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Last October, I wrote a blog entry about the dangers associated with
blood transfusions. It was triggered by a study out of Duke University
that found that transfusions increase your risk of heart attack and
death. According to the study, the problem is that the oxygen-
transporting efficacy of stored blood begins to decay almost
immediately. This is because stored red blood cells become deficient
in nitric oxide, thus limiting their ability to get oxygen to tissues
that need it. Nitric oxide opens up blood vessels, which allows oxygen
carrying blood to reach the tissues served by those vessels. In vitro
studies show that levels of S-nitrohemoglobin (the molecule that
carries nitric oxide in the blood) decline rapidly in stored red blood
cells. There is a 70%% drop in the first day of storage. By the twenty-
first day, the molecule was below the level of detectability. In the
U.S., red blood cells can legally be stored up to 42 days before blood
banks are required to discard them. But the problem is even worse than
it sounds. Not only is transfused blood deficient in nitric oxide, but
because it's deficient, it actually sucks nitric oxide out of the
surrounding tissue to compensate. This causes that tissue to constrict
and become deoxygenated. If that tissue happens to be heart muscle,
you have a real problem.

Well, the issue is back in the news, thanks to a couple of new
studies.

_Transfusions increase the risk of complications and reduce survival
rates_

The first study, which appears in the March 20th issue of the New
England Journal of Medicine, essentially confirms the Duke study. It
reports that heart surgery patients who receive transfusions with
blood that has been stored more than 14 days are far likelier to
suffer complications and may face significantly reduced survival rates
-- both short and long term. The study of more than 9,000 patients in
the US has shown that those given blood more than 14 days old are 65
percent more likely to die before discharge and 50 percent more likely
to die within a year. Recipients of older blood are also at much
higher risk of blood poisoning and multi-organ failure according to
the survey conducted at the Cleveland Clinic in Ohio. Considering that
nearly half of heart surgery patients receive transplants and that the
FDA allows blood to be stored for up to 42 days before it must be
discarded, this news carries major implications for any heart surgery
patients...and their doctors. In point of fact, transfused blood
usually takes several days to even reach a hospital. That means that
the average patient getting a transfusion is quite likely receiving
blood that is pushing two weeks old -- with a sizeable number (60%% of
O RH negative, for example) receiving blood that is up to four weeks
old.

In their study, the Cleveland Clinic researchers examined data on
6,002 patients who had received blood transfusions while undergoing
bypass grafting and/or heart-valve surgery between June 30, 1998 and
January 30, 2006. Of the patients, 2,872 received 8,802 units of blood
that had been stored 14 days or less, whereas 3,130 patients received
10,782 units of blood that had been stored longer than 14 days. The
results were disturbing.

* in-hospital death (2.8%% vs. 1.7%%, P=0.004)
* prolonged intubation (9.7%% vs. 5.6%%, P<0.001)
* kidney failure (2.7%% vs. 1.6%%, P=0.003)
* sepsis (4.0%% vs. 2.8%%, P=0.01)

But it gets worse!

_Transfusions increase the risk of stroke_

A second study, published in November and conducted by scientists at
the University of Bristol and the Bristol Heart Institute in the UK,
found that patients who received a red blood cell transfusion
experienced a three-fold increase in complications arising from lack
of oxygen to key organs -- complications such as heart attack or
stroke. The study looked at the association between red blood cell
transfusion and adverse outcomes in over 8,500 cardiac surgery
patients over eight years. The age of the blood used in the
transfusions was not a factor in this study. Nevertheless, the study
found that the risks associated with transfusions of blood of all ages
occurred regardless of the hemoglobin levels in the blood, age, or
level of patient disability at the time of transfusion.

Professor Peter Weissberg, Medical Director of the Bristol Heart
Foundation said, "Red blood cells carry oxygen around the body to
supply vital organs. Not unreasonably therefore, heart surgeons have
assumed that patients who have low red blood cell counts after surgery
-- as a result of blood loss during or shortly after surgery -- would
benefit from a 'top up' transfusion of donated red blood cells. This
study shows the importance of putting such widespread beliefs to the
test since it suggests that such transfusions may cause more problems
than they solve."

As in the US, over half of all heart surgery patients in the United
Kingdom receive blood. However, only about 3%% of these transfusions
are given because of life-threatening bleeding. The vast majority are
given on the basis of low hemoglobin levels, regardless of whether the
patient has any physical symptoms indicating that they actually need
blood -- sort of a better safe than sorry precautionary procedure. But
based on the recent study results, it looks like it may not be so
safe, and might, in fact, provide a whole lot of reasons to be sorry.

_Rethinking transfusions except in dire emergencies_

The bottom line is that red blood cell transfusions in patients having
cardiac surgery is strongly associated with both infection and
ischemic postoperative morbidity, hospital stay, increased early and
late mortality, and hospital costs. And significantly, the majority of
those transfusions, the ones used on a precautionary basis, may in
fact have been responsible for many millions of patient deaths over
the last hundred years.

Fortunately, there appears to be a simple remedy for at least one
aspect of the problem -- not the infection risks, but the inability of
transfused blood to carry sufficient oxygen. Doctors and hospitals
just need to implement it. Studies have shown that treating red blood
cells with a solution of aqueous nitric oxide results in a 10-fold
increase in S-nitrohemoglobin (again, the molecule that carries nitric
oxide in the blood) compared with untreated samples so that the levels
of S-nitrohemoglobin are not significantly different from fresh blood.
As we discussed earlier, this is crucial because stored red blood
cells quickly become deficient in nitric oxide, which limits their
ability to get oxygen to tissues that need it. Adding nitric oxide to
stored blood restores the ability of hemoglobin to dilate blood
vessels and oxygenate tissue. In other words, it helps restore the
oxygenating power of blood. If you ever need a transfusion, you might
want to ask your doctor if the hospital treats their banked blood this
way before using it for transfusion. (Unfortunately, there aren't many
at the moment.)

_Sea water transfusions_

When I wrote my blog entry on blood transfusions, several readers
wrote in asking about the viability of using sea water transfusions
instead of blood transfusions. And in fact, that can work -- sort of.

During World War I, the French Army used a specially filtered and
sterilized form of sea water for blood transfusions when blood
supplies ran out. And it works if done correctly! The problem is that
although such sea water can be used in an emergency to keep blood
volume up and maintain proper electrolyte levels for the functioning
of the heart muscle, it does not provide the oxygen/carbon dioxide/
nitric oxide carrying capabilities of blood since it contains no
hemoglobin. It can help in an emergency, but it does not replace
blood.

_Conclusion: Clinical evidence vs anecdotal evidence_

But all that said, that's not my main reason for discussing this issue
in today's newsletter. As I said in my blog on the issue, think about
it for a moment! Blood transfusions have been used as a standard
medical procedure for over 100 years. And now it turns out they may be
responsible for many millions of unnecessary deaths worldwide during
that time. How could this be? Unlike alternative health, modern
medicine is based on science -- not anecdotal evidence. So why didn't
all those scientific studies on blood transfusions figure out that
blood transfusions are, at best, an iffy proposition that should be
reserved only for the most dire of emergencies?

The answer is quite simple. Until recently, there were no studies
either supporting or negating blood transfusions -- or at least none
that the medical community paid attention to. As I have frequently
pointed out, most medical procedures and drug usage are not backed by
studies -- only by anecdotal evidence. The lack of clear evidence
supporting blood transfusions as a medical procedure is not the
exception; it is perfectly in line with the rule. According to the US
Government's Office of Technology Assessment (Congress of the United
States, Office of Technology Assessment: Assessing the efficacy and
safety of medical technologies. Washington, DC: US Government Printing
Office, 1978), only 10-20%% of all medical procedures and off-label
drug usage is backed by clinical studies.

Is that a bad thing? Not necessarily. Things would grind to a
standstill if doctors had to wait for definitive studies before
implementing any new procedure that seemed to offer benefit. And yes,
a key point was missed in the blood transfusion issue for the last
hundred years that has probably killed many millions of people during
that time. But make no mistake; this is not an indictment of anecdotal
evidence. Strong anecdotal evidence among informed professionals is
actually quite reliable -- at least as reliable as clinical testing.
Just think of how many clinical tests come to diametrically opposed
conclusions. In fact, the only reason that these clinical studies were
conducted on blood transfusions in the first place is because
anecdotal evidence suggesting there was a problem in the first place
had been building over the years. You could say that the problem was
discovered through anecdotal evidence -- and merely confirmed through
a peer reviewed study.

No, the problem isn't with the use of anecdotal evidence. It's with
the double standard applied by the establishment (medical and
regulatory) that holds complementary medicine to an absurdly higher
standard, allowing medical doctors to do pretty much whatever they
want. If informed anecdotal evidence is allowable for 85%% of all
medical procedure and drug usage, why is alternative health held to an
impossible 0%% standard -- particularly since it doesn't kill anywhere
near as many people as modern medicine does? (Remember, we're talking
about potentially millions of deaths from transfusions alone.) And
we're not even talking about a standard as it applies to actually
implementing an alternative health procedure or supplement. No, that
0%% standard applies to even "talking" about it. I kid you not.
Government regulators do not allow alternative health practitioners to
even talk about the possible medical benefits of most supplements and
herbs. As we discussed in a key newsletter last year, government
regulators in the US, Canada, and much of Europe don't allow you to
even talk about using stevia as a sweetener in food. The FDA has
actually seized stevia recipe books. That's insane.

All I'm saying is, "Let's play fair."