The science or not behind deferrals of blood donors with a history of cancer.

BACKGROUND: In the United States (US), each blood center's medical director sets policy for donors with a cancer history. STUDY DESIGN AND METHODS: A subgroup of America's Blood Centers' (ABC) Scientific, Medical, and Technical Committee developed a survey to measure the determination of eligibility, policies for deferral and/or lookback when a donor reports a current diagnosis or history of cancer. A 31-question survey was sent to 47 ABC blood centers in North America via email. Survey results were compiled and literature evaluating the risk of cancer transmission by transfusion was reviewed. RESULTS: Responses were received from 37 centers (79%). Donors with a history of carcinoma or sarcoma who had completed treatment were accepted at 73% of centers with no further deferral. Donors with a history of leukemia or lymphoma were permanently deferred at 76% of centers. Donors with a myelodysplastic or myeloproliferative syndrome were deferred permanently at 86% of centers. Handling of donors with high white cell counts varied. Donors with cancer not in active treatment (i.e., prostate cancer) were subject to various deferrals. Center response to post-donation reports of cancer vary widely. Literature review yielded no evidence of transfusion-transmitted cancer. CONCLUSION: Cancer deferral policies vary widely among blood centers, and are not generally based on evidence, but on some aspect of the precautionary principle. As the donor population ages and so becomes more at risk of cancer, this approach may further reduce the available donor pool.

A case for a national registry of red blood cell antibodies.

BACKGROUND AND OBJECTIVES: Red blood cell (RBC) antibody levels diminish over time and negative antibody screen are commonly seen in patients with a history of antibodies. Most hospitals do not have access to a shared registry of antibodies previously detected at other hospitals. MATERIALS AND METHODS: We describe a case where the patient was found to be at high risk of bleeding during liver transplantation. Antibody screen on admission was negative but a history of anti-Jka was identified on reviewing patient's history in local registry of RBC antibodies. The surgery was pushed back to arrange for antigen-negative units. The patient received a total of 16 Jk(a-) RBC units during the admission. RESULTS: No acute or delayed transfusion adverse reactions were seen. However, if the history of anti-Jka identified at another local hospital was not known, approximately three-quarters of the units transfused would have been Jk(a+). Transfusing Jk(a+) units could have potentially exposed the patient to risk of developing an acute and/or delayed haemolytic transfusion reaction which could have led to significant morbidity and perhaps mortality. CONCLUSION: With this case report, we build a case for developing a national registry of RBC antibodies to help improve patient safety and outcomes.

Tissue plasminogen activator vs heparin for locking central venous catheters between apheresis procedures.

BACKGROUND: Central venous catheters (CVCs) for apheresis procedures require regular locking/flushes to maintain adequate flow rates. Literature comparing locking solutions for apheresis, where the time interval between procedures can be longer than for hemodialysis (many days to weeks), is lacking. In this study, catheter malfunction rates using recombinant tissue plasminogen activator (rt-PA) vs heparin for locking CVC between apheresis procedures were compared. STUDY DESIGN AND METHODS: A retrospective review of 93 extracorporeal photopheresis procedures in 10 patients was performed at our institution. About 1000 U/mL heparin or 2 mg rt-PA was used as the locking solution. Heparin locks were changed at least once per week and rt-PA locks could be left in place for up to 4 weeks. Following these locks, inadequate blood flow noted on accessing CVC and/or during the procedure was scored on as: no issues, some issues, or significant issues. Binary logistic regression was used to evaluate for potential statistical difference in outcomes. Cost analysis was also performed. RESULTS: No statistically significant difference was noted in outcomes between heparin and rt-PA lock (P value = 0.15). Total cost of heparin lock administration ($91-$362.50) was found to be more than rt-PA lock ($76) when more than one flush was needed between procedures. CONCLUSIONS: For apheresis use, rt-PA and heparin CVC locks seem to have similar outcomes in preventing CVC malfunction. The convenience of not needing any flushes between procedures and overall cost of administering fewer locks favors rt-PA use when the interval between procedures is >7 days.

Solutions to technical challenges during therapeutic plasma exchange using the Spectra Optia on a 4 kilogram neonate.

Therapeutic plasma exchange (TPE) on severely ill neonates poses many technical challenges, including obtaining adequate vascular access. In addition, clinical challenges such as risk of hypotension and cardiovascular instability are more pronounced in these patients. We report an approach to successfully managing these challenges while performing TPE on a 4 kilogram neonate using the Spectra Optia and 22 G venous access.

Predicting changes in hemoglobin S after simple transfusion using complete blood counts.

BACKGROUND: Hemoglobin S percentages are used in the management of patients who have sickle cell disease. However, hemoglobin S measurements often are not routinely or rapidly performed. Rapid and accurate methods to estimate hemoglobin S levels after simple transfusion may improve the care of patients with sickle cell disease. STUDY DESIGN AND METHODS: A comprehensive review of the electronic medical record identified 24 stable patients with sickle cell disease who received simple red blood cell transfusions and had hemoglobin S measurements before and after the transfusion that were less than 72 hours apart. Examination of these patients identified 62 separate transfusions that met our criteria. Three simple equations that utilized complete blood count values and readily available information from the medical record were used to predict the post-transfusion hemoglobin S level after transfusion (Equation 1: predicted post-transfusion hemoglobin = pre-transfusion hemoglobin S × [pre-transfusion hemoglobin/post-transfusion hemoglobin]; Equation 2: predicted post-transfusion hemoglobin S = pre-transfusion hemoglobin S × [pre-transfusion hematocrit/post-transfusion hematocrit]; and Equation 3: predicted post-transfusion hemoglobin S = pre-transfusion hemoglobin S × total pre-transfusion hemoglobin/[total pre-transfusion hemoglobin + (red blood cell volume × 20)]). RESULTS: The predicted hemoglobin S values for all three equations showed a highly significant correlation with the measured post-hemoglobin S value. The coefficient of determination (R2 ) for Equations 1, 2, and 3 was 0.95, 0.92, and 0.97, respectively. Predicting the post-transfusion hemoglobin S value using estimates of the patient's total hemoglobin and the transfused hemoglobin (Equation 3) was the most precise. CONCLUSION: Reductions in hemoglobin S values in patients with sickle cell disease who receive simple red blood cell transfusions can be reliably predicted using complete blood cell measurements and simple arithmetic equations.

High clinical suspicion of donor-derived disease leads to timely recognition and early intervention to treat solid organ transplant-transmitted lymphocytic choriomeningitis virus.

Despite careful donor screening, unexpected donor-derived infections continue to occur in organ transplant recipients (OTRs). Lymphocytic choriomeningitis virus (LCMV) is one such transplant-transmitted infection that in previous reports has resulted in a high mortality among the affected OTRs. We report a LCMV case cluster that occurred 3 weeks post-transplant in three OTRs who received allografts from a common organ donor in March 2013. Following confirmation of LCMV infection at Centers for Disease Control and Prevention, immunosuppression was promptly reduced and ribavirin and/or intravenous immunoglobulin therapy were initiated in OTRs. The liver recipient died, but right kidney recipients survived without significant sequelae and left kidney recipient survived acute LCMV infection with residual mental status deficit. Our series highlights how early recognition led to prompt therapeutic intervention, which may have contributed to more favorable outcome in the kidney transplant recipients.

Factors influencing platelet clumping during peripheral blood hematopoietic stem cell collection.

BACKGROUND: Platelet clumping is a common occurrence during peripheral blood hematopoietic stem cell (HSC) collection using the Spectra Optia mononuclear cell (MNC) protocol. If clumping persists, it may prevent continuation of the collection and interfere with proper MNC separation. This study is the first to report the incidence of clumping, identify precollection factors associated with platelet clumping, and describe the degree to which platelet clumping interferes with HSC product yield. STUDY DESIGN AND METHODS: In total, 258 HSC collections performed on 116 patients using the Optia MNC protocol were reviewed. Collections utilized heparin in anticoagulant citrate dextrose to facilitate large-volume leukapheresis. Linear and logistic regression models were utilized to determine which precollection factors were predictive of platelet clumping and whether clumping was associated with product yield or collection efficiency. RESULTS: Platelet clumping was observed in 63% of collections. Multivariable analysis revealed that a lower white blood cell count was an independent predictor of clumping occurrence. Chemotherapy mobilization and a lower peripheral blood CD34+ cell count were predictors of the degree of clumping. Procedures with clumping had higher collection efficiency but lower blood volume processed on average, resulting in no difference in collection yields. Citrate toxicity did not correlate with clumping. CONCLUSION: Although platelet clumping is a common technical problem seen during HSC collection, the total CD34+ cell-collection yields were not affected by clumping. WBC count, mobilization approach, and peripheral blood CD34+ cell count can help predict clumping and potentially drive interventions to proactively manage clumping.

Use of a data warehouse at an academic medical center for clinical pathology quality improvement, education, and research.

BACKGROUND: Pathology data contained within the electronic health record (EHR), and laboratory information system (LIS) of hospitals represents a potentially powerful resource to improve clinical care. However, existing reporting tools within commercial EHR and LIS software may not be able to efficiently and rapidly mine data for quality improvement and research applications. MATERIALS AND METHODS: We present experience using a data warehouse produced collaboratively between an academic medical center and a private company. The data warehouse contains data from the EHR, LIS, admission/discharge/transfer system, and billing records and can be accessed using a self-service data access tool known as Starmaker. The Starmaker software allows users to use complex Boolean logic, include and exclude rules, unit conversion and reference scaling, and value aggregation using a straightforward visual interface. More complex queries can be achieved by users with experience with Structured Query Language. Queries can use biomedical ontologies such as Logical Observation Identifiers Names and Codes and Systematized Nomenclature of Medicine. RESULT: We present examples of successful searches using Starmaker, falling mostly in the realm of microbiology and clinical chemistry/toxicology. The searches were ones that were either very difficult or basically infeasible using reporting tools within the EHR and LIS used in the medical center. One of the main strengths of Starmaker searches is rapid results, with typical searches covering 5 years taking only 1-2 min. A "Run Count" feature quickly outputs the number of cases meeting criteria, allowing for refinement of searches before downloading patient-identifiable data. The Starmaker tool is available to pathology residents and fellows, with some using this tool for quality improvement and scholarly projects. CONCLUSION: A data warehouse has significant potential for improving utilization of clinical pathology testing. Software that can access data warehouse using a straightforward visual interface can be incorporated into pathology training programs.

Streamlined sign-out of capillary protein electrophoresis using middleware and an open-source macro application.

BACKGROUND: Interfacing of clinical laboratory instruments with the laboratory information system (LIS) via "middleware" software is increasingly common. Our clinical laboratory implemented capillary electrophoresis using a Sebia(®) Capillarys-2™ (Norcross, GA, USA) instrument for serum and urine protein electrophoresis. Using Data Innovations Instrument Manager, an interface was established with the LIS (Cerner) that allowed for bi-directional transmission of numeric data. However, the text of the interpretive pathology report was not properly transferred. To reduce manual effort and possibility for error in text data transfer, we developed scripts in AutoHotkey, a free, open-source macro-creation and automation software utility. MATERIALS AND METHODS: Scripts were written to create macros that automated mouse and key strokes. The scripts retrieve the specimen accession number, capture user input text, and insert the text interpretation in the correct patient record in the desired format. RESULTS: The scripts accurately and precisely transfer narrative interpretation into the LIS. Combined with bar-code reading by the electrophoresis instrument, the scripts transfer data efficiently to the correct patient record. In addition, the AutoHotKey script automated repetitive key strokes required for manual entry into the LIS, making protein electrophoresis sign-out easier to learn and faster to use by the pathology residents. Scripts allow for either preliminary verification by residents or final sign-out by the attending pathologist. CONCLUSIONS: Using the open-source AutoHotKey software, we successfully improved the transfer of text data between capillary electrophoresis software and the LIS. The use of open-source software tools should not be overlooked as tools to improve interfacing of laboratory instruments.

Four postmortem case reports with quantitative detection of the synthetic cannabinoid, 5F-PB-22.

In January 2014, the US government temporarily designated 5F-PB-22, along with three other synthetic cannabinoids (AB-FUBINACA, ADB-PINACA and PB-22), into Schedule I. Over the course of a 4-month time period (July-October 2013), our laboratory quantitatively identified 5F-PB-22 in specimens obtained from four postmortem cases. We describe the four cases, to include pertinent autopsy findings and decedent histories, together with quantitative results for 5F-PB-22 determined in postmortem blood and antemortem serum. Samples were prepared via a liquid-liquid extraction at pH 10.2 into hexane : ethyl acetate. Instrumental analysis was achieved with liquid chromatography coupled with electrospray ionization tandem mass spectrometry operating in multiple reaction monitoring mode. Two ion transitions were monitored for the analyte of interest, and one ion transition was monitored for the internal standard. The observed concentration range of 5F-PB-22 is 1.1-1.5 ng/mL for three postmortem blood specimens and one antemortem serum specimen. Three of the decedents experienced abrupt, sudden death; however, one decedent expired after a rapidly deteriorating hospital course.

Clinical profile and mortality among novel influenza A (H1N1) infected patients: 2009-2010 Jodhpur, Rajasthan pandemic.

OBJECTIVES: Influenza causes annual seasonal epidemics around the world. Periodically, a genetically novel strain of influenza circulates worldwide, causing an influenza pandemic. The present study aims to assess the clinical profile, factors determining the response, prognosis of the disease and outcome in H1N1 positive patients during 2009-2010 H1N1 pandemic, so that epidemiology of the disease could be known and high risk groups can be identified. METHODS: Medical records of the H1N1 positive patients, confirmed by RT-PCR method, admitted in ICU/Isolation ward in M.D.M. Hospital, Jodhpur during pandemic of H1N1 influenza (2009-2010) were retrieved and retrospectively studied, the data collected was analysed. RESULTS: During the study period there were 221 H1N1 positive admissions. The age group most affected was 21-40 years in both males (52%) and females (67%). There were 80 deaths; mortality was high in rural population (64%) and pregnant women particularly in third trimester (80%). Common presenting symptoms were Cough, Fever, Breathlessness, Sore throat, Nasal Discharge, Expectoration and Body aches, other less common symptoms were Headache, Vomiting, Diarrhoea and Fatigue. CONCLUSION: Swine flu influenza infection took its heaviest toll in terms of human lives and economy because the young and productive population was mostly affected. Pregnant women and the patients with co-morbid conditions were the susceptible population and thus preventive and therapeutic interventions should be directed to them. Early vaccination of high risk groups and high index of suspicion in the symptomatic patients and chemoprophylaxis accordingly can save many human lives.