Emotional and Psychological Effects of the COVID-19 Pandemic on Nursing Students.

ABSTRACT: The COVID-19 pandemic impacted the mental health and educational experiences of nursing students in undergraduate and graduate programs. A larger mixed-methods study aimed to understand how COVID-19 impacted personal lives and learning experiences of students across all programs levels. This article reports on qualitative data obtained from focus groups organized by student program level. Six themes emerged, including fear and uncertainty, trust in God, educational and career concerns, concerns about family, mental health issues, and isolation/lack of human touch. Key areas covered are the emotional and psychological effects of COVID-19 and its factors and the role of faith during COVID-19 among nursing students.

Closed system processing variables affect post-thaw quality characteristics of cryopreserved red cell concentrates.

BACKGROUND: Differences in manufacturing conditions using the Haemonetics ACP 215 cell processor result in cryopreserved red cell concentrates (RCCs) of varying quality. This work studied the effect of processing method, additive solution, and storage duration on RCC quality to identify an optimal protocol for the manufacture of cryopreserved RCCs. MATERIALS AND METHODS: RCCs were pooled-and-split and stored for 7, 14, or 21 days before cryopreservation. Units were glycerolized with the ACP 215 using a single or double centrifugation method. After thawing, the RCCs were deglycerolized, suspended in AS-3, SAGM, ESOL, or SOLX/AS-7, and stored for 0, 3, 7, 14, or 21 days before quality testing. Quality assessments included hemoglobin content, hematocrit, hemolysis, adenosine triphosphate (ATP), supernatant potassium, and mean cell volume. RESULTS: Both glycerolization methods produced RCCs that met regulatory standards for blood quality. Dual centrifugation resulted in higher hemoglobin content, fewer processing alerts, and a shorter deglycerolization time than single centrifugation processing. Units processed with AS-3 and ESOL met regulatory standards when stored for up to 21 days pre-cryopreservation and 21 days post-deglycerolization. However, ESOL demonstrated superior maintenance of ATP over RBCs in AS-3. Some RCCs suspended in SAGM and SOLX exceeded acceptable hemolysis values after 7 days of post-deglycerolization storage regardless of pre-processing storage length. CONCLUSIONS: When manufacturing cryopreserved RCCs using the ACP 215, dual centrifugation processing with AS-3 or ESOL additive solutions is preferred, with storage periods of up to 21 days both pre-processing and post-deglycerolization.

Impact of COVID-19 on Nursing Students: Factors Associated with PTSD Risk.

ABSTRACT: The COVID-19 pandemic rapidly transformed nursing education, creating multiple stressors for students. The researchers in this study examined how undergraduate and graduate nursing students at a faith-based university perceived the impact of COVID-19. A multiple linear regression model explored the effect of 17 variables on the Impact of Events Scale-Revised (IES-R) scores. Anxiety level, quality of sleep, and perceived health demonstrated a statistically significant influence on IES-R scores; 27% of students had IES-R scores above 33, indicating high risk for posttraumatic stress disorder. Strategies to help address student stress and anxiety are discussed.

Graded exercise therapy for patients with chronic fatigue syndrome in secondary care - a benchmarking study.

OBJECTIVE: We investigated the effectiveness of graded exercise therapy (GET) delivered to patients with chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME) in a routine, specialist clinic by measuring patient-reported outcome data collected prospectively over several timepoints alongside therapy. Benchmarking analyses were used to compare our results with those found in randomised controlled trials (RCTs). METHODS: Data were collected from patients, with a diagnosis of CFS/ME, who had been referred to a specialist clinical service in South London. Measures included Chalder Fatigue Questionnaire, Physical Functioning Subscale of the Short-Form Health Questionnaire, and the Work and Social Adjustment Scale. Change on each measure was calculated over time using linear mixed-model analyses. Within group effect sizes were calculated and compared with previous RCTs. RESULTS: Fatigue scores were significantly reduced by session 4 (-5.18, 95%CIs -7.90, -2.45) and at follow-up (-4.73, 95%CIs -7.60, -1.85). Work and social adjustment and physical functioning progressively improved over the course of therapy, reaching significance at discharge and maintained at follow-up (WSAS -4.97, 95%CIs -7.97, -1.97; SF-36 10.75, 95%CIs 2.19, 19.31). CONCLUSIONS: GET is an effective treatment for CFS/ME within clinical practice. However, effect sizes were smaller in routine clinical practice than RCTs suggesting that avenues for augmentation need to be considered.Implications for rehabilitationIt is important to assess whether patient reported outcomes of treatments that have been evaluated in the context of clinical trials are similar in routine clinical practice.This study shows fatigue severity, physical functioning, and work and social adjustment can significantly improve after graded exercise therapy for patients with chronic fatigue syndrome within a specialist service.Benchmarking methods showed clinical outcomes obtained smaller effect sizes than randomised controlled trials - techniques to maximise patient outcomes should be considered.

Hypothermic storage of leukoreduced red blood cells for greater than 21 days is a safe alternative to irradiation.

BACKGROUND: Irradiation of red blood cells (RBCs) inactivates residual donor T lymphocytes to prevent transfusion-associated graft-vs-host disease (TA-GVHD) but can have adverse effects on recipients and inventory management. Reported incidence of TA-GVHD is lower when leukoreduced RBCs and older blood products are transfused; therefore, the impact of leukoreduction and storage was evaluated as an alternative prevention strategy. STUDY DESIGN AND METHODS: Effectiveness of leukoreduction filters on white blood cell (WBC) proliferation was evaluated by filtering buffy coat (BC) products and isolating residual WBCs. Additionally, leukoreduced RBCs were spiked with 5 × 106 WBCs on Day 21 of hypothermic storage, then stored and processed on Days 7, 14, and 21 to obtain residual WBCs to investigate the impact of hypothermic storage on their viability and proliferative ability. Viability of residual WBCs was assessed by staining with annexin V and an antibody cocktail for flow cytometry analysis. Proliferative ability was assessed by placing carboxyfluorescein diacetate succinimidyl ester-labeled residual WBCs into culture for 6 days with phytohemagglutinin before flow cytometry assessment. RESULTS: Filtration of BC units depleted WBCs, particularly T lymphocytes, to 0.001% ± 0.003% cells/unit, although proliferative activity remained consistent with prefiltration levels of WBCs. WBCs in stored RBCs remained viable even on Day 21 of storage; however, the proliferative activity decreased to 0.24% ± 0.41%. CONCLUSIONS: Hypothermic storage of RBCs for 21 days or more is sufficient to inactivate T lymphocytes, which may help prevent TA-GVHD when irradiated RBCs are not available.

Donor-dependent aging of young and old red blood cell subpopulations: Metabolic and functional heterogeneity.

BACKGROUND: Characteristics of red blood cells (RBCs) are influenced by donor variability. This study assessed quality and metabolomic variables of RBC subpopulations of varied biologic age in red blood cell concentrates (RCCs) from male and female donors to evaluate their contribution to the storage lesion. STUDY DESIGN AND METHODS: Red blood cell concentrates from healthy male (n = 6) and female (n = 4) donors were Percoll separated into less dense ("young", Y-RCCs) and dense ("old", O-RCCs) subpopulations, which were assessed weekly for 28 days for changes in hemolysis, mean cell volume (MCV), hemoglobin concentration (MCHC), hemoglobin autofluorescence (HGB), morphology index (MI), oxygen affinity (p50), rigidity, intracellular reactive oxygen species (ROS), calcium ([Ca2+ ]), and mass spectrometry-based metabolomics. RESULTS: Young RCCs having disc-to-discoid morphology showed higher MCV and MI, but lower MCHC, HGB, and rigidity than O-RCCs, having discoid-to-spheroid shape. By Day 14, Y-RCCs retained lower hemolysis and rigidity and higher p50 compared to O-RCCs. Donor sex analyses indicated that females had higher MCV, HGB, ROS, and [Ca2+ ] and lower hemolysis than male RBCs, in addition to having a decreased rate of change in hemolysis by Day 28. Metabolic profiling indicated a significant sex-related signature across all groups with increased markers of high membrane lipid remodeling and antioxidant capacity in Y-RCCs, whereas O-RCCs had increased markers of oxidative stress and decreased coping capability. CONCLUSION: The structural, functional, and metabolic dissimilarities of Y-RCCs and O-RCCs from female and male donors demonstrate RCC heterogeneity, where RBCs from females contribute less to the storage lesion and age slower than males.

Objective assessment of stored blood quality by deep learning.

Stored red blood cells (RBCs) are needed for life-saving blood transfusions, but they undergo continuous degradation. RBC storage lesions are often assessed by microscopic examination or biochemical and biophysical assays, which are complex, time-consuming, and destructive to fragile cells. Here we demonstrate the use of label-free imaging flow cytometry and deep learning to characterize RBC lesions. Using brightfield images, a trained neural network achieved 76.7% agreement with experts in classifying seven clinically relevant RBC morphologies associated with storage lesions, comparable to 82.5% agreement between different experts. Given that human observation and classification may not optimally discern RBC quality, we went further and eliminated subjective human annotation in the training step by training a weakly supervised neural network using only storage duration times. The feature space extracted by this network revealed a chronological progression of morphological changes that better predicted blood quality, as measured by physiological hemolytic assay readouts, than the conventional expert-assessed morphology classification system. With further training and clinical testing across multiple sites, protocols, and instruments, deep learning and label-free imaging flow cytometry might be used to routinely and objectively assess RBC storage lesions. This would automate a complex protocol, minimize laboratory sample handling and preparation, and reduce the impact of procedural errors and discrepancies between facilities and blood donors. The chronology-based machine-learning approach may also improve upon humans' assessment of morphological changes in other biomedically important progressions, such as differentiation and metastasis.

A Canadian perspective on the use and preparation of cryopreserved red cell concentrates.

Canadian Blood Services (CBS) operates a national rare blood program to meet the needs of a highly diverse Canadian civilian population. This program manages the frozen inventory of red blood cell products maintaining upwards of 800 units of strategically identified phenotypes for patient use. Red cell concentrates (RCCs) are collected from identified donors with rare blood types as whole blood and are further processed into leukocyte reduced red cell concentrates in SAGM. These units can be stored for up to 21 days prior to glycerolization and frozen storage. The use of the ACP 215, a closed system cell processor, for cryopreservation using the high glycerol method allows for an extended expiry date of 14 days post deglycerolization when RBCs are suspended in AS-3 and stored hypothermically prior to transfusion. This method produces units that meet all Canadian regulatory standards. Introduction of extended outdates has allowed CBS to decrease operational costs and improve cryopreserved RCC product quality.

Transient warming affects potency of cryopreserved cord blood units.

BACKGROUND AIMS: Cryopreserved cord blood units (CBUs) can be exposed to transient warming events (TWEs) during routine banking operations, which may affect their potency. NetCord-FACT guidelines recommend removal of these CBUs from inventory. The objective of this work was to evaluate warming kinetics of frozen CBUs in different settings to determine the optimal working environment and define the impact of different TWE scenarios on CB post-thaw quality and potency. METHODS: The warming kinetics of frozen CBUs was influenced by both working surfaces and ambient working temperature, with cold plates providing better protection than vinyl or metal surfaces. Measurement of time for required operational activities revealed that CBUs are probably exposed to core temperatures greater than -150°C even when cold plates are used to reduce warming rates. RESULTS: On the basis of the warming kinetics and observed operational activities, three TWE causing scenarios (control, typical, worst case) were investigated using a pool-and-split design and cell viability, recovery and potency (colony-forming unit [CFU]) assays were performed. TWEs were found to have little impact on the recovery of total nucleated cells or on the viability of CD34+ cells. In contrast, the viability and recovery of CD45+ cells in the smaller CBU compartments were reduced by TWEs. Moreover, the worst-case TWE reduced CFU recovery from CBUs, whereas the typical-scenario TWE had little effect. CONCLUSIONS: Our results demonstrate that the distal segment underestimates the viability and potency of CBUs and that TWEs can affect the post-thaw viability and potency of CBUs. Although TWEs are almost inevitable during cord-blood banking operations, their effects must be diminished by reducing exposure time, using cold plates and strict operational protocols, to prevent worst-case TWEs.

Evaluating the quality of red blood cell concentrates irradiated before or after cryopreservation.

BACKGROUND: Cryopreserved red blood cell concentrates (RCCs) are often required for patients with rare blood groups. Although transfusions from blood relatives are irradiated before transfusion, research has yet to make clear if this is necessary in cryopreserved RCCs. Given insufficient evidence to the contrary, irradiation of cryopreserved RCCs has been recommended, but the effect of irradiation timing is unknown. Therefore, this study was performed to assess the effect of RCC irradiation pre- and postcryopreservation on RCC quality. STUDY DESIGN AND METHODS: Nine whole blood units from healthy donors were processed into RCCs using the buffy coat method. ABO- and Rh-matched units were pooled and split into three groups: precryopreservation irradiation (pre-CIG), postcryopreservation irradiation (post-CIG), and nonirradiated controls. Hemoglobin, hematocrit, white blood cell (WBC) count, extracellular potassium, mean cell volume, red blood cell (RBC) morphology, and RBC deformability were measured. RESULTS: Extracellular potassium was greater in the irradiated conditions when compared to the nonirradiated controls and was greater in the post-CIG group when compared to the pre-CIG group (p < 0.05). WBC counts decreased after cryopreservation in all groups to values lower than the sensitivity of the assay. RBC deformability was greater in the post-CIG group when compared to the pre-CIG group and control group. No other significant differences were observed between groups. CONCLUSION: Irradiation of RCCs can be performed pre- or postcryopreservation with little effect on the RCC product, as both irradiated groups resulted in RCCs that were comparable to the nonirradiated cryopreserved RCCs.

Label-Free Analysis of Red Blood Cell Storage Lesions Using Imaging Flow Cytometry.

Deleterious changes, collectively termed as storage lesions, alter the characteristics of red blood cell (RBC) morphology during in vitro storage. Due to gradual loss of cellular membrane, RBCs lose their original biconcave disk shape and begin a process of spherical deformation that is characterized by well-defined morphological criteria. At the spheroechinocyte stage, the structure of RBC is irreversibly damaged and lacks the elasticity necessary to efficiently deliver oxygen. Quantifying the prevalence of spheroechinocytes could provide an important morphological measure of the quality of stored blood products. Unlike the conventional RBC morphology characterization assay involving light microscopy, we introduce a label-free assay using imaging flow cytometry (IFC). The technique captures 100,000 images of a sample and calculates a relative measure of spheroechinocyte population in a fraction of the time required by the conventional method. A comparative method study, measuring a morphological index for 11 RCC units through storage, found that the two techniques measured similar trends with IFC reporting the metric at an average of 3.9% higher. We monitored 18 RCC units between Weeks 1 and 6 of storage and found that the spheroechinocyte population increased by an average of 26.2%. The large (3.5-64.1%) variation between the units' spheroechinocyte population percentage at Week 1 suggests a possible dependence of blood product quality on donor characteristics. Given our method's ability to rapidly monitor large samples and refine morphological characterization beyond conventional methods, we believe our technique offers good potential for studying the underlying relationships between RBC morphology and blood storage lesions. © 2019 International Society for Advancement of Cytometry.

From Development to Implementation: Adjusting the Hematocrit of Deglycerolized Red Cell Concentrates to Meet Regulatory Standards.

BACKGROUND: Before transfusion, thawed frozen red cell concentrates (RCCs) must be deglycerolized. In order to ensure that these products meet regulatory standards for hematocrit, an approach to manipulate hematocrit post deglycerolization was developed and implemented. METHODS: Glycerolized and frozen RCCs were thawed and deglycerolized using the COBE 2991 cell processor, and the final product's hematocrit was adjusted by addition of various volumes of 0.9% saline / 0.2% dextrose. The in vitro quality of RCCs (hematocrit, hemolysis, hemoglobin content, volume, recovery, ATP, supernatant potassium, and others) were compared to Canadian Standards Association (CSA) and other standards for deglycerolized RCCs. RESULTS: Addition of saline/dextrose re-suspension solution in a range of 65-90 g post deglycerolization led to acceptable hematocrits. In the pilot study, this approach resulted in RCCs meeting all CSA standards for deglycerolized RCCs, with stimulation of RBC metabolism demonstrated by increased ATP concentration. In the validation phase, results were similar, although the CSA hemolysis standard was not met. Pre- and post-implementation data confirmed that manipulated RCCs met CSA hematocrit standards. CONCLUSION: This process was implemented at Canadian Blood Services to provide deglycerolized RCCs that meet the CSA hematocrit standard. However, pre- and post-implementation data reveal that this deglycerolization process is not sufficient to have RCCs consistently meet hemolysis standards.

Small molecule ice recrystallization inhibitors mitigate red blood cell lysis during freezing, transient warming and thawing.

During cryopreservation, ice recrystallization is a major cause of cellular damage. Conventional cryoprotectants such as dimethyl sulfoxide (DMSO) and glycerol function by a number of different mechanisms but do not mitigate or control ice recrystallization at concentrations utilized in cryopreservation procedures. In North America, cryopreservation of human red blood cells (RBCs) utilizes high concentrations of glycerol. RBC units frozen under these conditions must be subjected to a time-consuming deglycerolization process after thawing in order to remove the glycerol to <1% prior to transfusion thus limiting the use of frozen RBC units in emergency situations. We have identified several low molecular mass ice recrystallization inhibitors (IRIs) that are effective cryoprotectants for human RBCs, resulting in 70-80% intact RBCs using only 15% glycerol and slow freezing rates. These compounds are capable of reducing the average ice crystal size of extracellular ice relative to a 15% glycerol control validating the positive correlation between a reduction in ice crystal size and increased post-thaw recovery of RBCs. The most potent IRI from this study is also capable of protecting frozen RBCs against the large temperature fluctuations associated with transient warming.

O-Aryl-Glycoside Ice Recrystallization Inhibitors as Novel Cryoprotectants: A Structure-Function Study.

Low-molecular-weight ice recrystallization inhibitors (IRIs) are ideal cryoprotectants that control the growth of ice and mitigate cell damage during freezing. Herein, we describe a detailed study correlating the ice recrystallization inhibition activity and the cryopreservation ability with the structure of O-aryl-glycosides. Many effective IRIs are efficient cryoadditives for the freezing of red blood cells (RBCs). One effective cryoadditive did not inhibit ice recrystallization but instead inhibited ice nucleation, demonstrating the significance of inhibiting both processes and illustrating the importance of this emerging class of cryoprotectants.

Quality of red blood cells washed using a second wash sequence on an automated cell processor.

BACKGROUND: Washed red blood cells (RBCs) are indicated for immunoglobulin (Ig)A-deficient recipients when RBCs from IgA-deficient donors are not available. Canadian Blood Services recently began using the automated ACP 215 cell processor (Haemonetics Corporation) for RBC washing, and its suitability to produce IgA-deficient RBCs was investigated. STUDY DESIGN AND METHODS: RBCs produced from whole blood donations by the buffy coat (BC) and whole blood filtration (WBF) methods were washed using the ACP 215 or the COBE 2991 cell processors and IgA and total protein levels were assessed. A double-wash procedure using the ACP 215 was developed, tested, and validated by assessing hemolysis, hematocrit, recovery, and other in vitro quality variables in RBCs stored after washing, with and without irradiation. RESULTS: A single wash using the ACP 215 did not meet Canadian Standards Association recommendations for washing with more than 2 L of solution and could not consistently reduce IgA to levels suitable for IgA-deficient recipients (24/26 BC RBCs and 0/9 WBF RBCs had IgA levels < 0.05 mg/dL). Using a second wash sequence, all BC and WBF units were washed with more than 2 L and had levels of IgA of less than 0.05 mg/dL. During 7 days' postwash storage, with and without irradiation, double-washed RBCs met quality control criteria, except for the failure of one RBC unit for inadequate (69%) postwash recovery. CONCLUSION: Using the ACP 215, a double-wash procedure for the production of components for IgA-deficient recipients from either BC or WBF RBCs was developed and validated.

Small molecule ice recrystallization inhibitors enable freezing of human red blood cells with reduced glycerol concentrations.

In North America, red blood cells (RBCs) are cryopreserved in a clinical setting using high glycerol concentrations (40% w/v) with slow cooling rates (~1°C/min) prior to storage at -80°C, while European protocols use reduced glycerol concentrations with rapid freezing rates. After thawing and prior to transfusion, glycerol must be removed to avoid intravascular hemolysis. This is a time consuming process requiring specialized equipment. Small molecule ice recrystallization inhibitors (IRIs) such as ß-PMP-Glc and ß-pBrPh-Glc have the ability to prevent ice recrystallization, a process that contributes to cellular injury and decreased cell viability after cryopreservation. Herein, we report that addition of 110 mM ß-PMP-Glc or 30 mM ß-pBrPh-Glc to a 15% glycerol solution increases post-thaw RBC integrity by 30-50% using slow cooling rates and emphasize the potential of small molecule IRIs for the preservation of cells.

A quality monitoring program for red blood cell components: in vitro quality indicators before and after implementation of semiautomated processing.

BACKGROUND: Canadian Blood Services has been conducting quality monitoring of red blood cell (RBC) components since 2005, a period spanning the implementation of semiautomated component production. The aim was to compare the quality of RBC components produced before and after this production method change. STUDY DESIGN AND METHODS: Data from 572 RBC units were analyzed, categorized by production method: Method 1, RBC units produced by manual production methods; Method 2, RBC units produced by semiautomated production and the buffy coat method; and Method 3, RBC units produced by semiautomated production and the whole blood filtration method. RBC units were assessed using an extensive panel of in vitro tests, encompassing regulated quality control criteria such as hematocrit (Hct), hemolysis, and hemoglobin (Hb) levels, as well as adenosine triphosphate, 2,3-diphosphoglycerate, extracellular K(+) and Na(+) levels, methemoglobin, p50, RBC indices, and morphology. RESULTS: Throughout the study, all RBC units met mandated Canadian Standards Association guidelines for Hb and Hct, and most (>99%) met hemolysis requirements. However, there were significant differences among RBC units produced using different methods. Hb content was significantly lower in RBC units produced by Method 2 (51.5 ± 5.6 g/unit; p < 0.001). At expiry, hemolysis was lowest in Method 2-produced RBC units (p < 0.05) and extracellular K(+) levels were lowest in units produced by Method 1 (p < 0.001). CONCLUSION: While overall quality was similar before and after the production method change, the observed differences, although small, indicate a lack of equivalency across RBC products manufactured by different methods.

Quality of red blood cells washed using an automated cell processor with and without irradiation.

BACKGROUND: Sterile washing of red blood cells (RBCs) and use of an additive solution permits longer postwash storage. The effect of irradiation during this extended storage time is unclear. STUDY DESIGN AND METHODS: RBCs were washed 14 days after collection using an automated cell processor and stored in saline-adenine-glucose-mannitol. To determine how long washed and irradiated RBCs could be stored, units were irradiated 1, 4, 5, and 7 days after washing and in vitro quality was assessed. Determined limits of postwash storage time for washed and washed and irradiated RBCs were validated. Quality assessment included percent recovery, hemoglobin (Hb), hemolysis, extracellular K(+) , and adenosine triphosphate. Immunoglobulin (Ig)A levels were measured in the nonirradiated arm. RESULTS: RBCs irradiated 1 and 4 days after washing had unacceptably high hemolysis by Day 7 postwash, not meeting the acceptance criterion (<0.8% hemolysis in 98% of units with 95% confidence). Therefore, a 48-hour maximum storage time after irradiation was chosen. Storage limits tested in the validation phase were as follows: washing on Day 14 and subsequent storage for 7 days (washed RBCs) and washing on Day 14, irradiation on Day 19, and subsequent storage for 48 hours (washed and irradiated RBCs). All units met criteria for Hb, hematocrit, hemolysis, and sterility for washed RBCs. However, RBCs were washed with less than 2 L of saline, and IgA levels in 27 of 40 units were too high to be suitable for transfusion to IgA-deficient recipients. CONCLUSION: The extended expiry for washed and washed and irradiated RBCs met requirements for all indications except transfusion to IgA-deficient recipients.