American Red Cross Research Articles

Treatment refractory hypothyroidism as a result of excessive donation of plasma

Treatment refractory hypothyroidism as a result of excessive donation of plasma has not been previously reported in the literature. A 43-year-old woman with past medical history of Grave’s disease and post thyroidectomy hypothyroidism was evaluated for treatment refractory hypothyroidism. She weighed 90 kg and was started on levothyroxine (150 mcg) 3 months after thyroidectomy. Two months after starting levothyroxine her thyroid profile rapidly improved toward normal (TSH 6.99 lU/mL, T4 1.52 ng/dL) and subsequently, her TSH began to rise and levothyroxine was gradually increased to 225 mcg over eleven months, however, her thyroid profile did not normalize (TSH 30.4 lU/mL, T4 0.79 ng/dL). Her other medication included Aspirin, Ergocalciferol, Pantoprazole, Calcium carbonate, and Diltiazem. Poor medication adherence, ineffective timing of medication with meals and concomitant use of medication with Calcium carbonate and Pantoprazole were ruled out as causes for sub-optimal treatment. Basic metabolic profile, complete blood count and urinalysis were within normal limits. Total protein and Albumin were low (6.1 and 3.1 g/dL) respectively and antimicrosomal and thyroglobulin antibodies were negative. She had no symptoms of diarrhea or food intolerance to suggest malabsorption. At this point the etiology of her persistently elevated TSH level was a mystery. Exploration of her ideas, concerns, and expectations revealed that she was going through a divorce, and was having financial difficulty, so she resorted to donating plasma for income. She wondered if donating plasma was somehow responsible for her lack of response to treatment. Further enquiry revealed that she was donating plasma twice weekly at different sites. She was advised to stop donating plasma for 6 months and repeat her TSH/T4 before her next appointment. Her thyroid hormone levels had normalized by the next appointment three months later with a trend toward over treatment at 5 months (Fig. 1) and her dose of levothyroxine was appropriately reduced. Persistently elevated TSH in patients on thyroxine replacement therapy can result from medication non-adherence, inadequate dosing, concomitant use of levothyroxine with meals, coffee, competing medications, coexisting medical conditions such as celiac disease, autoimmune gastritis, and rarely, interference of the TSH/T4 laboratory assay by rheumatoid factor and heterophil antibodies [1]. The recommended frequency of plasma donation by the American Red Cross is every 28 days and hypothyroid patients on replacement therapy can donate blood products if feeling well and euthyroid on thyroxine for 6 months [2]. In contrast, our patient was donating plasma every 4 days which was clearly in excess of the recommended frequency of donation. We postulate that the likely pathophysiological mechanism of reduced efficacy of levothyroxine in our patient is via rapid removal of levothyroxine which is bound to plasma proteins. This is analogous to what happens in patients with hypothyroidism secondary to nephrotic syndrome [3]. In the latter, patients become hypothyroid secondary to excessive urinary losses of binding proteins, such as thyroxine binding globulin, prealbumin, and albumin, resulting in a reduction of serum total thyroxine (T4) and, sometimes triiodothyronine (T3) A. T. Abegunde (&) B. Mba Department of Internal Medicine, John H. Stroger Jr. Hospital of Cook County, 1900 W, Polk Street, Chicago, IL 60612, USA e-mail: abegs@doctors.org.uk

Psychiatrists Provide Help, Advice Following Newtown School Murders

Back to table of contents Next article Community NewsFull AccessPsychiatrists Provide Help, Advice Following Newtown School MurdersAaron LevinAaron LevinSearch for more papers by this authorPublished Online:4 Jan 2013https://doi.org/10.1176/appi.pn.2013.1a23AbstractLocal psychiatrists volunteer to help Newtown, Conn., residents recover from last month’s shooting tragedy.The Connecticut Psychiatric Society (CPS) reacted swiftly to the tragic shooting at Sandy Hook Elementary School in Newtown, Conn., on Friday, December 14.Society President John Santopietro, M.D., and Disaster Committee Chair Shaukat Khan, M.D., consulted that afternoon with APA experts including members of APA’s Committee on the Psychiatric Dimensions of Disasters. Within hours, 100 society members responded to Santopietro’s e-mail requesting volunteers to help in the stricken town.A woman comforts a young girl during a vigil service for victims of the Sandy Hook Elementary School shooting in Newtown, Conn., on December 14. Connecticut Psychiatric Society members were among those who offered their services to the grieving community.AP Photo/Andrew Gombert, PoolMeanwhile, Khan contacted the Red Cross and the Connecticut State Medical Society to let them know about the CPS volunteers. Khan was already registered with the Red Cross as a mental health volunteer.By coincidence, the CPS had conducted a disaster-response training session for members just a month earlier. That course was led by Frederick Stoddard, M.D., a clinical professor of psychiatry at Harvard Medical School and a psychiatrist at Massachusetts General Hospital. Stoddard is coauthor with Anand Pandya, M.D., and Craig Katz, M.D., of Disaster Psychiatry Readiness, Evaluation, and Treatment (American Psychiatric Publishing).The class covered such points as the psychiatric impact of disasters, grief and resilience, psychological first aid, and the postacute stages of a disaster.“The training helped prepare us for the situation at Newtown, but, of course, not entirely,” said Khan, a psychiatrist at the VA Connecticut Health Systemin West Haven and a clinical assistant professor at Yale.“You can’t be completely prepared for something like this,” said Stoddard. “It is such an atrocity.”Psychiatrists gathered at Reed Intermediate School in Newtown, Conn., to assist community members after December’s shooting. From left: Frederick Stoddard, M.D., of Massachusetts General Hospital; Irvin Jennings, M.D., executive and medical director of nonprofit Family and Children’s Aid; and Shaukat Khan, M.D., disaster chair of the Connecticut Psychiatric Society.Shaukat Khan, M.D.Perhaps the most helpful aspect of the training in light of the later Newtown tragedy was the inclusion of a speaker from the American Red Cross, said CPS President-elect Carolyn Drazinic, M.D., Ph.D., an assistant professor of psychiatry at the University of Connecticut. The speaker explained how the Red Cross coordinates the overall response to disasters, an insight that was helpful in integrating the CPS volunteers into the general emergency response. By Saturday afternoon, Khan had completed a needs assessment. Working through the Red Cross and state and local health agencies, the society arranged for at least two psychiatrists to be on duty along with other mental health professionals for three-hour shifts from 7 a.m. to 7 p.m. at a crisis-response center in Newtown. On Sunday, Drazinic and colleagues met with more than 300 children and adults.“The handoffs between professionals is critically important and were done at Newtown in a collegial and careful ways,” said Stoddard, who drove from Boston to consult with the CPS. More such help will be needed in the future to contain the suffering and anxiety, said Santopietro, chief medical officer at Community Health Resources in Windsor, Conn.“I consider this to be the psychological equivalent of a nuclear blast,” said Santopietro. “The immediate damage is unthinkable, and there is some rate of decay, but the fallout will continue for weeks and months and years.”Robyn Hoffman, A.P.R.N., of Family and Children’s Aid coordinates mental health volunteers at the Reed Intermediate School after the Newtown shooting.Shaukat Khan, M.D.The CPS will continue working with health agencies in that long-term effort.“Concentric waves of psychological pain are rippling out from Newtown, and we want people to get excellent care,” said Santopietro. Pausing between meetings and phone calls in the days just after the shooting, he reflected on the task ahead for the society’s members.“This is the work we do,” he said. “We deal with human suffering and the complexity of the brain and human behavior. We deal with communities and human relationships. We help people through personal, psychological, family, and community crises. This is psychiatry.” ■ ISSUES NewArchived

Comments on: Molecular matching of red blood cells is superior to serological matching in sickle cell disease patients

Comments on: Molecular matching of red blood cells is superior to serological matching in sickle cell disease patients

Service Learning

When I began considering adding a service learning component to my Introduction to Ethics class, I thought that this would be a no-brainer. There are so many organizations in the community that are designed to benefit others to which students could contribute service that finding service learning opportunities would be easy. Students could contribute to, for example, the local food bank, the American Red Cross, the United Way of Omaha, the YMCA or YWCA, a women’s shelter, any one of many hospitals, after school programs for kids, any one of many homes for seniors, and so on. Even if some of these organizations only wanted students to make coffee and copies, there were certainly enough others that really would use the service of my students. As I began to explore these possibilities, however, it became less clear and more problematic how students’ service to the community would benefit their understanding of ethics. It turns out that ethics is an odd case for service learning, and in this paper I want to share with you why I believe that including a service learning component in a class on ethics is not as simple as it might first appear to be. In order to give a comprehensive account of service learning and ethics I will begin by considering service learning in relation to ethics classes and then I will consider the nature of ethics and what that means for service learning.

Disaster-Related Injuries and Illnesses Treated by American Red Cross Disaster Health Services During Hurricanes Gustav and Ike

To describe the injuries and illnesses treated by the American Red Cross (Red Cross) during Hurricanes Gustav and Ike disaster relief operations reported on a new Aggregate Morbidity Report Form. From August 28 to October 18, 2008, 119 Red Cross field service locations in Louisiana, Mississippi, Tennessee, and Texas addressed the healthcare needs of people affected by the hurricanes. From these locations, individual client visit data were retrospectively collated per site onto new 24-hour Aggregate Morbidity Report Forms. A total of 3863 clients were treated. Of the clients, 48% were girls and women and 44% were boys and men; 61% were 19 to 64 years old. Ninety-eight percent of the visits occurred in shelters. The reasons for half of the visits were acute illness and symptoms (eg, pain) and 16% were for routine follow-up care. The majority (65%) of the 2516 visits required treatment at a field location, although 34%, or 1296 visits, required a referral, including 543 healthcare facility transfers. During the hurricanes, a substantial number of displaced evacuees sought care for acute and routine healthcare needs. The capacity of the Red Cross to address the immediate and ongoing health needs of sheltered clients for an extended period of time is a critical resource for local public health agencies, which are often overwhelmed during a disaster. This article highlights the important role that this humanitarian organization fills, to decrease surge to local healthcare systems and to monitor health effects following a disaster. The Aggregate Morbidity Report Form has the potential to assist greatly in this role, and thus its utility for real-time reporting should be evaluated further.

Introduction: Philhellenism, Philanthropy, or Political Convenience?

© The American School of Classical Studies at Athens hesperia 82 (2013) Pages 1–14 INTRODUCTION Philhellenism, Philanthropy, or Political Convenience? The papers collected in this issue of Hesperia were originally presented at a workshop held at the American School of Classical Studies at Athens (ASCSA) on May 18, 2010, titled “Philhellenism, Philanthropy, or Political Convenience? American Archaeology in Greece.” This work evolved from the study of philanthropic activities documented in the School’s administrative records, now in the ASCSA Archives.Through their participation in the American Red Cross (1918–1919), the Refugee Settlement Commission (1922–1928), the Marshall Plan (1948–1952), and other American welfare programs,American archaeologists greatly facilitated the development of Greece’s social infrastructure during periods of difficulty for the Greek state, such as the Balkan Wars (1912–1913), the Asia Minor Catastrophe (1922), and post–World War II rehabilitation. At the same time, their philanthropic actions also made it possible to advance, with the help of the Greek state, archaeological and other research programs that would otherwise not have been possible. But how exactly does one understand the philanthropic activities of the ASCSA? To be sure, America’s presence in Greece, first as an economic force, then as a military power, increased in the wake of World War I and expanded in the course of the 20th century. Yet the ASCSA is a nonprofit institution,not associated with the U.S.government either officially or unofficially, and as an institution it has been careful to assume a position of political neutrality in public arenas for most of its history. Thus, initially, the relationship between the philanthropic activities of the ASCSA’s members and the ability of the institution to exercise power in Greek affairs seemed to us as ambiguous and difficult to comprehend as the iconography of an anonymous poster, dated 1919 (Fig. 1).1 The poster 1. The poster was purchased by Davis in an auction (Frattis Auctions , March 14–15, 2009, Catalogue, no. 1234) and is currently hanging in the director’s residence at the American School. It was also used in promotional materials for the Philhellenism workshop in 2010. Despite laborious research , we have been unable, so far, to associate the circumstances of the creation of the poster with a specific event. We are not even certain whether the poster was produced in Greece or in the United States. In style and content it differs significantly from chromolithographs that were manufactured in Greece before 1920; they tend to be “busy” in their design and are frequently accompanied by long explanatory texts. (On the history of Greek posters, see Karachristos 2003, pp. 12–15.) Three clues in the image itself suggest that the poster might not have been produced in Greece. The first is the use of the Statue of Liberty as a symbol for the United States. Until the end of World War I, America was jack l. davis and natalia vogeikoff-brogan 2 depicts the Statue of Liberty draped in the American flag, standing behind a personification of Greece, while a legend loudly proclaims ΖΗΤΩ Η ΕΛΛΑΣ, “Long Live Greece.” Over the past two decades, we have found ourselves increasingly attracted to the richness of the ASCSA archives as a focus for personal research concerning facets of the American School’s institutional history.2 While we pursued separate research agendas, about six years ago we found ourselves riding together on a train to Sleepy Hollow, New York, in pursuit of the archives of the Rockefeller Foundation; a year later we traveled together to the National Archives and Records Administration in College Park,Maryland,to look at the records of the American Embassy at Athens. By then, it had become clear to both of us that it was not possible to research any aspect of the institutional history of the ASCSA without access to records of the many other institutions, philanthropic and governmental, with which its members have interacted. Furthermore, in the process of expanding our own horizons, we met other scholars from other fields who were interested in the American School and its history. In the conviction that we had much to learn from the histories and sociologies of other institutions, the interests of which...

Comment on: "Temporal distribution of blood donations in three Brazilian blood centers and its repercussion on the blood supply"

As pointed out by Lorenzo Oliveira et al., the primary role of a blood center is the provision of a safe, economical and adequate blood supply(1). However, different factors govern the provision and the use of blood. An adequate supply of blood is based upon the availability of willing donors, while its usage depends upon medical need. It is clear that the concept of need only stimulates donors when dramatic circumstances such as natural disasters occur. It is frequently the case that modern disasters do not actually need a great deal of blood and indeed, the generosity of donors may be wasted. In view of this, a more effective system of communication and blood resource sharing in emergency situations has been developed in the United States. However, it is well-recognized that seasonal variation in the supply of blood is a pervasive problem. In the USA, there are times of the year when local or national appeals for blood donors may well be anticipated - for example during the summer or the Christmas/New Year holiday season. Careful inspection of Figure 1 shows the general reduction in collections during the middle part of the year (summer in the Northern hemisphere). Less apparent is the fact that the demographic structure of the donor population changes seasonally, unexpectedly affecting (for example) the prevalence if infectious disease markers. We have noted more first-time donors in the summer, and as might be expected, fewer donors in schools and colleges. This is, to a large extent, a consequence of the practice of collecting blood in locations away from the blood center itself, along with an increasing focus on younger blood donors. Figure 1 Blood collections by week, American Red Cross. Week 1 starts on the first Sunday in the calendar year: weeks zero and 52 may therefore be truncated. Certainly in the USA, a great deal of effort is put into recruitment of donors and such efforts are managed in the context of awareness of the drivers of blood shortages. Consequently, analysis of the number of blood units collected does not tell us as much as we may anticipate, because the data are a result of more or less successful efforts to overcome predictable shortages. Nevertheless, prompted by the accompanying paper, we analyzed weekly blood collection data for the American Red Cross, which collects about 40% of the 14 million blood donations in the USA (Figure 1). Clearly evident are repeated decrements around Weeks 21-22 (end of May), 26-27 (early July), 34-36 (beginning of September) and 46-47 (mid-late November). Also, as might be expected, there is a decline in the first and last weeks of the year, although it should be noted that the analysis is based upon each week starting on a Sunday, so the steep decline for week 52 is, in part, an artefact due to the truncation of this 'week'. The periods noted correspond to national holiday periods: Memorial Day, Independence Day, Labor Day, Thanksgiving and Christmas/New Year, respectively. Memorial and Labor days are held on a Monday, Independence Day is always July 4th (but observed on a weekday if falling on the weekend) and Thanksgiving is the fourth Thursday in November (many individuals are also on leave the following Friday). There are other holidays within the year, but they do not enjoy universal celebration, so do not clearly impact the collection data. On the whole, it is evident that blood collection organizations can adjust to predictable reductions in collections, but some logistic difficulties will be apparent for platelets, with a 5-day shelf-life. However, modeling studies suggest that unexpected surges in blood use, or shortages due to severe weather, an outbreak of influenza, etc. may have severe impacts upon blood availability. Where feasible, such events may be ameliorated by carefully organized resource sharing - that is, blood components may be shopped from locations that are less affected. However, in the absence of such mechanisms, local plans for donor mobilization should be developed and in place as part of emergency planning.

Fresh frozen plasma induced thrombocytopenia

Transfusions of blood products are common in medical practice and can be lifesaving in certain situations. Potentially life threatening reactions could occur and physicians should be alerted. Here we describe a case of thrombocytopenia that was induced by transfusion of fresh frozen plasma (FFP). A 52 years old male presented to the emergency department after two episodes of hematochezia that resolved spontaneously. Since he was anticoagulated for atrial fibrillation he was given a unit of FFP to reverse a slightly elevated INR. Within 6 hours from the administration of the FFP he developed an acute decrease only in his platelet count. He was managed conservatively and his thrombocytopenia started resolving gradually. After excluding other causes the potential diagnosis was fresh frozen plasma induced thrombocytopenia. The pathophysiologic mechanism is postulated to be immune mediated by passive transfer of antibodyies from the donor to the recipient. The antibodies that are described in the literature are anti-HPA-1a and anti-CD-36. We reported the event to the American Red Cross. Interestingly a male was the donor of the plasma while in all cases in the literature the donors are females with a prior history of pregnancy. Therefore this is the first reported case of a male blood donor whose blood product caused immune mediated thrombocytopenia post transfusion.

Nursing Students Make the World a Better Place Through Policy Development

Nursing students enter the profession wanting to make the world a better place. To achieve this, members of the National Student Nurses' Association (NSNA) practice policy development that contributes to professional formation. The authors use the example of how the rigorous process of writing and submitting resolutions to the NSNA House of Delegates influences policy development at the state and national levels. The American Red Cross Disaster Health and Sheltering certification course grew out of resolutions passed by NSNA delegates. Ultimately, the engagement of nursing students in the NSNA results in the preparation of leaders for shared governance and decision making as entry-level registered nurses.

Use of fear and threat-based messages to motivate preparedness: Costs, consequences and other choices Part One

Over the last several decades, billions of dollars have been spent in the USA to increase its disaster readiness and response capacity. Virtually every poll and survey shows that the US public remains woefully underprepared. At the 2012 ‘Awareness to Action’ workshop convened by the Federal Emergency Management Agency (FEMA) and the American Red Cross to examine the future of the long-standing ‘Have a Kit. Make a Plan. Be Informed’ preparedness campaign, FEMA Administrator Craig Fugate acknowledged that traditional efforts have not ‘moved the preparedness needle’. The most frequently cited causes for lack of preparedness in the general public are consumer apathy, lack of time, lack of money and the lack of knowledge on how best to prepare. This paper explores the reliance on fear- and threat-based messages (also referred to as ‘fear appeals’ to promote preparedness as a significant cause for this lack of preparation. It will look at the growing body of fear research, how fear and threat appeals are pervasive in emergency management, as well as its costs, unintended consequences and the other choices that can be made. The author asserts that by eliminating fear and threat-based messages, new messengers can share readiness as an accessible, empowering and valued pursuit for all communities — entirely distinct from the disasters and threats that people face.

Initial Observations of Elevated Alpha-N-Acetylgalactosaminidase Activity Associated with Autism and Observed Reductions from GC Protein—Macrophage Activating Factor Injections

Background: Autism spectrum disorders (ASD) are developmental disorders affecting 1:88 children, and which appear to be associated with a variety of complex immune dysregulations including autoimmunity. The enzyme, alpha-N-acetylgalactosaminidase (Nagalase) deglycosylates serum Gc protein (vitamin D 3 – binding protein) rendering it incapable of activating macrophage defenses. Increased Nagalase activity has been associated with a variety of malignancies, immune disorders and viral infections. Macrophage activating factor (GcMAF) has been repeatedly published as an intervention to lower serum Nagalase activity for a variety of cancer and HIV patients. GcMAF is a naturally occurring protein with well-established safety and therapeutic benefit(s) supported by numerous human studies. Methods: Initially, parents of 40 individuals with ASD sought testing for Nagalase serum activity as part of an evaluation of immune dysregulation. Nagalase enzyme activity measurement was performed by the European Laboratory of Nutrients (ELN), Bunnik, the Netherlands, using an end-point enzymatic assay of a chromogenic substrate. Some parents of patients with elevated Nagalase activity opted for weekly GcMAF injections provided by Immuno Biotech Ltd., Guernsey UK (www.gcmaf.eu). GcMAF is purified from human serum obtained from the American Red Cross using 25-hydroxyvitamin D3-Sepharose high affinity chromatography. The pro tein is then further diluted to obtain therapeutically appropriate levels for patients based on their clinical presentations. Results: Individuals with ASD (32 males and 8 females, n = 40, ages: 1 year 4 months - 21 years 2 months) had initial and post treatment assessment of Nagalase activity. Dosing of GcMAF was recommended based on previously reported response curves adjusted by the treating clinician for age, weight, and Nagalase levels. The average pre-treatment Nagalase activity of the autism group was 1.93 nmol/min/mg of substrate. This was well above the laboratory reported normal range of ,0.95 nmol/min/mg. For the ASD group the average level at the time of second testing was 1.03 nmol/min/mg, reflecting an average reduction of 0.90 nmol/min/mg ( P , 0.0001). Apart from the likely immunological benefits of lowering the Nagalase activity of these individuals, uncontrolled observations of GcMAF therapy indicated sub stantial improvements in language, socialization and cognition. No significant side-effects were reported during the course of injections. Conclusions: In this first report of Nagalase activity in patients with autism, it appears that most individuals have substantially higher levels than the expected healthy ranges. Although Nagalase is a nonspecific marker of immune dysregulation, its observed levels in autism may have both etiological and therapeutic significance. Importantly, this is also the first report of reduction of Nagalase activity in an autism population with GcMAF injections.

Black Nurses in the Great War: Fighting for and with the American Military in the Struggle for Civil Rights

Black nurses in the Great War waged a campaign for acceptance into the American Red Cross and U.S. military that blended professionalism with race consciousness in ways that would be felt ever since. This article challenges the traditional interpretation of this struggle as one of professional frustration and racial discrimination, and instead argues that the black nurses’ protest expanded their role as political activists. Black nurses saw themselves not only as health care professionals, but also as dedicated civil rights fighters. Their battle against the white power structure encouraged others to demand Increased opportunities and responsibilities. It also transformed the postwar environment, particularly in the field of public health. Finally, black nurses’ campaign for acceptance during World War I served as an important foundational movement. While not all of their goals were accomplished, black nurses developed many of the strategies later used during a similar campaign in World War II.

Novel electronic refreshers for cardiopulmonary resuscitation: a randomized controlled trial

BackgroundCurrently the American Red Cross requires that individuals renew their cardiopulmonary resuscitation (CPR) certification annually; this often requires a 4- to 8-hour refresher course. Those trained in CPR often show a decrease in essential knowledge and skills within just a few months after training. New electronic means of communication have expanded the possibilities for delivering CPR refreshers to members of the general public who receive CPR training. The study’s purpose was to determine the efficacy of three novel CPR refreshers - online website, e-mail and text messaging – for improving three outcomes of CPR training - skill retention, confidence for using CPR and intention to use CPR. These three refreshers may be considered “novel” in that they are not typically used to refresh CPR knowledge and skills.MethodsThe study conducted two randomized clinical trials of the novel CPR refreshers. A mailed brochure was a traditional, passive refresher format and served as the control condition. In Trial 1, the refreshers were delivered in a single episode at 6 months after initial CPR training. In Trial 2, the refreshers were delivered twice, at 6 and 9 months after initial CPR training, to test the effect of a repeated delivery. Outcomes for the three novel refreshers vs. the mailed brochure were determined at 12 months after initial CPR training.ResultsAssignment to any of three novel refreshers did not improve outcomes of CPR training one year later in comparison with receiving a mailed brochure. Comparing outcomes for subjects who actually reviewed some of the novel refreshers vs. those who did not indicated a significant positive effect for one outcome, confidence for performing CPR. The website refresher was associated with increased behavioral intent to perform CPR. Stated satisfaction with the refreshers was relatively high. The number of episodes of refreshers (one vs. two) did not have a significant effect on any outcomes.ConclusionsThere was no consistent evidence for the superiority of novel refreshers as compared with a traditional mailed brochure, but the low degree of actual exposure to the materials does not allow a definitive conclusion. An online web-based approach seems to have the most promise for future research on electronic CPR refreshers.

Graft-Specific HLA-Antibodies Do Not Influence Unit Dominance and Do Not Prevent High Rates of Sustained Donor Engraftment in Recipients of Double-Unit Cord Blood Transplantation

AbstractAbstract 960 Background:Pre-transplant human leukocyte antigen (HLA)-antibodies have an established role in failed engraftment after single-unit cord blood (CB) transplantation (CBT). Their role in double-unit CBT (DCBT) engraftment, however, is more controversial. Some transplant centers advocate pre-transplant screening of the recipient for HLA-antibodies, and avoidance of units with the corresponding antigens if antibodies are detected. Methods:We evaluated the influence of pre-transplant HLA-antibodies on sustained donor neutrophil engraftment and unit dominance in 82 recipients (median 48 years, range 2–69) of 4–6/6 HLA-A, B antigen, DRB1 allele matched double-unit CB grafts, and transplanted for hematologic malignancies at MSKCC from July 2008 to July 2012. HLA-antibodies were measured by the HLA Laboratory of the American Red Cross Blood Service using Single Antigen Luminex beads and analyzed by HLA Fusion software. The cut-off for positive results was a normalized mean fluorescence intensity value > 1000. Results:Overall, 28/82 (34%) patients were positive for HLA-antibodies [16 (19.5%) had antibodies without graft specificity, and 12 (14.5%) had antibodies with graft specificity]. These patients were more likely to be female with acute leukemia and cytomegalovirus seropositive. All patients with graft-specific antibodies received myeloablative conditioning; 5 had antibodies against class I HLA, 6 against class II, and one patient had antibodies to both Class I/II. Moreover, of these 12 patients, 6 had antibodies against one unit, and 6 had antibodies against both units. Neutrophil engraftment according to antibody presence is summarized in the Table. 64 of 66 (97%) evaluable myeloablative DCBT recipients (Table 1A) engrafted at a median of 24 days (range 12–40); one patient without antibodies and one with antibodies against both units had primary graft failure, both in the setting of early onset multi-organ failure. Both patients were 100% donor with one unit but did not recover counts. Of the 6 patients with antibodies to one unit, 3 engrafted with that unit and 3 with the opposite unit. Of the 6 patients with antibodies against both units, one had clinical graft failure as described above, and the 5 others had sustained donor engraftment (4 with one unit and one with both). In engrafting myeloablative recipients, the median time to neutrophil recovery was 8 days slower in patients with graft-specific antibodies, but the engrafting unit in these patients also had the lowest infused dose: median CD34+ cell dose/kg if no antibodies 0.83 × 105/kg, non-specific antibodies 1.09 × 105/kg, and antibodies specific to graft 0.65 × 105/kg. In non-myeloablative recipients, 15/16 (94%) engrafted (Table 1B). The single patient with graft rejection and autologous recovery had HLA-antibodies that were not graft specific. Conclusions:11 of 12 double-unit CBT recipients with graft-specific antibodies engrafted successfully. While myeloablative recipients with graft-specific antibodies engrafted more slowly, this may be explained by a lower infused CD34+ cell dose of their engrafting units. Multivariate analysis of larger patient numbers will be required to further evaluate the effect of graft-specific antibodies on engraftment speed. At this time, however, the presence of graft-specific antibodies should not preclude DCBT, and whether their presence should influence graft selection is not clear. Furthermore, there is no suggestion that the presence of HLA-antibodies influences unit dominance after DCBT.TableSustained Donor Neutrophil Engraftment According to HLA-antibodies1A) Myeloablative Conditioning (n=67)Median (Range) Time to Neutrophil Recovery (> 0.5)N (%) Sustained EngraftmentNo antibodies (n=41)23 days (range 12–38)39/40 (1 non-evaluable)Antibodies: not graft-specific (n=14)23 days (range 12–37)14/14Antibodies: graft-specific (n=12)31 days (range 13–40)11/12Against engrafting unit (n=3)28 days (range 24–31)3/3Against non-engrafting unit (n=3)31 days (range 25–32)3/3Antibodies against both units (n=6)33 days (range 13–40)5/61B) Non-Myeloablative Conditioning (n=15)Median (Range) Time to Neutrophil Recovery (> 0.5)N (%) Sustained EngraftmentNo antibodies (n=13)10 days (range 8–20)13/13Antibodies: not graft specific (n=2)19 days in 1 patient (other had graft failure/autologous recovery)1/2Antibodies: graft specific (n=0)-- Disclosures:Giralt:Celgene: Honoraria, Research Funding.

Current efforts to reduce the risk of syncope among young blood donors

This review examines recent research on syncope after whole blood donation and efforts by blood centers to improve safety for young blood donors. Young (16-18-year-old) volunteers contribute about 14% of the whole blood collected by the American Red Cross each year. Although quite safe, blood donation has some attendant risk, and syncopal reactions are more common among the youngest donors. Precautionary measures include predonation education, environmental controls, water ingestion shortly before phlebotomy, and distraction and muscle tension during collection. American Red Cross and Blood Systems, Inc. introduced new criteria to select donors with an estimated blood volume above 3.5 l. The changes led to about a 20% decrease in reactions among young blood donors, with the greatest benefit observed among the youngest, most susceptible donors. Although the risk to blood donors cannot be eliminated, a systematic approach can achieve a significant and sustained improvement among vulnerable donor populations. Further research should explore novel ways to reduce the risk of syncope and prevent the uncommon, but potentially serious, associated injuries after whole blood donation.

The residual risk of transfusion‐related acute lung injury at the American Red Cross (2008‐2011): limitations of a predominantly male‐donor plasma mitigation strategy

The American Red Cross began preferentially distributing plasma from male donors in 2007 and subsequently observed an 80% decrease in reported cases of transfusion-related acute lung injury (TRALI) after plasma transfusion. Plasma distributions from male donors now exceed 99% for groups A, B, and O, but only approximately 60% for group AB. We evaluated the ongoing risk of TRALI and the ABO blood group of involved plasma donors. The rate of suspected TRALI per distributed components before (2006) and after (2008-2011) implementing the predominantly male-donor plasma strategy is compared. The risk of TRALI from the general inventory of distributed plasma decreased significantly from 18.6 cases per million units in 2006 to 4.2 cases per million units in 2008 to 2011 (p < 0.0001). However, the risk from AB plasma did not change (26.3 cases per million units) and was significantly greater than group A, B, and O plasma in 2008 to 2011 (1.8 per million units; odds ratio 14.5; 95% confidence interval, 6.8-30.9). Group AB plasma from female donors with HLA or HNA antibodies accounted for 14 of 28 (50%) of TRALI cases but less than 4% of all plasma units distributed in 2008 to 2011. The risk of TRALI after plasma transfusion has been markedly reduced for blood groups A, B, and O but not for AB, reflecting continued reliance on group AB plasma from female donors to meet increasing demand.

St. Francis and the Wolf by Malvina Hoffman

Malvina C. Hoffman (1887-1966), a rare woman of her time whose amazing life is hard to summarize in one paragraph, was born on June 15, 1887, in New York, New York, and was exposed very early in life to the art world as the daughter of the famed pianist and composer Richard Hoffman (1831-1909). Showing an affinity for sculpture, Hoffman began studying at the Art Students League in New York when she was 14 years old. After the death of her father, Hoffman moved abroad and was accepted as a student of world-renowned sculptor Auguste Rodin. In World War I, Hoffman served with the American Red Cross and assisted President Hoover in the Balkans during the war restoration period. It is no surprise that many of her sculptures memorialize battles and war heroes. Hoffman also exhibited sculpture in the 1933 Chicago World's Fair and throughout the United States and Europe, and she was commissioned to create a series of sculptures (109) to document the “Races of Mankind,” which can be seen in the Field Museum, Chicago, Illinois. Hoffman continued sculpting right up to the time of her death.1-4 St. Francis (the inspiration for this sculpture) was born into a wealthy family in Assisi, Italy, and after hearing the prayer of Christ, “Rebuild My Church,” as a young man, he renounced the privileges of his family position and embraced a life of radical poverty. His love inspired many, including the community of Sisters who pioneered Saint Marys Hospital in Rochester, Minnesota. St. Francis and the Wolf depicts one of the events in the great saint's life and the relationship that he had with all of creation. The story tells of a wolf that was terrorizing the people of Gubbio, Italy, and St. Francis made a pact with the wolf requesting that it stop killing the people. The wolf shook hands/paws with St. Francis and was tamed. The wolf forever became a symbol of God's grace and forgiveness.5 As the patron saint of the Sisters of St. Francis, the image of St. Francis in St. Francis and the Wolf inspires care for the poor and wonder in all things. St. Francis and the Wolf, a life-sized bronze casting and the gift of Mr. and Mrs. Charles Lamson Hoffman in 1960, is located on the front lawn of the Domitilla Building on the Saint Marys Hospital grounds in Rochester, Minnesota.

The Effectiveness of Psychological First Aid as a Disaster Intervention Tool: Research Analysis of Peer-Reviewed Literature From 1990-2010

The Advisory Council of the American Red Cross Disaster Services requested that an independent study determine whether first-aid providers without professional mental health training, when confronted with people who have experienced a traumatic event, offer a "safe, effective and feasible intervention." Standard databases were searched by an expert panel from 1990 to September 2010 using the keyword phrase "psychological first aid." Documents were included if the process was referred to as care provided to victims, first responders, or volunteers and excluded if it was not associated with a disaster or mass casualty event, or was used after individual nondisaster traumas such as rape and murder. This search yielded 58 citations. It was determined that adequate scientific evidence for psychological first aid is lacking but widely supported by expert opinion and rational conjecture. No controlled studies were found. There is insufficient evidence supporting a treatment standard or a treatment guideline. Sufficient evidence for psychological first aid is widely supported by available objective observations and expert opinion and best fits the category of "evidence informed" but without proof of effectiveness. An intervention provided by volunteers without professional mental health training for people who have experienced a traumatic event offers an acceptable option. Further outcome research is recommended.

A comparison of human immunodeficiency virus, hepatitis C virus, hepatitis B virus, and human T‐lymphotropic virus marker rates for directed versus volunteer blood donations to the American Red Cross during 2005 to 2010

At most US blood centers, patients may still opt to choose specific donors to give blood for their anticipated transfusion needs. However, there is little evidence of improved safety with directed donation when compared to volunteer donation. The percentage of directed donations made to the American Red Cross (ARC) from 1995 to 2010 was determined. Infectious disease marker rates for human immunodeficiency virus (HIV), hepatitis C virus (HCV), hepatitis B virus (HBV), and human T-lymphotropic virus (HTLV) were calculated for volunteer and directed donations made from 2005 to 2010. Odds ratios (ORs) were calculated to compare marker-positive rates of directed donations to volunteer donations. The percentage of donations from directed donors declined from 1.6% in 1995 to 0.12% in 2010. From 2005 to 2010, the ARC collected 38,894,782 volunteer and 69,869 directed donations. Rates of HIV, HCV, HBV, and HTLV for volunteer donations were 2.9, 32.2, 12.4, and 2.5 per 100,000 donations, respectively; for directed, the rates were 7.2, 93.0, 40.1, and 18.6 per 100,000. After demographics and first-time or repeat status were adjusted for, corresponding ORs of viral marker positivity in directed versus volunteer donations were not significant for HIV, HBV, or HTLV and significant for HCV (OR, 0.7; 95% confidence interval, 0.50-0.90). Directed donations have declined by 92% at the ARC since 1995, but have higher viral marker rates than volunteer donations. The difference can be explained in part by the effects of first-time or repeat status of the donors. Patients considering directed donation should be appropriately counseled about the potential risks.

Antibody levels correlate with detection of Trypanosoma cruzi DNA by sensitive polymerase chain reaction assays in seropositive blood donors and possible resolution of infection over time

BACKGROUND: The clinical significance of anti‐Trypanosoma cruzi low‐level reactive samples is incompletely understood. Polymerase chain reaction (PCR)‐positive rates and antibody levels among seropositive blood donors in three countries are described.STUDY DESIGN AND METHODS: Follow‐up samples were collected from T. cruzi–seropositive donors from 2008 through 2010 in the United States (n = 195) and Honduras (n = 58). Also 143 samples from Brazil in 1996 to 2002, originally positive by three serologic assays, were available and paired with contemporary follow‐up samples from these donors. All samples were retested with Ortho enzyme‐linked immunosorbent assay (ELISA). PCR assays were performed on coded sample panels by two laboratories (Blood Systems Research Institute [BSRI] and American Red Cross Holland Laboratory [ARC]) that amplified kinetoplast minicircle DNA sequences of T. cruzi.RESULTS: PCR testing at BSRI yielded slightly higher overall sensitivity and specificity (33 and 98%) compared with those at the ARC (28 and 94%). Among seropositive donors, PCR‐positive rates varied by country (p &lt; 0.0001) for the BSRI laboratory: Brazil (57%), Honduras (32%), and the United States (14%). ELISA signal‐to‐cutoff ratios (S/CO) were significantly higher for PCR‐positive compared to PCR‐negative donors (p &lt; 0.05 for all comparisons). Additionally, PCR‐negative Brazilian donors exhibited greater frequencies of antibody decline over time versus PCR‐positive donors (p = 0.003).CONCLUSION: For all three countries, persistent DNA positivity correlated with higher ELISA S/CO values, suggesting that high‐level seroreactivity reflects chronic parasitemia. Significant S/CO declines in 10% of the PCR‐negative Brazilian donors may indicate seroreversion after parasite clearance in the absence of treatment.