Highly Effective, Easy, & Simple Model for the Day-to-Day Monitoring of Blood Bank Inventory Leading to Successful Operations to Provide Blood Products in the Times of Blood Product Shortage Nationally Due to COVID-19 Pandemic

Introduction/Objective

Providing blood products in a timely manner is very important and is an integral part of the health care system to provide best patient care. Transfusion medicine services should be well prepared to respond to blood product demands in a timely manner. Due to the COVID-19 pandemic, all the transfusion medicine services nationally have been facing blood product shortages. A model was created in Pathology & Laboratory services (P&LMS) at the Corporal Michael J. Crescenz Veteran Affairs Medical Center (CMC VAMC) to communicate effectively to the patient care team to keep up with ongoing clinical care demands despite the national blood shortage.

Methods/Case Report

Transfusion medicine team at CMC VAMC communicated to patient care team about the national shortage of blood products. All blood requests were evaluated for appropriate usage of blood. Also, PACS (Peri Operative cells Savers) services was considered for Operating room for patient with major blood loss. Daily blood inventory was evaluated, closely monitored, and communicated to patient care team to meet the demands from Jan 16th, 2022, to April 11th, 2022. Importantly, P&LMS created a simple model where each blood product in reduction was recorded every morning and evening. This simple method of 24/7 real time monitoring of the supply of blood products helped tremendously in decision making for procedure prioritization based on clinical indications and contributed to the continued successful clinical operation.

Results (if a Case Study enter NA)

Procedures were successfully prioritized according to the blood supply. Simultaneously, there was no delay in issuing blood products as clinically needed. A significant amount of reduced inventory noted from Jan 16th, 2022, to April 11th, 2022; the average reduction was O+ 53% reduced and A+ 44% reduced.

Conclusion

By monitoring the day-to-day blood bank inventory effectively, P&LMS at CMC VAMC was able to support all the critical clinical needs by providing blood products in a timely manner. P&LMS services was able to reduce the wastage and was able to provide all the critical blood product without any significant delays by monitoring in Realtime. The value of collaborating and communicating to the patient care team cannot be understated as it is both simple and highly cost effective.

A Holistic Approach for an Efficient Day to Day Operation for Blood Bank Market Withdrawals and Recalls Using Departmental Electronic Occurrence System: A CMCVAMC Experience

Introduction/Objective

Donor centers and reagent manufacturers may issue recalls or market withdrawals. Donor center withdrawals of blood components involve units that have a reason that may present a risk to the patient, that subsequently require discarding the product if not transfused or appropriate clinical notification and follow-up if already transfused prior to the notification. Reagent recalls involve problems with reagents that require appropriate corrective action as per the circumstances. Patient safety event reporting systems are universal in hospitals and are a backbone of efforts to detect patient safety events and quality problems. Pathology and Laboratory Medicine (P&LMS) at the Corporal Michael J. Crescenz Veteran Affairs Medical Center (CMC VAMC) has established an electronic occurrence reporting (EOR) program to track and respond to these in the blood bank. The authors explored the usefulness of the holistic approach of this initiative.

Methods/Case Report

EOR is available to all the employees of Blood Bank in P&LMS, who regularly report all received recalls and market withdrawals into the system. These are reviewed by the supervisor and blood bank medical director and co-director to ensure appropriate steps are taken. Information on all market recalls and withdrawals affecting blood bank were compiled from January 1st, 2021, to June 1st, 2022, for quality assurance review.

Results (if a Case Study enter NA)

The EOR plays a significant role in organizing the data from all the recalls and market withdrawals to guide improvement in patient care. There were seven market withdrawals during the study period, all from the donor center for blood product component withdrawals. All seven cases were recorded efficiently with review by the blood bank supervisor and blood bank medical director and co-director. Appropriate follow-up action was performed and recorded for all seven cases in the EOR.

Conclusion

The EOR for withdrawals recalls in Blood Bank is highly effective, successful program in terms of electronic organized monitoring. This monitoring is part of ensuring quality care in real time, and plays an important role as part of Veteran Affairs position as a High reliability Organization (HRO).

Continuing Profound Impact of Continued Education Sessions on Blood Bank Specimen Labeling Years Later at the Veteran Affairs Medical Center

Introduction/Objective

Proper patient identification is a critical safety element for transfusion medicine, particularly for the prevention of acute hemolytic transfusion reactions (AHTR). Mislabeled specimens have been documented to carry an increased risk of patient misidentification. Therefore, the submission of a mislabeled specimen to the blood bank generally results in a specimen rejection with a redraw. At the Philadelphia Veteran Affairs Medical Center, an identification bracelet with alphanumeric code is used to help improve transfusion safety but also has additional patient labeling requirements. The redrawing of blood bank specimens poses risks in phlebotomy, and a quality improvement initiative was previously undertaken to educate staff on proper blood specimen and band labeling and usage to prevent labeling errors, improve safety in patient care, and reduce intended redraws.

Methods/Case Report

Colorful laminated posters delineating the labeling requirements and process for blood bank specimens collected using the blood bank system were made and distributed at the time of in-service training by the blood bank in 2017 to the areas of the hospital whereby errors had been noted to occur in the past. The dedicated in-service training was repeated prior to the change in the identification blood band from the Hollister Ident-ATM Blood Recipient Band (Precision Diagnostics Corporation, Valencia CA) to the Typenex Blood Bands (Typenex Medical, Chicago IL) on 11/12/2019. As part of the quality metrics of the blood bank, blood bank specimen labeling errors was tracked from 2017 to track the persistence of the effect of the initial training.

Results (if a Case Study enter NA)

The percentage of properly labeled specimens as a percentage of total specimens increased after the in-service training; specifically, an increase from a low of 97% (December 2017) to a high of 99% (August 2018). The percentage of properly labeled specimens remains at the increased level of 99% and above even at the 4.5-year mark in mid-2022.

Conclusion

The continued availability of laminated educational posters on blood specimen labeling for the clinical service areas combined with initial in-service education can have lasting effects to improve the quality of care even years after the initial in-service education sessions.

Early Biomarker Signatures in Surgical Sepsis

INTRODUCTION

Sepsis has complex, time-sensitive pathophysiology and important phenotypic subgroups. The objective of this study was to use machine learning analyses of blood and urine biomarker profiles to elucidate the pathophysiologic signatures of subgroups of surgical sepsis patients.

METHODS

This prospective cohort study included 243 surgical sepsis patients admitted to a quaternary care center between January 2015 and June 2017. We applied hierarchical clustering to clinical variables and 42 blood and urine biomarkers to identify phenotypic subgroups in a development cohort. Clinical characteristics and short-term and long-term outcomes were compared between clusters. A naïve Bayes classifier predicted cluster labels in a validation cohort.

RESULTS

The development cohort contained one cluster characterized by early organ dysfunction (cluster I, n = 18) and one cluster characterized by recovery (cluster II, n = 139). Cluster I was associated with higher Acute Physiologic Assessment and Chronic Health Evaluation II (30 versus 16, P < 0.001) and SOFA scores (13 versus 5, P < 0.001), greater prevalence of chronic cardiovascular and renal disease (P < 0.001) and septic shock (78% versus 17%, P < 0.001). Cluster I had higher mortality within 14 d of sepsis onset (11% versus 1.5%, P = 0.001) and within 1 y (44% versus 20%, P = 0.032), and higher incidence of chronic critical illness (61% versus 30%, P = 0.001). The Bayes classifier achieved 95% accuracy and identified two clusters that were similar to development cohort clusters.

CONCLUSIONS

Machine learning analyses of clinical and biomarker variables identified an early organ dysfunction sepsis phenotype characterized by inflammation, renal dysfunction, endotheliopathy, and immunosuppression, as well as poor short-term and long-term clinical outcomes.

National epidemiologic trends (2008-2018) in the United States for the incidence and expenditures associated with incisional hernia in relation to abdominal surgery

PURPOSE

It is unknown whether the trend of rising incisional hernia (IH) repair (IHR) incidence and costs until 2011 currently persists. We aimed to evaluate how the IHR procedure incidence, cost and patient risk-profile have changed over the last decade relative to all abdominal surgeries (AS).

METHODS

Repeated cross-sectional analysis of 38,512,737 patients undergoing inpatient 4AS including IHR within the 2008-2018 National Inpatient Sample. Yearly incidence (procedures/1,000,000 people [PMP]), hospital costs, surgical and patient characteristics were compared between IHR and AS using generalized linear and multinomial regression.

RESULTS

Between 2008-2018, 3.1% of AS were IHR (1,200,568/38,512,737). There was a steeper decrease in the incidence of AS (356.5 PMP/year) compared to IHR procedures (12.0 PMP/year) which resulted in the IHR burden relative to AS (2008-2018: 12,576.3 to 9,113.4 PMP; trend difference P < 0.01). National costs averaged $47.9 and 1.7 billion/year for AS and IHR, respectively. From 2008-2018, procedure costs increased significantly for AS (68.2%) and IHR (74.6%; trends P < 0.01). Open IHR downtrended (42.2%), whereas laparoscopic (511.1%) and robotic (19,301%) uptrended significantly (trends P < 0.01). For both AS and IHR, the proportion of older (65-85y), Black and Hispanic, publicly-insured, and low-income patients, with higher comorbidity burden, undergoing elective procedures at small- and medium-sized hospitals uptrended significantly (all P < 0.01).

CONCLUSION

IH persists as a healthcare burden as demonstrated by the increased proportion of IHR relative to all AS, disproportionate presence of high-risk patients that undergo these procedures, and increased costs. Targeted efforts for IH prevention have the potential of decreasing $17 M/year in costs for every 1% reduction.

PKD1 and PKD2 mRNA cis-inhibition drives polycystic kidney disease progression

Autosomal dominant polycystic kidney disease (ADPKD), among the most common human genetic conditions and a frequent etiology of kidney failure, is primarily caused by heterozygous PKD1 mutations. Kidney cyst formation occurs when PKD1 dosage falls below a critical threshold. However, no framework exists to harness the remaining allele or reverse PKD1 decline. Here, we show that mRNAs produced by the noninactivated PKD1 allele are repressed via their 3'-UTR miR-17 binding element. Eliminating this motif (Pkd1∆17) improves mRNA stability, raises Polycystin-1 levels, and alleviates cyst growth in cellular, ex vivo, and mouse PKD models. Remarkably, Pkd2 is also inhibited via its 3'-UTR miR-17 motif, and Pkd2∆17-induced Polycystin-2 derepression retards cyst growth in Pkd1-mutant models. Moreover, acutely blocking Pkd1/2 cis-inhibition, including after cyst onset, attenuates murine PKD. Finally, modeling PKD1∆17 or PKD2∆17 alleles in patient-derived primary ADPKD cultures leads to smaller cysts, reduced proliferation, lower pCreb1 expression, and improved mitochondrial membrane potential. Thus, evading 3'-UTR cis-interference and enhancing PKD1/2 mRNA translation is a potentially mutation-agnostic ADPKD-arresting approach.

Accessory articulation of the transverse processes in the cervical spine

Accessory articulation between the transverse processes of the C6 and C7 vertebrae is an extremely rare anatomic variant that has only been previously described in two instances. In this report, we present the case of a 25-year-old male who sustained numerous injuries associated with a physical assault. A CT study of the cervical spine revealed a linear lucency mimicking a fracture but found on closer inspection to represent an accessory articulation between the anterior tubercles of the right transverse processes of the C6 and C7 vertebrae. In this report, we summarize this patient's clinical course, and provide an up-to-date review of the current literature, imaging characteristics, and potential mechanisms of the development of this anatomic variant. Our case also includes an incomplete version of the anomaly contralaterally as well as features of secondary osseous stress hypertrophy; these features have not been previously described and may aid in diagnosis. Finally, we provide the first-ever augmented reality model of this variant to fully convey its geometry and facilitate its unequivocal identification.

Ultra-high field 7 T MRI localizes regional brain volume recovery following corticotroph adenoma resection and hormonal remission in Cushing's disease: A case series

Background

Cushing's disease (CD) is defined by glucocorticoid excess secondary to the increased section of corticotropin by a pituitary adenoma. Magnetic resonance imaging (MRI) studies performed at 1.5 or 3 Tesla (T) have demonstrated correlations between regional changes in brain structure and the progression of CD. In this report, we examine the changes in brain volume following corticotroph pituitary adenoma resection using ultra-high field 7 T MRI to increase the accuracy of our volumetric analyses.

Methods

Thirteen patients were referred to the endocrinology clinic at our institution from 2017 to 2020 with symptoms of cortisol excess and were diagnosed with ACTH-dependent endogenous Cushing syndrome. Five patients had follow-up 7 T imaging at varying time points after a transsphenoidal resection.

Results

Symmetrized percent change in regional volumes demonstrated a postoperative increase in cortical volume that was relatively larger than that of cerebral white matter or subcortical gray matter (percent changes = 0.0172%, 0.0052%, and 0.0120%, respectively). In the left cerebral hemisphere, the medial orbitofrontal, lateral orbitofrontal, and pars opercularis cortical regions experienced the most robust postoperative percent increases (percent changes = 0.0166%, 0.0122%, and 0.0068%, respectively). In the right cerebral hemisphere, the largest percent increases were observed in the pars triangularis, rostral portion of the middle frontal gyrus, and superior frontal gyrus (percent changes = 0.0156%, 0.0120%, and 0.0158%).

Conclusion

Cerebral volume recovery following pituitary adenoma resection is driven by changes in cortical thickness predominantly in the frontal lobe, while subcortical white and gray matter volumes increase more modestly.

The Abdominal Hernia-Q: a critical analysis of the components that impact quality-of-life

PURPOSE

Ventral hernias (VH) are a common surgical problem associated with significant morbidity. While assessment tools have examined quality-of-life (QoL), the relative change in specific domains of hernia-related QoL measures from pre- to post-operative period has yet to be comprehensively examined. Using the Abdominal Hernia-Q (AHQ), this study aims to assess the impact of ventral hernia repair (VHR) on key components of QoL.

METHODS

A retrospective chart review was conducted of patients undergoing VHR between September 2017 and September 2019 who had completed at least one pre- and post-operative AHQ. Post-operative intervals were created to capture AHQ responses around standard follow-up visits (< 1.5 months, 1.5-4.5 months, 4.5-11 months, and 11 + months) and scores were statistically analyzed.

RESULTS

A total of 136 patients were included, with an average age of 54.8 years at the time of VHR. Compared to the pre-operative period, the appearance score increased significantly (p < 0.05). The physical domain score increased from < 1.5 month to the 1.5-4.5 month period (p = 0.03) and remained significantly higher in later time period. The appearance score decreased from the 1.5-4.5 month to 4.5-11 month period (p = 0.05).

CONCLUSIONS

VHR leads to a sustained multi-dimensional increase in hernia-specific QoL measures during the post-operative course driven by early positive changes in appearance and sustained physical functioning. The initial increase in QoL is mainly driven by an improvement in appearance, while the sustained increase may be due to restored physical function.

POS0343 TREATMENT PERSISTENCE AND ADHERENCE AMONG PATIENTS WITH JUVENILE IDIOPATHIC ARTHRITIS RECEIVING ABATACEPT OR TNF INHIBITORS USING US CLAIMS DATA

Background

Juvenile idiopathic arthritis (JIA) is the most common rheumatic condition among children and teens1 and contributes to a diminished quality of life.2 Previous data underscore the potential for abatacept to improve health-related outcomes in patients with JIA after demonstrating poor responses to other DMARDs.3 Patients with RA show greater persistence on abatacept vs TNF inhibitors (TNFi), and this should also be confirmed in patients with JIA.4

Objectives

To evaluate treatment persistence and adherence at 12- and 18-month follow-up in patients with JIA newly initiating either abatacept or a TNFi.

Methods

This analysis used data from the IQVIA PharMetrics Plus claims database from Jan 2008–Apr 2021. We identified patients with ≥ 1 claim of JIA diagnosis after Jan 2008, who were < 18 years old at initial diagnosis, had ≥ 1 claim of abatacept or TNFi treatment (adalimumab, etanercept, golimumab) following diagnosis, had continuous enrollment in medical and pharmacy benefits for ≥ 12 months before index date (first prescription of abatacept or TNFi), and had 12 or 18 months’ continuous medical and pharmacy enrollment after index date. Patients receiving abatacept or TNFi treatment ≤ 12 months prior to index date and patients initiating combined abatacept + TNFi treatment on the index date were excluded. Specific outcomes included: discontinuation (absence of a new prescription for index treatment within the gap of 5× treatment half-life), persistence rate (proportion of patients continuing index medication without any gaps exceeding 5× treatment half-life), and treatment adherence (defined as medication possession ratio [MPR, proportion of follow-up period where medication supply is available] and proportion of days covered [PDC, proportion of follow-up period where a patient is covered by a given drug]). All outcomes were reported at 12 and 18 months. All statistical analyses are descriptive with the intent for hypothesis generation.

Results

There were 2847 patients (abatacept, n = 111; TNFi, n = 2736) at 12-month follow-up; fewer completed the 18-month follow-up (2403 patients: abatacept, n = 94; TNFi, n = 2309). At index date, treatment groups were similar for sex, geographic location, and comorbidities (Table 1). Numerically higher persistence was observed in patients prescribed abatacept compared with TNFi overall at both time points. Abatacept persistence was higher than etanercept but similar to adalimumab (Figure 1). At 12 months, the percent of patients with PDC ≥ 0.8 was 57% for abatacept, 51% for adalimumab, and 38% for etanercept, while MPR ≥ 0.8 was 63% for abatacept, 55% for adalimumab, and 42% for etanercept. Patients prescribed abatacept had numerically greater proportions of PDC ≥ 0.8 (abatacept, 48%; adalimumab, 40%; etanercept, 29%) and MPR ≥ 0.8 (abatacept, 53%; adalimumab, 44%; etanercept, 33%) at 18 months.

Table 1.

Baseline characteristics of patients with 12-month follow-up data

CharacteristicAbatacept (n = 111)TNFi (n = 2736)Age, years, mean (SD)14.4 (3.8)12.6 (4.6)Female sex89 (80.2)1930 (70.5)Geographic region South43 (38.7)865 (31.6) Midwest40 (36.0)818 (29.9) West9 (8.1)408 (14.9) East19 (17.1)540 (19.7) Unknown0 (0)105 (3.8)Comorbidities Asthma9 (8.1)275 (10.1) COPD11 (9.9)323 (11.8) Cardiovascular disease14 (12.6)222 (8.1) Uveitis14 (12.6)321 (11.7) Iridocyclitisa12 (10.8)216 (7.9)CCI score, mean (SD)0.58 (0.73)0.46 (0.68)

Data are shown as n (%) unless otherwise specified.

aSubgroup disease under uveitis.

CCI, Charlson Comorbidity Index; COPD, chronic obstructive pulmonary disease.

Conclusion

The present findings suggest that patients with JIA initiating abatacept treatment display numerically higher persistence and adherence compared with patients treated with TNFis at both 12- and 18-months’ follow-up.

References

[1]Prakken B, et al. Lancet 2011;377:2138–49.

[2]Lovell DJ, et al. Arthritis Rheumatol 2015;67:2759–70.

[3]Ruperto N, et al. Lancet 2008;372:383–91.

[4]Han X, et al. J Health Econ Outcomes Res 2021;8:71–8.

Acknowledgements

This study was sponsored by Bristol Myers Squibb. Medical writing and editorial assistance were provided by Ryan Miller, of Caudex, and were funded by Bristol Myers Squibb. Project analysis was provided by Akshay Vinod (Mu Sigma).

Disclosure of Interests

Ching-An Wang Consultant of: Novartis (used to work there as an external contractor from Jan 2016 to Apr 2021), Employee of: Bristol Myers Squibb, Robert Wong Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Tzuyung Douglas Kou Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Hanke Zheng Employee of: Bristol Myers Squibb, Keith Wittstock Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Vadim Khaychuk Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Vardhaman PATEL Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb

A Large Lipoma of the Tongue: A case report

This report discusses a rare case of a 75-year-old male presenting with a large lipoma of the tongue. It examines the investigations carried out to aid in diagnosing the lesion and the management options. Since oral lipomas rarely cause symptoms, there tends to be a general delay in seeking treatment. This case report aims to help dental practitioners diagnose intra-oral soft tissue lesions and provide appropriate management for their patients.