Blood transfusion practice: a nationwide survey in Italy

Background

Blood transfusion is a complex activity. Some of the components of this activity are implementation of standard procedures, evaluation of appropriateness of the blood use, methods for bedside identification of patients and the release of blood in emergencies, during out-of-routine hours and from hospitals lacking a Blood Centre. An overview about how these issues are managed in Italy could be of interest.

Materials and methods

A survey dealing with some issues regarding blood release was performed, using a questionnaire sent to 278 Italian Blood Centres.

Results

Out of the 278 Centres, 179 (64%) returned the questionnaire. The geographic distribution of the Centres that responded (80 in the north, 46 in the centre and 53 in the south of Italy) offers a good picture of the Italian reality. Globally there seems to be a relatively uniform application of procedures and guidelines, of methods to identify patients, and of evaluating transfusion appropriateness. The systems used to deal with emergency blood release and blood release in non-routine conditions are more variable. The use of technological resources seems to be disappointingly low.

Discussion

Although many aspects of the blood transfusion process should be improved, the picture that emerged from the survey seems to show, on the whole, a fair quality of blood transfusion practice in Italian Blood Centres.     

Molecular biology in transfusion medicine: current applications and future practice

Alloantibodies to blood group antigens are produced because there are differences between the blood group antigens on recipient and donor (or mother and fetus) red blood cells. Historically and currently, blood group antibodies and antigens are detected by hemagglutination, which can require considerable skill. Over the past 2 decades, there has been an astounding pace of growth in the field of molecular biology techniques and even more recently in the understanding of the basis of many blood group antigens and phenotypes. Thus, we are now able to consider identification of blood group antigens in genetic terms and identification of blood group antibodies using molecular approaches. Indeed, this knowledge is being applied to help resolve some long-standing clinical problems that cannot be resolved by classic hemagglutination. This article reviews our current knowledge of molecular approaches for identifying blood group antigens and antibodies as applied to transfusion medicine.     

转化医学:基础研究与临床应用间的纽带

转化医学(translational medicine)是欧美生物医学界于上世纪末提出的一个新概念,其目的主要是促进基础研究成果向临床应用的转化。后来其概念进一步演变,内涵和外延不断加深和拓展,目前转化医学通常泛指以解决疾病预防、诊断和治疗等实际问题为导向的医学科研活动,既包括从基础研究成果转化为临床应用的科研活动,也包括从临床问题出发凝练出科学问题、在实验室研究出解决问题的方法再应用于临床的过程。     

Epigenetics: principles and practice

Epigenetics is defined as heritable changes in gene expression that are, unlike mutations, not attributable to alterations in the sequence of DNA. The predominant epigenetic mechanisms are DNA methylation, modifications to chromatin, loss of imprinting and non-coding RNA. Epigenetic regulation of gene expression appears to have long-term effects and wide-ranging effects on health. Diet and environmental exposures may potentially alter the level and scope of epigenetic regulation, thus interesting developments in the study of epigenetics might explain correlations that researchers have found between lifestyle and risk of disease. Aberrant epigenetic patterns have been linked to a number of digestive diseases including Barrett's esophagus, cirrhosis, inflammatory bowel disease, and numerous gastrointestinal malignancies. In fact, many exciting discoveries about epigenetics in general have been made by studying diseases of the gastrointestinal tract and hepatobiliary tree. Epigenetic modifications of DNA in cancer and precancerous lesions offer hope and the promise of novel biomarkers for early cancer detection, prediction, prognosis, and response to treatment. Furthermore, reversal of epigenetic changes represents a potential target of novel therapeutic strategies and medication design. In the future, it is anticipated that innovative diagnostic tests, treatment regimens, and even lifestyle modifications will be based on epigenetic mechanisms and be incorporated into the practice of medicine.     

HIV: implications for blood transfusion and banking in Africa

African countries with an appreciable HIV problem receive assistance in screening blood for HIV antibodies as part of WHO's Global Program on AIDS (GPA). This article describes the health problems with blood transfusions and offers suggestions on ways to minimize the prevalence of HIV in blood banks. Ways to minimize blood transfusions include appropriate use of plasma volume expanders and electrolyte solutions. Stopping the practice of using soldiers and prisoners as group blood donors and substituting secondary school students as donors was recommended to prevent HIV contamination of the blood banks. Since HIV antibody tests are being improved and simplified, HIV test kits should not be ordered too far in advance. To verify a positive test, the use of 2 differently manufactured ELISA tests on each positive blood sample was recommended because most African labs do not have the expertise or money to do Western blot analysis. Testing facilities were advised to tell blood donors with donated HIV positive blood that they were infected and hopefully this would help minimize the possibility that the infected individual would infect others.     

Colonoscopy: basic principles and novel techniques

Colonoscopy is considered the 'gold standard' for detection and removal of premalignant lesions in the colon. However, studies suggest that colonoscopy is less protective for right-sided than for left-sided colorectal cancer. Optimizing the effectiveness of colonoscopy is a continuous process, and during the past decade several important quality indicators have been defined that can be used to measure the performance of colonoscopy and to identify areas for quality improvement. The quality of bowel preparation can be enhanced by split-dose regimens, which are superior to single-dose regimens. Cecal intubation rates should approximate 95% and can be optimized by good technique. In selected patients, specific devices can be used to facilitate cecal intubation. Adenoma detection rates should be monitored and exceed a minimum of 25% in men and 15% in women. To this aim, optimal withdrawal technique and adequate time for inspection are of utmost importance. Of all advanced imaging techniques, chromoendoscopy is the only technique with proven benefit for adenoma detection. Finally, the technique of polypectomy affects the number of complications as well as the success of completely removing a lesion. In this Review, we provide an overview of both standard and novel colonoscopy techniques and their impact on quality indicators.     

The relevance of practice misalignments to trials in transfusion medicine

Practice misalignments can occur in any clinical trial investigating a pre‐existing therapy that is typically adjusted based on clinical characteristics outside of the trial setting. To eliminate the heterogeneity in clinical practice, recent trials investigating titrated therapies have randomized patients to fixed‐dose regimens without including a routine care control group receiving titrated therapy. In these trials, the normal relationships between clinically important characteristics and therapy titration are disrupted. Within each arm of the trial, randomization creates subgroups of patients receiving levels of therapy inconsistent with current practices outside of the trial. These practice misalignments may have outcomes worse than routine care and may compromise patient safety. In addition, comparisons of trial arms with practice misalignments have limited interpretability and generalizability. In this review, we use examples from the literature to discuss how practice misalignments can impact the safety, results and conclusions of clinical trials. In addition, we discuss methods to characterize relationships between therapy titration and clinical characteristics and trial design strategies that may minimize practice misalignments.     

Myocardial contrast echocardiography: basic principles

Myocardial contrast echocardiography (MCE) is a new technique that can be used to examine the myocardial microcirculation. It uses gas-filled microbubbles that behave similarly to red blood cells in the microcirculation. This report describes the parts of the coronary microcirculation visualized by MCE. It also describes the types of microbubbles currently available for research. The properties of microbubbles and their interaction with ultrasound are also described as well as different imaging techniques. This information is necessary to understand the basics of MCE.     

Blood loss,predictors of bleeding,transfusion practice and strategies of blood cell salvaging during liver transplantation

Blood loss during liver transplantation (OLTx) is a common consequence of pre-existing abnormalities of the hemostatic system,portal hypertension with multiple collateral vessels,portal vein thrombosis,previous abdominal surgery,splenomegaly,and poor "functional" recovery of the new liver.The intrinsic coagulopathic features of end stage cirrhosis along with surgical technical difficulties make transfusion-free liver transplantation a major challenge,and,despite the improvements in understanding of intraoperative coagulation profiles and strategies to control blood loss,the requirements for blood or blood products remains high.The impact of blood transfusion has been shown to be significant and independent of other well-known predictors of posttransplant-outcome.Negative effects on immunomodulation and an increased risk of postoperative complications and mortality have been repeatedly demonstrated.Isovolemic hemodilution,the extensive utilization of thromboelastogram and the use of autotransfusion devices are among the commonly adopted procedures to limit the amount of blood transfusion.The use of intraoperative blood salvage and autologous blood transfusion should still be considered an important method to reduce the need for allogenic blood and the associated complications.In this article we report on the common preoperative and intraoperative factors contributing to blood loss,intraoperative transfusion practices,anesthesiologic and surgical strategies to prevent blood loss,and on intraoperative blood salvaging techniques and autologous blood transfusion.Even though the advances in surgical technique and anesthetic management,as well as a better understanding of the risk factors,have resulted in a steady decrease in intraoperative bleeding,most patients still bleed extensively.Blood transfusion therapy is still a critical feature during OLTx and various studies have shown a large variability in the use of blood products among different centers and even among individual anesthesiologists within the same center.Unfortunately,despite the large number of OLTx performed each year,there is still paucity of large randomized,multicentre,and controlled studies which indicate how to prevent bleeding,the transfusion needs and thresholds,and the "evidence based" perioperative strategies to reduce the amount of transfusion.     

Iron and transfusion medicine

Blood bankers have focused their energy to secure blood transfusion, and only recently have studies been published on the effect of blood donation on iron metabolism. In many facilities, hemoglobin measurement is only performed just before or even during blood donation, but the determination of iron stores is largely ignored. The 2013 paradox of transfusion medicine is due to the fact that blood donation may be harmful and leads to iron deficiency with or without anemia, but for other individuals, it may be a healthy measure preventing type 2 diabetes. The purpose of this review is to discuss iron metabolism in the perspective of blood donation, notably regarding their possible genetic profiles that eventually will discriminate “good” iron absorbers from “bad” iron responders.