Transfusion protocols for such patients have been “predominantly guided by tradition rather than evidence from large, multicenter randomized trials,” said Dr. John B. Holcomb of the Center for Translational Injury Research, University of Texas Health Science Center, Houston, and his associates in the PROPPR (Pragmatic, Randomized Optimal Platelet and Plasma Ratios) trial. In the last decade, many clinicians changed over to the 1:1:1 ratio because it is more balanced and more closely replicates the ratio present in whole blood than does the traditional 1:1:2 ratio.
Vitals Key clinical point: In severe trauma patients with major bleeding, increasing the ratio of red blood cells did not improve early and late mortality. Major finding: At 24 hours, mortality was 12.7% in the group given a 1:1:1 ratio of plasma to platelets to red blood cells and 17% in the 1:1:2 group; at 30 days, mortality 22.4% in the 1:1:1 group and 26.1% 1:1:2 group. Data source: A phase III multicenter partially blinded, randomized trial comparing two strategies for hemorrhage control in 680 profoundly injured adults treated during a 16-month period. Disclosures: This study was supported by the U.S. National Heart, Lung, and Blood Institute, the U.S. Department of Defense, Defense Research and Development Canada, and the Canadian Institutes of Health Research-Institute of Circulatory and Respiratory Health. Dr. Holcomb reported having no financial disclosures; two associates reported ties to TEM International, CSL Behring, and Decision Health. |
The researchers described the study as the first multicenter randomized trial to use approved blood products to compare the two transfusion ratios with mortality as the primary end point. The 680 adults enrolled in the study were treated for severe injury with major bleeding during a 16-month period at 12 Level 1 trauma centers in North America.
Overall 24-hour mortality was not significantly different, at 12.7% in the 1:1:1 group and 17% in the 1:1:2 group, and 30-day mortality also was not significantly different at 22.4% and 26.1%, respectively. However, exsanguination, the predominant cause of death within 24 hours, was significantly decreased in the 1:1:1 group (9.2% vs. 14.6%), and significantly more patients in the 1:1:1 group achieved anatomic homeostasis (86.1% vs. 78.1%). Thus, clinicians “should consider using a 1:1:1 transfusion protocol,” Dr. Holcomb and his associates said (JAMA 2015 Feb. 3 [doi:10.10001/jama.2015.12]).
There also were no significant differences between the two study groups in 23 complications, including transfusion-related complications. “Despite significant concerns that the 1:1:1 group would experience higher rates of multiple inflammatory-mediated complications, such as acute respiratory distress syndrome, multiple organ failure, infection, venous thromboembolism, and sepsis, no differences were detected between the two treatment groups,” the researchers noted.
Stress tests in ED lead to unneeded cardiac interventions
BY NICOLA GARRETT
FROM JAMA INTERNAL MEDICINE
Noninvasive testing in the emergency department of patients who have chest pain and have not had a myocardial infarction can result in overdiagnosis and unnecessary interventions, based on the results of a retrospective analysis.
After 6 months of follow-up, 0.33% of 421,774 privately insured patients who presented to the emergency department (ED) with chest pain were hospitalized with an MI. There was no difference in the rate of MIs in patients who did and did not undergo exercise and stress electrocardiography, myocardial perfusion scintigraphy (MPS), or coronary CT angiography, Dr. Andrew. J. Foy of Penn State Milton S. Hershey Medical Center in Hershey, Pa., and his colleagues reported in an article published online in JAMA Internal Medicine (2015 Jan. 26 [doi:10.1001/jamainternmed.2014.7657]).
Vitals Key clinical point: Guidelines for treatment of chest pain in low-risk patients in the emergency department may need revision, as noninvasive testing of these patients may be leading to unneeded interventions. Major finding: An unnecessary catheterization is performed in 1 of every 27 patients who undergo myocardial perfusion scintigraphy instead of an initial strategy of no testing. Data source: A retrospective analysis of health insurance claims data. Disclosures: The researchers reported having no conflicts of interest. |
However, interventions were increased without a concomitant reduction in MI in patients who underwent tests in the ED. “Overdiagnosis is a legitimate concern in this patient population,” the study authors wrote.
Using data from the analysis, the researchers estimated that an unnecessary catheterization is performed in 1 of every 27 patients who undergo MPS instead of an initial strategy of no testing.
“When viewed in the broader context of the approximately 6 million ED visits for a chief symptom of chest pain, for every 100,000 patients who undergo MPS instead of an initial strategy of no testing, approximately 3,700 patients will undergo an unnecessary catheterization,” they wrote.
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