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recommendations&#44; along with radiological tests&#44; laboratory tests and antibiotic treatments&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Since 2013&#44; the Spanish Society of Hematology and Hemotherapy &#40;through the project Commitment to Quality by the Scientific Societies in Spain&#44; coordinated by the Spanish Ministry of Health&#44; Social Services and Equality&#41; has recommended the following&#58; Do not transfuse more packed red blood cells than is necessary to relieve the symptoms of anemia or to return a patient to a safe hemoglobin range &#40;7 to 8<span class="elsevierStyleHsp" style=""></span>g&#47;dL for cardiac unstable patients&#41; and do not transfuse packed red blood cells in iron-deficiency anemia without hemodynamic instability&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> The World Health Organization has warned of the transfusion risks and the risks of inappropriately using PRBC transfusions&#44; urging health authorities&#44; scientific authorities and healthcare practitioners to implement cross-sectional and multidisciplinary programs in patient blood management&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> The implementation of these programs mainly for surgical patients has resulted in a reduction in the volume of transfusions for surgical and critically ill patients&#44; while the use could have increased in oncohematology and emergency departments&#46; In a recent Spanish multicenter study conducted in emergency departments&#44; up to 58&#37; of the PRBC transfusions were considered inappropriate&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">A frequently observed problem is the poor therapeutic indication for transfusion when requesting these components&#46; This decision carries the risk of adverse effects such as acute and delayed hemolytic transfusion reactions&#44; anaphylaxis&#44; alloimmunization&#44; immunomodulation&#44; allergic reactions&#44; graft-versus-host disease and the transmission of infectious diseases&#46; Moreover&#44; blood components are scarce&#44; and improving transfusion practices can considerably reduce costs&#44; although studies on this subject are scarce&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Therefore&#44; the aim of this multicenter study was to reassess the suitability of the indication for PRBC transfusion and the volumes transfused in emergency departments&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Patients and methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Design</span><p id="par0030" class="elsevierStylePara elsevierViewall">We conducted a multicenter&#44; observational&#44; cross-sectional&#44; noninterventional study on the appropriateness of blood transfusions&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Inclusion criteria</span><p id="par0195" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">&#8226;</span><p id="par0035" class="elsevierStylePara elsevierViewall">Adult patients &#40;&#8805;18 years&#41; who underwent at least one PRBC transfusion episode&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">&#8226;</span><p id="par0040" class="elsevierStylePara elsevierViewall">Admission to the emergency department of any of the participating centers&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">&#8226;</span><p id="par0045" class="elsevierStylePara elsevierViewall">Admission during November 2017&#46;</p></li></ul></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Exclusion criteria</span><p id="par0200" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">&#8226;</span><p id="par0050" class="elsevierStylePara elsevierViewall">Critical hemorrhages or massive transfusions&#44; defined as any life-threatening hemorrhage that requires the urgent and massive transfusion of blood products&#44; considering the clinical parameters&#58; obvious blood loss &#40;class 3 and 4 of the American College of Surgeons classification&#41;&#44; hypotension &#40;systolic blood pressure &#60;85<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>Hg&#41;&#44; tachypnea &#40;&#62;30<span class="elsevierStyleHsp" style=""></span>breaths&#47;min&#41; and central nervous system disorders &#40;low level of consciousness&#44; confusion or lethargy&#41;&#44; any significant blood loss that causes hemorrhagic shock and a score &#62;2 on the Assessment of Blood Consumption scale&#46; The definition also covers temporary parameters such as measurable blood loss &#8805;150<span class="elsevierStyleHsp" style=""></span>mL&#47;min for 10<span class="elsevierStyleHsp" style=""></span>min or more&#44; 50&#37; loss of blood volume in 3<span class="elsevierStyleHsp" style=""></span>h or 4<span class="elsevierStyleHsp" style=""></span>units of PRBC in 1<span class="elsevierStyleHsp" style=""></span>h and still bleeding&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">&#8226;</span><p id="par0055" class="elsevierStylePara elsevierViewall">Patients with plasma and platelet transfusions &#40;did not reach 3&#37; of the total transfusions&#41;&#46;</p></li></ul></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Definitions</span><p id="par0060" class="elsevierStylePara elsevierViewall">A <span class="elsevierStyleItalic">transfusion episode</span> is defined as the interval between the prescription of blood components transfusion and the completion of its administration&#46; When administering several units of blood components to the same patient under the same condition&#44; all units received are considered part of a single transfusion episode&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Participating centers</span><p id="par0065" class="elsevierStylePara elsevierViewall">La Paz University Hospital &#40;HULP&#41; and Hospital of Salamanca &#40;HoS&#41;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Variables</span><p id="par0070" class="elsevierStylePara elsevierViewall">The main study endpoint was the <span class="elsevierStyleItalic">appropriateness</span> of the prescription for PRBC transfusion and the volume transfused&#46; To this end&#44; we assessed the appropriateness of the transfusion according to the pretransfusion Hb levels and the patient&#8217;s characteristics&#44; according to the 5th edition of the 2015 guidelines on transfusing blood components and plasma derivatives of the Spanish Society of Blood Transfusion and Cell Therapy &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">We also recorded the hospital where the transfusion was performed and the patients&#8217; demographic and clinical variables &#40;age&#44; sex&#44; history&#44; reason for admission and department they were admitted to&#44; length of stay in the emergency department&#44; reason for the transfusion&#44; biochemical values&#44; transfused component and quantity transfused&#41;&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">To evaluate the <span class="elsevierStyleItalic">effectiveness</span> of the transfusion volume&#44; we assessed the posttransfusion Hb value&#46; According to the recommendations of the 2013 Forum of Seville&#44; we defined &#8220;overtransfusion&#8221; when the Hb level after the transfusion was more than 2<span class="elsevierStyleHsp" style=""></span>g&#47;dL above the Hb transfusion threshold for each particular indication &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Data collection</span><p id="par0085" class="elsevierStylePara elsevierViewall">We created an electronic case report form for the data for the transfusions&#46; The form was then downloaded in Excel format for subsequent analysis&#46; These calculation sheets contained the data provided by the transfusion department of each hospital&#44; especially the transfusion episodes of the emergency department during the study period&#46; Additional data on the patients who underwent PRBC transfusion in the emergency department during the study period were obtained from the hospitals&#8217; computer systems and added to complete the database&#46; Subsequently&#44; the databases from each of the hospitals was merged and imported into STATA&#47;SE 14&#46;0&#174; for statistical analysis&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Statistical analysis</span><p id="par0090" class="elsevierStylePara elsevierViewall">The qualitative variables are listed using frequency distributions&#46; For the quantitative variables&#44; we calculated the mean values and standard deviations &#40;&#177;SD&#41; or medians and interquartile ranges&#46; We employed the Shapiro-Wilk test to compare the normal distribution of the quantitative variables&#59; For the qualitative variables&#44; we employed the chi-squared test&#46; For the continuous variables&#44; we employed Student&#8217;s t-test or the Mann&#8211;Whitney U test to compare whether the transfusion was appropriate&#44; depending on the normality of the data&#46; We considered a type 1 error &#60;0&#46;05 &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41; statistically significant for all analyses&#46;</p></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0095" class="elsevierStylePara elsevierViewall">In total&#44; we obtained data from 381 patients admitted to the emergency department during the study period&#59; 220 were men &#40;57&#46;74&#37;&#41;&#44; with an average age of 71&#46;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>14&#46;0 years&#44; and 161 women &#40;42&#46;26&#37;&#41;&#44; with an average age of 75&#46;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>15&#46;3 years &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46; Some 93&#46;19&#37; of the patients were directly admitted to the emergency department due to medical causes&#44; while the rest were referred from other departments &#40;4&#46;02&#37; after surgery&#44; generally due to loss of blood during the procedure&#59; 1&#46;86&#37; from the gynecology department&#59; and 0&#46;93&#37; from the trauma department&#41;&#46; Also&#44; 69&#46;35&#37; of these patients were discharged from the emergency department the same day they were admitted&#44; while 28&#46;79&#37; were discharged the following day&#46; Of the 381 study patients&#44; 323 were from HULP &#40;84&#46;78&#37;&#41; and 58 were from HoS &#40;15&#46;22&#37;&#41;&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">The transfused patients received a median of 2 units of PRBCs &#40;range&#44; 1&#8211;7&#41;&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">The most prevalent underlying diseases in the patients who underwent transfusions were heart disease&#44; which included hemorrhaging due to antiplatelet or anticoagulant therapy &#40;57&#46;7&#37;&#41;&#44; hemato-oncologic &#40;15&#46;3&#37;&#41; diseases and neurological disease &#40;4&#46;2&#37;&#41;&#46; The most common reason for the transfusion was based on laboratory criteria &#40;22&#46;29&#37; of the sample&#44; a rate very similar to that of subacute symptoms&#44; which reached 20&#46;43&#37;&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0110" class="elsevierStylePara elsevierViewall">The mean pretransfusion hemoglobin level was 7&#46;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;8<span class="elsevierStyleHsp" style=""></span>g&#47;dL &#40;7&#46;22<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;49 in HoS and 7&#46;91<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;83 in HULP&#41;&#44; while the mean post-transfusion hemoglobin level was 9&#46;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;7<span class="elsevierStyleHsp" style=""></span>g&#47;dL &#40;8&#46;77<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;13 in HoS and 9&#46;31<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;79 in HULP&#41;&#46; In all cases&#44; there were statistically significant differences between the two values &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0115" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows the rest of the pretransfusion and posttransfusion values&#44; both for the laboratory results and the case history&#46; There were significant differences in all measures&#44; except body temperature &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;438&#41; and diastolic blood pressure &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;211&#41;&#46; It is worth noting that posttransfusion values were recorded in only 54&#46;79&#37; of the patients&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Appropriateness</span><p id="par0120" class="elsevierStylePara elsevierViewall">As shown in <a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#44; only 54&#46;9&#37; &#40;209&#47;381&#41; of the prescriptions for transfusion were considered <span class="elsevierStyleItalic">appropriate</span>&#44; with significant differences according to the indication &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0125" class="elsevierStylePara elsevierViewall">Of the 209 patients with an appropriate prescription&#44; 143 &#40;68&#46;4&#37;&#41; received an improper volume of blood components &#40;overtransfusion&#41;&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Appropriateness analysis</span><p id="par0130" class="elsevierStylePara elsevierViewall">In terms of the potential differences between hospital type&#44; we found that 75&#46;86&#37; of the transfusions performed by HoS were appropriate&#44; while only 51&#46;08&#37; of those performed by HULP were appropriate&#44; a difference that was statistically significant &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a> lists the rates of transfusion appropriateness in HoS and HULP&#44; showing differences in the distribution of PRBC transfusion appropriateness in the various criteria&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0140" class="elsevierStylePara elsevierViewall">When considering the diagnoses of acute and chronic anemia &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41;&#44; there are differences only in the rates of appropriate transfusions in acute anemia&#44; where 69&#46;23&#37; of the transfusions were appropriate in HoS and 31&#46;29&#37; of the transfusions were appropriate in HULP &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46; For chronic anemia&#44; the difference was not significant &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;123&#41;&#44; despite the higher appropriateness rate for PRBC transfusion in HoS&#46;</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia></span></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Discussion</span><p id="par0145" class="elsevierStylePara elsevierViewall">Evidence from 10 years ago showed that more than 50&#37; of all PRBC transfusions in Spain were administered to surgical patients and those in critical condition&#46; The transfusion of red blood cells was the most widely used&#44; and anesthesiologists were responsible for approximately 50&#37; of transfusions&#46; In recent years&#44; however&#44; the use of transfusions has decreased in surgical areas&#44; and currently the 2 departments that employ most employ transfusions are the oncohematology and emergency departments&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">Although PRBC transfusions have been employed for many years and can save many patients with acute or chronic anemia&#44; the results of this study conducted in emergency departments show that there is a high rate of unnecessary transfusions in both diseases&#46; In HoS&#44; which has a commitment to train practitioners on the appropriateness of PRBC transfusion&#44;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#8211;10</span></a> we observed that the management of blood products had greater appropriateness&#46; A recent survey by the American Association of Blood Banks showed that only 38&#37; of public hospitals had an established program for managing blood products and patient transfusions&#46; This program should be extended to all hospitals because it has been shown that local transfusion programs and committees promote patient safety&#44; improve the quality of medical care and reduce unnecessary expenses&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">Anemia is characterized by an insufficient quantity of healthy red blood cells&#44; which are responsible for oxygenating the tissues and organs of the body and whose deficiency can therefore cause severe damage in these vital organs&#46; In general&#44; anemia is considered hemoglobin values &#60;12<span class="elsevierStyleHsp" style=""></span>g&#47;dL and &#60;14<span class="elsevierStyleHsp" style=""></span>g&#47;dL and hematocrit levels &#60;36&#37; and &#60;41&#37; for women and men&#44; respectively&#46; This disease is often underdiagnosed and undertreated and has a very high rate of comorbidity&#46; Detection and appropriate treatment help reduce the need for transfusions&#44; given that transfusions&#44; although effective against anemia&#44; are associated with numerous risks and complications&#46; It is therefore essential to implement patient blood management programs&#44; as urged by the World Health Organization in the 63rd Assembly of June 2010 and promoted the same year by the Council of Europe in the so-called &#8220;optimal use of blood&#8221;&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a></p><p id="par0160" class="elsevierStylePara elsevierViewall">Depending on the mechanism of red blood cell destruction&#44; the treatment for anemia should focus on its origin and not prioritize increasing hemoglobin levels&#46; Blood transfusion is currently one of the most widely used treatments in Spanish emergency departments to treat anemia&#46; Although this disease is generally accompanied by a reduction in erythrocyte mass&#44; a reduction in the number of red blood cells does not have to occur&#46; Therefore&#44; a PRBC transfusion is perhaps not the best treatment option in these cases&#46; Our study showed that only 54&#46;86&#37; of the PRBC transfusions were performed appropriately following the clinical guidelines criteria based on the patients&#8217; hemoglobin levels and previous diseases&#59; however&#44; there was a considerable difference between the two diagnoses&#44; with 69&#46;71&#37; of the cases of chronic anemia having appropriate PRBC transfusions versus 36&#46;99&#37; in the case of acute anemia&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">For this reason and because PRBC transfusions are an expensive and scarce resource associated with known complications and adverse effects to be considered when prescribing them to patients&#44; other better alternatives for the treatment of anemia should be considered&#44; based on the disease&#8217;s etiology&#44; symptom severity and associated comorbidity&#46; In these cases&#44; a detailed medical history and anamnesis are essential when administering the best treatment for the patient&#46; Logically&#44; treating anemia will depend on its cause and severity&#46; On many occasions&#44; however&#44; the prescription of iron&#44; vitamin B12 and folic acid supplements&#44; erythropoietin and medications that inhibit the immune system can be good alternatives to blood component transfusion&#46; In fact&#44; in countries such as the US and the UK&#44; treatment based on PRBC transfusion fell 30&#8211;50&#37; within a few years&#44;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#44;13</span></a> with a priority on therapeutic alternatives&#46; Morbidity and mortality&#44; hospital stays and readmissions also fell&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">Article 40 of the Spanish Royal Decree 1088&#47;2005<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> governs the existence and functions of hospital and independent transfusion centers and committees&#46; Within their delegated powers&#44; the autonomous communities of Spain have established that all centers with transfusion practices require a transfusion committee for the correct use of blood and blood components&#46; The committee&#8217;s functions&#44; as a minimum&#44; are the following&#58; a&#41; Determine the standards and procedures for the transfusion practice adapted to the clinical activities performed in each hospital center&#59; b&#41; Periodically analyze and evaluate the transfusion practice&#59; c&#41; Analyze and assess the adverse reactions associated with transfusions&#59; d&#41; Develop educational programs that promote the optimal use of blood components&#59; e&#41; Develop and implement preventive and&#47;or corrective safety measures&#59; and f&#41; Any other functions they consider would help promote the optimal use of blood&#44; components and derivatives and in reducing their consumption&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">Other options studied in the context of the politics of managing patients&#8217; blood include multifactorial strategies&#46; Langlais et al&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> adopted a series of strategies aimed at improving the transfusion practices in surgery departments through seminars&#44; classes&#44; periodic consultations and the creation of information points&#46; Through these measures&#44; the authors improved transfusion appropriateness from 37&#46;7&#37; to 64&#46;5&#37;&#46; In other studies&#44; the rate of appropriateness was only 8&#46;3&#37; for patients with trauma&#44; 11&#46;5&#37; for patients who underwent surgery and 12&#46;8&#37; for transfusions ordered by a specialist&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> The introduction of policies that help improve these figures would therefore be a short-term objective that can help increase the appropriateness of PRBC transfusions&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">In our study&#44; we observed high overtransfusion rates&#44; which were also found in other studies&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> As a result and as proposed by a number of these studies&#44; we emphasize the concept of reassessing the patient&#8217;s state after each unit of transfused PRBC and before prescribing additional units&#46; A zero-tolerance policy can be effectively implemented only with exhaustive work with local physicians&#44; including repeated rounds of information&#44; updates on current transfusion practices and the knowledge of established regimens over time&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17&#8211;19</span></a></p><p id="par0185" class="elsevierStylePara elsevierViewall">The limitations of our study include the heterogeneity between the 2 hospitals&#44; given the fact that the transfusion policy employed by each hospital is different&#46; The appropriateness results therefore differ between them&#46; Further studies are warranted to analyze the shortcomings in these types of policies&#44; as well as to create a commitment to improve the transfusion policies for all public hospitals in Spain to determine the effects on patient health and on the healthcare cost of these policies&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conflicts of interest</span><p id="par0190" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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            0 => "Transfusi&#243;n sangu&#237;nea"
            1 => "Anemia"
            2 => "Hemoglobina"
          ]
        ]
      ]
    ]
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      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Increasing haemoglobin and haematocrit levels with blood transfusions has been the gold standard for treating severe anaemia&#59; however&#44; the indication for transfusing concentrated red blood cells is based merely on a few laboratory markers&#44; such as haemoglobin and haematocrit levels&#44; rather than based on the symptoms according to clinical practice guidelines&#44; the implementation of legal regulations and the consensus achieved by the hospitals&#8217; transfusion committees&#46; The aim of this multicentre study was to reassess the suitability of the indication for transfusing concentrated red blood cells and the volumes transfused in emergency departments&#46; We established an observational&#44; multicentre&#44; cross-sectional design with 2 participating centres&#58; the La Paz University Hospital and the Hospital of Salamanca&#46; In total&#44; we obtained data from 381 patients&#44; 220 &#40;57&#46;74&#37;&#41; of whom were men with an average age of 71&#46;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>14&#46;0 years and 161 &#40;42&#46;26&#37;&#41; of whom were women with an average age of 75&#46;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>15&#46;3 years &#40;P<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46; The most prevalent underlying diseases in the patients who underwent transfusions were heart disease&#44; which included haemorrhaging due to antiplatelet or anticoagulant therapy &#40;57&#46;7&#37;&#41;&#44; haematooncologic &#40;15&#46;3&#37;&#41; diseases and neurological disease&#46; Only 54&#46;9&#37; &#40;209&#47;381&#41; of the prescriptions for transfusion were considered appropriate&#44; with significant differences according to the indication&#46;</p></span>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">La elevaci&#243;n del nivel de hemoglobina y de hematocrito con transfusiones sangu&#237;neas ha sido el est&#225;ndar de oro para el tratamiento de la anemia grave&#46; Sin embargo&#44; la indicaci&#243;n para la transfusi&#243;n de concentrado de hemat&#237;es se basa meramente en unos marcadores anal&#237;ticos&#44; como el nivel de hemoglobina o hematocritos&#44; en lugar de basarse en la cl&#237;nica &#40;seg&#250;n las gu&#237;as de pr&#225;ctica cl&#237;nica&#41;&#44; en la implementaci&#243;n de regulaciones legales o en los consensos alcanzados por los comit&#233;s de transfusi&#243;n de los hospitales&#46; El objetivo de este estudio multic&#233;ntrico es reevaluar la idoneidad de la indicaci&#243;n de transfusi&#243;n de concentrado de hemat&#237;es y los vol&#250;menes transfundidos en los servicios de urgencias&#46; Se plantea un dise&#241;o observacional multic&#233;ntrico y transversal en 2 centros participantes&#58; el Hospital Universitario de La Paz y el Hospital de Salamanca&#46; En total se obtuvieron datos de 381 pacientes&#59; 220 eran hombres &#40;57&#44;74&#37;&#41;&#44; con una edad promedio de 71&#44;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>14&#44;0 a&#241;os y 161 eran mujeres &#40;42&#44;26&#37; con una edad promedio de 75&#44;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>15&#44;3 a&#241;os p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#46; Las enfermedades subyacentes m&#225;s prevalentes en los pacientes que recibieron transfusi&#243;n fueron las cardiol&#243;gicas&#44; que incluyeron hemorragia debido a la terapia antiagregante plaquetaria o anticoagulante 57&#46;7&#37;&#41;&#44; las hematooncol&#243;gicas &#40;15&#46;3&#37;&#41; y las neurol&#243;gicas&#46; Solo el 54&#46;9&#37; &#40;209&#47;381&#41; de las prescripciones de transfusi&#243;n se consideraron apropiadas&#44; con diferencias significativas observadas seg&#250;n la indicaci&#243;n&#46;</p></span>"
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Quintana-D&#237;az M&#44; et al&#46; Transfusi&#243;n en Urgencias&#58; algo m&#225;s que una transfusi&#243;n de sangre&#46; Rev Clin Esp&#46; 2020&#59;220&#58;393&#8211;399&#46;</p>"
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          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Differences between values before and after hemoglobin transfusion&#44; according to the type of anemia&#46;</p>"
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Hemoglobin&#44; g&#47;dL&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Clinical situation&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Acute anemia&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#60;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Any clinical situation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&#8211;8&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Hemodynamically unstable or associated risk factors&#58; coronary artery disease&#44; heart failure&#44; cerebrovascular disease and myocardial infarction&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#8805;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Distress controlling the hemorrhaging or signs and symptoms of anemia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">Chronic anemia&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#60;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Signs and symptoms of anemia or associated risk factors&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No signs or symptoms of anemia&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Other values&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">SD&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">25th percentile&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">75th percentile&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " colspan="6" align="left" valign="\n
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                  \t\t\t\t">&#91;0&#44;1-6&#93;<span class="elsevierStyleItalic">Pretransfusion values</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Hematocrit&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">24&#46;35&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">6&#46;44&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">23&#46;75&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">21&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">26&#46;20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Mean corpuscular volume&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">87&#46;24&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">11&#46;96&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">89&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">79&#46;85&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">95&#46;05&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Mean corpuscular hemoglobin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">38&#46;55&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">177&#46;46&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">29&#46;50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">26&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">32&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Prothrombin time&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">69&#46;73&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">26&#46;99&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">78&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">53&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">92&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>International Normalized Ratio &#40;INR&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46;59&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13&#46;53&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;18&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;05&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;59&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Platelets&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">239&#46;03&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">154&#46;27&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">224&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">132&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">314&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Creatinine&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;88&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&#46;97&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;80&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;67&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Total bilirubin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;05&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46;09&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;85&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Temperature&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">36&#46;38&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;57&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">36&#46;40&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">36&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">36&#46;70&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Systolic blood pressure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">126&#46;18&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">31&#46;59&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">129&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">105&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">145&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Diastolic blood pressure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">65&#46;34&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14&#46;09&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">64&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">57&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">73&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " colspan="6" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#91;0&#44;1-6&#93;</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " colspan="6" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#91;0&#44;1-6&#93;<span class="elsevierStyleItalic">Posttransfusion values</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Hematocrit&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">28&#46;13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#46;99&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">28&#46;20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">25&#46;20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">31&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Mean corpuscular volume&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">88&#46;16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9&#46;20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">90&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">82&#46;70&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">94&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Mean corpuscular hemoglobin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">29&#46;33&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#46;64&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">30&#46;40&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">27&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">32&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Prothrombin time&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">73&#46;68&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">18&#46;74&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">78&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">61&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">89&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>International Normalized Ratio &#40;INR&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;31&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;43&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;17&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;09&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;41&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Platelets&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">197&#46;75&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">126&#46;07&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">165&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">108&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">270&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Creatinine&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;38&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;71&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;59&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Total bilirubin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;84&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;03&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;40&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;90&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Temperature&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">36&#46;56&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;67&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">36&#46;50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">36&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">36&#46;70&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Systolic blood pressure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">120&#46;52&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">22&#46;90&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">119&#46;50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">108&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">130&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Diastolic blood pressure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">62&#46;02&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&#46;31&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">60&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">55&#46;00&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">70&#46;00&nbsp;\t\t\t\t\t\t\n
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                  """
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                    0 => array:2 [
                      "titulo" => "Transfusion thresholds and red blood cells transfusion focused on tissue oxygenation"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "J&#46; Ripoll&#233;s-Melchor"
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                  "referenciaCompleta" => "Sociedad Espa&#241;ola de Hematolog&#237;a y Hemoterapia&#46; Recomendaciones de la SEHH de 2013 &#91;consultado 22 octubre 2019&#93;&#46; Disponible en&#58; <a target="_blank" href="http://www.mscbs.gob.es/organizacion/sns/planCalidadSNS/pdf/SOCIEDAD_ESP_HEMATOLOGIA_HEMOTERAPIA_0K.pdf">http&#58;&#47;&#47;www&#46;mscbs&#46;gob&#46;es&#47;organizacion&#47;sns&#47;planCalidadSNS&#47;pdf&#47;SOCIEDAD&#95;ESP&#95;HEMATOLOGIA&#95;HEMOTERAPIA&#95;0K&#46;pdf</a>&#46;"
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                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Hemolysis&#44; hyperkalemia and the transfusion of packed old red blood cells in critically ill patients"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
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                      "titulo" => "USEES-URG ResearchGrup&#46; Appropriate use of red blood cell transfusion in emergency departments&#58; a study in five emergency departments"
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                      "doi" => "10.2450/2016.0324-15"
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                        "paginaInicial" => "199"
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                      "titulo" => "International Consensus Conference on Transfusion Outcomes Group&#46; Appropiateness of allogeneic red bllod cell transfusi&#243;n&#58; the international consensus conference on transfusion outcome"
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                            1 => "A&#46; Fink"
                            2 => "M&#46; Javidroozi"
                            3 => "J&#46; Erhard"
                            4 => "S&#46;L&#46; Farmer"
                            5 => "H&#46; Corwin"
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                        "tituloSerie" => "Transf Med Rev"
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Original article
Transfusions in the Emergency department: More than a blood transfusion
Transfusión en Urgencias: algo más que una transfusión de sangre
M. Quintana-Díaza, E.M. Andrés-Estebanb, J. Sánchez-Serranoc, A. Martínez-Virtoa, R. Juárez-Velad,e,
Corresponding author
raul.juarez@unirioja.es

Corresponding author.
, J.A. García-Ercef
a Servicio de Urgencias, Hospital Universitario La Paz, Grupo PBM, Instituto de Investigación-IdiPAZ, Madrid, Spain
b Universidad Rey Juan Carlos, Grupo PBM, Instituto de Investigación-IdiPAZ, Madrid, Spain
c Servicio de Urgencias, Hospital Universitario de Salamanca, Instituto de Investigación-IdiPAZ, Salamanca, Spain
d Universidad de La Rioja, Logroño, Spain
e Instituto de Investigación Sanitaria de Aragón, Zaragoza, Spain
f Banco de Sangre y Tejidos de Navarra (Navarra), Grupo PBM, Instituto de Investigación-IdiPAZ, Madrid, Spain
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recommendations&#44; along with radiological tests&#44; laboratory tests and antibiotic treatments&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Since 2013&#44; the Spanish Society of Hematology and Hemotherapy &#40;through the project Commitment to Quality by the Scientific Societies in Spain&#44; coordinated by the Spanish Ministry of Health&#44; Social Services and Equality&#41; has recommended the following&#58; Do not transfuse more packed red blood cells than is necessary to relieve the symptoms of anemia or to return a patient to a safe hemoglobin range &#40;7 to 8<span class="elsevierStyleHsp" style=""></span>g&#47;dL for cardiac unstable patients&#41; and do not transfuse packed red blood cells in iron-deficiency anemia without hemodynamic instability&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> The World Health Organization has warned of the transfusion risks and the risks of inappropriately using PRBC transfusions&#44; urging health authorities&#44; scientific authorities and healthcare practitioners to implement cross-sectional and multidisciplinary programs in patient blood management&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> The implementation of these programs mainly for surgical patients has resulted in a reduction in the volume of transfusions for surgical and critically ill patients&#44; while the use could have increased in oncohematology and emergency departments&#46; In a recent Spanish multicenter study conducted in emergency departments&#44; up to 58&#37; of the PRBC transfusions were considered inappropriate&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">A frequently observed problem is the poor therapeutic indication for transfusion when requesting these components&#46; This decision carries the risk of adverse effects such as acute and delayed hemolytic transfusion reactions&#44; anaphylaxis&#44; alloimmunization&#44; 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of the total transfusions&#41;&#46;</p></li></ul></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Definitions</span><p id="par0060" class="elsevierStylePara elsevierViewall">A <span class="elsevierStyleItalic">transfusion episode</span> is defined as the interval between the prescription of blood components transfusion and the completion of its administration&#46; When administering several units of blood components to the same patient under the same condition&#44; all units received are considered part of a single transfusion episode&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Participating centers</span><p id="par0065" class="elsevierStylePara elsevierViewall">La Paz University Hospital &#40;HULP&#41; and Hospital of Salamanca &#40;HoS&#41;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Variables</span><p id="par0070" class="elsevierStylePara elsevierViewall">The main study endpoint was the <span class="elsevierStyleItalic">appropriateness</span> of the prescription for PRBC transfusion and the volume transfused&#46; To this end&#44; we assessed the appropriateness of the transfusion according to the pretransfusion Hb levels and the patient&#8217;s characteristics&#44; according to the 5th edition of the 2015 guidelines on transfusing blood components and plasma derivatives of the Spanish Society of Blood Transfusion and Cell Therapy &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">We also recorded the hospital where the transfusion was performed and the patients&#8217; demographic and clinical variables &#40;age&#44; sex&#44; history&#44; reason for admission and department they were admitted to&#44; length of stay in the emergency department&#44; reason for the transfusion&#44; biochemical values&#44; transfused component and quantity transfused&#41;&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">To evaluate the <span class="elsevierStyleItalic">effectiveness</span> of the transfusion volume&#44; we assessed the posttransfusion Hb value&#46; According to the recommendations of the 2013 Forum of Seville&#44; we defined &#8220;overtransfusion&#8221; when the Hb level after the transfusion was more than 2<span class="elsevierStyleHsp" style=""></span>g&#47;dL above the Hb transfusion threshold for each particular indication &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Data collection</span><p id="par0085" class="elsevierStylePara elsevierViewall">We created an electronic case report form for the data for the transfusions&#46; The form was then downloaded in Excel format for subsequent analysis&#46; These calculation sheets contained the data provided by the transfusion department of each hospital&#44; especially the transfusion episodes of the emergency department during the study period&#46; Additional data on the patients who underwent PRBC transfusion in the emergency department during the study period were obtained from the hospitals&#8217; computer systems and added to complete the database&#46; Subsequently&#44; the databases from each of the hospitals was merged and imported into STATA&#47;SE 14&#46;0&#174; for statistical analysis&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Statistical analysis</span><p id="par0090" class="elsevierStylePara elsevierViewall">The qualitative variables are listed using frequency distributions&#46; For the quantitative variables&#44; we calculated the mean values and standard deviations &#40;&#177;SD&#41; or medians and interquartile ranges&#46; We employed the Shapiro-Wilk test to compare the normal distribution of the quantitative variables&#59; For the qualitative variables&#44; we employed the chi-squared test&#46; For the continuous variables&#44; we employed Student&#8217;s t-test or the Mann&#8211;Whitney U test to compare whether the transfusion was appropriate&#44; depending on the normality of the data&#46; We considered a type 1 error &#60;0&#46;05 &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41; statistically significant for all analyses&#46;</p></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0095" class="elsevierStylePara elsevierViewall">In total&#44; we obtained data from 381 patients admitted to the emergency department during the study period&#59; 220 were men &#40;57&#46;74&#37;&#41;&#44; with an average age of 71&#46;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>14&#46;0 years&#44; and 161 women &#40;42&#46;26&#37;&#41;&#44; with an average age of 75&#46;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>15&#46;3 years &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46; Some 93&#46;19&#37; of the patients were directly admitted to the emergency department due to medical causes&#44; while the rest were referred from other departments &#40;4&#46;02&#37; after surgery&#44; generally due to loss of blood during the procedure&#59; 1&#46;86&#37; from the gynecology department&#59; and 0&#46;93&#37; from the trauma department&#41;&#46; Also&#44; 69&#46;35&#37; of these patients were discharged from the emergency department the same day they were admitted&#44; while 28&#46;79&#37; were discharged the following day&#46; Of the 381 study patients&#44; 323 were from HULP &#40;84&#46;78&#37;&#41; and 58 were from HoS &#40;15&#46;22&#37;&#41;&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">The transfused patients received a median of 2 units of PRBCs &#40;range&#44; 1&#8211;7&#41;&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">The most prevalent underlying diseases in the patients who underwent transfusions were heart disease&#44; which included hemorrhaging due to antiplatelet or anticoagulant therapy &#40;57&#46;7&#37;&#41;&#44; hemato-oncologic &#40;15&#46;3&#37;&#41; diseases and neurological disease &#40;4&#46;2&#37;&#41;&#46; The most common reason for the transfusion was based on laboratory criteria &#40;22&#46;29&#37; of the sample&#44; a rate very similar to that of subacute symptoms&#44; which reached 20&#46;43&#37;&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0110" class="elsevierStylePara elsevierViewall">The mean pretransfusion hemoglobin level was 7&#46;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;8<span class="elsevierStyleHsp" style=""></span>g&#47;dL &#40;7&#46;22<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;49 in HoS and 7&#46;91<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;83 in HULP&#41;&#44; while the mean post-transfusion hemoglobin level was 9&#46;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;7<span class="elsevierStyleHsp" style=""></span>g&#47;dL &#40;8&#46;77<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;13 in HoS and 9&#46;31<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;79 in HULP&#41;&#46; In all cases&#44; there were statistically significant differences between the two values &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0115" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows the rest of the pretransfusion and posttransfusion values&#44; both for the laboratory results and the case history&#46; There were significant differences in all measures&#44; except body temperature &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;438&#41; and diastolic blood pressure &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;211&#41;&#46; It is worth noting that posttransfusion values were recorded in only 54&#46;79&#37; of the patients&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Appropriateness</span><p id="par0120" class="elsevierStylePara elsevierViewall">As shown in <a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#44; only 54&#46;9&#37; &#40;209&#47;381&#41; of the prescriptions for transfusion were considered <span class="elsevierStyleItalic">appropriate</span>&#44; with significant differences according to the indication &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0125" class="elsevierStylePara elsevierViewall">Of the 209 patients with an appropriate prescription&#44; 143 &#40;68&#46;4&#37;&#41; received an improper volume of blood components &#40;overtransfusion&#41;&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Appropriateness analysis</span><p id="par0130" class="elsevierStylePara elsevierViewall">In terms of the potential differences between hospital type&#44; we found that 75&#46;86&#37; of the transfusions performed by HoS were appropriate&#44; while only 51&#46;08&#37; of those performed by HULP were appropriate&#44; a difference that was statistically significant &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a> lists the rates of transfusion appropriateness in HoS and HULP&#44; showing differences in the distribution of PRBC transfusion appropriateness in the various criteria&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0140" class="elsevierStylePara elsevierViewall">When considering the diagnoses of acute and chronic anemia &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41;&#44; there are differences only in the rates of appropriate transfusions in acute anemia&#44; where 69&#46;23&#37; of the transfusions were appropriate in HoS and 31&#46;29&#37; of the transfusions were appropriate in HULP &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46; For chronic anemia&#44; the difference was not significant &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;123&#41;&#44; despite the higher appropriateness rate for PRBC transfusion in HoS&#46;</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia></span></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Discussion</span><p id="par0145" class="elsevierStylePara elsevierViewall">Evidence from 10 years ago showed that more than 50&#37; of all PRBC transfusions in Spain were administered to surgical patients and those in critical condition&#46; The transfusion of red blood cells was the most widely used&#44; and anesthesiologists were responsible for approximately 50&#37; of transfusions&#46; In recent years&#44; however&#44; the use of transfusions has decreased in surgical areas&#44; and currently the 2 departments that employ most employ transfusions are the oncohematology and emergency departments&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">Although PRBC transfusions have been employed for many years and can save many patients with acute or chronic anemia&#44; the results of this study conducted in emergency departments show that there is a high rate of unnecessary transfusions in both diseases&#46; In HoS&#44; which has a commitment to train practitioners on the appropriateness of PRBC transfusion&#44;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#8211;10</span></a> we observed that the management of blood products had greater appropriateness&#46; A recent survey by the American Association of Blood Banks showed that only 38&#37; of public hospitals had an established program for managing blood products and patient transfusions&#46; This program should be extended to all hospitals because it has been shown that local transfusion programs and committees promote patient safety&#44; improve the quality of medical care and reduce unnecessary expenses&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">Anemia is characterized by an insufficient quantity of healthy red blood cells&#44; which are responsible for oxygenating the tissues and organs of the body and whose deficiency can therefore cause severe damage in these vital organs&#46; In general&#44; anemia is considered hemoglobin values &#60;12<span class="elsevierStyleHsp" style=""></span>g&#47;dL and &#60;14<span class="elsevierStyleHsp" style=""></span>g&#47;dL and hematocrit levels &#60;36&#37; and &#60;41&#37; for women and men&#44; respectively&#46; This disease is often underdiagnosed and undertreated and has a very high rate of comorbidity&#46; Detection and appropriate treatment help reduce the need for transfusions&#44; given that transfusions&#44; although effective against anemia&#44; are associated with numerous risks and complications&#46; It is therefore essential to implement patient blood management programs&#44; as urged by the World Health Organization in the 63rd Assembly of June 2010 and promoted the same year by the Council of Europe in the so-called &#8220;optimal use of blood&#8221;&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a></p><p id="par0160" class="elsevierStylePara elsevierViewall">Depending on the mechanism of red blood cell destruction&#44; the treatment for anemia should focus on its origin and not prioritize increasing hemoglobin levels&#46; Blood transfusion is currently one of the most widely used treatments in Spanish emergency departments to treat anemia&#46; Although this disease is generally accompanied by a reduction in erythrocyte mass&#44; a reduction in the number of red blood cells does not have to occur&#46; Therefore&#44; a PRBC transfusion is perhaps not the best treatment option in these cases&#46; Our study showed that only 54&#46;86&#37; of the PRBC transfusions were performed appropriately following the clinical guidelines criteria based on the patients&#8217; hemoglobin levels and previous diseases&#59; however&#44; there was a considerable difference between the two diagnoses&#44; with 69&#46;71&#37; of the cases of chronic anemia having appropriate PRBC transfusions versus 36&#46;99&#37; in the case of acute anemia&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">For this reason and because PRBC transfusions are an expensive and scarce resource associated with known complications and adverse effects to be considered when prescribing them to patients&#44; other better alternatives for the treatment of anemia should be considered&#44; based on the disease&#8217;s etiology&#44; symptom severity and associated comorbidity&#46; In these cases&#44; a detailed medical history and anamnesis are essential when administering the best treatment for the patient&#46; Logically&#44; treating anemia will depend on its cause and severity&#46; On many occasions&#44; however&#44; the prescription of iron&#44; vitamin B12 and folic acid supplements&#44; erythropoietin and medications that inhibit the immune system can be good alternatives to blood component transfusion&#46; In fact&#44; in countries such as the US and the UK&#44; treatment based on PRBC transfusion fell 30&#8211;50&#37; within a few years&#44;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#44;13</span></a> with a priority on therapeutic alternatives&#46; Morbidity and mortality&#44; hospital stays and readmissions also fell&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">Article 40 of the Spanish Royal Decree 1088&#47;2005<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> governs the existence and functions of hospital and independent transfusion centers and committees&#46; Within their delegated powers&#44; the autonomous communities of Spain have established that all centers with transfusion practices require a transfusion committee for the correct use of blood and blood components&#46; The committee&#8217;s functions&#44; as a minimum&#44; are the following&#58; a&#41; Determine the standards and procedures for the transfusion practice adapted to the clinical activities performed in each hospital center&#59; b&#41; Periodically analyze and evaluate the transfusion practice&#59; c&#41; Analyze and assess the adverse reactions associated with transfusions&#59; d&#41; Develop educational programs that promote the optimal use of blood components&#59; e&#41; Develop and implement preventive and&#47;or corrective safety measures&#59; and f&#41; Any other functions they consider would help promote the optimal use of blood&#44; components and derivatives and in reducing their consumption&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">Other options studied in the context of the politics of managing patients&#8217; blood include multifactorial strategies&#46; Langlais et al&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> adopted a series of strategies aimed at improving the transfusion practices in surgery departments through seminars&#44; classes&#44; periodic consultations and the creation of information points&#46; Through these measures&#44; the authors improved transfusion appropriateness from 37&#46;7&#37; to 64&#46;5&#37;&#46; In other studies&#44; the rate of appropriateness was only 8&#46;3&#37; for patients with trauma&#44; 11&#46;5&#37; for patients who underwent surgery and 12&#46;8&#37; for transfusions ordered by a specialist&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> The introduction of policies that help improve these figures would therefore be a short-term objective that can help increase the appropriateness of PRBC transfusions&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">In our study&#44; we observed high overtransfusion rates&#44; which were also found in other studies&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> As a result and as proposed by a number of these studies&#44; we emphasize the concept of reassessing the patient&#8217;s state after each unit of transfused PRBC and before prescribing additional units&#46; A zero-tolerance policy can be effectively implemented only with exhaustive work with local physicians&#44; including repeated rounds of information&#44; updates on current transfusion practices and the knowledge of established regimens over time&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17&#8211;19</span></a></p><p id="par0185" class="elsevierStylePara elsevierViewall">The limitations of our study include the heterogeneity between the 2 hospitals&#44; given the fact that the transfusion policy employed by each hospital is different&#46; The appropriateness results therefore differ between them&#46; Further studies are warranted to analyze the shortcomings in these types of policies&#44; as well as to create a commitment to improve the transfusion policies for all public hospitals in Spain to determine the effects on patient health and on the healthcare cost of these policies&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conflicts of interest</span><p id="par0190" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Increasing haemoglobin and haematocrit levels with blood transfusions has been the gold standard for treating severe anaemia&#59; however&#44; the indication for transfusing concentrated red blood cells is based merely on a few laboratory markers&#44; such as haemoglobin and haematocrit levels&#44; rather than based on the symptoms according to clinical practice guidelines&#44; the implementation of legal regulations and the consensus achieved by the hospitals&#8217; transfusion committees&#46; The aim of this multicentre study was to reassess the suitability of the indication for transfusing concentrated red blood cells and the volumes transfused in emergency departments&#46; We established an observational&#44; multicentre&#44; cross-sectional design with 2 participating centres&#58; the La Paz University Hospital and the Hospital of Salamanca&#46; In total&#44; we obtained data from 381 patients&#44; 220 &#40;57&#46;74&#37;&#41; of whom were men with an average age of 71&#46;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>14&#46;0 years and 161 &#40;42&#46;26&#37;&#41; of whom were women with an average age of 75&#46;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>15&#46;3 years &#40;P<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46; The most prevalent underlying diseases in the patients who underwent transfusions were heart disease&#44; which included haemorrhaging due to antiplatelet or anticoagulant therapy &#40;57&#46;7&#37;&#41;&#44; haematooncologic &#40;15&#46;3&#37;&#41; diseases and neurological disease&#46; Only 54&#46;9&#37; &#40;209&#47;381&#41; of the prescriptions for transfusion were considered appropriate&#44; with significant differences according to the indication&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">La elevaci&#243;n del nivel de hemoglobina y de hematocrito con transfusiones sangu&#237;neas ha sido el est&#225;ndar de oro para el tratamiento de la anemia grave&#46; Sin embargo&#44; la indicaci&#243;n para la transfusi&#243;n de concentrado de hemat&#237;es se basa meramente en unos marcadores anal&#237;ticos&#44; como el nivel de hemoglobina o hematocritos&#44; en lugar de basarse en la cl&#237;nica &#40;seg&#250;n las gu&#237;as de pr&#225;ctica cl&#237;nica&#41;&#44; en la implementaci&#243;n de regulaciones legales o en los consensos alcanzados por los comit&#233;s de transfusi&#243;n de los hospitales&#46; El objetivo de este estudio multic&#233;ntrico es reevaluar la idoneidad de la indicaci&#243;n de transfusi&#243;n de concentrado de hemat&#237;es y los vol&#250;menes transfundidos en los servicios de urgencias&#46; Se plantea un dise&#241;o observacional multic&#233;ntrico y transversal en 2 centros participantes&#58; el Hospital Universitario de La Paz y el Hospital de Salamanca&#46; En total se obtuvieron datos de 381 pacientes&#59; 220 eran hombres &#40;57&#44;74&#37;&#41;&#44; con una edad promedio de 71&#44;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>14&#44;0 a&#241;os y 161 eran mujeres &#40;42&#44;26&#37; con una edad promedio de 75&#44;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>15&#44;3 a&#241;os p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#46; Las enfermedades subyacentes m&#225;s prevalentes en los pacientes que recibieron transfusi&#243;n fueron las cardiol&#243;gicas&#44; que incluyeron hemorragia debido a la terapia antiagregante plaquetaria o anticoagulante 57&#46;7&#37;&#41;&#44; las hematooncol&#243;gicas &#40;15&#46;3&#37;&#41; y las neurol&#243;gicas&#46; Solo el 54&#46;9&#37; &#40;209&#47;381&#41; de las prescripciones de transfusi&#243;n se consideraron apropiadas&#44; con diferencias significativas observadas seg&#250;n la indicaci&#243;n&#46;</p></span>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Hemoglobin&#44; g&#47;dL&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Acute anemia&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#60;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Any clinical situation&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&#8211;8&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Hemodynamically unstable or associated risk factors&#58; coronary artery disease&#44; heart failure&#44; cerebrovascular disease and myocardial infarction&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8805;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Distress controlling the hemorrhaging or signs and symptoms of anemia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">Chronic anemia&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#60;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Signs and symptoms of anemia or associated risk factors&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No signs or symptoms of anemia&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">25th percentile&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">75th percentile&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " colspan="6" align="left" valign="\n
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                  \t\t\t\t">&#91;0&#44;1-6&#93;<span class="elsevierStyleItalic">Pretransfusion values</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Hematocrit&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">24&#46;35&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&#46;44&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">23&#46;75&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">21&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">26&#46;20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Mean corpuscular volume&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">87&#46;24&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11&#46;96&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">89&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">79&#46;85&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">95&#46;05&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Mean corpuscular hemoglobin&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">38&#46;55&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">177&#46;46&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">29&#46;50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">26&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">32&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Prothrombin time&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">69&#46;73&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">26&#46;99&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">78&#46;00&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">53&#46;00&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">92&#46;00&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>International Normalized Ratio &#40;INR&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46;59&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13&#46;53&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1&#46;18&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;05&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;59&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Platelets&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">239&#46;03&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">154&#46;27&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">224&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">132&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">314&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Creatinine&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;88&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&#46;97&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;80&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;67&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Total bilirubin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;05&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46;09&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;85&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Temperature&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">36&#46;38&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;57&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">36&#46;40&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">36&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">36&#46;70&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Systolic blood pressure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">126&#46;18&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">31&#46;59&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">129&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">105&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">145&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Diastolic blood pressure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">65&#46;34&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14&#46;09&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">64&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">57&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">73&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " colspan="6" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#91;0&#44;1-6&#93;</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " colspan="6" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#91;0&#44;1-6&#93;<span class="elsevierStyleItalic">Posttransfusion values</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Hematocrit&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">28&#46;13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#46;99&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">28&#46;20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">25&#46;20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">31&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Mean corpuscular volume&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">88&#46;16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9&#46;20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">90&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">82&#46;70&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">94&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Mean corpuscular hemoglobin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">29&#46;33&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#46;64&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">30&#46;40&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">27&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">32&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Prothrombin time&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">73&#46;68&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">18&#46;74&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">78&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">61&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">89&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>International Normalized Ratio &#40;INR&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;31&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;43&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;17&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;09&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;41&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Platelets&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">197&#46;75&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">126&#46;07&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">165&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">108&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">270&#46;00&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Creatinine&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1&#46;38&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1&#46;11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1&#46;10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#46;71&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1&#46;59&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Total bilirubin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#46;84&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1&#46;03&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#46;50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#46;40&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#46;90&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Temperature&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">36&#46;56&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#46;67&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">36&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">36&#46;70&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Systolic blood pressure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">120&#46;52&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">22&#46;90&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">108&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">130&#46;00&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Diastolic blood pressure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  "contribucion" => array:1 [
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                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "J&#46; Ripoll&#233;s-Melchor"
                            1 => "J&#46;A&#46; Garc&#237;a-Erce"
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                      "doi" => "10.1016/j.redar.2018.03.006"
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                0 => array:1 [
                  "referenciaCompleta" => "Sociedad Espa&#241;ola de Hematolog&#237;a y Hemoterapia&#46; Recomendaciones de la SEHH de 2013 &#91;consultado 22 octubre 2019&#93;&#46; Disponible en&#58; <a target="_blank" href="http://www.mscbs.gob.es/organizacion/sns/planCalidadSNS/pdf/SOCIEDAD_ESP_HEMATOLOGIA_HEMOTERAPIA_0K.pdf">http&#58;&#47;&#47;www&#46;mscbs&#46;gob&#46;es&#47;organizacion&#47;sns&#47;planCalidadSNS&#47;pdf&#47;SOCIEDAD&#95;ESP&#95;HEMATOLOGIA&#95;HEMOTERAPIA&#95;0K&#46;pdf</a>&#46;"
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            2 => array:3 [
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              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Hemolysis&#44; hyperkalemia and the transfusion of packed old red blood cells in critically ill patients"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "J&#46;A&#46; Garc&#237;a Erce"
                            1 => "M&#46; Quintana D&#237;az"
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                    0 => array:2 [
                      "doi" => "10.1016/j.medin.2018.01.011"
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              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "USEES-URG ResearchGrup&#46; Appropriate use of red blood cell transfusion in emergency departments&#58; a study in five emergency departments"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "M&#46; Quintana D&#237;az"
                            1 => "A&#46;M&#46; Borobia"
                            2 => "J&#46;A&#46; Garc&#237;a Erce"
                            3 => "C&#46; Maroun-Eid"
                            4 => "S&#46; Fabra"
                            5 => "A&#46; Carcas"
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                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.2450/2016.0324-15"
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                        "tituloSerie" => "Blood Transfus"
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            4 => array:3 [
              "identificador" => "bib0025"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "International Consensus Conference on Transfusion Outcomes Group&#46; Appropiateness of allogeneic red bllod cell transfusi&#243;n&#58; the international consensus conference on transfusion outcome"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "A&#46; Shander"
                            1 => "A&#46; Fink"
                            2 => "M&#46; Javidroozi"
                            3 => "J&#46; Erhard"
                            4 => "S&#46;L&#46; Farmer"
                            5 => "H&#46; Corwin"
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                        ]
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                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Transf Med Rev"
                        "fecha" => "2011"
                        "volumen" => "25"
                        "paginaInicial" => "232"
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            5 => array:3 [
              "identificador" => "bib0030"
              "etiqueta" => "6"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
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                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "J&#46; Ripoll&#233;s-Melchor"
                            1 => "C&#46; Jeric&#243;-Alba"
                            2 => "M&#46; Quintana-D&#237;az"
                            3 => "J&#46;A&#46; Garc&#237;a-Erce"
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                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.medcli.2018.02.027"
                      "Revista" => array:5 [
                        "tituloSerie" => "Med Clin &#40;Barc&#41;"
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                        "paginaFinal" => "373"
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            6 => array:3 [
              "identificador" => "bib0035"
              "etiqueta" => "7"
              "referencia" => array:1 [
                0 => array:1 [
                  "referenciaCompleta" => "Gu&#237;a sobre la transfusi&#243;n de componentes sangu&#237;neos y derivados plasm&#225;ticos de 2015&#46; 5&#46; edici&#243;n&#46; Sociedad Espa&#241;ola de Transfusi&#243;n Sangu&#237;nea y terapia celular 2015&#46; &#91;consultado 22 octubre 2019&#93;&#46; Disponible en&#58; <a target="_blank" href="http://www.prioridadcero.com/wp-content/uploads/2014/03/Guia_transfusion_quinta_edicion2015.pdf">http&#58;&#47;&#47;www&#46;prioridadcero&#46;com&#47;wp-content&#47;uploads&#47;2014&#47;03&#47;Guia&#95;transfusion&#95;quinta&#95;edicion2015&#46;pdf</a>&#46;"
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              "identificador" => "bib0040"
              "etiqueta" => "8"
              "referencia" => array:1 [
                0 => array:2 [
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                      "titulo" => "An individualized pre-operative blood saving protocol can increase pre-operative haemoglobin levels and reduce the need for transfusion in elective total hip or knee arthroplasty"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "J&#46;R&#46; Gonzalez-Porras"
                            1 => "E&#46; Colado"
                            2 => "M&#46;P&#46; Conde"
                            3 => "T&#46; Lopez"
                            4 => "M&#46;J&#46; Nieto"
                            5 => "M&#46; Corral"
                          ]
                        ]
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                    0 => array:2 [
                      "doi" => "10.1111/j.1365-3148.2009.00908.x"
                      "Revista" => array:6 [
                        "tituloSerie" => "Transfus Med"
                        "fecha" => "2009"
                        "volumen" => "19"
                        "paginaInicial" => "35"
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            8 => array:3 [
              "identificador" => "bib0045"
              "etiqueta" => "9"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Prospective evaluation of a transfusion policy of D&#43; red blood cells into D- patients"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "J&#46;R&#46; Gonzalez-Porras"
                            1 => "I&#46;F&#46; Graciani"
                            2 => "J&#46;A&#46; Perez-Simon"
                            3 => "J&#46; Martin-Sanchez"
                            4 => "C&#46; Encinas"
                            5 => "M&#46;P&#46; Conde"
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                      ]
                    ]
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                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/j.1537-2995.2008.01700.x"
                      "Revista" => array:6 [
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