American College of Physicians: Internal Medicine — Doctors for Adults ®

Monday, January 7, 2013

QD: News Every Day--3 studies question the role of blood transfusion

Three studies question the role of blood transfusions for cardiological and gastroenterological conditions, or at least question the thresholds for the procedure.

First, a meta-analysis in Archives of Internal Medicine concluded that blood transfusion or a liberal blood transfusion strategy for myocardial infarction is associated with higher all-cause mortality rates compared with no blood transfusion or a restricted blood transfusion strategy.

Ten studies published between January 1966 and March 2012 revealed the association (18.2% vs. 10.2%; risk ratio [RR], 2.91; 95% confidence interval [CI], 2.46-3.44; P<.001, with a weighted absolute risk increase of 12% and a number needed to harm of 8 (95% CI, 6-17).

Blood transfusion was associated with a higher risk for mortality independent of baseline hemoglobin level, nadir hemoglobin level, and change in hemoglobin level during the hospital stay. It was also significantly associated with a higher risk for subsequent myocardial infarction (RR, 2.04; 95% CI, 1.06-3.93; P=.03).

A journal editor noted, "[U]ntil high-quality randomized trials are performed to test the efficacy of transfusions in the setting of acute myocardial infarction, physicians should transfuse patients only when there is sufficient clinical reason, supported by evidence. Merely having a hematocrit below 27% or 30% should not be sufficient to justify transfusion. In this case, it seems likely that less transfusing may be associated with better outcomes."

Another commentary said, "Do blood transfusions kill more patients with an acute myocardial infarction than anemia? Chatterjee and colleagues would have you believe that they do. We remain unconvinced."

A second study found an association between red blood cell transfusion following nonvariceal upper gastrointestinal bleeding (NVUGIB) and subsequent rebleeding.

Researchers conducted an observational study of a Canadian registry of nearly 1,700 patients with NVUGIB. In the study, 53.7% received transfusions (2.9 +/- 1.6 units of blood), 31.6% had hemodynamic instability, 5.1% fresh blood on rectal examination and 8.6% in the nasogastric tube.

Overall rebleeding and mortality rates were 17.9% and 5.4%, respectively. Red blood cell transfusion within 24 hours of presentation was significantly and independently associated with an increased risk of rebleeding (odds ratio [OR], 1.8; 95% CI; 1.2 to 2.8), but not death (OR, 1.0; 95% CI; 0.6 to 1.8).

Finally, a blood transfusion threshold of 7 g/dL of hemoglobin significantly improved outcomes in patients with acute upper gastrointestinal bleeding compared to 9 g/dL, a study found.

Researchers randomly assigned 444 patients with severe acute upper gastrointestinal bleeding to a restrictive transfusion strategy (transfusion when hemoglobin fell below 7 g/dL with a target range post-transfusion of 7 to 9 g/dL) and 445 patients to a liberal strategy (transfusion when hemoglobin fell below 9 g/dL with a target range post-transfusion of 9 to 11 g/dL). Safety and efficacy of both strategies were compared.

A total of 225 patients assigned to the restrictive strategy did not receive transfusions compared with 65 assigned to the liberal strategy (51% vs. 15%; P less than 0.001). The restrictive-strategy group had a higher survival rate at six weeks compared to the liberal-strategy group (95% vs. 91%; hazard ratio [HR] for death with restrictive strategy, 0.55; 95% CI, 0.33 to 0.92; P=0.02).

Deaths attributed to unsuccessfully controlled bleeding occurred in three patients in the restrictive-strategy group and in 14 patients in the liberal-strategy group (0.7% vs. 3.1%; P=0.01). Complications of treatment were the cause of death in one patient in the restrictive-strategy group and two in the liberal-strategy group. Hemorrhage was controlled and death was due to associated diseases in 19 patients in the restrictive-strategy group and 25 in the liberal-strategy group.

Less bleeding occurred in the restrictive-strategy group compared with the liberal-strategy group (10% vs. 16%; P=0.01), and there were fewer adverse events (40% vs. 48%; P=0.02). Further bleeding was significantly lower with the restrictive strategy group after adjustment for baseline risk factors (HR, 0.68; 95% CI, 0.47 to 0.98). Length of hospital stay was shorter in the restrictive-strategy group than in the liberal-strategy group.

Researchers noted that improvement in survival rates observed with the restrictive transfusion strategy "was probably related to a better control of factors contributing to death, such as further bleeding, the need for rescue therapy, and serious adverse events. All these factors were significantly reduced with the restrictive strategy."

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Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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