Obstetric and Newborn Weak D-Phenotype RBC Testing and Rh Immune Globulin Management Recommendations: Lessons From a Blinded Specimen-Testing Survey of 81 Transfusion Services

CONTEXT.—

Modern RHD genotyping can be used to determine when patients with serologic weak D phenotypes have RHD gene variants at risk for anti-D alloimmunization. However, serologic testing, RhD interpretations, and laboratory management of these patients are quite variable.

OBJECTIVE.—

To obtain interlaboratory comparisons of serologic testing, RhD interpretations, Rh immune globulin (RhIG) management, fetomaternal hemorrhage testing, and RHD genotyping for weak D-reactive specimens.

DESIGN.—

We devised an educational exercise in which 81 transfusion services supporting obstetrics performed tube-method RhD typing on 2 unknown red blood cell challenge specimens identified as (1) maternal and (2) newborn. Both specimens were from the same weak D-reactive donor. The exercise revealed how participants responded to these different clinical situations.

RESULTS.—

Of reporting laboratories, 14% (11 of 80) obtained discrepant immediate-spin reactions on the 2 specimens. Nine different reporting terms were used to interpret weak D-reactive maternal RhD types to obstetricians. In laboratories obtaining negative maternal immediate-spin reactions, 28% (16 of 57) performed unwarranted antiglobulin testing, sometimes leading to recommendations against giving RhIG. To screen for excess fetomaternal hemorrhage after a weak D-reactive newborn, 47% (34 of 73) of reporting laboratories would have employed a contraindicated fetal rosette test, risking false-negative results and inadequate RhIG coverage. Sixty percent (44 of 73) of laboratories would obtain RHD genotyping in some or all cases.

CONCLUSIONS.—

For obstetric and neonatal patients with serologic weak D phenotypes, we found several critical problems in transfusion service laboratory practices. We provide recommendations for appropriate testing, consistent immunohematologic terminology, and RHD genotype-guided management of Rh immune globulin therapy and RBC transfusions.

The role of therapeutic plasma exchange in clinically amyopathic dermatomyositis with MDA-5 antibody: A case report and review of the literature

Clinically amyopathic dermatomyositis (CADM) is a rare, aggressive variant of dermatomyositis associated with interstitial lung disease (ILD) and refractoriness to immunosuppressants. Antibodies against melanoma differentiation-associated gene 5 (MDA-5) are often found in patients with CADM. We report a patient with advanced CADM with ILD and MDA-5 antibodies who failed to improve with immunosuppressants. We performed 2 TPE over 3 days, using 5% albumin as replacement fluid. Although five total TPE were planned, he was transferred for lung transplant evaluation after the second TPE; he died 16 days after transfer without receiving a transplant. A literature review identified four patients with CADM and MDA-5 antibodies treated with TPE; all experienced symptomatic improvement of their ILD. We attribute our patient's outcome to the advanced nature of his disease rather than a failure of TPE. Additional research may indicate a possible reclassification of CADM with MDA-5 antibodies in future ASFA guidelines.

Correlating Transfusion Medicine In-Service Examination Scores With Outcomes of the American Board of Pathology Transfusion Medicine Subspecialty Certifying Examination

OBJECTIVES

The Transfusion Medicine In-Service Examination (TMISE) is offered twice a year to transfusion medicine (TM) fellows. We examined the relationship between TMISE scores and outcomes of the American Board of Pathology (ABP) TM subspecialty certifying examination (TM boards).

METHODS

TM fellowship programs were contacted to provide anonymous data about TM fellows, their scores on TMISE, and outcome of TM boards.

RESULTS

Of 48 TM fellowship programs contacted, 24 (50%) responded with data for 170 fellows. Average TMISE score of fellows who passed their first TM boards attempt was 71.3, while the average TMISE score of fellows who failed their first TM boards attempt was 64.3 (P = .009).

CONCLUSIONS

TMISE scores correlated with passing TM boards on the first attempt. Fellows who took the TM boards the same year that they graduated from TM fellowship had a significantly higher first-time pass rate than fellows who delayed taking TM boards.

Dilution is not the solution: acute hemolytic transfusion reaction after ABO-incompatible pooled platelet transfusion

The short shelf life of platelets makes providing ABO-compatible platelets a challenge, and many institutions issue ABO-incompatible platelets when compatible units are not available. It is presumed that ABO antibodies that exist in donor plasma are diluted when platelets from multiple donors are combined to make a pooled product for transfusion. We present a case of a hemolytic transfusion reaction in a 73-year-old man with myelodysplastic syndrome who received an ABO-incompatible pooled platelet unit. This case report demonstrates that the dilution theory is not always true for pooled platelet units, and any patient receiving ABO-incompatible platelet transfusions must be closely monitored for potential hemolytic transfusion reactions.

Statistical Literacy Among Academic Pathologists: A Survey Study to Gauge Knowledge of Frequently Used Statistical Tests Among Trainees and Faculty

Context.—Statistical literacy can be defined as understanding the statistical tests and terminology needed for the design, analysis, and conclusions of original research or laboratory testing. Little is known about the statistical literacy of clinical or anatomic pathologists.

Objective.—To determine the statistical methods most commonly used in pathology studies from the literature and to assess familiarity and knowledge level of these statistical tests by pathology residents and practicing pathologists.

Design.—The most frequently used statistical methods were determined by a review of 1100 research articles published in 11 pathology journals during 2015. Familiarity with statistical methods was determined by a survey of pathology trainees and practicing pathologists at 9 academic institutions in which pathologists were asked to rate their knowledge of the methods identified by the focused review of the literature.

Results.—We identified 18 statistical tests that appear frequently in published pathology studies. On average, pathologists reported a knowledge level between “no knowledge” and “basic knowledge” of most statistical tests. Knowledge of tests was higher for more frequently used tests. Greater statistical knowledge was associated with a focus on clinical pathology versus anatomic pathology, having had a statistics course, having an advanced degree other than an MD degree, and publishing research. Statistical knowledge was not associated with length of pathology practice.

Conclusions.—An audit of pathology literature reveals that knowledge of about 12 statistical tests would be sufficient to provide statistical literacy for pathologists. On average, most pathologists report they can interpret commonly used tests but are unable to perform them. Most pathologists indicated that they would benefit from additional statistical training.

Medical and ethical challenges in the case of a prenatally undiagnosed massive congenital brain tumor

Fetal and neonatal brain tumors are rare. Prenatal ultrasound aids early tumor detection. Nonetheless, we encountered a preterm neonate born at 32 weeks gestation with a massive supratentorial glioma, which was undetected on ultrasound at 19-6/7 weeks gestation. The patient presented at birth with unanticipated massive macrocephaly. Resuscitation and stabilization were difficult, but the medical team felt that futility of care was not established and opted to transfer the baby to an academic center for further imaging and specialist consultations. Diagnosis of an extensive, inoperable tumor was confirmed and support withdrawn. Postmortem histologic examination and immunohistochemical stains identified the majority of tumor cells as glial in origin. This case report illustrates well how a severe and potentially fatal anomaly, which remained undetected prenatally, presented the medical team and family with multiple medical, ethical and emotional challenges at birth; decisions regarding futility of care in the neonatal transport setting are difficult.

Transfusion-related acute lung injury in an era of TRALI risk mitigation

Transfusion-related acute lung injury (TRALI) is a rare complication of transfusion, for which the true incidence remains obscure, since there are a number of factors that may lead to misdiagnosis. Despite this, it continues to be the leading cause of transfusion-associated mortality. Here we present a historical case of TRALI in an elderly female who received group AB plasma and discuss how current mitigation strategies would likely have prevented its occurrence. It is important to remember that both immune and non-immune factors play a role in TRALI pathogenesis, and although current preventative strategies may decrease TRALI's incidence, they likely will not eliminate it.

Transfusion medicine on American television

BACKGROUND

Television is a beloved American pastime and a frequent American export. As such, American television shapes how the global public views the world.

OBJECTIVES

This study examines how the portrayal of blood transfusion and blood donation on American television may influence how domestic and international audiences perceive the field of transfusion medicine.

MATERIALS AND METHODS

American television programming of the last quarter-century was reviewed to identify programmes featuring topics related to blood banking/transfusion medicine. The included television episodes were identified through various sources.

RESULTS

Twenty-seven television episodes airing between 1991 and 2013 were identified as featuring blood bank/transfusion medicine topics. Although some accurate representations of the field were identified, most television programmes portrayed blood banking/transfusion medicine inaccurately.

CONCLUSION

The way in which blood banking/transfusion medicine is portrayed on American television may assist clinicians in understanding their patient's concerns about blood safety and guide blood collection organisations in improving donor recruitment.

Pulse granuloma involving Meckel's diverticulum: a case report and literature review

Pulse granuloma is a rare, benign entity that most likely represents a reaction to vegetable material and is characterized by hyaline rings and foreign-body giant cells. We report a case of a pulse granuloma involving Meckel's diverticulum. The patient presented with abdominal pain and radiological findings consistent with Meckel's diverticulum. Microscopic examination of the resected tissue confirmed diagnosis of Meckel's diverticulum with small bowel mucosa. Peridiverticular foreign-body giant cells, hyaline rings and circular structures containing calcified basophilic granules were also identified, consistent with pulse granuloma. Pulse granulomas have been reported in a variety of locations, most commonly in the oral cavity. To the best of our knowledge, this is the first reported example of pulse granuloma in Meckel's diverticulum. Familiarity with pulse granuloma allows for the timely and accurate diagnosis of this entity, particularly in sites not previously described in the literature.

Conversion to low transfusion-related acute lung injury (TRALI)-risk plasma significantly reduces TRALI

BACKGROUND

Transfusion-related acute lung injury (TRALI) is an uncommon but serious transfusion reaction. Studies have shown that the transfusion of HLA and HNA antibodies in donor plasma can lead to TRALI. Female donors are more likely to have such antibodies due to alloantigen exposure during pregnancy. Many blood suppliers have now implemented various TRALI risk reduction strategies to unknown effect. A retrospective analysis of TRALI reactions in plasma recipients before and after the conversion to low-TRALI-risk plasma (all-male donor plasma, male-predominant plasma, nulliparous female plasma, and HLA antibody-tested plasma) is reported.

STUDY DESIGN AND METHODS

Transfusion reaction reports at three large hospitals 16 months before and 16 months after the conversion to low-TRALI-risk plasma were analyzed. Respiratory reactions were categorized as TRALI, possible TRALI, or other (e.g., transfusion-associated circulatory overload or allergic reactions). Reactions were reported as a percentage of total units transfused and rates for the two time periods were compared. Trends in reaction rates for other components were also compared.

RESULTS

A total of 2156 transfusion reactions in association with 461,598 transfused blood components were reviewed. The incidence of combined TRALI or possible TRALI reactions, due to the transfusion of plasma, decreased from 0.0084% to zero (p = 0.052). The rate of TRALI or possible TRALI reactions in red blood cell and platelet recipients did not change significantly.

CONCLUSION

The conversion to low-TRALI-risk plasma has reduced the incidence of TRALI reactions in plasma recipients.

Autoimmune hepatitis in patients with primary Sjögren's syndrome: a series of two-hundred and two patients

Based on the revised criteria of the American-European Consensus Group, we retrospectively established the diagnosis of primary or secondary Sjögren's syndrome for 202 patients referred to a Sjögren's syndrome clinic. Of these, 58 patients and 8 patients fulfilled criteria for primary and secondary Sjögren's syndrome, respectively. Of the 58 patients with primary Sjögren's syndrome, one (1.7%) had definite autoimmune hepatitis, as defined by the International Autoimmune Hepatitis Group diagnostic criteria. One additional symptomatic patient who did not fulfill criteria for primary Sjögren's syndrome had definite autoimmune hepatitis. None of the patients with secondary Sjögren's syndrome had definite autoimmune hepatitis. Two (1%) of the 194 patients with primary Sjögren's syndrome or clinical symptoms had primary biliary cirrhosis. These values are lower than those reported by prior studies with smaller patient populations and likely represent a more accurate estimate of the true prevalence of these diseases in patients with primary Sjögren's syndrome.

International variation in volunteer whole blood donor eligibility criteria

BACKGROUND

This study assesses international variation in volunteer whole blood donor eligibility criteria.

STUDY DESIGN AND METHODS

In February 2008, Web sites of major blood collection organizations in 17 countries were queried for the volume of whole blood donations and six donor eligibility criteria: allowed donation frequency, donor age, hemoglobin (Hb), weight, and deferrals for tattoo and pregnancy/breast-feeding.

RESULTS

The allowed frequency of whole blood donation ranged from 56 to 120 days, some with sex- and age-specific limitations. While blood collection agencies in three countries did not have an upper age limit for donation, the remainder mandated donor retirement at ages from 60 to 81 years. The minimum Hb level was 11.5 to 12.5 g/dL for women and 12.5 to 13.5 g/dL for men. Blood collection organizations in only three countries required a minimum donor weight of less than 50 kg. Tattoo and pregnancy deferrals ranged from 4 to 12 months and 6 weeks to 12 months, respectively. The volume of whole blood donations ranged from 300 to 500 mL. The percentage of total blood volume donated, the absolute grams of Hb expected to be restored per deferral period and per day of donor deferral, and the concentration of Hb expected to be restored per deferral period were calculated.

CONCLUSIONS

International volunteer whole blood donor eligibility criteria demonstrate marked variation. These differences likely cause international variation in the prevalence of adverse donor reactions and iron deficiency anemia. The reasons underlying these dissimilarities are unclear, but may include varying cultural influences and average donor body habitus.