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The hospital environment, across multidisciplinary transfusion processes, is complex involving various organizations and agencies, staff and patients. A comprehensive, robust, collaborative, inclusive and effective clinical governance framework for transfusion/blood management activities is essential for patient safety and optimal outcomes; this should include integrated systems across the transfusion chain which is intrinsically high risk, given the possible severe adverse outcomes of error, multiple potential vulnerabilities and various components not being supported by electronic systems. Strong, informed clinician leadership provides inspiration, motivation and support to staff to achieve excellence in transfusion practice; key leaders should be involved with patient care and facilitate a culture of collaborative teamwork, accountability, openness, engagement and improvement. The transfusion committee (TC) should focus on actions, outcomes, improvement and staff/consumer engagement and be integral to the hospital's overall governance structure; clear accountability to executive is essential so that effective change can be supported, resourced, implemented and maintained. TC membership, activities and reporting lines should be clearly documented. Key clinical personnel, the laboratory, quality and executive all contribute as well as relevant external agencies, for example the blood supplier. The TC leadership team should have expertise in transfusion, leadership qualities and should include a haematologist, transfusion nurse/officer and laboratory scientist. The TC agenda should encompass regular items and reports, policy review, illustrative cases, improvement projects, education, guidelines/research and information sharing/benchmarking with other groups. Small TC working groups facilitate progress between meetings. Enablers and barriers to good transfusion practice include system issues, evidence barriers and individual factors. [ABSTRACT FROM AUTHOR]

The ratio of osteoprotegerin [OPG, tumour necrosis factor receptor superfamily, member 11b (TNFRSF11B)] to receptor activator of nuclear factor κB ligand [RANKL, tumour necrosis factor (ligand) superfamily, member 11 (TNFSF11)] in bone is critical for the regulation of bone remodelling. Myeloma cells can home to bone, triggering increased RANKL and decreased OPG expression by stromal cells, leading to osteolysis. Whether myeloma cells contribute directly to the pool of RANKL or OPG in bone has been contentious. Here we provide evidence of RANKL expression by reverse transcription polymerase chain reaction and in situ hybridization, demonstrating transcripts encoding both the membrane-bound and secreted forms of RANKL in five human multiple myeloma cell lines (LP-1, NCI-H929, OPM-2, RPMI8226, U266) and myeloma cells purified from bone marrow aspirates of myeloma patients. We demonstrated that RANKL encoding mRNAs are translated to protein by antibody detection of RANKL. In vitro assays showed that myeloma cells induced bone marrow derived mononuclear cells to differentiate into adherent tartrate-resistant acid phosphatase positive multinucleated cells, indicative of the formation of functional osteoclasts. This differentiation could also be achieved with passaged myeloma media alone, implicating secreted products. Finally, we provide evidence that the differentiation observed is at least in part the result of myeloma cell expression of RANKL. We therefore conclude that myeloma cells can directly contribute to the pool of RANKL in bone. [ABSTRACT FROM AUTHOR]

Background: There continues to be uncertainty about the optimal approach to documenting bleeding data in platelet transfusion trials, with a desire to apply a common assessment tool across all trials. With this in mind, a consensus bleeding assessment tool (BAT) has been developed by the Biomedical Excellence for Safer Transfusion (BEST) collaborative, based on review of data collection forms used in published randomized trials and following content validation with a range of healthcare professionals at seven haematology centres through BEST members. This study aimed to evaluate reliability and reproducibility of the consensus BAT. Methods: Replicated clinical assessments of bleeding were undertaken by participants with haematological malignancies recruited at four haematology centres in an international, multicentred, observational study. Concordance of repeat assessments was calculated for agreement in site and grade of bleeding observed. Results: Forty patients consented to participate, and 13 trained bleeding assessors collected these data. Bleeding assessments were carried out on 113 separate days. Of all 225 bleeding assessments, 204 were compared for grade concordance, and 160 were compared for site concordance. There was very good grade concordance (83%, 95% confidence interval 74–93%) and good bleeding site concordance (69%, 95% confidence interval 57–79%) in observations of bleeding. Discordance was primarily in relation to assessing skin bleeding. Conclusions: Alongside a structured training programme, levels of concordance for a consensus BAT were high. Researchers using assessment tools for bleeding need to balance comprehensive data collection against potential loss of accuracy for some types of bleeding, such as skin findings. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented in response to the article "Management of iron deficiency in patients admitted to the hospital: time for a rethink of treatment principles," by Ahmed I, Gibson P.R., in the 2007 issue.

CONTEXT: Current literature suggests that contact with specialist palliative care for patients diagnosed with hematological malignancy is infrequent. As part of an investigation into patterns of care, the symptom profile of this patient group required elucidation. OBJECTIVES: The purpose of this study was to determine the patterns of symptoms and level of distress in patients diagnosed with a hematological malignancy. METHODS: One hundred eighty patients diagnosed with a hematological malignancy attending a tertiary referral hospital completed the Memorial Symptom Assessment Scale-Short Form. Comparisons were made to published symptom prevalence studies of those with nonhematological malignancies. RESULTS: Patients with hematological malignancy had a considerable physical and psychological symptom burden, with an overall mean of 8.8 (±5.9) symptoms. The mean number of symptoms was significantly greater in those on treatment (P<0.05), those with poorer performance status (P<0.001), inpatients (P<0.01), and those with a more advanced disease stage (P<0.001) than their respective counterparts. Symptom prevalence ranged from 69% for fatigue to 9% for vomiting. Global, physical, and psychological distress scores were high and varied significantly according to disease stage, Eastern Cooperative Oncology Group status, and patient location. The mean number of symptoms and level of distress were comparable to those patients with metastatic nonhematological malignancy. CONCLUSION: Patients with hematological malignancy are likely to have symptom control needs similar to those with metastatic cancer. Because such symptom burden appears to affect those at all phases of illness, comprehensive symptom assessment is suggested throughout. The introduction of palliative care services during times of increased symptom burden may assist hematologists and other carers in the management of their patients' distress and quality of life. [ABSTRACT FROM AUTHOR]

The article presents case studies of a two men with a 12-year history of HIV and a 24-year-old man with a two-year history of HIV. The first has previous complication of AIDS-defining illness (ADIs) while the second and the third patient have none but with relapsed acute myeloid leukemia (AML) and T-cell acute lymphoblastic leukemia (ALL), respectively. Researchers found that allo-stem cell transplantation is a feasible therapy for hematological malignancies in patients who are HIV-positive.

SUMMARY Objectives To evaluate the use of routinely collected data to determine the cause(s) of critical bleeding in patients who receive massive transfusion (MT). Background Routinely collected data are increasingly being used to describe and evaluate transfusion practice. Materials/methods Chart reviews were undertaken on 10 randomly selected MT patients at 48 hospitals across Australia and New Zealand to determine the cause(s) of critical bleeding. Diagnosis-related group (DRG) and International Classification of Diseases (ICD) codes were extracted separately and used to assign each patient a cause of critical bleeding. These were compared against chart review using percentage agreement and kappa statistics. Results A total of 427 MT patients were included with complete ICD and DRG data for 427 (100%) and 396 (93%), respectively. Good overall agreement was found between chart review and ICD codes (78·3%; κ = 0·74, 95% CI 0·70-0·79) and only fair overall agreement with DRG (51%; κ = 0·45, 95% CI 0·40-0·50). Both ICD and DRG were sensitive and accurate for classifying obstetric haemorrhage patients (98% sensitivity and κ > 0·94). However, compared with the ICD algorithm, DRGs were less sensitive and accurate in classifying bleeding as a result of gastrointestinal haemorrhage (74% vs 8%; κ = 0·75 vs 0·1), trauma (92% vs 62%; κ = 0·78 vs 0·67), cardiac (80% vs 57%; κ = 0·79 vs 0·60) and vascular surgery (64% vs 56%; κ = 0·69 vs 0·65). Conclusion Algorithms using ICD codes can determine the cause of critical bleeding in patients requiring MT with good to excellent agreement with clinical history. DRG are less suitable to determine critical bleeding causes. [ABSTRACT FROM AUTHOR]

The BTK (Bruton's tyrosine kinase) inhibitor ibrutinib is associated with an increased risk of bleeding. A previous study reported defects in collagen- and adenosine diphosphate (ADP)-dependent platelet responses when ibrutinib was added ex vivo to patient samples. Whereas the collagen defect is expected given the central role of BTK in glycoprotein VI signaling, the ADP defect lacks a mechanistic explanation. In order to determine the real-life consequences of BTK platelet blockade, we performed light transmission aggregometry in 23 patients receiving ibrutinib treatment. All patients had reductions in collagen-mediated platelet aggregation, with a significant association between the degree of inhibition and the occurrence of clinical bleeding or bruising (P=0.044). This collagen defect was reversible on drug cessation. In contrast to the previous ex vivo report, we found no in vivo ADP defects in subjects receiving standard doses of ibrutinib. These results establish platelet light transmission aggregometry as a method for gauging, at least qualitatively, the severity of platelet impairment in patients receiving ibrutinib treatment. [ABSTRACT FROM AUTHOR]

Background Fatigue is a common symptom in patients with advanced malignancy, and has been associated with both physiological and psychological factors in patients with solid tumours. Aim This study sought to explore the predictors of fatigue in a population with haematological malignancy. Methods Consecutive outpatients and inpatients attending a haematology centre completed the Memorial Symptom Assessment Scale, and clinical, treatment and demographic information were noted. Results Of 180 patients, fatigue was present in 69%, and causing considerable distress in 26%. Univariate analysis revealed fatigue was associated with poor performance status, low haemoglobin, feeling sad, worried, irritable and nervous. Multivariate modeling revealed that those factors predictive of fatigue were poor performance status, having active disease, feeling sad and irritable, while haemoglobin level was not predictive of fatigue. Conclusions Fatigue is a multidimensional symptom in patients with haematological malignancy whose presence must prompt a holistic assessment of potential contributors that goes beyond correction of haemoglobin levels. [ABSTRACT FROM AUTHOR]

The article presents a set of questions to get information on the educational practise in transfusion medicine around the world from medical students and doctors. Some of the questions includes in the list are involvement of one's organization in the education of medical students and residents, knowledge transfer in clinical transfusion medicine and completion of a transfusion module before or during internship.

Abstract We report here two cases of dyserythropoietic anaemia associated with long-term linezolid use that share striking similarities to chloramphenicol-associated myelotoxicity. (Intern Med J 2005; 35: 626–628) [ABSTRACT FROM AUTHOR]

The article discusses the case of a male patient with microspherocystosis following sulphuric acid exposure. The patient was admitted to the hospital following an explosion at the metal foundry. He sustained sulphuric acid exposure to 80% of his body. Microspherocytes are a characteristic finding following thermal injury to red cells. The patient was treated with surgical debridement and supportive measures. The patient made a full recovery.

Presents papers to be published in forthcoming issues of "British Journal of Haematology."