***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: UNLABELLED Bleeding is a feared complication of invasive procedures in patients with cirrhosis and significant coagulopathy ( as defined by routine coagulation tests ) and is used to justify preprocedure use of fresh frozen plasma ( FFP ) and /or platelets ( PLT ) . Thromboelastography ( TEG ) provides a more comprehensive global coagulation assessment than routine tests ( international normalized ratio [ INR ] and platelet count ) , and its use may avoid unnecessary blood product transfusion in patients with cirrhosis and significant coagulopathy ( defined in this study as INR > 1.8 and /or platelet count < 50 × 10(9 ) /L ) who will be undergoing an invasive procedure . Sixty patients were r and omly allocated to  TEG-guided transfusion strategy or st and ard of care ( SOC ; 1:1 TEG : SOC ) . The TEG group would receive FFP if the reaction time ( r ) was > 40 min and /or PLT if maximum amplitude ( MA ) was < 30 mm . All SOC patients received FFP and /or PLT per hospital guidelines . Endpoints were blood product use and bleeding complications . Baseline characteristics of the two groups were similar . Per protocol , all subjects in the SOC group received blood product transfusions versus 5 in the TEG group ( 100 % vs. 16.7 % ; P < 0.0001 ) . Sixteen SOC ( 53.3 % ) received FFP , 10 ( 33.3 % ) PLT , and 4 ( 13.3 % ) both FFP and PLT . In the TEG group , none received FFP alone ( P < 0.0001 vs. SOC ) , 2 received PLT ( 6.7 % ; P = 0.009 vs. SOC ) , and 3 both FFP and PLT ( not significant ) . Postprocedure bleeding occurred in only 1 patient ( SOC group ) after large-volume paracentesis . CONCLUSIONS In patients with cirrhosis and significant coagulopathy before invasive procedures , TEG-guided transfusion strategy leads to a significantly lower use of blood products compared to SOC ( transfusion guided by INR and platelet count ) , without an increase in bleeding complications . Remarkably , even in patients with significant coagulopathy , postprocedure bleeding was rare , indicating that TEG thresholds should be reevaluated Background Abnormal bleeding after cardiopulmonary bypass ( CPB ) is a common complication of cardiac surgery , with important health and economic consequences . Coagulation test – based algorithms may reduce transfusion of non-erythrocyte allogeneic blood in patients with abnormal bleeding . Methods The authors performed a r and omized prospect i ve trial comparing allogeneic transfusion practice s in 92 adult patients with abnormal bleeding after CPB . Patients with abnormal bleeding  were r and omized to one of two groups : a control group following individual anesthesiologist ’s transfusion practice s and a protocol group using a transfusion algorithm guided by coagulation tests . Results Among 836 eligible patients having all types of elective cardiac surgery requiring CPB , 92 patients developed abnormal bleeding after CPB ( incidence , 11 % ) . The transfusion algorithm group received less allogeneic fresh frozen plasma in the operating room after CPB ( median , 0 units ; range , 0–7 units ) than the control group ( median , 3 units ; range , 0–10 units ) ( P = 0.0002 ) . The median number of platelet units transfused in the operating room after CPB was 4 ( range , 0–12 ) in the algorithm group compared with 6 ( range , 0–18 ) in the control group ( P = 0.0001 ) . Intensive care unit ( ICU ) mediastinal blood loss was significantly less in the algorithm group . Multivariate analysis demonstrated that transfusion algorithm use result ed in reduced ICU blood loss . The control group also had a significantly greater incidence of surgical reoperation of the mediastinum for bleeding ( 11.8%vs . 0%;P = 0.032 ) . Conclusions Use of a coagulation test – based transfusion algorithm in cardiac surgery patients with abnormal bleeding after CPB  reduced non-erythrocyte allogeneic transfusions in the operating room and ICU blood loss Introduction : The current investigation aim ed to study the efficacy of hemostatic therapy guided either by conventional coagulation analyses or point-of-care ( POC ) testing in coagulopathic cardiac surgery patients . Methods : Patients undergoing complex cardiac surgery were assessed for eligibility . Those patients in whom diffuse bleeding was diagnosed after heparin reversal or increased blood loss during the first 24 postoperative hours were enrolled and r and omized to the conventional or  POC  group . Thromboelastometry and whole blood impedance aggregometry have been performed in the POC group . The primary outcome variable was the number of transfused units of packed erythrocytes during the first 24 h after inclusion . Secondary outcome variables included postoperative blood loss , use and costs of hemostatic therapy , and clinical outcome parameters . Sample size analysis revealed a sample size of at least 100 patients per group . Results : There were 152 patients who were screened for eligibility and 100 patients were enrolled in the study . After r and omization of 50 patients to each group , a planned interim analysis revealed a significant difference in erythrocyte transfusion rate in the conventional compared with the POC group [ 5 ( 4;9 ) versus 3 ( 2;6 ) units [ median ( 25th and 75th percentile ) ] , P < 0.001 ] . The study was terminated early . The secondary outcome parameters of fresh frozen plasma and platelet transfusion rates , postoperative mechanical ventilation time , length of intensive care unit stay , composite adverse events rate , costs of hemostatic therapy , and 6-month mortality were lower in the POC group . Conclusions : Hemostatic therapy based on POC testing reduced patient exposure to allogenic blood products and provided significant benefits with respect to clinical outcomes Background : Massive transfusion protocol s ( MTPs ) have become st and ard of care in the management of bleeding injured patients , yet strategies to guide them vary widely . We conducted a pragmatic , r and omized clinical trial ( RCT ) to test the hypothesis that an MTP goal directed by the viscoelastic assay thrombelastography ( TEG ) improves survival compared with an MTP guided by conventional coagulation assays ( CCA ) . Methods : This RCT enrolled injured patients from an academic level-1 trauma center meeting criteria for MTP activation . Upon MTP activation , patients were r and omized to be managed either by an MTP goal directed by TEG or by CCA ( ie , international normalized ratio , fibrinogen , platelet count ) . Primary outcome was 28-day survival . Results : One hundred eleven patients were included in an intent-to-treat analysis ( TEG = 56 , CCA = 55 ) . Survival in the TEG group was significantly higher than the CCA group ( log-rank P = 0.032 , Wilcoxon P = 0.027 ) ; 20 deaths in the CCA group ( 36.4 % ) compared with 11 in the TEG group ( 19.6 % ) ( P = 0.049 ) . Most deaths occurred within the first 6 hours from arrival ( 21.8 % CCA group vs 7.1 % TEG group ) ( P = 0.032 ) . CCA patients required similar number of red blood cell units as the TEG patients [ CCA : 5.0 ( 2–11 ) , TEG : 4.5 ( 2–8 ) ] ( P = 0.317 ) , but more plasma units [ CCA : 2.0 ( 0–4 ) , TEG : 0.0 ( 0–3 ) ] ( P = 0.022 ) , and more platelets units [ CCA : 0.0 ( 0–1 ) , TEG : 0.0 ( 0–0 ) ] ( P = 0.041 ) in the first 2 hours of resuscitation . Conclusions : Utilization of a goal -directed , TEG-guided MTP to resuscitate severely injured patients improves survival compared with an MTP guided by CCA and utilizes less plasma and platelet transfusions during the early phase of resuscitation Flaws in the design , conduct , analysis , and reporting of r and omised trials can cause the effect of an intervention to be underestimated or overestimated . The Cochrane Collaboration ’s tool for assessing risk of bias aims to make the process clearer and more Background Postpartum hemorrhage ( PPH ) is the leading cause of maternal mortality in Sub-Saharan-Africa ( SSA ) . Although clinical guidelines treating PPH are available , their implementation remains a great challenge in re source poor setting s. A better underst and ing of the factors associated with PPH maternal mortality is critical for preventing risk of hospital-based maternal death . The purpose of this study was thus to assess which factors contribute to maternal death occurring during PPH . The factors were as follows : women ’s characteristics , aspects of pregnancy and delivery ; components of PPH management ; and organizational characteristics of the referral hospitals in Senegal and Mali . Methods A cross-sectional survey nested in a cluster r and omized trial ( QUARITE trial ) was carried out in 46 referral hospitals during the pre-intervention period from October 2007 to September 2008 in Senegal and Mali . Individual and hospital characteristics data were collected through st and ardized question naires . A multivariable logistic mixed model was used to identify the factors that were significantly associated with PPH maternal death . Results Among the 3,278 women who experienced PPH , 178 ( 5.4 % ) of them died before hospital discharge . The factors that were significantly associated with PPH maternal mortality were : age over 35 years ( adjusted OR = 2.16 [ 1.26–3.72 ] ) , living in Mali ( adjusted OR = 1.84 [ 1.13–3.00 ] ) , residing outside the region location of the hospital ( adjusted OR = 2.43 [ 1.29–4.56 ] ) , pre-existing chronic disease before pregnancy  ( adjusted OR = 7.54 [ 2.54–22.44 ] ) , prepartum severe anemia  ( adjusted OR = 6.65 [ 3.77–11.74 ] ) ,  forceps or vacuum delivery ( adjusted OR = 2.63 [ 1.19–5.81 ] ) ,  birth weight greater than 4000 grs ( adjusted OR = 2.54 [ 1.26–5.10 ] ) , transfusion ( adjusted OR = 2.17 [ 1.53–3.09 ] ) , transfer to another hospital ( adjusted OR = 13.35 [ 6.20–28.76 ] ) . There was a smaller risk of PPH maternal death in hospitals with gynecologist-obstetrician ( adjusted OR = 0.55 [ 0.35–0.89 ] ) than those with only a general practitioner trained in emergency obstetric care ( EmOC ) . Conclusions Our findings may have direct implication s for preventing PPH maternal death in re source poor setting s. In particular , we suggest anemia should be diagnosed and treated before delivery and inter-hospital transfer of women should be improved , as well as the management of blood banks for a quicker access to transfusion . Finally , an extent training of general practitioners in EmOC would contribute to the decrease of PPH maternal mortality BACKGROUND Using algorithms based on point of care coagulation tests can decrease blood loss and blood component transfusion  after cardiac surgery . We wished to test the hypothesis that a management algorithm based on near-patient tests would reduce blood loss and blood component use after routine coronary artery surgery with cardiopulmonary bypass when compared with an algorithm based on routine laboratory assays or with clinical judgement . METHODS Patients ( n=102 ) undergoing elective coronary artery surgery with cardiac bypass were r and omized into two groups . In the point of care group , the management algorithm was based on information provided by three devices , the Hepcon , thromboelastography and the PFA-100 platelet function analyser . Management in the laboratory test group depended on rapidly available laboratory clotting tests and transfusion of haemostatic blood components only if specific criteria were met . Blood loss and transfusion was compared between these two groups and with a retrospective case-control group ( n=108 ) , in which management of bleeding had been according to the clinician 's discretion . RESULTS All three groups had similar median blood losses . The transfusion of packed red blood cells ( PRBCs ) and blood components was greater in the clinician discretion group ( P<0.05 ) but there was no difference in the transfusion of PRBCs and blood components between the two algorithm-guided groups . CONCLUSION Following algorithms based on point of care tests or on structured clinical practice with st and ard laboratory tests does not decrease blood loss , but reduces the transfusion of PRBCs and blood components after routine cardiac surgery , when compared with clinician discretion . Cardiac surgery services should use transfusion guidelines based on laboratory-guided algorithms , and the possible benefits of point of care testing should be tested against this st and ard OBJECTIVE To investigate if the use of preoperative platelet function testing ( PFT ) as part of a transfusion algorithm reduced blood product usage in coronary artery bypass surgery ( CABG ) . DESIGN Prospect i ve , r and omized , controlled trial . SETTING A cardiothoracic hospital . PARTICIPANTS 249 patients having CABG surgery . INTERVENTIONS The patients were allocated r and omly to PFT preoperatively with Multiple Electrode Aggregometry ( MEA , Group A ) , TEG 
    Output:
    
Although blood product use was reduced , rates of mortality remained comparable between the TEG group and control group .
Conclusions This systematic review and analysis indicate that TEG‐guided hemostatic therapy can enhance blood product management and improve key patient outcomes , including LoS , bleeding rate , and mortality