March 2015 – Lablogatory

Can I Use This Figure in My Talk?

Ever found that perfect figure that beautifully illustrates a point you’re trying to make? Ever wonder if it’s okay to use that perfect figure in your presentation? Are you infringing on someone’s copyright when you do? I attended a nice session on copyright the other day and I learned a few things I thought I’d share.

The first thing I learned is that when you create something, a text, a picture, a figure, a song, it is automatically copyrighted. You don’t have to apply for a copyright, nor put the little copyright designation on it (c inside a circle). It’s belongs to you unless you sign away your copyright to someone else.

The next thing I learned is that in general, use of a single figure from something does not constitute copyright infringement, especially if you attribute it to the source. It is considered “fair use” of that figure. That may not be true in some circumstances however, depending on other factors. There are basically four factors that are considered when it comes to the courts deciding on copyright infringement versus fair use. Put very, very simply (and from what I consider most important to least important), the four factors are:

If your use of another person’s (or company’s) work will affect their bottom line, then you are infringing on their copyright.
Is it transformative use or derivative? Are you using the figure or text in the same way that it was originally used, or are you using it for a different purpose entirely? For example a figure from a published paper, with a clear attribution allowing anyone to find the original, used in an educational lecture is fair use.
If you copy an entire textbook and pass it to your students, that’s copyright infringement, and also goes to the fact that you’re eating into the publisher’s bottom line since now your students don’t have to buy the textbook. In general if you use less than 10% of a published work, you’re still in the fair use ballpark. Again, bottom line money can affect this.
Facts and ideas cannot be copyrighted. Expression of facts or ideas, or fixing them into a written work or figure, is copyrighted.

Another thing I learned is that Google images is probably not your best place to find images to use, especially if you want an image in something that you plan to publish. They are all copyrighted, and you will need to track them to their source and get permission to use them. However, for an occasional image in an educational powerpoint, including the attribution (usually in a link) is probably sufficient.

Of course, being a legal thing, copyright and fair use can be much more complicated than this, and lawyers and courts make their living making those decisions. I would say in general though, for a few random images in your powerpoint presentation, you are not breaking any copyright laws.

-Patti Jones PhD, DABCC, FACB, is the Clinical Director of the Chemistry and Metabolic Disease Laboratories at Children’s Medical Center in Dallas, TX and a Professor of Pathology at University of Texas Southwestern Medical Center in Dallas.

Food and Drug Administration and Next Generation Sequencing

As readers of this blog are probably aware, The Food and Drug Administration (FDA) is currently considering how to tailor its oversight of Next Generation Sequencing (NGS), methodologies that can produce extremely high quantities of genetic sequences. In turn, these sequences can be used to identify thousands of genetic variants carried by a particular patient. NGS will usher in an age of truly personalized medicine in terms of patient risk assessment, diagnostics, and personal treatment plans.

Currently, the FDA approves all in vitro diagnostic (IVD) tests with the exception of laboratory defined tests (LDTs). These tests are used in clinical laboratories and typically detect one substance or analyte in a patient sample, and this result is used to diagnose a limited number of conditions. (One example would be a cholesterol test; every manufacturer that makes the analyzer and reagents to detect cholesterol in a blood samples has to get their methodology approved.) However, NGSs have the potential to detect billions of base pairs in the human genome, and therefore the potential exists to diagnose or discover thousands of diseases and risk factors for disease. Also, many NGS tests are developed by individual laboratories, not big companies, and so would be considered an LDT.

The FDA has opened a public docket to invite comments on this topic. American Society for Clinical Pathology, as well as other professional societies—American Association of Clinical Chemistry and Association for Molecular Pathology among them—has publically commented on the FDA preliminary discussion paper “Optimizing FDA’s Regulatory Oversight of Next Generation Sequencing Diagnostic Tests.” In its comments to the draft paper, ASCP stated that the “CLIA framework offers a more logical model for providing federal regulatory oversight of LDTs.” Similar points were made by AACC and AMP. The associations also agree that any regulations should not interfere with the practice of medicine.

What do you think? How involved should the FDA be in genomic testing in the clinical setting?

Further reading:

AMP comments

AACC comments

Match Day Musings

I remember my match day. I actually didn’t go to the ceremony because I was two years behind having done a year of PhD before quitting and was in the midst of my MPH at Columbia the year after graduating medical school. So my original class had matched two years before and I was in NYC during exam period on Match Day and not in South Jersey. So I didn’t experience all the “bells and whistles” associated with Match Day festivities. But I do remember the anxiety of wondering at first if I would match, and then after that fateful Monday after I found out that I matched somewhere, wondering where that would be. It’s stressful and yet at the same time, a relief once you get your match results.

Now, it’s three years later. I’ve matched to two fellowships for 2016-2019 at my first choice program and I have one year left during which I will serve as Chief Resident. Match Day seems like a lifetime ago, really. So fellow, future pathology residents, enjoy this time. If you do want to do some prep because you just *have* to study, then brush up on your histology at your leisure. You can’t learn the abnormal if you don’t know the normal solidly. The first six months is the steepest in terms of learning curve and it will be expected that you already know your histology. You don’t want to fall behind because you will be learning so many new things from the get-go. Or start prepping to get your Step 3 out of the way as early as possible because the further we get out of med school, the less we will remember patient care practices and procedures that we do not practice in every resident life.

Senior residents, think back to what you wish you had known or wish that someone would have impressed upon you as to its importance when you were a first year. These are the things to pass down to your incoming juniors to help them with the transition from medical student to pathology resident. I believe that things happen in this life for a reason. So match day will bring us in contact with each other, to somehow touch each other’s lives in some way – whether it is to teach or to support each other or to work together to advocate for and transform our profession. We’ve started the journey to July 1^st when we the circle of resident life begins anew.

-Betty Chung, DO, MPH, MA is a third year resident physician at Rutgers – Robert Wood Johnson University Hospital in New Brunswick, NJ.

But How does it Work?

There’s an old saying that goes like this: if you understand it, it’s obsolete. Sadly, in this day and age of rapidly advancing technology, this saying is truer than ever. I say “sadly” because what this means for us in the laboratory is that we are becoming less and less likely to be able to troubleshoot and repair our own instruments. This is another thing I sometimes miss about bygone laboratory medicine. Taking instruments apart used to be fun.

Many instruments now are considered “black boxes” by clinical laboratory scientists. They may not understand the principles behind how the instrument works, and even if they do know, they are not inclined or encouraged to attempt to fix it if it stops working. In the early days of laboratory medicine, we could repair most of the instruments we used in the laboratory. Now we can repair almost none of them. Instruments have become so sophisticated, with so many bells, whistles and extras, that even if you know the basics of how the instrument works, being able to fix it when it goes down is no longer a possibility.

For example, most big main chemistry analyzers work on the basis of two principles: some type of photometry and ion-selective electrodes (ISE). Knowing that information used to make it possible to troubleshoot and do some repairs on the photometer system, as well as replace ISEs. Troubleshooting and repair was a matter of checking the functioning of your optics and cleaning as necessary, replacing tubing and replacing electrodes and fluids for the ISE part. Medical technologists were much more likely to repair systems themselves than to call Service in. That ability is rapidly becoming a lost art however.

Modern instruments are much more than a photometer and a set of ISEs. The sheer volume of working parts in current instrumentation is orders of magnitude higher than in old instruments, and most of those parts are robotics in the instrument rather than analytical components. With more sophistication and technical abilities though, come more things that can go wrong. And these are things that cannot be fixed by the clinical laboratory scientist working the instrument.

Of course, for every lost ability is a gained ability. While local troubleshooting may not be possible, many of these major instruments are now connected to the internet. Troubleshooting can be done remotely by the people who do have the knowledge to service them. Honestly, I probably do not want to return to the days of fixing my own instruments in the case of the big chemistry analyzers, but I still do enjoy troubleshooting my mass spectrometers. And it was nice to know I could fix things.

What Does a Global Outreach Volunteer Consultant Do?

So what exactly do I do on my international escapades? I work with my laboratory professional association (mostly), American Society of Clinical Pathology (ASCP) who is under contract with the CDC to help improve laboratory capacity, quality, standards and processes in developing nations. Basically, I work with labs around the world to help them establish lab processes and procedures that meet international standards to collect, handle and process and test laboratory specimens safely and with accuracy, so that the results: 1) are the right patient 2) can be counted on for accuracy and 3) provide info to the clinician in a timely manner so he/she can diagnose and initiate treatment if necessary. And, most of the lab work in these nations are for the “big three” HIV/AIDS, tuberculosis, hepatitis (and in some places, malaria). So…I get called to work closely with international colleagues, review processes and procedures, help mentor lab scientists with quality and process improvement—and do a lot of training, especially in the blood collection part of the process. My last trips over the past several years have included a variety of these things and recently in Central Asia, mostly blood collection training.

The work I get to do is rewarding, engaging, energizing, humbling, and one small way to give back some knowledge and experience to things I am passionate about—but it’s always so good to be home!

Hosh Ohmadet!

-Beverly Sumwalt, MA, DLM, CLS, MT(ASCP) is an ASCP Global Outreach Volunteer Consultant.

Microbiology Case Study–Infection at Wisdom Tooth Extraction Site

Clinical

56 year old male with stage IV chronic kidney disease, hypertension, and gout who underwent a left lower wisdom tooth extraction presented two days post-op with throbbing pain on left side of his face and neck, dysphagia and dyspnea. He was sent to an outside ED by his dentist. He was given 900 mg of clindamycin, a dose of steroids and pain management and was sent to our institution. Surgical site was intact, but there was massive swelling of the floor of the mouth, submandibular gland, and neck. Symptoms worsened despite being given IV clindamycin. Infectious disease was consulted he was started on meropenem and blood cultures were drawn.

Microbiology

Two anaerobic blood culture bottles became positive at 48 and 61 hours.

Gram stain:

Plates:

Isolate of organism 1 on anaerobic blood agar showing dry, white colonies.

Isolate of organism 2 on anaerobic blood agar showing small, white colonies with no hemolysis

Discussion:

Two organisms were identified.

Organism 1: Fusobacterium nucleatum – anaerobic gram-negative, non-spore-forming rods. They are pale-staining, long, slender, spindle-shaped rods with sharply pointed or tapered ends; occasionally the cells occur in pairs end to end. Sometimes there are spherical swellings. Cells are usually 5-10 µm long, but can be shorter. They grow well on anaerobic blood agar plates under anaerobic conditions and are killed readily by exposure to ambient air. Colonies on anaerobic blood agar are 1-2 mm in diameter, slightly convex with slightly irregular margins and have a characteristic internal flecking referred to as “crystalline internal structures”. They can have three morphologies: bread crumblike (white), speckled, or smooth (gray to gray-white). There is greening of the agar on exposure to air, they are usually nonhemolytic and fluoresce chartreuse under UV light.

The Fusobacterium species are normally found in the upper respiratory, gastrointestinal, and genitourinary tracts of humans. They are common causes of serious infections in multiple body sites. They are associated with infections of the mouth, bite wounds, and respiratory tract. F. nucleatum are the most frequently involved in anaerobic pleuropulmonary infections (aspiration pneumonia, lung abscess, necrotizing pneumonia, thoracic empyema). They are also fairly common pathogens in brain abscesses, chronic sinusitis, metastatic osteomyelitis, septic arthritis, liver abscess, and other intraabdominal infections. Fusobacterium nucleatum is the species most commonly found in clinical materials. It can cause severe systemic infection in patients with neutropenia and mucositis following chemotherapy.

They can be differentiated from similar species of Bacterioides, Prevotella, Porphyromanas, and Leptotrichia by their production of butyric acid but not isobutyric or isovaleric acid. Bacterioides and Porphyromanas species produce all three acids.

Organism 2: Parvomonas micra – formerly called Peptostreptococcus micros or Micromonas micros, are anaerobic, gram-positive cocci, <0.7 µm in diameter; occur in packets and short chains. Grow on anaerobic blood agar. Colonies are tiny, white, opaque, nonhemolytic. This is a periodontal pathogen that contributes to periodontitis.

Kirsten J. Threlkeld, MD is a 4^th year anatomic and clinical pathology resident at the University of Vermont Medical Center.

-Christi Wojewoda, MD, is the Director of Clinical Microbiology at the University of Vermont Medical Center and an Assistant Professor at the University of Vermont.

Tumor Boards and Multidisciplinary Conferences (MDC)

Even if we are not as visible to the patients that we care for as other physicians, pathologists are amazing! Of course, I admit that I’m biased since I am a pathology resident but, this does not make this fact any less true. Others may not always realize that pathologists often have to make life altering diagnoses on the most miniscule of tissue samples. Or that we need to incorporate clinical histories, imaging, and previous clinical test and pathology results just as much as the primary clinician, I’ll dare say, sometimes, even more so, since we often do not have the opportunity to talk with the patient face-to-face. And that in the future, especially as precision medicine develops an increasing foothold in the treatment decision making process, we should, and will be, taking more active leadership roles within multidisciplinary teams.

One of the places where I feel that pathologists can show their value to the patient care team is in the multidisciplinary conference (MDC) setting. These can include tumor boards where we discuss specific patient cancer cases or other interdepartmental conferences where we explore an area of common interest that doesn’t necessarily have to be neoplastic. “Doctor” is derived from the Latin word, docere, which means “to teach” and it is within MDC’s that we can shine as teachers. It is impossible to learn about you need to know in medical school in terms of patient care. Not only is the fount of knowledge ever increasing but also our training directs us toward subspecialization since the volume knowledge is so vast, we have to choose which areas we will spend more time mastering.

Way back in the day, surgery residents had to spend significant time (often at least six months) rotating on the surgical pathology service. I find that these more experienced attendings are often the ones who scrub out and sit with our pathologists at the multi-headed scope during frozen sections. And they are also the ones who can make the surgical pathology diagnosis and know the staging summaries even better than junior, and even some senior, pathology residents. But training requirements change. Most of the other clinical physicians we will interact with as colleagues were not trained in this manner.

One of the reasons I chose hematopathology was because I enjoy the daily increased face-to-face interaction I experienced while on this rotation. At most of the hospital sites I’ve trained (four at my previous program and two at my current program), hem/onc physicians and fellows often make the trek to the pathology department to discuss patient cases with the hematopathologist, especially over the microscope. They had some idea of what they were looking at, too. In fact, at a couple of the programs I interviewed (Hopkins and UW), hem/onc physicians are, or were in past in the case of UW, responsible for reading the liquid specimens (peripheral blood smears and aspirates). They also often had multiple interdisciplinary conferences – leukemia, lymphoma, coagulation/benign heme.

But, since I’m on a surgical pathology rotation right now, I was thinking about when we interact most with our surgeons – and I think that is during tumor board. A few of the “old school” surgeons will scrub out and come to the department to look over a frozen with us but most often than not, this is not the case. But during tumor boards, there is always active discussion which includes the pathology in order to come to a treatment decision on not-so-straightforward cases. And these are opportunities to demonstrate just how important the pathologist is to the process. At least in the difficult cases, we do not merely write out diagnoses for other doctors to read and move on without us to treat the patient. It is in these moments when we not only educate but can also actively participate in helping to direct care. But in order to do so, we need to be able to integrate the clinical, epidemiologic, morphologic, radiologic, ancillary diagnostic, and prognostic (lots of “-ogics” there) factors along with know the potential treatment alternatives. We don’t just deal with the morphologic and leave everything else to the referring physicians…at least, if you want to be the best pathologist that you can be. This is also the time when we can leave a lasting impression on other trainees (medical students, residents, and fellows) about how a pathologist can contribute when added to the team mix so that they will be more apt to seek out and work together with pathologists when they become attending physicians.

We are the physicians who understand the intricacies and implications of many of the ancillary tests if we understand well how they are performed and why and also what can cause erroneous or false positive/negative results. I think that I learned a lot of those types of things through serving as an accredited lab inspector (or you can help with your department’s lab self-inspections) and also by being more pro-active during my CP rotations to work with the lab staff and not just sit at my desk and read a book (or study for boards). And we can help guide other physicians regarding which tests are useful for specific situations and which tests really won’t impact prognosis or treatment management. So, be deliberate during your rotations! Try to understand the “big picture” and how important we can be (and really are) in the patient safety and care process! I think that tumor boards and interdepartment MDC’s are a great venue for us to showcase the “true” contributory potential of what pathologists to the patient care team.

-Betty Chung, DO, MPH, MA is a third year resident physician at Rutgers – Robert Wood Johnson University Hospital in New Brunswick, NJ.

Illinois Summit on Antibiotic Stewardship

Last week, I attended the Illinois Summit on Antimicrobial Stewardship at Northwestern Memorial Hospital. While the target audience was physicians, nurses, pharmacists, and administrators, as a clinical laboratory scientist I found the presentations (with a few caveats, which I’ll get to in a moment) quite informative.

The morning sessions covered the relationship between antibiotic use and resistance patterns; interpretations and implementation of the national guideless for stewardship; and using behavioral science to increase compliance with stewardship programs. Participants spent part of the afternoon in small groups to discuss designing and implementing a stewardship program.

A few notes:

-50% of antibiotics for upper respiratory infections aren’t needed; 50% of antibiotics for inpatients aren’t needed, either

-antibiotics are the only drug where use in one person impacts it effectiveness in another

-based on the literature, antibiotic stewardship programs have at least a transient effect on antibiotic effectiveness—eventually, resistance numbers begin to climb again

-hospital antibiograms are the most widely available measure of resistant organisms, but we aren’t using them as effectively as we could. For example, we typically report that, say, “62.5% of E. coli isolates are resistant to ciprofloxacin,” but we don’t say where those isolates come from. Are they urinary tract infections or upper respiratory infections? What’s the rate of resistance for infected wounds?

-a weighted antibiogram might make empirical treatments for effective. For example, “what % of urinary tract infections are resistant to ciprofloxacin?”

-it’s important to note that the IT department, hospital information systems, and laboratory information systems play a huge role in stewardship programs

-stewardship programs depend on the “5 D’s” Diagnosis, drug selection, dose, duration, and de-escalation of use

-diagnostic uncertainty—driven by lack of early organism identification—drives a significant amount of antibiotic use

-when combined with stewardship, rapid bacterial identification methods such as MALDI-ToF platforms decrease parameters such as length of patient say, time to treatment, etc.

-we can use peer pressure to drive improvements. No one wants to perform worse than the doctor next door

-our efforts might be moot, anyway; other countries take a much laxer stance on antibiotic use

While the laboratory in general and clinical microbiology departments specifically were mentioned during the presentations, I must say they were only mentioned in the context of how little perceived impact we have on stewardship. (“Well, we know the laboratory isn’t going to give us any useful information for another three days…”) It wasn’t until I participated in the small group sessions in the afternoon that attendees at my table admitted that the laboratory is an important piece of the stewardship puzzle. We have mountains of data we can assimilate (antibiogram creation, anyone?). We can bring in new technologies to make identifications faster. We can work closely with the infectious disease doctors to help guide treatment. That brings up a good point—if microbiology labs aren’t in-house, then creating an antibiotic stewardship program becomes that much harder because results can be delayed.

If you’d like to see the powerpoints from the presentations, you can do so by clicking the “downloadable content” tab at Northwestern Memorial Hospital’s antibiotic stewardship page.

–Kelly Swails, MT(ASCP), is a laboratory professional, recovering microbiologist, and web editor for Lab Medicine.

Can You Identify This Structure?

What is this dark structure in the center of this biopsy of a thyroid nodule?

A. Foreign body
B. Artifact
C. Psammoma body
D. Area of necrosis
E. Collection of fungal organisms

The structure at the center of this image is a psammoma body. Psammoma bodies are lamellated, calcific structures commonly seen in papillary carcinomas, such as this papillary carcinoma of the thyroid. The exact underlying cause or mechanism of psammoma bodies is not well understood. However, some studies have shown that in papillary thyroid carcinoma, psammoma bodies are associated with a lower disease-free survival and an overall worse prognosis.

-Kristine Krafts, MD, is an Assistant Professor of Pathology at the University of Minnesota School of Medicine and School of Dentistry and the founder of the educational website Pathology Student.

Issues for Blood Management in Hematology/Oncology

Hematology/Oncology patients comprise a unique subpopulation for whom transfusion therapy is often necessary in both the acute care setting as well as for long-term support. Red blood cells (RBCs) and platelets are the most common components transfused particularly in patients undergoing high-dose chemotherapy, intensive radiation therapy and human hematopoietic stem cell transplantation (HSCT).

Restrictive transfusion practice has become the “new world order” particularly for general medical and surgical patients. Those with hematologic malignancies or solid tumors have not frequently been a large part of many of the randomized controlled trials that speak to this approach. Literature is available, however, that provides evidence that judicious use of blood components via restrictive transfusion and single unit transfusions for inpatients and outpatients can be clinically effective, safe, and will decrease the potential for transfusion-associated adverse events.

Feasibility studies of restrictive RBC transfusion in the Hematology/Oncology population have been reported. These studies provide compelling evidence that lower transfusion triggers, targets and single unit use are not associated with increased bleeding episodes and will reduce overall transfusion exposure.¹ ² ³ The American Society of Hematology (ASH), as part of their Choosing Wisely Campaign, advises against liberal transfusion of RBCs with hemoglobin (Hgb) targets of 7- 8 g/dL, along with implementation of single-unit transfusions when possible.⁴

Recent RCTs and consensus from the AABB point to similar restrictive practice for platelet transfusion with a trigger of 10,000/µL for prophylactic transfusion in most patients.⁵ Subgroups of patients, such as those with autologous HSCTs, may not require prophylactic transfusion at this level, but can be effectively transfused using a therapeutic-only strategy.⁶ The use of lower doses of platelets has been shown to be safe and effective.⁷ Similar strategies may also be applicable for outpatients.⁸

Pursuant to those patients receiving radiation therapy, historically, there have been reports in the literature that found loco-regional control to be improved in patients whose Hgb is maintained at a higher level, typically > 10 g/dL. Many, if not most of these studies had significant confounding and have not adjusted for comorbidities. A publication in 2012, however, concluded “…that hypoxia is a well-established cause of radio-resistance, but modification of this cannot be achieved by correcting low Hgb levels by…transfusion and/or [ESAs[.”⁹ Similarly, a recent study covering over 30 years of experience with cervical cancer patients undergoing radiation therapy (the original target population from a historical perspective) adjusted for confounders and found no evidence that anemia represented an independent predictor of outcomes associated with diagnosis or treatment. ¹° Transfusion, in and of itself, has significant negative immunomodulatory effects via cell-to-cell interactions and cytokines. Thus, maintenance of Hgb levels for these patients should not be considered an absolute necessity.

Other interventions may prove successful for Hematology/Oncology patients as part of a Blood Management Program. Identification and treatment of concomitant iron deficiency anemia or other nutritional deficiencies can potentially decrease or eliminate the need for transfusion. Drugs that might increase the risk for bleeding or hemolysis should be eliminated if possible as these cause or potentiate anemia. Use of new targeted drugs such as lenalidomide in patients with 5q deletion-associated MDS may prevent the need for long-term transfusion dependence. The use of antifibrinolytics in patients who have become refractory to platelet transfusions can enable platelet function even at low levels and prevent the unnecessary use of limited platelet resources.

Outpatient transfusion in the Hematology/Oncology arena comes with some unique circumstances. Many outpatients remain stable and will be capable of lower transfusion thresholds and longer intervals for both RBCs and platelets. Evidence-based restrictive transfusion can and should be a part of outpatient treatment strategy, just as with inpatients if the accessibility to post-transfusion care is adequate. No national guidelines are available for outpatient transfusion and each patient scenario must be considered on an individual basis, but certainly the absolute need for “standing” transfusions and obligatory 2-unit transfusions should be discouraged. Consider, as well, that patients often have their own view of the “need” for transfusion when symptoms and signs do not necessarily make it requisite. Discussion with our patients is essential to allow them to understand transfusion decisions.

The risks of transfusion are both immediate and delayed, particularly for those with chronic transfusion needs. Febrile non-hemolytic, allergic, hemolytic reactions, TRALI and TACO may occur as in other patient populations and should be recognized and treated as appropriate. Alloimmunization and transfusion-related iron overload are more common in the Hem/Onc arena given the potential for increased component exposure during the acute care setting and the high percentage of those that necessitate chronic transfusion support. The potential for transfusion-associated graft vs. host disease is also more worrisome given the degree of immunosuppression in these patients. Specialized products are often necessary including leukoreduced, antigen negative, irradiated or HLA-matched components. These specialized products may not be available on a STAT basis and add significantly to the overall transfusion cost. Careful consideration is warranted and inclusion of the Transfusion Service is key.

In the end, transfusion practice for Hematology/Oncology patients should include restrictive transfusion practices with assessment of the risks and benefits at the time of each potential transfusion episode. Each patient, whether inpatient or outpatient, should be evaluated based on their current state of stability, clinical course and availability and access to care. Nutritional assessments and subsequent interventions along with pharmaceutical agents may provide additional ways by which transfusion exposure can be decreased. Special products are often necessary and needs should be discussed with the Transfusion Service. Limiting transfusion ultimately avoids unpleasant, potentially severe acute and delayed adverse events as well as preserving resources within our communities.

References:

Jansen et al. Transfus Med 2004; 14: 33
Berger et al. Haematologica 2012; 97: 116
Webert et al. Transfus 2008; 48: 81
choosingwisely.com
Kaufman et al. Ann Intern Med 2014; doi: 10.7326/M14-1589
Stanworth et al. Transfus 2014; 54: 2385
Slichter et al. N Engl J Med 2010; 362: 600
Sagmeister et al. Blood 1999; 93: 3124
Hoff Acta Oncologica 2012; doi: 10.3109/0284186X.2011.653438
Bishop et al. Int J Radiat Oncol Biol Phys 2014; doi: 10.1016/j.ijrobp.2014.09.023

-Dr. Burns was a private practice pathologist, and Medical Director for the Jewish Hospital Healthcare System in Louisville, KY. for 20 years. She has practiced both surgical and clinical pathology and has been an Assistant Clinical Professor at the University of Louisville. She is currently available for consulting in Patient Blood Management and Transfusion Medicine. You can reach her at cburnspbm@gmail.com.