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Neil Blumberg

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Neil Blumberg last won the day on February 27

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    Hematologist/Transfusion Medicine Physician

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  1. One might add that use of transfusion in acute chest syndrome has almost no evidence base and may indeed do more harm than good. In transfusion, less is usually better than more.
  2. " I know we will be getting another order for an Erythrocytapheresis" That's not to say that is good clinical judgment. There is not a shred of evidence that 30% is better than 35%, and to expose the patient to the risk of another 6-8 units of red cells and an invasive procedure is, in my opinion a serious misreading of the benefits and risks of transfusion in this setting. Not to mention that the same goal (30%) could be achieved by simple transfusion of AA red cells. But neither apheresis exchange nor transfusion is indicated for clinical benefit.
  3. One unit of hemoglobin AS blood will contribute perhaps 5% to the S level in a patient with hemoglobin SS whose overall post-apheresis hemoglobin level is 10 g/dl. Not enough to make a real difference. A lot of work for pretty much nothing in my view. But we do it anyway. Probably would be less work to test donor units if the %S doesn't drop quite as far as expected. Hemoglobin S in AS red cells does not behave the way it does in SS red cells, so this has absolutely no clinical implications. The hemoglobin S goal for most treatment is 30% or less. 5% is not going to make any difference in treatment plans. Just an alternative view from the usual :).
  4. There is no such thing as never in science and medicine. But while leukoreduced transfusions may on rare occasions be associated with a CMV seroconversion, the same is true of CMV seronegative, since it is possible to have a donor who is viremic but not yet seropositive. There are those who believe CMV is almost never transmitted by transfusion, but that these seroconversions are by the usual route of individual to individual environmental transmission. I am close to that point of view. We have not used CMV seronegative, as pointed out above, for the last 20 years plus. We have a 70 bed+ neonatal intensive care unit, do about 80-100 allogeneic transplants of stem cells, heart transplants, etc. CMV seronegative is totally unnecessary and provides little or no benefit to patients. Leukoreduction is much more important overall and provides enough CMV safety on its own, in my view, to beat a dead horse here :).
  5. This is something that only works when there is expert physician to physician communication. Your medical director needs to undertake this project. There are substantial data from randomized trials and observational cohort studies that leukoreduction abrogates CMV seroconversion. These are the studies we used twenty plus years ago to convince our practitioners that leukoreduction was not only good enough, but almost certainly superior in overall clinical outcomes to CMV seronegative non-leukoreduced transfusions. Of course no patient should be receiving non-leukoreduced transfusions at this late date, but in the USA not all transfusion medicine physicians are convinced of this, in my opinion, strongly justified clinical practice.
  6. We do the same thing, for historical reasons. Probably totally unnecessary :). The amount of S hemoglobin in one unit of donor blood is not clinically significant in patient management.
  7. No guidelines, just clinical common sense. There are absolutely no data to support the need for excluding heterozygous donors, nor the need for heterozygous recipients to receive only AA blood. Heterozygous patients are physiologically normal except for some data to suggest that under extreme conditions of dehydration, altitude they are slightly more susceptible to complications that occur even among hemoglobin AA patients.
  8. TACO is congestive heart failure. Hypertension is not congestive heart failure, but may be of concern. Transient rises in the range of 170 to 200 that last minutes, not hours, are usually not of concern. That can happen with rapidly climbing a flight of stairs.
  9. Most CMV infections are acquired through environmental exposure, including breastfeeding from and close contact with a CMV infected mother. The likely source of the infection in question was exposure to family members, not transfusion. That's why close to 80% of adults in some populations are CMV seropositive. The virus is ubiquitous and highly infectious, but rarely causes any serious clinical effects except in utero and in severely immunocompromised patients.
  10. There remains controversy about this, but we have been using leukoreduction as our only method of CMV risk reduction for close to 30 years, with no reported cases of CMV transmission. We have a 70 bed newborn intensive care unit, do about 180 stem cell transplants (about 40% allogeneic), and do the occasional intrauterine exchange transfusion. CMV serotesting is never necessary for donor blood in my opinion. The existing literature isn't entirely definitive but studies have not shown that combining leukoreduction and CMV serotesting has much, if any clinical benefit. Both observational series and randomized trials demonstrate that CMV transmission after leukoreduction is not any more common than after CMV serotesting. Indeed, most CMV transmissions are likely due to seronegative donors who have recently acquired virus, but are still seronegative, or at least that's one theory. Bottom line, if you are 100% leukoreduced there is no need for CMV serotesting.
  11. In my 40 years of practice since finishing training we have never ordered Lewis negative units for transfusion. We give crossmatch compatible (IgG/37 degrees) units, although even that is probably overkill. Lewis antibodies do not cause hemolytic transfusion reactions with IgG/37 degree non-reactive units. Your pathologist is perhaps not a full time transfusion medicine physician? Not that there's anything wrong with that :).
  12. Because of the rare risk of a fatal hemolytic reaction, we only use washed group O red cells for our premature newborns. For other newborns and readmits we use ABO identical unless there is detectable maternal anti-A and/or anti-B, in which case we again use washed group O's. There is about 20-40 ml of residual plasma in almost all red cell units, more than enough to cause severe hemolysis in rare instances. We should not ignore that risk for our own convenience/inventory management/etc. in my view. We only transfuse unwashed group O red cells to patients of unknown ABO type in emergencies. There is additional evidence that ABO non-identical transfusions of incompatible antibody or soluble antigen causes harm to patients, in addition to the rare risk of life-threatening hemolysis. We have published a summary of this evidence. Is It Time to Reconsider the Concepts of "Universal Donor" and "ABO Compatible" Transfusions? Refaai MA, Cahill C, Masel D, Schmidt AE, Heal JM, Kirkley SA, Blumberg N. Anesth Analg. 2018 Jun;126(6):2135-2138. doi: 10.1213/ANE.0000000000002600.
  13. Sorry about the incomplete references. Here are the full references for the two missing :). ABO identical and washed blood transfusions as candidate strategies to reduce early mortality in acute promyelocytic leukemia. Sahai T, Henrichs K, Refaai M, Heal JM, Kirkley SA, Schmidt AE, Mendler JH, Masel D, Liesveld J, Aquina C, Blumberg N. Leuk Res. 2017 Nov;62:1-3. doi: 10.1016/j.leukres.2017.09.011. ABO-immune complex formation and impact on platelet function, red cell structural integrity and haemostasis: an in vitro model of ABO non-identical transfusion. Zaffuto BJ, Conley GW, Connolly GC, Henrichs KF, Francis CW, Heal JM, Blumberg N, Refaai MA. Vox Sang. 2016 Apr;110(3):219-26. doi: 10.1111/vox.12354.
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