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Buckstein R, Callum J, Prica A, Bowen D, Wells RA, Leber B, Heddle N, Chodirker L, Cheung M, Mozessohn L, Yee K, Gallagher J, Parmentier A, Jamula E, Zhang L, Mamedov A, Stanworth SJ, Lin Y. Red cell transfusion thresholds in outpatients with myelodysplastic syndromes: Results of a pilot randomized trial RBC-ENHANCE. Transfusion 2024; 64:223-235. [PMID: 38323704 DOI: 10.1111/trf.17721] [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: 07/27/2023] [Revised: 11/16/2023] [Accepted: 11/18/2023] [Indexed: 02/08/2024]
Abstract
BACKGROUND The optimal hemoglobin (Hb) threshold for red blood cell transfusions in adult patients with myelodysplastic syndromes (MDS) has not been defined. STUDY DESIGN AND METHODS We conducted a pilot randomized multi-center study of two transfusion algorithms (liberal, to maintain Hb 110-120 g/L, transfuse 2 units if Hb < 105 g/L and 1 unit if Hb 105-110 g/L vs. restrictive, 85-105 g/L, transfuse 2 units when Hgb < 85 g/L). Primary objectives were 70% compliance in maintaining the q2 week hemoglobin within the targeted range and the achievement of a 15 g/L difference in pre-transfusion Hb. Secondary outcomes included measures of quality of life (QOL), iron studies and safety. RESULTS Twenty-eight patients were randomized between February 2015-2020, 13 to the restrictive arm and 15 to the liberal arm in three tertiary care centers. The compliance was 66% and 45% and the mean pre-transfusion Hb thresholds were 86 (standard deviation [SD] 8) and 98 g/L (SD 10) in the restrictive and liberal arms, (mean difference 11.8 g/L, p < .0001), respectively. Patients in the liberal arm experienced a mean of 3.4 (SD 2.6) more transfusion visits and received a mean of 5.3 (SD 5.5) more units of blood during the 12-week study. Ferritin increased by 1043 (SD 1516) IU/L and 148 (SD 1319) IU/L in the liberal and restrictive arms, respectively. Selected QOL scores were superior pre-transfusion and more patients achieved clinically important improvements in the liberal arm compared with the restrictive arm for selected symptoms and function domains. CONCLUSION The results establish that policies for transfusion support can be delivered in practice at multiple hospitals, but further research is required to understand the full clinical effects and safety of liberal transfusion policies in MDS outpatients.
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Affiliation(s)
- Rena Buckstein
- Department of Medicine, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Jeannie Callum
- Department of Pathology and Molecular Medicine, Kingston Health Sciences Centre and Queen's University, Kingston, Ontario, Canada
| | - Anca Prica
- Department of Medicine, Princess Margaret Hospital, United Health Network, Toronto, Ontario, Canada
| | - David Bowen
- Department of Medicine, University of York, York, UK
| | - Richard A Wells
- Department of Medicine, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Brian Leber
- Department of Medicine, Mcmaster University, Hamilton, Ontario, Canada
| | - Nancy Heddle
- Mcmaster Centre for Transfusion Research, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Lisa Chodirker
- Department of Medicine, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Matthew Cheung
- Department of Medicine, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Lee Mozessohn
- Department of Medicine, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Karen Yee
- Department of Medicine, Princess Margaret Hospital, United Health Network, Toronto, Ontario, Canada
| | - Jennifer Gallagher
- Department of Medicine, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Anne Parmentier
- Department of Medicine, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Erin Jamula
- Department of Medicine, Mcmaster University, Hamilton, Ontario, Canada
| | | | - Alex Mamedov
- Department of Medicine, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Simon J Stanworth
- NHS Blood and Transplant, Oxford, UK
- Oxford University NHS Trust, The John Radcliffe Hospital, Oxford, UK
- Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Yulia Lin
- Precision Diagnostics and Therapeutics Program, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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2
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Mo A, Wood E, Shortt J, Charlton A, Evers D, Hoeks M, Pritchard E, Daly J, Hodgson C, Opat S, Bowen D, Reynolds J, Thi Phung Thao L, Stanworth SJ, McQuilten Z. Rethinking the transfusion pathway in myelodysplastic syndromes: Study protocol for a novel randomized feasibility n-of-1 trial of weekly-interval red cell transfusion in myelodysplastic syndromes. Transfusion 2024; 64:236-247. [PMID: 38214417 DOI: 10.1111/trf.17706] [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: 07/29/2023] [Revised: 11/30/2023] [Accepted: 12/07/2023] [Indexed: 01/13/2024]
Abstract
BACKGROUND Anemia in myelodysplastic syndromes (MDS) is associated with poorer health-related quality of life (HRQoL) and physical function, and is frequently treated with transfusions. The current common practice of transfusing multiple red blood cells (RBC) units every 2-4 weeks may result in peaks/troughs in hemoglobin (Hb) level, yet maintaining a stable Hb may better improve HRQoL. We describe a study protocol aiming to investigate the feasibility of weekly low-dose RBC transfusion in MDS patients, including assessing HRQoL and physical function outcomes. STUDY DESIGN AND METHODS In this n-of-1 pilot study, patients receive two treatment arms, with randomly allocated treatment sequence: arm A (patient's usual transfusion schedule) and arm B (weekly transfusion, individualized per patient). To facilitate timely delivery of weekly transfusion, extended-matched RBCs are provided, with transfusion based upon the previous week's Hb/pre-transfusion testing results to eliminate delays of awaiting contemporaneous cross-matching. Primary outcome is the feasibility of delivering weekly transfusion. Secondary outcomes include HRQoL, functional activity measurements, RBC usage, and alloimmunization rates. A qualitative substudy explores patient and staff experiences. RESULTS The trial is open in Australia, Netherlands, and UK. The first patient was recruited in 2020. Inter-country differences in providing RBCs are observed, including patient genotyping versus serological phenotyping to select compatible units. DISCUSSION This pilot trial evaluates a novel personalized transfusion approach of weekly matched RBC transfusion and challenges the dogma of current routine pre-transfusion matching practice. Findings on study feasibility, HRQoL, and physical functional outcomes and the qualitative substudy will inform the design of a larger definitive trial powered for clinical outcomes.
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Affiliation(s)
- Allison Mo
- Transfusion Research Unit, School of Public Health & Preventive Medicine, Monash University, Australia
- Department of Haematology, Monash Health, Clayton, Australia
- Austin Pathology & Department of Haematology, Austin Health, Heidelberg, Australia
| | - Erica Wood
- Transfusion Research Unit, School of Public Health & Preventive Medicine, Monash University, Australia
- Department of Haematology, Monash Health, Clayton, Australia
| | - Jake Shortt
- Department of Haematology, Monash Health, Clayton, Australia
- Department of Medicine, School of Clinical Sciences, Faculty of Medicine, Nursing & Health Sciences, Monash University, Melbourne, Australia
| | - Andrew Charlton
- Department of Haematology, The Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK
- Transfusion Medicine, NHS Blood and Transplant, Oxford, UK
| | - Dorothea Evers
- Department of Haematology, Radboudumc, Nijmegen, The Netherlands
| | - Marlijn Hoeks
- Department of Haematology, Radboudumc, Nijmegen, The Netherlands
| | - Elizabeth Pritchard
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - James Daly
- Australian Red Cross Lifeblood, Melbourne, Australia
| | - Carol Hodgson
- The Australian and New Zealand Intensive Care-Research Centre, Monash University, Melbourne, Australia
- The Alfred, Melbourne, Australia
- The George Institute for Global Health, Sydney, Australia
- Department of Critical Care, The University of Melbourne, Melbourne, Australia
| | - Stephen Opat
- Department of Haematology, Monash Health, Clayton, Australia
| | - David Bowen
- Department of Health Sciences, University of York, York, UK
| | - John Reynolds
- Department of Clinical Haematology, The Alfred, Melbourne, Australia
- Australian Centre for Blood Diseases, Central Clinical School, Monash University, Melbourne, Australia
| | - Le Thi Phung Thao
- Transfusion Research Unit, School of Public Health & Preventive Medicine, Monash University, Australia
| | - Simon J Stanworth
- Transfusion Medicine, NHS Blood and Transplant, Oxford, UK
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Zoe McQuilten
- Transfusion Research Unit, School of Public Health & Preventive Medicine, Monash University, Australia
- Department of Haematology, Monash Health, Clayton, Australia
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3
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Guarente J, Tormey C. Transfusion Support of Patients with Myelodysplastic Syndromes. Clin Lab Med 2023; 43:669-683. [PMID: 37865510 DOI: 10.1016/j.cll.2023.07.002] [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: 10/23/2023]
Abstract
Patients with MDS often suffer from anemia, and less often thrombocytopenia, and thus are a frequently transfused population. Red blood cell (RBC) transfusion may be used to improve functional capacity and quality of life in this population, while platelet transfusion is typically used to decrease bleeding risk. Despite the frequency of transfusion in patients with MDS, there are few well-defined guidelines for RBC and platelet transfusion support in this patient population. Transfusion is not without risk-patients with MDS who are frequently transfused may develop alloantibodies to RBC antigens, which can lead to hemolytic transfusion reactions and delays in obtaining compatible RBCs. Regular communication between clinicians and blood bank physicians is crucial to ensure that patients with MDS receive the most appropriate blood products.
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Affiliation(s)
- Juliana Guarente
- Department of Pathology and Genomic Medicine, Pathology Residency Program, Thomas Jefferson University Hospital, 111 South 11th Street Gibbon Building, Room 8220, Philadelphia, PA 19107, USA
| | - Christopher Tormey
- Department of Laboratory Medicine, Transfusion Medicine Fellowship, Yale University School of Medicine, Yale-New Haven Hospital, 55 Park Street, Floor 3, Room 329D, New Haven, CT 06511, USA
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4
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Stempel JM, Podoltsev NA, Dosani T. Supportive Care for Patients With Myelodysplastic Syndromes. Cancer J 2023; 29:168-178. [PMID: 37195773 DOI: 10.1097/ppo.0000000000000661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/18/2023]
Abstract
ABSTRACT Myelodysplastic syndromes are a heterogeneous group of bone marrow disorders characterized by ineffective hematopoiesis, progressive cytopenias, and an innate capability of progressing to acute myeloid leukemia. The most common causes of morbidity and mortality are complications related to myelodysplastic syndromes rather than progression to acute myeloid leukemia. Although supportive care measures are applicable to all patients with myelodysplastic syndromes, they are especially essential in patients with lower-risk disease who have a better prognosis compared with their higher-risk counterparts and require longer-term monitoring of disease and treatment-related complications. In this review, we will address the most frequent complications and supportive care interventions used in patients with myelodysplastic syndromes, including transfusion support, management of iron overload, antimicrobial prophylaxis, important considerations in the era of COVID-19 (coronavirus infectious disease 2019), role of routine immunizations, and palliative care in the myelodysplastic syndrome population.
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5
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Tonino RPB, Zwaginga LM, Schipperus MR, Zwaginga JJ. Hemoglobin modulation affects physiology and patient reported outcomes in anemic and non-anemic subjects: An umbrella review. Front Physiol 2023; 14:1086839. [PMID: 36875043 PMCID: PMC9975154 DOI: 10.3389/fphys.2023.1086839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 01/31/2023] [Indexed: 02/17/2023] Open
Abstract
Background: An abnormal hemoglobin concentration has a substantial effect on a person's quality of life and physiology. Lack of tools that effectively evaluate hemoglobin-related outcomes leads to uncertainty regarding optimal hemoglobin levels, transfusion thresholds and treatment targets. We therefore aim to summarize reviews that assess the effects of hemoglobin modulation on the human physiology at various baseline hemoglobin levels, and identify gaps in existing evidence. Methods: We conducted an umbrella review of systematic reviews. PubMed, MEDLINE (OVID), Embase, Web of Science, Cochrane Library and Emcare were searched from inception to the 15th of April 2022 for studies that reported on physiological and patient reported outcomes following a hemoglobin change. Results: Thirty-three reviews were included of which 7 were scored as of high quality and 24 of critically low quality using the AMSTAR-2 tool. The reported data generally show that an increase in hemoglobin leads to improvement of patient reported and physical outcomes in anaemic and non-anaemic subjects. At lower hemoglobin levels, the effect of a hemoglobin modulation on quality of life measures appears more pronounced. Conclusion: This overview has revealed many knowledge gaps due to a lack of high-quality evidence. For chronic kidney disease patients, a clinically relevant benefit of increasing the hemoglobin levels up until 12 g/dL was found. However, a personalized approach remains necessary due to the many patient-specific factors that affect outcomes. We strongly encourage future trials to incorporate physiological outcomes as objective parameters together with subjective, but still very important, patient reported outcome measures.
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Affiliation(s)
- R P B Tonino
- Research, TRIP, Leiden, Netherlands.,Hematology, Haga Teaching Hospital, The Hague, Netherlands.,Hematology, LUMC, Leiden, Netherlands
| | | | - M R Schipperus
- Research, TRIP, Leiden, Netherlands.,Hematology, Haga Teaching Hospital, The Hague, Netherlands.,Department of Clinical Affairs, Sanquin Bloodbank, Amsterdam, Netherlands
| | - J J Zwaginga
- Research, TRIP, Leiden, Netherlands.,Hematology, LUMC, Leiden, Netherlands
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6
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Vijenthira A, Starkman R, Lin Y, Stanworth SJ, Bowen D, Harrison L, Wintrich S, Callum J, Buckstein R. Multi-national survey of transfusion experiences and preferences of patients with myelodysplastic syndrome. Transfusion 2022; 62:1355-1364. [PMID: 35686926 DOI: 10.1111/trf.16946] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 04/04/2022] [Accepted: 04/06/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Transfusion dependence on red blood cells (RBCs) is common for patients with myelodysplastic syndromes (MDS) but transfusion practice and experience for outpatients with MDS are largely unknown. METHODS We conducted a web-based cross-sectional multi-national survey to audit real-world transfusion practices and understand the experiences and preferences of patients with MDS requiring RBC transfusion. The survey comprised 57 questions and was distributed to patients in the United States of America, Canada, and the United Kingdom. RESULTS 447 respondents (45% female) with a median age of 72 years (IQR 66-77) were eligible on the basis of receiving an RBC transfusion in the last 8 weeks. There was wide variability in the hemoglobin thresholds for transfusion with the most common being <80 g/L. 40% of patients were transfused at a lower threshold (<70-75 g/L), with the largest proportion of these patients from the United States. Patients experienced significant symptoms prior to receiving a transfusion with fatigue and dyspnea having the most negative impacts on quality of life. Finally, patients endorsed two potential alterations to transfusion care that could improve their quality of life, including self-administered point of care testing of hemoglobin and higher hemoglobin transfusion thresholds. Of these patients, 62% preferred a threshold of at least 85 g/L, and 20% preferred a threshold of at least 100 g/L. DISCUSSION In summary, this multi-national survey of patients with MDS requiring RBC transfusions demonstrated substantial variation in patients' experiences and preferences that differed also by country, supporting the need for further comparative clinical trials of transfusion practice interventions.
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Affiliation(s)
- Abi Vijenthira
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | | | - Yulia Lin
- Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Simon J Stanworth
- Transfusion Medicine, NHS Blood and Transplant, Oxford, UK.,Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Radcliffe Department of Medicine, University of Oxford, Oxford, UK.,NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - David Bowen
- Department of Hematology, Leeds Teaching Hospitals, Leeds, United Kingdom
| | | | | | - Jeannie Callum
- Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Rena Buckstein
- MDS Research Program, Sunnybrook Odette Cancer Center, Toronto, Ontario, Canada
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7
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Vignjević Petrinović S, Jauković A, Milošević M, Bugarski D, Budeč M. Targeting Stress Erythropoiesis Pathways in Cancer. Front Physiol 2022; 13:844042. [PMID: 35694408 PMCID: PMC9174937 DOI: 10.3389/fphys.2022.844042] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Accepted: 05/09/2022] [Indexed: 11/13/2022] Open
Abstract
Cancer-related anemia (CRA) is a common multifactorial disorder that adversely affects the quality of life and overall prognosis in patients with cancer. Safety concerns associated with the most common CRA treatment options, including intravenous iron therapy and erythropoietic-stimulating agents, have often resulted in no or suboptimal anemia management for many cancer patients. Chronic anemia creates a vital need to restore normal erythropoietic output and therefore activates the mechanisms of stress erythropoiesis (SE). A growing body of evidence demonstrates that bone morphogenetic protein 4 (BMP4) signaling, along with glucocorticoids, erythropoietin, stem cell factor, growth differentiation factor 15 (GDF15) and hypoxia-inducible factors, plays a pivotal role in SE. Nevertheless, a chronic state of SE may lead to ineffective erythropoiesis, characterized by the expansion of erythroid progenitor pool, that largely fails to differentiate and give rise to mature red blood cells, further aggravating CRA. In this review, we summarize the current state of knowledge on the emerging roles for stress erythroid progenitors and activated SE pathways in tumor progression, highlighting the urgent need to suppress ineffective erythropoiesis in cancer patients and develop an optimal treatment strategy as well as a personalized approach to CRA management.
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Affiliation(s)
- Sanja Vignjević Petrinović
- Laboratory for Neuroendocrinology, Institute for Medical Research, National Institute of Republic of Serbia, University of Belgrade, Belgrade, Serbia
| | - Aleksandra Jauković
- Laboratory for Experimental Hematology and Stem Cells, Institute for Medical Research, National Institute of Republic of Serbia, University of Belgrade, Belgrade, Serbia
| | - Maja Milošević
- Laboratory for Neuroendocrinology, Institute for Medical Research, National Institute of Republic of Serbia, University of Belgrade, Belgrade, Serbia
| | - Diana Bugarski
- Laboratory for Experimental Hematology and Stem Cells, Institute for Medical Research, National Institute of Republic of Serbia, University of Belgrade, Belgrade, Serbia
| | - Mirela Budeč
- Laboratory for Neuroendocrinology, Institute for Medical Research, National Institute of Republic of Serbia, University of Belgrade, Belgrade, Serbia
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8
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Finelli C, Parisi S, Paolini S. Exploring the rationale for red cell transfusion in myelodysplastic syndrome patients: emerging data and future insights. Expert Rev Hematol 2022; 15:411-421. [PMID: 35549626 DOI: 10.1080/17474086.2022.2077721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
INTRODUCTION Anemia is often present in mostly elderly patients with myelodysplastic syndromes (MDS), and is associated with a poorer outcome. Although Red blood cell (RBC) transfusions are the most immediate treatment, waiting for the response to disease-specific therapy, or in case of non-response, the choice of the optimal transfusion regimen is still controversial. AREAS COVERED The main objectives of RBC transfusion are the control of anemia-related symptoms and complications and the improvement of functional status and of health-related quality of life (HRQoL). However, RBC transfusions are associated with several negative clinical consequences, mainly adverse transfusion reactions and iron overload, which can be counteracted by iron chelation therapy. Recent few pilot prospective trials have shown a benefit, in terms of HRQoL, of more liberal transfusion regimens, with higher haemoglobin (Hb) targets, compared to conventional restrictive regimens, but these results need confirmation by larger studies. EXPERT OPINION : A patient-oriented RBC transfusion therapy in MDS patients must take into account several laboratory (Hb), clinical (age, comorbidities), psychological, family and social factors, and evaluation of HRQoL should become a fundamental parameter in assessing the clinical benefit of therapy. Many questions remain to be clarified, including why some patients report little benefit from transfusions.
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Affiliation(s)
- Carlo Finelli
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Istituto di Ematologia "Seràgnoli", Bologna, Italy
| | - Sarah Parisi
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Istituto di Ematologia "Seràgnoli", Bologna, Italy
| | - Stefania Paolini
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Istituto di Ematologia "Seràgnoli", Bologna, Italy
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9
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Shallis RM, Zeidan AM. Management of the Older Patient with Myelodysplastic Syndrome. Drugs Aging 2021; 38:751-767. [PMID: 34342860 DOI: 10.1007/s40266-021-00881-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/11/2021] [Indexed: 01/19/2023]
Abstract
No two diagnoses of myelodysplastic syndrome are genuinely alike, owing to differing and dynamic mutational topography and epigenetic aberrancy. Consequently, no two patients with myelodysplastic syndrome are identical and disease-specific and patient-specific factors are considered in formulating the optimal treatment, which includes few that are disease modifying. Age itself should not be an absolute contraindication to therapy, including intensive therapy such as allogeneic hematopoietic stem cell transplantation, which is the only curative therapy. However, age associates with an increased prevalence of frailty and comorbidities that must be considered and may preclude a path to cure. Palliative therapies are the mainstay for many patients with myelodysplastic syndrome, which is a disease of older adults with the majority of patients diagnosed at age ≥ 75 years. The older patient requires heightened attention to end organ function/reserve and drug-drug interactions as well as insurance, income, cost, and socioeconomic and psychosocial issues that influence management. Many prior studies have included relatively younger populations or have not specifically performed high-quality subgroup analyses of older patients. In this review, we discuss the available standard-of-care therapies for myelodysplastic syndrome as they specifically relate to the older population and assess the emerging therapeutics that may further the pursuit for personalized treatment and improve both the outcomes and quality of life of the older patient with myelodysplastic syndrome.
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Affiliation(s)
- Rory M Shallis
- Section of Hematology, Department of Internal Medicine, Yale University School of Medicine and Yale Cancer Center, Yale University, 333 Cedar Street, PO Box 208028, New Haven, CT, 06520-8028, USA
| | - Amer M Zeidan
- Section of Hematology, Department of Internal Medicine, Yale University School of Medicine and Yale Cancer Center, Yale University, 333 Cedar Street, PO Box 208028, New Haven, CT, 06520-8028, USA.
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10
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Mo A, Stanworth SJ, Shortt J, Wood EM, McQuilten ZK. Red cell transfusions: Is less always best?: How confident are we that restrictive transfusion strategies should be the standard of care default transfusion practice? Transfusion 2021; 61:2195-2203. [PMID: 34075594 DOI: 10.1111/trf.16429] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Revised: 04/19/2021] [Indexed: 12/16/2022]
Affiliation(s)
- Allison Mo
- Transfusion Research Unit, School of Public Health & Preventive Medicine, Monash University, Melbourne, Australia.,Department of Haematology, Monash Health, Melbourne, Australia.,Austin Pathology and Department of Haematology, Austin Health, Melbourne, Australia
| | - Simon J Stanworth
- Transfusion Medicine, NHS Blood and Transplant (NHSBT), Oxford, UK.,Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Radcliffe Department of Medicine, University of Oxford, Oxford, UK.,NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Jake Shortt
- Department of Haematology, Monash Health, Melbourne, Australia.,School of Clinical Sciences, Faculty of Medicine, Nursing & Health Sciences, Monash University, Melbourne, Australia
| | - Erica M Wood
- Transfusion Research Unit, School of Public Health & Preventive Medicine, Monash University, Melbourne, Australia.,Department of Haematology, Monash Health, Melbourne, Australia
| | - Zoe K McQuilten
- Transfusion Research Unit, School of Public Health & Preventive Medicine, Monash University, Melbourne, Australia.,Department of Haematology, Monash Health, Melbourne, Australia
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11
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Chapalain X, Ozier Y, Le Niger C, McQuilten Z, Huet O, Aubron C. Is there an optimal trade-off between anaemia and red blood cell transfusion in surgical critically ill patients after oncologic surgery? Vox Sang 2021; 116:808-820. [PMID: 33493382 DOI: 10.1111/vox.13068] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 12/16/2020] [Accepted: 12/16/2020] [Indexed: 01/28/2023]
Abstract
BACKGROUND AND OBJECTIVES Equipoise remains on the optimal transfusion strategy in surgical oncologic patients. The primary objective of our study was to determine the impact of anaemia and red blood cells (RBCs) transfusion on severe postoperative complications in surgical oncologic critically ill patients. MATERIALS AND METHODS Retrospective single-centre study. Adults admitted to intensive care unit after major oncologic surgery were eligible. Analyses to determine the independent risk factors, including anaemia or RBC transfusion, for postoperative complications and/or hospital mortality were performed. RESULTS Of the 283 patients included, 246 patients (86.9%) had anaemia. Fifty-five patients (19·4%) were transfused. Patients exposed to moderate-to-severe anaemia or RBC transfusion had more often severe complications, especially acute kidney injury and infectious complications. Multivariate analysis found an independent association between moderate and severe anaemia and severe postoperative complications (moderate anaemia: OR 14·02 [2·52-264]; severe anaemia: OR 16·25 [2·62-318·5]; P < 0·05). Elderly, obese patients and patients operated from abdominal surgery appeared to be more vulnerable to anaemia than other patients. Transfusion was also an independent risk factor for postoperative complications (OR 4·19 [2·12-8·39]; P < 0·001). When considering moderate-to-severe anaemic patients, RBC transfusion was no longer associated with postoperative complications. CONCLUSIONS Anaemia was associated with severe postoperative complications, and this association was stronger in elderly, obese patients and after abdominal surgery. RBC transfusion also negatively impacts on patients' prognosis. However, this association was not found in case of moderate-to-severe anaemia exposure (haemoglobin < 10 g/dl).
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Affiliation(s)
- Xavier Chapalain
- Department of Anaesthesiology and Surgical Intensive Care, Centre Hospitalier et Universitaire de Brest - Université de Bretagne Occidentale, Brest, France
| | - Yves Ozier
- Department of Anaesthesiology and Surgical Intensive Care, Centre Hospitalier et Universitaire de Brest - Université de Bretagne Occidentale, Brest, France
| | - Catherine Le Niger
- Haemovigilance Unit, Centre Hospitalier et Universitaire de Brest, Brest, France
| | - Zoe McQuilten
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Olivier Huet
- Department of Anaesthesiology and Surgical Intensive Care, Centre Hospitalier et Universitaire de Brest - Université de Bretagne Occidentale, Brest, France
| | - Cécile Aubron
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia.,Medical Intensive Care Unit, Centre Hospitalier et Universitaire de Brest - Université de Bretagne Occidentale, Brest, France
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12
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Wood EM, McQuilten ZK. Outpatient transfusions for myelodysplastic syndromes. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2020; 2020:167-174. [PMID: 33275745 PMCID: PMC7727529 DOI: 10.1182/hematology.2020000103] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/07/2023]
Abstract
Patients with myelodysplastic syndromes (MDS) often need extended periods of red blood cell or platelet transfusion support, with the goal to manage symptoms of anemia and thrombocytopenia, respectively, and improve quality of life. Many questions about the optimal approach to transfusion management in MDS, especially in the outpatient setting, remain unanswered, including hemoglobin and platelet thresholds for transfusion. Restrictive transfusion approaches are often practised, but whether these are appropriate for outpatients with MDS, who are often older and may be frail, is not known. Current schedules for transfusion-dependent patients are burdensome, necessitating frequent visits to hospitals for sample collection and blood administration. Questions of optimal schedule and dosage are being explored in clinical trials, including the recently completed REDDS study. Patient-reported outcomes and functional assessments are increasingly being incorporated into research in this area so that we can better understand and improve transfusion support for patients with MDS.
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The effect of red blood cell transfusion on fatigability after hospital discharge. Blood Adv 2020; 4:5690-5697. [PMID: 33211825 DOI: 10.1182/bloodadvances.2020003364] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 10/20/2020] [Indexed: 11/20/2022] Open
Abstract
In patients with anemia, there is interest in understanding the impact of red blood cell (RBC) transfusion on patient-reported outcomes such as fatigue. However, data from previous studies are mixed as to whether transfusion improves fatigue. One explanation for this is that prior studies have not examined whether changes in fatigue from transfusion may also affect patient activity levels. This is important because if transfusion reduces fatigue, patients may become more active, which could increase their fatigue. Thus, testing whether transfusion affects patients' fatigability, a measure of fatigue in the context of activity, may be more useful than testing the effect of transfusion on fatigue alone. The objective of this study was to test the effect of transfusion during hospitalization on patients' fatigability 7 days postdischarge. This prospective observational study included hospitalized general medicine patients with hemoglobin levels <10 g/dL. Patient-reported fatigability was collected during hospitalization and by telephone 7 days after discharge. Multivariable linear regression was used to test the association between receipt of a transfusion and fatigability 7 days postdischarge. Among the 350 patients participating, larger reductions in fatigability were observed with more transfused RBCs. Receipt of 1 U of RBCs was associated with a smaller reduction in fatigability, whereas receipt of 2 to 3 U of RBCs was associated with reductions in fatigability nearly 1 standard deviation from baseline and 3 times greater than patients receiving 1 U of RBCs. In hospitalized patients with anemia, receipt of a transfusion is associated with reductions in fatigability 7 days after hospital discharge.
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Melo-Alvim C, Miguel-Semedo P, Paiva RS, Lobo-Martins S, Luna-Pais H, Costa AL, Santos AR, Florindo A, Vasconcelos AL, Abrunhosa-Branquinho AN, Palmela P, Fernandes L, Presa DL, Costa L, Ribeiro L. Pretreatment hemoglobin level as a prognostic factor in patients with locally advanced head and neck squamous cell carcinoma. Rep Pract Oncol Radiother 2020; 25:768-774. [PMID: 32802001 DOI: 10.1016/j.rpor.2020.07.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Revised: 05/30/2020] [Accepted: 07/24/2020] [Indexed: 02/06/2023] Open
Abstract
Aim Evaluate pretreatment hemoglobin values as a prognostic factor in patients with locally advanced head and neck squamous cell carcinoma treated with concurrent chemoradiotherapy. Background Anemia is one of the most prevalent laboratory abnormalities in oncological disease. It leads to a decrease in cellular oxygen supply, altering radiosensitivity of tumor cells and compromising therapeutic outcomes. Materials and Methods Retrospective evaluation of patients with HNSCC treated with cCRT. Primary and secondary endpoint was to evaluate the correlation of Hb levels (≥12.5 g/dL or <12.5 g/dL) at the beginning of cCRT with overall survival (OS) and progression-free survival (PFS), respectively. Results A total of 108 patients were identified. With a median follow-up of 16.10 months median OS was 59.70 months for Hb ≥12.5 g/dL vs. 14.13 months for Hb <12.5 g/dL (p = 0.004). PFS was 12.29 months for Hb ≥12.5 g/dL and 1.68 months for Hb <12.5 g/dL (p = 0.016). Conclusions In this analysis, Hb ≥12.5 g/dL correlated with significantly better OS and PFS. Further studies are needed to validate these findings.
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Affiliation(s)
- Cecília Melo-Alvim
- Medical Oncology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisbon 1649-035, Portugal
| | - Patrícia Miguel-Semedo
- Medical Oncology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisbon 1649-035, Portugal
| | - Rita Silva Paiva
- Medical Oncology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisbon 1649-035, Portugal
| | - Soraia Lobo-Martins
- Medical Oncology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisbon 1649-035, Portugal
| | - Helena Luna-Pais
- Medical Oncology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisbon 1649-035, Portugal
| | - Ana Lúcia Costa
- Medical Oncology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisbon 1649-035, Portugal
| | - Ana Rita Santos
- Otorhinolaryngology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisbon 1649-035, Portugal
| | - André Florindo
- Radiology Oncology, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisbon 1649-035, Portugal
| | - Ana Luísa Vasconcelos
- Radiology Oncology, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisbon 1649-035, Portugal
| | - André N Abrunhosa-Branquinho
- Radiology Oncology, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisbon 1649-035, Portugal
| | - Paulo Palmela
- Stomatology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisbon 1649-035, Portugal
| | - Leonor Fernandes
- Imaging Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisbon 1649-035, Portugal
| | - Dolores Lopez Presa
- Pathology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisbon 1649-035, Portugal
| | - Luís Costa
- Medical Oncology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisbon 1649-035, Portugal.,Luís Costa Lab, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, 1649-028 Lisbon, Portugal
| | - Leonor Ribeiro
- Medical Oncology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisbon 1649-035, Portugal
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Early and sustained improvement in fatigue-related quality of life following red blood cell transfusion in outpatients. Qual Life Res 2020; 29:2737-2744. [PMID: 32382935 DOI: 10.1007/s11136-020-02517-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/24/2020] [Indexed: 01/06/2023]
Abstract
PURPOSE Outpatients with hematologic disease often receive red cell transfusion to treat anemia and fatigue. The effect of transfusion on fatigue-related quality of life and how well this effect is sustained has not been quantified. The study aim was to describe the early and sustained impact over 4 weeks of red cells on patient-reported fatigue in outpatients age ≥ 50 receiving transfusion as routine clinical care. METHODS FACIT-Fatigue scale scores were measured pre-transfusion and at visits targeting 3, 7, and 28 days post-transfusion. Group-based trajectory modeling of patient fatigue scores by study day was used to identify the number of distinct trajectories (Groups), then longitudinal mixed effects modeling of fatigue scores was used to estimate group-specific mean improvements early after transfusion and between days 3 and 28 post-transfusion. RESULTS Four distinct fatigue score trajectory groups were identified and were found to be correlated with baseline fatigue scores (means 12, 26, 34, and 47 points). In the three groups with the lowest fatigue trajectories (indicating greater fatigue), improvements in fatigue early after transfusion achieved the established minimum clinically important difference (≥ 3 points, Group p = 0.0039). In all trajectory groups, mean fatigue levels did not change significantly between 3 and 28 days (± 1 point, Group p = 0.60). CONCLUSION Patient-reported fatigue varies widely among older adult outpatients with hematologic disorders. Nonetheless, trajectory modeling suggests that most anemic patients can expect a noticeable improvement in fatigue in the first few days after transfusion that generally is sustained up to 4 weeks.
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Crispin P. Effect of anemia on muscle oxygen saturation during submaximal exercise. Transfusion 2019; 60:36-44. [PMID: 31714628 DOI: 10.1111/trf.15588] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 10/17/2019] [Accepted: 10/17/2019] [Indexed: 12/24/2022]
Abstract
BACKGROUND Objective measures to assess the need for transfusion in chronic anemia are lacking. Near-infrared spectroscopy may be used, but there is wide variability. Assessment of muscle oxygen saturation (SmO2 ) during exercise could be used to measure the impact of anemia on performance of everyday activities. STUDY DESIGN AND METHODS Hematology patients and controls were recruited to undertake a 6-minute walk test (6MWT) and a 20-second isometric handgrip exercise. Muscle oxygen saturation in the exercising muscles was measured before and during exercise. Changes in saturation during exercise were described. Correlations between identified variables, hemoglobin concentration, and 6MWT distance were undertaken. The effect of transfusion was assessed on a transfused subset. RESULTS There were 95 sets of exercises conducted in 74 participants. Baseline SmO2 correlated with hemoglobin concentration and negatively with 6MWT distance. Paradoxically, a higher hemoglobin was associated with a greater SmO2 fall during the 6MWT, likely due to greater consumption from improved walk distances. The fall in SmO2 was independent of hemoglobin during isometric contraction, although levels were lower during contraction due to the lower starting SmO2 . There was a longer time to peak SmO2 during recovery following isometric exercise in anemia. There were 17 paired tests following a change in hemoglobin, with SmO2 not predicting improvement in those who had improved exercise capacity. CONCLUSION While baseline SmO2 correlated with hemoglobin concentration, the correlation was not strong enough to predict transfusion requirements. Recovery after isometric forearm contraction correlated with hemoglobin and warrants further investigation.
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Affiliation(s)
- Philip Crispin
- Canberra Hospital, Australian National University Medical School, John Curtin School of Medical Research, Australian National University, Canberra, Australian Capital Territory, Australia
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Karafin MS, Bruhn R, Roubinian NH, Chowdhury D, Qu L, Snyder EL, Murphy EL, Brambilla D, Cable RG, Hilton JF, St Lezin E. The impact of recipient factors on the lower-than-expected hemoglobin increment in transfused outpatients with hematologic diseases. Transfusion 2019; 59:2544-2550. [PMID: 31270827 DOI: 10.1111/trf.15439] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 05/14/2019] [Accepted: 05/15/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Patients with cancer or chronic hematologic disorders frequently receive red blood cell (RBC) transfusions. Based on long-standing assumptions, each RBC unit is thought to increase recipient hemoglobin by 1 g/dL, but smaller increments can occur. A better understanding of recipient factors affecting hemoglobin increments could help providers manage these patients. METHODS Data were collected as a part of the observational Red Cells in Outpatients Transfusion Outcomes (RETRO) study of outpatients with hematologic or cancer-related diagnoses. Hemoglobin was measured before transfusion and 30 minutes after transfusion. A classification and regression tree (CART) analysis was performed to identify statistically significant associations with clinical variables. A corresponding prediction equation was developed and validated using linear regression. RESULTS A total of 195 participants had both pre- and posttransfusion hemoglobin values for analysis. The median age was 66 years, and patients received one (73%) or two (27%) RBC units during the transfusion episode. The overall median change in hemoglobin was 0.6 g/dL per RBC unit. Both CART analysis and linear regression identified the following significant predictors of hemoglobin increment: number of units received (positive correlation), patient estimated circulating blood volume (negative correlation), pretransfusion hemoglobin (negative correlation), and patient age (negative correlation). CONCLUSION In this study of outpatients with hematologic disease, most patients had a hemoglobin increment of less than 1 g/dL/unit. Recipient-specific factors influenced the hemoglobin increment at 30 minutes, and providers should consider circulating blood volume, pretransfusion hemoglobin, and recipient age, when developing patient-specific RBC transfusion plans for this unique cohort.
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Affiliation(s)
- Matthew S Karafin
- Versiti, Medical Sciences Institute, Milwaukee, Wisconsin.,Department of Pathology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Roberta Bruhn
- Vitalant Research Institute, San Francisco, California
| | - Nareg H Roubinian
- Vitalant Research Institute, San Francisco, California.,Division of Research Northern California, Kaiser Permanente, San Francisco, California
| | - Dhuly Chowdhury
- Department of Pathology, Division of Transfusion Medicine, RTI International, Rockville, Maryland
| | - Lirong Qu
- University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Edward L Snyder
- Department of Laboratory Medicine, Yale University, New Haven, Connecticut
| | - Edward L Murphy
- Vitalant Research Institute, San Francisco, California.,Department of Laboratory Medicine, University of California, San Francisco, California
| | - Don Brambilla
- Department of Pathology, Division of Transfusion Medicine, RTI International, Rockville, Maryland
| | | | - Joan F Hilton
- Department of Laboratory Medicine, University of California, San Francisco, California
| | - Elizabeth St Lezin
- Department of Laboratory Medicine, University of California, San Francisco, California.,Laboratory Medicine, SF Veterans Affairs HCS, San Francisco, California
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