Low-dose erythropoietin treatment is not associated with clinical benefits in severely anaemic Jehovah's Witnesses: a plea for a change.

BACKGROUND: Jehovah's Witnesses who refuse blood transfusion have high mortality. Erythropoietin (EPO) has been used as an alternative to blood transfusion. The optimal dosing of EPO in anaemic Jehovah's Witnesses is unknown. The aim of our study was to evaluate the clinical benefits of treatment with a low dose (<600 IU/kg/week) of epoietin beta (EPO-ß). MATERIALS AND METHODS: This was an observational study, retrospectively considering a 10-year period during which 3,529 adult Jehovah's Witnesses with a total of 10,786 hospital admissions were identified from databases of four major public hospitals in New Zealand. Patients with severe symptomatic anaemia (haemoglobin <80 g/L) who were unable to tolerate physical activity were included in the study. Patients treated without EPO were assigned to the conventional therapy group and those treated with EPO to the EPO treatment group. RESULTS: Ninety-one Jehovah's Witnesses met the eligibility criteria. Propensity score matching yielded a total of 57 patients. Patients treated with conventional therapy and those treated with EPO had similar durations of severe anaemia (average difference 6.25 days, 95% confidence interval [CI]: -3.77-16.27 days; p=0.221). The mortality rate among Jehovah's Witnesses treated with conventional therapy was 4.68 per year (95% CI: 2.23-9.82), while that in those treated with EPO was 2.77 per year (95% CI: 0.89-8.60). Treatment with EPO was associated with a mortality ratio of 0.59 (95% CI: 0.1-2.6; p=0.236). Both groups of patients had similar in-hospital survival (p=0.703). DISCUSSION: Treatment with low-dose EPO-ß was not associated with either shorter duration of severe anaemia or a reduction in mortality.

Gastrointestinal complications and cardiac surgery.

Gastrointestinal (GI) complications are an uncommon but potentially devastating complication of cardiac surgery. The reported incidence varies between .3% and 5.5% with an associated mortality of .3-87%. A wide range of GI complications are reported with bleeding, mesenteric ischemia, pancreatitis, cholecystitis, and ileus the most common. Ischemia is thought to be the main cause of GI complications with hypoperfusion during cardiac surgery as well as systemic inflammation, hypothermia, drug therapy, and mechanical factors contributing. Several nonischemic mechanisms may contribute to GI complications, including bacterial translocation, adverse drug reactions, and iatrogenic organ injury. Risk factors for GI complications are advanced age (>70 years), reoperation or emergency surgery, comorbidities (renal disease, respiratory disease, peripheral vascular disease, diabetes mellitus, cardiac failure), perioperative use of an intra-aortic balloon pump or inotrope therapy, prolonged surgery or cardiopulmonary bypass, and postoperative complications. Multiple strategies to reduce the incidence of GI complications exist, including risk stratification scores, targeted inotrope and fluid therapy, drug therapies, and modification of cardiopulmonary bypass. Currently, no single therapy has consistently proven efficacy in reducing GI complications. Timely diagnosis and treatment, while tailored to the specific complication and patient, is essential for optimal management and outcomes in this challenging patient population.

Fluid therapy and outcome: balance is best.

The use of intravenous fluids is routine in patients undergoing surgery or critical illness; however, controversy still exists regarding optimum fluid therapy. Recent literature has examined the effects of different types, doses, and timing of intravenous fluid therapy. Each of these factors may influence patient outcomes. Crystalloids consist of isotonic saline or balanced electrolyte solutions and widely distribute across extracellular fluid compartments, whereas colloids contain high-molecular-weight molecules suspended in crystalloid carrier solution and do not freely distribute across the extracellular fluid compartments. Colloids vary in composition and associated potential adverse effects. Recent evidence has highlighted safety and ethical concerns regarding the use of colloid solutions in critically ill patients, particularly the use of synthetic starch solutions, which have been associated with increased morbidity and mortality. Crystalloid solutions with a chloride-rich composition (e.g., isotonic saline) have been associated with metabolic acidosis, hyperchloremia, increased incidence of acute kidney injury, and increased requirement for renal replacement therapy. An optimum dose of intravenous fluids remains controversial with no definitive evidence to support restrictive versus liberal approaches. Further high-quality trials are needed to elucidate the optimum fluid therapy for patients, but currently a balanced approach to type, dose, and timing of fluids is recommended.

Comparison of two treatment techniques for breast irradiation including internal mammary nodes.

Techniques to treat breast cancer inclusive of the internal mammary lymph node chain (IMC) vary. This study compared a presently accepted technique implemented at the Radiation Oncology Department at Barnes-Jewish Hospital/Washington University School of Medicine (BJ/WU) to a proposed technique for irradiation of breast tissue and the IMC. The present technique consists of parallel-opposed breast tangential beams in combination with photon and electron IMC fields angled along the chest wall. The proposed method involves a wide medial tangent field covering the IMC, with an angled electron IMC field for a portion of the treatment regimen and an opposed lateral breast-only tangent. This technique uses a multileaf collimation (MLC) reduction to treat the IMC aspect following the wide medial tangent, to supplement the IMC to a tumorcidal dose. These techniques were compared by reviewing isodoses with subsequent isodensity confirmation. Computerized tomography imaging sets of patients with various body types (chest wall, small and large breasts) for left-sided tumors were planned using a three-dimensional treatment planning system (FOCUS, Computerized Medical Systems). The plans were evaluated by comparing irradiated heart and lung volumes and the respective dose distribution at the IMC field/medial tangent junction. Specific treatment aids and photon/electron energies were employed to produce desirable isodose distributions, with a dose prescription of 4680-cGy total dose. The efficiency of the radiation treatments itself was also evaluated. The proposed technique decreases treatment time by eliminating an additional IMC field that involves repositioning and placement of a block. Phantom-based film isodensity measurements were evaluated to validate the calculated dosimetry for these techniques.