Influence of immunohematological markers on severity of in vivo hemolysis in human warm autoimmune haemolytic anemia.

Autoantibody production in autoimmune haemolytic anemia (AIHA) is the result of the loss of self-immunological tolerance of the host. Here we investigated the various immunohematological markers that may influence the severity of in vivo hemolysis in warm AIHA (WAIHA). Complete direct antiglobulin test (DAT) evaluation and immunohematological characterization were performed in 247 patients of WAIHA following departmental protocols. Clinical and laboratory details of patients were obtained from patient file. The median age of WAIHA patients was 47 years with a female preponderance. Lymphoproliferative diseases were the major underlying causes of secondary WAIHA. The mean haemoglobin (Hb) and reticulocyte count (Retic) were 6.43 gm/dL and 7.58% respectively. Single autoantibody bound to red cells was investigated in 151 patients. The main IgG subclass was IgG1. Multiple autoantibodies like IgG+ C, IgG+IgA and IgG+IgA+C were found in 87 (35.2%) patients. Free autoantibodies were observed in 112 patients with a median indirect antiglobulin test (IAT) reactivity of 2+. Derangement of haematological and biochemical values was statistically significant with increase in DAT reactivity, presence of multiple autoantibodies on red cells, coating of red cells by IgG3 or multiple IgG subclass, higher DAT dilution and increasing IAT reactivity. We conclude that several important but simple immunohematological parameters may influence the degree of in vivo hemolysis in WAIHA. Since a set of common haematological and biochemical test determines the severity of in vivo hemolysis therefore a comprehensive clinical and immunohematological evaluation is advisable for a correct diagnostic and therapeutic workup of WAIHA.

Application of flow cytometry in transfusion medicine: The Sanjay Gandhi Post Graduate Institute of Medical Sciences, India experience.

The application of flow cytometry (FC) is diverse and this powerful tool in used in multiple disciplines such as molecular biology, immunology, cancer biology, virology, and infectious disease screening. FC analyzes a single cell or a particle very rapidly as they flow past single or multiple lasers while suspended in buffered solution. FC has a great impact in the field of transfusion medicine (TM) due to its ability to analyze individual cell population and cell epitopes by sensitive, reproducible, and objective methodologies. The main uses of FC in TM are detection of fetomaternal hemorrhage, diagnosis of paroxysmal nocturnal hemoglobinuria, quantification of D antigen, detection of platelet antibody, quality control of blood components, for example, residual leukocyte counts and evaluation of CD34-positive hematopoietic progenitor cells in stem cell grafts. In recent years, FC has been implemented as an alternative method for the detection and characterization of red cell autoantibodies in autoimmune hemolytic anemia. Many workers considered FC as a very good complement when aberrant expression of various erythrocyte antigens needs to be elucidated. It has been extensively used in the resolution of ABO discrepancies and chimerism study. FC has also been used successfully in various platelet immunological studies. In the recent past, FC has been used in several studies to assess the platelet storage lesions and elucidate granulocyte/monocyte integrity and immunology. FC analysis of CD34+ stem cells is now the method of choice to determine the dosage of the collected progenitor cells. The technique is vastly used to evaluate residual leukocytes in leukodepleted blood components. We conclude that flow cytometers are becoming smaller, cheaper, and more user-friendly and are available in many routine laboratories. FC represents a highly innovative technique for many common diagnostic and scientific fields in TM. Finally, it is the tool of choice to develop and optimize new cellular and immunotherapeutic trials.

An insight into the utilization of allogenic blood transfusion and factors affecting blood transfusion in total knee replacement surgery in a tertiary care hospital in Eastern India.

BACKGROUND: Significant blood loss and requirement of allogenic blood transfusion during or after total knee replacement (TKR) have been reported. Incidence of blood transfusion in TKR is highly variable and depends on several factors. We investigated the blood utilization in patients undergoing TKR in our hospital and depicted the important risk factors that determine the need of allogenic blood transfusion in primary unilateral TKR. MATERIALS AND METHODS: The study included 1241 consecutive patients undergoing primary unilateral total knee arthroplasty. All the surgeries were performed by a single surgical team of orthopedists following standard procedure. Patient and disease details were obtained from patient file and hospital information system. Compatibility test was performed in blood bank before blood reservation following mandatory guidelines. Details of test, blood issue, and blood transfusion were documented in the blood bank. RESULTS: Of 1241 enrolled patients, 1069 (86.2%) were female. The median age of patients was 66 years with mean preoperative hemoglobin of 9.9 g/dL. Allogenic blood transfused was needed in 223 (17.9%) patients. Diabetes mellitus, hypertension, thyroid disorders, and chronic heart diseases were the major comorbid conditions. Risk factors such as gender, American Society of Anesthesiologists score, preoperative hemoglobin, and intraoperative and postoperative blood losses were significantly associated with blood transfusion. CONCLUSION: The risk factors determining blood transfusion in TKR vary between studies, however, all centers should establish standard operating procedures describing the surgical procedure and transfusion support in TKR. In addition, each center may develop specific blood management strategy to rationalize blood transfusion in TKR and overall successful care in TKR.

Seroprevalence of COVID-19 Amongst Health Care Workers in a Tertiary Care Hospital of a Metropolitan City from India.

BACKGROUND: Seroprevalence studies for COVID-19 evaluate the extent of undetected transmission in a defined community, with special significance among health care workers (HCW) owing to their greater exposure and potential to transmit. METHODS: A total of 1122 HCW (approximately 25% of the employees) of a large tertiary care hospital in India were recruited for this cross-sectional study. COVID PCR-positive HCW were excluded. Based on their risk-assessment, participants were grouped into three categories. A questionnaire was administered and they were tested for SARS-CoV-2-IgG antibodies using the chemiluminescence. RESULTS: The overall seroprevalence among workers was 11.94%, which included 19.85% in COVID units, 11.09% in non-COVID units, and 8% in administrative workers (p=0.007). Antibody prevalence was highest in the department of gastroenterology (11.94%), followed by oncology (10.53%), pathology (10.26%), emergency medicine (7.84%) and critical care medicine (7%). Housekeeping staff, food and beverage staff, lab assistants and technicians had higher seroprevalence rate than doctors and nurses (p < 0.0001). HCW with a history of BCG vaccination in childhood and those who received an adequate prophylactic dose of hydroxychloroquine (HCQ) had a lower seroprevalence as compared to those who did not (7.31% vs. 16.8% and 1.30% vs. 11.25% respectively). CONCLUSION: BCG vaccination, HCQ prophylaxis, and the job profile influence the seroprevalence rate in HCW. Seroprevalence rate and follow-up evaluation of its durability may help hospitals to triage their staff at risk, rationalize their placement, prioritize the use of PPE, thereby potentially reducing the risk.

Rationalizing blood transfusion in elective breast cancer surgery: Analyzing justification and economy.

BACKGROUND: Transfusion of allogeneic blood in breast cancer surgery is variable, and differences of transfusion incidence have been observed in the literature. Most hospital guidelines including ours dictate group and reserve policy of blood before breast surgery. Here, we aimed to audit the blood utilization in patients undergoing elective breast surgery in our hospital and thereby optimize the blood ordering schedule, economic burden, and loss of clinical resources. MATERIALS AND METHODS: The study included 478 breast cancer surgeries over a period of 6 years. Patient and disease details were obtained from patient file and hospital information system. Blood samples sent to blood bank were subjected to compatibility test and reserved. All transfusions were documented, and statistical analysis was done. RESULTS: Of the total 478 patients, most underwent wide local excision of the breast and modified radical mastectomy. A total of 16 patients received 71 units of blood and blood components in all categories of surgeries. Only 103 were younger women (≤40 years), with a mean age of 31 years. Nontransfused patients were significantly more than transfused ones (P < 0.05). Frequency of blood transfusion was more in young patients (4.9%). Seven (22.6%) of the total 31 Stage IV patients received blood transfusions. Frequency of blood transfusion was more in patients undergoing surgery after chemotherapy (8.8%). A significant loss of time and loss of revenue was observed. CONCLUSION: We conclude that routine compatibility test is not justified for all patients undergoing breast surgery. A more targeted approach is needed to reduce blood demand and associated cost to patient and blood transfusion services.

Successful surgical procedure in a patient of aplastic anemia with platelet refractoriness, using cross-match compatible platelets.

This case marks the beginning of issuing cross-matched platelet products in Eastern India. A known case of aplastic anemia, on regular transfusion support, now presented with obstructed ventral periumbilical hernia requiring urgent surgical intervention. Platelet count at presentation was 13,000/µL. Platelet cross-matching was done by solid phase method. Ten units of random donor platelets were crossmatched. Five units were compatible and transfused. Counts rose to 84,000/µL after 1 h. Surgery was completed successfully. Thus, 50% units were compatible. This indicates possible underlying alloimmunization. Rapid count rise enabled completion of this urgent surgery. This rapid rise of platelet count would not have been possible without cross matching. We conclude that platelet cross matching is a powerful tool for alloimmunized patients.

Clinical and serological characterization of cold agglutinin syndrome in a Tertiary Care Hospital in Eastern India.

BACKGROUND AND AIM: Cold agglutinin syndrome (CAS) primary or secondary represents approximately 16-32% of autoimmune hemolytic anemia cases. Most patients present with mild, chronic hemolytic anemia with exacerbation of the condition in the cold environment. Red cell transfusions are only indicated when there is a life-threatening anemia causing crisis. We studied the clinical and serological characterization of CAS with the aim that the information gained from this study would help in proper diagnosis and management of these patients. MATERIALS AND METHODS: The prospective study included nine patients who were admitted with severe anemia. Detailed work-up were conducted to establish the diagnosis, severity of in vivo hemolysis and transfusion management. RESULTS: All patients presented with pallor, weakness, fatigue and painful fingers and toes with exacerbation of symptoms in winter months. Secondary CAS was observed in three patients suffering from malignant lymphoma. Red cells of all patients were coated with complements (C3) more specifically C3d. In one patient suffering from malignant lymphoma, the cold autoagglutinin titer was as high as 4096. Autoantibody in seven patients was specific to "I" antigen and one to "i" antigen. CONCLUSIONS: We conclude that detailed clinical and serological characterization is needed to diagnose and manage CAS. Whereas avoidance of cold exposure is the primary therapy, but no critical patient should be denied blood transfusion due to serological complications. All transfusion services should follow the correct protocol to maximize blood safety in CAS.

Autoimmune hemolytic anemia: From lab to bedside.

Autoimmune hemolytic anemia (AIHA) is not an uncommon clinical disorder and requires advanced, efficient immunohematological and transfusion support. Many AIHA patients have underlying disorder and therefore, it is incumbent upon the clinician to investigate these patients in detail, as the underlying condition can be of a serious nature such as lymphoproliferative disorder or connective tissue disorder. Despite advances in transfusion medicine, simple immunohematological test such as direct antiglobulin test (DAT) still remains the diagnostic hallmark of AIHA. The sensitive gel technology has enabled the immunohematologist not only to diagnose serologically such patients, but also to characterize red cell bound autoantibodies with regard to their class, subclass and titer in a rapid and simplified way. Detailed characterization of autoantibodies is important, as there is a relationship between in vivo hemolysis and strength of DAT; red cell bound multiple immunoglobulins, immunoglobulin G subclass and titer. Transfusing AIHA patient is a challenge to the immunohematologist as it is encountered with difficulties in ABO grouping and cross matching requiring specialized serological tests such as alloadsorption or autoadsorption. At times, it may be almost impossible to find a fully matched unit to transfuse these patients. However, transfusion should not be withheld in a critically ill patient even in the absence of compatible blood. The "best match" or "least incompatible units" can be transfused to such patients under close supervision without any serious side-effects. All blood banks should have the facilities to perform the necessary investigations required to issue "best match" packed red blood cells in AIHA. Specialized techniques such as elution and adsorption, which at times are helpful in enhancing blood safety in AIHA should be established in all transfusion services.

Managing uncontrolled postsplenectomy reactive thrombocytosis in idiopathic thrombocytopenic purpura: role of thrombocytapheresis.

Reactive thrombocytosis occurs in response to infection, trauma, or surgery. Splenectomy alone accounts for 19% of all possible causes of extreme thrombocytosis. We performed thrombocytapheresis in a young lady with chronic idiopathic thrombocytopenic purpura (ITP) who developed postsplenectomy reactive thrombocytosis. Her post splenectomy platelet count was 227 × 10(6)/ml which elevated to 1623 × 10(6)/ml on the 7th postoperative day. A single thrombocytapheresis procedure reduced her platelet to 403 × 10(6)/ml. She was discharged on the 10th postoperative day and then maintained a count of 204-238 × 10(6)/ml with aspirin. Thrombocytapheresis reduces the platelet count rapidly in thrombocytosis and prevents patients from having thrombotic events. However, such procedures should be performed very meticulously to ensure patient safety.

Thrombocytapheresis: managing essential thrombocythemia in a surgical patient.

A 73-year-old man presented with acute chest pain and shortness of breath suggestive of unstable angina. A detailed investigation revealed essential thrombocythemia and coronary artery pathology. With a baseline platelet count of 2,650×10(3)/µL, coronary artery bypass grafting became nearly impossible. Three therapeutic plateletpheresis procedures successfully lowered the platelet count to 367×10(3)/µL. Thereafter, surgery was performed with no complications. Although a drop and rise in platelet counts were observed postoperatively, the patient could be discharged in stable condition after 14 days. Thus, therapeutic plateletpheresis reduces platelet count rapidly in essential thrombocythemia and relieves patients of acute symptoms.