Vox sanguinis
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Some of the basic principles behind evidence-based medicine have been known for many years; however, the concept and approach to integrating evidenced-based decision making into clinical practice on a day-to-day basis has only evolved over the past 15 years. This paper focuses on five important steps in evidence-based decision making: (1) the importance of a well-defined question; (2) ways to effectively search the scientific literature; (3) the process of critical appraisal for an article about therapy; (4) the role of clinical expertise, patient values, clinical circumstances and society's expectations in the decision-making process; and (5) continuous quality improvement of the process.
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Recently, the Groupe d'Intérêt en Hémostase Périopératoire reviewed the pathophysiology of coagulopathy in massively transfused, adult and previously haemostatically competent patients in both elective surgical and trauma settings. In this article, we focus on our main observations. First, in most cases, the onset and severity of coagulopathy associated with massive transfusion differs depending on whether haemorrhage occurs as a result of trauma or elective surgery. ⋯ Coagulopathy associated with massive transfusion remains an important clinical problem. Treatment strategies must be adapted to the context and to the blood products available. Nevertheless, the level of evidence supporting specific treatment options is low and more studies are required to guide our management of massively transfused patients.
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Analyses of fatal transfusion reactions in the UK and USA have shown that transfusion-related acute lung injury (TRALI) is among the most common causes of fatal transfusion reactions. ⋯ By virtue of its morbidity and mortality, TRALI has become one of the most serious current complications of transfusion. To prevent further antibody-mediated cases, the evaluation of TRALI should include leucocyte antibody testing of implicated donors. However, further studies are necessary for the prevention of this serious transfusion complication.
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The cloning of blood group genes and subsequent identification of the molecular bases of blood group polymorphisms has made it possible to predict blood group phenotypes from DNA with a reasonable degree of accuracy. The major application of this technology, which has now become the standard of care, is the determination of a fetal RHD genotype in women with anti-D, to assess whether the fetus is at risk of haemolytic disease of the fetus and newborn (HDFN). ⋯ Since the discovery of fetal DNA in maternal plasma in 1997, the technology of detecting an RHD gene in this very small quantity of fetal DNA has developed rapidly, so that non-invasive fetal D typing can now be provided as a diagnostic service for D-negative pregnant women with anti-D. Within a few years, it is probable that fetuses of all D-negative pregnant women will be tested for RHD, to establish whether the mother requires antenatal anti-D immunoglobulin prophylaxis.