***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: A multicenter , r and omized , open-label , parallel-group study was conducted to compare the safety and efficacy of perioperative recombinant human erythropoietin ( Epoetin alfa ) with the safety and efficacy of preoperative autologous donation ( PAD ) in total joint arthroplasty . A total of 490 patients scheduled for total joint ( i.e. , hip or knee ) surgery and having hemoglobin ( Hb ) levels > or = 11 to < or = 13 g/dL were r and omized to receive weekly doses of subcutaneous Epoetin alfa on preoperative Days -21 , -14 , and -7 , and on the day of surgery , or to participate in a PAD program . The mean baseline Hb level in both groups was 12.3+/-0.6 g/dL , increasing to 13.8 g/dL in the Epoetin alfa-treated group and decreasing to 11.1 g/dL in the PAD group before or on the day of surgery . In the PAD group , 156/219 ( 71.2 % ) patients were transfused with autologous blood , and 42/219 ( 19.2 % ) patients were transfused with allogeneic blood . A smaller proportion , 27/209 ( 12.9 % ) patients , in the Epoetin alfa-treated group were transfused with allogeneic blood ( P = .078 compared with the PAD group ) . Moreover , patients in the PAD group received a total of 325 units of blood ( 79 allogeneic units and 246 autologous units ) compared with patients in the Epoetin alfa group who received a total of 54 units of blood . The mean postoperative Hb level was 11.0 g/dL in the Epoetin alfa-treated group and 9.2 g/dL in the PAD group . Compared with the PAD arm , mean Hb levels measured preoperatively , postoperatively on Day 1 , and at discharge visits were significantly greater in the Epoetin alfa-treated arm ( P < .0001 ) PURPOSE Allogeneic blood transfusions have reportedly been associated with a poor prognosis in patients with curatively resected cancer . To control for immunosuppression induced by a speculatively causal allogeneic blood transfusion , we design ed a r and omized study in which the control group received autologous blood transfusions not related to any condition of immunosuppression . PATIENTS AND METHODS One hundred twenty patients with potentially curative resectable colorectal cancer and the capability to predeposit autologous blood were r and omly selected to receive either  st and ard allogeneic blood transfusion or predeposited autologous blood . RESULTS In curatively resected cancer patients , the number who needed allogeneic blood transfusions  was reduced from 60 % in the allogeneic blood group to 33 % in the autologous blood group ( P = .009 ) . After a median follow-up duration of 22 months ( range , 8 to 48 ) tumor recurrence was observed in 28.9 % of the allogeneic blood group and 16.7 % of the autologous blood group . Life-table analysis established a tendency toward a shorter tumor-free survival for the allogeneic blood group ( log-rank P = .11 ) . The problem with this analysis was the strong association of allogeneic blood transfusions  with tumor recurrence , which interfered in 33 % of patients in the autologous blood group who required additional allogeneic blood transfusions . Multivariate analysis of established risk factors for tumor recurrence and surgery-related variables reflecting potential immunosuppressive conditions showed that only pT stage ( relative risk , 6.61 ; 95 % confidence interval [ CI ] , 1.82 to 23.99 ; P = .004 ) , pN stage ( relative risk , 8.39 ; 95 % CI , 3.15 to 22.33 ; P < .001 ) , and the need for allogeneic blood  ( relative risk , 6.18 ; 95 % CI , 2.20 to 17.37 ; P < .001 ) were independent predictors of tumor recurrence . Subgroup analysis of patients who received a transfusion of < or = 2 U blood found a significantly higher risk of tumor recurrence in the allogeneic blood group ( relative risk , 5.16 ; 95 % CI , 1.13 to 23.62 ; P = .034 ) , which was reduced to borderline significance ( relative risk , 3.54 ; 95 % CI , 0.76 to 16.51 ; P = .107 ) by adjustment for tumor ( T ) and node ( N ) stage . CONCLUSION As indicated by these first results , the blood transfusion modality has a significant effect on tumor recurrence after surgical treatment of colorectal cancer . A change in the practice of blood transfusion might thus potentially surpass the impact of any recent adjuvant treatment strategies & NA ; Even though blood transfusion‐associated immunomodulatory effects have been reported , the basic immune mechanism is still not understood . Data from studies on the clinical effects of allogeneic blood‐induced immunosuppression are contradictory . However , there are indications that autologous blood transfusion is not immunologically neutral but has intrinsic immunomodulatory potential . Therefore we investigated in vivo different immunological mediators in 56 r and omized patients of a study comparing autologous and allogeneic blood transfusion in colorectal cancer surgery .  Soluble IL‐2 receptor , which is an indicator of general immune activation and the following immunologic refractory phase , indicated immunosuppression was more elevated at the seventh postoperative day in patients with  allogeneic transfusions ( p = .013 ) and autologous transfusions ( p = .0003 ) . The immunologic determination of TNF‐&agr ; showed a significant postoperative increase in patients with autologous transfusions only ( p = .0031 ) . However , postoperative increase of soluble TNF‐receptors p55 and p75 was also significant in patients transfused with allogenic blood ( p = .022 ; p = .0014 ) . The response to tetanus toxoid vaccination  , an indicator of humoral immunity , was higher in patients transfused with allogeneic rather than autologous blood ( p = .082 ) , whereas responses of patients with autologous transfusions were even lower than in nontransfused patients . The reciprocal was already found for cell‐mediated immunity determined by epicutaneously tested delayed‐type hypersensitivity‐reactions . IL‐10 levels , an indicator of cellular immunosuppression , were determined in 27 additional patients before operation , immediately postoperative , and at the seventh postoperative day . IL‐10 was found elevated immediately postoperative in allogeneic ( p = .011 ) and nontransfused patients only ( p = .042 ) . The data from this study substantiate recent findings of a different immunomodulatory potential of allogeneic and autologous blood transfusion . They furthermore support the hypothesis that autologous blood transfusion does not contain immunologically neutral effects of allogeneic blood , but itself exerts an immunomodulatory effect Background Allogeneic blood transfusions cause immunosuppression . The aim of this study was to determine whether complement anaphylatoxins , cytokines , or both are released in the recipient , after blood transfusions in general , and after autologous blood transfusions in particular . Methods Thirty-one patients having total hip joint replacement surgery were r and omized to receive either allogeneic red blood cells ( n = 15 ) or predeposited autologous whole blood transfusion ( n = 16 ) . Plasma concentrations of the anaphylatoxins C3a and C5a , the terminal C5b-9 complement complex , and cytokines IL-6 and IL-8 in the recipients were repeatedly analyzed before , during , and after surgery . Results Significantly increased concentrations of IL-6 and IL-8 appeared in both groups , with a significantly greater increase in the autologous blood group . Patients in both groups developed a moderate but significant increase of C3a without a significant difference between them . C5a and terminal C5b-9 complement complex were not greatly changed . Conclusions The study showed a greater increase in cytokine concentration after autologous blood transfusion than after allogeneic blood transfusion . The lower response in the latter may result from transfusion-induced suppression of cellular immunity The aim was to assess the cost-effectiveness of erythropoietin ( EPO ) to reduce patients ' exposure to perioperative allogenic blood products in orthopaedic surgery . The use of EPO was assessed for EPO used alone and for EPO , to augment preoperative autologous donation ( PAD ) . A decision analytical model was design ed incorporating ( i ) the risk of receiving allogeneic blood , ( ii ) the costs of blood products , ( iii ) the likelihood of developing transfusion-related diseases , ( iv ) the costs of transfusion-related diseases , ( v ) the impact of transfusion-related diseases on patient morbidity and mortality and ( vi ) the effect of EPO upon the probability of transfusion . The efficacy of EPO was derived from data from a meta- analysis of published r and omized trials . Estimates for the other parameters were obtained by a systematic review of the literature . EPO alone led to only modest incremental benefit compared to no intervention for orthopaedic surgery ( 0.000024 life-years gained per patient ) . As an augmentation to PAD , EPO also led to modest benefits ( 0.000006 life-years gained per patient ) . For EPO compared to no intervention , the incremental cost per life-year gained was $ 66 million ( Canadian ) . For EPO to augment PAD , the incremental cost per life-year gained was $ 329 million ( Canadian ) . Detailed sensitivity analysis did not reveal any circumstances in which the cost-effectiveness ratios reached a level generally considered attractive . On the basis of cost-effectiveness , the use of EPO to reduce perioperative allogeneic transfusions in orthopaedic surgery did not meet criteria conventionally considered acceptable The hematologic and transfusion data of a multicenter r and omized trial investigating the effect of blood transfusions on the 5-year survival were used to study the feasibility of an autologous blood donation program in colorectal cancer patients . Three hundred and ten patients were r and omized for autologous blood transfusions  ( predeposition of 2 units ) or homologous blood transfusions , and transfusion rules were st and ardized . The Hb level in the patients who donated blood decreased by 20.1 + /- 1.3 g/l ( mean + /- SEM ) preoperatively and 4.5 + /- 1.8 g/l postoperatively , and in controls 3.7 + /- 1.1 g/l and 16.5 + /- 1.9 g/l ( significantly different between the two groups , both pre- and postoperatively : p less than 0.01 ) . Because blood loss and number of transfusions were similar in both groups , this indicated that either preoperative or postoperative erythropoiesis is stronger in patients who had donated blood . Twenty-three percent of the autologous patients and 61 % of the homologous patients were exposed to homologous blood . The effectiveness of the procedure differed per tumor localization . In patients with a right-sided colon carcinoma , 22 % of the control patients needed homologous blood , compared to 10 % of the autologous patients . In patients with other colon carcinomas , this was 52 and 16 % , respectively , and in patients with a rectal carcinoma 85 and 41 % . We conclude that predeposition of 2 units of blood for colorectal cancer surgery is feasible and useful to prevent homologous blood usage in a significant number of patients with left colon carcinoma or rectal carcinoma OBJECTIVES Due to the discovery in the 1980s that blood transfusion can transmit HIV , there has been increased interest in technologies that reduce the amount of allogeneic blood used during and after surgery . These technologies include drugs ( aprotinin , tranexamic acid , epsilon-aminocaproic acid , erythropoietin ) , devices ( cell salvage ) , and techniques ( acute hemodilution , predeposited autologous donation ) . The purpose of this study was to ascertain the degree of practice variation , if any , that exists for eight technologies in nine countries in orthopedic and cardiac surgery . METHODS In each country , either all hospitals or a r and om sample of hospitals with medical/surgical beds were surveyed between 1995 and 1997 . Two instruments were used . The first instrument was a postcard that asked recipients whether the technologies were currently being used in their hospital for orthopedic and /or cardiac surgery to reduce perioperative allogeneic transfusion . The second question naire elicited information regarding the degree of use both in qualitative and quantitative terms . Data were collected , entered , and analyzed in each country , with summary results su bmi tted to the Canadian coordinating center on a st and ardized data collection form . RESULTS Pharmaceuticals were generally used in a much smaller proportion of hospitals in orthopedic than in cardiac surgery .  Aprotinin and tranexamic acid  were the drugs most frequently used in cardiac surgery . Nonpharmacological technologies  were used to a greater degree than drugs in orthopedic surgery , although there was wide variation among technologies and countries . Acute hemodilution and cell salvage were used in a greater proportion of hospitals for cardiac surgery than orthopedic surgery . CONCLUSIONS The results of this survey indicate 
    Output:
    
REVIEW ER 'S CONCLUSIONS Although the trials of PAD showed a reduction in the need for allogeneic blood the method ological quality of the trials was poor and the overall transfusion rates ( allogeneic and /or autologous ) in these trials were high , and were increased by recruitment into the PAD arms of the trials .
This raises questions about the true benefit of PAD .
In the absence of large , high quality trials using clinical endpoints , it is not possible to say whether the benefits of PAD outweigh the harms