Publications by authors named "Axel Hofmann"

57 Publications

Activity-based cost of platelet transfusions in medical and surgical inpatients at a US hospital.

Vox Sang 2021 Mar 27. Epub 2021 Mar 27.

Institute for Bloodless Medicine and Patient Blood Management, Englewood Hospital & Medical Center, Englewood, NJ, USA.

Background And Objectives: Previous studies by the Cost of Blood Consensus Conference (COBCON) have used a comprehensive, standardized and generalizable activity-based costing (ABC) model to estimate the cost of red blood cell transfusions and plasma transfusion. The objective of this study was to determine the total cost of platelet transfusions in a real-world US hospital inpatient setting.

Materials And Methods: This database analysis study retrospectively collected costs for all activities related to platelet transfusion in a single-acute care US teaching hospital in 2017. Costs were collected in a stepwise manner using a custom ABC model which mapped the technical, administrative and clinical processes involved in the transfusion of platelets.

Results: For the 15 024 inpatients included in the analysis, 6335 (42·2%) were given a blood type and screen, and 941 (6·3%) received a transfusion of one or more blood products. A total of 333 platelet units were transfused in 131 patients (mean 2·54 units per patient): 211 (63·4%) units in medical inpatients and 122 (36·6%) in surgical inpatients. The total cost was $1359·99 per platelet unit, corresponding to $3457·06 per inpatient. Acquisition costs made up the largest proportion of the total cost (45·1%) followed by direct and indirect overheads (38·7%) and hospital processes costs (16·3%).

Conclusion: This is the first study to use an ABC costing model to determine the full cost of platelet transfusions within a US inpatient setting. This provides a useful reference point for comparisons with other transfusion products, and considerations for cost reduction.
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http://dx.doi.org/10.1111/vox.13095DOI Listing
March 2021

Iron deficiency in PREVENTT.

Lancet 2021 Feb;397(10275):668-669

Institute of Anesthesiology, University Hospital Zurich, 8091 Zurich, Switzerland. Electronic address:

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http://dx.doi.org/10.1016/S0140-6736(21)00226-9DOI Listing
February 2021

A Review of Clinical Guidelines on the Management of Iron Deficiency and Iron-Deficiency Anemia in Women with Heavy Menstrual Bleeding.

Adv Ther 2021 01 27;38(1):201-225. Epub 2020 Nov 27.

Department of Women's and Children's Health, Karolinska Institutet, and Karolinska University Hospital, Stockholm, Sweden.

Introduction: Up to one-third of women of reproductive age experience heavy menstrual bleeding (HMB). HMB can give rise to iron deficiency (ID) and, in severe cases, iron-deficiency anemia (IDA).

Aim: To review current guidelines for the management of HMB, with regards to screening for anemia, measuring iron levels, and treating ID/IDA with iron replacement therapy and non-iron-based treatments.

Methods: The literature was searched for English-language guidelines relating to HMB published between 2010 and 2020, using the PubMed database, web searching, and retrieval of clinical guidelines from professional societies.

Results: Overall, 55 guidelines mostly originating from North America and Europe were identified and screened. Twenty-two were included in this review, with the majority (16/22) focusing on guidance to screen women with HMB for anemia. The guidance varied with respect to identifying symptoms, the criteria for testing, and diagnostic hemoglobin levels for ID/IDA. There was inconsistency concerning screening for ID, with 11/22 guidelines providing no recommendations for measurement of iron levels and four contrasting guidelines explicitly advising against initial assessment of iron levels. In terms of treatment, 8/22 guidelines provided guidance on iron therapy, with oral iron administration generally recommended as first-line treatment for ID and/or IDA. Four guidelines recommended intravenous iron administration for severe anemia, in non-responders, or before surgery. Three guidelines provided hemoglobin thresholds for choosing between oral or intravenous iron treatment. Four guidelines discussed the use of transfusion for severe IDA.

Conclusion: Many of the guidelines for managing HMB recognize the importance of treating anemia, but there is a lack of consensus in relation to screening for ID and use of iron therapy. Consequently, ID/IDA associated with HMB is likely to be underdiagnosed and undertreated. A consensus guidance, covering all aspects of screening and management of ID/IDA in women with HMB, is needed to optimize health outcomes in these patients.
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http://dx.doi.org/10.1007/s12325-020-01564-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7695235PMC
January 2021

Restrictive Versus Liberal Transfusion Trials: Are They Asking the Right Question?

Anesth Analg 2020 12;131(6):1950-1955

From the School of Population and Global Health, The University of Western Australia, Perth, Australia.

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http://dx.doi.org/10.1213/ANE.0000000000005227DOI Listing
December 2020

Is patient blood management cost-effective? Comment on Br J Anaesth 2020.

Br J Anaesth 2021 01 26;126(1):e7-e9. Epub 2020 Sep 26.

Medical School, University of Western Australia, Perth, Australia; Institute of Anaesthesiology, University of Zurich and University Hospital Zurich, Zurich, Switzerland.

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http://dx.doi.org/10.1016/j.bja.2020.09.003DOI Listing
January 2021

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

Blood Transfus 2020 Sep 18. Epub 2020 Sep 18.

Hospital Universitario Jiménez Díaz.

Background: Patient 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 Methods: The 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.

Results: In 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.

Conclusion: The MAPBM initiative aims to become a useful tool for healthcare organisations to implement PBM programmes and improve patients' safety and outcomes.
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http://dx.doi.org/10.2450/2020.0105-20DOI Listing
September 2020

Machine learning-based prediction of transfusion.

Transfusion 2020 Sep 28;60(9):1977-1986. Epub 2020 Jun 28.

Department of Anesthesiology and Critical Care Medicine, Kepler University Hospital GmbH and Johannes Kepler University, Linz, Austria.

Background: The ability to predict transfusions arising during hospital admission might enable economized blood supply management and might furthermore increase patient safety by ensuring a sufficient stock of red blood cells (RBCs) for a specific patient. We therefore investigated the precision of four different machine learning-based prediction algorithms to predict transfusion, massive transfusion, and the number of transfusions in patients admitted to a hospital.

Study Design And Methods: This was a retrospective, observational study in three adult tertiary care hospitals in Western Australia between January 2008 and June 2017. Primary outcome measures for the classification tasks were the area under the curve for the receiver operating characteristics curve, the F score, and the average precision of the four machine learning algorithms used: neural networks (NNs), logistic regression (LR), random forests (RFs), and gradient boosting (GB) trees.

Results: Using our four predictive models, transfusion of at least 1 unit of RBCs could be predicted rather accurately (sensitivity for NN, LR, RF, and GB: 0.898, 0.894, 0.584, and 0.872, respectively; specificity: 0.958, 0.966, 0.964, 0.965). Using the four methods for prediction of massive transfusion was less successful (sensitivity for NN, LR, RF, and GB: 0.780, 0.721, 0.002, and 0.797, respectively; specificity: 0.994, 0.995, 0.993, 0.995). As a consequence, prediction of the total number of packed RBCs transfused was also rather inaccurate.

Conclusion: This study demonstrates that the necessity for intrahospital transfusion can be forecasted reliably, however the amount of RBC units transfused during a hospital stay is more difficult to predict.
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http://dx.doi.org/10.1111/trf.15935DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7540018PMC
September 2020

Systematic reviews and meta-analyses comparing mortality in restrictive and liberal haemoglobin thresholds for red cell transfusion: an overview of systematic reviews.

BMC Med 2020 06 24;18(1):154. Epub 2020 Jun 24.

School of Population and Global Health, The University of Western Australia, Perth, Australia.

Background: There are no overviews of systematic reviews investigating haemoglobin thresholds for transfusion. This is important as the literature on transfusion thresholds has grown considerably in recent years. Our aim was to synthesise evidence from systematic reviews and meta-analyses of the effects of restrictive and liberal transfusion strategies on mortality.

Methods: This was a systematic review of systematic reviews (overview). We searched MEDLINE, Embase, Web of Science Core Collection, PubMed, Google Scholar, and the Joanna Briggs Institute EBP Database, from 2008 to 2018. We included systematic reviews and meta-analyses of randomised controlled trials comparing mortality in patients assigned to red cell transfusion strategies based on haemoglobin thresholds. Two independent reviewers extracted data and assessed methodological quality. We assessed the methodological quality of included reviews using AMSTAR 2 and the quality of evidence pooled using an algorithm to assign GRADE levels.

Results: We included 19 systematic reviews reporting 33 meta-analyses of mortality outcomes from 53 unique randomised controlled trials. Of the 33 meta-analyses, one was graded as high quality, 15 were moderate, and 17 were low. Of the meta-analyses presenting high- to moderate-quality evidence, 12 (75.0%) reported no statistically significant difference in mortality between restrictive and liberal transfusion groups and four (25.0%) reported significantly lower mortality for patients assigned to a restrictive transfusion strategy. We found few systematic reviews addressed clinical differences between included studies: variation was observed in haemoglobin threshold concentrations, the absolute between group difference in haemoglobin threshold concentration, time to randomisation (resulting in transfusions administered prior to randomisation), and transfusion dosing regimens.

Conclusions: Meta-analyses graded as high to moderate quality indicate that in most patient populations no difference in mortality exists between patients assigned to a restrictive or liberal transfusion strategy.

Trial Registration: PROSPERO CRD42019120503.
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http://dx.doi.org/10.1186/s12916-020-01614-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7313211PMC
June 2020

[Multi-Resistant Bacteria in Patients in Hospitals and Medical Practices as well as in Residents of Nursing Homes in Saxony - Results of a Prevalence Study 2017/2018].

Gesundheitswesen 2020 May 7. Epub 2020 May 7.

Institut für Hygiene, Krankenhaushygiene und Umweltmedizin, Universitatsklinikum Leipzig, Leipzig.

Objective: The aim of this study was to determine the prevalence of methicillin-resistant (MRSA), multi-resistant gram-negative bacteria (MRGN) and vancomycin-resistant enterococci (VRE) in three study groups (hospital patients, residents in nursing homes for the elderly and patients in GP practices) and additionally, risk factors for carriage of multidrug-resistant organisms (MDRO).

Methods: Screening for MDRO was performed as a point prevalence study by obtaining nasal, pharyngeal and rectal swabs or stool samples from voluntary participants in 25 hospitals, 14 nursing homes for the elderly as well as 33 medical practices in 12 of 13 districts of Saxony. Suspicious isolates were further examined phenotypically and partially by molecular methods. The participants completed a questionnaire on possible risk factors for MDRO colonisation; the data were statistically evaluated by correlation analyses.

Results: In total, 1,718 persons, 629 from hospitals, 498 from nursing homes and 591 from medical practices, were examined. MDRO was detected in 8.4% of all participants; 1.3% persons tested positive for MRSA, 5.2% for 3MRGN, 0.1% for 4MRGN and 2.3% for VRE. Nine persons were colonized with more than one MDRO. The following independent risk factors could be significantly associated with the detection of MDRO: presence of a degree of care (MDRO), male sex (MDRO/VRE), current antibiosis (MDRO/VRE), antibiosis within the last 6 months (MDRO/MRSA/MRGN/VRE), current tumour disease (MDRO/3MRGN), peripheral artery disease (PAD) (MRSA) as well as urinary incontinence (3MRGN).

Conclusions: To our knowledge, this study represents the first survey of prevalence of different multiresistant pathogen groups in 3 study groups including outpatients in Germany. 3MRGN were the pathogens most frequently detected and were also found in patients of younger age groups. VRE were found almost exclusively in specific clinics. In addition to current and past antibiotic therapy, in particular the presence of PAD for MRSA detection, urinary incontinence for 3MRGN detection and a current tumour disease for MDRO and 3MRGN detection were determined as independent risk factors.
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http://dx.doi.org/10.1055/a-1138-0489DOI Listing
May 2020

Essential Role of Patient Blood Management in a Pandemic: A Call for Action.

Anesth Analg 2020 07;131(1):74-85

Institute of Anesthesiology, University of Zurich and University Hospital Zurich, Zurich, Switzerland.

The World Health Organization (WHO) has declared coronavirus disease 2019 (COVID-19), the disease caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), a pandemic. Global health care now faces unprecedented challenges with widespread and rapid human-to-human transmission of SARS-CoV-2 and high morbidity and mortality with COVID-19 worldwide. Across the world, medical care is hampered by a critical shortage of not only hand sanitizers, personal protective equipment, ventilators, and hospital beds, but also impediments to the blood supply. Blood donation centers in many areas around the globe have mostly closed. Donors, practicing social distancing, some either with illness or undergoing self-quarantine, are quickly diminishing. Drastic public health initiatives have focused on containment and "flattening the curve" while invaluable resources are being depleted. In some countries, the point has been reached at which the demand for such resources, including donor blood, outstrips the supply. Questions as to the safety of blood persist. Although it does not appear very likely that the virus can be transmitted through allogeneic blood transfusion, this still remains to be fully determined. As options dwindle, we must enact regional and national shortage plans worldwide and more vitally disseminate the knowledge of and immediately implement patient blood management (PBM). PBM is an evidence-based bundle of care to optimize medical and surgical patient outcomes by clinically managing and preserving a patient's own blood. This multinational and diverse group of authors issue this "Call to Action" underscoring "The Essential Role of Patient Blood Management in the Management of Pandemics" and urging all stakeholders and providers to implement the practical and commonsense principles of PBM and its multiprofessional and multimodality approaches.
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http://dx.doi.org/10.1213/ANE.0000000000004844DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7173035PMC
July 2020

Systematic reviews and meta-analyses comparing mortality in restrictive and liberal haemoglobin thresholds for red cell transfusion: protocol for an overview of systematic reviews.

BMJ Open 2019 08 24;9(8):e029828. Epub 2019 Aug 24.

School of Population and Global Health, The University of Western Australia, Crawley, Western Australia, Australia.

Introduction: There has been a significant increase in the number of systematic reviews and meta-analyses of randomised controlled trials investigating thresholds for red blood cell transfusion. To systematically collate, appraise and synthesise the results of these systematic reviews and meta-analyses, we will conduct an overview of systematic reviews.

Methods And Analysis: This is a protocol for an overview of systematic reviews. We will search five databases: MEDLINE, Embase, Web of Science Core Collection, PubMed (for prepublication, in process and non-Medline records) and Google Scholar. We will consider systematic reviews and meta-analyses of randomised controlled trials evaluating the effect of haemoglobin thresholds for red blood cell transfusion on mortality. Two authors will independently screen titles and abstracts retrieved in the literature search and select studies meeting the eligibility criteria for full-text review. We will extract data onto a predefined form designed to summarise the key characteristics of each review. We will assess the methodological quality of included reviews and the quality of evidence in included reviews.

Ethics And Dissemination: Formal ethics approval is not required for this overview as we will only analyse published literature. The findings of this study will be presented at relevant conferences and submitted for peer-review publication. The results are likely to be used by clinicians, policy makers and developers of clinical guidelines and will inform suggestions for future systematic reviews and randomised controlled trials.

Prospero Registration Number: CRD42019120503.
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http://dx.doi.org/10.1136/bmjopen-2019-029828DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6719757PMC
August 2019

A paleosol record of the evolution of Cr redox cycling and evidence for an increase in atmospheric oxygen during the Neoproterozoic.

Geobiology 2019 11 22;17(6):579-593. Epub 2019 Aug 22.

Department of Geology and Geophysics, Yale University, New Haven, CT, USA.

Atmospheric oxygen levels control the oxidative side of key biogeochemical cycles and place limits on the development of high-energy metabolisms. Understanding Earth's oxygenation is thus critical to developing a clearer picture of Earth's long-term evolution. However, there is currently vigorous debate about even basic aspects of the timing and pattern of the rise of oxygen. Chemical weathering in the terrestrial environment occurs in contact with the atmosphere, making paleosols potentially ideal archives to track the history of atmospheric O levels. Here we present stable chromium isotope data from multiple paleosols that offer snapshots of Earth surface conditions over the last three billion years. The results indicate a secular shift in the oxidative capacity of Earth's surface in the Neoproterozoic and suggest low atmospheric oxygen levels (<1% PAL pO ) through the majority of Earth's history. The paleosol record also shows that localized Cr oxidation may have begun as early as the Archean, but efficient, modern-like transport of hexavalent Cr under an O -rich atmosphere did not become common until the Neoproterozoic.
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http://dx.doi.org/10.1111/gbi.12360DOI Listing
November 2019

Getting patient blood management Pillar 1 right in the Asia-Pacific: a call for action.

Singapore Med J 2020 Jun 2;61(6):287-296. Epub 2019 May 2.

Department of Laboratory Medicine, Inje University Ilsan Paik Hospital, South Korea.

Preoperative anaemia is common in the Asia-Pacific. Iron deficiency anaemia (IDA) is a risk factor that can be addressed under patient blood management (PBM) Pillar 1, leading to reduced morbidity and mortality. We examined PBM implementation under four different healthcare systems, identified challenges and proposed several measures: (a) Test for anaemia once patients are scheduled for surgery. (b) Inform patients about risks of preoperative anaemia and benefits of treatment. (c) Treat IDA and replenish iron stores before surgery, using intravenous iron when oral treatment is ineffective, not tolerated or when rapid iron replenishment is needed; transfusion should not be the default management. (d) Harness support from multiple medical disciplines and relevant bodies to promote PBM implementation. (e) Demonstrate better outcomes and cost savings from reduced mortality and morbidity. Although PBM implementation may seem complex and daunting, it is feasible to start small. Implementing PBM Pillar 1, particularly in preoperative patients, is a sensible first step regardless of the healthcare setting.
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http://dx.doi.org/10.11622/smedj.2019037DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7905123PMC
June 2020

Effect of ultra-short-term treatment of patients with iron deficiency or anaemia undergoing cardiac surgery: a prospective randomised trial.

Lancet 2019 06 26;393(10187):2201-2212. Epub 2019 Apr 26.

Department of Cardiothoracic and Vascular Surgery, German Heart Centre Berlin, Berlin, Germany; German Centre for Cardiovascular Research, Berlin, Germany; Department of Cardiothoracic Surgery, Charité - Universitätsmedizin Berlin Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.

Background: Anaemia and iron deficiency are frequent in patients scheduled for cardiac surgery. This study assessed whether immediate preoperative treatment could result in reduced perioperative red blood cell (RBC) transfusions and improved outcome.

Methods: In this single-centre, randomised, double-blind, parallel-group controlled study, patients undergoing elective cardiac surgery with anaemia (n=253; haemoglobin concentration (Hb) <120 g/L in women and Hb <130 g/L in men) or isolated iron deficiency (n=252; ferritin <100 mcg/L, no anaemia) were enrolled. Participants were randomly assigned (1:1) with the use of a computer-generated range minimisation (allocation probability 0·8) to receive either placebo or combination treatment consisting of a slow infusion of 20 mg/kg ferric carboxymaltose, 40 000 U subcutaneous erythropoietin alpha, 1 mg subcutaneous vitamin B12, and 5 mg oral folic acid or placebo on the day before surgery. Primary outcome was the number of RBC transfusions during the first 7 days. This trial is registered with ClinicalTrials.gov, number NCT02031289.

Findings: Between Jan 9, 2014, and July 19, 2017, 1006 patients were enrolled; 505 with anaemia or isolated iron deficiency and 501 in the registry. The combination treatment significantly reduced RBC transfusions from a median of one unit in the placebo group (IQR 0-3) to zero units in the treatment group (0-2, during the first 7 days (odds ratio 0·70 [95% CI 0·50-0·98] for each threshold of number of RBC transfusions, p=0·036) and until postoperative day 90 (p=0·018). Despite fewer RBC units transfused, patients in the treatment group had a higher haemoglobin concentration, higher reticulocyte count, and a higher reticulocyte haemoglobin content during the first 7 days (p≤0·001). Combined allogeneic transfusions were less in the treatment group (0 [IQR 0-2]) versus the placebo group (1 [0-3]) during the first 7 days (p=0·038) and until postoperative day 90 (p=0·019). 73 (30%) serious adverse events were reported in the treatment group group versus 79 (33%) in the placebo group.

Interpretation: An ultra-short-term combination treatment with intravenous iron, subcutaneous erythropoietin alpha, vitamin B12, and oral folic acid reduced RBC and total allogeneic blood product transfusions in patients with preoperative anaemia or isolated iron deficiency undergoing elective cardiac surgery.

Funding: Vifor Pharma and Swiss Foundation for Anaesthesia Research.
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http://dx.doi.org/10.1016/S0140-6736(18)32555-8DOI Listing
June 2019

Limited oxygen production in the Mesoarchean ocean.

Proc Natl Acad Sci U S A 2019 04 20;116(14):6647-6652. Epub 2019 Mar 20.

Department of Geology, University of Johannesburg, 2092 Johannesburg, South Africa.

The Archean Eon was a time of predominantly anoxic Earth surface conditions, where anaerobic processes controlled bioessential element cycles. In contrast to "oxygen oases" well documented for the Neoarchean [2.8 to 2.5 billion years ago (Ga)], the magnitude, spatial extent, and underlying causes of possible Mesoarchean (3.2 to 2.8 Ga) surface-ocean oxygenation remain controversial. Here, we report δN and δC values coupled with local seawater redox data for Mesoarchean shales of the Mozaan Group (Pongola Supergroup, South Africa) that were deposited during an episode of enhanced Mn (oxyhydr)oxide precipitation between ∼2.95 and 2.85 Ga. Iron and Mn redox systematics are consistent with an oxygen oasis in the Mesoarchean anoxic ocean, but δN data indicate a Mo-based diazotrophic biosphere with no compelling evidence for a significant aerobic nitrogen cycle. We propose that in contrast to the Neoarchean, dissolved O levels were either too low or too limited in extent to develop a large and stable nitrate reservoir in the Mesoarchean ocean. Since biological N fixation was evidently active in this environment, the growth and proliferation of O-producing organisms were likely suppressed by nutrients other than nitrogen (e.g., phosphorus), which would have limited the expansion of oxygenated conditions during the Mesoarchean.
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http://dx.doi.org/10.1073/pnas.1818762116DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6452703PMC
April 2019

Hepcidin predicts response to IV iron therapy in patients admitted to the intensive care unit: a nested cohort study.

J Intensive Care 2018 10;6:60. Epub 2018 Sep 10.

2School of Medicine, University of Western Australia, Perth, Western Australia 6009 Australia.

Background: Both anaemia and red blood cell (RBC) transfusion are common and associated with adverse outcomes in patients admitted to the intensive care unit (ICU). The aim of this study was to determine whether serum hepcidin concentration, measured early after ICU admission in patients with anaemia, could identify a group in whom intravenous (IV) iron therapy decreased the subsequent RBC transfusion requirement.

Methods: We conducted a prospective observational study nested within a multicenter randomized controlled trial (RCT) of IV iron versus placebo. The study was conducted in the ICUs of four tertiary hospitals in Perth, Western Australia. Critically ill patients with haemoglobin (Hb) of < 100 g/L and within 48 h of admission to the ICU were eligible for participation after enrolment in the IRONMAN RCT. The response to IV iron therapy compared with placebo was assessed according to tertile of hepcidin concentration.

Results: Hepcidin concentration was measured within 48 h of ICU admission in 133 patients. For patients in the lower two tertiles of hepcidin concentration (< 53.0 μg), IV iron therapy compared with placebo was associated with a significant decrease in RBC transfusion requirement [risk ratio 0.48 (95% CI 0.26-0.85),  = 0.013].

Conclusions: In critically ill patients with anaemia admitted to an ICU, baseline hepcidin concentration predicts RBC transfusion requirement and is able to identify a group of patients in whom IV iron compared with placebo is associated with a significant decrease in RBC transfusion requirement.

Trial Registration: Australian New Zealand Clinical Trials Registry: ANZCTRN12612001249 Registered 26/11/2012.
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http://dx.doi.org/10.1186/s40560-018-0328-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6131742PMC
September 2018

The efficacy of pre-operative preparation with intravenous iron and/or erythropoietin in anaemic patients undergoing orthopaedic surgery: An observational study.

Eur J Anaesthesiol 2018 04;35(4):289-297

From the Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Kepler University, Linz, Austria (MH, HG, BH-E, JM), Department of Anesthesiology and Critical Care Medicine, University and University Hospital Zürich, Zürich, Switzerland (AH) and Department of Orthopaedics, Faculty of Medicine, Kepler University, Linz, Austria (NB).

Background: Pre-operative anaemia and transfusion are common among patients undergoing elective orthopaedic surgery. Application of 'patient blood management' might be the most effective way to reduce both anaemia and transfusion. Pre-operative administration of iron and/or erythropoietin (EPO) is one of the cornerstones of the first pillar of patient blood management, but in a daily clinical setting, efficacy and long-term safety of this measure have not been analysed thoroughly to date.

Objective: To investigate the influence of pre-operative preparation (PREP) of patients with iron and/or EPO on peri-operative transfusion needs and long-term survival.

Design: Single-centre, retrospective study.

Setting: Anaesthesia department, University hospital.

Interventions: Pre-operative preparation with iron and/or EPO versus no preparation.

Methods: After approval of our local ethics committee, data of 5518 patients who received total hip or total knee replacement between 2008 and 2014 were included. Patients receiving iron and/or EPO were included in the PREP group, whereas patients without iron and/or EPO were included in the no preparation group. From the full data set, a bias-reduced subset of 662 patients was obtained by means of propensity score-matching to compare peri-operative red blood cell utilisation and long-term survival of patients between groups.

Results: Patients in the PREP group needed a lower number of units of red blood cells than patients in the no preparation group (0.2 ± 0.8 vs. 0.5 ± 1.3, P < 0.001), had a lower transfusion rate (12 vs. 24%, P < 0.05) and had a similar haemoglobin concentration (10.7 ± 1.3 vs. 10.6 ± 1.1 g dl, not significant) at discharge. No differences in long-term survival were observed between the two study groups.

Conclusion: PREP of patients with iron and/or EPO in orthopaedic patients can be considered highly effective in terms of transfusion reduction, without influencing long-term survival.
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http://dx.doi.org/10.1097/EJA.0000000000000752DOI Listing
April 2018

Titanium isotopic evidence for felsic crust and plate tectonics 3.5 billion years ago.

Science 2017 09;357(6357):1271-1274

Department of Geology, University of Johannesburg, Post Office Box 524, Auckland Park, 2006, Republic of South Africa.

Earth exhibits a dichotomy in elevation and chemical composition between the continents and ocean floor. Reconstructing when this dichotomy arose is important for understanding when plate tectonics started and how the supply of nutrients to the oceans changed through time. We measured the titanium isotopic composition of shales to constrain the chemical composition of the continental crust exposed to weathering and found that shales of all ages have a uniform isotopic composition. This can only be explained if the emerged crust was predominantly felsic (silica-rich) since 3.5 billion years ago, requiring an early initiation of plate tectonics. We also observed a change in the abundance of biologically important nutrients phosphorus and nickel across the Archean-Proterozoic boundary, which might have helped trigger the rise in atmospheric oxygen.
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http://dx.doi.org/10.1126/science.aan8086DOI Listing
September 2017

Development of Multivariable Models to Predict and Benchmark Transfusion in Elective Surgery Supporting Patient Blood Management.

Appl Clin Inform 2017 06 14;8(2):617-631. Epub 2017 Jun 14.

Dieter Hayn, AIT Austrian Institute of Technology, Reininghausstr. 13, 8020 Graz, Austria, Email:

Background: Blood transfusion is a highly prevalent procedure in hospitalized patients and in some clinical scenarios it has lifesaving potential. However, in most cases transfusion is administered to hemodynamically stable patients with no benefit, but increased odds of adverse patient outcomes and substantial direct and indirect cost. Therefore, the concept of Patient Blood Management has increasingly gained importance to pre-empt and reduce transfusion and to identify the optimal transfusion volume for an individual patient when transfusion is indicated.

Objectives: It was our aim to describe, how predictive modeling and machine learning tools applied on pre-operative data can be used to predict the amount of red blood cells to be transfused during surgery and to prospectively optimize blood ordering schedules. In addition, the data derived from the predictive models should be used to benchmark different hospitals concerning their blood transfusion patterns.

Methods: 6,530 case records obtained for elective surgeries from 16 centers taking part in two studies conducted in 2004-2005 and 2009-2010 were analyzed. Transfused red blood cell volume was predicted using random forests. Separate models were trained for overall data, for each center and for each of the two studies. Important characteristics of different models were compared with one another.

Results: Our results indicate that predictive modeling applied prior surgery can predict the transfused volume of red blood cells more accurately (correlation coefficient cc = 0.61) than state of the art algorithms (cc = 0.39). We found significantly different patterns of feature importance a) in different hospitals and b) between study 1 and study 2.

Conclusion: We conclude that predictive modeling can be used to benchmark the importance of different features on the models derived with data from different hospitals. This might help to optimize crucial processes in a specific hospital, even in other scenarios beyond Patient Blood Management.
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http://dx.doi.org/10.4338/ACI-2016-11-RA-0195DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6241749PMC
June 2017

Posttransfusion Increase of Hematocrit per se Does Not Improve Circulatory Oxygen Delivery due to Increased Blood Viscosity.

Anesth Analg 2017 05;124(5):1547-1554

From the *Departments of Mechanical Engineering; †Bioengineering, University of California, San Diego, La Jolla, California; ‡Department of Experimental Medicine, School of Medicine, Universidad Nacional Autónoma de México, México, DF, México; §Department of Odontology, Universidad Juárez del Estado de Durango, Durango, Dgo, México; ‖School of Surgery, Faculty of Medicine Dentistry and Health Sciences, University of Western Australia, and Centre for Population Health Research, Curtin University, Perth, Western Australia, Australia; ¶Institute of Anesthesiology, University of Zurich and University Hospital Zurich, Zurich, Switzerland; #Clinic of Anesthesiology and Intensive Care, Faculty of Medicine, Kepler University Linz, Austria; **Department of Anesthesiology, Critical Care Medicine, Pain Management and Hyperbaric Medicine at Englewood Hospital & Medical Center, Director TeamHealth Research Institute, Englewood, New Jersey; and ††Department of Physiology and Biophysics, Albert Einstein College of Medicine, Bronx, New York.

Background: Blood transfusion is used to treat acute anemia with the goal of increasing blood oxygen-carrying capacity as determined by hematocrit (Hct) and oxygen delivery (DO2). However, increasing Hct also increases blood viscosity, which may thus lower DO2 if the arterial circulation is a rigid hydraulic system as the resistance to blood flow will increase. The net effect of transfusion on DO2 in this system can be analyzed by using the relationship between Hct and systemic blood viscosity of circulating blood at the posttransfusion Hct to calculate DO2 and comparing this value with pretransfusion DO2. We hypothesized that increasing Hct would increase DO2 and tested our hypothesis by mathematically modeling DO2 in the circulation.

Methods: Calculations were made assuming a normal cardiac output (5 L/min) with degrees of anemia ranging from 5% to 80% Hct deficit. We analyzed the effects of transfusing 0.5 or more units of 300 cc of packed red blood cells (PRBCs) at an Hct of 65% and calculated microcirculatory DO2 after accounting for increased blood viscosity and assuming no change in blood pressure. Our model accounts for O2 diffusion out of the circulation before blood arriving to the nutritional circulation and for changes in blood flow velocity. The immediate posttransfusion DO2 was also compared with DO2 after the transient increase in volume due to transfusion has subsided.

Results: Blood transfusion of up to 3 units of PRBCs increased DO2 when Hct (or hemoglobin) was 60% lower than normal, but did not increase DO2 when administered before this threshold.

Conclusions: After accounting for the effect of increasing blood viscosity on blood flow owing to increasing Hct, we found in a mathematical simulation of DO2 that transfusion of up to 3 units of PRBCs does not increase DO2, unless anemia is the result of an Hct deficit greater than 60%. Observations that transfusions occasionally result in clinical improvement suggest that other mechanisms possibly related to increased blood viscosity may compensate for the absence of increase in DO2.
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http://dx.doi.org/10.1213/ANE.0000000000002008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5654531PMC
May 2017

Improved outcomes and reduced costs associated with a health-system-wide patient blood management program: a retrospective observational study in four major adult tertiary-care hospitals.

Transfusion 2017 06 2;57(6):1347-1358. Epub 2017 Feb 2.

School of Surgery, Faculty of Medicine Dentistry and Health Sciences, The University of Western Australia.

Background: Patient blood management (PBM) programs are associated with improved patient outcomes, reduced transfusions and costs. In 2008, the Western Australia Department of Health initiated a comprehensive health-system-wide PBM program. This study assesses program outcomes.

Study Design And Methods: This was a retrospective study of 605,046 patients admitted to four major adult tertiary-care hospitals between July 2008 and June 2014. Outcome measures were red blood cell (RBC), fresh-frozen plasma (FFP), and platelet units transfused; single-unit RBC transfusions; pretransfusion hemoglobin levels; elective surgery patients anemic at admission; product and activity-based costs of transfusion; in-hospital mortality; length of stay; 28-day all-cause emergency readmissions; and hospital-acquired complications.

Results: Comparing final year with baseline, units of RBCs, FFP, and platelets transfused per admission decreased 41% (p < 0.001), representing a saving of AU$18,507,092 (US$18,078,258) and between AU$80 million and AU$100 million (US$78 million and US$97 million) estimated activity-based savings. Mean pretransfusion hemoglobin levels decreased 7.9 g/dL to 7.3 g/dL (p < 0.001), and anemic elective surgery admissions decreased 20.8% to 14.4% (p = 0.001). Single-unit RBC transfusions increased from 33.3% to 63.7% (p < 0.001). There were risk-adjusted reductions in hospital mortality (odds ratio [OR], 0.72; 95% confidence interval [CI], 0.67-0.77; p < 0.001), length of stay (incidence rate ratio, 0.85; 95% CI, 0.84-0.87; p < 0.001), hospital-acquired infections (OR, 0.79; 95% CI, 0.73-0.86; p < 0.001), and acute myocardial infarction-stroke (OR, 0.69; 95% CI, 0.58-0.82; p < 0.001). All-cause emergency readmissions increased (OR, 1.06; 95% CI, 1.02-1.10; p = 0.001).

Conclusion: Implementation of a unique, jurisdiction-wide PBM program was associated with improved patient outcomes, reduced blood product utilization, and product-related cost savings.
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http://dx.doi.org/10.1111/trf.14006DOI Listing
June 2017

Gender disparities in red blood cell transfusion in elective surgery: a post hoc multicentre cohort study.

BMJ Open 2016 12 13;6(12):e012210. Epub 2016 Dec 13.

Department of Anaesthesiology, University Hospital Zurich, Zurich, Switzerland.

Objectives: A post hoc gender comparison of transfusion-related modifiable risk factors among patients undergoing elective surgery.

Settings: 23 Austrian centres randomly selected and stratified by region and level of care.

Participants: We consecutively enrolled in total 6530 patients (3465 women and 3065 men); 1491 underwent coronary artery bypass graft (CABG) surgery, 2570 primary unilateral total hip replacement (THR) and 2469 primary unilateral total knee replacement (TKR).

Main Outcome Measures: Primary outcome measures were the number of allogeneic and autologous red blood cell (RBC) units transfused (postoperative day 5 included) and differences in intraoperative and postoperative transfusion rate between men and women. Secondary outcomes included perioperative blood loss in transfused and non-transfused patients, volume of RBCs transfused, perioperative haemoglobin values and circulating red blood volume on postoperative day 5.

Results: In all surgical groups, the transfusion rate was significantly higher in women than in men (CABG 81 vs 49%, THR 46 vs 24% and TKR 37 vs 23%). In transfused patients, the absolute blood loss was higher among men in all surgical categories while the relative blood loss was higher among women in the CABG group (52.8 vs 47.8%) but comparable in orthopaedic surgery. The relative RBC volume transfused was significantly higher among women in all categories (CABG 40.0 vs 22.3; TKR 25.2 vs 20.2; THR 26.4 vs 20.8%). On postoperative day 5, the relative haemoglobin values and the relative circulating RBC volume were higher in women in all surgical categories.

Conclusions: The higher transfusion rate and volume in women when compared with men in elective surgery can be explained by clinicians applying the same absolute transfusion thresholds irrespective of a patient's gender. This, together with the common use of a liberal transfusion strategy, leads to further overtransfusion in women.
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http://dx.doi.org/10.1136/bmjopen-2016-012210DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5168603PMC
December 2016

Intravenous iron or placebo for anaemia in intensive care: the IRONMAN multicentre randomized blinded trial : A randomized trial of IV iron in critical illness.

Intensive Care Med 2016 Nov 30;42(11):1715-1722. Epub 2016 Sep 30.

School of Medicine and Pharmacology, University of Western Australia, Perth, WA, 6009, Australia.

Purpose: Both anaemia and allogenic red blood cell transfusion are common and potentially harmful in patients admitted to the intensive care unit. Whilst intravenous iron may decrease anaemia and RBC transfusion requirement, the safety and efficacy of administering iron intravenously to critically ill patients is uncertain.

Methods: The multicentre, randomized, placebo-controlled, blinded Intravenous Iron or Placebo for Anaemia in Intensive Care (IRONMAN) study was designed to test the hypothesis that, in anaemic critically ill patients admitted to the intensive care unit, early administration of intravenous iron, compared with placebo, reduces allogeneic red blood cell transfusion during hospital stay and increases the haemoglobin level at the time of hospital discharge.

Results: Of 140 patients enrolled, 70 were assigned to intravenous iron and 70 to placebo. The iron group received 97 red blood cell units versus 136 red blood cell units in the placebo group, yielding an incidence rate ratio of 0.71 [95 % confidence interval (0.43-1.18), P = 0.19]. Overall, median haemoglobin at hospital discharge was significantly higher in the intravenous iron group than in the placebo group [107 (interquartile ratio IQR 97-115) vs. 100 g/L (IQR 89-111), P = 0.02]. There was no significant difference between the groups in any safety outcome.

Conclusions: In patients admitted to the intensive care unit who were anaemic, intravenous iron, compared with placebo, did not result in a significant lowering of red blood cell transfusion requirement during hospital stay. Patients who received intravenous iron had a significantly higher haemoglobin concentration at hospital discharge. The trial was registered at http://www.anzctr.org.au as # ACTRN12612001249842.
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http://dx.doi.org/10.1007/s00134-016-4465-6DOI Listing
November 2016

Critical Role of Iron in Epoetin Alfa Treatment of Chemotherapy-Associated Anemia.

J Clin Oncol 2016 11;34(31):3819-3820

Irwin Gross, Eastern Maine Medical Center, Bangor, ME; Accumen, San Diego, CA; Shannon Farmer, University of Western Australia; Curtin University, Perth, Western Australia, Australia; Axel Hofmann, University of Western Australia; Curtin University, Perth, Western Australia, Australia; University of Zurich, Zurich, Switzerland; Sherri Ozawa, Englewood Hospital and Medical Center, Englewood, NJ; Aryeh Shander, Englewood Hospital and Medical Center, Englewood, NJ; Icahn School of Medicine at Mount Sinai, New York, NY; Matti Aapro, IMO Clinique de Genolier, Genolier, Switzerland.

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http://dx.doi.org/10.1200/JCO.2016.67.7377DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5477928PMC
November 2016

Patient Blood Management Bundles to Facilitate Implementation.

Transfus Med Rev 2017 01 28;31(1):62-71. Epub 2016 May 28.

Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt am Main, Germany.

More than 30% of the world's population are anemic with serious economic consequences including reduced work capacity and other obstacles to national welfare and development. Red blood cell transfusion is the mainstay to correct anemia, but it is also 1 of the top 5 overused procedures. Patient blood management (PBM) is a proactive, patient-centered, and multidisciplinary approach to manage anemia, optimize hemostasis, minimize iatrogenic blood loss, and harness tolerance to anemia. Although the World Health Organization has endorsed PBM in 2010, many hospitals still seek guidance with the implementation of PBM in clinical routine. Given the use of proven change management principles, we propose simple, cost-effective measures enabling any hospital to reduce both anemia and red blood cell transfusions in surgical and medical patients. This article provides comprehensive bundles of PBM components encompassing 107 different PBM measures, divided into 6 bundle blocks acting as a working template to develop institutions' individual PBM practices for hospitals beginning a program or trying to improve an already existing program. A stepwise selection of the most feasible measures will facilitate the implementation of PBM. In this manner, PBM represents a new quality and safety standard.
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http://dx.doi.org/10.1016/j.tmrv.2016.05.012DOI Listing
January 2017

Data Driven Methods for Predicting Blood Transfusion Needs in Elective Surgery.

Stud Health Technol Inform 2016 ;223:9-16

AIT Austrian Institute of Technology GmbH, Austria.

Research in blood transfusions mainly focuses on Donor Blood Management, including donation, screening, storage and transport. However, the last years saw an increasing interest in recipient related optimizations, i.e. Patient Blood Management (PBM). Although PBM already aims at reducing transfusion rates by pre- and intra-surgical optimization, there is still a high potential of improvement on an individual level. The present paper investigates the feasibility of predicting blood transfusions needs based on datasets from various treatment phases, using data which have been collected in two previous studies. Results indicate that prediction of blood transfusions can be further improved by predictive modelling including individual pre-surgical parameters. This also allows to identify the main predictors influencing transfusion practice. If confirmed in a prospective dataset, these or similar predictive methods could be a valuable tool to support PBM with the ultimate goal to reduce costs and improve patient outcomes.
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April 2017

Implementation and validation of a conceptual benchmarking framework for patient blood management.

Stud Health Technol Inform 2015 ;212:190-7

AIT Austrian Institute of Technology GmbH, Digital Safety & Security Department, Assistive Health Information Technology, Graz, Austria.

Background: Public health authorities and healthcare professionals are obliged to ensure high quality health service. Because of the high variability of the utilisation of blood and blood components, benchmarking is indicated in transfusion medicine.

Objectives: Implementation and validation of a benchmarking framework for Patient Blood Management (PBM) based on the report from the second Austrian Benchmark trial.

Methods: Core modules for automatic report generation have been implemented with KNIME (Konstanz Information Miner) and validated by comparing the output with the results of the second Austrian benchmark trial.

Results: Delta analysis shows a deviation <0.1% for 95% (max. 1.4%).

Conclusion: The framework provides a reliable tool for PBM benchmarking. The next step is technical integration with hospital information systems.
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November 2016

Supra-plasma expanders: the future of treating blood loss and anemia without red cell transfusions?

J Infus Nurs 2015 May-Jun;38(3):217-22

University of California, San Diego, Department of Bioengineering, La Jolla, California (Drs Tsai, Salazar Vázquez, and Intaglietta); Universidad Nacional Autónoma de México, Hospital General de México "Dr. Eduardo Liceaga," Department of Experimental Medicine, México DF, México (Dr Salazar Vázquez); Universidad Juárez del Estado de Durango, Victoria de Durango, Faculty of Medicine, Dgo, Mexico (Dr Salazar Vázquez); University Hospital, Institute of Anesthesiology, Zürich, Switzerland (Dr Hofmann); University of Western Australia, School of Surgery, Perth, Australia (Dr Hofmann); and Albert Einstein College of Medicine, Department of Hematology and Medicine, Bronx, New York (Dr Acharya). Amy G. Tsai, PhD, is a research scientist and principal investigator in the Department of Bioengineering of the University of California, San Diego. She specializes in the study of in vivo microvascular responses to hemorrhagic shock and acute anemia, with the aim of developing new resuscitation fluids, next-generation plasma expanders, and oxygen carriers. Beatriz Y. Salazar Vázquez, MD, PhD, is a visiting scholar at the University of California, San Diego, and a research scientist at the Universidad Nacional Autónoma de México, where she studies the cardiovascular effects of hematocrit changes. Axel Hofmann, ME, is a visiting professor at the Institute of Anesthesiology at University Hospital in Zürich, Switzerland, and an adjunct associate professor in the School of Surgery at the University of Western Australia. Seetharama A. Acharya, PhD, is a professor of hematology and biophysics at the Albert Einstein College of Medicine in New York. He is an expert on protein peglylation design as applied to its use as blood replacement fluids. Marcos Intaglietta, PhD, is a distinguished professor of bioengineering at the University of California, San Diego, and is an authority in the analysis of the microcirculation and how it behaves during changes of blood composition resul

Oxygen delivery capacity during profoundly anemic conditions depends on blood's oxygen-carrying capacity and cardiac output. Oxygen-carrying blood substitutes and blood transfusion augment oxygen-carrying capacity, but both have given rise to safety concerns, and their efficacy remains unresolved. Anemia decreases oxygen-carrying capacity and blood viscosity. Present studies show that correcting the decrease of blood viscosity by increasing plasma viscosity with newly developed plasma expanders significantly improves tissue perfusion. These new plasma expanders promote tissue perfusion, increasing oxygen delivery capacity without increasing blood oxygen-carrying capacity, thus treating the effects of anemia while avoiding the transfusion of blood.
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http://dx.doi.org/10.1097/NAN.0000000000000103DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5608479PMC
December 2016

Patient blood management in cardiac surgery results in fewer transfusions and better outcome.

Transfusion 2015 May 6;55(5):1075-81. Epub 2015 Jan 6.

Institute of Anesthesiology, University and University Hospital Zurich, Zurich, Switzerland.

Background: The aim of this study was to investigate the impact of the introduction of a patient blood management (PBM) program in cardiac surgery on transfusion incidence and outcome.

Study Design And Methods: Clinical and transfusion data were compared between the pre-PBM epoch (July 2006-March 2007) and the PBM epoch (April 2007-September 2012).

Results: There were a total of 2662 patients analyzed, 387 in the pre-PBM and 2275 in the PBM epoch. Red blood cell (RBC) loss decreased from a mean (±SD) of 810 ± 426 mL (median, 721 mL) to 605 ± 369 mL (median, 552 mL; p < 0.001) and pretransfusion hemoglobin decreased from 7.2 ± 1.4 to 6.6 ± 1.2 g/dL (p < 0.001) in the pre-PBM versus the PBM epoch. In conjunction, this resulted in a reduction of the RBC transfusion rate from 39.3% to 20.8% (p < 0.001). Similar reductions were observed for the transfusion of fresh-frozen plasma (FFP; from 18.3% to 6.5%, p < 0.001) and platelets (PLTs; from 17.8% to 9.8%, p < 0.001). Hospital mortality and cerebral vascular accident incidence remained unchanged in the PBM epoch. However, the incidence of postoperative kidney injury decreased in the PMB epoch (from 7.6% to 5.0%, p = 0.039), length of hospital stay decreased from 12.2 ± 9.6 days (median, 10 days) to 10.4 ± 8.0 days (median, 8 days; p < 0.001), and total adjusted direct costs were reduced from $48,375 ± $28,053 (median, $39,709) to $44,300 ± $25,915 (median, $36,906; p < 0.001).

Conclusions: Implementing meticulous surgical technique, a goal-directed coagulation algorithm, and a more restrictive transfusion threshold in combination resulted in a substantial decrease in RBC, FFP, and PLT transfusions; less kidney injury; a shorter length of hospital stay; and lower total direct costs.
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http://dx.doi.org/10.1111/trf.12946DOI Listing
May 2015

Increased hospital costs associated with red blood cell transfusion.

Transfusion 2015 May 8;55(5):1082-9. Epub 2014 Dec 8.

School of Medicine and Pharmacology, University of Western Australia, Perth, Western Australia.

Background: Red blood cell (RBC) transfusion is independently associated in a dose-dependent manner with increased intensive care unit stay, total hospital length of stay, and hospital-acquired complications. Since little is known of the cost of these transfusion-associated adverse outcomes our aim was to determine the total hospital cost associated with RBC transfusion and to assess any dose-dependent relationship.

Study Design And Methods: A retrospective cohort study of all multiday acute care inpatients discharged from a five hospital health service in Western Australia between July 2011 and June 2012 was conducted. Main outcome measures were incidence of RBC transfusion and mean inpatient hospital costs.

Results: Of 89,996 multiday, acute care inpatient discharges, 4805 (5.3%) were transfused at least 1 unit of RBCs. After potential confounders were adjusted for, the mean inpatient cost was 1.83 times higher in the transfused group compared with the nontransfused group (95% confidence interval, 1.78-1.89; p < 0.001). The estimated total hospital-associated cost of RBC transfusion in this study was AUD $77 million (US $72 million), representing 7.8% of total hospital expenditure on acute care inpatients. There was a significant dose-dependent association between the number of RBC units transfused and increased costs after adjusting for confounders.

Conclusion: RBC transfusions were independently associated with significantly higher hospital costs. The financial implication to hospital budgets will assist in prioritizing areas to reduce the rate of RBC transfusions and in implementing patient blood management programs.
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http://dx.doi.org/10.1111/trf.12958DOI Listing
May 2015