Transfusion medicine reviews
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Meta Analysis
Risks and Benefits of Chimeric Antigen Receptor T-Cell (CAR-T) Therapy in Cancer: A Systematic Review and Meta-Analysis.
Promising efficacy results of chimeric antigen receptor (CAR) T-cell therapy have been tempered by safety considerations. Our objective was to comprehensively summarize the efficacy and safety of CAR-T cell therapy in patients with relapsed or refractory hematologic or solid malignancies. MEDLINE, Embase, and the Cochrane Register of Controlled Trials (inception - November 21, 2017). ⋯ Limitations include heterogeneity of study populations, as well as high risk of bias of included studies. There was a strong signal for efficacy of CAR-T cell therapy in patients with CD19+ hematologic malignancies and no overall signal in solid tumor trials published to date. These results will help inform patients, physicians, and other stakeholders of the benefits and risks associated with CAR-T cell therapy.
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Obstetric hemorrhage is one of the leading, as well as one of the most treatable, causes of maternal morbidity and mortality worldwide. As obstetric hemorrhage often occurs in patients without risk factors, there is virtually unanimous agreement from obstetric professional societies to establish obstetric hemorrhage protocols in anticipation of these emergencies. These protocols involve multidisciplinary teams in which the transfusion service plays an essential and vital role. This manuscript will examine the epidemiology of obstetric hemorrhage, risk factors that may be present, and recommendations for these protocols, with a focus on massive transfusion protocols, laboratory testing, cell salvage and use of pharmacologic adjuvant therapy including tranexamic acid and factor concentrates.
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Inherited bleeding disorders increase the risk of bleeding in the obstetric patient. Randomized controlled trials to compare prophylactic or therapeutic interventions are rare, and guidance documents rely heavily on expert opinion. Here we report the results of a systematic review of the literature for the treatment and prevention of peripartum bleeding in women with an inherited bleeding disorder. ⋯ Goal factor levels have not been studied or systematically established in any of these diseases, although observational data suggest that achieving normal levels may be inadequate, particularly for VWF and factor VIII, which are physiologically elevated in pregnancy. For factor deficiencies in which no specific concentrate is available, such as factors II (prothrombin) and V, prothrombin complex concentrate or fresh frozen plasma may be used, and for platelet defects or deficiencies, such as Glanzmann thrombasthenia or Bernard-Soulier syndrome, platelet transfusion is generally first line, although use of recombinant FVIIa has been reported in patients with Glanzmann thrombasthenia to avoid development of, or treat patients with, antibodies to platelet glycoprotein IIbIIIa. Ultimately, data are lacking to definitively support an evidence-based approach to management in any of these disorders, and prospective, controlled studies are desperately needed.
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Postoperative anemia is a common occurrence in surgical patients and leads to an increased risk for allogeneic blood transfusions. The efficacy of iron therapy in treating postoperative anemia has not been firmly established. The objective of this systematic review was to evaluate the efficacy of postoperative oral and intravenous (IV) iron therapy in increasing hemoglobin levels and improving patient outcomes following elective surgery. ⋯ This systematic review found no evidence to support the routine use of postoperative iron therapy in all elective surgery patient populations; however, results are based largely on studies with non-iron-deficient patients preoperatively. Further research on the role of postoperative IV iron is warranted for certain high-risk groups, including patients with iron deficiency or anemia prior to surgery. This systematic review is registered in PROSPERO (CRD42017057837).
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Tranexamic acid (TXA) is an effective hemostatic agent used for the reduction of blood loss and transfusion. However, the safety profile of TXA remains in question due to a potential increased risk of venous thromboembolism. By applying TXA topically as opposed to intravenously, systemic absorption may be reduced and unwanted side-effects mitigated. ⋯ The topical application of TXA effectively reduces both transfusion risk and blood loss compared to placebo, without increasing thromboembolic risks. There were no major differences between topical and intravenous tranexamic acid with respect to safety and efficacy, and both were superior to placebo with regards to blood loss and transfusion requirements. Further study of the topical application is required outside of the field of orthopedics.