COVID-19 pandemic and transfusion medicine: the worldwide challenge and its implications

Decreased Transfusions in Premenopausal Patients Undergoing Allogeneic Hematopoietic Stem-Cell Transplantation Given Leuprolide According to an Abnormal Uterine Bleeding Algorithm

PURPOSE

Abnormal uterine bleeding (AUB) during allogeneic hematopoietic stem-cell transplantation (HSCT) leads to an increased need for transfusions. We developed an algorithm for the management of AUB that incorporated leuprolide and oral contraceptive pills (OCPs). Our aim was to evaluate whether treatment according to this algorithm reduced the number of transfusions.

METHODS

All premenopausal patients who underwent first HSCT from June 2016 to January 2022 were included in this retrospective cohort study. Patients were divided into three groups on the basis of whether they received no medications, treatment according to the algorithm (leuprolide 11.25 mg intramuscular every three months with or without OCPs), or continuous OCPs. The primary outcome was the total number of units of RBCs and platelets transfused.

RESULTS

Two hundred fourteen patients with a mean age of 36.6 years were studied. Diagnoses were AML/myelodysplastic syndrome (n = 136), ALL (n = 47), or other hematologic malignancies (n = 31). One hundred twenty-five patients (58.4%) experienced AUB. Patients who received leuprolide with or without OCP according to the algorithm had a significant reduction in the likelihood of RBC transfusions, odds ratio (OR), 0.91 (95% CI, 0.85 to 0.98), and platelet transfusions, OR, 0.84 (95% CI, 0.79 to 0.91), compared with patients who received no medications or continuous OCP.

CONCLUSION

AUB is a common complication in premenopausal patients undergoing HSCT. Our algorithm of leuprolide with or without OCPs administered before HSCT led to reductions in the number of platelet and RBC transfusions.

COVID-19 associated thrombotic thrombocytopenic purpura: a case report and review of the literature

INTRODUCTION

Thrombotic thrombocytopenic purpura (TTP) is a rare but potentially life-threatening complication whose association with COVID-19 is controversial. Understanding this connection is essential due to its significant impact on patient outcomes, and timely diagnosis and intervention are critical in managing this condition effectively.

AREAS COVERED

This paper presents a case of TTP triggered by COVID-19 infection in a 48-year-old female. Additionally, a comprehensive literature review was conducted using PubMed and Google Scholar databases, from inception through August 2024, to identify all published cases of COVID-19-associated TTP. The literature search focused on adult cases of TTP secondary to COVID-19 infection, highlighting the treatments used and patient outcomes.

EXPERT OPINION

In this report, we highlight the importance of recognizing TTP as a possible complication of COVID-19. While the standard treatment for TTP - plasma exchange and corticosteroids - remains the primary approach, we note that COVID-19-related cases exhibit a high risk of early relapse, as seen in our patient. The literature review suggests that TTP triggered by COVID-19 may have unique characteristics, such as a persistent low ADAMTS13 activity and increased relapse rates. Larger studies are necessary to develop optimal treatment guidelines and understand whether the presence of COVID-19 alters the typical clinical course of TTP.

Research on blood donation and supply of red blood cell products to medical institutions under the spread of COVID-19 disease in Japan

Due to the spread of SARS-CoV-2 virus infectious disease (COVID-19), blood donation events had to be cancelled, and there were concerns about a decrease in the number of blood donors from late February 2020 in Japan. The purpose of this study is to investigate the numbers of whole blood donation, manufacture and inventory adjustment of red blood cell (RBC) products at the Japanese Red Cross Society (JRCS), and to evaluate the effects of COVID-19 on the donation of blood and the supply of RBC products to medical institutions for transfusion medicine in Japan. We focused on RBC products, which are the most frequently used blood products and are easily reflected under the spread of COVID-19. The status of whole blood donation and RBC product transfusion was investigated based on the data provided by the JRCS from January 2020 to August 2021 on whole blood donation, manufacture and inventory adjustment of RBC products, and supply to medical institutions. Although there were some fluctuations since January 2020, the amount of estimated donated whole blood, manufactured RBC products, inventory, and supply to medical institutions remained almost stable. The reasons are thought to be the contribution of registered repeaters cooperating in blood donation, the accurate prediction of supply and demand by the JRCS, the call for blood donations in accordance with the prediction, and the timely exchange of products between block centers, and the utilization of a safe supply system established previously by the JRCS. As a result, it can be concluded that the stable provision of medical care was possible without depleting the inventory of RBC products even under the spread of COVID-19.

Single-center experience of venetoclax combined with azacitidine in young patients with newly diagnosed acute myeloid leukemia

Background

Medical resources, especially blood products, were in short supply during the COVID-19. Less intensive therapy with hypomethylating agents/venetoclax (VEN) seems an effective treatment option for patients with acute myeloid leukemia (AML).

Objectives

To retrospectively analyze the efficacy and safety of VEN combined with azacitidine (AZA) in young adult patients with newly diagnosed (ND) AML.

Design

This was a retrospective study.

Methods

The clinical data of 25 AML patients treated with the VEN + AZA regimen from January 2021 to December 2023 at our center were collected, compared with a randomized historical study cohort that was administered intensive chemotherapy (IC) from January 2018 to December 2019.

Results

No rate of complete remission/complete remission with incomplete count recovery differences observed between the two arms reached statistical significance. Compared to traditional IC, minimal residual disease (MRD)-negative remission was achieved more quickly in patients treated with VEN + AZA regimens (after cycle 1: 8% in the IC group vs 56% in the VEN group, p = 0.0004; after cycle 2: 16% in the IC group vs 72% in the VEN group, p = 0.0001), especially in those AML patients who had a poor prognosis. The dependency of transfusion of red blood cell (RBC) and platelets during induction treatment was significantly lower in the VEN + AZA group (RBC: p = 0.0269; platelet: p = 0.0054). Compared with the standard IC, the incidence rate of non-hematological adverse events in VEN + AZA group was significantly decreased (infection: 100% vs 20%, p = 0.0001; gastrointestinal side effects: 48% vs 12%, p = 0.0055). The total hospitalization cost of the VEN group was significantly less than that of the IC group (p = 0.0395).

Conclusion

In conclusion, our study indicated that VEN + AZA with a higher MRD-negative remission rate and less toxic appeared to be a therapy option for young patients with ND AML. However, further well-designed studies with larger numbers of patients are needed to confirm the benefits of VEN + AZA in this population.

Development, validation, and usability evaluation of machine learning algorithms for predicting personalized red blood cell demand among thoracic surgery patients

INTRODUCTION

Preparing appropriate red blood cells (RBCs) before surgery is crucial for improving both the efficacy of perioperative workflow and patient safety. In particular, thoracic surgery (TS) is a procedure that requires massive transfusion with high variability for each patient. Hence, the precise prediction of RBC requirements for individual patients is becoming increasingly important. This study aimed to 1) develop and validate a machine learning algorithm for personalized RBC predictions for TS patients and 2) assess the usability of a clinical decision support system (CDSS) integrating this artificial intelligence model.

METHODS

Adult patients who underwent TS between January 2016 and October 2021 were included in this study. Multiple models were developed by employing both traditional statistical- and machine-learning approaches. The primary outcome evaluated the model's performance in predicting RBC requirements through root mean square error and adjusted R2. Surgeons and informaticians determined the precision MSBOS-Thoracic Surgery (pMSBOS-TS) algorithm through a consensus process. The usability of the pMSBOS-TS was assessed using the System Usability Scale (SUS) survey with 60 clinicians.

RESULTS

We identified 7,843 cases (6,200 for training and 1,643 for test sets) of TSs. Among the models with variable performance indices, the extreme gradient boosting model was selected as the pMSBOS-TS algorithm. The pMSBOS-TS model showed statistically significant lower root mean square error (mean: 3.203 and 95% confidence interval [CI]: 3.186-3.220) compared to the calculated Maximum Surgical Blood Ordering Schedule (MSBOS) and a higher adjusted R2 (mean: 0.399 and 95% CI: 0.395-0.403) compared to the calculated MSBOS, while requiring approximately 200 fewer packs for RBC preparation compared to the calculated MSBOS. The SUS score of the pMSBOS-TS CDSS was 72.5 points, indicating good acceptability.

CONCLUSIONS

We successfully developed the pMSBOS-TS capable of predicting personalized RBC transfusion requirements for perioperative patients undergoing TS.

Comparing the effects of problem- and task-based learning on knowledge and clinical decision-making of nursing students concerning the use of transfusion medicine in pediatric nursing: An educational quasi-experimental study in Iran

Background

In the pediatric care field, ensuring safe and effective blood transfusions, promptly identifying adverse reactions, and implementing appropriate interventions are crucial. Therefore, undergraduate nursing curricula need to be structured to meet these professional standards and prepare nursing students, as future team members, to respond to relevant clinical situations. The objective of this study was to investigate how problem- and task-based learning affects knowledge and clinical decision-making of undergraduate nursing students concerning the use of transfusion medicine in pediatric nursing.

Material and methods

This quasi-experimental study involved 82 nursing students recruited from two nursing schools in Iran using convenience sampling. Participants received educational content through either problem- (n = 40) or task-based learning (n = 42) methods. A researcher-made tool, comprising three parts and proven to be valid and reliable, was utilized for data collection. The tool was administered both before and immediately after the intervention. Data were analyzed using Wilcoxon rank-sum, Mann-Whitney U, Spearman's correlation and multivariate analysis of covariance tests via SPSS v16.0. A p-value of <0.05 was considered significant for all tests.

Results

The median post-test knowledge and clinical decision-making scores within problem- and task-based learning groups were 62.68 vs. 74.65 and 53.33 vs. 76.67, respectively. Significant differences were observed between the mean pre- and post-test scores of both variables within both intervention groups (p < 0.05). Multivariate analysis of covariance revealed that task-based learning resulted in significant differences between the two groups in terms of knowledge (F = 87.9 %, p = 0.002, Eta2 = 0.114) and clinical decision-making (F = 99.9 %, p < 0.001, Eta2 = 0.271).

Conclusions

Given the greater effectiveness of task-based learning, nursing schools are advised to utilize this method in undergraduate nursing curricula to ensure the adequacy of the clinical skills acquired by nursing students prior to graduation.

Paradigm shift in transfusion practices during early COVID-19 pandemic: A single center retrospective study

BACKGROUND

The advent of coronavirus disease 2019 (COVID-19) unveiled the worst national blood crisis that the United States had witnessed in over a decade. With the pandemic influencing the different stages of the acquisition of blood products outside the hospital setting, we aimed to explore the possible barriers contributing to the shortage of blood products within the medical community.

AIM

To assess the adherence to restrictive blood transfusion practices for patients in the COVID era and pre-COVID era.

METHODS

We conducted a retrospective cross-sectional study on hospitalized patients distinguishing the pattern of blood transfusion during the COVID and pre-COVID era in a community hospital. Data was tabulated to include the number of red blood cell (RBC) transfusions and if transfusions met restrictive blood transfusion criteria as per institutional guidelines. Chi-square was applied to test the statistical association between qualitative variables. Unpaired t test and Mann Whitney U test were applied respectively to test the mean difference of quantitative variables.

RESULTS

A total of 208 patients were included in the study, of which 108 were during COVID era and 100 were during pre-COVID era. The leading reason for admission in both the COVID era and pre-COVID era transfused patients was shortness of breath (53.7% and 36% P = 0.001), followed by gastrointestinal bleeding (25.9% and 21% P = 0.001). There was a higher percentage of RBC transfusions in the intensive care unit in the COVID-era group than in the pre-COVID era group (38.9% vs 22%, P = 0.008). The restrictive transfusion criteria were met in 62% vs 79% in the COVID and pre-COVID eras, respectively (P = 0.008).

CONCLUSION

The COVID-era group received RBC transfusions with less stringent adherence to restrictive blood transfusion practices in comparison to pre-COVID era group.

Blood donation during COVID-19 lockdown and its association with anger and stress: A cross-sectional study from Syria

BACKGROUND

The demand for blood donations in Syria was high as the country has suffered for 9 years from war, and this demand has substantially increased during and after the lockdown from the COVID-19 pandemic. This study aims to assess blood donations in Syria and their association with multiple factors.

METHODS

Online questionnaires were distributed to social media groups, with questions related to stress, anger, and COVID-19 distress.

RESULTS

This study included 1,423 participants, of which 899 (63.2%) were women. Only 48.5% have ever donated blood, of which 33.3% donated only once in their lifetime. Not having a good reason to donate blood was the main reason for not donating. Obtaining documents was the main reason for blood donation among people who donated blood (64.8%). Stress, anger, and fear of infection were not associated with blood donation and its patterns. Losing someone close and being endangered by war were associated with more frequent blood donations in contrast to being distressed by war.

CONCLUSION

COVID-19 distress, stress, and anger were not associated with the decrease in blood donation. Spreading awareness on volunteer blood donation is crucial to combat blood shortage during stressful times.

Blood Transfusion, All-Cause Mortality and Hospitalization Period in COVID-19 Patients: Machine Learning Analysis of National Health Insurance Claims Data

This study presents the most comprehensive machine-learning analysis for the predictors of blood transfusion, all-cause mortality, and hospitalization period in COVID-19 patients. Data came from Korea National Health Insurance claims data with 7943 COVID-19 patients diagnosed during November 2019−May 2020. The dependent variables were all-cause mortality and the hospitalization period, and their 28 independent variables were considered. Random forest variable importance (GINI) was introduced for identifying the main factors of the dependent variables and evaluating their associations with these predictors, including blood transfusion. Based on the results of this study, blood transfusion had a positive association with all-cause mortality. The proportions of red blood cell, platelet, fresh frozen plasma, and cryoprecipitate transfusions were significantly higher in those with death than in those without death (p-values < 0.01). Likewise, the top ten factors of all-cause mortality based on random forest variable importance were the Charlson Comorbidity Index (53.54), age (45.68), socioeconomic status (45.65), red blood cell transfusion (27.08), dementia (19.27), antiplatelet (16.81), gender (14.60), diabetes mellitus (13.00), liver disease (11.19) and platelet transfusion (10.11). The top ten predictors of the hospitalization period were the Charlson Comorbidity Index, socioeconomic status, dementia, age, gender, hemiplegia, antiplatelet, diabetes mellitus, liver disease, and cardiovascular disease. In conclusion, comorbidity, red blood cell transfusion, and platelet transfusion were the major factors of all-cause mortality based on machine learning analysis. The effective management of these predictors is needed in COVID-19 patients.

Lyophilized platelets inhibit platelet aggregation with simultaneous paradoxical promotion of platelet adhesion

Lyophilized platelets have been explored as a potential hemostatic agent due to their long-term ambient storage capabilities that make them readily available in various scenarios. Additionally, their high biocompatibility and the key role of platelet interactions in various clinical conditions make them a promising platform for drug delivery. To explore these applications and for wider clinical deployment, the interactions between lyophilized platelets and fresh platelets must be examined. This project characterized receptor expression on the lyophilized platelet surface and their ability to bind fibrinogen using flow cytometry. The effect of lyophilized platelets on aggregation of unaltered platelets was assessed using light transmission aggregometry while the effect on adhesion was evaluated using static and microfluidic assays. Lyophilized platelets maintained significant levels of GPIIb and GPVI receptors on their surface, though the expression was reduced from fresh platelets. Additionally, lyophilized platelets maintained GPIb expression similar to fresh platelets. Furthermore, 15.8% of the lyophilized platelets exhibited the active conformation of the GPIIb/IIIa receptor, indicating a significant increase over fresh platelets. Lyophilized platelets also exhibited an increase in exposed phosphatidylserine and fibrinogen binding. Despite the effect of lyophilized platelets in promoting the adhesion of fresh platelets on a collagen-coated surface, their net effect was inhibitory on platelet aggregation. This study demonstrates that lyophilized platelets can have paradoxical effects on platelet adhesion and aggregation, which could have an impact for clinical applications. Detailed characterization and engineering of these effects will be important for their continued development as a drug delivery platform.

Passive order auditing associated with reductions in red blood cell utilization: National blood shortage experience

BACKGROUND

Decreased blood collection during the Coronavirus Disease 2019 (COVID-19) pandemic resulted in long-term red blood cell (RBC) shortages in the United States. In an effort to conserve RBCs, the existing passive alert system for auditing inpatient transfusions was modified to activate at a lower hemoglobin threshold (6.5 g/dL instead of 7.0 g/dL for stable, nonbleeding inpatients) during a 9-month shortage at an academic medical center. Hemoglobin levels prior to RBC transfusions were compared for inpatients receiving RBC transfusions to determine whether RBC utilization changed during the intervention.

STUDY DESIGN AND METHODS

This retrospective study compared the number of single-unit RBC transfusions and hemoglobin levels prior to RBC transfusion among inpatients during the 9 months of the intervention (Period 2, 06/01/2021-2/28/2022) to the same period of the previous year (Period 1, 06/01/2020-2/28/2021).

RESULTS

Overall full unit RBC transfusions to inpatients decreased by 15% from 5182 to 4421. Of all transfusions, 50.3% and 49.8% were single-unit RBC transfusions in Period 1 and Period 2, respectively. The incidence rate difference and incidence rate ratio of single RBC units transfused per 1000 patient days were significantly decreased (p = 0.0007). The average pre-transfusion hemoglobin level significantly decreased from 7.18 g/dL to 7.05 g/dL (p = 0.0002), largely due to significant decreases in hemoglobin transfusion triggers for adult inpatient ward transfusions.

DISCUSSION

Modification of the passive alert system was associated with significantly decreased RBC utilization during a long-term RBC shortage. Modification of transfusion criteria recommended by passive alerts may be a feasible option to decrease RBC utilization at centers during long-term RBC shortages.

Blood Transfusion Reactions-A Comprehensive Review of the Literature including a Swiss Perspective

Blood transfusions have been the cornerstone of life support since the introduction of the ABO classification in the 20th century. The physiologic goal is to restore adequate tissue oxygenation when the demand exceeds the offer. Although it can be a life-saving therapy, blood transfusions can lead to serious adverse effects, and it is essential that physicians remain up to date with the current literature and are aware of the pathophysiology, initial management and risks of each type of transfusion reaction. We aim to provide a structured overview of the pathophysiology, clinical presentation, diagnostic approach and management of acute transfusion reactions based on the literature available in 2022. The numbers of blood transfusions, transfusion reactions and the reporting rate of transfusion reactions differ between countries in Europe. The most frequent transfusion reactions in 2020 were alloimmunizations, febrile non-hemolytic transfusion reactions and allergic transfusion reactions. Transfusion-related acute lung injury, transfusion-associated circulatory overload and septic transfusion reactions were less frequent. Furthermore, the COVID-19 pandemic has challenged the healthcare system with decreasing blood donations and blood supplies, as well as rising concerns within the medical community but also in patients about blood safety and transfusion reactions in COVID-19 patients. The best way to prevent transfusion reactions is to avoid unnecessary blood transfusions and maintain a transfusion-restrictive strategy. Any symptom occurring within 24 h of a blood transfusion should be considered a transfusion reaction and referred to the hemovigilance reporting system. The initial management of blood transfusion reactions requires early identification, immediate interruption of the transfusion, early consultation of the hematologic and ICU departments and fluid resuscitation.

Severe Acute Respiratory Syndrome Coronavirus 2 and Blood Safety: An Updated Review

Background

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a novel human coronavirus first identified in late 2019 and subsequently declared a worldwide pandemic in March 2020. In this review, we provide an overview of the implications of SARS-CoV-2 for blood safety and sufficiency.

Summary

Approximately one-third of SARS-CoV-2 infections are asymptomatic. The reported mean incubation period typically varies from 2 to 11 days, but longer periods up to 22 days have been reported. The blood phase of SARS-CoV-2 appears to be brief and low level, with RNAaemia detectable in only a small proportion of patients, typically associated with more severe disease and not demonstrated to be infectious virus. A small number of presymptomatic and asymptomatic blood phase cases have been reported. Transfusion-transmission (TT) of SARS-CoV-2 has not been reported. Therefore, the TT risk associated with SARS-CoV-2 is currently theoretical. To mitigate any potential TT risk, but more importantly to prevent respiratory transmission in donor centers, blood services can implement donor deferral policies based on travel, disease status, or potential risk of exposure and encourage staff vaccination.

Key Messages

The TT risk of SARS-CoV-2 appears to be low. The biggest risk to blood services in the current COVID-19 pandemic is to maintain the sufficiency of the blood supply while minimizing respiratory transmission of SARS-CoV-2 to donors and staff while donating blood.

A simple empirical inventory model for managing the processed corneal tissue equitably in hospitals with demand differentiation

This paper peruses one of the most challenging healthcare concerns related to human organ transplantation. In this regard, a medical system’s health-economic objectives are investigated to (1) achieve a desirable level of health equity in offering healthcare services to patients who are differentiated in terms of medical conditions, and (2) minimize total costs incurred across managing the inventory. This paper presents the first-ever operational research study to manage processed corneal tissue (PCT). Besides, hybrid demand-oriented policies have been proposed to equitably issue and assign specific inventories to demands with distinct medical urgent levels (ULs). In this regard, a practical multi-objective mixed-integer linear programming (MOMILP) model is proposed for a system with multiple products that can be substituted with each other according to medical priorities. A goal programming (GP) approach is utilized to find the optimum solution. The applicability of the model is validated through a real case study. Finally, several sensitivity analyses are conducted to examine the effect of critical parameters on the solutions to gain useful managerial insights. The results show that the proposed health-economic trade-off is well performed and can efficiently handle the real case.