Umbilical Cord Blood: Counselling, Collection, and Banking

Inconsistencies in Pregnant Mothers' Attitudes and Willingness to Donate Umbilical Cord Stem Cells: A Cross-Sectional Analysis from Saudi Arabia

The collection and storage of umbilical cord stem cells (UCSCs) have a crucial role in improving and expanding stem cell-based therapies, which are becoming popular in Saudi Arabia and other Middle East countries. Many patients and families in Saudi Arabia depend on private cord banks in foreign countries to purchase stem cells, which has financial and medical implications. The current study aims at determining the predictors of current registration status and willingness to donate cord blood stem cells among expectant mothers in Saudi Arabia. A cross-sectional study collected data from 714 expectant mothers from all thirteen regions of Saudi Arabia in December 2022. The online survey questionnaire assessed women's awareness, direct and indirect exposure to stem-cell therapy, sources of knowledge, willingness, reluctance, and current registration status to donate cord blood. Although women demonstrated higher acceptance and lower rejection towards the donation of UCSCs, just one percent (n = 7; 1%) of expectant mothers in this sample are registered with the Saudi Stem Cell Registry. Overall, 48% indicated their willingness to register in the future. Both correlational analysis and multiple regression analysis demonstrated that awareness significantly predicted willingness to donate (p < 0.01), and rejection attitudes were negatively related to willingness to donate (p < 0.001). Although the mean scores on acceptance were high, they were not found to be significantly associated with willingness to donate. Prior direct and indirect exposure to stem cell therapy appeared to be the strongest predictor of pregnant women's willingness to register (p < 0.001). Findings suggest that acceptance attitudes do not have a symmetrical relationship with intention. Women's prior exposure to stem cell therapy was the most significant factor; therefore, findings demonstrate that currently women are relying on their firsthand experience to decide about cord blood donation rather than the information obtained from other sources, such as social media and the internet. Though attitudes were not identified as significant predictors in the statistical models, awareness was a relevant factor, and the findings signify increasing awareness in various target populations to enhance the probability of intention to donate cord stem cells.

Clinical Outcomes of Umbilical Cord Blood Transplantation Using Ex Vivo Expansion: A Systematic Review and Meta-Analysis of Controlled Studies

Greater use of umbilical cord blood (UCB) for hematopoietic cell transplantation (HCT) is limited by the number of cells in banked units. Ex vivo culture strategies have been increasingly evaluated in controlled studies, but their impact on transplantation-related outcomes remains uncertain owing to the small patient numbers in these studies, necessitating an updated systematic review and meta-analysis. A systematic literature search was conducted using the MEDLINE, Embase, and Cochrane databases to March 18, 2022. Nine cohort-controlled phase I to III trials were identified, and data of 1146 patients undergoing umbilical cord blood transplantation (UCBT) were analyzed (308 ex vivo expanded and 838 unmanipulated controls). Expansion strategies involved cytokine cocktails plus the addition of small molecules (UM171, nicotinamide [NiCord], copper chelation, Notch ligand, or Stem regenin-1 [SR-1]) and coculture with mesenchymal stromal cells in a single-unit transplant strategy (5 studies) or a double-unit transplant strategy with 1 unmanipulated unit (4 studies). The included trials reported a median ex vivo expansion of CD34⁺ cells from 28-fold to 330-fold. Eight of the 9 studies demonstrated a significantly faster time to initial neutrophil and platelet engraftment using expanded cells compared with controls. Studies using UM171 and NiCord in single-unit UCBT and SR-1 or NiCord double-unit UCBT demonstrated long-term donor chimerism of the expanded unit at 100 days to 36 months post-transplantation in all single-unit recipients and in 35% to 78% of double-unit recipients. Our meta-analysis revealed a lower risk of death at the study endpoint in patients who received ex vivo expanded grafts (odds ratio [OR], .66; 95% confidence interval [CI], .47 to .95; P = .02), while the risk of grade II-IV acute graft-versus-host disease was unchanged (OR, .79; 95% CI, .58 to 1.08; P = .14). This review indicates that UCBT following ex vivo expansion can accelerate initial engraftment. Durable donor chimerism can be achieved after transplanting cord blood units expanded using NiCord, UM171, or SR-1; however, long term outcomes remain unclear. Larger studies with longer-term outcomes are needed to better understand the merits of specific expansion strategies on survival.

Bioengineered 3D microfibrous-matrix modulates osteopontin release from MSCs and facilitates the expansion of hematopoietic stem cells

The osteopontin released from mesenchymal stem cells (MSC) undergoing lineage differentiation can negatively influence the expansion of hematopoietic stem cells (HSCs) in co-culture systems developed for expanding HSCs. Therefore, minimising the amount of osteopontin in the co-culture system is important for the successful ex vivo expansion of HSCs. Towards this goal, a bioengineered 3D microfibrous-matrix that can maintain MSCs in less osteopontin-releasing conditions has been developed, and its influence on the expansion of HSCs has been studied. The newly developed 3D matrix significantly decreased the release of osteopontin, depending on the MSC culture conditions used during the priming period before HSC seeding. The culture system with the lowest amount of osteopontin facilitated a more than 24-fold increase in HSC number in 1 week time period. Interestingly, the viability of expanded cells and the CD34+ pure population of HSCs were found to be the highest in the low osteopontin-containing system. Therefore, bioengineered microfibrous 3D matrices seeded with MSCs, primed under suitable culture conditions, can be an improved ex vivo expansion system for HSC culture. This article is protected by copyright. All rights reserved.

Guidelines on Deferred Cord Clamping and Cord Milking: A Systematic Review

CONTEXT

Deferred cord clamping (DCC) saves lives. It reduces extremely preterm infants' mortality by 30%, yet a minority of eligible infants receive it. This may in part be due to lack of awareness or confidence in evidence, or conflicting or vague guidelines.

OBJECTIVE

To systematically review clinical practice guidelines and other statements on DCC and cord milking.

DATA SOURCES

Ten academic and guideline databases were searched.

STUDY SELECTION

Clinical practice guidelines and other statements (position statements and consensus statements) providing at least 1 recommendation on DCC or umbilical cord milking among preterm or term infants were included.

DATA EXTRACTION

Data from included statements were extracted by 2 independent reviewers, and discrepancies were resolved through consensus. Guideline quality was appraised with modified Appraisal of Guidelines for Research and Evaluation II and Appraisal of Guidelines for Research and Evaluation Recommendation Excellence tools.

RESULTS

Forty-four statements from 35 organizations were included. All endorsed DCC for uncompromised preterm infants, and 11 cautiously stated that cord milking may be considered when DCC is infeasible. Only half (49%) of the recommendations on the optimal duration of DCC were supported by high-quality evidence. Only 8% of statements cited a mortality benefit of DCC for preterm infants.

LIMITATIONS

Because systematic reviews of guidelines are relatively novel, there are few tools to inform study execution; however, we used the Appraisal of Guidelines for Research and Evaluation II and the Appraisal of Guidelines for Research and Evaluation Recommendation Excellence to assess quality and were methodologically informed by previous systematic reviews of guidelines.

CONCLUSIONS

Statements worldwide clearly encouraged DCC. Their implementability would benefit from noting the preterm mortality benefit of DCC and more granularity.

Identifying Barriers to Umbilical Cord Blood Banking in Jordan: A Cross-Sectional Survey of Obstetricians

Background: The expansion of umbilical cord blood (UCB) banking necessitates a greater understanding among obstetricians in order to responsibly inform parents about UCB collection and storage. Gaps in knowledge can compromise public UCB banking efforts and result in missed opportunities and public misguidance about UCB banking. Materials and Methods: A cross-sectional survey was disseminated among obstetricians in Amman, Jordan. The questionnaire aimed to evaluate obstetricians' knowledge of and attitude toward UCB storage and applications, as well as current practice patterns. Results: Ninety-six obstetricians responded (55% response rate), most of whom were Jordanian (71%), female (83%), resident physicians (59%), and working in either private (43%) or public (42%) hospitals, with an average of 6.5 years in practice. Only 26% had personal experience in UCB collection, and 20% had received education on UCB collection. Nearly 75% said their hospitals lacked standard operating procedures, guidelines, or infectious disease screening for UCB units. Overall knowledge about UCB was moderate, and the internet was the most common information source (54%). Overall attitudes were positive, especially in desire to expand personal knowledge about UCB, integrate information into medical residency curricula, and establish a public UCB bank in Jordan. However, many believed that ethical (61%) and religious (56%) controversies surround UCB donation. Conclusion: This study identifies deficiencies in quality control and experience in UCB collection in Jordan, as well as areas of inadequate knowledge and ethical controversies among obstetricians. These issues contribute to public misinformation and limit public UCB donation programs, and requires improved medical education on this topic.

Umbilical cord stem cells: Background, processing and applications

Stem cells have currently gained attention in the field of medicine not only due to their ability to repair dysfunctional or damaged cells, but also they could be used as drug delivery system after being engineered to do so. Human umbilical cord is attractive source for autologous and allogenic stem cells that are currently amenable to treatment of various diseases. Human umbilical cord stem cells are -in contrast to embryonic and fetal stem cells- ethically noncontroversial, inexpensive and readily available source of cells. Umbilical cord, umbilical cord vein, amnion/placenta and Wharton's jelly are all rich of many types of multipotent stem cell populations capable of forming many different cell types. This review will focus on umbilical cord stem cells processing and current application in medicine.

Ex Vivo-expanded Natural Killer Cells Derived From Long-term Cryopreserved Cord Blood are Cytotoxic Against Primary Breast Cancer Cells

With over 600,000 units of umbilical cord blood (CB) stored on a global scale, it is important to elucidate the therapeutic abilities of this cryopreserved reservoir. In the advancing field of natural killer (NK) cell cancer immunotherapy, CB has proven to be a promising and noninvasive source of therapeutic NK cells. Although studies have proven the clinical efficacy of using long-term cryopreserved CB in the context of hematopoietic stem cell transplantations, little is known about its use for the ex vivo expansion of effector immune cells. Therefore, our group sought to derive ex vivo-expanded NK cells from long-term cryopreserved CB, using an artificial antigen presenting cell-mediated expansion technique. We compared the expansion potential and antitumor effector function of CB-derived NK (CB-NK) cells expanded from fresh (n=4), short-term cryopreserved (<1-year old, n=5), and long-term cryopreserved (1-10-year old, n=5) CB. Here, we demonstrated it is possible to obtain an exponential amount of expanded CB-NK cells from long-term cryopreserved CB. Ex vivo-expanded CB-NK cells had an increased surface expression of activating markers and showed potent antitumor function by producing robust levels of proinflammatory cytokines, interferon-γ, and tumor necrosis factor-α. Moreover, expanded CB-NK cells (n=3-5) demonstrated cytotoxicity towards primary breast cancer cells (n=2) derived from a triple-negative breast cancer and an estrogen receptor-positive/progesterone receptor-positive breast cancer patient. Long-term cryopreservation had no effect on the expansion potential or effector function of expanded CB-NK cells. Therefore, we propose that long-term cryopreserved CB remains clinically useful for the ex vivo expansion of therapeutic NK cells.

A hands-on resident umbilical cord blood educational curriculum compared to online education of post-residency obstetricians: comparison of the volume of collected cord blood units

BACKGROUND

Umbilical cord blood unit (CBU) volume is a predictor of its later clinical utility. Many studies suggest the need to increase the volume of CBU collected, but most obstetrical providers receive no formal collection training.

STUDY DESIGN AND METHODS

We designed and implemented an educational curriculum for obstetrics residents aimed at improving collection methods and increasing CBU volumes (CBUV). Residents were required to attend grand rounds and interactive didactic sessions on CBU collection followed by work with a simulated collection kit and then performed training collections under observation by a trained collector. Residents completed a self-assessment after each collection and received immediate personal feedback. Outside providers (non-UAMS physicians) received written instructional materials with the collection kits and had access to online training materials. They received feedback regarding their collection via standard mail. CBU donated to Cord Blood Bank of Arkansas for public use from 2014-2016 were analyzed. CBUV from residents were compared to those from outside providers.

RESULTS

After adjusting for maternal age and race, infant gender, gestational age, and birth weight, the least-squared mean CBUV was 92.1 mL for UAMS collections and 65.5 mL for outside provider collections. The improved CBUV of UAMS providers is statistically significant (p < 0.0001).

CONCLUSION

Our educational intervention was successful, and we believe that it can be replicated in other obstetrical residency programs. Cord blood collection education involving hands-on training with a model and immediate feedback improves CBUV, decreases kit waste, increases likelihood of CBU storage, and, therefore, inventory for transplantation.

Cord Blood Banking: Antenatal Care Provider's Roles and Responsibilities

BACKGROUND

Umbilical Cord Blood (UCB) banking done either for private storage or for donation to public cord blood banks involves active participation of obstetricians. Counseling the expectant parents, providing them with unbiased and balanced information, and collecting the UCB with diligence confer a lot of social as well as moral responsibility upon obstetricians. This makes it even more important that the obstetricians in current practice stay well-informed and updated with UCB collection and its storage guidelines. The present study was conducted to assess the current status of obstetricians about UCB banking in terms of their awareness, attitude, and expectations from it.

MATERIALS AND METHODS

A cross-sectional study was conducted across three hospitals. A self-administered 22-item questionnaire was given to obstetricians to assess their awareness, attitude, and expectations about UCB banking. Finally, 154 completed questionnaires were analyzed using SPSS software (version 15.0). The awareness, attitude, and expectations were assessed and reported as primary endpoints and the self-rated knowledge levels, and sources of information were reported as secondary endpoints.

RESULTS

Overall, the awareness was poor, but the attitude was favorable for UCB banking amongst obstetricians. Around 74% felt that obstetricians must be well-informed about UCB banking-related counseling and collection protocols. However, 55% felt it to be an additional burden for the obstetrician, and 57% believed that financial compensation must be given to obstetricians involved with cord blood collection procedures. The majority remained unclear about their expectations from UCB banking. The self-rated knowledge was poor and very poor for 75% obstetricians. 89.6% derived their information from representatives of private cord blood companies.

CONCLUSION

Although poor in awareness levels, obstetricians possessed a favorable attitude towards UCB banking. Continuing medical education needs to focus more on such current issues of public importance to keep professionals updated. This is one way to minimise percolation of wrong facts and figures by the industries with conflicting interest to the healthcare providers.

Bone Tissue Engineering Using Human Cells: A Comprehensive Review on Recent Trends, Current Prospects, and Recommendations

The use of proper cells for bone tissue engineering remains a major challenge worldwide. Cells play a pivotal role in the repair and regeneration of the bone tissue in vitro and in vivo. Currently, a large number of differentiated (somatic) and undifferentiated (stem) cells have been used for bone reconstruction alone or in combination with different biomaterials and constructs (e.g., scaffolds). Although the results of the cell transplantation without any supporting or adjuvant material have been very effective with regard to bone healing. Recent advances in bone scaffolding are now becoming new players affecting the osteogenic potential of cells. In the present study, we have critically reviewed all the currently used cell sources for bone reconstruction and discussed the new horizons that are opening up in the context of cell-based bone tissue engineering strategies.

Italian Recommendations for Placental Transfusion Strategies

At delivery, if the cord is not clamped, blood continues to pass from the placenta to the newborn during the first minutes of life, allowing the transfer of 25-35 ml/kg of placental blood to the newborn, depending on gestational age, the timing of cord clamping, the position of the infant at birth, the onset of respiration, and administration of uterotonics to the mother. However, deriving benefits from delayed cord clamping (DCC) are not merely related to placental-to-fetal blood transfusion; establishing spontaneous ventilation before cutting the cord improves venous return to the right heart and pulmonary blood flow, protecting the newborn from the transient low cardiac output, and systemic arterial pressure fluctuations. Recent meta-analyses showed that delayed cord clamping reduces mortality and red blood cell transfusions in preterm newborns and increases iron stores in term newborns. Various authors suggested umbilical cord milking (UCM) as a safe alternative when delayed cord clamping is not feasible. Many scientific societies recommend waiting 30-60 s before clamping the cord for both term and preterm newborns not requiring resuscitation. To improve the uptake of placental transfusion strategies, in 2016 an Italian Task Force for the Management of Umbilical Cord Clamping drafted national recommendations for the management of cord clamping in term and preterm deliveries. The task force performed a detailed review of the literature using the GRADE methodological approach. The document analyzed all clinical scenarios that operators could deal with in the delivery room, including cord blood gas analysis during delayed cord clamping and time to cord clamping in the case of umbilical cord blood banking. The panel intended to promote a more physiological and individualized approach to cord clamping, specifically for the most preterm newborn. A feasible option to implement delayed cord clamping in very preterm deliveries is to move the neonatologist to the mother's bedside to assess the newborn's clinical condition at birth. This option could safely guarantee the first steps of stabilization before clamping the cord and allow DCC in the first 30 s of life, without delaying resuscitation. Contra-indications to placental transfusion strategies are clinical situations that may endanger mother 's health and those that may delay immediate newborn's resuscitation when required.

The role of policies and networks in development of cord blood usage in China

Research regarding the use of cord blood (CB) has focused on antigen match and the number of stem cells, with policies and networks related to its use being under researched. This article is based on fieldwork in China from 2013 to 2015 and examines ways that the studied CB bank enhances CB usage in China. This article identifies that in addition to finding a match, CB use is linked to the policies and networks, release fee and public awareness that enable CB usage development.