Hematology
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Systematic reviews can help practitioners keep abreast of the medical literature by summarizing large bodies of evidence and helping to explain differences among studies on the same question. A systematic review involves the application of scientific strategies, in ways that limit bias, to the assembly, critical appraisal, and synthesis of all relevant studies that address a specific clinical question. ⋯ Used increasingly to inform medical decision making, plan future research agendas, and establish clinical policy, systematic reviews may strengthen the link between best research evidence and optimal health care. In this article, we discuss key steps in how to critically appraise and how to conduct a systematic review or meta-analysis.
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Pain is the insignia of sickle cell disease and the acute painful crisis is the number-one cause of hospital admissions. Tissue damage due to vaso-occlusion releases numerous inflammatory mediators that initiate the transmission of painful stimuli and the perception of pain. The acute sickle cell painful crisis evolves along four distinct phases coupled with changes in certain markers of the disease. ⋯ Failure to treat acute pain aggressively may lead to chronic pain syndrome. Management of sickle pain is primarily pharmacologic in nature, and opioids are the analgesics used most often. Cellular and molecular mechanisms of opioids explain individual differences among patients and justify the use of individualized treatment plans.
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Injuries are common and account for almost 15% of all blood use in the U. S. The historic view that the coagulopathy associated with severe injury was largely dilutional is being replaced by epidemiologic and molecular evidence for a distinct syndrome of trauma-associated coagulopathy. ⋯ Preventing the coagulopathy of trauma is best accomplished by preventing injury and hypothermia. Treating the coagulopathy of trauma requires its early recognition, prompt control of hemorrhage with local and systemic treatments, including in some patients the use of plasma instead of crystalloid solutions, and the prompt treatment of acidosis and hypothermia. The planned early use of allogenic plasma to treat many tens of thousands of massively transfused patients each year creates new demands for the immediate availability and improved safety of plasma products.
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There continues to be a general but unfounded enthusiasm for fresh frozen plasma (FFP) or frozen plasma (FP) usage across a range of clinical specialties in hospital practice. Plasma for transfusion is most often used where there are abnormal coagulation screening tests, either therapeutically in the face of bleeding, or prophylactically in nonbleeding patients prior to invasive procedures or surgery. Little evidence exists to inform best therapeutic transfusion practice, and most studies describe plasma use in a prophylactic setting. ⋯ There is a need to undertake new trials evaluating the efficacy and adverse effects of plasma, both in bleeding and non-bleeding patients, to understand whether the presumed benefits outweigh the real risks. In addition, new hemostatic tests that better define the risk of bleeding and monitor the effectiveness of the use of FFP should be validated. Last, there is an opportunity to develop effective educational strategies aimed at addressing understanding and compliance with recommendations in guidelines.
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An introduction to foundation and industry-sponsored research: practical and ethical considerations.
Investigators face formidable challenges in securing adequate support for their research efforts. Federal subsidies for biomedical research have not expanded in the past several years, while applications to the National Institutes of Health for investigator-initiated studies have increased substantially. Faced with stiffening competition, investigators, particularly those at the outset of their careers, may consider alternative sources of funding and support. ⋯ Emphasis is given to the development and support of investigator-initiated clinical research. Ethical considerations that frame investigators' acceptance and utilization of research subsidies from for-profit entities, i.e., pharmaceutical or biotechnology companies, are reviewed. The importance of the protection of intellectual property and the preservation of academic integrity and autonomy, especially in the context of corporate sponsorship, also are highlighted.