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Transfusion May 2015Platelet (PLT) transfusion is indicated either prophylactically or therapeutically to reduce the risk of bleeding or to control active bleeding. Significant uncertainty... (Review)
Review
BACKGROUND
Platelet (PLT) transfusion is indicated either prophylactically or therapeutically to reduce the risk of bleeding or to control active bleeding. Significant uncertainty exists regarding the appropriate use of PLT transfusion and the optimal threshold for transfusion in various settings. We formulated 12 key questions to assess the role of PLT transfusion.
STUDY DESIGN AND METHODS
We performed a systematic review (SR) of randomized controlled trials (RCTs) and observational studies. A comprehensive search of PubMed, Web of Science, and Cochrane registry of controlled trials was performed. Methodologic quality of included studies was assessed and a meta-analysis was performed if more than two studies with similar designs were identified for a specific question.
RESULTS
Seventeen RCTs and 55 observational studies were included in the final SR. Results from RCTs showed a beneficial effect of prophylactic compared with therapeutic transfusion for the prevention of significant bleeding in patients with hematologic disorders undergoing chemotherapy or stem cell transplantation. We found no difference in significant bleeding events related to the PLT count threshold for transfusion or the dose of PLTs transfused. Overall methodologic quality of RCTs was moderate. Results from observational studies showed no evidence that PLT transfusion prevented significant bleeding in patients undergoing central venous catheter insertions, lumbar puncture, or other surgical procedures. The methodologic quality of observational studies was very low.
CONCLUSION
We provide a comprehensive assessment of evidence on the use of PLT transfusions in a variety of clinical settings. Our report summarizes current knowledge and identifies gaps to be addressed in future research.
Topics: Humans; Platelet Transfusion; Randomized Controlled Trials as Topic
PubMed: 25387589
DOI: 10.1111/trf.12943 -
Pediatric Emergency Care Aug 2018Balanced resuscitation of plasma, platelets, and red blood cells is now recognized as improving outcomes in traumatic bleeding in adults. The correct approach in... (Review)
Review
INTRODUCTION
Balanced resuscitation of plasma, platelets, and red blood cells is now recognized as improving outcomes in traumatic bleeding in adults. The correct approach in children has yet to be determined.
METHODS
We performed a systematic review of the literature into transfusion protocols in traumatic hemorrhage in children by conducting an article search of significant databases to identify relevant articles. Studies of interest included interventional trials with comparisons relating to the transfusion of blood including blood component therapy. The search identified 422 articles of interest, the abstracts of which were independently reviewed by 2 authors for inclusion in the trial. This revealed 35 articles, the full texts of which were reviewed. There were no randomized controlled trials and 4 nonrandomized trials with a further 21 articles that were deemed relevant. The data were insufficient for meta-analysis, and so a descriptive analysis was performed.
RESULTS
There were 4 main trials. Two trials were small (approximately 100 patients) nonrandomized trials into pediatric hemorrhage managed as per a massive transfusion protocol or at physician discretion. One was a retrospective analysis of pediatric trauma patients who received red blood cell transfusion with differing platelet ratios, and one was a trauma database review of component ratios in hemorrhaging children. All 4 trials found increased ratios had no effect on mortality.
DISCUSSION
As well as blood component therapy, adjunctive therapies used in the management of bleeding children are discussed. These include tranexamic acid, viscoelastic hemostatic assays, factor VIIa, and fibrinogen use.
CONCLUSIONS
There is little evidence for improved outcomes using component-based transfusion in a rigid 1:1:1 strategy in children. A goal-directed approach using viscoelastic hemostatic assay-guided treatment with early institution of tranexamic acid and fibrinogen replacement is considered the way forward.
Topics: Adult; Blood Transfusion; Child; Hemorrhage; Humans; Survival Rate; Wounds and Injuries
PubMed: 30080793
DOI: 10.1097/PEC.0000000000001570 -
Dermatologic Surgery : Official... Jan 2022Melasma is a common relapsing hyperpigmentation disorder, which is often difficult to treat. Platelet-rich plasma (PRP) is a novel modality often used to treat acne...
BACKGROUND
Melasma is a common relapsing hyperpigmentation disorder, which is often difficult to treat. Platelet-rich plasma (PRP) is a novel modality often used to treat acne scars, androgenic alopecia, chronic wounds, and skin rejuvenation. Recently, it has had a promising role in the treatment of melasma.
OBJECTIVE
To review the published evidence on the efficacy and safety of PRP in the treatment of melasma.
MATERIALS AND METHODS
A systematic review was performed. A meta-analysis could not be performed because of methodological differences across studies and data heterogeneity.
RESULTS
Seven studies were fulfilled and analyzed. Most studies used intradermal injections of PRP and have shown significant improvement in melasma. Microneedling mediated delivery of PRP has been tried in melasma with good results. A single study showed no additional benefit of PRP in patients treated with topical tranexamic acid. Another study showed no benefit of intense pulsed light in patients treated with intradermal PRP.
CONCLUSION
Platelet-rich plasma inhibits the melanin synthesis through its various components acting through several mechanisms. It demonstrates a moderate grade of recommendation according to the Oxford Center for Evidence-Based Medicine 2011 standards.
Topics: Administration, Cutaneous; Blood Transfusion, Autologous; Combined Modality Therapy; Humans; Melanins; Melanosis; Platelet-Rich Plasma; Randomized Controlled Trials as Topic; Skin; Skin Pigmentation; Tranexamic Acid; Treatment Outcome
PubMed: 34904579
DOI: 10.1097/DSS.0000000000003266 -
Tropical Medicine & International... Apr 2023Arboviruses are emerging as a relevant threat to transfusion safety. Pathogen inactivation methods (PIMs) may reduce the risk of transmission through transfusion, as... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
Arboviruses are emerging as a relevant threat to transfusion safety. Pathogen inactivation methods (PIMs) may reduce the risk of transmission through transfusion, as long as they meet minimum standards for effectiveness. This study aims to assess the log reduction of viral load achieved with different PIMs, according to the blood product they are used on and the arbovirus targeted.
METHODS
Systematic literature review and meta-analysis. Searches were conducted in MEDLINE and Embase. The study protocol was registered in PROSPERO CRD42022312061. We selected records reporting the log reduction of viral load achieved with the main PIMs (amotosalen + UVA light [INTERCEPT], riboflavin + UV light [Mirasol], methylene blue + visible light/UVC light [THERAFLEX], solvent detergent, amustaline [INTERCEPT] and PEN110 [Inactine]), applied to any blood product (plasma, platelets, red blood cells or whole blood) and for any arbovirus. The log reduction of viral loads was assessed by obtaining the mean log reduction factor (LRF). We compared and classified the LRF of different techniques using statistical methods.
RESULTS
We included 59 publications reporting LRF results in 17 arboviruses. For 13 arboviruses, including Chikungunya virus, Dengue virus, West Nile virus and Zika virus, at least one of the methods achieves adequate or optimal log reduction of viral load-mean LRF ≥4. The LRF achieved with riboflavin + UV light is inferior to the rest of the techniques, both overall and specifically for plasma, platelets preserved in platelet additive solution (PAS)/plasma, and red blood cells/whole blood. The LRF achieved using Mirasol is also lower for inactivating Chikungunya virus, Dengue virus and Zika virus. For West Nile virus, we found no significant differences. In plasma, the method that achieves the highest LRF is solvent/detergent; in platelets, THERAFLEX and INTERCEPT; and in red blood cells/whole blood, PEN110 (Inactine).
CONCLUSION
Not all PIMs achieve the same LRF, nor is this equivalent between the different arboviruses or blood products. Overall, the LRFs achieved using riboflavin + UV light (Mirasol) are inferior to those achieved with the rest of the PIMs. Regarding the others, LRFs vary by arbovirus and blood product. In light of the threat of different arboviruses, blood establishments should have already validated PIMs and be logistically prepared to implement these techniques quickly.
Topics: Humans; Arboviruses; Detergents; Polyamines; Zika Virus; Riboflavin; Zika Virus Infection
PubMed: 36806816
DOI: 10.1111/tmi.13863 -
The Lancet. Gastroenterology &... Sep 2023The diagnosis of clinically significant portal hypertension is crucial for prognosis and treatment guidance in patients with compensated advanced chronic liver disease...
Accuracy of spleen stiffness measurement for the diagnosis of clinically significant portal hypertension in patients with compensated advanced chronic liver disease: a systematic review and individual patient data meta-analysis.
BACKGROUND
The diagnosis of clinically significant portal hypertension is crucial for prognosis and treatment guidance in patients with compensated advanced chronic liver disease (ACLD). Spleen stiffness measurement (SSM) might improve the non-invasive diagnosis of clinically significant portal hypertension, but previous studies have reported heterogeneous SSM cutoffs. We aimed to evaluate the accuracy of SSM and SSM-based algorithms in this setting.
METHODS
In this systematic review and individual patient data meta-analysis, we searched PubMed, Embase, Scopus, Web of Science, and the Cochrane Library from database inception to Dec 31, 2022, for articles, abstracts, and letters, with no restrictions on language. Cross-sectional studies reporting hepatic venous pressure gradient and SSM by different techniques (transient elastography; two-dimensional shear-wave elastography [2D-SWE]; point shear-wave elastography [p-SWE]) in adults (≥18 years) with compensated ACLD were eligible for inclusion. The main outcome was the diagnostic performance of two SSM-based algorithms, with the Baveno VII model as a reference, evaluating sensitivity and specificity, as well as summary negative predictive values (NPVs) and positive predictive values (PPVs). In the Baveno VII model, clinically significant portal hypertension was ruled out if patients had a liver stiffness measurement (LSM) of 15 kPa or less and a platelet count of 150 × 10 platelets per L or higher and ruled in if they had an LSM of greater than 25 kPa. The two SSM-based models combined these same cutoffs with additional criteria. In the Baveno VII-SSM single cutoff model, clinically significant portal hypertension was ruled out if at least two of the following were present: LSM of 15 kPa or less, platelet count of 150 × 10 platelets per L or higher, and SSM of 40 kPa or less; and ruled in if at least two were present: LSM of greater than 25 kPa, platelet count of less than 150 × 10 platelets per L, and SSM of greater than 40 kPa. The Baveno VII-SSM dual cutoff model used the same criteria, but with a cutoff of SSM of less than 21 kPa to rule out, and greater than 50 kPa to rule in, clinically significant portal hypertension. This study is registered with PROSPERO, CRD42019127164.
FINDINGS
Of the 44 records assessed for eligibility, 17 studies (with 1245 patients) were included in the meta-analysis. In the transient elastography cohort (n=600), the Baveno VII algorithm was validated for both ruling out (NPV 100%, 95% CI 64-100; sensitivity 100%, 95% CI 70-100) and ruling in (PPV 95%, 85-98; specificity 94%, 95% CI 87-97) clinically significant portal hypertension, but the proportion of patients with indeterminate results (grey zone) was 48% (95% CI 44-52); 57% (95% CI 52-62) of patients with clinically significant portal hypertension were included in the rule-in zone. The Baveno VII-SSM dual cutoff model had adequate NPV (98%, 95% CI 58-100; sensitivity 100%, 95% CI 91-100) and PPV (93%, 95% CI 84-97; specificity 89%, 95% CI 84-93), with 32% (95% CI 28-36) of patients in the grey zone; 76% (95% CI 72-80) of the patients with clinically significant portal hypertension were in the rule-in zone. The Baveno VII-SSM single cutoff model had a sensitivity of 93% (95% CI 85-97) and a NPV of 85% (95% CI 60-96) for ruling out, and a specificity of 86% (95% CI 80-91) and a PPV of 92% (95% CI 83-95) for ruling in, clinically significant portal hypertension. 88% (95% CI 84-91) of patients with clinically significant portal hypertension were included in the rule-in zone and 9% (95% CI 7-12) of patients were in the grey zone. In the 2D-SWE cohort (n=225), all three algorithms could safely rule in clinically significant portal hypertension with adequate PPV (≥90%), but NPV was inadequate for ruling out clinically significant portal hypertension. Insufficient data were available to evaluate the performance of SSM assessed by p-SWE. Heterogeneity was low (I<25%) for most estimates.
INTERPRETATION
Algorithms combining Baveno VII criteria with SSM showed good performance and reduced the diagnostic grey zone for clinically significant portal hypertension compared with Baveno VII criteria alone. Future studies should evaluate whether SSM-based diagnosis allows for the identification of patients who would benefit from non-selective β-blocker treatment.
FUNDING
None.
PubMed: 37478880
DOI: 10.1016/S2468-1253(23)00150-4 -
Vox Sanguinis Nov 2016The storage time of platelet products negatively affects bacterial safety and platelet function. However, low maximum storage time increases outdating of valuable... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
The storage time of platelet products negatively affects bacterial safety and platelet function. However, low maximum storage time increases outdating of valuable products. Thus, to quantify the effect of platelet storage time on platelet measurements after platelet transfusion, a systematic review and meta-analyses were performed.
METHODS
Reports and meeting abstracts of randomized trials and observational studies, performed in humans, reporting platelet measurements after transfusion of platelet products of different storage times, were selected until February 2016. Meta-analyses were performed for four different storage time contrasts, each answering a different question. Random-effects models were used to account for substantial heterogeneity and the weighted mean differences calculated.
RESULTS
Our search strategy yielded 4234 studies of which 46 papers satisfied the inclusion criteria. As judged by the 1-h corrected count increment, transfusions of fresher platelets compared to stored platelets showed better increment. The weighed mean difference varied from 2·11 (95%CI: 1·51-2·71) to 2·68 (95%CI: 1·92-3·45). For the 24-h corrected count increment, the weighted mean difference varied from 1·36 (95%CI: 0·12-2·60) to 1·68 (95%CI: 1·07-2·28) depending on the contrast. Recovery and survival of old platelets as percentage of fresh platelets were 81% and 73% for the original definition contrast. For the extended storage contrast, recovery and survival were 75% and 68%.
CONCLUSIONS
Fresh platelets were superior to old platelets for all platelet measurements and for all storage time contrasts meta-analysed.
Topics: Blood Platelets; Blood Safety; Humans; Platelet Activation; Platelet Function Tests; Platelet Transfusion; Time Factors; Treatment Outcome
PubMed: 27564401
DOI: 10.1111/vox.12443 -
Transfusion Mar 2021Guidelines for platelet (PLT) transfusion are an important source of information for clinicians. Although guidelines intend to increase consistency and quality of care,...
BACKGROUND
Guidelines for platelet (PLT) transfusion are an important source of information for clinicians. Although guidelines intend to increase consistency and quality of care, variation in methodology and recommendations may exist that could impact the value of a guideline. We aimed to determine the quality of existing PLT transfusion guidelines using the Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument and to describe the inconsistencies in recommendations.
STUDY DESIGN AND METHODS
A systematic search was undertaken for evidence-based guidelines from January 1, 2013, to January 25, 2019. Citations were reviewed in duplicate for inclusion and descriptive data extracted. Four physicians appraised the guideline using the AGREE II instrument and the scaled score for each item evaluated was calculated. The protocol was registered in PROSPERO.
RESULTS
Of 6744 citations, 6740 records were screened. Seven of 28 full-text studies met the inclusion criteria. The median scaled score (and the interquartile range of the scaled score) for the following items were as follows: scope and purpose, 94% (8%); stakeholder involvement, 63% (18%); rigor of development, 83% (14%); clarity of presentation, 94% (6%); applicability, 58% (20%); and editorial independence, 77% (4%). Overall quality ranged from 4 to 7 (7 is the maximum score). Inconsistent recommendations were on prophylactic PLT transfusion in hypoproliferative thrombocytopenia in the presence of risk factors and dose recommendations.
CONCLUSION
Inconsistencies between guidelines and variable quality highlight areas for future guideline writers to address. Areas of specific attention include issues of stakeholder involvement and applicability.
Topics: Databases, Bibliographic; Humans; Platelet Transfusion; Practice Guidelines as Topic
PubMed: 33483953
DOI: 10.1111/trf.16257 -
Transfusion Medicine Reviews Apr 2015Critical bleeding (CB) requiring massive transfusion (MT) can occur in a variety of clinical contexts and is associated with substantial mortality and morbidity. In... (Review)
Review
Critical bleeding (CB) requiring massive transfusion (MT) can occur in a variety of clinical contexts and is associated with substantial mortality and morbidity. In 2011, the Australian National Blood Authority (NBA) published patient blood management guidelines for CB and MT, which found limited high-quality evidence from which only 2 recommendations could be made. The aim of this systematic review (SR) was to update these guidelines and identify evidence gaps still to be addressed. A comprehensive search was performed for randomized controlled trials (RCTs) and SRs using MeSH index and free text terms in MEDLINE, the Cochrane Library (Issue 11, 2012), EMBASE, CINHAL, PUBMED, and the Transfusion Evidence Library up to July 15, 2014. The evidence was grouped according to 4 questions based on the original guideline relating to transfusion interventions: (1) effect of dose, timing, and ratio of red blood cells (RBCs) to component therapy on patient outcomes; (2) effect of RBC transfusion on patient outcomes; (3) effect of fresh frozen plasma, platelet, cryoprecipitate, fibrinogen concentrate, and prothrombin complex concentrate on patient outcomes; and (4) effect of recombinant activated factor VII (rFVIIa) on patient outcomes. From this search, 19 studies were identified: 6 RCTs and 13 SRs. Two of the RCTs were pilot/feasibility studies, 3 were investigating rFVIIa, and 1 compared restrictive versus liberal RBC transfusion in upper gastrointestinal hemorrhage. Overall, limited new evidence was identified and substantial evidence gaps remain, particularly with regard to the effect of component therapies, including ratio of RBC to component therapies, on patient outcomes. Clinical trials to address these questions are required.
Topics: Blood Component Transfusion; Blood Transfusion; Combined Modality Therapy; Critical Care; Data Accuracy; Evidence-Based Medicine; Factor VIIa; Feasibility Studies; Guideline Adherence; Hemorrhage; Humans; Meta-Analysis as Topic; Pilot Projects; Practice Guidelines as Topic; Randomized Controlled Trials as Topic; Recombinant Proteins; Review Literature as Topic; Transfusion Reaction; Treatment Outcome
PubMed: 25716645
DOI: 10.1016/j.tmrv.2015.01.001 -
Whole blood transfusion in the treatment of acute hemorrhage, a systematic review and meta-analysis.The Journal of Trauma and Acute Care... Aug 2023Whole blood (WB) transfusion received renewed interest after recent armed conflicts. The effectiveness as compared with blood component transfusion (BCT) is, however,... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Whole blood (WB) transfusion received renewed interest after recent armed conflicts. The effectiveness as compared with blood component transfusion (BCT) is, however, still topic of debate. Therefore, this study investigated the effect of WB ± BCT as compared with BCT transfusion on survival in trauma patients with acute hemorrhage.
METHODS
Studies published up to January 16, 2023, including patients with traumatic hemorrhage comparing WB ± BCT and BCT were included in meta-analysis. Subanalyses were performed on the effectiveness of WB in the treatment of civilian or military trauma patients, patients with massive hemorrhage and on platelet (PLT)/red blood cell (RBC), plasma/RBC and WB/RBC ratios. Methodological quality of studies was interpreted using the Cochrane risk of bias tool. The study protocol was registered in PROSPERO under number CRD42022296900.
RESULTS
Random effect pooled odds ratio (OR) for 24 hours mortality in civilian and military patients treated with WB as compared with BCT was 0.72 (95% confidence interval [CI], 0.53-0.97). In subanalysis of studies conducted in civilian setting (n = 20), early (4 hours, 6 hours, and emergency department) and 24 hours mortality was lower in WB groups compared with BCT groups (OR, 0.65; 95% CI, 0.44-0.96 and OR, 0.71; 95% CI, 0.52-0.98). No difference in late mortality (28 days, 30 days, in-hospital) was found. In military settings (n = 7), there was no difference in early, 24 hours, or late mortality between groups. The WB groups received significant higher PLT/RBC ( p = 0.030) during early treatment and significant higher PLT/RBC and plasma/RBC ratios during 24 hours of treatment ( p = 0.031 and p = 0.007). The overall risk of bias in the majority of studies was judged as serious due to serious risk on confounding and selection bias, and unclear information regarding cointerventions.
CONCLUSION
Civilian trauma patients with acute traumatic hemorrhage treated with WB ± BCT as compared to BCT had lower odds on early and 24-hour mortality. In addition, WB transfusion resulted in higher PLT/RBC and plasma/RBC ratios.
LEVEL OF EVIDENCE
Systematic Review and Meta-Analysis; Level III.
Topics: Humans; Blood Transfusion; Hemorrhage; Blood Component Transfusion; Resuscitation; Emergency Service, Hospital; Wounds and Injuries
PubMed: 37125904
DOI: 10.1097/TA.0000000000004000 -
BMC Musculoskeletal Disorders Mar 2016Femoral neck fractures in the elderly make up a large proportion of Orthopaedic surgical admissions each year. Operating on patients with clopidogrel poses a challenge... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Femoral neck fractures in the elderly make up a large proportion of Orthopaedic surgical admissions each year. Operating on patients with clopidogrel poses a challenge because of the risk of bleeding and the difficulty deciding the optimal timing of surgery. The aim of this systematic review is to examine the published evidence to establish a set of guidelines for approaching neck of femur patients who are on clopidogrel.
METHODS
All comparative studies with an intervention group and a control group were considered. Data on patient blood transfusion exposures, units transfused, haemoglobin concentration and drop in haemoglobin were extracted and pooled using the fixed effects model. Heterogeneity of the intervention effect was assessed with the I (2) statistic.
RESULTS
A total of 4219 studies were identified. After removal of duplicates and after exclusion criteria were applied, there were 14 studies to be included. All 14 were case series with controls. There was no significant heterogeneity amongst the studies. Pooled odds ratio for transfusion exposures was 1.24 (95 % confidence interval 0.91 to 1.71) however this was not statistically significant (p = 0.14). No significant mean differences were found for other primary outcome measures.
CONCLUSIONS
On the available evidence, we recommend that these patients can be managed by normal protocols with early surgery. Operating early on patients on clopidogrel is safe and does not appear to confer any clinically significant bleeding risk. As reported in other studies, we believe clopidogrel, if possible, should not be withheld throughout the perioperative period due to increased risk of cardiovascular events associated with stopping clopidogrel. Care should be taken intraoperatively to minimise blood loss due to the increased potential for bleeding.
TRIAL REGISTRATION
This systematic review and meta-analysis has been registered on Research Registry on July 16, 2015. The Review Registry Unique Identifying Number is: reviewregistry61 .
Topics: Blood Loss, Surgical; Chi-Square Distribution; Clopidogrel; Drug Administration Schedule; Femoral Neck Fractures; Fracture Fixation; Humans; Odds Ratio; Platelet Aggregation Inhibitors; Risk Assessment; Risk Factors; Ticlopidine; Treatment Outcome
PubMed: 27005816
DOI: 10.1186/s12891-016-0988-9