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A Canadian survey of transfusion practices in critically ill patients
308 (21%) of the components were traced to living recipients, 22 of whom were tested for anti-HCV. Ten recipients (45% of those tested) were RIBA positive; seven of these were also PCR positive. Three of the seven recipients that were RIBA and PCR positive had abnormal liver function tests and underwent liver biopsy; two of the three were also heavy drinkers, and none were thought to require interferon treatment at the time of the study. Interestingly, all 10 recipients that received components from the four donors that were PCR negative were antibody and PCR negative, whereas 10 of 12 recipients of blood from PCRpositive donors had at least two bands present on RIBA-3, and seven were PCR positive on initial or repeat testing. Although this is a small study, it is interesting in several respects. PCR testing was done by the same reference laboratory for donors and recipients. PCR positivity in donors correlated strongly with infectivity of previous donations, suggesting that PCR-negative donors had cleared the virus at the time of previous donations. Compared with lookback studies done in other countries, fewer recipients had died (26% v up to 72%), and the average age of anti-HCV-positive recipients was lower (mean age, 43, v up to 62), perhaps reflecting different demographics in Northern Ireland compared with Canada and other European countries. The study is also interesting because clinical information is available on all the recipients. The authors do not state whether any of the recipients were already aware of their HCV status. Although none of the recipients was thought to need treatment, this may change during the course of their disease. In addition, at least two patients were heavy drinkers and may benefit from counseling, because alcohol appears to be an important cofactor in the progression of HCV infection.
A Canadian survey of transfusion practices in critically ill patients. H6bert PC, Wells G, Martin C, et al. Crit Care Med 26:482-487, 1998. Recent transfusion guidelines have emphasized that decisions to transfuse should be based on clinical characteristics and not on a specific transfusion trigger. This article summarizes a scenario-based national survey of Canadian critical care practitioners. The objectives of the survey were to characterize transfusion practice in critically ill patients and define clinical characteristics that influence administration of red cell transfusions. The study population consisted of 254 critical care practitioners identified using the Canadian and Provincial Critical Care Societies membership mailing lists. Each was mailed two medical and two surgical scenarios that specified the patient's age, gender, diagnosis, hemodynamic status, and the presence or absence of hypoxia. The basic scenarios were (1) a 24-year-old man in a motor vehicle accident; (2) a 70-year-old woman with an upper gastrointestinal hemorrhage; (3) a 45-yearold alcoholic man with sepsis and respiratory failure; and (4) a 55-year-old man with an acute myocardial infarction 4 days after abdominal aortic aneurysm repair. Each basic scenario was accompanied by three separate changes in clinical characteristics that could potentially modify baseline responses, such as age, coronary ischemia, chronic anemia, and shock. The response rate to the survey was 76%. Physician characteristics such as year of graduation, primary specialty, and number of years in intensive care unit (ICU) practice had no effect on transfusion thresholds. Physicians with an academic affiliation transfused at a lower transfusion threshold. In the basic trauma and sepsis scenarios (1 and 3), the most frequent hemoglobin
CURRENT LITERATURE concentration resulting in a transfusion at baseline was 8.0 g/dL, whereas in the gastrointestinal bleeding and postoperative acute myocardial infarction scenarios (2 and 4), the most frequent hemoglobin concentration was 10.0 g/dL. Transfusion thresholds ranged from 5.0 to 12.0 g/dL, depending on the scenario. Changes in clinical characteristics such as age resulted in changes in the transfusion threshold. This study shows that, at least in idealized "on paper" scenarios, critical care physicians have moved away from the arbitrary transfusion trigger of 10 g/dL and adjust the threshold depending on clinical factors. The authors attribute much of the variation in transfusion practice to the paucity of clinical trials evaluating different transfusion strategies in critically ill patients and believe that such trials should be undertaken before developing practice guidelines for this patient population.
A prospective multicenter study of hepatocellular carcinoma in Italian hemophiliacs with chronic hepatitis C. Tradati F, Colombo PM, Mannucci PM, et al. Blood 91:1173-1177, 1998. Hepatocellular carcinoma (HCC) is an important cause of death in hemophilia patients infected with hepatitis C virus (HCV). The objectives of this study were to assess the natural history of HCC in patients with hemophilia and to determine whether screening with annual ultrasound and alpha-fetoprotein (AFP) measurements improves survival because of earlier tumor detection. Patients with a focal lesion on abdominal ultrasound and serum AFP higher than 400 ng/mL were considered to have HCC; patients with a focal lesion on ultrasound and serum AFP less than 400 ng/mL were considered suspect and underwent lower biopsy. Three hundred eighty-five patients followed-up in 11 hemophilia centers in Italy were enrolled in the study; however, only 40 patients had cirrhosis based on clinical and endoscopic signs of portal hypertension and abdominal ultrasound features. Patients ranged in age from 10 to 83 years (median, 31). Twenty-nine had both anti-HCV and hepatitis B surface antigen (HBsAg), and 141 had anti-HCV and anti-HIV (human immunodeficiency virus). During the 4-year follow-up period, 36 patients died, 20 of HIV-related events, one of other causes, and 15 (3.9%) of liver-related disease. Of these 15, 6 had developed HCC. On average, these patients had first been transfused at age 40 years, compared with age 12 years for the other patients. All of the tumors were multicentric at the time of diagnosis, and therefore the patients did not meet criteria for surgery or arterial chemoembolization. AFP was higher than 400 ng/mL in one patient and was above the upper limit of normal (7 ng/mL) but less than 400 ng/mL in five patients. The time from diagnosis to death varied from 4 to 19 months. Age, presence of cirrhosis, and high AFP level at the time of enrollment were significantly associated with increased risk of HCC. This study confirms the observation that patients infected later in life are at increased risk of cirrhosis; the reasons for this are unknown. HCV genotypes among patients with HCC were similar to those in the entire Italian hemophiliac population. The rate of multicentric tumors was much higher than the rates reported in nonhemophilic patients. However, the actual number of cases is small, and therefore it is difficult to draw firm conclusions from these observations. Because this annual screening protocol did not result in any survival benefit, the authors are now conducting a study using 6-month screening intervals.
A Canadian survey of transfusion practices in critically ill patients. H6bert PC, Wells G, Martin C, et al. Crit Care Med 26:482-487, 1998. Recent transfusion guidelines have emphasized that decisions to transfuse should be based on clinical characteristics and not on a specific transfusion trigger. This article summarizes a scenario-based national survey of Canadian critical care practitioners. The objectives of the survey were to characterize transfusion practice in critically ill patients and define clinical characteristics that influence administration of red cell transfusions. The study population consisted of 254 critical care practitioners identified using the Canadian and Provincial Critical Care Societies membership mailing lists. Each was mailed two medical and two surgical scenarios that specified the patient's age, gender, diagnosis, hemodynamic status, and the presence or absence of hypoxia. The basic scenarios were (1) a 24-year-old man in a motor vehicle accident; (2) a 70-year-old woman with an upper gastrointestinal hemorrhage; (3) a 45-yearold alcoholic man with sepsis and respiratory failure; and (4) a 55-year-old man with an acute myocardial infarction 4 days after abdominal aortic aneurysm repair. Each basic scenario was accompanied by three separate changes in clinical characteristics that could potentially modify baseline responses, such as age, coronary ischemia, chronic anemia, and shock. The response rate to the survey was 76%. Physician characteristics such as year of graduation, primary specialty, and number of years in intensive care unit (ICU) practice had no effect on transfusion thresholds. Physicians with an academic affiliation transfused at a lower transfusion threshold. In the basic trauma and sepsis scenarios (1 and 3), the most frequent hemoglobin
CURRENT LITERATURE concentration resulting in a transfusion at baseline was 8.0 g/dL, whereas in the gastrointestinal bleeding and postoperative acute myocardial infarction scenarios (2 and 4), the most frequent hemoglobin concentration was 10.0 g/dL. Transfusion thresholds ranged from 5.0 to 12.0 g/dL, depending on the scenario. Changes in clinical characteristics such as age resulted in changes in the transfusion threshold. This study shows that, at least in idealized "on paper" scenarios, critical care physicians have moved away from the arbitrary transfusion trigger of 10 g/dL and adjust the threshold depending on clinical factors. The authors attribute much of the variation in transfusion practice to the paucity of clinical trials evaluating different transfusion strategies in critically ill patients and believe that such trials should be undertaken before developing practice guidelines for this patient population.
A prospective multicenter study of hepatocellular carcinoma in Italian hemophiliacs with chronic hepatitis C. Tradati F, Colombo PM, Mannucci PM, et al. Blood 91:1173-1177, 1998. Hepatocellular carcinoma (HCC) is an important cause of death in hemophilia patients infected with hepatitis C virus (HCV). The objectives of this study were to assess the natural history of HCC in patients with hemophilia and to determine whether screening with annual ultrasound and alpha-fetoprotein (AFP) measurements improves survival because of earlier tumor detection. Patients with a focal lesion on abdominal ultrasound and serum AFP higher than 400 ng/mL were considered to have HCC; patients with a focal lesion on ultrasound and serum AFP less than 400 ng/mL were considered suspect and underwent lower biopsy. Three hundred eighty-five patients followed-up in 11 hemophilia centers in Italy were enrolled in the study; however, only 40 patients had cirrhosis based on clinical and endoscopic signs of portal hypertension and abdominal ultrasound features. Patients ranged in age from 10 to 83 years (median, 31). Twenty-nine had both anti-HCV and hepatitis B surface antigen (HBsAg), and 141 had anti-HCV and anti-HIV (human immunodeficiency virus). During the 4-year follow-up period, 36 patients died, 20 of HIV-related events, one of other causes, and 15 (3.9%) of liver-related disease. Of these 15, 6 had developed HCC. On average, these patients had first been transfused at age 40 years, compared with age 12 years for the other patients. All of the tumors were multicentric at the time of diagnosis, and therefore the patients did not meet criteria for surgery or arterial chemoembolization. AFP was higher than 400 ng/mL in one patient and was above the upper limit of normal (7 ng/mL) but less than 400 ng/mL in five patients. The time from diagnosis to death varied from 4 to 19 months. Age, presence of cirrhosis, and high AFP level at the time of enrollment were significantly associated with increased risk of HCC. This study confirms the observation that patients infected later in life are at increased risk of cirrhosis; the reasons for this are unknown. HCV genotypes among patients with HCC were similar to those in the entire Italian hemophiliac population. The rate of multicentric tumors was much higher than the rates reported in nonhemophilic patients. However, the actual number of cases is small, and therefore it is difficult to draw firm conclusions from these observations. Because this annual screening protocol did not result in any survival benefit, the authors are now conducting a study using 6-month screening intervals.