Apheresis practice variation during the COVID-19 pandemic: Results of a survey.

BACKGROUND: The COVID-19 pandemic affected healthcare delivery across all specialties including apheresis. To describe the changes in apheresis service practices that occurred during the pandemic, the American Society for Apheresis (ASFA) Apheresis Medicine Attending Physician Subcommittee conducted a survey study. STUDY DESIGN AND METHODS: A 32-question survey was designed and distributed to 400 ASFA physician members on September 7, 2022. Attending physicians responded to questions about whether and how apheresis service practices changed during the COVID-19 pandemic compared with the time period prior to the pandemic in terms of: (1) procedure types and volumes, (2) patient consultation workflow, and (3) the use of telemedicine. Descriptive analyses were reported as number and frequency of responses. RESULTS: The survey response rate was 13.8% (55/400). Of these respondents, 96.4% (53/55) were attending physicians. The majority of respondents (42/53, 79.2%) indicated that the types of procedures performed during COVID-19 compared to pre-pandemic did not change. Most frequently for apheresis procedure volume, respondents reported: no change in their monthly inpatient volume (21/47, 44.7%) and a decrease in their monthly outpatient volume (28/46, 60.9%). Prior to COVID-19, 75.0% (30/40) of respondents performed consultations at bedside for inpatients and 67.4% (29/43) performed consultations at bedside for outpatients. Bedside consultations decreased in both settings during the pandemic but were still most frequently performed by attending physicians. At the same time, the use of telemedicine increased for 15.4% of survey respondents during COVID-19. CONCLUSION: Some, but not all, respondents observed or made changes to their apheresis service during the COVID-19 pandemic. A subset of changes, such as increased utilization of telemedicine, may persist.

Apheresis physician well-being during the COVID-19 pandemic: Results of a survey.

BACKGROUND: The COVID-19 pandemic has placed additional stressors on physician lives. In this study, we report findings from a survey conducted among attending physician (AP) members of the American Society for Apheresis (ASFA) to elucidate the status of their well-being during the COVID-19 pandemic as well as resources provided or actions taken by their institutions and themselves personally to maintain or improve their well-being. STUDY DESIGN AND METHODS: A 17-question, voluntary, IRB-approved survey regarding well-being was distributed to the ASFA AP members between August 26, 2020 and September 16, 2020. The descriptive analyses were reported as number and frequency of respondents for each question. Non-parametric chi-square tests, ANOVA, and paired t-tests were performed to determine differences in categorical variables, changes in well-being scores, and compare time points, respectively. RESULTS: Based on the responses of 70 attending level physicians representing the United States (U.S., 53, 75.7%) and outside the U.S. (17, 24.3%), the following were observed: (1) COVID-19 negatively affects the well-being of a sub-population of APs, (2) neither institutional nor individual measures to improve well-being completely resolved the problem of decreased AP well-being during the pandemic, and (3) personal actions may be superior to institutional resources. CONCLUSION: There is a widespread decline in AP well-being during the COVID-19 pandemic that was not adequately improved by institutional or personal resources/actions taken. Institutions and physicians must work together to implement strategies including resources and actions that could further improve AP physician well-being during a public health crisis.

How do I manage O- red blood cell inventory.

Currently there are no widely accepted guidelines regarding the appropriate use of O- red blood cells (RBCs). Although there has been a decline in overall RBC utilization since 2010, the use of O- RBCs has continued to proportionally increase over this time period resulting in frequent shortages. When faced with these shortages, we implemented some simple strategies that resulted in a significant decrease in annual O- RBC utilization from 10% to 7.5% despite an increase in total RBC utilization. These strategies included collaboration with the clinical staff, improving practices within the blood bank, and having our health system partner with our blood supplier. Herein, we detail our strategies for hospital transfusion services to improve O- RBC utilization. Most of these can be easily implemented and do not require additional resources.

Vascular access practices for therapeutic apheresis: Results of a survey.

INTRODUCTION: Obtaining vascular access (VA) is a critical part of the therapeutic apheresis (TA) treatment plan. Currently, there are no guidelines for VA decision-making and maintenance related to TA procedures. MATERIALS AND METHODS: A 28-question survey to gather qualitative information regarding VA practices was distributed to the American Society for Apheresis (ASFA) 2018 Annual Meeting attendees and all ASFA members for voluntary participation. The descriptive analyses were reported as the number and frequency of responses for each question. RESULTS: Total participation was 206 with 147 (71.4%) answering some or all 16 VA focused questions. The majority of respondents were nurses or physicians (89.0%) at sites providing ≥100 procedures. The most common TA procedures were plasma exchange, red cell exchange, and leukocytapheresis. The VA evaluation was predominantly performed by the TA service (80.3%, 118/147). The majority of TA physicians and/or providers do not insert (91.7%, 132/144) or remove (81.2%, 117/143) VA catheters. When an emergent TA procedure is needed, the majority of respondents felt <2 hours was an acceptable turnaround time for VA placement (64.3%, 92/143). The most common anticoagulant for locking catheters and/or ports was heparin. The majority of TA services (54.3%, 76/140) collect data on aborted procedures due to catheter/line/port problems unrelated to infection, but only 41.4% (58/140) collect data on infections. CONCLUSION: VA contributes significantly to the overall risks associated with and the safety of TA. Our survey shows that there is substantial variation but common themes in TA VA practices. Several areas for future research may be identified.

Choosing Wisely for apheresis.

The Choosing Wisely campaign has stimulated clinicians to think about the appropriateness of various tests and procedures, compelling physicians to make smarter, safer and more effective choices for high quality patient care and to reduce healthcare cost. The American Society for Apheresis (ASFA) strives to advance apheresis medicine through education, evidence-based practice, research and advocacy. To complement these shared missions, ASFA created a working group, consisting of representatives from the various ASFA committees, to produce recommendations for apheresis medicine that reflect the Choosing Wisely guiding principles. A diverse group of ASFA physician and allied health members reviewed, rated and ranked 9 original draft proposals. Additional revisions and refinements were made prior to external review and adoption of five final recommendations by the ASFA Board of Directors. The ASFA Choosing Wisely recommendations encourage apheresis practitioners, patients and donors to discuss and prioritize best clinical practices that avoid harm and waste while optimizing clinical benefit.

Is group A thawed plasma suitable as the first option for emergency release transfusion? (CME).

BACKGROUND: Group AB plasma, which lacks anti-A and anti-B isohemagglutinins, is issued for emergency transfusion when a patient's ABO group is unknown, but the relative scarcity of group AB blood donors limits its availability. We sought to establish a thawed plasma inventory to improve the rapid availability of plasma in the emergency release setting but were concerned about potential wastage of group AB plasma. STUDY DESIGN AND METHODS: Recognizing that plasma-incompatible apheresis platelets are routinely transfused and only rarely result in hemolytic reactions if the donor is blood group O, and considering that group A plasma would be compatible with approximately 85% of our patient population, we instituted an emergency release policy whereby thawed group A plasma is issued to all patients of unknown blood group or if compatible plasma is not available. ABO-compatible plasma is then issued, if needed, once the patient's blood group is determined. We prospectively assessed the outcomes of all patients who received incompatible plasma under our policy. RESULTS: During the first 5 years under this policy, 385 emergency release requests for plasma were received by our blood bank. Among them, 23 group B or AB patients met criteria for receiving a median of 2 units of incompatible group A plasma. No hemolytic transfusion reactions or other adverse events related to transfusion were seen in any of these 23 patients. CONCLUSION: We propose that group A plasma may be an acceptable alternative to AB plasma as the first option in the emergency release setting.

Safety and efficacy of autologous hemopoietic progenitor cell collection in tandem with hemodialysis in multiple myeloma with myeloma cast nephropathy.

Autologous hemopoietic progenitor cell (HPC) collection is the most frequent indication for an apheresis procedure in patients with multiple myeloma, up to 10% of whom may also require hemodialysis because of myeloma kidney. We investigated whether HPC collection could be performed in tandem with hemodialysis, to avoid extra outpatient visits for extracorporeal procedures, without compromising the efficacy of the hemodialysis, the HPC collection efficiency (CE) or patient safety. Four dialysis-dependent patients with multiple myeloma underwent 5 large volume leukapheresis HPC collections in tandem with hemodialysis. Under our protocol, all of the blood processed through the apheresis instrument was dialyzed against a standard calcium-rich bath prior to being returned to the patient, therefore no supplemental calcium was needed. No significant changes in pulse rate (P = 0.625) or mean arterial pressure (P = 0.188) were noted between the start and end of the procedures. The patients exhibited no signs or symptoms of hypocalcemia or other adverse effects. Calculated urea reduction ratios ranged between 62.5 and 73.9%, and HPC CE was between 53 and 84% for 4 of the 5 procedures, indicating that there was no compromise of either procedure when performed in tandem. Ionized calcium measured at the beginning, midpoint and end of every procedure did not change (P = 0.954). The two patients who proceeded to autologous HPC transplant engrafted on Days 11 and 10, respectively. We conclude that autologous HPC collection can safely be performed in tandem with hemodialysis without compromising the efficacy of dialysis, HPC CE, or patient safety.

Evidence-based review of therapeutic plasma exchange in neurological disorders.

Several neurologic disorders have been treated with therapeutic plasma exchange (TPE). Case reports, case series, and clinical trials have published results regarding the outcomes in such patients. The data gathered have been used to formulate evidence-based guidelines, which can be used to guide therapy in patients with these neurological disorders. Adequately designed and powered randomized controlled trials have proven the efficacy of TPE in some disease entities, while other diseases are lacking such data. In the latter, decisions for the use of TPE must be made using the limited published data available. In this review, we discuss the published evidence regarding the use of TPE in neurological disorders, focusing on the most recent guidelines published by the American Society of Apheresis in 2010 and the American Academy of Neurology in 2011.

Streamlining ABO antibody titrations for monitoring ABO-incompatible kidney transplants.

BACKGROUND: We have monitored ABO antibody titers in 53 ABO-incompatible kidney transplants (INKTs) using a time-consuming, conventional test tube (CTT) method that included a 30-minute room temperature (RT) phase, followed by incubation for 30 minutes at 37 degrees C and conversion to the anti-human globulin (AHG) phase. Our studies have indicated that AHG ABO antibody titers are critical for clinical management, but RT titers do not supplement clinical decision making. Therefore, we assessed AHG titers by two methods: 1) a revised test tube (TT) method without RT and 2) an anti-immunoglobulin G (IgG) gel microcolumn (IgG gel) method with a goal of streamlining ABO antibody titrations. STUDY DESIGN AND METHODS: Fifty frozen samples from our INKT collection with anti-A and/or anti-B AHG titers of 2 to 512 were titrated by revised TT method with 30 minutes at 37 degrees C and conversion to AHG and by IgG gel method with 15 minutes at 37 degrees C and centrifugation. RESULTS: The titers using the revised TT and IgG gel methods had 64 and 52% concordance, respectively, with CTT AHG titers. Neither the revised TT AHG titers nor the IgG gel titers varied by more than one standard dilution from the CTT AHG titers, which is within acceptable limits for titration techniques. CONCLUSIONS: The revised TT and IgG gel titers are comparable to the CTT AHG titers. The IgG gel method offers the best titer turnaround time, eliminating 45 minutes of incubation time alone. Implementation of this technique would benefit ABO INKT patients by providing titer results in a more timely manner.

Promise and challenges of anticoagulation with dabigatran.

Dabigatran, marketed as Pradaxa (Boehringer Ingelheim) in the USA, is a direct thrombin inhibitor that holds great promise. It has been shown to reduce the risk of stroke and venous thromboembolism with similar if not greater efficacy than warfarin and with far fewer side effects. However, like other anticoagulants, it can cause severe bleeding complications and lacks a specific antidote with proven efficacy. The patient presented here was on dabigatran and sustained a traumatic intracranial hemorrhage (ICH). The ICH continued to progress despite prompt initiation of 3h of hemodialysis in an effort to remove the offending drug from the circulation. Through this case report, we highlight the challenges of anticoagulation with dabigatran including the lack of routine testing for monitoring its effect and of a specific antidote. We also discuss the potential role of dialysis in treating patients with life-threatening bleeding on dabigatran.

Ductal eccrine carcinoma with squamous differentiation: apropos a case.

Sweat gland carcinomas are rare. Given this, they can pose a diagnostic challenge especially in shave biopsy specimens. We present a case of ductal eccrine carcinoma with extensive squamoid differentiation that was repeatedly misdiagnosed by multiple dermatopathologists as squamous cell carcinoma in the initial few biopsies. As the distinction between these two neoplasms is crucial to patient management, we highlight the histologic features of this uncommon entity to highlight the potential diagnostic pitfalls.