National Comparative Audit of Blood Transfusion: report on the 2014 audit of patient information and consent.

OBJECTIVES: The aim of this study was to assess current practices around obtaining consent for blood transfusion and provision of patient information in hospitals across the UK and identify areas for improvement. BACKGROUND: Recommendations from the Advisory Committee on the Safety of Blood, Tissues and Organs (SaBTO) (2011) state that valid consent should be obtained for blood transfusion and documented in clinical records. A standardised source of information should be available to patients. Practices in relation to this have historically been inconsistent. METHODS: The consent process was studied in hospitals across the UK over a 3-month period in 2014 by means of an audit of case notes and simultaneous surveys of patients and staff. RESULTS: In total, 2784 transfusion episodes were reviewed across 164 hospital sites. 85% of sites had a policy on consent for transfusion. Consent was documented in 43% of case notes. 68% of patients recalled being given information on benefits of transfusion, 38% on risks and 8% on alternatives and 28% reported receiving an information leaflet. In total, 85% of staff stated they had explained the reason for transfusion, but only 65% had documented this. 41% of staff had received training specifically on transfusion consent in the last 2 years. CONCLUSIONS: There is a need to improve clinical practice in obtaining valid consent for transfusion in line with existing national guidelines and local Trust policies, with emphasis on documentation within clinical records. Provision of patient information is an area particularly highlighted for action, and transfusion training for clinicians should be strengthened.

A retrospective wound review of standard four-port laparoscopic cholecystectomy: is there need for single-port laparoscopic surgery?

BACKGROUND: This study was designed to assess the satisfaction or otherwise of a proportion of the U.K. population who have undergone standard four-port laparoscopic cholecystectomy within the past 18 months. The results should indicate whether there is potential demand for a new, improved approach to surgery. METHODS: Patients who underwent laparoscopic cholecystectomy between October 2008 and October 2009 in two geographically separated general hospitals were identified from hospital databases. Notes were reviewed to confirm the technique and lack of conversion to an open procedure. Those who had immediate complications were excluded. A telephone questionnaire was conducted to answer questions related to long-term cosmetic and general satisfaction of the current procedure. RESULTS: Of the patients surveyed, 93% were happy or extremely happy with the current procedure, 48% experienced some wound-related issues (pain, infection), and 65% of those were at the umbilicus (a possible reflection of location and retrieval site for gallbladder). Cosmesis was rated less important than hospital cleanliness and experience of the surgeon. CONCLUSIONS: Overall satisfaction was high with the existing technique. The high rate of umbilical wound problems is an issue that will not be eradicated by introduction of single-port laparoscopic surgery.

Informed consent and patient understanding of blood transfusion.

BACKGROUND: Obtaining separate informed consent for blood transfusion is mandatory in some countries. Although patients should be informed about risks and benefits of transfusion, studies suggest this does not happen routinely in the UK and the patient perspective is lacking in the current literature. AIM: To explore provision of information and the consent process for patients receiving blood transfusions at our hospital. OBJECTIVES: To assess patient recall of the consent process, information conveyed, ease in understanding discussions and perceived knowledge of transfusion afterwards. METHODS: All 342 adult patients for whom blood was cross-matched between 1 March 2008 and 30 April 2008 were sent postal questionnaires. RESULTS: One hundred and sixty-four questionnaires were returned. Overall, 59·1% of patients said someone explained they might need a transfusion; of those 86·7% felt the reason had been explained. Only 58·8% of patients felt informed of what transfusion involves, with 67·0% told of the benefits and 27·8% informed of risks. Overall, 51·5% of patients said this information was easy to understand, but only 26·8% were aware of a transfusion information leaflet. Of those receiving leaflets, all said they read it and had no questions. Despite this, 61·9% were satisfied overall with the information received. CONCLUSION: Information leaflets could increase the information available to patients, with minimal impact on health care professionals' time. Leaflets are available, free of charge, from the National Health Service Blood and Transplant website. These have been introduced at each bedside, in pre-op packs and in outpatient clinics, with re-assessment planned in 6 months.

Two-week target for laparoscopic cholecystectomy following gallstone pancreatitis is achievable and cost neutral.

BACKGROUND: The British Society of Gastroenterology recommends that all patients with gallstone pancreatitis should undergo cholecystectomy within 2 weeks. This study assessed whether these guidelines are feasible and cost-effective. METHODS: Admissions for gallstone pancreatitis between January 2006 and January 2008 were reviewed. Readmissions for subsequent pancreatitis or biliary pathology were noted together with additional investigations, severity scores, hospital stay and time to cholecystectomy. The costs of readmission and theoretical costs of developing a dedicated operating list were provided by independent accountants. RESULTS: During the 2 years, 153 patients were admitted. Twenty-one patients (13.7 per cent) had further attacks requiring 40 readmissions. There were no deaths. Additional hospital costs related to readmissions were 172,170 pound sterling, including bed occupancy (67,860 pound sterling), investigations (12,510 pound sterling) and 153 cholecystectomies on an existing theatre list (91,800 pound sterling). The estimated cost of staffing a half-day theatre list every fortnight, performing 153 cholecystectomies, was 170,391 pound sterling. CONCLUSION: Instigating a dedicated theatre for cholecystectomy after biliary pancreatitis has many potential benefits. The costs of readmissions and ad hoc operating are balanced by those of a dedicated theatre list in the long term. Implementation of the guidelines would save approximately 900 pound sterling annually and be cost neutral.

An investigation of the MEK/ERK inhibitor U0126 in acute myeloid leukemia.

Blockade of mitogen-activated protein kinase kinase (MEK1/2), part of the extracellular signal-regulated kinase (ERK) or p44/42 mitogen-activated protein kinase (MAPK) pathway, has been shown in some instances to cause apoptosis in leukemic blast cells. This investigation examined the effect of the potent MEK/ERK inhibitor U0126 on apoptosis in acute myeloblastic leukemia (AML) cell lines, and acute leukemic and non-leukemic patient samples. The pro-apoptotic effect of the inhibitor varied across the five cell lines tested (KG1a, HEL, TF-1, MO7e, and THP-1) from highly significant induction of apoptosis to no apparent response. The pro-apoptotic effect of U0126 in the most sensitive cell line, KG1a, appeared to be related to its CD34 positivity. Three of five leukemic bone marrow samples showed considerable sensitivity to the inhibitor and a similar association with CD34 expression was evident. Interestingly, control marrow cells from six non-leukemic patients did not show a significant effect when exposed to U0126. These results suggest that this agent may offer a potential alternative to standard chemotherapy with a particular role in the most primitive types of leukemia, these often being the most resistant to standard chemotherapy.

C-kit mutation screening in patients with acute myeloid leukaemia: adaptation of a Giemsa-stained bone-marrow smear DNA extraction technique.

The scarcity of viable tissue samples for leukaemia research is widely recognised and currently restrictive. Archival bone-marrow smears present a valuable resource that can be exploited easily for mutational analysis. Here, a modified technique to extract DNA is described, and used subsequently for mutation/polymorphism screening of the stem-cell factor receptor proto-oncogene c-kit in 23 patients with acute myeloid leukaemia (AML). The selected method was straightforward and used bone-marrow material scraped from periodic acid-Schiff, sudan black B and May-Grünwald/Giemsa-stained preparations, and treated initially with proteinase K prepared in digestion buffer to digest all proteinaceous matter. Following incubation, saturated sodium chloride was added and DNA extracted from the supernatant by phenol/chloroform/isoamyl alcohol treatment. Retrieved DNA was precipitated with ethanol at -20 degrees C overnight, washed with 95% ethanol, air-dried, resuspended using purite water and stored at -20 degrees C prior to use in mutational analysis. The extraction method described was compared with a commercial reagent for combined DNA, RNA and protein isolation using cryopreserved cells from 20 patients with AML. The quality of extracted DNA isolated by the two methods was comparable by polymerase chain reaction (PCR) and single-strand conformation polymorphism (SSCP) techniques. Bone-marrow biopsies are performed regularly on each AML patient to monitor the disease; therefore, an extraction method using this resource could liberate a valuable source of DNA for study (e.g. molecular investigations, including mutation/polymorphism screening etc.). This would allow fresh and programme-frozen cells to be reserved for those investigations requiring intact, viable cells. The use of archived bone-marrow smears would permit vast increase in the scope for retrospective testing and large-scale analyses.

Stem cell factor: laboratory and clinical aspects.

Stem cell factor is an essential haemopoietic progenitor cell growth factor with proliferative and anti-apoptotic functions. Molecular biologists have now dissected some of the various pathways through which this cytokine signals to the nucleus. At the same time, new molecules have become available which can inhibit SCF signalling. This provides an exciting prospect for the treatment of Kit+ malignancies such as acute myeloblastic leukaemia. The capacity of SCF to synergize with other cytokines has been exploited in the ex vivo expansion of haemopoietic progenitors and dendritic cells, which may also hold therapeutic promise. In this review the last 5 years' literature on these issues is reviewed and collated.

Lupus anticoagulants: pathogenesis and laboratory diagnosis.

The pathogenesis of the lupus anticoagulant (LA) has been the focus of much research over the past decade, and a plethora of laboratory tests have been developed to detect it. This essay reviews the nature of LA and its pathogenesis, and a number of approaches employed in its diagnosis. These range from well established tests such as the kaolin clotting time (KCT), activated partial thromboplastin time (APTT) and tissue thromboplastin inhibition test (TTI), to the 'newer' tests such as the dilute Russell's viper venom time (DRVVT) and more recent snake venom tests such as the textarin/ecarin ratio and Taipan snake venom time (TSVT). The criteria for diagnosis are discussed, including pre-analytical variables such as sample preparation, and the effects of therapeutic anticoagulants used to treat thrombotic manifestations of the syndrome or an underlying disease process.