TimOz

Hi Yanxia, This was not my case but one I know of. The notes I have are this: 60 year old female with endometrial and ovarian Carcinoma. Had been transfused with 26 units of blood uneventfully Case notes: 1200 hrs Transfusion commenced 1230 hrs C/O back, neck and chest pain, dyspnoea and very distressed, Transfusion stopped Temp 36.7 – 36.7, Pulse 94 – 102, BP 90/60 – 120/60 1245 hrs Feeling better so transfusion recommenced 1300 hrs Rigors started, Temp 37.5, Pulse 112, BP 140/80, TRANSFUSION STOPPED AND CEASED! Follow up: Antibody screen negative, DAT negative, Unit gave 12 reaction in DiaMed AHG crossmatch, Crossmatch repeated with same result. Reference lab reproduced findings + Antibody detected in Saline 22 and 37 when tested against the donor cells. Antibody did not react by enzyme technique Plasma positive with: Plasma negative with: Vw Mi VII Mi III Hil and MINY- Mi IV Mi VI Mi X At the time (2005) this was interpreted as an Anti-Vw reacting with Mi III cells but the pattern (if the reference cell phenotypes are correct) looks like an anti-Mia. Donor cells were typed as M POS, N NEG, S NEG, AND s POS. Typing with antibodies to various Miltenberger classes showed the donor is almost certainly Mi III (GP.Mur). This was a first time donor of unknown ethnicity. Shily, If you can get your hands on the clinical case review publication mentioned above you can see quite a bit of data that you should find useful. In summary, there is likely to be a very significant underreporting of these cases. There are a total of 35 clinical cases attributed to antibodies to MNS system hybrid glycophorins reported in the literature, 8 (23%) detailed HTRs, one of which was associated with a fatality. In all 8 reported HTR cases there has been IgG present, and in 1 case, only IgG was present. IgG titers in reported cases range from 8 to 512, although in only 3 cases were titers reported. Unsurprisingly, to date, there have been no cases of HTR reported in which only IgM alloantibodies were present.

Hi Malcolm, 1. IVF, donor egg? 2. Advice on the paint. Use peanut butter (or peanut oil). Rub it in and it should help the paint slip off the hair shafts.

Hi All, I have been away for a while. The article Damien mentioned is in print. the reference is: Heathcote D, Carroll T, Flower R. Sixty years of antibodies to MNS system hybrid glycophorins: What have we learned?. Transfusion Medicine Reviews (Volume 25 #2); April 2011 Shily, We have seen an HTR case similar to your in Australia. Negative antibody screen (no MNS system hybrid glycophorin phenotypes on the screening cells used). No IAT crossmatch performed as blood was issued on a "Group, Screen Electronic Blood Release" protocol. 2 unit crossmatch. Reaction to second unit with haemolysis. Patient was female and incompatible with her husband's red cells in an IAT crossmatch.

I wonder why the Echo will not do an Auto control? A DAT is looking for in-vitro antibody binding and an auto is a cl,assic IAT looking for in-vivo binding. It is not uncommon for negative DAT cells to have a positive auto control and this is commonly due to the LISS effecting antibody uptake (as it is designed to do). If you see pan agglutination in your ID panel, what do you do then? May be the Echo thinks you will switch to alternative technology. I think in these cases most experienced Immunohaematologists will go straight to tube technique and set up an auto anyway.

Hi XBSYB, Please put your country in your profile. It makes a big difference as the analysers mentioned are not available in some regions and are known by a number of different names. We do not use an Innova but I am very familiar with the AutoVue (earlier software) and the Innova and installed a few. This Innova instrument is Swiss and made by Tecan. The engineering is excellent and very reliable and built like a Swiss watch. The provue is a Spanish built unit (I beleive) by Grifols or a consulant engineering company and it is called the Diana or ID-WA or ID Walkaway or ID WA Compact or ID GelExpress and so on. It has been available in many variations. The second main benefit that is not obvious is that the Innova has 2 doors compared to the Provue's one door. This means that the Provue/Diana is basically a batch analyser as once running, does not like the door being opened once running. For this reason, often 2 units are installed, one for routine samples and one for stat samples. The Innova, on the other hand, has a main door and a second sample and reagent entry door on the left that is independant of the main door that can be opened at any time. This means that the instrument can be loaded with a batch os samples and a stat can be added later at any time and the software does a pretty good job of feeding the stat test into the system as soon as possible without interrupting the routines. The Innova has new Windows based software is very nice and allows flexibility in reagent red cell choice. The previous version had OS2Warp based software that was pretty nasty. You need to check that the throughput and turn around time suit your needs. Some labs in Australia have a single instrument that runs well. Other labs will have 2 units to cope with workload, TAT. routine samples plus stats and allow downtime for service. FYI, there are 2 new large throughput analysers coming from Grifols and DiaMed/BioRad but they are unlikely to be available in the US any time soon due to FDA license timing. These have not been really seen and the jury is still out but the quoted throughput is higher than current instruments. In summary, the Innova appears to be a much better instrument for most labs than the Provue/diana instrument.

Three in a row may just be Murphy's law but I would also check the gel cards. Is the liquid level where it normally is? If they are a little dried out the increase in liquid density may be increasing non-specific type reactions or altering the sensitivity.

I agree with the gurus above. There is a temptation to directly compare tube AHG with Gel AHG without considering the differences that washing makes. Gel picks up IgM quite well depending on how it behaves and the thermal amplitude where the tube test this may be washed off. A few other points. "Gel only" reactions can have quite a few causes like high protein levels and I have seen CLL patients with high leucocyte counts having positive reactions in everything. The white cells just physically block the gel. In one case it seemed impossible to clean up the red cells anough to even get a good gel group. Only tube methods worked on this patient - while he lasted.

I agree with rravkin. OCD at one staged advised to prespin BioVue cards (these are not ID-MTS) if they were splashed in transport BUT this is a silica bead system. I understand the plastic (gel) beads can "pack down" in spinning and alter the reactions. I have not seen data to support this but I would check.

Hi Juliane, Note that In my post above I typed 2 hyphen 8oC but it has not displaying correctly!!!!!!! This is true in Australia, Europe and the whole world - except the US. From the current pace inserts in front of me: DiaMed ID-MTS LISS/Coombs Poly - "Storage requirements 18 - 25oC . Do not store near any heat, air conditioning sources or ventilation outlets". Ortho Clinical Diagnostics BioVue Anti-IgG, C3d; polyspecific - "Storage requirement: Store cassettes upright at 2 to 25oC. Do not store in a self defrosting refrigerator/freezer. Do not store cassettes near any heat source (i.e Heat Block, radiator, large instrumentation, refrigerator, freezer, etc., or in any area receiving direct sunlight." OCD will tell customers to store tham at 2 to 8oC if they have room in the cold room and bring out the cassettes for use and leave them at RT as long as they are not heated in any way - see above. The US is different as you have OCD ID-MTS gel system and neither product above is available . Like I said, this gets confusing if the geography is not defined or the exact product used is clear. DiaMed Gel and Ortho gels are similar but not the same. Many people outside the US call the Ortho BioVue product a gel as they use this as a generic term and it is not correct.

Not that I want to disagree with Rashmi but to add to her comments about validation. Please make sure that you do not go into this with the thought that a validation process is just testing and documenting the test performance. You should (especially in this case) make sure that you are testing the actual performance and ensuring that it is acceptable!!! You need to establish what is acceptable performance before testing and make sure you test appropriately - see my comments on plastic tube variability as an example of what should be covered. If I tried to validate plasrtic tubes for IAT testing in my lab they would simply fail and not be usable.

Hi HWalker, Just a suggestion. Could you add where you are from in your profile? I just realised my comments above refer to Ortho BioVue that is NOT the gel ID-MTS system available in the US and is not a gel but silica bead based. Ortho BioVue likes to be stored at 2-8oC and will eventually evaporate if stored at higher temperatures or on a bench in the sun where it can warm up. Ortho ID-MTS gel is similar but not the same as the DiaMed ID-MTS system we have here. It does not like to be chilled and should be stored at RT. You will get more accurate advice if we are not confused about what you are actually using.

Hi, What ethicity is the patient? The D--/D-- phenotype is found in significant incidence in some ethnicities. For example the Bidayu are an aboriginal group from Borneo that have anti-Rh17 sometimes and they are a problem to deal with. Checking family members and also members of the community of the patient has a defined and unusual ethnicity may be useful.

Walking blood banks are not uncommon in very remote part os Australia. It is organised and potential walking donors are prequalified, tested and are screened for infectious diseases on a routine basis. They are not used except as a last resort like a mining disaster in a very remote area. Better to preplan and keep the potential donors tested. There os not guarantee that you will hit a window period infection but this system lowers the risk significantly.

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In short - NO. We have not changed and will not. I think plastic is far inferior to glass for tube IAT. My post above is just relating my experiences in looking into the issues to generate an informed opinion. At the risk of being controversal, I think converting to glass is Health and Safety trying to fix a problem that does not exist and lowering the quality of the test in the process.