Andrei M. Beliaev

Clinical benefits and cost-effectiveness of allogeneic red-blood-cell transfusion in severe symptomatic anaemia.

Background  It is well known that blood transfusion is life‐saving, but also that it carries a serious risk of transmitting viral infections. Introduction of new methods of testing for transmissible diseases, blood banking and dispatch regulations has considerably increased the cost of blood products. However, the clinical benefits and cost‐effectiveness of allogeneic red‐blood‐cell (ARBC) transfusion remain assumed yet undetermined. We assessed the clinical benefits and cost‐effectiveness of ARBC transfusion in severe anaemia.

Denver screening protocol for blunt cerebrovascular injury reduces the use of multi-detector computed tomography angiography

Blunt cerebrovascular injury (BCVI) occurs in 0.2–2.7% of blunt trauma patients and has up to 30% mortality. Conventional screening does not recognize up to 20% of BCVI patients. To improve diagnosis of BCVI, both an expanded battery of screening criteria and a multi‐detector computed tomography angiography (CTA) have been suggested. The aim of this study is to investigate whether the use of CTA restricted to the Denver protocol screen‐positive patients would reduce the unnecessary use of CTA as a pre‐emptive screening tool.

The Denver screening protocol for blunt cerebro-vascular injury reduces the use of multi-detector CT angiography

Blunt cerebrovascular injury (BCVI) occurs in 0.2–2.7% of blunt trauma patients and has up to 30% mortality. Conventional screening does not recognize up to 20% of BCVI patients. To improve diagnosis of BCVI, both an expanded battery of screening criteria and a multi‐detector computed tomography angiography (CTA) have been suggested. The aim of this study is to investigate whether the use of CTA restricted to the Denver protocol screen‐positive patients would reduce the unnecessary use of CTA as a pre‐emptive screening tool.

Addressing the unmet need of life-threatening anemia with hemoglobin-based oxygen carriers

S evere life-threatening acute anemia is a peril for tissue and major organ damage and mortality owing to inadequate oxygen delivery with consequent tissue and organ hypoxia. Human response to acute normovolemic anemia includes increased heart rate, stroke volume, decreased systemic vascular resistance, and consequently increased cardiac output resulting in some compensatory oxygen delivery, as well as increased oxygen extraction. However, if the anemia becomes sufficiently severe, the response is inadequate; when the hemoglobin (Hb) concentration continues to decrease to less than 7 g/dL the immediate result is decreased oxygen delivery, placing specific organs at risk for dysfunction and damage. The human brain is very sensitive to acute anemia, and a Hb concentration of less than 7 g/dL results in a cerebral electrophysiologic finding (increased P300 latency) that is associated with impaired cognitive function and is a measure of “how well the CNS can process and incorporate incoming information” as well as measured neurocognitive deficits that are reversible when the arterial blood partial pressure of oxygen is increased or red blood cells (RBCs) are transfused shortly thereafter. Once moderate-to-severe anemia has developed, as Hb concentration decreases further there is a substantial increase in morbidity (organ damage) and mortality. Clinical trials have tested liberal versus conservative transfusion strategies, but the lower limits for transfusion in the conservatively transfused patients were 7 to 9.7 g/dL and therefore did not address morbidity and mortality outcomes associated with more severe anemia. None of the four recent meta-analyses identified a trial with a “restrictive” transfusion arm threshold of less than 7 g/dL Hb. Furthermore, patients in these studies likely remained at the “trigger” Hb concentration for a relatively brief period, and in the two large studies reporting such data patients in the restrictive arms were transfused for symptoms more frequently than those in the liberal arm. There is a relatively small population of patients for whom RBC transfusion is not an option, who then, at times, are confronted with severe life-threatening anemia. Data from this population, such as untransfused Jehovah’s Witness patients, treated with contemporary standard of care procedures and interventions provide the best source of information for outcomes associated with progressive life-threatening severe, acute anemia. In 2013 we reviewed the published information from patients with untransfused, severe, life-threatening anemia (most commonly owing to patient refusal of transfusion) in the context of assessing the balance of benefit:risk of Hb-based oxygen carriers (HBOCs). Since then, important additional information has been accrued, enabling a better assessment of the mortality of severe anemia and a comparison with patients treated with an HBOC. To provide a more

C-reactive protein has a better discriminative power than white cell count in the diagnosis of acute cholecystitis.

BACKGROUND The diagnosis of acute cholecystitis (AC) is challenging and may result in a delay in surgery, hospital discharge, and increased mortality. To improve its diagnosis, C-reactive protein (CRP) has been proposed as a benchmark. The aim of this study was to evaluate discriminative power of CRP against white cell count (WCC) in AC. METHODS This was a retrospective cohort study. Over a 5-y period, 1959 patients were identified from the audit of cholecystectomies. The exclusion criteria were coexisting acute surgical conditions, absence of blood tests within 3 d before hospital admission for elective surgery, and private patients. RESULTS The eligibility criteria were met by 1843 patients. Comparison of the area under receiver operating characteristic (AUC) curve of CRP and WCC in acute on chronic, edematous, necrotic, suppurative, and gangrenous AC showed a better discriminative power of CRP. Both tests performed equally well in patients with pericholecystic abscess and gallbladder perforation. CRP was superior than WCC in mild AC, AUC = 0.93 (95% confidence interval [CI], 0.9-0.95) and 0.79 (95% CI, 0.74-0.84), P < 0.00005, in moderate and severe AC, AUC = 0.99 (95% CI, 0.97-1.0) and 0.92 (95% CI, 0.88-0.97), P = 0.009, and in all forms of AC combined, AUC = 0.94; (95% CI, 0.92-0.97) and 0.83 (95% CI, 0.79-0.87), respectively, P < 0.00005. CONCLUSIONS CRP has a better discriminative power than WCC in most forms of AC and is a useful diagnostic marker of AC.

Treatment monitoring and mortality risk adjustment in anaemic Jehovah's Witnesses

Management of anaemic Jehovahs Witness (JW) patients, who refuse blood transfusion on religious grounds, is challenging. In the published literature, there are few cohort studies that consider causes of mortality in isolation and are lacking in their predictive power. This does not allow clinicians to monitor treatment progress of severely anaemic JW patients and adjust their risk of mortality. The study aims to develop an anaemia‐related mortality risk prediction instrument.

Low-dose erythropoietin treatment is not associated with clinical benefits in severely anaemic Jehovah's Witnesses: a plea for a change.

BACKGROUND Jehovahs Witnesses who refuse blood transfusion have high mortality. Erythropoietin (EPO) has been used as an alternative to blood transfusion. The optimal dosing of EPO in anaemic Jehovahs Witnesses is unknown. The aim of our study was to evaluate the clinical benefits of treatment with a low dose (<600 IU/kg/week) of epoietin beta (EPO-β). MATERIALS AND METHODS This was an observational study, retrospectively considering a 10-year period during which 3,529 adult Jehovahs Witnesses with a total of 10,786 hospital admissions were identified from databases of four major public hospitals in New Zealand. Patients with severe symptomatic anaemia (haemoglobin <80 g/L) who were unable to tolerate physical activity were included in the study. Patients treated without EPO were assigned to the conventional therapy group and those treated with EPO to the EPO treatment group. RESULTS Ninety-one Jehovahs Witnesses met the eligibility criteria. Propensity score matching yielded a total of 57 patients. Patients treated with conventional therapy and those treated with EPO had similar durations of severe anaemia (average difference 6.25 days, 95% confidence interval [CI]: -3.77-16.27 days; p=0.221). The mortality rate among Jehovahs Witnesses treated with conventional therapy was 4.68 per year (95% CI: 2.23-9.82), while that in those treated with EPO was 2.77 per year (95% CI: 0.89-8.60). Treatment with EPO was associated with a mortality ratio of 0.59 (95% CI: 0.1-2.6; p=0.236). Both groups of patients had similar in-hospital survival (p=0.703). DISCUSSION Treatment with low-dose EPO-β was not associated with either shorter duration of severe anaemia or a reduction in mortality.

An association between conversion of laparoscopic cholecystectomy to open surgery and intra-abdominal organ injury.

tion (0.2–0.9%). A transmesenteric hernia is an unusual type of internal hernia. It occurs more frequently after previous surgery in which mesentery has been incised but not closed after gastrointestinal reconstruction. On the other hand, a congenital mesenteric defect is very rare but can potentially cause internal hernia with consequent incarceration or strangulation of the small intestine. Congenital mesenteric defect causing internal hernia has been mostly reported in infants and children. In adults, the causes of mesenteric defect are mostly traumatic or post-operative state. Adult congenital mesenteric defect causing bowel obstruction has been documented in only a few reports. The pre-operative diagnosis is difficult because of wide range of acute abdominal symptoms and no specific radiological findings. The diagnosis has been made by surgery or autopsy. The causes of forming mesenteric defect still remain uncertain. The location of most mesenteric defect is reported in the ileo-caecal region just as in this patient. Surgical decision making is based on the clinical findings of intestinal strangulation or ischemia.

Thoracic outlet syndrome secondary to a mid-clavicle malunion

A 22-year-old man presented with a painful ‘clunking’ sensation in the right mid-clavicle, and pain and dysaesthesia along the medial aspect of his right arm and hand. Three months earlier, he had been involved in a vehicle accident and sustained a right clavicle fracture. He had a large step off of the right clavicle with a medialisation of the right shoulder. At 90° abduction in external rotation of both shoulders he developed pain, paraesthesia and disappearance of the right radial artery pulsation. CT of the right shoulder in the neutral position demonstrated the clavicle-to-first rib distance of 5.5 mm, MRI showed the clavicular bone callus had a mass effect with effacement of anterior fat adjacent to the brachial plexus cords. He was diagnosed with thoracic outlet syndrome and underwent a corrective right clavicle osteotomy with the use of an AcuMed superior clavicle plate.

Asymptomatic carotid blunt cerebrovascular injury: a new screening criterion

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