Special Article
Collection and Transfusion of Blood in the United States, 1982–1988
N Engl J Med 1990; 322:1646-1651June 7, 1990
- Abstract
- Abstract
Widespread concern about the safety of the national blood supply, particularly with respect to the human immunodeficiency virus (HIV), has reportedly affected the use of blood products to support patients. To examine these changes, we conducted national surveys of blood collection and transfusion in the United States in 1982, 1984, 1986, and 1987 and made a limited survey of these activities in 1988.
Transfusions of whole blood and red cells reached a peak of 12.2 million units in 1986, then declined to 11.6 million units in 1987 and continued to decline in 1988. Transfusions of plasma declined from a peak of 2.3 million units in 1984 to 2.1 million units in 1987. Growth in the use of platelet transfusions (6.4 million units in 1987) also slowed; however, the proportion of platelets transfused as platelets from single donors grew from 11 percent in 1980 to 25 percent in 1987. Donations of autologous blood increased sharply, from less than 30,000 units in 1982 to 397,000 units in 1987, equivalent to 3 percent of the homologous-blood collections. The growth in collections of homologous blood slowed after 1982. The supply of homologous blood reached a peak of 13.4 million units in 1986 and did not grow between 1986 and 1988. These trends in red-cell, plasma, and platelet transfusions appear to have continued through 1988.
We conclude that the unprecedented decline in transfusions of whole blood and red cells, coupled with the continued importation of packed red cells from Western Europe and the offsetting effect of autologous predeposits, forestalled serious shortages of blood that could have resulted from the decline in collections of homologous blood. We attribute these changes in blood collection and blood transfusion to the effects of the epidemic of HIV infection. (N Engl J Med 1990; 322:1646–51.)
Media in This Article
Figure 1
Rates of Blood Collection and Transfusion in the United States, 1971 to 1987.Figure 2
Rates of Transfusion, According to Region.Article Activity
- Article
THE epidemic caused by the human immunodeficiency virus (HIV) is having widespread effects on the national blood supply. Patients, blood donors, and the public at large are apprehensive about the safety of the blood supply, possible acquisition of HIV infection through blood transfusion, and even the safety of donating blood.1 , 2 Physicians, increasingly aware of the risks of HIV and other infections transmitted by transfusion, are reconsidering the risks and benefits of transfusions and are turning to alternatives, including that of avoiding transfusions altogether. We report the findings of a series of studies of transfusion practice in the United States and its effects on the adequacy of the blood supply during the period from 1982 through 1988.
Methods
Development of Estimates of National Activity, 1982–1987
On the basis of experience with the 1979 and 1980 surveys conducted by the National Heart, Lung, and Blood Institute,3 we devised a plan for a new set of national surveys. This involved acquiring, editing, and merging existing and new sets of data and then processing the merged data with use of standard estimation techniques to arrive at national estimates of specific activities. The American Association of Blood Banks (AABB), the American Red Cross, and the Council of Community Blood Centers shared the data reported to them by their member institutions. These represented blood collections at about 180 regional blood centers and collections and transfusions in some 1800 hospitals belonging to the AABB (AABB hospitals). To fill the gaps in these data, we surveyed collections and transfusions in approximately 3800 hospitals that were not members of the AABB (non-AABB hospitals).
Collections in Regional Blood Centers
Except in a few instances, the data from the national organizations, when suitably edited and merged, included almost all the collections by regional blood centers. In each instance of a regional center that did not report its collections, the gap was filled by the insertion of an estimate based on the collections reported by the center in previous years, adjusted for the average percentage of change in the collections made at all reporting centers during the interval preceding the year in question.
Surveys of Non-AABB Hospitals
For each study year, we identified all U.S. hospitals in which transfusions were likely to occur by removing the names of all known long-term and psychiatric hospitals from the list of hospitals on the annual data tape of the American Hospital Association (Chicago). Next, the hospitals for which data were reported by the AABB were removed. This left a roster of approximately 3800 non-AABB hospitals in which transfusions were likely to have occurred. We designed and developed a random sample of these hospitals on the basis of a 63-cell matrix of nine U.S. census regions and seven categories of hospital size, as determined by the number of beds. Approximately half the hospitals with fewer than 200 beds and all those with 200 or more beds were mailed survey questionnaires. To ensure comparability with the survey data of the AABB, the queries and definitions were taken from the association's annual institutional-membership questionnaire; to encourage responses, however, only certain questions were asked. The first questionnaire sought responses for 1982 and 1984; the second requested information for 1986 and 1987. The survey methods did not change with time. Hospitals that did not respond and that had more than 200 beds were contacted by telephone; a second questionnaire was mailed to all nonresponding hospitals. The average response rates for the surveys are shown in Table 1Table 1
Average Response Rates in Four Surveys of Non-AABB Hospitals, According to Hospital Size.*.We tested for bias in the surveys created by failure to respond to the questionnaire by characterizing the responding and nonresponding hospitals in each size category on the basis of four variables: the number of surgical procedures performed, the total number of inpatient days, the number of full-time-equivalent physicians, and the number of full-time-equivalent personnel. The values for these variables for each hospital were taken from the American Hospital Association data tapes. Standard t-tests for the differences in means between responding and nonresponding hospitals, with P≤0.05 as the principal criterion, revealed no statistically significant differences in the means for the number of surgical operations, the variable known to be correlated most closely with transfusion activity (unpublished data), and no statistically significant differences in 10 of 12 pairs of means for the other variables. On the basis of this and other evidence, we conclude that in the aggregate there was no evidence of a nonresponder bias in the surveys of non-AABB hospitals. If there was such a bias, it was small and unimportant in relation to the estimates of blood transfusions and collections reported nationally.
Merged Hospital Study Files
For each study year, the files for the AABB and non-AABB hospitals were merged. The character of the resulting file reflected both the differences in the mix of hospitals in the two source files, and the differences in the source of the data — from reporting hospitals in the case of the AABB file, and from responding hospitals within the survey sample in the case of the non-AABB file. Some characteristics of these merged hospital files and the distribution of the transfusions of whole blood and red cells reported for the United States in 1987 are shown in Table 2Table 2
Distribution, According to Hospital Size, of the Hospitals in the Merged File Used to Prepare Estimates of Transfusion and Collection Activities Nationwide, and of Total Transfusions of Whole Blood and Red Cells in the United States in 1987.*. These files were used to estimate hospital activities in the United States.Estimating Hospital Transfusions and Collections
For each transfusion or collection activity to be estimated, the data in the merged files for each study year were distributed across the 63-cell matrix — nine U.S. census regions times seven sizes of hospitals. Each cell contained the mean activity, the standard deviation of the mean, and the number of hospitals in the cell. A second 63-cell matrix contained the weights for each cell, expressed as the ratio of the number of hospitals in the cell to the total number of hospitals performing transfusions in the United States in the same cell. The two matrixes were combined for each activity for each study year by multiplying the cell means by the cell weights and summing the results to produce a weighted grand mean for the activity. The weighted grand mean was then multiplied by the total number of hospitals performing transfusions in the United States to yield the estimated annual activity. A similar although more complex procedure of weighting and analysis was used to arrive at the standard deviations of the grand mean, in order to establish the 95 percent confidence limits for each activity.
Activities in 1988
Since no survey of non-AABB hospitals was conducted in 1988, the estimates of certain transfusion activities in 1988 are expressed as percentage changes from 1987 to 1988. These are based on measures of the supply of transfusible units that were sent to and retained at hospitals by 85 regional blood centers, which distributed approximately half the reported whole-blood and red-cell units transfused in 1987. Thus, they only approximate the actual transfusion activities. No projection of the corresponding U.S. activities for 1988 on the basis of these 1987-to-1988 trends was warranted. Collections at regional blood centers were estimated from reports by 136 centers that made 91.4 percent of U.S. blood-center collections in 1987. The number of blood collections made by hospitals in 1988 was projected by linear regression from the survey findings for this function for the period 1982 through 1987.
Definitions and Terminology
The estimates given are for calendar years, and they are expressed in units equivalent to a single blood donation, except where otherwise indicated. Whole blood and red cells includes all units of homologous, autologous, and imported whole blood, modified whole blood, packed red cells, frozen-thawed red cells, white-cell-poor red cells, and washed red cells. Plasma includes all units of thawed fresh-frozen plasma and those of liquid plasma from a single donor. Total platelets includes all units of platelet concentrate plus six times the number of units of single-donor platelets; the quantity was estimated from the data reported by the hospital. It is not the arithmetic sum of platelet concentrates and single-donor platelets times six. Platelet concentrates refers to platelets prepared from collections from random single donors. Apheresis platelets includes the quantity of platelets obtained from apheresis involving a single donor. The proportion of platelets transfused as apheresis platelets is expressed as the percentage of single-donor platelets times six in the total platelets. Homologous-blood collections are expressed as standard 450-ml units of blood. "European blood" refers to units of packed red cells from blood donated voluntarily and collected in Western Europe. Very little blood is currently exported from the United States. The number of autologous units donated was reported separately. The supply of homologous units was the sum of the domestic collections and the imports of European blood. The net excess of collections over transfusions of whole blood and red cells was taken as the difference between the total collections and the total transfusions, where total collections was the sum of the homologous-blood supply plus the number of autologous units. Population data were obtained from the Statistical Abstract of the United States.4
Results
The findings from 1982 through 1987 are summarized in Table 3Table 3
Estimates of the Amount of Blood and Blood Components Used in Transfusions and of the Amount of Homologous and Autologous Blood Collected.*, together with the corresponding data from the 1980 survey conducted by the National Heart, Lung, and Blood Institute.3 The estimates of the number of units of whole blood and red cells transfused in 1982 were 15 percent greater than was reported in the 1980 survey. The rate of growth of transfusions declined to 4.5 percent between 1982 and 1984, then to 1.5 percent between 1984 and 1986. A peak of 12,159,000 units was registered in 1986. The number of transfusions then declined by half a million units to 11,612,000 units in 1987. The distribution of the 1987 whole-blood and red-cell transfusions according to hospital size is shown in Table 2. In the case of transfusions of plasma, the trend resembled that of transfusions of red cells, except that the peak occurred in 1984. A modest decline was registered after 1984. The number of units of platelets transfused grew vigorously until 1986, but only slightly between 1986 and 1987. Steady growth in the use of single-donor platelets was evident from 1980 to 1988. Transfusions of platelet concentrate reached a peak in 1986 and then declined in 1987. As a result, the proportion of platelets transfused as single-donor platelets increased from 11 to 25 percent between 1980 and 1987.Although the total collections of homologous blood in the United States in 1982 were 14 percent higher than was reported in the 1980 survey conducted by the National Heart, Lung, and Blood Institute, they increased by less than 8 percent between 1982 and 1986. The number of collections was flat between 1986 and 1988. The number of collections by regional blood centers increased until 1986 but was level between 1986 and 1988. The number of collections of homologous units by hospitals peaked in 1982 and then declined steadily through 1987. In a reflection of these dynamics, the proportion of U.S. blood donations collected by regional blood centers increased from 89 percent in 1982 to 90 percent in 1987. Imports of European blood ranged from a low of 232,000 in 1988 to a high of 287,000 in 1984, with no consistent trend. The ratio of the supply of homologous blood to transfusions of whole blood and red cells decreased between 1980 and 1984 but increased again between 1984 and 1987.
Donations of autologous blood by patients preparing to undergo elective surgery accelerated rapidly after 1984; the number of donations in 1987 was almost double that in 1986. During this period, half the predeposits were made in hospitals and half in regional blood centers. In 1987, autologous donations were equivalent to 3 percent of homologous-blood collections. The net excess of the total blood supply over the units of whole blood and red cells actually transfused was constant at 1.2 million units between 1980 and 1984. It increased to 2.3 million units in 1987. In accordance with these changes, the proportion of the blood collected that was not transfused increased from 9.5 percent in 1982 to 17.5 percent in 1987.
The transfusion and collection rates, expressed in units per 1000 population, take into account the population increase between 1971 and 1987; they are shown in Figure 1Figure 1
Rates of Blood Collection and Transfusion in the United States, 1971 to 1987.. These rates accentuate the magnitude of the changes that have occurred since 1984.When the transfusion rates were analyzed according to census region, large differences between regions were evident (Fig. 2Figure 2
Rates of Transfusion, According to Region.). In 1987 the ratio of the highest to the lowest rate5 was 1.59 for whole-blood and red-cell transfusions (57.1 units per 1000 population in New England vs. 35.8 in the Mountain region). For plasma transfusions, the ratio was 1.73 (11.1 units per 1000 population in the East South Central region vs. 6.4 in the Pacific region). For transfusions of total platelets, the ratio was 1.93 (31.2 units per 1000 in the mid-Atlantic region vs. 16.8 in the Mountain region). Longitudinally, the national trend toward lower rates of transfusion of red cells between 1984 and 1987 was reflected in every census region. With the exception of the East South Central region, the regions had rates that reflected the downward national trend in rates of plasma transfusions. In every census region, the number of autologous collections by hospitals increased rapidly, although differences among regions in 1987 were pronounced; the ratio of the highest to the lowest rate was 7.86 (1.73 in New England vs. 0.22 in the East South Central region). It was not possible to obtain a breakdown of blood collections according to census region, because several regional blood centers collect blood in more than one census region.Between 1987 and 1988 (Table 4Table 4
Measures of Transfusion and Blood-Collection Activity in 1988, as Estimated from Operational Data for 1987 and 1988 from Regional Blood Centers.), the number of estimated transfusions of whole blood and red cells diminished by 0.8 percent. The number of transfusions of plasma declined by 2.4 percent. The use of platelet concentrate was essentially unchanged, but the use of single-donor platelets increased by 21 percent. Homologous-blood collections by hospitals and regional blood centers continued their downward trend in 1988.Discussion
The practice of blood transfusion has grown vigorously in the United States since the organized collection of blood for use in transfusion to civilians began in 1947. By 1987 the cost of collecting, processing, and transfusing some 20 million units of blood and components to patients reached approximately $3.25 billion. The first survey of the national blood supply and its use was made under the sponsorship of the National Heart and Lung Institute in 1971.6 The next two surveys, sponsored by the National Heart, Lung, and Blood Institute in 1979 and 1980,3 revealed that the number of transfusions of blood and blood components had doubled between 1971 and 1980. At no time during that period was there any indication that the growth in transfusions had slowed. Now, however, confirming indications from our preliminary study in four sets of hospitals,7 we find that there have been unprecedented changes in the dynamics of transfusion in the United States.
The magnitude of these changes is remarkable. The linear projection of the national rates of red-cell transfusion registered between 1971 and 1984 suggests that the 1987 rate was 15 percent lower than could have been expected if the historic growth in transfusion rates had been sustained (Fig. 1). Moreover, changes in the distribution of transfusible products by regional blood centers indicate that the trends observed between 1984 and 1987 continued into 1988. Given the absence of accompanying overt changes in the dynamics of the diseases for which transfusions are indicated or in the availability of alternatives to human blood, the downturn in transfusion rates reported here strongly implies that physicians and surgeons have been modifying their practice by using less blood and giving transfusions to fewer patients. In the absence of any indications that patient outcomes have been adversely affected, this supports suggestions that there may be latitude in the decision to administer transfusions.13
These new studies do not identify the underlying causes of these changes. Their synchrony with the onset and development of the epidemic of the acquired immunodeficiency syndrome (AIDS) is notable, however. Evidence of antibodies to HIV in recipients of blood products began to appear in 1983.8 , 9 In January 1984, HIV type 1 was shown to be transmissible by blood transfusion.10 The testing of all units of donated blood for antibodies to HIV began in 1985.11 The resulting "look back" to identify patients who may have received anti-HIV—positive blood units and the many ensuing court cases have kept the issue of the transfusibility of HIV before the public almost constantly. Even today, public fears about the safety of transfusions remain widespread.2
This suggested relation between the AIDS epidemic and the downturn in the number of transfusions of blood and its components in the United States is supported by other findings from the new surveys. These include the sharp upswing in donations of autologous blood beginning in 1984 (which are made primarily to reduce the risk of HIV) and evidence of increases in the intraoperative salvage of blood. The strong trend toward a preference for the use of platelets obtained from the apheresis of a single donor for platelet therapy, even if it occurs partly for other reasons, represents a gain in the safety of transfusions. These moves are impressive evidence of the concerns of physicians for the safety of patients.
Support for reconsideration of the basic indications for many transfusions is mounting. The report of a 1984 consensus-development conference of the National Institutes of Health entitled "Fresh Frozen Plasma: Indications and Risks" concluded that plasma should not be used as a volume expander or a nutritional source.12 The small decline reported here in the number of plasma transfusions between 1984 and 1988 amounts to the first evidence of a response to the recommendations of this conference. A 1988 conference on perioperative red-cell transfusion questioned the clinical guideline that red cells or whole blood should be transfused when the hemoglobin level is below 10 g per deciliter or the hematocrit less than 30 percent. It concluded that "there is no evidence that mild to moderate anemia contributes to perioperative morbidity."13
The validity of these questions about the appropriateness of many blood transfusions is strengthened by the continued finding of wide differences in transfusion rates among the nine census regions, an issue that was first uncovered in the surveys conducted by the National Heart, Lung, and Blood Institute.3 The underlying causes of these differences have not been identified. One likely cause stems from regional differences in the rates at which the medical and surgical interventions that require transfusion support are used. Chassin et al.5 recently described large geographic differences in the use of medical and surgical procedures in Medicare patients in 13 geographic areas (not the census regions) in the United States. Among the procedures investigated were total knee replacement, total hip replacement, and coronary bypass surgery, in all of which blood transfusion is required for support. Could the regional differences in transfusion rates have resulted from an uneven geographic distribution of the major centers at which very large amounts of blood and blood components are transfused? We consider this unlikely to be a factor contributing to the differences in red-cell transfusion rates. Units of whole blood and red cells are given in transfusion in relatively small numbers to very large numbers of patients.14 Furthermore, the number of hospitals that use a large amount of blood in the provision of complex care is relatively large; in 1980 we identified more than 1000 hospitals in that category.3 For the transfusion rates of platelets, however, the situation might be different. In bone marrow transplantation, platelet transfusions commonly require more units per patient than do red-cell transfusions, by an order of magnitude. Moreover, the number of centers of bone marrow transplantation is small. It is possible that regional differences in transfusion rates of platelets were affected by these factors.
What about the adequacy of the national blood supply during the period we have studied? Our data provide several insights into this question. Since transfusions of whole blood and red cells are the driving force behind the demand for blood in the United States, the net excess of collections over transfusions of red-cell products provides a rough measure of the adequacy of the blood supply (Table 3). It must be noted, however, that this net excess includes units rejected during laboratory testing, autologous units not transfused, outdated units, and units lost or not accounted for. We do not know how small the net excess can be in proportion to the total blood supply before serious shortages are incurred. This is affected by special demands for type O units and by the relative excess of units of the other blood types. Whatever the case, the net excess did not fall below 9.3 percent of the total supply between 1980 and 1987. The size of the excess in 1987 requires special comment. Late in 1986, U.S. blood-collecting agencies began surrogate testing of all donated units for alanine aminotransferase and hepatitis B core antigen, the markers associated with non-A, non-B hepatitis. This resulted in the exclusion of an additional 5 to 6 percent of all units of blood. Thus, the sharp increase in net excess in 1987 did not represent an increase in the supply of transfusible blood. We conclude that there was a safe excess of blood throughout the study period. Nevertheless, the apparent existence of net excesses of more than 1.5 million units of blood in 1986 and 1987 would seem to warrant careful scrutiny.
Our findings strongly suggest that the absence of severe national shortages of blood after 1984 should be attributed to the sharp downturn in the rate of transfusions of whole blood and red cells in the United States that was registered in our surveys, to the sharp upswing in donations of autologous blood by patients scheduled to undergo elective surgery, and to the steady inflow of European blood, rather than to successes in the collection of homologous blood.
Supported by a grant (HL-33774) from the National Institutes of Health.
We are indebted to the late David D. Rutstein, M.D., and to Bruce Evatt, M.D., for advice on the conduct of these studies; to Vahid Lotfi, Ph.D., for suggestions concerning the design of the surveys of non-AABB hospitals; to Martha Gilpatrick, M.D., Suzanne G. Hale, M.B.A., and Maria Gluch for assistance in the administration of the survey questionnaire for non-AABB hospitals; and to the AABB, the American Red Cross, and the Council of Community Blood Centers for permitting us to use their data.
Source Information
From the Center for Blood Research and Harvard Medical School, Boston (D.MacN.S., R.H.C.); the School of Management, State University of New York at Buffalo (E.L.W., S.H.S.H.); and the Center for Management Systems, Williamsville, N.Y. (E.L.W.). Address reprint requests to Dr. Surgenor at the Center for Blood Research, 800 Huntington Ave., Boston, MA 02115.
- References
References
1
Dawson DA, Cynamon M, Fitti JE. AIDS knowledge and attitudes: provisional data from the National Health Interview Survey: United States. Advance data from vital and health statistics. No. 146. Hyattsville, Md.: Department of Health and Human Services, 1987:2–10. (DHHS publication no. (PHS) 88–1250.)
2
Dawson DA. AIDS knowledge and attitudes for January-March 1989: provisional data from the National Health Interview Survey. Advance data from vital and health statistics. No. 176. Hyattsville, Md.: Department of Health and Human Services, 1989. (DHHS publication no. (PHS) 89–1250.)
3
Surgenor DM, Schnitzer SS. The nation's blood resource: a summary report. Bethesda, Md.: National Institutes of Health, 1985. (NIH publication no. 85–2028.)
4
Bureau of the Census. Statistical abstract of the United States: 1989. 109th ed. Washington, D.C: Government Printing Office, 1989.
5
Chassin
Full Text | Web of Science | Medline6
Summary report: NHLI's blood resource studies. Bethesda, Md.: National Institutes of Health, 1972. (DHEW publication no. (NIH) 73–416.)
7
Surgenor
CrossRef | Web of Science | Medline8
Essex
CrossRef | Web of Science | Medline9
Evatt
CrossRef | Web of Science | Medline10
Curran
Full Text | Web of Science | Medline11
The impact of routine HTLV-III antibody testing of blood and plasma donors on public health . JAMA 1986; 256:1778–83.
CrossRef | Web of Science12
Fresh-frozen plasma: indications and risks . JAMA 1985; 253:551–3.
CrossRef | Web of Science13
Perioperative red blood cell transfusion . JAMA 1988; 260:2700–3.
CrossRef | Web of Science14
Surgenor
CrossRef | Web of Science | Medline
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CrossRef28
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CrossRef37
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CrossRef38
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CrossRef40
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CrossRef41
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David Cella, Dominique Bron. (1999) The Effect of Epoetin alfa on Quality of Life in Anemic Cancer Patients. Cancer Practice 7:4, 177-182
CrossRef43
Goodnough, Lawrence T., Brecher, Mark E., Kanter, Michael H., AuBuchon, James P., . (1999) Transfusion Medicine — Blood Transfusion. New England Journal of Medicine 340:6, 438-447
Full Text44
M-D. Levin, W. de Vries, J. de Veld, D. Doekharan, B. van der Holt, M. B. van 'T Veer. (1999) Platelet-bound immunogloblins before and after platelet transfusion: measurement of in vivo binding. British Journal of Haematology 104:2, 397-402
CrossRef45
Saroj Vadhan-Raj, Laura M. Currie, Carlos Bueso-Ramos, Stephen A. Livesey, Jerome Connor. (1999) Enhanced retention of in vitro functional activity of platelets from recombinant human thrombopoietin-treated patients following long-term cryopreservation with a platelet-preserving solution (ThromboSol) and 2% DMSO. British Journal of Haematology 104:2, 403-411
CrossRef46
D. S. Palmer, M. T. Aye, L. Dumont, D. Dumont, N. McCombie, A. Giulivi, B. Rutherford, E. Trudel, S. Hashemi-Tavoularis. (1998) Prevention of Cytokine Accumulation in Platelets Obtained with the COBE Spectra Apheresis System. Vox Sanguinis 75:2, 115-123
CrossRef47
Bruce D. Spiess, Catherine Ley, Simon C. Body, Lawrence C. Siegel, E.Price Stover, Rosemarie Maddi, Michael D'Ambra, Uday Jain, Fong Liu, Ahvie Herskowitz, Dennis T. Mangano, Jack Levin. (1998) Hematocrit value on intensive care unit entry influences the frequency of Q-wave myocardial infarction after coronary artery bypass grafting. The Journal of Thoracic and Cardiovascular Surgery 116:3, 460-467
CrossRef48
Stephanie J. Lee, Bengt Liljas, Peter J. Neumann, Milton C. Weinstein, Magnus Johannesson. (1998) The Impact of Risk Information on Patients' Willingness to Pay for Autologous Blood Donation. Medical Care 36:8, 1162-1173
CrossRef49
Mark H. Schwartz, Paul I. Tartter. (1998) Decreased Length of Stay for Patients with Colorectal Cancer: Implications of DRG Use. Journal for Healthcare Quality 20:4, 22-25
CrossRef50
Pinkerton, Tasev, Coovadia. (1998) Changes in red-cell transfusion practice in a tertiary care hospital during the 1990s ? a 7-year study. Transfusion Medicine 8:3, 179-184
CrossRef51
Lars L. Mielke, Elmar K. Entholzner, Michael Kling, Barbara E. M. Breinbauer, Rainer Burgkart, Stefan R. Hargasser, Rudolf F. J. Hipp. (1997) Preoperative Acute Hypervolemic Hemodilution with Hydroxyethylstarch. Anesthesia & Analgesia 84:1, 26-30
CrossRef52
Niki M. Dietz, Michael J. Joyner, Mark A. Warner. (1996) Blood Substitutes. Anesthesia & Analgesia 82:2, 390-405
CrossRef53
Dennis F. Landers, Gary E. Hill, K. C. Wong, Ira J. Fox. (1996) Blood Transfusion-Induced Immunomodulation. Anesthesia & Analgesia 82:1, 187-204
CrossRef54
Eleftherios C. Vamvakas. (1996) Epidemiology of red blood cell utilization. Transfusion Medicine Reviews 10:1, 44-61
CrossRef55
Lackritz, Eve M., Satten, Glen A., Aberle-Grasse, John, Dodd, Roger Y., Raimondi, Vincent P., Janssen, Robert S., Lewis, W. Frank, Notari, Edward P., Petersen, Lyle R., . (1995) Estimated Risk of Transmission of the Human Immunodeficiency Virus by Screened Blood in the United States. New England Journal of Medicine 333:26, 1721-1725
Full Text56
Terri G. Monk, Lawrence T. Goodnough. (1995) Blood conservation strategies to minimize allogeneic blood use in urologic surgery. The American Journal of Surgery 170:6, S69-S73
CrossRef57
M. R. Ravry, H. L. Paz. (1995) The impact of HIV testing on blood utilization in the intensive care unit in patients with gastrointestinal bleeding. Intensive Care Medicine 21:11, 933-936
CrossRef58
E.L. Wallace, W.H. Churchill, D.M. Surgenor, J. An, G. Cho, S. McGurk, L. Murphy. (1995) Collection and transfusion of blood and blood components in the United States, 1992. Transfusion 35:10, 802-812
CrossRef59
Randal S. Weber. (1995) A model for predicting transfusion requirements in head and neck surgery. The Laryngoscope 105:S2, 1-17
CrossRef60
Joseph T. Santoso, David W. Lin, David S. Miller. (1995) Transfusion Medicine in Obstetrics and Gynecology. Obstetrical & Gynecological Survey 50:6, 470-481
CrossRef61
Peter E. Keipert. (1995) Use of Oxygent™ , A Perfluorochemical-Based Oxygen Carrier, as An Alternative to Intraoperative Blood Transfusion. Artificial Cells, Blood Substitutes and Biotechnology 23:3, 381-394
CrossRef62
Louis Vaickus, James B. Breitmeyer, Robert L. Schlossmann, Kenneth C. Anderson. (1995) Platelet transfusion and alternatives to transfusion in patients with malignancy. Stem Cells 13:6, 588-596
CrossRef63
L.R. PETERSEN, E. LACKRITZ, W.F. LEWIS, D.S. SMITH, G. HERRERA, V. RAIMONDI, J. ABERLE-GRASSE, R.Y. DODD. (1994) The effectiveness of the confidential unit exclusion option. Transfusion 34:10, 865-869
CrossRef64
A Ballin, G Kenet, R Gutman, Z Samra, H Zakut, D Meytes. (1994) Autologous cord blood transfusion. Acta Paediatrica 83:7, 700-703
CrossRef65
H. G. Klein. (1994) Oxygen Carriers and Transfusion Medicine. Artificial Cells, Blood Substitutes and Biotechnology 22:2, 123-135
CrossRef66
S.Jody Heymann, Timothy F. Brewer. (1993) The infectious risks of transfusions in the United States: A decision-analytic approach. American Journal of Infection Control 21:4, 174-182
CrossRef67
William C. Sherwood. (1993) Donor Deferral Registries. Transfusion Medicine Reviews 7:2, 121-128
CrossRef68
H. Franklin Bunn. (1993) The use of hemoglobin as a blood substitute. American Journal of Hematology 42:1, 112-117
CrossRef69
David COGHLAN, Gareth JONES, Katharine A. DENTON, Michael T. WILSON, Bernard CHAN, Roy HARRIS, John R. WOODROW, Jill E. OGDEN. (1992) Structural and functional characterisation of recombinant human haemoglobin A expressed in Saccharomyces cerevisiae. European Journal of Biochemistry 207:3, 931-936
CrossRef70
Jill E. Ogden. (1992) Recombinant haemoglobin in the development of red-blood-cell substitutes. Trends in Biotechnology 10, 91-96
CrossRef71
Steven R. Eastaugh. (1991) Valuation of the Benefits of Risk-free Blood: Willingness to Pay for Hemoglobin Solutions. International Journal of Technology Assessment in Health Care 7:01, 51
CrossRef72
Charache, Samuel, . (1990) Problems in Transfusion Therapy. New England Journal of Medicine 322:23, 1666-1668
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