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Systematic review highlights high risk of bias of clinical prediction models for blood transfusion in patients undergoing elective surgery
Dhiman P, Ma J, Gibbs VN, Rampotas A, Kamal H, Arshad SS, Kirtley S, Doree C, Murphy MF, Collins GS, et al
Journal of clinical epidemiology. 2023
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Editor's Choice
Abstract
BACKGROUND Blood transfusion can be a lifesaving intervention after perioperative blood loss. Many prediction models have been developed to identify patients most likely to require blood transfusion during elective surgery, but it is unclear whether any are suitable for clinical practice. STUDY DESIGN AND SETTING We conducted a systematic review, searching MEDLINE, Embase, PubMed, The Cochrane Library, Transfusion Evidence Library, Scopus, and Web of Science databases for studies reporting the development or validation of a blood transfusion prediction model in elective surgery patients between 01/01/2000 to 30/06/2021. We extracted study characteristics, discrimination performance (c-statistics) of final models and data which we used to perform risk of bias assessment using the Prediction model Risk Of Bias ASsessment Tool (PROBAST). RESULTS We reviewed 66 studies (72 developed and 48 externally validated models). Pooled c-statistics of externally validated models ranged from 0.67 to 0.78. Most developed and validated models were at high risk of bias due to handling of predictors, validation methods, and too small sample sizes. CONCLUSION Most blood transfusion prediction models are at high risk of bias and suffer from poor reporting and methodological quality, which must be addressed before they can be safely used in clinical practice.
PICO Summary
Population
Patients undergoing elective surgery (66 studies).
Intervention
Blood transfusion prediction models used perioperatively.
Comparison
Outcome
This systematic review appraised 120 prediction models developed or validated for predicting blood transfusion in elective surgery (72 developed and 48 externally validated models). Pooled c-statistics of externally validated models ranged from 0.67 to 0.78. Most developed and validated models were at high risk of bias due to handling of predictors, validation methods, and too small sample sizes.
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The Impact of Time to Hemostatic Intervention and Delayed Care for Patients with Traumatic Hemorrhage: A Systematic Review
Lamb T, Tran A, Lampron J, Shorr R, Taljaard M, Vaillancourt C
The journal of trauma and acute care surgery. 2023
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Editor's Choice
Abstract
BACKGROUND Uncontrolled bleeding is a common cause of preventable mortality in trauma. While intuitive that delays to hemostasis may lead to worse outcomes, the impacts of these delays remain incompletely explored. This systematic review aimed to characterize the extant definitions of delayed hemostatic intervention and to quantify the impacts of delays on clinical outcomes. METHODS We searched EMBASE, MEDLINE, and Web of Science from inception to August 2022. Studies defining "delayed intervention" and those comparing times to intervention among adults presenting to hospital with blunt or penetrating injuries who required major hemostatic intervention were eligible. The co-primary outcomes were mortality and the definition of delay to hemostasis employed. Secondary outcomes included units of packed red blood cells received, length of stay in hospital, and length of stay in intensive care. RESULTS We identified 2,050 studies, with 24 studies including 10,168 patients meeting inclusion criteria. The majority of studies were retrospective observational cohort studies and most were at high risk of bias. A variety of injury patterns and hemostatic interventions were considered, with 69.6% of studies reporting a statistically significant impact of increased time to intervention on mortality. Definitions of delayed intervention ranged from ten minutes to four hours. Conflicting data were reported for impact of time on receipt of blood products, while one study found a significant impact on intensive care length of stay. No studies assessed length of stay in hospital. CONCLUSIONS The extant literature is heterogeneous with respect to injuries included, methods of hemostasis employed, and durations of delay examined. While the majority of the included studies demonstrated a statistically significant relationship between time to intervention and mortality, an evidence-informed definition of delayed intervention for bleeding trauma patients at large has not been solidified. Additional, standardized research is needed to establish targets which could reduce morbidity and mortality. LEVEL OF EVIDENCE Level IV, Systematic Review.
PICO Summary
Population
Patients with traumatic haemorrhage (24 studies, n= 10,168).
Intervention
Systematic review to characterize the extant definitions of delayed haemostatic intervention and to quantify the impacts of delays on clinical outcomes.
Comparison
Outcome
The majority of studies were retrospective observational cohort studies and most were at high risk of bias. A variety of injury patterns and haemostatic interventions were considered, with 69.6% of studies reporting a statistically significant impact of increased time to intervention on mortality. Definitions of delayed intervention ranged from ten minutes to four hours. Conflicting data were reported for impact of time on receipt of blood products, while one study found a significant impact on intensive care length of stay. No studies assessed length of stay in hospital.
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Predictors of transfusion in trauma and their utility in the prehospital environment: a scoping review
Yin G, Radulovic N, O'Neill M, Lightfoot D, Nolan B
Prehospital emergency care. 2022;:1-25
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Abstract
Background: Hemorrhage is a leading cause of preventable mortality from trauma, necessitating resuscitation through blood product transfusions. Early and accurate identification of patients requiring transfusions in the prehospital setting may reduce delays in time to transfusion upon arrival to hospital, reducing mortality. The purpose of this study is to characterize existing literature on predictors of transfusion and analyze their utility in the prehospital context.Objectives: The objectives of this study are to characterize the existing quantity and quality of literature regarding predictor scores for transfusion in injured patients, and to analyse the utility of predictor scores for massive transfusions in the prehospital setting and identify prehospital predictor scores for future research.Methods: A search strategy was developed in consultation with information specialists. A literature search of OVID MEDLINE from 1946 to present was conducted for primary studies evaluating the predictive ability of scoring systems or single variables in predicting transfusion in all trauma settings.Results: Of the 5824 studies were identified, 5784 studies underwent title and abstract screening, 94 studies underwent full text review, and 72 studies were included in the final review. We identified 16 single variables and 52 scoring systems for predicting transfusion. Amongst single predictor variables, fluids administered and systolic blood pressure had the highest reported sensitivity (100%) and specificity (89%) for massive transfusion protocol (MTP) activation respectively. Amongst scoring systems for transfusion, the Shock Index and Modified Shock Index had the highest reported sensitivity (96%), while the Pre-arrival Model had the highest reported specificity (95%) for MTP activation. Overall, 20 scores were identified as being applicable to the prehospital setting, 25 scores were identified as being potentially applicable, and seven scores were identified as being not applicable.Conclusions: We identified an extensive list of predictive single variables, validated scoring systems, and derived models for massive transfusion, presented their properties, and identified those with potential utility in the prehospital setting. By further validating applicable scoring tools in the prehospital setting, we may begin to administer more timely transfusions in the trauma population.
PICO Summary
Population
Trauma patients (72 studies).
Intervention
Scoping review to characterize the existing literature regarding predictor scores for transfusion in injured patients, to analyse the utility of predictor scores for massive transfusions in the prehospital setting, and to identify pre-hospital predictor scores for future research.
Comparison
Outcome
Sixteen single variables and fifty-two scoring systems were identified for predicting transfusion. Amongst single predictor variables, fluids administered and systolic blood pressure had the highest reported sensitivity (100%) and specificity (89%) for massive transfusion protocol (MTP) activation respectively. Amongst scoring systems for transfusion, the Shock Index and Modified Shock Index had the highest reported sensitivity (96%), while the Pre-arrival Model had the highest reported specificity (95%) for MTP activation. Overall, 20 scores were identified as being applicable to the pre-hospital setting, 25 scores were identified as being potentially applicable, and seven scores were identified as being not applicable.
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Viscoelastic versus conventional coagulation tests to reduce blood product transfusion in patients undergoing liver transplantation: A systematic review and meta-analysis
Aceto P, Punzo G, Di Franco V, Teofili L, Gaspari R, Wolfango Avolio A, Del Tedesco F, Posa D, Lai C, Sollazzi L
European journal of anaesthesiology. 2022
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Editor's Choice
Abstract
BACKGROUND Recent literature suggests viscoelastic test (VET)-guided transfusion management could be associated with reduced blood product administration in patients undergoing liver transplantation. OBJECTIVES To assess the effectiveness of coagulation management guided by VETs compared with conventional coagulation tests (CCTs) in reducing blood product transfusion in patients undergoing liver transplantation. DESIGN Systematic review and meta-analysis of randomised (RCTs) and nonrandomised clinical trials performed according to PRISMA guidelines. The protocol was previously published (PROSPERO CRD42021230213). DATA SOURCES The Cochrane Central Library, PubMed/MEDLINE, Embase and the Transfusion Evidence Library were searched up to 30th January 2022. ELIGIBILITY CRITERIA Setting: operating room. Patients: liver transplantation recipients. Intervention: use of VETs versus CCTs. Main outcome measures: the primary outcome was the mean number of transfused units for each blood product including red blood cells (RBCs), fresh frozen plasma (FFP), platelets (PLTs) and cryoprecipitate. Secondary outcomes included mortality rate, intensive care unit (ICU) and hospital length of stay (LOS). RESULTS Seventeen studies (n = 5345 patients), 15 observational and two RCTs, were included in this review. There was a mean difference reduction in RBCs [mean difference: -1.40, 95% confidence interval (95% CI), -1.87 to -0.92; P < 0.001, I2 = 61%) and FFP units (mean difference: -2.98, 95% CI, -4.61 to -1.35; P = < 0.001; I2 = 98%) transfused in the VETs group compared with the CCTs one. A greater amount of cryoprecipitate was administered in the VETs group (mean difference: 2.71, 95% CI, 0.84 to 4.58; P = 0.005; I2 = 91%). There was no significant difference in the mean number of PLT units, mortality, hospital and ICU-LOS. CONCLUSION Our meta-analysis demonstrated that VETs implementation was associated with reduced RBC and FFP consumption in liver transplantation patients without effects on mortality and hospital and ICU-LOS. The certainty of evidence ranged from moderate to very low. Further well conducted RCTs are needed to improve the certainty of evidence.
PICO Summary
Population
Patients undergoing liver transplantation (17 studies, n= 5,345).
Intervention
Coagulation management guided by viscoelastic tests (VETs group).
Comparison
Conventional coagulation tests (CCTs group).
Outcome
There was a mean difference reduction in red blood cells (mean difference: -1.40, 95% confidence interval (95% CI) -1.87 to -0.92, I2 = 61%) and fresh frozen plasma units (mean difference: -2.98, 95% CI -4.61 to -1.35; I2 = 98%) transfused in the VETs group compared with the CCTs group. A greater amount of cryoprecipitate was administered in the VETs group (mean difference: 2.71, 95% CI, 0.84 to 4.58; I2 = 91%). There was no significant difference in the mean number of platelets units, mortality, hospital and intensive care unit (ICU) and hospital length of stay (LOS).
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Postpartum hemorrhage drills or simulations and adverse outcomes: a systematic review and Bayesian meta-analysis
Mendez-Figueroa H, Bell CS, Wagner SM, Pedroza C, Gupta M, Mulder I, Lee K, Blackwell SC, Bartal MF, Chauhan SP
The journal of maternal-fetal & neonatal medicine : the official journal of the European Association of Perinatal Medicine, the Federation of Asia and Oceania Perinatal Societies, the International Society of Perinatal Obstetricians. 2022;:1-12
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Abstract
OBJECTIVE To compare the rates of adverse outcomes with postpartum hemorrhage (PPH) before and after implementation of drills or simulation exercises. STUDY ELIGIBILITY CRITERIA We included all English studies that reported on rates of PPH and associated complications during the pre- and post-implementation of interventional exercises. STUDY APPRASIAL AND SYNTHESIS METHODS Two investigators independently reviewed the abstracts, and full articles for eligibility of all studies. Inconsistencies related to study evaluation or data extraction were resolved by a third author. The co-primary outcomes were the rate of PPH and of any transfusion; the secondary outcomes included admission to the intensive care unit (ICU), transfusion ≥ 4 units of packed red blood cells, hysterectomy, or maternal death. Study effects were combined by Bayesian meta-analysis and reported as risk ratios (RR) and 95% credible intervals (Cr). RESULTS We reviewed 142 full length articles. Of these, 18 publications, with 355,060 deliveries-150,562 (42%) deliveries during the pre-intervention and 204,498 (57.6%) deliveries in the post-interventional period-were included in the meta-analysis. Using the Newcastle-Ottawa Scale, only three studies were considered good quality, and none of them were done in the US. The rate of PPH prior to intervention was 5.06% and 5.46% afterwards (RR 1.09, 95% CI 0.87-1.36; probability of reduction in the diagnosis being 21%). The likelihood of transfusion decreased from 1.68% in the pre-intervention to 1.27% in the post-intervention period (RR 0.80, 95% Cr 0.57-1.09). The overall probability of reduction in transfusion was 93%, albeit it varied among studies done in non-US countries (96%) versus in the US (23%). Transfusion of 4 units or more of blood occurred in 0.44% of deliveries before intervention and 0.37% afterwards (RR of 0.85, 95% CI 0.50-1.52), with the overall probability of reduction being 72% (76% probability of reduction in studies from non-US countries and 49% reduction with reports from the US). Surgical interventions to manage PPH, which was not reported in any US studies, occurred in 0.14% before intervention and 0.28% afterwards (RR 1.29; 95% CI 0.56-3.06; probability of reduction 27%). Admission to the ICU occurred in 0.10% before intervention and 0.08% subsequently (RR 0.92, 95% CI 0.58-1.43), with the overall probability of reduction being 65% (81% in studies from non-US countries and 27% from the study done in the US). Maternal death occurred in 0.17% in the pre-intervention period and 0.09% during the post-intervention (RR 0.62, 95% CI 0.33-1.05; probability of reduction 93% in studies from non-US countries and 82% in one study from the US). CONCLUSIONS Interventions to reduce the sequelae of PPH are associated with decrease in adverse outcomes. The conclusion, however, ought not to be accepted reflexively for the US population. All of the studies on the topic done in the US are of poor quality and the associated probability of reduction in sequelae are consistently lower than those done in other countries. SYNOPSIS Since the putative benefits of PPH drills or simulation exercises are based on poor quality pre- and post-intervention trials, policies recommending them ought to be revisited.
PICO Summary
Population
Postpartum haemorrhage patients (PPH), (18 studies with 355,060 deliveries).
Intervention
Systematic review and Bayesian meta-analysis to compare the rates of adverse outcomes with (PPH) before and after implementation of drills or simulation exercises.
Comparison
Outcome
The meta-analysis included 150,562 (42%) deliveries during the pre-intervention and 204,498 (57.6%) deliveries in the post-interventional period. The rate of PPH prior to intervention was 5.06% and 5.46% afterwards (RR 1.09, 95% CI 0.87-1.36; probability of reduction in the diagnosis being 21%). The likelihood of transfusion decreased from 1.68% in the pre-intervention to 1.27% in the post-intervention period (RR 0.80, 95% Cr 0.57-1.09). The overall probability of reduction in transfusion was 93%, albeit it varied among studies done in non-US countries (96%) versus in the US (23%). Transfusion of 4 units or more of blood occurred in 0.44% of deliveries before intervention and 0.37% afterwards (RR of 0.85, 95% CI 0.50-1.52), with the overall probability of reduction being 72% (76% probability of reduction in studies from non-US countries and 49% reduction with reports from the US). Surgical interventions to manage PPH, which was not reported in any US studies, occurred in 0.14% before intervention and 0.28% afterwards (RR 1.29; 95% CI 0.56-3.06; probability of reduction 27%). Admission to the ICU occurred in 0.10% before intervention and 0.08% subsequently (RR 0.92, 95% CI 0.58-1.43), with the overall probability of reduction being 65% (81% in studies from non-US countries and 27% from the study done in the US). Maternal death occurred in 0.17% in the pre-intervention period and 0.09% during the post-intervention (RR 0.62, 95% CI 0.33-1.05; probability of reduction 93% in studies from non-US countries and 82% in one study from the US).
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Predicting postpartum haemorrhage: A systematic review of prognostic models
Carr BL, Jahangirifar M, Nicholson AE, Li W, Mol BW, Licqurish S
The Australian & New Zealand journal of obstetrics & gynaecology. 2022
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Editor's Choice
Abstract
BACKGROUND Postpartum haemorrhage (PPH) remains a leading cause of maternal mortality and morbidity worldwide, and the rate is increasing. Using a reliable predictive model could identify those at risk, support management and treatment, and improve maternal outcomes. AIMS To systematically identify and appraise existing prognostic models for PPH and ascertain suitability for clinical use. MATERIALS AND METHODS MEDLINE, CINAHL, Embase, and the Cochrane Library were searched using combinations of terms and synonyms, including 'postpartum haemorrhage', 'prognostic model', and 'risk factors'. Observational or experimental studies describing a prognostic model for risk of PPH, published in English, were included. The Critical Appraisal and Data Extraction for Systematic Reviews of Prediction Modelling Studies checklist informed data extraction and the Prediction Model Risk of Bias Assessment Tool guided analysis. RESULTS Sixteen studies met the inclusion criteria after screening 1612 records. All studies were hospital settings from eight different countries. Models were developed for women who experienced vaginal birth (n = 7), caesarean birth (n = 2), any type of birth (n = 2), hypertensive disorders (n = 1) and those with placental abnormalities (n = 4). All studies were at high risk of bias due to use of inappropriate analysis methods or omission of important statistical considerations or suboptimal validation. CONCLUSIONS No existing prognostic models for PPH are ready for clinical application. Future research is needed to externally validate existing models and potentially develop a new model that is reliable and applicable to clinical practice.
PICO Summary
Population
Pregnant women (16 studies from eight different countries).
Intervention
Systematic review to identify and appraise existing prognostic models for post-partum haemorrhage (PPH) and ascertain suitability for clinical use.
Comparison
Various prognostic models for PPH, (e.g., based on prior hospital admissions for chronic diseases, based on medical history and clinical characteristics, using available antenatal and intrapartum variables, using prepartum fibrinogen levels).
Outcome
All studies were hospital settings. Models were developed for women who experienced vaginal birth (n= 7), caesarean birth (n= 2), any type of birth (n= 2), hypertensive disorders (n= 1) and those with placental abnormalities (n= 4). All studies were at high risk of bias due to use of inappropriate analysis methods or omission of important statistical considerations or suboptimal validation.
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Thromboelastography-Guided Therapy Enhances Patient Blood Management in Cirrhotic Patients: A Meta-analysis Based on Randomized Controlled Trials
Hartmann J, Dias JD, Pivalizza EG, Garcia-Tsao G
Seminars in thrombosis and hemostasis. 2022
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Editor's Choice
Abstract
Patients with cirrhosis often have abnormal hemostasis, with increased risk of hemorrhage and thrombosis. Thromboelastography provides a rapid assessment of the coagulation status and can guide product transfusions in adult patients with cirrhosis. This study aimed to determine whether the use of thromboelastography in adult patients with cirrhosis decreases blood product use and impacts adverse events or mortality compared with standard practice. A registered (PROSPERO CRD42020192458) systematic review and meta-analysis was conducted for randomized controlled trials (RCTs) comparing thromboelastography-guided hemostatic management versus standard practice (control). Co-primary outcomes were the number of transfused platelet units and fresh frozen plasma (FFP) units. Secondary outcomes were mortality, adverse events, utilization of individual blood products, blood loss or excessive bleeding events, hospital/intensive care unit stay, and liver transplant/intervention outcomes. The search identified 260 articles, with five RCTs included in the meta-analysis. Platelet use was five times lower with thromboelastography versus the control, with a relative risk of 0.17 (95% confidence interval [CI]: [0.03-0.90]; p = 0.04), but FFP use did not differ significantly. Thromboelastography was associated with less blood product (p < 0.001), FFP + platelets (p < 0.001), and cryoprecipitate (p < 0.001) use. No differences were reported in bleeding rates or longer term mortality between groups, with the thromboelastography group having lower mortality at 7 days versus the control (relative risk [95% CI] = 0.52 [0.30-0.91]; p = 0.02). Thromboelastography-guided therapy in patients with cirrhosis enhances patient blood management by reducing use of blood products without increasing complications.
PICO Summary
Population
Patients with cirrhosis (5 studies, n= 302).
Intervention
Thromboelastography-guided haemostatic management.
Comparison
Standard coagulation testing (standard practice).
Outcome
Platelet use was five times lower with thromboelastography vs. standard practice, with a relative risk of 0.17 (95% confidence interval [CI]: [0.03-0.90]), but fresh frozen plasma (FFP) use did not differ significantly. Thromboelastography was associated with less blood product, FFP + platelets, and cryoprecipitate use. No differences were reported in bleeding rates or longer-term mortality between groups, with the thromboelastography group having lower mortality at 7 days vs. standard practice (relative risk [95% CI] = 0.52 [0.30-0.91]).
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Risk factors for bleeding in people living with Hemophilia A and B treated with regular prophylaxis: a systematic review of the literature
Germini F, Noronha N, Philip BA, Olasupo O, Pete D, Navarro T, Keepanasseril A, Matino D, de Wit K, Parpia S, et al
Journal of thrombosis and haemostasis : JTH. 2022
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Editor's Choice
Abstract
BACKGROUND Knowledge about the risk for bleeding in patients with hemophilia (PWH) would be relevant for patients, stakeholders, and policy makers. OBJECTIVES to perform a systematic review of the literature on risk assessment models (RAMs) and risk factors for bleeding in PWH on regular prophylaxis. METHODS We searched MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, and the Cochrane Database of Systematic Reviews from inception through August 2019. In duplicate, reviewers screened the articles for inclusion, extracted data, and assessed the risk for bias using the QUIPS tool. A qualitative synthesis of the results was not performed due to high heterogeneity in risk factors, outcomes definition and measurement, and statistical analysis of the results. RESULTS From 1843 search results, 10 studies met the inclusion criteria. No RAM for the risk for bleeding in PWH was found. Most studies included only PWH A or both PWH A and B and were conducted in North America or Europe. Only one study had a low risk for bias in all the domains. Eight categories of risk factors were identified. The risk for bleeding was increased when factor levels were lower and in people with a significant history of bleeding or who engaged in physical activities involving contact. CONCLUSIONS Our findings suggest that plasma factor levels, history of bleeds, and physical activity should be considered for the derivation analysis when building a RAM for bleeding in PWH, and the role of other risk factors, including antithrombotic treatment and obesity, should be explored.
PICO Summary
Population
People living with haemophilia (PWH) A and B treated with regular prophylaxis (10 studies).
Intervention
Systematic review on risk assessment models and risk factors for bleeding.
Comparison
Outcome
No risk assessment model for the risk for bleeding was found. Most studies included only PWH A or both PWH A and B and were conducted in North America or Europe. Only one study had a low risk for bias in all the domains. Eight categories of risk factors were identified. The risk for bleeding was increased when factor levels were lower and in people with a significant history of bleeding or who engaged in physical activities involving contact.
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9.
Comparison of Risk Scores for Lower Gastrointestinal Bleeding: A Systematic Review and Meta-analysis
Almaghrabi M, Gandhi M, Guizzetti L, Iansavichene A, Yan B, Wilson A, Oakland K, Jairath V, Sey M
JAMA network open. 2022;5(5):e2214253
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Editor's Choice
Abstract
IMPORTANCE Clinical prediction models, or risk scores, can be used to risk stratify patients with lower gastrointestinal bleeding (LGIB), although the most discriminative score is unknown. OBJECTIVE To identify all LGIB risk scores available and compare their prognostic performance. DATA SOURCES A systematic search of Ovid MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials from January 1, 1990, through August 31, 2021, was conducted. Non-English-language articles were excluded. STUDY SELECTION Observational and interventional studies deriving or validating an LGIB risk score for the prediction of a clinical outcome were included. Studies including patients younger than 16 years or limited to a specific patient population or a specific cause of bleeding were excluded. Two investigators independently screened the studies, and disagreements were resolved by consensus. DATA EXTRACTION AND SYNTHESIS Data were abstracted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guideline independently by 2 investigators and pooled using random-effects models. MAIN OUTCOMES AND MEASURES Summary diagnostic performance measures (sensitivity, specificity, and area under the receiver operating characteristic curve [AUROC]) determined a priori were calculated for each risk score and outcome combination. RESULTS A total of 3268 citations were identified, of which 9 studies encompassing 12 independent cohorts and 4 risk scores (Oakland, Strate, NOBLADS [nonsteroidal anti-inflammatory drug use, no diarrhea, no abdominal tenderness, blood pressure ≤100 mm Hg, antiplatelet drug use (nonaspirin), albumin <3.0 g/dL, disease score ≥2 (according to the Charlson Comorbidity Index), and syncope], and BLEED [ongoing bleeding, low systolic blood pressure, elevated prothrombin time, erratic mental status, and unstable comorbid disease]) were included in the meta-analysis. For the prediction of safe discharge, the AUROC for the Oakland score was 0.86 (95% CI, 0.82-0.88). For major bleeding, the AUROC was 0.93 (95% CI, 0.90-0.95) for the Oakland score, 0.73 (95% CI, 0.69-0.77) for the Strate score, 0.58 (95% CI, 0.53-0.62) for the NOBLADS score, and 0.65 (95% CI, 0.61-0.69) for the BLEED score. For transfusion, the AUROC was 0.99 (95% CI, 0.98-1.00) for the Oakland score and 0.88 (95% CI, 0.85-0.90) for the NOBLADS score. For hemostasis, the AUROC was 0.36 (95% CI, 0.32-0.40) for the Oakland score, 0.82 (95% CI, 0.79-0.85) for the Strate score, and 0.24 (95% CI, 0.20-0.28) for the NOBLADS score. CONCLUSIONS AND RELEVANCE The Oakland score was the most discriminative LGIB risk score for predicting safe discharge, major bleeding, and need for transfusion, whereas the Strate score was best for predicting need for hemostasis. This study suggests that these scores can be used to predict outcomes from LGIB and guide clinical care accordingly.
PICO Summary
Population
Patients with lower gastrointestinal bleeding (LGIB), (9 studies).
Intervention
Systematic review and meta-analysis to identify all LGIB risk scores available and to compare their prognostic performance.
Comparison
Outcome
Four risk scores were identified: Oakland, Strate, NOBLADS, and BLEED. Summary diagnostic performance measures (sensitivity, specificity, and area under the receiver operating characteristic curve [AUROC]) determined a priori were calculated for each risk score and outcome combination. For the prediction of safe discharge, the AUROC for the Oakland score was 0.86. For major bleeding, the AUROC was 0.93 for the Oakland score, 0.73 for the Strate score, 0.58 for the NOBLADS score, and 0.65 for the BLEED score. For transfusion, the AUROC was 0.99 for the Oakland score and 0.88 for the NOBLADS score. For haemostasis, the AUROC was 0.36 for the Oakland score, 0.82 for the Strate score, and 0.24 for the NOBLADS score.
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10.
Non-Invasive Prenatal Fetal Blood Group Genotype and Its Application in the Management of Hemolytic Disease of Fetus and Newborn: Systematic Review and Meta-Analysis
Alshehri AA, Jackson DE
Transfusion medicine reviews. 2021
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Editor's Choice
Abstract
Hemolytic disease of fetus and newborn (HDFN) imposes great healthcare burden being associated with maternal alloimmunization against parental-inherited fetal red blood cell antigens causing fetal anemia or death. Noninvasive prenatal analysis (NIPT) provides safe fetal RHD genotyping for early identification of risk pregnancies and proper management guidance. We aimed to conduct systematic review and meta-analysis on NIPT's beneficial application, in conjunction with quantitative maternal alloantibody analysis, for early diagnosis of pregnancies at risk. Search for relevant articles was done in; PubMed/Medline, Scopus, and Ovid (January 2006April 2020), including only English-written articles reporting reference tests and accuracy data. Nineteen eligible studies were critically appraised. NIPT was estimated highly sensitive/specific for fetal RHD genotyping beyond 11-week gestation. Amplifications from ≥2 exons are optimum to increase accuracy. NIPT permits cost-effectiveness, precious resources sparing, and low emotional stress. Knowledge of parental ethnicity is important for correct NIPT result interpretations and quantitative screening. Cut-off titer ≥8-up-to-32 is relevant for anti-D alloantibodies, while, lower titer is for anti-K. Alloimmunization is influenced by maternal RHD status, gravida status, and history of adverse obstetrics. In conclusion, NIPT allows evidence-based provision of routine anti-D immunoprophylaxis and estimates potential fetal risks for guiding further interventions. Future large-scale studies investigating NIPT's non-RHD genotyping within different ethnic groups and in presence of clinically significant alloantibodies are needed.
PICO Summary
Population
Women whose pregnancy was at risk of haemolytic disease of foetus and new born (HDFN), (19 studies).
Intervention
Systematic review and meta-analysis on non-invasive prenatal analysis (NIPT) in conjunction with quantitative maternal alloantibody analysis.
Comparison
Outcome
NIPT was estimated highly sensitive/specific for foetal RHD genotyping beyond 11-week gestation. Amplifications from ≥2 exons were optimum to increase accuracy. NIPT permitted cost-effectiveness and was associated with low emotional stress. Knowledge of parental ethnicity was important for correct NIPT result interpretations and quantitative screening. Cut-off titre ≥8-up-to-32 was relevant for anti-D alloantibodies, while, lower titre was for anti-K. Alloimmunisation was influenced by maternal RHD status, gravida status, and history of adverse obstetrics.