Management of autoimmune haemolytic anaemia in low-to-middle income countries: current challenges and the way forward

Autoimmune haemolytic anaemia (AIHA) is a common term for several disorders that differ from one another in terms of aetiology, pathogenesis, clinical features, and treatment. Therapy is becoming increasingly differentiated and evidence-based, and several new established and investigational therapeutic approaches have appeared during recent years. While this development has resulted in therapeutic improvements, it also carries increased medical and financial requirements for optimal diagnosis, subgrouping, and individualization of therapy, including the use of more advanced laboratory tests and expensive drugs. In this brief Viewpoint review, we first summarize the diagnostic workup of AIHA subgroups and the respective therapies that are currently considered optimal. We then compare these principles with real-world data from India, the world's largest nation by population and a typical low-to-middle income country. We identify major deficiencies and limitations in general and laboratory resources, real-life diagnostic procedures, and therapeutic practices. Incomplete diagnostic workup, overuse of corticosteroids, lack of access to more specific treatments, and poor follow-up of patients are the rule more than exceptions. Although it may not seem realistic to resolve all challenges, we try to outline some ways towards an improved management of patients with AIHA.

Molecular basis of DEL phenotype in the Indian population: Insights from next-generation sequencing analysis of two cases

The DEL phenotype represents an intriguing and challenging aspect of blood group serology. This condition is characterized by an extremely weak expression of the D antigen on red blood cells, to the extent that it often eludes detection through routine serological methods. Identifying the DEL phenotype necessitates more specialized techniques, such as adsorption and elution tests, to reveal the presence of the D antigen. This distinctive phenotype underscores the complexity and subtlety of blood group genetics and highlights the importance of using advanced methods to accurately classify individuals with this condition, as their ability to form anti-D antibodies can have clinical implications during transfusion and pregnancy scenarios. There is a paucity of data for the DEL phenotype in the Indian population, and the molecular basis has not been elucidated yet. Our investigation delves into the genetic underpinnings of two distinct DEL phenotype cases that pose challenges for resolution through conventional serological techniques. We employ next-generation amplicon sequencing to unravel the intricate genetic landscape underlying these cases. In the D-negative donor, the DEL phenotype was first identified serologically, which was subsequently confirmed by molecular analysis. In the second case, it was associated with an anti-D antibody in a D-positive patient. Initial data analysis unveiled a substantial reduction in coverage across the exonic segments of the RHD gene in both samples, suggesting the potential presence of RHD exon deletions. On both occasions, we identified a homozygous intronic RHD polymorphism that is well established to be linked to the RHD* 01EL.32/RHD*DEL32 variant.

Current challenges of blood transfusions in patients with thalassemia in India and future perspectives

The introduction of regular red blood cell transfusions transformed thalassemia major from a fatal childhood disease into a chronic disorder. Thalassemia is highly prevalent in South Asia, including the Indian subcontinent, and blood transfusion remains the cornerstone of management for these patients. But safe blood transfusions still remain a major problem in India. Difficulties in maintaining adequate blood inventory, a lack of a national blood act, and fragmented blood transfusion services are some of the major contributing factors for the delay in blood supply. In most of the blood centers, alloantibody detection facilities and extended red cell antigen typing are unavailable. Awareness is the key to reducing alloimmunization, which limits the effectiveness of transfusions and the potential availability of blood. Patients with thalassemia are also at high risk of transfusion-transmitted infections unless appropriate blood screening is in place. Hence, many patients remain under-transfused, resulting in decreased health and quality-of-life outcomes. Facilities such as leucoreduction and immunohematological monitoring following a blood transfusion are often lacking in India, especially at the sub-district level. Continuous efforts to raise community awareness, regular training of health-care workers, and proper utilization of available resources are essential to ensuring safe blood transfusions for patients with thalassemia. Access to the new treatments at an affordable cost may reduce the blood transfusion burden for thalassemia patients in India.

Molecular analysis and transfusion management in a rare case of cis-AB blood group: A report from India

Molecular characterization of a rare cis-AB blood group has not been done in the Indian subcontinent. Herein, we report a case of A2B3 blood group in an Indian patient which was subsequently confirmed to be a case of cis-AB phenotype. Blood grouping was performed by the column agglutination technique (CAT), conventional tube technique (CTT) and subsequently, whole exome sequencing for molecular analysis. The patient was initially typed as AB, RhD positive in forward grouping. However, serum grouping showed agglutination (2+) with the B red cells in CAT. In CTT, an extra reaction was observed with A1 red cells and a strong agglutination was seen with Anti-H lectin. Thus, the blood group was identified serologically as A2B3. During the next-generation sequencing, a total of 10 exonic variants in the ABO gene were filtered, of which 2 (rs8176747 and rs7853989) were found to be non-synonymous and occurring on the same allele. The other allele was found to be ABO*A1.01. The sample analyzed in the study was found to carry two previously reported nucleotide changes of cis-AB (c.803G > C and c.526C > G) on the same allele which had not been reported before. Transfusion requirement was managed with type O red cells and type AB plasma.

Rare blood group registry in India-current challenges and future perspectives

Patients who require blood from rare blood group donors present great challenges even to the most advanced healthcare delivery system. It is most challenging to supply blood for a patient with an antibody to an antigen of high prevalence. The blood donor lacking the corresponding antigen would have an occurrence rate of less than one in 1,000. The International Rare Donor Panel was established in 1965, but since then there has been gross underrepresentation of South Asian countries, including India. There are several challenges to starting a rare blood group donor program in India that include technical, logistical, and administrative limitations. But the main limiting factors are poor availability of trained resources, lack of awareness, absence of antibody screening, inadequate number of laboratories with blood group genotyping facilities, and the decentralized nature of blood transfusion services. Despite that, there were several rare blood groups identified by Indian immunohematologists in the recent past. Recently, a transfusion genomic group has been established in collaboration with the clinical transfusion medicine specialists in India under the GUaRDIAN (Genomics for Understanding Rare Disease in India Alliance Network) initiative to address the domain of rare blood group genomics. Similarly, the National Institute of Immunohematology, Mumbai under the directive of the ICMR (Indian Council of Medical Research) has taken a step to start the RDRI (Rare Donor Registry of India). In this context, we explore the current challenges of setting-up a rare blood group registry in India and future goals from a developing nation's perspective.

Real-world data from India on clinical practices in the management of autoimmune haemolytic anaemia: A survey-based cross-sectional assessment

BACKGROUND

Autoimmune haemolytic anaemia (AIHA) is a decompensated acquired haemolysis caused by the host's immune system acting against its own red cell antigens. The aim of this national survey is to capture real-world data of clinical practices in AIHA by collecting responses from clinical haematologists across India.

METHODOLOGY

In this cross-sectional study, a structured, 26-question online survey was conducted in India by few members of the special interest group in immunohaematology between January and March, 2022. The final survey consisted of questions covering place of work, amount of AIHA cases being evaluated by the haematologist over preceding years, basic demographic, clinical and laboratory features of the patients being treated under them etc. Descriptive statistical analysis was performed during the assessment.

RESULTS

The survey response rate was 48.2% (53/110), 69.8% (37/53) have diagnosed and managed more than 10 AIHA cases in the last 3 years with a female preponderance. There was considerable variability in response. While 56.6% (30/53) of respondents do have the access to the facilities to subtype AIHA cases; 32.1% (17/53) of clinicians would prefer administering high dose steroids for 6 weeks or more in non-responding patients, and only 45.3% (24/53) would assess the risks of thrombosis in AIHA. There is unanimous agreement among the participants that health-related quality of life should be taken into consideration in patients and the need for a national registry of patients with AIHA in India.

CONCLUSION

The current national survey showed that some aspects of AIHA management were consistent; others were less so, but also significant variations were observed in certain clinical practices, where the evidence base is limited. A joint effort is needed to establish a national patient registry by including both clinical haematologists and transfusion medicine specialists which could potentially standardise AIHA management and future research in India.

Should we adopt an automated de-centralized model of chimeric antigen receptor- T cells manufacturing for low-and middle-income countries? A real world perspective

Autologous chimeric antigen receptor-T (CAR-T) cell therapy has proven itself as an effective therapeutic modality for cancers, especially hematological malignancies and is emerging as a potential candidate for solid organ cancers as well. However, the accessibility to treatment has been limited due to complexities and costs associated with manufacturing a genetically modified autologous product. The centralized model of CAR-T manufacturing which has emerged as the dominant model in developed nations does not seem well-suited to the needs and realities of the developing economies. In this context, we explore the relative advantages and disadvantages of the two models from a developing nation's perspective.

A multicenter prospective observational study on the use of type and screen method versus conventional type and crossmatch policy for pre-transfusion testing in the Indian population

Despite knowing the benefits of the type and screen (TS) method in pre-transfusion testing (PTT), most transfusion centers in developing countries continue to be reluctant to adopt a TS strategy over the conventional type and antihuman globulin (AHG) crossmatch (TX) policy in their routine laboratory practice because of the cost of obtaining antibody screening reagents. To generate strong evidence, this multicenter, observational study was conducted in which we collected data prospectively over a 1-year period from six major blood centers in India. The primary objective of this study was to identify the discordance between TS and TX results. A secondary objective was to identify the allo-antibody specificity in patients with positive antibody detection tests. All patients with orders for red blood cell transfusion who met patient selection criteria were subjected to parallel testing by column agglutination technology (CAT) for both the antibody detection test (screen) using a commercial three-cell panel and for the AHG crossmatch. A total of 21,842 patients were tested. In 148 patients with incompatible crossmatches, samples from six patients gave negative results with the antibody detection test, whereas the antibody detection test was positive in samples from 118 patients among the 21,694 crossmatch-compatible cases. The TS approach achieved a positive percent agreement of 95.95 and was found to be significantly effective in preventing the transfusion of serologically incompatible blood. The risk associated with abbreviating the AHG crossmatch was found to be 0.009 percent. Most of the identified clinically significant alloantibodies were directed to Rh antigens (D>E>c>C>e), followed by anti-K and anti-M. This study has generated sufficient robust data for the Indian population by including patients from all major geographical areas of the country and concluded a satisfactory agreement level as well as non-inferiority to the current PTT policy. Therefore, TS policy can be implemented in developing countries with no compromise on blood safety, provided sufficient technical and infrastructural support are available.

Use of Thromboelastography Platelet Mapping for Assessment of Individual Platelet Response Secondary to Oral Antiplatelet Therapy after Percutaneous Coronary Intervention: An Attempt to Start Personalized Antiplatelet Therapy in India

High on-treatment platelet reactivity (HPR) with P2Y12 receptor antagonists in patients treated with dual antiplatelet therapy (DAPT) is strongly associated with adverse ischemic events after percutaneous coronary intervention (PCI). This prospective study was conducted to assess individual platelet response and HPR to antiplatelet medications in post-PCI cases by thromboelastography platelet mapping (TEG-PM). Total 82 patients who were on aspirin and on either clopidogrel, prasugrel, or ticagrelor were evaluated. The percentage of platelet inhibition to arachidonic acid (AA) and adenosine diphosphate (ADP) was calculated by [100-{(MA ADP/AA–MA Fibrin) / (MA Thrombin–MA Fibrin) × 100}], taking 50% response as cut-off for HPR. HPR to clopidogrel and prasugrel was 14.29 and 12.5%, respectively. No HPR was detected to aspirin and ticagrelor. The mean percentage of platelet inhibition was significantly higher in patients with ticagrelor 82.99, 95% confidence interval (CI) of [77.3, 88.7] as compared with clopidogrel 72.21, 95% CI of [65.3, 79.1] and prasugrel 64.2, 95% CI of [52.5, 75.9] (p-value of 0.041 and 0.003, respectively). Aspirin along with ticagrelor is associated with a higher mean percentage of platelet inhibition, and lower HPR as compared with the usage of aspirin combined with clopidogrel or prasugrel. Additionally, it might also be concluded that TEG-PM could be used effectively to measure the individual platelet functions which would make oral antiplatelet therapy more personalized for cardiac patients.

Comparative evaluation of the conventional tube test and column agglutination technology for ABO antibody titration in healthy individuals: a report from India

Determination of accurate anti-A/-B titers is important for treatment selection in ABO-incompatible stem cell and solid-organ transplants. The standard method for ABO antibody titration is the conventional tube test (CTT). Dithiothreitol (DTT) is commonly used to inactivate the IgM antibody component. The aim of this study was to compare six different methods for ABO antibody titration and to observe the effectiveness of DTT on antibody estimation. A total of 90 healthy voluntary blood donors were enrolled in this study, including 30 each for blood groups A, B, and O. Antibody titrations were performed and tested using the CTT-immediate spin (IS), CTT-antihuman globulin (AHG) with and without DTT, column agglutination technology (CAT)-IS, and CAT-AHG with and without DTT methods. Bead-CAT was used, and the positive cutoff value was set to 1+ for each method to determine the endpoint of the titer. The median values of anti-A/-B titers by IS were found to be higher than those values by AHG in CTT and CAT among group B and A individuals, whereas no statistically significant differences were observed in values from group O individuals for IS and AHG anti-A/-B titers, estimated by each method. Although there was positive correlation between the anti-A/-B titer results obtained using the CTT and CAT in all blood groups, testing using AHG showed poor agreement with and without DTT pretreatment (kappa value of 0.11 and 0.20, respectively). Moderate agreement was observed between CTT-IS and CAT-IS (kappa value of 0.46). Median anti-A/-B AHG titers were reduced by the use of DTT in all blood group samples. Significant differences in the interpretability of anti-A/-B titers were observed among different methods. A uniform approach for selecting the method for ABO antibody titration is highly recommended, and DTT pretreatment of plasma to neutralize IgM activity should be considered to obtain precise values of IgG anti-A/-B titers. Immunohematology 2021;37:25-32 .

Determination of accurate anti-A/-B titers is important for treatment selection in ABO-incompatible stem cell and solid-organ transplants. The standard method for ABO antibody titration is the conventional tube test (CTT). Dithiothreitol (DTT) is commonly used to inactivate the IgM antibody component. The aim of this study was to compare six different methods for ABO antibody titration and to observe the effectiveness of DTT on antibody estimation. A total of 90 healthy voluntary blood donors were enrolled in this study, including 30 each for blood groups A, B, and O. Antibody titrations were performed and tested using the CTT-immediate spin (IS), CTT-antihuman globulin (AHG) with and without DTT, column agglutination technology (CAT)-IS, and CAT-AHG with and without DTT methods. Bead-CAT was used, and the positive cutoff value was set to 1+ for each method to determine the endpoint of the titer. The median values of anti-A/-B titers by IS were found to be higher than those values by AHG in CTT and CAT among group B and A individuals, whereas no statistically significant differences were observed in values from group O individuals for IS and AHG anti-A/-B titers, estimated by each method. Although there was positive correlation between the anti-A/-B titer results obtained using the CTT and CAT in all blood groups, testing using AHG showed poor agreement with and without DTT pretreatment (kappa value of 0.11 and 0.20, respectively). Moderate agreement was observed between CTT-IS and CAT-IS (kappa value of 0.46). Median anti-A/-B AHG titers were reduced by the use of DTT in all blood group samples. Significant differences in the interpretability of anti-A/-B titers were observed among different methods. A uniform approach for selecting the method for ABO antibody titration is highly recommended, and DTT pretreatment of plasma to neutralize IgM activity should be considered to obtain precise values of IgG anti-A/-B titers. Immunohematology 2021;37:25–32 .

Use of Thromboelastography Platelet Mapping for Assessment of Individual Platelet Response Secondary to Oral Antiplatelet Therapy after Percutaneous Coronary Intervention: An Attempt to Start Personalized Antiplatelet Therapy in India

High on-treatment platelet reactivity (HPR) with P2Y12 receptor antagonists in patients treated with dual antiplatelet therapy (DAPT) is strongly associated with adverse ischemic events after percutaneous coronary intervention (PCI). This prospective study was conducted to assess individual platelet response and HPR to antiplatelet medications in post-PCI cases by thromboelastography platelet mapping (TEG-PM). Total 82 patients who were on aspirin and on either clopidogrel, prasugrel, or ticagrelor were evaluated. The percentage of platelet inhibition to arachidonic acid (AA) and adenosine disdiphosphate (ADP) was calculated by [100-{(MA ADP/AA–MA Fibrin) / (MA Thrombin–MA Fibrin) × 100}], taking 50% response as cut-off for HPR. HPR to clopidogrel and prasugrel was 14.29 and 12.5%, respectively. No HPR was detected to aspirin and ticagrelor. The mean percentage of platelet inhibition was significantly higher in patients with ticagrelor 82.99, 95% confidence interval (CI) of [77.3, 88.7] as compared with clopidogrel 72.21, 95% CI of [65.3, 79.1] and prasugrel 64.2, 95% CI of [52.5, 75.9] (p-value of 0.041 and 0.003, respectively). Aspirin along with ticagrelor is associated with a higher mean percentage of platelet inhibition, and lower HPR as compared with the usage of aspirin combined with clopidogrel or prasugrel. Additionally, it might also be concluded that TEG-PM could be used effectively to measure the individual platelet functions which would make oral antiplatelet therapy more personalized for cardiac patients.

ABO, Rhesus, and Kell Antigens, Alleles, and Haplotypes in West Bengal, India

Background

Few studies have documented the blood group antigens in the population of eastern India. Frequencies of some common alleles and haplotypes were unknown. We describe phenotype, allele, and haplotype frequencies in the state of West Bengal, India.

Methods

We tested 1,528 blood donors at the Medical College Hospital, Kolkata. The common antigens of the ABO, Rhesus, and Kell blood group systems were determined by standard serologic methods in tubes. Allele and haplotype frequencies were calculated with an iterative method that yielded maximum-likelihood estimates under the assumption of a Hardy-Weinberg equilibrium.

Results

The prevalence of ABO antigens were B (34%), O (32%), A (25%), and AB (9%) with ABO allele frequencies for O = 0.567, A = 0.189, and B = 0.244. The D antigen (RH1) was observed in 96.6% of the blood donors with RH haplotype frequencies, such as for CDe = 0.688809, cde = 0.16983 and CdE = 0.000654. The K antigen (K1) was observed in 12 donors (0.79%) with KEL allele frequencies for K = 0.004 and k = 0.996. Conclusions: For the Bengali population living in the south of West Bengal, we established the frequencies of the major clinically relevant antigens in the ABO, Rhesus, and Kell blood group systems and derived estimates for the underlying ABO and KEL alleles and RH haplotypes. Such blood donor screening will improve the availability of compatible red cell units for transfusion. Our approach using widely available routine methods can readily be applied in other regions, where the sufficient supply of blood typed for the Rh and K antigens is lacking.

POEMS Syndrome with Biclonal Gammopathy: A Rare Association

Polyneuropathy, Organomegaly, Endocrinopathy, M protein and Skin changes (POEMS) syndrome is rare plasma cell dyscrasia with multisystem involvement. The name comes from the five characteristic features: Polyneuropathy, organomegaly, endocrinopathy, M protein and skin changes. The presence of biclonal M band is a rare manifestation. Here, we are describing the cases of a 60-year-old lady, presented with bilateral pedal oedema and pericardial effusion and peripheral neuropathy. She also had hepatosplenomegaly, hyperpigmented rash and hypothyroidism and hyperparathyroidism. The serum protein electrophoresis and the immunofixation electrophoresis revealed two distinct monoclonal bands, immunoglobulin IgG kappa and IgA lambda. There was a mild increase in plasma cells and sclerotic bone lesion in pelvis. The POEMS syndrome is generally associated with lambda light chain restriction. The presence of biclonal gammopathy involving kappa and lambda is a rare manifestation. The pathogenic or prognostic role of different paraprotein is not known. Further studies are required to delineate such effect.

Blood Group Discrepancy-First Sign of Autoimmune Hemolytic Anemia after Hematopoietic Stem Cell Transplantation in a Child

A 12-year-old male child was presented in the emergency with features of anemia and mild icterus on day+67 of HSCT. The child was suffering from Fanconi anemia and undergone HSCT from ABO-matched, fully HLA matched sibling donor. The diagnosis of mixed type AIHA due to cytomegalovirus reactivation was made in the immunohematology laboratory and blood group discrepancy was the first sign of AIHA in this patient. Though the cold agglutinin titer was not significant but the clinical symptoms and laboratory evidences were suggestive of significant hemolysis due to underlying IgG autoantibody. In addition the high complement avidity of IgM autoantibody might also be a contributing factor for clinically significant hemolysis in this case. The patient was successfully treated with phenotype matched blood transfusion, rituximab and oral steroid therapy.

Resolution of Serologic Problems Due to Cold Agglutinins in Chronic Lymphocytic Leukemia

INTRODUCTION

Autoimmune hemolytic anemia can be classified depending on presence of warm, cold or mixed type of autoantibodies that are directed against antigens on the red blood cell surface. Here we report a case of pathological cold agglutinin disease which was eventually detected due to blood group discrepancy.

CASE DETAILS

A request was sent to the blood bank for two units of packed red cells in a diagnosed case of CLL which showed type IV discrepancy during blood grouping.The discrepancy was subsequently resolved after warm saline washing of red cells along with repetition of reverse grouping with pre-warmed serum. The direct antiglobulin test was positive and revealed autoanibodies against C3b/C3d only. Indirect antiglobulin test was performed with 3-cell panel in a polyspecific gel card (IgG+C3d) showed a pan-reactive pattern along with a positive autocontrol. Subsequently a cold agglutinin titration was performed and titers of 1024 at 4 °C; titer of 2 at room temperature were detected. Dithiothreitol (DTT) treatment of serum was undertaken and IgM type of autoantibody was detected in this case confirming a case of secondary cold agglutinin disease in this patient. Two units of red cells were transfused to this patient after successfully performing cross-match with pre-warmed serum. It was advised from the blood bank that the blood should be transfused slowly through a blood-warmer and patient should be kept in warm condition to avoid in-vivo hemolysis due to high titer of cold agglutinin. The transfusion was uneventful and patient is on regular follow-up till now.

CONCLUSION

Thus we concluded that serological discrepancies observed in blood bank can successfully guide the bedside transfusion protocol in case of cold agglutinin disease.

Importance of Clinically Significant Anti-M Antibody in Hematopoietic Stem Cell Transplantation

Naturally occurring anti-M antibodies are mostly of the IgM class, however, an IgG component can also be present along with IgM. The IgM anti-M antibodies can be ignored if they are not reactive at 37 °C, but the patient should receive M antigen-negative red blood cells if the antibody is reactive at 37 °C or if it is of IgG class. Here we discuss a case of clinically significant naturally occurring anti-M antibody had both IgM and IgG components in a 3 years old child who was a hematopoietic stem cell donor for her 6 years old sister suffering from beta-thalassemia major. The specificity and immunoglobulin class of the antibody was confirmed by antibody screening at wide thermal range, dithiothreitol treatment of serum and reaction of serum with enzyme treated panel cells.

Warm autoimmune hemolytic anemia with mimicking anti-e specificity causing intravascular hemolysis in a chronic ITP patient

A 12-year-old male child presented to the emergency room with three days history of cola-colored urine, mild icterus, dyspnea, palpitation and fatigue. He had a history of chronic ITP two years ago and had since been on steroid for maintenance of platelet count. He was subsequently diagnosed as a case of warm autoimmune hemolytic anemia. Laboratory investigations were suggestive of intravascular hemolysis, and on immuno-hematological evaluation it was diagnosed that the patient had autoantibody with mimicking anti-e specificity. The specificity of autoantibody was further confirmed by adsorption study. The patient was successfully managed by transfusion of Rh(e)-negative red cells,steroid and rituximab therapy. So an autoantibody with mimicking anti-e specificity was identified in this case, which was significant in clinical point of view.

Response to post-donation counseling is still a challenge in outdoor voluntary blood donation camps: A survey from a tertiary care regional blood center in Eastern India

Background:

Blood transfusion carries the risk of transmission of several infectious agents. The latest method for blood screening, nucleic acid testing is not affordable in developing countries.

Aim:

The study was aimed to find response to post-donation counseling for reactive markers among the voluntary blood donors donating in blood donation camps.

Material and Methods:

This 1 year study was conducted in 2011. Transfusion transmitted infections testing was performed by routine enzyme linked immunosorbent assay method. The initial human immunodeficiency virus (HIV) reactive donors who returned back to the blood bank were confidentially counseled and referred to the Integrated Counseling Cum Testing Center (ICTC). The hepatitis B surface antigen (HBsAg) and anti-hepatitis C virus (HCV) reactive donors were referred to the gastroenterology department for confirmation by qualitative polymerase chain reaction (PCR, Roche Diagnostics, Germany) and followed-up.

Results:

Twenty seven thousand two hundred forty six 27,246 units were collected during the survey. One hundred twenty nine129 units were reactive for HIV 1 and 2, 99 were reactive for HCV, 206 for hepatitis B virus (HBV). Of these reactive donors, 138 could be personally communicated. Out of 47, 27 donors who returned for counseling were initially reactive for HIV 1 and 2, 8 for HBsAg and 12 for anti-HCV. Two were positive for HBV deoxyribonucleic acid and one was positive for HCV ribonucleic acid. The HIV positivity was detected in 1 of 27 donors at ICTC.

Conclusion:

The response to the post-donation counseling appears in this study to be only 34% (47/138), which is still a challenge.

The microfluidic post-array device: high throughput production of single emulsion drops

We present a microfluidic device that enables high throughput production of relatively monodisperse emulsion drops while controlling the average size. The device consists of a two-dimensional array of regularly-spaced posts. Large drops of a highly polydisperse crude emulsion are input into the device and are successively split by the posts, ultimately yielding a finer emulsion consisting of smaller, and much more monodisperse drops. The size distribution of the resultant emulsion depends only weakly on the viscosities of the input fluids and allows fluids of very high viscosities to be used. The average size and polydispersity of the drops depend strongly on the device geometry enabling both control and optimization. We use this device to produce drops of a highly viscous monomer solution and subsequently solidify them into polymeric microparticles. The production rate of these devices is similar to that achieved by membrane emulsification techniques, yet the control over the drop size is superior; thus these post-array microfluidic devices are potentially useful for industrial applications.

Knowledge, attitude and practices regarding swine flu among para-medical workers in a tertiary care hospital in Pondicherry

Para-medical workers (PMWs) are first contacts for suspected Swine flu patients and also the media to spread key messages regarding its prevention and control strategies. Present study was conducted to ascertain knowledge, attitude and practices regarding Swine flu among para-medical workers in a tertiary care hospital. A hospital based cross-sectional study was conducted among PMWs during May-July, 2010. KAP regarding Swine flu was collected through pre-designed questionnaire and information on attitude towards Swine flu was also collected through FGD-free list analysis. Data was analysed using Epi_Info and Anthropac software. A total of 237 PMWs responded. Majority of the PMWs knew about signs and symptoms (89.03%), mode of transmission (91.56%) and route of transmission (91.98%) of Swine flu. Television (67.51%) was the major source of information. 75.53% and 58.65% PMWs respectively knew about organ of the body chiefly affected and type of specimen to be collected during Swine flu. 196 (82.7%) and 191 (80.59%) PMWs respectively knew about availability of vaccine and treatment against Swine flu. 94.09% PMWs stated that extra precautions such as use of face mask, frequent handwashing, use of gloves etc. should be taken while handling any suspected Swine flu case and 73.84% PMWs do take such precautions. 80.17% PMWs opined that epidemic of Swine flu can be halted at current stage. In the present study, PMWs possessed good knowledge, attitude and practices regarding Swine flu and this fact should be utilized while designing and guiding containment strategies against existing Swine flu epidemic.

Antipsychotic medication for childhood-onset schizophrenia

BACKGROUND

Childhood-onset schizophrenia is schizophrenia with onset prior to the age of 13 years. Although it is rare, people who suffer from schizophrenia at an early age appear to have a clinically severe form of the illness with poor long-term prognosis. Antipsychotic medication is one way of managing this rare but serious mental illness.

OBJECTIVES

To examine the effects of antipsychotic medication for childhood-onset schizophrenia.

SEARCH STRATEGY

We searched the Cochrane Schizophrenia Group Trials Register (November 2006 and February 2007), inspected references of all identified studies for further trials and contacted relevant pharmaceutical companies and authors of trials for additional information.

SELECTION CRITERIA

We included all randomised clinical trials involving children and young people with a diagnosis of childhood onset schizophrenia (i.e. with a diagnosis of schizophrenia before the age of 13) comparing any antipsychotic drug with another antipsychotic or placebo.

DATA COLLECTION AND ANALYSIS

We reliably selected, quality assessed and extracted data from trials. We excluded data where more than 50% of participants in any group were lost to follow up. For homogenous dichotomous data we calculated random effects, relative risk (RR) and its 95% confidence interval (CI) and, where appropriate, number needed to treat (NNT) on an intention-to-treat basis. For normal continuous data we calculated the weighted mean difference (WMD).

MAIN RESULTS

From a total of 2062 citations, we identified six relevant trials. We categorised trials into three comparisons: atypical versus typical, atypical versus atypical and typical versus typical antipsychotic drugs. The only comparison to find any differences between treatment groups was atypical versus typical antipsychotic drugs. A few results from one study favoured the atypical antipsychotic clozapine over haloperidol in treating treatment resistant childhood-onset schizophrenia (n=21, WMD CGAS 17.00 CI 7.74 to 26.26; n=21, WMD Bunney-Hamburg Psychosis Rating Scale -3.60 CI -6.64 to -0.56). Participants on clozapine, however, were three times more likely to have drowsiness (1 RCT, n=21, RR 3.30 CI 1.23 to 8.85, NNH 2 CI 2 to 17) and half of the children receiving clozapine had neutropenia (1 RCT, n=21, RR 12, CI 0.75 to 192.86).

AUTHORS' CONCLUSIONS

There are few relevant trials and, presently, there is little conclusive evidence regarding the effects of antipsychotic medication for those with early onset schizophrenia. Some benefits were identified in using the atypical antipsychotic clozapine compared with haloperidol but the benefits were offset by an increased risk of serious adverse effects. Larger, more robust, trials are required.