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Changing Perspectives: Restrictive use of blood transfusion in critical care: the dawn of a new age?

Restrictive use of blood transfusion in critical care: the dawn of a new age?

Haemoglobin transports oxygen from the pulmonary capillaries to vital organs and other tissues. Acute anaemia, for example as a consequence of surgical blood loss, can lead to tissue hypoxia and organ damage. When haemoglobin concentration drops below critical levels, red blood cell (RBC) transfusion may be indicated and even lifesaving. However, RBC transfusion has also been associated with many complications, for instance transfusion reaction, infection transmission, and acute lung injury. Therefore, determining adequate transfusion triggers is of utmost importance.1 The prevailing Dutch transfusion guideline endorses the ‘4-5-6’ strategy, in which patient characteristics and clinical status influence the decision to apply RBC transfusion.2 In short, RBC transfusion is triggered by haemoglobin concentrations below 4 mmol/L in healthy adults, whereas this trigger is 6 mmol/L in cardiopulmonary restricted patients. Despite its simplicity, recent evidence suggests that the ‘4-5-6’ strategy does not benefit patient outcomes and that a more restrictive use of RBC transfusion might be beneficial. A recent, multicenter, randomized study comprising of more than five thousand cardiac surgery patients found no difference in clinical outcomes (stroke, renal failure, myocardial infarction and death) between a transfusion trigger of 4.5 and 6 mmol/L , respectively.3 Furthermore, a randomized study comprising of almost one thousand patients with acute upper gastrointestinal bleeding found an higher survival rate with a transfusion trigger of 4.3 compared to 5.5 mmol/L.1-4 Therefore, we expect that future guidelines will recommend restrictive use of RBC transfusion in critical care settings.

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Clinical Image: A child with kidney stones

A child with kidney stones

[headline_subtitle subtitle=”Can you come up with the proper diagnosis?”]
Case

This Syrian boy, the second child of consanguineous parents, presented with kidney stones in his country of origin at the age of 5½ years. In the following years he developed end stage kidney disease. He started hemodialysis treatment at the age of 11 years. In 2012 he underwent a kidney transplant, which failed soon after surgery. Hemodialysis was resumed. The following year he lost his ability to walk. In 2015 the patient moved to the Netherlands. Upon arrival, he was found to be underdialysed, underfed and to suffer from severe bone disease. An abdominal X-ray was performed.

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Solving statistics: Help! How do I get a normal distribution?

Help! How do I get a normal distribution?

Background

The distribution of a continuous numerical variable tells you something about how likely each possible outcome or groups of outcomes will occur. The distribution of a continuous numerical variable can be described as normal or non-normal. A normal distribution is the name for a specific mathematical concept that follows a symmetric bell shaped curve and is completely defined by its mean and standard deviation. Approximately 68% of the observations fall between one standard deviation below and one standard deviation above the mean. And approximately 95% of the observations fall between two standard deviations below and two standard deviations above the mean. Normal distribution is an important term within the field of statistics. If you have a normal distribution you can perform a certain number of statistical tests that you cannot perform if your distribution is non-normal.1

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Subject 101: Fundamentals and diagnostic challenges of viral hepatitis

Fundamentals and diagnostic challenges of viral hepatitis

Viral hepatitis is one of the leading causes of liver cirrhosis and hepatocellular carcinoma worldwide.1 Although the incidence rates in the Netherlands for viral hepatitis are low, the inhabitancy of populations from high-risk areas (sub-Saharan Africa, Asia) and the intensified travel habits of the Dutch population towards such places warrants adequate knowledge of this topic.2,3

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