Assessing the global burden of hemorrhage: The global blood supply, deficits, and potential solutions

Development and Validation of a Risk Model to Predict Intraoperative Blood Transfusion

Importance

Crossmatched packed red blood cells (pRBC) that are not transfused result in significant waste of this scarce resource. Efficient utilization should be part of a patient blood management strategy.

Objective

To develop and validate a prediction model to identify surgical patients at high risk of intraoperative pRBC transfusion.

Design, Setting, and Participants

This prognostic study used hospital registry data from 2 quaternary hospital networks from January 2016 to June 2021 (development: Montefiore Medical Center [MMC], Bronx, New York), June 2021 to February 2023 (internal validation: MMC), and January 2008 to June 2022 (external validation: Beth Israel Deaconess Medical Center [BIDMC], Boston, Massachusetts). Participants were patients aged 18 years or older undergoing surgery.

Main Outcome and Measures

The outcome was intraoperative transfusion of 1 or more pRBC units. Based on a priori-defined candidate predictors, stepwise backward regression was applied to develop a computational model of independent predictors for intraoperative pRBC transfusion.

Results

The development and validation cohorts consisted of 816 618 patients (273 654 at MMC: mean [SD], age 57.5 [17.2] years; 161 481 [59.0%] female; 542 964 at BIDMC: mean [SD] age, 56.0 [17.1] years; 310 272 [57.1%] female). Overall, 18 662 patients (2.3%) received at least 1 unit of pRBC. The final model contained 24 preoperative predictors: nonambulatory surgery; American Society of Anesthesiologists physical status; international normalized ratio; redo surgery; emergency surgery or surgery outside of regular working hours; estimated surgical duration of at least 120 minutes; surgical complexity; liver disease; hypoalbuminemia; thrombocytopenia; mild, moderate, or severe anemia; and surgery type. The area under the receiver operating characteristic curve (AUC) was 0.93 (95% CI, 0.92-0.93), suggesting high predictive accuracy and generalizability. Positive predictive value (PPV) and negative predictive value (NPV) were 8.9% (95% CI, 8.7%-9.2%) and 99.7% (95% CI, 99.7%-99.7%), respectively, with increased predictive values for operations with a higher a priori risk of pRBC transfusion. The model's performance was confirmed in internal and external validation. The prediction tool outperformed the established Transfusion Risk Understanding Scoring Tool (AUC, 0.64 [0.63-0.64]; PPV, 2.6% [95% CI, 2.5%-2.6%]; NPV, 99.2% [95% CI, 99.1%-99.3%]) (P < .001) and was noninferior to 3 machine learning-derived scores.

Conclusions and Relevance

In this prognostic study of surgical patients, the Transfusion Forecast Utility for Surgical Events (TRANSFUSE) model for predicting intraoperative pRBC transfusion was developed and validated. The instrument can be used independently of machine learning infrastructure availability to inform preoperative pRBC orders and to minimize waste of nontransfused red blood cell units.

Understanding variations in the use of tranexamic acid in surgery: A qualitative interview study

Despite robust supporting evidence, around a third of eligible surgical patients do not receive tranexamic acid (TXA). Effective strategies based on an understanding of clinical behaviour are needed to increase use and improve patient outcomes. We conducted semi-structured interviews with clinicians involved in perioperative care to explore perceived influences on TXA use. We identified key influences on practice using the theoretical domains framework. We matched these to behaviour change techniques and evidence-informed implementation intervention components. Across 22 interviews, we identified eight key influences within three overarching themes of capability, opportunity and motivation. Capability influences included the clinical context and variable familiarity with TXA. Opportunity concerned the availability of both TXA and checklists to support decision-making and whether TXA use was consistent with professional expectations and perceived responsibilities. Motivation concerned confidence in administering TXA, perceived benefits and risks and training received around potential risk factors. These influences varied across participants and specialities. Our resulting proposed implementation strategy included training, clinical prompts, comparative performance feedback and opinion leadership supported by specialty-specific guidance. Any strategy to increase TXA use that improves knowledge and skills without addressing wider influences on clinical behaviour is only likely to meet with limited success.

A qualitative study of community perceptions and practices relating to blood donation in Cameroon

INTRODUCTION

Blood and blood products are essential for patients in need of transfusion therapy, especially those undergoing surgical procedures, childbirth and other injuries. In Cameroon, there is an annual deficit of over 270 000 pints of blood, with a coverage rate of only 17%. This qualitative study investigates the barriers and motivators to blood donation among Cameroonian adults, with the aim of better understanding community perceptions and practices.

METHODS

This ethnographic study was performed using a purposive sampling strategy. Focus group discussions and in-depth interviews were conducted with community members to understand perceptions and practices that serve as motivators and deterrents to blood donation in Yaoundé, Cameroon. Data were transcribed verbatim and analysed thematically to identify emerging themes.

RESULTS

A total of 25 Cameroonian adults were interviewed. Some participants believed that donating blood is: (1) a humanitarian and life-saving gesture, (2) an act of social and religious responsibility and (3) a means for donors to access health services. Some people do not want to donate blood due to: (1) fear of needles, donor-site pain or possible ritualistic use of donated blood, (2) certain religious beliefs, such as those held by Jehovah's Witnesses, (3) local and cultural beliefs, (4) the perception that blood donation is a commercial activity for many health personnel and (5) lack of transparency from health personnel. The practice of free and voluntary donation, as well as donations specifically to family and friends, was common. Occasionally, requests for financial remuneration prior to blood donation also emerged.

CONCLUSIONS

Community members displayed both favourable and unfavourable perceptions as well as both safe and risky practices related to blood donation. The positive aspects highlighted the potential for creating a supportive environment for blood donation, while the negative aspects presented the significant challenges facing the development of high-quality blood donation and transfusion services. Efforts to reduce apathy toward blood donation and expand the pool of regular, repeat donors must carefully address the diverse perceptions and practices identified in this study.

Evolving patterns of first blood product use in trauma in the era of hemorrhage control resuscitation

BACKGROUND

We reviewed trauma blood use at our US regional trauma center 2011-2022-including PROPPR trial participation 2012-2014 and initiation of whole blood availability in 2019-to assess the implementation of early coagulation support in acute trauma care.

STUDY DESIGN/METHODS

We identified all acute trauma patients recorded by our Trauma Registry as arriving at our large US regional Level 1 trauma center from April 6, 2011 (Blood Bank opening) through December 2022. Patient cohort data were then linked directly to Blood Bank final-product-issue date/time data to identify patients receiving any blood product in the first 24 h of care and then, specifically, at least one unit of Red Blood Cells (RBC), Plasma, or Whole Blood (WB). Results were binned as: "RBC first," "Plasma first," "Both at the same time," or "WB first."

RESULTS

Over the study period, 73,634 acute trauma patients received care, and 12,927 received at least one unit of a blood product. The proportion receiving plasma or a combination of plasma and RBCs as the initial transfusion increased after 2015 from 33% to 66%, while the proportion receiving packed RBCs alone decreased from 57% to about 18%. Since its introduction in 2019, the use of WB as the first product has grown to 20%.

CONCLUSIONS

This retrospective cohort study documents the increasing use of plasma and now WB as initial products issued in trauma resuscitation, reflecting acceptance of coagulation support as the standard of care and the use of hemostatic resuscitation protocols.

Evaluating estimated health care resource utilization and costs in patients with myelofibrosis based on transfusion status and anemia severity: A retrospective analysis of the Medicare Fee-For-Service claims data

BACKGROUND

Myelofibrosis (MF) is a rare but aggressive myeloproliferative neoplasm that commonly affects older patients, with a mean age of onset of older than 60 years. At least a third of patients with primary MF are anemic at diagnosis, and nearly all patients become anemic over time; approximately half require red blood cell transfusions within a year of diagnosis. Anemia and transfusion dependence are leading negative prognostic factors for overall survival and are associated with diminished quality of life and increased health care-related economic burden in patients with MF.

OBJECTIVE

To describe baseline characteristics, health care resource utilization (HCRU), and costs as a function of transfusion status and anemia severity in patients diagnosed with MF among the US Medicare Fee-For-Service (FFS) population.

METHODS

This retrospective cohort study included patients diagnosed with MF appearing in the 100% Medicare FFS database enrolled between January 1, 2012, and December 31, 2020. Patients were segmented into hemoglobin level cohorts (no, mild, moderate, and severe anemia) and transfusion status cohorts (transfusion independent [TI], transfusion requiring [TR], or transfusion dependent [TD]). Across cohorts, demographics and disease characteristics were assessed at baseline; per patient per month all-cause HCRU and medical and pharmacy costs were reported during follow-up. All results were summarized descriptively.

RESULTS

The transfusion status cohort (N = 1,749) included TI (n = 980), TR (n = 559), and TD (n = 210) patients; the anemia severity cohort (N = 365) included patients with no (n = 100), mild (n = 128), moderate (n = 99), and severe (n = 38) anemia. On average, TR and TD patients or those with moderate or severe anemia had numerically higher Deyo-Charlson Comorbidity Index scores than those who were TI or had mild or no anemia. TR and TD cohorts reported numerically greater all-cause outpatient, inpatient, and emergency department utilization vs the TI cohort. All-cause costs were numerically higher in the TD and TR cohorts vs the TI cohort ($14,655 and $14,249 vs $8,191). Incremental increases in HCRU and costs were also observed with increasing anemia severity. All-cause medical and pharmacy costs for no, mild, moderate, and severe anemia cohorts were $4,689, $7,268, $10,439, and $13,590, respectively.

CONCLUSIONS

This retrospective analysis of the US Medicare FFS database descriptively evaluated patients by transfusion status and anemia severity and showed that costs and HCRU were numerically lower for patients with transfusion independence compared with those with transfusion dependence. Similar trends were seen when comparing patients based on anemia status, with numerically lower HCRU and cost observed with decreasing anemia severity.

The utility of the prehospital shock index, age shock index, and modified shock index for predicting hypofibrinogenaemia in trauma patients: an observational retrospective study

PURPOSE

Reduced fibrinogen levels are associated with worse outcomes in bleeding trauma patients. The purpose of this study was to evaluate the potential of the prehospital shock index (SI) and its derivatives, the age shock index (aSI) and the modified shock index (mSI), as predictors of hypofibrinogenaemia in trauma patients.

METHODS

This retrospective study included 2383 patients who presented to a regional trauma center. We reviewed the plasma fibrinogen levels upon admission to the trauma center and patients were divided into two groups: the hypofibrinogenaemia group and the normal group. The predictive performances of the SI, aSI, and mSI were assessed by the area under the receiver operating characteristic curve (AUC).

RESULTS

Of the 2383 patients, 235 (9.9%) had hypofibrinogenaemia. Patients with hypofibrinogenaemia were more likely to receive transfusions within 4 h and had significantly greater in-hospital mortality than patients with normal fibrinogen levels. The AUCs of prehospital SI, prehospital aSI, and prehospital mSI for the prediction of hypofibrinogenaemia were 0.75 (95% confidence interval [CI] 0.73-0.77), 0.70 (95% CI 0.68-0.72), and 0.75 (95% CI 0.73-0.77), respectively.

CONCLUSION

Prehospital SI and prehospital mSI demonstrated moderate performance for identifying trauma patients with hypofibrinogenaemia. The prehospital aSI had poor predictive performance. In the prehospital setting, the use of prehospital SI or prehospital mSI as the sole predictor of hypofibrinogenaemia in trauma patients is not recommended.

Impact of the COVID-19 Pandemic on Blood Transfusion among Hospitalized Patients with Chronic Kidney Disease

Background and Objectives: Hematological disorders, especially chronic anemia and coagulation disorders, are common in patients with chronic kidney disease (CKD). Severe anemia is associated with increased cardiovascular morbidity and mortality in this special group of patients and is also responsible for decreased hope and quality of life. Despite the use of appropriate iron therapy and erythropoietin-stimulating agents, red blood cell transfusion is occasionally required, usually in the setting of acute bleeding or for correction of perioperative anemia. The COVID-19 pandemic has accelerated the progression of chronic diseases and worsened the outcomes for patients with nephrological conditions. As a precautionary measure against infections, patients' access to hospitalization for their procedures has been reduced and their chronic complications, including hematological abnormalities, have gotten out of control. Materials and Methods: Our retrospective observational study was designed to evaluate the impact of the COVID-19 pandemic on blood transfusion for the patients with chronic kidney disease hospitalized in our emergency county medical unit, over a period of four years (2019-2022) who were admitted or at least referred for evaluation to the Nephrology department. We also followed the measures adopted to ensure the necessary blood products during this time. Results: Between 2190-2022, a total of 24,096 hospitalized patients were transfused at the Emergency County Clinical Hospital in Constanta, Romania. Meanwhile, in the nephrology and other medical or surgical wards of our medical unit, 1590 CKD patients were transfused with different blood derivatives. During the pandemic years, as expected, the number of transfused patients and transfused blood units decreased by 4% and 7%, respectively, in comparison with the pre-pandemic year, 2019. Unlike the general trend of transfusion activity, more patients with CKD transfused in 2022 (580) than before the pandemic (414 in 2019), and the number of blood units was higher in 2022 than in 2019 for red blood products and plasma. Between 2020-2022, from the total number of transfused patients in our study, 254 with CKD patients (16%) and 798 non-CKD (4%) died in-hospital. Conclusions: The adaptive strategies implemented to ensure the necessary blood products in the hospital during the COVID-19 pandemic mainly included restrictive transfusion and limitation of elective surgical procedures. The subject matter of the article is important as blood shortages are a problem that healthcare workers may encounter in future pandemics.

Prevalence of Transfusion-Transmissible Infections Among Voluntary Blood Donors in a Tertiary Care Hospital

Background Transfusion-transmissible infections (TTIs) pose a significant risk to blood transfusion safety, especially in low-resource settings. TTIs include infections such as HIV, hepatitis B virus (HBV), hepatitis C virus (HCV), syphilis, and malaria. Over four years, this study assesses the seroprevalence of TTIs among voluntary blood donors at a tertiary care center. Materials and methods This retrospective observational study was conducted at the blood bank of a tertiary care center from June 2019 to December 2022. A total of 4639 voluntary blood donors were screened for TTIs, including HIV, HBV, HCV, syphilis, and malaria, using third-generation enzyme-linked immunosorbent assay (ELISA) kits and rapid diagnostic tests. The data were analyzed to evaluate the seroprevalence of each infection and its trends over the study period. Results The overall prevalence of TTIs among the 4639 donors was 68 (1.46%). The highest seroprevalence was observed for HBV, with 33 (0.71%), followed by syphilis with 22 (0.47%), HIV with nine (0.19%), and HCV with four (0.08%). No cases of malaria were detected. The prevalence of TTIs was highest in 2021, with the seroprevalence of HBV peaking at 15 (1.14%). Male donors accounted for 4412 (98%) of all donations, and the prevalence of TTIs was significantly higher among males than females. Conclusion The study highlights the importance of continuous surveillance and screening for TTIs among blood donors to ensure transfusion safety. The higher seroprevalence of HBV underscores the need for effective vaccination programs, and the disparity in gender distribution calls for strategies to encourage female blood donations. TTIs remain a public health concern, necessitating improved donor screening and public awareness.

Expired blood transfusion and mortality outcomes in combat trauma patients

BACKGROUND

Expired blood can be transfused if clinically indicated but outcome data do not exist. We hypothesized that modestly outdated blood can effectively support a hemorrhaging patient until surgical control is achieved. This study assessed whether expired blood was associated with mortality in combat trauma patients.

STUDY DESIGN AND METHODS

A retrospective analysis of Armed Services Blood Program and Department of Defense Trauma Registry databases evaluated combat casualty records (2001-2023). The intervention of interest was transfusion of at least one unit of whole blood (WB), red blood cells (RBC), or platelets within one week past expiration. The outcome of interest was mortality at discharge. A control cohort that only received in-date blood was matched to the treatment cohort for logistic regression analysis.

RESULTS

One hundred patients received expired RBCs (86), WB (11), and platelets (3). Mortality at discharge was 11.6% for expired RBC recipients and 13.4% for the control cohort (p = .97). After adjustment for injury severity, expired RBCs were not associated with mortality (OR = 0.40 [95% CI, 0.14-1.16]; p = .09). Of 10 patients who received the most expired RBCs by volume or storage duration, two were deceased at discharge. All 14 expired WB and platelet recipients were alive at discharge, but sample sizes were underpowered for regression analysis.

DISCUSSION

Transfusion of modestly outdated RBCs was not associated with mortality in combat trauma patients. Expired WB and platelet recipients did well, but sample sizes were too small to draw significant conclusions. Expired blood should be further investigated for possible use in extenuating circumstances.

Transfusion-related cost offsets and time burden in patients with myelofibrosis on momelotinib vs. danazol from MOMENTUM

Aim: To estimate projected US-based cost and time burden for patients with myelofibrosis and anemia treated with momelotinib compared with danazol.Methods: Cost and time burden were calculated based on the transfusion status of patients in the MOMENTUM trial and estimates extracted from previous studies.Results: Reductions in transfusion associated with momelotinib are projected to result in cost and time savings compared with danazol in transfusion-dependent and transfusion-independent/requiring patients with myelofibrosis, respectively: annual medical costs ($53,143 and $46,455 per person), outpatient transfusion costs ($42,021 and $8,370 per person) and annual time savings (173 and 35 h per person).Conclusion: Fewer transfusions with momelotinib are projected to result in cost and time savings in patients with myelofibrosis and anemia compared with danazol.

The future of blood services amid a tight balance between the supply and demand of blood products: Perspectives from the ISBT Young Professional Council

BACKGROUND AND OBJECTIVES

Blood services manage the increasingly tight balance between the supply and demand of blood products, and their role in health research is expanding. This review explores the themes that may define the future of blood banking.

MATERIALS AND METHODS

We reviewed the PubMed database for articles on emerging/new blood-derived products and the utilization of blood donors in health research.

RESULTS

In high-income countries (HICs), blood services may consider offering these products: whole blood, cold-stored platelets, synthetic blood components, convalescent plasma, lyophilized plasma and cryopreserved/lyophilized platelets. Many low- and middle-income countries (LMICs) aim to establish a pool of volunteer, non-remunerated blood donors and wean themselves off family replacement donors; and many HICs are relaxing the deferral criteria targeting racial and sexual minorities. Blood services in HICs could achieve plasma self-sufficiency by building plasma-dedicated centres, in collaboration with the private sector. Lastly, blood services should expand their involvement in health research by establishing donor cohorts, conducting serosurveys, studying non-infectious diseases and participating in clinical trials.

CONCLUSION

This article provides a vision of the future for blood services. The introduction of some of these changes will be slower in LMICs, where addressing key operational challenges will likely be prioritized.

Mitigating the impact of blood shortages in England

The supply of blood components and products in sufficient quantities is key to any effective health care system. This report describes the challenges faced by the English blood service, NHS Blood and Transplant (NHSBT), towards the end of the COVID-19 pandemic, which in October 2022 led to an Amber Alert being declared to hospitals indicating an impending blood shortage. The impact on the hospital transfusion services and clinical users is explained. The actions taken by NHSBT to mitigate the blood supply challenges and ensure equity of transfusion support for hospitals in England including revisions to the national blood shortage plans are described. This report focuses on the collaboration and communication between NHSBT, NHS England (NHSE), Department of Health and Social Care (DHSC), National Blood Transfusion Committee (NBTC), National Transfusion Laboratory Managers Advisory Group for NBTC (NTLM), National Transfusion Practitioners Network, the medical Royal Colleges and clinical colleagues across the NHS.

Association of freeze-dried plasma with 24-h mortality among trauma patients at risk for hemorrhage

BACKGROUND

Blood products form the cornerstone of contemporary hemorrhage control but are limited resources. Freeze-dried plasma (FDP), which contains coagulation factors, is a promising adjunct in hemostatic resuscitation. We explore the association between FDP alone or in combination with other blood products on 24-h mortality.

STUDY DESIGN AND METHODS

This is a secondary data analysis from a cross-sectional prospective observational multicenter study of adult trauma patients in the Western Cape of South Africa. We compare mortality among trauma patients at risk of hemorrhage in three treatment groups: Blood Products only, FDP + Blood Products, and FDP only. We apply inverse probability of treatment weighting and fit a multivariable Cox proportional hazards model to assess the hazard of 24-h mortality.

RESULTS

Four hundred and forty-eight patients were included, and 55 (12.2%) died within 24 h of hospital arrival. Compared to the Blood Products only group, we found no difference in 24-h mortality for the FDP + Blood Product group (p = .40) and a lower hazard of death for the FDP only group (hazard = 0.38; 95% CI, 0.15-1.00; p = .05). However, sensitivity analyses showed no difference in 24-h mortality across treatments in subgroups with moderate and severe shock, early blood product administration, and accounting for immortal time bias.

CONCLUSION

We found insufficient evidence to conclude there is a difference in relative 24-h mortality among trauma patients at risk for hemorrhage who received FDP alone, blood products alone, or blood products with FDP. There may be an adjunctive role for FDP in hemorrhagic shock resuscitation in settings with significantly restricted access to blood products.

Innovative blood transfusion strategies to address global blood deserts: a consensus statement from the Blood Delivery via Emerging Strategies for Emergency Remote Transfusion (Blood DESERT) Coalition

In rural settings worldwide, many people live in effective blood deserts without access to any blood transfusion. The traditional system of blood banking is logistically complex and expensive for many resource-restricted settings and demands innovative and multidisciplinary solutions. 17 international experts in medicine, industry, and policy participated in an exploratory process with a 2-day hybrid seminar centred on three promising innovative strategies for blood transfusions in blood deserts: civilian walking blood banks, intraoperative autotransfusion, and drone-based blood delivery. Participant working groups conducted literature reviews and interviews to develop three white papers focused on the current state and knowledge gaps of each innovation. Seminar discussion focused on defining blood deserts and developing innovation-specific implementation agendas with key research and policy priorities for future work. Moving forward, advocates should prioritise the identification of blood deserts and address the context-specific challenges for these innovations to alleviate the ongoing crisis in blood deserts.

Impact of COVID-19 on intrapartum care at public hospitals in the Sidama region, Ethiopia: A mixed-methods study

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic has significantly impacted the health of pregnant women and their unborn babies.

OBJECTIVE

To explore the impact of COVID-19 on intrapartum care in Ethiopia.

DESIGN

A concurrent mixed-methods design was employed.

METHODS

An interrupted time series analysis was implemented using a Poisson regression model to estimate monthly changes in the incidence rates of institutional childbirth, instrumental vaginal birth, caesarean section, stillbirth, institutional neonatal death, institutional maternal death and availability of essential medical supplies before and during COVID-19. The dataset included data from all women who gave birth in 15 public hospitals, and the total number of childbirths in the cohort study before COVID-19 (12 months of data from March 2019 to February 2020) was 24,478, while during COVID-19 (6 months of data from March to August 2020), the total number of childbirths in the cohort study was 11,966, forming a combined final dataset of 36,444. Simultaneously, a descriptive qualitative study using a purposive sampling technique was conducted through in-depth interviews until data saturation was reached, with data were collected from 14 February to 10 May 2022. Data from the interviews were imported into NVivo 12 Plus to perform an inductive thematic analysis. Quantitative and qualitative data were integrated using joint display methods to identify corroboration or contradiction between the different forms of evidence.

RESULTS

Our findings indicate that the incidence rates of caesarean sections and instrumental vaginal births significantly increased in the first 6 months of COVID-19. Three themes were identified: 'Barriers to providing intrapartum care during COVID-19', 'Delays to provision of intrapartum care during COVID-19' and 'Inadequate COVID-19 preventive measures'.

CONCLUSION

In combination, the three themes contributed to a considerable increase in neonatal and maternal deaths. Interventions such as fully equipped labour wards and obstetric triage systems are needed to restore disrupted maternal and perinatal care during the ongoing and future pandemics. In addition, stakeholders should inform the public that blood donations can help the community recover from recent shocks in emergency health and future pandemics. Further research should investigate the long-term impact of COVID-19 on maternity care and maternal and infant outcomes.

Novel GH109 enzymes for bioconversion of group A red blood cells to the universal donor group O

Glycoside hydrolases (GHs) have been employed for industrial and biotechnological purposes and often play an important role in new applications. The red blood cell (RBC) antigen system depends on the composition of oligosaccharides on the surface of erythrocytes, thus defining the ABO blood type classification. Incorrect blood transfusions may lead to fatal consequences, making the availability of the correct blood group critical. In this regard, it has been demonstrated that some GHs may be helpful in the conversion of groups A and B blood types to produce group O universal donor blood. GHs belonging to the GH109 family are of particular interest for this application due to their ability to convert blood from group A to group O. This work describes the biochemical characterisation of three novel GH109 enzymes (NAg68, NAg69 and NAg71) and the exploration of their ability to produce enzymatically converted RBCs (ECO-RBC). The three enzymes showed superior specificity on pNP-α-N-acetylgalactosamine compared to previously reported GH109 enzymes. These novel enzymes were able to act on purified antigen-A trisaccharides and produce ECO-RBC from human donor blood. NAg71 converted type A RBC to group O with increased efficiency in the presence of dextran compared to a commercially available GH109, previously used for this application.

The Effect of Prehospital Clinical Trial-Related Procedures on Scene Interval, Cognitive Load, and Error: A Randomized Simulation Study

INTRODUCTION

Globally, very few settings have undertaken prehospital randomized controlled trials. Given this lack of experience, there is a risk that such trials in these settings may result in protocol deviations, increased prehospital intervals, and increased cognitive load, leading to error. Ultimately, this may affect patient safety and mortality. The aim of this study was to assess the effect of trial-related procedures on simulated scene interval, self-reported cognitive load, medical errors, and time to action.

METHODS

This was a prospective simulation study. Using a cross-over design, ten teams of prehospital clinicians were allocated to three separate simulation arms in a random order. Simulations were: (1) Eligibility assessment and administration of freeze-dried plasma (FDP) and a hemoglobin-based oxygen carrier (HBOC), (2) Eligibility assessment and administration of HBOC, (3) Eligibility assessment and standard care. All simulations also required clinical management of hemorrhagic shock. Simulated scene interval, error rates, cognitive load (measured by NASA Task Load Index), and competency in clinical care (assessed using the Simulation Assessment Tool Limiting Assessment Bias (SATLAB)) were measured. Mean differences between simulations with and without trial-related procedures were sought using one-way ANOVA or Kruskal-Wallis test. A p-value of <0.05 within the 95% confidence interval was considered significant.

RESULTS

Thirty simulations were undertaken, representing our powered sample size. The mean scene intervals were 00:16:56 for Simulation 1 (FDP and HBOC), 00:17:22 for Simulation 2 (HBOC only), and 00:14:24 for Simulation 3 (standard care). Scene interval did not differ between the groups (p = 0.27). There were also no significant differences in error rates (p = 0.28) or cognitive load (p = 0.67) between the simulation groups. There was no correlation between cognitive load and error rates (r = 0.15, p = 0.42). Competency was achieved in all the assessment criteria for all simulation groups.

CONCLUSION

In a simulated environment, eligibility screening, performance of trial-related procedures, and clinical management of patients with hemorrhagic shock can be completed competently by prehospital advanced life support clinicians without delaying transport or emergency care. Future prehospital clinical trials may use a similar approach to help ensure graded and cautious implementation of clinical trial procedures into prehospital emergency care systems.

Protocol: identifying policy, system, and environment change interventions to enhance availability of blood for transfusion in Kenya, a mixed-methods study

BACKGROUND

Safe blood is essential for the care of patients with life-threatening anemia and hemorrhage. Low blood donation rates, inefficient testing procedures, and other supply chain disruptions in blood administration affect patients in low-resource settings across Sub-Saharan countries, including Kenya. Most efforts to improve access to transfusion have been unidimensional, usually focusing on only point along the blood system continuum, and have excluded community stakeholders from early stages of intervention development. Context-appropriate interventions to improve the availability of safe blood at the point of use in low-resource settings are of paramount importance. Thus, this protocol proposes a multifaceted approach to characterize the Kenyan blood supply chain through quantitative and qualitative analyses as well as an industrial engineering approach.

METHODS

This study will use a mixed-methods approach in addition to engineering process mapping, modeling and simulation of blood availability in Kenya. It will be guided by a multidimensional three-by-three-by-three matrix: three socioeconomic settings, three components of the blood system continuum, and three levels of urgency of blood transfusion. Qualitative data collection includes one-on-one interviews and focus group discussions with stakeholders across the continuum to characterize ground-level deficits and potential policy, systems, and environment (PSE) interventions. Prospectively-collected quantitative data will be used to estimate blood collection and transfusion of blood. We will create a process map of the blood system continuum to model the response to PSE changes proposed by stakeholders. Lastly, we will identify those PSE changes that may have the greatest impact on blood transfusion availability, accounting for differences across socioeconomic settings and levels of urgency.

DISCUSSION

Identifying and prioritizing community-driven interventions to improve blood supply in low-resource settings are of utmost importance. Varied constraints in blood collection, processing, delivery, and use make each socioeconomic setting unique. Using a multifaceted approach to understand the Kenyan blood supply and model the response to stakeholder-proposed PSE changes may lead to identification of contextually appropriate intervention targets to meet the transfusion needs of the population.

Challenges and opportunities in prostate cancer surgery in South America: Insights into robot-assisted radical prostatectomies-A perspective

Background and Aims

Prostate cancer imposes a significant health burden, particularly in South America with its high incidence and mortality rates. This article explores the emergence of robot-assisted radical prostatectomy (RARP) as a potential solution in the region.

Methods

This study relies on a comprehensive review of relevant literature. The analysis highlights the advantages of RARP, identifies impediments to its implementation, and proposes strategies to overcome these barriers.

Results

RARP demonstrates notable benefits, including improved functional outcomes, reduced complications, and minimized incisions. However, the integration of RARP in South America is hindered by challenges such as regional disparities, financial limitations, and data gaps. Limited healthcare infrastructure and a scarcity of skilled professionals further compound the issues.

Conclusion

Despite its potential, RARP faces obstacles to widespread adoption in South America. Strategic solutions encompassing technology investment, healthcare infrastructure enhancement, and workforce training are imperative. Overcoming these challenges can establish RARP as a crucial tool in managing prostate cancer in the region, ultimately enhancing patient care and treatment outcomes.

Ethics in transfusion medicine: Are the intricate layers of ethics all universal? A global view

Ethical principles have been considered, and in several respects regulated, along the entire blood procurement chain from donor motivation to transfusion to the patient. Consent of donors and voluntary non-remunerated donation are fields which have been addressed by codes of ethics and legislation. Caring for donor health is an area of further development of ethical standards. In part, blood products have also become a market, where commercial principles may synergize, but also creating issues in equality and maintaining human dignity that challenge societal solutions. At the bedside, the main global challenge remains to procure enough blood products for each patient in medical need. Allocation of rare blood, ethical evaluation of transfusion triggers, attitudes towards refusing blood transfusion and provision of blood products to remote settings are areas which should receive consideration.

Blood donation practice and its predictors among undergraduate college students in Harari Regional State, Eastern Ethiopia

Objectives

The main objective of this study was to assess blood donation practice and its associated factors among undergraduate college students in Harari Region, Eastern Ethiopia.

Methods

An institutional-based cross-sectional study was employed among 518 college students selected by using a simple random sampling technique. Data was collected using pretested structured self-administered questionnaire. The collected data was entered into Epi-data 3.41 and exported to Statistical Package for Social Science version 22 for analysis. Bivariate and multivariable logistic regressions were utilized to identify factors associated with blood donation practice. p-Values of 0.05 or less was used to declare statistical significance.

Results

In this study, the overall blood donation practice was 35.7% (95% confidence interval: 31.6, 39.8). Students studying health sciences were more likely than non-health sciences students (53.5%) to donate blood. Having positive knowledge about blood donation (adjusted odds ratio = 4.17; 95% confidence interval: 2.50, 6.92), being male (adjusted odds ratio = 0.57; 95% confidence interval: 0.38, 0.87), being student of midwifery department (adjusted odds ratio = 2.16; 95% confidence interval: 1.07, 4.36) and nursing department (adjusted odds ratio = 2.42; 95% confidence interval: 1.18, 4.98) were significantly associated with blood donation practice.

Conclusion

Practice of blood donation among college students in the study is relatively low. Knowledge about blood donation, male sex and being a nursing and midwifery student were independently associated with blood donation practice. Therefore, the Regional Health Bureau and Blood Bank in collaboration with college administrators should design and implement appropriate strategies to improve blood donation practice.

The BLOODSAFE program: Building the future of access to safe blood in Sub-Saharan Africa

BACKGROUND

The supply of blood in many low- and middle-income nations in Sub-Saharan Africa (SSA) does not meet the patient care needs. Lack and delay of blood transfusion cause harm to patients and slow the rate of progress in other parts of the health system. Recognizing the power of implementation science, the BLOODSAFE Program was initiated which supports three SSA research study teams and one data coordinating center (DCC) with the goal to improve access to safe blood transfusion in SSA.

STUDY DESIGN AND METHODS

The study team in Ghana is focusing on studying and decreasing iron deficiency in blood donors and evaluating social engagement of blood donors through different approaches. The study team in Kenya is building a "vein to vein" workflow model to elucidate and devise strategies to overcome barriers to blood donation and improve infrastructural components of blood product production and use. The Malawi team is studying the infectious disease ramifications of blood donation as well as blood donor retention strategies aimed at blood donors who commence their donation career in secondary schools.

RESULTS AND DISCUSSION

Together the project teams and the DCC work as a consortium to support each other through a shared study protocol that will study donor motivations, outcomes, and adverse events across all three countries. The BLOODSAFE Program has the potential to lead to generalizable improvement approaches for increasing access to safe blood in SSA as well as mentoring and building the research capacity and careers of many investigators.

Intraoperative cell salvage as an effective intervention for postpartum hemorrhage—Evidence from a prospective randomized controlled trial

Background

Postpartum hemorrhage (PPH) is one of the leading causes of maternal mortality. Promptly recovering blood loss is critical for PPH. Intraoperative cell salvage (ICS) is a method to collect and process red blood cells (RBCs) from the blood lost during surgery and transfuse them to the patient’s circulation during or immediately after surgery. Its effectiveness in reducing the demand for allogeneic blood transfusion has been proven, but its effectiveness and safety as a sole treatment for PPH during Cesarean sections are unclear. This is particularly important for patients who cannot or do not want to accept allogeneic blood transfusion.

Materials and methods

In this prospective randomized controlled study, patients with high risks of PPH were randomized into the ICS group or the control group, receiving ICS or allogeneic RBC transfusion if their hemoglobin level was less than 80 g/L during operation. Data collected include clinical examination, blood cell count, hemoglobin level, coagulation function, and plasma levels of fetal hemoglobin, tissue factor, and alpha-fetoprotein before and after fetal delivery and 0, 2, and 12 h after treatment. Adverse events were recorded.

Results

A total of 130 patients were enrolled, aged 33 ± 1 years with a mean gestation period of 37 ± 1 week. The most common cause of Cesarean section was placenta previa, followed by twin pregnancy, scarred uterus, preeclampsia, placental abruption, fetal distress, and placenta accreta spectrum. Bleeding amount was similar between the two groups. The ICS group, compared to controls, had more efficient increases in levels of hemoglobin, RBC, and hematocrit (all p < 0.05). Coagulation function was maintained in the ICS group but reduced in controls 24 h after transfusion, indicated by significantly reduced fibrinogen level and prolonged prothrombin time (PT), thrombin time (TT), and activated partial thromboplastin time (aPTT) (all p < 0.05). There was a transient but significant decrease in plasma tissue factor and alpha-fetoprotein levels and an increase in plasma fetal hemoglobin level with ICS treatment in the postpartum period. No adverse event occurred with ICS intervention.

Conclusion

ICS is an effective and safe intervention for patients with a high risk of PPH during elective or emergency Cesarean section. It can effectively clear tissue factors and alpha-fetoprotein but not fetal hemoglobin.

Meeting demand—Obstetric hemorrhage and blood availability in Malawi, a qualitative study

Background

Postpartum haemorrhage (PPH) is the leading cause of maternal mortality in Malawi. Despite the presence of a centralized institution supplying blood and blood products for hospitals across the country, a lack of timely blood transfusion has been identified as a critical barrier to successful PPH management. This study aims to understand the factors that affect the blood delivery pipeline and adequate access to blood products for postpartum haemorrhage patients.

Methods

Qualitative data were collected through in-depth interviews with key stakeholders across the blood delivery pipeline. Interviews were conducted from July 2020 to January 2021 at Queen Elizabeth Central Hospital and Mulanje District Hospital, a referral and district hospital respectively, as well as the Malawi Blood Transfusion Service. Line by line, open coding was used to perform a thematic analysis of the data using Nvivo and Atlas.ti software.

Results

Five key themes were identified: 1) Lack of blood availability due to an inadequate donor pool, 2) Transportation of blood products and PPH patients is impeded by distance to target sites and competing interests for blood delivery vehicles, 3) The Malawi Blood Transfusion Service has difficulty meeting demand for blood products due to inadequate funding and difficulty retaining blood donors, 4) Current PPH management protocols and practices lead to delays due to inconsistent guidelines on delivery and analysis of patient samples, and 5) Communication between health cadres is inconsistent and affected by a lack of adequate resources.

Conclusions

Barriers to timely blood transfusion for PPH patients exist across the blood delivery pipeline. While an investment of infrastructure would alleviate many obstacles, several solutions identified in this study can be implemented without additional resources, such as establishing joint department meetings to improve communication between health cadres. Ultimately, given a resource limited setting, it may be worth considering de-centralizing the blood supply.