Objective design:In June of 2024, Becton Dickinson experienced a blood culture bottle shortage for their BACTEC system, forcing health systems to reduce usage or risk exhausting their supply. Virginia Commonwealth University Health System (VCUHS) in Richmond, VA decided that it was necessary to implement austerity measures to preserve the blood culture bottle supply. Setting:VCUHS includes a main campus in Richmond, VA as well as two affiliate hospitals in South Hill, VA (Community Memorial Hospital (CMH)) and Tappahannock Hospital in Tappahannock, VA. It also includes a free-standing Emergency Department in New Kent, VA. Patients:Blood cultures from both pediatric and adult patients were included in this study. Interventions:VCUHS intervened to decrease blood culture utilization across the entire health system. Interventions included communication of blood culture guidance as well as an electronic health record order designed to guide providers and discourage wasteful ordering. Results:Post-implementation analyses showed that interventions reduced overall usage by 35.6% (P < .0001) and by greater than 40% in the Emergency Departments. The impact of these changes in utilization on positivity were analyzed, and it was found that the overall positivity rate increased post-intervention from 8.8% to 12.1% (P = .0115) and in the ED specifically from 10.2% to 19.5% (P < .0001). Conclusions:These findings strongly suggest that some basic stewardship interventions can significantly change blood culture practice in a manner that minimizes the impact on patient care.

Hemoglobin S (HbS) polymerization inhibitor drugs such as voxelotor can result in a split peak in HbS as well as additional peaks with hemoglobin A in quantitative methods of HbS measurement. It is unclear how these results should be used to make transfusion decisions. The goal of this study is to compare RBC exchange (RBCX) replacement volumes calculated with HbS-Vox + HbS versus HbS alone. Patients aged 15-58 years who had variant hemoglobin quantitation performed for clinical care purposes with evidence of voxelotor treatment (split peak in HbS and/or additional peaks with hemoglobin A) were identified by investigator review of variant hemoglobin quantitation test results from the clinical laboratory. The RBCX replacement volume calculated with HbS% total (RBCX volume HbS% total) was compared to the RBCX replacement volume calculated with HbS unmod% (RBCX volume HbS unmod%) in each case. The mean difference between RBCX volume total HbS% and RBCX volume HbS% unmod is 398 mL with 95% CI (198, 598) and RBCX volume total HbS is significantly different from RBCX volume HbS unmod (p value = 0.0006). If the HbS total is not used to calculate RBCX replacement volumes in patients taking voxelotor, there is a significantly lower amount of RBC that would be ordered, which would lead to higher HbS after RBCX. Additional studies regarding the role of transfusion in such patients are necessary.

Background Medical educators seek innovative ways to engage learners efficiently and effectively. Gamification has been explored as one way to accomplish this feat; however, questions remain about which contexts gamification would be most useful. Time constraints and student interest present major barriers for teaching laboratory medicine to students. This study aims to compare two versions of an interactive online module, one gamified and one not, for teaching laboratory medicine concepts to pre-clinical medical students. Methods First-year medical students reviewed either a gamified or non-gamified version of an interactive online module in preparation for an in-person flipped classroom session on Laboratory Medicine. Learning theory guided the design of the modules and both contained identical content, objectives, and structure. The “gamified” module included the additional elements of personalization, progress meters, points, badges, and story/role play. After reviewing the module, students completed an anonymous knowledge check and optional survey. Results One hundred seventy-one students completed the post module knowledge check as assigned (82 gamified, 89 non-gamified). Knowledge check scores were higher for the students who reviewed the gamified module ( p < 0.02), corresponding to an effect size of 0.4 for the gamified module. Eighty-one students completed optional post-module surveys (46 gamified, 35 non-gamified). Instructional efficiency was calculated using task difficulty questions and knowledge check scores, and the resulting instructional efficiency was higher for the gamified module. There was no significant difference in the student-reported time required to complete the modules. Additionally, both versions of the module were well received and led to positive ratings related to motivation and confidence. Finally, examination of open-ended survey results suggested that the addition of game elements added value to the gamified module and enhanced engagement and enjoyment. Conclusions In this setting, the addition of gamification to an interactive online module enhanced learning outcome, instructional efficiency, student engagement and enjoyment. These results should inspire further exploration of gamification for teaching Laboratory Medicine concepts to pre-clinical medical students.

The use of blood transfusions to improve anemia resulting from sickle cell disease (SCD) is often limited by alloimmunization, which occurs due to exposure to incompatible antigen present on donor red blood cells (RBCs). This complication occasionally manifests as delayed hemolytic transfusion reactions (DHTRs) that cause hemolysis of the recipient's own RBCs and can lead to fatal anemia. In this case study, we report a patient with SCD who experienced a DHTR following chronic transfusion and was successfully treated with voxelotor, an orally administered sickle hemoglobin (HbS) polymerization inhibitor for the treatment of SCD. Laboratory tests following admission indicated pan-reactivity in antigens, and a rare donor registry was used to locate acceptable units. The patient experienced the DHTR 3 days after admission, which limited laboratory tests due to profound hemolysis. Alternative treatments were limited, and phenotypically matched units were incompatible, so voxelotor was selected as a last-resort treatment. Following initiation of voxelotor 1500 mg, the patient's hemoglobin levels returned to baseline (6 g/dl) within 10 days, with clinical improvements. This report provides evidence regarding the use of voxelotor in the treatment of profound anemia where other treatments could be unsafe or unavailable.

TransfusionVolume 63, Issue 1 p. 249-256 COMMENTARY Primum, non nocere: Whole blood, prehospital transfusion and anti-D hemolytic disease of the fetus and newborn Kerry L. O'Brien, Corresponding Author Kerry L. O'Brien [email protected] orcid.org/0000-0002-2579-8640 Department of Pathology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA Correspondence Kerry L. O'Brien, Blood Bank, Beth Israel Deaconess Medical Center, YA-309, 330 Brookline Avenue, Boston, MA 02215, USA. Email: [email protected]Search for more papers by this authorScott A. Shainker, Scott A. Shainker Division of Maternal Fetal Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USASearch for more papers by this authorJeannie Callum, Jeannie Callum Department of Pathology and Molecular Medicine, Kingston Health Sciences Centre and Queen's University, Kingston, Ontario, CanadaSearch for more papers by this authorRamen H. Chmait, Ramen H. Chmait Department of Obstetrics and Gynecology, Los Angeles Fetal Surgery, University of Southern California, Los Angeles, California, USASearch for more papers by this authorNoor Niyar N. Ladhani, Noor Niyar N. Ladhani Division of Maternal Fetal Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, CanadaSearch for more papers by this authorYulia Lin, Yulia Lin orcid.org/0000-0002-5562-9020 Department of Laboratory Medicine and Pathobiology, Sunnybrook Health Sciences Centre, Toronto, Ontario, CanadaSearch for more papers by this authorSusan D. Roseff, Susan D. Roseff Department of Pathology, Virginia Commonwealth University, Richmond, Virginia, USASearch for more papers by this authorAlireza A. Shamshirsaz, Alireza A. Shamshirsaz Division of Maternal Fetal Medicine, Boston Children's Hospital, Boston, Massachusetts, USASearch for more papers by this authorLynne Uhl, Lynne Uhl Department of Pathology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USASearch for more papers by this authorRichard L. Haspel, Richard L. Haspel orcid.org/0000-0003-1107-2125 Department of Pathology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USASearch for more papers by this author Kerry L. O'Brien, Corresponding Author Kerry L. O'Brien [email protected] orcid.org/0000-0002-2579-8640 Department of Pathology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA Correspondence Kerry L. O'Brien, Blood Bank, Beth Israel Deaconess Medical Center, YA-309, 330 Brookline Avenue, Boston, MA 02215, USA. Email: [email protected]Search for more papers by this authorScott A. Shainker, Scott A. Shainker Division of Maternal Fetal Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USASearch for more papers by this authorJeannie Callum, Jeannie Callum Department of Pathology and Molecular Medicine, Kingston Health Sciences Centre and Queen's University, Kingston, Ontario, CanadaSearch for more papers by this authorRamen H. Chmait, Ramen H. Chmait Department of Obstetrics and Gynecology, Los Angeles Fetal Surgery, University of Southern California, Los Angeles, California, USASearch for more papers by this authorNoor Niyar N. Ladhani, Noor Niyar N. Ladhani Division of Maternal Fetal Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, CanadaSearch for more papers by this authorYulia Lin, Yulia Lin orcid.org/0000-0002-5562-9020 Department of Laboratory Medicine and Pathobiology, Sunnybrook Health Sciences Centre, Toronto, Ontario, CanadaSearch for more papers by this authorSusan D. Roseff, Susan D. Roseff Department of Pathology, Virginia Commonwealth University, Richmond, Virginia, USASearch for more papers by this authorAlireza A. Shamshirsaz, Alireza A. Shamshirsaz Division of Maternal Fetal Medicine, Boston Children's Hospital, Boston, Massachusetts, USASearch for more papers by this authorLynne Uhl, Lynne Uhl Department of Pathology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USASearch for more papers by this authorRichard L. Haspel, Richard L. Haspel orcid.org/0000-0003-1107-2125 Department of Pathology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USASearch for more papers by this author First published: 30 November 2022 https://doi.org/10.1111/trf.17209Citations: 2 Kerry L. O'Brien and Scott A. Shainker contributed equally to this manuscript. Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL CONFLICT OF INTEREST All authors declare that they have no conflicts of interest relevant to this manuscript submitted to TRANSFUSION. Citing Literature Volume63, Issue1January 2023Pages 249-256 RelatedInformation

Voxelotor has recently been approved by the U.S. Food and Drug Administration (FDA) for the treatment of sickle cell disease (SCD). Voxelotor has been reported to interfere with hemoglobin quantification methodologies that are in common use for evaluating patients with hemoglobinopathies. There is still a general lack of awareness of potential voxelotor interference in assays for quantitative analysis of hemoglobin variants. In this How Do I article, the authors call attention to the effects of voxelotor on the daily practices of Apheresis and Transfusion Medicine specialists. The article emphasizes that apheresis/transfusion medicine physicians and the laboratory should work together to develop a communication process in order to notify the laboratory when patients are receiving voxelotor. The article briefly reviews published studies on interference mitigation approaches and describes how our institution developed a communication process to inform the laboratory when analyzing specimens from patients receiving voxelotor.

Objectives: The purpose of this study was to identify laboratory parameters representing erythrocyte engraftment to be used as an indicator to change the recipient to donor ABO group and Rh type following an ABO-incompatible hematopoietic stem cell transplant (HSCT). Studies have shown that ABO incompatibility does not have an effect on outcome of HSCT; however, the serologic consequences of these ABO-incompatible transplants can make it difficult to decide when to begin support with donor ABO/Rh-type blood products. Methods: This study explored the use of RBC distribution width (RDW), mean corpuscular volume, and hemoglobin as regularly tested laboratory parameters that could be used as surrogate markers for RBC engraftment in 65 patients who received ABO/Rh-incompatible HSCT. Results: The appearance of engrafted donor RBCs correlated with a peak in RDW (P=.002). In addition, our findings suggest that serologic changes in ABO/Rh appear to correspond with a peak in RDW (P=.002). Conclusions: High values of RDW likely result from a substantial proportion of large, young erythrocytes from recent engraftment with smaller, older pretransplant erythrocytes from the recipient. Our findings suggest that peak RDW may be an indicator of erythrocyte engraftment, following an ABO/Rh-incompatible HSCT.

Hepatic encephalopathy (HE) is characterized by altered sensorium and is the most common indication for hospitalization among patients with cirrhosis. Liver societal guidelines for inpatient HE revolve around identification of potential precipitants. In this retrospective study, we aimed to determine adherence to societal guidelines for evaluation of HE in 78 inpatients. The adherence rate to societal recommended guidelines for workup of HE was low, with only 17 (22%) patients having complete diagnostic workup within 24 hours of admission. Notably, 23 (30%) patients were not subjected to blood culture analysis, 16 (21%) were missing urinalysis, and 15 (20%) were missing chest radiograph. In patients with ascites (N = 34), 26 (77%) did not have a diagnostic paracentes is to exclude spontaneous bacterial peritonitis. In contrast, serum ammonia determination, a laboratory test not endorsed by societal guidelines for workup of HE, was ordered in 74 (95%) patients. These findings underscore the limited adherence to societal guidelines in hospitalized patients with HE.

The authors have disclosed no conflicts of interest.

Objective: To develop a survey instrument to identify adult sickle cell disease (SCD) patients on chronic opioid therapy who are at-risk for opioid abuse. Design: Prospective survey and interview.Setting: Adult SCD clinic in a large urban teaching facility.Patients/participants: Convenience sampling of adult patients presenting to the sickle cell clinic.Interventions: None.Main outcome: Primary outcome was “at-risk for opioid misuse,” defined as at least 3/8 “yes” answers (a positive composite score) on the Prescription Opioid Misuse Index (POMI) questionnaire. Secondary outcome was DSM-IV criteria for substance abuse using the DSM IV Diagnostic Interview Schedule.Results: Of the 99 patients who completed the POMI, the mean age was 36 years; 58.6 percent were female, 48 percent were hemoglobin SS (47/99), and 26 percent were SC (26/99). Twenty-four percent (24/99) were identified as at-risk for opioid misuse using the POMI. There were no differences in demographic, SCD genotype, or socioeconomic variables for at-risk versus not-at-risk patients.Conclusion: Twenty-four percent of unselected adult SCD patients on opioids were identified as at-risk for opioid misuse using a quick survey. This may represent as much as 2.5-7 times the national misuse rate. This group of patients may benefit from additional diagnostic and therapeutic interventions to help understand and manage their opioid usage.

Table 1 -1a.Patient and Liver MRI characteristics.1b.Sensitivity, specificity, positivepredictive values and negative-predictive values for each T2*(ms) cutpoint.Figure 1. A. T2* values according to occurrence of an inadequate elastography.The sample median for each group is shown with a solid horizontal line.B. ROC curve illustrating the ability of T2* to predict occurrence of an inadequate elastography.The area under the ROC curve (AUC) regarding the predictive ability of T2* was 0.95.

Despite adoption of the 2015 Accreditation Council for Graduate Medical Education (ACGME) and American Board of Pathology (ABP) Milestones for the assessment of resident education, very few tools are available to organize the longitudinal collection of residency trainee data relevant to milestones. With the goal of being able to efficiently and accurately convert resident accomplishment data into milestone scores during biannual resident evaluations, we devised a user-friendly tracking tool to collect, display, and map these data to relevant ACGME milestones. A committee was convened to overhaul the existing system, consisting of representatives from throughout the Department of Pathology. The committee assigned each resident accomplishment datapoint, which was historically tracked by the program (eg, frozen-section numbers, licensure status) to a corresponding ACGME milestone (eg, PC6, PROF1, respectively). A spreadsheet (tracking tool) was created to present these datapoints under the appropriate milestone. A prototype of the tool was piloted by a resident, and changes were made for clarity. The final version was populated by all residents and used by the clinical competency committee (CCC) during subsequent 6-month evaluation meetings. Deidentified data measuring the degree of milestone changes were abstracted to assess the impact of the tracking tool. The tracking tool was successfully used by the CCC for assessment of resident milestones and was favorably received by program leadership and faculty. Use of the tool was associated with increased (positive) changes in resident milestones in 8 of 12 residents, when compared to changes in paired milestone levels from the preceding evaluation period. Moreover, the degree of change in resident milestone level scores was statistically significant in 4 of 12 residents. The resident data tracking tool was used successfully for data collection and CCC milestone assessment. This tool may be associated with greater fidelity between milestone levels assessed and relevant internal resident performance.

Background:Pain diary assessment in sickle cell disease (SCD) may be expensive and impose a high respondent burden.Objective:To report whether intermittent assessment could substitute for continuous daily pain assessment in SCD.Design:Prospective cohort study.Setting:Academic and community practices in Virginia. Patients. A total of 125 SCD patients age 16 years or older in the Pain in Sickle Cell Epidemiology Study. Measurements. Using pain measures that summarized all diaries as the gold standard, we tested the statistical equivalence of four alternative strategies that summarized diaries only from the week prior or the month prior to study completion; one week per month; or one day per week (random day). Summary measures included percent pain days, percent crisis days (self-defined), mean pain (0-9 Likert scale) on all days, and mean pain on pain days. Equivalence tests included comparisons of means, regression intercepts, and slopes, as well as measurement of R2.Results:Compared with the gold standard, the one-day-per-week and one-week-per-month strategies yielded statistically equivalent means of six summary pain measures, and the week prior and month prior yielded equivalent means as some of the measures. Regression showed statistically equivalent slopes and intercepts to the gold standard using one-day-per-week and one-week-per-month strategies for percent pain days and percent crisis days, but almost no other equivalence. R2 values ranged from 0.64 to 0.989.Conclusions:It is possible to simulate five- to six-month daily assessment of pain in SCD. Either one-day-per-week or one-week-per-month assessment yields an equivalent mean and fair regression equivalence.

ObjectiveTo describe the indicidence and severity of iron deficiency anemia (IDA) in patients who have received extracorporeal photopheresis (ECP) treatment of cutaneous T-cell lymphoma (CTCL).MethodsWe performed a retrospective study during a 9-year period of patients with CTCL who were treated with ECP. ECP was performed with UVAR XTS and CELLEX (Therakos Inc). IDA was defined by a drop in hemoglobin (Hb), mean cell volume (MCV), and increased red blood cell distribution width (RDW).ResultsWe identified a total of 36 patients; 1 patient was excluded due to severe anemia. In 35 patients, initial hemoglobin values ranged from 9.8 g per dL to 15.9 g per dL, and patients received 4 to 327 ECP treatments. In all, 28 patients showed decreases in Hb of 0.8 g per dL to 6 g per dL during treatments.ConclusionChronic ECP led to IDA in 28 of 35 patients with CTCL. IDA occurs due to blood loss when ECP equipment does not return full blood volume to patients.

Background. Patients with SCD now usually live well into adulthood. Whereas transitions into adulthood are now often studied, little is published about aging beyond the transition period. We therefore studied age-associated SCD differences in utilization, pain, and psychosocial variables. Methods. Subjects were 232 adults in the Pain in Sickle Cell Epidemiology Study (PiSCES). Data included demographics, comorbidity, and psychosocial measures. SCD-related pain and health care utilization were recorded in diaries. We compared 3 age groups: 16-25 (transition), 26-36 (younger adults), and 37-64 (older adults) years. Results. Compared to the 2 adult groups, the transition group reported fewer physical challenges via comorbidities, somatic complaints, and pain frequency, though pain intensity did not differ on crisis or noncrisis pain days. The transition group utilized opioids less often, made fewer ambulatory visits, and had better quality of life, but these differences disappeared after adjusting for pain and comorbidities. However, the transition group reported more use of behavioral coping strategies. Conclusion. We found fewer biological challenges, visits, and better quality of life, in transition-aged versus older adults with SCD, but more behavioral coping. Further study is required to determine whether age-appropriate health care, behavioral, or other interventions could improve age-specific life challenges of patients with SCD.

As a resident rotating through the transfusion medicine service at Children's National Medical Center in Washington, DC, many years ago, I had a session with Naomi Luban, about T-activation and its importance for pediatric transfusion. At that time, lectins were readily available commercially, and the AABB's Technical Manual had a procedure dedicated to their use. I learned the importance of identifying T-activation in children and then providing the appropriate transfusion therapy. Decades later I became aware of the ongoing controversy surrounding the presence of T-activation and whether it had a direct role in red blood cell (RBC) destruction after transfusion. In this issue of TRANSFUSION, Moh-Klaren and colleagues1 present a case of an infant with necrotizing enterocolitis (NEC) and T-activation who died in temporal relationship to receiving blood products. To gain a better understanding of this patient's outcome, they performed a prospective study to more closely examine the relationship between NEC, T-activation, and hemolysis in patients in the neonatal intensive care unit (NICU). As stated in their introduction, “the causal relationship between T-activation and hemolysis has been called into question by many clinicians and serologists.”1 Their work adds more information to this provocative topic and also presents prospective data with more detailed laboratory testing than many previous studies. The first observations of polyagglutination of RBCs date back to the 1920s when RBCs were unexpectedly agglutinated by normal human adult sera that were ABO-compatible; this reaction did not occur with sera from newborns.2, 3 Hübener initially studied the phenomenon of polyagglutination secondary to in vitro contamination of blood samples with bacteria.4 Thomsen noticed that RBCs could change types from one day to the next and they could even be agglutinated with AB plasma, causing typing discrepancies. He called this characteristic “panagglutinable” and theorized it was secondary to RBCs agglutinating with bacteria.5 His student, Friedenreich, then showed that enzymes released from bacteria caused changes in RBC membranes that made them agglutinate. Due to the routine practice of using uncapped specimens that stood at room temperature for many hours, these laboratories, performing pioneering work in RBC serology, frequently saw polyagglutination secondary to environmental contamination by bacteria. This phenomenon could also be used to potentiate reactivity in the cold, also demonstrating the first uses of enzyme treatment to aid in antibody identification.4-6 Later, Friedenreich discovered that certain hidden antigens became exposed due to the actions of bacterial enzymes, and these hidden or “crypt-” antigens were responsible for the unexpected agglutination. This series of observations was called the Thomsen-Hübener-Friedenreich phenomenon and later T-activation, after Dr Thomsen.7-9 In 1938, the first in vivo case of polyagglutination was described in a 4-year-old with pneumococcus. The etiology was felt to be a soluble substance from the bacteria or medications used to treat the patient's infection.3 A variety of bacteria and viruses have been associated with polyagglutination, in vitro, including Pneumococcus, Streptococcus, Staphylococcus, Clostridia, Escherichia coli, Vibrio cholera, and influenza viruses.6 Alterations in the RBC membrane resulting in polyagglutination can occur due to the action of enzymes or incomplete biosynthesis of RBC membrane components or through inheritance of an uncommon haplotype.3 The T-antigen is normally masked by a structure composed of terminal N-acetyl neuraminic acid (NeuAc or sialic acid), d-galactose, N-acetyl-d-galactosamine (GalNac), and serine or threonine. Upon the cleavage of the terminal NeuAc by neuraminidase produced by microbial agents, the T-antigen is uncovered, leaving behind d-galactose, GalNac, and serine or threonine.2 This antigen is carried on the M and N sialoglycoproteins. The exposed galactose residues, in the correct three-dimensional state, become the receptor for anti-T. Th activation appears to represent an earlier and milder form of T-activation, where less sialic has been cleaved from the RBC surface. This type of activation is most common in newborns and their mothers.2, 6, 9 Tk activation is due to the action of bacterial B-galactosidases rather than neuraminidase.3, 9 Tx activation has been described in children with pneumococcal infection. Tn activation is the result of a somatic mutation. In contrast with the other forms of T-activation, which are transient, Tn activation is persistent.6 When polyclonal reagents were in common use, T-activation could be identified through routine testing and was usually first recognized by discrepancies in cell and serum types. Now, with the use of monoclonal reagents, other techniques have to be employed to seek out and detect T-activation. The various forms of T-activation can be identified and distinguished from each other by treatment with various plant lectins. T-activation is characterized by reactivity with both the peanut lectin, Arachis hypogaea, and the soy lectin, Glycine soya. After 2 months of age, infants start to develop anti-T, reaching adult levels by the ages of 2 to 5 years old. Anti-T is believed to develop due to exposure of bacterial gut flora, similar to the appearance of the isoagglutinins anti-A and anti-B. There was also speculation that their formation is the result of childhood immunizations.2 The appearance of anti-T is transient, lasting weeks to months. Anti-T is an immunoglobulin (Ig)M antibody, most active at 4°C (not usually active at 37°C), and does not fix complement. Based on these characteristics, it is unlikely that anti-T can cause clinically significant hemolysis.2, 3, 6 Anti-T is not always present in adults with T-activated RBCs, possibly due to neutralization by T-activated substances in the patient's plasma.2, 8 The serologic properties of anti-T do not support its role as a cause of clinically significant hemolysis. There are a variety of nonimmunologic mechanisms that can cause RBC hemolysis, which may occur in infected patients. The direct effect of toxins, such as phospholipase C (PLC), released from bacteria can damage the RBC membrane and lead to hemolysis. This effect is demonstrated in a report of an adult with sepsis secondary to Clostridia perfringens, E. coli, and enterococci, without evidence of T-activation, who died after massive hemolysis. In this patient, PLC was found to increase in concordance with levels of lactate dehydrogenase.10 The pore-forming toxin perfringolysin O, a cholesterol-dependent cytolysin, is more effective as cells age, pointing toward a role in RBC destruction at the end of their life span. Likewise, pneumolysin, another cholesterol-dependent cytolysin, can cause membrane pore formation in RBCs leading to hemolysis. With antibiotic use, as well as in the setting of sepsis, there can be increases in susceptibility to cholesterol-dependent cytolysin. When treatment with antimicrobials begins, there is an increase in the release of cytotoxins from lysis of bacteria that bind to membrane cholesterol that increase the risk of RBC membrane lysis.11-13 Finally, there are case reports of drugs such as cephalosporins causing acute hemolysis through their actions on RBCs.14 Hemolysis by anti-T is usually weak and only significant when there is profound desialylation of RBCs. Anti-T hemolysin has been found to be weaker than anti-A and anti-B hemolysins, speaking against its clinical significance. Using an in vitro system to assess anti-T-mediated hemolysis, Des Roziers and colleagues15 showed that hemolysis can significantly increase, independent of T antigen expression. These investigators showed that hemolysis after plasma administration is a rare event in patients with T-activation and NEC, possibly due to the weakness of anti-T, exhibiting titers less than 64. Low titers of anti-T are in contrast with anti-A and anti-B in group O plasma, which are usually much higher in titer, but still only rarely cause hemolysis when passively transfused. Likewise, Issitt and Anstee2 found only weak titers of 2, 4, and 8 in tested plasma. They likened anti-T to anti-P1 and Leb, antibodies that are not considered clinically significant.7, 15, 16 With sialic acid expression correlating with hemolysis of T-activated RBCs, there is no need for special blood products, except with profound desialylation and use in plasma exchange.15 Neuraminidase released by bacteria will break down sialic acid (NeuAc) in the RBC membrane, resulting in damage that causes hemolysis. Early reports in animals showed that T-activated RBCs had decreased survival and increased clearance in the presence of anti-T. To induce T-activation, the RBCs were exposed to either neuraminidase or influenza virus.7 This nonimmune mechanism of hemolysis, in the setting of T-activation, can be explained by understanding the RBC structure. Sialic acid appears to protect RBC membranes from degradation. When sialic acid is removed by hydrolysis, there is increased binding with A. hypogaea, showing that physically removing sialic acid, as opposed to immunologic actions, can destabilize the RBC membrane.17 Therefore, anti-T binding to the T-antigen is not causing the hemolysis, but it is the breakdown of sialic acid that causes RBC membrane damage and subsequent hemolysis. The presence of sialic acid is important to prevent complement-mediated lysis. Sialic acid binds to complement factor H, enhancing its affinity for C3b, inhibiting C3 convertase of the alternate pathway. The enhancement of the classic pathway on cell surfaces by desialylation has been reported.15, 18, 19 Further evidence from animal models and models using RBCs from healthy human blood donors show that there is desialylation as RBCs age, which plays a role in RBC senescence. This pathway provides additional evidence of the important role of sialic acid in maintaining RBC integrity.15, 20 Therefore, anti-T-mediated hemolysis is dependent on the degree of desialylation of RBCs, without the presence of anti-T.15 T-activation is most common in infants and young children with bacterial infections, in particular in the setting of NEC with C. perfringens and nondiarrheal hemolytic uremic syndrome (HUS) with Streptococcus pneumoniae. There are also case reports of T-activation in adults with bacterial infection.10, 21 It is important to recognize that hemolysis is more difficult to diagnose and assess in newborns and young children. Since normal ranges for analytes are different from adults, there should be caution in interpreting laboratory values. Sick newborns are subject to various fluid shifts due to therapy and blood draws that can lead to variability of hemoglobin levels.8 In addition, since pretransfusion testing of neonates is truncated to reduce iatrogenic blood loss, there are fewer opportunities to uncover T-activation. It is always important to formulate a broad differential diagnosis to rule out all other causes of hemolysis, when evaluating these very ill, complex infants.7, 8 There have been decades of case reports, case series, and discussions of the association between NEC in infants, T-activation, hemolysis, and hemolysis after transfusion. Many cases of hemolysis reported in patients with NEC occurred in patients infected with C. perfringens. In this setting, neuraminidase from C. perfringens cleaves sialic acid from the RBC membrane, exposing the T-antigen. In some patients who are T-activated and transfused with blood products from adults, whose plasma contains anti-T, severe and even deadly hemolysis has been reported. In one study of four patients, two children received standard transfusions before the diagnosis of NEC; one died and the other required two RBC exchanges, using washed RBCs suspended in albumin. Two patients who were transfused after the diagnosis and only received washed RBCs, washed platelets (PLTs), albumin, or protein fraction had no evidence of increased RBC destruction. Since this publication7-9, 22-25 and others cite worse outcomes due to T-activation and the temporal relationship with the transfusion and hemolysis, some have called for exclusive use of washed and lower-risk blood products. Conversely, some posit that T-activation is actually a marker of severity of disease, being associated with an increased risk for the need for surgery, worse outcomes including higher mortality, and the presence of C. perfringens and that the transfusion is not related to hemolysis.1, 7, 9, 24, 26-28 Although some publications show an association between T-activation and transfusion, there is no consistency in these reports. In some of the reports, serologic data, such as testing to confirm presence of anti-T, the direct antiglobulin test (DAT), and temperature of testing may be missing or contradictory. The reported cases are not consistent; some patients with T-activation do not hemolyze, some without T-activation hemolyze, some with T-activation hemolyze with unwashed products, and some with T-activation hemolyze with washed products. It is important to remember that T-activation is rare and hemolysis with T-activation is rare.1, 7-9, 16, 26, 27, 29-31 If there is a true linkage between T-activation, transfusion, and hemolysis, this variation should not exist. Nondiarrheal HUS has also been associated with T-activation, primarily in children infected with P. pneumoniae.32 As with NEC, it is associated with a reduction in sialic acid in the RBC membrane, secondary to neuraminidase, leading to hemolysis. Huang and colleagues33 have shown that T-activation is a sensitive marker for HUS in invasive pneumococcal disease, in both HUS and invasive pneumococcal disease with hemolytic anemia. They recommend that early testing can be helpful to serve as a marker of invasive disease once pneumococcus is diagnosed, since T-activation appears to precede microangiopathic anemia and thrombocytopenia. Galectins, soluble proteins that have an affinity for T-antigen, may also serve as an additional marker for T-activation.32 T-antigen is present not only on RBCs, but also on PLTs and renal glomerular cells, possibly having a role in the thrombocytopenia and renal failure seen in HUS, although these findings may be solely related to the microangiopathic changes of HUS.3, 7, 34, 35 There are case reports where children with severe HUS, who are only transfused with washed blood products and undergo plasma exchange with albumin to avoid plasma, have good outcomes.35-38 As with NEC, there are conflicting and incomplete data, creating controversy as to whether or not washed components and low anti-T-titer plasma products improve outcomes; T-activation is associated with hemolysis whether or not the patient has received a transfusion; reports of no hemolysis after transfusion of anti-T-containing products; and reports of patients receiving only low-risk products with poor outcomes.4, 7-9, 34, 39 Waters and associates34 found that using fresh-frozen plasma (FFP) or albumin for plasma exchange did not seem to have an impact on patient outcomes. Therefore, with decades of data, much of it conflicting, where are we left? Can we make some decisions and feel comfortable that these decisions will yield the best patient outcomes? In the report by Moh-Klaren and coworkers in this issue of TRANSFUSION, their patient received antibiotics and FFP due to low fibrinogen and then developed hemolysis, with tests showing T-activation; the DAT and eluate were negative. Due to worsening clinical status, the patient underwent an exchange transfusion with washed RBCs suspended in 4% albumin. The infant then developed renal failure, disseminated intravascular coagulation, and multiple organ failure leading to his death. Additional studies showed that the transfused FFP agglutinated neuraminidase-treated RBCs at 4 and 22°C, but only weakly at 37°C. DTT treatment showed that the anti-T was IgM and the titer at 4°C was 8. No hemolysis of neuraminidase-treated RBCs was observed in vitro with a serum sample from the plasma donor.1 Their accompanying prospective study included 266 infants in the NICU who were tested for T-activation. Fifty-six of 238 patients without NEC were septic or were suspected of sepsis; only mild Th activation was detected in one of these patients. Of 28 patients with NEC, three had 4+ reactivity with lectins. They received unwashed RBCs and plasma-containing blood products without evidence of hemoglobinuria; all patients were discharged from the hospital.1 Based on these findings, Moh-Klaren and coworkers concluded that the poor outcome of their patient was not due to passively transfused anti-T to their patient, but was due to nonimmune destruction. Therefore, they concluded that there is no convincing evidence for routine screening for T-activation in infants with NEC and there is no reason for the use of plasma-containing blood products to be withheld from infants with NEC, even in the presence of T-activation. The strict avoidance of plasma could be harmful, especially in the setting of coagulopathy, and manipulations of cellular products and plasma could create potentially dangerous delays.1 I am in agreement with Moh-Klaren and coworkers. There are many robust mechanisms that account for the nonimmune RBC destruction. In addition, patients studied have infections with exposure to bacterial toxins and are being treated with antibiotics that can play a role in increased RBC destruction. Reports of children with the highest risk of T-activation and hemolysis show that those children are usually the sickest, with multiple comorbidities. Some patients might have needed early transfusion before T-activation was identified, due to the severity of their disease, explaining poorer outcomes in transfused patients.7 I believe that T-activation may represent a correlate of the degree of toxin present and serve as a possible marker for disease severity. This information could be helpful for patients and their parents to understand when discussing possible prognosis and outcomes. It is difficult to find fault with practitioners trying to follow a conservative course of treatment for sick children, fragile newborns and premature infants by providing special blood products. On the other hand, there are no consistent data that transfusion of blood products with anti-T is the etiology for hemolytic events. The serologic principles we adhere to show that anti-T is not clinically significant and titers are usually low; there is also no proven “safe” threshold. Since anti-T begins to appear in infants after the age of 2 months and those older than 2 years may already have adult levels that do not appear to be causing hemolysis, it seems unlikely that passive anti-T is dangerous. Striving to work toward evidence-based treatments that result in the best patient outcomes, I think we can conclude that there is not good evidence for worsening outcomes being directly caused by transfusing standard blood products in the setting of T-activation in patients with NEC and HUS. Due to the rarity of hemolysis with T-activation and reports from various colleagues of the inability to consistently have commercial reagents readily available, conducting a randomized controlled trial may not be feasible. We are in an era of changes in the paradigms of medical practice. There are many efforts to reduce unnecessary laboratory testing and unnecessary medical interventions, understanding that doing more is not necessarily doing better. As transfusion medicine practitioners, we have been brought up with the precautionary principle that any risk needs to be mitigated, but based on literature that is more than 50 years old and more current studies, like that of Moh-Klaren and colleagues, we have not proven causality. It may be time to consider that testing to determine the need for special blood products, and supplying special blood products for the treatment of infants and children with T-activation is not necessary. The author has disclosed no conflicts of interest. Susan D. Roseff Department of Pathology VCU School of Medicine Richmond, VA e-mail: [email protected]

A TARGETED APPROACH TO INCREASING THE AFRICAN AMERICAN BLOOD DONOR POOL By Arnethea L. Sutton A dissertation submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy at Virginia Commonwealth University Virginia Commonwealth University, 2017 Advisor: William Korzun, Ph.D., DABCC, MT(ASCP), Associate Professor, Department of Clinical Laboratory Sciences A continuous need for blood products, specifically for those who require frequent transfusions, such as individuals with sickle cell disease, warrants the need for targeted interventions to increase blood donations from underrepresented populations. One population in particular, African Americans, only account for 1% of blood donors in the United States. Literature indicates numerous reasons why this population is underrepresented amongst donors, including fear, lack of knowledge about the blood donation, and specific to this population, lack of trust in the medical community. This study involves the development, implementation, and assessment of a targeted educational approach, incorporating the Theory of Planned Behavior and various teaching methods, to motivate African Americans non-donors to attempt to donate blood. Participants attended a 1-hour educational session where they completed two surveys, one before the session and one directly after. A third survey was completed 2 months after the session. Of the 155 individuals enrolled in the study, 142 subjects were included in the data analysis. Sixteen percent of the study participants presented to donate as a result of attending the educational session. This resulted in a statistically significantly higher proportion of African Americans presenting to donate than the current proportion in Virginia. Analysis of results from the first two surveys indicated that subjective norm and attitude were significant predictors of one’s intent to donate blood, while perceived behavioral control was not a factor. The educational session increased survey scores related to intent to donate in comparison to scores obtained prior to the session. While this study resulted in a significant proportion of new donors, there is still a need for interventions that will focus specifically on changing attitudes toward blood donation and a need for methods to motivate African Americans to educate individuals in the community on the importance of becoming blood donors.

Background: Although opioid prescribing in sickle cell disease (SCD) can be controversial, little is published about patterns of opioid use.Objective: To report on home opioid use among adults with SCD.Design: Cohort study.Participants: Adults with SCD (n = 219) who completed daily pain diaries for up to 6 months and had at least one home pain day.Main measures: Use of long-acting or short-acting opioids, other analgesics, or adjuvants; the proportion of home days, home pain days, and home crisis days with opioid use; these two outcomes according to patient characteristics.Key results: Patients used opioids on 12,311 (78 percent) of 15,778 home pain days. Eighty-five patients (38.8 percent) used long-acting opioids with or without short-acting opioids and 103 (47.0 percent) used only short-acting opioids. Twenty-one (9.6 percent) patients used only non-opioid analgesics and 10 (4.6 percent) used no analgesics. Both pain intensity and pain frequency were higher among opioid users (analysis of variance [ANOVA], p < 0.0001). Opioid users used hydroxyurea more often than nonusers, even when controlling for mean pain on pain days. Among all patients, significant relationships were found between any opioid use and somatic symptom burden, SCD stress, negative coping, and physical and mental quality of life (QOL); the relationship with SCD stress and physical QOL remained when controlled for mean pain. Among opioid users, similar associations were found between frequency of opioid use and some disease-related and psychosocial variables.Conclusions: In this adult SCD sample, opioids were used by the majority of patients. Pain was the overwhelming characteristic associated with use, but disease-related and psychosocial variables were also associated.

In this issue, Sandler and colleagues1 report the results of the College of American Pathologists (CAP) J-B Transfusion Medicine (Comprehensive) and Educational Survey, in which more than 3100 institutions describe how they perform Rh typing for blood donors, pregnant women, and hospital patients. In accordance with American Association of Blood Banks (AABB) Standards for Blood Banks and Transfusion Services,2 most hospital laboratories reported that they do not routinely perform a serologic weak-D test on pregnant women or transfusion recipients. This practice results in most pregnant women and hospital patients with a weak-D phenotype being categorized and managed as Rh− (Table 1).2,3 In contrast, a weak-D test is performed routinely on blood donors whose red blood cells test D− by direct agglutination, resulting in most blood donors with a weak D being categorized and managed as Rh+.2 This 50-year practice appears to be relatively safe,4 and there are only a few published reports of persons with a weak-D phenotype forming anti-D antibodies.5–8 However, this practice confuses patients, blood donors, and caregivers and uses Rh immune globulin (RhIG) and Rh− red blood cells for many persons with a weak D, who could be safely managed as Rh+, if their genotypes were known.3,9,10 The CAP Transfusion Medicine Resource Committee (TMRC) reviewed this practice in the context of the current state of science for RHD genotyping.1 The TMRC concluded that selective integration of RHD genotyping of weak D phenotypes could improve the accuracy of Rh typing results, thereby reducing unnecessary administration of RhIG in women with a weak D phenotype, and decrease transfusions of Rh− red blood cells in recipients with a weak D phenotype.1The process of phasing-in RHD genotyping in clinical practice has begun in many hospitals, but as the CAP survey indicates, most pregnant women and hospital patients in the United States continue to have their Rh type determined by dated serologic methods.1 Those laboratories that do not routinely perform weak-D tests for patients typing Rh− by direct agglutination with anti-D should now begin to introduce Rh typing reagents and procedures selected to detect, not to avoid detection of, weak-D phenotypes.We recently encountered a 27-year-old North African woman who was designated as Rh− for a cesarean section. Her medical history and laboratory test results are representative of a common subset of patients11 and illustrate how RHD genotyping can improve the management of patients with a weak-D phenotype. We have summarized recommended guidance for diagnostic testing and clinical decision making in women with a weak-D phenotype after delivery of a D+ newborn (Table 2).The woman's routine postpartum blood sample result was strongly positive by a rosette fetal bleed screening test, suggesting the presence of D+ fetal red blood cells in her circulation (fetomaternal hemorrhage). However, a quantitative, acid-elution (Kleihauer-Betke) assay result was negative, indicating that the D+ red blood cells in her circulation did not contain a significant amount of hemoglobin F; that is, the red blood cells were not of fetal origin. A weak-D test was positive, confirming the clinical impression that her red blood cells expressed an inherited weak-D phenotype. Red blood cells from approximately 0.2% to 1.0% of white people express a weak-D phenotype.12 A weak-D phenotype has been reported in 0.1% to 10% of all pregnancies that were initially typed as D−.13–15 We estimate that approximately 90% of patients in the United States with a weak-D phenotype will have one of the prevalent RHD genotypes (types 1, 2, 3, or 4.1).5,7,11,16 Women with one of these RHD genotypes may be managed as Rh+ and do not require RhIG for prenatal or postpartum Rh immunoprophylaxis.7,17 However, that decision can only be made by RHD genotyping. Even monoclonal anti-D reagents, which were initially believed to be capable of identifying RHD genotypes, cannot distinguish among the most prevalent weak-D genotypes (Table 3).6,18,19 We performed molecular testing on our patient20 and established that she had inherited the uncommon weak-D type 25,21 which required management as Rh− for purposes of Rh immunoprophylaxis and transfusion of red blood cells.The second step in phasing-in RHD genotyping will be establishing standardized, cost-effective, RHD genotyping protocols for laboratories. Most hospitals will not have a sufficient volume of patients with a weak-D phenotype to justify establishing in-hospital RHD genotyping services. Hospitals are likely to refer blood samples to regional reference laboratories where high test volumes will support both basic and complex genotyping services. A molecular test in D− pregnancies may pay for itself by avoiding the costs associated with often unnecessary multiple administrations of RhIG.4,17,22 Presently, there are no US Food and Drug Administration–approved molecular test kits for determining the Rh type, but several unlicensed products are marketed commercially in the United States. These products use polymerase chain reaction with detection by gels, bioarray chips, or bead chips. Any of these test kits and test platforms can be used for patient care as tests of either "high" or "moderate" under the Clinical Laboratory Improvement Amendments of 1988.Based on the results of its 2012 survey and review of the science of RHD genotyping, the CAP TMRC has recommended a multiorganizational collaboration among obstetricians, transfusion medicine specialists, serologists, and molecular scientists to update current practice guidelines and establish a nationwide, uniform practice.1 The CAP and AABB have formed the Work Group on Phasing-In RHD Genotyping. We believe that the time has come to transition from serologic to molecular methods for managing weak-D phenotypes. Our case illustrates how easily this transition can be accomplished. In conclusion, we support the CAP TMRC's initiative.We thank S. Gerald Sandler, MD, and Harvey G. Klein, MD, for reviewing the manuscript; A. Hallie Lee-Stroka, MT(ASCP)SBB; Neil Bangs, MS MT(ASCP)SBB; Sherry L. Sheldon, MT(ASCP)SBB; and Debrean Ann Loy, MT(ASCP)ASQ, for performing serology; David Allan Stiles, MS, and Supatta Mary Lucas, MLT(ASCP), for performing RHD sequencing; and Kshitij Srivastava, PhD, for nucleotide sequence data entry.