Effective reduction of blood product use in a community teaching hospital: when less is more.

BACKGROUND: The increased morbidity and mortality associated with liberal blood product usage have been convincingly demonstrated. The clinical problems they pose have prompted development of more restrictive evidence-based transfusion criteria. Education alone has a limited impact on the adoption of these criteria into practice. New York Methodist Hospital undertook a proactive approach to reduce unnecessary transfusions. METHOD: In November 2008, an interventional monitoring program to ensure adherence to transfusion criteria for packed red blood cells (PRBC), platelets, fresh frozen plasma (FFP), and cryoprecipitate transfusions was started. Blood bank technologists routinely monitored transfusion requests against a list of established criteria and experienced clinicians reviewed and adjudicated transfusion requests when the blood bank technologist's action was appealed. RESULTS: Transfusion usage decreased sharply in Year 1 (November 2008-October 2009) and continued to decrease in Year 2 (November 2009-October 2010). PRBC use decreased by 30.1% and 37.7%, with a 47.6% decrease in multi-unit transfusions; platelet use decreased by 24.3% and 41.2%; fresh frozen plasma use decreased by 41.8% and 31.1%; and cryoprecipitate use decreased by 38.7% and 56.1% during monitoring Years 1 and 2, respectively. Decreases occurred despite a 4.0% increase in hospital admissions during the monitoring years. The decreased blood product usage was accompanied by 28.6% reduction in complications. A 26.1% decrease in blood product requests from Year 1 to Year 2 suggested a practice change by the ordering physicians themselves. The total cost of blood products decreased by $2,235,676. CONCLUSION: We established a successful method to reduce transfusions of all blood products using strict adherence to evidence-based criteria and continuous monitoring. Our model translates into improved patient safety by decreasing the number of unnecessary transfusions. This also led to a significant reduction in hospital expenses.

Iron Deficiency Anemia in Adult Onset Still's Disease with a Serum Ferritin of 26,387 µg/L.

Serum ferritin rises in the anemia of chronic inflammation reflecting increased iron storage and other changes mediated by inflammation. When iron deficiency coexists, the ferritin may not always decline into the subnormal range. We describe the rare interaction of iron deficiency with the extreme hyperferritinemia characteristic of adult onset Still's disease. The combination has clinical relevance and allows deductions about the presence of serum ferritin at 26,387 µg/L despite obvious iron depletion. The diagnosis of iron deficiency anemia was delayed and became fully obvious when her Still's disease remitted and serum ferritin decreased to 6.5 µg/L. The coexistence of iron deficiency should be considered when evaluating a patient with anemia of chronic inflammation even when the ferritin level is elevated several hundredfold. Further insights on ferritin metabolism in Still's disease are suggested by the likelihood that the patient's massive hyperferritinemia in the acute phase of Still's disease was almost entirely of the iron-free apoferritin form.

Short communication: no evidence of HTLV-3 and HTLV-4 infection in New York State subjects at risk for retroviral infection.

The primate T-cell lymphoma viruses (PTLV) are divided into six distinct species. The biology and epidemiology of PTLV-1 and PTLV-2 are very well understood. However, that of PTLV-3, 4, 5, and 6 are not. Recently, in Cameroon, three and one humans were shown to be infected with HTLV-3 and HTLV-4, respectively. We undertook a study to ascertain whether any of these two retroviruses were present in the peripheral blood mononuclear cell DNA of New York State subjects deemed at risk for PTLV infection. Samples were analyzed by PTLV-3 and PTLV-4 specific PCR assays from the following human and simian subject types: African-American medical clinic patients; HTLV EIA+, WB indeterminate blood donors; intravenous drug users; patients with leukemia, lymphoma, myelopathy, polymyositis, or AIDS; and African chimpanzees. None of the 1200 subjects was positive for HTLV-3 or 4. The data indicate that, at the time of sample collection, no evidence exists for the dissemination of HTLV-3 or 4 to New York State. Continued epidemiological studies are warranted to explore the worldwide prevalence rates and dissemination patterns of HTLV-3 and 4 infections, and their possible disease associations.

A study of adult T-cell leukemia/lymphoma incidence in central Brooklyn

Adult T-cell leukemia/lymphoma (ATL), a rare outcome of infection with human T-lymphotropic virus (HTLV-I), is endemic in central Brooklyn, which has a large Caribbean migrant population. Previous studies have suggested that HTLV-I prevalence in central Brooklyn may be similar to that recorded in the Caribbean islands. We established a pilot 1-year surveillance program to identify cases of ATL in 7 of 10 hospitals serving the residents of 18 zip codes of central Brooklyn with a combined population of 1,184,670. Of the 6,198 in-patient beds in the catchment area, approximately 83 percent were covered. Twelve incident cases of ATL were ascertained, all among persons of Afro-Caribbean descent, indicating an annual incidence in African-Americans in this community of approximately 3.2/100,000 person-years. Unexplained hypercalcemia was the most useful screening method, identifying 3 of 5 patients not referred for possible ATL by a local hematologist. The female:male ratio was 3:1. The age pattern was different from that reported in the Caribbean Basin and closer to the pattern seen in Japan. Our study supports evidence that HTLV-I infection and ATL are endemic in central Brooklyn and suggests that a more intensive surveillance program for this disease coupled with intervention efforts to reduce HTLV-I transmission are warranted.(Au)