Search

Identification and prevention of transfusion-transmitted disease is essential for blood transfusion safety. However, current surveillance systems are largely driven by reports of sentinel events, which is an approach that might be inadequate for identifying transmission of pathogens not known to be transmissible or pathogens with long incubation periods. Using a combination of health-data registers and blood-bank databases, we aimed to perform an agnostic search for potential transfusion-transmitted diseases and to identify unknown threats to the blood supply.

BackgroundLong-term prognosis associated with low–high-sensitivity cardiac troponin T (hs-cTnT) concentrations in patients with chest pain is unknown. We investigated these prognostic implications compared with the general population.MethodsAll first visits to seven emergency departments (ED)s in Sweden were included from 9 December 2010 to 31 August, 2017 by patients presenting with chest pain and at least one hs-cTnT measured. Patients with myocardial injury (any hs-cTnT >14 ng/L), including patients with myocardial infarction (MI) were excluded. Standardised mortality ratios (SMRs) and standardised incidence ratios (SIRs) were calculated as the ratio of the number of observed to expected events. The expected number was computed by multiplying the 1-year calendar period-specific, age-specific and sex-specific follow-up time in the cohort with the corresponding incidence in the general population. HRs were calculated for all-cause mortality and major adverse cardiovascular events (MACE), defined as acute MI, heart failure hospitalisation, cerebrovascular stroke or cardiovascular death, between patients with undetectable (<5 ng/L) and low (5–14 ng/L) hs-cTnT.ResultsA total of 1 11 916 patients were included, of whom 69 090 (62%) and 42 826 (38%) had peak hs-cTnT concentrations of <5 and 5–14 ng/L. Patients with undetectable peak hs-cTnT had a lower mortality risk compared with the general Swedish population (SMR 0.83, 95% CI 0.79 to 0.87), with lower risks observed in all patients ≥65 years of age, but a slightly higher risk of being diagnosed with a future MI (SIR 1.39, 95% CI 1.32 to 1.47). The adjusted risk of a first MACE associated with low versus undetectable peak hs-cTnT was 1.6-fold (HR 1.61, 95% CI 1.53 to 1.70).ConclusionPatients with chest pain and undetectable hs-cTnT have an overall lower risk of death compared with the general population, with risks being highly age dependent. Detectable hs-cTnT concentrations are still associated with increased long-term cardiovascular risks.

ObjectiveMany patients who present with chest pain have previous measurements of high-sensitivity cardiac troponin T (hs-cTnT). The clinical usefulness of incorporating these measurements in identifying patients who are at a high risk of myocardial infarction (MI) is unknown. We investigated if the relative change between a historical hs-cTnT and the admission hs-cTnT could improve early identification of patients with a high risk of MI.MethodsWe included all patients presenting with chest pain to seven different emergency departments (EDs) in Sweden from December 2009 to December 2016, who had at least one hs-cTnT measurement at the presentation and at least one available prior measurement. We used logistic regression to investigate the diagnostic performance of using various combinations of current and historical hs-cTnT measurements in diagnosing MI within 30 days.ResultsA total of 27 809 visits were included, among whom 2686 (9.7%) had an MI within 30 days. A cut-off value for historical hs-cTnT-adjusted admission hs-cTnT with similar specificity (91.2%) as an admission hs-cTnT of ≥52 ng/L identified 4% more MIs (43% vs 39%) and had a higher positive predictive value, 42.6% (95% CI, 41.0% to 44.3%) vs 38.9% (95% CI 37.4% to 40.4%), as well as a higher positive likelihood ratio, 6.95 (95% CI 6.69 to 7.22) vs 5.95 (95% CI 5.73 to 6.18). Among patients with an admission hs-cTnT of <52 ng/L who were classified as high-risk patients when incorporating past hs-cTnT measurements, 28% suffered an MI.ConclusionsHistorical hs-cTnT levels can be used with admission hs-cTnT to improve early risk stratification of MI in the ED.

Background Long-term deleterious effects of repeated blood donations may be masked by the donors' healthy lifestyle. To investigate possible effects of blood donation and iron loss through blood donation on cancer incidence while minimizing 'healthy donor effects,' we made dose-response comparisons within a cohort of Swedish and Danish blood donors. Methods We used a nested case-control study design, in which case patients were defined as all donors who were diagnosed with a malignancy between their first recorded blood donation and study termination (n = 10866). Control subjects (n = 107140) were individually matched on sex, age, and county of residence. Using conditional logistic regression, we estimated relative risks of cancer according to number of blood donations made or estimated iron loss 3-12 years before a case patient was diagnosed with cancer. All statistical tests were two-sided. Results No clear association was observed between number of donations and risk of cancer overall. However, between the lowest ([less than or equal to] median, 90th percentile, >2.7 g) categories of estimated iron loss, there was a trend ([P.sub.trend] < .001) of decreasing risk for cancers of the liver, lung, colon, stomach, and esophagus, which are thought to be promoted by iron overload (combined odds ratio [OR] = 0.70, 95% confidence interval [CI] = 0.58 to 0.84), but only among men and only with a latency of 3-7 years. The risk of non-Hodgkin lymphoma was higher among frequent plasma donors (>25 vs 0 donations, OR = 2.14, 95% CI = 1.22 to 3.74). Conclusions Repeated blood donation was not associated with increased or decreased risk of cancer overall. The lack of consistency across latency periods casts doubt on an apparent association between reduced cancer risk and iron loss in men. The positive association between frequent plasma donation and risk of non-Hodgkin lymphoma deserves further exploration.

Background Blood transfusions may influence the recipients' cancer risks both through transmission of biologic agents and by modulation of the immune system. However, cancer occurrence in transfusion recipients remains poorly characterized. Methods We used computerized files from Scandinavian blood banks to identify a cohort of 888843 cancer-free recipients transfused after 1968. The recipients were followed from first registered transfusion until the date of death, emigration, cancer diagnosis, or December 31, 2002, whichever came first. Relative risks were expressed as ratios of the observed to the expected numbers of cancers, that is, standardized incidence ratios (SIRs), using incidence rates for the general Danish and Swedish populations as a reference. All statistical tests were two-sided. Results During 5652918 person-years of follow-up, 80990 cancers occurred in the transfusion recipients, corresponding to a SIR of 1.45 (95% confidence interval [CI] = 1.44 to 1.46). The SIR for cancer overall decreased from 5.36 (95% CI = 5.29 to 5.43) during the first 6 months after transfusion to 1.10 or less for follow-up periods more than 2 years after the transfusion. However, the standardized incidence ratios for cancers of the tongue, mouth, pharynx, esophagus, liver, and respiratory and urinary tracts and for squamous cell skin carcinoma remained elevated beyond 10 years after the transfusion. Conclusions The marked increase in cancer risk shortly after a blood transfusion may reflect the presence of undiagnosed occult cancers with symptoms that necessitated the blood transfusion. The continued increased risk of tobacco- and alcohol-related cancers suggests that lifestyle and other risk factors related to conditions prompting transfusion rather than transfusion-related exposures per se are important to the observed cancer occurrence in the recipients.

IMPORTANCE: Prior evidence suggests that plasma and platelet transfusions from female and parous donors are associated with adverse clinical outcomes, which has led to the predominant use of male donors for plasma and platelets in many countries. However, studies on red blood cell transfusions have been conflicting. OBJECTIVE: To determine whether blood donor sex and parity affect mortality of patients undergoing transfusion with red blood cells. DESIGN, SETTING, AND PARTICIPANTS: This cohort study used nationwide blood bank and health register data in Sweden and involved a natural experiment created by donor sex and parity being concealed and randomly allocated. Patients were included if they were 18 to 90 years old, did not have a history of blood transfusion, and received a transfusion between January 1, 2010, and December 31, 2017. Patients were followed up from their first red blood cell transfusion until death, emigration, or end of study (June 30, 2018). Data analysis was performed between June 15 and December 15, 2021. EXPOSURES: (1) Female vs male donors and (2) parous or nonparous female vs male donors. MAIN OUTCOMES AND MEASURES: Overall survival up to 2 years estimated using inverse probability–weighted Kaplan-Meier estimates and relative risk for additional transfusions within 24 hours. RESULTS: Among the 368 778 included patients (mean [SD] age, 66.3 [17.7] years; 57.3% female), 2-year survival differences comparing red blood cell transfusions from female and parous donors to male donors were −0.1% (95% CI, −1.3% to 1.1%) and 0.3% (95% CI, −0.6% to 1.2%), respectively. No statistically significant survival differences were observed regardless of patient sex or age. Median (IQR) hemoglobin counts for female donors (13.5 [13.0-14.0] g/dL) were lower than for male donors (14.9 [14.4-15.5] g/dL). Red blood cell transfusions from female donors were associated with a relative risk of 1.12 (95% CI, 1.08-1.17) for additional transfusions within 24 hours but not after adjusting for donor hemoglobin counts (relative risk, 1.03; 95% CI, 0.98-1.08). Pretransfusion patient characteristics were naturally distributed as-if randomized. CONCLUSIONS AND RELEVANCE: In this nationwide cohort study involving a natural experiment, after accounting for the lower hemoglobin values in blood from female donors, patients undergoing transfusion with blood from female or parous donors did not have higher 2-year mortality compared with recipients of blood from male donors.

After quickly devouring the latest issue of your terrific magazine, I have to point out a tiny, yet not insignificant, error in the Answer Fella column (Man at His Best) [...]

IMPORTANCE: Following animal model data indicating the possible rejuvenating effects of blood from young donors, there have been at least 2 observational studies conducted with humans that have investigated whether donor age affects patient outcomes. Results, however, have been conflicting. OBJECTIVE: To study the association of donor age and sex with survival of patients receiving transfusions. DESIGN, SETTING, AND PARTICIPANTS: A retrospective cohort study based on the Scandinavian Donations and Transfusions database, with nationwide data, was conducted for all patients from Sweden and Denmark who received at least 1 red blood cell transfusion of autologous blood or blood from unknown donors between January 1, 2003, and December 31, 2012. Patients were followed up from the first transfusion until death, emigration, or end of follow-up. Data analysis was performed from September 15 to November 15, 2016. EXPOSURES: The number of transfusions from blood donors of different age and sex. Exposure was treated time dependently throughout follow-up. MAIN OUTCOMES AND MEASURES: Hazard ratios (HRs) for death and adjusted cumulative mortality differences, both estimated using Cox proportional hazards regression. RESULTS: Results of a crude analysis including 968 264 transfusion recipients (550 257 women and 418 007 men; median age at first transfusion, 73.0 years [interquartile range, 59.8-82.4 years]) showed a U-shaped association between age of the blood donor and recipient mortality, with a nadir in recipients for the most common donor age group (40-49 years) and significant and increasing HRs among recipients of blood from donors of successively more extreme age groups (&lt;20 years: HR, 1.12; 95% CI, 1.10-1.14; ≥70 years: HR, 1.25; 95% CI, 1.08-1.44). Higher mortality was also noted among recipients of blood from female donors (HR, 1.07; 95% CI, 1.07-1.07). Adjustments for number of transfusions with a linear term attenuated the associations, but the increased mortality for recipients of blood from young, old, and female donors was not eliminated. Closer examination of the association between number of transfusions and mortality revealed a nonlinear pattern. After adjustments to accommodate nonlinearity, donor age and sex were no longer associated with patient mortality. CONCLUSIONS AND RELEVANCE: Donor age and sex were not associated with patient survival and need not be considered in blood allocation. Any comparison between common and less common categories of transfusions will inevitably be confounded by the number of transfusions, which drives the probability of receiving the less common blood components. Previous positive findings regarding donor age and sex are most likely explained by residual confounding.

Supplemental Digital Content is available in the text.

Supplemental Digital Content is available in the text.

The aim of this in-vitro study was to evaluate haemostasis analysed with thromboelastometry and blood gas and blood count variables, in stored blood components and the effects after dilution with Ringeŕs acetate, albumin and hydroxyethyl starch (HES). Aliquots from stored red blood cells, plasma and platelet concentrates were mixed in the proportion of 4 : 4 : 1 and analysed with rotational thromboelastometry (ROTEM), blood count [haemoglobin (Hb), haematocrit, platelet count] and blood gas (pH, calcium, sodium, potassium, glucose levels). The blood mix was thereafter diluted 20 and 33% with Ringer's acetate, albumin or HES. The stored blood component mix in a ratio of 4 : 4 : 1 had a low pH (7.11 ± 0.03, mean ± standard deviation), nonmeasurable calcium level, and high concentrations of sodium, potassium and glucose but ROTEM curves within normal range after recalcification. With Ringer's acetate dilution, the ROTEM variables changed almost linearly with increasing dilution volume. When albumin was used in the 33% dilution, the clot firmness of the fibrin clot (FibTEM) was further reduced, and with HES dilution, there was a pronounced impairment. The stored blood mix had a low pH and calcium level, both of which might have a significant influence on the coagulation process but normal ROTEM curves after recalcification. Dilution with Ringer's acetate and albumin resulted in moderate deterioration, while dilution with HES showed severely impaired haemostasis.

Supplemental Digital Content is Available in the Text.On account of increased risks of severe infections, splenectomized patients often receive a range of vaccinations. However, the extent to which vaccination has translated into lowered risks remains unclear. In this large population-based study, we saw little or no decreased risks in patients splenectomized after implementation of routine vaccination.

A small group of frequent visitors to emergency departments accounts for a disproportional large number of total emergency department visits. Previous interventions in this population have shown mixed results.

It is unclear to what extent cancer history affects posttransplantation mortality in solid organ transplant recipients.

The treatment of coagulopathy and bleeding in severe trauma requires rapid delivery of large amounts of plasma to emergency wards. The resulting need for adequate supplies of nonfrozen or thawed plasma has consequences for storage strategies. Using extensive population data from a setting where both fresh-frozen plasma (FFP) and cold-stored liquid plasma were used, this study investigates whether there is an association between short-term mortality after receipt of FFP or liquid plasma of different storage times.

At current safety levels, with adverse events from transfusions being relatively rare, further progress in risk reductions will require large-scale investigations. Thus, truly prospective studies may prove unfeasible and other alternatives deserve consideration. In this review, we will try to give an overview of recent and historical developments in the use of blood donation and transfusion databases in research. In addition, we will go over important methodological issues.

Monoclonal B-cell lymphocytosis (MBL) is a precursor of chronic lymphocytic leukemia (CLL). Observations of MBL in blood donors raise concern that transmitted MBL may cause recipient CLL. Using a database with health information on 1.5 million donors and 2.1 million recipients, we compared CLL occurrence among 7413 recipients of blood from 796 donors diagnosed with CLL after donation cessation, and among 80 431 recipients of blood from 7477 matched CLL-free donors. During follow-up, 12 and 107 cases of CLL occurred among the exposed and unexposed recipients, respectively, yielding a relative risk of 0.94 (95% confidence interval, 0.52-1.71). Analyses using the entire database showed no evidence of CLL clustering among recipients of blood from individual donors. In conclusion, when donor MBL was approximated by subsequent donor CLL diagnosis, data from 2 countries’ entire computerized transfusion experience over more than 30 years indicate that MBL/CLL transmission does not contribute importantly to recipient CLL risk.

Introduction: The Brutons Tyrosine Kinase (BTK) inhibitor ibrutinib has dramatically improved treatment of patients with chronic lymphocytic leukemia (CLL) resulting in markedly increased progression free and overall survival (OS), particularly for those with chemoimmuno-refractory or TP53-mutated disease. However, pivotal clinical studies, such as the RESONATE trial, have also identified ibrutinib-associated complications including infections, hemorrhagic events and atrial arrythmias. Real-world evidence using nationwide-wide records have so far been scarce. Here we present population-based data extracted from multiple national registers on ibrutinib-treated CLL patients with focus on OS and adverse events.

While urinary bladder cancer is consistently more common in men worldwide, women have poorer prognosis. The aim of this study was to outline sex differences in prognostic factors and clinical management and to explore whether these can explain the poorer urinary bladder cancer outcome in women.

Mast: Novo Nordisk: Research Funding.

Björkholm: Novartis: Research Funding; Shire: Research Funding; Merck: Research Funding; Amgen: Honoraria, Research Funding; Pfizer: Research Funding; Bristol-Myers Squibb: Honoraria; Celgene: Honoraria; Akinon: Honoraria; Nordic Nanovector: Honoraria. Själander:Novartis: Honoraria. Richter:Ariad: Honoraria; Bristol-Myers Squibb: Honoraria; Novartis: Honoraria.

Introduction The association between SES and survival in MM and AML has not been studied in detail and the limited results are inconclusive. In the present study the impact of SES on survival was analyzed in a large population-based cohort of MM and AML patients. Patients and Methods From the Swedish Cancer Register we identified all individuals diagnosed with MM and AML between 1973 and 2003. We used type of occupation, combined into seven groups (blue-collar worker, farmer, lower white-collar worker, higher white-collar worker, self-employed, retired, and unknown), from the Swedish National Census Databases as a proxy for SES. The relative risk of death (any cause) in relation to type of occupation and calendar period was estimated using Cox’s proportional hazards regression adjusted for age, sex, calendar period and area of residence. We also conducted analyses stratified by calendar period (1973–1979, 1980–1989, 1990–1999, and 2000–2003). Results A total of 14,200 and 8,831 patients were diagnosed with MM and AML, respectively. The median age at diagnosis was 71.8 years in patients with MM and 69.1 years in AML. The SES distribution was similar between the two diseases. The majority of patients were blue-collar (38.0; 39.5%) and white-collar workers (36.4; 37%), with lower white-collar workers dominating the latter group. Women had a significantly lower mortality than men both among MM (p<0.001) and AML (p<0.05) patients. The mortality among patients diagnosed in more recent calendar periods was lower than among patients diagnosed earlier (p<0.001) Overall, higher white-collar workers had a significantly lower mortality compared to blue-collar workers for both MM (p<0.001) and AML (p<0.001). No significant differences were found between the other SES groups. In MM, analyses stratified by calendar period revealed that the mortality did not differ between the SES groups in the first two calendar periods, but in the third calendar period, 1990–1999, both higher and lower white-collar workers had a significantly lower mortality compared to blue collar workers, hazard ratios (HR) 0.85 (95% CI, 0.75–0.96) and 0.91 (95% CI 0.85–0.98), respectively. In the fourth period the mortality followed the same pattern as in the third period with lower mortality among both higher [HR 0.66 (95% CI, 0.50–0.88)] and lower [HR 0.82 (95% CI, 0.69–0.96)] white-collar workers. In AML patients no difference in mortality in relation to SES was found during the first calendar period. During the last three periods, however, a lower mortality was observed in higher white-collar workers compared to blue-collar workers, HR: 0.79 (0.66–0.95), 0.79 (0.67–0.93) and 0.74 (0.57–0.96) in the periods 1980–1989, 1990–1999 and 2000–2003, respectively. Conclusion SES, here defined as occupational profession, was significantly associated with prognosis in both MM and AML. Most conspicuously, a lower mortality was recorded in white-collar workers during more recent calendar periods. Differences in time to diagnosis (lead-time bias) and treatment strategies may be important factors contributing to this finding. Future studies may identify the relative impact of these and potentially other factors.

Several letters to the editor are presented in response to articles in previous issues including "The Better Man 2006," which focused on active sex life, "Nasdijj," which profiled writer Tim Barrus and "The Case for Corn," which discussed the economic aspects of ethanol.