Informing blood donors about AIDS and risk factors: reactions to information provided in a regional blood bank in the Netherlands.

To safeguard blood transfusion therapy, anti-HIV testing has been standard in routine blood bank practice in the Netherlands since mid-1985. Despite the availability of serological testing for HIV infection, donor deferral remains of prime importance because of the period between HIV-infection and development of antibodies (the 'window phase'). Therefore blood and plasma donors are informed about AIDS and risk factors. Reactions of donors to such information were investigated in a regional blood bank in the Netherlands (1985-1987). Although there seems to be a good understanding of the necessity of reading information about AIDS, personal motives (not belonging to a risk group, having read information before, etc.) resulted in insufficient attention to the written information (a circular letter) by more than one third of respondents. We recommend that information on risk factors is given by a personal approach (i.e. interview) and by emphasizing the personal responsibility of donors for the safety of the blood supply used in blood transfusion therapy.

Intensive chemotherapy with autologous bone marrow transfusion as primary treatment in women with breast cancer and more than five involved axillary lymph nodes.

Patients with breast cancer and a high number of involved axillary lymph nodes have a poor prognosis, despite adjuvant chemotherapy. The 5-year disease-free survival (DFS) in this group amounts to 30-40% and the 10-year DFS is only 15-20%. Therefore, new treatment modalities are being sought for this group of patients. The aim of the present study was the evaluation of the efficacy of high-dose chemotherapy combined with autologous bone marrow support. 24 patients with a primary breast cancer with more than five involved axillary lymph nodes received, after surgery, six courses of induction chemotherapy followed by ablative chemotherapy and reinfusion of autologous bone marrow. All patients were premenopausal or less than 2 years postmenopausal. Induction chemotherapy consisted of methotrexate (MTX) 1.5 g/m2 intravenous (i.v.) and 5-fluorouracil (5-FU) 1.5 g/m2 i.v. on day 1, prednisone 40 mg/m2 orally on days 2-14, doxorubicin 50 mg/m2 i.v. and vincristine 1 mg/m2 i.v. on day 14. Courses were repeated six times every 4 weeks. 10 patients received cyclophosphamide 7 g/m2 i.v. and etoposide 1.5 g/m2 i.v. as intensive regimen, in 14 patients this comprised mitoxantrone 50 mg/m2 i.v. and thiotepa 800 mg/m2 i.v. Reinfusion of autologous marrow followed on day 7. Finally, patients received locoregional radiotherapy for extranodal disease and tamoxifen 40 mg daily orally over a period of 2 years. The median age of patients was 42 years, range 29-54. The median number of involved nodes was 10. During induction therapy, fever requiring i.v. antibiotics occurred in 4% of 144 courses, 14% of patients suffered from mucositis WHO grade 2-3, and the other patients had mucositis grade 1. During the ablative chemotherapy, 1 patient died, 6 developed septicaemia, 5 showed mucositis grade 3-4 and the other patients had mucositis grade 1 or 2. In the follow-up, 1 patient died from acute cardiac failure. Reversible radiation-induced pneumonitis occurred in 7 out of 14 irradiated patients; symptoms started directly following radiotherapy and lasted for several weeks, but disappeared in due course. During follow-up, 2 patients with six and > 10 positive nodes, respectively, have relapsed after 18 and 36 months, both in the cyclophosphamide/etoposide regimen. Median observation is 3 years, disease-free survival at 5 years is predicted to be 84%. Intensive treatment in these patients with high numbers of involved axillary lymph nodes is a toxic regimen, but may improve the chance of surviving free of disease.

Heparin small pool high yield purified factor VIII: in vivo recovery and half-life of routinely produced freeze-dried concentrate.

New approaches and techniques for improving source material collection and Factor VIII production at Blood Bank level have been reported recently. Heparin has been shown to be of importance in increasing yields and stability of FVIII in the purification and concentration process. Work has been done to develop on a routine scale the heparin double cold precipitation technique for the production of a freeze-dried high yield purified FVIII concentrate. The product has been tested clinically in 4 severe hemophilia A patients for recovery, half-life and acute side-effects, using two dosages over 8 infusions. There was no significant difference between the two dosages. Mean recovery 99.1% and mean half-life 8 hr, ranging from 6.5 to 10.3 hr. No side-effects justify further exploration of the potential of heparin for high yield purified FVIII production.

Autologous stem cell transplantation in multiple myeloma after VAD and EDAP courses: a high incidence of oligoclonal serum Igs post transplantation.

Thirty-seven patients with multiple myeloma (stage II and III, 65% increased beta2-microglobulin level) were prospectively treated with a median of 3.7 VAD courses (range 2-8) followed by cyclophosphamide (6 g/m2) in conjunction with G-CSF (5 microg/kg filgrastrim (n = 14), or 3.5 microg/kg lenograstrim (n = 22)), and peripheral stem cell (PSC) isolation. After regeneration this was followed by one EDAP course and high-dose melphalan (HDM, 200 mg/m2) in combination with re-infusion of PSC. Adequate stem cell mobilization was obtained with both G-CSF regimens. A median of 41x10(6) CD34+ cells/kg (range 4.5-161) was collected in a median of 1.6 leukapheresis procedures following filgrastrim (n = 14) and 24x10(6) CD34+ cells/kg (range 2. 3-80) in a median of 1.7 leukapheresis procedures following lenograstrim (n = 22) which indicated no significant difference (P = 0.24) between both G-CSF regimens. A rapid hematological recovery was obtained after HDM with reinfusion of a median of 9.3x10(6) CD34+ cells/kg. After the total courses the overall response was 84% with a complete remission rate of 30%. Currently the median overall survival is 44.0 months (95% CI 38.9-49.1) with a median follow-up of 33 months (range 3-51) and a median event-free survival of 29.0 months (95% CI 25.3-32.7) (n = 33). Post transplantation a high incidence of oligloclonal serum immunoglobulins (Igs) was observed. In 73% of the patients new oligoclonal or monoclonal serum bands were noticed 3 months post transplantation. IgG-lambda and IgG-kappa bands predominated. In 48% of the cases the oligoclonal Igs disappeared after a median follow-up of 22 months (range 8-36), whereas in 52% of the cases the oligoclonal Igs persisted with a median follow-up of 31 months (range 21-45), which did not correlate with a significant difference in overall, and event-free survival between both subgroups.

Effects of peripheral stem cell or bone marrow reinfusion on peripheral serotonin metabolism.

Reinfusion of autologous hematopoietic peripheral blood stem cells (PBSC) or bone marrow is often accompanied by flushing, dyspnea, abdominal cramping, nausea and diarrhea. These symptoms and the observation that they can be prevented by ondansetron, a selective 5-HT3 receptor antagonist, led to the assumption that these side-effects are due to infusion of free serotonin during the reinfusion of PBSC or bone marrow. Twenty-five patients with solid tumors received, after myeloblative chemotherapy, a total of 30 reinfusions of PBSC and/or bone marrow. In 17 patients, serotonin levels in the bags containing the PBSC were measured. In all patients, platelet serotonin levels were determined before and 1 h post-reinfusion. In addition, before and 24 h after reinfusion urine was collected for determination of 5-hydroxyindole acetic acid (5-HIAA) and serotonin concentrations. Mean (+/- s.d.) total serotonin concentration in the bags was 2404 +/- 1555 nmol/l. Mean total volume reinfused was 471 +/- 185 ml. After reinfusion, the mean (+/- s.d.) levels of serotonin in platelets in patients increased from 3.2 +/- 1.4 nm/10(9) at baseline to 3.8 +/- 2.0 nm/10(9) (P = 0.02). Neither 24 h urinary 5-HIAA nor serotonin levels were affected. These results indicate that reinfusion of PBSC or bone marrow is accompanied by substantial infusion of free serotonin, which might explain the observed side-effects and justify the use of 5-HT3 receptor antagonists as pre- medication for this procedure.

Factor VIII:C assay: influence of buffer components used in immunoaffinity chromatography for purification of factor VIII/von Willebrand factor.

A monoclonal antibody purified factor VIII concentrate containing FVIII/vWF complex has been assayed by one-stage clotting (CA) and chromogenic substrate (CSA) methods. The influences of potassium iodide (KI) and albumin in combination with predilution buffers, standards and storage of samples have been examined. These components are compared for their effect on FVIII potencies in final product and in-process controls. FVIII:C purified by immunoaffinity chromatography can not be measured reliably by CA or CSA, because of KI which interfere on the assay. Overall yield of FVIII, efficiency of IAC step and purity of FVIII can be determined by assaying the desalted samples.

Recovery of fibrinogen in cryoprecipitate pasteurized in the presence of sucrose and glycine.

The effect of sucrose (60% w/w) and 1 M glycine as thermal stabilizers for fibrinogen in cryoprecipitate was studied. Sucrose (9.2 g) and glycine (0.9 g) were dissolved in 6 g of cryoprecipitate and the solution was pasteurized at 60 degrees C for 10 h. The preparation was then dialyzed for 20 h in phosphate buffered saline (PBS), lyophilized, stored for one week at -40 degrees C and resuspended in distilled water. The recovery of total proteins and fibrinogen in the final product averaged 66.4 +/- 4.1% and 43.8 +/- 6.4% of the initial contents, respectively (mean +/- SEM, N = 9). The pasteurization of cryoprecipitate in the presence of PBS (control experiments) produced extensive precipitation, which is characteristic of protein denaturation. Thus, this method partially protected fibrinogen and other proteins in cryoprecipitate from inactivation by prolonged exposure to heat during pasteurization.

A simplified method for purification, concentration and freezing of bone marrow cells for autologous transplantation.

Autologous bone marrow (BM) transplantation is being increasingly applied in hematological and oncological patients. However, because of the need to purify and preserve BM requiring high technology, such treatments are virtually concentrated in the "developed" countries. This paper examines methods of BM purification and freezing that could make the technique potentially applicable in developing countries. Hemapheresis is routinely applied for BM purification in our Dutch Centre, where the buffy coats obtained from routine blood donations were utilised in experimental settings. Using DMSO as cryoprotectant, semi-purified white cells were frozen in liquid N2 (LN2), by mechanical freezer or snap-frozen at -55 degrees C. Different types of containers were compared including plastic tubes and ordinary blood bags. After thawing the results show that snap-freezing had a deleterious effect but the cell yields and viability were similar in LN2 or the mechanical freezer where the tubes and the bag were equally effective as containers (86% cell recovery with 90% viability). In the purification/concentration stage, reduction of the volume of the material by extra centrifugation, thus requiring less DMSO, produced better results--96% cell yield and 90% viability after thawing. This simplified method was applied in a general hospital in Sao Paulo where four oncology patients underwent BM collection. BM was purified and concentrated within a blood bank facility. Hydroxyethyl starch sedimentation and centrifugation of the material in plastic blood bags gave 80% BM cell harvest. After thawing from the mechanical freezer 1 x 10(8) BM cells/kg were available for reinfusion to patients. There was no immediate untoward reaction. Three of the patients showed signs of bone marrow regeneration by three weeks, but one patient died 16 days after transplantation, of septicemia. We conclude that certain high-technology procedures for ABMT can be adapted for existing facilities in developing countries.

Comparison of apheresis and other methods for separation and purification of hemopoietic stem cells: initial experience with a blood buffy coat model for the use of autologous bone marrow transplantation.

With an increasing number of bone marrow transplantations (BMT) being contemplated in leukemia and cancer patients, it is prudent for blood banks to develop a suitable program within their resources for harvesting, purifying and freezing bone marrow stem cells. In order to do this, initially a prototype has been developed involving buffy coat model (BC) using normal donor blood. Centrifugation, sedimentation and machine apheresis methods were separately evaluated leading to a combined and sequential handling procedure. Blood was passed through a cell separator resulting collection of BC with 90% reduction of the volume showing 80% recovery of total leucocytes and 87% yield of mononuclear cells. Following centrifugation the cells with DMSO were frozen in a controlled freezing system and stored in liquid nitrogen. After thawing 94% cells were recovered with 93% viability. The initial experience gained in the model system could be incorporated in autologous BMT program in patients but requires modifications for improved results; the latter will be described separately.

Plasma exchange in five patients with acute Guillain Barré syndrome.

During the last 3 years plasma exchanges were undertaken in 5 patients with acute Guillain Barré syndrome (G.B.S.). All the patients were admitted in the intensive respiratory care unit and had received six plasma exchange procedures over two weeks (each procedure consists of 2-3 L exchange). The first patient improved dramatically after the second exchange. Moderate success was obtained in two patients. One patient did not show any effect. The fifth patient received plasma exchange one day after her recovery phase had begun but the course of recovery remained uneffected. The effect of plasma exchange was analysed as the patients' response to motor activity, and compared with a historical control group consisting of 50 acute G.B.S. patients admitted in the intensive respiratory care area over the last 25 years. Plasma exchange does not seem to have exerted any significant effect although at any given time the plasma exchange group had higher motor activity than that of the control group. A controlled clinical trial especially in the early phase of the disease is emphasized.

Bone marrow separation, purification and cryopreservation: application for autologous bone marrow transplant (ABMT).

Autologous bone marrow transplantation is used in the treatment of patients suffering from malignant diseases. The intention of this study was to develop a technique for cryopreservation of bone marrow stem cells. A technique of purification described elsewhere (2), gave recoveries of 80% of nucleated blood cells and 87% of mononucleated blood cells after apheresis and centrifugation of buffy-coat, but when applied to bone marrow only 59% of NBC and 32% of CFUc have been harvested. We therefore modified the apheresis technique and replaced the centrifugation step by sedimentation with hydroxy-ethyl-starch. This change resulted in a small but significant increase in the yield of bone marrow cells and improved the asepsis of the procedure. From a second group of bone marrow handled with this modified protocol, final yields of 46% of NBC and 62% of MNC were obtained. After cryopreservation 87% of NBC were recovered as assessed by counting.

Risk management: an important tool for improving quality.

Risk management implies that one has identified and analysed the root cause of the risk. In blood transfusion public and political opinion on the perceived risks are mainly related to product stigmatisation, to cognitive aspects of risk. Therefore this perception is affective, and has a negative connotation. In order to manage risk in an optimal manner, we need to understand how people think about it, and recognise that thoughts, feelings and behaviour are determined not only by psychological factors, but also by social, cultural and political influences. Perception of risk is always situated within a context, which may differ. Therefore people (i.e., public and political opinion) seem to act inconsistently from one risk context to another. Crucial for understanding the logic behind different risk perceptions is how people think about a hazard and organise information about it. The blood supply system has aspects that make it very vulnerable to crises of confidence, as the subject of blood can easily become stigmatised. The impact of the latter on the perception of blood transfusions and their recipients as well as the willingness of the public to accepttransfusions can be dramatic. Risk perception needs to be monitored in order to anticipate and adequately deal with public and political acceptance. We know that risk and stigmatisation are closely interconnected, and that the costs are likely to be high both for human health and for the maintenance of the healthcare system. Thus there is a global need to carefully monitor the safety of the blood supply systems and communicate risk information in a way that both informs people and builds up public and political confidence. It is therefore not sufficient to simply state that the blood supply is safe; it must also be made safe. So risk management becomes an integral part of quality management, as it deals with the public perception of the blood supply system and its respective elements: procurement and use.

[Subspecialty blood transfusion medicine]. / Aandachtsgebied bloedtransfusiegeneeskunde.

The unification of Europe, the related principle of self-sufficiency and the prevention of blood banks turning into bureaucratic institutes that lose connection with bedside medicine underscores the need for training in transfusion medicine and its international organization. In most European countries transfusion medicine is now recognized as a specialty in its own right. In the Netherlands it was decided to recognize transfusion medicine as subspecialty of Internal Medicine. This new initiative led to a training programme of 6 years in all, of which the last 18 months are devoted to transfusion medicine exclusively. The importance of continuous education and practice in both fields is recognized.

[The use of blood and blood products in total hip arthroplasty in 31 European hospitals, 1990/'91]. / Het gebruik van bloed en bloedproducten bij totale heupartroplastieken in 31 Europese ziekenhuizen, 1990/'91.

OBJECTIVE: To compare the use of blood products and artificial colloids during total hip arthroplasty in European hospitals. DESIGN: Descriptive. SETTING: Europe. METHODS: During the period October 1990-October 1991 transfusion data were obtained about patients who underwent a planned total hip replacement for the first time. The investigations were performed in 31 teaching hospitals in ten countries of the EC, as a part of the ¿Safe and good use of blood in surgery' (SANGUIS)-project. RESULTS: Red cells were ordered preoperatively in 97.4% of the 1647 cases and transfused in 81% (ranges among hospitals: 29-100). Hospitals in the Mediterranean area used more auto-transfusion than those in Central and Northern Europe. Plasma was transfused in 6% of the patients, predominantly in hospitals in southern European countries. Albumin was used especially in Central and Northern European countries. The reasons for red cell transfusion were stated in the medical records in 23% of the cases, for plasma transfusions in 7% and for albumin in 1%. Averaged transfusion-related costs were 192 ecu per patient (ranges per hospital: 60-383 ecu). CONCLUSION: Differences between European hospitals in the use of blood products for total hip arthroplasty are considerable.

Small-pool high-yield factor VIII production.

Hemophilia care depends on several factors for the production of purified FVIII: plasma procurement, plasma logistics, production method, and efficacy. The latter two are restrictive factors, both for the supply and the safety of FVIII preparations. Conventional production methodology unavoidably recovers only 10 to 20% of usable protein, therefore requiring large pools of source plasma. Related to pool size is the transmission of diseases, which poses unnecessary risks for patients. The development of new technologies to better recover FVIII allows reduction of the pool size: crush-thaw, controlled pore-glass chromatography, and heparin double-cold precipitation techniques. This review will reflect on current production methods, pool size concept, small-pool approaches in FVIII production, and future developments.

Total quality management in blood transfusion.

Quality management is an ongoing development resulting in consistency products and services and ever increasing customer satisfaction. The ultimum is Total Quality Management. Quality systems and quality management in transfusion medicine have gained considerable attention since the outbreak of the AIDS epidemic. Where product orientation has long been applied through quality control, Good Manufacturing Practice (GMP) principles were introduced, shifting the developments in the direction of process orientation. Globally, and particularly in the more industrialised world people and system orientation has come along with the introduction of the ISO9001 concept. Harmonisation and a degree of uniformity are needed to implement a universally applicable Quality System and related Quality Management. Where the American Association of Blood Banks (AABB) is the professional organisation with the most extensive experience in quality systems in blood transfusion, the European Union and the Council of Europe now are in the process to design a quality system and management applicable to a larger variety of countries, based on a hybrid of current GMP and ISO9001 principles. The International Federation of Red Cross and Red Crescent Societies has developed a more universally to implement Quality Manual, with a pilot project in Honduras. It is recommendable to harmonise the various designs and bring the approaches under one common denominator.