Programmes for the management of preoperative anaemia: audit in ten European hospitals within the PaBloE (Patient Blood Management in Europe) Working Group

BACKGROUND AND OBJECTIVES

Preoperative anaemia is an independent risk factor for a higher morbidity and mortality, a longer hospitalization and increased perioperative transfusion rates. Managing preoperative anaemia is the first of three pillars of Patient Blood Management (PBM), a multidisciplinary concept to improve patient safety. While various studies provide medical information on (successful) anaemia treatment pathways, knowledge of organizational details of diagnosis and management of preoperative anaemia across Europe is scarce.

MATERIALS AND METHODS

To gain information on various aspects of preoperative anaemia management including organization, financing, diagnostics and treatment, we conducted a survey (74 questions) in ten hospitals from seven European nations within the PaBloE (Patient Blood Management in Europe) working group covering the year 2016.

RESULTS

Organization and activity in the field of preoperative anaemia management were heterogeneous in the participating hospitals. Almost all hospitals had pathways for managing preoperative anaemia in place, however, only two nations had national guidelines. In six of the ten participating hospitals, preoperative anaemia management was organized by anaesthetists. Diagnostics and treatment focused on iron deficiency anaemia which, in most hospitals, was corrected with intravenous iron.

CONCLUSION

Implementation and approaches of preoperative anaemia management vary across Europe with a primary focus on treating iron deficiency anaemia. Findings of this survey motivated the hospitals involved to critically evaluate their practice and may also help other hospitals interested in PBM to develop action plans for diagnosis and management of preoperative anaemia.

The systematic use of evidence-based methodologies and technologies enhances shared decision-making in the 2018 International Consensus Conference on Patient Blood Management

BACKGROUND AND OBJECTIVES

Patient Blood Management (PBM) aims to optimize the care of patients who might need a blood transfusion. The International Consensus Conference on PBM (ICC-PBM) aimed to develop evidence-based recommendations on three topics: preoperative anaemia, red blood cell transfusion thresholds and implementation of PBM programmes. This paper reports how evidence-based methodologies and technologies were used to enhance shared decision-making in formulating recommendations during the ICC-PBM.

MATERIALS & METHODS

Systematic reviews on 17 PICO (Population, Intervention, Comparison, Outcomes) questions were conducted by a Scientific Committee (22 international topic experts and one methodologist) according to GRADE (Grades of Recommendation, Assessment, Development and Evaluation) methodology. Evidence-based recommendations were formulated using Consensus Development Conference methodology.

RESULTS

We screened 17 607 references and included 145 studies. The overall certainty in the evidence of effect estimates was generally low or very low. During the ICC, plenary sessions (100-200 stakeholders from a range of clinical disciplines and community representatives) were followed by closed sessions where multidisciplinary decision-making panels (>50 experts and patient organizations) formulated recommendations. Two chairs (content-expert and methodologist) moderated each session and two rapporteurs documented the discussions. The Evidence-to-Decision template (GRADEpro software) was used as the central basis in the process of formulating recommendations.

CONCLUSION

This ICC-PBM resulted in 10 clinical and 12 research recommendations supported by an international stakeholder group of experts in blood transfusion. Systematic, rigorous and transparent evidence-based methodology in a formal consensus format should be the new standard to evaluate (cost-) effectiveness of medical treatments, such as blood transfusion.

Patient Blood Management: Recommendations From the 2018 Frankfurt Consensus Conference

IMPORTANCE

Blood transfusion is one of the most frequently used therapies worldwide and is associated with benefits, risks, and costs.

OBJECTIVE

To develop a set of evidence-based recommendations for patient blood management (PBM) and for research.

EVIDENCE REVIEW

The scientific committee developed 17 Population/Intervention/Comparison/Outcome (PICO) questions for red blood cell (RBC) transfusion in adult patients in 3 areas: preoperative anemia (3 questions), RBC transfusion thresholds (11 questions), and implementation of PBM programs (3 questions). These questions guided the literature search in 4 biomedical databases (MEDLINE, EMBASE, Cochrane Library, Transfusion Evidence Library), searched from inception to January 2018. Meta-analyses were conducted with the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) methodology and the Evidence-to-Decision framework by 3 panels including clinical and scientific experts, nurses, patient representatives, and methodologists, to develop clinical recommendations during a consensus conference in Frankfurt/Main, Germany, in April 2018.

FINDINGS

From 17 607 literature citations associated with the 17 PICO questions, 145 studies, including 63 randomized clinical trials with 23 143 patients and 82 observational studies with more than 4 million patients, were analyzed. For preoperative anemia, 4 clinical and 3 research recommendations were developed, including the strong recommendation to detect and manage anemia sufficiently early before major elective surgery. For RBC transfusion thresholds, 4 clinical and 6 research recommendations were developed, including 2 strong clinical recommendations for critically ill but clinically stable intensive care patients with or without septic shock (recommended threshold for RBC transfusion, hemoglobin concentration <7 g/dL) as well as for patients undergoing cardiac surgery (recommended threshold for RBC transfusion, hemoglobin concentration <7.5 g/dL). For implementation of PBM programs, 2 clinical and 3 research recommendations were developed, including recommendations to implement comprehensive PBM programs and to use electronic decision support systems (both conditional recommendations) to improve appropriate RBC utilization.

CONCLUSIONS AND RELEVANCE

The 2018 PBM International Consensus Conference defined the current status of the PBM evidence base for practice and research purposes and established 10 clinical recommendations and 12 research recommendations for preoperative anemia, RBC transfusion thresholds for adults, and implementation of PBM programs. The relative paucity of strong evidence to answer many of the PICO questions supports the need for additional research and an international consensus for accepted definitions and hemoglobin thresholds, as well as clinically meaningful end points for multicenter trials.

[Transfusion practice: what's new?]

Transfusion practice: what's new? Among many novelties in the field of transfusion, three are particularly noteworthy, as they significantly impact clinical practice of blood components transfusion and patients' safety. Patient blood management, evidence based and multidisciplinary, aims to optimize the management of each patient who may require transfusion. A medical and rational application of restrictive transfusion policies combined with alternatives to transfusion will lead to both better patient management and a reduction in exposure to blood components and related risks. Multidisciplinary training on prescribing and transfusion counseling, a suitable haemovigilance and a developed clinical research will support the development of patient blood management. The application of mitigation methods for infectious agents is now widespread for platelets and therapeutic plasma. And the concomitant transfusion of plasma, platelets and red blood cells has become a therapeutic standard for patients with severe haemorrhagic shock.

Measurement of GPV Released by Activated Platelets Using a Sensitive Immunocapture ELISA – Its Use to Follow Platelet Storage in Transfusion

Thrombin, the most potent platelet agonist, plays a central role in haemostasis and in the occurrence of thrombotic events. This agonist activates platelets by cleaving the PAR G-protein coupled receptors and by binding to glycoprotein (GP) Ib and also cleaves GPV at the platelet surface to liberate the soluble 69 kDa fragment GPVf1. Monoclonal antibodies (MoAbs) to GPV were developed as tools to study the mechanism of platelet GPV cleavage and measure release of GPV in pathological situations. Specificity of the MoAbs for GPV was confirmed by flow cytometry and immunoprecipitation of proteins from human platelets and Dami megakaryocytic cells. A sensitive immunocapture sandwich ELISA for soluble GPV was developed using two MoAbs recognizing different epitopes of GPV and purified platelet or recombinant GPV as reference protein. This ELISA was employed to determine the mean plasma concentration of GPV in 100 normal individuals (17.3 ng/ml), to demonstrate the dose-dependent release of GPVf1 from washed platelets stimulated with thrombin and to follow the progressive release of GPVf1 during storage of therapeutic platelet concentrates. The present report describes a sensitive GPV ELISA of direct application to survey the processing and storage of platelet concentrates for transfusion and of potential value to monitor platelet activation in thrombotic states.

[Blood transfusion: the challenges for tomorrow?]

As any therapeutic means, blood transfusion requires regular evaluation, particularly for its indications, effectiveness and risks. The availability of randomized clinical trials, the evolution of the quality of blood components, and the economic constraints shared by all countries, all lead to rethink both transfusion therapy as a whole and the organization of the transfusion chain from donor to recipient. The main tools available to improve transfusion and the transfusion chain management are the following: programs of patient blood management (PBM) to optimize the use of blood products with a patient centred approach, blood supply management tools to improve the effectiveness and efficiency of the transfusion chain, donor management tools to adapt donor collections to the patients' needs in compliance with safety requirements for patients and donors, and coordination of these activities. A better understanding of these tools and their implementation will certainly be major challenges for transfusion medicine in the near future. Integrating these evolutions in regulations through the revision of the European Directives on blood and blood components (the review process is expected to be launched in 2015) should enroll them in the long term, for the benefit of patients, donors and all other stakeholders involved in the transfusion chain.

Donor cycle and donor segmentation: new tools for improving blood donor management

BACKGROUND AND OBJECTIVES

An adequate donor population is of key importance for the entire blood transfusion chain. For good donor management, a detailed overview of the donor database is therefore imperative. This study offers a new description of the donor cycle related to the donor management process. It also presents the outcomes of a European Project, Donor Management IN Europe (DOMAINE), regarding the segmentation of the donor population into donor types.

MATERIALS AND METHODS

Blood establishments (BEs) from 18 European countries, the Thalassaemia International Federation and a representative from the South-Eastern Europe Health Network joined forces in DOMAINE. A questionnaire assessed blood donor management practices and the composition of the donor population using the newly proposed DOMAINE donor segmentation. 48 BEs in 34 European countries were invited to participate.

RESULTS

The response rate was high (88%). However, only 14 BEs could deliver data on the composition of their donor population. The data showed large variations and major imbalances in the donor population. In 79% of the countries, inactive donors formed the dominant donor type. Only in 21%, regular donors were the largest subgroup, and in 29%, the proportion of first-time donors was higher than the proportion of regular donors.

CONCLUSION

Good donor management depends on a thorough insight into the flow of donors through their donor career. Segmentation of the donor database is an essential tool to understand the influx and efflux of donors. The DOMAINE donor segmentation helps BEs in understanding their donor database and to adapt their donor recruitment and retention practices accordingly. Ways to use this new tool are proposed.

[European Blood Alliance (EBA) and EuroNet TMS: what challenges for the transfusion of tomorrow?]

The primary mission of the European Blood Alliance (EBA) is to contribute to the safety and efficiency of the supply of blood products, cells and tissues, in developing an active network of blood establishments in Europe (25 countries). Its strategic objectives are to improve performance (through working groups and projects funded by the European Union), to engage in regulatory affairs (particularly at the European Commission level) to promote best practices and to facilitate a network to collect and share knowledge and experiences. The main objective of EuroNet TMS, combining the blood scientific societies from more than 30 countries in Europe, is to update and publish regularly, intended for policymakers, a White Book on the transfusion chain from donor to patient and probable or possible changes in the coming 5 years. Since 2008, EBA and EuroNet TMS actively collaborate on the drafting of the 2nd edition to be published in 2011. The two presidents jointly drafted the final chapter outlining the major issues of transfusion for tomorrow, summarized thereafter. Transfusion will still be useful for a long time and for reasons of safety and ethics the voluntary and unpaid donations, with non-profit blood establishments, will remain, the cornerstone of the supply of blood products. This renders crucial the continuous improvement of donor management and optimal blood use. On the regulatory side, after 5 years of implementation, EU directives must be independently evaluated and the Blood Guide of the Council of Europe should gradually become a regulatory standard. Finally, if a competition should be introduced for the blood products, it should be strictly regulated to prevent any threat to the security of their supply and quality for patients.

Discrimination between the main activating and inhibitory killer cell immunoglobulin-like receptor positive natural killer cell subsets using newly characterized monoclonal antibodies

Natural killer (NK) cells are key components of the innate anti-viral and anti-tumour immune responses. NK cell function is regulated by the interaction of killer cell immunoglobulin-like receptors (KIR) with human leucocyte antigen (HLA) class I molecules. In this study, we report on the generation of KIR-specific antibodies allowing for discrimination between activating and inhibitory KIR. For this purpose, BALB/c mice were immunized with human KIR2DS2 recombinant protein. The precise specificity of KIR2DS2-specific clones was determined on KIR-transfected BW cells and KIR-genotyped NK cells. When used in combination with EB6 (KIR2DL1/2DS1) or GL183 (KIR2DL2/2DL3/2DS2), two KIR-specific monoclonal antibodies (mAbs), 8C11 (specific for KIR2DL1/2DL2/2DL3/2DS2) and 1F12 (specific for KIR2DL3/2DS2), discriminated activating KIR2DS1 (8C11(-) EB6(+)) from inhibitory KIR2DL1 (8C11(+) GL183(-)) and KIR2DL2 (1F12(-) GL183(+)), while excluding the main HLA-Cw-specific KIR. Using these mAbs, KIR2DS1 was shown to be expressed on the surface of NK cells from all individuals genotyped as KIR2DS1(+) (n = 23). Moreover, KIR2DS1 and KIR2DL1 were independently expressed on NK cells. We also determined the amino acid position recognized by the 8C11 and 1F12 mAbs, which revealed that some KIR2DL1 allele-encoded proteins are not recognized by 8C11. Because most available anti-KIR mAbs recognize both inhibitory and activating forms of KIR, these newly characterized antibodies should help assess the expression of activating and inhibitory KIR and their functional relevance to NK biology.

[Evaluation of the professional practices of physicians in transfusion technology and medicine]

The evaluation of the professional practices (EPP) is obligatory for all the physicians since July 1, 2005 for a first five-year period. It represents one of the components of the continuous medical training (CMT). The French Society of Blood Transfusion and National Institute of Blood Transfusion are the promoters of the EPP in transfusion technology and medicine. Initially, the programs of EPP will be conceived and controlled by experts and will relate to their basic activities. During a five years cycle, the physician taking part in a program must validate a specific action and take part in a rolling programme. At the end of the programme, the physician will receive a certificate issued by National Institute of Blood Transfusion and will have to submit it to a committee placed under the responsibility of the regional physicians' committee.

Design of cocaethylene and cocaine conjugates to produce highly selective polyclonal antibodies

With the aim to obtain specific anti-cocaine antibodies directed against cocaine and active metabolites for use in immunotherapy, a series of six haptens were prepared, based on the structure of cocaine. The haptens differed by 3 positions of linkers: nitrogen, carboxyl group, and aromatic nucleus. The haptens were grafted onto 3 carrier proteins: bovine serum albumin, tetanus toxoid or keyhole limpet hemocyanin according to different methods of coupling: carbodiimide or mixed anhydride techniques. The immuno-conjugates were administered to rabbits and the antisera elicited were analyzed in term of titer, affinity and specificity. Variation in antisera properties were observed and attributed to the site of coupling the hapten, to the carrier proteins, and to the method of coupling. Antisera titers were in the range of 1/1 (no significant response) to 1/12,832, with antisera affinity up to 5.9 × 10(11) M-1. This strategy allowed the selection of a new hapten, which after coupling on carrier proteins, led to the production of antisera with a high specificity toward cocaine and cocaethylene, but exclude the inactive metabolites of cocaine.

Development of murine monoclonal antibodies to methamphetamine and methamphetamine analogues

Methamphetamine and ecstasy are addictive drugs that cause major health problems in young people. Here we report on the development of high-affinity monoclonal antibodies to methamphetamine and its analogues, which may constitute powerful tools for antibody-based therapy. Six haptens, methamphetamine and ecstasy analogues, were synthesized, linked to a carrier protein and injected into mice. Several specific monoclonal antibodies were subsequently obtained following fusion of splenocytes from the immunized animals, with Sp2/O cells. Antibody specificity was fully investigated by competition ELISA, using a series of analogues, to identify specific amphetamine and/or ecstasy-specific antibodies. Antibody affinity was estimated to be in the range of 10(8) M(-1) with an enantiomeric hapten. Finally, two characteristic hybridoma clones (DAS-M243-6H5 and DAS-M278-4B12), secreting specific and potent mAbs were isolated. The development of drug-specific antibodies as in this study may provide promising therapeutic insight into how to neutralize methamphetamine in vivo during acute intoxication.

Satisfaction survey in general hospital personnel involved in blood transfusion: implementation of the ISO 9001: 2000 standard

As part of its policy of constant quality improvement, Etablissement francais du sang (EFS) des pays de la Loire (Pays de la Loire Regional Blood Transfusion Centre) carried out a satisfaction survey among the hospital personnel involved in prescribing and using immunohaematological tests and labile blood products (LBP). The polling tool selected by agreement between the Saint Nazaire's hospital management and Quality Assurance (QA) Department was a questionnaire that permitted item rating and free commentary. It addressed the personnel's perception of the quality of erythrocyte immunohaematological (EIH) testing and of the products administered, as well as their perception of the quality of communications with the local EFS. The questionnaire was sent to 26 physicians and 32 senior nurses in 15 hospital departments. The reply rate was 60% and expressed an 85% overall satisfaction level. Dissatisfaction causes were more specifically analysed, the main one involving LBP distribution in emergency situations. A joint undertaking by the EFS and the hospital led to the implementation of corrective measures, including the writing and implementation of a common standard operating procedure for emergency transfusion management. The results obtained demonstrated the feasibility of this type of survey and the interest, to a blood transfusion centre and the hospital personnel involved in transfusion, of assessing their very own perception of service quality.

[Satisfaction survey in general hospital personnel involved in blood transfusion: implementation of the ISO 9001: 2000 standard]

As part of its policy of constant quality improvement, Etablissement Français du Sang (EFS) des Pays de la Loire (Pays de la Loire Regional blood transfusion institution) carried out a satisfaction survey among the hospital personnel involved in prescribing and using immuno-hematological tests and labile blood products. The polling tool selected by agreement between the hospital management and quality assurance department was a questionnaire that permitted item rating and free commentary. It addressed the personnel's perception of the quality of erythrocyte immuno-hematological (EIH) testing and of the products administered, as well as their perception of the quality of communications with the local EFS. The questionnaire was sent to 26 physicians and 32 senior nurses in 15 hospital departments. The reply rate was 60% and expressed a 85% overall satisfaction level. Dissatisfaction causes were more specifically analysed, the main one involving labile blood product distribution in emergency situations. A joint undertaking by the EFS and the hospital led to the implementation of corrective measures, including the writing and implementation of a common standard operating procedure for emergency transfusion management. The results obtained demonstrated the feasibility of this type of survey and the interest, to a blood transfusion centre and the hospital personnel involved in transfusion, of assessing their very own perception of service quality.

Development of Monoclonal Antibodies Directed Against Cocaine and Cocaethylene: Potential New Tools for Immunotherapy

Cocaine abuse is a major health problem, with the number of overdose-related incidents on a constant increase. Monoclonal antibodies against cocaine and its major toxic metabolite cocaethylene, have been developed for immunotherapeutical neutralization in vivo. A series of monoclonal antibodies with high affinity for cocaethylene and cocaine were obtained. Clones DASm244-4D8A4A4 (4D8) and DASm244-5B3C3C6 (5B3) were selected and fully characterized. The antibodies secreted exhibited 1.40 x 10(8) and 3.69 x 10(7) M(-1) affinity constants for [3H]-cocaine and cocaethylene, respectively. In addition to cocaine, they bound to cocaethylene and did not recognize non-toxic cocaine metabolites. They did not bind to blood cells, indicating that they may be potential tools for cocaine neutralization in vivo in cases of overdose.

Identification of a new HLA-DRB1 allele, DRB1*0321

This communication reports the identification of a new HLA-DRB1*03 allele identified in three members of a Caucasian French family. This new allele has been officially named HLA-DRB1*0321 by the World Health Organization Nomenclature Committee. The complete exon 2 sequence of DRB1*0321 is identical to that of DRB1*0307 except for the first and second nucleotides of codon 37 (TT replacing AA), which lead to the substitution of a tyrosine for a phenylalanine (AAC-->TTC at position 37). The family study showed that this new allele was transmitted into the HLA-A*0101/09, -B*0801/14, -Cw*0701, -DRB1*0321, -DRB3*0101, -DQB1*0503 and -DPB1*0401 haplotype. The complete exon 2 sequence of this new allele has been previously deposited in the EMBL Sequence Database under accession number AF297266.

Relevance of KIR gene polymorphisms in bone marrow transplantation outcome

Natural Killer (NK) cells may be involved both in allogeneic bone marrow transplantation (BMT) rejection and graft-versus-host disease (GVHD). The physiologic functions of NK cells appear to be regulated by diverse non-inhibitory and inhibitory receptors including the killer cell immunoglobulin-like receptors (KIR). Although human leukocyte antigen (HLA) epitope mismatches are well-known causes of NK alloreactivity, the role of KIR genes in transplantation remains to be further investigated. In this study, we have evaluated whether KIR genotype differences between donors and recipients of HLA identical (related and unrelated) compared with HLA non-identical unrelated BMT, had an impact on transplantation outcome. Our results show that 5 of 15 KIR genes were always identical in donors and recipients and most variations were observed in the number and specificity of noninhibitory KIR genes. Based on the presence or absence of particular KIR genes, 70 different genotypes were obtained from all individuals. According to the donor or recipient KIR genotype, different combination patterns were described. Interestingly, when the recipient KIR genotype was "included" in the donor KIR genotype, 100% (11/11 pairs) of unrelated BMT developed GVHD compared with 60% (18/30) in all other combinations (p = 0.012). In contrast, no GVHD was observed in related BMT when the recipient KIR genotype was "included" in the donor KIR genotype (p = 0.0001). In conclusion, our results reveal a great diversity for KIR genotypes in donors and recipients of BMT and that the risk of GVHD was maximum in unrelated BMT when the recipient KIR genotype was "included" in the donor KIR genotype.

Determinants of transfusion-associated bacterial contamination: results of the French BACTHEM Case-Control Study

BACKGROUND

Transfusion-associated bacterial contamination (TABC), probably the most frequent transfusion-transmitted infection, may induce serious adverse events. Systematic information and documentation on determinants are lacking.

STUDY DESIGN AND METHODS

The BACTHEM Study is a French matched case-control study assessing TABC determinants. Included were cases of TABC reported in France in a 2-year period, as determined from uniform definitions. Information on recipient-, blood component-, and donor-related potential determinants was collected on site. ORs were estimated by conditional logistic regression.

RESULTS

Of the 158 cases of suspected TABC reported, 41 that involved transfusion with 25 RBCs and 16 platelet concentrates were included. Gram-negative rods accounted for nearly half of the bacteria species involved and for all six deaths. In comparison with the risk of TABC for patients receiving RBCs for anemia, the risk was higher for patients receiving RBCs for pancytopenia (OR, 7.3; 95% CI, 1.3-41.0) and for those receiving platelets for thrombocytopenia (OR, 5.3; 95% CI, 1.2-24.1). Other potential determinants were platelet transfusion for pancytopenia (OR, 4.5; 95% CI, 0.5-40.0), immunosuppressive treatment (OR, 2.8; 95% CI, 0.7-10.6), shelf-life of more than 1 day for platelets or 8 days for RBCs (OR, 2.6; 95% CI, 0.7-9.6), and more than 20 previous donations by donors (OR, 1.9; 95% CI, 0.7-5.3).

CONCLUSION

This first comparative study revealed TABC determinants that suggest approaches for prevention.

[Labile blood products and their preparation]

Licensed labile blood components are put down on a regulatory list by the French Health Authority. They are prepared by the French National Blood Service and controlled according to regulatory and validated procedures. Depending on the origin of the blood, labile blood components are either homologous (donors) or autologous (from patients). Blood components (red cell concentrates, platelet concentrates and fresh frozen plasma) are processed within sterile closed disposable systems using either post-donation processing of whole blood or apheresis technology. All homologous blood components are leuco-reduced. Depending on specific settings, blood components could be washed, gamma irradiated or cryopreserved. Fresh frozen plasma is either "donor retested" after quarantine or viro-attenuated by solvent detergent treatment. Release is only allowed after a full conformity control of each blood component unit.

Measurement of GPV released by activated platelets using a sensitive immunocapture ELISA--its use to follow platelet storage in transfusion

Thrombin, the most potent platelet agonist, plays a central role in haemostasis and in the occurrence of thrombotic events. This agonist activates platelets by cleaving the PAR G-protein coupled receptors and by binding to glycoprotein (GP) Ib and also cleaves GPV at the platelet surface to liberate the soluble 69 kDa fragment GPVf1. Monoclonal antibodies (MoAbs) to GPV were developed as tools to study the mechanism of platelet GPV cleavage and measure release of GPV in pathological situations. Specificity of the MoAbs for GPV was confirmed by flow cytometry and immunoprecipitation of proteins from human platelets and Dami megakaryocytic cells. A sensitive immunocapture sandwich ELISA for soluble GPV was developed using two MoAbs recognizing different epitopes of GPV and purified platelet or recombinant GPV as reference protein. This ELISA was employed to determine the mean plasma concentration of GPV in 100 normal individuals (17.3 ng/ml), to demonstrate the dose-dependent release of GPVf1 from washed platelets stimulated with thrombin and to follow the progressive release of GPVf1 during storage of therapeutic platelet concentrates. The present report describes a sensitive GPV ELISA of direct application to survey the processing and storage of platelet concentrates for transfusion and of potential value to monitor platelet activation in thrombotic states.

[Evaluation of measurements intended to develop regularity of blood donation]

An increase in the regularity of blood donation is desirable for two main reasons. First, the lower incidence of viral disease markers in regular donors when compared to first donors could help to reduce risks of transmissible diseases. Second, a higher frequency of donation could contribute to a more satisfactory supply of blood products. Two measures implemented with the aim of increasing the regularity of blood donation were evaluated: (i) an increase in the annual frequency of blood collection by mobile teams at collection sites, and (ii) a "next donation document" given to each donor indicating the earliest possible date of the next donation. The regularity index was calculated as the mean number of cellular donations (whole blood and platelet apheresis) per donor per year, over two consecutive periods: 1-7-1993-30-6-1994 (P1) and 1-7-1994-30-6-1995 (P2). The junction of these two periods corresponded to the date of introduction of the "next donation document" and to the time of reinforcement of the mobile collection frequency. First donors in either period were not taken into account in the study. A significant relationship was observed between the annual frequency of mobile collection and the average number of donations per donor (comparison test of two means on large samples, p < 0.001 in all the cases excepted those of stable mobile collection numbers). Thus, in the first period, the average donation rate was the lowest on sites having only one mobile collection per year (M: 1.55, W: 1.38) and the highest on sites with five mobile collections per year (M: 2.05, W: 1.71). These average numbers significantly increased in the second period as compared to the first (M: +4.8%, W: +1.8%; comparison test of two means from paired series, p < 0.001), as did the yearly frequency of mobile blood collections (+9.2%). On the other hand, the "next donation document" was not associated to any change in the regularity index. The results of this study therefore showed an increase in the frequency of visits of mobile collection teams to be the main factor leading to an improvement in the regularity of blood donation. Moreover, this evolution was associated with a decrease in the incidence of viral markers detected at donation.

[Quality control of homologous blood collection activities: 5 years' experience]

Quality control (QC) of blood collection activities for transfusion is a regulatory requirement. The authors report on their experience in this field over the past 5 years. In their institution, this QC is based on both the recording and analyzing of predefined data, as well as the search for an active collaboration from each person involved in these activities. QC of medical selection relies on the assessment of several associated criteria: effectiveness of the information given to blood donors for recruitment, preparation of the medical interview and encouragement to perform regular donations; frequency of donors deferred after the medical interview; frequency of biological abnormalities detected at donation; results of the inquiries into the corresponding medical interviews following adverse transfusion reactions. The quantitative and qualitative evaluation of blood collection permits assessment of the quality of the blood collection program, collection procedures and directly derived blood products. Quality assessment of facilities and equipment is also included in this QC. Results have been improving in recent years, especially regarding medical selection. In particular, an increase in the mean donation rate of donors, a decrease in biological abnormalities detected at donation and an absence of adverse transfusion reactions attributed after inquiry to an inadequate medical interview have been noticed. A decrease in both shortage and outdating of labile blood products likewise indicates an improvement of blood collection planning. However, this QC reveals deficiencies in the information given to donors and a lack of analysis of the data specific to first time donors. In order to further improve the efficiency of QC, these results now require comparison with similar data collected on a nation-wide scale.

[Staff certification for mobile blood collection units]

Training and official acknowledgment of the competence of each staff member are essential to the quality and safety of collected blood products prepared and delivered by a blood transfusion center. A procedure was created to indicate in detail the methods employed to implement such accreditation. Based on individual training according to activity, it defines for each type of activity (secretary, physician, collector, driver) the required theoretical and practical knowledge of his/her position. Accreditation, consisting of assessment of the degree of competence attained in these areas of responsibility, was applied to the members of mobile blood collection teams in 1995. No major deficiency was detected, and this certification was well accepted by the staff. In order to complete this initial accreditation, blood collection abnormalities (inadequate blood volumes, clots or defective welding of tubing) were assessed for each collector individually. Comparison of these abnormalities in qualified nurses and laboratory technicians with a blood collection diploma showed no differences. On the other hand, significantly higher numbers of abnormalities were found in intermittent as compared to regular collectors and in senior as compared to new collectors. The applied corrective measures led to obviation of differences and improvement in performance. In 1996, in the first individual evaluation of medical selection carried out by each physician, discrepancies of one to 20 donors (0.7-14.2%) were observed from one doctor to another in the frequency of elimination of candidates for blood donation after the medical interview. Regular meetings with physicians resulted in reducing these discrepancies to one to 3.1 donors (4.6-14.1%) in 1997. In conclusion, the association of an initial accreditation procedure with an individual follow-up of work quality allowed satisfactory assessment of the training and competence of staff members. This kind of method could be extended to those working in other fields of transfusion medicine.

[Quantitative bacteriological evaluation of a method for skin disinfection in blood donors]

Skin disinfection at the site of venipuncture is a critical point in every blood transfusion collection procedure, as it contributes to ensure the bacterial safety of transfusion. Quantitative and qualitative analysis of bacteria present in the antecubital fossae before and after skin disinfection may be one method of assessing the anti-bacterial efficiency of disinfection. Swab culture systems and contact plates are the two techniques usually employed for this purpose. A washing and swabbing technique was used to quantify bacteria before and skin disinfection of the antecubital fossae in blood donors. This contra-placebo study was carried out on 32 donors, each of whom served as his own control, with a random choice of test arm and opposing control arm. Bacterial counts were determined in the antecubital fossae without skin disinfection (control, n = 32) and after a 3 step skin preparation procedure (cleaning, wiping, disinfection) using placebo (distilled water, n = 16) or an antiseptic product (mixture of chlorexidine, benzalkonium chloride and benzylic alcohol, n = 16). The absence of a statistical difference in bacterial counts between the right and left antecubital fossae without disinfection was controlled in a preliminary study of 20 subjects. Mean bacterial counts were 25,000/cm2 and 27,400/cm2 respectively for aerobic and anaerobic bacteria before disinfection, with a wide variation in results between individuals. When using placebo, preparation of the venipuncture site by the 3 step method (cleaning, wiping, disinfection) resulted in a non significant mean reduction of 0.56 log in aerobic and anaerobic bacteria. Using the antiseptic product, the same method resulted in a significant mean reduction of 1.8 and 1.7 log respectively in aerobic (p = 0.015) and anaerobic flora (p = 0.005). On an average, 2,750 aerobic bacteria/cm2 and 2,910 anaerobic bacteria/cm2 remained after disinfection, while qualitative analysis showed that disinfection suppressed the transitory flora in all cases but left part of the resident flora in 12/16 cases. These findings are comparable to those of other studies carried out to evaluate this kind of technique for the disinfection of operation sites. In comparison with other techniques classically employed for this type of evaluation (swab systems or contact plates), the method used in this study was the advantage of allowing the quantification of the reduction in bacteria. Hence this method could be employed for comparative assessment of skin disinfection techniques with the aim of improving their anti-bacterial efficiency and could also make possible the definition of a minimum bacterial count (resident flora) to be obtained in all cases after disinfection.

[Comparative validation of manual and automated methods for mixing and volume control of total blood samples]

During blood collection, agitation and volume limitations are critical to ensure thorough mixing of the blood with the anticoagulant and obtention of the predetermined volume. These 2 factors are essential to prevent blood activation and to obtain well standardized blood products. The objective of this study was to compare the quality of the blood collected using 2 types of collection method: tripping of a scale at a predetermined volume limit of 450 mL in the presence of manual agitation, and the 3 blood collection monitors currently available in France. A minimum of 100 collection procedures was performed for each of the 4 methods tested. Results were found to be equivalent using either the manual or the automated procedures with regard to both the accuracy and reproducibility of the blood volumes obtained and the collection times and flow rates. The characteristics of the red blood cell concentrates, platelet concentrates and plasma units prepared from the first 30 collections of each group were assessed and compared to regulatory requirements. The quality of all these products was found to be comparable to that currently observed at quality control and no product was rejected at the release control for reasons of poor collection. An assessment of the practicability of the different methods showed that the automated devices are subject to practical difficulties involving transport and battery loading. In addition, the cost of this equipment is approximately 5 times higher than that of the scales. In conclusion, the results of this study show that in our hands, no significant advantage could be expected from the use of automated blood collection monitors as compared to simple scales with manual mixing. These results further raise the question of the applicability to labile blood products of the comparative validations currently accepted in the pharmaceutical industry, in order to allow the use of correctly validated alternative methods.