UAB Magazine Weekly - Features on Health Care
Collections Up, Usage Down at UAB
Donna Salzman, Sherry Polhill, and Marisa Marques explain how new transfusion protocols have helped make UAB Hospital an example for centers around the country.
In the last decade, hospitals have realized that the best way to use blood is very carefully. At a major emergency and trauma center such as UAB, however, the demands for blood transfusions—for accident victims, patients recovering from surgery, and dozens of other uses—are constant.
Until 2007, blood use at UAB Hospital seemed to be on a permanent upward trajectory, with annual usage reaching 40,231 units, the hospital’s highest total ever. That same year, the hospital started widespread educational efforts to instruct staff on new transfusion protocols. The new protocols were a response to studies demonstrating that patients often benefit the most when they are given less transfused blood.
By the end of fiscal year 2010, annual usage at the hospital had dropped to 30,104 units—and UAB became an example for centers around the country. At the same time, increased promotional efforts led to a marked increase in blood donations, with collections rising about 300 percent. “We’re the poster child, both in terms of improved blood utilization and blood collections,” says Donna Salzman, M.D., co-chair of the UAB Blood Utilization and Management Committee.
Physicians and staff have accepted and adopted the new way of working, Salzman says, particularly in the critical care units, cardiovascular services, and trauma service.
Click on the image above to enlarge.
Blood by the Numbers
Before new transfusion protocols were in place, “we were using on average 770 units a week, or 110 a day,” says Marisa B. Marques, M.D., Salzman’s co-chair on the committee. In fiscal year 2010, which ended September 30, “we used on average 582 units a week,” she says—a decrease of more than 24 percent.
Because the number of patients seen fluctuates from year to year—as does the number of blood-intensive trauma cases—a more meaningful measure of UAB’s success is the decline in average units of blood used per patient at discharge. “When we started this project, on average just about every single person who entered the hospital got a unit of blood,” Salzman says. “The transfusion-to-discharge ratio was 0.9, and now it is 0.68.”
In fact, “UAB Hospital has not had any blood shortages since we began increasing our collections and reducing our utilization,” says Laboratory Administrative Director Sherry R. Polhill, MT, M.B.A., who is responsible for blood collections at UAB.
Reduced blood usage means less blood needs to be collected, Salzman says, and it also reduces expenses for the hospital. The next step is to incorporate the new protocols at UAB Highlands, she adds. Then staff will turn their attention to the other two blood components commonly used in hospitals: platelets and plasma.
New Truths About Transfusions
By Tara Hulen
Blood transfusions are a vital part of modern medicine, but recent research shows that patients who receive fewer transfusions often fare better. These findings have spurred changes in the way blood is used at UAB Hospital.
Blood is known as the “gift of life,” but the present isn’t as welcome as scientists once thought. Research over the past decade has revealed that patients fare better when blood transfusions are kept to a minimum, a realization that has brought major changes in the way UAB and other medical centers across the country handle their blood.
When a patient gets a transfusion—to replace blood lost during surgery or after a car accident, for example—the blood the patient receives isn’t the same as the blood flowing through that patient’s own body, even if it’s the same blood type, says Marisa B. Marques, M.D., director of the Transfusion Service at UAB and co-chair of the UAB Blood Utilization and Management Committee. That is where the problems start.
The fluid we call blood actually includes many components, including red blood cells (which carry oxygen), plasma (the liquid portion that carries the red blood cells), and platelets (cell fragments that, among other things, cause blood to clot). Blood donated to the American Red Cross and other collection organizations is separated into these three components for storage. Each has its own use in a blood transfusion.
Because the original plasma that surrounded the red blood cells has been removed, “the red cells are re-suspended in a fluid to keep them ‘alive,’” Marques says. “What is becoming more and more clear is that as these cells sit in a bag in a blood bank for up to six weeks, a lot of things are happening inside.”
New Medications Face Tough Scrutiny
By Tara Hulen
People looking to lose a little extra padding now have help from two new Food and Drug Administration (FDA)-approved devices (see main story). But obese patients who need to lose serious amounts of weight for their health will not have the assistance of three much-anticipated diet drugs. In October 2010, the FDA rejected initial applications for Qnexa and lorcaserin in the same week, taking these treatment options off the table. In December 2010, a third drug, Contrave, received an endorsement from an FDA panel of experts, but the agency ultimately declined to approve Contrave on January 31, 2011.
These decisions do not necessarily represent the end of the road for any of the three drugs. The FDA asked Contrave’s manufacturer to complete a long-term study of heart attack risk. It requested more information on cardiac effects, risks of birth defects, and marketing issues for Qnexa, and rejected lorcaserin in its current form because it caused tumors in lab rats. Concern over side effects has been an ongoing issue for diet drugs, however. In early October 2010, the manufacturer of the weight-loss drug Meridia withdrew it from the market after 13 years over concerns of heart attack and stroke risk for certain patients.
Such examples illustrate a clear need for caution, but the standards for weight-loss drugs are extraordinarily high, say UAB researchers. “The FDA has been very hard on drugs for metabolic diseases in the last year, and so it is very risk-adverse,” says W. Timothy Garvey, M.D., chair of the UAB Department of Nutrition Sciences and a principal investigator in clinical trials of Qnexa; UAB was one of a small group of test sites for the drug.
Garvey recognizes the necessity for caution because “there’s a lot of abuse potential with diet drugs.” He adds that “the FDA has to do its job carefully and assess risks, but consider benefit as well. These drugs, I think, offer a lot of promise for benefit, and there’s a huge clinical need.”
UAB weight-loss expert Jamy Ard, M.D., a member of the advisory board for the company that makes lorcaserin, Arena Pharmaceuticals, says that perceptions often come into play. The attitude that obesity is a lifestyle choice can lead to the misconception that diet pills are just for cosmetic use, akin to elective surgery, rather than life-saving options for people with real weight problems, he explains.
Devices such as cosmetic “fat-zapping” machines get approved with much less scrutiny, Ard says. “The number of studies required for these devices to be approved is a handful, but you have to devote millions and millions of dollars of research on medications to get them approved.”
Serious Need for Diet Drugs
Both Garvey and Ard say that people haven’t gotten used to the idea that obesity is a disease and a major public health issue. “It’s not just because people eat more than they should,” Garvey says. “It’s highly genetically determined, and we as clinicians need medications to treat this disease.”
Ard describes a serious need for diet drugs that are safe for long-term use so that obesity can be treated as a chronic disease, just like high blood pressure. When patients stop taking a helpful weight-control medication, they often gain the weight back despite other efforts, just as high blood pressure might return without drugs to lower it, he says.
Every time a drug is rejected, even temporarily, Garvey worries that it will have a chilling effect on research for obesity drugs—although there is a huge profit potential if they win approval and prove effective. And Garvey is optimistic that new treatments will eventually reach patients. Two of the three drugs now under scrutiny consist of drugs approved to treat other conditions, such as epilepsy and migraine headaches. Garvey says that might make it easier to satisfy FDA requests for more information by using existing data from similar patient populations.
Both researchers stress that responsible physicians will administer diet drugs only in combination with a comprehensive diet, exercise, and support plan. “All of the clinical trials were done with the patient taking the drug in combination with lifestyle intervention and regular physician follow-ups," Garvey says.
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New Devices Zap Excess Pounds, but Are They Safe?
By Tara Hulen
Fat-zapping lasers and other new technologies offer appealing nonsurgical options for weight loss, but the techniques may not be for everyone.
For every woman who has squeezed into torturously tiny shapewear and every man who wants to flatten a fleshy spare tire, fantasy has now become reality. Two new devices recently approved by the U.S. Food and Drug Administration can cause fat cells to die and disappear, along with an inch or so of bulges. But they aren’t for everyone, a UAB expert says.
Zeltiq freezes fat cells and causes them to shrivel and die over several months; Zerona uses low-level laser therapy to purge fat from surface-level cells over a period of weeks. The treatments don’t produce the same results as liposuction, but they offer a noninvasive option to smooth small trouble spots without any incisions, anesthesia, or downtime, and typically they are less expensive than surgery.
UAB Cardiologists Seek and Destroy Arrhythmias
By Tara Hulen
UAB specialists are focused on correcting heart arrhthmias as well as on preventing the most dangerous heart rhythm issues.
When the heart skips a beat, it may not be love. A little too much coffee, a just-missed fender bender, or a strange sound in the middle of the night can all cause a heart to flutter, race, and pound. But when those sensations are frequent, last more than a few seconds, or cause dizziness, fatigue, or fainting, it’s time to see an expert to find out why.
Cardiac arrhythmias—the term for abnormal heart rhythms—affect more than 14 million Americans, says Tom McElderry, M.D., a cardiologist in the electrophysiology program at the UAB Heart and Vascular Center.
Arrhythmias, in simple terms, are caused by faulty wiring. They occur when the electrical pathways that make each part of the heart beat in sequence develop short circuits or other irregularities, which can make the heart inefficient and reduce the amount of blood it pumps through the rest of the body.
The consequences are often relatively benign. “For most people who have not had heart attacks in the past and don’t have cardiomyopathy or a weak heart, palpitations are typically only a nuisance,” McElderry says. People with mild or infrequent symptoms might simply need to avoid caffeine, certain cold medicines, and similar triggers. Or they may benefit from starting medications such as beta blockers or calcium channel blockers.
But some heart rhythms—including atrial fibrillation and ventricular tachycardia—can signal a greatly increased risk of stroke, heart failure, and death, McElderry says. At the Heart and Vascular Center, electrophysiologists specialize in finding and fixing the source of the trouble. Meanwhile, in UAB’s Cardiac Rhythm Management Laboratory (CRML), researchers are searching for better ways to treat and prevent the most dangerous heart rhythm issues—and to increase our understanding of what causes the problems in the first place.
See how UAB electrophysiologists repaired one patient's heart in this video. Story continues below video