Efficacy of stem cell in improvement of left ventricular function in acute myocardial infarction--MI3 Trial.

BACKGROUND & OBJECTIVES: Acute myocardial infarction (AMI) is characterized by irreparable and irreversible loss of cardiac myocytes. Despite major advances in the management of AMI, a large number of patients are left with reduced left ventricular ejection fraction (LVEF), which is a major determinant of short and long term morbidity and mortality. A review of 33 randomized control trials has shown varying improvement in left ventricular (LV) function in patients receiving stem cells compared to standard medical therapy. Most trials had small sample size and were underpowered. This phase III prospective, open labelled, randomized multicenteric trial was undertaken to evaluate the efficacy in improving the LVEF over a period of six months, after injecting a predefined dose of 5-10 × 10 [8] autologous mononuclear cells (MNC) by intra-coronary route, in patients, one to three weeks post ST elevation AMI, in addition to the standard medical therapy. METHODS: In this phase III prospective, multicentric trial 250 patients with AMI were included and randomized into stem cell therapy (SCT) and non SCT groups. All patients were followed up for six months. Patients with AMI having left ventricular ejection fraction (LVEF) of 20-50 per cent were included and were randomized to receive intracoronary stem cell infusion after successfully completing percutaneous coronary intervention (PCI). RESULTS: On intention-to-treat analysis the infusion of MNCs had no positive impact on LVEF improvement of ≥ 5 per cent. The improvement in LVEF after six months was 5.17 ± 8.90 per cent in non SCT group and 4.82 ± 10.32 per cent in SCT group. The adverse effects were comparable in both the groups. On post hoc analysis it was noted that the cell dose had a positive impact when infused in the dose of ≥ 5 X 10 [8] (n=71). This benefit was noted upto three weeks post AMI. There were 38 trial deviates in the SCT group which was a limitation of the study. INTERPRETATION & CONCLUSIONS: Infusion of stem cells was found to have no benefit in ST elevation AMI. However, the procedure was safe. A possible benefit was seen when the predefined cell dose was administered which was noted upto three weeks post AMI, but this was not significant and needs confirmation by larger trials.

Transfusion medicine and solid organ transplant - Update and review of some current issues.

Transfusion medicine holds a place of prime importance in organ transplant surgeries. There is a huge demand of organs worldwide with long waiting periods before the organ is available for transplant. Currently the dependency on ABO and HLA matching has decreased considerably with the use of modern immunosuppressant drugs and transplant techniques. The greatest advance in clinical implementation of ABO-incompatible transplants came about through desensitization and isoagglutinin elimination techniques with immunoadsorption and anti-CD20 antibodies becoming the norm, and spleenectomy fading out. The implications and practices of transfusion medicine in organ transplant are also undergoing drastic changes. The practice of infusion of one unit of donor's blood preoperatively for immunomodulation is no longer practiced. Use of leuco-reduced products has shown decreasing trends of alloimmunization and graft rejection in cases of multiple surgeries related to organ transplants. Worldwide donor and recipient registry programmes are being setup and existing ones are being upgraded. Such a registry system has been opened in India for kidney transplant cases very recently. Due to such registry programmes the dependency on siblings and directed donations have decreased considerably. This review deals with some of the current issues contributing to the successful outcome of mismatched transplants and the changing concepts of transfusion medicine related to it.

Proportion of Rh phenotypes in voluntary blood donors.

BACKGROUND: The Rh system is the major blood group system besides ABO system. Even after proper blood grouping and cross matching there is a possibility of alloimmunization and antibody production in the recipients against the Rh or minor blood group antigens like Kell, MNSs, Duffy etc. Keeping in view the heavy financial burden of complete phenotyping of blood; the determination of only Rh phenotypes can play a major role in preventing alloimmunization and adverse events in multitransfusion cases. To determine the proportion of Rh phenotypes in voluntary blood donors with a view to generate blood bank data for constitution of panel of blood donors for multipurpose utilities. METHOD: Identification of Rhesus factors (Rh) was done by the antigen antibody agglutination test by the test tube method on 10,133 healthy voluntary donors. RESULTS: The phenotypic frequencies of Rh blood groups in the studied population were D-92.25%, C-87.55%, E-26.55%, c-51.06% and e-98.42%. Thus 'e' was the most common and E was the least common of all the Rh types. Phenotypically DCCee group was the most common phenotype and dccee was least common type. CONCLUSION: Determination of Rh phenotypes can play a major role in preventing alloimmunization and avoiding adverse events in multitransfusion cases.

Effect of gamma irradiation with 30 gy on the coagulation system in leukoreduced fresh frozen plasma.

BACKGROUND: Fresh Frozen Plasma (FFP) is a blood component prepared from whole blood or from apheresis donation. Donor leukocytes including lymphocytes are present in FFP in significant numbers inspite of freezing, responsible for Transfusion Associated Graft versus Host Disease (TA-GvHD). STUDY DESIGN AND METHODS: 75 units of FFP prepared at our centre were analysed. After thawing of FFP a small aliquot was made under sterile conditions and another after irradiating the product. In both the parts, variables of haemostasis were measured in parallel, using automated coagulation analyser. Activated partial thromboplastin time (APTT), prothrombin time (PT), International Normalized Ratio (INR), Thrombin time (TT), coagulation factors FI, FII, FV, FVIII, FIX, FX, FXI, FXII, vWF Ag, inhibitors of coagulation (protein C & S) and d-dimer were measured. RESULTS: Gamma irradiation of FFP with 30 Gy resulted in weak activation of coagulation system which was evident in the form of shortening of PT, APTT and TT. The activity of coagulation factors FIX, FX, FXI, and FXII were significantly raised after irradiation. No reduction in the activity of inhibitors of coagulation (protein C & S) or increase in d-dimers was observed following irradiation of FFP. CONCLUSION: Gamma irradiation of FFP with 30 Gy resulted in a significant but very weak alteration of coagulation system in FFP.

Seroprevalence of human parvovirus B19 in healthy blood donors.

BACKGROUND: Human parvovirus B19 is an emerging transfusion transmitted infection. Although parvovirus B19 infection is connected with severe complications in some recipients, donor screening is not yet mandatory. To reduce the risk of contamination, plasma-pool screening and exclusion of highly viraemic donations are recommended. In this study the prevalence of parvovirus B19 in healthy blood donors was detected by ELISA. METHODS: A total of 1633 samples were screened for IgM and IgG antibodies against parvovirus B19 by ELISA. The initial 540 samples were screened for both IgM and IgG class antibodies and remaining 1093 samples were screened for only IgM class antibodies by ELISA. RESULTS: Net prevalence of IgM antibodies to human parvovirus B19 in our study was 7.53% and prevalence of IgG antibodies was 27.96%. Dual positivity (IgG and IgM) was 2.40%. CONCLUSION: The seroprevalence of human parvovirus B19 among blood donor population in our study is high, and poses an adverse transfusion risk especially in high-risk group of patients who have no detectable antibodies to B19. Studies with large sample size are needed to validate these results.

Evolution of the role of army transfusion services in the management of trauma patients and battle casualties with massive hemorrhage.

Providing blood at the times of national emergencies and war-like scenarios is a challenge to the blood transfusion services. The dictum should be adequate bleeding, minimum storage time, quick transportation and maximum utilization of blood as soon as possible. For the successful implementation of its role, forward transfusion services should be fully mobile with integral transportation and communication systems. Supplementation of blood supplies has to be prompt, & for this adequate air transport facilities will have to be established. A rational approach to using blood products in patients with bleeding, requires an understanding of the principles of managing hemorrhagic shock. The main priorities are controlling hemorrhage and restoring adequate oxygen delivery to the tissues. Surgical control and treatment of coagulopathy are required to stop hemorrhage in these patients. Resuscitation with fluids and red cells are necessary to improve perfusion and oxygen delivery to tissues. Once patients are resuscitated and further bleeding is stopped, use of conservative transfusion triggers is recommended to avoid excessive transfusion and adverse outcomes. A host of new technologies are being developed that have the potential of reducing blood loss. These will help in reducing the transfusion requirements in trauma patients with massive hemorrhage.

Is seroprevalence of anti-IGM CMV among blood donors relevant in India?

BACKGROUND: Infection with cytomegalovirus (CMV) is more common in developing nations and the people belonging to the lower socioeconomic section of the society. The immunosuppressed population for whom CMV-seronegative blood products are requested is increasing due to advances in medical care. AIM: To study the prevalence of CMV antibodies among the different sexes and age groups in healthy blood donors. MATERIALS AND METHODS: A retrospective study was done on 5600 serum samples stored frozen in a repository for CMV antibodies using the ELISA technique. RESULTS: Five thousand three hundred and fifty (95.5%) were male and 250 (4.5%) were female. Four cases (0.071%) out of 5600 samples were positive for anti-IgM CMV with 95% Confidence Interval (95% C.I) of 0.02 - 0.17. CONCLUSION: In a developing country like India, screening for IgM antibody on a routine basis may not be feasible, given the likely positive yield to be low and the cost being high. It is recommended that in a tertiary care hospital, blood units to be transfused to neonates, organ transplant recipients, those suffering from malignancies and other immunocompromised patients should be screened for anti-IgM CMV or preventive strategies like universal leucodepletion to be implemented to decrease the transmission of CMV in these groups of patients.

Reliability and validity of telephonic Barthel Index: an experience from multi-centric randomized control study.

Telephonic Barthel Index (BI) assessment is less time-consuming and more feasible than a face-to-face interview. The aim of this study was to test the validity as well as reliability of the BI administered by telephone in comparison with face-to-face assessment in a multi-centric study. The study was conducted during the course of a randomized controlled trial in which 120 patients with subacute strokes from five teaching hospitals from different parts of India were recruited. Central telephonic follow-up and face-to-face assessment of BI and modified Rankin Scale (mRS) at 3 and 6 months were done by trained and certified blinded researchers. Kappa or weighted kappa (wK) was estimated. Sensitivity and specificity at various cutoff levels of telephonic BI were calculated. Concurrent validity of the telephonic BI was assessed by correlating it with the mRS and National Institutes of Health Stroke Scales (NIHSS) at 3 and 6 months. We observed high sensitivity and specificity at various cutoff levels of BI. Moderate to substantial agreement was observed between the two methods at 6 months wK 0.72 (95% CI 0.70-0.77). Item-wise and center-wise kappa also reflected substantial agreement. The study shows that telephonic assessment of activities of daily living with the BI in moderate to severely disabled stroke patients is valid and reliable compared to face-to-face assessment. Our study shows that telephonic assessment requires smaller sample size compared to face-to-face assessment of BI.

Leucodepletion and Blood Products.

BACKGROUND: Leucoreduction of blood products is increasingly being employed to produce blood products with residual WBCs < 5 × 10(6) per unit (99.9 percent or a log 3 leucoreduction). Clinical data suggests that non-haemolytic febrile transfusion reactions can be prevented by leucodepletion. The procedure also prevents alloimmunisation to HLA antigens in patients who will repeatedly require transfusion of blood/blood products. METHOD: Of the methods available to reduce the number of WBC in blood products washing of red cells, freezing and deglycerolisation are effective and yield a product with only a 24 hour shelf life. Other methods such as leucodepletion filters are relatively inexpensive, simple and the final product has a normal shelf life. Modern generation of leucoreduction filters and apheresis machines can provide greater than 4 log reduction of WBC. RESULTS: After the introduction of leucodepletion of blood for Thalassemics at our center in 2003, the incidence of non haemolytic febrile transfusion reactions (NHFTR) fell from 4% in 2002 to 1% in 2003. CONCLUSION: In patients undergoing long-term blood transfusion therapy e.g. Thalassemics, alloimmunisation against the HLA antigens on donor white cells is prevented by leucodepletion and prevents NHFTRs.

Difficulties in Immunohaematology : The Weak D Antigen.

BACKGROUND: The Rh blood system is one of the most polymorphic and immunogenic systems known to humans. The expression of Rh blood group antigen is complex. The Rh D antigen is the most important of the antigens that constitute the Rh antigen system. In most cases, D antigen can easily be detected. However, due to variability of expression, weak forms antigen are encountered. The reactivity of weak D with antisera is variable and presents as a problem in blood banking. METHODS: A retrospective analysis for a five-year period was done. Blood samples that were negative for Rh D by immediate spin tube method were tested for weak D antigen by additional lab tests. RESULT: Of 34932 serial Rh grouping tests done in our Blood Bank, the incidence of weak D Rh antigen was 0.189%. All these were confirmed by the antiglobulin test. CONCLUSION: These patients present as a problem for the blood banker and a curiosity to the clinician. Although uncommon, all health care workers should be aware of this entity to avoid anti D alloimmunisation.

Detection and Identification of Platelet-Associated Alloantibodies by a Solid-Phase Modified Antigen Capture Elisa (MACE) Technique and Its Correlation to Platelet Refractoriness in Multi platelet Concentrate Transfused Patients.

Platelets express glycoproteins (IIb/IIIa, Ib/IX, Ia/IIa, IV, and HLA-1) that are polymorphic and can become targets for antibody responses. Patients at threat are those who received multiple platelet transfusions. Modified antigen capture elisa (MACE) is a qualitative solid phase Elisa designed to detect IgG antibodies against platelet specific antigens. The study has been carried out over a period of 2 years. A total of 100 patients were selected, who had been transfused with at least 15 units of platelet concentrate. All patients were having either hematological malignancies or bone marrow failure syndromes. Platelet antibodies were identified using MACE-1&2. Data was analysed statistically, using odds ratio (OR) with 95 % confidence interval. 39 % of the patients were found to be alloimmunized against platelet antigens, of which eleven showed refractoriness. Six patients (54.5 %) with HLA-1, two patients (9.5 %) with GPIb/IX, two patients (40 %) with both HLA-1 and GPIIb/IIIa, and one patient with GPIIb/IIIa antibodies showed refractoriness. Production of HLA-1 antibody and the development of refractoriness was found to be significant with OR 14.05 and P value 0.0025. MACE-1&2 enabled specific detection and identification of platelet antibodies, which in turn correlated well with the development of refractoriness in multi transfused patients. GPIb/IX was detected as the commonest antibody in our patient population, which is in variance with Europian studies where it is GPIa/IIIa (HPA-1a/5b). This technique should be utilised in patients who are at an increased risk of developing alloimmunisation due to repeated platelet transfusions.

A single-centre study of vasovagal reaction in blood donors: Influence of age, sex, donation status, weight, total blood volume and volume of blood collected.

CONTEXT: Vasovagal reactions (VVRs) in blood donors. AIM: To find an association of age, sex, donation status, weight, total blood volume and volume of blood collected with occurrence of immediate VVR. SETTINGS AND DESIGN: Retrospective single-centre study. MATERIALS AND METHODS: The study was conducted from March 2000 to November 2010 at a tertiary care blood transfusion centre. All VVRs with or without syncope occurring during or at the end of donation were noted. STATISTICAL ANALYSIS USED: For qualitative association, c (2)-test was used. Unpaired 't' test was used for assessing difference between two groups with respect to VVR status. Simultaneous impact of all risk factors was assessed using multivariate logistic regression analysis. The data entry software SPSS (version 17.0) was used for statistical analysis. A P-value <0.05 was considered statistically significant. RESULTS: Overall 1085 VVRs were reported in relation to 88,201 donations, resulting in an overall VVR rate of 1.23%, that is, an incidence of 1 in every 81 donations. Donors with low blood volume, first-time donors, with low weight and female donors had higher absolute donation VVR rates than other donors. CONCLUSIONS: Donation-related vasovagal syncopal reactions are a multifactorial process determined largely by weight, age, first-time donor status and total blood volume. Our study reinforces the fact that blood donation is a very safe procedure, which could be made even more event-free by following certain friendly, reassuring practices and by ensuring strict pre-donation screening procedures.

The effect of repeated freezing and thawing on levels of vitamin K-dependent coagulation factors and fibrinogen in fresh frozen plasma.

BACKGROUND: Fresh frozen plasma (FFP) is considered adequate for transfusion immediately after thawing or for up to 24 hours if kept at 1-6°C, and is currently used very often to replace deficient clotting factors. If factor levels in refrozen FFP are within normal limits, then this component can possibly be transfused, thus avoiding wastage of FFP. AIM: To study the fate of vitamin K-dependent coagulation factors (F II, F VII, F IX, F X) and fibrinogen activity levels in repeatedly (twice) frozen and thawed FFP. MATERIALS AND METHODS: Two hundred FFP units comprising 50 units of each major blood group (A, B, AB, and O) were thawed at 37°C and 10-20 mL of FFP transferred to transfer bags with the help of a sterile connecting device (SCD). The FFP samples were taken into tubes (first sampling), and then the transfer bags were kept for 24 hours at 4°C. After 24 hours, repeat samples were taken in tubes from the transfer bag (second sampling), and then the bags were re-stored at < -18°C. One week later, the above procedure was repeated. Activity of coagulation factors and fibrinogen levels were measured by the automated coagulation analyzer. RESULTS: The levels of F II, F VII, F IX, F X, and fibrinogen of all the 200 FFP units, at all four time points, were above the lower normal value, but well within the normal range. CONCLUSION: The levels of F II, F VII, F IX, F X, and fibrinogen remain stable and adequate for transfusion in twice-thawed-and-refrozen FFP. This component can be safely used for transfusion as a source of vitamin K-dependent clotting factors and fibrinogen.