Rh immune globulin immunoprophylaxis after RhD-positive red cell exposure in RhD-negative patients via transfusion: A survey of practices.

BACKGROUND: Current Association for the Advancement of Blood & Biotherapies (AABB) standards require transfusion services to have a policy on Rh immune globulin (RhIG) immunoprophylaxis for when RhD-negative patients are exposed to RhD-positive red cells. This is a survey of AABB-accredited transfusion services in the United States (US) regarding institutional policies and practices on RhIG immunoprophylaxis after RhD-negative patients receive RhD-positive (i.e., RhD-incompatible) packed red blood cell (pRBC) and platelet transfusions. RESULTS: Approximately half of the respondents (50.4%, 116/230) have policies on RhIG administration after RhD-incompatible pRBC and platelet transfusions, while others had policies for only pRBC (13.5%, 31/230) or only platelet (17.8%, 41/230) transfusions, but not both. In contrast, 18.3% (42/230) report that their institution has no written policies on RhIG immunoprophylaxis after RhD-incompatible transfusions. Most institutions (70.2%, 99/141) do not have policies addressing safety parameters to mitigate the risk of hemolysis associated with the high dose of RhIG required to prevent RhD alloimmunization after RhD-incompatible pRBC transfusions. DISCUSSION: With approximately half of US AABB-accredited institutions report having policies on RhIG immunoprophylaxis after both RhD-incompatible pRBC and platelet transfusions, some institutions may not be in compliance with AABB standards. Further, most with policies on RhIG immunoprophylaxis after RhD-incompatible pRBC transfusion do not have written safeguards to mitigate the risk of hemolysis associated with the high dose of RhIG required. CONCLUSION: This survey underscores the diverse and inadequate institutional policies on RhIG immunoprophylaxis after RhD exposure in Rh-negative patients via transfusion. This observation identifies an opportunity to improve transfusion safety.

Three Contrasting Accounts of Electronic Gambling Machine Related Harm: Impacts on Community Views Towards Gambling Policy and Responsibility.

This study investigated whether there was community support for prominent gambling harm reduction policies, as well as perceived responsibility for electronic gambling machine (EGM) related harm in an Australian sample (n = 906). Using a randomised experimental design, we also explored whether these outcomes were influenced by three alternative explanations for EGM-related harm: a brain-based account of gambling addiction, an account that highlighted the intentional design of the gambling environment focused on the "losses disguised as wins" (LDWs), and a media release advocating against further government intervention in the gambling sector. We observed clear majority support for most policies presented, including mandatory pre-commitment, self-exclusion, and a $1 limit on EGM bets. A substantial majority of participants agreed that individuals, governments, and industry should be held responsible for EGM-related harm. Participants presented with the explanation of LDWs attributed greater responsibility for gambling-related harm to industry and government, less agreement that electronic gambling machines are fair, and more agreement that EGMs are likely to mislead or deceive consumers. There was some limited evidence of greater support for policy intervention in this group, including a blanket ban of EGMs, clinical treatment funded by gambling taxes, mass media campaigns, and mandatory pre-commitment for EGMs. We found no evidence that a brain-based account of gambling addiction substantially undermined support for policy intervention. We predicted that the information about LDWs and the brain-based account of EGM related harm would soften attributions of personal responsibility for gambling harm. Our results did not support either of these predictions.

How do we direct a transfusion service/blood bank with limited laboratory staff.

BACKGROUND: Transfusion services and blood banks in the United States have struggled with staffing shortages for decades. Unfortunately, the COVID-19 pandemic and other factors have exacerbated these challenges to the point of crisis for many. Meanwhile, providing quality patient care continues to demand accurate test results and safe blood products delivered in a timely fashion. MATERIALS AND METHODS: A group of academic Transfusion Medicine Physicians and a Medical Laboratory Scientist from five academic medical centers in the United States met and discussed the steps we explored and took during the staffing crisis that hit during the pandemic. Our goal was to assist our colleagues and the community by detailing the strategies that helped keep us operational during the most extreme staffing shortage we have experienced to date. RESULTS AND CONCLUSIONS: We provide both short-term solutions to include hiring temporary and per diem technologists, consolidating testing, and sending out non-time-sensitive testing; and long-term strategies such as recruiting and hiring laboratory assistants, providing retention and referral bonuses, and increasing compensation. The objective is to address the staffing shortage on multiple fronts (e.g., personnel management, testing, and organization) with the objective of not compromising safety, quality, or patient care. The ultimate long-term goal is to advocate for and build a stronger laboratory workforce for tomorrow.

Can counter-advertising exposing alcohol sponsorship and harms influence sport spectators' support for alcohol policies? An experimental study.

BACKGROUND: Exposure to alcohol advertising and sponsorship through elite sport is associated with harmful use of alcohol. Owing to strong financial and cultural ties between alcohol and sport in Australia, policy action to restrict alcohol sport sponsorship is unlikely to occur without strong public support for change. This study tested whether exposure to counter-advertising exposing industry marketing of harmful products-a technique shown to be effective in tobacco control-promotes higher support for policy change and less favourable beliefs about the alcohol industry among sport spectators. METHODS: A sample of 1,075 Australian adults aged 18-49 years who planned to watch an National Rugby League (NRL) State of Origin series game, featuring prominent alcohol sponsorship, was recruited through an online panel and randomly assigned to one of three conditions: control (neutral advertisement); counter-advertisement exposing alcohol harms; counter-advertisement exposing alcohol sponsorship and harms. Participants completed a pre-test questionnaire and viewed their assigned counter-advertisement multiple times in the 5-7 days before the NRL game. Within four days of watching the game, participants completed post-test measures. RESULTS: Compared to both the control advertisement and the counter-advertisement exposing alcohol harms, participants who viewed the counter-advertisement exposing alcohol sponsorship and harms were significantly more likely to indicate support for each of four policies aimed at restricting sports-related alcohol marketing, including the complete removal of alcohol sponsorship from sport (51% vs. 32% and 37%). They were also significantly less likely to agree with statements such as "alcohol companies should be allowed to sponsor sport since their products are legal" (39% vs. 63% and 60%) and significantly less likely to report liking alcohol companies in general (38% vs. 59% and 54%). There were no significant differences in policy support or industry beliefs between participants who saw the counter-advertisement exposing alcohol harms and those who saw the control advertisement. CONCLUSION: Counter-advertising employing messages that expose and critique the intent and impact of pervasive alcohol sponsorship in sport has potential to bolster public support for policies targeting alcohol sport sponsorship, diminish beliefs supportive of alcohol industry marketing strategies and enhance negative views of alcohol companies and their marketing practices.

Intentional self-harm in culturally and linguistically diverse communities: A study of hospital admissions in Victoria, Australia.

PURPOSE: To examine the rates and profiles of intentional self-harm hospital admissions among people from culturally and linguistically diverse and non-culturally and linguistically diverse backgrounds. METHODS: A retrospective analysis of 29,213 hospital admissions for self-harm among people aged 15 years or older in Victoria, Australia, was conducted using data from the Victorian Admitted Episodes Dataset between 2014/2015 and 2018/2019. The Victorian Admitted Episodes Dataset records all hospital admissions in public and private hospitals in Victoria (population 6.5 million). Population-based incidence of self-harm, logistic regression and percentages (95% confidence intervals) were calculated to compare between culturally and linguistically diverse groups by birthplaces and the non-culturally and linguistically diverse groups of self-harm admissions. RESULTS: When grouped together culturally and linguistically diverse individuals had lower rates of (hospital-treated) self-harm compared with the non-culturally and linguistically diverse individuals. However, some culturally and linguistically diverse groups such as those originating from Sudan and Iran had higher rates than non-culturally and linguistically diverse groups. Among self-harm hospitalised patients, those in the culturally and linguistically diverse group (vs non-culturally and linguistically diverse group) were more likely to be older, Metropolitan Victorian residents, from the lowest socioeconomic status, and being ever or currently married. Self-harm admissions by persons born in Southern and Eastern Europe were the oldest of all groups; in all other groups number of admissions tended to decrease as age increased whereas in this group the number of admissions increased as age increased. CONCLUSION: There was considerable heterogeneity in rates of hospital-treated self-harm in culturally and linguistically diverse communities, with some countries of origin (e.g. Sudan, Iran) having significantly higher rates. Some of this variation may be due to factors relating to the mode of entry into Australia (refugee vs planned migration), and future research needs to examine this possibility and others, to better plan for support needs in the culturally and linguistically diverse communities most affected by self-harm. Combining all culturally and linguistically diverse people into one group may obscure important differences in self-harm. Different self-harm prevention strategies are likely to be needed for different culturally and linguistically diverse populations.

Repeat self-harm and mental health service use after self-harm in Culturally and Linguistically Diverse communities: Insights from a data linkage study in Victoria, Australia.

PURPOSE: To examine the associations between Culturally and Linguistically Diverse backgrounds (vs non-Culturally and Linguistically Diverse) and in-hospital death due to self-harm, repeat self-harm and mental health service use after self-harm. METHOD: A retrospective study of 42,127 self-harm hospital inpatients aged 15+ years in Victoria, Australia, from July 2008 to June 2019. Linked hospital and mental health service data were used to assess in-hospital death, repeat self-harm and mental health service use in the 12 months following index self-harm hospital admission. Logistic regression and zero-inflated negative binomial regression models were used to estimate associations between cultural background and outcomes. RESULTS: Culturally and Linguistically Diverse people accounted for 13.3% of self-harm hospital inpatients. In-hospital death (0.8% of all patients) was negatively associated with Culturally and Linguistically Diverse background. Within 12 months, 12.9% of patients had self-harm readmission and 20.1% presented to emergency department with self-harm. Logistic regression components of zero-inflated negative binomial regression models showed no differences in the odds of (hospital-treated) self-harm reoccurrence between Culturally and Linguistically Diverse and non- Culturally and Linguistically Diverse self-harm inpatients. However, count components of models show that among those with repeat self-harm, Culturally and Linguistically Diverse people (e.g. born in Southern and Central Asia) made fewer additional hospital revisits than non-Culturally and Linguistically Diverse people. Clinical mental health service contacts following self-harm were made in 63.6% of patients, with Culturally and Linguistically Diverse people (Asian backgrounds 43.7%) less likely to make contact than the non-Culturally and Linguistically Diverse group (65.1%). CONCLUSIONS: Culturally and Linguistically Diverse and non-Culturally and Linguistically Diverse people did not differ in the likelihood of hospital-treated repeat self-harm, but among those with self-harm repetition Culturally and Linguistically Diverse people had fewer recurrences than non-Culturally and Linguistically Diverse people and utilised mental health services less following self-harm admissions.

Effectiveness of an educational intervention targeting homophobic language use by young male athletes: a cluster randomised controlled trial.

OBJECTIVE: Homophobic language is common in male sport and associated with negative physical and mental health outcomes for all sport participants, but particularly for gay or bisexual youth populations. Evidence-based interventions are needed to reduce such language and mitigate harm. This study evaluated the effectiveness of a short social-cognitive educational intervention delivered by professional rugby union players in youth sport. METHODS: In a two-arm, cluster randomised controlled trial, 13 Australian youth rugby teams from 9 clubs (N=167, ages 16-20, mean 17.9) were randomised into intervention or control groups. Professional rugby players delivered the intervention in-person. Frequency of homophobic language use was measured 2 weeks before and 2 weeks after the intervention. Hypothesised factors underpinning homophobic language were also measured, including descriptive (other people use), prescriptive and proscriptive injunctive norms (approval/disapproval by others), and attitudes towards the acceptability of homophobic language. RESULTS: At baseline, 49.1% of participants self-reported using homophobic language in the past 2 weeks and 72.7% reported teammates using homophobic language. Significant relationships were found between this behaviour and the hypothesised factors targeted by the intervention. However, generalised estimating equations found the intervention did not significantly reduce homophobic language, or alter the associated norms and attitudes, relative to controls. CONCLUSION: Use of professional rugby athletes to deliver education on homophobic language was not effective. Other approaches to reduce homophobic language (and other forms of discrimination) such as peer-to-peer education, and enforcement of policies prohibiting specific language by coaches, should be explored.

How we manage blood product support and coagulation in the adult patient requiring extracorporeal membrane oxygenation.

Use of extracorporeal membrane oxygenation (ECMO) is increasing among critically ill adults with cardiac and/or respiratory failure. Use of ECMO is associated with hemostatic alterations requiring use of anticoagulation and blood product support. There are limited guidelines to direct transfusion management in the adult patient supported with ECMO. The objective of this article is to describe (1) the role of the transfusion service in providing transfusion support and current understanding of transfusion thresholds, (2) the complexities of monitoring anticoagulation, and (3) the consideration regarding additional factor concentrates and antifibrinolytics within the context of ECMO support. The information provided should assist ECMO care teams in informing transfusion and anticoagulation practice while highlighting key areas for future research and collaboration.

The Validated Features of Psychological Interventions for Weight Loss: An Integration.

Many psychological inclinations, such as maladaptive beliefs, can diminish the capacity of individuals to manage their weight effectively and sustainably. Yet, interventions that purportedly address these psychological inclinations and improve weight management are not always beneficial. To be effective, these interventions should offer participants several choices, should be devoid of features that have not been validated in isolation, and should arrange the various activities in an efficient and effective sequence. Few if any programs fulfill these criteria. The aim of this paper was to construct an intervention that assimilates all the validated features of interventions that overcome the psychological impediments to weight loss. To achieve this goal, we blended a technique called intervention component analysis with thematic analysis. Specifically, we extracted refereed journal articles about weight loss from PsycInfo, distilled the practical recommendations from these articles, excluded recommendations that had not been validated in isolation of other features, integrated overlapping recommendations, and applied several principles to arrange these recommendations into the most effective sequence. This procedure generated an intervention that could comprise up to 43 features and activities, including self-affirmation to foster openness to change, anecdotes about dramatic improvements, ambitious rather than modest targets, an emphasis on strategies rather than targets, rewards for attempts, implementation intentions with partners, self-hypnosis, cognitive reframing, and distancing. If these features are unsuccessful, practices that demand more resources-such as group disclosure, virtual environments, motivational interviewing, and customized programs-were also recommended.

Psychological distress and internet-related behaviors between schoolchildren with and without overweight during the COVID-19 outbreak.

OBJECTIVE: The novel coronavirus disease 2019 (COVID-19) pandemic, and its resulting social policy changes may result in psychological distress among schoolchildren with overweight. This study thus aimed to (1) compare psychological distress (including fear of COVID-19 infection, stress, anxiety, and depression), perceived weight stigma, and problematic internet-related behaviors between schoolchildren with and without overweight; (2) assess whether perceived weight stigma and problematic internet-related behaviors explained psychological distress. METHODS: Schoolchildren (n = 1357; mean age = 10.7 years) with overweight (n = 236) and without overweight (n = 1121) completed an online survey assessing their fear of COVID-19 infection, stress, anxiety, depression, perceived weight stigma, problematic smartphone application use, problematic social media use, and problematic gaming. RESULTS: Schoolchildren with overweight had significantly higher levels of COVID-19 infection fear, stress, depression, perceived weight stigma, and problematic social media use than those without overweight. Regression models showed that perceived weight stigma and problematic internet-related behaviors were significant predictors of psychological distress among schoolchildren with overweight. CONCLUSION: Strategies to manage perceived weight stigma and problematic internet-related behaviors may have a positive influence on mental health among schoolchildren with overweight under health-threatening circumstances, such as the current COVID-19 pandemic.

3D printed vascular phantoms for high-resolution biophotonic image quality assessment via direct laser writing.

Fluorescence imaging techniques such as fluorescein angiography and fundus autofluorescence are often used to diagnose retinal pathologies; however, there are currently no standardized test methods for evaluating device performance. Here we present microstructured fluorescent phantoms fabricated using a submicron-scale three-dimensional printing technology, direct laser writing (DLW). We employ an in situ DLW technique to print 10 µm diameter microfluidic channels that support perfusions of fluorescent dyes. We then demonstrate how broadband photoresist fluorescence can be exploited to generate resolution targets and biomimetic models of retinal vasculature using standard DLW processes. The results indicate that these approaches show significant promise for generating better performance evaluation tools for fluorescence microscopy and imaging devices.

Assessing inpatient platelet ordering practice: evaluation of computer provider order entry overrides.

BACKGROUND AND OBJECTIVES: Judicious utilization of platelet products protects a limited resource and mitigates risks of transfusion. At many institutions, computer physician order entry systems provide prompts to guide transfusion decisions; many capture the indication for transfusion, and generate metadata when orders are dissonant with guidelines. We conducted a retrospective review to examine adherence to and overrides of hospital guidelines for platelet transfusion to identify opportunities for improved transfusion practice. MATERIALS AND METHODS: Physician override reports (1/1/2018-3/31/2019) were examined and physician-entered justification comments accompanying override orders were extracted, in addition to patient-specific data (clinical service, age, sex, and pretransfusion platelet count). Two transfusion medicine physicians independently assessed comments in context of patient data and institutional guidelines and categorized as: indicated, protocol driven, or not indicated. Following adjudication, consensus was reached between the two reviewers. Override keyword frequencies were also determined. RESULTS: Over 15-months, 1373 override orders were placed for 558 unique patients (25% of all adult inpatient platelet transfusions). haematology/oncology providers placed 573 (42%) override orders (261 unique patients), 46% of which were categorized as "not indicated", based on consensus review. Overall, 470 (34%) override orders were categorized as "not indicated". Examples of recurring key words included "bleeding/risk of bleeding", "falling platelet count", "platelet goal of XX". CONCLUSIONS: A large percentage of override orders for platelet transfusions were determined to be "not indicated" and out of compliance with institutional guidelines. The metadata captured identified concerns regarding clinical transfusion practice and opportunities for revised indications (e.g. threshold for retinal haemorrhage).

The relationship between endometriosis-related pelvic pain and symptom frequency, and subjective wellbeing.

BACKGROUND: This exploratory study sought to establish the relationship between endometriosis-related pelvic pain, endometriosis symptom-frequency, and women's subjective wellbeing (SWB). METHODS: A purposive sample (N = 2061) of women with endometriosis aged between 18 and 62 years (M = 30.49 ± 7.45) completed an online questionnaire containing a measure of pelvic pain (Biberoglu & Behrman Scale; B&B), endometriosis symptom frequency, and an established measure of SWB (Personal Wellbeing Index: PWI). RESULTS: Mean SWB total scores (58.35 ± 17.90) were considerably lower than those of women in the general population (western normative range = 70-80; mean = 76). On average, women reported moderate levels of pelvic pain (B&B mean = 5.96 ± 1.84), with a mean of 10.87 (± 4.81) endometriosis-related symptoms across the sample. Significant relationships were found between pelvic pain and SWB dimension and total scores (r's = - 0.20 to - 0.43, all p's < .001), and significant small to medium associations between symptom frequency and all but one of the dimensions of SWB (r's = - 0.12 to - 0.23, all p's < .007). In multivariate regression models accounting for age and delay in diagnosis, higher levels of pelvic pain were significantly associated with lower SWB scores across all eight dimensions of the PWI and total score (all p's < .002). Greater symptom frequency was significantly associated with lower levels of SWB for the dimensions of health, future security, life as a whole, and total scores (all p's < .002). CONCLUSIONS: SWB was lower in women with endometriosis than SWB in women from the general population, and endometriosis related symptoms and pelvic pain explain significant proportions of the unique variance in women's SWB scores. Psychosocial support is needed for women dealing with endometriosis-related symptoms and pain in order to improve their wellbeing and quality of life.

A preoperative risk score for transfusion in infrarenal endovascular aneurysm repair to avoid type and cross.

OBJECTIVE: Preoperative type and cross are often routinely ordered before elective endovascular aneurysm repair (EVAR), but the cost of this practice is high, and transfusion is rare. We therefore aimed to stratify patients by their risk of transfusion to identify a cohort in whom a type and screen would be sufficient. METHODS: We queried the targeted vascular module of the National Surgical Quality Improvement Program (NSQIP) for all elective EVARs from 2011 to 2015. We included only infrarenal aneurysms and excluded ruptured aneurysms and patients transfused within 72 hours preoperatively. Two-thirds of the cases were randomly assigned to a model derivation cohort and one third to a validation cohort. We created and subsequently validated a risk model for transfusion within the first 24 hours of surgery (including intraoperatively), using logistic regression. RESULTS: Between 2011 and 2015, there were 4875 patients who underwent elective infrarenal EVAR, only 221 (4.5%) of whom received a transfusion within 24 hours of surgery. The frequency of transfusion during the study period declined monotonously from 6.5% in 2011 to 3.2% in 2015. The factors independently associated with transfusion were preoperative hematocrit <36% (odds ratio [OR], 3.4 [95% confidence interval, 2.1-5.4]; P < .001), aortic diameter (per centimeter increase: OR, 1.2 [1.03-1.4]; P = .02), preoperative dependent functional status (OR, 2.5 [1.1-5.5]; P = .03), and chronic obstructive pulmonary disease (OR, 1.7 [1.04-2.9]; P = .04). A risk prediction model based on these criteria produced a C statistic of 0.69 in the prediction cohort and 0.76 in the validation cohort and a Hosmer-Lemeshow goodness of fit of 0.62 and 0.14, respectively. A score of <3 of 9, corresponding to a <5% probability of transfusion, would avoid preoperative type and cross in 86% of patients. Of the 4203 patients (86%) with a hematocrit >36%, only 6 (0.1%) had a risk score of >3. CONCLUSIONS: Perioperative transfusion for EVAR is becoming increasingly uncommon and is predicted well by a transfusion risk score or simply a hematocrit of <36%. Application of this risk score would avoid unnecessary type and cross in the majority of patients, leading to significant savings in both time and cost.

Blood product transfusion and wastage rates in obstetric hemorrhage.

BACKGROUND: Bleeding emergencies can complicate pregnancies. Understanding the disposition of the products that are issued in this clinical setting can help inform inventory levels at hospitals where obstetric patients are seen. STUDY DESIGN AND METHODS: Patients who had an obstetric hemorrhage of any etiology between January 2013 and June 2017, and whose resuscitation began with uncrossmatched red blood cells (RBCs) or emergency-issued plasma or platelets (PLT), were included. The disposition of all blood products issued within 6 hours of the first uncrossmatched or emergency-issued product was documented, as was basic patient demographic information. RESULTS: In total, 301 women with an obstetric hemorrhage from seven academic institutions were identified. Their mean ± standard deviation age was 30.9 ± 6.1 years, 45.2% delivered by Cesarean section, and 40.5% delivered vaginally, while 12% did not deliver. The largest single etiology of hemorrhage was related to abnormal placentation. Of the 2280 issued RBC units, 55% were transfused, 43% were returned, and 2% were wasted. The rates of transfusion of the other blood products ranged from 58% for plasma units to 82% for cryoprecipitate. Seventeen percent of the issued cryoprecipitate units were wasted, the highest of any blood product. The rate of a patient receiving a transfusion when at least one blood product had been ordered ranged from 74% for PLTs to 91% for cryoprecipitate. CONCLUSION: Although the rates of receiving a transfusion of at least one blood product when one is ordered was high, many of the issued units were returned, especially for RBCs.

How do we manage blood product support in the massively hemorrhaging obstetric patient?

Obstetric hemorrhage remains a leading cause of maternal mortality with more than 140,000 deaths annually worldwide. Abnormal placentation has increased to become the most common diagnosis requiring massive blood transfusion in obstetrics, with uterine atony a close second. At our institution, as well as nationwide, there has been a steady increase in pregnancies complicated by abnormal placentation, including accreta, increta, and percreta. Providers at our facility created the New England Center for Placental Disorders in May 2015 to address these complex patients. The incidence of accreta has actually increased 10-fold over the past 50 years, becoming the most common reason for cesarean hysterectomy in highly industrialized countries. The most common risk factor for accreta is repeat cesarean sections, particularly those with associated placenta previa. Contemporary cesarean section rates have risen, with more than 1.2 million women having had a cesarean section in the United States in 2014. We present a case vignette of a multiparous woman presenting with heavy vaginal bleeding at 30 weeks' gestation with imaging concerning for placenta accreta and possible percreta. We describe our approach to the management of these complicated patients.