bluuebunny/crossref_metadata_2025 huggingface dataset:
Implementation of CPOE, ERBI, and ePPID in Critical Care Operating Rooms at a Tertiary Care Academic Center
Authors: Grewal A , Anders M , Rock P , Williams N A , Fontaine M , Lokhandwala P
Published: October 2024

Introduction/Objective

Blood transfusion in operating rooms (ORs) is a critical and complex process, often complicated by issues such as paper-based orders, lack of guidelines, and delays in blood delivery. In response, a multidisciplinary task force developed a quality improvement plan. This study assesses the impact of implementing an electronic positive patient identification (ePPID) system, standardized computer provider order entry (CPOE), and electronic remote blood issue (ERBI) process in a critical care OR setting at our institution.

Methods/Case Report

The team initially implemented ePPID in cardiac surgery ORs before expanding hospital-wide. CPOE was developed in collaboration with the laboratory information systems (LIS) and hospital information technology (IT). ERBI required cross-departmental coordination to establish a bi-directional interface between LIS and ERBI software. Staff received training through a train-the-trainer approach, interactive sessions, videos, and surveys. CPOE focused on order set development and creating the Maximum Surgical Blood Order Schedule (MSBOS). ePPID began with a pilot program and expanded with training sessions. Data collection tracked blood ordering, ERBI workflow, and transfusion data for compliance and utilization rates.

Results (if a Case Study enter NA)

The implementation of ePPID saw a rise in compliance rates from 71% to 98%, with 60 completed cases and 233 blood products transfused by 24 clinicians. ePPID’s utilization for blood products increased from 60% to 98% within 90 days. ERBI lowered RBC return rates from 30% to 15% and plasma return rates from 45% to 35% over a 2.5 year span. ERBI utilization rates reached 81% at 24 months post-implementation.

Conclusion

The implementation of ePPID, CPOE, and ERBI in critical care ORs was well-received among clinicians. Significant improvements in compliance and utilization rates for blood products following ePPID implementation were evident. ERBI implementation also led to substantial reductions in return rates of blood products allocated to ORs. The steady increase in ERBI utilization indicates successful integration into OR workflows.
Lost in the Ds: Unexplained Loss of Rh(D) Antigen Expression By Serological Testing In Two Patients
Authors: Carmichael G , Lee E S , Tormey C , Yurtsever N , Shah B , Bizzario L
Published: October 2024

Introduction/Objective

While the loss of ABOH antigens has been well documented, reduced-to-absent expression of the RHD antigen is comparatively rare. Here, we describe two cases with D antigen loss presenting associated clinical settings, smear results, and red blood cell (RBC) genotyping findings to elucidate this unusual phenomenon.

Methods/Case Report

Cases (n=2) were retrospectively reviewed based on discovery during routine serological testing in our Blood Bank. RhD blood typing was performed via gel methods [Grifols, Los Angeles, CA]. Clinical information and laboratory data were extracted via the electronic medical record.

Case 1 is a 79-year-old female with metastatic breast cancer. She initially typed as D positive (4+) in at least two separate analyses, but her D front type progressively became weaker until turning entirely negative after several weeks. Spherocytes and stomatocytes were present on her peripheral blood smear. This patient received 10 D+ red blood cell (RBC) units without anti-D formation. RBC genotyping revealed traditional “dce” by standard polymerase chain reaction (PCR).

Case 2 is a 61-year-old male with a history of pre-B acute lymphocytic leukemia post-stem cell transplant, myelodysplastic syndrome, and progressive loss of D antigen expression (4+ to 0). Standard RBC genotyping revealed “Dce” by PCR. The peripheral blood smear was significant for RBC anisopoikilocytosis with increased stomatocytes, spherocytes, and ovalocytes.

Results (if a Case Study enter NA)

NA

Conclusion

The disappearance of the D antigen is rare, and our experience suggests an association between malignancies (both hematopoietic and non-hematopoietic) and D antigenic loss. Beyond these disease associations, however, loss of RhD is not otherwise readily explained in either case. Further analysis to test for other RHAG and RHCE mutational variants is an ongoing area of investigation in these cases, as more sensitive testing may reconcile the traditional PCR results with our initial detection of the D antigen.
Quality Improvement Assessment of Massive Transfusion Protocol (MTP) Utilization and Blood Component Return to Blood Bank in a Level 1 Trauma Center
Authors: Poonam F , Makuria A , Causey B , Ballengee S , Duncan H , Steffee C , Fallon J
Published: October 2024

Introduction/Objective

The goal of MTP in management of patients with hemorrhage is to restore coagulation factors, oxygen carrying capacity, and platelets by transfusing equal amount of plasma, RBC, and platelets. Upon activation of MTP, blood components are released in rounds until deactivation. This quality improvement study was initiated to assess blood products transfused versus returned during MTP activation at our Level1 Trauma Medical Center.

Methods/Case Report

Upon MTP activation, the Blood Bank (BB) prepares first round of cooler with components at 5:5:1 ratio of plasma, RBC, apheresis platelets. We reviewed retrospective MTP data of eleven-month, from 10/2022- 08/2023. We analyzed patterns of blood component usage by service line, number of MTP rounds issued, and number of units transfused versus returned.

Results (if a Case Study enter NA)

MTP data was reviewed for 195 patients. MTP activation by service line included emergency department 58.5%, medical ICU (MICU) 14.4%, and surgical ICU (SICU) 11.8%. In many MTP activations, only one round of components was released. Overall, an average of 1.5 rounds were issued. Data of units transfused and returned by component type showed more RBC (43.1%) units were transfused than plasma (39.4%) suggesting MTP transfusion did not follow 1:1:1 ratio. Out of all issued blood units 58% were returned. The high fraction of returned blood components suggests MTP activation may not always truly indicate massive hemorrhage. This finding, and the notable frequency of MTP activation for MICU and SICU patients suggests that individual component order on an emergency-release basis may have been the appropriate option.

Conclusion

In general, the data suggests implementation of a quality improvement initiative focused on increasing awareness of criteria for MTP activation, and training of staff surrounding MTP is essential. We recently implemented an electronic emergency transfusion order set that allows providers to order individual components for non-massively bleeding patients.
A 6-month Review of O pRBC Utilization in Non-O Blood Type Patients in a Level 1 Trauma Center
Authors: Rana-Gupta T , Talabong D , Yakut E , NGICHABE J , Gabutan E , Kang S , Haque A , Agaronov M
Published: October 2024

Introduction/Objective

Using O pRBCs for non-O patients for acute events is not unusual in a level 1 trauma hospital. However, we occasionally utilize this blood type to meet the needs of our patients that are not acutely bleeding. In this study, we evaluated the utilization of O units in non-O patients to improve our transfusion practices.

Methods/Case Report

We reviewed the indications of the O pRBCs transfused to non-O patients from October 2023 to March 2024. We evaluated the number of units used in acute events such as massive transfusion protocol (MTP), acute blood loss, sickle cell disease (SCD) patients in crises, bleeding associated with surgery and in patients with symptomatic anemia.

Results (if a Case Study enter NA)

There were 258 O pRBCs transfused to non-O blood type from October 2023 to March 2024. 135(52%) of these units were used for bleeding patients, of which 91%(124/135) were used for acute events. Most of the units utilized for acute hemorrhage had activated MTP (92%, 89/124) due to trauma (88%, 78/89). Only 12%(31/258) were used by SCD patients, with a little over half of these units being used acutely and the rest used prophylactically. About 69% of the 16 units used in surgery were due to bleeding. Lastly, 76 units (29%) were used for symptomatic anemia patients with 45% of these units transfused for anemia of prematurity.

Conclusion

In a level 1 trauma hospital, advocating for conserving O units is crucial to ensure enough units are available for trauma. As anticipated, acute bleeding was found to be the leading cause for patients with non-O blood types to receive O pRBCs. Notably, the prevalence of using O units for acute and prophylactic transfusion is relatively the same for SCD patients and phenotypically matching the Rh and Kell systems likely plays a role.
A rare case of Anti-Jk3 Alloimmunization
Authors: Abdelmonem M , Ngo N , Cabungan M , Cai W , Yunce M , Virk M S , Lee J , Yoshizuka S , Osterlund A
Published: October 2024

Introduction/Objective

The Kidd blood group system was discovered in 1951 and consists of two antithetical antigens, Jka and Jkb, in addition to a third high-incidence antigen, Jk3. Jk null, also known as Jk(a-b-), is an extremely rare blood group in which all Kidd antigens are absent. Jk is a urea transporter found in the renal medulla, and Jk-deficient individuals are unable to concentrate urine to its maximum concentration. If these individuals are exposed to the Jk antigen via transfusion or pregnancy, they are able to produce antibodies against the Jk3 antigen with a high incidence. Jk3 is expressed in over 99.9% of the blood donor pool, which has severe clinical implications and complicates transfusion.

Methods/Case Report

CASE PRESENTATION:

A 68-year-old male was admitted to the Stanford Medical Center with chronic right midshaft tibia osteomyelitis and a sinus drainage tract for a right tibial diaphysectomy. His test for antibodies was positive. Plasma from the patient is reactive with all tested cells except auto control, AHG in PEG, and solid phase. Phenotyping yielded negative results for Jka and Jkb, suggesting that the antibody is Jk3. Anti-Jk3 was eliminated by adsorption and rendered nonreactive.

Results (if a Case Study enter NA)

NA

Conclusion

Anti-Jk3 should be suspected in a previously pregnant or transfused patient during antibody screening and identification if it demonstrates the pattern of an antibody reacting to all cells in the panel, i.e., reacting to a high- frequency antigen with negative autocontrol. Awareness on the part of blood bank personnel regarding the variability of the blood group phenotype and the capricious nature of Kidd antibodies may aid in the improved management of these patients. It is recommended that patients with rare antibodies carry an antibody ID card indicating the rare antibody they have to prevent further exposure. A patient may be advised to undergo an autologous transfusion.

Fortunately, the patient’s procedures were uncomplicated, so a blood transfusion was unnecessary. Awareness on the part of blood bank staff regarding the variability of the blood group phenotype and the unpredictability of Anti-Jk3 may aid in improving patient care. To prevent further exposure, it is recommended that patients with rare antibodies carry an Antibody ID card indicating the rare antibody they possess.Jk3 antigen blood donors are underrepresented in the general donor pool. It is recommended to develop a systematic recruitment for Jk3 antigen donors.
Buffy coat removal to mitigate reporting false normal G6PD phenotype results in patients undergoing rasburicase therapy for tumor lysis syndrome
Authors: Mathewson Nicole , Hunsaker Joshua , Young Brittany , Doyle Kelly
Published: October 2024

Glucose-6-phosphate dehydrogenase (G6PD) is the primary source of NADPH in red blood cells (RBCs). NADPH reduces reactive oxygen species (ROS) thereby protecting RBCs from oxidative stress-mediated hemolytic anemia (HA). Individuals with partial or full G6PD deficiency are therefore susceptible to acute HA provoked by medications that generate high ROS loads in vivo, e.g., rasburicase. Rasburicase is an enzyme-based therapeutic used to degrade uric acid (UA) in patients with tumor lysis syndrome (TLS); however, catalysis of UA generates H2O2, a potent ROS, which poses a risk of HA in individuals who are deficient in G6PD activity. Screening G6PD activity prior to rasburicase administration is clinically indicated in ethnic groups with high rates of G6PD deficiency, although reports of HA in rasburicase-treated patients have been reported across low prevalence ethnic groups as well. TLS occurs most commonly during the treatment of highly proliferative neoplasms, such as leukemia and lymphoma. Since WBCs contain significant G6PD activity, an elevated WBC count in these patients can cause the false assurance of low HA risk due to a falsely normal G6PD activity. We sought to establish and evaluate a novel method to mitigate WBC contamination of G6PD measurements in patients undergoing rasburicase therapy. In this study, we first developed and validated an innovative method (“piercing method”) to minimize the interference of WBCs in G6PD measurements. The piercing method demonstrated acceptable accuracy (slope: 1.008; bias: -6.22%) and precision (1.4% CV between 9.9 to 20.7 U/g Hb) and was effective at eliminating a broad range of WBC types and concentrations from whole blood samples (N = 85, tested range = 0.31 – 413.05 K/μL, 93% reduction in WBCs). We compared G6PD activity in rasburicase-treated patients (N = 39) with varying WBC counts before and after buffy coat removal using the piercing method. Average percent change in G6PD activity (post-pierce – pre-pierce) between patients with and without elevated WBCs was substantial (45% versus 12%). In comparing G6PD activity in patients before and after the initiation of rasburicase therapy, there is no evidence that in vivo-generated ROS from rasburicase affect G6PD measurement in vitro in an assay that relies on monitoring absorbance of NADPH (22.2 U/g Hb versus 22.9 U/g Hb, p=0.721). Results demonstrate how WBCs increase risk for false elevation in G6PD activity in patients being considered for rasburicase therapy. At greatest risk are patients with partial G6PD deficiency, e.g., heterozygous females, where G6PD from WBCs could mask deficiency. Literature describing testing of G6PD in specimens with elevated WBCs is lacking. This study shows that the piercing method provides accurate G6PD results in samples with elevated WBCs from patients at risk of TLS, who might develop HA after starting rasburicase therapy.
Pre-operative CBC reflex testing prior to cardiac surgery identifies treatable causes of anemia
Authors: Maucione Carly , Jackups Ron
Published: October 2024

Blood transfusion during or after cardiac surgery has been linked to poor patient outcomes. It is therefore desirable to optimize hemoglobin status by identifying and treating anemia pre-operatively. In order to identify reversible causes of anemia efficiently in this patient cohort, we implemented a reflex order for our institution’s cardiothoracic surgery center, to be ordered for patients undergoing assessment for cardiac surgery. When ordered, complete blood count (CBC) results with a hemoglobin (Hgb) of less than 13 g/dL reflex automatically to the following laboratory tests: iron profile, ferritin, vitamin B12, and reticulocyte count.

Methods

The purpose of our study was to investigate the impact of this reflex order over the initial 6 months of implementation. Test results and patient notes were extracted from the electronic health record and analyzed.

Results

Over six months, the order was placed 99 times (median Hgb 13.4 g/dL), with 36 (36%) triggering the reflex (Hgb < 13 g/dL). Of these 36 patients, 19 were women and 17 were men, and the cohort had a median age of 69 years. The median Hgb was 11.9 g/dL, ranging from 7.1 to 12.9 g/dL, with a median mean corpuscular volume (MCV) of 89.6 fl. The median Hgb differed by sex: 11.6 g/dL for men, 12.2 g/dL for women. Of these 36 patients, 16 had signs of iron deficiency anemia (IDA) based on laboratory results (below reference interval for iron, transferrin saturation, or ferritin), and two patients were found with vitamin B12 below the reference interval. Chart review demonstrated that 13 of the 36 patients underwent follow-up after reflex laboratory tests resulted, defined as a new diagnosis, new treatment, and/or new consult addressing the patient’s anemia. Five of these patients were given a new diagnosis of IDA, all of which were started on iron therapy. Three patients were transfused packed red blood cells prior to surgery; one was started on vitamin B12 supplementation; two had consults placed to address anemia; and two were given a new diagnosis of unspecified anemia.

Conclusion

Pre-operative CBC reflex testing facilitates the efficient and timely identification of reversible causes of anemia in patients undergoing diagnostic workup prior to cardiac surgery, while avoiding unnecessary panel testing in non-anemic patients.
Bringing Calm to Antibiotic Stewardship: Customizing and Automating Antibiogram Creation at a Multi-Hospital Institution
Authors: Rogers John , Christensen Paul , Olsen Randy , Long Scott
Published: October 2024

We sought to automate antibiogram creation at our multi-hospital institution with custom features including transparency into data filtering, expanding the granularity to include multi-resistant organisms, and additional conditional formatting based on sensitivity percentages.

We automated creation of the antibiogram using a python framework with embedded SQL scripts. The sensitivity data for isolates from the prior year was retrieved from our lab information system. It was filtered to include only inpatient, emergency department, and observation patients across all seven hospitals in our system. Additionally, the data was filtered to only include the first organism per patient per year. Finally, organisms meeting specific sensitivity criteria (i.e. methicillin resistant Staphylococcus aureus) were included as separate rows beneath the parent organism. This data was inserted into an excel workbook with customized formatting to include the institutional logo, coloring based on sensitivity percentages, and customizable comments. Each of these steps are easily editable year-to-year to allow for changing requirements. At each step of filtering, the integrity of the data was extensively validated to make sure it was performing as intended.

The antibiograms are generated within a few minutes in a fully automated manner (Figure 1). These will be distributed systemwide after review by the Medical Microbiology directors and Antimicrobial Stewardship Committee in January of each year. The code was made in an easily editable, modular way such that requests for additional separation of organisms by sensitivity, removing drugs not pertinent to our formulary, and editing what organisms appear is easily managed by the informatics team on a year-to-year basis.
Optimizing Patient Care through Analysis of HIV-1 Genotyping: Insights into Test Ordering Strategies, Clinical Relevance, and Implications for Managing Drug Resistance
Authors: Simonyan Hayk , Dabash Abdelrahman , Yee Rebecca
Published: October 2024

Background

Antiretroviral resistance can lead to treatment failure and disease progression, especially in HIV patients. HIV-1 sequencing/genotyping tests (e.g., GenoSure) can be ordered by clinicians to detect HIV drug resistance (HIVDR). Here, we investigated our institution’s ordering practices, clinical relevance, and rates of HIVDR.

Methods

A total of 94 patients positive for HIV-1 between 01/2019-08/2021 were included (n=46 pre-COVID-19 prior to 03/11/2020; n=48 post-COVID-19). Patients’ charts were reviewed for demographics, laboratory results, clinical presentation, and antiviral management. Student t-test and Fisher exact test were used for statistical analyses.

Results

HIV-1 genotyping was ordered most by Medicine (67%), Surgery, (7%), Emergency medicine (6%), Neurology and Obstetrics & Gynecology (5% each). Only 70% of patients with GenoSure ordered and sent out had sufficient viral loads for genotyping. Among the patients with insufficient viral loads, the GenoSure test was most ordered by Medicine (68%), Surgery (9%) and Ob/Gyn (9%) departments. Our HIV patient population was predominantly male (70%) and had a mean age of 49 years (range: 25 to 90 years). Lower viral loads (1.8x105 vs. 3.4x105 copies/mL, p=0.05), CD4 counts (174 vs. 196 cells/mcL, p=0.7), CD8 counts (555 vs. 800 cells/mcL, p=0.04), and higher CD4/CD8 ratio (0.312 vs. 0.266, p=0.57) were seen in our post-COVID-19 patients. The overall prevalence of HIVDR was 20%. There was a 9% increase in HIVDR, predominantly in non-nucleotide reverse transcriptase inhibitors (NNRTI), after the COVID-19 pandemic. For example, higher resistance was documented for antiviral drugs Efavirenz (16%), Nevirapine (16%), and Rilpivirine (13%). Increased prevalence of mutations in G190A, K101, K103, and E138 positions which confer resistance to NNRTIs was seen. The GenoSure test results helped optimize antiviral therapy in 47.8% (42/88) of total cases, with an increase of 12.5% in patients from post-COVID-19 era. Infectious disease consultations led to more actionable changes (16% increase) and ordering of the updated version of the GenoSure test that includes integrase inhibitors (20% increase, p=0.005).

Conclusion

We have implemented stringent clinical criteria including pathologist approval and changed our electronic health record ordering system to ensure GenoSure is appropriately ordered. Diagnostic stewardship of sequencing tests needs to be implemented to ensure actionable clinical changes in the right patient population and to control testing costs. Additionally, our findings revealed increased HIVDR in our patient population post-COVID-19. Continued surveillance and collaboration with antimicrobial stewardship are critical to managing HIVDR and improving patient outcomes, particularly given the significant strain that the COVID-19 pandemic has placed on our healthcare system.
Clinical Test Comparison for Improved Diagnosis of Mucormycosis
Authors: Haas Allison , Hanson Kimberly
Published: October 2024

Mucormycosis is a rapidly progressive and invasive fungal infection caused by members of the order Mucorales. Proper treatment relies on a timely diagnosis. However, traditional fungal culture takes several days to weeks and has low sensitivity for recovering Mucorales, as these organisms are sensitive to specimen preparation, including tissue homogenization, and low storage temperatures. More rapid and sensitive diagnostic methods are needed to promptly detect infection. Our laboratory previously developed a real-time PCR assay that detects the most common genera associated with mucormycosis to help improve diagnosis. The assay was analytically validated for a variety of specimen types including serum, tissue (both fresh and FFPE), respiratory secretions and body fluids. Little is known about the agreement between our laboratory developed PCR and other detection methods such as culture or sequencing. We reviewed 6 years of laboratory data to assess overall PCR positivity rate, positivity rate across sample types, and agreement with culture and/or pan-fungal sequencing. We also calculated turnaround time to results to gauge the diagnostic value of Mucorales PCR. Test comparisons with fungal culture and/or pan-fungal sequencing were performed if testing was ordered within 30 days of each other. In our study, we reviewed 3,804 total PCR orders for 2,195 patients. The overall positivity rate of Mucorales PCR orders was 3.81% and varied among different sample types, with fresh tissue and body fluid having the highest positivity rates (18.11% total tissue (33.3% lung tissue) and 10.94% all body fluid (12.5% pleural fluid)) and sputum and CSF having the lowest positivity rates (<1% positivity for both). In a cohort of 428 patients with fungal culture and/or sequencing also performed, 29 patients tested positive for Mucorales by at least one method. PCR detected Mucorales on average 7.83 days sooner than fungal culture (average time to positive result: 3.65 vs. 11.47 days). In patients with culture- or sequencing-confirmed Mucorales infection, PCR had a 100% agreement when comparing shared samples from the same source and collection time. Mucorales PCR was also able to detect infection in 10 (34.5%) other patients who were culture-negative for Mucorales. Our findings suggest that PCR could be a valuable diagnostic tool for suspected mucormycosis, especially tissue invasive disease. PCR increased case detection by 34.5% with a faster turnaround time than culture with lesser cost than sequencing. The main limitation of our study was lack of access to patient information to assess pretest probability of Mucormycosis.
Detection of Enteroviruses in a Pediatric Oncology Patient Population
Authors: Asowata Osaretin , McMillen Tracy , Jani Krupa , Clark Brenden , Babady Esther
Published: October 2024

Enteroviruses are responsible for around 10 to 15 million infections and tens of thousands of hospitalizations annually. Infants, children, and people with weakened immune systems are more likely to get hospitalized and can have serious complications from enterovirus infection. Non-polio enteroviruses like EV-D68 can cause mild to severe symptoms like wheezing, difficulty breathing and acute flaccid myelitis (AFM). Therefore, it is crucial to continue to monitor the prevalence of enteroviruses, especially those that can potentially cause severe symptoms like EV-D68. This study focused on determining the prevalence of enteroviruses in a pediatric oncology patient population. Residual Nasopharyngeal swabs (NPS) specimens, collected from pediatric patients (<18 years old) presenting to a cancer hospital in New York between September 2022 and December 2022, and September 2023 and December 2023 for cancer care were included in the study. Rhinovirus/Enterovirus (RV/EV) was detected using the BioFire FilmArray Respiratory Panel (bioMerieux, Inc.) or the ePlex Respiratory Pathogen Panel (GenMark/Roche Molecular). For Enterovirus identification, RNA was extracted from the RV/EV positive NPS using the KingFisher™ Flex Magnetic Particle Processors (Thermo Scientific, USA), followed by RT-PCR in the ABI 7500 Fast real-time PCR instrument (ThermoFisher, USA) for enteroviruses and EV-D68 using pan-Enterovirus and EV-D68 specific primers, respectively. A total of 880 and 694 NPS samples from patients <18 years old were tested during the study period in 2022 and 2023, respectively. Of these, 238 (238/880; 27%) and 225 (225/694; 32%) RV/EV positives NPS were detected in 2022 and 2023 respectively. A total of 370 (370/463; 80%) RV/EV positive samples (182 samples from 2022 and 188 samples from 2023) were selected for additional testing and 14 samples (14/370; 4%) were positive for Enteroviruses. Of note, EV-D68 was not detected. In this study, we report a high prevalence of RV/EV which is consistent with the higher detection rate in the fall seasons, when our samples were collected. The low prevalence of EV suggests a high prevalence of RV, although this was not tested. Despite a nationwide surge in the USA in 2022, there was no EV-D68 circulating in these patients. Further analysis, using Whole genome sequencing of the enteroviruses detected in this study will provide additional information on specific circulating Enterovirus genotypes.
Determination of Citrate Content of Commonly Transfused Blood Products
Authors: Mehr Noah , Simon Richard , Carll Timothy
Published: October 2024

Background

Citrate is a calcium-chelating anion used as an anticoagulant in the collection and manufacturing of blood products for transfusion. Overwhelming of normal hepatic catabolism of infused citrate, such as in liver failure or in massive transfusion, may cause citrate toxicity. Resultant hypocalcemia, impaired coagulation, and metabolic alkalosis results in increased patient mortality and morbidity. The citrate load per blood product unit is rarely known to the transfusionist, precluding precise calcium repletion. Manufacturing data of citrate content is available, but it is unreliable and often contradictory. The aim of this project is to directly measure the citrate concentrations of common blood products including packed red blood cells (pRBCs), plasma, and apheresis platelets.

Methods

Blood products (or samples thereof) were obtained, centrifuged, and assayed using a benchtop enzymatic citrate assay (Sigma-Aldrich). This technique generates a chromogenic product detectable via spectrophotometry at 570nm via conversion of citrate to a pyruvate intermediate. Blood products were serially diluted to the assay’s concentration measurement range based on estimations from the product manufacturing processes. Validation studies were performed to verify no significant interference from native pyruvate or from hemolysis at the dilutions used. All samples were run with a paired reference standard. Product type, storage duration, volume, and anticoagulant/preservative solution were recorded.

Results

Preliminary testing was performed on eleven pRBC units, twelve apheresis platelet units, and four whole blood(WB)-derived plasma. Measured citrate content of AS-1 and AS-5 units ranged from 43.56 - 114.5 mg while that of AS-3 units ranged from 327.23 – 816.82 mg, compared to manufacturing estimates of 188 mg and 883 mg, respectively. Measured citrate content of apheresis platelets ranged from 822-1533 mg compared to manufacturing estimates of 805 mg. Measured citrate content of WB-derived plasma also exceeded the manufacturing estimate of 1201 mg. Interference from pyruvate and hemolysis were insignificant at the dilutions used for testing. Validation of pRBC segment sampling is ongoing.

Conclusion

Varying guidelines exist for the correction of hypocalcemia during ongoing trauma resuscitation; however, guidance is limited regarding repletion by specific blood product. Our investigation affirms significant heterogeneity in pRBC citrate concentrations by collection method and identifies lower citrate concentrations than expected. This may be due to citrate metabolism by RBCs during storage. Platelet and FFP products contain significantly greater citrate masses by comparison, with a high degree of variation observed due to inherent product volume variability. Further sampling and testing are ongoing to establish reliable expected citrate loads for commonly transfused blood products.
Impact of a New Departmental Awards Program on Faculty Engagement and Promotion
Authors: Guarner Jeannette , Bradley Kyle , Neish Andy , Lewis Melinda , Hanley Krisztina
Published: October 2024

Background

Many academic institutions recognize contributions to individual departments by awarding faculty departmental awards for their achievement in service, teaching and scholarship. Before 2019, our department had teaching awards chosen by residents, but there were no awards given to the faculty by peers for academic accomplishments. The objective of this abstract is to present the impact of the newly implemented departmental awards on the promotion and academic advancement of our faculty.

Design

Based on the already established awards in other departments within the School of Medicine a committee of six faculty members proposed six annual awards: Educator Impact, Outstanding Service, Outstanding Citizenship, Mentoring, and Basic and Clinical Science Publications. The committee defined activities and eligibility for each award category (for example, faculty could not receive the same award within 3 years). The categories and eligibility criteria are distributed to all faculty (around 120) each year. The first call for nominations occurred in 2019. Assessment of the awards program included the number of nominators and nominees each year and the impact on recipients’ academic advancement and recognition.

Results

In 2019, 17 faculty nominated 16 other faculty for the six awards. These numbers grew steadily, and by 2023, 42 faculty nominated 28 other faculty for the awards. The awards have been included in the curriculum vitae of five faculty who have been promoted to either the Associate Professor or Professor level and six faculty inducted into our institution’s Clinical Distinctions program. During the five years this awards program has existed, two faculty received two awards in different categories, whereas the remaining 26 awardees each received one award. Anecdotes from faculty during this time have been overwhelmingly positive.

Conclusion

Based on the increased engagement of faculty nominating their peers and the overall impact of the awards on faculty promotion and clinical distinction recognition, the new departmental awards program has been very successful.
Two Concurrent Cases of NAIT in Pregnant Sisters
Authors: Costa Victoria , Hilbert Timothy
Published: October 2024

Neonatal alloimmune thrombocytopenia (NAIT) is caused by maternal antibodies directed against fetal platelet antigens inherited from the father. Approximately 80% of cases of NAIT are attributed to antibodies against human platelet antigen (HPA)-1a and less commonly to antibodies against HPA-5b. We present two cases of possible NAIT attributed to anti-HPA-5b that were identified in sisters requiring concurrent management.

Patient #1 is a 32-year-old G9P4044 woman with one pregnancy complicated by intrauterine growth retardation and partial placental abruption, another pregnancy complicated by fetal anomaly (intracerebral hemorrhage) status post termination of pregnancy at 23 weeks’ gestation and three miscarriages (one with chromosomal abnormality). The patient is homozygous for HPA-1a and HPA-5a, and the partner is homozygous for HPA-5b. HPA-5b antibodies and HLA antibodies were identified in the patient’s serum. Deemed at high risk for subsequent NAIT, she was started on intravenous immunoglobulin twice weekly and steroids during her second trimester until delivery. The patient underwent weekly fetal sonograms during pregnancy which were normal. The patient’s platelet counts were stable. The patient refused caesarean delivery. At 38 weeks’ gestation, the patient gave birth to a healthy female via normal spontaneous vaginal delivery. HPA-5b negative platelets were procured from our blood supplier, but neither the mother nor neonate required transfusion. The neonate showed no signs of bleeding and had normal platelet counts. Ultrasound imaging of the head was unremarkable. The patient and neonate were discharged home.

Patient #2 is a 33-year-old G13P6156 woman with a prior pregnancy complicated by stillbirth at 32 weeks’ gestation. Considering her personal and family history, HPA testing was performed and HPA-5b antibodies were identified in the patient’s serum. The patient’s partner is heterozygous for HPA-5b. Crossmatched platelets were procured from our blood supplier. The patient refused caesarean delivery. The patient gave birth at 37 weeks’ gestation to a healthy male via normal spontaneous vaginal delivery. The fetus had mild thrombocytopenia (107 x 103/uL), with no bleeding or bruising identified. Neither the mother nor neonate required transfusion. The patient and neonate were discharged home. Ultrasound imaging of the head was unremarkable, and his thrombocytopenia resolved.

While some studies postulate that anti-HPA-5b identification may be coincidental rather contributory to the disease process, these cases re-emphasize the importance of obtaining pregnancy, neonatal and family history to best risk stratify patients and determine management from both the clinical and transfusion medicine perspectives. If transfusion is needed, transfusion options include HPA negative platelets, crossmatched platelets and random donor platelets depending on clinical urgency and platelet availability.
A maternal germline mutator phenotype in a family affected by heritable colorectal cancer
Authors: Young Candice L , Beichman Annabel C , Mas Ponte David , Hemker Shelby L , Zhu Luke , Kitzman Jacob O , Shirts Brian H , Harris Kelley
Published: October 2024

Variation in DNA repair genes can increase cancer risk by elevating the rate of oncogenic mutation. Defects in one such gene, MUTYH, are known to elevate the incidence of colorectal cancer in a recessive Mendelian manner. Recent evidence has also linked MUTYH to a mutator phenotype affecting normal somatic cells as well as the female germline. Here, we use whole-genome sequencing to measure germline de novo mutation rates in a large extended family containing both mothers and fathers who are affected by pathogenic MUTYH variation. By developing novel methodology that uses siblings as “surrogate parents” to identify de novo mutations, we were able to include mutation data from several children whose parents were unavailable for sequencing. In the children of mothers affected by the pathogenic MUTYH genotype p.Y179C/V234M, we identify an elevation of the C>A mutation rate that is weaker than mutator effects previously reported to be caused by other pathogenic MUTYH genotypes, suggesting that mutation rates in normal tissues may be useful for classifying cancer-associated variation along a continuum of severity. Surprisingly, we detect no significant elevation of the C>A mutation rate in children born to a father with the same MUTYH genotype, and we similarly find that the mutator effect of the mouse homolog Mutyh appears to be localized to embryonic development, not the spermatocytes. Our results suggest that maternal MUTYH variants can cause germline mutations by attenuating the repair of oxidative DNA damage in the early embryo.
Busy Ethic: A Validation of a Popular Concept
Authors: van Solinge Hanna , Ekerdt David J , Henkens Kène
Published: October 2024

Background and Objectives

The busy ethic for retirement, as proposed by Ekerdt (1986), is a prescriptive norm that esteems an occupied, active lifestyle. This research is a first attempt to measure the busy ethic in a standardized way and apply it to a population-based sample. Objectives are: to examine whether a busy ethic is affirmed by retirees; to test busy ethic endorsement by different segments of the retired population; and to examine whether endorsement is associated with selected activities.

Research Design and Methods

We developed a scale measuring the busy ethic for a survey among 1,143 Dutch retirees. We tested two sets of hypotheses about social factors that might explain subscription to a busy norm: a hypothesis about modernization (i.e., individual autonomy from social control) that would reduce busy ethic endorsement and a hypothesis about differential exposure to expectations.

Results

Greater consent to the busy ethic was associated with circumstances that enable active lifestyles (perceived income adequacy, self-reported health), that raise one’s social value (education), and that entail more social connectedness (religious service attendance). Busy ethic agreement was positively associated with engagement in paid work, productive social activities, and group recreation.

Discussion and Implications

We found substantial endorsement of the importance of activity for oneself and others. The idealization of a busy retirement as a good retirement may be a seeming way for retirees to defer old age. At the same time, a prescriptive norm of activation may put strain on older adults who are less capable of conforming.
Modern venomics—Current insights, novel methods, and future perspectives in biological and applied animal venom research
Authors: von Reumont Bjoern M , Anderluh Gregor , Antunes Agostinho , Ayvazyan Naira , Beis Dimitris , Caliskan Figen , Crnković Ana , Damm Maik , Dutertre Sebastien , Ellgaard Lars , Gajski Goran , German Hannah , Halassy Beata , Hempel Benjamin-Florian , Hucho Tim , Igci Nasit , Ikonomopoulou Maria P , Karbat Izhar , Klapa Maria I , Koludarov Ivan , Kool Jeroen , Lüddecke Tim , Ben Mansour Riadh , Vittoria Modica Maria , Moran Yehu , Nalbantsoy Ayse , Ibáñez María Eugenia Pachón , Panagiotopoulos Alexios , Reuveny Eitan , Céspedes Javier Sánchez , Sombke Andy , Surm Joachim M , Undheim Eivind A B , Verdes Aida , Zancolli Giulia
Published: October 2024

Venoms have evolved >100 times in all major animal groups, and their components, known as toxins, have been fine-tuned over millions of years into highly effective biochemical weapons. There are many outstanding questions on the evolution of toxin arsenals, such as how venom genes originate, how venom contributes to the fitness of venomous species, and which modifications at the genomic, transcriptomic, and protein level drive their evolution. These questions have received particularly little attention outside of snakes, cone snails, spiders, and scorpions. Venom compounds have further become a source of inspiration for translational research using their diverse bioactivities for various applications. We highlight here recent advances and new strategies in modern venomics and discuss how recent technological innovations and multi-omic methods dramatically improve research on venomous animals. The study of genomes and their modifications through CRISPR and knockdown technologies will increase our understanding of how toxins evolve and which functions they have in the different ontogenetic stages during the development of venomous animals. Mass spectrometry imaging combined with spatial transcriptomics, in situ hybridization techniques, and modern computer tomography gives us further insights into the spatial distribution of toxins in the venom system and the function of the venom apparatus. All these evolutionary and biological insights contribute to more efficiently identify venom compounds, which can then be synthesized or produced in adapted expression systems to test their bioactivity. Finally, we critically discuss recent agrochemical, pharmaceutical, therapeutic, and diagnostic (so-called translational) aspects of venoms from which humans benefit.
MitoSort: Robust Demultiplexing of Pooled Single-cell Genomic Data Using Endogenous Mitochondrial Variants
Authors: Tang Zhongjie , Zhang Weixing , Shi Peiyu , Li Sijun , Li Xinhui , Li Yueming , Xu Yicong , Shu Yaqing , Hu Zheng , Xu Jin
Published: October 2024

Multiplexing across donors has emerged as a popular strategy to increase throughput, reduce costs, overcome technical batch effects, and improve doublet detection in single-cell genomic studies. To eliminate additional experimental steps, endogenous nuclear genome variants are used for demultiplexing pooled single-cell RNA sequencing (scRNA-seq) data by several computational tools. However, these tools have limitations when applied to single-cell sequencing methods that do not cover nuclear genomic regions well, such as single-cell assay for transposase-accessible chromatin with sequencing (scATAC-seq). Here, we demonstrate that mitochondrial germline variants are an alternative, robust, and computationally efficient endogenous barcode for sample demultiplexing. We propose MitoSort, a tool that uses mitochondrial germline variants to assign cells to their donor origins and identify cross-genotype doublets in single-cell genomic datasets. We evaluate its performance by using in silico pooled mitochondrial scATAC-seq (mtscATAC-seq) libraries and experimentally multiplexed data with cell hashtags. MitoSort achieves high accuracy and efficiency in genotype clustering and doublet detection for mtscATAC-seq data, addressing the limitations of current computational techniques tailored for scRNA-seq data. Moreover, MitoSort exhibits versatility, and can be applied to various single-cell sequencing approaches beyond mtscATAC-seq provided that the mitochondrial variants are reliably detected. Furthermore, we demonstrate the application of MitoSort in a case study where B cells from eight donors were pooled and assayed by single-cell multi-omics sequencing. Altogether, our results demonstrate the accuracy and efficiency of MitoSort, which enables reliable sample demultiplexing in various single-cell genomic applications. MitoSort is available at https://github.com/tangzhj/MitoSort.
Effect of dietary calcium and vitamin D supplements on plasma bone turnover biomarkers, bone mineralization, bone strength, and lameness score in gilts
Authors: Bruun Thomas S , Jensen Søren K , Larsen Torben , Nielsen Mai Britt F , Roger Laurent , Feyera Takele
Published: October 2024

This study investigated the impact of calcium (Ca) and vitamin D supplements on bone metabolism, bone measurement, lameness, and selection rate in gilts fed 5 dietary treatments. Two Ca levels (6.85/6.42 [adequate; ACa] or 8.99/8.56 [high; HCa] g/kg) were combined with either 856 IU/kg vitamin D3 (Danish feeding standards; adequate; AD3) or 50 μg/kg 25-hydroxyvitamin D3 (high; HHyD) to create ACaAD3, HCaAD3, ACaHHyD, and HCaHHyD diets. The values 6.85/6.42 and 8.99/8.56 g/kg correspond to adequate and high Ca supply for gilts weighing 32 to 100 and 100 to 180 kg body weight (BW), respectively. The fifth diet was a combination of HCa and 2,000 IU/kg vitamin D3 (high; HD3) to create HCaHD3. Two hundred gilts were phase fed the dietary treatments from 32 to 100 and 100 to 180 kg BW until they were slaughtered, either at 100 or 180 kg BW. The gilts were weighed fortnightly, and plasma and urine samples were collected at 100 and 180 kg BW. At slaughter, the 2nd and 3rd metacarpal bones were collected for bone parameters measurements. Lameness and selection rate were assessed within the last 7 d at 100 and 180 kg BW. Dietary treatments did not affect gilts’ growth performance and plasma concentration of Ca, but the urinary concentration of Ca was greater in HCa-supplemented gilts at both 100 (P = 0.003) and 180 (P = 0.05) kg BW. Plasma concentration of vitamin D3 (P < 0.001) and 25-hydroxyvitamin D3 (P < 0.001) showed dose-dependent responses at both 100 and 180 kg BW. Bone-specific alkaline phosphatase was greater (P = 0.02) in the plasma sample collected at 180 kg BW in gilts fed the HCaHD3 diet and tended to be greater in gilts fed the ACaAD3 diet (P = 0.06). The bone ash content (P = 0.02) was greater in gilts fed the HCaAD3 diet and slaughtered at 100 kg BW compared with gilts fed the ACaAD3 and ACaHHyD diets. However, bone weight, length, thickness, dry matter, and mineral content did not differ among the dietary treatments at both 100 and 180 kg BW (P > 0.05). Neither lameness nor selection rate was affected by the dietary treatments. The average daily gain of gilts weighing 32 to 100 and 100 to 180 kg BW showed a positive correlation with bone strength (r = 0.37; P < 0.001) and bone ash content (r = 0.24; P = 0.02), respectively. In conclusion, higher Ca and vitamin D3 supplementation slightly increased bone ash content but had no effect on the lameness or selection rate of the gilts compared to those fed according to the Danish nutrient standards.