Successful treatment of pure red cell aplasia using therapeutic plasma exchange after ABO-incompatible hematopoietic stem cell transplant.

Hematopoietic stem cell transplants (HSCTs) are widely used in the treatment of hematologic malignancies and bone marrow failure syndromes. ABO compatibility is typically of secondary importance, and up to 50% of HSCT are performed in ABO-incompatible pairings. In the literature, pure red cell aplasia (PRCA) occurs in 1% to 50% of all major/bidirectional ABO-incompatible stem cell transplants, but treatment of PRCA remains heterogeneous. Here, we report two cases in which patients with transfusion-dependent PRCA following HSCT were successfully treated with therapeutic plasma exchange (TPE). Case 1: A 52-year-old type O-positive male with acute myeloid leukemia underwent HSCT using apheresis-derived HSCs from a fully human leukocyte antigen (HLA)-matched, related type A-positive male donor. He developed PRCA that was refractory to multiple therapies, so a series of 10 TPE was performed over 3 weeks. Case 2: A 21-year-old type A-positive male with aplastic anemia underwent HSCT using bone marrow-derived HSCs from a fully HLA-matched related type B-positive female donor. He developed PRCA that was refractory to multiple therapies, so a series of 5 TPE was performed over 2 weeks. Case 1: The patient has been transfusion independent since TPE #7, and type A red blood cells (RBCs) were seen on the ABO type after TPE #9. Case 2: The patient has been transfusion independent since after TPE #1, and type B RBCs were seen on the ABO type after TPE #5. TPE was successful in treating two patients with PRCA after ABO-incompatible HSCT transplants. Isoagglutinin titers decreased below the level of detection for both our patients. Ultimately both patients became transfusion independent and showed evidence of erythroid cell recovery.

How do I perform therapeutic phlebotomy?

BACKGROUND: Therapeutic phlebotomy (TP) is a well-established medical intervention that evolved from the historical practice of bloodletting. METHODS: Patients who require TP are not infrequently told by their health-care providers to "just go donate blood," but TP should always be offered in the context of a prescribed course of therapy. Providers can prescribe a course of TP for a number of indications, including hereditary hemochromatosis, polycythemia vera, iron overload, and testosterone replacement therapy. RESULTS: A course of prescribed TP specifies that patients can be phlebotomized more frequently than volunteer blood donors and reassures patients that TP is being performed per the orders of their provider. Prescribed TP also facilitates two-way communication between the referring provider and the transfusion medicine (TM) physician overseeing the TP. The College of American Pathologists TM checklist describes several requirements regarding the documentation and performance of TP, and electronic medical record systems can be used to demonstrate compliance with these requirements. CONCLUSIONS: TM physicians should discuss the advantages of prescribing TP with providers who mutually care for patients requiring this intervention.

The role of therapeutic plasma exchange in clinically amyopathic dermatomyositis with MDA-5 antibody: A case report and review of the literature.

Clinically amyopathic dermatomyositis (CADM) is a rare, aggressive variant of dermatomyositis associated with interstitial lung disease (ILD) and refractoriness to immunosuppressants. Antibodies against melanoma differentiation-associated gene 5 (MDA-5) are often found in patients with CADM. We report a patient with advanced CADM with ILD and MDA-5 antibodies who failed to improve with immunosuppressants. We performed 2 TPE over 3 days, using 5% albumin as replacement fluid. Although five total TPE were planned, he was transferred for lung transplant evaluation after the second TPE; he died 16 days after transfer without receiving a transplant. A literature review identified four patients with CADM and MDA-5 antibodies treated with TPE; all experienced symptomatic improvement of their ILD. We attribute our patient's outcome to the advanced nature of his disease rather than a failure of TPE. Additional research may indicate a possible reclassification of CADM with MDA-5 antibodies in future ASFA guidelines.

Dilution is not the solution: acute hemolytic transfusion reaction after ABO-incompatible pooled platelet transfusion.

CONCLUSIONS: The short shelf life of platelets makes providing ABO-compatible platelets a challenge, and many institutions issue ABO-incompatible platelets when compatible units are not available. It is presumed that ABO antibodies that exist in donor plasma are diluted when platelets from multiple donors are combined to make a pooled product for transfusion. We present a case of a hemolytic transfusion reaction in a 73-year-old man with myelodysplastic syndrome who received an ABO-incompatible pooled platelet unit. This case report demonstrates that the dilution theory is not always true for pooled platelet units, and any patient receiving ABO-incompatible platelet transfusions must be closely monitored for potential hemolytic transfusion reactions.

Apheresis education in pathology residency.

INTRODUCTION: Physicians from diverse training backgrounds practice apheresis medicine. Pathology residents' exposure to apheresis may vary depending on which department performs these procedures. Milestones for Apheresis education were published in 2012, but the degree of utilization in residency curriculum development is unknown. This study describes the current state of apheresis education for pathology residents. METHODS: We sent a 15 question electronic survey to 141 pathology programs identified through the American Medical Association Residency and Fellowship Database. RESULTS: Forty-three (30.5%) of the 141 programs responded. Pathology performed apheresis procedures in 29 (67.4%) programs. In the remaining 14 programs, apheresis was performed by nephrology (10), hematology (4), and a regional blood center (1); in one program, both nephrology and hematology performed apheresis procedures. For combined anatomic and clinical pathology (AP/CP) residents, 26 of 28 (93%) were required to train in apheresis medicine when pathology performed the procedures compared to only 5 of 14 (36%) when they were performed by another department (P = 0.0002). For CP-only residents, 18 of 19 (95%) were required to train in apheresis medicine when pathology performed the procedures compared to 5 of 7 (71%) when they were performed by another department (P = 0.1669). Thirty (68.9%) respondents had a written apheresis medicine curriculum. Seventeen (39.5%) of the 43 respondents were aware of the Milestones for Apheresis education, and 8 (18.6%) used the milestones in creating their apheresis curriculum. CONCLUSIONS: The pathology department performed apheresis procedures in two-thirds of pathology residency programs surveyed. AP/CP residents were more likely to be required to train in apheresis medicine if the pathology department performed these procedures at their institution. Apheresis medicine practitioners should review the Milestones for Apheresis education with their residency program director to optimize learning and clinical skills development.

Two cases of asymptomatic massive fetomaternal hemorrhage.

Evaluation of fetomaternal hemorrhage (FMH) in the immediate postpartum period is critical for the timely administration of Rh immunoglobulin (RhIG) prophylaxis to minimize the risk of alloimmunization in D-negative mothers of D-positive newborns. We report a series of two clinically-unsuspected cases of massive FMHs identified at our university medical center. Retrospective records of two cases of massive FMH were investigated using the electronic medical record. After positive fetal bleed screens, flow cytometric analysis for hemoglobin F was performed to quantify the volume of the hemorrhages in both cases. Flow cytometric enumeration with anti-D was also performed in one case. The two patients had 209.5 and 75 mL of fetal blood in circulation, resulting in 8 and 4 doses of RhIG administered, respectively. For the former patient, flow cytometric analysis with anti-D ruled out hereditary persistence of fetal hemoglobin and supported the fetal origin of the red cells. Due to the clinically-silent nature of both hemorrhages, further evaluation of the newborns' blood was not performed. These cases highlight the importance of rapidly obtaining accurate measurements of fetal blood loss via flow cytometric analysis in cases of FMH, particularly in clinically-unsuspected cases, to ensure timely administration of adequate immunoprophylaxis to D-negative mothers.

Optimizing Utilization of Blood Products in the Hematologic Malignancy Clinic: Less Is More.

PURPOSE: There are no universal guidelines for blood product transfusions in patients with hematologic malignancies (HMs). Excess utilization of platelet and RBC transfusion in patients with HM increases the cost of care and likelihood of adverse events. We aim to decrease the total number of transfused units and multiunit orders of platelets and RBCs in the HM clinic by 25% from March 2020 to December 2020. METHODS: A multidisciplinary, interprofessional team was formed. Baseline rates of blood product utilization were determined using Qlik Analytic software. Strategies to improve utilization were developed, and three interventions were initiated. Data were collected on monthly intervals. Data for total number of platelet and RBC units ordered, total multiunit orders, average number of units ordered per encounter, and pretransfusion hemoglobin thresholds were collected from May 2019 to December 2020. RESULTS: Through our Plan-Do-Study-Act cycles from March 2020 to December 2020, the total number of platelet transfusion orders per month decreased from 164 to 98, multiunit platelet orders decreased from 63 to 2, and the average number of platelet transfusions per encounter decreased from 1.62 to 1.03. The total number of RBC transfusion orders decreased from 172 to 141, multiunit RBC orders decreased from 25 to 16, and the average number of RBC transfusions per encounter decreased from 1.21 to 1.18. CONCLUSION: Implementation of our multidisciplinary interventions led to more appropriate use of blood products in the outpatient setting. Ongoing efforts are underway to continue to improve utilization in the inpatient and outpatient setting.

Update in Transfusion Medicine Education.

Despite the high frequency with which blood transfusions are performed, transfusion medicine education remains variable in the United States and around the world. Educating medical students and nonpathology physicians is critical for safe and evidence-based transfusion. Many innovative curricula have been published to meet the needs of physicians training in a variety of specialties. Learners' knowledge can be assessed using validated knowledge assessment tools and objective structured clinical examinations. In this review, transfusion medicine curricula and assessment tools are reviewed. Strategies for virtual teaching and learning are also introduced.

Educational Case: A Case of Transfusion-Transmitted Babesiosis: Diagnostic Perspectives Across the Clinical Laboratory.

The following fictional case is intended as a learning tool within the Pathology Competencies for Medical Education (PCME), a set of national standards for teaching pathology. These are divided into three basic competencies: Disease Mechanisms and Processes, Organ System Pathology, and Diagnostic Medicine and Therapeutic Pathology. For additional information, and a full list of learning objectives for all three competencies, see http://journals.sagepub.com/doi/10.1177/2374289517715040.1.

Correlating Transfusion Medicine In-Service Examination Scores With Outcomes of the American Board of Pathology Transfusion Medicine Subspecialty Certifying Examination.

OBJECTIVES: The Transfusion Medicine In-Service Examination (TMISE) is offered twice a year to transfusion medicine (TM) fellows. We examined the relationship between TMISE scores and outcomes of the American Board of Pathology (ABP) TM subspecialty certifying examination (TM boards). METHODS: TM fellowship programs were contacted to provide anonymous data about TM fellows, their scores on TMISE, and outcome of TM boards. RESULTS: Of 48 TM fellowship programs contacted, 24 (50%) responded with data for 170 fellows. Average TMISE score of fellows who passed their first TM boards attempt was 71.3, while the average TMISE score of fellows who failed their first TM boards attempt was 64.3 (P = .009). CONCLUSIONS: TMISE scores correlated with passing TM boards on the first attempt. Fellows who took the TM boards the same year that they graduated from TM fellowship had a significantly higher first-time pass rate than fellows who delayed taking TM boards.

The Impact of an Undergraduate Biology Class on Donor Recruitment at a Hospital-Based Blood Donor Center.

OBJECTIVES: A biology class, BIOL 294H, taught undergraduates about platelet donation while partnering with the University of North Carolina's (UNC's) hospital-based Blood Donation Center to recruit apheresis platelet donors. We identified our platelet donors' demographics and learned how BIOL 294H affected recruitment. METHODS: Every platelet donor presenting to the UNC Blood Donation Center from February 7, 2017, to March 10, 2017, was asked to complete an electronic 10-question survey. RESULTS: A total of 159 unique donors completed the survey; 64% were female and 75% were between ages 18 and 25 years. Overall, 70% were UNC undergraduate students. Over half (56%) reported first learning about platelet donation through word of mouth, and 22% cited specific efforts associated with BIOL 294H. CONCLUSIONS: Recruitment of undergraduate platelet donors primarily included BIOL 294H peer interactions and deliverables from the class, such as social media updates and events on campus. The sustained recruiting efforts of our students over many years contributed to recruitment of a majority of our platelet donors.

Transfusion Rates and the Utility of Type and Screen for Pelvic Organ Prolapse Surgery.

OBJECTIVES: Limited data exist directly comparing the likelihood of blood transfusion by route of apical pelvic organ prolapse (POP) surgery. In addition, limited evidence is available regarding the risk of not ordering preoperative type and screen (T&S) in apical POP surgery. The objectives of the study are to (1) provide baseline data regarding the current need for preoperative T&S by comparing perioperative blood transfusion rates between 3 routes of apical POP surgery and (2) determine the rate of a positive preoperative antibody screen in women who underwent apical POP surgery. METHODS: This was a retrospective cohort study of women who underwent apical POP surgery by 3 different routes: abdominal (abdominal sacrocolpopexy), robotic (robotic sacrocolpopexy), or vaginal (uterosacral or sacrospinous ligament fixation). RESULTS: Among 610 women who underwent apical POP surgeries between May 2005 and May 2016, 24 women (3.9%) received a perioperative blood transfusion. The rate of transfusion was higher in the abdominal group (11.1%) compared with robotic (0.5%, P < 0.001) and vaginal (0.5%, P < 0.001). In a logistic regression model, abdominal route of POP surgery remained significantly associated with transfusion (odds ratio, 20.7; 95% confidence interval, 2.7-156.6). Among the 572 women who had a preoperative T&S performed, 9 (1.5%) had a positive antibody screen. CONCLUSIONS: Blood transfusion was significantly more common in abdominal compared with robotic and vaginal apical POP surgeries. The rate of a positive antibody screen was low, suggesting that type O blood is low risk if cross-matched blood is not available. Thus, it may be reasonable to not order a preoperative T&S prior to robotic or vaginal apical POP surgery.

The top 10 things to know about transfusion medicine before intern year: an evidence-based course for graduating medical students.

BACKGROUND: Transfusion medicine (TM) knowledge varies widely among physician trainees. In addition, there have been few instances in which curricular changes have been meaningfully assessed for TM education in medical school. METHODS: We created and presented a novel lecture to improve TM knowledge for graduating medical students using eight objectives designed to reinforce critical information about blood management. Each objective was coded according to unique color schemes, fonts, and graphics to create visual associations while quickly and clearly presenting complex concepts. The validated BEST Collaborative exam was used to measure changes in student TM knowledge, while a survey was conducted to gauge changes in confidence for each objective. Students were asked to submit anonymous feedback about their experiences. RESULTS: The mean student post-course exam score was 50.0%, while the pre-course baseline score was 27.5% (P<0.0001). Mean confidence levels increased significantly for all objectives. Student feedback was universally positive. CONCLUSION: This study improved knowledge and confidence for graduating medical students by utilizing engaging and visually stimulating presentations to display high-impact TM material. However, further efforts are needed to optimize learning.