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   Table of Contents - Current issue
Coverpage
July-December 2017
Volume 2 | Issue 2
Page Nos. 73-172

Online since Monday, September 11, 2017

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EDITORIAL  

Ethics that apply to blood banks, apply to newspapers as well. How about some responsible reporting by the print media? Highly accessed article p. 73
Shivaram Chandrashekar
DOI:10.4103/GJTM.GJTM_47_17  
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REVIEW ARTICLES Top

The human leukocyte antigen system … simplified p. 77
Anand Deshpande
DOI:10.4103/GJTM.GJTM_45_17  
Human leukocyte antigen (HLA) and transfusion medicine go hand in hand. Transfusion medicine experts are involved in transplants, particularly hematopoietic stem cell transplant. A lot of clinical challenges such as febrile nonhemolytic transfusion reactions, transfusion-related acute lung injury, and also graft versus host disease are caused by HLA antibodies. It is a unique genetic system located on chromosome 6 and its protein products situated on white cells. Histocompatibility in transplant scenario is not the only function of HLA antigens but the main role is to present peptides to immune system and regulate cellular and humoral immunity. HLA Class I (A, B, and C) and HLA Class II (DR, DQ, and DP) antigens are different in structure and function. Typing methods have progressed from earlier serology-based techniques to sequence-based typing to next-generation sequencing. Cross matching techniques have also changed from complement-dependent cytotoxicity (which is still considered a gold standard) to microbead-based assay to flow cytometry. Finally, HLA and its disease association has long been established, particularly so in cases of ankylosing spondylitis.
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Existing and recommended legislative framework for a national blood transfusion policy p. 89
Cees Th. Smit Sibinga
DOI:10.4103/GJTM.GJTM_35_17  
Blood transfusion contributes to saving millions of lives every year, improves life expectancy, and the quality of life of patients suffering from life-threatening conditions and supports complex medical and surgical procedures. Every country should put in place policies, a legislative framework, systems and structures to ensure the safety, quality, accessibility, and timely availability of blood and blood products to meet the needs of all patients who require transfusion. However, there are numerous situations, particularly in the less developed world, where these prerequisites have barely been implemented. A literature search was done on matching combinations of legislation, regulation, legislation framework, with blood and blood transfusion, which resulted in almost exclusively references with respect to national and international legislation. The Ministry of Health should provide effective leadership and governance in developing a national blood system that is fully integrated into the health-care system. Essential functions of a national blood system include policy formulation, a legislation framework spelling out the principles and boundaries, standard setting, strategic and operational planning, provision of resources and national coordination, and management to ensure an adequate supply of blood and blood products and safe clinical transfusion. The structure of the national blood system will depend on the organization and level of development of the health-care system. However, all critical activities within a national blood system should be coordinated nationally to promote uniform standards, economies-of-scale, consistency in quality and safety of blood and blood products. and best transfusion practices. Keys are formulation and oversight of the implementation of the national blood policy and strategic plan; defining the roles, responsibilities, and accountability of institutions; and setting national standards for blood and blood products, services, processes, and systems; defining requirements for the registration, licensing, and operation.
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ORIGINAL ARTICLES Top

Total leukocyte count-based predictor tool for calculating hematopoietic progenitor cell dose in bone-marrow harvest p. 97
Dinesh Arora, Aseem K Tiwari, Ruchira Misra, Ravi C Dara, Geet Aggarwal, Nitin Sood, Gunjan Bhardwaj
DOI:10.4103/GJTM.GJTM_27_17  
Background: Hematopoietic progenitor cell transplantation is increasingly being used as the curative therapy in India for various clinical conditions. There are three main sources of hematopoietic progenitor cells; hematopoietic progenitor cell-apheresis (HPC-A), hematopoietic progenitor cell-bone marrow (HPC-M) and hematopoietic progenitor cell-Umbilical Cord (HPC-C). The number of CD34+ cells in HPC-C is fixed. In HPC-A, the number of CD34+ cells collected is based on the baseline peripheral blood counts and a second harvest can be easily performed. The trickiest calculation of CD34+ cells adequacy is in case of HPC-M harvest, where the end point of harvest cannot be predetermined. Aim: The aim was to study the accuracy of a total leukocyte count (TLC)-based predictor tool in predicting CD34+ dose in comparison to the actual CD34+ cell counts in the harvest. Materials and Methods: This was a prospective study to validate the tool. The data captured included patient and donor demographic data, disease condition, mobilization regimen of the donor, progenitor cell harvest data, dose collected, cryopreservation if any, progenitor cell infusion data, engraftment, and follow-up of the patient including day thirty and day hundred chimerism in a tertiary care hospital. Results: Five patients were included in the study. For each patient, the target dose and volume were collected in a single HPC-M harvest attempt, and no repeat harvests were required. The average volume of HPC-M harvest collected was 195 ml. The average CD-34+ cell dose in HPC-M harvest achieved was 4.3 × 106/kg (Range = 3.39–6.42). This was 85.7% of the targeted dose calculated on the basis of TLC-based predictor tool. Conclusion: This study reiterates the importance of a simple TLC-based predictor tool (formula) for estimation of HPC-M volume to be harvested.
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Comparison of “Amicus and COBE Spectra” for autologous peripheral blood stem cell harvest: An Indian experience p. 102
Rasika Dhawan Setia, Satyam Arora, Anil Handoo, Dharma Choudhary, Sajeev Kumar Sharma, Tina Dadu, Divya Doval, Meenu Kapoor, Shalu Bajaj, Virendra Bachchas
DOI:10.4103/GJTM.GJTM_43_17  
Background: Adequate collection of peripheral stem cells from the patients depends on the disease condition, efficient mobilization and the equipment used for PBSC harvest. COBE Spectra has been the major platform for collecting these PBSC for more than 2 decades. Now with introduction of PBSC harvest option with Amicus cell separators (which was used primarily for plateletpheresis) in India, it is worth while comparing both the platforms for stem cells collections. Materials and Methods: Our study is a retrospective analysis of autologous PBSC harvest procedures done at our centre. The study included the data of autologous PBSC collections from January 2015 to June 2016. Total 61 patients underwent 85 autologous PBSC harvests for both haematological and non haematological indications. Results: Out 61 patients, 40 patients collected their target number of cell in a single harvest, 18 patient required dual harvests and 3 patients required three consecutive days of harvest. Pre-Apheresis WBC, platelets and CD45/CD34 cell counts were comparable. COBE Spectra collects significantly higher product volume and higher number of platelets in the apheresis product. Whereas WBC counts of the product, total CD45/CD34 cell dose and collection efficiency (CE2) and collection ratio (CR) were comparable on both the platforms. Conclusions: Amicus took more time to harvest the anticipated number of cells in the graft as well as COBE Spectra resulted in higher platelets loss during the process of cell collection. Our analysis is first of its kind from Indian subcontinent and indicates that with gradual phasing out of COBE spectra from the market Amicus offers a comparative platform for PBSC harvest.
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Audit of clinical use of red blood cells in a tertiary care setting: An algorithmic approach! p. 109
Aseem K Tiwari, Ankita Ratan, Dinesh Arora, Geet Aggarwal, Swati Pabbi Mehta, Divya Setya, Devi P Acharya
DOI:10.4103/GJTM.GJTM_36_17  
Objective: There have been quite a few publications on audit of clinical use of blood components. However, there is paucity of studies on red blood cell (RBC) clinical use. Therefore, a study was designed to determine the appropriate clinical use of RBC in various departments in a tertiary care setting. Materials and Methods: It was a prospective observational study conducted from January 2017 to April 2017 in a large tertiary care hospital in north India. The study population included all consecutive admitted patients who received RBC transfusion during the study period. Patients undergoing RBC transfusions the in operation theater were excluded. An algorithmic approach was used which analyzed the “appropriateness” on the basis of hemoglobin thresholds, symptoms in patient, comorbidities, and imminent blood loss in a sequential manner. Results and Discussion: Of a total of 1024 transfusions, 924 (90.02%) episodes were appropriate. This was higher than the previous published reports because of algorithmic approach, higher hemoglobin threshold (8 g%), and possibly better informed physicians in tertiary care setting. Conclusion: There were a high percentage of appropriate RBC transfusions in large tertiary care settings.
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Evaluation of blood requisition and utilization practices at a tertiary care hospital blood bank in Islamabad, Pakistan Highly accessed article p. 113
Usman Waheed, Muneeba Azmat, Akhlaaq Wazeer, Sadia Sultan, Syed Muhammad Irfan, Hasan Abbas Zaheer
DOI:10.4103/GJTM.GJTM_30_17  
Introduction: The significance of appropriate completion of blood request forms (BRFs) is frequently underrated by the clinicians which results in wastage and increased risk of inappropriate therapy. The judicious use of blood components can be assessed by the crossmatch-to-transfusion ratio (C:T), transfusion probability (%T), and transfusion index (TI). The current study assessed the standard of completion of BRFs and blood components utilization at a Tertiary Care Hospital Blood Bank. Materials and Methods: This was a cross-sectional, prospective study conducted at the Department of Blood Transfusion Services, Shaheed Zulfiqar Ali Bhutto Medical University Hospital, Islamabad, from January to April 2016. A total of 5957 BRFs received between January and April 2016 were reviewed. The data were entered in SPSS version 20.0 (IBM SPSS Statistics for Windows, IBM Corp., Armonk, NY, USA) and analyzed for completeness, legibility, and blood component utilization through calculation of key indicators including C:T ratio, transfusion probability (%T), and TI. Results: Out of the 5957 request forms reviewed, only 12.7% forms were completed in full. The overall C:T ratio, %T, and TI were 1.52, 65.38, and 0.65, respectively. The same indicators for the Maternal and Child Health Centre (MCHC) were 10.7, 9.32, and 0.09. Conclusion: Incomplete blood transfusion request forms create difficulties for the blood bank staff in comprehending the requests which may compromise patient safety. Similarly, the efficiency of MCHC blood transfusion services is far from optimum. The Hospital Transfusion Committee can play a key role in solving this problem and thus improving the standards of Patient Blood Management.
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Monitoring errors in a blood bank immunohematology laboratory: Implementing strategies for safe blood transfusion p. 118
Sudipta Sekhar Das, Ritam Chakrabarty, RU Zaman
DOI:10.4103/GJTM.GJTM_40_17  
Background: Errors occurring at patient bedside during specimen collection are the most common causes of adverse outcomes. We planned this prospective study to estimate the incidence and nature of transfusion errors, identify the source, site of occurrence, and assess the underlying problems in the system with the aim to prevent the potentially fatal human error. Materials and Methods: The study was performed over a period of 5 years at a hospital based blood transfusion service where all errors and discrepancies both in the recipient and donor samples were reported into an 'incident and error reporting register' and then analyzed. Results: While a total of 72,381 patient samples were received for pretransfusion testing, 43,762 samples were from blood donors for ABO and Rh grouping. A total of 79782 blood components were issued to patients during the study. Out of 229 errors in the blood transfusion chain, 164 (0.22% of total requisitions and 0.21% of total component issued) were reported in patient pretransfusion samples, and 65 errors (0.15%) were reported in donor samples. Majority of the errors were clerical in nature and related to human errors. Of the 164 errors in pretransfusion testing samples, 107 (65.2) were observed in night shift. The overall error frequency per 1000 requisitions was 2.26. Conclusion: Near miss event reporting can prevent potential transfusion associated mortality and morbidity caused by simple human ignorance. A good error reporting not only helps in accurate collection and analysis of data but also makes recommendations that improve transfusion safety.
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Recipient hemovigilance study in a university teaching hospital of South India: An institutional report for the year 2014–2015 p. 124
Pallavi Prakash, Vijaya Basavaraj, Rashmi B Kumar
DOI:10.4103/GJTM.GJTM_32_17  
Background and Aim: Blood transfusion plays an important role in improving the health and saves lives. However, it is a double-edged sword, which should be used judiciously as it is also inherently embedded with adverse reactions ranging in severity from minor to life threatening events. Haemovigilance programme of India (HvPI) aims to ensure the transfusion safety by monitoring every step of transfusion process from donor to recipient. Recipient hemovigilance is reporting of adverse transfusion reactions (ATRs) in the patient. Contributing to this program as registered member, this study aimed to determine the frequency and type of ATRs in blood recipients. Materials and Methods: The study was conducted in the Department of Transfusion Medicine of a University Teaching Hospital of South India. This was a retrospective, observational study in which all ATRs reported by the department to HvPI observed in patients admitted in various clinical departments over a period of 24 months (January 2014 to December 2015) were reviewed and analyzed. Results: During the study, a total of 31,687 blood and blood components were issued, out of which a total of 66 (0.2%) ATRs were reported. The most common type of reaction observed was febrile nonhemolytic transfusion reaction (FNHTR) 54.55% (n = 36), followed by allergic 33.33% (n = 22). The other reactions observed were nonspecific reactions 9.09% (n = 6), acute hemolytic reaction 1.52% (n = 1), and mixed type reaction of FNHTR and allergic reaction in 1.52% (n = 1). No case of transfusion-related acute lung injury, transfusion-associated circulatory overload, anaphylaxis, and transfusion-related sepsis was reported. The ATRs were seen mostly with packed red blood cells (78.8%). Conclusion: The frequency of ATR in our institution was 0.2%. Febrile and allergic reactions were the most common type.
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Analysis on discard of blood and its products with suggested possible strategies to reduce its occurrence in a blood bank of tertiary care hospital in Western India p. 130
Ashishkumar Nathabhai Kanani, Jitendra H Vachhani, Spruha K Dholakiya, Shweta B Upadhyay
DOI:10.4103/GJTM.GJTM_34_17  
Background: Blood is precious and should be utilized judiciously with minimal wasting. By analyzing the data and the reasons for discard, the blood transfusion service can develop plans to evaluate causes that lead to discard of blood and its components and interventions that can be used to optimize their use by training and education. Aim: (1) The aim of the study was to evaluate causes that lead to discard of blood and its components and interventions that can be used to optimize their use by training and education, (2) to introduce possible strategies for minimizing blood wastage, and to observe and compare the discard rate after the implementation of strategies. Materials and Methods: The study of analysis on discard of blood and its products was carried out retrospectively from January 2014 to December 2016 (36-month period), and the data were collected from the blood bank database system using Easy Software in the Department of Transfusion Medicine, Shri M P Shah Govt. Medical College, Jamnagar in Western India. The results were analyzed using Microsoft Excel 2007 database sheet, percentage calculated and Chi-square test was applied between different variables with P value set a significant when <0.05. Results: A total of 66,255 blood units were collected during the study period of 36 months. Out of 66,255 blood units collected, 44,617 were whole blood (WB) whereas components were prepared from remaining blood units. A total of 21,638 packed red blood cells (PRBCs), 6840 platelet concentrate (PC), and 14,372 fresh frozen plasma (FFP) were prepared. Average discard rate of the present study was 6.95%. Discard rate for WB, PRBC, PC, FFP was 3.15%, 2.26%, 28.39%, and 5.36%, respectively. Conclusion: To minimize wastage of blood, there should be proper implementation of blood transfusion policies and coordination between hospital and blood bank staff. Strict adherence to donor selection criteria, taking proper predonation history and counseling, software to identify transfusion transmitted infection (TTI) positive donors, and deferring suspected professional donors who have been screened previously may help in reducing discard due to TTI positivity. Process improvements such as technical expertise in phlebotomy, prevent red blood cells (RBC) contamination during platelet and FFP preparation, precaution during thawing of FFP to prevent leakage, and increased use of apheresis technique prevent wastage of blood components. Continued medical education for technical staff to maintain self-audit, tracking quality indicators of processing and preparation of the blood components, rational use of blood and components, and review the blood management system will further help in reducing the discard rate.
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Evaluation of glucose-6-phosphate dehydrogenase enzyme deficiency and methemoglobin concentration in blood donors in a Nigerian Tertiary hospital-based blood bank p. 137
John C Aneke, Nancy C Ibeh, Chide E Okocha, Ebelechukwu Orakpor
DOI:10.4103/GJTM.GJTM_21_17  
Background: Glucose-6-phosphate dehydrogenase (G6PD) enzyme deficiency and methemoglobinemia adversely impact on blood transfusion safety by significantly increasing blood storage lesion. Objective: To determine G6PD enzyme deficiency and methemoglobin levels among blood donors in a tertiary hospital-based blood bank in Nigeria. Subjects and Methods: One hundred blood donors who met the criteria for blood donation were prospectively studied. Two milliliters of venous blood was collected from each participant into potassium-ethylenediaminetetraacetic acid specimen containers and analyzed for G6PD status and methemoglobin levels by spectrophotometry, on the same day of sample collection. Results: Among the donors, 43% had normal G6PD activity (9.32 ± 2.26 U/gHb), 44% had partially enzyme deficiency (4.92 ± 1.33 U/gHb), while 13% had total deficiency (0.47 ± 3.49 U/gHb); these were statistically different (P < 0.001). Methemoglobin concentration was elevated in 25% of study participants (3.05 ± 2.30%), while it was normal in 75% (0.99% ± 0.60%); these differences were statistically different (P < 0.001). Conclusion: A significant proportion of our blood donor set has G6PD enzyme deficiency (partial or total) as well as evidence of oxidation of hemoglobin; these findings have adverse implications on transfusion safety.
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Olfactory function and its association with ABO blood group in adults: A cross-sectional study p. 143
Anuran Mukherjee, Abhishekh Basavarajegowda, KT Harichandrakumar
DOI:10.4103/GJTM.GJTM_20_17  
Background: The effect of blood group antigens in human olfactory performance has not been established yet. This study was designed to find out the association if any of blood groups ABO of a person with the olfactory performance by some simple standard established olfactory tests. Materials and Methods: Olfactory threshold testing and olfactory identification testing were performed using the standard “i-smell” test using the common household items such as asafoetida (heeng), camphor, cardamom, clove oil, cumin seeds, lemon, and Vicks. The results were compared to see for association with ABO blood groups. The statistical analysis was done using IBM SPSS Statistics for Windows, Version 21.0., 2013 (Armonk, NY; IBM Corp.). Results: Among the 329 individuals participated in the study who were age and sex matched, there was an equal representation of all ABO blood groups. There was no statistically significant difference between the ABO groups either with olfactory threshold testing or with olfactory identification testing. Conclusion: Blood group is not proximally associated with olfactory function of an individual. A more objective test which may include complex or invasive studies in controlled environment with bigger sample may be planned for.
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Various aspects of plateletpheresis: Its impact on donor and patients p. 149
Dibyajyoti Sahoo, Smita Mahapatra, Pankaj Parida, Rashmita Panigrahi
DOI:10.4103/GJTM.GJTM_24_17  
Background and Aim: Platelet transfusion plays an important role in the treatment of hematological, oncological, surgical, and transplant patients. Aphaeresis technology is widely available in the world and some part of India, but it is new for our region. The present study aims at various aspects of plateletpheresis including donor safety, donor hematological changes following single donor platelet (SDP) donation, quality of product, and impact on patient following SDP transfusion. Materials and Methods: Preprocedural hematological count such as total platelet count (TPC), hemoglobin, red blood cells, and white blood cells count was recorded. All donors were observed for adverse donor reactions. Postdonation (after 30 min) sample was drawn to see the hematological parameters and compared to that of pre donation hematological parameters. Quality control of all SDP products was done. All recipients were observed for any transfusion reactions. Post 24 h transfusion sample was obtained from the SDP recipient and compared to that of pretransfusion sample to see the platelet increment. Results: A total of 135 plateletpheresis procedures were performed on cell separator. SDP was collected from the donors as per standard operating procedure. All donors were observed for adverse donor reaction. We found an adverse event with one donor. There was decrease in mean value of all hematological parameters in the postdonation sample. There was no thrombocytopenia either clinically or from laboratory value. Similar trend was seen with double yield collection. Mean acid citrate dextrose (ACD) used was 328, mean blood volume processed 3385 ml, mean product volume was 249 ml, mean time was 76.8 min during the procedure. Quality control of all SDP products was done. Mean yield was found to be 4.18 ± 0.95 × 1011 per unit. A positive correlation was seen between pre TPC of donor and product yield. Post 24 h transfusion sample was obtained from the SDP recipient and compared to that of pretransfusion sample to see the platelet increment. We observed mean increment of platelet count to be 76.15 × 109/L. Overall therapeutic benefit was observed in all cases. Conclusion: The study found that plateletpheresis procedure is very safe from donor point of view and SDP product is effective from recipient's point of view.
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Spontaneous cold agglutination phenomenon associated with auto-anti-“N”-like antibody in a healthy blood donor p. 155
Sanmukh Ratilal Joshi, Ankita Sheladiya, Kinjal V Mendapara-Dobariya
DOI:10.4103/GJTM.GJTM_19_17  
Background: The low titer cold autoagglutinins (CAs) are found in every individual; the high-titer CAs are associated with certain infections, malignancies, or autoimmune disorders. Usually, they have specificities as anti-I; occasionally, they occur as anti-i or anti-Pr. However, CAs found that as spontaneous cold autoagglutinations (SpCAs) among the healthy blood donors are predominantly anti-i or anti-Pr besides being anti-I for their specificities. Aim: The present study is aimed to ascertain the specificity of autoantibody associated with SpCA. Study Design: The antibody in the donor's plasma and the eluate augmented from his red blood cells (RBCs) was studied. Specificity was determined using commercial and in-house RBCs panel. Standard serological methods were used. Results: A 49-year-old male volunteer donor grouped as B, RhD-negative, and M+N+ and showed a positive test for antibody screening. Direct antiglobulin test was negative though the autocontrol test was strongly positive at 4°C. The antibody eluted from the donor's RBCs showed anti-“N”-like specificity when it reacted with the trypsin-treated RBCs but not with the papain-treated RBCs. Its specificity as anti-“N” was ascertained by the failure of its reactivity with the RBCs from the M+N-S-s-U-phenotype that lacks the “N” antigen. Conclusion: SpCA phenomenon observed in this case differs from the reported cases for its specificity as anti-“N”-like.
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SHORT ARTICLE Top

Red cell autoantibodies: Selection of blood for transfusion p. 159
Sadhana Mangwana, Neha Bedi, Nikhil Simon
DOI:10.4103/GJTM.GJTM_23_17  
Introduction: Transfusion of serological safe blood is an essential requirement in transfusion medicine. Development of anti- red blood cell antibodies remains a major problem. Materials and Methods: A study was conducted on 24237 donors and 25155 patients between August 2013 and July 2016 to determine the prevalence of RBC autoantibodies and management of autoantibody screen positive cases. Results: 19 donors (0.078%) were identified with RBC autoantibodies. 16 of 19 donors showed warm autoantibodies (WAAs), one showed cold autoagglutinin and two showed autoantibodies; type not identified. Ten patients (0.039%) were identified with autoantibodies, of which nine showed warm autoantibodies and one showed cold autoagglutinin. Conclusion: Autoantibodies are mostly formed against the high incidence antigens and therefore react with red cells of random donors' blood, causing difficulty in interpretation of cell typing, compatibility testing, antibody detection and antibody identification. There are wide variations in testing and RBC selection practices in patients with WAAs, further studies are required to evaluate and compare different testing algorithms and transfusion strategies.
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CASE REPORT Top

Daratumumab (Anti-CD38) interference with serological testing: An emerging challenge for blood banks in developing countries p. 163
Rasika Setia, Mitu Dogra, Prerna Sachdeva, Anil Handoo, Dharma Choudhary, Amit Agarwal
DOI:10.4103/GJTM.GJTM_42_17  
Daratumumab (DARA), a monoclonal anti-CD38 antibody, belongs to the new generation of immunotherapy in refractory relapsed multiple myeloma. CD38 is weakly expressed on human erythrocytes. By its intrinsic anti-CD38 activity, DARA also interferes in routine pretransfusion compatibility testing such as antibody screening for red blood cells (RBCs) alloantibodies and compatibility testing. Treating RBCs with dithiothreitol eliminates the DARA interference. We report two cases of serological interference of DARA in pretransfusion testing and how timely information before starting the second patient on DARA prevented the delay in pretransfusion compatibility testing and blood availability.
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COMMENTARY Top

Daratumumab affecting the pre-transfusion testing: Approach to finding compatible RBC unit! p. 166
Aseem K Tiwari, Geet Aggarwal
DOI:10.4103/GJTM.GJTM_44_17  
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CASE REPORT Top

Bacterial contamination: Are we thinking less of liss? p. 168
Aikaj Jindal, Rupinder Kaur
DOI:10.4103/GJTM.GJTM_25_17  
Mixed field reactions on column agglutination test have been attributed to various factors such as mismatched blood transfusions, transplanted bone marrows, or peripheral blood stem cells of a different ABO type, exchange transfusions and fetal-maternal bleeding apart from rare chimerism. An interesting and unusual case of mixed field reaction is described here possibly due to crystallization of low ionic strength solution and contamination with Escherichia vulneris.
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LETTERS TO EDITOR Top

Effectuating process improvement through better equipment handling in component laboratory p. 170
Manish Raturi, Shamee Shastry, Kankula Vijay Ram Reddy
DOI:10.4103/GJTM.GJTM_22_17  
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Letter to the Editor: Ethical dilemmas and legislation p. 171
Yetmgeta Eyayou Abdella, Rana Hajjeh, Cees Th. Smit Sibinga
DOI:10.4103/GJTM.GJTM_33_17  
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