US public cord blood banking practices: recruitment, donation, and the timing of consent

Scoring system for optimal cord blood unit selection for single cord blood transplantation

BACKGROUND

We conducted a retrospective study to categorize the cord blood unit (CBU)s to identify the optimal units.

METHODS

A total of 8503 adults (female, n = 3592; male, n = 4911) receiving their first single cord blood transplantation (CBT) in 2000-2019 were analyzed. Factors associated with CBUs affecting overall survival (OS) and neutrophil engraftment were selected to create ranked categorization for each outcome, followed by comparison with transplantation using HLA-matched bone marrow (BMT)/peripheral blood stem cell (PBSCT) from unrelated (n = 6052) and related donors (n = 4546).

RESULTS

Sex-mismatch, CD34+ cell and CFU-GM counts were selected in the OS analysis. Considering the strong interaction between sex mismatch and CD34+ cell counts, we analyzed females and males separately. For females, female CBU with CD34+ cell counts {greater than or equal to} 0.5 × 10e5/kg and CFU-GM counts {greater than or equal to} 15 × 10e3/kg offered the best OS (Group I), followed by other groups with any (Groups II-IV) or all (Group V) of the risk factors. Group I consistently showed favorable OS (Group IV: HR1.22, P = 0.027; Group V: HR1.31, P = 0.047), comparable to those of rBMT/PBSCT (OS: HR1.02, P = 0.654) and uBM/PBSCT in patients with higher rDRI (HR1.07, P = 0.353). Male patients lacked significant factors affecting OS. Categorization for neutrophil engraftment consisting of CD34+ cell and CFU-GM counts, sex-mismatch, presence of donor-specific antibodies, and the number of HLA-mismatches was effective but not predicted OS.

CONCLUSION

Our ranked categorizations sufficiently predicted female OS and engraftment. The best-ranked CBUs offered preferable outcomes comparable to conventional BM/PB donors in female but not in male patients.

Determinants of the intention to donate umbilical cord blood in pregnant women

Background and Objectives

Umbilical cord blood (UCB) donation is a behaviour promoted by many countries' health systems. However, UCB donation is not a widespread behaviour among expectant mothers, and little is known about the reasons that may lead to it. The aim of the present study was to analyse the contribution of Theory of Planned Behaviour (TPB) variables among both primiparous and multiparous women in predicting intention to donate UCB.

Materials and Methods

Three hundred seventy‐six expectant mothers completed questionnaires that captured sociodemographic data, parity, previous donation, attitudes, subjective norms, perceived behavioural control (PBC) and intention to donate UCB. Multigroup analysis structural equation modelling was conducted using Mplus (version 8.02).

Results

Multigroup path analyses showed that intentions were strongly predicted by subjective norms and moderately predicted by positive attitudes and PBC in both primiparous and multiparous women. TPB constructs explained 71% of the variance in intentions for both groups.

Conclusions

Future interventions to increase intention to donate among primiparous and multiparous women could primarily consider the influence of partner and significant others in determining positive intentions and secondarily target increasing positive attitudes and perceptions of control.

Antenatal predictors of stem cell content for successful umbilical cord blood donation

Purpose

The most important HLA-independent factor for the selection of cord blood units (CBU) for hematopoietic stem cell transplantation is the total nucleated cell (TNC) count over 150 × 10⁷ as a surrogate marker for stem cell content. The purpose of this prospective study was to define prenatal clinical predictors for TNC count that would help to identify successful CBU donors before the onset of active labor.

Methods

This was a prospective analysis of 594 CBUs, collected from all eligible term singleton pregnancies at Basel University Hospital between 4/2015 and 9/2016 analyzing several maternal and fetal factors. The impact of these factors on TNC count (< 150 × 10⁷ cells vs. ≥ 150 × 10⁷ cells) of the CBUs was modeled in a multivariate analysis.

Results

A total of 114 (19.2%) CBUs had a TNC count of ≥ 150 × 10⁷. In a ROC analysis there was no significant difference between the AUC of all prenatal factors (AUC 0.62) and estimated fetal birth weight by ultrasound alone (AUC 0.62). For women planning a trial of labor a recruitment cut-off at an estimated birth weight of 3300 g would allow 72.6% of all donors with sufficient TNC count to be recruited and 22.8% of all collected CBUs would have a sufficient TNC count for banking. For women planning for elective CS a cut-off of 3400 g would allow 71.4% of all donors with sufficient TNC count to be recruited and 22.7% of all collected CBUs would have sufficient TNC count for banking.

Conclusion

The estimated fetal birth weight within 2 weeks of delivery by ultrasound as single parameter can be considered at the time of recruitment to estimate the chances of a successful CBU donation.

Contextual factors influencing donor recruitment and cord blood collection: perspectives of frontline staff of the Canadian Blood Services' Cord Blood Bank

BACKGROUND

Umbilical cord blood (CB) is an important source of hematopoietic stem cells that are used to treat blood- and immune-system disorders. Public CB banks aim to build inventories with high-quality CB units to meet healthcare needs. While research has noted the influence of broader contextual factors on donor recruitment and CB collection processes, to date, no published study has identified the specific contextual factors and challenges to donor recruitment and CB collection. This paper addresses this gap in the literature.

STUDY DESIGN AND METHODS

A qualitative case study focusing on donor recruitment and CB collection processes was conducted to identify the contextual factors influencing these processes. This paper reports the findings from in-depth, semi-structured interviews conducted with 15 frontline staff of the Canadian Blood Services' Cord Blood Bank. Interview data were analyzed using inductive interpretive methods to identify the contextual conditions and factors that influence recruitment and collection.

RESULTS

Frontline staff described various social factors that influenced and challenged the processes of donor recruitment and CB collection. These were categorized into four overlapping contexts: birthing context, hospital context, CB bank organizational context, and sociocultural context.

CONCLUSION

Consideration of social context is necessary in order to effectively address the factors and challenges that influence the successful development of high-quality CB inventories, and to guide resource allocation. Further examination of contextually-rooted factors and their interactions is necessary to optimize donor recruitment and CB collection processes.

Motivating Cord Blood Donation with Information and Behavioral Nudges

Umbilical cord blood is a source of hematopoietic stem cells essential to treat life-threatening diseases, such as leukemia and lymphoma. However, only a very small percentage of parents donate upon delivery. The decision to donate the cord blood occurs at a very specific time and when parents likely experience emotional, informational, and decisional overloads; these features of cord blood donation make it different from other pro-social activities. In collaboration with an OB-GYN clinic in Milan, Italy, we conducted the first randomized controlled trial that applies tools from behavioral science to foster cord blood donation, and quantified the gains that informational and behavioral "nudges" can achieve. We found that information and "soft" commitments increased donations; approaching expecting parents closer to the delivery date and providing them with multiple reminders, moreover, had the strongest impact. However, a significant portion of women who expressed consent to donate could not do so because of organizational constraints. We conclude that simple, non-invasive behavioral interventions that address information gaps and procrastination, and that increase the salience of the activity can substantially enhance altruistic donations of cord blood, especially when coupled with organizational support.

Umbilical Cord Blood: Counselling, Collection, and Banking

OBJECTIVE

To review current evidence regarding umbilical cord blood counselling, collection, and banking and to provide guidelines for Canadian health care professionals regarding patient education, informed consent, procedural aspects, and options for cord blood banking in Canada.

OPTIONS

Selective or routine collection and banking of umbilical cord blood for future stem cell transplantation for autologous (self) or allogeneic (related or unrelated) treatment of malignant and non-malignant disorders in children and adults. Cord blood can be collected using in utero or ex utero techniques.

OUTCOMES

Umbilical cord blood counselling, collection, and banking, education of health care professionals, indications for cord blood collection, short- and long-term risk and benefits, maternal and perinatal morbidity, parental satisfaction, and health care costs.

EVIDENCE

Published literature was retrieved through searches of Medline and PubMed beginning in September 2013 using appropriate controlled MeSH vocabulary (fetal blood, pregnancy, transplantation, ethics) and key words (umbilical cord blood, banking, collection, pregnancy, transplantation, ethics, public, private). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. There were no date limits, but results were limited to English or French language materials. Searches were updated on a regular basis and incorporated in the guideline to September 2014. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, and national and international medical specialty societies.

VALUES

The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1).

BENEFITS, HARMS, AND COSTS

Umbilical cord blood is a readily available source of hematopoetic stem cells used with increasing frequency as an alternative to bone marrow or peripheral stem cell transplantation to treat malignant and non-malignant conditions in children and adults. There is minimal harm to the mother or newborn provided that priority is given to maternal/newborn safety during childbirth management. Recipients of umbilical cord stem cells may experience graft-versus-host disease, transfer of infection or genetic abnormalities, or therapeutic failure. The financial burden on the health system for public cord blood banking and on families for private cord blood banking is considerable. Recommendations 1. Health care professionals should be well-informed about cord blood collection and storage and about factors that influence the volume, quality, and ability to collect a cord blood unit. (III-A) 2. Health care professionals caring for women and families who choose private umbilical cord blood banking must disclose any financial interests or potential conflicts of interest. (III-A) 3. Pregnant women should be provided with unbiased information about umbilical cord blood banking options, including the benefits and limitations of public and private banks. (III-A) 4. Health care professionals should obtain consent from mothers for the collection of umbilical cord blood prior to the onset of active labour, ideally during the third trimester, with ample time to address any questions. (III-A) 5. Health care professionals must be trained in standardized procedures (ex utero and in utero techniques) for cord blood collection to ensure the sterility and quality of the collected unit. (II-2A) 6. Umbilical cord blood should be collected with the goal of maximizing the content of hematopoietic progenitors through the volume collected. The decision to bank the unit will depend upon specific measures of graft potency. (II-2A) 7. Umbilical cord blood collection must not adversely affect the health of the mother or newborn. Cord blood collection should not interfere with delayed cord clamping. (III-E) 8. Health care professionals should inform pregnant women and their partners of the benefits of delayed cord clamping and of its impact on cord blood collection and banking. (II-2A) 9. Cord blood units collected for public or private banking can be used for biomedical research, provided consent is obtained, when units cannot be banked or when consent for banking is withdrawn. (II-3B) 10. Mothers may be approached to donate cells for biomedical research. Informed consent for research using cord blood should ideally be obtained prior to the onset of active labour or elective Caesarean section following established research ethics guidelines. (II-2A).

Institutional Knots: A Comparative Analysis of Cord Blood Policy in Canada and the United States

Umbilical cord blood is a rich source of blood stem cells, which are of critical clinical importance in the treatment of a variety of malignant and genetic conditions requiring stem cell transplantation. Many countries have established national public cord blood banks; such banks often coexist with a panoply of private options for cord blood banking. Until recently, Canada was the only G8 country without a national cord blood bank. This differs markedly from the United States, which years ago established a national cord blood bank policy and inventory. This article investigates potential reasons for this discrepancy through a comparative analysis of the evolution of programs and policies on national cord blood banking in Canada and the United States. My analysis suggests that cross-national discrepancies in policy on public cord blood banking were determined primarily by institutional factors, principal among them formal governmental structure and the legacy of past policies. Institutional entrepreneurialism in the health sector played a constitutive role in the earlier evolution of national cord blood policy in the United States as compared to Canada.

Factors That Influence a Mother's Willingness to Preserve Umbilical Cord Blood: A Survey of 5120 Chinese Mothers

BACKGROUND

Umbilical Cord blood (UCB), which contains a substantive number of stem cells, could be widely used in transplants to treat a variety of oncologic, genetic, hematologic, and immunodeficiency disorders. However, only a small portion of mothers preserve or donate their UCB in China. The limited availability of UCB has hampered stem cell research and therapy nowadays. To date, no systemic investigations regarding factors that influence a mother's willingness to preserve UCB have been performed in China. In the current study, we are trying to determine those factors which will provide useful information for national health policy development and will raise awareness of the importance of UCB preservation.

METHODS

During 2011 to 2013, 5120 mothers with the average age of 26.1±8.4 years were included in this study. Those mothers participated in a standardized survey. The information gathered consisted of delivery time, occupation, level of education, knowledge of preservation of UCB, willingness to store UCB, and related concerns. The results have been analyzed with SPSS 16.0.

RESULTS

The results showed that first-time mothers showed a greater willingness to preserve their UCB (73.3%) compared to those having their second (48.9%) or third child (40.3%). Mothers who were employed at Government Agencies and Organizations were more willing to preserve their UCB (87.3%) than those employed at factories (62.0%), and those who were unemployed (27.3%). Mothers holding master's or college degrees were more willing to preserve their UCB (72.5% and 71.1%, respectively) than mothers with high school diplomas (48.7%) or those who only went to preliminary school or middle school (40.7%). The two strongest factors that influenced an unwillingness to preserve UCB were the high cost and concerns regarding the safety of the preservation.

CONCLUSIONS

The results showed that mothers with higher education or those having better occupations are more likely to preserve their UCB in China. These mothers have related knowledge and understand the importance of the preservation and they could more readily afford the relatively high cost. The government, clinicians and UCB banks should combine efforts to take measures, such as increasing public knowledge of the importance of UCB preservation and decreasing the high cost for its storage will most likely increase the frequency of UCB preservation which will further benefit stem cell research and therapy.

The Royan Public Umbilical Cord Blood Bank: Does It Cover All Ethnic Groups in Iran Based on HLA Diversity?

BACKGROUND

Umbilical cord blood (UCB) stem cells allow the transplantation of partially human leukocyte antigen (HLA)-matched grafts and are a valuable resource for the treatment of hematologic malignancies and heritable hematologic, immunologic and metabolic diseases, especially when a compatible bone marrow donor is unavailable. The aim of this study was to determine how many ethnic groups in Iran are covered by the available UCB units based on HLA diversity.

METHODS

From 2009 until mid-2013, 4,981 (30.3%) of the 16,437 UCB samples collected met the storage criteria and were cryopreserved at a public cord blood bank (CBB) in Tehran, Iran. HLA-A, -B and -DRB1 were typed in 1,793 samples.

RESULTS

The mean volume of the cryopreserved samples was 81.25 ± 20.3 ml. The range of total nucleated cells per unit was 51 × 10(7)-107 × 10(7). The most common HLA alleles were HLA-A*2 (17%) and HLA-A*24 (15.6%), HLA-B*35 (16.8%) and HLA-B*51 (13.9%), and HLA-DRB1*11 (20%) and HLA-DRB1*15 (14%). The predominant haplotypes were HLA-A*24-B*35-DRB1*11 (2%), HLA-A*02-B*50-DR*07 (1.8%), and HLA-A*02-B*51-DRB1*11 (1.5%).

CONCLUSIONS

Based on the HLA-DRB1 profiles, the UCB units available at the Royan public UCB bank are a potentially adequate resource for hematopoietic stem cell transplantation for Iranian recipients belonging to particular ethnic groups. Regular educational programs to improve the public knowledge of UCB for transplantation can enhance the public CBB stocks for all Iranian ethnic groups in the future.

Molecular genetics research in ADHD: ethical considerations concerning patients' benefit and resource allocation

Immense resource allocations have led to great data output in genetic research. Concerning ADHD resources spent on genetic research are less than those spent on clinical research. But there are successful efforts made to increase support for molecular genetics research in ADHD. Concerning genetics no evidence based conclusive results have significant impact on prevention, diagnosis or treatment yet. With regard to ethical aspects like the patients' benefit and limited resources the question arises if it is indicated to think about a new balance of resource allocation between molecular genetics and non-genetics research in ADHD. An ethical reflection was performed focusing on recent genetic studies and reviews based on a selective literature search. There are plausible reasons why genetic research results in ADHD are somehow disappointing for clinical practice so far. Researchers try to overcome these gaps systematically, without knowing what the potential future benefits for the patients might be. Non-genetic diagnostic/therapeutic research may lead to clinically relevant findings within a shorter period of time. On the other hand, non-genetic research in ADHD may be nurtured by genetic approaches. But, with the latter there exist significant risks of harm like stigmatization and concerns regarding data protection. Isolated speeding up resources of genetic research in ADHD seems questionable from an ethical point of view. There is a need to find a new balance of resource allocation between genetic and non-genetic research in ADHD, probably by integrating genetics more systematically into clinical research. A transdisciplinary debate is recommended.