Transfusion Medicine Specialists Research Articles

'Old is gold' does conventional test tube method still reign supreme? An immuno-haematological survey of anti-D detection and titration in ante-natal cases among major hospitals across India.

Anti-D detection and titration plays a major role in RhD negative antenatal cases both, for monitoring maternal as well as fetal status as well as initiation of early therapeutic interventions, such as intra-uterine transfusions (IUT) to improve maternal as well as fetal morbidity and mortality and reduce the adverse effects of haemolytic disease of fetus and newborn (HDFN). We conducted a survey focusing on the policies and procedures of anti-D detection and titration among major tertiary care centres across India. The survey was drafted by a working group of transfusion medicine and immunohematology specialists from six different centres in India. Data were obtained via the use of an online questionnaire. Results were categorised into four categories, Hospital information, immuno-haematological testing methodology, clinical significance of anti-D testing and the role of transfusion medicine specialists. The survey highlighted the modalities as well as the methodologies of anti-D detection and titration in antenatal women across different major tertiary care centres in India. This survey provided a unique snapshot of the prevalent methodologies being employed by major tertiary care centres across the country for detection and titration of anti-D levels as well as the important role it plays in the therapy of affected antenatal women to minimise adverse effects on the fetus.

A national survey of current immunohematologic testing practices for the diagnosis of autoimmune hemolytic anemia in India.

Autoimmune hemolytic anemia (AIHA) is a common term for several disorders that differ from one another in terms of etiology, pathogenesis, clinical features, and treatment. Management of patients with AIHA has become increasingly evidence-based in recent years. While this development has resulted in therapeutic improvements, it also carries increased requirements for optimal diagnosis using more advanced laboratory tests. Unfortunately, limited data are available from developing countries regarding the testing and transfusion management of patients with AIHA. The main objective of this survey was to explore the current immunohematologic testing practices for the diagnosis of AIHA in India. This online survey consisted of 30 questions, covering the place of work, the number of AIHA cases encountered in the 3 preceding years, testing method(s), transfusion management, and so forth. Individuals representing 89 laboratories completed the survey; only 78 of which responded that AIHA testing was performed in their facility's laboratory. The majority of respondents agreed that the most commonly affected age-group comprised individuals of older than 20 years, with a female preponderance. Regarding transfusion management, respondents indicated that transfusion with "best-match" red blood cell units remains the most common practice. Column-agglutination technology is used by 92 percent of respondents as the primary testing method. Although a monospecific direct antiglobulin test is available at 73 percent of the sites, most of them have limited access to other resources that could diagnose cold or mixed AIHA. Merely 49 percent of responding laboratories have the resources to perform adsorption studies for the detection of alloantibodies. Furthermore, three-cell antibody screening reagents are unavailable at 32 percent of laboratories. In 72 percent of centers, clinical hematologists would prefer to consult a transfusion medicine specialist before administering treatment to AIHA patients. There is unanimous agreement regarding the need for a national registry. The survey data indicate wide variability in testing practices for patients with AIHA in India. Future studies are needed to focus on the feasibility and cost-effectiveness of different testing strategies for developing countries.

Challenges in organising blood donation camps at remote military base and its impact on blood component quality: A unique helicopter-based whole blood transport experience

BackgroundThere is a huge gap between safe blood supply and clinical demand in India and voluntary blood donation camps (BDSs) are vital to address this gap. The study evaluates the challenges faced in organizing remote setting voluntary BDCs and assess the impact of helicopter-flight on the quality of the whole blood units (WBU) and blood components (BC) prepared. MethodsThis is an observational study in which two voluntary BDCs were organised in remote military-based setting in 2021. Pre-camp activities, camp organisation, community engagement, and transportation logistics were evaluated. All WBU collected were exposed to helicopter-flight for transportation to the main blood centre with cold-chain maintenance. Impact of helicopter-flight on WBU and BC prepared was evaluated by performing extensive quality control (QC) testing. ResultsA total of 123 WBU were collected in both camps with transportation time of 160 and 150 min for camp-1 and −2 respectively. 123 PRBC, 22 BC-PC, 75 FFP and 48 CRYO units were prepared in-total within recommended time-limits. No haemolysis was detected in WBU, and all BC met QC criteria as per National guidelines. ConclusionsProper pre-camp planning, prior screening of donors, clear collection process policy, feasibility of efficient transport system, regular communication, and maintenance of cold-chain are crucial factors in determining the success of remote BDCs and quality of BC. Our study provides practical recommendations for policymakers, military healthcare providers, transfusion medicine specialists and public health professionals to enhance the effectiveness and sustainability of voluntary blood donation programs in remote settings.

Classification of posttransfusion adverse events using a publicly available artificial intelligence system.

Correct classification of transfusion reactions is important not only for effective patient care and donor management but also for accurate tracking of events in hemovigilance systems. We compared the ability of a generative artificial intelligence (AI) system to correctly diagnose hypothetical clinical situations as transfusion reactions in comparison to previous studies reporting the accuracy of transfusion medicine (TM) specialists in assessing these cases. An AI system was requested to assess 36 case scenarios to provide a diagnosis, severity, and imputability of the transfusion reactions using the CDC National Healthcare Safety Network (NHSN) criteria. Responses were compared to an expert panel's classifications and to the published responses of a panel of TM specialists. Additionally, the AI's responses were compared to the TM specialists' prior attempts to use the TrDDx web-based algorithm for the five most challenging cases. The AI's classification accuracy varied widely depending on the NHSN category. The AI accurately classified all transfusion-associated circulatory overload and transfusion-related acute lung injury cases, exceeding TM specialists' assessments. Conversely, it did not correctly identify any cases in select NHSN categories such as DSTR. Overall accuracy among all diagnostic categories was 48.7% for AI responses versus 72.1% for prior TM specialist responses (p = 0.005). AI-generated responses included non-standard terminology, limited severity assessments, and no imputability determinations. A generative AI system may have a role in helping healthcare providers to consider transfusion reaction categories that might be missed, but caution is advised in applying the AI's output to transfusion reaction classification at present.

Patient blood management in major digestive surgery: Recommendations from the Italian multisociety (ACOI, SIAARTI, SIdEM, and SIMTI) modified Delphi consensus conference

Patient blood management (PBM) is defined as the timely application of evidence-based medical and surgical concepts designed to maintain a surgical patient’s hemoglobin concentration, optimize hemostasis, and minimize blood loss in an effort to improve the outcomes. PBM is able to reduce mortality up to 68%, reoperation up to 43%, readmission up to 43%, composite morbidity up to 41%, infection rate up to 80%, average length of stay by 16%–33%, transfusion from 10% to 95%, and costs from 10% to 84% after major surgery. It should be noticed, however, that the process of PBM implementation is still in its infancy, and that its potential to improve perioperative outcomes could be strictly linked to the degree of adherence/compliance to the whole program, with decoupling and noncompliance being significant factors for failure. Therefore, the steering committees of four major Italian scientific societies, representing general surgeons, anesthesiologists and transfusion medicine specialists (Associazione Chirurghi Ospedalieri Italiani; Società Italiana di Anestesia, Analgesia, Rianimazione e Terapia Intensiva; Società Italiana di Emaferesi e Manipolazione Cellulare; Società Italiana di Medicina Trasfusionale e Immunoematologia), organized a joint modified Delphi consensus conference on PBM in the field of major digestive surgery (upper and lower gastrointestinal tract, and hepato-biliopancreatic resections), whose results and recommendations are herein presented.

Role of Transfusion Medicine Specialist in Stem Cell Transplant: Experience in Bangladesh

Over the years, the field that was once known as blood banking has evolved into the discipline of Transfusion Medicine. Transfusion Medicine has become a broad, multidisciplinary field which include various facets of clinical medicine. Transfusion medicine specialist plays a vital role in the supportive care of patients undergoing stem cell transplantation, with a spectrum of applications including peripheral blood stem cell collection, graft manipulation, cryopreservation, donor lymphocyte infusions and evaluation of immunohematological issues in ABO and RhD mismatched and other transplant situations.
 Pulse Vol.15, 2023 P: 34-37

I-JAMM-(I): A survey providing an insight into the practices of isoagglutinin titration in ABO incompatible kidney and liver transplantation

Background and objectivesABO-incompatible transplantations allow patients to receive timely transplants. Isoagglutinin titration to ascertain levels of incompatible antibodies in the recipient is important in determining patient selection and transplant survivability. To find out the prevalent trends in India, the largest, first of its kind survey was carried out among the transplant centers regarding their practices in isoagglutinin titration. MethodsThe survey was drafted by a working group of Transfusion and Transplant Immunology specialists from six different centers. Data was obtained via the use of an online questionnaire. ResultsResults were categorized into four categories, Hospital information, Titration methodology, Role of transfusion specialists and cut-off titers. Most centers had a well-established solid-organ transplant program with considerable number of ABO-incompatible transplantations. Most centers performed isoagglutinin titration in Transfusion Medicine department. Column Agglutination Technique (CAT) was the most common method, using EDTA blood samples and freshly-prepared in-house pooled cells. Most centers had a turn-around time of less than 12 h. While the policy for ascertaining baseline and threshold titers is well-defined in ABO-incompatible renal transplants, variations from center to center still exist for ABO-incompatible liver transplants. Most centers required a Transfusion Medicine consultation for the patients before such transplants. ConclusionWith increasing ABO-incompatible kidney and liver transplants across the country, the role of Transfusion medicine specialists has become vital in pre-conditioning regimes enabling the viability and success of such transplants. This was a unique survey that provided a snapshot of current trends and practices of isoagglutinin titration for ABO-incompatible transplants in India.

Adverse Events Among Plateletpheresis Donors in a Tertiary Care Hospital at Dhaka, Bangladesh

Introduction: The rising demand for platelet transfusions among patients has increased the usage of automated blood collections. Many of the same reactions and injuries are found with pooled platelets received from whole blood donation, although notable differences exist. Objective: To study the adverse events (AEs) during plateletpheresis procedures in a tertiary care hospital and plateletpheresis procedure session profiles. Materials and Methods: This retrospective study was conducted from January 2021 to December 2021 by analyzing records of two-hundred and thirteen (213) plateletpheresis procedures done in transfusion medicine department. All the donors were male. All adverse effects were recorded and noted in the registrar. Results: A total of 13 (Thirteen) AEs were noted, of which 08 (61.53%) events were associated with donors, 03 (23.07 %) were owed to a fault in the kit/equipment, and 02 (15.38 %) were due to technical faults. Donor-related AEs included hematoma (23.07%), vasovagal (23.07%), and perioral tingling sensation (15.38%). Technique-related AEs were 23.07%, and faulty kit/equipment-related AEs were 15.38%. Conclusion: Apheresis donations performed on apheresis machines are safe. Careful donor selection, well-trained expert technical personnel, and supervision of experienced transfusion medicine specialists will make the donor’s experience more pleasant. Sir Salimullah Med Coll J 2023; 31: 67-72

Rare blood group registry in India-current challenges and future perspectives.

Patients who require blood from rare blood group donors present great challenges even to the most advanced healthcare delivery system. It is most challenging to supply blood for a patient with an antibody to an antigen of high prevalence. The blood donor lacking the corresponding antigen would have an occurrence rate of less than one in 1,000. The International Rare Donor Panel was established in 1965, but since then there has been gross underrepresentation of South Asian countries, including India. There are several challenges to starting a rare blood group donor program in India that include technical, logistical, and administrative limitations. But the main limiting factors are poor availability of trained resources, lack of awareness, absence of antibody screening, inadequate number of laboratories with blood group genotyping facilities, and the decentralized nature of blood transfusion services. Despite that, there were several rare blood groups identified by Indian immunohematologists in the recent past. Recently, a transfusion genomic group has been established in collaboration with the clinical transfusion medicine specialists in India under the GUaRDIAN (Genomics for Understanding Rare Disease in India Alliance Network) initiative to address the domain of rare blood group genomics. Similarly, the National Institute of Immunohematology, Mumbai under the directive of the ICMR (Indian Council of Medical Research) has taken a step to start the RDRI (Rare Donor Registry of India). In this context, we explore the current challenges of setting-up a rare blood group registry in India and future goals from a developing nation's perspective.

Guideline on the investigation and management of acute transfusion reactions.

Guideline on the investigation and management of acute transfusion reactions.

Requests for Directed Blood Donations.

This Ethics Rounds presents a request for directed blood donation. Two parents feel helpless in the setting of their daughter's new leukemia diagnosis and want to directly help their child by providing their own blood for a transfusion. They express hesitancy about trusting the safety of a stranger's blood. Commentators assess this case in the setting of blood as a scarce community resource during a national blood shortage. Commentators review the child's best interest, future risks, and harm-benefit considerations. Commentators recognize the professional integrity, humility, and courage of the physician to admit his own lack of knowledge on the subject and to seek help rather than claim directed donation is not possible without further investigation into options. Shared ideals such as altruism, trust, equity, volunteerism, and solidarity are recognized as values relevant to sustainment of a community blood supply. Pediatric hematologists, a blood bank director, transfusion medicine specialists, and an ethicist conclude that directed donation is only justified by lower risks to the recipient in particular circumstances.

Real-world data from India on clinical practices in the management of autoimmune haemolytic anaemia: A survey-based cross-sectional assessment.

Autoimmune haemolytic anaemia (AIHA) is a decompensated acquired haemolysis caused by the host's immune system acting against its own red cell antigens. The aim of this national survey is to capture real-world data of clinical practices in AIHA by collecting responses from clinical haematologists across India. In this cross-sectional study, a structured, 26-question online survey was conducted in India by few members of the special interest group in immunohaematology between January and March, 2022. The final survey consisted of questions covering place of work, amount of AIHA cases being evaluated by the haematologist over preceding years, basic demographic, clinical and laboratory features of the patients being treated under them etc. Descriptive statistical analysis was performed during the assessment. The survey response rate was 48.2% (53/110), 69.8% (37/53) have diagnosed and managed more than 10 AIHA cases in the last 3years with a female preponderance. There was considerable variability in response. While 56.6% (30/53) of respondents do have the access to the facilities to subtype AIHA cases; 32.1% (17/53) of clinicians would prefer administering high dose steroids for 6weeks or more in non-responding patients, and only 45.3% (24/53) would assess the risks of thrombosis in AIHA. There is unanimous agreement among the participants that health-related quality of life should be taken into consideration in patients and the need for a national registry of patients with AIHA in India. The current national survey showed that some aspects of AIHA management were consistent; others were less so, but also significant variations were observed in certain clinical practices, where the evidence base is limited. A joint effort is needed to establish a national patient registry by including both clinical haematologists and transfusion medicine specialists which could potentially standardise AIHA management and future research in India.

Academic Productivity of Early Career Transfusion Medicine Specialists: A Workforce Study.

Blood Banking/Transfusion Medicine (BB/TM) specialists oversee all aspects of blood component transfusions and are often involved with apheresis, coagulation, and cellular therapy services as well. This study characterizes the BB/TM workforce to determine the scholarly productivity in the first 3 to 5 years after obtaining board certification and the impact of job type, job location, and academic rank on scholarly productivity. Academic productivity was assessed among individuals passing the American Board of Pathology BB/TM board exam between 2016 and 2018 using the National Institutes of Health (NIH) Office of Portfolio Analysis tool, iCite. One hundred and 28 BB/TM specialists were included in the analysis. The majority of BB/TM specialists work in academia, are located in the Great Lakes and Mid-Atlantic regions, and have a rank of Assistant Professor. Since passing the board exam, 76.5% (98/128) of BB/TM specialists have published papers, with 4.0 (IQR=1-8) total number of published papers per individual, and 791 total papers amongst the group. The median publications per individual per year since passing boards is 0.9 (IQR=0.2-2.3) the number of publications per year since passing boards for BB/TM specialists in academia is significantly higher compared to other jobs at 1.33 (IQR, 0.5-2.89, Kruskal-Wallis P=.03) per individual Assistant Professors and Associate Professors (1.3, IQR= 0.4-2.7 and 1.4, IQR=0.6-3.3, Mann-Whitney test P > .99). BB/TM specialists who passed the board exam between 2016 and 2018 are highly academically productive, especially those working in academia where publications are necessary for promotion. BB/TM physicians are an extensively trained and academically-minded group of practitioners.

Transfusion thresholds in cardiac surgery: Commentary on Bracey et al., 1999.

Transfusion thresholds in cardiac surgery: Commentary on Bracey et al., 1999.

Evaluation of Blood Requisition Forms Submitted to Transfusion Medicine Department of a Tertiary Care Hospital in Dhaka, Bangladesh

Introduction: Blood requisition form (BRF) analysis is one of the most efficient and effective approaches to assess and monitor rational use of blood and its product. BRF is the first line of communication between the clinicians and transfusion medicine specialists which helps to recognize and evaluate inappropriate use of blood. This issue is frequently underrated by the clinicians which results in increased risk of inappropriate transfusion. The current study is aimed to examine the pattern of completion of blood requisition forms and to ensure safe blood transfusion. Materials and methods: This cross sectional prospective study was conducted from January 2020 to December 2021, at the Department of Transfusion Medicine, Sir Salimullah Medical College Mitford Hospital, Dhaka, Bangladesh. A total of 32,133 blood requisition forms that were submitted during the study period were compiled and reviewed anonymously. The data were analyzed using Microsoft Excel. Results: During the study period, a total of 32,133 Blood requisition forms were analyzed. Only 15.2% of these forms were duly completed. Rest of the forms had one or more important parameters left blank. The most common incomplete BRF items were the clinical history or differential diagnosis of the patient (52.66%), presumed date and time of transfusion (95.19%), previous transfusion history (95.9%), and referring doctor’s name and designation (88%). Blood requests were more for females (52.02%) than males (47.98%) during the period. Requisitions were more for adults (90%) than pediatric patients. Conclusion: The current study provides evidence that the rate of completion of BRFs is not satisfactory. The request forms evaluated were not covering acceptable demographic and clinical data of the patients. Both the Hospital Transfusion Committee (HTC) and the Department of Transfusion Medicine can help to improve and standardize transfusion practice by working together. Sir Salimullah Med Coll J 2022; 30: 142-147

National Blood Foundation 2021 Research and Development summit: Discovery, innovation, and challenges in advancing blood and biotherapies.

National Blood Foundation 2021 Research and Development summit: Discovery, innovation, and challenges in advancing blood and biotherapies.

Quality of surgical management of placenta accreta spectrum in a tertiary center in Sri Lanka: baseline study for quality improvement project: problems and solutions

IntroductionPlacenta accreta spectrum (PAS) is associated with a multitude of maternal and fetal complications. Events related to its management have resulted in significant psychological morbidity, with lifelong consequences which warrant continuous support to cope with their lives. The objective of the study is to highlight the importance of multidisciplinary holistic care and explore room for improvement in the provision of care for women with PAS.MethodsOur study was conducted on deliveries complicated with PAS from January 2019 to June 2021. 27 women were diagnosed with PAS during this period and received treatment. Impact of life event scale- revised (IES-R) and short form health survey-36(SF-36) questionnaires were administered to assess the impact of PAS on their lives. In depth interviews were conducted with the women. A multidisciplinary team meeting was later conducted to formulate a comprehensive care plan for women with PAS.ResultsThe response rate was 96.2%. Mean age of the sample is 34.1 years (SD 4.3). Interval to current pregnancy varies from 0.6 years to 10 years with mean of 4.6 years. Mean gestational age of diagnosis of PAS was 25.4(SD 6.7) weeks. The care bundle provided for women with PAS was evaluated in all cases.Surgery was conducted electively in 82% of patients. Blood transfusions were noted in 85%. Mean pre-operative stay was 9.5 days (SD 8.3) and mean post-operative stay was 8.8 days (SD 8). Total hospital stay ranged from 6 to 48 days (mean 19.5 days, SD 11.4).IES-R scores were significant in 4/26 patients. There was no correlation with the interval from the surgery with any of the subscales or with the total scores. The lapsed time after the surgery had a significant correlation with physical functioning and pain domains of the SF-36 questionnaire.Description of the experience, loss of femininity with loss of the uterus, concerns and fears about the future and measures to improve the quality of care were the themes identified and described.A multidisciplinary team meeting, consisting of consultant obstetricians performing surgery for PAS, anesthetists, hematologist, transfusion medicine specialist, urologist, physiotherapist, nutritionist and nursing officers from ICU and wards, was held and their contributions helped to map out a definitive care plan.ConclusionsPAS is associated with long term physical and psychological morbidity. Continuous support through quarterly clinic visits and telephone conversations may alleviate the psychological trauma. However, some physical disabilities may be lifelong and life changing. Importance of reducing primary caesarean section and promoting trial of labour after caesarean delivery should be promoted among patients and caregivers.

TRANSFUSION PRACTICES IN OBSTETRICS AND GYNAECOLOGY

Blood transfusion plays a vital role in Obstetrics and Gynaecology and appropriate transfusion practices can prove as a boon to patient with minimal adverse reactions. Several diseases in obstetrics like, Obstetric haemorrhage, especially postpartum haemorrhage and antepartum haemorrhage, severe anaemia, ectopic pregnancy, molar pregnancy requires immediate transfusion of blood to reduce maternal mortality. In gynaecological practice, certain conditions like broids, cervical cancer, endometrium cancer, ovarian cancer, hysterectomy requires transfusion of blood mostly to recover operative loss of blood. Written informed consent and pre-transfusion testing is very important before start of transfusion. For this purpose, role of transfusion medicine specialist is equally important e.g. from the selecting of appropriate blood and blood components to the pre-transfusion testing and antibody screening of patient's sample. Though, blood transfusion is a lifesaving process in critical conditions but it is not without side effects and risks. Therefore, some strategies have been designed to avoid blood transfusion. In conclusion, we can say that before every transfusion risk benet ratio must be kept in mind and appropriate transfusion practices should be adopted for every blood transfusion.

U is Dissimilar to U for Human Immunodeficiency Virus Transmission Through the Infected Whole Blood Unit

It is a known fact that antiretroviral treatment (ART) is highly efficacious in reducing the sexual transmission of human immunodeficiency virus (HIV). In addition, it is clear now that those infected and living with HIV and having an undetectable viral load below 200 copies per mL, measured 4 to 6 monthwise, do not transmit it sexually to their partners. Therefore, U = U (Undetectable = Untransmittable; where symbol = means similar to) campaign is the message of a new UNAIDS explainer. The authors herein report the blood donation made by an HIV-I positive Indian male under the existing policy of confidential unit exclusion at their blood center. It was alarming because he was driven by an incorrect belief that being in a state of sexual nontransmissibility, due to the regular intake of ART, his donated blood was safe and suitable for blood transfusion too. He firmly believed that the ART he was receiving was highly efficacious in reducing the transmission of HIV through sexual intercourse and misconstrued the same for blood transfusion. After a thorough consultation and discussion with the transfusion medicine specialist, the individual could understand that U = U certainly, does not ascribe to the blood transfusion-related transmission due to a bigger inoculum and the intravenous route of administration.

West Nile Virus in Germany: An Emerging Infection and Its Relevance for Transfusion Safety

West Nile virus (WNV) is an arthropod-borne virus (arbovirus). It circulates in an enzootic cycle between ornithophilic mosquitoes as vectors and reservoirs and avian host species for amplification, but humans can be infected as accidental hosts. In most individuals, WNV infection remains silent, while 20% develop mild symptoms of West Nile fever, and only 1% develop neuroinvasive disease (WNND). Human WNV cases have been identified in Southern and Eastern Europe for more than 20 years, but until 2018, Germany was considered to be a non-endemic country. This changed when in the exceptionally warm summer of 2018, conditions for viral replication in mosquitoes were ideal, and the first WNV cases among birds and horses were identified. The widespread domestic Culexmosquitoes are efficient vectors for WNV. Autochthonous mosquito-borne WNV infections in humans were reported in all following years, indicating a continuous circulation in the affected areas of Central-East Germany. So far, no clear expansion of the affected areas is discernible but may develop. WNV is a transfusion-transmissible-infection, and donor deferral or testing of donations after a stay in an affected area are effective means to ensure transfusion safety. WNV transmissions via blood products often result in WNND due to the predisposing underlying medical conditions of transfusion recipients. From 2020 onwards, roughly 80% of all blood establishments in Germany tested their donations for WNV using nucleic acid amplification techniques in the transmission season. Altogether, 19 confirmed WNV infections were identified from 2020–2021. As long as effective and affordable pathogen reduction is not available for all blood components, WNV testing or donor deferral will be essential. In order to timely identify affected areas, combined results of human and veterinary surveillance are needed. Partnerships between public health experts, transfusion medicine specialists, veterinarians, and entomologists should be strengthened to ensure a One Health approach.