Kellar

It is great to see consensus from these six important groups involved with clinical transfusion medicine practice.  
 
Researchers are already working towards the point-of-care style platforms mentioned in the article, and I suspect it is not as far in the future as one might think.
 
I think genotyping should become routine.  Personally, I don't understand why we have been trying to approach RhD as simply positive or negative.  Transfusion medicine professionals, whether bench techs or physicians, are smart enough to handle the complexity of RhD in particular without putting blinders on and pretending D variants don't exist. (Here, I'm referring to the article where it says "some labs conduct the test for weak D serological testing for women when they’re patients, but then, no matter what the result is, report it as Rh-negative".) 
 
Maybe with routine molecular testing available, we can change the way we think and talk about RhD and incorporate the true complexity of the situation into transfusion practice to improve patient treatment on both individual and systemic levels.  That said, routine molecular testing does not mean abandonment of serological testing.  Each has a niche and they complement each other well.

It is great to see consensus from these six important groups involved with clinical transfusion medicine practice.  
 
Researchers are already working towards the point-of-care style platforms mentioned in the article, and I suspect it is not as far in the future as one might think.
 
I think genotyping should become routine.  Personally, I don't understand why we have been trying to approach RhD as simply positive or negative.  Transfusion medicine professionals, whether bench techs or physicians, are smart enough to handle the complexity of RhD in particular without putting blinders on and pretending D variants don't exist. (Here, I'm referring to the article where it says "some labs conduct the test for weak D serological testing for women when they’re patients, but then, no matter what the result is, report it as Rh-negative".) 
 
Maybe with routine molecular testing available, we can change the way we think and talk about RhD and incorporate the true complexity of the situation into transfusion practice to improve patient treatment on both individual and systemic levels.  That said, routine molecular testing does not mean abandonment of serological testing.  Each has a niche and they complement each other well.

I have heard similar stories many times and am a bit disheartened that the narrative never changes.  Do you think there would be value in having a person from the transfusion service "issued" along with the first units when a mass hemorrhage plan is activated?  I imagine this person acting as a liaison/translator/educator/helping hand/cool head with respect to transfusion.  I can imagine that when things are going badly in OR or Emergency, all the little details that are important for transfusion are NOT priority in the minds of those involved in direct treatment of the patient.  Perhaps the TM service could provide a little assistance. 
 
From a broader perspective, as lab professionals, are we too attached to our labs? Whether it is true or not, we tend to feel that we are undervalued and under appreciated, but at the same time we stay hidden away in the lab making demands that seem like nit picking to those without training in laboratory practices.  I think, traditionally, that pathologists have been the link between lab professionals and primary care providers (i.e. physicians and nurses).  But pathologists can be very busy with their many other duties, is there a place for non-pathologist lab professionals to step in make more direct connections with primary care providers?  

I have heard similar stories many times and am a bit disheartened that the narrative never changes.  Do you think there would be value in having a person from the transfusion service "issued" along with the first units when a mass hemorrhage plan is activated?  I imagine this person acting as a liaison/translator/educator/helping hand/cool head with respect to transfusion.  I can imagine that when things are going badly in OR or Emergency, all the little details that are important for transfusion are NOT priority in the minds of those involved in direct treatment of the patient.  Perhaps the TM service could provide a little assistance. 
 
From a broader perspective, as lab professionals, are we too attached to our labs? Whether it is true or not, we tend to feel that we are undervalued and under appreciated, but at the same time we stay hidden away in the lab making demands that seem like nit picking to those without training in laboratory practices.  I think, traditionally, that pathologists have been the link between lab professionals and primary care providers (i.e. physicians and nurses).  But pathologists can be very busy with their many other duties, is there a place for non-pathologist lab professionals to step in make more direct connections with primary care providers?  

I will try to answer this without completely boring everyone with the insanity that is RH genetics.
For a true weak D, the antigenic epitopes of the RhD protein are the same as those in a D-positive individual, they just have fewer of them so serologic testing comes up weak. RhIg actually does nothing for these women because they will never become immunized. You are on the right track about the "mosaic", now referred to as partial D. There are many genetic alterations that cause partial D and the RhD protein in these individuals can differ significantly from the "normal" protein. Actually, there are many genetic alterations for weak D as well, but I digress.
From what I have read, the mechanism by which RhIg prevents immunization isn't well understood, but the theory that it binds to the foreign RhD protein and blocks recognition by the mom's immune system in common. The wonderful thing about human sourced RhIg is that it is polyclonal and can therefore recognize the modified protein in partial D. It will, in theory, also recognize the normal parts of the protein, but this generally doesn't cause significant problems even in those with weak D. Studies with monoclonal RhIg have shown incomplete protection against immunization. I believe most transfusion services act conservatively and administer RhIg to all mom's with weakened reactions in serologic D typing tests, mainly because serology cannot differentiate between weak D and partial D. Literature suggests that RhIg need not be given to those where genetic testing has classified them as weak D types 1, 2 or 3.
I'm sorry if I have managed to confuse you with this quick and dirty explanation. You may find this paper helpful.
Flegel WA, Denomme GA, Yazer MH. On the complexity of D antigen typing: a handy decision tree in the age of molecular blood group diagnostics. Journal of obstetrics and gynaecology Canada. 2007;29(9):746-52