The wider perspective: cord blood banks and their future prospects.

Over the past three decades, cord blood transplantation (CBT) has established its role as an alternative allograft stem cell source. But the future of stored CB units should be to extend their use in updated transplant approaches and develop new CB applications. Thus, CBT will require a coordinated, multicentric, review of transplantation methods and an upgrade and realignment of banking resources and operations. Significant improvements have already been proposed to support the clinical perspective including definition of the cellular threshold for engraftment, development of transplantation methods for adult patients, engraftment acceleration with single cell expansion and homing technologies, personalised protocols to improve efficacy, use of adoptive cell therapy to mitigate delayed immune reconstitution, and further enhancement of the graft-versus-leukaemia effect using advanced therapies. The role of CB banks in improving transplantation results are also critical by optimizing the collection, processing, storage and characterization of CB units, and improving reproducibility, efficiency and cost of banking. But future developments beyond transplantation are needed. This implies the extension from transplantation banks to banks that support cell therapy, regenerative medicine and specialized transfusion medicine. This new "CB banking 2.0" concept will require promotion of international scientific and technical collaborations between bank specialists, clinical investigators and transplant physicians.

Assessing the impact of an automated Web-based motivational interview on the intention and return behavior of Australian O-negative donors.

BACKGROUND: O-negative donors are a critical resource for blood collection agencies, and their recruitment and retention provides an ongoing challenge. Motivational interviewing shows promise as a tool to promote donor retention, although concerns about scalability remain. The current study examined the effect of an automated Web-based interview drawing on motivational interviewing and self-determination theory on O-negative donors' motivation, intention, and behavior. STUDY DESIGN AND METHODS: Within 13 days of donating, 2820 O-negative donors completed baseline measures of motivation and intention before being randomly assigned to complete either a motivational interview (MI) or active control interview (ACI). Motivation and intention were assessed at 2 days and at 7 weeks after participation in the MI or ACI, with return behavior tracked for 6 months following trial completion. RESULTS: Changes in donor motivation and intention, rate, and time to return did not vary by participation in the MI or ACI. When compared with O-negative donors who experienced business-as-usual practices, donors completing the MI or ACI returned to donate more, and they returned more quickly. However, subsequent exploratory analyses considering the behavior of those who did not accept the invitation to participate and those who completed only baseline measures showed that the improved return behavior of donors in the MI or ACI conditions was likely not due to any specific properties of the MI or ACI activities. CONCLUSIONS: Australian O-negative donors were highly internally motivated and committed to donating. An automated Web-based motivational interview appears to be of limited effectiveness in promoting the return of such donors.

Population-based projections of blood supply and demand, China, 2017-2036.

OBJECTIVE: To estimate the long-term effect of the changing demography in China on blood supply and demand. METHODS: We developed a predictive model to estimate blood supply and demand during 2017-2036 in mainland China and in 31 province-level regions. Model parameters were obtained from World Population Prospects, China statistical yearbook 2016, China's report on blood safety and records from a large tertiary hospital. Our main assumptions were stable age-specific per capita blood supply and demand over time. FINDINGS: We estimated that the change in demographic structure between 2016 (baseline year) and 2036 would result in a 16.0% decrease in blood supply (from 43.2 million units of 200 mL to 36.3 million units) and a 33.1% increase in demand (from 43.2 million units to 57.5 million units). In 2036, there would be an estimated shortage of 21.2 million units. An annual increase in supply between 0.9% and 1.8% is required to maintain a balance in blood supply and demand. This increase is not enough for every region as regional differences will increase, e.g. a blood demand/supply ratio ≥ 1.45 by 2036 is predicted in regions with large populations older than 65 years. Sensitivity analyses showed that increasing donations by 4.0% annually by people aged 18-34 years or decreasing the overall blood discard rate from 5.0% to 2.0% would not offset but help reduce the blood shortage. CONCLUSION: Multidimensional strategies and tailored, coordinated actions are needed to deal with growing pressures on blood services because of China's ageing population.

Past, present, and future: a qualitative and literature study identifying historical trends, drivers, and transformational factors for the future demand of blood supply in the Netherlands.

BACKGROUND: As blood transfusion has evolved, there is a need to understand its historical trends and underlying drivers. Furthermore, for blood bank management to make decisions about the future, they need to consider what transformational factors (defined as developments in science, society, and technology) could significantly impact blood demand and to what effect. This study has a two-fold aim: to explore transfusion experts' perspectives regarding 1) historical trends and drivers of red blood cells (RBCs) in the past 20 years and 2) transformational factors that would impact the future demand of RBCs and to what effect. STUDY DESIGN AND METHODS: Forty-two semi-structured interviews were held with transfusion experts from the Netherlands and abroad, supplemented with a literature review of Pubmed, Google Scholar, and gray literature. RESULTS: With regard to historical trends and drivers, experts shared two main trends: decreased or increased demands for RBCs. Various drivers were reported for each trend, coupled with evidence from literature. With regard to the future, experts anticipated that RBC demands will either increase (17%), decrease (45%), decrease but stabilize (12%), or stabilize as is (7%). Various transformational factors were found to support each trend (e.g., gene therapy will reduce RBC demand), although there were factors for which experts were unsure about its effects (e.g., cultured RBCs). Seven groups of transformation factors were identified in the literature review. CONCLUSION: While the future of blood transfusion is uncertain, there are actions that blood banks may take now to prepare for potential future developments.

Banking feces: a new frontier for public blood banks?

Fecal microbiota transplantation (FMT) is an effective treatment for recurrent Clostridioides difficile infection and is potentially beneficial in other microbiota-related disorders. The provision of FMT in routine clinical practice requires an extensive infrastructure that is reliant on voluntary donors. Alongside an increasing demand for FMT, the logistic barriers of a large-scale donor-dependent operation and the difficulties among health authorities to regulate FMT limit the dissemination of sustainable FMT services. Blood centers are large organizations that handle a multitude of donor-dependent operations on a daily basis. Blood and feces share many of the same dependencies, and feces may present a new opportunity for the blood services to handle. In this paper, we describe how an FMT service may be established and embedded within the blood service infrastructure, and we explain the benefits of using blood donors as feces donors. We further explore the current indications of FMT, the challenges related to the lack of legislation, and the future perspectives for blood banks to meet a new and increasing demand.

Trends in antigen-negative red blood cell distributions by racial or ethnic groups in the United States.

BACKGROUND: The overall number of red blood cell (RBC) units distributed to hospitals throughout the world and in the United States has decreased lately. This study was performed to determine if the number of antigen-negative RBC units distributed to hospitals has followed this trend. STUDY DESIGN AND METHODS: Stratified by ethnicity, data on total RBC distributions and antigen-negative RBC distributions from six large blood collectors in the United States were obtained from 2009 through 2016. An antigen-negative unit was defined as a unit with a specific RBC phenotype that had been specially ordered as such by a hospital. RESULTS: Overall, 10,103,703 RBC units were distributed by these six blood collectors; 650,516 (6.4%) were distributed as antigen-negative units. While the overall number of RBCs distributed decreased by 27.2% between 2009 and 2016, the number of antigen-negative RBC distributions increased by 39.5%. In each year, the majority of the distributed antigen-negative RBCs were donated by whites. However, antigen-negative RBC units from black or African American donors were distributed in a disproportionately high fraction compared to the overall number of RBCs distributed from these donors. Most of the one through four antigen-negative RBCs were donated by whites. However, as antigen matching became more extensive, the proportion of units distributed from black or African American donors increased such that they were the predominant donors of five or more antigen-negative units. CONCLUSION: Blood collectors will need to be aware of the trend of increasing antigen-negative distributions despite decreased overall distributions.

Trends in US minority red blood cell unit donations.

BACKGROUND: To provide the appropriately diverse blood supply necessary to support alloimmunized and chronically transfused patients, minority donation recruitment programs have been implemented. This study investigated temporal changes in minority red blood cell (RBC) donation patterns in the United States. STUDY DESIGN AND METHODS: Data on donor race and ethnicity from 2006 through 2015, including the number of unique donors, collections, RBCs successfully donated, and average annual number of RBC donations per donor (donor fraction), were collected from eight US blood collectors. Minority donors were stratified into the following groups: Asian, black or African American, Hispanic or Latino, Native Indian or Alaska Native, Native Hawaiian or other Pacific Islander, white, multiracial/other, and no answer/not sure. RESULTS: Over the 10-year period, white donors annually constituted the majority of unique donors (range, 70.7%-73.9%), had the greatest proportion of collections (range, 76.1%-79.8%), and donated the greatest proportion of RBC units (range, 76.3%-80.2%). These donors also had the highest annual donor fraction (range, 1.82-1.91 units per donor). Black or African American donors annually constituted between 4.9 and 5.2% of all donors during the study period and donated between 4.0 and 4.3% of all RBC units. Linear regression analysis revealed decreasing numbers of donors, collections, and donated RBC units from white donors over time. CONCLUSION: Although the US population has diversified, and minority recruitment programs have been implemented, white donors constitute the majority of RBC donors and donations. Focused and effective efforts are needed to increase the proportion of minority donors.

Continued decline in blood collection and transfusion in the United States-2015.

BACKGROUND: In 2011 and 2013, the National Blood Collection and Utilization Survey (NBCUS) revealed declines in blood collection and transfusion in the United States. The objective of this study was to describe blood services in 2015. STUDY DESIGN AND METHODS: The 2015 NBCUS was distributed to all US blood collection centers, all hospitals performing at least 1000 surgeries annually, and a 40% random sample of hospitals performing 100 to 999 surgeries annually. Weighting and imputation were used to generate national estimates for units of blood and components collected, deferred, distributed, transfused, and outdated. RESULTS: Response rates for the 2015 NBCUS were 78.4% for blood collection centers and 73.9% for transfusing hospitals. In 2015, 12,591,000 units of red blood cells (RBCs) (95% confidence interval [CI], 11,985,000-13,197,000 units of RBCs) were collected, and 11,349,000 (95% CI, 10,592,000-11,747,000) were transfused, representing declines since 2013 of 11.6% and 13.9%, respectively. Total platelet units distributed (2,436,000; 95% CI, 2,230,000-2,642,000) and transfused (1,983,000; 95% CI, 1,816,000 = 2,151,000) declined by 0.5% and 13.1%, respectively, since 2013. Plasma distributions (3,714,000; 95% CI, 3,306,000-4,121,000) and transfusions (2,727,000; 95% CI, 2,594,000-2,859,000) in 2015 declined since 2013. The median price paid per unit in 2015-$211 for leukocyte-reduced RBCs, $524 for apheresis platelets, and $54 for fresh frozen plasma-was less for all components than in 2013. CONCLUSIONS: The 2015 NBCUS findings suggest that continued declines in demand for blood products resulted in fewer units collected and distributed Maintaining a blood inventory sufficient to meet routine and emergent demands will require further monitoring and understanding of these trends.

How do i participate in T-cell immunotherapy?

T cells play a key role in the adaptive immune response, and the ability to manipulate T cells for therapeutic uses has advanced in the past decade. Infusion of expanded or engineered T cells can potentially be used to treat cancer, viral infections, graft-versus-host disease, and organ transplant rejection. The role that blood banks play in the manufacture and distribution of T-cell therapeutics is still being defined. Given the regulatory framework of blood banks, they are well positioned to collect raw material for manufacture of T-cell therapies and to distribute finished product to hospitals in support of clinical trials or eventually for licensed products. A deeper level of involvement in manufacture of T-cell therapeutics is also possible, although that requires more substantial investment in physical facilities and personnel with the regulatory and scientific expertise to prepare and produce cellular therapy products. Examples of physical infrastructure needed would be a laboratory with a clean room for culture of T cells, specialized equipment for expansion of the cells, and adequate administrative and storage support space. Processes that would need to be developed to produce T-cell therapeutics would include development of standard operating procedures and an appropriate quality assurance program. As blood banks consider supporting this novel class of therapies, they will need to weigh capital and expertise requirements with the benefits of providing a novel therapy and the potential of growth for their operations.

Declining blood collection and utilization in the United States.

BACKGROUND: The Department of Health and Human Services National Blood Collection and Utilization Survey (NBCUS) has been conducted biennially since 1997. Data are used to estimate national blood collection and utilization. STUDY DESIGN AND METHODS: The 2013 Department of Health and Human Services NBCUS is a cross-sectional survey of all US blood collection centers and hospitals as listed in the 2012 American Hospital Association Annual Survey database that perform at least 100 inpatient surgical procedures annually. The study objective was to estimate, with 95% confidence intervals (CIs), the number of blood and blood components collected and transfused in the United States. RESULTS: In 2013, a total of 14,237,000 whole blood and apheresis red blood cell (RBC) units (95% CI, 13,639,000-14,835,000) were collected with 13,395,000 available for transfusion. Of these, 13,180,000 (95% CI, 12,389,000-13,972,000) whole blood and RBC units were transfused. This represented a 4.4% decline in the number of transfused units compared to 2011. Outdated (i.e., expired without being transfused) whole blood and RBC units declined by 17.3%. Apheresis (2,318,000; 95% CI, 2,154,000-2,482,000) and whole blood-derived platelet (PLT; 130,000; 95% CI, 23,000-237,000) distribution declined in 2013. Total PLT transfusions increased in 2013 (2,281,000) in comparison to 2011 (2,169,000). Total plasma units distributed (4,338,000) and transfused (3,624,000) declined. CONCLUSION: Both blood collection and utilization have declined, but the gap between collection and utilization is narrowing. As collections decline further and hospitals decrease transfusions and manage products more efficiently, the decline in surplus inventory may be a concern for disaster preparedness or other unexpected utilization needs.

US Army blood program: 2025 and beyond.

In preparing to support the Army in 2025 and beyond, the Army Blood Program remains actively engaged with the research and advanced development of blood products and medical technology to improve blood safety and efficacy in conjunction with the US Army Medical Research and Materiel Command. National and International Blood Bank authorities have noted that the US Army research and development efforts in providing new blood products and improving blood safety operate on the cutting edge of technology and are transformational for the global blood industry. Over the past 14 years, the Army has transformed how blood support is provided and improved the survival rate of casualties. Almost every product or process developed by or for the military has found an application in treating civilian patients. Conflicts have many unwanted consequences; however, in times of conflict, one positive aspect is the identification of novel solutions to improve the safety and efficacy of the blood supply.

Cytomegalovirus in Australian blood donors: seroepidemiology and seronegative red blood cell component inventories.

BACKGROUND: Cytomegalovirus (CMV) can lead to severe disease in high-risk subpopulations. To prevent transfusion-transmitted CMV in these patient groups, the Australian Red Cross Blood Service maintains inventories of CMV-seronegative fresh blood components. STUDY DESIGN AND METHODS: Donor demographic data and CMV seroscreening results for all blood donations and blood components issued in Australia between financial years (FYs) 2008/09 to 2012/13 inclusive were obtained. Population estimates were also extracted for the calculation of age-weighted seroprevalence estimates. Linear regression was used to model trends in red blood cell (RBC) component acquisition and demand. RESULTS: The estimated age-weighted seroprevalence of CMV in 20- to 69-year old Australians was 76.12 ± 0.13%, with higher seroprevalence in females and older age groups. Seroprevalence decreased over the study period, while the demand for CMV-seronegative RBC components increased. It was predicted that component acquisition may be insufficient by FY 2017/18 if current trends persist. CONCLUSION: These findings represent an evaluation of CMV seroepidemiology in Australia and form a basis to predict the future status of CMV-seronegative RBC component inventories. The results will serve to guide Blood Service operations and inform current international debate on CMV-safe blood components.

Cord Blood Banking in the Arab World: Current Status and Future Developments.

Umbilical cord blood transplants are now used to treat numerous types of immune- and blood-related disorders and genetic diseases. Cord blood (CB) banks play an important role in these transplants by processing and storing CB units. In addition to their therapeutic potential, these banks raise ethical and regulatory questions, especially in emerging markets in the Arab world. In this article, the authors review CB banking in five countries in the region, Jordan, Saudi Arabia, Egypt, Qatar, and the United Arab Emirates, selected for their different CB banking policies and initiatives. In assessing these case studies, the authors present regional trends and issues, including religious perspectives, policies, and demographic risk factors. This research suggests strong incentives for increasing the number of CB units that are collected from and available to Arab populations. In addition, the deficit in knowledge concerning public opinion and awareness in the region should be addressed to ensure educated decision-making.

Are hybrid umbilical cord blood banks really the best of both worlds?

Since the first use of umbilical cord blood (UCB) as a medical therapy, the number of UCB banks worldwide has grown. Public UCB banks offer the option of altruistic donation, whereas private banks allow a product to be stored for the exclusive use of the paying client. With many more UCB products banked privately than publicly in countries such as the USA, hybrid models blending aspects of public and private banking have been proposed. One such bank is in operation in the UK. In this paper we review the hybrid UCB model and conclude that it offers limited benefit to the general public. Furthermore, compared with private banking, this model provides few advantages and potential disadvantages to private clients.

Reduction in red blood cell transfusion associated with engagement of the ordering physician.

BACKGROUND: Data on red blood cell (RBC) transfusion in the United States show variation in practice and overprescribing or overdosing is considered to be prevalent. Education or restrictive interventions could modify practice. STUDY DESIGN AND METHODS: RBC transfusion and mortality rates were recorded in a single institution over a 15-year period. The first 3 years were used as a baseline. Education measures were used to influence practice for 3 years followed by a 9-year period when questionable RBC orders in nonbleeding inpatients resulted in prospective physician notification for potential modification. Physician notification was done by blood bank technologists with transfusion medicine physician support, if needed. Pretransfusion hemoglobin levels of more than 9 g/dL were recommended for cancellation and levels between 8 and 9 g/dL advised for a single unit, if 2 or more units were requested. RBC transfusion rates were described as inpatient units per 1000 discharges to allow for interyear comparison. RESULTS: A downward trend in RBC transfusion was noted for the intervention period. Comparison of the baseline period with the past 3 years of the intervention period showed an approximate 33% decrease, which was highly significant (508 ± 66 vs. 341 ± 32, p < 0.01). Inpatient mortality rates declined over this period. CONCLUSION: Physician education in appropriate transfusion practice is desirable but may not greatly impact RBC use. Engagement of physicians who prescribe RBCs that appear inappropriate for indication or dose was associated with a significant decline in RBC use without evidence of a change in mortality.

Blood safety and availability: continuing challenges in China's blood banking system.

Social and economic development, along with increased health care coverage, has caused a sharp increase in the clinical demand for blood in China. Whole blood collection has increased rapidly in the past decade but has failed to keep pace with the ever-increasing demand. Overall, the country's blood safety has been improved with 99% of whole blood donations collected from voluntary unpaid donors. However, the unmet clinical demand for blood and the increasing incidence of human immunodeficiency virus and syphilis in the general population pose new challenges to China's blood banking system. To ensure a safe and adequate blood supply, continued efforts are required to recruit and retain a sufficient number of low-risk voluntary blood donors, improve donor prescreening and blood testing process, ease donor restrictions, and strengthen patient blood management.

The success of our patient blood management program depended on an institution-wide change in transfusion practices.

BACKGROUND: Patient blood management (PBM) programs seek to optimize the utilization of blood components. Since our institution's program started, the annual number of red blood cell (RBC) units transfused has decreased by 27% overall. STUDY DESIGN AND METHODS: We collected data for 6 months in 2007 (pre-PBM) compared with the same months in 2011 (post-PBM) to determine which changes in practice decreased RBC utilization. Indications for transfusion of nonsurgical patients were collected from the electronic medical records, while surgical indications were assigned to the admitting physician's specialty. RESULTS: Pre-PBM, we transfused 19,888 RBC units for a mean of 0.96 units per patient discharged, compared with 14,472 post-PBM, for a mean of 0.55 units per discharge. This represents a 43% reduction in RBC units transfused per patient discharged. While transfusion episodes decreased only slightly from 9519 to 9261, the success can be explained by the overall reduction in mean number of units per transfusion from 2 to 1.5 (p < 0.0001). Pre-PBM, 22 and 48% of patients received 1 or 2 units of RBCs per transfusion episode, respectively, while in 2011, the percentages were 51 and 33%, respectively (p < 0.0001). The mean number of RBC units per transfusion decreased significantly for approximately 50% of the indications. CONCLUSION: Our success was achieved through hospital-wide physician buy-in toward a restrictive transfusion approach. We hope to encourage others to consider PBM for improved patient outcomes and blood conservation.

The evolving role of lyophilized plasma in remote damage control resuscitation in the French Armed Forces Health Service.

Freeze-dried plasma was developed by the US Army for the resuscitation of combat casualties during World War II. The French Military Blood Institute began producing French lyophilized plasma (FLYP) in 1949, in accordance with French blood product guidelines. Since 2010, a photochemical pathogen inactivation process has been implemented to reduce the remaining transfusion-related infectious risk. All quality controls for this procedure verify that the hemostatic properties of FLYP are conserved. FLYP is compatible with all blood types, can be stored at room temperature for 2 years, and its reconstitution requires less than 6 minutes. As a result, FLYP allows quick delivery of all the coagulation proteins and the application of a 1:1 ratio of FLYP and red blood cells in the context of a massive transfusion. Hemovigilance data collected in France since 1994 have included FLYP. Results indicate no reporting of infection related to the use of FLYP. Clinical monitoring with a focus on hemostasis was implemented in 2002 and expanded in 2010. The data, obtained from overseas operations, confirmed the indications, the safety and the clinical efficacy of FLYP. Further research is needed to determine specific indications for FLYP in the therapeutic management of civilian patients with severe hemorrhage.