BackgroundDefinitions of massive transfusion following injury help identify patients at the greatest risk of death. However, these definitions primarily use blood component therapy. The use of whole blood (WB) transfusion protocols has seen a resurgence, with evidence of improved outcomes compared to component therapy. Therefore, our aim was to define and stratify patients into low, intermediate, and high risk for death based on volume of blood products transfused utilizing a WB-first resuscitation strategy.MethodsPatients that received at least 1 unit of whole blood following injury between January 2016 and November 2021 were identified. Receiver operating characteristic (ROC) curves to predict death based on volume of blood products transfused were constructed. Patients were stratified to low, intermediate, and high risk of death based on positive likelihood ratios.ResultsThere were 785 patients identified to have received at least 1 unit of WB following injury during the study period. Based on ROC curve analysis, the best predictor of death was volume of whole blood plus packed red blood cells (PRBC) in the first hour (AUC 0.66, P < 0.001). Low risk of mortality was defined as WB + PRBC volume <3400 cc in the first hour (14.9% mortality), intermediate risk 3400-5100 cc in the first hour (39.1% mortality), and high risk >5100mL in the first hour (66.7% mortality).DiscussionThe combination of WB + PRBC volume within the first hour following injury is the best predictor of death. Further, volumes of WB + PRBC transfused within the first hour can be used to stratify patients' risk of death.Level of EvidenceLevel IV.Study TypePrognostic and Epidemiological.

Blood component therapy serves as a primary modality in transfusion practices. However, the regulatory requirement of 6h holding time of whole blood (WB) at room temperatures (RT), restricts the overall capacity for component separation. The aim of this study was to evaluate the quality of the blood components specifically random donor platelets (RDP) prepared from WB after extended holding times. A prospective experimental study involving three distinct groups (1) Control group: WB processed after a standard hold time of 6h at RT, (2) Overnight whole blood (OWB) group: WB processed after 18-24h hold at RT and (3) Overnight buffy coat (OBC) group: RDPs prepared after 18-24h hold of buffy coat at RT. Basic biochemical and quality parameters, as per national standards were evaluated and compared for all the components. All blood components in three groups were within normal limit of quality parameters. However, RDPs in OWB group had lower pH and glucose and higher MPV levels, whereas in OBC group lower pH, and higher glucose and PaCO2 levels at the end of storage. Both the test groups had lower pH (6.9 in OWB and OBC vs 7.2 in control) and higher PaCO2 (66.94mmHg in OWB & 44mmHg in OBC vs 41.9mmHg in control), and glucose levels (306.3 mg/dl in OWB & 306mg/dl in OBC vs 370.3 mg/dl in control). Components prepared from all three methods had almost similar quality parameters and coincide within national standards. Either of these methods can be used for better utilisation of resources.

Sepsis is an important cause of morbidity and mortality in foals. Early diagnosis can improve outcome but is complicated by non-specific clinical signs and delayed confirmation of infection via blood culture. Molecular assays represent a rapid and more sensitive alternative. To evaluate and compare bacterial load and composition in blood and blood culture media (BCM) of sick and healthy foals using molecular assays and to compare results with traditional bacterial culture. Cross-sectional observational clinical study. Thirteen septic foals, 10 sick non-septic and 8 healthy foals were included. Bacterial load and composition from whole blood (WB), pre-enriched BCM and contamination controls were analysed by quantitative PCR and sequencing of the universal bacterial 16S rRNA marker gene. WB sequencing yielded more positive samples (25/31) than BCM (6/62; p < 0.01). Positive blood culture and WB sequencing were comparable in only 3/12 foals. Sequencing samples were at high potential for contamination, with most samples having high relative abundances (RAs) of Paucibacter and Ralstonia. High RAs of Actinobacillus and Staphylococcus in septic foals may, however, suggest true pathogen detection. No significant differences in bacterial RAs, 16S rRNA gene load (qPCR), or other sequencing-based metrics were found between foal groups and between WB and contamination controls. Inherent inaccuracies of classification schemes for septic and sick non-septic foals and the impact of contamination when sequencing low biomass samples. High-throughput sequencing represents a possible avenue for the diagnosis of bacteraemia in foals but has high potential for environmental and extraction-related contamination and cannot replace blood culture at this time. Further research to optimise detection yield and sensitivity on WB samples is warranted.

Dried plasma is an attractive option when provision of frozen plasma is challenging. FrontlineODP™ system (Velico Medical) is a spray drying system producing a unit of spray dried plasma (SDP), in a blood bag, in around 30 min. This study evaluates coagulation parameters before and after drying, using two types of starting plasma: Whole blood (WB) derived, and apheresis derived. A minimum of 15 units each of WB derived CPD-anticoagulated plasma and plasmapheresis (Aurora, Fresenius Kabi) sodium citrate-anticoagulated plasma were sampled and frozen within 12-18 h of venepuncture. Units were spray dried using the Velico FrontlineODP™ system. Following rehydration with sterile water, further samples were taken. All samples (pre drying, immediately post rehydration and 6 h post rehydration) were tested in parallel for a range of coagulation parameters, including thrombin generation, as well as biochemical parameters and bacterial contamination. All dried plasma units rehydrated in an average of 6 min. All coagulation parameters were within ±20% pre to post drying, except von Willebrand factor (vWF) activity and FXIII activity, which decreased by approximately 50% and 25%, respectively. Further investigation of vWF showed a change in the ratio of high and low molecular weight multimers. No bacterial contamination was detected in any of the units. The FrontlineODP system can be incorporated into a standard blood service laboratory environment and successfully produce SDP with acceptable levels of coagulation proteins. Clinical data assessing SDP in a relevant patient population are now needed.

To assess the effects of storage time on erythrocyte fragility and morphology, packed cell volume (PCV), hemolysis, biochemical composition, and bacterial growth in caprine whole blood (WB) and packed RBCs (pRBCs). This was a longitudinal experimental study. Blood was collected from 6 healthy goats and stored as WB in citrate phosphate dextrose adenine and as pRBCs in citrate phosphate dextrose with Optisol at 4 to 7 °C for 42 days. Packed cell volume, osmotic fragility, glucose, and lactate concentrations were measured weekly, and CBC, biochemistry, and aerobic culture analyses were performed every 14 days. Repeated-measures ANOVA or the Friedman test was performed as appropriate. Changes in erythrocyte morphology were observed by day 14 in both WB and pRBCs. Increased hemolysis and leukocyte morphologic changes were observed by day 28, whereas osmotic fragility and PCV did not significantly change over time in either product. Potassium concentrations increased to 15 and 27 mmol/L by day 14 in WB and pRBCs, respectively, with a maximum concentration of 43.8 mmol/L on day 42. Lactate concentrations exceeded 2 mmol/L by day 14 in both products. Storage of caprine WB and pRBCs results in progressive changes consistent with erythrocyte storage lesions that may impact product quality over time. Caprine blood products stored for up to 14 days may present a viable alternative when fresh blood is unavailable. However, the clinical effects of transfusing stored caprine blood products to recipients require further in vivo investigations.

Cold-stored platelets (CSPs) are used in active bleeding due to their extended shelf life and preserved hemostatic function. Although both CSPs and cold-stored whole blood (CS-WB) are used clinically, the comparative effects of cold storage on their hemostatic and immunological properties remain partially understood. This study evaluated longitudinal changes in platelet function and immune markers stored at 4°C for 21 days. Eight healthy donors each provided an apheresis platelet (AP) unit in plasma and a whole blood (WB) unit, leukoreduced using a platelet-sparing filter. Baseline samples were collected prior to cold-storage and on days 2, 7, 14, and 21 of cold-storage. Hemostatic, metabolic, and immunological parameters were assessed by aggregometry, clot retraction assays, and flow cytometry. At baseline, CD62P, Annexin V binding, CD47 expression, and aggregation amplitude did not differ significantly between products. CD154 was higher in apheresis platelets. Over 21-day cold storage, CS-WB exhibited a more pronounced decline in aggregation and metabolic functions. Expression of activation markers (CD62P, Annexin V) increased in both products, with a stronger rise in CS-WB. CD47+ platelets remained high in both products, whereas CD154+ platelets transiently increased in CS-WB but remained low in CSPs. Cold-storage differentially affects platelet in vitro characteristics across product types. While CS-WB exhibited greater functional and metabolic deterioration, both products retained viable platelet function through the end of 21-day cold storage. Larger studies are required to determine whether the observed in vitro differences translate into clinical outcomes.

Mass casualty and disaster events (MCEs) and national blood donation appeals generate surges in blood donation, but how these responses differ by product type, donor demographics, and retention remains incompletely understood, particularly for apheresis platelets. We analyzed donation data from five major U.S. MCEs and five national blood donation appeals between 2000 and 2024, characterizing whole blood (WB) and platelet donations by donor age, first-time versus repeat status, and return within 1 year. WB donation demonstrated rapid, high-amplitude surges during MCEs that resolved within 1-2 weeks, driven in part by younger and first-time donors. In contrast, appeals produced smaller increases sustained through the duration of the appeal. Platelet donation followed a distinct pattern, with a smaller, yet slightly longer surge response during MCEs and more robust increases during national blood donation appeals, while both relied almost exclusively on older, repeat donors. Donor retention differed primarily by donor history. Repeat donors were substantially more likely to return than first-time donors across age groups and event types, with older repeat donors showing the highest retention. These findings highlight structural differences between WB and platelet donor systems with direct implications for disaster preparedness and long-term blood supply resilience in the United States.

Data-driven best practices recommend balanced resuscitation in a 1:1:1 (RBC:FFP:PLT) ratio - supported by a randomized trial demonstrating a reduction in mortality from exsanguination. Although adoption of this is widely advertised, recent civilian literature has shown that adherence is poor. We sought to evaluate the adherence to balanced resuscitation in the first 6 hours among combat casualties injured in Iraq and Afghanistan. A retrospective analysis was performed using the Deployed Hemostatic Emergency Resuscitation of Traumatic Exsanguinating Shock data set. Injured combat casualties, with available transfusion timing data, treated at US military medical treatment facilities in Afghanistan and Iraq between 2002 and 2022, were included. Patients who received any whole blood (WB) were compared with those who received only component therapy (CT). Primary outcomes were calculated as RBC:FFP and RBC:PLT ratios, at 15-minute intervals from the time of injury through 6 hours. In all, 4,500 casualties met the inclusion criteria, with 793 receiving WB and 3,707 receiving only CT. The median age was 25 (21, 30), 96% were male, with a mortality rate of 13.5%. Among these, 66% sustained blast/explosion mechanism, with a median injury severity score of 18 (12, 29). By 6 hours, 52% versus 48% and 80% versus 69% of WB versus CT patients had achieved a 1:1 and 1.5:1 RBC:FFP ratio, respectively. Median RBC:PLT ratios showed greater variability, ranging from 1:1 to 2:1 in WB patients and 2:1 to 4:1 in CT patients. At all time points, WB patients achieved better ratios for both plasma and platelets. Approximately 50% of US combat casualties are resuscitated in a balanced fashion, far greater than that observed in recent civilian data. However, a higher proportion of patients with an early use of WB achieved 1:1:1. Wider availability of WB and increasing inventory of platelets and plasma products should be explored to improve battlefield resuscitation. (J Trauma Acute Care Surg 2026;00:000-000. Copyright © 2026 Wolters Kluwer Health, Inc. All rights reserved.). Prognostic and Epidemiological (Retrospective comparative study with up to two negative criteria); Level III.

Nyctanthes arbor-tristis L. has been used in Ayurvedic medicine to manage inflammatory diseases. It primarily contains iridoid glycosides and phenylethanoid glycosides. The objective of present studies was to identify anti-inflammatory constituent/s from N. arbor-tristis. The studies resulted in isolation of four compounds (1–4) including, an undescribed compound, a phenylethanoid glycoside named nyctanthesin B (1) and three known iridoid glycosides (2–4). The structure of the new compound (1) was elucidated as 3, 4-dihydroxy-β-phenylethyl-3′-O-benzoyl-β-D-glucopyranoside by analysing 1D, 2D NMR and HREI-MS. Compound 1 revealed potent anti-inflammatory activity by inhibiting ROS (reactive oxygen species) in both whole blood (WB) phagocytes (IC50 = 8.5 ± 0.6 µg/mL) and isolated human polymorphonuclear leukocytes (PMNLs) (IC50 = 2.2 ± 0.06 µg/mL). Ibuprofen was used as standard.

Background.Data on the course of Epstein-Barr virus (EBV) DNAemia are limited in the pediatric liver transplant (LT) setting. This study aims to analyze the kinetics and clinical outcomes of EBV DNAemia in whole blood (WB) and plasma, and to evaluate the incidence and risk factors for EBV DNAemia, chronic high EBV load (CHL) carriage, and posttransplant lymphoproliferative disorder (PTLD).Methods.A retrospective analysis of longitudinal EBV DNAemia and clinical data from 237 children undergoing LT between April 2014 and May 2022 was performed. EBV DNAemia was measured in WB, switching to plasma on September 1, 2018. There was a 20-mo transitional period, during which both matrices were used.Results.CHL occurred in 23 (22.1%) patients monitored in WB. Peak EBV DNAemia and EBV DNAemia exposure (measured as the area under the concentration-time curve) >1 y post-LT were higher in PTLD cases, regardless of the matrix used. Among CHL carriers, 21.7% (5/23) developed PTLD. In age-adjusted analyses, cytomegalovirus (CMV) DNAemia within 1 y post-LT was associated with EBV DNAemia (relative risk [RR], 1.16; P = 0.026). CHL carriage was associated with CMV DNAemia within 1 y post-LT (RR, 2.33; P = 0.044), EBV donor-positive/recipient-negative (D+/R–: RR, 3.62; P = 0.036), ABO-incompatible graft (RR, 3.03; P < 0.001), and early EBV DNAemia (<6 mo: RR, 3.46; P = 0.030). PTLD development was associated with early EBV DNAemia (<6 mo: RR, 3.58; P = 0.022) and CMV D+/R– (RR, 2.49; P = 0.030).Conclusions.The study provides longitudinal data on EBV DNAemia in the context of CHL and PTLD. Prospective studies are warranted to validate the identified factors associated with EBV-related outcomes.

Recommendations for establishing metrological traceability for in vitro diagnostic measurement procedures intended to be used for whole blood samples.

Plasma and cryoprecipitate are stored below -25°C for optimal preservation of component quality. However, there may be situations in which components are exposed to higher temperatures and therefore discarded. This study aimed to determine the quality of plasma and cryoprecipitate following a short-term temperature excursion to inform a possible shelf life. Apheresis and whole blood (WB)-derived fresh frozen plasma (FFP; n = 68 and n = 37, respectively) and cryoprecipitate components (apheresis n = 78 and WB n = 80) that incurred a temperature excursion up to -11°C were returned to -25°C. Coagulation factors were measured at 1 month (baseline), 3 months and 6 months post excursion. There were no significant differences in factor VIII (FVIII) concentrations in apheresis- and WB-derived plasma and apheresis-derived cryoprecipitate between 1 month, 3 months and 6 months (p = 0.236, p = 0.249 and p = 0.815, respectively). Activated partial thromboplastin time and prothrombin time increased slightly in plasma over storage but were not significantly different from baseline. Fibrinogen, von Willebrand Factor (VWF), protein C and immunoglobulin G were stable in plasma and cryoprecipitate. The data demonstrate that plasma and cryoprecipitate that incurred a temperature excursion can meet quality control specifications when stored for 6 months post temperature excursion.

BackgroundMassive transfusion (MT) protocols improve survival in trauma patients. Elderly trauma patients requiring MT represent a high-risk population, yet outcome data remain limited. Understanding age-related differences is critical to guide resuscitation and resource allocation.ObjectiveTo characterize the association between MT and mortality in elderly vs younger trauma patients.ParticipantsTrauma patients at a Level I trauma center (1/2013-09/2024) who required MT (≥10 units of whole blood (WB) and/or packed red blood cells (pRBC) within 24h) were included. Patients ≥65 (elderly) were compared to <65 (non-elderly). The primary outcome was 30-day mortality. Secondary outcomes included ICU and hospital length of stay (LOS), and ventilator days.ResultsOf 368 patients meeting inclusion criteria, 30 (8%) were elderly. Elderly patients were equally likely to be male (70% vs 83%, P = 0.06), but were significantly less likely to present with GCS ≤8 (20% vs 45%, P < 0.01) despite a significantly higher incidence of severe head trauma (AIS head >3 [53% vs 32%, P = 0.02]). There was no difference in median blood products transfused within the first 24 hours (23 vs 22 units, P = 0.95). Overall mortality was 51%, higher in elderly patients (73% vs 49%, P < 0.01), with shorter time to death (median 14 vs 34days, P < 0.01). Adjusted Cox regression confirmed significantly higher adjusted mortality in the elderly (HR 1.25, P = 0.04).ConclusionElderly trauma patients requiring MT experience earlier and significantly higher mortality than younger patients, highlighting the need for improved risk stratification and tailored resuscitation strategies.

Methotrexate (MTX) remains the first-choice treatment for rheumatoid arthritis (RA), but individual variability in response and adherence underscores the need for reliable biomarkers of long-term drug exposure. Intracellular methotrexate polyglutamates (MTXPGs), typically measured in red blood cells (RBCs), fulfill this role but require invasive venous sampling. This study aimed to develop and validate a multi-matrix LC–MS/MS method for measuring MTXPGs in capillary blood samples obtained via volumetric absorptive microsampling (VAMS) and dried blood spots (DBS), and to compare these methods with traditional matrices. The method was validated in accordance with ICH M10 guidelines across RBC, whole blood (WB), VAMS, and DBS samples. MTX and MTXPG2–5 and total MTXPG were measured in 40 matched clinical samples. MTXPG6–7 were not detected across the tested clinical samples. Validation using Passing–Bablok regression, Bland–Altman analysis, and Spearman correlation showed strong agreement between VAMS and DBS (slopes 0.95–1.07; bias −4.21% to 0.36%; SRCC ≥ 0.969), with up to 100% of samples within ±20% of the agreement limits for total MTXPG. Significant differences were observed between capillary matrices and RBCs, with higher MTXPG levels in erythrocytes (bias up to −28%). Whole blood showed closer agreement with microsampling methods. ISR pass rates ranged from 84% to 95%, and stability tests indicated matrix- and chain length-dependent degradation, particularly for long-chain MTXPGs. These findings show that VAMS and DBS yield comparable results and can be considered interchangeable within a capillary-sampling framework. However, interpretation must account for matrix-specific differences when relating measurements to RBC-based reference values. This validated method could support the analytical feasibility of decentralized MTXPG monitoring in RA. However, prospective studies linking matrix-specific thresholds with disease activity, adherence, and toxicity are required before implementation for therapeutic decision-making.

Iron deficiency (ID) poses a non-negligible risk for blood donors, yet longitudinal data on iron status and whether low-dose iron-containing supplements improve ID among Japanese donors are scarce. This study aimed to elucidate these issues. Sixty-six healthy Japanese donated 400 mL of whole blood (WB) and underwent scheduled blood samplings. Fourteen participants discontinued follow-up; 52 donors completed the second 400 mL WB donation at Week 48. Participants were subsequently provided supplements containing 6 mg/day of ferric citrate for 12 weeks, with continued monitoring through Week 48; the total duration of participation in the study was 96 weeks. Haematological data were analysed using a linear mixed-effects model. In men, serum ferritin (sFer) declined from 116.2 ng/mL (95% confidence interval [95% CI]: 88.0-144) to 83.7 ng/mL (55.5-112) at Week 4 and returned to baseline by Week 36. In women, sFer decreased from 29.2 ng/mL (21.74-36.7) to 16.6 ng/mL (9.16-24.1) at Week 4 and returned to baseline at Week 24. Recovery of sFer was slower than that of haemoglobin (Hb) in both sexes. Iron supplementation did not affect the recovery of Hb and sFer in men and Hb in women, whereas women showed a significant increase in sFer at Week 16. Although Hb recovered quickly after 400 mL WB donation, replenishment of iron stores took longer. Low-dose iron supplementation facilitated the recovery of iron stores in women. These findings highlight the need for monitoring iron status and may inform strategies to support donor safety and maintain adequate blood supply.

In cases of massive transfusion, intravenous access can be limited. Additionally, delivering different products through separate lines and infusion methods adds unnecessary steps. RBC, plasma, and whole blood (WB) are delivered via rapid infusers; cryoprecipitate (CRYO) is infused through separate access and is not approved with these devices. We examined the impact of different transfusion methods on hemostatic performance and factor activity using two available CRYO products. Ten bags of CRYO, ten bags pathogen-reduced CRYO (Intercept® Fibrinogen Complex, IFC), and 20 units of WB were obtained. Each CRYO bag was infused with one unit of WB by three techniques: (1) gravity infusion with filter, (2) rapid infuser at 70 mL/min, and (3) pressure bag and filter. Hemostatic potential was measured by thrombelastography (TEG), thrombin generation (CAT), and factor levels (ACLTOP). Post-each infusion, disposable tubing and infusion parts were inspected for evidence of clumping or clogging. Both standard CRYO and IFC demonstrated maintained or improved TEG, CAT, and factor levels when subjected to a rapid infuser device and pressure bag. When compared with gravity infusion, a rapid infuser device and pressure bag demonstrated maintained or improved values by TEG, CAT, and factor activity. No evidence of clumping or clogging of tubing was encountered in the 20 runs performed. No evidence of system dysfunction with use of CRYO through these devices was found either. Restriction of CRYO infusion through rapid infuser devices or with pressure bags should be reconsidered. Future clinical trials are warranted.

Environmental exposure biomonitoring commonly requires a laboratory blood draw followed by processing, frozen storage, and transport of plasma or serum. Self-collection of blood onto matrices that are stable at ambient temperatures is an attractive approach for the measurement of circulating environmental chemicals. To validate the measurement of per- and polyfluoroalkyl substances (PFAS) in capillary whole blood (WB) collected and dried onto a paper matrix using the Drawbridge Health OneDraw device. To explore sources of personal and environmental PFAS exposure in Veterans receiving care at the Central Arkansas Veterans Healthcare System (CAVHS). PFAS concentrations in dried capillary WB collected with the OneDraw device were compared to matched venous blood plasma PFAS concentrations in 133 Veterans receiving care at the CAVHS. PFAS were quantified using ultra-high-performance liquid chromatography/tandem mass spectrometry (UHPLC-MS/MS). Associations between subjects' demographic characteristics, self-reported exposure factors, and PFAS concentrations in dried capillary WB were assessed. Geometric mean PFAS concentrations were visualized by subjects' county of residence. Measurement of 27 PFAS in dried capillary WB on OneDraw collection strips was robust with limits of quantification of 0.1 ng/mL for most analytes. In 133 Veterans, dried capillary WB levels of 10 PFAS were strongly correlated with venous blood plasma PFAS levels. WB PFAS concentrations were lower than venous blood plasma PFAS concentrations, reflecting selective partitioning of these compounds into plasma versus blood cells. WB concentrations of four PFAS (PFOA, PFOS, PFHxS, and PFNA) varied by sex and age at the time of blood draw and were associated with the primary source of drinking water. WB samples collected onto dried paper matrices, are a practical and scalable alternative to conventional venous blood draws for PFAS biomonitoring. This approach facilitates remote, repeated sampling without the need for clinical infrastructure, enabling broader participation in exposure studies. Tracking environmental exposures in military, occupational, and community contexts has been challenging, particularly due to the lack of a practical workflow for capturing biological samples without a clinical infrastructure. This has led to a reduced ability to capture personal exposure data, in turn, limiting the analyses of the impact of these exposures on long-term health. We developed and validated a robust method using a self-contained, blood collection device for PFAS exposure biomonitoring as a proof-of-concept for broader adoption of this approach to enable larger-scale, longitudinal studies of exposure to PFAS and other classes of environmental chemicals. This method can be used to improve the evaluation of exposure-outcome relationships and provides a foundation for evidence-based policy decisions for health care and benefits.

While supported by a randomized trial and America College of Surgeon Trauma Quality Improvement Program(TQIP) guidelines, the inflection point in transfusion volumes at which balanced ratios (1:1) begin to affect mortality has not been fully explored. We sought to evaluate transfusion volumes at which a difference in mortality is observed. Four studies of bleeding trauma patients were analyzed: two conducted before whole blood (WB) availability; a single institution experience (Pre-WB Single Center, 2010-2016) and a randomized, multicenter trial [Pre-WB Pragmatic Randomized Optimal Platelet and Plasma Ratios (PROPPR), 2012-2013] and two conducted with WB use; one single institution experience (WB Single Center 2017-2021) and a prospective, multicenter study [WB Shock, Whole blood And Traumatic brain injury (SWAT), 2018-2021]. Patients were divided into balanced [1:1 or less, red blood cell (RBC):plasma] and unbalanced (>1:1) cohorts. RBC units transfused in the first four hours were evaluated (0-6, 7-10, then 10-unit intervals). Primary outcome was 30-day mortality. Secondary outcomes were four-hour and 24-hour mortality. The Pre-WB Single Center (n = 730 1:1 or less, n = 536 >1:1) and Pre-WB PROPPR (n = 342, n = 338) noted mortality differences once >10 units of RBCs were transfused (11-20 units: 26% vs. 32%, P = 0.151 and 20% vs 30%, P = 0.090; 21-30 units: 43% vs. 71%, P = 0.013 and 32% vs. 61%, P = 0.017). The WB Single Center study (n = 1,239, n = 879) and WB SWAT (n = 447, n = 587) noted outcome separation >6 units (7-10 units: 14% vs. 22%, P = 0.139 and 14% vs. 18%, P = 0.198; 11-20: 28% vs. 41%, P = 0.118 and 17% vs. 31%, P = 0.030). Absolute differences tended to widen with greater units transfused. Differences remained at 24-hours for 7 to 10 units for Pre-WB Single Center and 11 to 20 units for Pre-WB PROPPR, WB Single Center, and WB SWAT studies. In this analysis of almost 5,000 patients, balanced resuscitation had a protective effect during or after the second transfusion cooler (>6 or >10 units of RBCs). This highlights the need for early 1:1 resuscitation with suspicion for massive hemorrhage, utilizing early WB to stay balanced and storing more immediately available plasma. Retrospective comparative study without negative criteria, Study type: Therapeutic; Level III.

Vasovagal reaction (VVR) is the most frequent adverse reaction in blood donation, which usually recovers soon without complications. However, syncopal VVR can result in severe injury due to a fall. Some reports have shown the possibility to prevent VVR with salt-loading prior to blood donation. This semi-randomized controlled study aims to clarify the preventive effect of salt-loading on VVR among whole blood (WB) donors. During the study period, donors who donated 400 mL of WB on odd days were assigned to the salt-loading group and those who donated on even days to the control group. Participants in the salt-loading group were asked to take three tablets containing 0.3 g salt in total. The incidence of VVRs occurring >20 min after needle removal (delayed VVR [dVVR]) did not significantly differ between the two groups. Secondary analysis suggested a possible dose-dependent preventive effect against dVVR (odds ratio [OR]: 0.70; 95% confidence interval [CI]: 0.52-0.94; p = 0.02). The number of delayed syncopal VVR episodes in summerwas lower in the salt-loading group than in the control group (n = 1 vs. 8; OR: 0.13; p = 0.04; pre-specified α = 0.0125). There was no significant preventive effect of pre-donation salt-loading on VVR. Further investigations with sufficient number of participants are needed to conclude the suggested dose dependency and seasonal preventive effect on dVVRs.

Whole blood (WB) transfusion is increasingly used for trauma patients with hemorrhagic shock; however, sex-based differences in utilization and outcomes remain incompletely understood. The purpose of this study was to examine sex-based differences in WB utilization and survival using a large national trauma dataset. We performed a retrospective cohort study using the 2021 to 2022 American College of Surgeons Trauma Quality Improvement Program database. Trauma patients (16y) with blunt or penetrating trauma, shock index >1, and receipt of 4 units of blood within 4 hours were included. Patients were then stratified by sex and WB receipt within 4 hours. Multivariable logistic regression assessed associations between WB transfusion and 4-hour, 24-hour, and 30-day mortality. Cox proportional hazards models evaluated in-hospital mortality. Models were adjusted for patient demographics, injury characteristics, and institutional factors. Sensitivity analyses using facility-clustered generalized estimating equations (GEE) were performed. Dose-response was evaluated using WB proportion of total transfusion volume within 4 hours. Among 8,631 patients (6,743 males and 1,888 females), WB was administered more frequently to males (33.8% vs. 22.3%, p<0.001). In adjusted analysis, WB was associated with lower 24-hour mortality among males (odds ratio [OR]: 0.76, 95% confidence interval [CI]: 0.63-0.92, p=0.004) and reduced in-hospital mortality risk (hazard ratio [HR]: 0.88, 95% CI: 0.79-0.99, p=0.028). Facility-clustered models confirmed reduced 24-hour mortality in males (OR 0.77, 95% CI: 0.61-0.96, p=0.022). Increasing WB exposure demonstrated a dose-response association with lower early and in-hospital mortality among males (p<0.022), with no significant associations observed in females. WB was not associated with increased rates of major complications for either sex. In this nationwide study, WB was used less frequently in females and was associated with improved survival only among males. These findings underscore the need for prospective studies to clarify biological and systemic contributors to these disparities. (J Trauma Acute Care Surg. 2026;00: 00-00. Copyright © 2026 Wolters Kluwer Health, Inc. All rights reserved.). Prognostic/epidemiological; Level IV.