Autoimmune anti-D in an RhD-positive young infant: Learning from a rare case.

BACKGROUND AND OBJECTIVES: Anti-D is usually immune in nature and is formed in individuals lacking D antigen or having variants/altered D phenotypes. In the Indian population, 93.8% are RhD positive, and R1 R1 is the commonest Rh phenotype. Here we report a rare and interesting case of autoimmune anti-D in an RhD-positive 3-month-old infant leading to warm autoimmune haemolytic anaemia. STUDY DESIGN AND METHODS: Auto-anti-D was detected serologically by immunohaematological techniques such as direct antiglobulin test, antibody detection and identification, dithiothreitol, enzyme treatment, antibody titration and elution. Molecular studies were performed to rule out genetic variants of RhD. RESULTS: Anti-D was confirmed in eluate and blood group post elution was B RhD positive. On genotyping using the Indian-specific RHD genotyping assay, the sample was found to be negative for the RHD*01W.150 (most common RhD variant in Indians) but positive for RHD exon 5 and RHD exon 10 along with glyceraldehyde-3-phosphate dehydrogenase (GAPDH). The sample was further sequenced for RHD exons 1-10 by Sanger sequencing and found to be a wild type, thus, ruling out the presence of an RhD variant. CONCLUSION: This case is of interest because of the rare occurrence of autoimmune anti-D in an RhD-positive patient of such a young age (3 months). To the best of our knowledge, only two case reports have been published on autoimmune anti-D in infancy (in 1961 and 1964).

Analysis of reasons of blood donor deferral at a tertiary care institute in India and its reflections on community health status.

INTRODUCTION: Safe blood donors form the backbone of safe blood transfusion services.[1] Donor eligibility policies are a critical layer of blood safety designed to ensure selection of healthy donors and to protect recipients from any harm. This study was planned to analyze the pattern of whole blood donor deferrals and its characteristics and reasons at a tertiary care institute in northern India, as the pattern varies according to epidemiology of diseases in different demographic areas. MATERIALS AND METHODS: It was a cross-sectional study of 2 years' duration from December 2015 to November 2017. The data of the potential donors who were deferred were recorded on a separate pro forma which included their demographic details, type of donation - voluntary donor and replacement donor; first time and repeat donor; type of deferrals (permanent and temporary); and the reasons of deferrals. RESULTS: A total of 3133 donors (voluntary - 1446 and replacement - 1687) donated and 597 donors were deferred (deferral rate - 16%) during this period. Majority of the deferrals, i.e., 525 (88%) were temporary, while 72 (12%) were permanent. The most common reason of temporary deferral was anemia. The most common reason of permanent deferrals was a medical history of jaundice. CONCLUSIONS: Our study results indicate that the blood donor deferral can have subtle variations based on regional aspects that should be considered when national policies are developed as pattern of deferral varies according to the epidemiology of diseases in different demographic areas.

Irregular erythrocyte antibodies among antenatal women and their neonatal outcome at a tertiary care hospital in Northern India.

BACKGROUND: Red blood cell alloimmunisation during the pregnancy is a significant cause for neonatal mortality and morbidity. This study was planned to determine the prevalence and specificity of irregular erythrocyte antibodies in antenatal mothers and their neonatal outcome. METHODS: In this observational study, blood grouping and red cell antibody screening of mothers were performed at first visit and after 28 weeks of gestation and positive cases were identified and followed up monthly till delivery by repeating antibody titre and middle cerebral artery-peak systolic velocity. After delivery of alloimmunised mothers, cord blood haemoglobin, bilirubin and direct antiglobulin tests (DAT) were analysed and further outcome of neonate was recorded. RESULTS: Among 652 registered antenatal cases, 18 multigravida women were found to be alloimmunised, accounting to prevalence of 2.8%. Most common alloantibody identified was anti D (>70%) followed by anti-Lea, anti-C, anti-Leb, anti-E and anti-Jka. Only 47.7% Rh D negative women received anti-D prophylaxis during previous pregnancies or whenever indicated. DAT was positive in 56.2% of neonates. Among nine DAT positive neonates, two early neonatal deaths due to severe anaemia were observed following birth resuscitation. Four antenatal mothers required intrauterine transfusion in view of fetal anaemia while three neonates received double volume exchange transfusion and top up transfusions after birth. CONCLUSIONS: This study emphasises importance of red cell antibody screening for all multigravida antenatal women at registration of pregnancy and additionally at 28 weeks or later in high-risk cases irrespective of RhD status.

Challenges in the transfusion management of a 15-month-old pediatric patient with Bombay blood group phenotype.

Bombay blood group phenotype is often mistyped as O group which can lead to hemolytic transfusion reactions. There are a very few case reports of Bombay blood group phenotype in pediatric age group. Herein, we report an interesting case of Bombay blood group phenotype in a fifteen-month-old pediatric patient who presented with features of raised intracranial pressure and required an emergency surgery. The Bombay blood group was detected on detailed immunohematology work up which was further confirmed by molecular genotyping. The challenges faced in developing countries for transfusion management of such a case have been discussed.

High Titer Antibodies Demonstrating Prozone in Two Repeat Blood Donors.

Introduction: - Prozone phenomenon due to excess unbound antibodies may sometimes lead to failure of detection of ABO incompatibility. . The case series describes immunohematology work up of blood group discrepancies of two blood donors. Materials and Methods: - Blood grouping was performed by a fully automated immune hematology analyzer (FAIHA Diagast, Qwalys 3, France) based on the principle of erythrocyte magnetized technology. Further immunohematology workup was done by tube technique (at different temperatures and phases) and column agglutination technique (CAT). Antibody titration was done by tube technique at saline and AHG (anti human globulin) phase. Results: - Type I blood group discrepancy was detected on initial blood grouping done by an automated analyzer. The discrepancy was resolved by repeat blood grouping by tube technique with a remarkable finding of hemolysis in reverse grouping. The lysis was attributed to high titer antibodies (anti-B titer of 512) with demonstration of prozone phenomenon. However, there was no discrepancy between cell and serum grouping by column agglutination technique (CAT). Conclusion: - Tube technique is the gold standard method for blood grouping and detects blood group discrepancies optimally. Hemolysis which is taken as a positive result, can be best appreciated by tube technique.

A prospective interventional study to assess the impact of a 'structured compact training' on knowledge and skills of safe blood transfusion practices among nurses working in a tertiary care institute.

INTRODUCTION: There is scarce information on the baseline knowledge and practices of nursing officers in relation to administration of blood components. We set out to evaluate the influence of training on their knowledge and skills through Kirkpatrick's levels of Training Evaluation. MATERIALS AND METHODS: This interventional cross sectional study of 7 months duration conducted in a tertiary care teaching institute involved 200 nursing officers. Hundred were assigned to study/intervention group and 100 were assigned to control/ comparison group by systematic random sampling. Knowledge was tested in different domains-blood components, pre-transfusion checks, transfusion process, post-transfusion process and blood administration practice. RESULTS: The baseline knowledge scores of intervention and control group were similar-15.16 ± 4.11 and 15.02 ± 4.75 (p = 0.831). Post-intervention (phase I) after 1 month, the scores improved significantly for domain A, B, C, D and E to 4.3 ± 2.21 (p = 0.0001), 3.46 ± 2.15 (p = 0.0001), 7.02 ± 3.55 (p = 0.0001), 2.51 ± 1.46 (p = 0.0012), and 5.86 ± 3.61 (p = 0.0018) respectively. In phase II, after 3 months of training, and the scores were significantly better from baseline for all domains except E. For domain A, B, C, D and E, scores were 3.82 ± 2.46 (p = 0.0001), 3.53 ± 1.98 (p = 0.0001), 7.38 ± 3.87 (p = 0.0001), 2.48 ± 1.55 (p = 0.0035), and 5.86 ± 3.61 (p = 0.95) respectively. CONCLUSIONS: Our study showed that baseline scores were low in the nursing officers. No significant difference was found in baseline scores in subject and control population. However, post-intervention, a significant improvement in scores was observed in the study group across all domains.

Just not cosmesis! Role of low-density lipoprotein apheresis in familial hypercholesterolemia: Experience at a newly developed tertiary care institution in Northern India.

Familial hypercholesterolemia (FH) is characterized by an increase in plasma low-density lipoprotein-cholesterol (LDL-C) levels. It presents with tendon/skin xanthomas and premature atherosclerotic cardiovascular disease. The most available treatment options for FH are lipid-lowering medications such as statins, lifestyle modification, and LDL apheresis. As per American Society for Apheresis guidelines 2019, the treatment of FH using LDL apheresis falls under Category I. Here, we are reporting an interesting case of a young patient who presented with chief complaints of progressively increasing yellowish lesions around eyes, neck, hands, and legs. She was thoroughly investigated and was diagnosed provisionally as a case of Type 2 FH. Her total serum cholesterol and LDL-C were 717.2 mg/dl and 690.6 mg/dl, respectively, at presentation. One cycle of LDL apheresis was planned for her. We found immediate post-procedural reduction of 55.8% and 55.3% for total serum and LDL cholesterol levels respectively while 70.58% and 77.41% reduction in the levels from the day of presentation to the hospital.

Palliative Radiotherapy Within the Veterans Health Administration: Barriers to Referral and Timeliness of Treatment.

PURPOSE: Most Veterans Health Administration hospitals do not have radiation oncology (RO) departments on-site. The purpose of this study is to determine the impact of on-site RO on referral patterns and timeliness of palliative radiation therapy (PRT). MATERIALS AND METHODS: A survey was sent to medical directors at 149 Veterans Health Administration centers. Questions evaluated frequency of referral for PRT, timeliness of RO consults and treatment, and barriers to referral for PRT. Chi-square analysis was used to evaluate differences between centers that have on-site RO and centers that refer to outside facilities. RESULTS: Of 108 respondents, 33 (31%) have on-site RO. Chi-square analysis revealed that RO consult within 1 week is more likely at centers with on-site RO (68% v 31%; P = .01). Centers with on-site RO more frequently deliver PRT for spinal cord compression within 24 hours (94% v 70%; P = .01). Those without on-site RO were more likely to want increased radiation oncologist involvement (64% v 26%; P < .001). Barriers to referral for PRT included patient ability to travel (81%), patient noncompliance (31%), delays in consult and/or treatment (31%), difficulty contacting a radiation oncologist (14%), and concern regarding excessive number of treatments (13%). Respondents with on-site RO less frequently reported delays in consult and/or treatment (6% v 41%; P < .0001) and difficulty contacting a radiation oncologist (0% v 20%; P = .0056) as barriers. CONCLUSION: Respondents with on-site RO reported improved communication with radiation oncologists and more timely consultation and treatment initiation. Methods to improve timeliness of PRT for veterans at centers without on-site RO should be considered.

Irregular erythrocyte antibodies among antenatal women and their neonatal outcome at a tertiary care hospital in Northern India.

BACKGROUND: Red blood cell alloimmunisation during the pregnancy is a significant cause for neonatal mortality and morbidity. This study was planned to determine the prevalence and specificity of irregular erythrocyte antibodies in antenatal mothers and their neonatal outcome. METHODS: In this observational study, blood grouping and red cell antibody screening of mothers were performed at first visit and after 28 weeks of gestation and positive cases were identified and followed up monthly till delivery by repeating antibody titre and middle cerebral artery-peak systolic velocity. After delivery of alloimmunised mothers, cord blood haemoglobin, bilirubin and direct antiglobulin tests (DAT) were analysed and further outcome of neonate was recorded. RESULTS: Among 652 registered antenatal cases, 18 multigravida women were found to be alloimmunised, accounting to prevalence of 2.8%. Most common alloantibody identified was anti D (>70%) followed by anti-Lea, anti-C, anti-Leb, anti-E and anti-Jka. Only 47.7% Rh D negative women received anti-D prophylaxis during previous pregnancies or whenever indicated. DAT was positive in 56.2% of neonates. Among nine DAT positive neonates, two early neonatal deaths due to severe anaemia were observed following birth resuscitation. Four antenatal mothers required intrauterine transfusion in view of fetal anaemia while three neonates received double volume exchange transfusion and top up transfusions after birth. CONCLUSIONS: This study emphasises importance of red cell antibody screening for all multigravida antenatal women at registration of pregnancy and additionally at 28 weeks or later in high-risk cases irrespective of RhD status.

Routine indirect antiglobulin testing of blood donors-a further step toward blood safety: an experience from a tertiary care center in northern India.

CONCLUSIONS: This scientific article emphasizes the importance of a policy for antibody screening of all blood donors as a step to further improve blood safety. We also report the incidence of red blood cell (RBC) alloimmunization in healthy blood donors obtained using a cross-sectional prospective study from September 2017 to January 2019 in the Department of Transfusion Medicine of a tertiary care referral and teaching institute in northern India. The indirect antiglobulin test (IAT) for unexpected RBC antibodies was performed by the conventional tube test with pooled group O RBCs on all donor units irrespective of their D status. Samples with positive IATs were sent to the Immune Hematology Reference Laboratory for further immunohematolo-gy workup, maintaining predefined optimal storage and transport conditions. Of the 10,390 donors studied, 9959 were males and 431 were females. The incidence of unexpected antibodies (antibodies other than those of the ABO blood system) among the blood donors was found to be 0.18 percent (19 of 10,390 with 25 alloantibodies). Of the 19 alloimmunized donors, 16 (84.2%) were male (alloimmunization rate 0.16%, 16 of 9959) and 3 (15.8%) were female (alloimmunization rate 0.69%, 3 of 431) (p = 0.01; chi-square test). In our study, the most frequent alloantibodies identified were of the Lewis blood group system (17 of 25 [68%] in 14 of the 19 alloimmunized donors). The second most common allo-antibodies belonged to the Rh blood group system (4 of 25 [16%] in 3 of the 19 alloimmunized donors), followed by those of the MNS blood group system (3 of 25 [12%] in 2 of 19 alloimmunized donors). Anti-K was found in one donor (1 of 25 [4%]). Based on the results of the study, we recommend that a policy of routinely performing IATs on all donor units, irrespective of their D status, be adopted as an essential component of safe blood transfusion practices.

Radiotherapeutic Care of Patients With Stage IV Lung Cancer with Thoracic Symptoms in the Veterans Health Administration.

BACKGROUND: Radiotherapy plays an important role in the palliation of lung cancer, which is the second most common cancer diagnosed in the Veterans Health Administration (VHA). The American Society for Radiation Oncology (ASTRO) developed evidenced-based treatment guidelines for the management of patients with metastatic lung cancer. METHODS: In May 2016, an electronic survey of 88 VHA radiation oncologists (ROs) was conducted to assess metastatic lung cancer management. Demographic information was obtained and 2 clinical scenarios were presented to glean opinions on dose/fractionation schemes preferred, preferences for/against concurrent chemotherapy, and use of endobronchial brachytherapy (EBB) and/or yttrium aluminum garnet (YAG) laser technology. Survey results were assessed for concordance with published ASTRO guidelines. RESULTS: The survey response rate was 61%, with 93% of the 40 VHA radiation departments represented. Among respondents, 96% were board certified, and 90% held academic appointments. 88% were familiar with ASTRO guidelines. Preferred fractionation schemes were 20 Gy in 5 fractions (69%) and 30 Gy in 10 fractions (22%). The vast majority (98%) did not recommend concurrent chemotherapy for palliation. In the setting of bronchial obstruction with lung collapse, about half (49%) recommended EBB or YAG lung reexpansion before external beam radiotherapy. A minority of respondents use stereotactic body radiotherapy or EBB for palliation. CONCLUSION: Most respondents demonstrated up-to-date knowledge of current evidence-based treatment guidelines. We found no distinction in clinical decisions based on demographic profiles.

Severe hemolytic disease of the fetus and newborn due to anti-E and anti-Jka.

CONCLUSIONS: Red blood cell alloimmunization to antigens other than D, such as C, c, E, e, and antigens in the Kell, MNS, and Duffy blood group systems, has emerged as an important cause of hemolytic disease of the fetus and newborn (HDFN). Antibody screening for these antibodies is not routinely practiced for all antenatal patients in developing countries, mainly because of financial constraints. Here we report a rare case of HDFN due to dual antibodies to Rh and Kidd blood group system antigens: anti-E and anti-Jka. This case report highlights the importance of routine and regular antenatal screening of all pregnant women for proper monitoring and follow-up.

Adding further evidence for clinically significant anti-Leb antibody in a voluntary blood donor.

Herein, we report a case of naturally occurring anti-Leb alloantibody identified in the plasma of a first time voluntary blood donor. The immunohematology workup was done on the pilot sample tubes collected during blood donation by the conventional tube technique and using ID-Micro Column System Glass Beads card (anti-IgG, C3d; Ortho-Clinical Diagnostics, Raritan, New Jersey, USA). Blood group of the donor was confirmed to be B RhD positive, and the alloantibody in his plasma was identified as anti-Leb, having clinically significant characteristics. Since in this particular case, anti-Leb was IgM and IgG in nature, it was clinically significant and can lead to hemolytic transfusion reaction, especially if such fresh frozen plasma unit is transfused to Leb negative patients.