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Learning Curve for a Dual Attending Surgeon Strategy in Posterior Spinal Fusion (PSF): An Analysis of 105 Severe Adolescent Idiopathic Scoliosis Patients (Cobb Angle ≥90°)

Chan CYW, Lee SY, Ch'ng PY, Chung WH, Chiu CK, Hasan MS, et al.

Spine (Phila Pa 1976), 2021 Jun 15;46(12):E663-E670.
PMID: 33306608 DOI: 10.1097/BRS.0000000000003866

STUDY DESIGN: Retrospective study.
OBJECTIVE: To assess the learning curve of a dual attending surgeon strategy in severe adolescent idiopathic scoliosis patients.
SUMMARY OF BACKGROUND DATA: The advantages of a dual attending surgeon strategy in improving the perioperative outcome in scoliosis surgery had been reported. However, the learning curve of this strategy in severe scoliosis had not been widely studied.
METHODS: A total of 105 patients with adolescent idiopathic scoliosis with Cobb angle of 90° or greater, who underwent posterior spinal fusion using a dual attending surgeon strategy were recruited. Primary outcomes were operative time, total blood loss, allogeneic blood transfusion requirement, length of hospital stay from time of operation and perioperative complications. Cases were sorted chronologically into group 1: cases 1 to 35, group 2: cases 36 to 70, and group 3: case 71 to 105. Mean operative time (≤193.3 min), total blood loss (≤1612.2 mL), combination of both and allogeneic blood transfusion were the selected criteria for receiver operating characteristic analysis of the learning curve.
RESULTS: The mean Cobb angle was 104.5° ± 12.3°. The operative time, total blood loss, and allogeneic blood transfusion requirement reduced significantly for group 1 (220.6 ± 54.8 min; 2011.3 ± 881.8 mL; 12 cases) versus group 2 (183.6 ± 36.7 min; 1481.6 ± 1035.5 mL; 3 cases) and group 1 versus group 3 (175.6 ± 38.4 min; 1343.7 ± 477.8 mL; 3 cases) (P blood loss) (area under the curve 0.740; P blood loss when comparing group 1 versus group 2 and group 1 versus group 3. The cut-off point for the learning curve was 57 cases when the preset criteria were fulfilled (≤193.3 min operative time and ≤1612.2 mL of total blood loss).Level of Evidence: 4.

Matched MeSH terms: Blood Transfusion/statistics & numerical data
Domestic and imported products--the Malaysian experience in assuring safe and sufficient plasma products

Ayob Y

Dev Biol (Basel), 2007;127:169-73.
PMID: 17486890
Matched MeSH terms: Blood Transfusion/statistics & numerical data
An analysis of blood utilization for elective surgery in a tertiary medical centre in Malaysia

Jayaranee S, Prathiba R, Vasanthi N, Lopez CG

Malays J Pathol, 2002 Jun;24(1):59-66.
PMID: 16329557

The purpose of this study is to determine the efficiency of blood utilization for elective surgery at the University of Malaya Medical Centre (UMMC). A similar study conducted six years earlier in the same unit resulted in the introduction and implementation in December 1997 of the local Maximum Surgical Blood Order Schedule (MSBOS) and the Group Screen and Hold (GSH) procedure instead of a full crossmatch. This paper compares the findings of the current study with that conducted earlier.

Matched MeSH terms: Blood Transfusion/statistics & numerical data
Fulltext Blood transfusion reactions in Malaysian newborn infants

Boo NY, Chan BH

Med J Malaysia, 1998 Dec;53(4):358-64.
PMID: 10971978

A prospective observational study was carried out over a seven month period in the neonatal intensive care unit (NICU) of a large Malaysian maternity hospital to determine the rate of blood transfusion and the incidence of transfusion reactions in newborn infants. During the study period, the rates of blood transfusion was 6.1% (n = 117) of NICU admission or 8.2 per 1,000 live births. The median birth weight of the infants who had received blood transfusion was 1,740 grams (range: 725-4,350), and their mean gestational age was 33.6 weeks (sd = 5.1, range = 24-41 weeks). The median age of infants when they first received blood transfusion was 4.0 days (range: 1-27 days). When compared with infants of birth weight between 3,000 and 3,499 grams, infants of birth weight less than 1,500 grams received significantly higher median number of transfusions per infant, (p < 0.001). The incidence of transfusion reaction was 2.7% (3/110) of all transfused infants or 1.3% (3/223) of all blood transfusions. Febrile nonhemolytic reaction was the only type of transfusion reaction detected during the study period. This study showed that transfusion reactions in newborn infants were not common.

Matched MeSH terms: Blood Transfusion/statistics & numerical data
Hydroxyurea for reducing blood transfusion in non-transfusion dependent beta thalassaemias

Foong WC, Ho JJ, Loh CK, Viprakasit V

Cochrane Database Syst Rev, 2016 Oct 18;10:CD011579.
PMID: 27755646

BACKGROUND: Non-transfusion dependent beta thalassaemia is a subset of inherited haemoglobin disorders characterised by reduced production of the beta globin chain of the haemoglobin molecule leading to anaemia of varying severity. Although blood transfusion is not a necessity for survival, it is required when episodes of chronic anaemia occur. This chronic anaemia can impair growth and affect quality of life. People with non-transfusion dependent beta thalassaemia suffer from iron overload due to their body's increased capability of absorbing iron from food sources. Iron overload becomes more pronounced in those requiring blood transfusion. People with a higher foetal haemoglobin level have been found to require fewer blood transfusions. Hydroxyurea has been used to increase foetal haemoglobin level; however, its efficacy in reducing transfusion, chronic anaemia complications and its safety need to be established.
OBJECTIVES: To assess the effectiveness, safety and appropriate dose regimen of hydroxyurea in people with non-transfusion dependent beta thalassaemia (haemoglobin E combined with beta thalassaemia and beta thalassaemia intermedia).
SEARCH METHODS: We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group's Haemoglobinopathies Trials Register, compiled from electronic database searches and handsearching of relevant journals. We also searched ongoing trials registries and the reference lists of relevant articles and reviews.Date of last search: 30 April 2016.
SELECTION CRITERIA: Randomised or quasi-randomised controlled trials of hydroxyurea in people with non-transfusion dependent beta thalassaemia comparing hydroxyurea with placebo or standard treatment or comparing different doses of hydroxyurea.
DATA COLLECTION AND ANALYSIS: Two authors independently applied the inclusion criteria in order to select trials for inclusion. Both authors assessed the risk of bias of trials and extracted the data. A third author verified these assessments.
MAIN RESULTS: No trials comparing hydroxyurea with placebo or standard care were found. However, we included one randomised controlled trial (n = 61) comparing 20 mg/kg/day with 10 mg/kg/day of hydroxyurea for 24 weeks.Both haemoglobin and foetal haemoglobin levels were lower at 24 weeks in the 20 mg group compared with the 10 mg group, mean difference -2.39 (95% confidence interval - 2.8 to -1.98) and mean difference -1.5 (95% confidence interval -1.83 to -1.17), respectively. Major adverse effects were significantly more common in the 20 mg group, for neutropenia risk ratio 9.93 (95% confidence interval 1.34 to 73.97) and for thrombocytopenia risk ratio 3.68 (95% confidence interval 1.13 to 12.07). No difference was reported for minor adverse effects (gastrointestinal disturbances and raised liver enzymes). The effect of hydroxyurea on transfusion frequency was not reported.The overall quality for the outcomes reported was graded as very low mainly because the outcomes were derived from only one small study with an unclear method of allocation concealment.
AUTHORS' CONCLUSIONS: There is no evidence from randomised controlled trials to show whether hydroxyurea has any effect compared with controls on the need for blood transfusion. Administration of 10 mg/kg/day compared to 20 mg/kg/day of hydroxyurea resulted in higher haemoglobin levels and seems safer with fewer adverse effects. It has not been reported whether hydroxyurea is capable of reducing the need for blood transfusion. Large well-designed randomised controlled trials with sufficient duration of follow up are recommended.

Matched MeSH terms: Blood Transfusion/statistics & numerical data*
Single vs two attending senior surgeons: assessment of intra-operative blood loss at different surgical stages of posterior spinal fusion surgery in Lenke 1 and 2 adolescent idiopathic scoliosis

Kwan MK, Chiu CK, Chan CY

Eur Spine J, 2017 Jan;26(1):155-161.
PMID: 27734195 DOI: 10.1007/s00586-016-4803-y

PURPOSE: To assess the pattern of intra-operative blood loss at various surgical stages comparing between single and two surgeons.
METHODS: Lenke 1 and 2 adolescent idiopathic scoliosis (AIS) patients who underwent instrumented posterior spinal fusion (PSF) surgery from two centres between June 2014 and December 2015 were prospectively recruited into this study. The patients were grouped into Group 1 (single surgeon) and Group 2 (two surgeons). One to one matching using 'prospective propensity score-matched cohort patient sampling method' was done. The surgery was divided into six stages: stage 1-exposure, stage 2-screw insertion, stage 3-release, stage 4-correction, stage 5-corticotomies and bone grafting and stage 6-closure.
RESULTS: A total of 116 patients were recruited. Of 86 patients who were operated by the two surgeons, 30 patients were matched with 30 patients that were operated by a single surgeon. Operation duration was significantly longer in Group 1 (257.3 ± 51.4 min) compared to Group 2 (164.0 ± 25.7 min). The total blood loss was significantly higher in Group 1 (1254.7 ± 521.5 mL) compared to Group 2 (893.7 ± 518.4 mL). Total blood loss/level fused was significantly higher in Group 1 (117.5 ± 42.8 mL/level) compared to Group 2 (82.6 ± 39.4 mL/level). Group 1 had significantly higher blood loss and blood loss/level fused for stages 1, 2 and 3. Group 2 had lower incidence of allogenic blood transfusion.
CONCLUSIONS: In PSF surgery for AIS patients, two-surgeon strategy was associated with shorter operation duration, lesser blood loss and lower incidence of allogenic blood transfusion.

Matched MeSH terms: Blood Transfusion/statistics & numerical data
Fulltext Craniofacial deformities in transfusion-dependent thalassemia patients in Malaysia: prevalence and effect of treatment

Toman HA, Hassan R, Hassan R, Nasir A

Southeast Asian J. Trop. Med. Public Health, 2011 Sep;42(5):1233-40.
PMID: 22299450

This comparative cross-sectional study was conducted in the pediatric daycare unit, Hospital Universiti Sains Malaysia to determine the prevalence of craniofacial deformities (CFD) and the association between these deformities and different clinical presentations among thalassemia patients. Patients were classified as either craniofacial deformity positive (CFD+) or craniofacial deformity negative (CFD-) by two examiners based on the presence or absence of deformity of the cheeks, frontal and/or maxillary bones. Fifteen clinical parameters were compared between the groups. Nineteen out of 43 patients (44.2%; confidence interval, 30.2-58.2%) had craniofacial deformities (CFD+). Both groups were comparable among the clinical parameters studied. Patients in the CFD+ group did not start their blood transfusions significantly earlier than the CFD- group (p = 0.50) and had a nonsignificantly lower mean pretransfusion hemoglobin level than the CFD- group (p = 0.71). Patients receiving regular monthly blood transfusions had a nonsignificantly smaller percentage of CFD than those transfused less often (p = 0.495). CFD+ patients had a splenectomy at a nonsignificantly younger age than CFD- patients (p = 0.36). HbE/beta thalassemia patients were not significantly less likely to develop CFD than other varieties (p = 0.50) and males had a nonsignificantly higher percentage of CFD than females (p = 0.29). This study shows CFD in thalassemia patients are still prevalent but no significant associated factors were found; however, a nonsignificantly higher prevalence of CFD was observed in patients with signs of severe disease and less efficient treatment.

Matched MeSH terms: Blood Transfusion/statistics & numerical data
Fulltext Carbetocin versus oxytocin for the prevention of postpartum hemorrhage: A meta-analysis of randomized controlled trials in cesarean deliveries

Voon HY, Suharjono HN, Shafie AA, Bujang MA

Taiwan J Obstet Gynecol, 2018 Jun;57(3):332-339.
PMID: 29880160 DOI: 10.1016/j.tjog.2018.04.002

OBJECTIVE: Postpartum hemorrhage remains the leading cause of maternal mortality in developing countries and a significant proportion of these cases are attributable to uterine atony. In contrast to the advances made in the treatment of postpartum hemorrhage, there has been few novel prophylactic agents. This study was undertaken to analyze the effectiveness of carbetocin compared to oxytocin for the prevention of postpartum hemorrhage, in the context of cesarean deliveries.
MATERIALS AND METHODS: Major electronic databases were searched for randomized-controlled trials comparing carbetocin with oxytocin. Only trials involving cesarean deliveries were included. Non-randomized trials, non-cesarean deliveries, studies which did not directly compare carbetocin to oxytocin and studies which did not analyze the intended outcomes were excluded. Outcomes analysed were postpartum hemorrhage, additional use of uterotonic and transfusion requirement.
RESULTS: Seven studies involving 2012 patients were included in the meta-analysis. There was a significant reduction in the rates of postpartum hemorrhage (RR 0.79; 95% CI 0.66 to 0.94; p = 0.009), use of additional uterotonics (RR 0.57; 95% CI 0.49 to 0.65; p

Matched MeSH terms: Blood Transfusion/statistics & numerical data
Hemovigilance in developing countries

Ayob Y

Biologicals, 2010 Jan;38(1):91-6.
PMID: 20133151 DOI: 10.1016/j.biologicals.2009.10.002

Hemovigilance like quality systems and audits has become an integral part of the Blood Transfusion Service (BTS) in the developed world and has contributed greatly to the development of the blood service. However developing countries are still grappling with donor recruitment and efforts towards sufficiency and safety of the blood supply. In these countries the BTS is generally fragmented and a national hemovigilance program would be difficult to implement. However a few developing countries have an effective and sustainable blood program that can deliver equitable, safe and sufficient blood supply to the nation. Different models of hemovigilance program have been introduced with variable success. There are deficiencies but the data collected provided important information that can be presented to the health authorities for effective interventions. Hemovigilance program modeled from developed countries require expertise and resources that are not available in many developing countries. Whatever resources that are available should be utilized to correct deficiencies that are already apparent and obvious. Besides there are other tools that can be used to monitor the blood program in the developing countries depending on the need and the resources available. More importantly the data collected should be accurate and are used and taken into consideration in formulating guidelines, standards and policies and to affect appropriate interventions. Any surveillance program should be introduced in a stepwise manner as the blood transfusion service develops.

Matched MeSH terms: Blood Transfusion/statistics & numerical data