Search

Patients undergoing gastrointestinal cancer surgery often receive packed red blood cell transfusions. Understanding practice variation is critical to support efforts working toward responsible transfusion use. We measured the extent and importance of variation in perioperative packed red blood cell transfusion use across physicians and hospitals among gastrointestinal cancer surgery patients.We identified patients who underwent elective gastrointestinal cancer resection between 2007 and 2019 using linked administrative health data sets in Ontario, Canada. We used funnel plots to describe variation in transfusion use, adjusted for patient case mix. Hierarchical regression models quantified patient-level, between-physician, and between-hospital variation in transfusion use with ROf 59,964 included patients (median age 69 years; 43.2% female; 75.8% colorectal resections), 18.0% received perioperative packed red blood cell transfusions. Funnel plots showed variation in transfusion use among physicians and hospitals. Patient characteristics, such as age, comorbidity, and procedure type, combined to explain 12.8% of the variation. After adjusting for case mix, systematic between-physician and between-hospital differences were responsible for 2.8% and 2.1% of the variation, respectively. This translated to an approximately 30% difference in the odds of transfusion for 2 similar patients treated by distinct physicians (median odds ratio: 1.35, 95% confidence interval 1.30-1.40) and hospitals (median odds ratio: 1.30, 95% confidence interval 1.23-1.42). We observed comparable effects across procedure-type subgroups.Transfusion provision is highly driven by patient factors. Yet the impact of the treating physician and hospital on variation relative to other factors is important and reflects opportunities to target modifiable processes of care to standardize perioperative packed red blood cell transfusion practice.

Background: Cardiorespiratory transfusion reactions drive most transfusion-related morbidity and mortality. Transfusion-associated circulatory overload and transfusion-related acute lung injury have established causes, important impacts, mitigation options, and revised definitions, while non-conforming CRTRs fall into a category known as transfusion-associated dyspnea. Though procedures to investigate high-risk febrile transfusion reactions are typically rooted in detecting incompatibility or bacterial contamination, a common standard for examining CRTRs is lacking. CRTRs are further challenged by charting limitations, confounding (or enhanced susceptibility) by comorbidities, and/or overlapping insults. Deeper profiling of CRTRs could improve categorizations, reveal best-value diagnostics, and decipher the nature of (and/or minimize) reactions coded as TAD. Methods: The primary objective of this multi-center study is to reduce uncertainty in final conclusions drawn on CRTRs (cases), defined by dyspnea with objective disturbances and/or significant hemodynamic insults, with/without fever (±F). HRFTRs (controls) represent higher-grade F (T≥39°C or chills/rigors or lower-grade F (≥38°C by +Δ1°C) with non-respiratory effects). Patients (goal: 200) consent to additional sampling (≤24h post-TR) to identify contributing factors in case/control presentations, and in diagnostic groups (TRALI, TACO±F, TAD). Mechanistic axes of interest are cardiorenal, hemolytic, leukoagglutinating, biolipid, vasoactive, and inflammatory. Secondary goals include elucidation of real-life “insult-multiplicity” in CRTRs, tests of greatest yield, and distinguishing features in TRALI/TACO/TAD. Conclusions: A deep systematic CRTR probe may not only reduce diagnostic uncertainty but frame biomarker performance and pathologic signatures in definition-specific CRTRs. The re-classifiability or biology of TAD may be better understood. High-quality, mechanistic, true-to-quantity hemovigilance better exposes burdens and management options. Trial Registration: The trial is registered with ClinicalTrials.gov. with registry number NCT04267029.

Iron deficiency is highly prevalent worldwide and is an issue of health inequity. Despite its high prevalence, uncertainty on the clinical applicability and evidence-base of iron-related lab test cut-offs remains. In particular, current ferritin decision limits for the diagnosis of iron deficiency may not be clinically appropriate nor scientifically grounded.A modified Delphi study was conducted with various clinical experts who manage iron deficiency across Canada. Statements about ferritin decision limits were generated by a steering committee, then distributed to the expert panel to vote on agreement with the aim of achieving consensus and acquiring feedback on the presented statements. Consensus was reached after two rounds, which was defined as 70% of experts rating their agreement for a statement as 5 or higher on a Likert scale from 1 to 7.Twenty-six clinical experts across 10 different specialties took part in the study. Consensus was achieved on 28 ferritin decision limit statements in various populations (including patients with multiple comorbid conditions, pediatric patients, and pregnant patients). For example, there was consensus that a ferritin30 μg/L rules in iron deficiency in all adult patients (age ≥ 18 years) and warrants iron replacement therapy.Consensus statements generated through this study corresponded with current evidence-based literature and guidelines. These statements provide clarity to facilitate clinical decisions around the appropriate detection and management of iron deficiency.

Treatment for postpartum anaemia frequently entails iron supplementation, but questions remain regarding its optimal dosing, frequency, and efficacy. Our objective was to learn about the current prescribing practices of obstetrical providers at multiple hospitals, including indications and regimens used; further, we sought to understand how these practices are learned.A 10-question web-based survey was developed via expert consensus. The survey was distributed via email to obstetrical providers (including trainees) practising at seven hospitals affiliated with the University of Toronto, including from ObstetricsGynaecology (OBGYN), Family Practice (FP-OB) and midwifery.The survey was directly sent to 469 participants and 140 responses were collected from the direct email recruitment pool (response rate 30%). Half of respondents were OBGYN physicians. The most common indication was a post-partum haemoglobin threshold of 90 g/L. Both intravenous and oral formulations were used; the most common oral formulation was ferrous fumarate (77%). Prescribing practices were most commonly shaped using passed-down knowledge.Through this survey, we have learned about the most common post-partum iron supplementation indications, formulations and regimens used in both academic and community hospitals in the greater Toronto area. This insight will help inform future studies investigating the efficacy of oral iron supplementation in the treatment of post-partum anaemia.

The second blood group determination or group check sample is a process of verifying the ABO group with a second blood sample prior to transfusion. It has been used to detect errors related to wrong blood in tube (WBIT) events and reduce the risk of ABO-incompatible transfusions. To prevent the clinical team from collecting the group check sample at the same time as the first sample, a tan top tube only available from the blood bank was introduced for second blood group determinations if drawn within 24 h of the first group and screen.This is a retrospective study analyzing data from 2005 to 2020 before and after the implementation of the blood bank supplied tan top tube for group check. The number of WBIT events, transfusion delays, and health care costs were determined.The number of WBIT events remained unchanged throughout the time period. No delays in transfusion or procedure were reported due to the tan top tube group check. There was no increase in group O transfusions over time. In comparison to using an ethylenediaminetetraacetic acid (EDTA) tube, the tan top tube was estimated to add an extra yearly cost of $790.79 Canadian dollars.Second blood group determination using the blood bank supplied tan top tube did not increase the number of WBIT events detected but ensured an independent sample draw. A minimal incremental cost of implementing the tan top tube was noted with no delay in transfusions or procedures.

Humoral anti-platelet factors such as autoantibodies are thought to primarily clear platelets by triggering macrophage phagocytosis in immune thrombocytopenia (ITP). However, there are scarce studies characterizing the capacity and mechanisms of humoral factor-triggered macrophage phagocytosis of platelets using ITP patient specimens. Here, we assessed sera from a cohort of 24 ITP patients for the capacity to trigger macrophage phagocytosis of normal donor platelets and characterized the contribution of humoral factors to phagocytosis. Sera that produced a phagocytosis magnitude greater than a normal human serum mean plus two standard deviations were considered phagocytosis positive. Overall, 42% of ITP sera were phagocytosis positive. The indirect monoclonal antibody immobilization of platelet antigens assay was used to detect IgG autoantibodies to GPIIb/IIIa, GPIb/IX, and GPIa/IIa. Autoantibody positive sera triggered a higher mean magnitude of phagocytosis than negative sera. Phagocytosis correlated inversely with platelet counts among autoantibody positive patients but not autoantibody negative patients. Select phagocytosis positive sera were separated into IgG purified and depleted fractions via protein G and reassessed for phagocytosis. Phagocytosis was largely retained in the purified IgG fractions. Additionally, we assessed serum concentrations of C-reactive protein, serum amyloid P, and pentraxin 3 as potential phagocytosis modulators. Pentraxin 3 concentrations correlated inversely with platelet counts among patients positive for autoantibodies. Taken together, approximately half of the ITP patient sera studied triggered macrophage phagocytosis of platelets beyond a normal level. An important role for anti-platelet autoantibodies in phagocytosis is supported; a role for pentraxins such as pentraxin 3 may be suggested.

The optimal hemoglobin (HgB) threshold for red blood cell transfusions in adult patients with myelodysplastic syndromes (MDS) has not been defined. We conducted a randomized multi-center study of two transfusion algorithms (liberal, to maintain Hgb 110-120 g/L, versus restrictive, 85-105 g/L) and combined our findings from RBC-ENHANCE with those of REDDS a previously published study of similar design. Primary objectives were measures of compliance to transfusion thresholds and the achievement of a 15 g/L difference in pre-transfusion Hgb. Secondary outcomes included measures of QOL, iron studies and safety. 66 patients were randomized between February 2015-2020, 33 to each arm in 15 international participating sites. The compliance was 58% and 81% in the restrictive and liberal arms respectively and the mean pre-transfusion Hgb thresholds for restrictive and liberal arms were 85.9 (SD 9) and 98.8 g/L (SD 9). Patients in the liberal arms experienced a mean of 3.4 (SD 2.6) more transfusion visits and received a mean of 5.3 (SD 5.5) extra units of blood during the 12-week study. Selected QOL scores were superior pre-transfusion and more patients achieved clinically important differences in the liberal arm. Further data are needed to establish the feasibility of liberal transfusion policies in MDS outpatients. Trial Registration: REDDS: ISRCTN26088319 RBC-ENHANCE: NCT 02099669

To report a rare case of acute hemolytic transfusion reaction (AHTR) following an ABO plasma incompatible group B platelet transfusion.AHTR is an uncommon, but potentially fatal event. Most reported cases of platelet transfusions associated with AHTR involve group O donors.A 34-year-old man, recipient of a group AB haploidentical haematopoietic stem cell transplantation (HSCT), had received re-induction chemotherapy for leukaemia relapse. A group B whole blood-derived buffy coat platelet pool was transfused. He developed rigours/fever, profound hemolytic anaemia, and hemodynamic instability. Serological investigations revealed AHTR from passive transfer of high titre anti-A (256 for IgM and 8192 for IgG).This case highlights the potential risks associated with ABO-mismatched transfusions, and the complexity associated with transfusing HSCT recipients and red cell transfusion recipients with dual populations of circulating red cells. The literature on minor ABO plasma incompatible transfusions, challenges in establishing local policies to limit the risks of AHTR and risk mitigation strategies are discussed.Clinicians must maintain a high level of suspicion for AHTR after ABO plasma incompatible platelet transfusions. Patients must be aware of the risks of AHTR, and early recognition and diagnosis of this complication may be lifesaving.

BackgroundAnaemia is prognostically important and affects 30-40% of cardiac surgical patients. The objective of this study was to examine the association of pre- and postoperative anaemia with outcomes in cardiac surgical patients.MethodsThis was a single-institution retrospective cohort study including cardiac surgical patients from October 26, 2020 to December 3, 2021. Patients were classified as preoperatively non-anaemic (hemoglobin ≥ 130 g/L), anaemic, or treated with IV Iron. The main predictors of interest were nadir haemoglobin on postoperative days 1-2 and preoperative anaemia and receipt of IV iron therapy. The primary outcome was number of red blood cell units (RBC) transfused on postoperative days 1-7. Secondary outcomes included acute kidney injury, hospital length of stay, and 30 day in-hospital mortality. Regression models, adjusted for demographics, comorbidities, and surgical characteristics, examined the association between predictors and outcomes.ResultsA total of 844 patients were included [528 (63%) non-anaemic, 276 (33%) anaemic, and 40 (5%) anaemic, treated with IV iron]. There was no difference between groups in RBC transfusion or mortality, however anaemic patients had a higher adjusted risk for acute kidney injury [aOR 2.69 (95% CI, 1.37 to 5.30), p=0.004] and longer hospital length of stay [aRR 1.38 (95% CI, 1.24 to 1.54), pConclusionsPostoperative anaemia confers additional risk regardless of preoperative anaemia status. Further research is needed to better clarify these associations.

Objectives This survey aims to assess the scope of transfusion e-learning courses in blood establishments and transfusion services internationally. Background E-learning/online education is increasingly used in the education of medical professionals. There is limited published data on the use of e-learning for transfusion medicine. Material and Methods An International survey was designed and distributed to all members of the International Society of Blood Transfusion to assess utilisation of e-learning in their institutions. Descriptive statistics were used to summarise the results. Results A total of 177 respondents participated, 68 of which had e-learning modules in their institutions. Approximately two-thirds of the courses were developed in-house (66%), and 63% are available to learners from outside the host institutions. In one-third of institutions, these courses were established during the COVID-19 pandemic, while 15% had used e-learning courses for more than 10 years. The courses target different audiences and topics ranging from blood donation to hemovigilance. The most common audiences were physicians (71%), laboratory scientists/technologists (69%) and transfusion practitioners (63%). Formal assessment of learning outcomes is used in 70% of the programs. Conclusions The survey demonstrates the widespread use of e-learning courses in transfusion education, with a substantial proportion being developed during the COVID-19 pandemic.

BACKGROUND/OBJECTIVES Transfusion reactions (TRs) may cause or contribute to death. Cardiopulmonary TRs are distressing, and collectively account for most transfusion fatalities, though the degree to which they alter survival more broadly is unclear. Deaths (and their timing) after TRs may provide further insights. MATERIALS/METHODS Adult (tri-hospital network) haemovigilance data (2013-2016) recorded referrals with conclusions ranging from unrelated to transfusion (UTR) to entities such as: septic TRs, serologic/haemolytic reactions, transfusion-associated circulatory overload (TACO), transfusion-associated dyspnoea (TAD), transfusion-related acute lung injury (TRALI), allergic transfusion reaction (ATR), and others. For (in- or out-patient) visits involving suspected TRs (VISTRs), all-cause mortalities (% [95% confidence interval]) and associated time-to-death (TTD) (median days, [interquartile range]) were compared. Diagnoses were defined inclusively (possible-to-definite) or strictly (probable-to-definite). RESULTS Of 1144 events, rank order VISTR mortality following (possible-to-definite) TRs, and associated TTDs, were led by: DHTR 33% [6-19], 1 death at 123d; TRALI 32% [15-54], 6 deaths: 3d [2-20]; BaCon 21% [14-31], 17 deaths: 10d [3-28]; TACO 18% [12-26], 23 deaths: 16d [6-28]; TAD 17% [11-26]: 18 deaths, 6d [3-12]. Higher-certainty TRs ranked similarly (DHTR 50% [9-91]; BaCon 29% [12-55], 4 deaths: 12d [3-22]; and TACO 25% [16-38], 15 deaths: 21d [6-28]). VISTR mortality after TACO or TRALI significantly exceeded ATR (3·3% [2·4-5·8], P

BACKGROUND Platelets are the most commonly discarded blood product in Canada, with the most common cause of in-date product loss being improper storage. Transport containers to maintain temperature and extend acceptable return time may represent a method to reduce wastage. The objective of this study was to evaluate the impact of a validated Platelet Transport Bag (PTB) on platelet wastage. STUDY DESIGN AND METHODS Thirty-six hospitals with the highest platelet discards were invited to participate in a before-after observational study. Hospitals were instructed to utilize a validated 4-h PTB for clinical situations where immediate transfusion was not planned. Five hospitals audited in-date platelet discards from July 2018 to November 2019 to characterize wastage causes. In-date platelet discard data 12 months before and after the start date for each site were analyzed to determine changes in wastage. RESULTS Of 36 hospital sites, 16 agreed to participate. Pre- and postdiscards were 277 and 301, respectively, for all sites combined. There were no significant before-after change in wastage rate (+0.05%, p = .51). Fifty discards were included in the detailed audit; the most common reasons were return to the blood bank after more than 60 min outside a PTB (n = 17, 34%) and return in a red cell cooler (n = 10, 20%). CONCLUSION Implementation of PTB did not improve wastage. Common causes of in-date discards were return after 1 h outside of a PTB and placement in a red cell cooler in error. Further research is required to investigate potential strategies to mitigate in-date platelet wastage.

This sub-study of the FIBRES trial sought to examine the patterns of ABO-compatible cryoprecipitate administration and to identify adverse consequences of ABO-incompatible cryoprecipitate.This was a post hoc analysis of data collected from the FIBRES randomized clinical trial comparing fibrinogen concentrate with cryoprecipitate in the treatment of bleeding related to hypofibrinogenemia after cardiac surgery. The primary outcome was the percentage of administered cryoprecipitate that was ABO-compatible. Secondary outcomes were adverse events at 28 days. A follow-up survey was distributed to the FIBRES participating sites to examine the rationale behind the identified cryoprecipitate ABO-matching practice patterns.A total of 363 patients were included: 53 (15%) received ABO-incompatible cryoprecipitate and 310 (85%) received ABO-compatible cryoprecipitate. There was an increased incidence of post-operative anaemia in the ABO-incompatible group (15; 28.3%) in comparison to the ABO-compatible (44; 14.2%) group (p = 0.01) at 28 days, which was unrelated to haemolysis, without a significant difference in transfusion requirement. In the multivariable logistic regression models accounting for clustering by site, there was no observed statistically significant association between the administration of ABO-incompatible cryoprecipitate and any other adverse outcomes. Nine out of 11 sites did not have a policy requiring ABO-matched cryoprecipitate.This sub-study demonstrated that most cryoprecipitate administered in practice is ABO-compatible, despite the absence of guidelines or blood bank policies to support this practice. A signal towards increased risk of post-operative anaemia may be explained by higher rates of urgent surgery (vs. elective) in the ABO-incompatible group. Future studies should prospectively examine the impact of ABO-compatible versus incompatible cryoprecipitate to conclusively establish if there is a meaningful clinical impact associated with the administration of ABO-incompatible cryoprecipitate.

Objective:To evaluate the utility of autologous bone-flap swab cultures performed at the time of cranioplasty in predicting postcranioplasty surgical site infection (SSI).Design:Retrospective cohort study.Participants:Patients undergoing craniectomy (with bone-flap storage in tissue bank), followed by delayed autologous bone-flap replacement cranioplasty between January 1, 2010, and November 30, 2020.Setting:Tertiary-care academic hospital.Methods:We framed the bone-flap swab culture taken at the time of cranioplasty as a diagnostic test for predicting postcranioplasty SSI. We calculated, sensitivity, specificity, positive and negative predictive values, and positive and negative likelihood ratios.Results:Among 282 unique eligible cases, 16 (5.6%) developed SSI after cranioplasty. A high percentage of bone-flap swab cultures were positive at the time of craniectomy (66.7%) and cranioplasty (59.5%). Most organisms from bone-flap swab cultures were Cutibacterium acnes or coagulase-negative staphylococci (76%–85%), and most SSI pathogens were methicillin-susceptible Staphylococcus aureus (38%). Bone-flap swab culture had poor sensitivity (0.07; 95% CI, 0.01–0.31), specificity (0.4; 95% CI, 0.34–0.45), and positive likelihood ratio (0.12) for predicting postcranioplasty SSI.Conclusion:Overall, autologous bone-flap swab cultures performed at the time of cranioplasty have poor utility in predicting postcranioplasty SSI. Eliminating this low-value practice would result in significant workload reductions and associated healthcare costs.

BACKGROUND Transfusion of red blood cells (RBC) is a common procedure, which when prescribed inappropriately can result in adverse patient outcomes. This study sought to determine the impact of a multi-faceted intervention on unnecessary RBC transfusions at hospitals with a baseline appropriateness below 90%. STUDY DESIGN AND METHODS A prospective medical chart audit of RBC transfusions was conducted across 15 hospitals. For each site, 10 RBCs per month transfused to inpatients were audited for a 5-month pre- and 10-month post-intervention period, with each transfusion adjudicated for appropriateness based on pre-set criteria. Hospitals with appropriateness rates below 90% underwent a 3-month intervention which included: adoption of standardized RBC guidelines, staff education, and prospective transfusion order screening by blood bank technologists. Proportions of RBC transfusions adjudicated as appropriate and the total number of RBC units transfused per month in the pre- and post-intervention period were examined. RESULTS Over the 15-month audit period, at the 13 hospital sites with a baseline appropriateness below 90%, 1950 patients were audited of which 81.2% were adjudicated as appropriate. Proportions of appropriateness and single-unit orders increased from 73.5% to 85% and 46.2% to 68.2%, respectively from pre- to post-intervention (P

Background Hemolysis following the administration of intravenous immunoglobulin (IVIG) is an important adverse event (AE). While the monocyte monolayer assay (MMA) has been used to predict in vivo hemolysis when serologically incompatible blood may be transfused, it has also been shown to correlate with IVIG-associated hemolysis. In this study, the MMA was examined for its utility in assessing the risk of hemolysis after IVIG. Study design and methods Forty-two non-blood group O patients receiving high-dose IVIG (≥2 g/kg) were examined using an autologous and allogeneic MMA. Hemolysis was defined by a drop in hemoglobin of ≥1 g/L, a positive direct antiglobulin test (DAT) and eluate, and a decrease in haptoglobin or increase in lactate dehydrogenase and/or reticulocytes. Results Forty-two patients provided 50 assessable postinfusion samples, with hemolysis observed in 20 (40%) of cases. Autologous MMA using post-IVIG red blood cells significantly correlated with clinical outcomes when compared to allogeneic MMA (P = .0320 vs .5806, t test). No significant difference in receiver operating characteristics was observed when comparing autologous MMA testing against DAT for the diagnosis of IVIG-associated hemolysis. However, when using samples collected 5 to 10 days after receipt of high-dose IVIG, the autologous MMA had higher sensitivity than the DAT. Conclusion MMA testing with autologous monocytes collected 5 to 10 days after receipt of high-dose IVIG can be used for the diagnosis of IVIG-associated hemolysis and may be of particular value in cases in which the Day 5 to 10 DAT is negative.

Background Platelet transfusions are used to prevent or control bleeding in patients with thrombocytopenia or platelet dysfunction. The pretransfusion platelet count threshold has been studied extensively in multiple patient settings yielding high-quality evidence that has been summarized in several comprehensive evidence-based platelet guidelines. Study design and methods A prospective 12-week audit of consecutive platelet transfusions using validated and evidence-based adjudication criteria was conducted. Patient demographic, laboratory, and transfusion details were collected with an electronic audit tool. Each order was adjudicated either electronically or independently by two transfusion medicine physicians. The aim was to determine platelet transfusion appropriateness and common scenarios with deviations from guidelines. Results Fifty-seven (38%) of 150 hospitals provided data on 1903 platelet orders, representing 90% of platelet usage in the region during the time period. Overall, 702 of 1693 adult (41.5%) and 133 of 210 pediatric orders (63.3%) were deemed inappropriate. The most common inappropriate platelet order was for prophylaxis in the absence of bleeding or planned procedure in patients with hypoproliferative thrombocytopenia and a platelet count over 10 x 109 /L (53% of inappropriate orders in adults and 45% in pediatrics). Platelet transfusions ordered with either a preprinted transfusion order set (odds ratio [OR], 1.97; 95% confidence interval [CI], 1.44-2.73) or technologist prospective screening (OR, 1.40; 95% CI, 1.10-1.78) were more likely to be appropriate. Conclusion There is a discrepancy between clinical practice and evidence-based platelet guidelines. Broad educational and system changes will be needed to align platelet transfusion practice with guideline recommendations.

Background Alloimmunization can impact both the fetus and neonate. Study objectives (a) calculate the incidence of clinically significant RBC isoimmunization during pregnancy, (b) review maternal management and neonatal outcomes, (c) assess the value of prenatal and postnatal serological testing in predicting neonatal outcomes. Study design and methods A retrospective audit of consecutive alloimmunized pregnancies was conducted. Data collected included demographics, clinical outcomes, and laboratory results. Outcomes included: incidence of alloimmunization; outcomes for neonates with and without the cognate antigen; and sensitivity and specificity of antibody titration testing in predicting hemolytic disease of the fetus and newborn (HDFN). Results Over 6 years, 128 pregnant women (0.4%) were alloimmunized with 162 alloantibodies; anti-E was the most common alloantibody (51/162; 31%). Intrauterine transfusions (IUTs) were employed in 2 (3%) of 71 mothers of cognate antigen positive (CoAg+) neonates. Of 74 CoAg+ neonates, 58% required observation alone, 23% intensive phototherapy, 9% top up transfusion, and 3% exchange transfusion; no fetal or neonatal deaths occurred. HDFN was diagnosed in 28% (21/74) of neonates; anti-D was the most common cause. The sensitivity and specificity of the critical gel titer >32 in predicting HDFN were 76% and 75%, respectively (negative predictive value 95%; positive predictive value 36%). The sensitivity and specificity of a positive direct antiglobulin test (DAT) in predicting HDFN were 90% and 58%, respectively (NPV 97%; PPV 29%). Conclusion Morbidity and mortality related to HDFN was low; most alloimmunized pregnancies needed minimal intervention. Titers of >32 by gel warrant additional monitoring during pregnancy.

Background: Patients with immune thrombocytopenia are at risk of bleeding during surgery, and intravenous immunoglobulin is commonly used to increase the platelet count. We aimed to establish whether perioperative eltrombopag was non-inferior to intravenous immunoglobulin. Methods: We did a randomised, open-label trial in eight academic hospitals in Canada. Patients were aged at least 18 years, with primary or secondary immune thrombocytopenia and platelet counts less than 100 × 109 cells per L before major surgery or less than 50 × 109 cells per L before minor surgery. Previous intravenous immunoglobulin within 2 weeks or thrombopoietin receptor agonists within 4 weeks before randomisation were not permitted. Patients were randomly assigned to receive oral daily eltrombopag 50 mg from 21 days preoperatively to postoperative day 7 or intravenous immunoglobulin 1 g/kg or 2 g/kg 7 days before surgery. Eltrombopag dose adjustments were allowed weekly based on platelet counts. The randomisation sequence was generated by a computerised random number generator, concealed and stratified by centre and surgery type (major or minor). The central study statistician was masked to treatment allocation. The primary outcome was achievement of perioperative platelet count targets (90 × 109 cells per L before major surgery or 45 × 109 cells per L before minor surgery) without rescue treatment. We did intention-to-treat and per-protocol analyses using an absolute non-inferiority margin of –10%. This trial is registered with ClinicalTrials.gov, NCT01621204. Findings: Between June 5, 2013, and March 7, 2019, 92 patients with immune thrombocytopenia were screened, of whom 74 (80%) were randomly assigned: 38 to eltrombopag and 36 to intravenous immunoglobulin. Median follow-up was 50 days (IQR 49–55). By intention-to-treat analysis, perioperative platelet targets were achieved for 30 (79%) of 38 patients assigned to eltrombopag and 22 (61%) of 36 patients assigned to intravenous immunoglobulin (absolute risk difference 17·8%, one-sided lower limit of the 95% CI 0·4%; pnon-inferiority=0·005). In the per-protocol analysis, perioperative platelet targets were achieved for 29 (78%) of 37 patients in the eltrombopag group and 20 (63%) of 32 in the intravenous immunoglobulin group (absolute risk difference 15·9%, one-sided lower limit of the 95% CI –2·1%; pnon-inferiority=0·009). Two serious adverse events occurred in the eltrombopag group: one treatment-related pulmonary embolism and one vertigo. Five serious adverse events occurred in the intravenous immunoglobulin group (atrial fibrillation, pancreatitis, vulvar pain, chest tube malfunction and conversion to open splenectomy); all were related to complications of surgery. No treatment-related deaths occurred. Interpretation: Eltrombopag is an effective alternative to intravenous immunoglobulin for perioperative treatment of immune thrombocytopenia. However, treatment with eltrombopag might increase risk of thrombosis. The decision to choose one treatment over the other will depend on patient preference, resource limitations, cost, and individual risk profiles. Funding: GlaxoSmithKline and Novartis.

BACKGROUND Blood transfusion is common and potentially lifesaving but is associated with risk and overuse. Nurse practitioners (NPs) in multidisciplinary care teams are increasingly expanding their scope of practice to transfusion medicine (TM). Resources aimed at NPs are lacking, and little is known about NP TM knowledge. Thus, we developed a pilot TM curriculum for NP credentialing and assessed its impact. METHODS NP leads and TM directors adapted the successful Canadian Transfusion Camp for medical postgraduate trainees into a 3-day curriculum for NPs. Two modalities were used to assess the pilot: 1) a participant demographics survey and needs assessment; and 2) the validated BEST-TEST knowledge assessment exam administered before and after the course. RESULTS Of the 23 volunteer participants, the majority reported prescribing blood products within the last year, primarily red blood cells. Minimal opportunities to undertake continuing medical education in TM were identified. NPs often used preprinted order forms, consultation with physicians sharing care, or local fact sheets to guide transfusion; rather than TM physician consultation or guidelines. Exam scores significantly improved after the course (before, 35.2% vs. after, 50.3%; p = 0.005), suggesting average initial knowledge being below medical postgraduate trainee-level improving to postgraduate trainee level. Questions on appropriate transfusion triggers and correct recipient identification were most correctly answered; and responses to transfusion reaction questions required improvement. CONCLUSIONS Our needs assessment suggests that TM resources for NPs are relevant but lacking. Our initiative supports the generalizability, scalability, and effectiveness of the Transfusion Camp program. Further implementation, refinement, and future impact assessments are required.

Transfusion dependence on red blood cells (RBCs) is common for patients with myelodysplastic syndromes (MDS) but transfusion practice and experience for outpatients with MDS are largely unknown.We conducted a web-based cross-sectional multi-national survey to audit real-world transfusion practices and understand the experiences and preferences of patients with MDS requiring RBC transfusion. The survey comprised 57 questions and was distributed to patients in the United States of America, Canada, and the United Kingdom.447 respondents (45% female) with a median age of 72 years (IQR 66-77) were eligible on the basis of receiving an RBC transfusion in the last 8 weeks. There was wide variability in the hemoglobin thresholds for transfusion with the most common being80 g/L. 40% of patients were transfused at a lower threshold (70-75 g/L), with the largest proportion of these patients from the United States. Patients experienced significant symptoms prior to receiving a transfusion with fatigue and dyspnea having the most negative impacts on quality of life. Finally, patients endorsed two potential alterations to transfusion care that could improve their quality of life, including self-administered point of care testing of hemoglobin and higher hemoglobin transfusion thresholds. Of these patients, 62% preferred a threshold of at least 85 g/L, and 20% preferred a threshold of at least 100 g/L.In summary, this multi-national survey of patients with MDS requiring RBC transfusions demonstrated substantial variation in patients' experiences and preferences that differed also by country, supporting the need for further comparative clinical trials of transfusion practice interventions.

IntroductionDespite use of operative and non-operative interventions to reduce blood loss during liver resection, 20%–40% of patients receive a perioperative blood transfusion. Extensive intraoperative blood loss is a major risk factor for postoperative morbidity and mortality and receipt of blood transfusion is associated with serious risks including an association with long-term cancer recurrence and overall survival. In addition, blood products are scarce and associated with appreciable expense; decreasing blood transfusion requirements would therefore have health system benefits. Tranexamic acid (TXA), an antifibrinolytic, has been shown to reduce the probability of receiving a blood transfusion by one-third for patients undergoing cardiac or orthopaedic surgery. However, its applicability in liver resection has not been widely researched.Methods and analysisThis protocol describes a prospective, blinded, randomised controlled trial being conducted at 10 sites in Canada and 1 in the USA. 1230 eligible and consenting participants will be randomised to one of two parallel groups: experimental (2 g of intravenous TXA) or placebo (saline) administered intraoperatively. The primary endpoint is receipt of blood transfusion within 7 days of surgery. Secondary outcomes include blood loss, postoperative complications, quality of life and 5-year disease-free and overall survival.Ethics and disseminationThis trial has been approved by the research ethics boards at participating centres and Health Canada (parent control number 177992) and is currently enrolling participants. All participants will provide written informed consent. Results will be distributed widely through local and international meetings, presentation, publication and ClinicalTrials.gov.Trial registration numberNCT02261415.

Treatment for post-partum anemia frequently entails oral iron supplementation, but questions remain regarding optimal dosing, frequency, and efficacy. The objective of this study was to describe oral iron prescribing practices in post-partum women deliveredA retrospective review of Cesarean section deliveries at a single tertiary center between May 2019 and April 2020 was undertaken. Patient demographics, hematological indices, indication for Cesarean section and discharge prescriptions were collected. Univariate and multivariable analyses were performed to identify factors associated with oral iron prescription at discharge.During the study period, 1470 women were eligible for inclusion. The mean age at delivery was 34.4 ± 4.9 years and mean gestational age was 37.2 ± 3.6 weeks. Most pregnancies (92%) were singleton. Ninety-six total patients (6.5%) received intravenous iron post-partum. Fourteen percent of women (210/1470) received prescriptions for oral iron at discharge, most commonly ferrous fumarate (61.9%, 130/210). The most common dose provided was 300 mg (145/210). Ante-partum ferritin was available for most patients (64.3%, 945/1470), but only for 17 post-partum patients (1.2%). Factors significantly associated with oral iron prescription were earlier gestational age at birth (aOR 0.93, 95% CI 0.89-0.97), history of complications during pregnancy or labor (aOR 1.92, 95% CI 1.26-2.98), higher blood loss (aOR 2.66, 95% CI 1.36-5.44), post-partum anemia (aOR 6.28, 95%-CI 4.41-8.96), blood transfusion (aOR 5.43, 95%-CI 1.81-18.19) and antenatal iron supplementation (aOR 5.70, 95%-CI 4.02-8.17).In summary, a relatively small proportion of women following Cesarean section were prescribed oral iron at discharge. We identified several factors associated with post-partum iron supplementation. This information will inform future prospective studies investigating the efficacy of iron supplementation in the treatment of post-partum anemia.