A study of an educational intervention to decrease inappropriate preoperative autologous blood donation: its effectiveness and the effect on subsequent transfusion rates in elective hysterectomy.

BACKGROUND: Decreasing the overcollection of preoperative autologous blood is difficult to achieve. The purpose of this study was to determine whether an educational intervention designed to outline the risks of preoperative autologous collection can decrease such donations and, if so, to determine how this decrease will affect subsequent transfusion rates. STUDY DESIGN AND METHODS: An educational intervention consisting of a didactic presentation to the Department of Gynecology staff about the risks and benefits of autologous blood was implemented. Written material with similar information was given to patients. Subsequently, the percentage of patients donating autologous blood, the number of autologous units donated, and the rates of transfusion in patients eligible for autologous donation who were admitted for elective abdominal or vaginal hysterectomy were measured. These rates were compared to those in similar patients admitted in the 2 years before the educational intervention. RESULTS: After an educational intervention, the proportion of patients donating autologous blood decreased from 53 percent to 26 percent (p<0.01), and the number of units collected per patient decreased from 0.86 to 0.31 (p<0.01); this resulted in a savings of 80 autologous donations per year. Despite no difference in estimated blood loss (p = 0.46), the overall transfusion rate decreased from 10 percent to 3.7 percent (p = 0.03), while the allogeneic transfusion rate demonstrated no significant change (1.1% vs. 2.2%; p = 0.40). CONCLUSIONS: Unnecessary preoperative autologous donations by elective hysterectomy patients can be decreased by educating physicians and patients about the risks of preoperative autologous blood donation. Decreasing such unnecessary donations can decrease the subsequent autologous transfusion rate, with its attendant risks, without increasing the risk of allogeneic transfusion.

Localization of human BRCA1 and its loss in high-grade, non-inherited breast carcinomas.

Although the link between the BRCA1 tumour-suppressor gene and hereditary breast and ovarian cancer is established, the role, if any, of BRCA1 in non-familial cancers is unclear. BRCA1 mutations are rare in sporadic cancers, but loss of BRCA1 resulting from reduced expression or incorrect subcellular localization is postulated to be important in non-familial breast and ovarian cancers. Epigenetic loss, however, has not received general acceptance due to controversy regarding the subcellular localization of BRCA1 proteins, reports of which have ranged from exclusively nuclear, to conditionally nuclear, to the ER/golgi, to cytoplasmic invaginations into the nucleus. In an attempt to resolve this issue, we have comprehensively characterized 19 anti-BRCA1 antibodies. These reagents detect a 220-kD protein localized in discrete nuclear foci in all epithelial cell lines, including those derived from breast malignancies. Immunohistochemical staining of human breast specimens also revealed BRCA1 nuclear foci in benign breast, invasive lobular cancers and low-grade ductal carcinomas. Conversely, BRCA1 expression was reduced or undetectable in the majority of high-grade, ductal carcinomas, suggesting that absence of BRCA1 may contribute to the pathogenesis of a significant percentage of sporadic breast cancers.

The transfusion audit as a tool to improve transfusion practice: a critical appraisal.

Transfusion audits have a long history and they are required by many regulatory agencies. These audits have been touted as effective in reducing unnecessary transfusions as evidenced by many published articles on the subject. Most of these studies, however, have one or more flaws in their design including the use of historical controls, disregard of the Hawthorne effect, use of multiple interventions, and publication bias. Studies differ in the baseline rate of inappropriate transfusions and have different methods of measuring these rates. There is also little data on how long the effect of implementing a transfusion audit system may last. Transfusion audits appear most successful when there is a high baseline rate of inappropriate transfusions and interventions other than the audit itself are performed. Individual institutions should critically evaluate whether or not their current system of transfusion audits is useful.

Effectiveness of a prospective physician self-audit transfusion-monitoring system.

BACKGROUND: The purpose of this study was to search for a more effective transfusion-monitoring system than the existing system of retrospective peer review. STUDY DESIGN AND METHODS: This research used a study-control, preintervention and postintervention design, to evaluate the effectiveness of a prospective physician self-audit transfusion-monitoring system that functioned without the direct involvement of transfusion service physicians. This research also evaluated the effectiveness of issuing to physicians a memo with transfusion guidelines. Three process indicators were used to assess physician behavior at various stages of the blood-ordering process: 1) the number of crossmatches ordered per admission, 2) the transfusion-to-crossmatch ratio, and 3) the number of blood units returned to the laboratory after physician self-auditing. The study used two outcome indicators to reflect overall blood utilization: 1) the percentage of patients who received red cell transfusions and 2) the number of blood units transfused per recipient each month. RESULTS: The prospective physician self-audit system implemented at the study hospital did not reverse physician transfusion decisions, and the process of issuing to physicians a memo with transfusion guidelines at the control hospital failed to reduce blood usage. However, a transient reduction in blood utilization was observed at the study hospital. CONCLUSION: The reduction was hypothesized to be due to a Hawthorne effect, in which observed behavior is affected by the subject's awareness of the research study.

Are retrospective peer-review transfusion monitoring systems effective in reducing red blood cell utilization?

OBJECTIVE: This research used a study-control group design and examined data collected from five hospitals to evaluate the effectiveness of retrospective peer-review systems on reducing utilization of red blood cells (RBCs). DESIGN: The effects of retrospective peer-review systems were studied in three parts: (1) trends of RBC utilization were compared by the slopes of linear regression lines that assessed the effect of time on RBC utilization among four study hospitals and one control hospital, (2) diagnosis-specific RBC utilization was compared between the control hospital and one matched study hospital, and (3) the effect of the retrospective review system of one study hospital was assessed by linear regression using data accumulated 1 year before and 2 years after implementation of the program. RESULTS: Three study hospitals showed no significant changes in RBC utilization during the 10-month study period. One study hospital and the control hospital demonstrated trends of reduced RBC use with negative slopes of regression lines; however, there was no difference in the degree of the two slopes, and the diagnosis-specific RBC utilization was not lower at the study hospital than at the control hospital. Furthermore, implementation of the retrospective peer-review system at one study hospital demonstrated no effect on RBC utilization. CONCLUSIONS: We conclude that the retrospective peer-review systems implemented at these four hospitals had no effect on reducing red blood cell utilization.

Preoperative autologous blood donations before elective hysterectomy.

OBJECTIVE: To determine whether preoperative autologous blood donation is justified for patients undergoing elective abdominal or vaginal hysterectomy. DESIGN: Retrospective cohort study. PATIENTS AND SETTING: A total of 263 consecutive patients admitted for elective abdominal or vaginal hysterectomy to a community health maintenance organization hospital during 1993 and 1994. MAIN OUTCOME MEASURES: Evaluation of transfusion rates for patients who did and did not donate autologous blood; determination of any risk factors that would predict the need for transfusion; and evaluation of the need for transfusion based on chart review. RESULTS: Of 263 patients, 26 received a blood transfusion. The major risk factor identified for transfusion was the donation of autologous blood. Of 140 patients who donated autologous blood, 25 were transfused, whereas just 1 patient of 123 who did not donate autologous blood was transfused (P<.001). Patients who donated autologous blood had significantly lower mean admission hemoglobin level than patients who did not donate (119 g/L vs 132 g/L; P<.05); logistic regression showed that autologous donation was an independent risk factor for transfusion. CONCLUSION: For hysterectomy patients, donation of autologous blood causes anemia and is associated with a more liberal transfusion policy. These 2 factors result in a markedly increased incidence of transfusion with its associated risks. Elimination of preoperative autologous donation for these patients should not result in frequent exposure to allogeneic blood.

Accuracy of statistical methods in TRANSFUSION: a review of articles from July/August 1992 through June 1993.

BACKGROUND: Statistical errors have been noted in a large percentage of articles appearing in medical journals. Their incidence in a blood banking journal, however, has not been studied. STUDY DESIGN AND METHODS: Original articles appearing in the journal TRANSFUSION from July 1992 through June 1993 were analyzed for correctness of statistical methods. Each article was reviewed by both a transfusion medicine physician and a statistician. RESULTS: There were 122 original articles, of which 59 contained statistical methods and were reviewed. Of these, 23 (39%) contained an error in the statistical description of their data, 47 (80%) failed to describe clearly the statistical tests performed, and 44 (75%) involved an incorrect statistical test or contained an error in test calculation or interpretation. As a result of these errors, 13 (22%) of the 55 articles analyzed reported conclusions not supported by the data. CONCLUSION: Misuse of statistical methodology may not be uncommon in transfusion medicine research, and it would be prudent to give more attention to statistical methodology in such research.

Pleomorphic adenoma of the breast: cytology of fine-needle aspiration and its differential diagnosis.

The cytologic findings of a case of pleomorphic adenoma of the breast are presented. This rare tumor appeared identical to pleomorphic adenoma of salivary glands. It presented diagnostic difficulties, however, because of its rarity and the fact that its associated clinical findings suggested a malignancy. The cytologic differential diagnosis includes a phyllodes tumor, fibroadenoma, and metaplastic carcinoma. Awareness of this entity should permit a definitive diagnosis by aspiration biopsy.

Bowel injury from rollerball ablation of the endometrium.

A woman underwent apparently uneventful rollerball endometrial ablation but presented with an acute abdomen 2 days later. At laparotomy, a large uterine serosal burn was found and a nearby loop of ileum contained two small injuries: a serosal burn and a perforation. The ileal injuries were oversewn and the patient recovered. Pathologic examination of the uterus showed full-thickness coagulative myometrial necrosis but no uterine perforation. More experience is needed to establish the incidence of this complication.

Transfusion-associated graft-versus-host disease: do transfusions from second-degree relatives pose a greater risk than those from first-degree relatives?

When a patient receives blood from a closely related donor, there is the potential for transfusion-associated graft-versus-host disease (TA-GVHD). With a mathematical model, the potential risk of TA-GVHD was derived for six classes of related donors. This risk was considered to be present when an HLA-heterozygous patient received blood from a donor who was homozygous for one of the patient's haplotypes. Calculations showed that second-degree related donors present a greater risk of TA-GVHD than some (siblings) but not all (parents, children) first-degree related donors. Moreover, there is, in general, no sharp cutoff of risk among the various classes of donors. These results should be considered in the determination of a policy for the irradiation of directed-donor units.

Expectant management of focal nodular hyperplasia during pregnancy. A case report.

A patient with unresectable focal nodular hyperplasia of the liver completed an uncomplicated pregnancy. Although there is a risk of hepatic rupture during pregnancy, expectant management may be an option for some cases of focal nodular hyperplasia.