A rare report of H-partially deficient, non-secretor phenotype from India. An Ah like the rèunion and unlike a Para Bombay-Clarifying misinterpretations.

BACKGROUND: H-deficient phenotypes are classified as H-deficient non- secretors (Bombay Oh), H-deficient secretors (Para Bombay), and H-partially deficient non-secretors (O h reunion, Ah and Bh, ABh). REPORT: We report the first case of H-partially deficient non-secretor- the Ah phenotype from India. What makes this report interesting is that they do not fit into the Bombay, or the Para Bombay series of H-deficient phenotypes and these partially deficient non-secretors were exclusively found on Réunion Island, off the East Coast of Africa in 1982. These reunion type phenotypes have not been reported since then and may lead to misinterpretations and confusions when encountered in the current existing laboratory settings especially in the low income (LIC's) and low middle income (LMIC's) countries like our own. Moreover, literature from LMIC and LIC incorrectly uses Ah/Bh for parabombay phenotypes. CONCLUSIONS: H-deficient phenotypes are rare, challenging to identify and assign correct notations. Hence, we have highlighted characteristic differences between H-deficient phenotypes and illustrated a diagnostic laboratory approach to correctly identify and assign notations to them especially in the resource constrained settings.

Surgical blood ordering schedule for better inventory management: An experience from a tertiary care transfusion center.

Background: Overordering of blood has been a challenge faced by the blood bank staff. The present study addresses the role of maximum surgical blood ordering schedule (MSBOS) in optimizing the blood inventory management. Methods: The blood requests for elective surgical procedures from various surgical departments were reviewed to constitute MSBOS. Transfusion profile was assessed using crossmatch to transfused units (C/T) ratio, transfusion probability (TP), and transfusion index (TI). A cutoff of 0.3 and 5% value of TI and TP, respectively, was considered to decide on the type of crossmatch. The efficacy of MSBOS implementation has been determined prospectively by unpaired t test using SPSS software, version 20 (IBM, USA). Results: A total of 2674 patients were studied. Overall red cell usage rate was 15%. The comprehensive C/T ratio was 4.57. The C/T ratios for the various departments ranged from 1 to 8.5 (adjusted C/T ratio). Highest C/T ratio was observed for surgical procedures performed in the specialties of otorhinolaryngology and urology. A C/T ratio greater than 5 was noted in 30.4% of different types of surgical procedures. Of the 176 different types of elective surgical procedures studied, type and screen protocol was applicable for 75.5% (133) of the procedures. After implementation of MSBOS, the number of crossmatches reduced by 2152 and total working time saved in our laboratory is close to 75,320 man hours. Conclusion: MSBOS helps in identifying the common surgical procedures with low TP and is one of the efficient tools in preventing the overordering of the blood.

Impact of Regular Whole-Blood Donation on Body Iron Stores.

BACKGROUND AND OBJECTIVES: Regular and repeat blood donations may cause reduced body iron stores (BIS), which may lead to a shrinking donor pool. Furthermore, hemoglobin (Hb) itself is quite an inadequate measure to detect iron deficiency. Hence, our primary aim was to understand the effect of repeated blood donations on BIS in regular blood donors. STUDY DESIGN AND SETTING: We conducted a prospective study on voluntary whole-blood donors (September 2015 through August 2017). Donor demographics were noted. Donors were further divided into four groups, depending on their number of donations. Their samples were tested for Hb, red cell indices, and serum ferritin to check for reduced BIS. The data obtained were analyzed using SPSS version 20 (IBM, USA). RESULTS: A total of 374 regular voluntary blood donors were included in the study. The mean serum ferritin levels in males and females were 75.4 and 36.2µg/L, respectively. There was a 45% decrement in the mean serum ferritin values in Group I (101.57 µg/L) in contrast to Group III (56.69 µg/L) (p < 0.0032). In the study, 9.8, 11.2, and 4.8% of the donors were in Stage 1, Stage 2, and Stage 3 of reduced BIS, respectively. Of the donors, 11.2% were in Stage 2 of reduced BIS. Further donations in such cases can compromise donor safety. CONCLUSION: The present study demonstrates iron depletion in regular voluntary blood donors. In 11.2% of the donors, iron deficiency erythropoiesis was noted. A ferritin screening after the first donation followed up at the tenth donation might help detect iron-deficient individuals. Iron supplementation for all regular blood donors and female donors in particular will help prevent the shrinking donor pool due to iron deficiency.

Significance of mandating a dedicated hemovigilance nurse and objectification of 'imputability' levels. Experience from a hospital-based blood centre in India.

BACKGROUND: National Hemovigilance Programme aims at improving patient and donor outcomes by monitoring adverse reactions. This requires an additional effort by existing manpower that is already a handful and may offer a leeway if not mandated and designated to a hemovigilance nurse. AIMS AND OBJECTIVES: To analyse the reported adverse transfusion reactions (ATR) and their subsequent uplink/upload into the Hemovigilance program of India (HvPI) and to observe subjective discrepancy in the diagnosis of ATR and their imputability to transfusion. MATERIAL AND METHODS: ATR were analysed from May 2016 to October 2021 in a hospital-based blood centre in India. Two groups were formed, Group I constituted ATR that were reported and uplinked to HvPI, and Group II constituted all reported ATR irrespective of the uplink/upload. All ATR were reanalysed for a subjective discrepancy in diagnosis and imputability levels. Results were analysed online statistical software MedCalc using the "Exact Poissons Method" and the Chi-square test with a significant p-value of <0.05. RESULTS: In total 169 ATR were reported in 166 patients and 89 (52.6%) were uplinked, with an incident rate of 1 in 1412 and 1 in 743 in Group I and Group II respectively. The difference was statistically significant (p < 0.0001). Allergic reactions were the most common type in both groups followed by FNHTR with PRBC as the most implicated blood product. A discrepancy of around 4.3% and 17.9% in diagnosis and imputability level respectively was observed. CONCLUSIONS: The difference in incidence rates in the two groups indicates a mandate for dedicated hemovigilance nurses in every centre to aid in accurate data sharing with the National hemovigilance systems. Discrepancies in diagnosis can be mitigated by identification and understanding of ATR through case-based objective approach. Discrepancy in assigning imputability levels to adverse reactions can be minimised by objectifying the scales followed by spreading awareness though campaigns. These initiatives can effectively be aided by the hemovigilance nurse.

Blood Inventory Management During COVID-19 Pandemic Using a Simple Mathematical Tool: A Two-Year Study from a Tertiary Care Hospital in North India.

Multiple recurrent waves of the coronavirus disease 2019 (COVID-19) resulted in major fluctuations in blood supply and demand, which presented a major challenge for the blood centres to maintain adequate blood inventory. Hence, the primary aim of the present study was to determine whether safety stock as a simple mathematical tool can be used to maintain optimum blood inventory to meet all blood demands. The secondary aim of the study was to test whether daily blood stock index (DBSI), which was a novel index developed by the authors and derived from the calculated safety stock, can be used to minimize blood wastage due to the outdating of packed red blood cells (PRBC)/whole blood (WB) units. The present study was a descriptive, cross-sectional study conducted from 1st October 2019 to 31st December 2021 at a blood centre of a tertiary care hospital. For the purpose of data analysis, the time period of study was divided into 7 periods signifying different phases during the COVID-19 outbreak. Data of PRBC/WB (referred to as red cell) collection, red cell issue and the daily red cell stock were collected for these 7 time periods. Safety stock, percentage of out-dated whole blood/packed red blood cell units (OB) and DBSI were calculated based on the data extracted. Red cell collection as well as red cell utilization decreased during the 1st as well as the 2nd wave of the COVID-19 outbreak. The blood centre was able to meet the blood demand of the hospital at all times, as the daily average red cell stock remained above the calculated safety stock during all periods. OB (12.4%) and DBSI (2.3) were highest during the lockdown period of second wave of COVID-19 outbreak (period E). A strong direct relationship was seen between OB (dependent variable) and DBSI (predictor variable) [R = 0.79; p = 0.03]. Firstly, safety stock is a simple, user-friendly mathematic tool which can be used for efficient blood inventory management not only at times of a pandemic/disaster but also during routine times. Secondly, DBSI is a logical and empirical tool to reduce OB units and consequently reduce blood wastage.

Extended blood group phenotyping of donors from the lower and middle Himalayan region of Uttarakhand India: A pilot study.

BACKGROUND: The state of Uttarakhand, bordering countries such as Tibet and Nepal, is a multi-ethnic region. Further, erythrocyte alloimmunization may arise from the incompatibility of major and/or minor blood groups between ethnically diverse donors and recipients. We aimed to screen Uttarakhand blood donors (UBDs) for extended phenotyping of their erythrocytes serologically. METHODS: This prospective cross-sectional analysis involved all UBD samples collected at the blood centre of our tertiary-care hospital. Samples were obtained over 9 months (Mar'22 to Nov'22). Donors who were O-typed, DAT-negative and non-reactive for TTI markers were processed further for serological testing using the column agglutination technique utilizing 21 different monoclonal antisera (Ortho diagnostics Pvt ltd, Mumbai India). The research was financially aided by UCOST, Uttarakhand, Government of India. RESULTS: Of the 5,407 blood samples collected, the total number of O-typed samples collected was 1622. Of these 1622, 329 (20.2 %) O-typed samples were selected based on our inclusion criteria and hence further phenotyped. Amongst these 329 UBDs, the average age was 32.7 ± 9.32 (18-52) years and the male-to-female ratio was (M: F = 12:1). The prevalence of high- and low-frequency blood antigens in our study was Rh (D 96.6 %, C 84.8 %, c 63.5 %, E 27.9 % and e 92 %), Lewis (Lea 6.3 %, Leb 31.9 %), Kidd (Jka 87.8 %, Jkb 63.2 %), Kell (K 1.8 %, k 96.3 %) and Duffy (Fya 63.5 %, Fyb 10.6 %). And in the MNS system we received 21.2 % as M, 10.9 % N, 37 % S and 51.3 % as s respectively. We also identified some very rare minor antigens such as Dia 1.8 %, Ina 1.8 %, Cw 0.6 % and, 1.2 % Mur positive donors, which are not common in our population, as per the published literature. Moreover, we also identified one Bombay blood phenotype (Oh) in one of our UBD recruits. CONCLUSION: To sum up, practically with the outcome of this research, we were also able to identify rare phenotypes among the local people and a rare blood donor registry was created. This repository shall also come in use for our multi-transfused patients having different oncological and haematological ailments.

Pure Red Cell Aplasia Encountered in a Tertiary Care Hematology Laboratory: A Series of Nine Distinctive Cases.

Pure red cell aplasia (PRCA) is characterized by severe anemia with reticulocytopenia and bone marrow erythroblastopenia. The early erythroblasts are markedly decreased; however, in rare instances, they may be normal or raised in number. There are varied etiologies, namely congenital or acquired and primary or secondary. The congenital PRCA is known as "Diamond-Blackfan anemia." Thymomas, autoimmune disease, lymphomas, infections, and drugs also may be familiar associates. However, the etiologies of PRCA are numerous, and many diseases/infections can be associated with PRCA. The diagnosis rests on clinical suspicion and appropriate laboratory workup. We evaluated nine cases of red cell aplasia, having severe anemia with reticulocytopenia. Nearly half of the cases showed adequate erythroid (> 5% of the differential count) but with a maturation arrest. The adequacy of the erythroid could confuse the hematologist and may even delay the diagnosis. Hence, it is empirical that PRCA could be considered a differential in every case of severe anemia with reticulocytopenia, even in the presence of adequate erythroid precursors in the bone marrow.

A novel scoring system for selecting the target patients of COVID-19 convalescent plasma therapy: A hypothesis.

The primary cause of mortality in patients of coronavirus disease 2019 (COVID-19) is the cytokine storm and not directly due to the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus. Therefore, it is being stressed by transfusion medicine specialists to use COVID-19 convalescent plasma (CCP) therapy early in the course of the disease, preferably within 72h of diagnosis. The authors herein, propose a scoring system for the rapid assessment of the patients who have tested positive for SARS-CoV-2. Therefore, a systematic approach may be followed where the patients are categorised into two groups, namely, the low-risk group [LRG; score<5] and the high-risk group [HRG; score ≥ 5] based on this scoring system. Those classified as an HRG should be administered CCP therapy within 72h of a confirmed diagnosis of COVID-19 to neutralise the SARS-CoV-2 virus and prevent the occurrence of the cytokine storm. This in turn could help reduce the overall mortality in the recipients.

A Cross-Sectional Comparative Characterization of Hematological Changes in Patients with COVID-19 Infection, Non-COVID Influenza-like Illnesses and Healthy Controls.

INTRODUCTION: Studies have documented the role of the "neutrophil-to-lymphocyte ratio" (NLR) in influenza virus infection. In addition, morphometric parameters derived from automated analyzers on the volume, scatter and conductivity of monocytes, neutrophils and lymphocytes in many viral etiologies have helped with their early differentiation. With this background, we aimed to characterize the hematological changes of coronavirus-positive cases and also compare them with the healthy controls and patients affected by non-COVID Influenza-like illnesses so that early isolation could be considered. MATERIAL AND METHODS: This was a cross-sectional analytical study carried out in the years 2020-2022. All cases with COVID-19 and non-COVID-19 Influenza-like illnesses and healthy controls above 18 years were included. Cases were diagnosed according to the WHO guidelines. All samples were processed on a Unicel DxH 800 (Beckman Coulter, California, USA) automated hematology analyzer. The demographic, clinical and regular hematological parameters along with additional parameters such as volume, conductivity and scatter (VCS) of the three groups were compared. RESULTS: The 169 COVID-19 cases were in the moderate to severe category. Compared with 140 healthy controls, the majority of the routine hematological values including the NLR (neutrophil-to-lymphocyte ratio) and PLR (platelet-to-lymphocyte ratio) showed statistically significant differences. A cutoff of an absolute neutrophil count of 4350 cell/cumm was found to have a sensitivity of 76% and specificity of 70% in differentiating moderate and severe COVID-19 cases from healthy controls. COVID-19 and the non-COVID-19 Influenza-like illnesses were similar statistically in all parameters except the PLR, mean neutrophilic and monocytic volume, scatter parameters in neutrophils, axial light loss in monocytes and NLR. Interestingly, there was a trend of higher mean volumes and scatter in neutrophils and monocytes in COVID-19 cases as compared to non-COVID-19 Influenza-like illnesses. CONCLUSION: We demonstrated morphological changes in neutrophils, monocytes and lymphocytes in COVID-19 infection and also non-COVID-19 Influenza-like illnesses with the help of VCS parameters. A cutoff for the absolute neutrophils count was able to differentiate COVID-19 infection requiring hospitalization from healthy controls and eosinopenia was a characteristic finding in cases with COVID-19 infection.

Ethical issues facing hematopoietic stem cell transplantation in India.

A successful Hematopoietic stem cell transplantation (HSCT) is often the only hope of survival for children suffering from a range of potentially life-threatening hematological malignancies. The financial, ethical, and emotional problems faced by the matched sibling donor and their recipient siblings during the HSCT are extremely complex and challenging. Herein, the authors have attempted to pen down these in the configuration of a poem.

Reviewing the Ethical Concerns of the Convalescent Plasma Therapy in COVID-19.

The understanding of coronavirus disease 2019 (COVID-19) is evolving periodically. There is also a marked increase in COVID-19 patients' demand for the provision of COVID-19 convalescent plasma (CCP) therapy. With the review of the literature, the stage of speculation is quickly moving towards conformity, with the interim guidelines given by the Food and Drug Administration (FDA) in the United States, United Kingdom's blood transfusion services, Saudi's FDA, and the Indian Council for Medical Research, in addition to the European health authorities. It is prudent to address the ethical concerns that merit consideration while harvesting and utilizing CCP as a therapeutic tool in local hospital setting.

Zeroing in on the root cause of the clots in a blood bag: Reinforcing improvement in blood collection practices.

Blood clots in the packed red blood cell [PRBC] unit can sometimes go unrecognized and could eventually give rise to flow problems while administering the same. We herein report our observation of a moderately elongated threadlike clot in a PRBC unit prepared from a whole blood donated by a young Indian male donor. The PRBC unit was returned to us from the ward by the nursing staff citing "flow issues". In fact, this warranted the initiation of root-cause analysis of the entire event led by two faculty members, one post-graduate student and the technical supervisor at our blood centre.

Strawberry milky-white blood donor's plasma: signaling uncontrolled diabetic lipemia.

Intake of a fatty meal before donating blood can lead to an increased level of plasma triglyceride concentration for several hours. This may cause either turbid and or "milky-white" appearance of their venous plasma samples. We, however, report a peculiar case about a male blood donor from India, whose plasma appeared to be "strawberry milky-white" in colour. On inquiry, he gave a history of poorly controlled diabetes mellitus type-II. Further, this was affirmed by his high blood glucose concentration [nearly 326mg/dL] and HbA1c [13.7%] respectively. Moreover, his plasma triglyceride concentration was elevated up to 376mg/dL. His treatment was started at our hospital and the strawberry colour of his plasma, dramatically recovered to normal straw-colour after achieving a fairly good glycemic control with the insulin therapy.

Locally harvested Covid-19 convalescent plasma could probably help combat the geographically determined SARS-CoV-2 viral variants.

The only effective way to provide individuals with herd immunity against the novel coronavirus [SARS-CoV-2] is to administer an effective vaccine that will help check the current pandemic status. In India, the central drugs standard control organization (CDSCO) has granted the emergency-use authorization [EUA] to three vaccines namely, Covishield (live vaccine, Oxford AstraZeneca, United Kingdom being manufactured by the Serum Institute of India), Covaxin (inactivated vaccine, Bharat Biotech, India) and Sputnik V (live vaccine, Gamaleya, Russia). However, there is a rising need for the efficacy of the vaccines to be proven against the "SARS-CoV-2 viral variants." Also, human plasma is polyclonal in nature with an inherent propensity to identify multiple epitopes of either an antigen or pathogen. With this context in mind, the researchers hypothesize that using COVID-19 convalescent plasma [CCP] harvested from the locally recovered individuals [i.e. potential CCP donors] may be particularly beneficial in combating not only the founder SARS-CoV-2 virus but also the geographically determined SARS-CoV-2 variants among the regionally affected COVID-19 patients.

Blood donation must go on.

Reacting to the repeated messages on his phone, the blood donor goes to a blood center and donates his AB Rh D negative blood. There, he sees the blood center technician whose mother requires this rare blood unit as she is undergoing treatment at the hospital. The very act of blood donation is soul-satisfying for him as he pens down his experience in the configuration of a poem.

Current Perspectives of convalescent plasma therapy in COVID-19.

The outbreak of the coronavirus disease 2019 (COVID-19) has posed an unprecedented challenge to the health care communities across the globe. As of June 2, 2020, a total of 6,418,968 confirmed COVID-19 cases with 378,954 deaths have been reported. Different regions of the world have reported varying intensity of COVID-19 severity. The disease burden for COVID-19 depends on multiple factors like the local infection rate, susceptible population, mortality rate, and so on. The COVID-19 pandemic is a rapidly evolving emergency and is a subject of regular debate and advanced research. As of today, there is a lack of definitive treatment options for COVID-19 pneumonia. In search of alternative options, few drugs are being tested for their efficacy and repurposing. Preliminary reports have shown positive outcomes with Remdesivir and tocilizumab, but this needs further confirmation. Recently, the therapeutic application of Convalescent Plasma therapy in critically ill patients suffering from COVID-19 has gained momentum. We hereby discuss the convalescent plasma as a potential therapeutic option, its challenges of finding the ideal donors, transfusion medicine responsibilities, and the current global experience with its use.