Practice Of Transfusion Medicine Research Articles

Characterization of blood bank and transfusion medicine practices for pregnant individuals with fetuses at risk of hemolytic disease in the United States.

Hemolytic disease of the fetus and newborn (HDFN) is caused by maternal alloantibody-mediated destruction of fetal/neonatal red blood cells (RBCs). While the pathophysiology has been well-characterized, the clinical and laboratory monitoring practices are inconsistent. We surveyed 103 US institutions to characterize laboratory testing practices for individuals with fetuses at risk of HDFN. Questions included antibody testing and titration methodologies, the use of critical titers, paternal and cell-free fetal DNA testing, and result reporting and documentation practices. The response rate was 44% (45/103). Most respondents (96%, 43/45) assess maternal antibody titers, primarily using conventional tube-based methods only (79%, 34/43). Among respondents, 51% (23/45) rescreen all individuals for antibodies in the third trimester, and 60% (27/45) perform paternal RBC antigen testing. A minority (27%, 12/45) utilize cell-free fetal DNA (cffDNA) testing to predict fetal antigen status. Maternal antibody titers are performed even when the fetus is not considered to be at risk of HDFN based on cffDNA or paternal RBC antigen testing at 23% (10/43) of sites that assess titers. There is heterogeneity across US institutions regarding the testing, monitoring, and reporting practices for pregnant individuals with fetuses at risk of HDFN, including the use of antibody titers in screening and monitoring programs, the use of paternal RBC antigen testing and cffDNA, and documentation of fetal antigen results. Standardization of laboratory testing protocols and closer collaboration between the blood bank and transfusion medicine service and the obstetric/maternal-fetal medicine service are needed.

Enhancing clinical insight: Implementing validated questionnaires for comprehensive assessment of clinician expertise in transfusion medicine practices

BackgroundBlood transfusion is a cornerstone of modern healthcare, pivotal in saving countless lives annually. However, inadequate knowledge among healthcare providers can lead to serious complications. Despite the availability of assessment tools like the Biomedical Excellence for Safer Transfusion (BEST) test, there is a need for indigenous-validated questionnaires to address knowledge gaps effectively. This study aimed to evaluate bedside transfusion medicine knowledge among clinical residents using a validated questionnaire, focusing on knowledge gaps. Study design and methodsA cross-sectional study was conducted at a tertiary care referral center in Northern India. The questionnaire, developed based on national and international transfusion guidelines, was validated by an expert panel, and administered to 245 clinical residents. The questionnaire covered six domains related to transfusion medicine: blood component storage, blood bank procedures, transfusion-transmitted infections, administration of blood components, transfusion reactions, and transfusion practices. ResultsThe study revealed varying levels of knowledge across specialties and residency years. Overall, residents scored 61 % in transfusion medicine knowledge, with Pediatrics residents demonstrating the highest scores. The incremental increase in knowledge from first to third-year residents underscores the value of continuous, experience-based learning throughout the residency period. DiscussionStudy highlights significant knowledge gaps in bedside transfusion practices among clinical residents, emphasizing the need for structured educational interventions. Tailored programs, integrated into undergraduate and postgraduate curricula, are essential to improve transfusion safety and patient outcomes. Addressing these gaps can lead to better bedside transfusion practices, reducing risks and improving the quality of patient care.

PREVALENCE OF KELL BLOOD GROUP SYSTEM IN BLOOD DONORS ATTENDING A TERTIARY CARE CENTRE IN NORTHWESTERN INDIA

Objective: The Kell blood group system is amongst one of the clinically significant blood group system in blood transfusion, consisting of different types of antigens with high immunogenicity which can be a potential cause of serious transfusion reactions and hemolytic disease of fetus and newborn. Knowledge of the antigenic frequency is crucial to assess the risk of alloimmunisation and to guide the probability of finding antigen-negative donor blood, which can be useful for a patient with corresponding or multiple red cell alloantibodies. Methods: This is a retrospective study which was done at Department of Immunohematology and Transfusion medicine, SMS Medical College, Jaipur over a period of one year from 1st Jan to 31st Dec 2020. During the study period, blood both voluntary donors as well as replacement donors were typed for Kell antigens by automated red cell antigen typing by capture-R technology in neo immucor. Results: A Total of 9677(Nine Thousand Six Hundred Seventy Seven) Blood donors were typed for Kell Antigens. Out of these 9677 samples, 288 were Positive for Kell positive (K+) resulting in overall frequency of Kell (K) Antigen as 2.9%. Conclusion: This is the first study that set out to determine the prevalence of Kell antigens among Blood Donors in Northwestern India. These results appear to be useful in providing better care for patients by implementing tests that should become a routine in blood banks. The Kell system is very important in Transfusion medicine practice.

Transfusion Support in Hematopoietic Stem Cell Transplantation: A Contemporary Narrative Review.

Hematopoietic stem cell transplantation (HSCT) is a cornerstone of modern medical practice, and can only be performed safely and effectively with appropriate transfusion medicine support. Patients undergoing HSCT often develop therapy-related cytopenia, necessitating differing blood product requirements in the pre-, peri-, and post-transplant periods. Moreover, ensuring optimal management for patients alloimmunized to human leukocyte antigens (HLA) and/or red blood cell (RBC) antigens, as well as for patients receiving ABO-incompatible transplants, requires close collaboration with transfusion medicine and blood bank professionals. Finally, as updated transfusion guidelines and novel blood product modifications emerge, the options available to the transplant practitioner continue to expand. Herein, we detail contemporary blood transfusion and transfusion medicine practices for patients undergoing HSCT.

Transfusion Camp Rwanda 2023: A train-the-trainer workshop establishing locally driven leadership in knowledge translation and sustainability in transfusion medicine education.

Blood transfusion is performed daily in hospitals. Gaps exist between transfusion guidelines and day-to-day clinical care. These gaps are prevalent in resource-limited settings due to scarce continuing medical education. Transfusion Camp Rwanda aims to bridge this gap by (1) delivering context-appropriate up-to-date education, (2) teaching participants how to independently deliver a case-based curriculum and (3) identifying strategies to promote change in transfusion practice in Rwanda. In May 2023, a multidisciplinary team from Canada and Rwanda carried out a Transfusion Camp train-the-trainer workshop for clinicians from all five provinces in Rwanda. Participants attended in-person lectures, seminars and workshop group discussions on the implementation of the Rwanda National Directives on Rational Use of Blood and Blood Components. Course feedback was based on the Kirkpatrick Model of Training and Evaluation. Fifty-one physicians and laboratory technicians participated in the course. Confidence in caring for patients based on transfusion guidelines was self-rated as 'excellent' by 23% of participants before and 77% after, while 84% reported they planned to teach Transfusion Camp to others and 100% responded that they will apply course content to clinical practice. Workshop groups recommended strategies to improve transfusion medicine practice in Rwanda in four domains: Communication, Institutional Approval, Practice Audits and Education. Transfusion medicine education in Rwanda using a train-the-trainer approach was well-received by participants and allowed for a more detailed understanding of the local medical and educational environment. These observations can inform the further expansion of the Transfusion Camp Rwanda project.

Integrating Artificial Intelligence into the Practice of Transfusion Medicine

Integrating Artificial Intelligence into the Practice of Transfusion Medicine

Current state of technical transfusion medicine practice for out-of-hospital blood transfusion in Canada.

Canadian out-of-hospital blood transfusion programmes (OHBTPs) are emerging, to improve outcomes of trauma patients by providing pre-hospital transfusion from the scene of injury, given prolonged transport times. Literature is lacking to guide its implementation. Thus, we sought to gather technical transfusion medicine (TM)-specific practices across Canadian OHBTPs. A survey was sent to TM representatives of Canadian OHBTPs from November 2021 to March 2022. Data regarding transport, packaging, blood components and inventory management were included and reported descriptively. Only practices involving Blood on Board programme components for emergency use were included. OHBTPs focus on helicopter emergency medical service programmes, with some supplying fixed-wing aircraft and ground ambulances. All provide 1-3 coolers with 2 units of O RhD/Kell-negative red blood cells (RBCs) per cooler, with British Columbia trialling coolers with 2 units of pre-thawed group A plasma. Inventory exchanges are scheduled and blood components are returned to TM inventory using visual inspection and internal temperature data logger readings. Coolers are validated to storage durations ranging from 72 to 124 h. All programmes audit to manage wastage, though there is no consensus on appropriate benchmarks. All programmes have a process for documenting units issued, reconciliation after transfusion and for transfusion reaction reporting; however, training programmes vary. Common considerations included storage during extreme temperature environments, O-negative RBC stewardship, recipient notification, traceability, clinical practice guidelines co-reviewed by TM and a common audit framework. OHBTPs have many similarities throughout Canada, where harmonization may assist in further developing standards, leveraging best practice and national coordination.

Would doctors dream of electric blood bankers? Large language model-based artificial intelligence performs well in many aspects of transfusion medicine.

Large language models (LLMs) excel at answering knowledge-based questions. Many aspects of blood banking and transfusion medicine involve no direct patient care and require only knowledge and judgment. We hypothesized that public LLMs could perform such tasks with accuracy and precision. We presented three sets of tasks to three publicly-available LLMs (Bard, GPT-3.5, and GPT-4). The first was to review short case presentations and then decide if a red blood cell transfusion was indicated. The second task was to answer a set of consultation questions common in clinical transfusion practice. The third task was to take a multiple-choice test experimentally validated to assess internal medicine postgraduate knowledge of transfusion practice (the BEST-TEST). In the first task, the area under the receiver operating characteristic curve for correct transfusion decisions was 0.65, 0.90, and 0.92, respectively for Bard, GPT-3.5 and GPT-4. All three models had a modest rate of acceptable responses to the consultation questions. Average scores on the BEST-TEST were 55%, 40%, and 87%, respectively. When presented with transfusion medicine tasks in natural language, publicly available LLMs demonstrated a range of ability, but GPT-4 consistently scored very well in all tasks. Research is needed to assess the utility of LLMs in transfusion medicine practice. Transfusion Medicine physicians should consider their role alongside such technologies, and how they might be used for the benefit and safety of patients.

Survey of blood collection and transfusion practices among institutions in Africa.

Dramatic improvements in blood transfusion have occurred during the last two decades. Transfusion medicine services and practices in Africa remain underexplored. A survey of blood bank/transfusion medicine (BBTM) practices, available blood products, blood product source(s), pre-transfusion testing, and blood donor infectious disease testing methodologies across Africa was performed using the American Society for Clinical Pathology (ASCP) listserv. Survey recipients included hospital-based laboratories/blood banks, national transfusion medicine services, and free-standing laboratories (collectively referred to as institutions). Responses from a total of 81 institutions across 22 countries were analyzed. All 81 institutions provide at least one type of blood product-whole blood, red blood cells (RBCs), platelets, plasma, and cryoprecipitate, with whole blood (90.1%, 73 of 81) and RBCs (79.0%, 64 of 81) most common, while cryoprecipitate is least common (12.4%, 10 of 81). Only five countries had a responding institution that provides all types of products. Among institutions that collect blood onsite, the most common sources of blood products are patients' family members (94.1%, 48 of 51) and pre-screened on-demand volunteer donors (82.4%, 42 of 51). The most commonly screened infectious agents are HIV and hepatitis B virus (both 81.5%), while 70.4% (57 of 81) test for hepatitis C virus (HCV) and Treponema pallidum. This study highlights significant variability and restrictions in blood product availability, pre-transfusion testing, and blood donor infectious disease testing across Africa. Further studies are needed to ascertain barriers to improving blood donor availability, blood product safety, and infectious disease testing.

Red cell transfusion in critical care: Could less be more?

Blood transfusion has a very important place in ancient medicine where it is associated with vitality. In the era of modern medicine, it still holds an important place. Critical events in the history led to the development of the physiological knowledge of blood flow and pathological processes associated with anemia. These still have a strong foothold in the practice of transfusion medicine which until very recently led physicians to liberally transfuse red blood cells to patients. However, the past few decades have revealed the darker side associated with transfusion of red blood cells. Recent evidences strongly suggest that the arbitrary transfusion triggers that had been historically set might have been too high, possibly causing unnecessary harm. Here, in this narrative review, the authors have tried to explore the evidences favoring lower transfusion threshold and without added adverse events thus supporting the notion – less is more.

Haemovigilance and its Significance in Transfusion Safety and its Adverse Effect

Blood transfusion saves lives and improves health, but many patients requiring transfusion do not have timely access to safe blood. Blood transfusion is always associated with some level of risk. Haemovigilance is a continuous process of data collection and analysis of transfusion-related adverse reactions/events in order to investigate their causes and outcomes, and prevent their occurrence or recurrence. It is a risk monitoring system integral to the practice of transfusion medicine whose ultimate purpose is to improve the quality and safety of transfusion Blood transfusion has certain risks, and any unfavorable event occurring in a patient during or after transfusion, for which no other reason can be found, is called a transfusion reaction. These untoward effects vary from being relatively mild to severe and require rapid recognition and management. Transfusion services rely on transfusion reaction reporting to provide patient care and protect the blood supply. Unnecessary discontinuation of blood is a major wastage of scarce blood, as well as man, hours, and funds. Although strict procedures are applied during blood donations preparations and transfusions, errors in transfusion and infection complications still serve a problem in clinical practice. Hemovigilance is intended for the detection and analyzing all untoward effects of blood transfusion to correct their cause and prevent recurrence. In this review, we will discuss hemovigilance and transfusion Safety and its adverse effect.

An investigation of the early and late period effects of the COVID-19 pandemic on blood use and destruction rates: An example of a tertiary hospital, Antalya, Türkiye

Introduction and Objective: The Coronavirus 2019 (COVID-19) pandemic has affected many healthcare services as well as transfusion medicine practices. In this study, it is aimed to examine the early and late effects of the pandemic on the use and destruction rates of blood and blood components.
 Material and method: This retrospective study was conducted at a tertiary hospital transfusion center. Unit numbers of blood and blood components used and destroyed in 2018-2021 were grouped according to the pre-pandemic period (27 months), early pandemic period (6 months), and late pandemic period (15 months). Monthly use and disposals in the early and late pandemic periods were compared with the pre-pandemic period. 
 Results: A total of 144114 units of blood and blood components were used. The most commonly used components were erythrocyte concentrate (EC), fresh frozen plasma (FFP) and thrombocyte concentrate (TC), respectively. Their monthly usages in the pre-pandemic period, the early pandemic period and the late pandemic period were 2067.1±147.2, 840±161.3 and 285.4±77.4; 1564.5±287.5, 576.7±146.2 and 261.5±52.6; 1803.5±122.1, 718.6±118.8 and 325.7±52.1; respectively. EC and FFP were used significantly less in the early and late pandemic periods than in the pre-pandemic period (p

An audit to estimate the quality of practices followed during bedside blood transfusion in a tertiary care hospital and role of continuous medical education in it.

Blood transfusion is an integral component of the health Service system and it becomes imperative that its benefits, risks as well as prospective and viable alternatives of this common medical intervention are explained explicitly to the patients. Appropriate compliance to bedside blood transfusion practices can also help in avoiding adverse transfusion outcomes. At the same time, it is also crucial to document a patient's valid consent based on their decision after evaluation of the risk to benefit ratio. This audit aims to assess the compliance and adherence to bedside blood transfusion practices in a tertiary care hospital and role of Continuous Medical education (CME) on it. The study involved collection of data for blood transfusion services and practices in two periods, for adults and children, who received transfusion from the month of June 2021 to October 2021 and a re-audit beginning from November 2021 to February 2022 following few CMEs in between involving doctors and nurses. A total of 3240 transfusion procedures were assessed in this duration. In them 1500 (46.3%) took place before CME and remaining 1740 (53.7%) procedures took place after CME. There were statistically significant differences between pre-CME and post-CME bedside transfusion practices. During CME/training session, pre-training and post training knowledge has been evaluated by test which also showed statistically significant difference in knowledge of transfusion medicine & bedside transfusion practices. Our study recommends that there is a need of frequent audit on bedside transfusion practices to check the quality and standards associated with it and also points out the need of continuous medical education on this issue.

SARS-CoV-2 pandemic and its impact on blood transfusion services: challenges, experience and lessons learnt at king Abdullah medical city, Makkah, Saudi Arabia

SARS-COVID (COVID-19) epidemic is a great challenge for blood transfusion practice. Hospitals were overwhelmed with increasing number of admitted patients with severe COVID-19 infections as well as limitation of variable medical and pharmaceutical resources partly due to lockdown. This retrospective study analyzes the transfusion medicine practice and approach of health institution toward the pandemics before and during the pandemic era over the four years period, 2018 through 2021. Data was collected from blood bank records and laboratory information system for the whole blood donors, apheresis platelets donors, numbers and types of prepared blood components, details of blood components storage and expiry, and blood components for the study period. The data analyzed showed that the total number of whole blood donors dropped during 2020. However, there is a steady increase in number of voluntary non-numerated whole blood donors. The production of packed Red Blood Cells units, Fresh Frozen Plasma units, and Cryoprecipitate units were actually more or less similar or slightly higher in 2020 compared to 2019 and 2018. However, the production of Platelets components showed a drop during 2020. The transfusion for patients at the institution has slightly increased for 2020 compared to 2019. Therefore, the need to procure blood components from other facilities was increased in 2020 compared to pre COVID-19 pandemics. The percentage of expired and wasted blood components units steadily decreasing over the past few years. The data of expired and or wasted collected blood components were compared through the study period and it illustrates that the percentage of expired and wasted units was steadily dropped over the years. This to mention that automated blood transfusion system was implemented late 2019 and put in full effect in 2020. The presence of validated and secured electronic system supports blood bank to eliminate the number of expired and wasted units due to proper inventory management. Along with all the hard work to maintain adequate and safe blood supply to increasing requests of blood transfusion, blood bank at KAMC participated in the national multidisciplinary study of Convalescent Plasma use for critically ill COVID-19 patients.

Blood Donation in Lebanon: A Six-Year Retrospective Study of a Decentralized Fragmented Blood Management System.

IntroductionIn developing countries, the lack of a sufficient and safe blood supply is a significant impediment to providing health care. Lebanon is notable for its absence of a Donor Management System to ensure continuous donor recruitment and scheduling. Herein, we report the findings of Lebanon's first large retrospective population-based study to investigate blood types and donation that is critical for managing community blood supply.MethodsThe non-remunerated voluntary blood donors were recruited by the non-profit organization “Donner Sang Compter”. The study spanned six years, from August 2015 to May 2021, and included 36,002 people from 18 districts throughout Lebanon's nine governorates.ResultsThe most prevalent blood type was A (42%), followed by O (37.48%), B (13.86%), and the AB group (6.84%). RhD+ groups were predominant (88.45%), with A+ being the most (37.84%) and AB- being the least prevalent (1.05%). Furthermore, blood type and donation profiling revealed a substantial geographical variation in the frequency of blood groups, despite the relatively small country’s area. As for blood donation, when gender and age were considered, young male donors dominated the pool across the country.ConclusionThis study on blood type prevalence and blood donor demographics may pave the way for the development of a more coherent and integrated blood management system in Lebanon, as opposed to the fragmented and decentralized system now in existence. These findings also provide crucial clinical information for the country's future transfusion medicine policies and practices, which is vital in such a precarious part of the world.

Determination of C,c,E and e Antigens Section Prevalence in Rh D Negative Individuals: Is it Good Exercise with Utilities in Clinical Blood Transfusion Practices?

Introduction: Besides D antigen, C,c,E and e antigens of Rh blood group system are the most important antigens involved in alloimmunisation. The prevalence of C,c,E and e antigens in Rh D negative individuals in local population has many utilities in transfusion medicine practice. Aim: To determine the prevalence of C,c,E and e antigens in Rh D negative individuals. Materials and Methods: This prospective observational study was performed at Bhanumati clinical laboratory, Navsari, Gujarat, India, from January 2020 to January 2022. A total of 270 Rh D negative samples irrespective of ABO blood group status were typed for C,c,E and e antigen using monoclonal reagents from two different manufacturers using conventional tube technique. The most likely phenotype and genotype were determined using reference textbooks. Possibility of weak D in these 270 samples was ruled out using polyspecific Antihuman Globulin Reagent performing test for weak D antigens. Results were analysed using Excel spread sheet. Results: Prevalence of C,c,E, and e antigen in the 270 Rh D negative samples were, C (17, 6.29%), c (267, 98.88%), E (1, 0.37%) and e (270, 100%). Most probable genotypes were dce/ dce(rr), dCe/dce(r’r), dCe/dCe(r’r’) and dcE/dce(r’’r). Conclusion: Data obtained of C,c,E and e antigen prevalence in Rh D negative individuals is having varied utilities in blood transfusion services such as formulating rare blood group registry, preparing in house screening and panel red cells, and maintaining inventory of rare blood group units using freezing technology, if available.

Therapeutic apheresis and non‐blood donor related apheresis current practices at various blood centres of healthcare organisations of India: A brief online survey

AbstractObjectivesTo determine the variability in therapeutic apheresis (TA) and non‐blood donor related apheresis practices, and the extent of expertise and knowledge of blood centre staff.BackgroundApheresis activity that was earlier limited to therapeutic plasma exchange (TPE) and donor apheresis at few centres in India has seen remarkable surge involving many centres practising TA and non‐blood donor related apheresis. The decentralised transfusion medicine practice in country has resulted in wide variability of knowledge and practice of TA. An online survey was conducted to achieve study objectives.Study design and methodsA 22 questionnaire survey was sent to the 215 blood centres through e‐mail link focussing on three aspects; basic information of the participating centres, details of TA procedures and education and training levels of the staff.ResultsMajority (71.9%) of centres were teaching institutions among analysed 57 centres. TPE (85.9%) and therapeutic cytapheresis (71.9%) were the most common TA procedures. The clinical haematology (68.4%) followed by neurology (64.9%) were the specialities utilising TA. The 64.9% centres used continuous flow cell separator and central venous access (52%) was preferred vascular access. A combination of normal saline, fresh frozen plasma and 5% albumin replacement fluid was first choice. Doctors involved in TA were trained in apheresis during their MD/DNB degree, but no structured training program existed for other category of staff.ConclusionThere was a wide variability in TA practice in India and a dedicated training program for all categories of staff was emphasised by majority of participants.

Recent advances in blood group genotyping

: Red blood cell (RBC) antigen typing of both recipients and donors is vital for safe and effective transfusion. Despite the existence of >330 RBC antigens, current routine pre-transfusion testing only includes matching the patient and donor for ABO and D, since serologic typing methods are difficult to scale for routine non-ABO/D antigen typing (i.e., extended antigen typing). While PCR-based genotyping can be used to broadly genotype most antigens, current assay formats limit the number of genetic changes and samples that can be simultaneously tested (~50 genetic changes and ~100 samples per run). However, the emergence of RBC antigen genotyping using next-generation sequencing (NGS) and high-density DNA arrays have the potential to overcome many of these limitations. NGS allows an unprecedented evaluation of genetic changes including novel genetic changes and complex structural variations (SVs), representing the new gold standard for RBC antigen genotyping. High-density DNA arrays allow for low cost evaluation of all known genetic changes including SV with the ability to run 1,000s of samples at a time. As such, NGS will likely replace conventional PCR genotyping for discordants and complex serologic workups and offer an unprecedented level of discovery for new RBC antigens. High-density DNA arrays have the potential to allow for routine genotyping of all blood donors for all genetically understood antigens, something that will fundamentally change the practice of transfusion medicine.

Modeling global transfusion medicine education.

Modeling global transfusion medicine education.

Informed Consent in Transfusion Medicine: An Ethical Obligation Or a Legal Compulsion to Avert Liabilities for Negligence to the Health Care Provider

Blood transfusion is oftentimes life-saving but associated with risks which ought to be disclosed by the health care provider as an ethical obligation and legal requirement. The practice of informed consent to transfusion medicine is quite new and few studies have comprehensively x-rayed its historical, ethical and legal implications with an in depth consideration of professional negligence using decided cases by the adversarial and arbitration systems. PubMed, PubMed Central, Google Scholar, African Journal on Line (AJOL) electronic databases were searched using combined keywords like; “Blood transfusion and informed consent” “informed choice to transfusion medicine practice”, “consent in transfusion medicine”, “health care giver and consent to transfusion therapy”, “transfusion consent and the health care seeker”, “liability and informed consent to transfusion” and “contemporary issues in medical negligence”. Relatedly, printed materials were considered. The 91 studies that met the inclusion criteria were considered with highlights showing that, informed consent to medical treatment generally is an age long practice running from roman civilization to the present but its advocated practice in transfusion medicine a recent event. The practice is also generally low in comparison with informed consent taken for other treatments in similar settings. The consequences of dereliction including infamous conduct amongst professionals or negligence with direct and vicarious liabilities in adversary systems has been set in precedent judgments. These in addition to the present day patient-centered care model as global best practice and quality in health care delivery is compelling for health care providers to imbibe the practice not as a form of defensive medicine but a repertoire to quality and responsive Medicare service.