A study of blood transfusion services at a district hospital in Malawi.

BACKGROUND AND OBJECTIVES: Severe anaemia is an important cause of mortality in developing countries. However, few studies have explored the use of and possibilities for blood transfusion services. The aims of this study are to explore the use of blood transfusion services at a hospital in sub-Saharan Africa and to assess the quality of the transfusion services according to WHO guidelines. MATERIALS AND METHODS: Patient age, gender, haemoglobin (Hb) level, diagnosis, hospital department and replacement donations were recorded for all blood transfusions administered at a district hospital in Malawi in January 2010. The laboratory equipment and procedures were scored according to WHO guidelines. RESULTS: The mean Hb of transfused patients was 4·8 g/dl. Fifty-seven per cent (59/104) of the transfusions were given to children diagnosed with malaria, and 17% (18/104) were given to pregnant women. During the study period, blood was in stock and available for transfusion within 1 h of requisition. The equipment and procedures at this hospital met the main criteria for an adequate WHO stage of development. CONCLUSION: In contrast to the advanced transfusion medicine in developed nations, our findings highlight the persistent and urgent need for life-saving blood transfusions in especially young children and pregnant women in Africa. The results indicate that blood transfusion services adapted to local conditions may be a realistic solution for providing safe blood products in developing countries. Serious challenges, such as HIV transmission and sustainable organization of low-risk blood donations should be addressed to assure access to safe blood products.

Gender differences in presentation rates, deferrals and return behaviour among Norwegian blood donors.

BACKGROUND AND OBJECTIVES: Women are under-represented among long-term blood donors. Reasons for this were sought in the donor pool of the Blood Bank of Oslo, Norway, which comprises only voluntary, non-remunerated donors and has a high degree of stability. METHODS: Three sources of data were analyzed: (1) the subsequent six-year donation patterns of 17 812 donors who donated at least once in 1999; (2) reasons for pre-donation deferral of 484 prospect donors in 2004; (3) reasons for deferrals and absence during a 6.5-year period, retrieved from a follow-up study of 1029 donors who took part in a questionnaire study on motivation for blood donation in 2000. RESULTS: Women were over-represented among first-time donors and under-represented among regular donors. Women below the age of 45 years in 1999 were less likely than men to donate regularly throughout the 6-year study period, whereas the donation behaviour of women and men above 45 years of age was similar. Young (18-29 years) female prospect donors were more frequently deferred at first-time donation than males. In the 6.5-year follow-up study, pregnancy was the most frequently reported cause of absence from or termination of donation, and was reported by 32% of the female respondents that were 45 years or younger. Among the donors that reported having been pregnant, 42% stated to have resumed donation and < 4% stated that they no longer were blood donors. Reported termination of donation by female donors was associated with reported practical obstacles and discomfort related to donation, but not with loss of motivation. CONCLUSION: Most of the gender differences in donation patterns could be ascribed to absence because of pregnancy and lactation. Practical problems and discomfort during donation were important reasons why women reported to have stopped donation. Current deferral criteria pose problems for the recruitment and retention especially of young women.

Antibody dependent cell mediated cytotoxicity against anti-D sensitized human erythrocytes. Influence of various effector cells and enzyme treatment of the target cells.

Antibody dependent cell mediated cytotoxicity (ADCC) was measured against anti-D sensitized erythrocytes using various mononuclear cell populations from peripheral blood in a chromium release assay. Adherent effector cells gave stronger cytotoxicity than unseparated and non-adherent cells, and were less dependent on pretreatment of the target cells with papain. However, close correlations were found between the cytotoxicity obtained with the various effector cell populations, indicating that either of them might be used for the purpose of establishing in vitro methods to determine the clinical significance of erythrocyte antibodies. The optimal choice of effector cells is discussed.

Backscatter electron imaging of double immunogold labeled erythrocytes using two primary monoclonal IgM antibodies.

The majority of mouse monoclonal antibodies reacting with blood group epitopes on erythrocytes are of the IgM class, have equal light chain type, and are available as culture supernatants only. To study the interrelationship of the blood group antigens, a method is presented which allows double labeling applying two unconjugated monoclonal antibodies of the same class and species. The method comprises two indirect, sequential labelings using mouse IgM anti-A and anti-H as primary antibodies and two goat anti-mouse IgM conjugated to 30 and 20 nm colloidal gold particles as secondary antibodies. After labeling for the first antigen, free binding sites on the primary antibody are blocked by incubation with an unconjugated goat anti-mouse antibody. The free anti-species on the secondary antibody, conjugated to 30 nm gold particles, are inactivated by silver enhancement. The silver enhancement also enlarges the gold particle for optimal discrimination between the two particle sizes, which are chosen accordingly. Semiquantitations of double labeled cells from subgroup A2 and A3 were found to be in good agreement with the counts of the corresponding single labelings as well as between experiments, irrespective of which of the two antibodies was applied in the first labeling sequence. The results were in accordance with a reciprocal but nonlinear relationship between the A and H antigens and suggest different affinities of the two antibodies for the epitopes in the subgroups investigated, indicating different biochemistry of the antigen determinants.

Expression of B and H antigens on red cells from a group B(weak) individual studied by serologic and scanning electron microscopic techniques.

The proposita was classified as B(el), B(y), or B(m), Le(b+) by routine blood grouping and by adsorption/elution studies using anti-A and -B hyperimmune pregnancy sera. Red cells from the proposita adsorbed as much anti-B from the hyperimmune sera as did red cells from normal B individuals, but adsorbed less anti-A,B (group O serum). Saliva contained H, but not B, soluble substance. Red cells from the proposita and a normal B donor were sensitized with monoclonal A and B blood group antibodies immunolabeled with colloidal gold particles, and examined in a scanning electron microscope. B antigens were found on more than 95 percent of normal B cells, but on only 2-3 percent of red cells from the proposita. However, when the same cells were sensitized with anti-A,B that reacted strongly with B oligosaccharides other than type 2 chains, half of the labeled red cells from the proposita were labeled more strongly than any normal B cells. Our results explain why red cells from the proposita adsorb significant amounts of anti-B and anti-A,B without being agglutinated by these antibodies. The results of both adsorption/elution and immunolabeling suggest that the B antigen on her cells differs biochemically from that on normal B cells.

The influence of therapeutic irradiation of blood and peripheral lymph lymphocytes.

This paper reviews the changes of blood and peripheral lymph lymphocytes induced by therapeutic irradiation as given for a variety of lymphoid and nonlymphoid neoplastic diseases. The irradiation brings about an abrupt reduction of the numbers of blood B and T lymphocytes. The number of lymphocytes seems to be restored within a few months after irradiation, while at least 3-5 years appear to pass before the number of blood T lymphocytes is restored. The pattern of recovery seems to be the same whether the thymus has been included in the fields of irradiation or not. In the adult organism, considerable differences apparently exist between the capacities for reproduction of B and T lymphocytes. The number of lymphocytes in peripheral lymph is also much reduced in the irradiated patient and remains so for a long period. This is compatible with the concept that migration from blood to peripheral lymph is a feature quite specific for T lymphocytes. These results are discussed in relation to the immune defense against infection and autologous tumor, and also in relation to the influence of radiotherapy on the immune defect in Hodgkin's disease.

C1q-binding substances in peripheral lymph in bronchial carcinoma.

Peripheral leg lymph has been studied for the presence of C1q-binding substances by the I-C1q binding radioassay in six male patients with untreated bronchial carcinoma. In serum, this assay is highly specific for antigen-antibody complexes (immune complexes). Three of the patients had immune complexes in serum, and they all also had C1q-binding substances in peripheral lymph. The C1q-binding activity was quite similar in serum and peripheral lymph. In the other three patients, immune complexes were not found in serum, but in ome of them, moderate amounts of C1q-binding substances were found in peripheral lymph. The results suggest that immune complexes may be found in peripheral lymph in cancer patients in about the same amounts as in serum. However, formal proof is lacking that the C1q-binding substances of peripheral lymph are real immune complexes.

Early and late effects of irradiation for seminoma testis on the number of blood lymphocytes and their B and T subpopulations.

High voltage irradiation of the iliac and paraaortic lymph nodes for seminoma testis induces a grave, acute blood lymphocytopenia. A major part of this effect is probably caused by irradiation of the blood. Indications are presented that B lymphocytes are more gravely affected than T lymphocytes. It is possible that the treatment leaves a relatively radioresistant subpopulation of lymphocytes, mostly consisting of T lymphocytes. The total number of blood lymphocytes is normalized five to ten years after treatment. Six months after treatment the percentage of B lymphocytes is clearly higher than normal, remaining so for the first three years. The percentage of T lymphocytes is unchanged both during therapy and at all intervals thereafter. The results therefore indicate that the number of B lymphocytes is more rapidly normalized after radiotherapy than that of T lymphocytes, and that the post-irradiation lymphocytopenia is mainly a T lymphocytopenia. However, this shift in B/T lymphocyte ratio is not permanent, being completely or nearly normalized after ten years. This pattern of regeneration seems to be essentially the same in patients who have received additional treatment to the mediastinum, probably meaning that the thymus has only a marginal influence on the regeneration of T lymphocytes in the adult organism. It is possible that the rapid recovery of B lymphocytes relates to the ability of the bone marrow to extend into non-irradiated parts of the skeleton after radiation destruction.

Seroepidemiological study after a long-distance industrial outbreak of legionnaires' disease.

Following a long-distance outbreak of Legionnaires' disease from an industrial air scrubber in Norway in 2005, a seroepidemiological study measuring levels of immunoglobulin G (IgG) and IgM antibodies to Legionella pneumophila was performed with a polyvalent enzyme-linked immunosorbent assay. One year after the outbreak, IgG levels in employees (n = 213) at the industrial plant harboring the scrubber and in blood donors (n = 398) from the outbreak county were low but significantly higher (P < or = 0.002) than those in blood donors (n = 406) from a nonexposed county. No differences in IgM levels among the three groups were found after adjustment for gender and age. Home addresses of the seroresponders in the exposed county clustered to the city of the outbreak, in contrast to the scattering of addresses of the seroresponding donors in the nonexposed county. Factory employees who operated at an open biological treatment plant had significantly higher IgG and IgM levels (P < or = 0.034) than those working >200 m away. Most of the healthy seroresponders among the factory employees worked near this exposure source. Immunoblotting showed that IgG and IgM antibodies in 82.1% of all seroresponders were directed to the lipopolysaccharide of the L. pneumophila serogroup 1 outbreak strain. In conclusion, 1 year after the long-distance industrial outbreak a small increase in IgG levels of the exposed population was observed. The open biological treatment plant within the industrial premises, however, constituted a short-distance exposure source of L. pneumophila for factory employees working nearby.

Recruiting and retaining young people as voluntary blood donors.

OBJECTIVES: Reasons for predonation deferral of young potential donors and prospects of recruiting and retaining young people (age 18-29) as voluntary blood donors were studied. STUDY DESIGN AND METHODS: Three different sources of data were analysed: (i) the subsequent donation history of 2057 donors who started their donation career at the Blood Bank of Oslo (BBO) in 1999, age and gender of all new donors accepted for donation at BBO in 2004 was retrieved from electronic data files; (ii) data on reasons for predonation deferral, age and gender of all deferred prospect donors at BBO in 2004 was obtained from original screening questionnaires; and (iii) results from a national telephone survey of the general population's attitudes regarding blood donation, conducted in 2005. RESULTS: Twenty-five per cent of the first-time donors recruited in 1999 remained active in 2005, but the percentage was higher among older than younger donors. Change of residency was the most frequent reason for termination of donation among young donors. Young prospect donors were more frequently than older ones deferred for lifestyle-related reasons. Prospect donors older than 30 years were more frequently deferred for health-related reasons. A large proportion (57.7%) of young adults reported a favourable attitude towards becoming blood donors. Lack of a personal request (not being asked) was the most frequently reported reason for not giving blood among young people with no donation record. Only a minor proportion of young non-donors considered themselves disqualified from donating blood due to health status. CONCLUSIONS: Lifestyle-related eligibility criteria and changes of residency pose problems for recruitment and retention of young donors. However, a large proportion of young adults state that they are able and willing to donate blood; therefore, the prospects of recruiting young people as voluntary blood donors seem generally positive.

Transfusion vs. alternative treatment modalities in acute bleeding: a systematic review.

BACKGROUND AND METHODS: The practice of transfusion varies a great deal between countries and hospitals. Therefore, a systematic literature review was performed to evaluate the evidence underlying practice of transfusion and alternative treatment modalities in acute bleeding. After a stepwise evaluation, 79 out of 2438 abstracts were approved as the evidence base. RESULTS: Albumin for volume therapy is not better than artificial colloids or crystalloids and may be detrimental in trauma patients. No outcome difference has been proved between artificial colloids and crystalloids. Use of hypertonic solutions remains controversial, as do the concepts of delayed and hypotensive resuscitation. Healthy individuals tolerate acute, normovolaemic anaemia at 5 g haemoglobin/dl, but pre-operative haemoglobin < 6 g/dl gives increased mortality from surgical interventions. Keeping haemoglobin higher than 8-9 g/dl has not been associated with any positive effect on mortality or morbidity, even in patients with cardiovascular disease. The changes induced in erythrocytes by storage may be clinically insignificant. No alternative to erythrocyte transfusion was established. Evidence underlying the practice of thrombocyte and plasma transfusion is scarce. Available evidence on recombinant coagulation factor VIIa is insufficient to define its future role in acute bleedings. Antifibrinolytic drugs in general seem to reduce the need for transfusion. CONCLUSIONS: Intravenous volume replacement and transfusion policies seem largely based on local tradition and expert opinions. As a result of the difficulties in performing controlled studies in patients with acute bleeding and the large number of patients needed to prove effects, other scientific evidence should be sought to better define best practice in this important field.

Motivation, recruitment and retention of voluntary non-remunerated blood donors: a survey-based questionnaire study.

BACKGROUND AND OBJECTIVES: The aim of this study was to establish which motivational and socio-demographic factors are important for the development of a long-term commitment as a voluntary, non-remunerated blood donor. STUDY DESIGN AND METHODS: A cross-sectional sample survey of active blood donors in Oslo, Norway, was conducted. Donors filled in a self-administered questionnaire during donation. Data on motivation were analysed using factor analysis. RESULTS: The blood donors' socio-demographic characteristics were found to be similar to those of the population as a whole. The single, most important, recruitment channel was the influence of active blood donors. Five dimensions of blood-donor motivation were identified with factor analysis. These were: altruism and empathy; social reasons (such as the influence of friends and family); strengthening of one's self-esteem; positive experiences associated with donation; and a moral obligation to donate. Support for statements on altruistic motives for donation was strong and similar in long-time and short-time donors. In contrast, short-time donors were more likely to be motivated by factors related to self-esteem than were long-term donors. CONCLUSION: The 'good habit' of continued blood donation seems not to be exclusively linked to a high degree of reported other-regarding ('altruistic') reasons, but also to a combination of motives, including some modestly self-regarding motives.

[Production and consumption of blood and blood products in Norway. Factors of quality assurance in transfusion medicine]. / Produksjon og forbruk av blod og blodprodukter i Norge. Momenter til kvalitetssikring i transfusjonsmedisin.

In Norway self-sufficiency has been achieved with regard to all major blood products, despite a relatively low number of blood donations. There is good balance in the consumption of the various products. The total consumption of erythrocytes has gone down only slightly since pre-HIV times, while consumption of thrombocytes has increased. There is probably an over consumption of erythrocytes, albumin and plasma, and more attention should be given to the consistent application of principles of modern haemotherapy. If each department is given responsibility for its own economy, improvement may be achieved in this respect.

[How soon will we have artificial blood?]. / Får vi snart kunstig blod?

The development of red cell substitute oxygen-carriers has reached a stage where stroma-free haemoglobin solutions (SFHSs) and perfluorocarbon-based substitutes are undergoing clinical trials. However, there is no evidence to suggest that such products will become available, other than for restricted, well-defined indications. Where SFHSs are concerned, the supply of haemoglobin, the strictly limited shelf-life, and the short intravascular half-life are the most important problems to be solved, whereas the use of perfluorocarbons is limited, in particular due to the need of positive pressure ventilation to maintain high oxygen tension. Red cell substitutes for general use will remain a dream in the foreseeable future. Measures to enhance blood preservation and to promote the optimal use of blood products will be the most important areas of transfusion research in the immediate future.

[Changing the use of albumin at the Oslo hospital]. / Endret bruk av albumin ved Oslos sykehus.

An increasing demand for albumin in Oslo hospitals in the early 1990s instigated measures to reduce its use. During the autumn of 1993 a letter was sent to all doctors at Ullevål hospital informing them about the lack of documentation that albumin supplementation has a positive effect on outcome in critically ill with an albumin concentration of more than 20 g/l. In May 1994 the blood bank at Ullevål hospital stopped supplying 4% albumin solutions. A 20% reduction in use of albumin was observed after the letter of information, followed by a 50% reduction after the 4% solution was withdrawn. It is concluded that greater awareness of lack of information about the effects of albumin in critically ill patients has led to a more restrictive use of albumin. During the same period the use of polygeline increased, leading to the assumption that colloids other than albumin are being used for volume substitution.

[External national quality control of blood group typing 1983-92. Significance for quality assurance in transfusion medicine]. / Ekstern, nasjonal kvalitetskontroll i blodtypeserologi 1983-92. Betydning for kvalitetssikring i transfusjonsmedisin.

A programme for external quality control in blood group serology has been run in Norway since 1983 by the National Institute of Public Health. Uncomplicated AB0 and Rh(D) grouping, including Du typing, has been performed satisfactorily. Rh(D) grouping of presensitized, Rh (D) negative cells is still a problem, but one which has been reduced significantly. Both indirect and direct antiglobulin reactions have given about 15% false negative results, mainly with weak antibodies and weakly sensitized cells. Poor training of technicians in reading weak agglutination reactions may be an important source of error. The importance of post-graduate training of blood bank staff is emphasized.

Silver enhancement of gold probes (5-40 nm): single and double labeling of antigenic sites on cell surfaces imaged with backscattered electrons.

Silver enhancement of immunogold-labeled cells was carried out to increase the applicability of colloidal gold probes for visualization in the backscatter electron imaging (BEI) mode of a scanning electron microscope. Optimum conditions were established for single particle discrimination and differential counting of labeling density at low magnifications. Red blood cells double-labeled with 15 + 40 nm and 5 + 20 nm gold probes were silver-enhanced for 6 min and 20 min, respectively, at which times both pairs of labels increased to about 25 + 50 nm. The gold probes still appeared spherical after enhancement and were easily discriminated. Cells were also single-labeled with the above probes and enhanced accordingly. The present method enables visualization of individual particles of any probe size, labeling one, or simultaneously two, antigenic sites on cell surfaces. The silver enhancement procedure thereby allows cells to be labeled with small probes with increased labeling efficiency.

A human autoantibody to renal collecting duct cells associated with thyroid and gastric autoimmunity and possibly renal tubular acidosis.

A complement fixing autoantibody reacting with certain renal collecting duct cells, possibly so called dark cells, is described in 113 patients. Clinically, the antibody was strongly associated with thyroid disorders and pernicious anaemia. The patients also showed a markedly increased frequency of thyroid antibodies and antibodies to gastric parietal cells and to intrinsic factor. One of the patients had a distal renal tubular acidosis (RTA) and pernicious anaemia. The antibody was also found in all of three other patients with either latent or manifest RTA. RTA is associated with various immunological diseases, and the renal collecting duct cell antibody may turn out to be a marker of this disorder, either involved in its pathogenesis or representing a secondary phenomenon.

Long-term effect of pneumococcal polysaccharide vaccination on serum IgM and IgG antibody levels in individuals splenectomized for trauma.

The IgM and IgG pneumococcal antibody levels were measured one year after vaccination with a 14-valent pneumococcal polysaccharide vaccine in 12 individuals splenectomized due to trauma and 10 non-splenectomized individuals. The results were compared with the antibody levels before and four weeks after vaccination. One year after vaccination there were only minor differences between the two groups. The IgM response to most of the serotypes had almost vanished. There were only significant IgG responses to a few serotypes after one year, but the mean antibody levels of all the 14 serotypes showed some persistence of the IgG response. There was a tendency for the splenectomized individuals that were younger than 15 years of age to have a somewhat reduced antibody response after pneumococcal vaccination. This could indicate that pneumococcal vaccination might be less efficient in that group of individuals where the need for a protective vaccine is most urgent.