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   Table of Contents - Current issue
July-December 2018
Volume 3 | Issue 2
Page Nos. 83-146

Online since Wednesday, October 24, 2018

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Hospital-Acquired anemia: A hazard of hospitalization p. 83
Shivaram Chandrashekar
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The risk of transfusion transmissible infections. Where do we stand in 2018? p. 88
Ranjeeta Adhikary, Malavalli Venkatesh Bhavana
Blood transfusion is an important aspect of medicine and patient safety plays a very important role. A myriad of blood-borne infectious agents can be potentially transmitted through transfusion of blood and blood products donated by apparently healthy and asymptomatic donors. The diversity of infectious agents includes human immunodeficiency viruses 1 and 2, hepatitis B virus, hepatitis C virus, malaria, syphilis, human T-lymphotropic virus types 1 and 2 and in certain circumstances, hepatitis A virus, cytomegalovirus, parvovirus B19, and many more. Besides the established viral, bacterial, and parasitic diseases, novel agents have now appeared and are still emerging as potential threats in transfusion medicine. While transmission of prion protein causing variant Creutzfeldt–Jakob disease is of prime concern in countries like the United Kingdom (UK), bacterial infections and viruses such as Dengue and Chikungunya are of prime concern in the Asian region. Transfusion centers employ three levels of screening to ensure blood safety: donor screening interventions to exclude high-risk donors, testing for infectious markers by serology, nucleic acid testing methods and processing technologies like leukoreduction, use of diversion pouch in blood collection, and use of aseptic blood collection technique. Implementing new technologies like pathogen reduction to destroy/inactivate pathological substances in blood components using chemicals or UV lights coupled with expanding testing for emerging diseases will certainly increase the safety of blood. The ultimate aim is to minimize the risks of transfusion-transmitted infection during the window period of infectious agent in a cost-effective and efficient manner. Although considerable effort and resources have been invested, no single technique is yet effective and we are far from achieving zero risk. The main challenges are faced by developing countries due to limited resources.
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Current practices in pediatric transfusion p. 98
Charusmita Modi
The article opens with an account of red cell and platelet transfusion guidelines in fetal and neonatal period. This is followed by a discussion on the special requirements for transfusion in pediatric surgeries and hemostatic disorders. A scheme for the long term transfusion management in thalassemia and sickle cell anemia is summarised. Finally, the complications of transfusion seen in pediatric patients are described.
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Role of red cell and platelet indices as a predictive tool for transfusions in dengue Highly accessed article p. 103
Ambuja Kantharaj
Review of literature and prevalent practices show the importance of red cell indices, especially hematocrit(HCT )in the diagnosis and prognosis of dengue. Platelet indices also may act as a tool to assess the prognosis and decide on the need for red cell and platelet transfusions in dengue. Platelet indices such as platelet count, mean platelet volume (MPV), platelet distribution width (PDW), and plateletcrit (PCT) are simple indices which can be done by any 3-part differential cell counter. However, immature platelet fraction (IPF) can be done only at advanced centres using more advanced cell counters. In dengue fever, red cell indices give indirect information on whether the patient is bleeding or going into impending shock. An increased HCT suggests haemoconcentration and warrants treatment with bolus IV fluids while a decreased HCT in an unstable patient may indicate bleeding and act as a predictor for red cell transfusions, whereas it suggests recovery from disease in a stable patient. Platelet counts have no role in determining need for transfusion in dengue. Platelet indices give information on whether the platelet destruction is ongoing (necessitating an impending platelet transfusion) or whether the bone marrow is responsive and platelet transfusions can be put on hold. An increase MPV with falling platelets implies destruction of platelet and signals need for platelet transfusion while a decrease in MPV with low platelets <20,000/ul coupled with hemorrhagic tendency warrant need for red cell transfusions. An increase in IPF suggestive of responsive marrow and platelet transfusions could be possibly put on hold. Low platelet count, low MPV, low PCT, high PDW, and high P-LCR may be used as probable indicators for dengue in endemic area and also as a predictor of severity of dengue infection. However Platelet indices are still underutilised parameters both by the laboratory personnel as well as the clinicians due to various reasons like variability or lack of standardization in testing and reporting. Further platelet indices are not specific for (or predictive of) any particular pathological condition and large epidemiological, randomized, control studies are needed to establish utility of these parameters in dengue beyond doubt.
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Evaluation of utilization pattern of fresh frozen plasma in a tertiary care oncology center p. 109
Priti Desai, Anisha Navkudkar, Sunil B Rajadhyaksha
Introduction: Blood component therapy is widely used in an oncology center. Fresh frozen plasma (FFP) transfusions are mainly used for the treatment of certain clinical conditions such as coagulation derangements. Transfusion audits are important to understand clinical transfusion practices. This study evaluates the utilization pattern of FFP in a tertiary care oncology center. Materials and Methods: Retrospective analysis of 1338 FFP transfusions in 216 patients was done for 3 months. Analysis according to age, sex, clinical indications, requesting clinical unit, time of requisition and pre- and post-transfusion prothrombin time (PT), activated plasma thromboplastin time (aPTT), and international normalized ratio (INR) was carried out. Results: Of 1338 FFP transfusions, 63% transfusions were in males and 37% in females. Adult patients received 75% while pediatrics received 25% of all transfusions. Surgical oncology patients received maximum transfusions (56%), followed by medical oncology (41%) and least by radiation oncology (3%). Based on clinical indications, patients with deranged coagulation profile required maximum transfusions (55%) followed by bleeding patients (43%) and least for patients with disseminated intravascular coagulation (2%). Mean pre- and post-transfusion PT, aPTT, and INR values were 25.6 s, 36.8 s, 2.1 and 20.56 s, 31.9 s, and 1.6 respectively; it was statistically significant (P < 0.05). Conclusion: FFP transfusion plays a significant role in oncology patients as many of them experience deranged coagulation during the course of treatment. Evaluation of utilization pattern would help in better understanding of clinical transfusion practices.
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Use of two methods to elute anti-IgG and anti-(IgG + C3d) type autoantibody from sensitized erythrocytes p. 113
He Ziyi, Hu Yingming, Cui Siping
Background: Autoimmune hemolytic anemia (AIHA) is an immunological disease caused by autoantibodies. Warm autoantibody mainly includes anti-IgG and anti-(IgG+C3d) type, which can cause direct antiglobulin test (DAT) positive. In order to correctly identify blood group and cross match, we compare the effect of using two elution methods to elute anti-IgG and anti-(IgG+C3d) type autoantibody sensitized erythrocyte. Methods: Twenty cases of anti-IgG type autoantibody and 20 cases of anti-(IgG+C3d) type autoantibody were eluted from sensitized erythrocytes using ZZAP (cysteine activated papain and dithiothreitol) and CP (chloroquine phosphate) reagents. Results: The effect of elution on anti-IgG type autoantibody sensitized erythrocytes is better than anti-(IgG+C3d) type with two elution methods (P < 0.05). The effect of absorption on anti-IgG and anti-(IgG+C3d) type autoantibody sensitized erythrocytes by ZZAP reagent is better than CP (P < 0.05), and the effect of absorption autoantibody after anti-IgG autoantibody sensitized erythrocytes with ZZAP is better than anti-(IgG+C3d) type (P < 0.05). Conclusion: Anti-(IgG+C3d) type autoantibody sensitized erythrocytes are all not eluted by ZZAP and CP, but ZZAP are better than CP on anti-IgG type autoantibody sensitized erythrocyte.
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Effect of therapeutic phlebotomy on plasma volume in polycythemia patients p. 117
Mohandoss Murugesan, Soumya Das, Shamee Shastry
Background: Therapeutic phlebotomy (TP) helps in reducing the red cell mass thereby whole blood viscosity to improve tissue perfusion and oxygen delivery in polycythemia patients. We aimed to determine the plasma volume changes in polycythemia patients undergoing TP. Materials and Methods: We studied TP procedures in 134 patients undergoing 236 episodes prospectively. Patient clinical details were recorded to assess improvement in symptoms after the procedure. Plasma volume changes were calculated based on the difference between the pre- and postcollection blood volume. The influence of frequency of blood collected on plasma volume was analyzed. Results: A progressive reduction in hematocrit (1.7 ± 2.6 %) and hemoglobin (0.78 ± 0.5 g/dL) in relation to volume removed and frequency was observed . The mean blood removed during TP in these patients was 304 ± 58.1 mL. There was a progressive increase in plasma volume with respect to the frequency of TP (2.51 ± 1.58 mL/kg). Conclusion: Symptomatic improvements following TP were noted in 60% of patients. TP though commonly performed for reducing red cell mass in polycythemia had poor compliance from patients, resulting in failure to achieve desired levels.
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Optimization of blood safety through essential characterization of naturally occurring lewis antibody p. 121
Sudipta Sekhar Das, Ritam Chakrabarty
Background: Lewis (Le) antibodies are usually naturally occurring; however, they may be clinically significant, may be immunoglobulin G (IgG) type, and may cause hemolytic transfusion reactions. The present study depicts the clinical significance and detailed characterization of Le antibodies in blood donors and patient populations and their implication in safe blood transfusion. Materials and Methods: The prospective study included seven individuals who were detected with Le antibodies. Further investigations were performed for detailed characterization of these antibodies with regard to antibody type, thermal amplitude, titer, and enzyme study and secretor status of the individuals. Results: Of the 69,354 donors and patients subjected to antibody screening, anti-Lea was detected in 7 individuals with none having anti-Leb. All showed the Le (a−b−) phenotype with 4 individuals presenting with IgG anti-Lea optimally reacting at 37°C, with a highest titer of 32. Where all seven individuals were ABH secretors, however none revealed any Le substances. For patients requiring transfusion, compatible Lea antigen-negative red cell units were issued without any adverse events. Conclusions: As naturally occurring Le antibodies may be clinically significant and cause hemolytic transfusion reaction, therefore identification and detailed characterization of antibody in blood donor or recipient is very crucial to blood safety.
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Are we missing out something in donor notification? p. 125
Rasika D Setia, Mitu Dogra, Anil Handoo
Background: Donor notification is an integral part of any blood collection facility. But regarding DAT positive donors there are no standard guidelines to notify them or to refer them to any clinician. Aim of this study was to suggest possible ways to manage DAT positive donors. Material and Methods: This was a retrospective study extended over past 5 years from 2013-2017 in a tertiary care health center. All whole blood donations were tested for ABO Rh, irregular antibody, HIV, HBV, HCV, SYPHILIS, and Malaria parasite. At the time of blood request if crossmatch came incomnpatible and antibody screen was negative we do DAT of the unit and if it comes positive then DAT work up was done. Result: Of total 55,310 donations, Twenty-two (0.04%) donors were DAT positive. From DAT positive donors, in 72% of cases IgG alone was responsible for DAT positivity of the unit, and in 18% of cases, involved IgG was subtyped as I gG1/IgG3. Conclusion: With the evidence of a significantly increased risk of cancer, especially hematologic malignancies, among blood donors with a positive DAT, donor notification is suggested. There should be a standardized protocol across the country about donor notification to avoid confusion and variations seen in different blood collection facilities.
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The role of conventional tube and column agglutination technique in predicting hemolysis in various clinical conditions p. 128
Shamee Shastry, Rajendra Chaudhary
Introduction: The correlation of positive result in direct antiglobulin test (DAT) with in vivo hemolysis is important for the patient management. This study compares the correlation of tube-DAT and -DAT by column agglutination technique (CAT) with in vivo hemolysis and reviews the appropriateness of the requests for DAT in patients with various clinical conditions. Patients and Methods: A total of 250 consecutive patients referred for DAT were enrolled for the study. Laboratory indicators of hemolysis were obtained from the computerized hospital data management system. Hemolysis in patients was graded using predetermined criteria. DAT was done using CAT and tube techniques and graded on the agglutination pattern. Results: Among 250 patients studied, 160 patients were from the hemato-oncology unit, and 47 had an autoimmune disease. Laboratory evidence of hemolysis was seen in 170 patients (severe: 45.88% and moderate: 54.12%). Positive DAT by tube technique was seen in only 41 out of 65 patients whose DAT was positive by CAT. Hemolytic anemia was the single largest cause in this group. Positive predictive values (PPVs) of tube and CAT were comparable. On comparing the strength of agglutination with the in vivo-hemolysis, 1+ reaction by CAT had low PPV. Conclusion: The present study shows that mere DAT positivity does not always indicate in vivo hemolysis. Hence, while recommending the routine use of CAT for DAT, we suggest to incorporate the strength of agglutination reaction in laboratory report for the ease of interpretation.
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Salvage of red blood cell units using remote electronic blood issue system in operation theater: A pilot study from India p. 132
Aseem K Tiwari, Geet Aggarwal, Devi Prasad Acharya, Dinesh Arora, Gunjan Bhardwaj, Divya Setya, Vijay Vohra, Arvinder S Soin
Introduction: Anesthetists procure pre-defined number of blood units in advance for surgical patients for ‘just-in-case’ scenarios. This often results in non-usage and discarding of blood units. Blood bank discards blood units returned from operation theatre due to disruption of cold chain. In an effort to reduce this wastage an intervention from transfusion medicine team was undertaken in collaboration with liver transplant team with help of an electronically controlled remote inventory and bedside transfusion management system called BloodTrack Courier. Effectiveness of BloodTrack® Courier in tracing and reducing red cell unit wastage was studied over a four-month period and compared with four-month historical control. Materials and Method: intervention was limited to red cell units issued in elective live-donor liver transplant cases through BloodTrack (Haemonetics Corporation, USA). Controlled access linked to hospital identity cards was provided to Transfusion Medicine Specialists and Liver Transplant anesthetists with different access levels. Pre-allocated RBC units were kept at OT refrigerator for a period of 24-36 hours after which unused units were retrieved by BTS and re-inventoried. Results: Transfusion of RBC units in 60 liver transplant recipients donor before installation was compared with similar 86 liver transplant recipient-donor after installation of BloodTrack. Mean number of RBC units transfused in recipient-donor decreased from 6.2 and 1.0 unit before installation to 5.9 and 0.76 units after installation, respectively. RBC units discarded due to breakage of cold-chain reduced to zero and RBC units successfully returned to blood bank increased 7.6 times. Conclusion: Blood inventory management and remote issue function of Blood Track was very effective in saving RBC units during four-month study period.
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Therapeutic plasma exchange: A study of indications and efficacy p. 136
Gita Negi, Rashi Ahuja, Vibha Gupta, Dushyant Singh Gaur, Deepak Goel, Reshma Kaushik
Background and Objectives: Therapeutic plasma exchange has been in use to treat a variety of diseases and for the purpose of rational decision-making, the American Society for Apheresis has proposed guidelines for the same. The present study was undertaken to study various aspects of the plasma exchange facility in a tertiary care center at Uttarakhand, India. Methods: The relevant demographical details (age, sex, BMI), clinical history of patient (any previous illness, any chromic disease, medications etc.), relevant investigations performed (basic haematology and immunology tests), plasma exchange procedure notes (total time taken, any adverse reactions noted), and replacement fluids used (type and amount used) were recorded and analyzed. Results: A total of 157 plasma exchange procedures were performed on 47 patients. Of these, maximum procedures were done for patients with Guillain–Barre syndrome (GBS), myasthenic crisis, and disseminated intravascular coagulation (DIC). The other indications were multiple myeloma, plasma cell dyscrasia, thrombotic thrombocytopenic purpura, and DIC after scrub typhus and dengue. The most common adverse reaction noted was urticaria (8/19), followed by perioral tingling (3/19) and hypotension (7/19). Interpretation and Conclusions: Fifteen out of 17 patients suffering from GBS and all patients of myasthenic crisis showed recovery, however, one patient of myasthenia gravis did not show immediate improvement, but recovered after some delay. Among the patients with thrombotic thrombocytopenic purpura with neurological manifestations, 3 out of 5 patients showed significant improvement. Patients who presented with other indications of plasma exchange also showed clinical benefits and the procedure resulted in quick recovery.
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Reagent-dependent reactivity: A noise in the immunohematology laboratory p. 140
Rajeswari Subramaniyan
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Effect of rapamycin on gene expression of nuclear factor-κB p65 and STAT-1 in sprague–dawley rats with acute lung injury p. 142
LW Li, ZQ Li
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Establishment of fluorescence-based quantitative real-time polymerase chain reaction for the detection of barcode DNA in the novel bio-barcode assay p. 144
Ji Chang-fu, Yin Hui-qiong, Jia Jun-ting, Wang Rui, Zhu Feng-xuan, Jin-Gang Zhang
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