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Age of Transfused Blood in Critically Ill Adults — NEJM, 2015

"N Engl J Med. 2015 Mar 17. [Epub ahead of print]" Is fresh best? The ABLE study provides reassuring evidence about current transfusion practices. Check out the results in NEJM.

Clear As Blood's insight:

-ABLE Study: Multicentre randomized & blinded trial of critically ill adults in Canadian & European ICUs 

-Patients received either fresh RBCs (<8 days old) or standard RBCs, all units leukoreduced. 

-Mean age of units transfused: 6.1 days (fresh) & 22 days (standard).

-Primary outcome: 90-day mortality not significantly different between groups. 

-No significant difference in major illness, LOS, transfusion reactions, or duration of pulmonary/renal/cardiac support between groups or in subgroup analysis.

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Informed Consent for Transfusion/Patient Information from Dr. Jeannie Callum

"Dr. Jeannie Callum, a transfusion medicine specialist, explains blood transfusion as part of a treatment plan. This video covers the process, benefits, risks and alternatives. For more information, please visit http://transfusionontario.org"

Clear As Blood's insight:

Wondering how to explain blood transfusion to patients? This is a great video from one of Canada's expert TM physicians explaining, in plain language, the various aspects of transfusion that should be included in an informed consent-type discussion.

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Ideal Body Weight (IBW) Calculator with IVIg Dosing

Ideal Body Weight (IBW) Calculator with IVIg Dosing | Transfusion Medicine | Scoop.it
Calculates Ideal Body Weight IBW LBW Adjusted Body Weight ABW and IVIg Dose
Clear As Blood's insight:

Incredibly handy and non-glitchy IBW calculator for IVIg dosing. Courtesy of ORBCoN.

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Guidance on Platelet Transfusion for Patients With Hypoproliferative Thrombocytopenia - Transfusion Medicine Reviews - 2015

Guidance on Platelet Transfusion for Patients With Hypoproliferative Thrombocytopenia - Transfusion Medicine Reviews - 2015 | Transfusion Medicine | Scoop.it

Nahirniak & colleages outline the International Collaboration for Transfusion Medicine Guidelines for platelet transfusion in hypoproliferative thrombocytopenia.

Clear As Blood's insight:

-Chemo & HSCT patients: prophylactic PLT transfusions when count ≤10 × 109/L recommended. 

-Whole blood-derived PLT concentrates interchangeable with apheresis PLTs

-ABO-compatible PLT recommended-> improves increment and lower refractoriness.

-Give RhIg to RhD- female with child-bearing potential if given RhD+ platelets.

-Platelet refractoriness: ABO-matched and HLA-selected or crossmatched products are of some benefit.

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PROPPR Trial: Transfusion of Plasma, Platelets, and Red Blood Cells in a 1:1:1 vs a 1:1:2 Ratio and Mortality in Patients With Severe Trauma

PROPPR Trial: Transfusion of Plasma, Platelets, and Red Blood Cells in a 1:1:1 vs a 1:1:2 Ratio and Mortality in Patients With Severe Trauma | Transfusion Medicine | Scoop.it
This randomized trial reports that among patients with severe trauma and major bleeding, early administration of plasma, platelets, and red blood cells in a 1:1:1 ratio compared with a 1:1:2 ratio did not result in significant differences in mortality at 24 hours or at 30 days.
Clear As Blood's insight:

-Multicentre RCT of 680 severe trauma patients.

-1:1:1 vs. 1:1:2

-Primary outcomes: 24 hour and 30-day all cause mortality

-More 1:1:1 achieved hemostasis.

-No significant difference in 24 hour or 30-day mortality between groups.

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Health Care–Associated Infection After RBC Transfusion

Health Care–Associated Infection After RBC Transfusion | Transfusion Medicine | Scoop.it
Rohde and coauthors evaluate whether red blood cell (RBC) transfusion thresholds are associated with the risk of infection and whether risk is independent of leukocyte reduction in this meta-analysis of 17 trials.
Clear As Blood's insight:

-Restrictive strategy à lower risk  of serious infection vs. liberal strategy (11.8% vs. 16.9%)

-NNT to avoid serious infection = 38

-Results similar even with LR product

-Risk difference greatest in sepsis and orthopaedic surgery

-No difference in cardiac dz, critical illness, GIB or LBW infants.

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Transfusion Strategies for Acute Upper Gastrointestinal Bleeding — NEJM

Transfusion Strategies for Acute Upper Gastrointestinal Bleeding — NEJM | Transfusion Medicine | Scoop.it
NEJM. 2013 Jan 3;368(1):11-21BACKGROUND:

The hemoglobin threshold for transfusion of red cells in patients with acute gastrointestinal bleeding is controversial. We compared the efficacy and safety of a restrictive transfusion strategy with those of a liberal transfusion strategy.

METHODS:

We enrolled 921 patients with severe acute upper gastrointestinal bleeding and randomly assigned 461 of them to a restrictive strategy (transfusion when the hemoglobin level fell below 7 g per deciliter) and 460 to a liberal strategy (transfusion when the hemoglobin fell below 9 g per deciliter). Randomization was stratified according to the presence or absence of liver cirrhosis.

RESULTS:

A total of 225 patients assigned to the restrictive strategy (51%), as compared with 61 assigned to the liberal strategy (14%), did not receive transfusions (P<0.001) [corrected].The probability of survival at 6 weeks was higher in the restrictive-strategy group than in the liberal-strategy group (95% vs. 91%; hazard ratio for death with restrictive strategy, 0.55; 95% confidence interval [CI], 0.33 to 0.92; P=0.02). Further bleeding occurred in 10% of the patients in the restrictive-strategy group as compared with 16% of the patients in the liberal-strategy group (P=0.01), and adverse events occurred in 40% as compared with 48% (P=0.02). The probability of survival was slightly higher with the restrictive strategy than with the liberal strategy in the subgroup of patients who had bleeding associated with a peptic ulcer (hazard ratio, 0.70; 95% CI, 0.26 to 1.25) and was significantly higher in the subgroup of patients with cirrhosis and Child-Pugh class A or B disease (hazard ratio, 0.30; 95% CI, 0.11 to 0.85), but not in those with cirrhosis and Child-Pugh class C disease (hazard ratio, 1.04; 95% CI, 0.45 to 2.37). Within the first 5 days, the portal-pressure gradient increased significantly in patients assigned to the liberal strategy (P=0.03) but not in those assigned to the restrictive strategy.

CONCLUSIONS:

As compared with a liberal transfusion strategy, a restrictive strategy significantly improved outcomes in patients with acute upper gastrointestinal bleeding.

Clear As Blood's insight:

-RCT 921 patients with severe UGI

-Restrictive (Hb <70g/L) vs liberal (Hb <90g/L)

-Significantly improved outcomes in restrictive group.

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Current incidence and residual risk of HIV, HBV and HCV at Canadian Blood Services

Vox Sang. 2012 Jul;103(1):83-6.

 

Abstract: Estimates of the viral residual risk should be updated to reflect current incidence of infection in blood donors. Incidence rates were estimated for allogeneic whole-blood donations made to Canadian Blood Services from 2006 to 2009 based on transmissible disease conversions of repeat donations within a 3-year period. Residual risk was estimated as the incidence multiplied by the window period. The residual risk of HIV was 1 per 8 million donations, HCV 1 per 6·7 million donations and HBV 1 per 1·7 million donations. The residual risk remains low and has decreased for HCV since our previous estimates due to reduced incidence.

 

Clear As Blood's insight:

Estimated residual risk in Canada based repeat blood donor seroconversion.

-HBV: 1 in 1.7 million donations

-HCV: 1 in 6.7 million donations

-HIV: 1 in 8 million donations

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Transfusion of older stored blood and risk of death: a meta-analysis.

Transfusion. 2012 Jun;52(6):1184-95. 

BACKGROUND:

Blood for transfusion is stored for up to 42 days. Older blood develops lesions and accumulates potentially injurious substances. Some studies report increasing toxicity as blood ages. We assessed the safety of transfused older versus newer stored blood.

STUDY DESIGN AND METHODS:

PubMed, Scopus, and Embase were searched using terms new and old and red blood cell and storage through May 6, 2011, for observational and randomized controlled studies comparing outcomes using transfused blood having longer and shorter storage times. Death was the outcome of interest.

RESULTS:

Twenty-one studies were identified, predominantly in cardiac surgery (n=6) and trauma (n=6) patients, including 409,966 patients. A test for heterogeneity of these studies' results was not significant for mortality (I(2)=3.7%, p=0.41). Older blood was associated with a significantly increased risk of death (odds ratio, 1.16; 95% confidence interval [CI], 1.07-1.24). Using available mortality data, 97 (95% CI, 63-199) patients need to be treated with only new blood to save one life. Subgroup analysis of these trials indicated that the increased risk was not restricted to a particular type of patient, size of trial, or amount of blood transfused.

CONCLUSION:

Based on available data, use of older stored blood is associated with a significantly increased risk of death.

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TRICC Trial, NEJM, 1999

N Engl J Med. 1999 Feb 11;340(6):409-17. 

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 randomly 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 clinically 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 infarction and unstable angina.

 

Clear As Blood's insight:

-Canadian ICU trial

-Restrictive (Hb <70g/L) vs. liberal (Hb <90g/L)

-No demonstrated benefit of liberal strategy.

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Bloody Easy for Healthcare Professionals

Bloody Easy for Healthcare Professionals | Transfusion Medicine | Scoop.it

Available free online courtesy of ORBCoN. 

 

Clear As Blood's insight:

Bloody Easy 3 is a high-quality yet concise guide to transfusion medicine in Canada. Check out their coagulation book too. 

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Impact of more restrictive blood transfusion strategies on clinical outcomes: a meta-analysis and systematic review.

Am J Med. 2014 Feb;127(2):124-131.e3. doi: 10.1016/j.amjmed.2013.09.017. Epub 2013 Oct 7. Meta-Analysis; Review
Clear As Blood's insight:

-Pooled results of three RCTs comparing restrictive vs. liberal transfusion strategies in critical illness or bleed.

-Restrictive strategy (trigger <70g/L) associated with fewer cardiac events, rebleeds, bacterial infections, and lower total mortality. 

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Transfusion Reactions Part 2

The December 2012 Blood Bank Guy Podcast is the second of a two-part series on transfusion reactions. In this podcast, I discuss important details of a wide ...
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Platelet transfusions in platelet consumptive disorders are associated with arterial thrombosis and in-hospital mortality - Blood - 2015.

Platelet transfusions are frequently administered to hospitalized patients with platelet consumptive/destructive disorders such as TTP, HIT, and ITP.

Platelet transfusions are associated with higher odds of arterial thrombosis and mortality among TTP and HIT patients.

Clear As Blood's insight:

Platelet transfusion in TTP, HIT, and ITP

Evaluation of in-hospital platelet transfusions & association with arterial/venous thrombosis, MI, stroke, and in-hospital mortality.

HIT: Plt transfusion in 7.1% of cases; higher odds of arterial thrombosis & mortality, but not venous thrombosis

TTP: PLT transfusion in 10.1%; higher odds of arterial thrombosis, MI, and mortality, but not venous thrombosis.

ITP: PLT transfusion in 25.8%; no thrombotic associations.

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How I use fibrinogen replacement therapy in acquired bleeding - 2015 - Blood

How I use fibrinogen replacement therapy in acquired bleeding - 2015 - Blood | Transfusion Medicine | Scoop.it

Levy & Goodnough review the use of fibrinogen in acquired bleeding.

Clear As Blood's insight:

Discussion includes:

-Fibrinogen measurements

-Fibrinogen targets

-Options for replacement

-Dosing strategies

-Review of evidence supporting fibrinogen replacement across a variety of clinical settings.

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Restrictive blood transfusion practices are associated with improved patient outcomes - 2014 - Transfusion

Restrictive blood transfusion practices are associated with improved patient outcomes - 2014 - Transfusion | Transfusion Medicine | Scoop.it

Goodnough & colleagues assess the impact of clinical decision support at computerized physician order entry, and education on RBC transfusions and clinical patient outcomes at their institution.

Clear As Blood's insight:

-Significant improvement in RBC utilization as assessed by RBC units transfused per 100 patient-days-at-risk.

-Outcome improvements most pronounced in patients who received blood transfusions, with decreased mortality, LOS, and 30-day readmission.

-Decrease in mean number of units transfused (3.6->2.7)

-Total estimated savings of $6.4 million 

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Effect of erythropoietin and transfusion threshold on neurological recovery after traumatic brain injury

Effect of erythropoietin and transfusion threshold on neurological recovery after traumatic brain injury | Transfusion Medicine | Scoop.it

JAMA. 2014 Jul 2;312(1):36-47

OBJECTIVE:

To compare the effects of erythropoietin and 2 hemoglobin transfusion thresholds (7 and 10 g/dL) on neurological recovery after traumatic brain injury.

DESIGN, SETTING, AND PARTICIPANTS:

Randomized clinical trial of 200 patients (erythropoietin, n = 102; placebo, n = 98) with closed head injury who were unable to follow commands and were enrolled within 6 hours of injury at neurosurgical intensive care units in 2 US level I trauma centers between May 2006 and August 2012. The study used a factorial design to test whether erythropoietin would fail to improve favorable outcomes by 20% and whether a hemoglobin transfusion threshold of greater than 10 g/dL would increase favorable outcomes without increasing complications. Erythropoietin or placebo was initially dosed daily for 3 days and then weekly for 2 more weeks (n = 74) and then the 24- and 48-hour doses were stopped for the remainder of the patients (n = 126). There were 99 patients assigned to a hemoglobin transfusion threshold of 7 g/dL and 101 patients assigned to 10 g/dL.

INTERVENTIONS:

Intravenous erythropoietin (500 IU/kg per dose) or saline. Transfusion threshold maintained with packed red blood cells.

MAIN OUTCOMES AND MEASURES:

Glasgow Outcome Scale score dichotomized as favorable (good recovery and moderate disability) or unfavorable (severe disability, vegetative, or dead) at 6 months postinjury.

RESULTS:

There was no interaction between erythropoietin and hemoglobin transfusion threshold. Compared with placebo (favorable outcome rate: 34/89 [38.2%; 95% CI, 28.1% to 49.1%]), both erythropoietin groups were futile (first dosing regimen: 17/35 [48.6%; 95% CI, 31.4% to 66.0%], P = .13; second dosing regimen: 17/57 [29.8%; 95% CI, 18.4% to 43.4%], P < .001). Favorable outcome rates were 37/87 (42.5%) for the hemoglobin transfusion threshold of 7 g/dL and 31/94 (33.0%) for 10 g/dL (95% CI for the difference, -0.06 to 0.25, P = .28). There was a higher incidence of thromboembolic events for the transfusion threshold of 10 g/dL (22/101 [21.8%] vs 8/99 [8.1%] for the threshold of 7 g/dL, odds ratio, 0.32 [95% CI, 0.12 to 0.79], P = .009).

CONCLUSIONS AND RELEVANCE:

In patients with closed head injury, neither the administration of erythropoietin nor maintaining hemoglobin concentration of greater than 10 g/dL resulted in improved neurological outcome at 6 months. The transfusion threshold of 10 g/dL was associated with a higher incidence of adverse events. These findings do not support either approach in this setting.

 

Clear As Blood's insight:

-RCT: 200 patients with closed brain injury.

-Hb 70g/L vs 100g/L

-EPO vs. placebo

-No neurologic outcome benefit of EPO or Hb of 100g/L

-More thrombosis in Hb 100

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HIV Transmission Through Transfusion --- Missouri and Colorado, 2008

HIV Transmission Through Transfusion --- Missouri and Colorado, 2008 | Transfusion Medicine | Scoop.it

A blood center in Missouri discovered that blood components from a donation in November 2008 tested positive for HIV infection.

 

A lookback investigation determined that this donor had last donated in June 2008, at which time he incorrectly reported no HIV risk factors and his donation tested negative for the presence of HIV.

 

One of the two recipients of blood components from this donation, a patient undergoing kidney transplantation, was found to be HIV infected, and an investigation determined that the patient's infection was acquired from the donor's blood products.

 

Even though such transmissions are rare, health-care providers should consider the possibility of transfusion-transmitted HIV in HIV-infected transfusion recipients with no other risk factors.

Clear As Blood's insight:

MMWR report of transfusion-transmitted HIV infection. 

-Infectious disease testing negative

-Donor incorrectly reported no HIV risk factors.

-Donation likely occurred during window period.

 

Transfusion-transmitted HIV is rare, but can and does still occur (Residual risk in Canada = ~1 in 8 million donations). Sensitivity of HIV testing is very good, but "window period" from time of infection remains about 9.5.

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FOCUS Trial

N Engl J Med. 2011 Dec 29;365(26):2453-62.

BACKGROUND:

The hemoglobin threshold at which postoperative red-cell transfusion is warranted is controversial. We conducted a randomized trialto determine whether a higher threshold for blood transfusion would improve recovery in patients who had undergone surgery for hip fracture.

METHODS:

We enrolled 2016 patients who were 50 years of age or older, who had either a history of or risk factors for cardiovascular disease, and whose hemoglobin level was below 10 g per deciliter after hip-fracture surgery. We randomly assigned patients to a liberal transfusion strategy (a hemoglobin threshold of 10 g per deciliter) or a restrictive transfusion strategy (symptoms of anemia or at physician discretion for a hemoglobin level of <8 g per deciliter). The primary outcome was death or an inability to walk across a room without human assistance on 60-day follow-up.

RESULTS:

A median of 2 units of red cells were transfused in the liberal-strategy group and none in the restrictive-strategy group. The rates of the primary outcome were 35.2% in the liberal-strategy group and 34.7% in the restrictive-strategy group (odds ratio in the liberal-strategy group, 1.01; 95% confidence interval [CI], 0.84 to 1.22), for an absolute risk difference of 0.5 percentage points (95% CI, -3.7 to 4.7). The rates of in-hospital acute coronary syndrome or death were 4.3% and 5.2%, respectively (absolute risk difference, -0.9%; 99% CI, -3.3 to 1.6), and rates of death on 60-day follow-up were 7.6% and 6.6%, respectively (absolute risk difference, 1.0%; 99% CI, -1.9 to 4.0). The rates of other complications were similar in the two groups.

CONCLUSIONS:

A liberal transfusion strategy, as compared with a restrictive strategy, did not reduce rates of death or inability to walk independently on 60-day follow-up or reduce in-hospital morbidity in elderly patients at high cardiovascular risk. (Funded by the National Heart, Lung, and Blood Institute; FOCUS ClinicalTrials.gov number, NCT00071032.).

 

Clear As Blood's insight:

-Orthopedic surgery in CVD

-Restrictive (Hb<80) vs. liberal (Hb <100) strategy

-Outcome: Death or inability to walk unassisted with 60 day f/u

-No difference in either outcome

 

 

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CRASH-2 Trial

Lancet. 2010 Jul 3;376(9734):23-32. 

BACKGROUND:

Tranexamic acid can reduce bleeding in patients undergoing elective surgery. We assessed the effects of early administration of a short course of tranexamic acid on death, vascular occlusive events, and the receipt of blood transfusion in trauma patients.

METHODS:

This randomised controlled trial was undertaken in 274 hospitals in 40 countries. 20 211 adult trauma patients with, or at risk of, significant bleeding were randomly assigned within 8 h of injury to either tranexamic acid (loading dose 1 g over 10 min then infusion of 1 g over 8 h) or matching placebo. Randomisation was balanced by centre, with an allocation sequence based on a block size of eight, generated with a computer random number generator. Both participants and study staff (site investigators and trial coordinating centre staff) were masked to treatment allocation. The primary outcome was death in hospital within 4 weeks of injury, and was described with the following categories: bleeding, vascular occlusion (myocardial infarction, stroke and pulmonary embolism), multiorgan failure, head injury, and other. All analyses were by intention to treat. This study is registered as ISRCTN86750102, Clinicaltrials.govNCT00375258, and South African Clinical Trial RegisterDOH-27-0607-1919.

FINDINGS:

10 096 patients were allocated to tranexamic acid and 10 115 to placebo, of whom 10 060 and 10 067, respectively, were analysed. All-cause mortality was significantly reduced with tranexamic acid (1463 [14.5%] tranexamic acid group vs 1613 [16.0%] placebo group; relative risk 0.91, 95% CI 0.85-0.97; p=0.0035). The risk of death due to bleeding was significantly reduced (489 [4.9%] vs 574 [5.7%]; relative risk 0.85, 95% CI 0.76-0.96; p=0.0077).

INTERPRETATION:

Tranexamic acid safely reduced the risk of death in bleeding trauma patients in this study. On the basis of these results, tranexamic acid should be considered for use in bleeding trauma patients.

Clear As Blood's insight:

Key RCT supporting the use of TXA in trauma.

Remember trauma dose: 1g over 10 minutes followed by 1g infused over 8 hours. 

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Pat's blood bank modules

Online modules from a Canadian blood bank educator covering: genetics, immunology, methods, ABO, Rh, and pretransfusion testing. 

Clear As Blood's insight:

One of the best technical immunohematology resources out there.

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Blood Bank Guy - Transfusion Medicine Education

Clear As Blood's insight:

Excellent TM educational resource: check out the Osler review notes.

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