The impact of dietary oregano essential oil supplementation on fatty acid composition and lipid stability in eggs stored at room temperature

1. In many countries, eggs are not refrigerated and must be stored at room temperature. The objective of this study was to explore the effects of dietary oregano oil (275 mg/ kg; ORE) versus an unsupplemented control diet (CON) on laying hens on the shelf life and fatty acid profile of eggs.2. Treatments were randomly distributed into 10 pens containing 27 birds each. A total of 200 eggs were collected from both groups on the same day and were stored for either 0, 10, 21 and 35 d. At each storage time, egg yolks were analysed for fatty acid profile and lipid peroxidation.3. The main indicator of lipid peroxidation, malondialdehyde (MDA), was significantly lower in ORE eggs compared to CON eggs (p = 0.001). Storage time had a significant impact on MDA concentrations (p = 0.023), with the highest found after 35 d. Significant differences were found for individual fatty acids, saturated (SFA), monounsaturated (MUFA) and polyunsaturated fatty acids (PUFA). Palmitic acid, stearic acid, oleic acid, linoleic acid and arachidonic acid were significantly lower in ORE eggs compared to CON eggs (p < 0.05). Palmitoleic acid (p = 0.002), linolenic acid (p = 0.001) and docosahexaenoic acid (DHA, p = 0.001) were significantly higher in ORE eggs.4. Storage only affected oleic, linolenic, linoleic, arachidonic and docosahexaenoic acids (p < 0.05). Total SFA, MUFA, n-6 and ratio of n-3 to n-6 (n-3:n-6) PUFA were significantly higher in CON eggs (p < 0.05). The ratio of SFA to PUFA (SFA:PUFA, p = 0.005) and total n-3 PUFA (p = 0.001) were significantly higher in ORE eggs.5. The n-3:n-6 ratio was significantly impacted by treatment (p = 0.021) and storage (p = 0.031) with no significant interaction. This ratio is important for human health indication and could lead to the development of designer eggs.

Association between Hashimoto's thyroiditis and melanoma: a retrospective matched cohort study

An inflammatory microenvironment has been shown to increase risk for malignant melanoma, suggesting that melanoma may be related to a pro-inflammatory state. Though Hashimoto's thyroiditis is one of the most common autoimmune diseases, there are no investigations of its relationship with melanoma. We aim to determine if Hashimoto's increases risk of developing melanoma. A retrospective, validated cohort of patients with a diagnosis of Hashimoto's between 2005 and 2020 were identified using the Olmsted County database. Patients were age and sex matched to controls without a Hashimoto's diagnosis. The primary outcomes were development of melanoma and time to first melanoma diagnosis. 4805 patients were included in the study, with 1726 (36%) having a diagnosis of Hashimoto's. Hashimoto's patients had no significant difference in risk of melanoma (relative risk 0.96, 95% CI 0.78-1.17) or nonmelanoma skin cancer (relative risk 0.95, 95% CI 0.86-1.06) compared with matched controls. This suggests that the local proinflammatory environment present in Hashimoto's does not contribute significantly to melanoma risk. Larger studies may be needed to further characterize the relationship between these diseases.

Using a qualitative co-design approach to identify recommendations for improving access to medication reviews for people from ethnic minority communities

Introduction

Reviews of medication are vital to support medicine effectiveness and optimise person-centred care outcomes. However, inequalities negatively impact ethnic minority populations when accessing medicine review services.1 It is important to identify opportunities to improve access for these communities. Previous studies have demonstrated the significance of overcoming accessibility barriers, but specific detail about how best to achieve this is lacking.2,3 Through co-design workshops, this study seeks to integrate the voices of those people from ethnic minority populations to gain better insight into improving access to medicines review services for ethnic minority communities.

Aim

This qualitative, person-centred co-design study sought to build greater knowledge and understanding by involving representatives from communities whose needs may remain unmet. When considering the value that medication reviews can offer in optimising a person’s medication, this study aimed to: (i) better understand existing barriers that may impact those from ethnic minority communities when accessing services and to (ii) identify measures that may facilitate improved service accessibility for these groups.

Methods

A series of co-design workshops, with four groups of patient-stakeholders, were conducted between September-November 2021; they took place in-person or via video call whilst adhering to COVID-19 restrictions. Existing evidence-based perceptions affecting access to medicines services were critiqued and recommendations were generated to improve access for ethnic minority patients. The workshops were audio-recorded and transcribed verbatim to enable thematic analysis. QSR NVivo (Version 12) facilitated data analysis. The Health Research Authority granted ethical approval (ref: 21/HRA/1426).

Results

Twelve participants were recruited: including 8 UK citizens, 2 asylum seekers and 2 participants in receipt of residency visas. In total, 4 different ethnic minority groups were represented. Each participant took part in a first and second workshop to share and co-create recommendations. Three recommendations were developed and centred on: (i) delivering culturally competent medicines review services; (ii) building awareness of medicines review services and how to access them; and (iii) enabling better discussions with patients from ethnic minority communities.

Discussion/Conclusion

The results have important implications for overcoming ethnic inequalities in access to medicines reviews. The data highlighted the significance of raising awareness of the medicine review services and understanding each person’s lived experiences in order to address barriers that currently affect access. Delivering medication review services with cultural competency is vital; steps should be taken to address potential language barriers and build patient-provider relationships through in-person medication reviews. Collaborative co-production approaches could enable better design, implementation and delivery of medication services that are accessible and culturally competent, in order to best meet the needs of ethnic minority communities. Steps should be taken to address knowledge gaps around cultural competence training to enable the creation of pharmacies as inclusive, person-centred healthcare settings. Methods for improving person-centred communication within pharmacies should be further explored. Close, collaborative working with individual populations could enable specific tailoring of medicines review services that best meet the needs of the community. The National Institute for Health Research Applied Research Collaboration (NIHR ARC) and Newcastle University Patient and Public Involvement and Engagement group had extensive input in the study design and conceptualisation. Seven patient champions were appointed to the steering group to ensure that the research was conducted, and the findings were reported, with cultural competence and sensitivity.

References

1. Robinson A, et al. A qualitative exploration of the barriers and facilitators affecting ethnic minority patient groups when accessing medicine review services: perspectives of healthcare professionals. Health Expectations, 2021. DOI: 10.1111/hex.13410.

2. Robinson A, et al. “He or she maybe doesn’t know there is such a thing as a review”: a qualitative investigation exploring barriers and facilitators to accessing medication reviews from the perspective of people from ethnic minority communities. Health Expectations, 2022. DOI: 10.1111/hex.13482.

3. Latif A, et al. A qualitative exploration to understand access to pharmacy medication reviews: views from marginalized patient groups. Pharmacy, 2020. DOI: 10.3390/pharmacy8020073.

Bridging the age gap in breast cancer: impact of omission of breast cancer surgery in older women with oestrogen receptor-positive early breast cancer on quality-of-life outcomes

BACKGROUND

Primary endocrine therapy may be an alternative treatment for less fit women with oestrogen receptor (ER)-positive breast cancer. This study compared quality-of-life (QoL) outcomes in older women treated with surgery or primary endocrine therapy.

METHODS

This was a multicentre, prospective, observational cohort study of surgery or primary endocrine therapy in women aged over 70 years with operable breast cancer. QoL was assessed using European Organisation for Research and Treatment of cancer QoL questionnaires QLQ-C30, -BR23, and -ELD14, and the EuroQol Five Dimensions 5L score at baseline, 6 weeks, and 6, 12, 18, and 24 months. Propensity score matching was used to adjust for baseline variation in health, fitness, and tumour stage.

RESULTS

The study recruited 3416 women (median age 77 (range 69-102) years) from 56 breast units. Of these, 2979 (87.2 per cent) had ER-positive breast cancer; 2354 women had surgery and 500 received primary endocrine therapy (125 were excluded from analysis due to inadequate data or non-standard therapy). Median follow-up was 52 months. The primary endocrine therapy group was older and less fit. Baseline QoL differed between the groups; the mean(s.d.) QLQ-C30 global health status score was 66.2(21.1) in patients who received primary endocrine therapy versus 77.1(17.8) among those who had surgery plus endocrine therapy. In the unmatched analysis, changes in QoL between 6 weeks and baseline were noted in several domains, but by 24 months most scores had returned to baseline levels. In the matched analysis, major surgery (mastectomy or axillary clearance) had a more pronounced adverse impact than primary endocrine therapy in several domains.

CONCLUSION

Adverse effects on QoL are seen in the first few months after surgery, but by 24 months these have largely resolved. Women considering surgery should be informed of these effects.

Bridging the age gap in breast cancer: cluster randomized trial of two decision support interventions for older women with operable breast cancer on quality of life, survival, decision quality, and treatment choices

BACKGROUND

Rates of surgery and adjuvant therapy for breast cancer vary widely between breast units. This may contribute to differences in survival. This cluster RCT evaluated the impact of decision support interventions (DESIs) for older women with breast cancer, to ascertain whether DESIs influenced quality of life, survival, decision quality, and treatment choice.

METHODS

A multicentre cluster RCT compared the use of two DESIs against usual care in treatment decision-making in older women (aged at least ≥70 years) with breast cancer. Each DESI comprised an online algorithm, booklet, and brief decision aid to inform choices between surgery plus adjuvant endocrine therapy versus primary endocrine therapy, and adjuvant chemotherapy versus no chemotherapy. The primary outcome was quality of life. Secondary outcomes included decision quality measures, survival, and treatment choice.

RESULTS

A total of 46 breast units were randomized (21 intervention, 25 usual care), recruiting 1339 women (670 intervention, 669 usual care). There was no significant difference in global quality of life at 6 months after the baseline assessment on intention-to-treat analysis (difference -0.20, 95 per cent confidence interval (C.I.) -2.69 to 2.29; P = 0.900). In women offered a choice of primary endocrine therapy versus surgery plus endocrine therapy, knowledge about treatments was greater in the intervention arm (94 versus 74 per cent; P = 0.003). Treatment choice was altered, with a primary endocrine therapy rate among women with oestrogen receptor-positive disease of 21.0 per cent in the intervention versus 15.4 per cent in usual-care sites (difference 5.5 (95 per cent C.I. 1.1 to 10.0) per cent; P = 0.029). The chemotherapy rate was 10.3 per cent at intervention versus 14.8 per cent at usual-care sites (difference -4.5 (C.I. -8.0 to 0) per cent; P = 0.013). Survival was similar in both arms.

CONCLUSION

The use of DESIs in older women increases knowledge of breast cancer treatment options, facilitates shared decision-making, and alters treatment selection. Trial registration numbers: EudraCT 2015-004220-61 (https://eudract.ema.europa.eu/), ISRCTN46099296 (http://www.controlled-trials.com).

Abstract P4-02-01: Analytical validation of an automated digital scoring protocol for Ki67: International multicenter collaboration study

Background/Goal: Ki67 expression has been a valuable prognostic marker in breast cancer, but has not seen broad adoption due to lack of standardization between institutions. Automation could represent a solution. Here we tested 3 automated digital image analysis (DIA) platforms including an open source platform to: (i) Investigate the reproducibility of Ki67 measurement across platforms with supervised classifiers performed by the same operator and by multiple operators. (ii) Compare accuracy of the 3 DIA platforms against outcome (prognostic potential). (iii) Assess inter-laboratory reproducibility of a calibrated DIA tool to evaluate Ki67 in breast cancer among 10 participating labs of the International Ki67 in Breast Cancer Working Group (IKWG).

Methods: The Mib-1 antibody (Dako) was used to detect Ki67 (dilution 1:100). HALO (H) (IndicaLabs), QuantCenter (QC) (3DHistech), QuPath (QP) (open-source software) digital image analysis (DIA) platforms were used to evaluate Ki67 expression. As a ground truth, we evaluated Ki67 LI with meticulous manual tissue segmentation using the Spectrum Webscope (SW) (Aperio). Calibration was performed using 30 ER+ breast cancer cases from phase 3 of the IKWG initiative where blocks were centrally cut and stained for Ki67. The inter-laboratory analysis was done with 10 participating laboratories divided into 2 groups where members within the same group were given the same set of images. The outcome cohort consisted of 149 breast cancer cases from the Yale Pathology archives in tissue microarray format. Intra-class correlation coefficient (ICC) was used to measure reproducibility with the pre-specified criterion for success being to exceed 0.80. Kaplan-Meier analysis supported with log-rank test was performed to assess prognostic potential.

Results: All 3 DIA platforms showed excellent inter-platform reproducibility (ICC: 0.933, CI: 0.879-0.966). Also, excellent reproducibility was found between all DIA platforms and the reference standard Ki67 values of SW (QP ICC: 0.970, CI: 0.936-0.986; H ICC: 0.968, CI: 0.933-0.985; QC ICC: 0.964, CI: 0.919-0.983). The intra-DIA reproducibility was also excellent for all platforms (QP ICC: 0.992, CI: 0.986-0.996; H ICC: 0.972, CI: 0.924-0.988; QC ICC: 0.978, CI: 0.932-0.991). Comparing each DIA against outcome, the hazard ratios were similar (QP=3.309, H=3.077, QC=3.731). The inter-operator reproducibility was particularly high (ICC: 0.962-0.995). As QP is open source software and also showed the lowest intra-DIA platform variability, we selected the QP platform to investigate inter-laboratory reproducibility among 10 IKWG labs. The different-section ICC across the 10 labs was 0.974 (CI: 0.954 - 0.986). The same-section ICC estimate was 0.984 (CI: 0.971-0.992) for group 1 and 0.978 (CI: 0.956-0.989) for group 2.

Conclusions: Our results showed outstanding reproducibility both within and between DIA platforms. We also found the platforms essentially indistinguishable with respect to prediction of breast cancer patient outcome. Automated Ki67 evaluation using a calibrated, open-source DIA platform (QuPath) met the pre-specified criterion of success in the multi-institutional setting. Assessment of clinical utility is planned.

Citation Format: Acs B, Leung SC, Pelekanou V, Bai Y, Martinez-Morilla S, Toki M, Chang MC, Gholap A, Jadhav A, Hugh JC, Bigras G, Laurinavicius A, Augulis R, Levenson R, Todd A, Piper T, Virk S, van der Vegt B, Hayes DF, Dowsett M, Nielsen TO, Rimm DL. Analytical validation of an automated digital scoring protocol for Ki67: International multicenter collaboration study [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P4-02-01.

A systematic review and thematic synthesis of patients' experience of medicines adherence

BACKGROUND

Medicines non-adherence continues to be problematic in health care practice. After decades of research, few interventions have a robust evidence-based demonstrating their applicability to improve adherence. Phenomenology has a place within the health care research environment.

OBJECTIVE

To explore patients' lived experiences of medicines adherence reported in the phenomenonologic literature.

METHODS

A systematic literature search was conducted to identify peer-reviewed and published phenomenological investigations in adults that aimed to investigate patients' lived experiences of medicines adherence. Studies were appraised using the Critical Appraisal Skills Programme (CASP) Qualitative Research Tool. Thematic synthesis was conducted using a combination of manual coding and NVivo10 [QSR International, Melbourne] coding to aid data management.

RESULTS

Descriptive themes identified included i) dislike for medicines, ii) survival, iii) perceived need, including a) symptoms and side-effects and b) cost, and iv) routine. Analytic themes identified were i) identity and ii) interaction.

CONCLUSIONS

This work describes adherence as a social interaction between the identity of patients and medicines, mediated by interaction with family, friends, health care professionals, the media and the medicine, itself. Health care professionals and policy makers should seek to re-locate adherence as a social phenomenon, directing the development of interventions to exploit patient interaction with wider society, such that patients 'get to know' their medicines, and how they can be taken, throughout the life of the patient and the prescription.

Performance of two Aspergillus IgG EIA assays compared with the precipitin test in chronic and allergic aspergillosis

Detection of Aspergillus IgG antibodies is important in the diagnosis of chronic pulmonary aspergillosis and allergic bronchopulmonary aspergillosis. Immunoprecipitation techniques to detect these antibodies appear to lack sensitivity and accurate quantitation compared with enzyme immunoassays (EIA). This study assessed the performance of two commercial EIAs compared with counterimmunoelectrophoresis (CIE). This was a prospective cohort study of 175 adult patients with chronic or allergic pulmonary aspergillosis. Aspergillus IgG antibodies were detected using CIE, Phadia ImmunoCap Aspergillus IgG and Bio-Rad Platelia Aspergillus IgG. Inter-assay reproducibility was determined for each method and 25 patients had two serum samples analysed within a 6-month interval. When compared with CIE, both ImmunoCap and Platelia Aspergillus IgG had good sensitivity (97 and 93%, respectively) for detection of Aspergillus IgG antibodies. The level of agreement between the two EIAs for positive results was good, but the concentration of antibodies was not correlated between the tests or with CIE titre. ImmunoCap IgG inter-assay coefficient of variation was 5%, whereas Platelia IgG was 33%. Median ImmunoCap IgG values for CPA and allergic aspergillosis were 95 and 32 mg/L, respectively, whereas Platelia IgG values were >80 and 6 AU/mL. The direction of CIE titre change over 6 months was mirrored by ImmunoCap IgG levels in 92% of patients, and by Platelia IgG in 72% of patients. Both ImmunoCap and Platelia Aspergillus IgG EIAs are sensitive measures of Aspergillus IgG antibodies compared with CIE. However, ImmunoCap appears to have better reproducibility and may be more suitable for monitoring patient disease.

Diabetic fatty liver disease is associated with specific changes in blood-borne markers

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD) can lead to cirrhosis and hepatocellular carcinoma and is strongly associated with obesity and insulin resistance. The aim of this study was to assess if plasma markers associated with NAFLD are increased in people with concomitant diabetes compared with those without.

METHODS

A total of 68 participants were recruited from diabetes and liver clinics. Fatty liver disease was indicated by routine blood tests and ultrasonography. Forty-seven participants had type 2 diabetes; of them, 18 had no fatty liver disease as defined previously (DNoFLD) and 29 had fatty liver disease (DFLD); the remaining 21 had fatty liver disease but no diabetes (NonDFLD). Serum samples were analyzed for adiponectin (APN), alanine and aspartate aminotransferases and plasma for cholesterol, triglyceride, hyaluronic acid (HA), procollagen peptide III, alkaline phosphatase and fibrinogen.

RESULTS

Hyaluronic acid and procollagen peptide III were significantly higher and adiponectin significantly lower in DFLD than NonDFLD and DNoFLD, the difference being particularly marked for hyaluronic acid and APN. There was no difference in these markers between NonDFLD and DNoFLD and no association between any plasma or serum marker and ultrasound grade of steatosis.

CONCLUSION

We have identified markers of hepatic steatosis that appear to be specific for people with type 2 diabetes. A further longitudinal study is merited to assess the role of these markers in understanding the progression of hepatic steatosis and fibrosis in people with and without diabetes.

A novel pneumococcus with a new association

A case of severe invasive pneumococcal disease in a 68 year old female is described. She presented following a holiday in Turkey with an uncommon but well documented complication of Streptococcus pneumoniae bacteraemia; Austrian's triad of meningitis, pneumonia and endocarditis. She then progressed to develop an atypical variant of Guillain Barre syndrome, never previously documented in association with pneumococcal disease. The pneumococcus was identified as serotype 6A and genetic typing by multi-locus sequence typing showed it to be a unique genetic profile (ST4533). We hypothesise that ST4533 may have resulted from genetic re-assortment from streptococci which had colonised the patient in the United Kingdom and bacteria encountered in Turkey. The ability to associate uncommon genotypes with uncommon clinical presentations may improve understanding of the pathogenesis of this organism, and this highlights the need for international invasive pneumococcal disease surveillance.

Cost analysis of a community pharmacy 'minor ailment scheme' across three primary care trusts in the North East of England

BACKGROUND

A large proportion of primary care medical consultations relate to minor ailments, placing a substantial burden on the UK National Health Service (NHS). In response, minor ailment schemes (MAS) have been introduced in several community pharmacies.

METHODS

Patients using MAS across three neighbouring primary care trusts were asked what action they would have taken if the MAS had not been in place. The net cost impact of the MAS was calculated using standard health-care reference costs. The observation period was one calendar month with annualized cost data.

RESULTS

During the observation period 396 patients used the MAS of whom 230 (58.1%) stated they would have made an appointment with their general practitioner (GP) if the MAS was not in place. A further 155 (39.1%) would have bought a medicine from the pharmacy. Other responses included attending the accident and emergency department at hospital (n= 2), consulting a health visitor (n= 1), or doing nothing (n= 8). The MAS is estimated to reduce local health-care costs by £6739 per month.

CONCLUSIONS

MAS release NHS resources (especially in relation to GP consultations) by preventing (or minimizing) patient use of alternative and more costly branches of the NHS.

Mobilisation and attenuation of boron during coal mine rehabilitation, Wangaloa, New Zealand

Environmental mobility and fate of boron has been traced from source to discharge waters through the rehabilitated Wangaloa coal mine in southern New Zealand. The boron is derived initially from coal, which has up to 450 mg/kg B. The coal also contains pyrite (2-5 wt.% S), which oxidizes to yield a low-pH environment (typical pH 2-5). Weathering of coal-bearing waste rock liberates B into rainwater that infiltrates into waste rock or evaporates to leave a gypsum crust enriched in B, possibly as boric acid or colemanite as inferred from geochemical modelling. Surface waters dissolve this evaporative material periodically, yielding total B concentrations up to 6 mg/L, at pH<4.5. Some of the available B is taken up by plants that have been established on the waste rock, resulting in foliage B concentrations of up to 230 mg/kg (dry weight). Partial attenuation of dissolved B by adsorption to iron oxyhydroxide occurs as groundwater passes through waste rock, but this is inhibited by adsorption competition with dissolved sulphate (up to 600 mg/L). Groundwater flows from the mine through a pit lake and wetland, with total dissolved B near 1 mg/kg after dilution and limited adsorption attenuation has occurred. Despite the widespread B mobility throughout the rehabilitated mine, there is little evidence of B toxicity in plants. The B concentrations in discharging waters are in the environmentally safe range for most aquatic organisms, being neither deficient in B as a micronutrient, nor boron-toxic.

Characterization of neurons that express preprotachykinin B in the dorsal horn of the rat spinal cord

Although it is established that neurokinin B is expressed by some neurons in laminae I-III of the rat spinal dorsal horn, little is known about the proportions of cells in these laminae that express neurokinin B, or whether these are excitatory or inhibitory neurons. Neurokinin B is derived from preprotachykinin B, and we have used an antibody against preprotachykinin B to address these issues. We found that preprotachykinin B-immunoreactive neurons were present throughout laminae I-III, constituting 10-11% of the neuronal population in laminae I-II, and 4% of that in lamina III. They formed a prominent band in the ventral half of lamina II (where they made up 16% of the population) and the dorsalmost part of lamina III. The great majority (99%) of preprotachykinin B-immunoreactive axonal boutons contained the vesicular glutamate transporter 2, while none contained glutamic acid decarboxylase. Since most of these boutons are likely to be derived from local preprotachykinin B-expressing cells, these observations suggest that most of the latter are excitatory interneurons. Although 9% of preprotachykinin B-labeled axonal varicosities were substance P-immunoreactive, none contained calcitonin gene-related peptide, which is consistent with reports that neurokinin B is not expressed by primary afferent axons. Many of the preprotachykinin B-immunoreactive cells contained compounds that are present in putative excitatory neurons in laminae I-III: calbindin (84%), protein kinase Cgamma (76%) or somatostatin (31%). However, there was little or no overlap between preprotachykinin B and three other markers associated with excitatory neurons in these laminae: the mu opioid receptor MOR-1, the neurokinin 1 receptor and neurotensin. These results suggest that neurokinin B is expressed by specific populations of excitatory neurons in the superficial dorsal horn. By examining expression of Fos protein in response to intraplantar injection of formaldehyde we provide evidence that many of the preprotachykinin B cells in lamina I and the outer part of lamina II respond to noxious stimulation.

Reducing red cell transfusion by audit, education and a new guideline in a large teaching hospital

Safety concerns combined with the greatly increased costs and difficulties of maintaining the blood supply are major considerations for transfusion services. Previous local surveys demonstrated that hospital blood use at our hospital could be improved. Excessive cross-matching, unnecessary transfusion and high return rates of unused blood were commonplace. Transfusion practice was audited over a 3-month period. An education package with guidelines for transfusion was delivered to all clinician groups within the hospital, over the following 9 months. The audit was repeated exactly 1 year later at the same time period. During the second audit, inpatient hospital numbers increased by 1.02% (from n = 7262 to n = 7336) but no differences in length of stay, cardiovascular morbidity or mortality were demonstrated. Twenty percent (n = 254, 2002; n = 316, 2001) fewer patients received blood, and the number of red cell packs used reduced by 19% (from n = 1093 to n = 880). Total number of patients transfused reduced from 4.4% to 3.5% which, as an absolute difference, is a reduction of 0.9% (CI 0.3-1.5, P = 0.006). The audit, guideline and education package had a major impact on red cell use within the hospital with no adverse effects. Blood use can be improved by the implementation of a suitable education package and guideline. If it is possible to replicate the results of this education programme nationwide, the effect on blood use, with subsequent savings and enhanced patient safety could be significant.