Long-Term Observation of SARS-CoV-2 Vaccination Response upon High Efficacy Treatment in Multiple Sclerosis-A Real-World Scenario.

Immunomodulatory and immunosuppressive therapy is needed in people with a chronic neuroinflammatory disease of the central nervous system such as multiple sclerosis (MS). Therefore, MS requires monitoring for and preventing against infectious diseases like SARS-CoV-2. Vaccination and anti-viral treatments are, in particular, recommended for elderly people and people at risk of a severe course of infection and of MS. Here, we asked whether repetitive infection or vaccination influenced responses upon receiving high efficacy treatments, namely sphingosine-1-phosphate receptor modulator (S1P) or anti-CD20 B cell antibody (anti-CD20) treatments. We performed a prospective real-world study of people with MS (pwMS) under S1P or anti-CD20 with repetitive exposure to the SARS-CoV-2 virus or vaccine. The measurement of anti-SARS-CoV-2 antibody titres was performed by two independent immunoassays after initial immunisation and after booster vaccination or infection. Other laboratory and clinical parameters were included in the analysis of influencing factors. As secondary outcomes, lymphocyte and immunoglobulin levels were observed longitudinally under intravenous and subcutaneous anti-CD20 treatment. In a long-term real-world cohort of 201 pwMS, we found that despite lymphopenia upon S1P drugs, the SARS-CoV-2 immunisation response increased both in selective and non-selective S1P (100% and 88% seroconversion, respectively), whereas those under anti-CD20 therapies merely exhibited a slight long-term increase in antibody titres (52% seroconversion). The latter was independent of immunoglobulin or total lymphocyte levels, which mostly remained stable. If the individual was immunised prior to therapy initiation, their levels of SARS-CoV-2 antibodies remained high under treatment. PwMS under non-selective S1P benefit from repetitive vaccination. The risk of an insufficient vaccination response mirrored by lower SARS-CoV-2 antibodies remains in pwMS receiving anti-CD20 treatment, even after repetitive exposure to the vaccine or virus. Due to the compromised vaccination response in CD20-depleting drugs, prompt antiviral treatment might be necessary.

Predictors for insufficient SARS-CoV-2 vaccination response upon treatment in multiple sclerosis.

BACKGROUND: Disease-modifying therapies (DMT) for multiple sclerosis (MS) influence SARS-CoV-2 vaccination response, which might have implications for vaccination regimens in individual patients. Expanding the knowledge of predictors for an insufficient vaccination response as a surrogate for protection against severe disease courses of infection in people with MS (pwMS) under DMT is of great importance in identifying high-risk populations. METHODS: Cross-sectional analysis of vaccination titre and its modifiers, in a prospective real-world cohort of 386 individuals (285 pwMS and 101 healthy controls) by two independent immunoassays between October 2021 and June 2022. FINDINGS: In our cohort, no difference in vaccination antibody level was evident between healthy controls (HC) and untreated pwMS. In pwMS lymphocyte levels, times vaccinated and DMT influence SARS-CoV-2 titre following vaccination. Those treated with selective sphingosine-1-phosphate receptor modulators (S1P) showed comparable vaccination titres to untreated; higher CD8 T cell levels prior to vaccination in B cell-depleted patients resulted in increased anti-spike SARS-CoV2 antibody levels. INTERPRETATION: PwMS under DMT with anti-CD20 treatment, in particular those with decreased CD8 levels before vaccination, as well as non-selective S1P but not selective S1P are at increased risk for insufficient SARS-CoV-2 vaccination response. This argues for a close monitoring of anti-spike antibodies in order to customize individual vaccination regimens within these patients. FUNDING: This work was supported by the German Research Foundation (DFG, CRC-TR-128 to TU, SB, and FZ).

Longitudinal Study of the Signal Strength in two Serologic Assays for Detection of SARS-CoV-2 Specific Antibodies.

BACKGROUND: In the course of the current SARS-CoV-2 pandemic, antibody assays provide an important means for guidance of public health efforts. Thus, characterization of the course of antibody signals on different widely used assays is needed. METHODS: We selected 25 PCR-confirmed SARS-CoV-2 cases among 3,273 healthcare workers and measured the course of the antibody signal using the Abbott Architect SARS-CoV-2 IgG assay and the Roche Elecsys® Anti-SARS-CoV-2 immunoassay. The signal strength was then modelled using linear mixed models adjusted for age. RESULTS: Since first sampling, the assay signal decreased per day in the Abbott assay (standardized slope (ß) = -0.46, 95% CI = -0.54 to -0.39). In contrast, an increase in the signal was ascertained by the Roche immunoassay per day (ß = 0.25, 95% CI = 0.09 to 0.41). CONCLUSIONS: Roche Elecsys® Anti-SARS-CoV-2 immunoassay may exhibit greater sensitivity in detecting SARS-CoV-2-specific antibodies in individuals in late stages of postinfection.

Prevalence of Severe Acute Respiratory Syndrome Coronavirus-2-specific Antibodies in German Blood Donors during the COVID-19 Pandemic.

BACKGROUND: Coronavirus disease-2019 (COVID-19) is a respiratory infection caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). While RT-PCR assays are used routinely to diagnose active COVID-19, serological testing offers a means of identifying individuals who previously experienced asymptomatic infections, as well as those who experienced symptomatic infections but no longer carry the virus. METHODS: The presence of SARS-CoV-2 IgG-positive antibodies in the sera of 673 blood donors residing in south-western Germany before and 3,880 donors after the advent of the COVID-19 pandemic was determined and confirmed using two highly sensitive serological tests. RESULTS: Approximately 0.40% of the donors assessed during the COVID-19 pandemic possessed SARS-CoV-2 IgG-positive antibodies, decidedly fewer than the percentage of SARS-CoV-2-infected individuals determined by real-time RT-PCR nationwide. CONCLUSIONS: These findings confirm the efficacy serological testing in identifying asymptomatic COVID-19 patients.

Containment of a Large SARS-CoV-2 Outbreak Among Healthcare Workers in a Pediatric Intensive Care Unit.

OBJECTIVE: Healthcare workers (HCWs) are particularly exposed SARS-CoV-2 because they are critical in preventing viral transmission and treating COVID-19 patients. Within HCWs, personnel of intensive care units (ICUs) are at the forefront of treating patients with a severe course of COVID-19 infection and therefore represent an extremely vulnerable group. Thus, our objective is to contribute to establish means of infection control protecting HCWs in the frontline of the current pandemic. DESIGN: An outbreak of SARS-CoV-2 was detected and contained in a pediatric ICU (PICU). The first positive case was identified with a point-of-care diagnostic system on site. Real-time PCR-based testing systems from self-collected nasopharyngeal samples swabs were used to test for viral RNA of SARS-CoV-2 in the follow-up. SETTING: PICU within a tertiary university hospital in Germany. PARTICIPANTS: Healthcare workers of the PICU. INTERVENTIONS: Positive HCWs were sent into quarantine. Containment measures were implemented including wearing of surgical-masks, physical distancing and systematic testing. RESULTS: Among 432 HCWs, 91 (25%) were tested. Forty-five percent reported symptoms corresponding to characteristics of COVID-19. Of those, only 19,5% (8 HCWs) were tested positive for SARS-CoV-2. No infection occurred outside the PICU. After the implementation of containment measures, viral transmission was stopped. CONCLUSIONS: In the present study, a large outbreak within a team of healthcare workers of a PICU, affecting almost one fifth of the entire personnel is documented, along with detailed insights about how the outbreak was contained and how operability of the unit was maintained.

Seroprevalence and Seroconversion of Cytomegalovirus in a Large Group of Healthy, German Blood Donors: Potential Contribution to Transfusion Transmitted Infections.

BACKGROUND: Immunocompromised patients are at increased risk of morbidity and mortality due to transfusion transmitted cytomegalovirus (CMV) infections. To avoid or minimize such risk, clinicians working in the field continually monitor the changing epidemiology of CMV infections. MATERIALS AND METHODS: A total of 234,192 blood donations obtained from 44,779 donors were tested. CMV seroprevalence and antibody conversion rates were determined over a 3-year period. RESULTS: A significant percentage (37.5%) of all male and female blood donors tested seropositive. Both age and gender were risk factors for CMV infection. A total of 177 seroconversions (0.4% of donors) were identified. The highest antibody conversion rate occurred among men between 30 and 39 years of age; women did not experience a similar peak in antibody conversion rate. Approximately 10% of infected blood donors were identified by CMV DNA testing prior to seroconversion. CONCLUSIONS: The high rates of seroprevalence and seroconversion and the identification of a significant number of CMV DNA-positive (infected) blood donors prior to seroconversion indicate that the routine testing of blood samples for CMV DNA could reduce the potential risk of CMV transmission to high-risk patients.

Platelet Pathogen Reduction Technologies Alter the MicroRNA Profile of Platelet-Derived Microparticles.

Despite improvements in donor screening and increasing efforts to avoid contamination and the spread of pathogens in clinical platelet concentrates (PCs), the risks of transfusion-transmitted infections remain important. Relying on an ultraviolet photo activation system, pathogen reduction technologies (PRTs), such as Intercept and Mirasol, utilize amotosalen, and riboflavin (vitamin B2), respectively, to mediate inactivation of pathogen nucleic acids. Although they are expected to increase the safety and prolong the shelf life of clinical PCs, these PRTs might affect the quality and function of platelets, as recently reported. Upon activation, platelets release microparticles (MPs), which are involved in intercellular communications and regulation of gene expression, thereby mediating critical cellular functions. Here, we have used small RNA sequencing (RNA-Seq) to document the effect of PRT treatment on the microRNA profiles of platelets and derived MPs. PRT treatment did not affect the microRNA profile of platelets. However, we observed a specific loading of certain microRNAs into platelet MPs, which was impaired by treatment with Intercept or its Additive solution (SSP+). Whereas, Intercept had an impact on the microRNA profile of platelet-derived MPs, Mirasol did not impact the microRNA profile of platelets and derived MPs, compared to non-treated control. Considering that platelet MPs are able to transfer their microRNA content to recipient cells, and that this content may exert biological activities, those findings suggest that PRT treatment of clinical PCs may modify the bioactivity of the platelets and MPs to be transfused and argue for further investigations into PRT-induced changes in clinical PC content and function.

Comparison of platelet function tests for the in vitro quality assessment of platelet concentrates produced under real-life conditions.

Platelet quality in different platelet concentrates (PCs) has been the subject of several studies. Nonetheless, there is a lack of robust data on the correlation and agreement among platelet function tests as a prerequisite for the association of PC functionality in vitro with platelet function in vivo post PC transfusion. The purpose of our study was to correlate a larger panel of platelet function assays in PCs and to assess whether the methods agree sufficiently and can be used interchangeably. Twelve apheresis platelet concentrates in plasma (APC), 16 pooled platelet concentrates in plasma (PPC), and 12 PPC in T-sol (PPCA) were examined on days 1 and 4 after production. PCs were tested for platelet count, light transmission aggregation (LTA) induced by ADP, collagen, or TRAP; platelet ATP release induced by collagen; and spontaneous and ADP and TRAP-induced increase in CD62P and PAC1 expression measured by flow cytometry. All tests were performed in undiluted platelet-rich plasma, recalcified and mixed with an inhibitor of factor Xa and thrombin. Most platelet function parameters correlated significantly with each other, but agreement among methods was insufficient. A proper inverse correlation was observed between ADP-induced LTA and spontaneous platelet activation assessed by CD62P expression (r = -0.61, p < 0.0001). Spontaneous CD62P correlated also significantly with spontaneous PAC1 (r = 0.69, p < 0.0001) and inversely with TRAP-induced CD62P expression (r = -0.86, p < 0.0001). We found significant correlations among all flow cytometric assays measuring platelet CD62P and PAC1 expression induced by ADP or TRAP. Subsequent Bland Altman analysis revealed insufficient agreement between methods. With one exception (collagen-induced LTA compared with TRAP-induced LTA, percentage error = 16%) the limits of agreement expressed as percentage error exceeded the chosen acceptable difference of 30%. In APC, platelet count was 41% and 44% higher, respectively, than in PPC and PPCA (p < 0.0001). Spontaneous CD62P and PAC1 expression were significantly greater, and ADP-induced aggregation and agonist-induced increase in CD62P and PAC1 were significantly lower in PPCA compared to APC and PPC on day 4 of storage. ADP and TRAP-induced CD62P and PAC1 activatability fell significantly during storage between day 1 and day 4 in APC and PPCA, but not in PPC. In conclusion, different platelet function tests capture different aspects of platelet function and do not correlate and agree sufficiently to be used interchangeably.

The platelets' perspective to pathogen reduction technologies.

A wide variety of clinical conditions, associated with low circulating platelet counts, require platelet transfusion in order to normalize hemostatic function. Although single-donor apheresis platelets bear the lowest risk of transfusion-transmitted infections, pathogen reduction technologies (PRT) are being implemented worldwide to reduce this risk further through inactivation of known, emergent and as yet to be discovered nucleic acid-based pathogens. Human blood platelets are now known to harbor a diverse transcriptome, important to their function and comprised of >5000 protein-coding messenger RNAs and different classes of non-coding RNAs, including microRNAs. Our appreciation of the nucleic acid-dependent functions of platelets is likely to increase. On the other hand, the side effects of PRT on platelet function are underappreciated. Recent evidences suggest that PRT may compromise platelets' responsiveness to agonists, and induce platelet activation. For instance, platelets have the propensity to release proinflammatory microparticles (MPs) upon activation, and the possibility that PRT may enhance the production of platelet MPs in platelet concentrates (PCs) appears likely. With this in mind, it would be timely and appropriate to investigate other means to inactivate pathogens more specifically, or to modify the currently available PRT so to better preserve the platelet function and improve the safety of PCs; platelets' perspective to PRT deserves to be considered.

Blood donor screening for West Nile virus (WNV) revealed acute Usutu virus (USUV) infection, Germany, September 2016.

Between 1 June and 31 December 2016, 13,023 blood donations from the University Hospital Aachen in Germany were routinely screened for West Nile virus (WNV) RNA using the cobas TaqScreen WNV Test. On 28 September 2016, one blood donor was tested positive. Subsequent analysis revealed an acute Usutu virus (USUV) infection. During the ongoing USUV epizootics in Germany, blood transfusion services, public health authorities and clinicians should be aware of increased human USUV infections.

Peculiarities of studying the effects of pathogen reduction technologies on platelets.

The transfusion of platelet concentrates (PCs) is mainly used for treatment of thrombocytopenic, trauma or surgery patients. The integrity and safety of these platelet preparations, however, is compromised by the presence of pathogens, such as viruses, bacteria and parasites. The transfer of allogeneic donor leukocytes contaminating PCs can also potentially cause adverse reactions in recipients. These considerations prompted the development and implementation of pathogen reduction technologies (PRT), which are based on chemically induced cross-linking and inactivation of nucleic acids. While the incumbent PRT may provide some protection against transfusion-transmitted infections, they are ineffective against infectious prions and may not inactivate other emerging pathogens. In addition, the safety of PRT concerning platelet viability and function has been questioned in several reports. Recent studies suggest that PRT, such as Intercept, may adversely affect the messenger RNA (mRNA) and microRNA content of platelets, as well as their functional integrity, which may compromise the clinical benefits of PRT. Here, we will discuss about the peculiarities of studying the effects of PRT on platelets, which will need to be taken into account in future studies aimed to characterize further, and polish, the rugged side of this otherwise useful and potentially important approach in transfusion medicine.

[Risk Assessment of Single-Donor (Apheresis) Platelet Concentrates and Pooled Whole-Blood-Derived Platelet Concentrates]. / Bewertung von Apherese- und Pool-Thrombozytenkonzentraten.

According to the risk estimates of the Robert-Koch-Institute (RKI) and the Paul Ehrlich-Institute (PEI) an equivalence cannot be assumed to exist between the two different platelet preparations. Differences between single-donor (apheresis) platelet concentrates (ATK) and pooled whole-blood-derived platelet concentrates (PTK) result from donor populations, donation intervals, and preparation techniques. There are no prospective randomized studies with regard to the clinical efficacy, which would unambiguously demonstrate equivalence of the therapeutic efficacy of PTK (buffy coat method) in comparison to ATK. The German Association of Blood Transfusion Services (StKB) points out that, due to the non-equivalence of PTK and ATK, it is incumbent on the transfusion physician to select the platelet concentrate, make the appropriate disclosures, and assume treatment responsibility. Proper compensation for ATK and PTK must be ensured by the health insurance companies, whereby a special indication for the selection of either PTK or ATK is not given. Exceptions are patients with known HLA antibodies in which only selected platelet concentrates may be administered. Otherwise, no indication exists in the selection of the different platelet concentrates (Article is in German).

Differential Expression Analysis by RNA-Seq Reveals Perturbations in the Platelet mRNA Transcriptome Triggered by Pathogen Reduction Systems.

Platelet concentrates (PCs) are prepared at blood banks for transfusion to patients in certain clinical conditions associated with a low platelet count. To prevent transfusion-transmitted infections via PCs, different pathogen reduction (PR) systems have been developed that inactivate the nucleic acids of contaminating pathogens by chemical cross-linking, a mechanism that may also affect platelets' nucleic acids. We previously reported that treatment of stored platelets with the PR system Intercept significantly reduced the level of half of the microRNAs that were monitored, induced platelet activation and compromised the platelet response to physiological agonists. Using genome-wide differential expression (DE) RNA sequencing (RNA-Seq), we now report that Intercept markedly perturbs the mRNA transcriptome of human platelets and alters the expression level of >800 mRNAs (P<0.05) compared to other PR systems and control platelets. Of these, 400 genes were deregulated with DE corresponding to fold changes (FC) ≥ 2. At the p-value < 0.001, as many as 147 genes were deregulated by ≥ 2-fold in Intercept-treated platelets, compared to none in the other groups. Finally, integrated analysis combining expression data for microRNA (miRNA) and mRNA, and involving prediction of miRNA-mRNA interactions, disclosed several positive and inverse correlations between miRNAs and mRNAs in stored platelets. In conclusion, this study demonstrates that Intercept markedly deregulates the platelet mRNA transcriptome, concomitant with reduced levels of mRNA-regulatory miRNAs. These findings should enlighten authorities worldwide when considering the implementation of PR systems, that target nucleic acids and are not specific to pathogens, for the management of blood products.

The impact of whole blood processing and freezing conditions on the quality of therapeutic plasma prepared from whole blood.

BACKGROUND: The quality of whole blood (WB)-derived plasma preparations has been the subject of several studies, but there has been a lack of robust, comparative data for the different methods of processing and freezing. STUDY DESIGN AND METHODS: Six WB-derived plasma units were pooled and split (n = 16) and frozen within either 8 or 24 hours after WB collection, stored at 4°C or at room temperature (RT), and then frozen either slowly at -20°C or rapidly to below -30°C. Plasma units were tested for fibrinogen, Factor (F)V, FVII, FVIII, FXI, and von Willebrand factor (VWF), protein C (PC), protein S (PS) activity and free PS, prothrombin time, and partial thromboplastin time. RESULTS: FVIII was reduced by 9% to 19% after having been stored for 24 hours irrespective of storage temperature. Slow freezing (SF) reduced FVIII by 17% to 25% compared to rapid freezing (RF) to below -30°C. Storage temperature, but not 24-hour storage, decreased PS activity by 20% to 28%. PS activity was 8% to 17% lower in plasma units frozen slowly compared to RF. Storage and freezing had no influence on free PS. SF caused small losses of FVII and FXI activity. CONCLUSION: Twenty-four-hour hold at RT and SF both reduce FVIII levels below 70 U/dL in many plasma units. PS activity is affected substantially by storage temperature and SF, but free PS is not. With regard to plasma quality, freezing to below -30°C within 1 hour is superior to SF at -20°C.

Effects of pathogen reduction systems on platelet microRNAs, mRNAs, activation, and function.

Pathogen reduction (PR) systems for platelets, based on chemically induced cross-linking and inactivation of nucleic acids, potentially prevent transfusion transmission of infectious agents, but can increase clinically significant bleeding in some clinical studies. Here, we documented the effects of PR systems on microRNA and mRNA levels of platelets stored in the blood bank, and assessed their impact on platelet activation and function. Unlike platelets subjected to gamma irradiation or stored in additive solution, platelets treated with Intercept (amotosalen+ ultraviolet-A [UVA] light) exhibited significantly reduced levels of 6 of the 11 microRNAs, and 2 of the 3 anti-apoptotic mRNAs (Bcl-xl and Clusterin) that we monitored, compared with platelets stored in plasma. Mirasol (riboflavin+ UVB light) treatment of platelets did not produce these effects. PR neither affected platelet microRNA synthesis or function nor induced cross-linking of microRNA-sized endogenous platelet RNA species. However, the reduction in the platelet microRNA levels induced by Intercept correlated with the platelet activation (p < 0.05) and an impaired platelet aggregation response to ADP (p < 0.05). These results suggest that Intercept treatment may induce platelet activation, resulting in the release of microRNAs and mRNAs from platelets. The clinical implications of this reduction in platelet nucleic acids secondary to Intercept remain to be established.

[Single-donor (apheresis) platelets and pooled whole-blood-derived platelets--significance and assessment of both blood products]. / Apherese- und Pool-Thrombozytenkonzentrat--Wertigkeit und Bewertung beider Blutkomponenten.

The transfusion efficacy of ATK, which contain fully functional platelets, is beyond all doubt. The equivalence of ATK and PTK has been subject of many studies. Some of those studies show the superiority of ATK's, while others do not, but there have been no studies that demonstrated a superiority of PTK's. The superiority of platelets stored in plasma and in third generation additive solution was demonstrated in clinical studies; therefore, it cannot be said that all the platelet concentrates on the German market are equivalent in efficacy. Of decisive importance, above all, is the risk of transfusion-transmitted infections with known pathogens, or those not yet discovered. This risk is different for ATK compared to PTK. Taking this difference in risk and the difference in donor exposure of transfused patients into account, it can definitely be said that ATK and PTK are not equivalent. In 2012, the Robert-Koch-Institute (RKI) published a mathematical risk model for different platelet concentrates and assessed the risk of transmitting known pathogens such as HIV, HCV, and HBV. The risk was higher for PTK compared to ATK. The relative risks for PTK derived from 4BCs were 2.2 (95%--CI: 2.1-2.4) for HIV, 2.7 (95%--CI: 2.5-3.0) for HCV, and 2.2 (95%--CI: 2.8-3.7) for HBV. At the present time, these are the relative risks of transfusion-transmitted infections with the traditional pathogens for PTK compared to ATK. In addition to the RKI assessed risks, there is the theoretical risk of a new, unknown agent, transmitted through blood exposure. The magnitude of this risk is hardly predictable for PTK. The experience gathered so far, especially in the last three decades, with the emergence of HIV, prions, and West Nil virus, shows that the biological nature of a next transfusion-transmissible infectious agent cannot be predictable. This agent, if we think at a conventional sexually transmissible agent with nucleic acid and long latent period, would spread first in areas with high population density and thereby reduce the theoretical advantage of ATK (but definitely would not nullify it!). It is equally plausible, however, that this agent would behave like a prion, non-sexual transmission, or like a West-Nil virus, a non-contagious vector-transmitted agent. For PTK this would mean a relative risk up to 4 times (PTK from 4 BCs) or 5 times (PTK from 5 BCs) higher than the risk estimated by the Robert-Koch-Institute. If, taking the passive surveillance data and the changing variables (donor frequency, donor population, and donor location) into account, the risk of transmission of an infection via ATK (exposure to 1 donor) with HIV, HCV, and HBV moves closer to the higher risk of PTK (exposure to 4 or 8 donors, in case of double ATK per patient), this result of the risk model calculation by no means indicates any equivalency between PTK and ATK with respect to the risk of transmission of infection. The modifiable variables of donor frequency, donor population, and donor location need to be modified, as scientific deductions, in such a way that the avoidable risk of ATK which is influenced by these variables can be corrected to the minimum risk of a transmission of infection of HIV, HBV, and HCV via ATK in comparison to PTK. The minimum risk of a possible transmission of infection via ATK (exposure to 1 donor) is the basic intrinsic risk of each individual blood donation. The basic intrinsic risk increases relative to the number of blood donations or exposure to donors (PtK has an unalterable, production-dependent exposure to 4 or 8 donors). Let us consider a 1:1.000 prevalence for a new pathogen, which is spread equally in each donor population (apheresis and whole blood) and the present case of approximately 500,000 transfused platelet concentrates in Germany. This means that for the production of 4 PTK about 2 million donations are processed, 2,000 infectious Buffy-Coats are obtained and, thereby, 2,000 infectious PTK. In the case of ATK, considering five (5) donations per year, theoretically, it would mean 100 donors infected and 500 infectious ATK. Considering 15 apheresis donations per donor per year, this would mean that 33 donors are infected, but still 500 infectious ATK would be produced. The prion is an example of a pathogen that, although its existence is well known, cannot be proven or pathogen-reduced. In addition, it has a very long incubation period compared to the donation intervals. Due to the manufacturing process, PTK has a 4-fold higher donor exposure and therefore a 4-fold higher risk for transfusion-transmitted infections compared to ATK. If a patient needs the transfusion of two platelet concentrates, by transfusing a double-ATK from the same donor the risk of transfusion-transmitted infections will remain the same. On the other hand, the risk will increase by 8-fold by transfusing two PTK. The only current possibility to prevent or to minimize the risk of infection with prions is to minimize the donor exposure by transfusing ATK instead of PTK. Hypothetical risk scenarios carry significant weight in law. This can be seen in the constant rulings of the German Federal Supreme Court (Bundesgerichtshofs (BGH)) on the so-called hypothetical risk explanations (BGH, NJW 1996, 776, 777; 2000, 1784, 1787; 2005, 2614, 2616). Therefore, a risk does not need to be confirmed to be subject to compulsory explanation. It is sufficient that serious voices in the medical scientific community point to specific risks, which cannot be set aside as insignificant outside opinions, but must be viewed as serious warnings. According to the rulings, patients must even be informed of rare and often extremely rare risks, which could, should they come true, significantly impact daily life and, despite their rarity, are specific to the treatment and are startling for the ordinary person (BGH, 15.02.2000- VI ZR 48199 -; BGH, 30.11.2004 - VI ZR 209104 -; OLG Hamm, 29.09.2010 - 1-3 V 169109). These conditions have been fulfilled for PTK according to current knowledge, especially since, in the meantime in several rulings, the federal supreme court has required the reference to as yet unknown risks (refer to BGH, 13.06.2006 - VI ZR 323104 - for the use of new medical treatment methods, BGH, 27.06.2007 - VI ZR 55105 for experimental therapy using new, unapproved medication BGH, 06.07.2010 - VI ZR 198109 - for unknown risks cannot be excluded, for example based on anatomical conditions). ATK and PTK are therapeutic alternatives with the same range of indications for treatment using thrombocytes, however, with differing risks of infection, with different exposures to donors, and with different efficacy. ATK and PTK. ATK and PTK are therapeutic alternatives in terms of pharmaceutical law based on the different risks and the different quality. Patients must be informed of therapeutic alternatives such as ATK and PTK according to the patient rights law. Denial of reimbursement for additional fees for ATK by individual insurance companies (or paying authorities) deviates blatantly, as seen in the ruling of the Social Court of of the Saarland in this matter, from the basic requirement of the Transfusion Law (Transfusionsgesetz (TFG)) and is legally incorrect. The legality of the question whether the transfusion of ATK is indicated or if PTK had sufficed, is not allowable within the context of an MDK-Test according to subsection 275 ff. SGB V. The denial is a direct infringment on the treatment authority of the attending hospital physician and is illegal according to subsection 275 Abs. 5 SGBV. It is certainly possible to establish a full ATK supply and can be immediately realized by increasing donation rates from 5 to 8.3 apheresis donations per year in the current scenario of apheresis structure and donor population. The donation interval between two apheresis donations would be 49 days. A complete supply with ATK can also be immediately implemented by enlarging the donor population, keeping the current apheresis donation frequency. The donor pool must be increased by 24,576 donors, which means a 67% increase of the existing donor population. A transition to an ATK supply that can cover the entire demand can certainly be realized in a short period of time, while assuring a complete supply with PTK is not a realistic option. All existing studies advise taking extreme caution with any alternative to the current German gold standard for the treatment of hyporegenerative thrombocytopenia. A prophylactic transfusion of a non-pathogen-inactivated platelet concentrate with on average 3 x 10(11) platelets is recommended when the platelet count drops below the threshold of 10,000/microL. All other alternatives to this strategy show an increase in intracranial bleeding events. The existing studies on platelet dose (PLADO-Trial and StoP-Trial) do not recommend deviating from 3 x 10(11) platelets per unit. On the contrary, these studies demonstrate that the only practicable way is to individually correlate every platelet transfusion to the patient body surface. Considering the current knowledge, it is not justified to lower the standard dose and, for certain patient groups, to switch from prophylaxis to therapeutic platelet transfusion. Applying ATK or PTK with a lower platelet content and only for therapeutic purposes, could considerably increase the bleeding risk, especially for WHO grades III and IV. This will also affect all the patients who receive an induction treatment. Through pathogen reduction, in parallel with platelet loss (Apoptosis), the function of the treated platelets is impaired. Alternatively, the cell destruction caused during this process could result in a release of platelet microRNA directly into the supernatant or in microvesicles. This reduction of microRNA will affect the storage of the platelets. (ABSTRACT TRUNCATED)

Ischemic-type biliary lesions after liver transplantation: a retrospective analysis of risk factors and outcome.

BACKGROUND: Ischemic-type biliary lesions (ITBL) are the most troublesome complications after liver transplantation. Their cause remains unknown and, although some risk factors have been identified, results from different research groups are often conflicting. The goal of this study was to investigate potential risk factors for ITBL. METHODS: 565 transplantations performed between September 1997 and August 2010 were identified and divided into two cohorts: 77 in which the patient developed ITBL and 488 in which no ITBL occurred. The following factors were analyzed: donor age, patient Child-Pugh score, cold ischemia time, total ischemia time, type of perfusion solution, shipped versus non-shipped organ, ABO-compatibility versus identity between donor and recipient, Rhesus-difference versus identity between donor and recipient, presence versus absence of HLA antibodies in the patient at the time of registration on the transplant waiting list, presence in the donor of at least one HLA-C group 1 allele versus at least one HLA-C group 2 allele. HLA-C is the major inhibitory ligand for killer immunoglobulin-like receptors (KIR) that regulate the cytotoxic activity of natural killer cells. HLA-C alleles can be allocated into two groups, HLA-C1 and HLA-C2, based on their KIR specificity. RESULTS: In a multivariate logistic regression analysis the donor age and patient Child-Pugh score C were found to be independent risk factors for ITBL (p < 0.001 and 0.007, respectively). However, the multivariate Cox regression analysis indicated that neither has an impact on graft survival. CONCLUSIONS: Donor age and patient Child-Pugh score predispose to ITBL, whereas other factors must intervene for their development.

Vitamin D status from dried capillary blood samples.

BACKGROUND: Given the huge impact of vitamin D deficiency on a broad spectrum of diseases such as rickets, osteoporosis, mineral bone disease-vascular calcification syndrome, infectious diseases, but also several types of cancer and CNS diseases, reliable and simple methods to analyze the vitamin D status are urgently needed. METHODS: We developed an easy technique to determine the 25-OH vitamin D status from dried blood samples on filter paper. This allows determination of the 25-OH vitamin D status independently of venous blood taking, since only sampling of capillary blood is required for this new method. We compared the results of vitamin D measurements from venous blood of 96 healthy blood donors with those from capillary blood taken from the same patients at the same time. The capillary blood was dried on filter paper using the D-Vital ID dry-blood collection system. RESULTS: 25-OH vitamin D concentration data from extracted dried capillary blood filters correlated very well with data obtained after direct measurement of venous blood samples of the same blood donor (R: 0.7936; p < 0.0001). The correlation was linear over the whole range of 25-OH vitamin D concentrations seen in this study. A Bland-Altman plot revealed good agreement between both tests. CONCLUSIONS: The D-Vital ID dry-blood collection system showed an excellent performance as compared to the classical way of 25-OH vitamin D measurement from venous blood. This new technique will facilitate easy and reliable measurement for vitamin D status, in particular, in rural or isolated areas, developing countries, and field studies.

Comparison of point-of-care methods for preparation of platelet concentrate (platelet-rich plasma).

PURPOSE: This study analyzed the concentrations of platelets and growth factors in platelet-rich plasma (PRP), which are likely to depend on the method used for its production. MATERIALS AND METHODS: The cellular composition and growth factor content of platelet concentrates (platelet-rich plasma) produced by six different procedures were quantitatively analyzed and compared. Platelet and leukocyte counts were determined on an automatic cell counter, and analysis of growth factors was performed using enzyme-linked immunosorbent assay. RESULTS: The principal differences between the analyzed PRP production methods (blood bank method of intermittent flow centrifuge system/platelet apheresis and by the five point-of-care methods) and the resulting platelet concentrates were evaluated with regard to resulting platelet, leukocyte, and growth factor levels. The platelet counts in both whole blood and PRP were generally higher in women than in men; no differences were observed with regard to age. Statistical analysis of platelet-derived growth factor AB (PDGF-AB) and transforming growth factor ß1 (TGF-ß1) showed no differences with regard to age or gender. Platelet counts and TGF-ß1 concentration correlated closely, as did platelet counts and PDGF-AB levels. There were only rare correlations between leukocyte counts and PDGF-AB levels, but comparison of leukocyte counts and PDGF-AB levels demonstrated certain parallel tendencies. CONCLUSIONS: TGF-ß1 levels derive in substantial part from platelets and emphasize the role of leukocytes, in addition to that of platelets, as a source of growth factors in PRP. All methods of producing PRP showed high variability in platelet counts and growth factor levels. The highest growth factor levels were found in the PRP prepared using the Platelet Concentrate Collection System manufactured by Biomet 3i.