtained using a survey and structured self-assessment checklist. The key performance indicators for process and outcomes are quantitative, and based on clinical data from the hospitals’ electronic medical records. Key performance indicators for process address major clinical recommendations in each PBM pillar, and are applied to six common procedures characterised by significant blood loss.ResultsIn its first 5 years, the MAPBM was deployed in 59 hospitals and used to analyse 181,826 hospital episodes, which proves the feasibility of implementing a sustainable model to measure and compare PBM clinical practice and outcomes across hospitals in Spain.ConclusionThe MAPBM initiative aims to become a useful tool for healthcare organisations to implement PBM programmes and improve patients’ safety and outcomes.     

Gender-based analysis of esophageal cancer patients undergoing preoperative chemoradiation: differences in presentation and therapy outcome

The purpose of this study was to identify gender-dependent differences in presentation at baseline and therapy outcome in esophageal carcinoma patients treated with preoperative chemoradiotherapy (CTRT). We stratified patients according to gender and statistically compared pretreatment clinical stage, post-CTRT effect on carcinoma in the resected specimen, overall survival (OS), and patterns of failure. Of the 235 patients who underwent preoperative CTRT, 203 were men and 32 were women. Carcinomas in women correlated significantly with clinical stage II classification (78%vs. 55%) while cancers in men correlated significantly with clinical stage III classification (39%vs. 16%; P = 0.02). Carcinomas in women also correlated significantly with lower clinical N classification; more women had cN0 (52%) compared to men (28%; P = 0.01). Similarly, in the surgical specimens, more women had pN0 (78%) compared to men (64%; P = 0.06). At a median follow-up of 37 months, 10% more women than men remain alive (63%vs. 53%; P = 0.3). Distant metastases-free survival time was longer for women than men. Our results suggest that localized esophageal carcinoma is diagnosed in more advanced stages in men than in women. The reasons for these differences remain unclear and further expansion of these observations and study of biologic differences that might exist are warranted.     

文化程度和个体化教育对2型糖尿病患者血糖控制的影响

目的 观察2型糖尿病患者文化教育程度和个体化教育与其血糖控制情况的关系.方法 8887例患者资料来自本中心糖尿病信息管理系统中2004年1月至2008年12月确诊的2型糖尿病患者,按文化程度分为大学组2968例,高中组2156例,小学组3763例.多次接受糖尿病现场教育或个体化咨询的患者2034例,未接受过糖尿病教育的患者6853例.比较糖尿病患者的文化程度以及接受糖尿病知识教育后血压、血糖、糖化血红蛋白(HbA1c)、胰岛素、血脂、体重指数等指标的控制情况.采用单因素方差分析、t检验、卡方检验进行统计学分析.结果 糖尿病患者文化程度越高,其血糖控制情况越为理想(χ2=24.71,P<0.01),大学组血糖控制情况明显好于高中组与小学组.多次接受糖尿病知识个体化教育患者与未接受过个体化教育患者之间血糖控制情况同样存在显著差异(χ2=15.52,P<0.01),未接受糖尿病个体化教育组的患者体重指数、HbA1c、餐后血糖明显高于接受糖尿病个体化教育组.结论 糖尿病患者的文化教育水平及个体化教育程度对其血糖控制、并发症顶防及生活质量改善有显著意义.     

The effect of human fit- 3 ligand on committed progenitor cell production from normal, aplastic anaemia and Diamond-Blackfan anaemia bone marrow

Summary. We investigated the effect of the human ligand for flt-3 (FL) on the committed progenitor colony formation of normal bone marrow (BM) (n = 9) and BM from four aplastic anaemia (AA) and three Diamond-Blackfan anaemia (DBA) patients. Methylcellulose committed progenitor cell assays were carried out using FL alone and in combinations with granulocyte-macrophage colony-stimulating factor (GM-CSF). interleukin-3 (IL-3) and c-kit ligand (KL). FL alone had a limited, though significant, effect on the production of granulocyte-macrophage colony-forming unit (CFU-GM) colonies from normal BM and showed an additive effect with IL- 3 and GM-CSF separately, but not in combination. FL did not increase the stimulation of KL and did not have an effect on the production of erythroid progenitor colonies. FL had no effect on the AA and DBA BMs studied.     

An association between obesity and the prevalence of colonic adenoma according to age and gender

Background Epidemiologic data on obesity as a risk factor for colonic adenoma with respect to gender have not yet been confirmed. Here, we aimed to compare the prevalence of colonic adenoma and of advanced polyps in age-stratified men and women at baseline, to examine the role of body mass index (BMI) on colonic adenoma risk according to age and gender, and to examine the influence of menopausal status. Methods A total of 1744 asymptomatic patients (946 men, 798 women) who underwent colonoscopy for cancer screening at Ewha Mokdong Hospital, Seoul, Korea, between February and June 2005, were eligible. BMI was assessed, and histology, size, and location of the adenoma were examined for each patient. Women were interviewed for menopausal status and a history of hormone replacement therapy. Results A significant increase in the prevalence of colonic adenoma and of advanced polyps was found to occur with age (P for trend < 0.01). The prevalences of adenoma and advanced polyps were higher in men in most age groups (P < 0.01), but no significant difference in prevalences was observed between genderes in patients 70 years of age or older. Moreover, a positive association between BMI and the prevalence of colonic adenoma and advanced polyps was shown in relatively young individuals of both gender (men in their thirties, P < 0.05; women in their forties, P < 0.05), and premenopausal women according to hormonal status (P = 0.01). Conclusions Our data suggest that obesity increases the risk of colonic adenoma in relatively young people and in premenopausal women subject to estrogen effects.     

Impact of adolescence and gender on asthma hospitalization: a population-based birth cohort study

Our objective was to determine the impact of gender and age on asthma hospitalization rates among children. We used a population-based retrospective birth cohort study to determine yearly age- and gender-specific asthma hospitalization rates between ages 2-18 years in a cohort of all children born in Washington State between 1980-1985. In addition, we assessed factors associated with the hospitalization of a given child for asthma both before and during adolescence, and factors associated with an initial asthma hospitalization during adolescence. Outcome measures included age- and gender-specific rates of hospitalization for asthma, diabetes, seizures/epilepsy, and nonasthma respiratory diagnoses. Asthma hospitalization rates for boys were significantly higher than for girls between ages 2-12 years, the gender gap in asthma hospitalizations reversed between ages 13-14 years, and rates for girls were significantly higher than boys between 16-18 years of age. The male peak asthma hospitalization rate per 100,000 cohort members occurred at age 4 years (12.7; 95% confidence interval (CI), 11.1-14.3), and the male trough rate occurred at age 18 years (4.1; 95% CI, 2.8-5.4), whereas the female peak asthma hospitalization rate occurred at age 17 years (9.4; 95% CI, 7.8-11) and the female trough rate at age 2 years (5.2; 95% CI, 4.2-6.2). Age-specific hospitalization rates for diabetes mellitus and epilepsy were similar for boys and girls throughout childhood. Female gender was strongly associated with asthma hospitalization occurring in an individual child both prior to and during adolescence (rate ratio (RR), 2.0; 95% CI, 1.4-2.9), and was modestly associated with initial hospitalization in adolescence (RR, 1.15; 95% CI, 1.0-1.3). In conclusion, asthma hospitalization rates for boys and girls exhibit strikingly different patterns during adolescence. Potential explanations for these gender differences include hormonal changes during puberty, or gender-specific differences in environmental exposures such as diet, obesity, allergen exposure, or cigarette smoking.     

Increased prevalence of potential right‐to‐left shunting in children with sickle cell anaemia and stroke

‘Paradoxical’ embolization via intracardiac or intrapulmonary right‐to‐left shunts (RLS ) is an established cause of stroke. Hypercoagulable states and increased right heart pressure, which both occur in sickle cell anaemia (SCA ), predispose to paradoxical embolization. We hypothesized that children with SCA and overt stroke (SCA  + stroke) have an increased prevalence of potential RLS . We performed contrasted transthoracic echocardiograms on 147 children (aged 2–19 years) with SCA  + stroke) mean age 12·7 ± 4·8 years, 54·4% male) and a control group without SCA or stroke (n  = 123; mean age 12·1 ± 4·9 years, 53·3% male). RLS was defined as any potential RLS detected by any method, including intrapulmonary shunting. Echocardiograms were masked and adjudicated centrally. The prevalence of potential RLS was significantly higher in the SCA +stroke group than controls (45·6% vs. 23·6%, P  < 0·001). The odds ratio for potential RLS in the SCA  + stroke group was 2·7 (95% confidence interval: 1·6–4·6) vs controls. In post hoc analyses, the SCA  + stroke group had a higher prevalence of intrapulmonary (23·8% vs. 5·7%, P  < 0·001) but not intracardiac shunting (21·8% vs. 18·7%, P  = 0·533). SCA patients with potential RLS were more likely to report headache at stroke onset than those without. Intrapulmonary and intracardiac shunting may be an overlooked, independent and potentially modifiable risk factor for stroke in SCA .     

Intravascular haemolysis and increased prevalence of myeloma and monoclonal gammopathy in congenital dyserythropoietic anaemia,type III

Abstract: A family with congenital dyserythropoietic anaemia type III was studied. Twenty patients and 10 of their healthy siblings were clinically examined and questioned about their medical history. Blood sampling and bone marrow aspirations were also performed. Forty-five percent of the patients reported symptoms of anaemia and 35% regularly felt weakness, fatigue, or headache. However, the majority of the patients regarded themselves as healthy. The bone marrow showed a uniform picture of erythroid hyperplasia with multinuclear erythroblasts and gigantoblasts with up to 12 nuclei. There was laboratory evidence of intravascular haemolysis and mild anaemia. We also observed a high prevalence of monoclonal gammopathy of undetermined significance (3 cases) and myeloma (1 case) among the patients.     

Impact of preoperative locoregional therapy on recurrence and patient survival following liver transplantation for hepatocellular carcinoma: a meta-analysis

Objective: To evaluate the impact of preoperative locoregional therapy on recurrence and patient survival following liver transplantation for hepatocellular carcinoma (HCC).

Methods: We searched medical literature databases to identify appropriate studies assessing the impact of preoperative locoregional therapy on recurrence and patient survival following liver transplantation from January 1962 to April 2014. Study inclusion criteria were the existence of a control group, a sufficiently long follow-up period and reporting of survival outcomes. We then performed a meta-analysis of these studies.

Results: Our search identified 12 studies from among a possible 1105. A total of 1504 patients were included in our analysis. There was no significant heterogeneity among the studies. In the meta-analysis, preoperative locoregional therapy was not statistically significant in affecting five-year survival rates following liver transplantation (hazard ratio [HR]?=?1.06; 95% confidence interval [CI]?=?0.82–1.38). For patients meeting the Milan criteria, preoperative locoregional therapy did not affect survival rates following liver transplantation (HR =1.04, 95% CI =0.74–1.45). The recurrence-free survival rate also had no association with preoperative locoregional therapy (HR =1.02, 95% CI =0.70–1.50).

Conclusion: Our meta-analysis suggests that preoperative locoregional therapy has no impact on survival following liver transplantation for HCC.     

The high prevalence of unrecognized anaemia in patients with diabetes and chronic kidney disease: a population-based study

Background Anaemia occurs early in the course of diabetes-related chronic kidney disease (CKD). There is little evidence about the prevalence of anaemia in people with diabetes. The aim of this study was to assess the prevalence of anaemia, by stage of CKD, in the general diabetic population. Methods Haemoglobin (Hb) was measured on all glycated haemoglobin (HbA_1c) samples and the most recent (< 4 months) estimated glomerular filtration rate (eGFR) was obtained. Anaemia (at treatment level) was defined as Hb < 110 g/l or the use of erythropoetic stimulating agents (ESA). Results Twelve per cent (10–14%) of people had Hb < 110 g/l. The prevalence of anaemia increased progressively with worsening CKD. People with CKD stage 3 accounted for the largest number of people with anaemia; 18% (95% CI 13–24%) had Hb < 110 g/l. Those with eGFR < 60 ml/min/1.73 m² and not on ESA or dialysis were four (2–7) times more likely than patients with better renal function to have Hb < 110 g/l. The relation between Hb and eGFR became approximately linear below an eGFR of 83 ml/min/1.73 m², where, for every 1 ml/min/1.73 m² fall in eGFR, there was a 0.4 (0.3–0.5) g/l fall in haemoglobin. Conclusions This study demonstrates that anaemia, at levels where treatment is indicated, occurs commonly in people with diabetes and CKD stage 3 or worse. The screening for anaemia in current diabetes management should be extended.     

坐位和卧位的血压测量

目的观察健康成人坐位和卧位间接血压测量值的差别,分析性别、年龄、身高、体重指数(BMI)、坐位血压与从坐位改为卧位后收缩压(SBP)和舒张压(DBP)改变程度的关系。方法2005-06-2006-07对7989例体检者(年龄>18岁)进行调查,排除慢性疾病(包括心血管疾病)和血压≥140/90mmHg体检者,最后用于本文分析的资料为6485例健康成人体检者。采用台式水银血压计柯氏音听诊法分别进行先坐位后卧位两种体位血压测量,同时进行身高和体重的测量,并行年龄段分组,分别进行比较。结果卧位测量的血压值显著高于坐位测量的血压值,以SBP的增高更明显,卧位SBP增高(4·3±6·1)mmHg;卧位DBP增高(1·0±4·5)mmHg。卧位SBP以20~29岁和80岁以上的年龄组明显,分别高(5·3±5·9)、(6·5±8·1)mmHg,而卧位DBP以80岁以上组明显,高(2·8±6·1)mmHg。多元回归分析结果显示,从坐位改为卧位后,对SBP改变程度有影响的自变量是年龄,呈负相关(r=-0·06,P<0·01);对DBP改变程度有影响的自变量是性别、年龄、身高和BMI,与年龄和BMI呈正相关(r=0·08,P<0·01;r=0·02,P<0·01),与身高呈负相关(r=-0·08,P<0·01)。坐位血压与卧位血压的改变呈负相关(P<0·01)。结论1)健康成人间接血压测量时,卧位的SBP、DBP高于坐位的SBP、DBP,以SBP的增高为著。2)老年人、肥胖、身高较矮、妇女、及坐位血压低的人群血压更易受到体位的影响。3)临床工作中,对血压进行评估时应注意体位的影响,并常规进行坐位和卧位血压的测量。     

Impact of vitamin A supplementation on anaemia and plasma erythropoietin concentrations in pregnant women: a controlled clinical trial

INTRODUCTION: Although studies suggest that vitamin A or its metabolites influence the synthesis of erythropoietin in vitro and in animal models, it is unclear whether vitamin A supplementation increases plasma erythropoietin concentrations in humans. OBJECTIVE: To determine whether daily vitamin A supplementation increases plasma erythropoietin concentrations in pregnant women with a high prevalence of anaemia. METHODS: A randomized, double-blind, controlled clinical trial was conducted to examine the effect of daily vitamin A (3000 microg retinol equivalent), iron (30 mg), and folate (400 microg) versus iron (30 mg) and folate (400 microg) (control) on haemoglobin and plasma erythropoietin concentrations in 203 pregnant women in Malawi, Africa. RESULTS: Mean gestational age at enrollment was 23 wk, at which time 50% of the women were anaemic (haemoglobin <110 g/L). Mean (+/-SEM) change in haemoglobin from enrollment to 38 wk was 4.7+/-1.6 g/L (p=0.003) and 7.3+/-2.3 g/L (p=0.003) in the vitamin A and control groups, respectively. Mean change in plasma erythropoietin concentrations from enrollment to 38 wk was 2.39+/-5.00 (p=0.63) and -2.87+/-3.92 IU/L (p=0.46) in the vitamin A and controls groups, respectively. There were no significant differences between vitamin A and control groups in the slope of the regression line between log10 erythropoietin and haemoglobin at enrollment or 38 wk, and between enrollment and follow-up within either group. CONCLUSIONS: Vitamin A supplementation does not appear to increase haemoglobin and plasma erythropoietin concentrations among pregnant women with a high prevalence of anaemia in Malawi.     

The prevalence,correlates and impact of anaemia among older people in Cuba,Dominican Republic,Mexico, Puerto Rico and Venezuela

Anaemia among older people is increasingly recognized as a matter of public health concern. Data from low‐ and middle‐income countries are sparse. We surveyed 10915 people aged 65 years and over (8423 with blood tests) in catchment areas in Cuba, Dominican Republic, Puerto Rico, Venezuela and Mexico, to assess prevalence and correlates of anaemia and impact on disability. Prevalence varied widely between sites, from 6·4% in rural Mexico to 9·2% in urban Mexico, 9·8% in Venezuela, 19·2% in Cuba, 32·1% in Puerto Rico and 37·3% in Dominican Republic. Prevalence was higher in men and increased with age, but sociodemographic composition did not account for prevalence differences between sites. Standardized morbidity ratios indicated a much higher prevalence in Cuba (173), Puerto Rico (280) and Dominican Republic (332) compared with USA National Health and National Examination Surveys. Anaemia was associated with undernutrition, physical impairments, and serum creatinine. There was an association with greater African admixture in Dominican Republic but not in Cuba. African admixture is therefore unlikely to fully explain the high prevalence in the Caribbean islands, which may also arise from environmental, possibly dietary factors. Given an important independent contribution of anaemia to disability, more research is needed to identify preventable and treatable causes.     

Impact of malaria control on childhood anaemia in Africa -- a quantitative review

OBJECTIVE: To review the impact of malaria control on haemoglobin (Hb) distributions and anaemia prevalences in children under 5 in malaria-endemic Africa. METHODS: Literature review of community-based studies of insecticide-treated bednets, antimalarial chemoprophylaxis and insecticide residual spraying that reported the impact on childhood anaemia. Anaemia outcomes were standardized by conversion of packed cell volumes into Hb values assuming a fixed threefold difference, and by estimation of anaemia prevalences from mean Hb values by applying normal distributions. Determinants of impact were assessed in multivariate analysis. RESULTS: Across 29 studies, malaria control increased Hb among children by, on average, 0.76 g/dl [95% confidence interval (CI): 0.61-0.91], from a mean baseline level of 10.5 g/dl, after a mean of 1-2 years of intervention. This response corresponded to a relative risk for Hb < 11 g/dl of 0.73 (95% CI: 0.64-0.81) and for Hb < 8 g/dl of 0.40 (95% CI: 0.25-0.55). The anaemia response was positively correlated with the impact on parasitaemia (P = 0.005, P = 0.008 and P = 0.01 for the three outcome measures), but no relationship with the type or duration of malaria intervention was apparent. Impact on the prevalence of Hb < 11 g/dl was larger in sites with a higher baseline parasite prevalence. Although no age pattern in impact was apparent across the studies, some individual trials found larger impacts on anaemia in children aged 6-35 months than in older children. CONCLUSION: In malaria-endemic Africa, malaria control reduces childhood anaemia. Childhood anaemia may be a useful indicator of the burden of malaria and of the progress in malaria control.