Enhancing clinical insight: Implementing validated questionnaires for comprehensive assessment of clinician expertise in transfusion medicine practices.

BACKGROUND: Blood transfusion is a cornerstone of modern healthcare, pivotal in saving countless lives annually. However, inadequate knowledge among healthcare providers can lead to serious complications. Despite the availability of assessment tools like the Biomedical Excellence for Safer Transfusion (BEST) test, there is a need for indigenous-validated questionnaires to address knowledge gaps effectively. This study aimed to evaluate bedside transfusion medicine knowledge among clinical residents using a validated questionnaire, focusing on knowledge gaps. STUDY DESIGN AND METHODS: A cross-sectional study was conducted at a tertiary care referral center in Northern India. The questionnaire, developed based on national and international transfusion guidelines, was validated by an expert panel, and administered to 245 clinical residents. The questionnaire covered six domains related to transfusion medicine: blood component storage, blood bank procedures, transfusion-transmitted infections, administration of blood components, transfusion reactions, and transfusion practices. RESULTS: The study revealed varying levels of knowledge across specialties and residency years. Overall, residents scored 61 % in transfusion medicine knowledge, with Pediatrics residents demonstrating the highest scores. The incremental increase in knowledge from first to third-year residents underscores the value of continuous, experience-based learning throughout the residency period. DISCUSSION: Study highlights significant knowledge gaps in bedside transfusion practices among clinical residents, emphasizing the need for structured educational interventions. Tailored programs, integrated into undergraduate and postgraduate curricula, are essential to improve transfusion safety and patient outcomes. Addressing these gaps can lead to better bedside transfusion practices, reducing risks and improving the quality of patient care.

Serial assessment of biochemical changes in irradiated red blood cells.

BACKGROUND: Transfusion associated graft vs host disease (TA-GVHD) is delayed effect of blood component therapy with a very high mortality rate. The use of irradiated blood components is the only proven method to prevent TA-GVHD in susceptible patients. AIM: Our study was designed to analyze the quality of irradiated PRBCs in terms of their biochemical parameters during a storage period up to 28 days post irradiation. METHODS: A total of 80 PRBC units were analyzed, 40 units each stored in CPDA-1 and additive solution-SAGM. The units were evaluated serially for the following biochemical parameters, plasma/ supernatant potassium, sodium, pH, glucose, lactate, plasma/supernatant hemoglobin and red cell ATP. We further evaluated the differences in these parameters between units irradiated on day 1 and day 7 of storage and stored these units up to 28 days and 35 days respectively. Ten units in each group were used as control. The assessment was done at weekly intervals from the day of irradiation. RESULTS: Within each group of red cells, there was a rise in mean concentration of plasma potassium (K(+)) from day 1 to last day of storage. There was a highly significant difference (P<0.01) between irradiated and control units after first week of storage in both types of PRBCs. Irradiated CPDA-1 PRBC had significantly higher (K(+)) than irradiated SAGM PRBC. Intergroup comparison revealed significantly higher (P<0.05) mean hemoglobin in irradiated CPDA-1 PRBC as compared to SAGM PRBC. The mean pH was significantly higher (P<0.05) in irradiated CPDA-1 PRBC as compared to irradiated SAGM PRBC only on day 7 of storage. ATP levels significantly decreased in irradiated units as compared to control units. SAGM PRBCs had significantly higher (P<0.05) mean ATP concentration than CPDA-1PRBCs. CONCLUSION: Our study demonstrates that SAGM-PRBCs show better stability after irradiation compared to CPDA-1 PRBCs. The limits of safety for CPDA-1 PRBCs appear to be two weeks after irradiation. SAGM-PRBCs on the other hand show acceptable limits of safety up to three weeks of irradiation. The shelf life of irradiated PRBCs may vary depending upon the storage solution and day of irradiation.

Scope and application of therapeutic apheresis: Experience from a tertiary care hospital in North India.

BACKGROUND: We present here our experience with therapeutic apheresis (TA) performed for various indications, clinical response and complications in a tertiary care center over last 10 years. STUDY DESIGN AND METHODS: Present study is a retrospective analysis of 492 TA procedures performed for 125 patients from January 2000 to December 2009. For each patient: age, gender, weight, clinical indication, pre-procedure hematological profile and ionized calcium levels were recorded. For every procedure following parameters were analyzed: type of venous access (central/peripheral), volume of blood and plasma processed, amount of anticoagulant used, procedure duration, blood flow rate, type of replacement fluid given, response to therapy and adverse reactions. RESULTS: Of 492 TA procedures, 68.8% were performed for neurology, 20.8% hematology-oncology, 9.6% renal and 0.8% for rheumatology patients. Therapeutic plasma exchanges (n=464; 94.3%) and therapeutic cytapheresis (n=28; 6.7%) were performed in 113 and 12 patients, respectively. Majority of patients belonged to ASFA category I and II (n=124; 99.2%). The overall response rate was 84%, with encouraging response in TTP (100%), aHUS (81.8%) and in neurological disorders (88.4%). Adverse events were reported in 52.8% of patients in 14.83% of procedures. CONCLUSION: Our results of TPE in neurological disorders and in atypical hemolytic uremic syndrome are encouraging and it is a cost effective alternative to IvIg in neurological disorders. Currently, there is a need for establishment of an Indian apheresis registry to understand the scenario of TA across the country and in the expansion of appropriate and applicable indications for TA in our setting.

Buffy coat pooled platelet concentrate: A new age platelet component.

BACKGROUND: Buffy coat pooled platelet concentrate (BCPP) is a new blood component mainly used in Europe, which has good attributes of both random donor platelets and apheresis platelets in terms of high platelet count, leukoreduced and available in emergency. We planned this study to compare quality parameters and biochemical activation markers among buffy coat pooled platelets and apheresis platelet concentrate (AP-PC) to establish the quality and safety of this new blood component during storage. MATERIALS AND METHODS: Three different preparations of BCPP were prepared: Nonleukoreduced (BCPP Part A), leukoreduced (BCPP Part B), and leukoreduced with platelet additive solution (PAS) (BCPP Part C) using a pool of 15 ABO-matched, nonreactive buffy-coats in each experiment to avoid any donor-related variations. Ten such experiments were done. Each BCPP was equivalent to 5 buffy coat units. Ten apheresis platelets were taken as control. Serial samplings were done on day 0, 3, and 5 of collection and were assessed for: volume, platelet count, white blood cell count, swirling, pH, sterility, glucose, lactate, soluble p-selectin, Interleukin (IL)-6, IL-1 ß, and tumor necrosis factor alpha (TNF-α). RESULTS: BCPP Part C (leukoreduced with PAS) maintained the best quality parameters in terms of maintenance of pH, least lactate accumulation, least sP-selectin levels, and least accumulation of inflammatory mediators (IL-6, IL-1 ß, and TNF-α) than the other groups >BCPP part B >AP-PC and >BCPP Part A. On day 5 of storage pH for BCPP Part A, Part B, Part C, and AP-PC was: 6.33, 6.42, 6.64, and 6.29, respectively, and soluble p-selectin (ng/ml) was 201 ± 22, 186 ± 11, 149 ± 18, 200 ± 23, respectively. BCPP Part B and AP-PC had comparable quality parameters and activation markers. CONCLUSIONS: Buffy coat pooled platelet has comparable and even better-quality control parameters (especially leukofiltered with PAS) than conventional platelet preparation and is a good alternative for meeting platelet transfusion requirements of critical patients during emergency hours in resource-constraint setting.

Prevalance of Anti-HLA antibodies in parous female blood donors: A pilot study from tertiary care hospital of North India.

BACKGROUND: Various studies have implicated that plasma causing transfusion-related acute lung injury is from alloimmunized females. The frequency of sensitization to human leukocyte antigen (HLA) was found to correlate with their parity score. No literature on the prevalence of anti-HLA antibodies in Indian blood donors is available to date. Hence, this pilot study was done to know the frequency of HLA alloimmunization in Indian blood donors. MATERIALS AND METHODS: A total of 192 consenting voluntary blood donors from blood donation camps were enrolled in the study. Test group: Parous female donors (n = 96) and control group: Nulliparous female donors (n = 48) and male donors (n = 48). HLA alloimmunization was tested on the Luminex platform by screening assay to detect IgG antibodies to HLA Class I and II molecules of human origin. A mean fluoresence index of more than 2000 was considered as a positive reaction, considering the high sensitivity of Luminex assay. RESULTS: Sixty-three out of 192 donors (32.8%) tested positive for anti-HLA antibodies, out of which 23 donors were in the control group (23.9%), and 40 donors were in the test group (41.7%); P = 0.002. On gender-based comparison, 9 out of 48 male donors (18.7%), as compared to 54 out of 144 female donors (37.5%), tested positive for HLA antibodies (P = 0.02). Based on an increase in parity score, the frequency of HLA alloimmunization was found to be significantly correlated (P = 0.002). A decrease in the trend of HLA alloimmunization was observed as the duration from the last pregnancy increased. A higher frequency of HLA alloimmunization was observed in female donors with a history of transfusion and bad obstetric history. CONCLUSION: The present study substantiates that plasma from parous female donors has a higher chance of containing anti-HLA antibodies as compared to nulliparous female and male donors.

Exploration of COVID-19 related fears deterring from blood donation in India.

INTRODUCTION: The coronavirus pandemic (COVID-19) has impacted and pushed the healthcare settings to extremes across the globe. It was extremely challenging to sustain blood donation, and strategies could be formulated on knowing fears hindering blood donation. METHODS: A cross-sectional survey using Google Forms® through WhatsApp and email after obtaining the ethical clearance. The survey questionnaire was validated for content using the Delphi technique, and pilot tested for finalization. RESULTS: The survey was attempted by 1066 participants, and 749 participants who had not donated since pandemic were included in the study. A little more than half, 415 (55%) reported either one or more than one fear during the pandemic which hindered blood donation. They reported lack of confidence in the safety measures at the hospitals and fear of transmitting infection to family, in 415 (55%) of the participants each, respectively. The fear of COVID-19 hospital infection risk and hospital entry was statistically significant across the age groups that are eligible for blood donation. CONCLUSIONS: The clear and dedicated confidence building measures to sustain blood donation using all communication modalities clearly emerge as the most important strategies to augment blood donation in the COVID-19 pandemic. The measures should include information about implementation of safety measures to mitigate COVID-19 transmission at the blood centres and that the act of blood donation does not increase risk of COVID-19 and therefore the risk of transmission of infection to family.

Lewis blood group phenotype vis-a-vis biochemical and physiological parameters of coronary artery disease: A study in North Indian population.

BACKGROUND: Many studies have proposed the lack of Lewis antigen as a marker for coronary artery disease (CAD); on the contrary, some of the studies found no association in this regard. This study aims to assess the association of the expression of Lewis antigen as an independent risk factor for CAD separately in males and females. MATERIALS AND METHODS: In this cross-sectional observational study, patients with angiographically proven CAD were taken as test group, and angiographically, negative patients were included as a control group. The individuals were examined for established CAD risk factor and Lewis antigen expression on red cell. Red cell Lewis phenotyping was done using microcolumn gel agglutination technology. Statistical tests were applied to see the association between lack of Lewis antigen expression and CAD. RESULTS: Of these 232 patients included in the study, 161 patients had more than 50% luminal stenosis in a major epicardial artery on coronary angiography (Test Group), and 71 were normal on angiography (Control Group). When males and females were considered together, there was an increased frequency of Lewis-negative phenotype among the angiography-positive group (26.7%) as compared to angiography normal control group (16.9 %), though was not statistically significant (P = 0.19). When males and females were segregated in multivariate analysis, Le (a-b-) females had a higher incidence of CAD (P = 0.03) with the odds ratio of 4.97, though an association was not found significant in males (P = 0.71). CONCLUSION: The association between Lewis phenotypes and CAD was not significant in males and in among the overall study population, but this association was statistically significant in females. Further studies based on a larger sample size may substantiate as well as delineate the possible hypotheses.

Dedicated donor unit transfusions reduces donor exposure in pediatric surgery patients.

BACKGROUND: Many strategies have been explored to reduce multiple donor exposures in neonates such as use of restrictive transfusion protocols, limiting iatrogenic blood loss, use of recombinant erythropoietin and single donor programs. METHOD: In our study we assessed the feasibility of dedicating single donor units with reserving all the components from the same donor for the specified neonates/infants undergoing surgery and estimating reduction of donor exposure. Fifty neonates undergoing surgery were included in the prospective study group and the transfusion details were compared with 50 retrospective cases with same inclusion criteria. RESULTS: An intra-operative blood loss of >13 ml/Kg was significantly associated with transfusion (P <0.05) which was most frequently administered in the intra-operative period. Donor exposure rate of overall transfusion was 1.15 in the study group as compared to 4.03 in the retrospective control group. In study group Donor Exposure Rate (DER): Transfusion Rate (TR) ratio was 1:1.5 and Transfusion per Donor Unit (TPDU) of 1.5, means that one donor unit contributed to 1.5 transfusions in each patient and contributed to 50% reduction in donor exposure in each patient as compared to retrospective control group. CONCLUSION: Our study showed that by practicing dedicated donor unit transfusion policy, for neonates undergoing surgery we could significantly reduce the donor exposure.

Successful Management of Refractory Dialysis Independent Wegener's Granulomatosis with Combination of Therapeutic Plasma Exchange and Rituximab.

Wegeners granulomatosis (WG) is an autoimmune, antineutrophil cytoplasmic antibody mediated necrotizing vasculitis involving renal, and upper and lower respiratory systems. Treatment relies on a combination of immunosuppressive drugs and tapering regimen of glucocorticoids. Therapeutic plasma exchange (TPE) has been recognized as a second line treatment. We report the successful use of TPE in combination with rituximab in achieving remission in a patient with WG (dialysis independent) not responding to conventional therapy.

Serial changes in morphology and biochemical markers in platelet preparations with storage.

BACKGROUND: This study was designed to perform serial assessment of alterations in platelet (PLT) count, morphology and biochemical markers of PLT activation during storage of platelet concentrates (PCs) and to correlate morphological changes with these activation markers. MATERIALS AND METHODS: Our study included the platelet-rich plasma (PRP)-PC and buffy coat reduced PC (BC-PC) prepared from whole blood (WB) donations and the apheresis platelets (AP-PC). Routinely evaluated in vitro PLT parameters were followed. Morphology score (MS) was performed using the light microscopy, glucose and lactate concentration and soluble P-selectin (sP-selectin) level were determined using commercial kits. RESULTS: The fall in mean pH from day 0 to the last day of storage was significant (P < 0.001) in all the groups. Glucose utilization was less in PRP-PC prepared from WB donations at Blood Donation Centre [PRP-PC (BDC)] when compared to PRP-PC prepared from WB donations at mobile blood drives [PRP-PC (M)] and BC-PC. Lactate accumulation was almost similar in these groups on day 3 of storage, but it was significantly lower in the AP-PC (67.54 mg/dl) except on day 5. The deterioration in MS (out of 200) was similar for PRP-PC and BC-PC on day 3 (145/144 and 145 respectively), whereas the AP-PC had a score of 161 and 147 on days 4 and 5 respectively. sP-selectin level was significantly higher in PRP-PC (BDC) in comparison to BC-PC (P = 0.001) from day 1 to day 3 and in AP-PC it was not so high (P = 0.067) even on day 5. A negative correlation existed between the MS and sP-selectin level on all days of storage within each group of PC (r = -0.351; P < 0.001) and a positive correlation was found between the MS and pH from day 0 to day 3 (r = 0.680; P = 0.004). CONCLUSION: The AP-PCs are superior to the BC-PC and PRP-PC with respect to in vitro quality control parameters, morphological changes and biochemical markers of PLT activation. The PRP-PCs prepared from WB donations at outstation exhibiting more rapid changes should be utilized earlier for transfusion.

Acute Hemolytic Transfusion Reaction in a Patient with Bombay Phenotype: Implications for ABO Grouping.

Bombay blood group is a rare phenotype that is characterized serologically by absence of H, A and B antigens on red cell surface and presence of corresponding antibodies in the serum. We report a case of 45-year old patient having Bombay blood group phenotype who experienced an acute reaction due to transfusion of mismatched blood unit.

Alloimmunization and autoimmunization in transfusion dependent thalassemia major patients: Study on 319 patients.

BACKGROUND: The development of anti-red blood cell antibodies (both allo-and autoantibodies) remains a major problem in thalassemia major patients. We studied the frequency of red blood cell (RBC) alloimmunization and autoimmunization among thalassemia patients who received regular transfusions at our center and analyzed the factors, which may be responsible for development of these antibodies. MATERIALS AND METHODS: The study was carried out on 319 multiply transfused patients with ß-thalassemia major registered with thalassemia clinic at our institute. Clinical and transfusion records of all the patients were examined for age of patients, age at initiation of transfusion therapy, total number of blood units transfused, transfusion interval, status of splenectomy or other interventions. Alloantibody screening and identification was done using three cell and 11 cell panel (Diapanel, Bio-rad, Switzerland) respectively. To detect autoantibodies, autocontrol was carried out using polyspecific coombs (IgG + C3d) gel cards. RESULTS: Eighteen patients out of total 319 patients (5.64%) developed alloantibodies and 90 (28.2%) developed autoantibodies. Nine out of 18 patients with alloantibodies also had autoantibodies. Age at first transfusion was significantly higher in alloimmunized than non-immunized patients (P = 0.042). Out of 23 alloantibodies, 52.17% belonged to Rh blood group system (Anti-E = 17%, Anti D = 13%, Anti-C = 13%, Anti-C(w) = 9%), 35% belonged to Kell blood group system, 9% of Kidd and 4% of Xg blood group system. CONCLUSION: Alloimmunization was detected in 5.64% of multitransfused thalassemia patients. Rh and Kell blood group system antibodies accounted for more than 80% of alloantibodies. This study re-emphasizes the need for RBC antigen typing before first transfusion and issue of antigen matched blood (at least for Rh and Kell antigen). Early institution of transfusion therapy after diagnosis is another means of decreasing alloimmunization.

Transfusion-related adverse events at the tertiary care center in North India: An institutional hemovigilance effort.

AIM: This study was designed to analyze the incidence and spectrum of adverse effects of blood transfusion so as to initiate measures to minimize risks and improve overall transfusion safety in the institute. MATERIALS AND METHODS: During the period from July 2002 to July 2003 all the adverse events related to transfusion of blood and blood components in various clinical specialties were recorded. They were analyzed and classified on the basis of their clinical features and laboratory tests. Attempt was also made to study the predisposing risk factors. RESULTS: During the study period 56,503 blood and blood components were issued to 29,720 patients. A total of 105 adverse reactions due to transfusion were observed during the study period. A majority of the adverse reactions was observed in hemato-oncology patients 43% (n = 45) and in presensitized patient groups 63% (n = 66). FNHTR 41% (n = 43) and allergic reactions 34% (n = 36) were the most common of all types of adverse transfusion reactions, followed by AcHTR 8.56% (n = 9). Majority of these AcHTR were due to unmonitored storage of blood in the refrigerator of wards resulting in hemolysis due to thermal injury. Less frequently observed reactions were anaphylactoid reactions (n = 4), bacterial sepsis (n = 4), hypervolemia (n = 2), hypocalcemia (n = 2), TRALI (n = 1), DHTR (n = 1), and TAGvHD (n = 1). CONCLUSION: Analysis of transfusion-related adverse outcomes is essential for improving safety. Factors such as improvement of blood storage conditions outside the blood bank, improvement in cross-matching techniques, careful donor screening, adherence to good manufacturing practices while component preparation, bedside monitoring of transfusion, and documentation of adverse events will help in reducing transfusion-related morbidity and mortality.

Anti-HBc screening in Indian blood donors: still an unresolved issue.

AIM: To study the seroprevalence of antibody to hepatitis B core antigen (anti-HBc) in healthy blood donors negative for HBsAg and to evaluate whether anti-HBc detection could be adopted in India as a screening assay for HBV in addition to HBsAg. METHODS: A total of 1700 serum samples collected from HBsAg-negative healthy blood donors were tested for the presence of anti-HBc antibody (IgM + IgG). All samples reactive for anti-HBc antibody were then investigated for presence of anti-HBs and for liver function tests (LFTs). One hundred serum samples reactive for anti-HBc were tested for HBV DNA by PCR method. RESULTS: Out of 1700 samples tested, 142 (8.4%) blood samples were found to be reactive for anti-HBc. It was significantly lower in voluntary (6.9%) as compared to replacement donors (10.4%, P = 0.011). Seventy-two (50.7%) anti-HBc reactive samples were also reactive for anti-HBs with levels > 10 mIU/mL and 70 (49.3%) samples were non-reactive for anti-HBs, these units were labeled as anti-HBc-only. These 142 anti-HBc reactive units were also tested for liver function test. HBV DNA was detected in only 1 of 100 samples tested. CONCLUSION: Keeping in view that 8%-18% of donor population in India is anti-HBc reactive, inclusion of anti-HBc testing will lead to high discard rate. Anti-HBs as proposed previously does not seem to predict clearance of the virus. Cost effectiveness of introducing universal anti-HBc screening and discarding large number of blood units versus considering ID NAT (Individual donor nucleic acid testing) needs to be assessed.