Tutorial 28 April 2014

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36.	Criticise paper. RBC transfusion &  infection JAMA. 2014;311(13):1317-1326. doi:10.1001/jama.2014.2726
37.	Viva. Operation waiting list prioritisation
38.	Role-play. Dyspareunia referral.
39.	Role-play: teach trainee fetal blood sampling.
40.	Role-play. 6/52 FU. FDIU. Normal pregnancy. PM: on 5th. centile for weight, but no other anomaly found. All other investigations normal. Smokes. Didn’t take folic acid. Now blames herself.

36. Health Care–Associated Infection After Red Blood Cell Transfusion. A Systematic Review and Meta-analysis

Jeffrey M. Rohde, MD¹; Derek E. Dimcheff, MD, PhD¹; Neil Blumberg, MD²; Sanjay Saint, MD, MPH^1,3,4,5; Kenneth M. Langa, MD, PhD^1,3,4,5; Latoya Kuhn, MPH^3,4; Andrew Hickner, MSI^1,3; Mary A. M. Rogers, PhD^1,3,5

JAMA. 2014;311(13):1317-1326. doi:10.1001/jama.2014.2726.

ABSTRACT 

Importance.  The association between red blood cell (RBC) transfusion strategies and health care–associated infection is not fully understood.

Objective  To evaluate whether RBC transfusion thresholds are associated with the risk of infection and whether risk is independent of leukocyte reduction.

Data Sources.  MEDLINE, EMBASE, Web of Science Core Collection, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, ClinicalTrials.gov, International Clinical Trials Registry, and the International Standard Randomized Controlled Trial Number register were searched through January 22, 2014.

Study Selection.  Randomized clinical trials with restrictive vs liberal RBC transfusion strategies.

Data Extraction and Synthesis  Twenty-one randomized trials with 8735 patients met eligibility criteria, of which 18 trials (n = 7593 patients) contained sufficient information for meta-analyses. DerSimonian and Laird random-effects models were used to report pooled risk ratios. Absolute risks of infection were calculated using the profile likelihood random-effects method.

Main Outcomes and Measures.  Incidence of health care–associated infection such as pneumonia, mediastinitis, wound infection, and sepsis.

Results.  The pooled risk of all serious infections was 11.8% (95% CI, 7.0%-16.7%) in the restrictive group and 16.9% (95% CI, 8.9%-25.4%) in the liberal group. The risk ratio (RR) for the association between transfusion strategies and serious infection was 0.82 (95% CI, 0.72-0.95) with little heterogeneity (I² = 0%; τ² <.0001). The number needed to treat (NNT) with restrictive strategies to prevent serious infection was 38 (95% CI, 24-122). The risk of infection remained reduced with a restrictive strategy, even with leukocyte reduction (RR, 0.80 [95% CI, 0.67-0.95]). For trials with a restrictive hemoglobin threshold of <7.0 g/dL, the RR was 0.82 (95% CI, 0.70-0.97) with NNT of 20 (95% CI, 12-133). With stratification by patient type, the RR was 0.70 (95% CI, 0.54-0.91) in patients undergoing orthopedic surgery and 0.51 (95% CI, 0.28-0.95) in patients presenting with sepsis. There were no significant differences in the incidence of infection by RBC threshold for patients with cardiac disease, the critically ill, those with acute upper gastrointestinal bleeding, or for infants with low birth weight.

Conclusions and Relevance.  Among hospitalized patients, a restrictive RBC transfusion strategy was associated with a reduced risk of health care–associated infection compared with a liberal transfusion strategy. Implementing restrictive strategies may have the potential to lower the incidence of health care–associated infection.

37. Waiting list prioritisation. See document lower down.

38. Dyspareunia referral.

GP Referral Letter.

Dr. P. Fella,

Green Road Surgery,

Halcion Street,

Bliss.

Re: Margaret Smith.

Please see Mrs Smith who complains of dyspareunia.

Candidate's Instructions.

This is a role-play station.

Take a history and discuss appropriate investigation and management.

39. Role-play: teach trainee fetal blood sampling.

Candidate's Instructions.

This is a role-play station.

Dr. Jones has recently joined your team as a new trainee in obstetrics & gynaecology.

The labour ward is quiet and the consultant has asked you to teach Dr. Jones about fetal blood sampling.

40. Roleplay. F/U after stillbirth.

Candidate's Instructions.

This is a roleplay station.

Mrs. Brown has come for follow-up 6/52 after delivery of a stillborn baby.

Reduced fetal movements had been noted at 38 weeks.

She was admitted and FDIU was confirmed.

The scan also showed IUGR.

She opted for induction of labour.

Prostin was used and she had a normal delivery 12 hours later.

Effective analgesia was provided by epidural anaesthesia.

There were no complications.

Full investigation, including PM, was normal apart from the birthweight, which was < 5^th. centile.

Your task is to explain the results and advise about the next pregnancy.

37. Waiting List Prioritisation.

Your consultant is away.

The waiting-list manager comes to see you.

The following patients have been listed by junior staff.

The waiting-list manager wants you to:

confirm the appropriateness of the proposed treatment,

decide the degree of urgency,

confirm the appropriateness of the proposed venue,

decide any special requirement(s) for each patient.

Name	Age	Clinical Problem	Proposed operation	Venue	Special Needs	Urgency
JK	5	chronic discharge. ? foreign body	EUA	Main theatre
JM	32	1ry. infertility	Laparoscopy + tubal patency tests	Main theatre
GN	77	Vulval cancer. Coronary thrombosis x 2. Unstable angina.	Radical vulvectomy agreed at MDT.	Main theatre
RU	55	PMB x1. Weight 20 stones. (127 kg.) 1 kg. = 2.2 lb. 1 stone = 14 lb.	D&C.	DCU.
LD	32	Menorrhagia. Fibroids. Anaemia.	Vaginal hysterectomy.	Main theatre.
DT	22	Does not want children.	Lap. Steril.	DCU
HB	14	Unwanted pregnancy at 10/52.	TOP	DCU. TOP list.	.
JY	44	GSI.	Anterior colporrhaphy.	Main theatre.
JS	23	Vaginal discharge. Cervical ectropion.	Diathermy to cervix.	DCU
DT	55	3 cm. ovarian mass.	Laparoscopy ? proceed to Hyst + BSO.	Main theatre.
EV	32	CIN3.	Cone biopsy.	DCU
UW	34	Endometriosis	Laparoscopic ablation	DCU
HT	88	Cystocoele/ rectocoele/ 2nd. degree uterine prolapse	Manchester Repair.	Main theatre.
KN	58	Haematuria	Cystoscopy	DCU
JW	18	Menorrhagia & copes badly with menstrual hygiene. Has Down’s syndrome. Sexually active.	Hysterectomy	Main theatre
TB	30	Menorrhagia. 2nd. degree uterine descent. Been sterilised. Jehovah’s witness.	Vaginal hysterectomy and repair.	Main theatre.
BM	55	Stage Ib cancer cervix. Been discussed at MDT. For Wertheim’s hysterectomy. Factor V Leiden. VTE on Pill. On warfarin.	Wertheim’s hysterectomy.	Main theatre.
NU	60	Recurrent rectocoele.	Posterior colporrhaphy.	Main theatre.