Vox Sanguinis International Forum on the use of prehospital blood products and pharmaceuticals in the treatment of patients with traumatic haemorrhage.

While specific practices and transported blood products vary around the world, most of the respondents in this International Forum transported at least one blood product for the transfusion to bleeding patients en route to the hospital. The most commonly carried product was RBCs, while the use of whole blood will likely increase given the recent reports of its successful use in the civilian setting, and because of the change in the AABB's Standards regulating its use. It will be interesting to see if plasma use in the prehospital setting becomes more widely used given today's enhanced appreciated of the coagulopathy of trauma and plasma's beneficial effect in reversing it, and if blood products are transported to the scene of injury by more vehicles, that is, not just predominantly in helicopters. It was not surprising that TXA is being widely administered as close to the time of injury as possible given its potential benefit in these patients. This International Forum highlights the importance of focusing attention on prehospital transfusion management with a need to further high­quality research in this area to guide optimal resuscitation strategies.

Prevalence of anti-hepatitis B surface antibodies among children and adolescents vaccinated in infancy and effect of booster dose administered within a pilot study.

We determined the prevalence of anti-hepatitis B surface antibodies (anti-HBs) among children and adolescents vaccinated for hepatitis B virus in infancy as part of the routine vaccination programme. A representative serum sample of the Israeli population age 0-19 was tested. In a separate pilot study, a booster dose of hepatitis B vaccine was administered to 31 candidates for national service, who were fully vaccinated in infancy and tested negative for hepatitis B surface antibodies at age 17-19 years and anti-HBs antibodies were assessed 8 weeks later. Of the 1273 samples tested, 631 (49·6%) were positive to anti-HBs antibodies. Seropositivity rates were 89·5% among infants aged 6-12 months and declined significantly with age to 20·7% at age 19 years. No differences in seropositivity rates were observed between Jews and Arabs, males and females and those born in Israel and in other countries. Seroconversion rate among the 31 individuals who received a booster dose was 90·3% (95% CI: 75·1-96·6%). We recommend a booster dose for healthcare personnel before starting to work at the health care facility.

The implementation of rapid cooling and overnight hold of whole blood at ambient temperature before processing into components in Israel.

BACKGROUND: The quality of blood components prepared from whole blood (WB) units rapidly cooled to 20 to 24°C and stored for prolonged periods using butane-1,4-diol "cooling plates," and the factors that determine the functional activity of these cooling systems under various temperature conditions were investigated. STUDY DESIGN AND METHODS: Validation of the cooling systems functions, performed in different environmental temperature-time schemes using WB-mock units, were recorded and analyzed in 106 temperature curves, simulating environmental conditions of blood storage at the blood drives and transport to the blood services component laboratory. The quality of red blood cells, fresh-frozen plasma, platelet concentrates, and cryoprecipitate units was studied on components routinely prepared in 2007 to 2009 from WB units collected in citrate-phosphate-dextrose-adenine or citrate-phosphate-dextrose (CPD), rapidly cooled, and stored in ambient temperature for up to 22 hours postdonation using the cooling systems. RESULTS: Quality variables of blood components prepared from WB units rapidly cooled and held overnight for up to 22 hours postcollection, using both cooling systems, met the allowed ranges of American, European, and Israeli standards. Temperature validation of the cooling systems resulted in national standard operating procedures for the proper use in different ambient temperature ranges. CONCLUSION: The rapid cooling of WB and prolonged storage under different environmental conditions using cooling plate systems enabled standardization of blood storage at and transportation from all collection sites. It provided an efficient, reproducible, and cost-effective way to ensure good quality blood components, while utilizing more efficient logistic and administrative means.

Inventory management.

A critical aspect of blood transfusion is the timely provision of high quality blood products. This task remains a significant challenge for many blood services and blood systems reflecting the difficulty of balancing the recruitment of sufficient donors, the optimal utilization of the donor's gift, the increasing safety related restrictions on blood donation, a growing menu of specialized blood products and an ever-growing imperative to increase the efficiency of blood product provision from a cost perspective. As our industry now faces questions about our standard practices including whether or not the age of blood has a negative impact on recipients, it is timely to take a look at our collective inventory management practices. This International Forum represents an effort to get a snap shot of inventory management practices around the world, and to understand the range of different products provided for patients. In addition to sharing current inventory management practices, this Forum is intended to foster an exchange of ideas around where we see our field moving with respect to various issues including specialty products, new technologies, and reducing recipient risk from blood transfusion products.

Predictors for non-compliance of notified hepatitis C virus-positive blood donors with recommendation to seek medical counselling.

BACKGROUND: Notification of blood donors represents the commonest method of informing asymptomatic individuals of abnormal test results indicating exposure to hepatitis C virus (HCV) infection. Such notification is therefore important from both health and economic perspectives. This study aimed to identify predictors for non-compliance of HCV-positive blood donors with the National Blood Services recommendation to seek medical counselling. STUDY DESIGN AND METHODS: The current research is a cross-sectional study. Telephone interviews were conducted with 201 blood donors identified as HCV positive following blood donation during 2001-2002 (40% response rate). RESULTS: About 25% of all the notified blood donors did not seek any counselling; 29% (44/150) of those who requested medical advice from their primary care physicians (general practitoner's) were not referred to specialists. Age, alcohol consumption and non-practice of health-promoting behaviour were independent predictors of non-compliance with the blood services' recommendation. In particular, smoking (odds ratio, 2.0; 95% confidence interval 1.0-4.2) and not undergoing professional teeth cleaning (odds ratio 2.8; 95% confidence interval 1.3-6.1) were found to be significant predictors of non-compliance. CONCLUSION: The study provides essential data regarding the extent and risk factors for non-compliance of HCV-positive blood donors with recommendation to seek medical advice. Our results can assist in identifying blood donors who would not seek counselling, based on demographic factors and past exposure to risk factors for HCV. Improvements in the notification process and additional training of general practitoners regarding the management of HCV disease are needed.

Why would young people donate blood? A survey-based questionnaire study.

BACKGROUND AND OBJECTIVES: Different issues associated with blood donation among young donors were studied, towards building a large and consistent blood donor base. METHODS: Data were collected from 221/285 donors in drives conducted among military personnel (response rate of 78%), through a self-administered questionnaire tailored to review knowledge, beliefs, attitudes and habits regarding blood and general donations. Data were then further analysed using a multivariate model. RESULTS: The most significant factors related to blood donation were the donors' perception of approval from a superior (the commander's request to donate blood) and the participant's military rank or position (P < 0.0001 and P = 0.0019, respectively). Experienced blood donors comprised 71.9 % of all donors and more donations were noted among men (P = 0.0013). CONCLUSIONS: The important role of a significant superior, and his or her personal involvement in the blood drive organization was elucidated. Various other factors, previously found to be related to readiness or reluctance to donate blood, were insignificant among the studied population. Our finding may assist blood centres in optimizing their efforts in recruiting and retention of young donors.

Impact of pooling on accuracy of hepatitis B virus surface antigen screening of blood donations.

Expenditure on screening blood donations in developing countries can be reduced by testing donations in pools. This study evaluated serological screening in pools for hepatitis B virus (HBV) at the Israeli national blood bank and a hospital blood bank in Gaza, the Palestinian Authority. The accuracy of HBV surface antigen (HBsAg) enzyme immunoassay performed on pools of 3-24 samples was compared with individual tests. Delay in detecting positive samples due to dilution in pools and the possibility of antibody-antigen neutralization were analyzed. The sensitivity of pooled testing for HBsAg was 93-99%, prolonging the window period by 5 days (8.3%). Neutralization of HBsAg by hepatitis B surface antibodies (anti-HBs) could be minimized by testing immediately after pooling. Serological testing for HBsAg in pools may be performed using manually created pools of up to six samples, with 5% loss in sensitivity and a risk of neutralization by anti-HBs present in the donor population. Pooling can therefore be considered as an option only in countries with a low prevalence of HBV.

Differing erythrocyte membrane skeletal protein defects in alpha and beta thalassemia.

Thalassemic red cells show irregular morphology and maldistribution of glycoproteins and sialic acids. These changes are compatible with damage to the red cell membrane skeleton. To test this possibility, we systematically studied the interconnections of skeletal proteins in patients with a form of alpha thalassemia (HbH disease), in patients with beta thalassemia intermedia, and in normal individuals. Alpha- and beta-thalassemic spectrin functions normally in spectrin self-association, binding to normal inside-out vesicles (IOVs), and binding to actin in the presence and absence of normal protein 4.1. Binding of normal spectrin to beta: thalassemic IOVs is normal but alpha-thalassemic IOVs are defective and bind only half the normal amount of spectrin (66 +/- 5 vs. 120 +/- 16 micrograms spectrin dimer/mg IOV protein, respectively). A different defect is detected in beta thalassemia, in which protein 4.1 shows markedly reduced ability (48 +/- 7% of normal) to enhance the binding of normal spectrin to actin and a decreased ability to bind normal spectrin in a binary interaction, compared with normal protein 4.1 (24 +/- 1 and 43 +/- 1 micrograms protein 4.1/mg spectrin, respectively). As no quantitative deficiency of beta-thalassemic protein 4.1 is detected, we assume an acquired lesion is present, which affects about half of the protein 4.1 molecules. These findings indicate that specific, localized, yet different defects exist in the skeletal proteins of alpha- and beta-thalassemic red cells. The different molecular lesions imply that the mechanism of hemolysis and probably the interaction of unpaired globin chains with the membrane differs in the two diseases.

Estimation of delay in detecting hepatitis C virus antibodies in pools compared to individual testing on seroconversion panels.

Testing for anti-hepatitis C virus (HCV) antibodies in pools may reduce blood screening costs, making this approach affordable for developing countries, provided that the dilution of infected blood does not significantly increase the number of undetectable viral particles, especially in seroconverters. This study assessed the delay in detection of HCV antibodies in five HCV seroconversion panels, tested in pools of 6-48 samples, and estimated the risk of transfusion-transmitted HCV caused by pooling. The delay in detection of positive samples was 5-12 days for pools of all sizes, adding 7% to the risk of HCV transmission that occurs when blood donors' samples are tested individually.

Rare blood donors: a personal approach.

The National Blood Group Reference Laboratory (NBGRL) in Israel was established in Jerusalem in 1971 and transferred to Magen David Adom (MDA), National Blood Services in 1995. This laboratory was the inspiration of the first author of this article for over 30 years. The realization of this vision was made possible by the cooperation of colleagues and laboratory workers in blood transfusion services throughout the country. The aim of the service was to provide diagnostic help in resolving immunohematologic problems found in the blood banks and clinics in Israel. In the beginning, only a part-time technician performed the work and testing was done using very limited reagents. The service was expanded by personal visits to all of the 22 blood banks in Israel to explain the aim of this new service and to educate them about the importance of resolving each and every case. One major issue was the cost involved in referring problems but it was decided at the outset that these would be covered by the government to ensure that a workup would be performed for all referred cases. The expansion of the service could not have been achieved without the help of the SCARF program. This voluntary service enabled us to identify the first rare donors in Israel, resolve complex cases, and find compatible blood for our patients. To illustrate the importance of the NBGRL in Israel and the rapid resolution of cases referred, several individual stories are described. The purpose of this review is to show the importance of the NBGRL in identifying rare blood groups and in providing and coordinating services and the importance of keeping in close contact with the rare donors to encourage and promote their donations, which may save lives.

Oxidative damage to human red cells induced by copper and iron complexes in the presence of ascorbate.

The role of trace metals in the generation of free radical mediated oxidative stress in normal human red cells was studied. Ascorbate and either soluble complexes of Cu(II) or Fe(III) provoked changes in red cell morphology, alteration in the polypeptide pattern of membrane proteins, and significant increases in methemoglobin. Neither ascorbate nor the metal complexes alone caused significant changes to the cells. The rate of methemoglobin formation was a function of ascorbate and metal concentrations, and the chemical nature of the chelate. Cu(II) was about 10-times more effective than Fe(III) in the formation of methemoglobin. Several metals were tested for their ability to compete with Cu(II) and Fe(III). Only zinc caused a significant inhibition of methemoglobin formation by Fe(III)-fructose. These observations suggest that site-specific as well as general free radical damage is induced by redox metals when the metals are either bound to membrane proteins or to macromolecules in the cytoplasm. The Cu(II) and Fe(III) function in two catalytic capacities: (1) oxidation of ascorbate by O2 to yield H2O2, and (2) generation of hydroxyl radicals from H2O2 in a Fenton reaction. These mechanisms are different from the known damage to red cells caused by the binding of Fe(III) or Cu(II) to the thiol groups of glucose-6-phosphate dehydrogenase. Our system may be a useful model for understanding the mechanisms for oxidative damage associated with thalassemia and other congenital hemolytic anemias.

Evaluation of the BioPlex 2200 ANA screen: analysis of 510 healthy subjects: incidence of natural/predictive autoantibodies.

The BioPlex 2200 ANA Screen is a fully automated system that determines levels for 13 different autoimmune antibodies of established clinical significance. The objective of this study was to determine the specificity of the BioPlex 2200 ANA Screen assay and to analyze the antibody profile samples collected from healthy subjects against comparative ELISA and IIF screening methods. A total of 510 specimens were randomly selected from a cohort of apparently healthy blood bank donors. Samples were distributed to five age brackets. All samples were tested using Bio-Rad's ANA Screen kit. Specificity was compared to IIF and ELISA results. Most of the samples were found negative in all ANA screening systems (84.5% by IIF, 92.5% by BioPlex 2200 ANA Screen kit, and 94.5% by ELISA). The frequency of positive results was highest (15.5%) using IIF, in comparison to almost similar results (5.5% vs. 7.5%) achieved by ANA ELISA and BioPlex 2200 ANA Screen kits. The positive rate of autoantibodies was significantly reduced when analyzed by different combinations of ANA screen assays (from 2.35% using IIF + BioPlex ANA Screen tests to 0.98% by using all three tests). Using the BioPlex 2200 ANA Screen system, we were able to identify samples with high levels of individual antibodies: anti-dsDNA at 20-63 IU/mL, antichromatin at 4-8 AI, anti-SmRNP at 2-6 AI, and anti-RNPA at 2-4.5 AI. Importantly, from 7 IIF and ELISA positive sera, 5 of these were also BioPlex 2200 positive, suggesting that the BioPlex is seeing the samples that are of the greatest interest, using the established techniques. The specificity of the BioPlex 2200 ANA Screen analysis of 13 different analytes (dsDNA, centromere B, chromatin, Jo1, ribosomal P, RNP 68, RNP A, Scl-70, Sm, SmPNP, SS-A52, SS-A60, SS-B) is comparable (P < 0.252) to the ELISA ANA screening test. Like the ELISA, the BioPlex 2200 has a lower (P < 0.001) positive rate than IIF for the autoantibody screening.

Persistent anti-Dra in two pregnancies.

The Drori (Dr(a)) antigen is one of the ten high-prevalence antigens of the Cromer blood system, which are carried on decayaccelerating factor (DAF, CD55). The Dr(a-) phenotype was first described in a 48-year-old Jewish woman from Bukhara. Her serum contained an antibody to a high-prevalence antigen named anti-Dra. Most known individuals with the Dr(a-) phenotype are Jews from the geographic area of Bukhara, but individuals from Japan have also been described. Antibodies in the Cromer blood group system, including anti-Dra,have never been reported to cause HDN. In most of the cases with anti-Dra examined in Israel, the antibodies have been subtyped as IgG2 and IgG4. This report is of a woman with Dr(a-) phenotype and an anti-Dr(a) titer of 256 to 512 in her serum, observed during two successive pregnancies. At birth, the RBCs of the first- and second-born child were negative and positive in the DAT, respectively, and neither manifested clinical signs of HDN. The disappearance of Cromer system antibodies, including anti-Dra in midpregnancy, has been described in a previous study. In that study, it was theorized that the antibodies in the serum of the women were adsorbed onto placental DAF. The finding of a high anti-Dra titer in two successive pregnancies in this patient, with a positive DAT for the RBCs of one of the two babies at term, differs from published reports, suggesting that a different mechanism might be involved.

Oxidative denaturation of red blood cells in thalassemia.

We believe that on the basis of all available data, severe oxidative damage occurs in alpha- and beta-thalassemic RBCs, as depicted schematically in Fig 6. The differences in the severity and pattern of the oxidative damage may be related to the type and, perhaps, quantity of precipitated globin chains. The detrimental effect of the excess chains is multifold. In the process of globin-chain precipitation, free radicals are generated. The end product of the precipitated hemoglobin chains is heme, from which eventually iron and globin are liberated. Globin chains have been found to interact and disrupt the RBC membrane, damaging the cytoskeleton. The role of heme has not yet been studied in detail in thalassemic RBCs. However, there is some evidence that it participates in damaging RBCs in other types of hemoglobinopathies. Excess of iron is known to be a catalyst of peroxidation via the Fenton reaction, causing damage to the various RBC membrane components (lipids, proteins, etc). The denatured hemaglobin, in the form of hemichromes, aggregates with protein 3, forming Actual proof of excessive free radical production in thalassemia is still warranted. It will not be easy to document since the amount of superoxide dismutase in RBCs is above and beyond that required for neutralizing excess amount of superoxide. The more active radicals, particularly hydroxyl free radical, are difficult to measure because they are so active an interact immediately with any given substrate in their vicinity. In addition, we have to better understand the finding of excess membrane lipids in thalassemic RBCs and whether there are changes in the formation and propagation of lipid peroxidation in these cells compared with normal RBCs. Regarding the proteins, further understanding is required concerning the exact type and sites of oxidation that occurs in the beta-thalassemia 4.1 protein, and whether the damage found in alpha-thalassemia is due to oxidation of ankyrin itself or its entrapment within the complex of the precipitated hemichromes of beta chains. What is the role of the different globin chain oxidation and precipitation in generating such different cytoskeletal protein alterations? Another point that needs to be elucidated is the role of different kinds of antibodies that are attached to the newly exposed antigenic sites on the thalassemic RBC membranes.(ABSTRACT TRUNCATED AT 400 WORDS)

Treatment of human ulcers by application of macrophages prepared from a blood unit.

Decubital ulcers contribute to morbidity and mortality in elderly patients. Macrophages play a major role in the process of wound healing. We compared the efficacy of local treatment of decubital ulcers in elderly patients using macrophages prepared from a blood unit, vs. conventional treatments. Patients with decubital ulcers (n = 199) hospitalized during one year in a Geriatric Hospital in Israel, were included in the study. The ulcers of 72 patients (average age 82), who provided informed consent, by themselves or by family, were treated by local injection of macrophages prepared from a blood unit in a closed sterile system. The remaining 127 patients (average age 79) were treated conventionally and served as controls. No exclusion criteria were applied. Only a completely healed ulcer was considered a positive outcome of treatment. In the macrophage-treated group 27% (36 out of 131 ulcers) were healed compared to 6% (15 out of 248) in the control group (p < 0.001). There was also a significantly faster healing in the experimental group (p < 0.02). No side effects were noted. We conclude that Macrophages prepared from a blood unit, in cost-effective, closed, sterile system, are significantly more effective than conventional methods for the treatment of ulcers in elderly patients.

High prevalence of complement C7 deficiency among healthy blood donors of Moroccan Jewish ancestry.

The incidence of the specific component deficiencies in various ethnic groups is not known, although there appears to be an ethnic predilection for C6 and C8alpha-gamma deficiencies in blacks, whereas C7 and C8beta deficiencies are predominantly noted in Caucasians. Infectious diseases, particularly recurrent meningococcal infections, are observed more commonly with late component deficiencies. In the current study, we have simplified the PCR technique by using site-directed mutagenesis and designer primers in a cohort of Israeli Moroccan Jewish blood donors to ascertain allele frequency in this ethnic group, which, based on earlier studies, was considered to be at risk for C7 deficiency. The total mutant allele frequency in this ethnic cohort was 1.1% of a total of 365 healthy Israeli Moroccan Jews, including one homozygote. The identification of mutant alleles was efficient and inexpensive, and hence a large cohort was studied. The finding of complement deficiency identifies individuals at risk for Neisserial infections, which are known to be potentially life-threatening. Conversely, when a patient of Moroccan ancestry is diagnosed with a Neisserial infection, it is important to determine the complement status.