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Neil Blumberg

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  1. Like
    Neil Blumberg got a reaction from David Saikin in Mismatch Kidney Transplants and Titers   
    "Just curious, can one give a group A1 kidney to a group B patient who has a very low isoagglutinin titer ?"
    It's been done.  Depends on the ability to suppress the anti-A titer low enough through immunosuppressive drugs and plasma exchange, the usual preparative regimen.  Obviously ABO identical is best, but this is an alternative at some centers with experience doing these transplants.
  2. Like
    Neil Blumberg got a reaction from exlimey in Mismatch Kidney Transplants and Titers   
    "Just curious, can one give a group A1 kidney to a group B patient who has a very low isoagglutinin titer ?"
    It's been done.  Depends on the ability to suppress the anti-A titer low enough through immunosuppressive drugs and plasma exchange, the usual preparative regimen.  Obviously ABO identical is best, but this is an alternative at some centers with experience doing these transplants.
  3. Like
    Neil Blumberg got a reaction from saralm88 in Emergency Neonatal Transfusion in Small Hospitals   
    There is reason NOT to use the freshest possible units. They may be more toxic than intermediate stored units. This is something that made sense but was almost certainly wrong.  See below for the reasoning and published data.  We use <21 days as fresh for this reason and avoid <7 days storage for everyone based upon the randomized trial data.
    BMJ 2019;366:l4968 doi: 10.1136/bmj.l4968 (Published 5 August 2019) Page 1 of 1
    Letters
    Trivella and colleagues present some caveats around the subject of duration of red cell storage and clinical outcomes.1 Studies have been widely interpreted as showing that transfusion is not associated with adverse clinical outcomes. I think this is a serious misinterpretation of the data.
    In addition to the concerns raised by the authors, another valid hypothesis, which has received little attention, is that very short storage red cells might be more dangerous than medium storage periods (say 7-21 days) and equally dangerous as longer storage red cells (say 28-42 days). An inverted U shaped curve. The evidence for this comes from a meta-analysis finding that “ultra short” storage of red cells was associated with a post-transfusion increase in nosocomial infection.2 Shorter storage red cells have a greater imbalance of oxidation-reduction potential than longer storage red cells in preliminary studies in vitro.3 Red cell storage duration is also a poor predictor of post-transfusion free haemoglobin and heme, putative mediators of toxicity from transfusions.4 5
    We need better metrics for predicting red cell transfusion efficacy and toxicity. The simple expedient of fresher red cells is clearly not that metric and might be leading us to transfuse more toxic red cells (very fresh) in the most fragile patients,
    such as premature newborns. A new approach is clearly called for by the current data. At our centre we define fresh as <21 days of storage, and we generally never transfuse a red cell that has been stored for much less than 7-10 days, for the above reasons as well as logistics of supply.
    Competing interests: None declared.
    1 Trivella M, Stanworth SJ, Brunskill S, Dutton P, Altman DG. Can we be certain that storage duration of transfused red blood cells does not affect patient outcomes?BMJ 2019;365:l2320. 10.1136/bmj.l2320 31186250
    2 Alexander PE, Barty R, Fei Y, etal . Transfusion of fresher vs older red blood cells in hospitalized patients: a systematic review and meta-analysis. Blood 2016;127:400-10. 10.1182/blood-2015-09-670950 26626995
    3 Schmidt A, Gore E, Cholette JM, etal . Oxidation reduction potential (ORP) is predictive of complications following cardiac surgery in pediatric patients[abstract]. Transfusion 2016;56(Supplement S4):20A-1A.
    4 Cholette JM, Pietropaoli AP, Henrichs KF, etal . Elevated free hemoglobin and decreased haptoglobin levels are associated with adverse clinical outcomes, unfavorable physiologic measures, and altered inflammatory markers in pediatric cardiac surgery patients. Transfusion 2018;58:1631-9. 10.1111/trf.14601 29603246
    5 Pietropaoli AP, Henrichs KF, Cholette JM, etal . Total plasma heme concentration increases after red blood cell transfusion and predicts mortality in critically ill medical patients. Transfusion 2019;59:2007-15. 10.1111/trf.15218 30811035
    Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/ permissions
    LETTERS
  4. Like
    Neil Blumberg got a reaction from albaugh in MTP cut-off policy, or Lethal Dose of Blood Products   
    "The bottom line was, if the treating physician wanted to use up the entire inventory trying to save a life, we could not deny them the blood, even though it places other patients at risk. "
    I would call this some combination of cowardice and insanity, speaking purely personally.  Taking responsibility for difficult decisions is why physicians get paid well, and avoiding decision making is irresponsible.
  5. Like
    Neil Blumberg got a reaction from exlimey in MTP cut-off policy, or Lethal Dose of Blood Products   
    "The bottom line was, if the treating physician wanted to use up the entire inventory trying to save a life, we could not deny them the blood, even though it places other patients at risk. "
    I would call this some combination of cowardice and insanity, speaking purely personally.  Taking responsibility for difficult decisions is why physicians get paid well, and avoiding decision making is irresponsible.
  6. Like
    Neil Blumberg got a reaction from Mabel Adams in MTP cut-off policy, or Lethal Dose of Blood Products   
    "The bottom line was, if the treating physician wanted to use up the entire inventory trying to save a life, we could not deny them the blood, even though it places other patients at risk. "
    I would call this some combination of cowardice and insanity, speaking purely personally.  Taking responsibility for difficult decisions is why physicians get paid well, and avoiding decision making is irresponsible.
  7. Like
    Neil Blumberg got a reaction from John C. Staley in MTP cut-off policy, or Lethal Dose of Blood Products   
    "The bottom line was, if the treating physician wanted to use up the entire inventory trying to save a life, we could not deny them the blood, even though it places other patients at risk. "
    I would call this some combination of cowardice and insanity, speaking purely personally.  Taking responsibility for difficult decisions is why physicians get paid well, and avoiding decision making is irresponsible.
  8. Like
    Neil Blumberg got a reaction from David Saikin in Facility location on SOPs   
    We are inspected by FDA, NY State, AABB, CAP and FACT.  Lots of opportunities for self-important, obsessive folks to make useless work for the people trying to take care of patients.  The stories I could tell. 
    We've also had many rational, balanced, thoughtful inspectors who clearly are only focused on the important stuff, to be fair.  But a significant portion of our profession(s)' people do not realize that getting staff to focus on minutiae that will not affect patient outcomes distracts staff from doing the important things well. A well known psychologic/cognitive fact.  Keep it simple and avoid worrying about unimportant stuff. 
    The notion that documentation is more important than anything else is the most pernicious piece of rubbish in medicine, and driven by the administrative/legal model (and billing of course).  And people proudly spout this nonsense as if it actually helped anyone but those in accounts receivable.  
    I'd personally like the technologist doing my pre-transfusion testing to get the ABO and antibody screen correct as a trillion fold more important relative to them documenting what time, date or temperature all of that was done.  Not to mention what that person had for lunch or dinner before the crossmatch (coming soon to an inspection near you). 
    For the record I'm a Gemini, which I assiduously and loyally document in every interpretation and progress note I write.
  9. Like
    Neil Blumberg got a reaction from exlimey in Facility location on SOPs   
    We are inspected by FDA, NY State, AABB, CAP and FACT.  Lots of opportunities for self-important, obsessive folks to make useless work for the people trying to take care of patients.  The stories I could tell. 
    We've also had many rational, balanced, thoughtful inspectors who clearly are only focused on the important stuff, to be fair.  But a significant portion of our profession(s)' people do not realize that getting staff to focus on minutiae that will not affect patient outcomes distracts staff from doing the important things well. A well known psychologic/cognitive fact.  Keep it simple and avoid worrying about unimportant stuff. 
    The notion that documentation is more important than anything else is the most pernicious piece of rubbish in medicine, and driven by the administrative/legal model (and billing of course).  And people proudly spout this nonsense as if it actually helped anyone but those in accounts receivable.  
    I'd personally like the technologist doing my pre-transfusion testing to get the ABO and antibody screen correct as a trillion fold more important relative to them documenting what time, date or temperature all of that was done.  Not to mention what that person had for lunch or dinner before the crossmatch (coming soon to an inspection near you). 
    For the record I'm a Gemini, which I assiduously and loyally document in every interpretation and progress note I write.
  10. Thanks
    Neil Blumberg got a reaction from John C. Staley in Facility location on SOPs   
    We are inspected by FDA, NY State, AABB, CAP and FACT.  Lots of opportunities for self-important, obsessive folks to make useless work for the people trying to take care of patients.  The stories I could tell. 
    We've also had many rational, balanced, thoughtful inspectors who clearly are only focused on the important stuff, to be fair.  But a significant portion of our profession(s)' people do not realize that getting staff to focus on minutiae that will not affect patient outcomes distracts staff from doing the important things well. A well known psychologic/cognitive fact.  Keep it simple and avoid worrying about unimportant stuff. 
    The notion that documentation is more important than anything else is the most pernicious piece of rubbish in medicine, and driven by the administrative/legal model (and billing of course).  And people proudly spout this nonsense as if it actually helped anyone but those in accounts receivable.  
    I'd personally like the technologist doing my pre-transfusion testing to get the ABO and antibody screen correct as a trillion fold more important relative to them documenting what time, date or temperature all of that was done.  Not to mention what that person had for lunch or dinner before the crossmatch (coming soon to an inspection near you). 
    For the record I'm a Gemini, which I assiduously and loyally document in every interpretation and progress note I write.
  11. Like
    Neil Blumberg got a reaction from Ensis01 in Facility location on SOPs   
    We are inspected by FDA, NY State, AABB, CAP and FACT.  Lots of opportunities for self-important, obsessive folks to make useless work for the people trying to take care of patients.  The stories I could tell. 
    We've also had many rational, balanced, thoughtful inspectors who clearly are only focused on the important stuff, to be fair.  But a significant portion of our profession(s)' people do not realize that getting staff to focus on minutiae that will not affect patient outcomes distracts staff from doing the important things well. A well known psychologic/cognitive fact.  Keep it simple and avoid worrying about unimportant stuff. 
    The notion that documentation is more important than anything else is the most pernicious piece of rubbish in medicine, and driven by the administrative/legal model (and billing of course).  And people proudly spout this nonsense as if it actually helped anyone but those in accounts receivable.  
    I'd personally like the technologist doing my pre-transfusion testing to get the ABO and antibody screen correct as a trillion fold more important relative to them documenting what time, date or temperature all of that was done.  Not to mention what that person had for lunch or dinner before the crossmatch (coming soon to an inspection near you). 
    For the record I'm a Gemini, which I assiduously and loyally document in every interpretation and progress note I write.
  12. Thanks
    Neil Blumberg got a reaction from Malcolm Needs in Facility location on SOPs   
    We are inspected by FDA, NY State, AABB, CAP and FACT.  Lots of opportunities for self-important, obsessive folks to make useless work for the people trying to take care of patients.  The stories I could tell. 
    We've also had many rational, balanced, thoughtful inspectors who clearly are only focused on the important stuff, to be fair.  But a significant portion of our profession(s)' people do not realize that getting staff to focus on minutiae that will not affect patient outcomes distracts staff from doing the important things well. A well known psychologic/cognitive fact.  Keep it simple and avoid worrying about unimportant stuff. 
    The notion that documentation is more important than anything else is the most pernicious piece of rubbish in medicine, and driven by the administrative/legal model (and billing of course).  And people proudly spout this nonsense as if it actually helped anyone but those in accounts receivable.  
    I'd personally like the technologist doing my pre-transfusion testing to get the ABO and antibody screen correct as a trillion fold more important relative to them documenting what time, date or temperature all of that was done.  Not to mention what that person had for lunch or dinner before the crossmatch (coming soon to an inspection near you). 
    For the record I'm a Gemini, which I assiduously and loyally document in every interpretation and progress note I write.
  13. Like
    Neil Blumberg got a reaction from CARMEN DELGADO in Platelet Compatibility   
    I should add the good news is that when one starts prioritizing ABO identical platelets over inventory management, one reduces the platelet transfusions needed by perhaps 50%.  So our platelet shortages will disappear in large part if we stick with ABO identical as much as possible.  See attached randomized trial from eons ago :).  ABO identical reduces transfusion reactions as well, HLA and rbc alloimmunization.  Not to mention decreasing bleeding and mortality.
    ABO randomized trial UR european j haematology 1993 copy.pdf ABO plt tx revisited cumulative effects.pdf Platelet transfusion worsens ICH Stroke 2020 copy.pdf
  14. Like
    Neil Blumberg got a reaction from CARMEN DELGADO in Platelet Compatibility   
    Another point.  Since group O whole blood has proven as safe or even safer than typical component therapy (A platelets, A or AB plasma) in massive transfusion of trauma patients, perhaps group O low titer platelets would be safer than group A or B platelets for an AB patient :)?  No one knows, but worth considering.  The big problem is probably giving non-O platelets to O patients. There is evidence this increases bleeding and mortality.  Just like red cells, only O platelets for O recipients is a good practice.  The AB patient may be less of a problem, since giving some small amount of antibody may be less dangerous. A risk of hemolytic reaction of about 1 in 700 or so.  The risk of mortality in transfusing an O patient with A platelets is probably 1 in 5 (see attached).
    ABO incompatible platelets intracranial bleeding 2021.pdf ABO plasma incompatible platelets and hemolytic reactions.pdf
  15. Haha
    Neil Blumberg got a reaction from John C. Staley in Facility location on SOPs   
    I am waiting for some conscientious, firm inspector to insist we add the blood bank director's hat size and astrological sign to each procedure.  About as relevant to health care as most of the stuff the accreditation and regulatory agencies obsess about.
  16. Like
    Neil Blumberg got a reaction from David Saikin in Facility location on SOPs   
    Just the person you want operating on your brain or reading your prostate biopsy, no doubt.  Makes one proud to be a part of the same profession.  Not.  Pettifogging fool.  Perhaps he is nice to his dog and children.
  17. Like
    Neil Blumberg got a reaction from jnadeau in Facility location on SOPs   
    Just the person you want operating on your brain or reading your prostate biopsy, no doubt.  Makes one proud to be a part of the same profession.  Not.  Pettifogging fool.  Perhaps he is nice to his dog and children.
  18. Haha
    Neil Blumberg got a reaction from jnadeau in Facility location on SOPs   
    I am waiting for some conscientious, firm inspector to insist we add the blood bank director's hat size and astrological sign to each procedure.  About as relevant to health care as most of the stuff the accreditation and regulatory agencies obsess about.
  19. Like
    Neil Blumberg got a reaction from jnadeau in Facility location on SOPs   
    Another bureaucratic authoritarian idiocy?  Sorry, couldn't restrain myself, but there is a cadre of "quality gurus" who are constantly thinking up irrelevant, pointless make work stuff for the rest of us.  This is how civilizations come to an end.  Why in the world would an SOP have to have the address, name, GPS co-ordinates, topographic elevation and postal code of the facility?  How does that address any patient care issue in the universe?  
  20. Like
    Neil Blumberg got a reaction from Malcolm Needs in Facility location on SOPs   
    Just the person you want operating on your brain or reading your prostate biopsy, no doubt.  Makes one proud to be a part of the same profession.  Not.  Pettifogging fool.  Perhaps he is nice to his dog and children.
  21. Like
    Neil Blumberg got a reaction from exlimey in Facility location on SOPs   
    Just the person you want operating on your brain or reading your prostate biopsy, no doubt.  Makes one proud to be a part of the same profession.  Not.  Pettifogging fool.  Perhaps he is nice to his dog and children.
  22. Haha
    Neil Blumberg reacted to David Saikin in Facility location on SOPs   
    i had an AABB inspection years ago. At the summation the inspector said:  "I know I'd have to dig to find something in Dave's lab."  That should have been a warning.  My only deficiency (which was cited by the Area Chair, who determined the deficiencies based on the Inspection report form) was that I did not have my facility ID on my antibody panel sheets.  I immediately called my area chair and told him I wanted to inspect his lab (UT@Knoxville), which of course is not allowed.  I became an AABB inspector/assessor after that fact.
  23. Like
    Neil Blumberg reacted to AMcCord in Facility location on SOPs   
    I had a CAP inspection years ago with someone who was also an AABB inspector. He made a 'recommendation/suggestion' that we include our facility name/address on antibody panel sheets even though they were not (and are not) scanned to patient EMR's. He had experience with  an FDA inspector requiring that and joked that they (FDA inspectors) must have been aware of a HUGE black market of filled out antibody panels available for purchase. I had a stamp made with our facility name/address and we plop that on those forms. It's silly, but we do it. Looks good if we send those worksheets off to a reference lab with a specimen I guess.
  24. Haha
    Neil Blumberg got a reaction from exlimey in Facility location on SOPs   
    I am waiting for some conscientious, firm inspector to insist we add the blood bank director's hat size and astrological sign to each procedure.  About as relevant to health care as most of the stuff the accreditation and regulatory agencies obsess about.
  25. Like
    Neil Blumberg got a reaction from Mabel Adams in MTP cut-off policy, or Lethal Dose of Blood Products   
    There are no data suggesting a particular limit.  Survival is very unusual after 30-50 units of red cells, but everyone has exceptional cases like those mentioned above. We have discussed futility of care many times, and our practitioners are quite amenable and forthcoming.  We have stopped resuscitation in a young man having a liver transplant go badly, when there was no surgical path to hemostasis after about 250 units, but this is unusual too.  Bottom line, a case by case decision as to whether care is futile and/or the patient's needs endanger the well being of other patients needing transfusion.  Those are the key issues in each case to my way of thinking.
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