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The second point concerns the declaration of conflicts-of-interests. This is, as Doctor Berry points out, an important issue. The rules are very clear. All authors are to declare all potential conflicts-of-interest, of their own and of those of their household / family, which includes dependants, spouse/partner and any close relatives. Importantly, these conflicts-of-interests are not limited to the content of a specific article but the global activity of a scientific journal. The field of potential conflict-of-interest thus is huge and most scientific journal advise authors to "err on the high side". Consequently, authors are to declare indeed all potential conflict-of-interests. Unfortunately, there is no short, easy and all-inclusive way of declaring all potential conflict-of-interests of the last 5 years.

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Muñoz M Gómez-Ramírez S Kozek-Langenecker Set al.  ‘Fit to fly’: overcoming the barriers to preoperative haemoglobin optimization in surgical patients. Br J Anaesth 2015; 115: 15–24

In a recently completed audit of preoperative anaemia in our hospital, we found clear association of anaemia with perioperative blood transfusions. After analysing the records of all elective surgical patients over a period of two weeks, we concentrated on a subgroup of patients likely to need perioperative transfusions. We collected prospective data over ten weeks, for patients undergoing major colorectal surgical procedures. This subgroup of patients had 38% prevalence of anaemia as defined by WHO definition. Half of these patients received perioperative transfusions. In a larger multicentre audit of cardiovascular surgical patients preoperative anaemia is associated with increased perioperative transfusion and morbidity. [3] As mentioned by Munoz and colleagues, [4] we noted that health care professionals were reluctant to treat anaemia. Some of the patients in our audit needed expedited operations due to cancer treatment targets; however the time from diagnosis of anaemia to surgical procedure was not utilised by appropriate management of anaemia. Patient Blood Management programme [5] clearly outlines the need to treat anaemia. The guidelines by British Committee for Standards in Haematology Guidelines on the Identification and Management of Pre-Operative Anaemia 6, focus on evidence base and need for a pathway for identification and management of preoperative anaemia.

3. Klein A A, Collier T J, Brar M S et al. The incidence and importance of anaemia in patients undergoing cardiac surgery in the UK - the first Association of Cardiothoracic Anaesthetists national audit. Anaesthesia 2016; 71: 627-635

Knowledge of clinical and preclinical management: Surgical procedures associated with frequent preoperative anaemia and considerable blood lossStructure and processes of preclinical evaluation to be reorganized and optimized

D.R.S. was the chairman of the ABC Faculty and is the co-chairman of the ABC-Trauma Faculty, both of which are managed by Physicians World Europe GmbH, Mannheim, Germany and sponsored by unrestricted educational grants from Novo Nordisk Health Care AG, Zurich, Switzerland; CSL Behring GmbH, Marburg, Germany; and LFB Biomédicaments, Courtaboeuf Cedex, France.

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In this edition of the British Journal of Anaesthesia, Muñoz and colleagues5 rightly alerted the medical community, reporting that preoperative anaemia is often left untreated. The paradox of known negative consequences of untreated anaemia and current practice is explained by the presentation of 10 widely held misconceptions. Moreover, we identified two additional reasons why physicians are still hesitating to treat preoperative anaemia systematically. First, the World Health Organization's definition of anaemia with a haemoglobin concentration of <120 g litre−1 in women and <130 g litre−1 in men is not sufficiently known by the majority of physicians. Furthermore, the notion that very mild forms of anaemia (haemoglobin values between 100–120 and 100–130 g litre−1, respectively) result in adverse clinical outcomes, such as increased mortality and a long list of complications,1,2 is also not well known. Second, there may be reluctance by some physicians to treat preoperative anaemia actively, because of the fact that they themselves will be held responsible for any adverse events occurring thereafter. In contrast, a perioperative transfusion in a patient who is anaemic before surgery is considered by most an inevitable event, for which medical staff cannot be held responsible. Therefore, some physicians prefer not to be involved in treating preoperative anaemia. We hope that the refuting by Muñoz and colleagues5 of 10 widely held misconceptions helps pave the way to widespread treatment of preoperative anaemia.

K.Z.'s department is receiving unrestricted educational grants from B. Braun Melsungen AG, Fresenius Kabi GmbH, CSL Behring GmbH, and ViforPharma GmbH.

Theusinger OM Kind SL Seifert B Borgeat L Gerber C Spahn DR. Patient blood management in orthopaedic surgery: a four-year follow-up of transfusion requirements and blood loss from 2008 to 2011 at the Balgrist University Hospital in Zurich, Switzerland. Blood Transfus 2014; 12: 195–203

It is well known that preoperative anaemia is frequent and associated with increased mortality and morbidity, even if only mild anaemia is present.1,2 In addition, preoperative anaemia is one of the most significant risk factors in subsequent red blood cell transfusion,3 which in itself has adverse effects on mortality and morbidity.4 Therefore, unmanaged preoperative anaemia is a contraindication for elective surgery.4

We read with interest the communication by Berry [1] along with the reply by Spahn and Zacharowski . The editorial by Spahn and Zacharowski [2] clearly elucidates the way forward in the treatment of preoperative anaemia in various European health care set ups.

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6. British Committee for Standards in Haematology Guidelines on the Identification and Management of Pre-Operative Anaemia. British Journal of Haematology 2015; 171(3): 322-331

Na HS Shin SY Hwang JY Jeon YT Kim CS Do SH. Effects of intravenous iron combined with low-dose recombinant human erythropoietin on transfusion requirements in iron-deficient patients undergoing bilateral total knee replacement arthroplasty. Transfusion 2011; 51: 118–24

Muñoz M Gómez-Ramírez S Cuenca Jet al.  Very-short-term perioperative intravenous iron administration and postoperative outcome in major orthopedic surgery: a pooled analysis of observational data from 2547 patients. Transfusion 2014; 54: 289–99

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In the past 3 years, K.Z. has received honoraria or travel support for consulting or lecturing from the following companies: Abbott GmbH & Co. KG, Aesculap Akademie GmbH, AQAI GmbH, Astellas Pharma GmbH, AstraZeneca GmbH, Aventis Pharma GmbH, B. Braun Melsungen AG, Baxter Deutschland GmbH, Biosyn GmbH, Biotest AG, Bristol-Myers Squibb GmbH, CSL Behring GmbH, Dr. F. Köhler Chemie GmbH, Dräger Medical GmbH, Essex Pharma GmbH, Fresenius Kabi GmbH, Fresenius Medical Care, Gambro Hospal GmbH, Gilead, GlaxoSmithKline GmbH, Grünenthal GmbH, Hamilton Medical AG, HCCM Consulting GmbH, Heinen+Löwenstein GmbH, Janssen-Cilag GmbH, med Update GmbH, Medivance EU B.V., MSD Sharp&Dohme GmbH, Novartis Pharma GmbH, Novo Nordisk Pharma GmbH, P. J. Dahlhausen & Co. GmbH, Pfizer Pharma GmbH, Pulsion Medical Systems S.E., Siemens Healthcare, Teflex Medical GmbH, Teva GmbH, TopMed Medizintechnik GmbH, Verathon Medical, and ViforPharma GmbH.

Yoo YC Shim JK Kim JC Jo YY Lee JH Kwak YL. Effect of single recombinant human erythropoietin injection on transfusion requirements in preoperatively anemic patients undergoing valvular heart surgery. Anesthesiology 2011; 115: 929–37

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A consortium of four large German University Hospitals (Frankfurt, Münster, Bonn, and Kiel) is engaged in the concept of patient blood management (PBM). The Frankfurt group has shown how to target and implement treatment of preoperative anaemia (ClinicalTrials.gov Identifiers: NCT01820949 and NCT02147795). Their investigation clearly highlights five key success factors (Table 1) for implementing a comprehensive preoperative anaemia treatment programme. The first factor, which is clearly the most important, was establishing a dedicated interdisciplinary PBM steering committee, with preoperative anaemia treatment being the first pillar of PBM.4 Second, the inclusion and support of senior hospital management is of utmost importance. Only with this support can the necessary reorganization of the preclinical procedures and structures be implemented. Additionally, the understanding of surgical and medical disciplines is crucial to the management and treatment of preoperative anaemia. Last, but not least, focusing our efforts on the knowledge of how operations are regularly performed in anaemic patients, who frequently require allogeneic red blood cell transfusions, is also essential (www.patientbloodmanagement.eu). Such favourable hospital conditions and improvements can be achieved only by continuous education over years and through the coordination of a dedicated interdisciplinary PBM steering committee. Should your hospital not yet have the aforementioned structure, then becoming a leader in PBM and establishing a steering committee is the way forwards.

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Knowledge of clinical and preclinical management: Surgical procedures associated with frequent preoperative anaemia and considerable blood lossStructure and processes of preclinical evaluation to be reorganized and optimized

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D.R.S.'s academic department is receiving grant support from the Swiss National Science Foundation, Berne, Switzerland; the Ministry of Health (Gesundheitsdirektion) of the Canton of Zurich, Switzerland for Highly Specialized Medicine; the Swiss Society of Anesthesiology and Reanimation (SGAR), Berne, Switzerland; the Swiss Foundation for Anesthesia Research, Zurich, Switzerland; Bundesprogramm Chancengleichheit, Berne, Switzerland; CSL Behring, Berne, Switzerland; and Vifor SA, Villars-sur-Glâne, Switzerland.

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However, we also cited prospective randomized studies in which preoperatively anaemic patients were randomized into active vs. placebo treatment. In these studies, actively treated patients received fewer red blood cell transfusions, had fewer complications and are likely to spend less days in hospital. This effect was also observed in trials when the introduction of patient blood management programms such as preoperative anaemia treatment were studied (partly also referenced in our editorial). In total, the scientific evidence is indeed strong and indicates that preoperative anaemia is a modifiable risk factor requiring attention and, hence treatment.

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D. R. Spahn, K. Zacharowski, Non-treatment of preoperative anaemia is substandard clinical practice, BJA: British Journal of Anaesthesia, Volume 115, Issue 1, July 2015, Pages 1–3, https://doi.org/10.1093/bja/aev099

Secondly, reading this editorial as a whole raises a question about the Declaration of Interests. In this case, this extends to five paragraphs. I have no personal knowledge whatsoever of the authors, and do not in any way intend to imply anything other than good faith. However, the universal practice of declaring interests exists to provide the reader with additional information in order to better judge the opinions presented by authors. How are we to use this information? In many cases, such as original research articles, the interpretation of the work is done according to well-known principles of scientific analysis. In others which are not reporting original research, and where authors are strongly - albeit indirectly - recommending the use of expensive drugs, it is less clear how we should use the declaration of interest. I do not know if the authors in this editorial have received funding from the manufacturers of erythropoietin or intravenous iron, but this would undoubtedly affect my own interpretation of the advice given. It cannot be right to simply ignore the possibility of a conflict of interest. Yet without personal knowledge of the authors, the refereeing process or the editorial process, I find it hard to interpret with confidence the editorial's advice. Perhaps we rely largely on the journal's editors, but I feel this article highlights the need for clarification of how the Declaration of Interests is interpreted and by whom.

We appreciate the interest of Doctor Berry in praeoperative anaemia and his comments on our editorial. It is certainly correct that the two large studies from the US and Europe are retrospective in nature. However, only disregarding them for their retrospective design would be inadequate. They clearly show in a total of more than 250,000 patients that already mild anaemia (haemoglobin in male 100/110-130 g/L, haemoglobin in women 100-120 g/L) - and not as Doctor Berry states "severe anaemia" - is independently associated with increased morbidity and mortality (+20 to +40%). Despite the power of big data, these studies do not allow to conclude a cause and effect relationship.

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Given the outcome implications, we hope that enough resource allocation will be provided for managing anaemia in surgical patients in NHS institutions.

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Editor The Editorial by Spahn and Zacharowski on Patient Blood Management is unusually didactic for this type of publication. I am concerned by the strength of the conclusion that "Untreated preoperative anaemia is indeed a contraindication to elective surgery, and failure to treat preoperative anaemia is substandard practice."

4. Munoz M, G?mez-Ram?rez S, Kozek-Langeneker S et al. 'Fit to fly': overcoming barriers to preoperative haemoglobin optimization in surgical patients. Br J Anaesth 2015; 115: 15-24

Knowledge of clinical and preclinical management: Surgical procedures associated with frequent preoperative anaemia and considerable blood lossStructure and processes of preclinical evaluation to be reorganized and optimized

2 Professor and Chairman, Department of Anaesthesiology, Intensive Care Medicine & Pain Therapy, University Hospital Frankfurt, Frankfurt, Germany.

Gombotz H Rehak PH Shander A Hofmann A. Blood use in elective surgery: the Austrian benchmark study. Transfusion 2007; 47: 1468–80

Hoist Fitness Systems is a San Diego-based exercise equipment company with more than 40 years of excellent track record in manufacturing premier fitness equipment. It was founded with a mission to help private consumers and commercial gym owners to lead a healthier way of life through their top-grade work-out equipment. Since 1977, Hoist Fitness still reigns as one of the industry’s top manufacturers of strength training equipment. The classic design and unmatched versatility of Hoist Fitness commercial and home gyms have gained various recognition's, including Men’s Health Home Gym Awards for 2020 and 2021, as well as the Good Design Award for multiple years.

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I would like to raise two points. First, the evidence as outlined in the editorial and the references does not support the strength of the conclusion. While it is an editorial and not a literature review, the two references cited refer to retrospective observational studies which correlated anaemia - severe anaemia in one study - with adverse outcome. This is not proof of causation, and is a long way from being evidence that mild anaemia should be treated.

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Musallam KM Tamim HM Richards Tet al.  Preoperative anaemia and postoperative outcomes in non-cardiac surgery: a retrospective cohort study. Lancet 2011; 378: 1396–407

Through sound scientific evidence, they disproved 10 misconceptions of perioperative anaemia treatment. Moreover, this medical need can be met with successful treatment options. Therefore, we conclude that there is no reason why treatment of preoperative anaemia anaemia should not be widely practised. Untreated preoperative anaemia is indeed a contraindication for elective surgery, and failure to treat preoperative anaemia is substandard clinical practice.

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In the past 5 years, D.R.S. has received honoraria or travel support for consulting or lecturing from the following companies: Abbott AG, Baar, Switzerland; AMGEN GmbH, Munich, Germany; AstraZeneca AG, Zug, Switzerland; Bayer (Schweiz) AG, Zürich, Switzerland; Baxter AG, Volketswil, Switzerland; Baxter S.p.A., Roma, Italy; B. Braun Melsungen AG, Melsungen, Germany; BoehringerIngelheim (Schweiz) GmbH, Basel, Switzerland; Bristol-Myers-Squibb, Rueil-Malmaison Cedex, France and Baar, Switzerland; CSL Behring GmbH, Hattersheim am Main, Germany and Berne, Switzerland; Curacyte AG, Munich, Germany; Ethicon Biosurgery, Sommerville, NJ, USA, Fresenius SE, Bad Homburg v.d.H., Germany; Galenica AG, Bern, Switzerland (including Vifor SA, Villars-sur-Glâne, Switzerland); GlaxoSmithKline GmbH & Co. KG, Hamburg, Germany; Janssen-Cilag AG, Baar, Switzerland; Janssen-Cilag EMEA, Beerse, Belgium; Merck Sharp & Dohme AG, Luzern, Switzerland; Novo Nordisk A/S, Bagsvärd, Denmark; Octapharma AG, Lachen, Switzerland; Organon AG, Pfäffikon/SZ, Switzerland; Oxygen Biotherapeutics, Costa Mesa, CA, USA; Photonics Healthcare GmbH, Munich, Germany; ratiopharm Arzneimittel Vertriebs-GmbH, Vienna, Austria; Roche Diagnostics International Ltd, Reinach, Switzerland; Roche Pharma (Schweiz) AG, Reinach, Switzerland; Schering-Plough International, Inc., Kenilworth, NJ, USA; Tem International GmbH, Munich, Germany; Verum Diagnostica GmbH, Munich, Germany; ViforPharma Deutschland GmbH, Munich, Germany; ViforPharma Österreich GmbH, Vienna, Austria; and Vifor (International) AG, St Gallen, Switzerland.

Knowledge of clinical and preclinical management: Surgical procedures associated with frequent preoperative anaemia and considerable blood lossStructure and processes of preclinical evaluation to be reorganized and optimized

Other centres have also succeeded in implementing treatment of preoperative anaemia. Theusinger and colleagues6 contacted the primary physician of each patient found to be anaemic before surgery. These patients were to undergo major orthopaedic surgery (n=8871), with suggested treatment of anaemia using erythropoietin α, i.v. iron, vitamin B12 and folic acid. Despite the fact that not all patients who were anaemic before surgery were treated, the incidence of anaemia on the day of operation decreased from 15 to 10% (P<0.01) and total allogeneic transfusion rate reduced from 20 to 10% (P<0.01). Short-term treatment of preoperative anaemia with erythropoietin and i.v. iron has also been shown to be successful in orthopaedic7 and cardiac surgery.8 Likewise, a group of four Spanish hospitals recently published their success in short-term preoperative treatment of anaemia with erythropoietin and i.v. iron in 2547 patients undergoing hip and knee arthroplasty or surgery for hip fracture.9 They could decrease the allogeneic transfusion rate from 37 to 24% (P<0.01), the postoperative infection rate from 12 to 8% (P<0.01), and the length of hospital stay from 12 to 11 days (P<0.01). In patients undergoing surgery for hip fracture, the 30 day mortality was reduced from 9 to 5% (P<0.01).

Baron DM Hochrieser H Posch Met al.  Preoperative anaemia is associated with poor clinical outcome in non-cardiac surgery patients. Br J Anaesth 2014; 113: 416–23

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1 Professor and Chairman, Institute of Anaesthesiology and Head Medical, Section Anaesthesiology, Intensive Care Medicine and OR- Management, University and University Hospital Zurich, Zurich, Switzerland.