***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: BACKGROUND Unilateral total knee replacement ( TKR ) results in a substantial blood loss and 30 to 50 percent of patients receive allogeneic blood transfusion ( ABT ) . Therefore , the effectiveness of a restrictive transfusion trigger ( hemoglobin [ Hb ] level < 8 g/dL ) plus stimulation of erythropoiesis was evaluated , with or without blood salvage , for reducing ABT in TKR patients . STUDY DESIGN AND METHODS A series of 139 consecutive of primary TKR patients received perioperative iron sucrose ( 2 x 200 mg/48 hr , intravenously [ IV ] ) , plus preoperative erythropoietin ( EPO ; 1 x 40.000 UI , sc ) if preoperative Hb level was less than 130 g per L ( Group A ) . This protocol was applied to another series of 173 consecutive TKR patients who also received postoperative unwashed shed blood ( USB ) if preoperative Hb level was less than 130 g per L ( Group B ) . Perioperative clinical and laboratory data were gathered . RESULTS No adverse effects of iron sucrose , EPO , or USB administration were witnessed , and only 13 patients received ABT overall ( 4 % ) . No major differences in perioperative blood counts or iron metabolism variables were observed between groups , but stimulation of erythropoiesis seemed to be more pronounced in those patients receiving EPO ( p < 0.05 ) . There were no differences in postoperative complications between groups , but length of hospital stay for patients with a preoperative Hb level of less than 130 g per L was shorter in Group B ( p < 0.05 ) . CONCLUSION This blood saving protocol seems to be effective for reducing ABT in TKR patients . Which patients are more likely to benefit from either perioperative iron administration or selective addition of postoperative blood salvage to pharmacologic treatment , however , needs to be further evaluated BACKGROUND The decision to transfuse intra-operatively is based on preoperative haemoglobin ( Hb ) , estimated blood loss and physiological variables . The visual estimate of blood loss is notoriously unreliable especially with small volumes of blood losses in children . OBJECTIVES We sought therefore to determine the appropriateness of intra-operative blood transfusion in a sample of children METHODS All children requiring intra-operative blood transfusion between May and June 2008 were prospect ively studied . Neonates and children already on blood transfusion at induction were excluded .  Transfusion was prescribed at the discretion of the attending anaesthetist . The Estimated blood volume ( EBV ) and estimated blood loss (EBL)were determined . Appropriate transfusion was defined as blood transfusion at EBL > 15 % of EBV , maximum allowable blood loss to PCV of 27 % and pre-transfusion Hb < 8g/dl . RESULTS Twenty-five patients were studied with a mean age of 4.16 + /- 3.59 years ( Range 0.33 - 11 years ) . The mean preoperative PCV was 31.14 + /- 3.53 % ( range 25 - 34 % ) . Twelve patients ( 48 % ) were appropriately transfused when MABL was calculated to PCV of 27 % . Nine patients ( 36 % ) had appropriate blood transfusion at an EBL greater or equal to 15 % of the EBV . Of the 12 patients that had pre-transfusion Hb measured , 2 ( 16.6 % ) were appropriately transfused at Hb < 8 g/dl . CONCLUSION The use of near patient monitoring devices should be encouraged as this will give an accurate assessment of Hb and appropriate indication for transfusion . Equipment should be made available to perform gravimetric estimation of blood loss as the visual method is notoriously unreliable BACKGROUND Transfusion thresholds for acute upper gastrointestinal bleeding are controversial . So far , only three small , underpowered studies and one single-centre trial have been done . Findings from the single-centre trial showed reduced mortality with restrictive red blood cell ( RBC ) transfusion . We aim ed to assess whether a multicentre , cluster r and omised trial is a feasible method to substantiate or refute this finding . METHODS In this pragmatic , open-label , cluster r and omised feasibility trial , done in six university hospitals in the UK , we enrolled all patients aged 18 years or older with new presentations of acute upper gastrointestinal bleeding , irrespective of comorbidity , except for exsanguinating haemorrhage . We r and omly assigned hospitals ( 1:1 ) with a computer-generated r and omisation sequence ( r and om permuted block size of 6 , without stratification or matching ) to either a restrictive ( transfusion when haemoglobin concentration fell below 80 g/L ) or liberal ( transfusion when haemoglobin concentration fell below 100 g/L ) RBC transfusion policy . Neither patients nor investigators were masked to treatment allocation . Feasibility outcomes were recruitment rate , protocol adherence , haemoglobin concentration , RBC exposure , selection bias , and information to guide design and economic evaluation of the phase 3 trial . Main exploratory clinical outcomes were further bleeding and mortality at day 28 . We did analyses on all enrolled patients for whom an outcome was available . This trial is registered , IS RCT N85757829 and NCT02105532 . FINDINGS Between Sept 3 , 2012 , and March 1 , 2013 , we enrolled 936 patients across six hospitals ( 403 patients in three hospitals with a restrictive policy and 533 patients in three hospitals with a liberal policy )  . Recruitment rate was significantly higher for the liberal than for the restrictive policy ( 62 % vs 55 % ; p=0·04 ) . Despite some baseline imbalances , Rockall and Blatchford risk scores were identical between policies . Protocol adherence was 96 % ( SD 10 ) in the restrictive policy vs 83 % ( 25 ) in the liberal policy ( difference 14 % ; 95 % CI 7 - 21 ; p=0·005 ) . Mean last recorded haemoglobin concentration was 116 ( SD 24 ) g/L for patients on the restrictive policy and 118 ( 20 ) g/L for those on the liberal policy ( difference -2·0 [ 95 % CI -12·0 to 7·0 ] ; p=0·50 ) . Fewer patients received RBCs on the restrictive policy than on the liberal policy ( restrictive policy 133 [ 33 % ] vs liberal policy 247 [ 46 % ] ; difference -12 % [ 95 % CI -35 to 11 ] ; p=0·23 ) , with fewer RBC units transfused ( mean 1·2 [ SD 2·1 ] vs 1·9 [ 2·8 ] ; difference -0·7 [ -1·6 to 0·3 ] ; p=0·12 ) , although these differences were not significant . We noted no significant difference in clinical outcomes . INTERPRETATION A cluster r and omised design led to rapid recruitment , high protocol adherence , separation in degree of anaemia between groups , and non-significant reduction in RBC transfusion in the restrictive policy . A large cluster r and omised trial to assess the effectiveness of transfusion strategies for acute upper gastrointestinal bleeding is both feasible and essential before clinical practice guidelines change to recommend restrictive transfusion for all patients with acute upper gastrointestinal bleeding . FUNDING NHS Blood and Transplant Research and Development BACKGROUND To determine whether a restrictive strategy of red-cell transfusion and a liberal strategy produced equivalent results in critically ill patients , we compared the rates of death from all causes at 30 days and the severity of organ dysfunction . METHODS We enrolled 838 critically ill patients with euvolemia after initial treatment who had hemoglobin concentrations of less than 9.0 g per deciliter within 72 hours after admission to the intensive care unit and r and omly assigned 418 patients to a restrictive strategy of transfusion  , in which red cells were transfused if the hemoglobin concentration dropped below 7.0 g per deciliter and hemoglobin concentrations were maintained at 7.0 to 9.0 g per deciliter , and 420 patients to a liberal strategy  , in which transfusions were given when the hemoglobin concentration fell below 10.0 g per deciliter and hemoglobin concentrations were maintained at 10.0 to 12.0 g per deciliter . RESULTS Overall , 30-day mortality was similar in the two groups ( 18.7 percent vs. 23.3 percent , P= 0.11 ) . However , the rates were significantly lower with the restrictive transfusion strategy among patients who were less acutely ill -- those with an Acute Physiology and Chronic Health Evaluation II score of < or = 20 ( 8.7 percent in the restrictive- strategy group and 16.1 percent in the liberal- strategy group ; P=0.03 ) -- and among patients who were less than 55 years of age ( 5.7 percent and 13.0 percent , respectively ; P=0.02 ) , but not among patients with clinical ly significant cardiac disease ( 20.5 percent and 22.9 percent , respectively ; P=0.69 ) . The mortality rate during hospitalization was significantly lower in the restrictive- strategy group ( 22.3 percent vs. 28.1 percent , P=0.05 ) . CONCLUSIONS A restrictive strategy of red-cell transfusion is at least as effective as and possibly superior to a liberal transfusion strategy in critically ill patients , with the possible exception of patients with acute myocardial infa rct ion and unstable angina BACKGROUND Shrinkage of the donor pool coupled with an increasing dem and for blood presents a major challenge to maintaining an adequate blood supply . Consequently it has become even more important to reduce inappropriate blood use , including decisions about when and how much blood to prescribe . This study aim ed to ascertain the levels of inappropriate practice and factors associated with it . STUDY DESIGN AND METHODS The medical records of a r and omly selected sample of hospital patients in Northern Irel and who received a red blood cell transfusion during 2005 ( n = 1474 ) were review ed , and inappropriate transfusion and overtransfusion criteria were applied . Logistic regression models were used to identify factors associated with inappropriate practice and overtransfusion . RESULTS In this study 23 % of transfusions were considered inappropriate , occurring most commonly where the lowest hemoglobin ( Hb ) threshold for transfusion applied . Younger patients , those undergoing surgery , and those with lower comorbidity and higher Hb values were most likely to have an inappropriate transfusion . Among patients appropriately transfused , 19 % were overtransfused . Females and those of lower weight ( < 65 kg ) were most likely to be overtransfused . CONCLUSION While the choice of criteria used to judge decisions will influence the absolute level of inappropriate or overtransfusion reported , our findings suggest that a significant minority of clinicians are either unaware of or are reluctant to accept lower transfusion thresholds . To improve further improve transfusion practice we suggest that barriers to the implementation of recommended transfusion thresholds should be examined and guidance on an appropriate posttransfusion Hb level developed OBJECTIVE To evaluate the effectiveness of prospect i ve review of orders for fresh-frozen plasma ( FFP ) and platelets in reducing blood-product use , and of the effectiveness of preparing pathology residents to serve as clinical consultants . DESIGN At our 572-bed tertiary-care hospital , we developed guidelines for the use of blood products in collaboration with a variety of departments . For patients whose condition(s ) met generally accepted criteria , we identified trigger points to allow for quick release by blood bank staff of blood products . For patients whose condition(s ) did not meet the applicable criteria , the on-call pathology resident review ed the medical record of that patient to determine whether there were any extenuating circumstances ; consulted with the ordering physician and attending pathologist , as needed ; and advised the house staff on appropriate use of blood products . We evaluated the change in use of blood products between the years 2009 and 2012 to assess the effectiveness of the program . RESULTS We observed a decrease of 38.8 % and 31.4 % in the use of FFP and platelets , respectively ( 29.7 % and 21.1 % , respectively , when normalized for the number of discharges ) . If projected to the national level , this improvement would translate to an annual cost reduction of approximately $ 130 million . CONCLUSIONS Prospect i ve review of orders for blood products can significantly improve use of these products , thereby reducing risk to patients and avoiding unnecessary healthcare costs . The involvement of pathology residents in the prospect i ve review process provides an excellent opportunity for their training as laboratory consultants OBJECTIVES To assess the appropriateness of  red blood cell ( RBC ) transfusions  and the effectiveness of an intervention to reduce inappropriate RBC transfusions . DESIGN Medical record audit by hospital staff using a data form , before and after r and omly allocated interventions ( letter only or letter+visit ) . Criteria for assessing appropriateness of RBC transfusions were based on a systematic literature review . SETTING Ten major urban hospitals in Sydney , New South Wales , in 1998 and 1999 . SUBJECTS Medical records of up to 120 patients at each hospital ( n=1117 ) . INTERVENTIONS  Letter-only ( 5 hospitals)-- results of first audit at the hospital mailed to chief executive officer of that hospital ; letter+visit ( 5 hospitals ) results of first audit at the hospital 
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The overall rates of inappropriate use were 36.7 % ( 95 % CI [ 30.2 , 43.6 ] ) in major cities and 37.5 % ( 95 % CI [ 31.2 , 44.3 ] ) in other cities , respectively ; there was no statistically significant difference ( P > 0.05).In conclusion , China has suffered from a disadvantage in the clinical appropriateness of blood transfusion , especially in plasma and RBC use .