Serum per- and polyfluoroalkyl substance concentrations in four municipal US fire departments.

BACKGROUND: Firefighters have occupational and environmental exposures to per- and polyfluoroalkyl substances (PFAS). The goal of this study was to compare serum PFAS concentrations across multiple United States fire departments to National Health and Nutrition Examination Survey (NHANES) participants. METHODS: Nine serum PFAS were compared in 290 firefighters from four municipal fire departments (coded A-D) and three NHANES participants matched to each firefighter on sex, ethnicity, age, and PFAS collection year. Only Departments A and C had sufficient women study participants (25 and six, respectively) to compare with NHANES. RESULTS: In male firefighters compared with NHANES, geometric mean perfluorohexane sulfonate (PFHxS) was elevated in Departments A-C, sum of branched perfluoromethylheptane sulfonate isomers (Sm-PFOS) was elevated in all four departments, linear perfluorooctane sulfonate (n-PFOS) was elevated in Departments B and C, linear perfluorooctanoate (n-PFOA) was elevated in Departments B-D, and perfluorononanoate (PFNA) was elevated in Departments B-D, but lower in A. In male firefighters compared with NHANES, perfluoroundecanoate (PFUnDA) was more frequently detected in Departments B and D, and 2-(N-methyl-perfluorooctane sulfonamido) acetate (MeFOSAA) was less frequently detected in Departments B-D. In female firefighters compared with NHANES, PFHxS and Sm-PFOS concentrations were elevated in Departments A and C. Other PFAS concentrations were elevated and/or reduced in only one department or not significantly different from NHANES in any department. CONCLUSIONS: Serum PFHxS, Sm-PFOS, n-PFOS, n-PFOA, and PFNA concentrations were increased in at least two of four fire departments in comparison to NHANES.

Maternal iron deficiency anaemia in pregnancy: Lessons from a national audit.

We describe the management and the prevalence of iron deficiency anaemia (IDA) during pregnancy by comparison to standards. A cross-sectional national cohort study of women who had given birth six weeks prior to data collection was conducted at maternity units in the UK and Ireland. Participating centres collected data from 10 consecutive pregnant women. Analysis was descriptive to define the prevalence of IDA in pregnancy and the puerperium, and to compare the outcomes in women who had IDA with women who did not have anaemia anytime during pregnancy. Eighty-six maternity units contributed data on 860 pregnancies and births. The overall prevalence of IDA during pregnancy was 30.4% and in the puerperium 20%. Anaemic women were more likely to be from ethnic minorities, odds ratio 2.23 (1.50, 3.32). Adherence to national guidance was suboptimal, and the prevalence of anaemia in pregnancy remains very high. There is pressing need to explore barriers to early identification and effective management of iron deficiency. IDA should be considered a major public health problem in the UK.

Assessing the Effect of Unit Champion-Initiated Audits on Fall Rates: Improving Awareness.

BACKGROUND: Inpatient falls remain challenging with repercussions that can include patient injury and increased hospital expense. Fall rates were consistently above the national benchmark. An initiative to reduce fall rates was use of Fall Champion Audits (FCAs). PURPOSE: The aim of this study was to assess the effect of FCAs on patient fall rates. METHODS: FCAs were piloted on a medical-oncology unit. An interrupted time series design was used to assess the effect of FCAs on fall rates. INTERVENTION: FCA is an audit conducted by the unit fall champion that assesses fall risk, interventions, and barriers among staff and patients. RESULTS: Analysis suggested a significant decrease in fall rates from pre- (3.75) to postimplementation (1.62). FCAs worked in conjunction with a division-wide fall program in reducing fall rate. CONCLUSIONS: FCAs, in conjunction with a fall program, are a feasible intervention in reducing fall rates.

Patient blood management knowledge and practice among clinicians from seven European university hospitals: a multicentre survey.

BACKGROUND AND OBJECTIVES: The aim of this survey was to evaluate the knowledge about Patient Blood Management (PBM) principles and practices amongst clinicians working in seven European hospitals participating in a European Blood Alliance (EBA) project. MATERIALS AND METHODS: A web-based questionnaire was sent to 4952 clinicians working in medical, surgery and anaesthesiology disciplines. The responses were analysed, and the overall results as well as a comparison between hospitals are presented. RESULTS: A total of 788 responses (16%) were obtained. About 24% of respondents were not aware of a correlation between preoperative anaemia (POA) and perioperative morbidity and mortality. For 22%, treatment of POA was unlikely to favourably influence morbidity and mortality even before surgery with expected blood loss. More than half of clinicians did not routinely treat POA. 29%, when asked which is the best way to treat deficiency anaemia preoperatively, answered that they did not have sufficient knowledge and 5% chose to 'do nothing'. Amongst those who treated POA, 38% proposed red cell transfusion prior to surgery as treatment. Restrictive haemoglobin triggers for red blood cell transfusion, single unit policy and reduction of number and volumes of blood samples for diagnostic purposes were only marginally implemented. CONCLUSION: Overall, the responses indicated poor knowledge about PBM. Processes to diagnose and treat POA were not generally and homogeneously implemented. This survey should provide further impetus to implement programmes to improve knowledge and practice of PBM.

National Comparative Audit of Blood Transfusion: report on the 2014 audit of patient information and consent.

OBJECTIVES: The aim of this study was to assess current practices around obtaining consent for blood transfusion and provision of patient information in hospitals across the UK and identify areas for improvement. BACKGROUND: Recommendations from the Advisory Committee on the Safety of Blood, Tissues and Organs (SaBTO) (2011) state that valid consent should be obtained for blood transfusion and documented in clinical records. A standardised source of information should be available to patients. Practices in relation to this have historically been inconsistent. METHODS: The consent process was studied in hospitals across the UK over a 3-month period in 2014 by means of an audit of case notes and simultaneous surveys of patients and staff. RESULTS: In total, 2784 transfusion episodes were reviewed across 164 hospital sites. 85% of sites had a policy on consent for transfusion. Consent was documented in 43% of case notes. 68% of patients recalled being given information on benefits of transfusion, 38% on risks and 8% on alternatives and 28% reported receiving an information leaflet. In total, 85% of staff stated they had explained the reason for transfusion, but only 65% had documented this. 41% of staff had received training specifically on transfusion consent in the last 2 years. CONCLUSIONS: There is a need to improve clinical practice in obtaining valid consent for transfusion in line with existing national guidelines and local Trust policies, with emphasis on documentation within clinical records. Provision of patient information is an area particularly highlighted for action, and transfusion training for clinicians should be strengthened.

Where do all the red blood cells (RBCs) go? Results of a survey of RBC use in England and North Wales in 2014.

BACKGROUND: Knowledge of blood utilization can assist clinicians in directing patient blood management (PBM) initiatives and can facilitate demand planning by blood services. We describe a national study of red blood cell (RBC) utilization in England and North Wales in 2014. STUDY DESIGN AND METHODS: All hospitals that are supplied with blood components by NHS Blood and Transplant (NHSBT) were asked to provide data on the age and sex of all recipients of transfusions of RBCs, and the clinical indication for every unit transfused, for two separate weeks in 2014. Clinical indication categories were derived from those used in previous studies in an English region. Completeness of data collection was checked against NHSBT issue and wastage data. RESULTS: Data on 46,111 RBC units were collected, representing 73% of all RBCs issued by NHSBT during the weeks surveyed. A total of 67% of RBC units were transfused for a medical indication, with 27 and 6% being transfused for surgical and obstetric/gynecologic indications, respectively. For comparison, figures from a study in the North of England in 2009, on which this national study was based, showed that 64% of RBCs were transfused to medical patients. All but 20 units could be ascribed to a broad clinical heading, for example, "gastrointestinal bleeding." CONCLUSION: Our findings confirm the previous regional finding that the percentage of RBC units that are transfused to surgical patients in England and North Wales is now much lower than for medical patients and suggest that PBM initiatives should now focus on medical patients.

Patient Blood Management in Europe: surveys on top indications for red blood cell use and Patient Blood Management organization and activities in seven European university hospitals.

BACKGROUND AND OBJECTIVES: Patient Blood Management (PBM) in Europe is a working group of the European Blood Alliance with the initial objective to identify the starting position of the participating hospitals regarding PBM for benchmarking purposes, and to derive good practices in PBM from the experience and expertise in the participating teams with the further aim of implementing and strengthening these practices in the participating hospitals. METHODS: We conducted two surveys in seven university hospitals in Europe: Survey on top indications for red blood cell use regarding usage of red blood cells during 1 week and Survey on PBM organization and activities. RESULTS: A total of 3320 units of red blood cells were transfused in 1 week at the seven hospitals. Overall, 61% of red cell units were transfused to medical patients and 36% to surgical patients, although there was much variation between hospitals. The organization and activities of PBM in the seven hospitals were variable, but there was a common focus on optimizing the treatment of bleeding patients, monitoring the use of blood components and treatment of preoperative anaemia. CONCLUSION: Although the seven hospitals provide a similar range of clinical services, there was variation in transfusion rates between them. Further, there was variable implementation of PBM activities and monitoring of transfusion practice. These findings provide a baseline to develop joint action plans to further implement and strengthen PBM across a number of hospitals in Europe.

Assessing transfusion competency in junior doctors: a retrospective cohort study.

BACKGROUND: There is scope to further improve the safety of transfusion practice within the United Kingdom. This study aims to identify the current role of junior doctors in the transfusion process and to assess their competency to appropriately prescribe blood and blood products to patients. STUDY DESIGN AND METHODS: Transfusion competency in junior doctors training in a single region was addressed through anonymized questionnaires assessing factual knowledge, personal reflection, and documented evidence of competency. Factual knowledge comprised 33 true-false questions (competency score) covering indications for transfusion, special requirements, risks of transfusion, and guidelines for testing in transfusion. Background data on current practice and education in transfusion medicine were addressed using multiple-choice and single-response questions. RESULTS: A total of 787 newly qualified doctors, comprising 79% of first-year (F1) and 62% of second-year (F2) Foundation doctors, completed the assessment over a 3-week period. There was no improvement in competency score between F1 and F2 doctors (p = 0.1). Competency scores correlated most strongly with undergraduate education in transfusion medicine and attendance at hospital induction (p < 0.01). Junior doctors had a high confidence level with regard to prescribing blood, although only 78% were aware they had been competency assessed against national standards. CONCLUSION: Junior doctors are involved in sampling, prescribing, consenting, and documenting transfusion practice frequently enough to maintain competency. They are rarely involved in the collection, bedside checking, or administration of blood despite current curriculum requirements. There is scope to significantly improve both the training and the assessment of transfusion competency in doctors.

Red blood cell transfusion practice in children: current status and areas for improvement? A study of the use of red blood cell transfusions in children and infants.

BACKGROUND: Patterns of red blood cell (RBC) transfusion are less well understood for children than adults. This study was undertaken to document current pediatric practice, to identify specific areas for improving patient care and safety. STUDY DESIGN AND METHODS: All UK hospitals were invited to participate. All children less than 18 years old admitted and receiving a RBC transfusion during a 3-month period in 2009 were eligible for inclusion. RESULTS: A total of 160 of 247 (65%) sites treating children or neonates responded; 119 provided data on 1302 pediatric patients transfused in nonneonatal wards. A total of 74% of patients received a single RBC transfusion during their admission. More than half (53%) of recipients had a hematologic or oncologic underlying diagnosis, and 33% were on general pediatric wards. The median pretransfusion hemoglobin (Hb) level was 7.9 g/dL (interquartile range [IQR], 6.9-9.4 g/dL), varying by location and diagnosis. The median volume prescribed was 15 mL/kg (IQR, 11.8-19.2 mL/kg). Prescribing by units instead of milliliters was recorded for 493 of 1264 (39%) of transfusions. For 734 of 1302 (56%) where Hb levels were available within 2 days between pre- and posttransfusion Hb, the median transfusion increment was 2.8 g/dL (IQR, 1.4-3.9 g/dL). CONCLUSION: This study of UK pediatric RBC transfusion practice has demonstrated significant variation in pretransfusion Hb, frequent prescribing in units rather than milliliters, and a high proportion of single transfusions during admissions. Future education and research should target transfusion triggers and prescription volumes for children in all clinical areas.

Firefighting, per- and polyfluoroalkyl substances, and DNA methylation of genes associated with prostate cancer risk.

Prostate cancer is the leading incident cancer among men in the United States. Firefighters are diagnosed with this disease at a rate 1.21 times higher than the average population. This increased risk may result from occupational exposures to many toxicants, including per- and polyfluoroalkyl substances (PFAS). This study assessed the association between firefighting as an occupation in general or PFAS serum levels, with DNA methylation. Only genomic regions previously linked to prostate cancer risk were selected for analysis: GSTP1, Alu repetitive elements, and the 8q24 chromosomal region. There were 444 male firefighters included in this study, with some analyses being conducted on fewer participants due to missingness. Statistical models were used to test associations between exposures and DNA methylation at CpG sites in the selected genomic regions. Exposure variables included proxies of cumulative firefighting exposures (incumbent versus academy status and years of firefighting experience) and biomarkers of PFAS exposures (serum concentrations of 9 PFAS). Proxies of cumulative exposures were associated with DNA methylation at 15 CpG sites and one region located within FAM83A (q-value <0.1). SbPFOA was associated with 19 CpG sites (q < 0.1), but due to low detection rates, this PFAS was modeled as detected versus not detected in serum. Overall, there is evidence that firefighting experience is associated with differential DNA methylation in prostate cancer risk loci, but this study did not find evidence that these differences are due to PFAS exposures specifically.

Occupational Years of Service and Leukocyte Epigenetic Aging: Relationships in United States Firefighters.

OBJECTIVE: The aim of the study is to examine associations between years of firefighting service and eight chronological age-adjusted measures of blood leukocyte epigenetic age acceleration: Horvath, Hannum, SkinBloodClock, Intrinsic, Extrinsic, PhenoAge, GrimAge, and DNAm telomere length. METHODS: The study used a repeated measures analysis of data from 379 incumbent firefighters from eight career departments and 100 recruit firefighters from two of the departments, across the United States. RESULTS: Incumbent firefighters had on average greater epigenetic age acceleration compared with recruit firefighters, potentially due to the cumulative effect of occupational exposures. However, among incumbent firefighters, additional years of service were associated with epigenetic age deceleration, particularly for GrimAge, a strong predictor of mortality. CONCLUSIONS: Long-term studies with more specific occupational exposure classification are needed to better understand the relationship between years of service and aging biomarkers.

Associations Between Epigenetic Age Acceleration and microRNA Expression Among U.S. Firefighters.

Epigenetic changes may be biomarkers of health. Epigenetic age acceleration (EAA), the discrepancy between epigenetic age measured via epigenetic clocks and chronological age, is associated with morbidity and mortality. However, the intersection of epigenetic clocks with microRNAs (miRNAs) and corresponding miRNA-based health implications have not been evaluated. We analyzed DNA methylation and miRNA profiles from blood sampled among 332 individuals enrolled across 2 U.S.-based firefighter occupational studies (2015-2018 and 2018-2020). We considered 7 measures of EAA in leukocytes (PhenoAge, GrimAge, Horvath, skin-blood, and Hannum epigenetic clocks, and extrinsic and intrinsic epigenetic age acceleration). We identified miRNAs associated with EAA using individual linear regression models, adjusted for sex, race/ethnicity, chronological age, and cell type estimates, and investigated downstream effects of associated miRNAs with miRNA enrichment analyses and genomic annotations. On average, participants were 38 years old, 88% male, and 75% non-Hispanic white. We identified 183 of 798 miRNAs associated with EAA (FDR q < 0.05); 126 with PhenoAge, 59 with GrimAge, 1 with Horvath, and 1 with the skin-blood clock. Among miRNAs associated with Horvath and GrimAge, there were 61 significantly enriched disease annotations including age-related metabolic and cardiovascular conditions and several cancers. Enriched pathways included those related to proteins and protein modification. We identified miRNAs associated with EAA of multiple epigenetic clocks. PhenoAge had more associations with individual miRNAs, but GrimAge and Horvath had greater implications for miRNA-associated pathways. Understanding the relationship between these epigenetic markers could contribute to our understanding of the molecular underpinnings of aging and aging-related diseases.

Platelet transfusions in haematology patients: are we using them appropriately?

BACKGROUND AND OBJECTIVES: A large proportion of all platelet components are given to haematology patients. As there are risks associated with their transfusion, costs associated with production, and shortages may occur, it is important that their use is appropriate. STUDY DESIGN AND METHODS: The study was split into two parts, a survey to assess local practice guidelines and an assessment of platelet usage. A total of 123 hospitals completed the survey and 168 hospitals submitted data of 40 haematology patients over a 3-month period. RESULTS: The organizational survey found that 36% of hospitals routinely give prophylactic platelet transfusions to patients with long-term bone-marrow failure. Also, a significant minority of hospitals administer platelet transfusions if the platelet count is below a certain threshold prior to performing a bone-marrow aspirate (11%) or a bone-marrow aspirate and trephine (23%); both of these are contrary to UK platelet transfusion guidelines. Data were collected on a total of 3402 patients, of which 3296 cases were eligible for analysis. They received approximately 46% of all platelet components issued to participating hospitals in England during the study period. The majority (69%) of platelet transfusions were prophylactic; of these only 33% were given when the platelet count was ≤10×10(9)/l. Using an algorithm, based on current UK guidelines, 60% of prophylactic transfusions were appropriate, 6% could not be assessed and 34% were inappropriate. A total of 10% of all prophylactic transfusions were double the standard adult dose. CONCLUSIONS: There is considerable potential for decreased use of platelet transfusions with a consequent improvement in their appropriate use and cost reduction.

Cryoprecipitate for transfusion: which patients receive it and why? A study of patterns of use across three regions in England.

BACKGROUND: Despite increasing interest in the use of fibrinogen concentrates, cryoprecipitate remains the major source of fibrinogen in England. OBJECTIVES: Understand patterns and indications for use of cryoprecipitate in hospitals from three English regions. METHOD/MATERIALS: Data collection over 3 months from adults, children and neonates receiving cryoprecipitate, including clinical scenario, indications, dose and levels of fibrinogen concentrations pre- and post-transfusion. RESULTS: Four hundred and twenty-three episodes of cryoprecipitate transfusion were analysed from 39 hospitals. Use varied from 0.1 to 4.9 units per 100 red cells transfused. The primary indication was haemorrhage [311 episodes (74%)]. The commonest clinical scenario in all age groups was cardiac surgery, followed by trauma in adults and critical/neonatal care for children. Pre-treatment fibrinogen levels were measured in 322 episodes. In 179 episodes, the level was ≥ 1.0 g L(-1) . CONCLUSION: Wide variation in practice and dose suggests inconsistent practice and uncertainty in the evidence informing optimal use of cryoprecipitate.

Effectiveness of Enhanced Performance Feedback on Appropriate Use of Blood Transfusions: A Comparison of 2 Cluster Randomized Trials.

Importance: Auditing and feedback are frequently used to improve patient care. However, it remains unclear how to optimize feedback effectiveness for the appropriate use of treatments such as blood transfusion, a common but costly procedure that is more often overused than underused. Objective: To evaluate 2 theoretically informed feedback interventions to improve the appropriate use of blood transfusions. Design, Setting, and Participants: Two sequential, linked 2 × 2 cluster randomized trials were performed in hospitals in the UK participating in national audits of transfusion for perioperative anemia and management of hematological disorders. Data were collected for a surgical trial from October 1, 2014, to October 31, 2016, with follow-up completed on October 31, 2016. Data were collected for a hematological trial through follow-up from July 1, 2015, to June 30, 2017. Trial data were analyzed from November 1, 2016, to June 1, 2019. Interventions: Hospitals were randomized to standard content or enhanced content to improve feedback clarity and usability and to standard support or enhanced support for staff to act on feedback. Main Outcomes and Measures: The primary end point was appropriateness of transfusions audited at 12 months. Secondary end points included volume of transfusions (aiming for reductions at patient and cluster levels) and transfusion-related adverse events and reactions. Results: One hundred thirty-five of 152 eligible clusters participated in the surgical audit (2714 patients; mean [SD] age, 74.9 [14.0] years; 1809 women [66.7%]), and 134 of 141 participated in the hematological audit (4439 patients; median age, 72.0 [IQR, 64.0-80.0] years; 2641 men [59.5%]). Fifty-seven of 69 clusters (82.6%) in the surgical audit randomized to enhanced content downloaded reports compared with 52 of 66 clusters (78.8%) randomized to standard reports. Fifty-nine of 68 clusters (86.8%) randomized to enhanced support logged onto the toolkit. The proportion of patients with appropriate transfusions was 0.184 for standard content and 0.176 for enhanced content (adjusted odds ratio [OR], 0.91 [97.5% CI, 0.61-1.36]) and 0.181 for standard support and 0.180 for enhanced support (adjusted OR, 1.05 [97.5% CI, 0.68-1.61]). For the hematological audit, 53 of 66 clusters (80.3%) randomized to enhanced content downloaded the reports compared with 53 of 68 clusters (77.9%) randomized to standard content. Forty-nine of 67 clusters sites (73.1%) assigned to enhanced support logged into the toolkit at least once. The proportion of patients with appropriate transfusions was 0.744 for standard content and 0.714 for enhanced content (adjusted OR, 0.81 [97.5% CI, 0.56-1.12]), and 0.739 for standard support and 0.721 for enhanced support (adjusted OR, 0.96 [97.5% CI, 0.67-1.38]). Conclusions and Relevance: This comparison of cluster randomized trials found that interventions to improve feedback usability and guide local action were no more effective than standard feedback in increasing the appropriate use of blood transfusions. Auditing and feedback delivered at scale is a complex and costly program; therefore, effective responses may depend on developing robust local quality improvement arrangements, which can be evaluated using rigorous experimental designs embedded within national programs. Trial Registration: isrctn.org Identifier: ISRCTN15490813.

The use of fresh-frozen plasma in England: high levels of inappropriate use in adults and children.

BACKGROUND: Fresh-frozen plasma (FFP) is given to patients across a range of clinical settings, frequently in association with abnormalities of standard coagulation tests. STUDY DESIGN AND METHODS: A UK-wide study of FFP transfusion practice was undertaken to characterize the current patterns of administration and to evaluate the contribution of pretransfusion coagulation tests. RESULTS: A total of 4969 FFP transfusions given to patients in 190 hospitals were analyzed, of which 93.3% were in adults and 6.7% in children or infants. FFP transfusions to adults were given most frequently in intensive-treatment or high-dependency units (32%), in operating rooms or recovery (23%), or on medical wards (22%). In adult patients 43% of all FFP transfusions were given in the absence of documented bleeding, as prophylaxis for abnormal coagulation tests or before procedures or surgery. There was wide variation in international normalized ratio (INR) or prothrombin times before FFP administration; in 30.9% of patients where the main reason for transfusion was prophylactic in the absence of bleeding the INR was 1.5 or less. Changes in standard coagulation results after FFP administration were generally very small for adults and children. CONCLUSIONS: This study raises important questions about the clinical benefit of much of current FFP usage. It highlights the pressing need for better studies to inform and evaluate quantitative data for the effect of plasma on standard coagulation tests.