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  Citation statistics : Table of Contents
   2017| January-June  | Volume 2 | Issue 1  
    Online since March 22, 2017

 
 
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REVIEW ARTICLE
Thromboelastography as a novel viscoelastic method for hemostasis monitoring: Its methodology, applications, and constraints
Anupam Verma, Hemlata
January-June 2017, 2(1):8-18
DOI:10.4103/GJTM.GJTM_4_17  
Thromboelastography (TEG) is a novel viscoelastic method which provides a comprehensive assessment of hemostasis from clot initiation and development to fibrinolysis involving both cellular and plasmatic components of hemostatic system. Apart from surgery its role is expanding into medical specialties with increasing integration into laboratory settings. TEG complements the conventional coagulation tests in assessment of bleeding disorders. Further hemotherapy based on TEG results has been shown to reduce transfusion requirements in varied clinical settings besides helping in identifying coagulopathies in patients with major bleedings. This review article addresses briefly the methodology, clinical applications, interpretation of TEG results including authors' own experience of TEG in different clinical scenarios and limitations of TEG. Overall, this technique seems to be helpful for evaluation of hypercoagulable state and in detecting fibrinolysis which are difficult to be detected with conventional coagulation tests. Kaolin activated citrated blood samples analyzed within 30-60 min of sampling can provide reliable results in a laboratory setting. However, multiple assays using different activators or modifiers may be required for accurate results in selected cases. The operator should be aware about the various preanalytical and analytical variables which can affect the results including limitations of this technique. The tracing of the thromboelastography should be interpreted cautiously taking into consideration the clinical picture of the patient and results of other laboratory tests. With improved model and availability of more assays it is hoped that TEG and other such hemostasis analyzers would bring in the paradigm shift in the hemostasis monitoring and treatment of patients in future.
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SHORT COMMUNICATIONS
Optimization of blood transfusion services: Analysis of blood requisition and utilization practices in cardiac surgical patients in a tertiary care hospital, India
Sadhana Mangwana, Neha Bedi, Pinky Yadav, Rakesh Chugh
January-June 2017, 2(1):47-51
DOI:10.4103/2468-8398.202713  
Objective: Blood products are vital resources to health-care institutions with constantly growing demands. Gross over-ordering of blood causes exhaustion of valuable supplies and resources and add financial burden to patients undergoing surgical procedure. Aims: Study was undertaken to evaluate blood requisition, utilization, and management in cardiac surgery patients in a tertiary care hospital. Materials and Methods: Prospective study was conducted in cardiac surgery patients over 3 years from 2013 to 2015. Blood utilization indices were computed. Cross match to transfusion ratio (C:T) ratio of 2.0 and below, transfusion index (TI) value of 0.5 or more, and transfusion probability (%T) value of 30% and above were considered indicative of significant blood usage. Statistical analysis was done using Student's t-test. Results: During the study, a total of 15,392 patients' requisitions were received. Out of 25,190 units of blood cross-matched, 18,741 units were issued (C:T ratio 1.34) implying that overall 25.60% of blood was unutilized. From a total of 2752 units cross-matched for cardiac surgery cases, only 1296 units were transfused with C:T Ratio 2.12 implying that 52.91% of blood was unutilized which was much higher and statistically highly significant than in total patients. Overall TI was 1.22 and %T as 83.07% while for cardiac patients, TI was 2.32 with %T as 85.84%. Conclusions: Blood transfusion plays a major role in resuscitation and management of cardiac surgery patients. Blood transfusion services need to adopt blood conserving policies. Efforts should be made to adopt more conservative transfusion thresholds, conduct regular auditing, and periodic feedback to improve blood ordering, handling, distribution, and utilization practices of this scarce resource.
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CASE REPORTS
Oh Rh (D)-Negative in vitro fertilization pregnancy: Obstacles surmounted
Ambuja Kantharaj, Shivaram Chandrashekar
January-June 2017, 2(1):56-58
DOI:10.4103/GJTM.GJTM_12_17  
We report a rare case of Oh (D)-negative female with in vitro fertilization (IVF) pregnancy. Blood grouping was reported as O Rh (D) negative elsewhere and was referred at 28 weeks gestation for anti-D titration to our center. Blood grouping repeated at our laboratory was Oh Rh (D) negative. Owing to the absence of H antigen-negative cells, we did anti-H adsorption studies on the patient serum to look for underlying red cell alloantibodies, which were absent. The Ig (G) anti-H titer was 256, but there were no signs of fetal anemia as seen on the fetal middle cerebral artery (MCA) peak systolic volume studies also. The patient was on follow-up with anti-H titers and fetal MCA-Doppler studies every 2 weeks. The patient was started on oral iron and erythropoietin as hemoglobin was 8.5 g% which then improved to 11.5 g% after two doses of erythropoietin. Owing to risk of bleeding due to low-lying placenta, the treating obstetrician wanted to keep two units of red cell concentrate ready before elective lower segment cesarean section. Hence, close family members of the patient were screened for Oh phenotype, but none of them were found to be of Oh phenotype. Hence, autologous predeposit with fetal monitoring was considered but not implemented owing to legal and patient concerns. Pregnancy was uneventful and a healthy female baby was delivered at term. The baby did not have any signs of hemolytic disease of newborn. Blood grouping of baby was O positive and direct antiglobulin test done at the referring center was negative.
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Protocol evolved for the management of red cell alloimmunization
Nidhi Mehta, Ishita R Chakraborty, Minal Rane, Manoj Gupta
January-June 2017, 2(1):59-63
DOI:10.4103/GJTM.GJTM_45_16  
Alloimmunization is a detrimental effect of transfusion therapy which makes availability of compatible blood difficult due to increased incidence of development of alloantibody and autoantibody, which can lead to mild-to- fatal adverse reactions. This case report illustrates the effective resolution of a case with multiple alloantibodies using advanced immuno-haematological workup with rare antisera. This report also re-emphasizes the need for universal antibody screening and identification for both donors and patients as part of pre-transfusion testing. The assessment of need for transfusion helped in deriving an effective plan of action for supportive care to the patient against the fear of hemolytic reaction. The provision of right and compatible (antigen negative) blood helped in management of patient during chemotherapy. This case emphasizes the indispensable need of devising and maintaining a Rare Blood Donor Register in developing nations. The Rare blood donor registry will help revolutionize the current transfusion practices, and will provide better means of managing critical care patients with single/ multiple antibodies.
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Kell alloimmunization in pregnancy: Lessons to be learnt
Rajeswari Subramaniyan
January-June 2017, 2(1):64-67
DOI:10.4103/GJTM.GJTM_10_17  
With the introduction of anti-D prophylaxis, the incidence of RhD alloimmunization in pregnancy has been significantly reduced. RhD remains the most common cause of hemolytic disease of fetus and newborn (HDFN). Next to anti-D, anti-K and anti-c have been implicated in severe HDFN. Hereby, we report a case of Kell alloimmunization in pregnancy which is a leading cause of HDFN worldwide. This case highlights the need for tertiary care hospitals to establish a well-defined protocol for the management of Kell alloimmunization in antenatal females. Most commonly, Kell alloimmunization is secondary to previous transfusions, and hence, every attempt should be made for primary prevention, i.e., Rh-Kell-matched transfusions for women of reproductive age group.
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EDITORIALS
Blood banker's ethical dilemma: To assure quality or contain costs
Shivaram Chandrashekar
January-June 2017, 2(1):1-4
DOI:10.4103/GJTM.GJTM_13_17  
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Legal issues in transfusion medicine
Gajendra Gupta
January-June 2017, 2(1):5-7
DOI:10.4103/GJTM.GJTM_14_17  
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LETTERS TO EDITOR
Variation in antibody detection in pretransfusion practice by different methods
Sadhana Mangwana, Neha Bedi
January-June 2017, 2(1):68-69
DOI:10.4103/GJTM.GJTM_44_16  
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Development of a national thalassemia policy in Pakistan
Hasan Abbas Zaheer, Usman Waheed
January-June 2017, 2(1):69-70
DOI:10.4103/GJTM.GJTM_53_16  
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White particulate matter in blood bag: Revisited
Rajeswari Subramaniyan
January-June 2017, 2(1):70-71
DOI:10.4103/GJTM.GJTM_9_17  
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ORIGINAL ARTICLES
Apheresis platelets in additive solution: Is it a good alternative to conventional group-specific apheresis platelets?
Amit Agrawal
January-June 2017, 2(1):19-23
DOI:10.4103/GJTM.GJTM_5_17  
Introduction: India is among the medium developed countries with a population over 1.25 billion with areas of difficult terrains, landslides, and there is requirement of platelets for dengue outbreaks,cancer patients or patients needing intensive care. Use of nongroup-specific platelets is common and the incompatible plasma comes with complications at times. Thus, finding group-specific platelets have always been difficult. Arranging group-specific donor is really a challenge, especially in cases of international patients, outstation patients, and patients that require numerous platelet transfusions, more so in hospital-based blood banks that have limited voluntary apheresis blood donor registry. Materials and Methods: This study was conducted in multispecialty tertiary health-care hospital of Delhi/NCR where the majority of patients are from a different place or different state or a different country. To make do with the available donors who are often replacement donors of a group different from the patient, platelet additive solution (PAS) was used to replace the incompatible plasma. Use of PAS was implemented on all apheresis prepared using storage solution for platelets (SSP+, Macopharma, France) using apheresis platform. PAS was added after collection of hyperconcentrated platelets units. Control group (n = 10) included patients receiving group-specific platelets during the study. Results: A total of 130 apheresis units were prepared on PAS during the study. 126 units were issued to 77 patients. 99.2% of donors under study were male and 47.7% in age group 18–30 years and 31.5% of blood Group O positive. Final platelet volume prepared was 300 ± 20 ml. Mean platelet volume and product pH were within normal range. Conclusion: Use of PAS for apheresis platelets eliminates the need for group-specific platelets converting all single-donor apheresis platelets to universal platelets, thereby helping in better management without compromise in patient safety.
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A study of centralized individual donor nucleic acid testing for transfusion transmitted infections to improve blood safety in Karnataka, India
Ankit Mathur, Sanjana Dontula, Latha Jagannathan
January-June 2017, 2(1):24-28
DOI:10.4103/GJTM.GJTM_8_17  
Introduction: Karnataka state has a total of 176 blood banks, with a total collection of around 650,000 units annually. From January 2014, all units under the Department of Health and Family Welfare services are tested at NAT Lab established at the Central facility and from September 2014, standalone Regional Blood Transfusion Centre was included in the State Government project. Aim and Objective: The aim of the study is to analyze the nucleic acid testing (NAT) for our donor population and demonstrate consolidation of blood transfusion service through a centralized testing center for NAT and also to assess safety benefits of implementing individual donor NAT (IDNAT). Materials and Methods: We collect nearly 40,000 units annually from voluntary donors with 30% repeat donations. The donors undergo strict predonation counseling, donor questionnaire, and medical examination. The units collected are tested for human immunodeficiency virus (HIV), hepatitis B virus (HBV) and hepatitis C virus (HCV) by ECI using VItros 3600. All the units are tested by NAT at Central NAT Lab, screened by Procleix® Panther System by Grifols. Results: From September 2014 to March 2016, total 50,903 samples tested for NAT. Of 50,903 samples, 588 samples (1.15%) were reactive by Chemiluminescence including 265 for HBV, 188 for HCV, and 135 for HIV. Total NAT reactive samples were 254, out of this 11 reactive for HIV-1 (0.02%), 2 reactive for HCV (0.003%), 235 (0.46%) reactive for HBV. There was one HIV and 10 HBV infection cases that were not detected by serology but reactive by NAT. The yield detected is 0.021% or one in 5000. Conclusion: The IDNAT project has helped in preventing window period infections thus reducing the treatment cost and burden on healthcare. It has added benefits in blood safety and should be considered along with the basic quality assured blood transfusion system such as volunteer base for blood donation, provision of donor self-deferral, donor notification, and quality assured sensitive serological methods.
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Evaluation of nonspecific treponemal test rapid plasma reagin in comparison with specific treponemal test immunochromatographic assay for screening healthy blood donors
Aseem K Tiwari, Devi Prasad Acharya, Ravi C Dara, Dinesh Arora, Geet Aggarwal, Ganesh Singh Rawat
January-June 2017, 2(1):29-33
DOI:10.4103/GJTM.GJTM_46_16  
Introduction: Serological tests for syphilis (STS) contributed greatly to the detection of Treponema pallidum infection in blood donors and especially in those who were not identified during the medical selection. Most of the blood centers use nontreponemal tests due to lesser cost, ease of performance, and their ability to pick up early primary stage infection, despite reported high false positivity. However, increasingly large number of blood centers have begun testing with the treponemal tests such as immuno-chromatographic assay (ICA) which is possibly easier and more objective than rapid plasma reagin (RPR), albeit slightly expensive. It is with this background that we undertook a head-to-head comparison of nontreponemal test RPR with treponemal test ICA in over 10,000 consecutive blood donor samples with confirmation of all reactive and discordant samples by fluorescent treponemal antibody absorption assay (FTA-ABS) as the gold standard. Materials and Methods: The study was conducted in the department of transfusion medicine in a large tertiary care hospital in India. Consecutive blood donors from July 2014 to January 2015 were evaluated simultaneously for antitreponemal antibodies by solid phase ICA (SD BIOLINE Syphilis 3.0, Alere Medical Pvt. Ltd., USA), RPR (Immutrep RPR, Omega Diagnostics, Scotland, UK) and FTA-ABS (Biocientifica SA, FTA-ABS, Argentina). Performances of both the assays were evaluated in statistical terms. Results: A total of 10,200 donor samples were evaluated. There were 10,124 confirmed concordant negatives. Thirty-eight samples were concordant positive. Thirty-eight samples (thirty samples were ICA positive and RPR negative and eight samples were RPR positive and ICA negative) were discordant. The sensitivity of ICA was higher (93%) as compared to that of RPR (66%), whereas the specificity of RPR was higher (83%) than that of ICA (66%). Positive predictive value (PPV) of both the tests was similar while negative predictive value (NPV) of ICA was higher (86%) than that of RPR (60%). Youden's index was 0.81 for ICA whereas it was 0.62 for RPR. Conclusion: ICA has a better sensitivity than the RPR and thus seems to be more appropriate test for screening in blood donors.
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Making type and screen policy an essential component of pretransfusion testing: Need of the hour in India
Rasika Setia, Prerna Sachdeva, Satyam Arora, Anil Handoo, Meenu Kapoor
January-June 2017, 2(1):34-37
DOI:10.4103/GJTM.GJTM_2_17  
Introduction: “Type and screen” policy involves the prior determination of patient blood group and antibody screening at the time of admission irrespective of the need of the blood transfusion to the patient. Materials and Methods: As a part of our retrospective analysis, we have evaluated our data from January 2014 to June 2016. Blood grouping was done by column agglutination technology (CAT) using DiaClon ABO/D+ Reverse Grouping cards (BIO-RAD, Switzerland). Antibody screening and identification were done using three cell panels (ID-DiaCell I-II-III Asia panel by BIO-RAD, Switzerland) and 11 cell panels (ID-DiaPanel-P by BIO-RAD, Switzerland) on CAT with LISS/Coombs cards. Results: A total of 17,896 patients requests for “type and screen” were received by the department during the study. Out of which 201 (1.12%; 1 in 89 patients) patients were found to have positive antibody screen. Out of 201 patients (132 females; 69 males); mean age group of 45.6 years (range: 1 day–85 years). Out of 201, 145 patients developed single antibody, 15 patients had double antibody, and in 41 positive antibody screens the specificity of alloantibodies were not identified either due to an interfering autoantibody (n = 10) or the specificity was not resolved on extended panels (n = 31) even with enzymes. Conclusion: “Type and screen” policy helps in timely blood group typing of the patients and providing enough time for the blood bank to arrange for blood. Our analysis shows the presence of an alloantibody in every 89 requests received for “type and screen.”
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Cumulative quality assessment for whole blood-derived platelets: A compliance review
Manish Raturi, Shamee Shastry, Pruthvi Raj
January-June 2017, 2(1):38-43
DOI:10.4103/GJTM.GJTM_50_16  
Background and Objectives: Quality control (QC) results of platelet-rich plasma and buffy coat-reduced platelet concentrates (PCs) are presented with the goal to assess their compliance with published guidelines and corrective action taken for any process deviation during their manufacture. Subjects and Methods: Retrospective QC of in-house prepared whole blood-derived platelets (2009–2013) was conducted. Their cumulative results were compared to the published quality standards given by the American Association of Blood Banks, Council of Europe, and Indian guidelines. Data was analyzed using SPSS Statistics version 20. Results: A total of 36,053 PCs were prepared during the study period, and 1.43% (n = 516) was subjected to QC. The aggregate five years mean ± standard deviation (range) of product per bag were volume 58.4 ± 9.5 (37–90) mL, platelet yield 5.89 ± 1.28 (3.1–8.7) × 1010, residual leukocyte count 1.5 ± 1.2 (0.02–5.5) × 107, pH 6.67 ± 0.48 (6.0–7.3), and erythrocyte contamination 0.29 ± 0.2 (0.03-2.0) mL. Swirling was present in all the units. None of the bags showed any microbial growth. Against volume, yield, and erythrocyte contamination 90.0%, 94.3%, and 87.0% units showed compliance to the Indian standards, respectively. All the PCs had pH and leukocyte counts well within the recommended norms. Conclusions: Quality of our platelet product although suboptimal to International standards was well within the national requirements.
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SHORT COMMUNICATIONS
Separation of autologous red blood cells from specimen of the transfused sickle cell disease patients using hypotonic saline
Ankita Sheladiya, Kinjal Mendapara-Dobariya, Sanmukh R Joshi
January-June 2017, 2(1):44-46
DOI:10.4103/GJTM.GJTM_1_17  
Background: Red blood cell (RBC) antigen typing in transfused sickle cell disease (SCD) patients is a difficult task due to contamination of the transfused red cells. Aim: This pilot study was aimed to standardize an easy approach to separate the autologous RBCs from the transfused patient for RBC antigen typing in SCD. Materials and Methods: The RBCs from transfused patients with SCD were separated by hypotonic saline and tested with various antisera by standard serological methods. Results: Ten antisera showing negative reaction with donors' RBCs reacted positively with the patients' autologous RBCs separated by treatment with hypotonic saline. Seven antisera reacted with the donors' RBCs were nonreactive with the patients' autologous RBCs after elimination of the donor's RBCs by treatment with hypotonic saline. Conclusion: The hypotonic saline can be used as method to separate the autologous RBCs from the mixture with the transfused RBC in patients with SCD.
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Blood transfusion request pattern in a medical center in Northwestern Nigeria
Ibrahim Aliyu, Godpower Michael, Haliru Ibrahim, Zainab F Ibrahim, Goni Aliyu, Ajayi T Isaiah
January-June 2017, 2(1):52-55
DOI:10.4103/GJTM.GJTM_51_16  
Introduction: Nigeria has a national policy on blood services, however, most medical facilities find difficulties in establishing a viable, efficient blood banking system; therefore, it becomes necessary to ensure judicious utilization of this scarce commodity. Therefore, this study hopes to determine the pattern of demand for blood transfusion in our institution. Materials and Methods: This study was a 1-year retrospective analysis of the request for blood transfusion. Results: There were 1958 blood requests, consisting of 554 for males (28.3%) and 1404 for females (71.7%) with male:female ratio of 1:2.5. The obstetrics and gynecology department (52.3%) had the highest request for blood transfusion, while medicine had the least (9.3%). Whole blood was the most common form of blood product requested (87.3%) while only two (0.1%) request for plasma was made. The most common indication for blood transfusion was anemia (52.2%), followed by the need for blood transfusion during surgery (30.4%); however, exchange blood transfusion was the least with only 16 requests (0.8%). A total of 3766.4 pints of blood were requested during the study period; however, obstetrics and gynecology had the highest request of 2350 pints (62.4%) while pediatrics had the least request of 255.4 pints (6.8%). Over 90% of requested blood and blood products were dispatched. The months of August, September, and October recorded the highest need for blood transfusion whereas January and February recorded the least. Conclusion: The obstetrics and gynecology department had the highest request for blood transfusion; this demand was experienced mostly toward the last quarter of the year, and most requests were dispatched, and there was judicious utilization of blood donated.
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