Strategies to reduce allogeneic blood transfusion

Blood is scarce and there will never be zero risk. Thus, multidisciplinary approaches to reduce or avoid allogeneic blood transfusion in medicine and surgery are discussed. In medical patients — depending on the situation — causes of anaemia should be investigated, nutritional deficiencies corrected and erythropoietic stimulating agents (ESA) used with or without intravenous (iv) iron. In surgical patients, it is important to check the blood count, evaluate the history of bleeding and drug therapy far in advance of surgery to allow time for diagnosis, anemia correction, haemostasis optimization or decision for a pre-deposit autologous donation. During intraoperative period bleeding can be minimized through the use of anaesthetic and surgical techniques, correcting hypothermia, acidosis, hypocalcaemia or hyperkaliemia. Also the use of pharmacological agents such as haemostatic sealants, antifibrinolytics, procoagulants and methods of autologous transfusion (acute normovolemic haemodilution, intracellular cell salvage) helps minimize the dependence on allogeneic blood transfusion. During acute bleeding, the use of thromboelastometry gives a full haemostasis overview and allows for more targeted use of platelet concentrates and fibrinogen. It has also been shown to reduce intraoperative transfusion requirements in high-risk surgical patients. In conclusion, the above-mentioned strategies, when included in protocols and guidelines, can substantially contribute to the reduction of the use of allogeneic blood

Rare autosomal dominant hereditary hemochromatosis associated with SLC40A1 gene: ferroportin disease or type 4 hereditary hemochromatosis?

Ferroportin (FPN1), encoded by the SLC40A1 gene, is the unique cellular iron exporter identified in mammals. FPN1 transfers iron from the intestine and macrophages into the bloodstream. This function is negatively regulated by hepcidin. Mutations in SLC40A1 may affect FPN1 function, originating distinct autosomal dominant diseases: (i) the Ferroportin Disease (FD), due to loss-of-function mutations, is characterized by decreased iron export from enterocytes and severely affected iron transfer in macrophages, giving rise to a marked iron accumulation in spleen and liver; and (ii) the Type 4 Hereditary Hemochromatosis (HH), resulting from gain-of-function mutations conferring resistance to hepcidin-mediated FPN1 degradation and consequently high cellular iron export. In this study, 335 individuals suspected of having non-classic HH were enrolled. Six genes related with iron metabolism were analysed by SSCP, dHPLC or NGS. The latter used TruSeq or Nextera XT libraries and a MiSeq platform (Illumina). Genetic variants found were validated by Sanger sequencing. Predictive consequences at protein level were evaluated using Polyphen-2 and SIFT softwares. From all patients analysed, three SLC40A1 pathogenic variants were detected in heterozygosity in three women: two missense, c.238G>A, p.Gly80Ser and c.610G>A, p.Gly204Ser; and one deletion, c.485_487delTTG; p.Val162del. These variants had been reported in public databases, but they were not known to be present in the Portuguese population. The p.Gly80Ser and the p.Val162del are FPN1 loss-of-function mutations and were found associated with hyperferritinemia and low transferrin saturation (FD). In contrast, the p.Gly204Ser induced a gain of FPN1 function with a full iron export capacity giving the patient a type 4-HH phenotype, which includes iron overload, hyperferritinemia and high transferrin saturation. Detailed clinical evaluation of the suspected patients are useful to unravel the effect of different mutations in FPN1 function, expression and regulation.This work was partially supported by INSA_2013DGH910 and GenomePT (POCI-01-0145-FEDER-022184).info:eu-repo/semantics/publishedVersio

Does Pelvic Exam in the Emergency Department Add Useful Information?

Objective: Physicians are taught that the pelvic exam is a key part of the evaluation of a woman presenting with abdominal pain or vaginal bleeding. However, the exam is time consuming and invasive, and its use in the emergency department (ED) has not been prospectively evaluated. We evaluated how often the findings of the pelvic exam changed management in a cohort of consecutive female patients presenting with acute abdominal pain or vaginal bleeding.Methods: We enrolled women who required a pelvic exam together with the providers caring for them in an academic ED from September 2004 to August 2005. We collected the results of the general history and physical exam. The provider was asked to predict the findings of the pelvic exam, and these were compared with the actual findings of the exam.Results: One hundred eighty-three patients were prospectively entered into the study. When compared with predicted findings, the pelvic exam was as expected in 131 patients (72%). In a further 40 patients (22%), the findings of the pelvic exam were not as predicted, but resulted in no change in the clinical plan. In 12 cases (6%) the exam revealed a finding that was both unexpected and changed the clinical plan. Only one of these patients was admitted. Of the 24 patients who were admitted, four had a pelvic exam that revealed unexpected results, but only one of these cases caused the physician to change the care planned for the patient.Conclusion: In 94% of women with acute abdominal pain or vaginal bleeding, the results of the pelvic exam were either predictable or had no effect on the clinical plan. This suggests that there may be a subset of women with abdominal pain or vaginal bleeding in whom a pelvic exam may safely be deferred. [West J Emerg Med. 2011;12(2):208-212.

Developing occupational therapy students’ information and historical literacy competencies: an interprofessional collaborative project

Objective: The study examined the efficacy of an interprofessional information and historical literacy project implemented by an occupational therapy educator and a librarian. Methods: A graduate course was revised to include information and historical literacy objectives and instruction. A course-specific questionnaire administered on the first and last day of class, assignment grades, and course evaluations provided measures of project outcomes for six years. Differences between questionnaire pre- and post-test means were determined using t-tests. Course evaluation comments were analyzed to obtain qualitative perceptions. Results: A significant difference (p<0.0001) was found between pre-test (M=3.93, SD=0.48) and post-test (M=4.67, SD=0.30) scores of total information and historical literacy competence across all years (n=242). Responses to individual items also differed significantly (p<0.0001). Student ratings (n=189) from the course evaluation historical literacy objectives were high (M=4.6 on a 5-point scale). Assignment quality and grades improved, and course evaluation comments reflected student satisfaction. Conclusions: The findings supported the hypothesis that students’ self-reported information and historical literacy competencies would increase after project participation. Acquired skills were evident in students’ assignments. Research to determine if these capabilities were used post-graduation is needed. Because this was a course-specific project, findings are not generalizable; however, the instructional methods developed for this project can serve as a model for effective interprofessional collaboration. The broadening of information literacy instruction to include discipline-specific historical literacy provides a unique opportunity for health sciences librarians and educators. Developing students’ historical literacy in their chosen fields can help them understand their profession’s present status and be informed participants in shaping its future

Distribution and quantitation of skin iron in primary haemochromatosis: correlation with total body iron stores in patients undergoing phlebotomy

Measurement of the concentration of iron in the skin, if correlated with total body iron stores, may enable better informed decisions on when to initiate, change or stop therapy in hereditary heamochromatosis. Naïve haemochromatosis patients with iron overload and with C282Y and/or H63D HFE mutations were evaluated at the following time-points: disease diagnosis, end of the therapy programme, and 6 months after the end of therapy. The distribution and concentration of iron in the skin were assessed by quantitative nuclear microscopy methods, in parallel with serum and plasma iron concentration. Iron content in the liver was determined by nuclear magnetic resonance. Iron accumulated in the epidermis; its concentration increased from outer to inner layers, being maximal in the basal layer (7.33?±?0.98 µmol/g). At all 3 time-points, most of the iron was associated with the extracellular space. During the phlebotomy programme the iron content of the skin and the liver decreased by a factor of 2. These data suggest that measurements of iron concentration in the epidermis, which is a readily accessible tissue, reflect iron overload in the liver