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   Table of Contents - Current issue
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July-December 2020
Volume 5 | Issue 2
Page Nos. 117-241

Online since Friday, November 13, 2020

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EDITORIAL  

The wait is over: Switch from hardcopies to E-Copies Highly accessed article p. 117
Shivaram Chandrashekar
DOI:10.4103/2468-8398.300616  
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REVIEW ARTICLES Top

Extended phenotyping of blood group antigens: Towards improved transfusion practices Highly accessed article p. 120

DOI:10.4103/GJTM.GJTM_56_20  
Even though the International Society of Blood Transfusion has defined 38 blood group systems, only ABO and RhD are matched while selecting a compatible unit for blood recipients of Indian origin. Genetic disparity between a donor and a patient with reference to minor blood group antigens creates the risk of alloimmunization. The presence of red blood cell alloantibodies further creates the potential for serologic incompatibility, makes the selection of appropriate units for future transfusion more difficult, delays blood transfusion, and presents the risk of hemolytic disease of the newborn. Hence, there is a need to carry out extended blood group typing for antigens of clinical importance among donors and patients so that prophylactic antigen-matched blood can be given to a patient. Provision of antigen-matched blood will help in management of alloimmunized transfused-dependent patients carrying alloantibodies and/or autoantibodies. Typing of blood group antigens among large number of donors will also help in the development of antigen-negative inventories, develop indigenous red cell panels, and identify rare donors. Selection of blood group antigens for typing is important as it may not be always feasible to phenotype all the antigens. Based on the prevalence and immunogenicity of an antigen in a population, specific antigens have to be selected for typing so that the risk of alloimmunization reduces by strategic level of antigen matching. The aim of this review is to highlight the need for extended blood group phenotyping in different case scenarios and the methods available to do so. This review was performed by searching for keywords such as blood transfusion, red cell alloimmunization, partial antigen matching, rare blood donors, multitransfused patients, transfusion in thalassemics, molecular blood group genotyping, serology, and reagent red cell panels in PubMed and Google databases.
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Analysis of the transfusion situation in Albania p. 126

DOI:10.4103/GJTM.GJTM_45_20  
The National Blood Transfusion Center in Albania was established in 1951. The establishment of the NBTC was followed by the creation of 26 blood banks near each hospital to provide patient services at every hospital. The National Blood Transfusion Center (NBTC) has developed a legal and regulatory framework beginning with the first law on blood transfusion approved in 1995. Blood donation in Albania began as a remunerated practice. The first attempts at voluntary and nonremunerated blood donation (VNRBD) began in 1994 with cooperation between NBTC and the Albanian Red Cross, but without a clear definition of a promotional strategy. In 2004, the NBTC realized the need for voluntary nonremunerated blood donors, and with the technical assistance of the WHO, NBTC drafted the National Strategy for a Safe Blood Transfusion. The strategy laid the foundation for standardization of two of the main blood safety factors; qualitative donors and qualitative testing. The implementation of this strategy and the law marked continued success in the work of NBTC by recording increase in VNRBD and reduction in remunerated blood donations. Centralized testing of infectious agents was started in NBTC Tirana, with the implementation of fully automated testing. A new strategy will be launched this year aiming for 100% voluntary nonremunerated blood donors.
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Seroprevalence and trend of human immunodeficiency virus infection among Indian blood donors: A systematic review and meta-analysis p. 129

DOI:10.4103/GJTM.GJTM_44_20  
Transfusion-transmitted infections remain a grave concern for blood transfusion services. Thus, our aim was to determine the seroprevalence of human immunodeficiency virus (HIV) infection among Indian blood donors (BDs) and its trend over the past few decades. We searched PubMed and Indmed for studies containing data on HIV seroprevalence among Indian BDs published from January 1989 to December 2017. Pooled HIV seroprevalence, subgroup analysis, and trend of HIV seroprevalence depending upon the year of publication were calculated. Twenty articles met the inclusion criteria. Overall pooled HIV seroprevalence among Indian BDs was 3.22 per 1000 BD (95% confidence interval [CI] 2.65–3.8). Overall pooled HIV seroprevalence was found to be higher among the replacement BD (3.24 per 1000; 95% CI 2.45–4.03) as compared to voluntary BD (1.67 per 1000; 95% CI = 1.09–2.25). Region-wise highest overall pooled HIV seroprevalence was noted among BD from West 4.33 per 1000 (95% CI 0.96–7.7) followed by South 3.49 per 1000 (95% CI 1.47–5.51), East 3.4 per 1000 (95% CI 1.71–5.08), and North 2.76 per 1000 (95% CI 2.05–3.48). A significant rise in overall pooled HIV seroprevalence was noted over the two decades (1995–2005-2.8 per 1000; 2006–2015-3.46 per 1000; I2 = 97.7%; P < 0.001). Overall pooled HIV seroprevalence rate among Indian BDs in our study was 0.32%. There is a need to perform studies that will help in recommending appropriate deferral, selection, and testing strategies in these donors.
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ORIGINAL ARTICLES Top

Accelerated hepatitis B vaccination: Efficacy in young, regular blood donors Highly accessed article p. 135
Maryam Zadsar, Esmail Sanei Moghaddam, Seyed Moayed Alavian, Fariba Seighali
DOI:10.4103/GJTM.GJTM_46_19  
Background and Objectives: Hepatitis B (HB) – a vaccine-preventable, transfusion-transmitted infection – has been estimated to have high residual risk, especially in medium- and high-endemic areas. This potent immunogenic vaccine is routinely injected at 0, 1, and 6 months. Accelerated schedule has been recommended in adults to increase the completion rate. We studied the response rate of accelerated schedule in young, regular blood donors in a high-prevalence area for HB virus (HBV) in Iran. Methods: Young, regular nonimmunized blood donors were vaccinated with recombinant DNA HB surface antigen vaccine (Pasteur Institute of Iran) containing 20 μg of material in 1-ml solution injected intramuscularly to the deltoid muscle at 0, 1, and 2 months. HB surface antibody (HBsAb) was titered 1 month after the completion of doses. Nonresponders took one additional dose and tested a month later. Results: A total of 357 donors with a mean age of 26 ± 3.5 years were enrolled, of whom 287 donors completed three doses of vaccination (80% adherence rate). HBsAb titer was >10 IU/ml in 274 donors (95.5% response rate), whereas after one booster dose injection, the titer in 13 nonresponder persons (4.5%) increased to >10 IU/ml. Conclusion: Accelerated HBV vaccination with near 100% response rate and 80% adherence rate in young, regular blood donors has been successful in the immunization of young blood donors. This strategy improves not only blood safety but also donors' health.
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Evaluation of a NATSpert test developed for low-resource countries for enhancing blood safety p. 139

DOI:10.4103/GJTM.GJTM_17_20  
Background: NATSpert ID TripleH Detection test is a qualitative multiplex real time PCR test for simultaneous screening of hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus type 1/2 in donated blood. Objective of the study was to evaluate NATSpert ID TripleH Detection test, developed indigenously for low resource countries for enhancing blood safety without compromising on blood safety in terms of sensitivity and specificity. Methods: The NATSpert ID TripleH Detection test consists of viral nucleic acid extraction using magnetic beads and multiplex real-time PCR based on hydrolysis probe technology for amplification and detection of the viral target. Quality controls are included for validity of the test. The performance of the test was evaluated for analytical sensitivity and specificity and precision using the World Health Organization international standards. Results: Analytical sensitivity of NATSpert ID TripleH Detection test is 2 IU/ml for HBV, 7 IU/ml for HCV, human immunodeficiency virus-1(HIV-1) M – 17.5 IU/ml, HIV-1O – 18.5 copies/ml, and HIV-2 8.17IU/ml using 1 ml sample input at 95% CI. The NATSpert ID TripleH Detection test detected all three viruses and their genotypes with high repeatability and reproducibility in validation studies. Conclusion: The NATSpert ID TripleH Detection test developed as a cost-effective solution was demonstrated to have the capability to identify either individually or simultaneously the presence of viral targets – HBV, HCV, and HIV in the donated blood. The NATSpert ID Triple H Detection test serves as a highly sensitive, specific, and accurate test for screening of donated blood for transfusion-transmitted viral infections.
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Predonation drink: A simple and cost-effective strategy to mitigate vasovagal reactions among whole blood donors, a study from North India p. 146

DOI:10.4103/GJTM.GJTM_60_20  
Background and Objectives: In various clinical studies, water drinking is used to counteract orthostatic hypotension in healthy individuals. Thus, predonation water drinking was used as a strategy to attenuate vasovagal donor reactions in whole blood donors. The objective was to assess the effectiveness of predonation water-drinking strategy on vasovagal reactions (VVRs) in whole blood donors. Methods: A total of 6478 healthy blood donors were assessed during the study period. These donors were randomly assigned in groups receiving or not receiving 300–500 ml of water 20–30 min before whole blood donation. Results: The rate of VVR was 1.2% in blood donors given predonation water versus 2.8% in donors not given a predonation water, P < 0.05. Ingestion of 300–500 ml of water before whole blood donation had significantly decreased VVRs 1.2% versus 2.8% (OR 0.48; 95% CI – 0.33–0.69 vs. OR 2.10; 95% CI – 1.44–3.04). Thus, predonation water drinking was associated with less VVRs. Conclusion: About 300–500 ml of water drinking significantly reduced the vasovagal donor reaction rate in otherwise healthy blood donors. The ingestion of water by blood donors did not interfere with the donor management process such as donor questioning, mini physical examination, blood collection, and sampling, and was judged by blood collection staff as donor friendly and an easy protocol to implement.
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Postulating a positive predictive value for HIV, HBV, and HCV screening tests using electrochemiluminescent assay by comparing with ID-NAT results p. 150

DOI:10.4103/GJTM.GJTM_49_20  
Background: In India, blood units reactive by the initial screening assays are discarded. A significant number of these are falsely positive, leading to wastage of precious blood. Also of importance is the dilemma created when it comes to donor disclosure. Hence, it is important to evaluate the positive predictive value (PPV) of the initial screening assay to identify false-positive screening results and implement a more balanced algorithm for donor disclosure and counseling. The study was undertaken with an objective of comparing signal-to-cutoff ratio (S/Co) of positive results in HBV, HCV, and HIV screening of electrochemiluminescent (ECI) assay with the results of ID-NAT so as to predict a S/Co ratio of indicative of true positives. Methods: The retrospective study was conducted in the transfusion-transmissible infection Laboratory in a Regional Blood Transfusion Centre in South India. Consecutive blood donors from January 2015 to December 2019 were evaluated simultaneously for HBV, HCV, and HIV by ECI (Vitros 3600, Ortho Clinical Diagnostics) and ID-NAT (Procleix Panther System by Grifols), and the positive results either by one or both were analyzed. Results: A total of 163,596 voluntary donor samples were evaluated. In case of HBV, a S/Co ratio of 1000 predicts a true positive more than 94% of the time. In case of HCV, a S/Co ratio of 8 predicts a true positive more than 95% of the time. Finally, a S/Co ratio of 30 predicts a true positive as well as true negative 100% of the time in case of HIV. Conclusions: It is challenging to propose a standard S/Co ratio because the performance of each assay varies across laboratories. However, the study throws light on the role of the S/Co ratio in reducing the perplexity during donor notification.
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Evaluation of crossmatch techniques for deceased donor transplant program – Need of the hour p. 155

DOI:10.4103/GJTM.GJTM_20_20  
Background and Objective: It is important to strengthen deceased donor organ transplant program to help the patients who do not have living kidney donor available. However, there are lots of challenges in deceased donor program. There are challenges to convince families of brain dead patients for organ donation, but transportation of organ as well as allocation is also difficult. One of the main challenges for transplant immunology laboratory is correct crossmatch technique which is sensitive as well as quick and easy to perform. The aim of this study is to evaluate the results of Luminex lysate donor-specific antibody (DSA) crossmatch (LumCross-match) testing for deceased donor renal transplant cases and correlate with graft dysfunction. Methods: We use Luminex lysate DSA crossmatch for human leukocyte antigen testing for deceased donor renal transplants. In 2 years, we had 177 deceased donations and 1184 crossmatches were done. Results: Total 342 patients received kidneys in 2 years. No hyperacute rejection was reported though 28 cases had signs of antibody-mediated rejection posttransplant. Conclusion: We found Luminex lysate crossmatch useful in deceased donor transplant program because of easy procedure, high throughput, more sensitive, and less laborious as well as for posttransplant monitoring.
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Efficacy of diversion pouch in prevention of transfusion-transmissible bacterial infections p. 159

DOI:10.4103/GJTM.GJTM_81_20  
Background and Objectives: Blood transfusion is a lifesaving therapeutic intervention; however, transfusion-transmissible bacterial infections pose a great risk to recipients. Adhering to stringent blood donor disinfection technique in conjunction with first aliquot diversion has mitigated the risks of bacterial sepsis. The aim of this study was to evaluate the prevalence of bacterial contamination and assessing the preventive effect of diversion pouches implemented during whole blood collections in a regional blood center in Rawalpindi, Pakistan. Methods: A cross-sectional study was performed from December 2019 to February 2020. A total of 300 diversion pouches filled with 20 mL of whole blood samples were included in the study. Aerobic and anaerobic blood culture vials were inoculated and incubated in the BD BACTEC™ FX40 instrument at 35°C until positive and for 7 days if negative. The culture vials flagged positive were subcultured onto a set of solid media to isolate and identify the implicated microbial species, followed by testing the whole blood-derived platelet component of the blood sample that tested positive. Results: The prevalence of bacterial contamination of whole blood using the diversion pouch was detected as 0.3% (n = 1/300). The bacterial species identified were coagulase-negative Staphylococcus. The platelet component of the positive whole blood sample showed an absence of the contaminant. Conclusion: The results of this study suggest the significance of diversion as an effective way of preventing bacterial contamination of whole blood components. This necessitates its usage in all other blood banks of Pakistan to enhance the safety of transfused blood.
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An insight into the encountered challenges and performances of a hospital-based blood transfusion service in Eastern India in the light of COVID-19 pandemic p. 163

DOI:10.4103/GJTM.GJTM_77_20  
Background: Every pandemic elaborates its own challenges that should be managed meticulously through proper initiative and planning, following existing guidelines and through population education. We encountered various challenges in our blood center which significantly affected the blood inventory and blood supply. Here, we share our experiences of managing blood donations, blood inventory, staff adequacy, and blood wastages in the light of COVID-19 pandemic. Methods: The retrospective study was performed from January 1, 2020, to June 30, 2020, that included major activities in a blood center. The initial 3 and later 3 months were considered as the pre-COVID and COVID periods, respectively. Data related to various affected parameters were retrieved, analyzed, and compared with the pre-COVID period. Results: The drop in blood donation, blood component preparation, and blood issue in the COVID-period was observed to be 51.2%, 49.1%, and 49.8%, respectively. Mean total blood donation time and turnaround time of blood issue in the COVID period were found to be statistically significant (P < 0.05). The COVID period observed increase wastages of blood components (P = 0.007). The mean number of staff per day in the COVID period was 9.67 as compared to 18.3 staff in the pre-COVID period (P = 0.040). The mean work time per staff per day in the COVID period was calculated to be 10.77 h (P = 0.029). The major causes of failure to donate blood were fear of COVID infection and lack of transportation. Conclusions: All blood centers including ours have observed an acute reduction in blood donation and blood transfusion. All centers should collectively follow set guidelines and develop plan strategically to respond to the challenges generated in this pandemic. Moreover, blood transfusion should be more rationalized and the practice of first in, first out method should be followed to prevent blood wastages.
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Challenges in the collection of convalescent plasma for COVID-19 patients at a plasma therapy trial site p. 169

DOI:10.4103/GJTM.GJTM_52_20  
Background and Objectives: With no proven treatment guidelines for COVID-19, human convalescent plasma is an option and has been under trial worldwide. In India, Indian Council for Medical Research (ICMR), started a Mulicentric Trial for the use of convalescent plasma in the treatment of COVID patients. The purpose of this paper is to analyse the challenges encountered in the collection of convalescent plasma from COVID recovered patients at a trial site. Methods: The current prospective study was carried out in a tertiary care hospital based blood centre catering to COVID patients and a trial site for Plasma therapy by ICMR. For analysing the challenges in the collection of convalescent plasma, the discharged patients were contacted telephonically. After applying eligibility criteria, the reasons of deferral were assessed. Data was collected and analysed. Results: The current prospective study was carried out during the period of 1st April 2020 to 15th May 2020. During this period, a total of 496 patients got discharged. After applying deferral criteria, 113 were eligible, out of which only 13 (11.5%) consented to come to donate plasma. Conclusion: In a global ongoing pandemic, the “Fear Factor” is a constraint and a major challenge to motivate and convince a COVID recovered patient for plasma donation. The challenge for the medical professionals is to motivate, convince and educate the potential donors and society about the likely benefits of COVID Convalescent Plasma.
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A retrospective study on patients of Guillain-Barre syndrome treated with therapeutic plasma exchange at a tertiary care hospital in Western Maharashtra p. 173

DOI:10.4103/GJTM.GJTM_90_20  
Background and Objectives: The procedure of removal of pathologic substances present in the plasma of the patients and its substitution with a suitable replacement fluid is known as therapeutic plasma exchange (TPE). It has been seen that this procedure has an ameliorating effect on the clinical condition of the patient of Guillain-Barré syndrome (GBS). This study aims to assess the clinical improvement in GBS patients treated with TPE at a tertiary care center. Methods: A retrospective chart review was conducted in a series of 57 GBS patients treated with TPE using an intermittent flow cell separator system. GBS disability and Medical Research Council (MRC) muscle strength scoring systems were used as final endpoints. Statistical analysis was done through the R software version 3.2.0. A value of P < 0.05 was considered to be statistically significant. Results: After 05 alternate day cycles, TPE treatment led to a significant improvement in both MRC muscle strength scores and GBS disability scores. Before TPE, the MRC muscle strength score was 1.38 ± 1.19 (range: 0–4) and this increased to 3.15 ± 1.57 (range: 0–5) after TPE, (P = 0.002). Similarly, before TPE, the mean GBS disability score was 4.00 ± 0.81 (range: 2–5) and this decreased to 2.69 ± 1.31 (range: 1–5) after TPE, (P = 0.003). Conclusion: The result of this study showed TPE to be an effective mode of treatment for GBS. The safety profile was found to be acceptable and going by the findings of this study, TPE must be considered as an early line of management.
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Frequency of alloantibody with their specification among multitransfused patients p. 178

DOI:10.4103/GJTM.GJTM_40_19  
Background and Objectives: Alloimmunization is a very common clinical problem in transfusion-dependent patients but rarely detected in Bangladesh. The risk of alloimmunization is especially high in patients who receive repeated transfusion, i.e., thalassemia patients. The objective of this study was to investigate the seroprevalence and specificity of red blood cell antibodies in multitransfused thalassemic patients. Methods: This cross-sectional study was conducted at a tertiary care referral center from January 1, 2013, to March 31, 2016. Blood specimens were sent from different facilities and also from daycare transfusion center of the same when cross-match difficulties occur. When the Coomb's test showed positive result, then Rhesus, Kell, Kid, Duffy, and Lewis blood group typing were done according to the patients' need. Serum was used to identify the presence of alloantibody by the indirect Coomb's test with known cell panels. An autocontrol, positive and negative control for each specimen was incorporated to detect autoantibody and correctness of the procedure done. We performed a simple percentage to evaluate the analysis. Results: Of 1286 cases, alloantibody was detected in 334 (25.97%) cases. Among the 334 cases, 80 (23.95%) cases were followed up by antibody identification. The remaining 254 cases were referred cases with insufficient history and were dropped from the study. The male-to-female ratio was 1:2.2. The age group of 21–30 years showed the maximum antibody specificity (7.48%). Among the 80 samples with alloantibodies, Rh antibodies were noted in 80% (64) samples. Other antibodies detected belong to Kell, Kid, Duffy, and Lewis systems. Conclusion: Multitransfused (thalassemic) patients are more vulnerable to develop alloantibody. Therefore, routine antibody screening of donors and patients and the provision of antigen negative blood is recommended.
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Assessment of noncryopreserved stem cell viability (CD34+) at 4°C p. 182

DOI:10.4103/GJTM.GJTM_87_20  
Background and Objectives: Stem cell transplantation is one of the mainstay treatment modality for many benign and malignant disorders. Long- and short-term storage of stem cell is a crucial step. Long-term storage is using temperature-controlled preservation with liquid or vapor nitrogen at − 196°C. Short-term storage at 4°C ± 2°C is done for those products, which are intended to be infused within a few days after the collection. The current study was done to assess the viability of noncryopreserved stem cells at 4°C up to 9 days. Methods: CD34 enumeration was done on day 0, 3, 5, 7, and 9 of the collection in 12 consecutive cases of stem cell harvest. Enumeration was done using ISHAGE protocol, and viability was measured using 7-AAD dye with “BD Stem kit” on single platform bead-based assay. Viability of the samples was compared at various time points and also with respect to their source (autologous versus allogeneic). The results were expressed as mean (range), and significance was calculated using Mann–Whitney test. Results: A total of seven allogeneic and five autologous products were included. All the autologous products are stable till 5th day when stored at 4°C ± 2°C with none of the product showing >15% viability loss. However, the allogeneic products are stable up to day 3 only. On day 5, most 29% of the allogeneic products were showing >15% loss of viability. Conclusions: Storage up to day 7 or 9 was associated with unacceptable loss of viability for both autologous and allogeneic products.
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Prevalence of high titered anti-A and anti-B antibodies among O blood group individuals and their associated factors p. 187

DOI:10.4103/GJTM.GJTM_38_20  
Background and Objectives: Severe hemolytic transfusion reactions due to minor incompatibility are usually associated with the so-called “High titred” antibodies in the plasma of donors especially the O group as it is generally regarded as universal donors. Critical titers of 1:64 or higher was considered high titered antibodies for IgM anti-A and anti-B. Critical titers of 1:256 or higher was considered high titered antibodies for IgG anti-A and anti-B. The objective of this study was to see the prevalence of such high titered antibodies among our donor population and to observe for an association if any with the age, gender, and diet type and probiotic intake of the donors. Methodology: This was a cross-sectional analytical study conducted over 20 months from September 2015 to May 2017. About 560 donors were chosen randomly after screening and counseling and titration of anti-A and anti-B antibodies was done by the double dilution tube agglutination technique. The information on age, gender, diet type, and probiotic intake was gathered from the donor history questionnaire and an association between the factors described and the distribution of critical titers of anti-A and anti-B was elicited. Results: In the present study, the prevalence of high titer anti-A and anti-B IgM antibodies was 36% and 32%, respectively. The prevalence of high titer anti-A and anti-B IgG antibodies was 9.6% and 5.5%, respectively. The median IgM antibody titers reduced with the increasing age of the donors starting 18 years. There was a statistically significant association between a vegetarian diet and high titers. Conclusion: There are a considerable proportion of O group donors with high titers of antibodies and hence a routine pretransfusion screening for such antibodies can prevent the development of hemolytic reactions by segregating units into “high titer” and “low titer” antibodies and issuing only low titer products for out of group transfusions.
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Serological evaluation and differentiation of subgroups of “A” and “AB” in healthy blood donor population in Eastern India p. 192

DOI:10.4103/GJTM.GJTM_34_20  
Background and Objectives: Weak subgroups of A antigen in A or AB blood group can be differentiated by various immunohematological investigations. These weak phenotypes mainly result from weaker expression of an alternate weak allele present at the ABO loci. Weak subgroups of A antigen either reacts weakly with anti-A antisera such as A3, Ax, and Aendor do not react at all such as Am, Ay, and Ael. In this study, we characterized and differentiated the broad and weak subgroups of A in ABO blood group system through various immunohematological investigations. Methods: The prospective study included 67,954 healthy blood donors. Initial blood grouping and antibody screening of all donor samples were performed using an automated solid-phase assay. Samples showing blood group discrepancy or weaker agglutination were subjected to battery of serological investigation including saliva hemagglutination inhibition test and adsorption-elution procedures. Results: Among 16,034 A group donors, A1were 13,276 (82.8%), A22750 (17.15%), and weak subgroups were 8 (0.05%). Among AB group, A1B donors were 5621 (84.93%), A2B 996 (15.05%), and weak subgroups of AB were 1 (0.015%). The unexpected naturally occurring anti-A1antibodies (1.9%) were of IgM type optimally reactive at 4°C with titer ranging from 1 to 8. Red cells' agglutination with anti-A and anti-AB varied from Wk + to 2+ with or without mixed field agglutination in A3, Ax, and Aendphenotypes. While saliva study revealed specific substances, adsorption-elution demonstrated “A” antigen specificity in different strengths in Am, Ay, and AmB phenotypes. Conclusion: The subgroups of A and AB are attributed to a reduced number of A antigen sites on the red cells. We conclude that differentiating weak subgroups of “A” by serological assays is possible to a great extend with technical expertise; however, molecular genotyping is essential because it confirms the result.
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Immunohematological characterization of direct antiglobulin test-negative autoimmune hemolytic anemia through simple, sensitive methods: Experience from a tertiary care hospital in India p. 197
Sudipta Sekhar Das, Anupam Chakrapani, Soumya Bhattacharya
DOI:10.4103/GJTM.GJTM_65_19  
Background and Objectives: A negative DAT does not rule out AIHA. The incidence of this clinical entity known as DAT negative AIHA has been reported to be 2-4%. Sensitive techniques like enzyme linked antiglobulin test (ELAT), flow cytometry (FC), complement-fixation antibody consumption test etc. have been described for diagnosis of DAT negative AIHA. Majority of blood bank laboratories lack these advanced methods. Here we share our experience of investigating DAT negative AIHA using simple, sensitive methods which are otherwise less practised. Methods: The prospective study included 377 anemic patients clinically suspected of AIHA. Blood samples received in blood bank were subjected to polyspecific DAT using both conventional tube test (CTT) and column agglutination technique (CAT). Polyspecific DAT negative results were further evaluated using sensitive but simple methods. Hematological and biochemical parameters of all patients were obtained from hospital information system. In vivo hemolysis was categorized as per the criteria established by previous workers. SPSS statistical software (version 13, USA) was used for all statistical evaluation. Results: Of the final 353 clinical AIHA patients evidence of autoimmunization by CTT was observed in 335. Where DAT negative AIHA was observed in 18 (5.1%) patients, 14 showed evidences of autoimmunization by extended sensitive methods. Four patients responded well to AIHA therapy despite DAT negativity by available methods. The mean Hb, Retic, S. Bil and LDH were found to be 6.9 g/dL, 3.25%, 2.8 mg/dL and 512 IU/mL respectively. Conclusion: We conclude that DAT negative patients with clinical suspicion of AIHA and positive laboratory evidences should be evaluated for the presence of autoantibody by alternate sensitive methods which are otherwise less practiced. Blood banks may establish these useful simple techniques and stick to the defined protocols to diagnose DAT negative AIHA.
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Utility of thromboelastography platelet mapping in bleeding disorders – An experience from Eastern India p. 202
Suvro Sankha Datta, De Dibyendu
DOI:10.4103/GJTM.GJTM_75_20  
Background and Objectives: Thromboelastography platelet mapping (TEG-PM) is primarily used to monitor the effectiveness of antiplatelet medications by assessing the inhibition of thromboxane A2 and adenosine diphosphate (ADP) receptors. The objective of this study was to understand the utility of TEG-PM assay in suspected cases of bleeding disorders. Materials and Methods: A total of 20 suspected cases of bleeding disorders were tested by TEG-PM assay as a primary screening test. The percentage of platelet aggregation to agonist was calculated by: ([MAADP/AA– MAFibrin]/[MAThrombin– MAFibrin] × 100) and inhibition by: (100% – % aggregation). The cutoff was defined as >50% inhibition for each agonist. Light transmittance aggregometry (LTA) was performed when the inhibition was >50% both with ADP and arachidonic acid (AA). Results: Ten out of 20 patients were showing an inhibition >50% with ADP and 5 among 20 had an inhibition >50% with AA. Among four patients who had >50% inhibition with both agonists, two cases were diagnosed as Glanzmann's thrombasthenia by LTA and one case was diagnosed as Wiskott–Aldrich syndrome by genetic analysis. Final diagnosis was not made in one case as LTA was inconclusive. Conclusion: We believe that TEG-PM assay may be introduced in preliminary algorithm for the diagnosis of bleeding disorders where facility such as LTA is not easily available.
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Blood utilization quality indicators in a tertiary care center in South India p. 206

DOI:10.4103/GJTM.GJTM_67_20  
Background: Injudicious over-ordering of blood components not only burdens the physical and human resources but also increases the cost of health care. Moreover, such practices have a greater implication in developing countries like ours where there is a scarcity of voluntary blood donors and insufficient blood supply to cater to increasing demands. Therefore, there is a need for continuous monitoring of the utilization of blood components and to audit the transfusion practices to identify areas of concern for blood usage. Ours is a 1600 bedded super specialty health center with 100% bed occupancy. The objective of the study was to analyze the trend of utilization of blood components and transfusion practices by various medical and surgical specialties by determining the blood utilization quality indicators at our center. Methods: This was a retrospective and cross-sectional study done over a period of 7 months from January 2018 to July 2018. The data for blood utilization quality indicators in the first half can be taken as the representative of the entire year. The data pertaining to the number of requisitions received as well as cross-matches done and issues made were collected from transfusion requisition forms, cross-match, and issue registers and analyzed. The parameters used in the analysis were crossmatch to transfusion ratio (CT ratio), transfusion index (TI), and transfusion probability (%T). Results: During the 7-months study period, a total of 28,317 transfusion requisitions were received and 34,701 blood components were issued. The total cross-matched red blood cell (RBC) units were 10,861 and the total RBC units transfused were 10,066. The overall C/T ratio was found to be 1.57. The transfusion probability (%T) and TI were calculated as 79% and 1.18, respectively, in our study. Conclusion: The CT ratio, transfusion probability, and TI demonstrated that there is an efficient blood utilization at our center. Regular auditing of blood transfusion services should be practiced at every hospital wherein the Maximum Surgical Blood Ordering Schedule can be modified and implemented progressively, following evidence-based blood transfusion guidelines.
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SHORT ARTICLES Top

COVID-19 convalescent plasma product: Harvesting plasma from single unit whole blood, a cost effective alternative to plasmapheresis Highly accessed article p. 209
Sanmukh R Joshi
DOI:10.4103/GJTM.GJTM_66_20  
The COVID-19 pandemic has affected people from almost all parts of the world. There is no specific pharmaceutical drug available. So also, there is no vaccine developed as yet. In the circumstance, the passive immunity imparted by the preformed antibody in the plasma from the convalescing patient could be a useful approach. COVID-19 convalescent plasma (CCP) can be collected by an automated apheresis device. However, the preparation becomes expensive, and average blood banks cannot afford to establish infrastructure in terms of machine and material requirements. The recommended dose of 200 mL of CCP for the treatment of a patient can easily be met from a single whole blood unit by any blood bank with the facility of blood component separation. This approach can significantly reduce the cost of the treatment to the patient with COVID-19.
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SHORT ARTICLES Top

White particulate matter – A mini review p. 212

DOI:10.4103/GJTM.GJTM_41_20  
White particulate matter has been an enigmatic entity inside blood bags. Frequent encounter with this uncommon phenomenon is described world over as a sporadic report or small series. Over the years, as its incidence keeps increasing so is the need to understand this strange entity that may provide valuable insights into the fascinating world of blood physiology and storage. An attempt to comprehend this strange phenomenon has been made in this brief review based on the literature available on this subject.
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Impact of COVID-19 outbreak in blood transfusion services in India: Experience from tertiary care blood centres in Kerala: A short review p. 215

DOI:10.4103/GJTM.GJTM_36_20  
Blood Transfusion Service (BTS) in India faced numerous challenges during the COVID-19 outbreak and the following imposed country lockdown. We aim to identify the challenges faced by selected blood centers and explore the mitigation strategies implemented during the COVID 19 pandemic and subsequent lockdown. Diminished donor inflow, lack of uniform donor selection criteria during the initial period, fear of COVID-19 spread to blood donors and staff personnel, shortage of available blood units, staff personnel transportation, handling of medical records, and concerns about transfusion-transmitted COVID-19 were the major challenges faced in our blood centers. Personal invitation of donors, public announcements, and in-house donation drives were implemented to improve donor inflow. Institute level donor selection protocol was developed and followed before the national guidelines were established. Restricted donor entry, stringent donor selection, and adequate sanitization strategies were the key steps adopted to ensure the safety of donors and staffs. In the interim, there was a reduction in blood unit requirement due to reduced patient inflow. Staff duty pattern was allocated on a rotation basis. The novel standard operating procedure was developed and implemented for handling COVID-19 positive or suspected blood samples. BTS should always be vigilant to adopt new practices even before guidelines are set by regulatory authorities and are liable to follow the guidelines. Restrictive blood transfusion strategies need to be emphasized in the country.
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CASE REPORTS Top

A report of rare p phenotype and anti-PP1Pk antibody from North India p. 218

DOI:10.4103/GJTM.GJTM_35_20  
A requisition for one unit of packed red blood cells (PRBCs) was received for a patient of carcinoma oral cavity admitted in our hospital. Blood group discrepancy was encountered while performing routine serological investigations on the patient's blood sample. Random cross-match with multiple ABO-identical and ABO-compatible PRBC units was found to be incompatible. Further immunohematological workup was performed which led to the discovery of the patient having rare p phenotype.
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A rare case of immune hydrops in an “Elevated D” pregnancy p. 221
Amit Kumar Biswas, Anantpreet Kaur Bajaj, Joseph Philip, Neerja Kushwaha
DOI:10.4103/GJTM.GJTM_89_20  
The D-/-phenotype is a rare variant of the Rh system, in which red blood cells express only D antigen. Sensitized D-/-women carry a risk of hemolytic disease of fetus and newborn (HDFN) and pose a challenge in management due to nonavailability of antigen negative blood for intra-uterine/exchange-transfusion. A 23y old G2P1L1A0, blood group “A” Rh D+C-c-E-e- presented at 20 weeks' period of gestation (POG) with a positive indirect antiglobulin test. Cordocentesis at 23 weeks' POG revealed fetal's blood group as “B” Rh D+, Direct Coombs Test 4+, Hemoglobin 2.8 g/dL. USG with MCA-PSV indicated rapid development of fetal anemia and hydrops. Patient's sibling had D-/-phenotype, but was ABO-incompatible with the fetus. Rapidity of progression of case resulted in intrauterine fetal demise at 27 weeks' POG. HDFN, in rare blood groups, leads to problems in arranging compatible units in developing countries due to lack of centralized rare donor registries.
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Resolving crossmatch incompatibility due to daratumumab in multiple myeloma p. 225

DOI:10.4103/GJTM.GJTM_78_20  
Daratumumab (DARA) is an anti-CD38 monoclonal antibody which has promising results in relapsed and refractory multiple myeloma. DARA interferes with blood compatibility testing by causing panagglutination in the indirect antiglobulin test. In all incompatibilities, immunohematology workup must be done to rule out allo- or autoantibody and to issue compatible unit to the patient. Transfusion support is vital for all these patients with incompatibility and should not be delayed. We encountered one such patient who was undergoing treatment with DARA for refractory multiple myeloma and had incompatibility during crossmatching. Many methods are available to sort out this problem. These include anti-CD38 idiotypes, cord blood, trypsin, papain, dithiothreitol (DTT) treatment, phenotyping, and genotyping. We hereby report resolving the above discrepancy by one of the simplest, cheapest, and feasible methods, i.e., DTT treatment in our blood centers.
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A case of naturally occurring anti-E mimicking anti-A1 p. 228

DOI:10.4103/GJTM.GJTM_23_20  
Rhesus (Rh) antibodies are usually of the acquired IgG type. Naturally occurring IgM type of Rh antibody is unusual. We report a case of naturally occurring IgM anti-E which mimicked anti-A1. ABO grouping of a 61-year-old man posted for surgery showed discrepancy. Cell group corresponded to A positive while reverse grouping showed weak agglutination with A cells. Nonreactivity of red cells with A1 lectin suggested the possibility of A subgroup with anti-A1. Anti-A1 was ruled out on further testing of serum with A1-positive red cells. Antibody screening and identification revealed the presence of anti-E. The presence of Rh E antigen in the reagent A cell was the reason for weak agglutination. Antibody titer of 4 and 2 was observed at 4°C and 37°C incubation, respectively, in the untreated serum. Antibody was undetectable in the dithiothreitol-treated serum both at 4°C and 37°C confirming the IgM nature of the antibody.
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COMMENTARY Top

An algorithm of pretransplant compatibility testing for deceased-donor kidney transplant program p. 230

DOI:10.4103/GJTM.GJTM_98_20  
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LETTERS TO EDITORS Top

Paid plasma in low- and middle-income countries: The strategy or the strategy-frustrating: A short account of Iran experience involved p. 232

DOI:10.4103/GJTM.GJTM_80_20  
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Hepatitis E virus RNA in Pakistani blood donors: An emerging transfusion transmitted infection p. 233

DOI:10.4103/GJTM.GJTM_85_20  
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Green plasma day … Was sterilization agent the culprit? p. 234

DOI:10.4103/GJTM.GJTM_69_20  
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COVID-19 pandemic: Implications on blood transfusion needs of thalassemia major patients p. 235

DOI:10.4103/GJTM.GJTM_82_20  
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SPECIAL COMMUNICATIONS Top

Changes in autologous blood of late pregnancy women during preservation p. 237
Sun Xiao-Yuan, Wang Hai-Yan
DOI:10.4103/2468-8398.300646  
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Clinical significance of C1q-human leukocyte antigen antibody in patients refractory to platelet transfusion p. 240
Li Dongmei, Wang Jie, Jing Yuanyuan, Wang Dongmei, Liu Na, Shan Xiaoyan, Jia Yanjun
DOI:10.4103/2468-8398.300647  
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