BACKGROUND:The COVID-19 pandemic affected healthcare delivery across all specialties including apheresis. To describe the changes in apheresis service practices that occurred during the pandemic, the American Society for Apheresis (ASFA) Apheresis Medicine Attending Physician Subcommittee conducted a survey study.STUDY DESIGN AND METHODS:A 32-question survey was designed and distributed to 400 ASFA physician members on September 7, 2022. Attending physicians responded to questions about whether and how apheresis service practices changed during the COVID-19 pandemic compared with the time period prior to the pandemic in terms of: (1) procedure types and volumes, (2) patient consultation workflow, and (3) the use of telemedicine. Descriptive analyses were reported as number and frequency of responses.RESULTS:The survey response rate was 13.8% (55/400). Of these respondents, 96.4% (53/55) were attending physicians. The majority of respondents (42/53, 79.2%) indicated that the types of procedures performed during COVID-19 compared to pre-pandemic did not change. Most frequently for apheresis procedure volume, respondents reported: no change in their monthly inpatient volume (21/47, 44.7%) and a decrease in their monthly outpatient volume (28/46, 60.9%). Prior to COVID-19, 75.0% (30/40) of respondents performed consultations at bedside for inpatients and 67.4% (29/43) performed consultations at bedside for outpatients. Bedside consultations decreased in both settings during the pandemic but were still most frequently performed by attending physicians. At the same time, the use of telemedicine increased for 15.4% of survey respondents during COVID-19.CONCLUSION:Some, but not all, respondents observed or made changes to their apheresis service during the COVID-19 pandemic. A subset of changes, such as increased utilization of telemedicine, may persist.

Purpose: This retrospective chart review investigates the association between maternal AB blood type and neonatal outcomes including birthweight, NICU transfer rate, Apgar scores, cord blood pH levels, clinical chorioamnionitis, and stillbirth compared to other maternal blood types (A, B, and O). Methods: Delivery records were examined from the electronic medical record (EMR) for deliveries occurring between 1/1/2020 and 12/31/2022. Some variables were autofilled from nurse-entered data into the EMR during the delivery encounter (blood type, maternal age, Body Mass Index (BMI), gestational age at delivery, mode of delivery, presence of Category 2 tracing, infant birth weight, NICU transfer, Apgar scores, and cord gas values). Missing data were obtained through chart review. Other variables obtained through chart review included maternal gravida and para numbers, clinical chorioamnionitis diagnosis, fetal growth restriction, stillbirth, indications for delivery and cesarean section, hypertensive disorders of pregnancy, and medical history including chronic hypertension and gestational and pregestational diabetes. Comparisons between maternal blood type AB vs. all other blood types (group containing blood types A, B, and O) were completed using Student’s t-tests, Mann Whitney U tests, Pearson’s chi-square tests, or Fisher’s Exact tests as statistically appropriate. Comparisons between the 4 individual blood types (AB, A, B, O) were completed using ANOVA, Pearson’s chi-square tests, or Kruskal-Wallace tests as statistically appropriate. Post-hoc multivariate linear regression was used to examine associations of interest identified on bivariate analysis. Results: A total of 3263 deliveries were reviewed between 1/1/2020 and 12/31/2022. Of these, 113 patients had blood type AB (3.46%) and 3150 had other blood types (1015 type A (31.07%), 463 type B (14.18%), 1672 type O (51.28%)). Patients with blood type AB had statistically higher age than other blood types (31.0 ± 5.2 vs. 29.9 ± 6.1, p = 0.046) and lower BMI (31.2 [interquartile range 7] vs. 33 [IQR 9.5], p = 0.009). There were no differences in nulliparity, gestational age at delivery, chronic hypertension, gestational diabetes, cholestasis of pregnancy, clinical chorioamnionitis, fetal growth restriction, stillbirth, category 2 tracing, or mode of delivery. No statistically significant differences were observed in birthweight between infants born to mothers with blood type AB (mean: 3227 grams, SD: 694 grams; p = 0.158) compared to those born to mothers with other blood types (mean: 3195 grams, SD: 734 grams; p = 0.158). The rates of NICU transfer were similar between the two groups, with 12% of infants born to blood type AB mothers requiring NICU admission compared to 17% of infants born to mothers with other blood types (p = 0.162). Apgar scores at 1, 5, and 10 minutes did not significantly differ between the two groups (p > 0.05). Additionally, there were no significant differences in cord arterial pH (AB: 7.26 ± 0.06 vs. others: 7.25 ± 0.07; p = 0.649) and cord venous pH (AB: 7.33 ± 0.06 vs. others: 7.32 ± 0.06; p = 0.860). Furthermore, when comparing the individual maternal blood types with 4-way comparisons, similar findings of no significance were observed for Apgar scores, cord arterial and venous pH levels, clinical chorioamnionitis diagnosis, fetal growth restriction diagnosis, stillbirth, category 2 notes, and delivery or C-section indication for category 2 tracing (p > 0.05). The Kruskal Wallace test comparing birthweight between the 4 blood types showed p = 0.055. A multivariate linear regression for birthweight did not show a significant association for blood type (p = 0.201) when controlling for maternal age, BMI, hypertensive disorder of pregnancy, chronic hypertension, diabetes, and gestational age. Conclusion: The impact of maternal ABO blood type on neonatal outcomes remains a topic of interest in obstetric and perinatal medicine. We have previously demonstrated newborn AB blood type is associated with significant morbidity and mortality with necrotizing enterocolitis (NEC), as well as a higher incidence of respiratory distress syndrome, retinopathy of prematurity, and sepsis (McMahon et al., 2019). Previous studies have independently provided evidence of adverse pregnancy outcomes for type AB mothers (Fan et al., 2023) and type AB neonates. However, there are conflicting findings regarding the association between maternal ABO blood type and neonatal outcomes. Our findings suggest that neonatal outcomes, including birthweight, NICU transfer rate, Apgar scores, cord blood pH levels, clinical chorioamnionitis, and stillbirth do not significantly differ between infants born to mothers with blood type AB and those born to mothers with other blood types. These results indicate that other factors may play a more substantial role in determining neonatal health and outcomes. Further research with additional perinatal measures is warranted to explore the potential influence of blood type and other factors on neonatal health.

Abstract: This retrospective chart review evaluates the potential role of maternal ABO blood type on various adverse obstetrical outcomes for both mother and neonate, including maternal hypertensive disorders, GDM, fetal growth restriction, clinical chorioamnionitis and other related disease processes. Methods: Delivery records were obtained from the electronic medical record (EMR) for deliveries occurring between 1/1/2020 and 12/31/2022. Data were extracted from nurse entered fields in the EMR during the delivery encounter (blood type, maternal age, body mass index (BMI), gestational age at delivery, quantitative blood loss, mode of delivery, and presence of Category 2 tracing,). Missing data were obtained through chart review. Other variables obtained through chart review included maternal pregnancy history, clinical chorioamnionitis diagnosis, fetal growth restriction, stillbirth, prolonged rupture of membranes, indications for cesarean section, hypertensive disorders of pregnancy, and medical history including chronic hypertension, gestational and pre-gestational diabetes, thrombophilia, bleeding disorder, venous thromboembolism, seizure disorder, cholestasis of pregnancy, and COVID infection. Comparisons between maternal blood type AB vs. all other blood types (group containing blood types A, B, and O) were completed using Student’s t-tests, Mann Whitney U tests, Pearson’s chi-square tests, or Fisher’s Exact tests as statistically appropriate. Comparisons between the 4 individual blood types (AB, A, B, O) were completed using ANOVA, Pearson’s chi-square tests, or Kruskal-Wallace tests as statistically appropriate. Post-hoc multivariate logistic regression was used to examine associations of interest identified on bivariate analysis. Results: A total of 3263 deliveries were reviewed from between 1/1/2020 and 12/31/2022. Of these, 113 patients had blood type AB (3.5%) and 3150 had other blood types (1015 type A, 463 type B, 1672 type O). Patients with blood type AB had statistically higher age than other blood types (31.0 ± 5.2 vs. 29.9 ± 6.1, p=0.046) and lower BMI (31.2 [IQR 7] vs. 33 [IQR 9.5], p =0.009). There were no differences in nulliparity, gestational age at delivery, chronic hypertension, gestational diabetes, cholestasis of pregnancy, quantitative blood loss, postpartum hemorrhage, clinical chorioamnionitis, fetal growth restriction, stillbirth, category 2 tracing, or mode of delivery. Patients with blood type AB had a gestational hypertension rate of 14% compared to 9% in other blood types (p=0.059). This association was further explored in multivariate logistic regression for prediction of gestational hypertension, which showed a statistically significant association for blood type AB vs. other (p=0.032, OR 1.91 (95% CI 1.06-3.43)) when controlling for age (p=0.074, OR 0.98 (95% CI 0.96-1.00)), BMI (p<0.001, OR 1.05 (1.04-1.07)), and gestational age (p=0.041, OR 1.06 (1.00-1.11)). However, patients with blood type AB had a rate of preeclampsia and superimposed preeclampsia of 3.6% compared to 8.9% in other blood types (p=0.05). This, too, was further explored in a regression for prediction of preeclampsia and superimposed preeclampsia, which did not show a statistically significant association for blood type AB vs. other (p=0.089, OR 0.36 (95% CI 0.11-1.17), when controlling for age (p=0.59, OR 0.99 (0.97-1.02)), BMI (p<0.001, OR 1.06 (1.05-1.08)), and gestational age (p<0.001, OR 0.88 (0.86-0.91)). A third regression model on any hypertensive disorder of pregnancy (including gestational hypertension, preeclampsia with or without severe features, eclampsia, and superimposed preeclampsia) did not show a statistically significant association for blood type AB vs. other (p=0.65, OR 1.13 (95% CI 0.66-1.95)) when controlling for age, BMI, and gestational age. Four-way comparisons between the 4 individual blood types (AB, A, B, O) did not show differences in any of the outcomes. Conclusion: Previous investigations have found variable results regarding maternal blood type and adverse obstetrical outcomes including hypertensive disorders, gestational diabetes, and perinatal diseases. A previous study by Burgess et al. found that mothers with type AB blood had an increased risk of developing late onset preeclampsia, while Hentschke et al. found no association between preeclampsia and maternal blood type. Reisig et al. found a significant correlation between type A+ mothers and the development of preeclampsia. This retrospective chart review of 3263 deliveries was performed to further investigate these associations and address this knowledge gap. It has been shown that AB blood type is associated with stimulated antigen response, an increased prothrombotic state and increased disease risk. In this study, maternal AB blood type was found to be associated with gestational hypertension. However, this association was likely due to a Type I error, as no other association with other hypertensive disorders, such as pre-eclampsia, was found to be significant. We found no other statistically significant correlations between maternal blood type and adverse obstetrical outcomes. Although previous studies have demonstrated a potential association between maternal AB blood type and adverse outcomes, our study, with a substantial sample size, did not yield similar results. In conclusion, physicians should not depend on maternal blood type as a reliable indicator of potential obstetrical outcomes or when identifying high-risk mothers.

Purpose: Massive transfusion protocols (MTP) commonly result in severe hypocalcemia due to the calcium -binding affinity of citrate in blood components. The purpose of this study is to determine the optimal grams (g) of citrate to repletion calcium (Ca) milliequivalents (mEq) (Citrate:Ca) ratio to reduce 30-day mortality.Methods: This was a retrospective, single-centered, cohort study at a level 1 trauma center evaluating trauma and surgical patients in need of MTP activation from January 1, 2010-July 31, 2021. Patients with severe hypocalce-mia at baseline, defined as ionized calcium (iCa) <0.9 mmol/L, were compared to patients without severe hypo-calcemia. The primary endpoint was to determine the optimal ratio of grams of citrate to calcium mEq to reduce mortality in patients receiving a MTP. Secondary endpoints included mortality at 24 h and 30 days, blood com-ponents used in MTP, and type of calcium used. Results: Overall, 501 patients were screened for inclusion. Of these patients, 193 were excluded, leaving 308 patients, of which 165 patients (53.6%) had an iCa <0.9 mmol/L within 24 h and 143 patients (46.4%) had iCa & GE;0.9 mmol/L within 24 h. The ratio of Citrate:Ca for each patient was not significantly associated with mortality at 24 h (P = 0.79) or 30 days (P = 0.91) at a repletion Citrate:Ca ratio of median 1.97 (IQR 1.14-2.91). The rate of mortality was lowest at a Citrate:Ca of 2 in both <24-h mortality and 30-day mortality.Conclusions: There were no differences in 24 h or 30 day mortality based on repletion ratios seen in this study. A Citrate:Ca ratio between 2 and 3 in patients undergoing MTP was sufficient to obtain a normalized iCa within 24 h of MTP activation regardless of baseline iCa level. Further prospective studies will be needed to determine the optimal Citrate:Ca ratio.& COPY; 2023 Elsevier Inc. All rights reserved.

BACKGROUND: A well-described but not universally appreciated side effect of IVIG administration is clinically apparent, sometimes severe hemolysis. We describe a severe case of Coombs-positive hemolytic anemia secondary to IVIG. IVIG is a blood derivative manufactured from pools of 5,000 to 10,000 individual plasma donations. IVIG is not ABO-type restricted, so anti-A, anti-B and anti-A,B isoagglutinins are measureable in IVIG. A number of other RBC alloantibodies to minor blood group antigens have also been detected. CASE REPORT: A 16-year-old male with PMH of OSA and obesity was admitted for adenoviral …

Background: More than half of all very low birth weight (VLBW) newborns will receive at least one transfusion during their stay in the neonatal intensive care unit (NICU). Several recent studies have detected a temporal relationship between anemia requiring red cell transfusion and the onset of necrotizing enterocolitis (NEC). The association between anemia, transfusion, and NEC is still debated, though transfusion associated NEC has a reported incidence of 5-17 per 1000 transfusion events. The effect of preservatives, additives, decreased ATP, and decreased 2,3-DPG in transfused components has an unknown effect on coagulation factors in …

Background: The presence of A and B tissue antigens in non-O (A, B, and AB) blood types in adults is associated with a higher incidence of ischemic stroke, myocardial infarction, arterial and venous thrombosis. In preterm and healthy newborns, plasma concentrations of coagulation system proteins like von Willebrand Factor (vWF) are >70% of normal adult values and higher levels of vWF and Factor VIII (FVIII) increases thrombotic risk. Previously we demonstrated an association between neonatal AB blood type and decreased survival in necrotizing enterocolitis (NEC). Although NEC is a multifactorial disease, a hypercoagulable state resulting in ischemic …

Physician burnout is a national crisis with medicine among occupations with higher suicide risk, at 1.8 times the national average. Few pathology departments address this issue, and even fewer residency programs offer formal resiliency training. We implemented a high-stress environment resiliency strategy and an Accreditation Council for Graduate Medical Education-compliant curriculum to our residency program. Its purpose was to apply initiatives employed in the finance industry, then to measure their effectiveness. Utilizing methods from financial companies such as Goldman Sachs, we adopted the following initiatives in our residency program: (1) approach burnout as a dilemma requiring a tridimensional strategy: providing wellness training for the individual, programmatic group strategies, and an institutional wellness plan; (2) formalize a wellness curriculum, implementing wellness talks focused on stress prevention, management, and treatment; (3) offer free sessions with resilience coaches, psychological help, Employee Assistance Program, and chaplain services; (4) modify our mentorship program, pairing first-year residents with senior residents; (5) implement mindfulness practices; (6) provide easy access to volunteer opportunities and networking; (7) offer fitness center discounts. Effectiveness was measured through 2 surveys of 13 residents representing day 0 (before wellness initiatives were implemented) and at 1 year. Results indicate a significant improvement in utilization of wellness tools. This study demonstrates that wellness and resilience can be taught. Our ultimate goals are to increase wellness among pathology residents, to prepare them for a high-stress environment before entering the workforce, and to prepare them to incorporate the tools they have learned into their new workplaces.

BACKGROUND Endocan-1, a soluble proteoglycan expressed on endothelial cells, has been reported as a marker of endothelial pathology in the adult population with sepsis, hypertension, myocardial infarction, and kidney disease. Necrotizing Enterocolitis (NEC) is an acute ischemic necrotizing disease of the GI tract of multifactorial etiology in very low birth weight newborns involving a large area of intestine. Spontaneous Intestinal Perforation (SIP) involves hemorrhagic necrosis involving a small focal lesion with an earlier onset than NEC. It appears both are separate and distinct pathologic and clinical entities. Although nonspecific biomarkers can detect inflammation, no specific biomarker has been found to predict onset of both diseases. OBJECTIVE Evaluate Endocan-1 serum levels in preterm neonates with and without NEC and SIP. DESIGN/METHODS Neonates less than 33 weeks gestational age (GA) were enrolled prospectively with informed consent. Citrated whole blood samples were collected at birth and weekly for six weeks in this IRB-approved study. Endocan-1 levels measured by ELISA (Abcam, Cambridge, MA) were stratified by presence of NEC or SIP. RESULTS A total of 86 neonates less than 33 weeks GA were enrolled. Seven of the neonates were diagnosed with NEC while 3 developed SIP. The mean day of life (DOL) for onset of SIP and NEC was 6 and 19 respectively. Two neonates developed surgical NEC and had serum levels of 1936 and 1938 pg/mL, respectively, on date of diagnosis. Figure 1 depicts individual serum Endocan-1 levels based on NEC, SIP, or without NEC or SIP. Day 0 is considered time of diagnosis for each patient with NEC or SIP. Those without disease begin on Day 0 of collection as there are no days prior to disease. Figure 2 depicts a 3-way Box Plot that compares the maximum Endocan-1 values of non-NEC/non-SIP neonates to those who develop SIP to those with NEC after they develop NEC. The increase in median Endocan-1 value across each group (p=.057) may suggest Endocan-1 could be indicative of NEC disease onset. CONCLUSIONS Serum Endocan-1 at the time of diagnosis of NEC may be associated with more extensive endothelial injury compared with SIP. Despite small numbers, the expected rise with SIP onset does not appear as robust compared to NEC onset supporting coagulative necrosis, inflammation and bacterial overgrowth in NEC. Further investigation is needed for Endocan-1 as a novel biomarker in clinical application of NEC and SIP as many other inflammatory mediators have been unsuccessful. Post-diagnosis Endocan-1 levels may assist in NEC staging, potential for perforation, and other sequelae of NEC or SIP.

The recognition and utility of diagnostic criteria for humoral antibody-mediated rejection (AMR) in solid organ transplantation besides renal transplants are not well characterized. The role of TPE in treatment of suspected humoral AMR of lung transplants is similarly indeterminate with little efficacy described for using apheresis in this setting. We present 2 cases of suspected AMR in lung transplant recipients …

Platelet transfusion refractoriness following allogeneic bone marrow transplantation usually stems from HLA alloimmunization. However other platelet antigens may serve as targets of alloimmune reactivity. A 24-year-old Palestinian male with atypical CML in chronic phase underwent matched unrelated donor bone marrow transplant from a 39-year-old female, HLA-A, B, C and DR allele level matched donor. Conditioning was with busulfan 0.8mg/Kg IV q6 hours day -8 through -4, cyclophosphamide 60mg/Kg IV daily day -3 & -2 and rabbit anti-thymocyte globulin 1.5mg/Kg IV daily day -5 & -4. Graft versus host disease prophylaxis was with mini-dose methotrexate and tacrolimus, with filgrastim given for hematopoietic reconstitution. The cell dose was 1.86x106 CD34+ cells/Kg recipient body weight (3.66x108 mononuclear cells/Kg). Neutrophil engraftment occurred on day +14, and was complicated by a diffuse purpuric skin rash, with hypoxia and pulmonary infiltrates which resolved with corticosteroid therapy. His post-transplant course was also complicated by severe, transfusion refractory thrombocytopenia (to random donor pools, apheresis and crossmatched platelet units) starting on day +5 with platelet counts of <5x103/μL. He developed intra-retinal hemorrhage of the right eye, scleral hemorrhage bilaterally, epistaxis and muco-cutaneous bleeding. During the first 30 days following BMT he received 53 doses of platelets in addition to aminocaproic acid. He did not have DIC, splenomegaly or evidence of microangiopathy. HLA alloantibodies were not identified. Antigen Capture ELISA and flow cytometry for platelet specific antibody identification however demonstrated antibodies specific for CD36 in the patient's serum (Fig). Platelets from the bone marrow donor typed positive for CD36. IVIG 0.5gm/Kg IV on d+13, 14, and 17 and Rituximab 375mg/m2 IV d + 17, 64, 72, and 82 were administered with no therapeutic response. The patient finally responded to transfusions of platelets collected from family members (parents, siblings and cousins) who were CD36negative. Bone marrow biopsies 2 months and 4 months following transplantation showed no evidence of residual disease with trilineage engraftment and adequate megakaryocytes, normal cytogenetics and >98% donor chimerism. As his immunosuppression has been tapered over time, the antibody titer has declined (Fig) as has his platelet transfusion requirement (41 doses transfused between day 31 and 120). However he remains dependent upon directed donor platelet transfusions from his CD36 negative family members at 120 days from transplant. The CD36 negative phenotype is rare in Caucasians, however, platelets from about 5% of individuals of Asian or African descent lack CD36. DNA sequencing to determine CD36 mutations in this patient is underway. We hypothesize that this patient developed a host vs. graft humoral response against donor derived and transfused platelets resulting in sustained severe thrombocytopenia.