How do we obtain and maintain patient blood management certification?

BACKGROUND: The creation of a patient blood management (PBM) certification program by The Joint Commission (TJC) and Association for the Advancement of Blood and Biotherapies (AABB) provides validation of an existing PBM program. MATERIALS AND METHODS: A team of subject matter experts in PBM formed a working group to develop a structured approach to guide PBM programs through the PBM certification. Program challenges and metrics were reviewed. RESULTS: Initial steps to establishing PBM certification include a multidisciplinary working group and hospital administration buy-in. Development of policies and procedures individualized to the facility will standardize practice. An institutional transfusion committee can provide PBM oversight including enforcing compliance. Using resources such as TJC and AABB standards and tools including electronic medical records (EMR) can track and trend hospital PBM performance and identify improvement opportunities. A gap analysis tool helps implementation. Challenges might include maintaining a PBM program during a merger, slow responsiveness of information systems (IS) to requests, PBM education for both the Transfusion Safety Officer (TSO) and hospital staff with constant turnover. Available metrics from one hospital system showed good compliance with transfusion thresholds (average all products: 97.9%, 2019, 2020). In 2020, through educational efforts the cost savings were $124,856.70 compared to 2019. Regarding single unit transfusion of RBCs, this was 62.25% (2019), 63.75% (2020), 72.00% (2021), and surpassed the target goal of 60%. CONCLUSIONS: Obtaining PBM certification highlights the success of an institution's PBM program. Facilities that have achieved PBM certification have seen significant reductions in transfusions and considerable cost savings.

Complicated diverticular disease: Position statement on outpatient management, Hartmann's procedure, laparoscopic peritoneal lavage and laparoscopic approach. Consensus document of the Spanish Association of Coloproctology and the Coloproctology Section of the Spanish Association of Surgeons. / Enfermedad diverticular complicada: toma de posición sobre tratamiento ambulatorio, intervención de Hartmann, lavado-drenaje peritoneal y cirugía laparoscópica. Documento de consenso de la Asociación Española de Coloproctología y Sección de Coloproctología de la Asociación Española de Cirujanos.

The Spanish Association of Coloproctology (AECP) and the Coloproctology Section of the Spanish Association of Surgeons (AEC), propose this consensus document about complicated diverticular disease that could be used for decision-making. Outpatient management, Hartmann's procedure, laparoscopic peritoneal lavage, and the role of a laparoscopic approach in colonic resection are exposed.

Long-term Outcomes of Adults With Single Ventricle Physiology Not Undergoing Fontan Repair: A Multicentre Experience.

BACKGROUND: To describe long-term survival and cardiovascular events in adult patients with single ventricle physiology (SVP) without Fontan palliation, focusing on predictors of mortality and comparing groups according to their cardiovascular physiology. METHODS: Multicentre observational and retrospective study including adult patients with SVP without Fontan palliation since their first adult clinic visit. The cohort was subdivided into 3 groups: Eisenmenger, restricted pulmonary flow, and aortopulmonary shunt. Death was considered as the main end point. Other clinical outcomes occurring during follow-up were considered as secondary end points. RESULTS: A total of 146 patients, mean age 32.5 ± 11.1 years, were analysed. Over a mean follow-up of 7.3 ± 4.1 years, 33 patients (22.6%) died. Survival was 86% and 74% at 5 and 10 years, respectively. Right ventricular morphology was not associated with higher mortality. Four variables at baseline were related to a higher mortality: at least moderate atrioventricular valve regurgitation, platelet count < 150 × 103/mm3, GFR < 60 mL/min/1.73 m2, and QRS > 120 ms). A total of 34.2% of patients were admitted to the hospital due to heart failure, and 7.5% received a heart transplant. Other cardiovascular outcomes were also frequent: atrial arrhythmias in 19.2%, stroke in 15.1%, and pacemaker/implantable cardioverter-defibrillator in 6.2%/2.7%. CONCLUSIONS: Adult patients with SVP who had not undergone Fontan exhibit a high mortality rate and frequent major cardiovascular events. At least moderate atrioventricular valve regurgitation, thrombocytopenia, renal dysfunction, and QRS duration > 120 ms at baseline visit allow identification of a cohort of patients at higher risk of mortality.

Systolic dysfunction of the subpulmonary left ventricle is associated with the severity of heart failure in patients with a systemic right ventricle.

BACKGROUND: The study aimed to assess the relation between echocardiographic parameters of subpulmonary left ventricular (LV) size and function, and the severity of heart failure in patients with a systemic right ventricle (SRV). METHODS AND RESULTS: A total of 157 patients (89 post Mustard/Senning operations, 68 with congenitally corrected transposition of great arteries [ccTGA]) were included. The size and function of the SRV and subpulmonary LV were assessed on the most recent echocardiographic exam. Clinical data were collected from the electronic records. The majority (133, 84.7%) were in NYHA functional class 1-2. Median BNP concentration was 79.5[38.3-173.3] ng/l, and 100 (63.7%) patients were receiving heart failure therapy. Both LV and SRV fractional area change (FAC) differed significantly between patients with NYHA class 1-2 vs 3-4 (48[41.5-52.8]% vs 34[28.6-38.6]%, p < 0.0001 and 29.5[23-35]% vs 22[20-27]%, p < 0.0001, respectively), but LV FAC had a higher discriminative power for functional class >2 than SRV FAC (AUC 0.90, p < 0.0001 vs 0.79; p < 0.0001, respectively). A LV FAC cut-off value <39.2% had the highest accuracy in identifying patients with NYHA class 3-4 (sensitivity 83% and specificity 88%). In multivariable logistic regression analysis, LV FAC and SRV FAC independently associated to NYHA class 3-4 (OR 0.80 [95%CI 0.72-0.88], p < 0.0001 and OR 0.85 [95%CI 0.76-0.96], p = 0.007, respectively). CONCLUSIONS: Subpulmonary LV systolic dysfunction is associated with NYHA functional class 3-4 in patients with ccTGA or after Mustard or Senning operation. Careful evaluation of the subpulmonary LV should be a part of the routine assessment of patients with a SRV.

Identification of an α-MoRF in the Intrinsically Disordered Region of the Escargot Transcription Factor.

Molecular recognition features (MoRFs) are common in intrinsically disordered proteins (IDPs) and intrinsically disordered regions (IDRs). MoRFs are in constant order-disorder structural transitions and adopt well-defined structures once they are bound to their targets. Here, we study Escargot (Esg), a transcription factor in Drosophila melanogaster that regulates multiple cellular functions, and consists of a disordered N-terminal domain and a group of zinc fingers at its C-terminal domain. We analyzed the N-terminal domain of Esg with disorder predictors and identified a region of 45 amino acids with high probability to form ordered structures, which we named S2. Through 54 µs of molecular dynamics (MD) simulations using CHARMM36 and implicit solvent (generalized Born/surface area (GBSA)), we characterized the conformational landscape of S2 and found an α-MoRF of ∼16 amino acids stabilized by key contacts within the helix. To test the importance of these contacts in the stability of the α-MoRF, we evaluated the effect of point mutations that would impair these interactions, running 24 µs of MD for each mutation. The mutations had mild effects on the MoRF, and in some cases, led to gain of residual structure through long-range contacts of the α-MoRF and the rest of the S2 region. As this could be an effect of the force field and solvent model we used, we benchmarked our simulation protocol by carrying out 32 µs of MD for the (AAQAA)3 peptide. The results of the benchmark indicate that the global amount of helix in shorter peptides like (AAQAA)3 is reasonably predicted. Careful analysis of the runs of S2 and its mutants suggests that the mutation to hydrophobic residues may have nucleated long-range hydrophobic and aromatic interactions that stabilize the MoRF. Finally, we have identified a set of residues that stabilize an α-MoRF in a region still without functional annotations in Esg.

Key science questions from the second conference on early Mars: geologic, hydrologic, and climatic evolution and the implications for life.

In October 2004, more than 130 terrestrial and planetary scientists met in Jackson Hole, WY, to discuss early Mars. The first billion years of martian geologic history is of particular interest because it is a period during which the planet was most active, after which a less dynamic period ensued that extends to the present day. The early activity left a fascinating geological record, which we are only beginning to unravel through direct observation and modeling. In considering this time period, questions outnumber answers, and one of the purposes of the meeting was to gather some of the best experts in the field to consider the current state of knowledge, ascertain which questions remain to be addressed, and identify the most promising approaches to addressing those questions. The purpose of this report is to document that discussion. Throughout the planet's first billion years, planetary-scale processes-including differentiation, hydrodynamic escape, volcanism, large impacts, erosion, and sedimentation-rapidly modified the atmosphere and crust. How did these processes operate, and what were their rates and interdependencies? The early environment was also characterized by both abundant liquid water and plentiful sources of energy, two of the most important conditions considered necessary for the origin of life. Where and when did the most habitable environments occur? Did life actually occupy them, and if so, has life persisted on Mars to the present? Our understanding of early Mars is critical to understanding how the planet we see today came to be.

Enfermedad diverticular complicada: toma de posición sobre tratamiento ambulatorio, intervención de Hartmann, lavado-drenaje peritoneal y cirugía laparoscópica. Documento de consenso de la Asociación Española de Coloproctología y Sección de Coloproctología de la Asociación Española de Cirujanos / Complicated diverticular disease: Position statement on outpatient management, Hartmann's procedure, laparoscopic peritoneal lavage and laparoscopic approach. Consensus document of the Spanish Association of Coloproctology and the Coloproctology Section of the Spanish Association of Surgeons

Desde la Asociación Española de Coloproctología (AECP) y la Sección de Coloproctología de la Asociación Española de Cirujanos (AEC), se propone un documento de consenso sobre la enfermedad diverticular complicada que pueda ser de utilidad en la toma de decisiones. En él se expone, principalmente, la actualidad en el tratamiento ambulatorio, la intervención de Hartmann, el lavado laparoscópico peritoneal, así como el papel del abordaje laparoscópico en la resección colónica (AU)

The Spanish Association of Coloproctology (AECP) and the Coloproctology Section of the Spanish Association of Surgeons (AEC), propose this consensus document about complicated diverticular disease that could be used for decision-making. Outpatient management, Hartmann's procedure, laparoscopic peritoneal lavage, and the role of a laparoscopic approach in colonic resection are exposed (AU)

Environmental effects of large impacts on Mars.

The martian valley networks formed near the end of the period of heavy bombardment of the inner solar system, about 3.5 billion years ago. The largest impacts produced global blankets of very hot ejecta, ranging in thickness from meters to hundreds of meters. Our simulations indicated that the ejecta warmed the surface, keeping it above the freezing point of water for periods ranging from decades to millennia, depending on impactor size, and caused shallow subsurface or polar ice to evaporate or melt. Large impacts also injected steam into the atmosphere from the craters or from water innate to the impactors. From all sources, a typical 100-, 200-, or 250-kilometers asteroid injected about 2, 9, or 16 meters, respectively, of precipitable water into the atmosphere, which eventually rained out at a rate of about 2 meters per year. The rains from a large impact formed rivers and contributed to recharging aquifers.