The association of preoperative anemia and perioperative allogeneic blood transfusion with the risk of surgical site infection

BACKGROUND: The purpose of the study was to investigate allogeneic blood transfusion (ABT) and preoperative anemia as risk factors for surgical site infection (SSI). STUDY DESIGN AND METHODS: A prospective, observational cohort of 5873 consecutive general surgical procedures at Basel University Hospital was analyzed to determine the relationship between perioperative ABT and preoperative anemia and the incidence of SSI. ABT was defined as transfusion of leukoreduced red blood cells during surgery and anemia as hemoglobin concentration of less than 120 g/L before surgery. Surgical wounds and resulting infections were assessed to Centers for Disease Control standards. RESULTS: The overall SSI rate was 4.8% (284 of 5873). In univariable logistic regression analyses, perioperative ABT (crude odds ratio [OR], 2.93; 95% confidence interval [CI], 2.1 to 4.0; p < 0.001) and preoperative anemia (crude OR, 1.32; 95% CI, 1.0 to 1.7; p = 0.037) were significantly associated with an increased odds of SSI. After adjusting for 13 characteristics of the patient and the procedure in multivariable analyses, associations were substantially reduced for ABT (OR, 1.25; 95% CI, 0.8 to 1.9; p = 0.310; OR, 1.07; 95% CI, 0.6 to 2.0; p = 0.817 for 1-2 blood units and >or=3 blood units, respectively) and anemia (OR, 0.91; 95% CI, 0.7 to 1.2; p = 0.530). Duration of surgery was the main confounding variable. CONCLUSION: Our findings point to important confounding factors and strengthen existing doubts on leukoreduced ABT during general surgery and preoperative anemia as risk factors for SSIs.

Does single use of an autologous transfusion system in TKA reduce the need for allogenic blood?: a prospective randomized trial

BACKGROUND Mechanical autotransfusion systems for washed shed blood (WSB) were introduced to reduce the need for postoperative allogenic blood transfusions (ABTs). Although some authors have postulated decreased requirements for ABT by using autologous retransfusion devices, other trials, mostly evaluating retransfusion devices for unwashed shed blood (USB), verified a small or no benefit in reducing the need for postoperative ABT. Because of these contradictory findings it is still unclear whether autologous retransfusion systems for WSB can reduce transfusion requirements. QUESTIONS/PURPOSES We therefore asked whether one such autologous transfusion system for WSB can reduce the requirements for postoperative ABT. METHODS In a prospective, randomized, controlled study, we enrolled 151 patients undergoing TKA. In Group A (n=76 patients), the autotransfusion system was used for a total of 6 hours (intraoperatively and postoperatively) and the WSB was retransfused after processing. In Control Group B (n=75 patients), a regular drain without suction was used. We used signs of anemia and/or a hemoglobin value less than 8 g/dL as indications for transfusion. If necessary, we administered one or two units of allogenic blood. RESULTS Twenty-three patients (33%) in Group A, who received an average of 283 mL (range, 160-406 mL) of salvaged blood, needed a mean of 2.1 units of allogenic blood, compared with 23 patients (33%) in Control Group B who needed a mean of 2.1 units of allogenic blood. CONCLUSIONS We found the use of an autotransfusion system did not reduce the rate of postoperative ABTs. LEVEL OF EVIDENCE Level II, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Intraoperative Continuous Norepinephrine Infusion Combined with Restrictive Deferred Hydration Significantly Reduces the Need for Blood Transfusion in Patients Undergoing Open Radical Cystectomy: Results of a Prospective Randomised Trial

BACKGROUND Open radical cystectomy (ORC) is associated with substantial blood loss and a high incidence of perioperative blood transfusions. Strategies to reduce blood loss and blood transfusion are warranted. OBJECTIVE To determine whether continuous norepinephrine administration combined with intraoperative restrictive hydration with Ringer's maleate solution can reduce blood loss and the need for blood transfusion. DESIGN, SETTING, AND PARTICIPANTS This was a double-blind, randomised, parallel-group, single-centre trial including 166 consecutive patients undergoing ORC with urinary diversion (UD). Exclusion criteria were severe hepatic or renal dysfunction, congestive heart failure, and contraindications to epidural analgesia. INTERVENTION Patients were randomly allocated to continuous norepinephrine administration starting with 2 μg/kg per hour combined with 1 ml/kg per hour until the bladder was removed, then to 3 ml/kg per hour of Ringer's maleate solution (norepinephrine/low-volume group) or 6 ml/kg per hour of Ringer's maleate solution throughout surgery (control group). OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Intraoperative blood loss and the percentage of patients requiring blood transfusions perioperatively were assessed. Data were analysed using nonparametric statistical models. RESULTS AND LIMITATIONS Total median blood loss was 800 ml (range: 300-1700) in the norepinephrine/low-volume group versus 1200 ml (range: 400-2800) in the control group (p<0.0001). In the norepinephrine/low-volume group, 27 of 83 patients (33%) required an average of 1.8 U (±0.8) of packed red blood cells (PRBCs). In the control group, 50 of 83 patients (60%) required an average of 2.9 U (±2.1) of PRBCs during hospitalisation (relative risk: 0.54; 95% confidence interval [CI], 0.38-0.77; p=0.0006). The absolute reduction in transfusion rate throughout hospitalisation was 28% (95% CI, 12-45). In this study, surgery was performed by three high-volume surgeons using a standardised technique, so whether these significant results are reproducible in other centres needs to be shown. CONCLUSIONS Continuous norepinephrine administration combined with restrictive hydration significantly reduces intraoperative blood loss, the rate of blood transfusions, and the number of PRBC units required per patient undergoing ORC with UD.

Transfusion efficacy of apheresis platelet concentrates irradiated at the day of transfusion is significantly superior compared to platelets irradiated in advance.

BACKGROUND Gamma irradiation is currently the standard care to avoid transfusion-associated graft-versus-host disease. Guidelines on gamma irradiation of blood components state that platelets (PLTs) can be irradiated at any stage in their 5-day storage and can thereafter be stored up to their normal shelf life of 5 days after collection. In this study, we explored whether the timing of irradiation has an effect on transfusion efficacy of apheresis PLT concentrates (APCs). METHODS Based on the 1-hour percent PLT recovery (PPR1h), transfusion efficacy of 1,000 eligible APCs transfused to 144 children were evaluated retrospectively. PPR1h was compared in transfused APCs irradiated at the day of transfusion and APCs irradiated in advance. RESULTS In univariate analysis, transfusion efficacy of APCs irradiated in advance was significantly lower than that of APCs irradiated at the day of transfusion (mean PPR1h 27.7 vs. 35.0%; p = 0.007). This was confirmed in multivariate analysis (p = 0.030). Compared to non-irradiated APCs, transfusion efficacy of APCs irradiated at the day of transfusion was not significantly inferior (mean difference -2.8%; 95% CI -6.1 to 0.5%; p = 0.092), but APCs irradiated in advance were clearly less efficient (mean difference -8.1%; 95% CI -12.2 to -4.0%; p < 0.001). CONCLUSION Our data strongly support that APCs should not be irradiated in advance, 1.e., ≥24 h before transfusion.

Effects of dialysis modality on blood loss, bleeding complications and transfusion requirements in critically ill patients with dialysis-dependent acute renal failure.

Blood loss and bleeding complications may often be observed in critically ill patients on renal replacement therapies (RRT). Here we investigate procedural (i.e. RRT-related) and non-procedural blood loss as well as transfusion requirements in regard to the chosen mode of dialysis (i.e. intermittent haemodialysis [IHD] versus continuous veno-venous haemofiltration [CVVH]). Two hundred and fifty-two patients (122 CVVH, 159 male; aged 61.5±13.9 years) with dialysis-dependent acute renal failure were analysed in a sub-analysis of the prospective randomised controlled clinical trial-CONVINT-comparing IHD and CVVH. Bleeding complications including severity of bleeding and RRT-related blood loss were assessed. We observed that 3.6% of patients died related to severe bleeding episodes (between group P=0.94). Major all-cause bleeding complications were observed in 23% IHD versus 26% of CVVH group patients (P=0.95). Under CVVH, the rate of RRT-related blood loss events (57.4% versus 30.4%, P=0.01) and mean total blood volume lost was increased (222.3±291.9 versus 112.5±222.7 ml per patient, P <0.001). Overall, transfusion rates did not differ between the study groups. In patients with sepsis, transfusion rates of all blood products were significantly higher when compared to cardiogenic shock (all P <0.01) or other conditions. In conclusion, procedural and non-procedural blood loss may often be observed in critically ill patients on RRT. In CVVH-treated patients, procedural blood loss was increased but overall transfusion rates remained unchanged. Our data show that IHD and CVVH may be regarded as equivalent approaches in critically ill patients with dialysis-dependent acute renal failure in this regard.

Data quality in trauma transfusion studies and the impact of missing data on predicting massive transfusion

Maximizing data quality may be especially difficult in trauma-related clinical research. Strategies are needed to improve data quality and assess the impact of data quality on clinical predictive models. This study had two objectives. The first was to compare missing data between two multi-center trauma transfusion studies: a retrospective study (RS) using medical chart data with minimal data quality review and the PRospective Observational Multi-center Major Trauma Transfusion (PROMMTT) study with standardized quality assurance. The second objective was to assess the impact of missing data on clinical prediction algorithms by evaluating blood transfusion prediction models using PROMMTT data. RS (2005-06) and PROMMTT (2009-10) investigated trauma patients receiving ≥ 1 unit of red blood cells (RBC) from ten Level I trauma centers. Missing data were compared for 33 variables collected in both studies using mixed effects logistic regression (including random intercepts for study site). Massive transfusion (MT) patients received ≥ 10 RBC units within 24h of admission. Correct classification percentages for three MT prediction models were evaluated using complete case analysis and multiple imputation based on the multivariate normal distribution. A sensitivity analysis for missing data was conducted to estimate the upper and lower bounds of correct classification using assumptions about missing data under best and worst case scenarios. Most variables (17/33=52%) had <1% missing data in RS and PROMMTT. Of the remaining variables, 50% demonstrated less missingness in PROMMTT, 25% had less missingness in RS, and 25% were similar between studies. Missing percentages for MT prediction variables in PROMMTT ranged from 2.2% (heart rate) to 45% (respiratory rate). For variables missing >1%, study site was associated with missingness (all p≤0.021). Survival time predicted missingness for 50% of RS and 60% of PROMMTT variables. MT models complete case proportions ranged from 41% to 88%. Complete case analysis and multiple imputation demonstrated similar correct classification results. Sensitivity analysis upper-lower bound ranges for the three MT models were 59-63%, 36-46%, and 46-58%. Prospective collection of ten-fold more variables with data quality assurance reduced overall missing data. Study site and patient survival were associated with missingness, suggesting that data were not missing completely at random, and complete case analysis may lead to biased results. Evaluating clinical prediction model accuracy may be misleading in the presence of missing data, especially with many predictor variables. The proposed sensitivity analysis estimating correct classification under upper (best case scenario)/lower (worst case scenario) bounds may be more informative than multiple imputation, which provided results similar to complete case analysis.^

Los mestizos no nacen sino que se hacen. En: Avá, nº 14

En este ensayo se analiza el proceso de construcción de la categoría social de las mestizas en los inicios de la colonización de hispano-América desde una perspectiva semántico-histórica y antropológica, así como las diferencias en su afianzamiento y gestión política en distintos contextos geopolíticos de la colonial. Partiendo de sus investigaciones previas, donde desarrolló una interpretación del racismo como doctrina legitimadora de la desigualdad socioeconómica junto con las formas de dominación y control socio-sexual, en especial de las mujeres, la autora explora los mecanismos utilizados por la administración colonial para distinguir formalmente a las mestizas de otros grupos sociales así como los criterios de identificación empleados para ello, examinando el significado cambiante de la doctrina peninsular de limpieza de sangre.

Con dos minas de oro, Belén no tiene caminos: Una interpretación ideológica de las investigaciones financiadas por el Banco Mundial

Entre 1998 y 2001 realicé trabajo de campo en el Departamento de Belén, en el Oeste dela provincia de Catamarca (NOA), con el objetivo de caracterizar los cambios sociales y las consecuencias que el aprovechamiento del yacimiento minero Bajo de la Alumbrera produce en la localidad. Esta información fue sistematizada en mi tesis de maestría (Mastrangelo 2004) y me permitió precisar que, para completar la descripción de lo que pasaba localmente, era necesario incluir en el campo empírico además de a los pobladores locales y a la empresa, al Estado (provincial y nacional) y al Banco Mundial que estaban implementando la política de desregulación minera al mismo tiempo que establecían las condiciones para lo que denominan “una minería sustentable”. Así fue que tomando entrevistas a funcionarios del Banco Mundial y el Estado argentino comencé a participar de un proyecto de investigación ejecutado por el Banco Mundial y la República Argentina. El año de participación como “técnica” en el “proyecto del Banco” fue usado para realizar trabajo de campo etnográfico entre los funcionarios estatales y representantes del Banco Mundial. En la tesis presento la información allí recogida interpretada en base a conceptos teóricos sobre la política, la ideología y la hegemonía elaborados por CliffordGeertz (1997), MijailBajtin (1999), Ernesto Laclau (1996) y SlavojZizek (1992). El contenido se presenta en dos grandes secciones temáticas. En la primera de ellas Describo las características y los problemas que los pobladores de Belén atribuyen a la minera y las formas en que la empresa toma relación con ellos e interviene en la realidad local (contratando fuerza de trabajo, generando encadenamientos con la economía local y realizando donaciones). En la segunda me detengo en la descripción y el análisis de cómo esos problemas locales son interpretados por instituciones globalizantes (el Estado –- y el Banco Mundial), haciendo énfasis en las descripción de las prácticas y representacionesque acompañan la entrega de los créditos que el Banco Mundial otorgó al Estado argentino para la modernización de las instituciones públicas relacionadas con la minería (Proyectos PASMA I y II, préstamo de 69,5 millones de dólares desembolsados entre1995 y 2001).

Marcelo D. Boeri. Apariencia y realidad en el pensamiento griego: Investigaciones sobre aspectos epistemológicos, éticos y de teoría de la acción en algunas teorías de la Antigüedad . 1ª ed. Buenos Aires, Colihue, 2007, 384 pp.

El eje temático que orienta la dirección y sentido de este libro es el clásico 'problema' que advierte todo el pensamiento antiguo y que, desde diversas concepciones, ha intentado resolver lo que podríamos denominar el tema de la apariencia-realidad, o tal vez parecer-ser. El Dr. Boeri dirige su mirada hacia los pensadores clásicos griegos y helenísticos y penetra hondo en sus textos no con un interés meramente histórico, sino, como él mismo lo advierte, filosófico y sistemático.

Investigaciones en ciencias humanas y sociales : del ABC disciplinar a la reflexión metodológica

Diversidad de objetos, variedad de enfoques, prácticas disciplinares y multidisciplinares, y ejemplos de ejecución de proyectos de investigación y desarrollo son los rasgos distintivos de los siete capítulos que integran esta obra. En ellos se recoge el material desplegado en los Seminarios-Talleres de Metodología de la Investigación en Humanidades que se realizaron en el marco de las V Jornadas de Investigación de la Facultad de Filosofía y Letras de la Universidad Nacional de Cuyo en setiembre de 2004: estudios sobre procesos sociales, cuestiones educativas, geográficas, históricas, lingüísticas y literarias. Algunos capítulos han mantenido el estilo y formato característicos del contexto de los seminarios-talleres, a veces con ligeras modificaciones; otros han sido enteramente reescritos para la convocatoria de esta publicación. Este libro refleja entonces abordajes disciplinares y pluridisciplinares diversos a problemáticas igualmente variadas. Por tratarse de propuestas orientadas a y/o basadas en seminarios-talleres, está claro que los autores involucrados no pueden abarcar todos los aspectos de los objetos de estudio respectivos. Sin embargo, la idea es al menos brindar algún punto de vista sobre el estadio de desarrollo de algunas de las investigaciones actualmente en ejecución en nuestra Facultad.

Dominique Ionga-Prat, Iglesia y sociedad en la Edad Media, Instituto de Investigaciones Históricas, UNAM, 2010, ISBN: 978- 607-02-1216-1. 73 pp.

Fil: Mendoza, José María Felipe.

Necesidad de plan de marketing en un banco de sangre

Pocos países en el mundo tienen organizado un sistema público de donación de sangre, entre los cuales están Argentina, España, Uruguay y Costa Rica. En estos países está prohibida la compraventa de sangre, que se considera un recurso público únicamente designado a instituciones sanitarias para el tratamiento de pacientes cuya donación es totalmente voluntaria. En los países en que no existe tal sistema, la donación es realizada por familiares, o se paga para encontrar un donante. Cabe destacar que se considera que una de las ventajas del donante voluntario es que en general representará un riesgo menor de estar contaminado. La necesidad del “Plan de Marketing" se ve claramente, ya que es sumamente necesario realizar un análisis de este tipo. La problemática de la donación de sangre es una política de Estado, para la cual el Ministerio de Salud puso en marcha en 2002 el Plan Nacional de Sangre, a través del cual se equipó los Bancos de Sangre de todo el país y se capacitó a sus recursos humanos. Este “Plan de Marketing" nos va permitir pasar de un modelo de reposición a otro basado en la donación altruista, voluntaria y sostenida, que garantiza mayor disponibilidad de sangre segura y sus derivados, así como su calidad, mediante una comunicación masiva y acciones de marketing que nos lleven a tomar conciencia de la importancia de donar sangre.

Sánchez Cuervo, Antolín y Ambrosio Velasco Gómez (coords.), Filosofía política de las independencias latinoamericanas. Madrid, Biblioteca Nueva / Consejo Superior de Investigaciones Científicas, 2012, 281 págs.

Fil: Ribas, Pedro. Universidad Autónoma de Madrid