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Alber S, Tanabe K, Hennigan A, Tregear H, Gilliland S. Year in Review 2023: Noteworthy Literature in Cardiothoracic Critical Care. Semin Cardiothorac Vasc Anesth 2024; 28:66-79. [PMID: 38669120 DOI: 10.1177/10892532241249582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/28/2024]
Abstract
This article reviews noteworthy investigations and society recommendations published in 2023 relevant to the care of critically ill cardiothoracic surgical patients. We reviewed 3,214 articles to identify 18 publications that add to the existing literature across a variety of topics including resuscitation, nutrition, antibiotic management, extracorporeal membrane oxygenation (ECMO), neurologic care following cardiac arrest, coagulopathy and transfusion, steroids in pulmonary infections, and updated guidelines in the management of acute respiratory distress syndrome (ARDS).
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Plaisted J, Christensen E, Kowalsky M, Rooke D, Clendenen N. Year in Review 2023: Noteworthy Literature in Cardiac Anesthesiology. Semin Cardiothorac Vasc Anesth 2024; 28:80-90. [PMID: 38593818 DOI: 10.1177/10892532241246431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/11/2024]
Abstract
Notable clinical research published in 2023 related to cardiac anesthesia included studies focused on resuscitation and pharmacology, regional anesthesia, technological advances, and novel gene therapies. We reviewed 241 articles to identify 25 noteworthy studies that represent the most significant research related to cardiac anesthesia from the past year. Overall, improvements in clinical practice have enabled decreased morbidity and mortality with a renewed focus on mechanical circulatory support and transplantation.
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Affiliation(s)
- Jacob Plaisted
- University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | | | - Markus Kowalsky
- University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Douglas Rooke
- University of Colorado Anschutz Medical Campus, Aurora, CO, USA
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Savage P, Cox B, Shahmohammadi M, Kelly B, Menown I. Advances in Clinical Cardiology 2023: A Summary of Key Clinical Trials. Adv Ther 2024:10.1007/s12325-024-02877-y. [PMID: 38743242 DOI: 10.1007/s12325-024-02877-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Accepted: 04/16/2024] [Indexed: 05/16/2024]
Abstract
INTRODUCTION Over the course of 2023, numerous key clinical trials with valuable contributions to clinical cardiology were published or presented at major international conferences. This review seeks to summarise these trials and reflect on their clinical context. METHODS The authors collated and reviewed clinical trials presented at major cardiology conferences during 2023 including the American College of Cardiology (ACC), European Association for Percutaneous Cardiovascular Interventions (EuroPCR), European Society of Cardiology (ESC), Transcatheter Cardiovascular Therapeutics (TCT), American Heart Association (AHA), European Heart Rhythm Association (EHRA), Society for Cardiovascular Angiography and Interventions (SCAI), TVT-The Heart Summit (TVT) and Cardiovascular Research Technologies (CRT). Trials with a broad relevance to the cardiology community and those with potential to change current practice were included. RESULTS A total of 80 key cardiology clinical trials were identified for inclusion. Key trials in acute coronary syndrome (ACS) and antiplatelet management such as HOST-IDEA, T-PASS and STOP-DAPT3 were included in addition to several pivotal interventional trials such as ORBITA 2, MULTISTARS-AMI, ILUMIEN-IV, OCTIVUS and OCTOBER. Additionally, several trials evaluated new stent design and technology such as BIOSTEMI, PARTHENOPE and TRANSFORM. Structural intervention trials included long-term data from PARTNER 3, new data on the durability of transcatheter aortic valve intervention (TAVI), in addition to major new trials regarding transcatheter tricuspid valve intervention from TRISCEND II. Heart failure (HF) and prevention covered several key studies including DAPA-MI, STEP-HF, ADVOR, DICTATE HF and CAMEO-DAPA. In cardiac devices and electrophysiology, several trial exploring novel ablation strategies in atrial fibrillation (AF) such as PULSED AF and ADVENT were presented with further data evaluating the efficacy of anticoagulation in subclinical AF in NOAH-AFNET 6, FRAIL AF and AZALEA-TIMI 71. CONCLUSION This article presents a summary of key clinical cardiology trials published and presented during the past year and should be of interest to both practising clinicians and researchers.
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Affiliation(s)
- Patrick Savage
- Craigavon Cardiology Department, Southern Health and Social Care Trust, Craigavon, Northern Ireland, UK.
| | - Brian Cox
- Craigavon Cardiology Department, Southern Health and Social Care Trust, Craigavon, Northern Ireland, UK
| | - Michael Shahmohammadi
- Craigavon Cardiology Department, Southern Health and Social Care Trust, Craigavon, Northern Ireland, UK
| | - Bronagh Kelly
- Craigavon Cardiology Department, Southern Health and Social Care Trust, Craigavon, Northern Ireland, UK
| | - Ian Menown
- Craigavon Cardiology Department, Southern Health and Social Care Trust, Craigavon, Northern Ireland, UK
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Raza S, Risk M, Cserti-Gazdewich C. Leading digit bias in hemoglobin thresholds for red cell transfusion. Transfusion 2024; 64:793-799. [PMID: 38581269 DOI: 10.1111/trf.17827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 03/14/2024] [Accepted: 03/17/2024] [Indexed: 04/08/2024]
Abstract
BACKGROUND Leading digit bias is a heuristic whereby humans overemphasize the left-most digit when evaluating numbers (e.g., 9.99 vs. 10.00). The bias might affect the interpretation of hemoglobin results and influence red cell transfusion in hospitalized patients. STUDY DESIGN AND METHODS Adults who received a red cell transfusion while registered at the University Health Network (Toronto, Canada) between January 1, 2016 and January 1, 2022 (n = 6 years) were included. The primary analysis excluded apheresis, red cell disorders, radiology suites, and operating rooms. The primary comparison was a regression discontinuity analysis of transfusion occurrence above and below the hemoglobin threshold of 79 g/L (local units). Additional analyses tested other leading digit and control thresholds (71, 81, and 91 g/L). Secondary analyses explored temporal covariates and clinical subgroups. RESULTS A total of 211,872 red cell transfusions were identified over the study period (median pre-transfusion hemoglobin 76 g/L; interquartile range = 69-92 g/L), with 107,790 inpatient transfusions in the primary analysis. The 79 g/L threshold showed 815 fewer red cell units above the threshold (95% confidence interval [CI]: -1215 to -415). The 69 g/L threshold showed 2813 fewer transfused units (95% CI: -4407 to -1220), and 89 g/L showed 40 fewer units (95% CI: -408 to 328). The effect was accentuated during daytime, weekday, and May-June months, persisted in analyses including all transfusions, and was absent at control thresholds. CONCLUSION Leading digit bias might have a modest influence on the decision to transfuse red cells. The findings may inform practice guidelines and quasi-experimental study design in transfusion research.
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Affiliation(s)
- Sheharyar Raza
- Division of Hematology, University of Toronto, Toronto, Canada
- Canadian Blood Services, Medical Affairs and Innovation, Canada
| | - Malcolm Risk
- Department of Biostatistics, University of Michigan, Ann Arbor, Michigan, USA
| | - Christine Cserti-Gazdewich
- Division of Hematology, University of Toronto, Toronto, Canada
- Blood Transfusion Laboratory, University Health Network, Toronto, Canada
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Costa LGVD, Papa FV, Hare GMT, Salgado-Filho MF, Lineburger EB, Schmidt AP. Anemia and outcomes in cardiac surgery. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ELSEVIER) 2024; 74:844504. [PMID: 38677651 PMCID: PMC11081777 DOI: 10.1016/j.bjane.2024.844504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/29/2024]
Affiliation(s)
| | - Fabio V Papa
- University of Toronto, St. Michael's Hospital, Department of Anaesthesia, Toronto, Canada
| | - Gregory M T Hare
- University of Toronto, St. Michael's Hospital, Department of Anaesthesia, Toronto, Canada
| | | | - Eric B Lineburger
- Hospital São José, Departamento de Anestesia e Tratamento da Dor, Criciúma, SC, Brazil; Hospital São José, Centro de Pesquisa, Criciúma, SC, Brazil; Universidade do Extremo Sul Catarinense, Criciúma, SC, Brazil
| | - André P Schmidt
- Hospital de Clínicas de Porto Alegre (HCPA), Serviço de Anestesia e Medicina Perioperatória, Porto Alegre, RS, Brazil; Santa Casa de Porto Alegre, Serviço de Anestesia, Porto Alegre, RS, Brazil; Hospital Nossa Senhora da Conceição, Serviço de Anestesia, Porto Alegre, RS, Brazil; Universidade Federal do Rio Grande do Sul (UFRGS), Programa de Pós-graduação em Ciências Pneumológicas, Porto Alegre, RS, Brazil; Universidade Federal do Rio Grande do Sul (UFRGS), Programa de Pós-graduação em Ciências Cirúrgicas, Porto Alegre, RS, Brazil; Programa de Pós-Graduação em Anestesiologia, Ciências Cirúrgicas e Medicina Perioperatória, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, Brazil
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Amin AM, Ali K, Elbenawi H, Saber A, Abuelazm M, Abdelazeem B. Efficacy and safety of restrictive versus liberal blood transfusion strategies in acute myocardial infarction and anemia: a systematic review and meta-analysis of randomized controlled trials. Coron Artery Dis 2024; 35:239-251. [PMID: 38411260 DOI: 10.1097/mca.0000000000001349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/28/2024]
Abstract
BACKGROUND Blood transfusion strategies in patients with acute myocardial infarction (AMI) and anemia are yet to be conclusively identified. Thus, we aim to assess the efficacy and safety of restrictive versus liberal blood transfusion strategies for AMI and anemia. METHODS A systematic review and meta-analysis of randomized controlled trials (RCTs) retrieved from PubMed, web of science, SCOPUS, EMBASE, and Cochrane Central Register of Controlled Trials were performed through November 2023. We used RevMan V. 5.4 to pool dichotomous data using risk ratio (RR) and continuous data using mean difference (MD) with a 95% confidence interval (CI). (PROSPERO): ID: CRD42023490692. RESULTS We included four RCTs with 4.325 patients. There was no significant difference between both groups regarding MACE whether at 30 days (RR: 0.93 with 95% CI [0.57-1.51], P = 0.76) or ≥ six months (RR: 1.17 with 95% CI [0.95-1.45], P = 0.14), all-cause mortality at 30 days (RR: 1.16 with 95% CI [0.95-1.40], P = 0.14) or ≥ six months (RR: 1.16 with 95% CI [0.88-1.53], P = 0.28). However, the liberal strategy was significantly associated with increased hemoglobin level change (MD: -1.44 with 95% CI [-1.68 to -1.20], P < 0.00001). However, the restrictive strategy was significantly associated with a lower incidence of acute lung injury (RR: 0.11 with 95% CI [0.02-0.60], P = 0.01). CONCLUSION There was no significant difference between the restrictive blood transfusion strategy and the liberal blood transfusion strategy regarding the clinical outcomes. However, restrictive blood transfusion strategy was significantly associated with a lower incidence of acute lung injury than liberal blood transfusion strategy.
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Affiliation(s)
| | - Karim Ali
- Internal Medicine, Hennepin Healthcare, Minneapolis, Minnesota, USA
| | | | | | | | - Basel Abdelazeem
- Department of Cardiology, West Virginia University, Morgantown, West Virginia, USA
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Bosch NA, Law AC, Shi Z, Jafarzadeh SR, Walkey AJ. A novel measure to summarize blood transfusion practice during critical illness. Transfusion 2024; 64:784-788. [PMID: 38515390 PMCID: PMC11088509 DOI: 10.1111/trf.17814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 03/14/2024] [Accepted: 03/16/2024] [Indexed: 03/23/2024]
Abstract
BACKGROUND Large-scale observational studies have summarized transfusion practice using traditional measures of central tendency (e.g., the mean hemoglobin concentration at the time of transfusion). However, the mean hemoglobin concentration fails to identify specific hemoglobin concentration thresholds that drive practice. In the following brief report, we propose a novel measure of "practice discontinuity" that identifies specific practice-defining hemoglobin thresholds. STUDY DESIGN AND METHODS We used the PINC AI Database (2016-2022) to identify adult patients admitted to an intensive care unit with at least one hemoglobin concentration measurement. For each day that hemoglobin was measured, we identified whether the patient received a red blood cell transfusion using hospital charge codes. We defined the "practice discontinuity" measure as the hemoglobin concentration at which there was the largest increase in transfusion use going from a higher to an incrementally lower hemoglobin concentration. We also calculated the mean and median pretransfusion hemoglobin concentrations. RESULTS We identified 1,298,367 patients and 4,905,839 patient-days for inclusion. RBC transfusion occurred in a total of 530,654 (10.8%) patient-days. The overall pre-transfusion mean and median hemoglobin concentrations were 8.4 and 8.0 g/dL, respectively. The practice discontinuity measure identified 7.0 g/dL as the hemoglobin concentration at which transfusion use increased the most, from 46.6% of patient-days at a concentration of 7.0 g/dL to 74.8% of patient-days at a concentration of 6.9 g/dL. DISCUSSION We propose that future studies of red blood cell transfusion practice consider inclusion of the practice discontinuity measure to more fully summarize clinical practice.
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Affiliation(s)
- Nicholas A. Bosch
- Section of Pulmonary, Allergy, Sleep & Critical Care Medicine, Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, MA
| | - Anica C. Law
- Section of Pulmonary, Allergy, Sleep & Critical Care Medicine, Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, MA
| | - Zhan Shi
- Section of Pulmonary, Allergy, Sleep & Critical Care Medicine, Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, MA
| | - S. Reza Jafarzadeh
- Section of Rheumatology, Boston University Chobanian & Avedisian School of Medicine, Department of Medicine, Boston, Massachusetts, United States of America
| | - Allan J. Walkey
- Division of Health Systems Science, Department of Medicine, UMass Chan Medical School, Worcester, Massachusetts, United States of America
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de Lemos JA, Lindahl B, Mills NL. Type 2 Myocardial Infarction-Poorly Understood, Underevaluated, and Too Often Ignored. JAMA Cardiol 2024; 9:411-412. [PMID: 38506815 DOI: 10.1001/jamacardio.2024.0127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/21/2024]
Abstract
This Viewpoint discusses diagnosis of type 2 myocardial infarction.
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Affiliation(s)
- James A de Lemos
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas
| | - Bertil Lindahl
- Department of Medical Sciences, Uppsala University, Sweden
| | - Nicholas L Mills
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
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Long B, Gottlieb M. Emergency medicine updates: Lower gastrointestinal bleeding. Am J Emerg Med 2024; 81:62-68. [PMID: 38670052 DOI: 10.1016/j.ajem.2024.04.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Revised: 03/26/2024] [Accepted: 04/14/2024] [Indexed: 04/28/2024] Open
Abstract
INTRODUCTION Lower gastrointestinal bleeding (LGIB) is a condition commonly seen in the emergency department. Therefore, it is important for emergency medicine clinicians to be aware of the current evidence regarding the diagnosis and management of this disease. OBJECTIVE This paper evaluates key evidence-based updates concerning LGIB for the emergency clinician. DISCUSSION LGIB is most commonly due to diverticulosis or anorectal disease, though there are a variety of etiologies. The majority of cases resolve spontaneously, but patients can have severe bleeding resulting in hemodynamic instability. Initial evaluation should focus on patient hemodynamics, the severity of bleeding, and differentiating upper gastrointestinal bleeding from LGIB. Factors associated with LGIB include prior history of LGIB, age over 50 years, and presence of blood clots per rectum. Computed tomography angiography is the imaging modality of choice in those with severe bleeding to diagnose the source of bleeding and guide management when embolization is indicated. Among stable patients without severe bleeding, colonoscopy is the recommended modality for diagnosis and management. A transfusion threshold of 7 g/dL hemoglobin is recommended based on recent data and guidelines (8 g/dL in those with myocardial ischemia), though patients with severe bleeding and hemodynamic instability should undergo emergent transfusion. Anticoagulation reversal may be necessary. If bleeding does not resolve, embolization or endoscopic therapies are necessary. There are several risk scores that can predict the risk of adverse outcomes; however, these scores should not replace clinical judgment in determining patient disposition. CONCLUSIONS An understanding of literature updates can improve the care of patients with LGIB.
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Affiliation(s)
- Brit Long
- SAUSHEC, Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, USA.
| | - Michael Gottlieb
- Department of Emergency Medicine Rush, University Medical Center, Chicago, IL, USA
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Kiyohara Y, Briasoulis A, Kuno T. Comparison of blood transfusion strategies for acute coronary syndrome patients with anemia: A meta-analysis of five randomized controlled trials. J Cardiol 2024:S0914-5087(24)00068-6. [PMID: 38642888 DOI: 10.1016/j.jjcc.2024.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 04/12/2024] [Accepted: 04/14/2024] [Indexed: 04/22/2024]
Affiliation(s)
- Yuko Kiyohara
- Department of Medicine, The University of Tokyo Hospital, Tokyo, Japan
| | - Alexandros Briasoulis
- Division of Cardiovascular Medicine, Section of Heart Failure and Transplantation, University of Iowa, Iowa City, IA, USA
| | - Toshiki Kuno
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, NY, Bronx, USA; Division of Cardiology, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.
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Robert Yao RJ, Fordyce CB. Optimal transfusion threshold for anemic patients presenting with myocardial infarction and heart failure: dream or REALITY? Can J Cardiol 2024:S0828-282X(24)00299-X. [PMID: 38604338 DOI: 10.1016/j.cjca.2024.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Revised: 04/01/2024] [Accepted: 04/04/2024] [Indexed: 04/13/2024] Open
Affiliation(s)
- Ren Jie Robert Yao
- Division of Cardiology, Department of Medicine, Vancouver General Hospital and Centre for; Cardiovascular Innovation, University of British Columbia, Vancouver, BC
| | - Christopher B Fordyce
- Division of Cardiology, Department of Medicine, Vancouver General Hospital and Centre for; Cardiovascular Innovation, University of British Columbia, Vancouver, BC.
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Pagano MB, Stanworth SJ, Valentine S, Metcalf R, Wood EM, Pavenski K, Cholette J, So-Osman C, Carson JL. The 2023 AABB international guidelines for red blood cell transfusions: What is new? Transfusion 2024; 64:727-732. [PMID: 38380850 DOI: 10.1111/trf.17764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Accepted: 02/06/2024] [Indexed: 02/22/2024]
Affiliation(s)
- Monica B Pagano
- Transfusion Medicine, Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington, USA
- AABB Clinical Transfusion Practice Committee, Bethesda, Maryland, USA
| | - Simon J Stanworth
- Department of Haematology, Oxford University Hospitals NHS Trust; NHSBT, Oxford, UK
- Radcliffe Department of Medicine, Department of Transfusion Medicine, NHS Blood and Transplant, Oxford, UK
| | - Stacey Valentine
- Department of Pediatrics, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Ryan Metcalf
- AABB Clinical Transfusion Practice Committee, Bethesda, Maryland, USA
- Department of Pathology, University of Utah, Salt Lake City, Utah, USA
| | - Erica M Wood
- Department of Haematology, Monash Health, Melbourne, Victoria, Australia
- Monash University School of Public Health and Preventive Medicine, Melbourne, Victoria, Australia
- International Society of Blood Transfusion, Amsterdam, Netherlands
| | - Katerina Pavenski
- Department of Laboratory Medicine and Pathobiology, University of Toronto and St Michael's Hospital-Unity Health Toronto, Toronto, Ontario, Canada
- International Collaboration for Transfusion Medicine Guidelines, British Columbia, Canada
| | - Jill Cholette
- Department of Pediatrics, University of Rochester, Golisano Children's Hospital, Rochester, New York, USA
| | - Cynthia So-Osman
- Department of Unit Transfusion Medicine (UTG), Sanquin Blood Bank, Amsterdam, the Netherlands
- Department Hematology, Erasmus Medical Center, Rotterdam, the Netherlands
- European Haematology Association, Transfusion-Specialized Working Group
| | - Jeffrey L Carson
- Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
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Thangaraj PM, Shankar SV, Huang S, Nadkarni G, Mortazavi B, Oikonomou EK, Khera R. A Novel Digital Twin Strategy to Examine the Implications of Randomized Control Trials for Real-World Populations. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.03.25.24304868. [PMID: 38585929 PMCID: PMC10996766 DOI: 10.1101/2024.03.25.24304868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/09/2024]
Abstract
Randomized clinical trials (RCTs) are essential to guide medical practice; however, their generalizability to a given population is often uncertain. We developed a statistically informed Generative Adversarial Network (GAN) model, RCT-Twin-GAN, that leverages relationships between covariates and outcomes and generates a digital twin of an RCT (RCT-Twin) conditioned on covariate distributions from a second patient population. We used RCT-Twin-GAN to reproduce treatment effect outcomes of the Systolic Blood Pressure Intervention Trial (SPRINT) and the Action to Control Cardiovascular Risk in Diabetes (ACCORD) Blood Pressure Trial, which tested the same intervention but had different treatment effect results. To demonstrate treatment effect estimates of each RCT conditioned on the other RCT patient population, we evaluated the cardiovascular event-free survival of SPRINT digital twins conditioned on the ACCORD cohort and vice versa (SPRINT-conditioned ACCORD twins). The conditioned digital twins were balanced by the intervention arm (mean absolute standardized mean difference (MASMD) of covariates between treatment arms 0.019 (SD 0.018), and the conditioned covariates of the SPRINT-Twin on ACCORD were more similar to ACCORD than a sprint (MASMD 0.0082 SD 0.016 vs. 0.46 SD 0.20). Most importantly, across iterations, SPRINT conditioned ACCORD-Twin datasets reproduced the overall non-significant effect size seen in ACCORD (5-year cardiovascular outcome hazard ratio (95% confidence interval) of 0.88 (0.73-1.06) in ACCORD vs median 0.87 (0.68-1.13) in the SPRINT conditioned ACCORD-Twin), while the ACCORD conditioned SPRINT-Twins reproduced the significant effect size seen in SPRINT (0.75 (0.64-0.89) vs median 0.79 (0.72-0.86)) in ACCORD conditioned SPRINT-Twin). Finally, we describe the translation of this approach to real-world populations by conditioning the trials on an electronic health record population. Therefore, RCT-Twin-GAN simulates the direct translation of RCT-derived treatment effects across various patient populations with varying covariate distributions.
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Affiliation(s)
- Phyllis M. Thangaraj
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Sumukh Vasisht Shankar
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Sicong Huang
- Department of Computer Science and Engineering, Texas A&M University, College Station, TX
| | - Girish Nadkarni
- The Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- The Division of Data Driven and Digital Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Bobak Mortazavi
- Department of Computer Science and Engineering, Texas A&M University, College Station, TX
| | - Evangelos K. Oikonomou
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Rohan Khera
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
- Section of Health Informatics, Department of Biostatistics, Yale School of Public Health, New Haven, CT
- Section of Biomedical Informatics and Data Science, Yale School of Medicine, New Haven, CT
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT, USA
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Khan MS, Spertus JA, Chan PS. Transfusion Strategy in Myocardial Infarction and Anemia. N Engl J Med 2024; 390:960-961. [PMID: 38446689 DOI: 10.1056/nejmc2400982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/08/2024]
Affiliation(s)
- Mirza S Khan
- University of Missouri, Kansas City, Kansas City, MO
| | | | - Paul S Chan
- Saint Luke's Mid America Heart Institute, Kansas City, MO
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Ramos JN, Calvão-Pires P, Gil I, Baptista T, Branco C, Branco G, Marto JP. Hemoglobin in large vessel occlusion: Look further than collaterals. J Clin Neurosci 2024; 121:100-104. [PMID: 38382284 DOI: 10.1016/j.jocn.2024.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 01/22/2024] [Accepted: 02/12/2024] [Indexed: 02/23/2024]
Abstract
BACKGROUND Abnormal hemoglobin (Hb) levels lead to poorer outcomes in ischemic stroke, though the mechanisms remain elusive. We aimed to study the role of Hb on imaging and clinical outcomes, namely on collaterals as it is a known mediator of infarct growth. METHODS Retrospective cohort study of patients with large vessel occlusion ischemic stroke admitted to our center. Demographics, clinical and imaging variables were collected, particularly baseline hemoglobin, presence of anemia and collateral score. Collaterals were scored from 0 to 3 and defined as poor if 0-1. Multivariable analyses were performed for collateral score and clinical outcomes (3-month mortality and good prognosis). RESULTS We included 811 patients, 215 (26.5 %) with anemia. Patients with anemia were older, had more comorbidities and more severe strokes. Hemoglobin levels and anemia were not associated with collateral score (OR 0.97, 95 % CI 0.89-1.05, p = 0.414 and OR 0.89, 95 % CI 0.64-1.24, p = 0.487, respectively) nor with poor collaterals (OR 0.96, 95 % CI 0.88-1.05, p = 0.398 and OR 0.86, 95 % CI 0.60-1.23, p = 0.406, respectively). Hb levels were associated with 3-month mortality (OR 0.85, 95 % CI 0.76-0.96, p = 0.008). CONCLUSION Hemoglobin or anemia were not found to be associated with collateral status. Our results raise further questions regarding the pathophysiology of anemia and outcomes in ischemic stroke, highlighting the need for future research.
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Affiliation(s)
- João Nuno Ramos
- Department of Neuroradiology, Hospital de Egas Moniz, Centro Hospitalar Lisboa Ocidental, Lisboa, Portugal.
| | - Pedro Calvão-Pires
- Department of Neuroradiology, Hospital de Egas Moniz, Centro Hospitalar Lisboa Ocidental, Lisboa, Portugal
| | - Inês Gil
- Department of Neuroradiology, Hospital de Egas Moniz, Centro Hospitalar Lisboa Ocidental, Lisboa, Portugal
| | - Tiago Baptista
- Department of Neuroradiology, Hospital de Egas Moniz, Centro Hospitalar Lisboa Ocidental, Lisboa, Portugal
| | - Cristina Branco
- Department of Neuroradiology, Hospital de Egas Moniz, Centro Hospitalar Lisboa Ocidental, Lisboa, Portugal
| | - Gabriel Branco
- Department of Neuroradiology, Hospital de Egas Moniz, Centro Hospitalar Lisboa Ocidental, Lisboa, Portugal
| | - João Pedro Marto
- Department of Neurology, Hospital de Egas Moniz, Centro Hospitalar Lisboa Ocidental, Lisboa, Portugal; CEDOC, NOVA Medical School, Lisboa, Portugal
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16
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Pedicino D, Vergallo R. More blood for patients with myocardial infarction and anaemia? Eur Heart J 2024; 45:651-652. [PMID: 38141126 DOI: 10.1093/eurheartj/ehad832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2023] Open
Affiliation(s)
- Daniela Pedicino
- Intensive Cardiac Care Unit, Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli-IRCCS, Catholic University of the Sacred Heart, Largo A. Gemelli 8, Rome 00168, Italy
| | - Rocco Vergallo
- Interventional Cardiology Unit, Cardiothoracic and Vascular Department (DICATOV), IRCCS Ospedale Policlinico San Martino, Genova, Italy
- Department of Internal Medicine and Medical Specialties (DIMI), Università di Genova, Genova, Italy
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17
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Ducrocq G, Cachanado M, Simon T, Puymirat E, Lemesle G, Lattuca B, Ariza-Solé A, Silvain J, Ferrari E, Gonzalez-Juanatey JR, Martínez-Sellés M, Lermusier T, Coste P, Vanzetto G, Cottin Y, Dillinger JG, Calvo G, Steg PG. Restrictive vs Liberal Blood Transfusions for Patients with Acute Myocardial Infarction and Anaemia by Heart Failure Status: An RCT Subgroup Analysis. Can J Cardiol 2024:S0828-282X(24)00179-X. [PMID: 38408702 DOI: 10.1016/j.cjca.2024.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 02/12/2024] [Accepted: 02/18/2024] [Indexed: 02/28/2024] Open
Abstract
BACKGROUND Red blood cell transfusion can cause fluid overload. We evaluated the interaction between heart failure (HF) at baseline and transfusion strategy on outcomes in acute myocardial infarction (AMI). METHODS We used data from the randomized REALITY trial (https://www. CLINICALTRIALS gov/study/NCT02648113), comparing restrictive versus liberal transfusion strategies in patients with AMI and anaemia. HF was defined as history of HF or Killip class > 1 at randomization. Primary outcome was major adverse cardiovascular events (MACE: composite of all-cause death, non-recurrent AMI, stroke, or emergency revascularization prompted by ischaemia) at 30 days. RESULTS Among 658 randomized patients, 311 (47.3%) had HF. HF patients had higher rates of MACE at 30 days and 1 year, and higher rates of non-fatal new-onset HF. There was no interaction between HF and effect of randomized assignment on the primary outcome or non-fatal new-onset HF. A liberal transfusion strategy was associated with increased all-cause death at 30 days and at 1 year in HF patients (Pinteraction = 0.009 and P = 0.049, respectively). The main numerical difference in cause of death between restrictive and liberal strategies was death by HF at 30 days (4 vs 11). CONCLUSIONS HF is frequent in AMI patients with anaemia and is associated with higher risk of MACE (including all-cause death) and non-fatal new-onset HF. While there was no interaction of HF with effect of transfusion strategy on MACE, a liberal transfusion strategy was associated with higher all-cause death that appears driven by a higher risk of early death due to HF.
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Affiliation(s)
- Gregory Ducrocq
- Université de Paris, Assistance Publique-Hôpitaux de Paris (AP-HP), French Alliance for Cardiovascular Trials (FACT), INSERM U1148, Paris, France
| | - Marine Cachanado
- Department of Clinical Pharmacology and Clinical Research Platform of the East of Paris (URC-CRC-CRB), AP-HP, Hôpital St Antoine; Sorbonne-Université; French Alliance for Cardiovascular Trials (FACT), Paris, France
| | - Tabassome Simon
- Department of Clinical Pharmacology and Clinical Research Platform of the East of Paris (URC-CRC-CRB), AP-HP, Hôpital St Antoine; Sorbonne-Université; French Alliance for Cardiovascular Trials (FACT), Paris, France
| | - Etienne Puymirat
- Université de Paris, AP-HP, Hôpital Européen Georges Pompidou, French Alliance for Cardiovascular Trials (FACT), Paris, France
| | - Gilles Lemesle
- Institut Cœur Poumon, Centre Hospitalier Universitaire de Lille, Faculté de Médecine de Lille, Université de Lille, French Alliance for Cardiovascular Trials (FACT), Institut Pasteur de Lille, Inserm U1011, F-59000 Lille, France; Paris, France
| | - Benoit Lattuca
- Cardiology department, Nimes University Hospital, Montpellier University, Nimes, France
| | - Albert Ariza-Solé
- Bellvitge University Hospital. Bioheart. Grup de Malalties Cardiovasculars. Institut d'Investigació Biomèdica de Bellvitge; IDIBELL; L'Hospitalet de Llobregat, Barcelona, Spain
| | - Johanne Silvain
- Sorbonne Université, ACTION Study Group, Institut de Cardiologie, AP-HP, Hôpital Pitié-Salpêtrière, INSERM UMRS 1166 Paris, France
| | - Emile Ferrari
- Université Côte d'Azur, and CHU de Nice, Hôpital Pasteur 1, Service de Cardiologie, French Alliance for Cardiovascular Trials (FACT), Nice, France
| | - Jose R Gonzalez-Juanatey
- Cardiology Department, University Hospital, IDIS, CIBERCV, University of Santiago de Compostela, Santiago de Compostela, Spain
| | - Manuel Martínez-Sellés
- Servicio de Cardiología, Hospital Universitario Gregorio Marañón, CIBERCV, and Universidad Europea, Universidad Complutense, Madrid, Spain
| | | | - Pierre Coste
- Cardiology Hospital, University of Bordeaux, Bordeaux, France
| | - Gerald Vanzetto
- Service de Cardiologie, CHU Grenoble Alpes; Université Grenoble Alpes; LRB INSERM U 1039, Grenoble, France
| | - Yves Cottin
- Centre Hospitalier Universitaire de Dijon; Université de Bourgogne, Dijon, France
| | - Jean G Dillinger
- Université Paris-Cité, Assistance Publique-Hôpitaux de Paris, Hôpital Lariboisière, and INSERM U-942, Paris, France
| | - Gonzalo Calvo
- Àrea del Medicament, Hospital Clínic of Barcelona, University of Barcelona, Barcelona, Spain
| | - Philippe Gabriel Steg
- Université Paris-Cité, INSERM-UMR1148; Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, FACT (French Alliance for Cardiovascular Trials); and Institut Universitaire de France; all in Paris, France.
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18
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Arynov A, Kaidarova D, Kabon B. Alternative blood transfusion triggers: a narrative review. BMC Anesthesiol 2024; 24:71. [PMID: 38395758 PMCID: PMC10885388 DOI: 10.1186/s12871-024-02447-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 02/07/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND Anemia, characterized by low hemoglobin levels, is a global public health concern. Anemia is an independent factor worsening outcomes in various patient groups. Blood transfusion has been the traditional treatment for anemia; its triggers, primarily based on hemoglobin levels; however, hemoglobin level is not always an ideal trigger for blood transfusion. Additionally, blood transfusion worsens clinical outcomes in certain patient groups. This narrative review explores alternative triggers for red blood cell transfusion and their physiological basis. MAIN TEXT The review delves into the physiology of oxygen transport and highlights the limitations of using hemoglobin levels alone as transfusion trigger. The main aim of blood transfusion is to optimize oxygen delivery, necessitating an individualized approach based on clinical signs of anemia and the balance between oxygen delivery and consumption, reflected by the oxygen extraction rate. The narrative review covers different alternative triggers. It presents insights into their diagnostic value and clinical applications, emphasizing the need for personalized transfusion strategies. CONCLUSION Anemia and blood transfusion are significant factors affecting patient outcomes. While restrictive transfusion strategies are widely recommended, they may not account for the nuances of specific patient populations. The search for alternative transfusion triggers is essential to tailor transfusion therapy effectively, especially in patients with comorbidities or unique clinical profiles. Investigating alternative triggers not only enhances patient care by identifying more precise indicators but also minimizes transfusion-related risks, optimizes blood product utilization, and ensures availability when needed. Personalized transfusion strategies based on alternative triggers hold the potential to improve outcomes in various clinical scenarios, addressing anemia's complex challenges in healthcare. Further research and evidence are needed to refine these alternative triggers and guide their implementation in clinical practice.
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Affiliation(s)
- Ardak Arynov
- Department of Anesthesiology and Intensive Care, Kazakh Institute of Oncology and Radiology, Abay av. 91, Almaty, Kazakhstan.
| | - Dilyara Kaidarova
- Kazakh Institute of Oncology and Radiology, Abay av. 91, Almaty, Kazakhstan
| | - Barbara Kabon
- Department of Anaesthesia, General Intensive Medicine and Pain Medicine Medical, University of Vienna, Spitalgasse 23, 1090, Vienna, Austria
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19
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Akca O. Perioperative blood transfusion-how do I interpret the evidence concerning transfusion triggers? J Clin Anesth 2024:111395. [PMID: 38342636 DOI: 10.1016/j.jclinane.2024.111395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Accepted: 01/13/2024] [Indexed: 02/13/2024]
Affiliation(s)
- Ozan Akca
- Department of Anesthesiology & Critical Care Medicine (ACCM), Neuro-anesthesia & Neuro-critical care, Johns Hopkins Medicine, United States of America; Department of Anesthesiology & Perioperative Medicine, University of Louisville, Louisville, KY, United States of America.
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20
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Fernández-Ruiz I. MINT trial signals potential benefit of liberal transfusion strategy in MI with anaemia. Nat Rev Cardiol 2024; 21:70. [PMID: 38036672 DOI: 10.1038/s41569-023-00969-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
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21
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Idowu A, Lo K, Adebolu O, Ibe F, Al-Madani M. Outcomes Of Restrictive Versus Liberal Blood Transfusion in Patients With Acute Myocardial Infarction and Anemia: An Updated Meta-Analysis of Randomized Controlled Trials. Am J Cardiol 2024; 212:48-50. [PMID: 38042271 DOI: 10.1016/j.amjcard.2023.11.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 11/26/2023] [Indexed: 12/04/2023]
Affiliation(s)
- Abiodun Idowu
- Department of Medicine, Einstein Medical Center, Philadelphia, Pennsylvania.
| | - Kevin Lo
- Division of Cardiovascular Medicine, Brigham and Women's Hospital Heart and Vascular Center, Boston, Massachusetts
| | - Olayinka Adebolu
- Department of Medicine, Einstein Medical Center, Philadelphia, Pennsylvania
| | - Festus Ibe
- Department of Medicine, Einstein Medical Center, Philadelphia, Pennsylvania
| | - Mohammad Al-Madani
- Division of Interventional Cardiology, Einstein Medical Center, Philadelphia, Pennsylvania
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22
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Coughlan JJ, Rossello X. Anaemia in patients with cardiogenic shock complicating acute myocardial infarction: Surrogate marker of poor outcome or therapeutic target? Eur J Heart Fail 2024; 26:458-459. [PMID: 38247170 DOI: 10.1002/ejhf.3135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2024] [Accepted: 01/02/2024] [Indexed: 01/23/2024] Open
Affiliation(s)
- J J Coughlan
- Cardiovascular Research Institute, Mater Private Network, Dublin, Ireland
| | - Xavier Rossello
- Health Research Institute of the Balearic Islands (IdISBa), Palma, Spain
- Cardiology Department, Hospital Universitari Son Espases, Palma, Spain
- Faculty of Medicine, Universitat de les Illes Balears (UIB), Palma, Spain
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain
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23
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UpToDate®. Nurse Pract 2024; 49:11. [PMID: 38271143 DOI: 10.1097/01.npr.0000000000000143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2024]
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24
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Bloch EM, Tobian AAR. Optimizing Blood Transfusion in Patients with Acute Myocardial Infarction. N Engl J Med 2023; 389:2483-2485. [PMID: 38157506 DOI: 10.1056/nejme2312741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Affiliation(s)
- Evan M Bloch
- From the Division of Transfusion Medicine, Department of Pathology, Johns Hopkins University School of Medicine, Baltimore
| | - Aaron A R Tobian
- From the Division of Transfusion Medicine, Department of Pathology, Johns Hopkins University School of Medicine, Baltimore
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