Transfusion Medicine




PL0I Turning Back the Tide S. Penny NHSBT, Filton Centre, Bristol, UK On 24th September 2012 a blocked railway culvert close to the NHSBT Filton Blood Centre was unable to cope with the volume of water created by a ‘1 in 30 year’ storm in the Bristol area. A surge of water passed rapidly through the facility causing the cessation of all operations in the building. The NHSBT Critical Incident Plan was activated and all blood and components were recovered from the building. The plan continued with two integrated strands of activity: 1. To ensure the continued supply of blood, blood components and other products to hospitals. This required that all donations collected were to be manufactured and tested at other centres around the country and distributed to hospitals served by the Filton centre and six other centres served by Filton. The standardisation of processes in NHSBT greatly facilitated this; 2. To ensure the rapid recovery of the facility and restore operations within it. Within 1 week, the Centre was fully operational. This was possible due to the motivation and flexibility of staff and experience gained from practising the Critical Incident Plan. Mitigating actions have been taken to ensure no repeat of the flood will occur.

PL02 ‘A Sting in the Tale?’ T. Allen NHSBT, Oxford, UK At 8·25 am on 24th September 2012 a call from a member of the Customer Services team based at Filton suggested that our hospital services staff in Filton were having to advise all the hospitals that they planned to supply with blood components that their blood deliveries might be delayed due to heavy rain. This call was the first of many taken by our Customer Services team in response to local flooding. We then adopted a key role in managing direct communications with hospitals across the country as well as helping our diagnostic laboratories and Hospital Services team at Filton to exchange critical information with local hospitals. During the course of the next 2 weeks, we co-ordinated the preparation and delivery of local, national and regional communications about the decisions we had taken as a service to protect, maintain and redirect service provision. This included messaging through a range of media including twice daily telephone calls with the hospitals who were normally supplied by Filton with faxed and web based written communications.

© 2013 The Authors Transfusion Medicine © 2013 British Blood Transfusion Society

Feedback from hospitals about our communications has been very positive, however we have learned a number of lessons from this incident which we are sharing so that others can learn from our experience.

PL03 ‘Conflagration’ – Friend or Foe? D. Alderson Trafford General Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK At about 6 am one morning in October 1993 I received a phone call from the on-call BMS to inform me that the laboratory was on fire and that the fire brigade was on the way. Living only 5 minutes away I quickly dressed and arrived on the scene to find the Transfusion Department completely engulfed by flames and also some of the Microbiology Department. The fire brigade arrived and put out the fire but this left a very dangerous building, i.e. the section occupied by transfusion. Sections had to be demolished to allow safe access to the rest of the Laboratory. The Consultants and Senior BMS staff met before 8 am and decided that we needed to approach management re: A+E closure, cancellation of some Surgery and to rapidly utilise our links with adjacent laboratories. We had lost many consumables and all our Blood Stocks/Fridges. The latter was potentially the most difficult to replace. Following a phone call to a Major in the RAMC, this was alleviated by help from the Army who despatched Fridges overnight with the simple request for local P.R. We found new areas for working within 24 hours but later utilised Portakabins to re-house Transfusion, in particular. The phoenix from this was the engagement of the Chief Executive to allow design and build of a new Laboratory. This was formally opened by Princess Margaret on Thursday 20th July 1995. The learning aspects here were: 1. Rapid communication with management. This allowed smooth transition of closing/opening A+E and cancellation/relisting of some surgery. 2. Relationships with our colleagues in adjacent Trusts. This ensured we were able to borrow vital equipment and restock with consumables that had been lost. 3. Updating NHSBT to allow for re-stocking once fridges were on site. 4. Pathology lends itself to team working. This initially involved salvage and taking an inventory. Then there was reconfiguration within a reduced footprint. 5. The pivotal role of the army. Demonstration from all the above of the central importance of pathology and in particular Transfusion to the ability of a DGH continued to function normally. This was key to deciding on a new-build Pathology Laboratory.

doi: 10.1111/tme.12070

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Examination of the Feasibility of Establishing a Peer Reviewed External Quality Assessment Scheme for Red Blood Cell Antibody Eluate Investigations

Evaluation of a Novel Serology-Based Multiplexed Protein Microarray Platform for Antigen Typing of Red Blood Cells (Project MosaiQ™)

J. Murphy, J. Crumlish & B. Doyle Irish Blood Transfusion Service, Dublin 8, Ireland

L. Welsh, Q. J. Rob & D. Robson

The work aimed to establish an experimental model to produce external quality assessment (EQA) samples which are suitable for use in a scheme to assess laboratory investigation of antibody eluates. The samples were validated through a series of optimisation procedures. Their suitability for use in the scheme was determined by performing a trial EQA. Participant laboratories reported the results of their investigation of the scheme samples to our laboratory, and results were interpreted cumulatively. Background/Case Studies: External Quality Assessment is an important component of a Quality System (QS) in a medical laboratory. Hospital blood banks in the Republic of Ireland (RoI) are required to be accredited to ISO 15189 standards. For testing to be included in their accreditation scope they must partake in some form of external assessment. No EQA scheme has been introduced in the RoI to assess red blood cell (RBC) antibody elution procedures. With the publication of the British Committee for Standards in Haematology guidelines for pre-transfusion compatibility testing, antibody elutions performed in routine blood transfusion practice may increase, thus increasing the requirement for an EQA scheme to assess the performance of these investigations. This study aimed to determine the feasibility of implementing a peer reviewed EQA scheme to assess the testing of RBC antibody elutions.

Background: All donor and patient samples must be tested pretransfusion to determine their blood type: routinely only the ABO and RhD blood group antigens are typed. To obtain an extended blood type profile, numerous automated and/or manual processes are subsequently required. Quotient is developing a new serology-based microarray which will enable multiplex testing of ABO and Rh plus full antigen phenotyping and direct antiglobulin testing (DAT) in a single assay platform (Project MosaiQ™). This platform will provide a single comprehensive test that will offer significant efficiency savings in the provision of blood for patients. Herein, we report the evaluation of the MosaiQ™ platform with the analysis of 500 random donor samples.

Study Design/Methods: A trial EQA was performed using samples containing two RBC phenotypes sensitised with monoclonal antiserum. The sample criteria were based on a series of optimisation procedures. Samples were tested on rapid acid elution kits in use in RoI: Immucor Gamma ELUKIT-II and BIORAD DiaCidel. Eleven laboratories were provided with two samples, one containing an Anti-Fya antibody and the other an Anti-Jka antibody. They were asked to investigate the samples and the results of their investigation were analysed and reported to participants. Results/Findings: With each sample 9 out of 11 (81·2%) participants identified the correct antibody. Each sample incurred a procedural error (misidentification/ no antibody identification) and a technical error (transcriptional error). Two laboratories returned their results after the closing date of the trial.

Conclusion: I believe the study established that the experimental design is suitable for the production of samples for said EQA scheme. The trial determined the level of difficulty was appropriate and capable of identifying faults in laboratory practices. A penalty score system was generated, but not implemented, based on clinical significance of the errors in the trial. Further work producing suitable samples and a Quality Management System for the trial will be required before it is established.

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Quotient,(formerly Alba Bioscience), Edinburgh, Scotland, UK

Methods: A range of antibody specificities were deposited by specialised non-contact printing technology in duplicate spots on a coated glass substrate. Subsequently, the surface was blocked and dried. A suspension of diluted test red cells was incubated on the microarray before washing, fixation and drying. The presence of bound red cells was then detected by imaging. Comparator testing was carried out in parallel on all samples by column agglutination and tube based methods.

Results: A 98% correlation with comparator techniques was achieved with several specificities (A, B, D, C, c, E and K), with testing including Ax positive cells (n = 3). Optimisation of these probes is on-going, along with work to extend the range of typing antibodies used on the system (including further Rh, Fy, Jk and MNSs).

Conclusions: This evaluation demonstrates the potential of the MosaiQ™ platform to comprehensively type human blood samples in a single test. Adaptations of this format have successfully demonstrated that antibody identification, DAT and virology assays can be performed simultaneously. Automation of the assay process would ultimately introduce efficiencies in the blood testing laboratory by minimising the need for repeat, extended or confirmatory testing, as well as reducing instrumentation requirements. We believe that this flexible platform has the potential to deliver an integrated approach for combined blood typing, antibody identification and pathogen testing.

SI01 Evaluating the Risk of RhD Sensitisation through Renal Transplantation B. Carey, S. Harle-Stephens, P. Rowe & J. Copplestone Derriford Hospital, Plymouth, UK Donor and recipient blood group data was obtained for all renal transplants performed in Plymouth over the last 10 years. Red cell screening results were then analysed pre and post transplantation, for all RhD negative individuals who received an RhD positive kidney © 2013 The Authors Transfusion Medicine © 2013 British Blood Transfusion Society

XXXI Annual Scientific Meeting of the British Blood Transfusion Society transplant. The sensitisation data was analysed in conjunction with patient demographics to predict the risk of female recipients developing anti-D antibodies. Introduction: Kidneys for transplant are perfused immediately on removal from the donor to prevent clotting. Whilst this involves significant amounts of perfusion fluid, trace amounts of blood may be left in the organ, there is therefore the possibility that RhD negative individuals may produce anti-D antibodies on receipt of a transplant from an RhD positive donor. The purpose of this study was to evaluate whether there is a risk of RhD sensitisation for women of child bearing age. Approach: Donor and recipient blood group data was obtained for all renal transplants performed at Derriford Hospital, Plymouth, over the last 10 years. Red cell screening results were then analysed pre and post transplantation, for all RhD negative individuals who received an RhD positive kidney transplant. The sensitisation data was analysed in conjunction with patient demographics to predict the risk of female recipients developing anti-D antibodies. Results: Between 2003 and 2012 a total of 541 transplants were carried out, of which 86 were RhD negative recipients of RhD positive organs. Of the 86 recipients, 18 were females less than 45 years of age. Blood transfusion data, at least 6 weeks post transplant, was available on 49 of the 86 recipients. One patient had anti-D antibodies prior to transplantation and was excluded, and 47 patients remained unsensitised to the antigen at all time points. One individual, a 61-year-old blood group A RhD negative male recipient of an A RhD positive kidney, developed anti-D antibodies within 3 months of transplantation in 2008. There was no other sensitising event identified which could have caused the antibody. Conclusion: Following transplantation, the risk of sensitisation to RhD, at 2% (95% CI 0–4%), is significantly less than after blood transfusion. This is likely due to the lower antigen load in a well perfused kidney, and the normal immunosuppressant regime of a transplant recipient. Our data suggests a risk that 1 transplant in 1000 may result in a female recipient of childbearing age developing anti-D antibodies. Whilst this risk is small, RhD immunisation does occur, and transplant centres should consider a policy of prophylactic protection of this group of recipients.


intervention (delivery at 36 weeks). The neonate rapidly developed haemolytic anaemia, which was treated with phototherapy, folic acid supplementation and top up transfusions (×2 over 6 weeks, ongoing). The baby’s red cells were strongly DAT positive, with anti-D eluted. Rh phenotyping results were inconclusive, with a weak reaction observed for RhD. The sample was genotyped as cDe/cde (R0 r), Weak D type 4·2 (DAR). A paternal sample genotyped as R1 R0 , and was heterozygous for Weak D type 4·2 (DAR).

Discussion: This case shows secondary stimulation of maternal anti-D by the D variant weak D type 4·2 (also known as DAR). DAR is a weak partial RhD variant where three amino acid substitutions, in RHD exons 4, 5 and 7, result in reduced and altered expression of the RhD antigen. It is important that patients with this variant should be treated as RhD negative, as they have the potential to generate anti-D against normal RhD. DAR is primarily found in the African population (∼5%). We believe this is the first reported case of DAR in a patient of Caucasian ethnicity.

SI03 Novel KEL Heterozygous Mutations Associated with Apparent Lack of Kell Antigens KEL1 AND KEL2 in Two Patients V. Karamatic Crew,1 N. Thornton,1 N. M. Burton,2 S. Lejon Crottet,3 H. Hustinx3 & G. Daniels1 1 BITS and IBGRL, Bristol, UK, 2 University of Bristol, Bristol, UK, and 3 Blutspendedienst SRK Bern AG, Bern, Switzerland

Background: Kell is a complex blood group system with 34 antigens expressed on a single type II red cell membrane glycoprotein encoded by the KEL gene located on chromosome 7q33-q35. Antigens of the Kell system, particularly K (KEL1), are clinically significant, with antiK causing HDN and severe HTR. Kell-null (Ko) is a rare phenotype defined by the complete lack of all the Kell antigens. There are at least 24 unique Ko genotypes, mostly resulting from either single point (inactivating or missense), or splice site mutations within KEL. A phenotype with very weak expression of Kell antigens is KELmod , usually resulting from homozygosity or heterozygosity for a missense mutation or heterozygosity for a null mutation within KEL. Methods: We report here the serological and genetic investigation

C. Pass, M. Greiss & S. Armstrong-Fisher SNBTS, UK

of two patients (Pt1 and Pt2), and examination of the detected novel mutations using a protein model of the Kell extracellular domain. Pt1 and Pt2 were investigated because of discrepancies between their KEL genotype and phenotype. Phenotyping was carried out using standard serological techniques, and genotyping using PCR-SSP. Subsequently, all 19 exons of the KEL gene were amplified by PCR and directly sequenced.

Introduction: Haemolytic disease of the fetus and newborn (HDFN)

Results: Pt1 was found to have KEL:1,-2 phenotype, but KEL*01/02

SI02 DAR Boosted Anti-D HDFN: Case Study

develops following maternal alloimmunisation to fetal red cell antigens, leading to the production of maternal allo-IgG and subsequent fetal red cell destruction following its transplacental passage. This causes anaemia-related clinical symptoms in the baby ranging in severity. Here we present a case of anti-D mediated HDFN, which was boosted by a rare RhD variant in a previously allo-immunised woman. Methods: Maternal anti-D levels were monitored throughout the pregnancy by antibody titration and quantification, to assess the risk of HDFN. Middle Cerebral Artery Doppler scanning was performed to monitor signs of fetal anaemia. Postnatally HDFN mediated anaemia was evaluated through serum bilirubin levels, full blood counts (in particular Hb) and blood film examination. Neonatal blood samples were also ABO and Rh phenotyped and analysed by direct agglutination test (DAT). Neonatal and paternal RhD genotyping was performed by PCR-SSP. Results: Maternal obstetric serology revealed anti-D in 2004, stimulated by an O RhD pos baby (mother A RhD neg). Rising anti-D titres were observed during this pregnancy (2013), with levels reaching those associated with severe HDFN. This prompted early © 2013 The Authors Transfusion Medicine © 2013 British Blood Transfusion Society

genotype by PCR-SSP. Pt2 was found to have KEL:-1,2 phenotype, but KEL*01/02 genotype by PCR-SSP. Direct sequencing of KEL revealed that Pt1 was heterozygous for a novel missense mutation c.1084C>A in exon 10, encoding p.Gln362Lys change in the Kell protein, apparently associated with the lack of detection of KEL2 by serological techniques. The Kell homology model predicts that Gln362 is in direct contact with residue 193 (associated with KEL1/KEL2 expression), explaining the loss of the KEL2 epitope. Direct sequencing of KEL from the Pt2 sample revealed a novel heterozygous deletion c.380delA in exon 4, introducing a reading frame shift and a premature termination of Kell synthesis at p.Leu188. This mutation would potentially result in a truncated Kell glycoprotein which would be misfolded and degraded before reaching the membrane and hence result in loss of expression of KEL1 antigen in this individual.

Conclusion: Our investigation revealed two novel heterozygous mutations associated with depressed expression of KEL2 and KEL1 antigens; a missense mutation c.1084C>A, p.Gln362Lys and a deletion c.380delAfsX, respectively.

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Collecting Blood for Transfusion from People with Haemochromatosis – More Than Just a Marriage of Convenience?

Inherent Variation in Donor Platelet Function: Potential Clinical Implications

W. G. Murphy Irish Blood Transfusion Service, Dublin, Ireland

NHSBT Cambridge and Department of Haematology, University of Cambridge, Cambridge, UK

Approximately 1 in 200 people in the UK have a genotype of hereditary haemochromatosis, with penetrance of disease probably higher than 30%, and of iron loading without disease higher than 50% by the late 50s. Half or more of these people will be eligible blood donors once they reach donation age, with the potential to donate four times per year every year without any significant risk of iron deficiency and a low deferral rate. At the top end of the estimates, these donors could supply 10% of the UK blood supply. While that is not insignificant in itself, the logistical advantages are also attractive: haemochromatosis donors can be scheduled for periods of maximum projected needs and in a way that maximises efficient use of collection resources; many will come at unsocial hours to donate so as to minimise the disruption to their work; they can give double doses to decrease donor exposures in linked donor–recipient pairs for transfusion dependent patients. The health service gains too, by having treatment given cost effectively and efficiently outside of GP or hospital clinics, freeing up resources there for more useful purposes. For the donor, there is a reward of usefulness and altruism; it is also more pleasant, usually, to be looked after in a donor clinic with its emphasis on well-being, rather than in a hospital environment, with its subliminal message of disease. Appointment times are often better managed and can be arranged to suit busy people. As a research resource haemochromatosis donors have proved to be very interesting in our hands – the regular four times per year donations have provided insights into haemoglobin recovery dynamics and seasonal fluctuations in population haemoglobin levels without the confounders of iron deficient erythropoiesis, as well as unexpected revelations into the mechanisms of iron capture in the erythron in haemochromatosis. They also have the potential to provide blood donations for novel approaches to component development – very early morning donations for clinical studies of same day fresh whole blood transfusions, for example. In Ireland, the prevalence is much higher, at 1 in 80 of the population, but the necessity to avoid financial incentives to donate while providing a service in a health care system where many have to pay quite hefty charges for venesection has tempered our approach. Nevertheless we have run a clinic for over 500 haemochromatosis donors in one centre for the past 5 years, and will begin expanding the programme this summer eventually to tap the potential of providing 30% or more of the blood supply from haemochromatosis donors. To achieve this we will also provide free venesection services to everyone regardless of donor status. Lastly, use of haemochromatosis donors in this way changes the equations for population screening.

Introduction: Platelet responses to agonists vary considerably

S. Garner

between individuals. This variation is to a large extent genetically controlled, implying that platelet function should be consistent over time. We characterised platelet function in 950 blood donors with the aims of identifying the variation within the donor population and assessing its consistency over time. This enabled us to measure the impact of inherent functional variation on apheresis platelets and ultimately its correlation with patients’ post-transfusion platelet increments.

Method: Donors were classified as having low or high responding platelets by using flow cytometry to determine the percentage of platelets with bound fibrinogen or expressing P-selectin following stimulation with either cross-linked collagen related peptide (0·1–0·5 μg mL−1 ), or adenosine diphosphate (10−7 M). Eighty-nine donors whose platelet responses were initially within the lower or upper 10% of observed reactivity for each agonist were re-tested between 4 months and five and a half years later. The activation level of apheresis platelets was defined by the percentage of platelets with bound fibrinogen.

Results: Donor platelet responses varied from being totally unresponsive with 90% of their platelets having bound fibrinogen or expressing P-selectin. There was a good correlation between the initial and repeat platelet activation for all assays (P ≤ 0·007); furthermore the range of results observed in the initial low and high responder groups remained significantly different at the second test (P ≤ 0·0005). The percentage of activated platelets in apheresis donations immediately after donation varied from 0·6 to 84·3%, and notably the most activated platelets were from high responder donors.

Conclusion: By studying almost 1000 individuals we highlighted that platelet function varies considerably between blood donors. Low and high responder donors retained their significant differences over time and hence the potential effect on the quality of platelet concentrates remains consistent. The donors will be studied further to assess the impact of donor variability on platelet storage. Furthermore, we are conducting a double-blinded clinical study to investigate any differences in the clinical efficacy of platelets produced from low or high responder donors.

SI06 Potassium Concentration in Stored Red Cells – the Effect of Familial Pseudohyperkalaemia L. Bruce NHSBT Filton Centre, Bristol, UK In the UK red blood cells (RBCs) may be stored for 35 days prior to transfusion. Normal RBC membranes are slightly permeable to monovalent cations and in vivo the cation gradients across the membrane

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© 2013 The Authors Transfusion Medicine © 2013 British Blood Transfusion Society

XXXI Annual Scientific Meeting of the British Blood Transfusion Society are constantly corrected by the NaKATPase. However at refrigerated temperatures, when the NaKATPase is not functional, the leak of cations goes uncorrected and potassium gradually builds up in the supernatant of stored RBCs. For this reason, RBCs for paediatric use are stored for less than 5 days to ensure that potassium levels in the supernatant are low. However, it is becoming apparent that donor RBCs vary in their permeability to cations resulting in a range of potassium levels in RBC packs after only 7 days storage. We have initiated a study of donors in the Cambridge BioResource to identify donor RBCs with high or low permeability to cations and to link these changes in permeability to their genetic cause. In a parallel study, we have been investigating families with familial pseudohyperkalaemia

© 2013 The Authors Transfusion Medicine © 2013 British Blood Transfusion Society


(FP), a condition in which RBCs are extremely leaky to potassium at refrigerated temperatures. We have identified a mutation in the ABCB6 gene, associated with FP, that is present at a frequency of about 1 : 500–1 : 1000 in the Caucasian population. This particular type of FP is asymptomatic and is not currently detectable by routine donor screening; the RBCs have normal cation permeability at body temperature. So it is possible that 1 : 500 donors may have this dominantly inherited heterozygous mutation. We have already identified two donors with this mutation. Work is ongoing to identify further donors with this mutation, to measure the rate of cation leak from their RBCs, and to characterise the properties of the RBCs from these donors.

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AW01 Blood Group Genotyping: has Gen2Phen Finally Arrived? N. Avent Plymouth University Schools of Medicine and Dentistry, Plymouth, UK Throughout the late 1980s and 1990s blood group alleles were rapidly defined at the level of the gene. This period was a remarkable one for those (like me) involved in this work as it was akin to the global explorers of the 15–17th centuries – most blood groups were completely undefined at the molecular level. The approaches used involved classical gene cloning using the robust methods of protein purification, sequence determination followed by direct gene cloning and sequencing. The data that followed produced some of the most exciting recent findings in transfusion medicine and substantially aided our understanding of the molecular biology of the red cell and immune responses made against it. Subsequently most major alleles of clinical significance were defined by sequencing blood-group active cDNAs that were isolated from individuals expressing known phenotypes. This discovery approach has recently been dubbed Phen2Gen the definition of genotype from phenotype, and has been the norm in Transfusion Medicine since the discovery of the genetic basis of blood group alleles. This period then involved the migration of a predominantly research based focus into clinical diagnostics, whereby difficult to obtain red cells had their phenotype predicted from genotype notably in prenatal diagnosis during the clinical management of haemolytic disease of the fetus and newborn (HDFN). Transfusion Medicine then trail blazed the introduction of non-invasive prenatal diagnosis, methods not requiring amniocentesis, that are particularly problematic in HDFN as it may exacerbate alloimmunisation. This process requires Gen2Phen – using genotype to predict phenotype, during which process it was observed that certain D-negative phenotypes were caused by mutated RHD genes. In the past decade the Gen2Phen was implemented in much larger scale blood group genotyping using DNA arrays, and is now routinely used to manage multi-transfused patients, for example those with sickle cell disease. Highly diagnostically accurate arrays with 100+ different probes directed to blood group and platelet alleles are used and have transformed the ability to predict rare blood group phenotypes, from genotype. However the arrays are limited in that they are constructed solely on the basis of pre-existing knowledge of the allele, and are not operating in discovery mode. Here ‘no score’ results often are generated based on the discovery of a new blood group genotype, not uncommon in the RH blood group system for example. The arrival of next-generation sequencing (NGS) is the next big transformation in blood group genotyping. This will operate in discovery mode as large tracts of DNA can be sequenced rapidly and relatively cheaply. We have shown at Plymouth that it can be readily applied to all clinically significant blood groups such as ABO, RH, KEL, JK and FY. This gives the opportunity to move to full Gen2Phen phenotype scoring, where, e.g. null (silencing) alleles can readily predict the abolition of a blood group, and is driven by the extreme confidence of statistics that a particular genotype generates a particular phenotype. NGS currently utilises the rapid sequencing of short fragments of DNA derived from genomic amplified sequences. This is problematic for determination of whether an allele lies in cis or trans to another allele on the same chromosome. This can be overcome by conventional cloning (but labour

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intensive), and eventually single-molecule pore-based sequencing that is capable of sequencing tracts of DNA up to 40–50 Kb in length and may provide the resolving power needed. Blood group genotyping invariably will become more commonplace in Transfusion Medicine, and Moore’s law of cost reduction predicts soon blood group genotyping may replace serological testing of blood donors economically, currently the biggest hurdle to mass implementation. Interesting, exciting and challenging times lie ahead.

AW02 Among Oldies and Orphans: Observations on Emerging Blood Groups M. L. Olsson Division of Haematology and Transfusion Medicine, Department of Laboratory Medicine, Lund University, Lund, Sweden Already when James Blundell performed the first human-to-human transfusions in the early 19th century, it was obvious that the clinical outcome in the individual patient was not always a roaring success but sometimes instead an unexplained disaster. In addition to many technical challenges regarding vein access and anticoagulation, transfusion across major blood group barriers, not yet discovered at that point in time, is a likely explanation underlying some of the difficulties encountered. Today, more than a century after the identification of the first blood group system, we still give blood matched only for a limited handful of antigens like A, B and RhD to most patients. Despite considerable efforts to increase matching by utilising more advanced typing systems, including those exploiting our newly gained genetic knowledge to predict blood phenotypes, only certain patient categories enjoy more extensively matched transfusions. This is an apparent paradox, since we strive for perfection in patient safety in so many other ways, both in Transfusion Medicine and other areas of medicine. For instance, a self-evident goal is to prevent all transfusion-transmitted infections. At the same time, blood group immunisation following transfusion is considered unfortunate but acceptable, even if many instances could be avoided by improved matching, i.e. more personalised transfusion strategies. A particular challenge in this regard is that we still do not know the detailed biochemical background of all blood group antigens. Among the 339 blood group antigens currently acknowledged by the International Society of Blood Transfusion (ISBT), 42 were still deemed to be socalled orphan blood groups at the latest ISBT meeting in 2012, i.e. lacked a genetic home or locus. This in turn means that the molecular carriers in the red cell membrane for many of these antigens remain unknown. Besides these already accepted blood group antigens, new ones keep on emerging every year. To facilitate genetic testing for all blood groups, and make recombinant antigen expression possible for antibody screening purposes, many investigators and their teams work diligently on resolving the molecular genetic bases of both orphan and emerging blood groups. This award lecture will discuss some recent progress in this field, especially regarding blood groups of (known or apparent) carbohydrate nature.

© 2013 The Authors Transfusion Medicine © 2013 British Blood Transfusion Society

XXXI Annual Scientific Meeting of the British Blood Transfusion Society




Conclusion: NHSBT and the pilot hospitals through the stock

An Integrated Approach to Managing Blood Stocks Effectively

management project have proved that it is possible for NHSBT and hospital systems to work together. Potential benefits include reducing costs, blood wastage and the age of blood at issue to hospitals and improving demand and collection planning. These are being measured and collated from the pilot sites and will be used to inform a business case for a wider roll out. This will be considered by the NHSBT board in July 2013.

L. Frith,1 S. Cotton,2 R. Gray,3 E. Addison,4 J. Johnson,5 P. Baker6 & J. Staves7 1 Brentwood, UK, 2 ITS Pilot Lead, NHSBT, Sheffield, UK, 3 NHSBT, Newcastle, UK, 4 Blackpool Teaching Hospitals Foundation Trust, Blackpool, UK, 5 Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust, Bournemouth, UK, 6 Royal Liverpool and Broad Green University Hospitals NHS Trust, Merseyside, UK, and 7 Oxford University Hospitals NHS Trust, Oxford, UK

Introduction: NHSBT’s stock management project is based on an integrated approach to managing blood stocks. NHSBT has partnered with four hospitals to pilot a stock replenishment model. The benefits of collaborative working through stock management will be evaluated to determine if blood stocks could be managed effectively.

SI08 Comparison of Washed Red Cell Concentrates Produced Using the Haemonetics® ACP™ 15 Automated Cell Processor with Cells Produced Using Manual Washing Methods S. Proffitt, S. Bashir & R. Cardigan Component Development Laboratory, NHSBT, Brentwood, UK

Method: Data was gathered from pilot hospitals on stock levels and

Introduction: Washed red cells are provided for patients who have a

usage patterns of blood components. This information was used to calculate the hospital’s stock requirements and the trigger levels for replenishment agreed. IT links were developed to provide the required stock visibility with stock data extracts sent to NHSBT every 30 minutes. A replenishment report was then generated and sent to the Stock Holding Unit (SHU). The SHU picked, packed and despatched the required blood components and the associated electronic dispatch note.

severe allergic reaction to plasma proteins in standard red cells. Washed units are currently produced using either a manual method or an automated Haemonetics ACP215. Using the manual method the red cells are washed and stored in saline with a shelf of 24 hours, whereas the ACP215 uses saline with glucose to wash and SAGM as the storage media with a shelf life of 14 days. The aim is to compare the quality of washed red cells produced using the ACP215 with those produced using manual methods with different combinations of wash and storage solutions to ascertain whether a shelf life of greater than 24 hours may be feasible with manual washing methods if other storage solutions are used.

Discussion: The pilot hospitals have demonstrated great enthusiasm for the project and all have indicated that they would like to continue to be replenished by the model. Detailed information on stock levels, use and ordering patterns was obtained from the hospital LIMS. This data was used to develop the model used to analyse the data and propose optimised stock holding and delivery patterns for discussion with hospitals. Potential changes to stock levels have been identified in all pilot hospitals. Early engagement with IT suppliers was crucial to the success of setting up the stock replenishment systems. Version upgrades of LIMS and blood tracking software take time to validate and implement.

Method: Five 14-day-old red cell concentrates (RCC) were pooled, split, washed and stored as follows: (i) using the ACP215, (ii) manually washed and stored in saline, (iii) manually washed in saline and stored in SAGM, (iv) manually washed in saline glucose and stored in SAGM, (v) manually washed and stored in SAGM. Units were stored for 14 days at 4 ± 2 ◦ C and measured for volume, haematocrit, protein, IgA, ATP, potassium, haemolysis, haemoglobin and red cell microvesicles.

Results: All washed RCC met specification for volume (200–320 mL)

and haemoglobin content (>40 g unit−1 ). All methods produced washed

Table 1. Washed RCC after 14 days of storage Washing method Wash solution Storage solution Haematocrit (%) (Day 1) ATP (μmol gHb−1 ) Potassium (mmol unit−1 ) Haemolysis (%) Red cell Microvesicles μL−1



Saline glucose



Saline glucose







70·8 (61·8–74·3) 3·05 (1·94–3·33) 1·84 (1·68–2·14) 0·32 (0·26–0·43) 3551 (1126–6514)

71·0 (69·4–71·9) 3·02 (2·02–3·43) 2·47 (2·20–2·78) 0·73 (0·55–1·04) 17899 (3107–36717)

71·8 (70·9–73·4) 3·59 (1·99–3·99) 1·75 (1·60–2·12) 0·30 (0·24–0·40) 1445 (895–3643)

77·8 (76·9–78·8) 3·40 (2·79–3·87) 1·64 (1·38–1·85) 0·25 (0·19–0·46) 1771 (511–4628)

77·4 (76·0–81·4) 3·65 (2·97–3·91) 1·44 (1·25–2·06) 0·22 (0·17–0·35) 1709 (498–3512)

Data (n = 9) shown is median and range. © 2013 The Authors Transfusion Medicine © 2013 British Blood Transfusion Society

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8 XXXI Annual Scientific Meeting of the British Blood Transfusion Society RCC with a residual plasma volume of 75% of units >50 IU and 140 mg per unit, respectively). PI treated units, as expected, contain lower

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J. P. Tung,1 W. Bierman,1,2 C. Knauth,2 R. Flower1,2 & M. Dean2 1 Research and Development, Australian Red Cross Blood Service, Brisbane, Qld, Australia, and 2 Queensland University of Technology, Brisbane, Qld, Australia been shown to be the leading cause of transfusion-related morbidity and mortality in the UK and the United States. The majority of TRALI cases are caused by transfusion of antibodies directed against human neutrophil antigens (HNA) or human leucocyte antigens (HLA). The contribution of these antibodies to the development of an inflammatory response in TRALI is poorly understood. Methods: In an in vitro transfusion model, fresh human whole blood (recipient) was mixed with combinations of culture media (control) or lipopolysaccharide (LPS) as a first event and 5 μg of monoclonal antibodies [MoAbs; mouse anti-human- HNA-2a, -HLA-class I (ABC), -HLA-class II (DR,DP,DQ)] as a second event, and incubated for 6 hours. Addition of protein transport inhibitor in one plate and not in another enabled measurement of neutrophil- and monocyte-specific inflammatory response in the former and overall inflammatory response in the latter, using multi-colour flow cytometry and cytometric bead array respectively (panel: IL-6, IL-8, IL-10, IL-12, IL-1α, IL-1β, TNF-α, MCP-1, IP-10, MIP-1α and MIP-1β). Paired t-test was used for analysis: ## P < 0·01 cf. media only control; * P < 0·05, ** P < 0·01, *** P < 0·001 cf. LPS alone. Results: In the absence of LPS, only the MoAb directed against HLA-class I resulted in any modulation of the inflammatory response (significantly reduced neutrophil IL-8 production## ). However, in the presence of LPS, exposure to the MoAbs resulted in extensive modulation of the inflammatory response. Anti-HNA-2a increased neutrophil IL-8* and overall production of MIP-1α* and MIP-1β*. Anti-HLA-class I reduced neutrophil IL-10* and increased overall MIP-1α**, MIP-1β**, MCP-1* and IL-8**. Anti-HLA-class II increased neutrophil MIP-1β*, monocyte TNF-α* and reduced monocyte IL-10* production. Anti-HLA class II also resulted in increased overall MIP-1α**, MIP-1β*, IL-8*, IP-10***, IL-1β** and TNF-α***. Conclusions: Treatment with MoAbs induced inflammatory responses that were predominantly dependent upon co-culture with LPS, highlighting the importance of patient factors in the development of TRALI. In addition, distinct profiles of immunomodulation were evident for each of the antibodies utilised indicating the likelihood of divergent pathophysiological mechanisms for antibody mediated TRALI.

SI09 Leaning the Blood Supply D. Edmondson & K. Price NHSBT, UK NHS Blood and Transplant (NHSBT) has applied ‘lean’ to improve quality and productivity in the blood supply chain, reducing costs and releasing monies to the NHS. NHSBT identified significant potential for improved productivity in the blood supply chain and an opportunity to release savings to the NHS, in the context of reducing demand for red cells. A ‘lean’ programme was developed in association with Simpler, embodying belief in a © 2013 The Authors Transfusion Medicine © 2013 British Blood Transfusion Society

XXXI Annual Scientific Meeting of the British Blood Transfusion Society culture of continuous improvement and service delivery, underpinned by respect for patients, donors, staff and resources. The programme focuses on the continuous elimination of ‘waste’ such as inventory, poor quality, excess variation or overproduction, and the creation of value defined by the customer, using principles of pull and flow. The programme has been organised around a series of analytical, planning and improvement activities and since 2009 over 200 events have been undertaken with over 750 staff attending on average 2 exercises. A comprehensive training programme has been established, exposing over 1200 staff to lean thinking, building in house capability. Lean contributed to implementation of bacterial screening of platelets without additional staff, thus saving c£1 M a year for our customers, and an increase in productivity of over 70%, placing NHSBT well into the upper quartile of blood services across Europe. Lean has been a factor in allowing NHSBT to reduce red cell price from £140 in 2007/2008 to £123 in 2012/2013 and release of over £10 M a year back to the NHS. Lean has supported a reduction in absence of 10% in blood collection, saving £515 K in overtime and agency costs, and a rationalisation of collection planning, removing over 80% of waste activities. The focus on value defined by the customer means that waste may be removed without detrimental effect on services or patients. It should be regarded as a long term commitment as the changes to culture required are significant. Lessons learned include the requirement for top level leadership and involvement of staff, and clear tracking of benefits to ensure continued investment. Celebration of success and continued effort to re-enforce improvement is essential. Lean is becoming part of the way NHSBT does business, becoming integrated with both quality and organisational workforce development. It will be there right at the start of any new initiative or service reconfiguration in order to ensure that NHSBT continues to achieve its core purpose, saving and improving lives.

© 2013 The Authors Transfusion Medicine © 2013 British Blood Transfusion Society


YS05 A Novel Mis-Sense Mutation R723Q in ABCB6 is Associated with Familial Pseudohyperkalaemia Cardiff W. Bawazir,1 J. Flatt,2 N. Burton, L. Page,1 C. Chapman,3 J. Wallis,3 G. Steward4 & L. Bruce2 1 University of Bristol, UK, 2 BITS, UK, 3 NHSBT Newcastle, UK, and 4 UCL, London, UK

Introduction: Familial pseudohyperkalaemia (FP) is the mildest form of the hereditary stomatocytosis haemolytic anaemias. FP is often asymptomatic as FP red cells have only subtle cation leaks at body temperature. However, the cation leak can increase up to six times normal when FP cells are stored at lower temperatures. A previous report showed that two missense mutations R375Q and R375W in ABCB6 (Ch2q35-36) are associated with one form of FP, known as FP-Chiswick. Methods: PCR and DNA sequencing were used to analyse the ABCB6 gene in pedigrees with FP. SDS-PAGE and immunoblotting were used to evaluate the red cell membrane protein expression. ABCB6 was modelled based on the ATP-bound human ABCB6 and AMP-PNP-bound human ABCB10 structures. CD34+ cell culture and confocal microscopy were used to determine ABCB6 expression during erythropoiesis. The single nucleotide polymorphisms (SNPs) database was used to assess the incidence of mutations in the European population. Results and Conclusions: We report the novel mutation R723Q found in an FP pedigree from Cardiff (FP-Cardiff). Our ABCB6 model shows the mutation located at the nucleotide binding domain and adjacent to the ATP-hydrolysis site. SDS-PAGE and immunoblotting of FP red cells demonstrated the protein at the red cell membrane in normal amounts suggesting that the mutant ABCB6 is expressed. Confocal microscopy of cultured CD34+ control cells showed that ABCB6 was mainly intracellular, co-localised with mitochondria, with minimal protein expression at the cell surface in early erythroblasts. As the cells differentiated, ABCB6 co-localised predominantly with lysosomes suggesting that ABCB6 proteins are mainly required at early stages of erythropoiesis and then degraded. The R723Q mutation was listed in the SNPs database, with an incidence of 1–2 : 1000 so must affect a significant number of donors. The increased rate of potassium loss from FP red cells stored at 4 ◦ C has serious implications for Transfusion Medicine.

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SI10 Use of INTERCEPT® for Pathogen Inactivation (PI) in Platelets: a 10-year Experience Jean Claude Osselaer, MD, JD Cliniques Universitaires de Mont Godinne, Yvoir, Belgium, and Blood Transfusion Center, Charleroi, Belgium

Background: Although screening sensitivity for HBV, HCV and HIV increased spectacularly in the last decades, bacterial contamination, protozoa and the eruption of new or disregarded pathogens puts a continuous threat on platelet transfusion. Actually 2 PI methods for platelets are commercially available : Amotosalen – UVA (Intercept®) and riboflavin – UV (Mirasol®), whereas a third one (UVC) is under development. The physico-chemical principles underlying these methods are not identical, and differences are observed in terms of array of pathogen inactivation, regulatory status and clinical trials. Intercept® was routinely introduced at Mont-Godinne BTC in October 2003. Results: From a blood bank perspective, the introduction of Intercept® leads to a platelet processing loss of 12%, which was easily compensated by a slight lengthening of the apheresis procedure. Intercept had hardly any influence on platelet availability (mean shelf life of platelets transfused increased from 3·4 to 3·7 days), and allowed a decrease in platelet expiry rate from 9·8% to 1·2% through an increase in maximum platelet storage from 5 to 7 days. Gamma-irradiation and CMV testing could be safely stopped after the introduction of Intercept®. From a clinical point of view, there was no increase in platelet needs, even in chronic platelet recipients. There was no increase in the number of red cell transfusions in hematology patients receiving platelets, both globally and during the periods of platelet support (1). The rate of CNS bleedings in thrombocytopenic patients remained unchanged, both after the introduction of Intercept and after the extension of maximum platelet shelf life from 5 to 7 days. Introduction of Intercept® significantly decreased the rate of febrile non haemolytic transfusion reactions in platelet recipients ; this benefit however was partly lost when the maximum shelf life rose from 5 to 7 days. After transfusion of more than 30,000 Intercept®-treated platelets, no case of sepsis, transfusion related acute lung injury or unexpected serious adverse effect was observed (2). The number of hematology patients who needed mechanical ventilation within 6 hours of a platelet transfusion remained unchanged. In 2009, Intercept® was adopted in half of the Belgian national platelet production (±30,000 platelets/year), whereas the other half still has no PI. This introduction had no influence on the national platelet needs. Interestingly no cases of sepsis have been observed since then with Intercept®-treated platelets, whereas in the untreated group, despite bacterial detection, the sepsis rate approximates 1/20,000. Intercept® was routinely introduced in EFS-Alsace in 2006, and in Switzerland in 2011. The results of these larger-scale introductions have already been extensively published, and are very close to ours (3). References 1. Osselaer JC, Doyen C, Defoin L et al. (2009) Universal adoption of pathogen inactivation of platelet components : impact on platelet and red cell component use. Transfusion 49: 1412-1422.

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2. Osselaer JC, Cazenave JP, Lambermont M et al. (2008) An active haemovigilance program characterizing the safety profile of 7437 platelet transfusions prepared with amotosalen photochemical treatment. Vox Sang 94: 315-323. 3. Cazenave JP, Isola H, Waller C et al. (2011) Use of additive solutions and pathogen inactivation treatment of platelet components in a regional blood center : impact on patient outcomes and component utilization during a 3-year period. Transfusion 51: 622-629.

SI11 Red Cell Pathogen Reduction: Current Status & Trends for Safer Transfusion J. Cancelas Hoxworth, Cincinnati, USA Implementation of improved diagnostic screening and donor selection has significantly decreased the risk of transfusion-transmitted infections by blood components. However, transfusion-transmitted diseases (TTD) persist. Blood donations within the window period of detection, containing a low pathogen copy number below the limit of detection of current screening tests, and emergence of new pathogens for which licensed tests are not available are the main causes of TTD persistence. Pathogen transmission remains a concern in red blood cell (RBC) transfusion to chronically transfused patients, patients in the developing world and military casualties in emerging conflicts. Pathogen reduction (PR) has been proposed as a complement, or even a possible alternative, to the screening methods currently employed. PR aims to reduce or eliminate viable pathogens and inactivate leukocytes in donated blood. PR treatment of plasma using solvent detergent, methylene blue, psoralen and light or riboflavin and light has been well documented and is in different phases of introduction or phase-out in clinical therapy. The treatment of cellular blood components has been more challenging and only the Amotosalen and Riboflavin/UV light methods are currently approved in Europe for platelet products. Despite the refrigeration of RBC during storage, RBC products have been shown to maintain a potential for viral and prion transmission and to allow survival of bacterial and parasitic pathogens, including not-so-exotic parasitic infections like trypanosomiases or babesioses. Also, PR technologies have been shown to be capable of preventing transfusion associated graft versus host disease (TA-GVHD) and possibly alloimmunization, replacing the need for irradiation (and potentially, leukocyte filtration) of blood components for susceptible patients. The development of safe, efficacious methods of pathogen reduction treatment of RBCs has been hampered by the biological/technical complications associated to the use of ‘traditional’ methods in a medium containing large amounts of lightquenching haemoglobin. Finally, the significant cost associated with the use of pathogen inactivation and the logistical requirements would favour the idea of validating PI methods that can be applied to whole blood, prior to component production. These methods would allow single-step PR, facilitate the process and logistics of PR implementation, and significantly reduce the cost of the procedure compared with alternative, component-specific PR methods. This presentation will focus on a summary of the current protocols used for PR of RBCs-containing products including whole blood. The © 2013 The Authors Transfusion Medicine © 2013 British Blood Transfusion Society

XXXI Annual Scientific Meeting of the British Blood Transfusion Society summary will analyse pros and cons of methods of pathogen reduction based on affinity filtration, photochemical and alkylant mechanisms of clinically relevant pathogen targeting in relation to classic and modern laboratory in vitro and in vivo parameters of efficacy and safety. While considerable progress has been made in the development of clinical methods for RBC/whole blood PR, the development of these procedures is still in developmental phase. This review will also identify the major hurdles for RBC PR implementation and the risk/benefit ratio analyses required. PR technologies should ideally inactivate pathogens (and leukocytes) in blood and its components without ‘significant’

© 2013 The Authors Transfusion Medicine © 2013 British Blood Transfusion Society


potency loss. In the absence of this ideal, what degree of loss of potency is acceptable? What are the potential hurdles affecting PR-RBC transfusion safety? Finally, although not a primary objective of this presentation, a final question will be raised. Even after these newer targeted pathogen-reduction technologies pass increasingly stringent regulatory requirements, will the current health care system pay the premium for safer RBC-containing products? A call for the advantage of an integrated PR system for blood components will be made.

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SI12 T is for Transfusion Teams A. J. Keidan, C. L. J. Atterbury, A. Ebbs & D. Knight Queen Elizabeth Hospital King’s Lynn NHS Foundation Trust, King’s Lynn, UK In this short informal talk, members of the transfusion team at Queen Elizabeth Hospital King’s Lynn will present their local experience of what makes a strong transfusion team and what such teams can achieve. We will also debate why this role will be increasingly important as hospital laboratories come under pressure to work within networks and with reduced numbers of specialist laboratory staff.

SI13 T is for Training A. Jones

choice. How can we in the NHS ensure with diminishing resources and staff, that patients are given this opportunity? As with all patients who are having an appropriate transfusion, the haemogloblin levels are a guide as to when a patient should be transfused, each patient with their own unique conditions will require an individual approach. With palliative care patients it is the symptoms the patient is experiencing and his/her quality of life which becomes the transfusion trigger. The benefits must always be greater than the burden of transfusion. As time progresses the benefits that transfusion brings becomes less, the relief felt now last for shorter periods. When is the time to stop and how is that decision made? Funding and resources will always be an issue, who can we look to for supporting patients who have end stage disease. During this session these and other issues will be discussed. What can or what do we do, in our own hospitals to ensure quality care in supporting patients with appropriate and timely transfusions who are receiving palliative care?

NHSBT, Bristol, UK Training is essential to achieving safe transfusion practice, and for minimising unnecessary and avoidable transfusion. The umbrella term of ‘training’ covers various elements, including knowledge, skills, competence and behaviours. Training can extend to qualification/certification and job roles. Training in transfusion can be, and is, delivered in a range of modes from self-directed, distance or e-learning, to peer training and assessment, face to face and direct group teaching. The important factor is that the mode of delivery must be capable of achieving the intended learning outcome. Through up to date, effective training, both laboratory and clinical staff involved in the care of patients at risk of needing a blood component transfusion, can be best supported to practice safely and in a way that adheres to the principles of Patient Blood Management.

SI14 T is for Terminal Care E. Wain Ysbyty Gwynedd, BangorWales, UK Terminal care was defined as ‘the management of patients during the last few days, weeks or months of life’ by Marco Maltoni and Dino Amadori in Annals of Oncology in 2001. This diagnosis can lead to difficulties in clinical and ethical decisions when looking at the appropriateness of administering blood components. What are the aims giving transfusion to patients who are receiving palliative care? What issues need to be addressed? Can/should we transfuse in the patients home? What obstacles are there and how do we as professionals overcome them? Most patients would prefer to spend as little time in hospital as possible, using this period to be with family and friends. The UK government recommends that care should be provided in the place of the patient’s

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SI15 T is for Triggers J. Birchall NHSBT, Bristol, UK Although it is accepted that clinical judgement plays an essential part in the decision to give a blood transfusion or not, the use of a threshold haemoglobin level, platelet count and coagulation result can support this assessment. As a consequence trigger levels such as these are frequently used to define appropriate use in both haematology and other specialty guidelines and have likely made a significant contribution to the decline in red cell use over the last decade. To make these trigger levels more accessible to clinical staff and facilitate documentation of the indication for transfusion, the National Blood Transfusion Committee (NBTC) now produce a short document summarising key recommended transfusion triggers entitled ‘Indications for transfusion – an audit tool’. The presentation will briefly discuss the triggers levels used and the evidence base for these. In addition, the methods by which these can be accessed will be covered and include availability on websites, as a poster and bookmark and for platelet transfusions as an app-style mobile website, designed to work on a Smartphone or Tablet.

SI16 T is for Tracking and Trending J. Lussier SNBTS, Edinburgh, UK ‘It’s good to be trendy!’ Monitoring and trending and review of all incidents should be an ongoing process. It is important that incidents are recorded and trends identified for a number of reasons: 1. The risk introduced by the incident is communicated and managed. © 2013 The Authors Transfusion Medicine © 2013 British Blood Transfusion Society

XXXI Annual Scientific Meeting of the British Blood Transfusion Society 2. To allow appropriate and effective remedial action to be taken, remove the hazard and subsequently to prevent a recurrence. 3. It allows for trending of incidents, looking for increased or decreased numbers in specific types of incident. Most NHS Scotland Health Boards have a dedicated incident management meeting led by the Hospital Transfusion Team (HTT) to review all transfusion related incidents. This type of meeting allows the HTT to confirm that the remedial actions are appropriate and that there is no increase in specific trends. Reviewing, monitoring and trending of incidents will: 1. Identify significant trends 2. Demostrate how actions and learning outcomes are achieved 3. Demostrate how lessons learned are communicated to the clinical area involved, the NHS Board and NHS Scotland Transfusion practitioners should assist with trending and liaise with clinical area if increasing trends are identified, providing education support to clinical areas as required and reporting all incidents locally to HTT and Hospital Transfusion Committee (HTC). Each HTC should provide regular updates to the NHS Board as part of the Clinical Governance and Risk Management agenda. Nationally the Better Blood Transfusion programme collates incidents by NHS Boards monthly and reviews significant incidents at local and national team meetings. NHS Grampian Experience: A trend of ‘wrong blood in tube’ events in NHS Grampian was identified. These incidents involve all staff groups who take samples for pre transfusion testing. On analysis there were three root causes: 1. Pre-labelling of blood sample tubes 2. Incorrect positive patient identification 3. Labelling the sample tubes remote from the patient.

© 2013 The Authors Transfusion Medicine © 2013 British Blood Transfusion Society


Lumadue et al. 1997 identified that inadequately or mislabelled samples are up to 40 times more likely to contain blood from the wrong patient. In NHS Grampian a number of samples received by blood bank do not fit the acceptance criteria. All of the incidents would have been detected, if correct positive patient identification as per the transfusion procedure had been followed. Sample errors rejected before testing are not classed as near miss errors and are not required to be reported to SABRE and SHOT. However they should be recorded for monitoring trends and areas or staff with poor compliance contacted accordingly to raise awareness. In partnership with senior management, Clinical Governance, HTT and the HTC a collaborative approach to address this patient safety issue has resulted in sustained interventions to reduce risk.

Conclusion/Best Practice Points: 1. Establish a regular incident management meeting to discuss and review trends, formulate an action plan to prevent similar incidents from happening again 2. Use information identified from RCA and establishing trends as a stimulus to review and re-design processes and services 3. Local policies for incident management should be in place and reviewed at regular intervals 4. Risks to patient safety are assessed and corrective actions are implemented where appropriate 5. Ensure learning is shared both, locally and nationally Reference Lamadue, J.A., Boyd, J.S., Ness, P.M. (1997) Adherence to strict specimen-labelling policy decreases the incident of erroneous blood grouping of blood bank specimens. Transfusion, 37, 1169–1172.

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AW03 Using In Vitro Erythroid Culture to Investigate Normal Red Blood Cell Membrane Protein Assembly & Its Disturbance During Red Cell Diseases A. Toye NHSBT, Filton Centre, Bristol, UK To date the majority of work conducted on human red cell disorders such as hereditary spherocytosis (HS) and Congenital Dyserythropoietic Anaemia (type II) (CDAII) has focused on the end point of erythropoiesis, the mature erythrocyte. HS is caused by genetic mutations that affect proteins involved in the vertical interactions between the membrane skeleton and the lipid bilayer (e.g. band 3, ankyrin and protein 4·2) and usually causes the specific secondary loss of membrane proteins and peripheral membrane proteins. CDAII is caused by genetic mutations in SEC23B, a component of the COPII coat which is important for trafficking during the early stages of the secretory pathway (between the endoplasmic reticulum and golgi). We are investigating the stage erythroid proteins are lost during HS to better understand how the red cell membrane is assembled, and also exploring why Sec23B mutations cause erythroid specific disease. To achieve this we developed an in vitro erythroid culture system to culture normal and patient peripheral blood stem cells from proerythroblasts to the reticulocyte stage. This has allowed us to determine the membrane protein expression profile in normal adult erythroblasts throughout terminal differentiation and also demonstrate

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that the hallmarks of protein 4·2 deficiency (decreased CD47 and simultaneous increased CD44 expression) are detectable from the basophilic stage. This is also the stage that the key membrane protein associations establish (e.g. band 3 with protein 4·2 and the Rh blood group proteins). More recently we studied the process of enucleation and showed that alongside the expected nuclear proteins, the bulk of ER and excess membrane proteins are normally lost with the extruded nucleus. The remaining ER remnants are then lost upon further reticulocyte maturation. CDAII is characterised by increased multinuclear erythroid progenitors, alterations in membrane protein glycosylation profiles and the presence of a double plasma membrane (which is derived from ER remnants). We find that Sec23B protein is expressed until the latest stages of differentiation but Sec23A expression rapidly reduces and is normally lost within 72 hrs. In cultured CDAII cells, hypoglycosylation precedes the multinuclear defect suggesting that the reducing levels of Sec23A can not fully compensate in the presence of mutated Sec23B. No disruption of ER loss during enucleation was observed in CDAII, but significant amounts of ER remnants were detected in cultured CDAII reticulocytes allowed to mature, raising the possibility that reticulocyte maturation is disrupted in the patient’s cells. In summary the availability of in vitro culture systems that reproduces all stages of erythropoiesis is dramatically improving our understanding of the normal generation and assembly of red blood cells, and represents a powerful tool for probing the basis of human diseases that disrupt red blood cell development.

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SI17 About Costs, Fear, Sanity and Silliness Prof Ben van Hout University of Sheffield, Sheffield, UK Over the last 25 years more and more attention has been given to the balance between costs and effects of medical interventions. The concept of evidence based medicine has been introduced and statistics have become a crucial science (or art) in the definition of treatment guidelines. Medical knowledge and evidence go well together leading to sensible conclusions. That is with respect to drugs that do or do not appear to work and with therapies which do or do not represent value for money. All for the better, one might think. That is . . . . until ‘safety’ comes into play. Drugs with a sub-optimal safety profile – but with a highly acceptable risk benefit ratio – are taken off the market, departments are closed and risks are minimised without any consideration of the costs. What is it with safety? A new medication preventing 100 strokes per 10 000 patients but causing a life threatening rash in 10 may never enter the market. It is the ex-post ‘identification’? One cannot find the 100 patients who did not get the stroke and one cannot celebrate this fact with them. But, the 10 who got the rash can be found and they will not be having a party. Is it this type of reasoning that blood safety measures have been accepted with cost effectiveness levels which are significantly above what is accepted in normal health care. With silly numbers, numbers above $1 000 000 per QALY gained. Is it because we don’t see the benefits of spending the money in other places in the health care sector but that we can find the infected individuals, infected due to miserly behaviour by the NHS.

© 2013 The Authors Transfusion Medicine © 2013 British Blood Transfusion Society

Different perspectives may be taken. Take the lottery. People seem to like to pay – say £10 – to have a remote probability to win £25 million. Here, people may like to pay an additional £10, to remove a similarly remote probability to be treated with an infected blood product. But while people may be irrational with their own money, one may want to realise that blood safety concerns public money and does one really want to spend millions to remove some remote probability while we know that the same money can be used elsewhere with greater benefits? Another perspective is to regard blood banks as organizations with sensitive public relationships and errors are easily referred to as scandals and scandals may lead to less blood donations and less blood donations may lead to insufficient blood supply. This may subsequently be referred to as a disaster. Nobody knows whether such things may ever happen, but we may fear it and this fear may, and has, affected decision making. It will be argued that we can go two ways. The first is to continue decision making as currently done, meaning that one may do cost effectiveness analyses, look at the advice that some safety measure is NOT cost effective and then implement it anyway. The second is to quantify our fears. How many people will stop giving blood because of sub/optimal safety measures? How bad is that? Let’s quantify that not every blood donation is as crucial as the lifesaving ones and that the last bag of blood may not be as necessary as the first. And let’s quantify the probability that some policy makers lose their job when matters turn nasty. We may even give a disproportionate high value to preventing this. In short one may continue to be fearful . . . or one may become creative and careful. That is not such a difficult choice, is it?

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SI18 ‘The Farther Backward you can Look, the Further Forward you can See’ C. Howell NHSBT Filton, Bristol, UK The Mid Staffordshire NHS Foundation Trust Public Inquiry was published on 6 February 2013. The report consisting of three volumes, an Executive Summary of >100 pages and a summary table of 290 recommendations marked a very humbling day in the history of the NHS. The Inquiry identifies a story of terrible and unnecessary suffering of hundreds of people who were failed by a system which ignored the warning signs of poor care and put corporate self interest and cost control ahead of patients and their safety. There was evidence of failure as early as 2001 when Dr Foster reported higher than expected mortality rates in Stafford Hospital in its first Hospital Guide. A catalogue of subsequent events demonstrated systemic failings with patients receiving sub-optimal care. Florence Nightingale laid the foundation stone of professional nursing famously quoting that ‘The very first requirement in a hospital is that it should do the sick no harm’. Reforms in the 1990s were supposed to make nursing care better. Instead, there’s a widely shared sense that this was how today’s compassion deficit began?

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When people have suffered on this scale, and died unnecessarily, our greatest responsibility lies not in our words but in our actions. If we are to learn the lessons of Mid Staffordshire, then every nurse needs to make the time to reflect on what went so badly wrong in the context of the service they deliver. The only way to improve standards in the profession is to listen to it, understand what has gone wrong from the nurse’s perspective and put it right.

SI19 BBTS CPD tool K. Shreeve Welsh Blood Service, Wales, Uk ‘Continual Professional Development is a core requirement of the AQ8 Nursing and Midwifery Council (NMC). Nurses and Midwives will historically know this as PREP or Post Registration Education and Practice, a set of NMC standards and guidance, of which CPD is one part. This session is intended to raise awareness of online CPD tools for nurses and midwives that will enable them to document their continual learning and development.’

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SI20 Labelling Transfusion Samples: Results of the National Comparative Audit D. Dalton,1 J. Davies,2 T. Davies,3 L. Delieu,4 J. Grant-Casey,5 J. Harris,6 D. Lowe,7 H. Tinegate8 & A. Varey9 1 Project officer, NHS Blood and Transplant (NHSBT), 2 Transfusion quality manager, Royal Devon and Exeter Hospital, 3 Better blood transfusion team, NHSBT, 4 Specialist practitioner of transfusion, Darent Valley Hospital, 5 Project manager, NHSBT, 6 National Association of Phlebotomists, 7 Medical Statistician, Royal College of Physicians, and 8 Consultant, NHSBT, and 9 Transfusion quality coordinator, The James Cook University Hospital On behalf of the National comparative Audit of Blood transfusion Background: The National Comparative Audit of Blood Transfusion programme carried out an audit of the process of sampling and labelling of blood specimens sent to the hospital transfusion laboratory in 2012. Standards: BCSH guidelines require sample tubes to carry, as a minimum, the patient’s first and family names, correctly spelt, date of birth and unique identification number, and that all staff who take transfusion samples should be trained and competency assessed. Study Design: All NHS Trusts and independent hospitals in the UK and New Zealand were invited to participate in the audit, and to provide 3 months’ data on transfusion samples sent in 2012. They were also asked about their sample acceptance policy. A minimum of three cases per week, where sample rejection had occurred, were followed to identify the reason for the error(s) that led to the sample being rejected. Any wrong blood in tube (WBIT) events were also recorded. Results: 221 sites participated and reported on, a total of 845445 samples, 2.99% of which (25279) were mislabelled. Although 154 sites (70%) stated that no amendments or additions to sample labels were allowed, 50 of these appeared to allow changes and hence deviations from their own policy. The identity of the sampler could not be determined in 38% of rejected samples. Of the rest, doctors were the staff group most likely to be responsible (22% of samples). On follow up, the commonest reasons for error were transcription errors (1755 responses, 33%) and distraction (1265 responses, 24%). 22% of samplers had not passed competency assessment. Ninety-nine WBIT instances were reported during the study period. Recommendations: All transfusion departments should have a clear sample acceptance policy and adhere to it. Obtaining positive patient ID is central to safer blood sample labelling (and to all aspects of patient care. Transfusion samples must be labelled by the patient’s side.

SI21 Inappropriate Blood Requests: A Laboratory Audit D. Knight & J. Keidan Queen Elizabeth Hospital NHS Foundation Trust, Kings Lynn, Norfolk, UK Introduction: A variety of factors (reduced availability, increased mortality and morbidity rates and financial constraints) have prompted © 2013 The Authors Transfusion Medicine © 2013 British Blood Transfusion Society

changes in transfusion practice aimed at reducing blood usage. To this end, all blood component requests at our Trust are assessed by laboratory staff and apparently inappropriate requests are referred to the Haematology clinical team for ratification, further tests or refusal. To enable all grades of laboratory staff (both qualified and unqualified) to do this correctly and confidently an algorithm was devised, along with a referral form. Method: To assess the impact of the procedures introduced, the laboratory practitioner retrospectively reviewed all referral forms over a 2-year period. A total of 56 requests were audited. Results: Twenty-seven per cent of all referrals were honoured in their entirety. Thirt-six per cent were completely refused as deemed inappropriate by the clinical haematology team, and the remaining 37% were only partly honoured, usually having one unit issued to alleviate severe symptoms of anaemia. Fifty-eight per cent of all referrals had additional testing requested by either the laboratory or clinical haematology staff, usually iron studies, ferritin, B12 or folate, where deficiencies were suspected and/or no recent test results available. Forty-nine per cent of referrals had alternative or additional treatment suggested by either laboratory or clinical haematology staff in patients with confirmed deficiencies. Conclusion: The audit demonstrates that with the introduction of clear decision algorithms and full support of the Haematology clinical team a significant number of inappropriate transfusions have been prevented. Initial reluctance by some laboratory staff to question clinicians about transfusion requests has greatly diminished since the referral process began, and they are much more confident. Some clinicians were also resistant to being questioned. However this has generally improved and the transfusion laboratory staff are now frequently phoned by clinicians for advice. Correct management of patients with pre existing anaemia is a key factor in reducing blood usage and our hospital has shown that by empowering staff, the laboratory can have a significant positive impact on this.

SI22 Parental Assent for Transfusion of Blood Components in Neonates-Audit of Current Practice & Documentation: The BLEED Initiative (Before Transfusing: Leaflet to Parents, Explain Benefits, Explain Risks, Document Discussion) S. Armitage, V. Kairamkonda & V. Venkatesh University Hospitals of Leicester NHS Trust, Leicester, UK Within the context of a tertiary neonatal unit, a baseline audit of documentation of parental assent (‘agreement’) for blood component transfusion was performed. Initial adherence to the three standards audited was low. To address this, A ‘Plan-Do-Check-Act’ quality improvement initiative was implemented. Re-audit showed improvement in gaining and documenting parental assent. Introduction: Obtaining consent before giving medical treatment is a medico-legal and ethical imperative. Gaining consent for blood component transfusion is now recommended as best practice; there are challenges in doing this in the context of neonatal intensive care. In our tertiary Neonatal Unit (NNU) previous audits showed poor compliance in obtaining & documenting parental assent (‘agreement’, a proxy for consent) for blood component transfusion. Our aim was to

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18 XXXI Annual Scientific Meeting of the British Blood Transfusion Society perform a baseline audit, formulate an initiative to address areas of poor compliance, followed by a re-audit.

Methods: A prospective baseline audit was done, measuring compliance against three standards. Following this a 3-month (January to March 2013) BLEED Initiative implementation programme was launched, based around the acronym BLEED: ‘Before transfusing, Leaflet for parents, Explain benefits, Explain risks, Document discussion’. This involved forming a multidisciplinary implementation group, opportunistic survey to identify barriers, displaying posters, simplifying guidelines and undertaking bedside teaching. Re-audit was done from March 2013. Data was collected from 41 neonates with gestational ages ranging from 23 to 42 weeks, in receipt of non-emergency blood components.

Results: Adherence to Standard 1 (‘Documentation of parental assent to transfuse’) improved from 59 to 71%, and to Standard 3 (‘Documentation of discussion of risks and benefits’) improved from 45 to 71%. However Standard 2 (‘Documentation of provision of information leaflet to parents’) fell from 45 to 33%.

Discussion: 1. A Plan-do-Check-Act quality improvement initiative was used to improve parental assent and documentation of blood transfusion in a busy NNU. 2. Value stream mapping helped to identify barriers and potential key areas for improvement. A key feature for the success of the BLEED Initiative was the use of a multidisciplinary team approach in strategically designing and delivering the implementation programme. 3. Further work is on-going to improve provision of information to all parents on admission, and to continue raising staff awareness of current best practice.

SI23 Major Haemorrhage Protocol Adherence in the Management of Trauma-Induced Bleeding at Four London’s Major Trauma Centres L. Green,1 M. Lawn,2 K. Feane,3 R. Moss,4 C. Brber,1 S. Allard,1 J. Uprichard1 & M. Rowley4 1 NHSBT and Barts Health NHS Trust, London, UK, 2 Kings college Hospital, London, 3 St George’s Healthcare NHS Trust, and 4 Imperial College Healthcare NHS Trust, London, UK

Background: In 2011 the major haemorrhage protocol (MHP) for the management of trauma-induced bleeding was harmonised between the four London Major Trauma Centres (LMTC) to state that for every six units of red blood cells (RBC), four units of fresh frozen plasma (FFP) should be transfused. Samples for group & save (G&S) should be taken as soon as possible and patients’ group-specific RBC should be administered as soon as the blood group is confirmed. Aim/Methods: From January to December 2012, the four LMTC audited: (i) the blood usage and wastage for trauma MHP, (ii) the RBC:FFP ratio transfused, (iii) the proportion of male patients who received group ORhD positive and group ORhD negative RBC and (iv) the number of patients in whom G&S samples were requested. Major haemorrhage was defined as transfusion of ≥6 RBC within 24 h of trauma. Data were extracted using transfusion laboratory data and patients’ electronic records system.

Results: Within the 12-month period 186 patients [male 151/female 35, median age 36 (range 13–92)] were admitted with trauma-associated major haemorrhage; of these 100/186 patients received ≥10 units of RBC. FFP, cryoprecipitate and platelet were transfused to 175, 114 and 139, respectively. The median RBC:FFP ratio was 1·5 (interquartile range 1·3–1·9). Of the 970 RBC units transfused to group O male patients (n = 74), 20% were group ORhD negative RBC and, of the 1204 RBC units transfused to non-group O male patients (n = 73), 39%

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were group ORhD positive RBC and 19% were group ORhD negative. Wastage data were available for 136 patients; this group was issued a total of 3515 blood components and of these 289 (123 RBC, 107 FFP, 55 cryoprecipitate and 4 platelets) were wasted. G&S samples were requested in 177/186 patients within 24 h. Conclusion: (i) The RBC:FFP ratio was in accordance with the MHP, (ii) more needs to be done to reduce the 8·2% wastage rate of components seen in this audit and in particular RBC and FFP, (iii) in order to reduce the unnecessary use of group ORhD negative RBC, male trauma patients should be transfused with group ORhD positive RBC (instead of group ORhD negative) where possible, until the patients’ blood group is confirmed and (iv) in 5% of patients, G&S samples were missing, implying that blood transfusion (if required) would have continued unnecessarily using group O blood, itself a precious resource.

SI24 Treating Anaemia in Heart Failure Patients M. Z. A. Mariyaselvam, S. Jafery & R. Nata The Queen Elizabeth Hospital NHS Foundation Trust, Kings Lynn, UK

Introduction: Anaemia can significantly worsen the impact of any chronic medical problem. In heart failure it is associated with a decrease in aerobic capacity, reduced functional status and poor quality of life. It has also been shown to be an independent risk factor for hospital admissions and mortality. Treating patient’s anaemia has been shown to improve left ventricular ejection fraction, improve exercise tolerance and quality of life and prevent hospital admissions. Despite the evidence, not all patients when found to be anaemic, are investigated or even treated. Methods: A 2-month audit was conducted of patients admitted to the medical assessment unit, at a district general hospital, with a diagnosis of ‘heart failure’ on their clinical coding. Patients found to be anaemic on their admission blood results were noted, and it was investigated whether these patients had their haematinics checked. Patients were allowed to have had their haematinics checked up to 6 months prior and throughout their admission. Patient’s haemoglobin, mean corpuscular volume (MCV), B12, folate, iron, iron binding capacity, ferritin and thyroid stimulating hormone blood results were recorded. All anaemic patients’ drug charts were checked in order to determine if they were treated during their hospital stay. As the audit results were poor, a teaching session was instigated and flow diagram posters were displayed in acute medical wards reminding junior staff to check the haematinics of any anaemic patient. A re-audit was conducted as above at 6 months. Results: Audit: Of 59 heart failure admissions, 34 patients were found to be anaemic. Only 7 (11%) of these patients had all their haematinics checked and of these only one patient was treated. 7 (20%) patients were found to be iron deficient. Re-audit: Of 66 heart failure admissions, 35 patients were found to be anaemic. 25 (71%) of these patients had all their haematinics checked and of these patients seven were treated. 14 (40%) patients of patients were found be iron deficient and three patients were successfully treated with intravenous iron. Conclusion: Teaching junior staff and having poster reminders showed a 60% improvement in checking patient’s bloods, however acting these blood results now seems to be the problem. This will hopefully improve with further teaching. A significant portion of patients were found to be iron deficient. We believe the actual number to be higher, as not all patients had iron level studies despite anaemia and low MCV. Therefore, to prevent admissions, our hospital has instigated an outpatient intravenous iron service, to which patients can be referred by hospital clinicians and GPs to treat their anaemia. Thus far, it appears to have reduced the number of hospital admissions; however we will audit the service in order to determine actual outcomes. © 2013 The Authors Transfusion Medicine © 2013 British Blood Transfusion Society

XXXI Annual Scientific Meeting of the British Blood Transfusion Society SI25 Improving the Management of Major Haemorrhage by Junior Doctors using Simulation Teaching R. Green NHS – Oxford University Hospitals, UK An audit cycle to improve knowledge of the Trust’s Major Haemorrhage Protocol amongst Foundation Year doctors and review its functioning Background: Major haemorrhage is a time-critical medical emergency that can be faced by new Foundation Year one (FY1) doctors. Some previous critical incidents had involved sub-optimal management. There had been no audit cycle of FY1 doctors’ knowledge of the Trust’s Major Haemorrhage Protocol (MHP) and no targeted training. Simulation training is increasingly used in training but its effectiveness is not frequently tested. Method: All FY1 doctors in Oxford University Hospitals were asked to complete a questionnaire assessment (Jan 2013) of the Trust MHP. There were 20 items covering 4 competencies: (i) awareness of MHP, (ii) knowledge of MHP, (iii) ability to prioritise, (iv) confidence level in its use. A mixture of yes/no and multiple choice responses were used. Doctors were subsequently invited to attend a MHP Simulation training session. The intervention was a one full day course at OxSTaR (Oxford Simulation Training and Research Centre), John Radcliffe Hospital (2 full day sessions with 10 participants in each). There was a targeted

© 2013 The Authors Transfusion Medicine © 2013 British Blood Transfusion Society


format. (i) Introduction to MHP, (ii) training on human factors and communication, (iii) four scenarios involving 2–3 participants (15 min), (iv) feedback and discussion (30–45 min for each scenario) and (v) a closing session to discuss what was learned and participant feedback. A total of 16 doctors attended the sessions. The questionnaire was repeated 3 months after intervention.

Results: Sixty pre-intervention and 43 post-intervention questionnaires were returned. Analysis used two tailed T-testing for unequal sample sizes. Pre-intervention showed that there was no significant difference in baseline scores between intervention and control group (P = 0·22). Post-intervention showed that the intervention group had significant improvement across all questionnaire domains and in total score (P = 10 others. Specificities for Vel negativity and Scianna have been included into HFA typing, recently. Conclusion: Analysis for Kell, Kidd and Duffy showed that genotyping worked qualitatively better and to costs comparable to serology. Consequently, genotyping Kell, Kidd and Duffy instead of routinely performing a second round of serotyping as mandatory for donors in Switzerland, is recommended. Ahead of comparable suggestions with regard to Rh and MNSs, a more detailed statistical analysis of existing raw data is needed. However, genetically identified donors with rare blood phenotypes, e.g. such as Yt(a−b+), are already selected for respective transfusions and are a strong indicator for the value of the presented project.

SI29 Clinical Applications of Molecular Rh Typing G. Daniels IBGRL, NHSBT, Bristol, UK Cloning of the Rh genes in the early 1990s has made it possible to predict Rh phenotypes from the DNA of patients and donors; not only the common phenotypes, but a vast array of variants. But what are the clinical benefits?

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22 XXXI Annual Scientific Meeting of the British Blood Transfusion Society One of the key benefits is to be able to determine the fetal D type of pregnant women with anti-D in order to manage the pregnancy in the most appropriate way. This is performed on cell-free fetal DNA in the plasma of the mother and is now routine practice in the UK for pregnant women with >4 IU mL−1 anti-D or with history of fetal/neonatal haemolysis. Fetal typing is also routinely performed for C, c, E and K. It is UK policy to offer all D− pregnant women routine antenatal anti-D prophylaxis. Since around 38% of these women will have a D− fetus, there would be a clear clinical benefit from testing all D− pregnant women for fetal D type, to avoid unnecessary treatment with blood products. This testing was introduced as a pilot in Bristol in April this year. A plethora of variants of D are known, often classified as weak D or partial D, but these terms are not adequately defined and this dichotomy is of little value in clinical practice. With the power of molecular analysis it is possible to identify all of these variants. The clinical benefits of

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this testing, however, are very limited. UK guidelines state that patients whose red cells give abnormal reactions with anti-D in routine testing should be treated as D+ unless they have childbearing potential or are transfusion dependent. NHSBT recommends that those patients should be treated as D− unless they have the phenotypes weak D types 1, 2 or 3, when they should be treated as D+. Consequently, a simple molecular typing platform that identifies weak D types 1, 2 or 3 would be very valuable. Some D antigens, named DEL, are expressed so weakly that they cannot be detected by routine serological techniques, yet might stimulate anti-D production in a D− recipient following transfusion. A few transfusion services in Europe test all D− donors for RHD to eliminate the risk of transfusing DEL to D− patients, though most services do not consider that necessary. In the near future molecular tests will be applied to extended blood grouping of donors. Then it would add no expense to include a test for RHD, so that a cohort of confirmed D− donors would be available.

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PL04 Delivering Quickly: Does it Make a Difference? Do Major Haemorrhage Protocols Work? K. Pendry NHS Blood and Transplant and Central Manchester University Hospitals NHS Foundation Trust Despite many retrospective studies evaluating 1 : 1 red cell : plasma formula driven resuscitation, the overall clinical value of such an approach remains unclear. Major haemorrhage protocols have been widely implemented in the UK following the recommendations of the National Patient Safety Agency Rapid Response Report in 2010. There is some evidence that such protocols do improve outcomes by ensuring a prompt and coordinated response to haemorrhage with standardisation of care, for example the use of tranexamic acid. Cases of patient harm Table: Key performance indicators for major haemorrhage Process measures a. Percentage of cases where major haemorrhage protocol activated b. Percentage of cases receiving two units or fewer of emergency Group O red cells c. FFP wastage due to mismanagement d. Platelet wastage due to mismanagement e. Red cell wastage due to mismanagement f. Emergency O red cell wastage due to mismanagement g. Percentage of cases of ruptured abdominal aortic aneurysm where cell salvage used h. Percentage of post partum haemorrhage cases with caesarean section where cell salvage used i. Baseline Hb within 4 h of activation j. Baseline platelet count within 4 h of activation k. Baseline PT & APTT within 4 h of activation l. Baseline Clauss fibrinogen within 4 h of activation m. Percentage of cases where thromboelastography/thromboelastometry used n. Percentage of cases where tranexamic acid given o. Time from activation to grouped red cells being available for use (allocated to patient on Lab system) p. Time from activation to fresh frozen plasma being available for use (allocated to patient on Lab system) q. Percentage of cases receiving rFVIIa r. Percentage of cases where lab informed of stand down Outcome measures a. Percentage of cases with complications: i. ii. iii. iv.

Organ failure Transfusion reaction Thromboembolism Other

associated with delays in transfusion are reported to SHOT and the National Reporting and Learning System. It will be interesting to review the trends with the widespread adoption of major transfusion protocols Although protocols have been designed primarily for the management of trauma haemorrhage, they are increasingly used for non trauma haemorrhage management. In most hospitals in North West England, gastrointestinal, obstetric and vascular cases account for the majority of major haemorrhage activations. Is it appropriate to apply the same protocol to patients with different types of haemorrhage? There is some evidence to suggest that such an approach is beneficial although outcomes in the non trauma patient may be worse because of underlying disease process. There is a risk of over-triage with patients receiving plasma when not required, or excessive plasma leading to a risk of complications such as transfusion associated circulatory overload, transfusion related lung injury and multi organ failure. There is also a risk of increased blood component wastage. Prospective randomised trials on the management of major haemorrhage are in progress. In the meantime, the standard of care should be monitored with the use of key performance indicators (KPIs) which look at process and outcome. Examples of KPIs being monitored in the North West Regional Major Haemorrhage audit are shown in the table. A mortality review looking for evidence of avoidable harm is also being undertaken. The analysis of KPIs and benchmarking between hospitals and within hospitals over time provides a mechanism for quality improvement leading to improved outcomes. The North West Major Haemorrhage Pathway is updated regularly to incorporate recommendations based on new evidence.

PL05 ‘Iron Bru’ – the Case for Pre & Post Operative IV Iron’ T. Richards University College London & University College Hospital, London, UK Anaemia is common in hospital patients. Traditionally regarded as ‘anaemia of chronic disease’ as a consequence of concurrent illness or following surgery, current standard of care is blood transfusion. Alternatives for anaemia management are directed at correction of the underlying aetiology; B12, folate or oral iron therapy. However, this approach will have little impact on patients while they are in hospital and minimal effect to reduce the use of blood transfusion. Used initially in the management of renal anaemia intravenous iron can produce a rapid rise in haemoglobin. Although early products carried side effects, including risk of anaphalaxis, new preparations enable a total body iron replacement in short period of time without the need for test doses or risk. The role for intravenous iron has expanded with recognition of functional iron deficiency in patients with heart failure, inflammatory bowel disease and patient undergoing surgery. This presentation describes the current problem of anaemia in surgery patients, functional iron deficiency and reviews the current roles of intravenous iron therapy. Attention and correction of anaemia in the hospital patient may reduce the reliance for blood transfusion, with improvement in patient quality of life and outcomes.

b. Percentage cases admitted to critical care c. Percentage of cases deceased at 24 h d. Percentage of cases deceased within 30 days

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SIMULTANEOUS SESSION IV TRANSFUSION & TRANSPLANTATION-MOVING THE BOUNDARIES SI30 The ABOUT-K Study – A Multi-Centre Evaluation of ABO Incompatible Kidney Transplantation in the UK – Single Operator Assessment of Antibody Titres A. Bentall Queen Elizabeth Hospital, Birmingham, UK

Introduction: The UK antibody incompatible registry finds poorer outcomes in ABOi recipients than expected from international comparator groups. Nevertheless this remains a potentially important treatment strategy particularly for blood group O recipients who inevitably accumulate in paired exchange schemes. Intracentre and intercentre variability in ABO blood group antibody titres has been reported in many cohorts. In the UK, ABOi kidney transplant centres use a range of techniques to quantify blood group antigen specific antibody (ABO-Ab). NHSBT-NEQAS have reported significant variability in titres reported on shared single samples. The ABOUT-K multicentre observational study of ABOi transplantation includes patients recruited from 10 centres in the UK. This abstract aims to report ABO-Ab titres in 100 participants in the ABOUT-K multicentre observational, comparing local titre variation between different centres with a central laboratory and report accepted titres on the day of transplant. Secondly, we report to study clinical variables that might usefully inform risk stratification and optimise outcome.

Methods: 1. A single technician undertook training in an RCI lab in NHSBT using Diamed cards. Reproducibility within same red cell batch; using different batches; freeze thaw repeats and different days was conducted. 100 patients from the ABOUT-K study were tested with pre-transplant samples. Local titre and Central titre results were compared at consent to study before therapy, before antibody removal and at the time of transplant. 2. Clinical variables were collated in an electronic database. Samples for central antibody assessment were returned to NHSBT Birmingham for storage at −80 ◦ C and subsequent analysis in parallel with clinical samples at seven different time-points. Patients were treated according to local protocols.

Results: 1. Results in historic ABO titres using different red cell batches demonstrated r-squared 0·98 for IgG assays and 0·93 for IgM assays reproducibility. Graph 1 demonstrates duplication testing of samples for a single operator for IgG for ABOUT-K samples. Graph 2 demonstrates the relationship of central and local assays Graph 1

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Graph 2

of titre dilution. Graph 3 shows the wide range of titres at which transplantation was undertaken, evident in both local and central ABO-Ab titres. 2. The mean age of recipients was 48·1 ± 13·6 years, 41% were female, 68% were blood group O. 59% of donors were blood group A1. One year follow-up has been reached in 80 patients. The median local titre against donor blood group at baseline was 32 (range 0–512) and at transplantation was 4 (0–64). 58% of patients received IA vs 28% PEx (either PEx or DFFP). The mean titre reduction per EART was 1·4 ± 1·2 (IA) and 1·8 ± 1·5 (PEx). One year patient survival was 98·9% and 1 year DCGS 95·5%. Acute rejection occurred in 25·5% of recipients of which 22·9% was reported as being antibody mediated (AMR). The three graft losses were reported to be secondary to AMR, in patients with baseline local titre against donor blood group >1/64. One year creatinine in patients reaching follow-up is 132·7 ± 46·2 micromol L−1 .

Conclusion: 1. It is possible to minimise intracentre variability in ABO-Ab titre measurement. This suggests that standardised protocols for measurement, the development of means to normalise results and QA activity could significantly reduce intercentre variability. This is an important intermediate goal in permitting multi-centre study and outcome optimisation in ABOi kidney transplantation. 2. In the ABOUT-K study 1 year patient and graft survival approach UK antibody compatible live donor outcomes. The incidence of acute rejection and graft loss attributed to AMR is high, although the current study has not reported on control groups. It provides preliminary data on treatment, outcome and complications that will inform future multi-centre study and outcome optimisation in ABOi kidney transplantation. [Correction added on 29 October, after print and first online publication. The author name A. Bental was changed to A. Bentall in the abstract SI30.]

SI31 NHSBT’s Extracorporeal Photopheresis Service in the Transplant Setting T. A. Callaghan NHS Blood and Transplant, Liverpool, UK Extracorporeal photopheresis (ECP) is an established treatment in the management of graft versus host disease (GVHD) occurring after Graph 3

© 2013 The Authors Transfusion Medicine © 2013 British Blood Transfusion Society

XXXI Annual Scientific Meeting of the British Blood Transfusion Society allogeneic haematopoietic stem cell transplant (HSCT). The lack of immunosuppressive side effects has made it an attractive second line treatment for patients who are poorly responsive or refractory to steroids. The technique of ECP incorporates collection of white cells by apheresis, exposure of these cells to ultraviolet light and then return of the treated cells to the patient. Provision of an ECP service requires operators who are trained and experienced in the technique. NHS Blood and Transplant (NHSBT) Specialist Therapeutic Services (STS) provides a range of therapeutic apheresis services, including ECP. In recent years, the ECP service has greatly expanded with new Units opening in Manchester and Bristol, and plans to further extend the service to Oxford in 2014. The service includes adult and paediatric

© 2013 The Authors Transfusion Medicine © 2013 British Blood Transfusion Society


patients. Although primarily an outpatient service, bedside treatment may be provided for patients who are too unwell to attend as outpatients. In Manchester, review of patients at time of referral and regular follow up assessment is carried out at a joint clinic by the referring consultant and the NHSBT consultant. NHSBT has forged a close working relationship with the Commissioner for ECP services, ensuring funding is in place for patients meeting the agreed criteria. In conclusion, the ECP service provided by NHSBT is a clear example of NHSBT working together with hospitals to support patients undergoing transplantation.

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SI32 Turning research into strategy: Similarities and differences across UK Blood Services – NIBTS perspective C. Kinney1 & P. McElkerney2 1 Donor Services General Manager, and 2 Donor Recruitment and Organisation Manager, Northern Ireland Blood Transfusion Service, Belfast, Northern Ireland Several years ago the Northern Ireland Assembly introduced a piece of legislation entitled Health & Social Care (Reform) Act (Northern Ireland) 2009. Primarily this set out the establishment of several new organisations including a new, regional Health and Social Care Board (responsible for commissioning), a new Public Health Agency (public health and health promotion), and several new Health and Social Care Trusts (combining hospitals and community-based health and social care) and a single Patient and Client Council. Underpinning all of this was a statutory duty of involvement on organisations, including the Blood Transfusion Service. Despite this new legislation the terms, consultation, engagement and involvement continue to be used interchangeably. So, from this then emerged Personal and Public Involvement (PPI) which in NIBTS acts as another driver for our BTS Communities Partnership, where we have three sub-groups – one Belfast-based, another covering rural areas, and one other named the Youth Forum. This sub-group of the Partnership has played a key role in helping us recruit new, younger donors – particularly at a time when research into this target area is revealing some interesting observations. Recruiting young people is vital to ensure a continuous supply of blood to all our hospitals and there are many challenges both internal and external to our organisations. As always, research is one of the tools that

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will help guide decision-making and point towards the best tactics to use in pursuit of a well-balanced donor age profile. Engaging with the young potential donor population is key to success and this is carried out through many channels, including – school talks, university fresher days, church groups, e-media and the NIBTS Youth Forum. In Northern Ireland the blood donor panel is relatively young with 20% falling within the 17–24 years age group (rising to 62% in the 17–44 years old age group). Whilst this profile is reasonably sound, future challenges and demand may require additional efforts to further strengthen this.

SI33 Youth Recruitment in Scotland J. Wilson Scottish National Blood Transfusion Service, Edinburgh, Scotland, UK In line with other UK Services, The Scottish National Blood transfusion Service (SNBTS) aims to increase the penetration of active blood donors within the youth sector. This presentation will cover the following areas: 1. Current challenges facing Scotland 2. Strategic balance ‘All Adults Across Scotland vs Youth’ – testing effectiveness of the current campaign 3. Targeting youth via the digital landscape 4. Conclusions: moving forward with recruitment and retention.

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Lessons from the Transfusion-Related Deaths Reported to SHOT in 2012

Is this Patient in the Risk Zone? An App for Checking Indicators for Irradiated and CMV Negative Blood

P. HB Bolton-Maggs,1,2 D. Poles,1 H.Cohen,3 C. Chapman,4 M.D Kilby5 & H. New4,6 1 SHOT Office, Manchester, 2 University of Manchester, 3 University College London Hospitals NHS Trust and University College London, 4 NHS Blood and Transplant, 5 President British Maternal and Fetal Medicine Society, University of Birmingham/Birmingham Women’s Foundation Trust, Birmingham, UK, and 6 Imperial College Healthcare NHS Trust

K. Monsen1 & B. McClelland (retired)2 1 University of Edinburgh, Scotland UK, UK, and 2 SNBTS, Edinburgh, Scotland

Background: Transfusion in the UK is very safe, with an estimated risk of death based on SHOT reporting in 2012 of 3·1 per million components issued. However, transfusion associated deaths do occur each year. Methods and results: Review of 16 years of SHOT reports shows that deaths directly caused by transfusion have decreased from 12 in 1996/7 to between 1 and 3 per year from 2001, while total reports submitted has increased from 169 (22% hospitals reporting) in 1996/97, to 3545 in 2012 (97·8% hospitals reporting). Transfusion was contributory to 3–12 other deaths per year in the last 10 years. Deaths from ABO-incompatible transfusions have decreased to none in 2012 although there were 4 cases of major morbidity. Transfusion-associated circulatory overload (TACO, reported separately since 2007) has emerged as a significant cause of death and major morbidity, with 6 and 29 cases respectively of a total 82 cases in 2012. Two causes of death in 2012 are notable. An infant died of transfusion-associated graft versus host disease (TA-GvHD), the first case since 2001) following an intrauterine transfusion (IUT) for parvovirus-induced anaemia at 21 weeks gestation. Maternal blood was transfused in an emergency (non-leucodepleted, non-irradiated). The infant was pancytopenic at birth (32/40 weeks) and died at the age of 3 months with confirmed TA-GvHD. This case prompted a survey of the 16 fetal medicine units in England and Scotland to establish wider transfusion practice, with a 100% response. Maternal blood was used very rarely apart from in one centre on more than 20 occasions over 5 years. Alternatives used in an emergency were irradiated or non-irradiated leucodepleted paedipacks. Maternal blood is not recommended and fetal medicine centres should develop protocols for emergencies when a standard IUT unit cannot be provided in time. The second unusual death resulted from high dose intravenous immunoglobulin (IVIg) given to a frail elderly patient who developed severe haemolysis with renal failure. This together with another case of IVIg-related haemolysis in 2011, and a case of possible transfusion-related acute lung injury in 2012 reminds clinical staff of the potentially serious complications from this widely used therapy.

Conclusion: Transfusion-related deaths are fortunately rare but every transfusion carries a risk and should be clearly indicated.

Introduction: Errors continue to occur in the ordering of special blood components. In 2011, 69 cases were reported in the UK where irradiated and cytomegalovirus (CMV) negative components were indicated but not requested. We have developed an app to aid prescription of irradiated and CMV negative blood. Methods: To better understand the causes of prescription errors, we analysed UK haemovigilance reports. We also reviewed the literature on clinical use of mobile devices and existing transfusion apps. Using an agile development approach we created the app in HTML5. This allows the app to run in smartphone, tablet and desktop browsers. The app design was iterated based on feedback by experts from relevant specialties. Results: The review suggests prescription errors are caused by several factors, including communication errors and a lack of knowledge among clinical staff. The guidelines for special components are complex and in some cases based on limited evidence. Furthermore, policies vary between hospitals. The app follows the current guidelines from the British Committee for Standards in Haematology (BCSH) and Advisory Committee on the Safety of Blood, Tissue and Organs (SaBTO). There are few apps available in transfusion medicine and none that address prescription of special components. We have created an app that allows the user to browse, search and sort indicators for special blood components. Selecting an indicator brings up a screen with prescription recommendations and links to online guidelines. A flash card mode enables users to practice active recall of indicators and test their knowledge. Conclusion: When deciding to create the app we were encouraged by the growing clinical use of smartphone apps by medical professionals and students. However there is a dearth of published evidence to demonstrate the effectiveness of apps in medicine. The next stage is to evaluate the app on criteria such as speed and accuracy of component selection, usability and learning.

SI36 Red Cell Transfusion in Cardiac Surgery: The Influence of Cardiac Risk K. Bailie,1 K. Forrester1 & G. Berg2 1 Scottish National Blood Transfusion Service, Scotland, UK, and 2 Golden Jubilee National Hospital, Glasgow, Scotland, UK Blood use in cardiac surgery has been declining however, there remain differences in blood use between centres. Variation in case mix could explain some of this difference. Red cell transfusion during coronary artery bypass grafting (CABG) or valve replacement was compared in patients in one centre, grouped by their Euroscore. A total of 2942 patients were included; they received a total of 4,473 units of red cells. The number of red cells received per person transfused increased as the

© 2013 The Authors Transfusion Medicine © 2013 British Blood Transfusion Society

Transfusion Medicine, 2013, 23, Suppl. 2, 1–29

28 XXXI Annual Scientific Meeting of the British Blood Transfusion Society Euroscore increased. The level of cardiac risk of patients operated upon should be taken into consideration when comparing blood use between cardiac surgical centres. Introduction: The Account for Blood (AfB) data mart provides information on blood use and transfusion recipients using data from hospital blood bank systems linked to hospital episode data. Blood use in cardiac surgery has been declining blood in all centres; however, there are differences in blood use between centres. Variation in case mix could explain some of this difference. The relationship between red cell transfusion and cardiac risk was explored using data from one centre.

Methods: Clinical details for patients undergoing coronary artery bypass grafting (CABG) or valve replacement in a single centre were extracted from the hospital cardiac dataset for the period 01 January 2009 to 31 December 2011 and linked to red cell transfusion data for the same period. Red cell units were attributed to a patient if the transfusion date fell during period 7 days before admission up to and including date of discharge. Cardiac risk was assigned using the Euroscore, which incorporates a weighting for age, gender, comorbidity and type of operative procedure. As the formula for Euroscore II was not available, the score calculation was modelled on the formula used in logistic Euroscore I but with the variables and constants specified in logistic Euroscore II. The median and range of red cell units transfused per transfused patient was compared across three categories of risk score defined as low (Euroscore 6 RCC marked the progression to MTP pack 2. Results: A total of 118 trauma MTP activations were reviewed. The mean ISS score was 27. Blunt trauma accounted for 81% of cases; 19% were due to penetrating injuries. RCC usage correlated with the TASH score (p= < 0·0001) (R2 = 0·6) and the ABC score (R2 = 0·28). A TASH score of ≥7 provided a sensitivity of 90% for progression to MTP pack two with a specificity of 67%. The TASH score had an area under ROC (AUROC) of 0·88 in our cohort. An ABC score of ≥2 had a sensitivity of 25 % with a specificity of 96% for the same outcome. The AUROC for ABC was 0·8. Conclusions: MT predictive tools are currently used as ‘gatekeepers’ to MTP activation. We propose that transfusion support should be started and escalated early but promptly de-escalated when the MTP is no longer required. Both TASH and the ABC predictive scores may be useful clinical tools to predict the point at which an MTP can be safely de-escalated.

Results: A total of 2942 patients were included; 1921 had a CABG and 1021 had valve replacements. The majority of patients (97% for CABG and 89% for valves) were in the low risk category. The patients received a total of 4,473 units of red cells, 2,587 for CABG procedures and 1,886 for valve replacement. The number of red cells received per person transfused increased as the Euroscore increased (P6 red cell concentrate (RCC)) in patients judged to be at risk of MH and already initiated on a MTP. Transfusion Medicine, 2013, 23, Suppl. 2, 1–29

SI38 Fresh Blood for Patients with Beta Thalassaemia-New Evidence that Older Blood Results in Similar Outcomes Compared to Patients Transfused with Younger Blood M Badat,1 A. Chew,2 E. Prestcott,2 N. Malone,2 J Dalton,2 F. Shah, S Trompeter3 & L Hunt4 1 The Royal London Hospital, 2 Royal Whittington, London, UK, 3 NHSBT, and 4 University of Bristol Thalassaemia major (TM) is an inherited disorder of haemoglobin (Hb) where patients are dependent on regular transfusions to maintain their Hb and prevent complications of marrow expansion. UK Guidelines recommend transfused blood is less than 14 days old. A recent published study on 9 patients suggested using blood less than 7 days old led to higher pre-transfusion Hb levels. Given the small scale of this study and lack of other published evidence, a retrospective analysis of 119 patients was performed over two 6 month periods to better inform current practice. The largest UK thalassaemia centre had a ‘less than 7 days old’ policy before 2009, but relaxed its rules in 2009 to use blood less than 14 days old. We collected data on pre-transfusion Hb levels on adult TM patients being transfused during this period and noted: gender, total units transfused; age of units and ferritin levels for two 6 month periods either side of the policy change. Average age of transfused blood was paired with subsequent pre-transfusion Hb levels (within patient) and analysed using a regression model. 119 patients were transfused in both periods; 46% female, 54% male. The median age of units per episode was 5·5 days (n=940) and 7 days (n=987) respectively. There was no difference in the mean intertransfusion interval; 24·8 days 1 vs. 24·3 days (Wilcoxon matched pairs: p=0·32, n=114). We pooled all data from both periods and grouped transfusion episodes based on average age of blood per transfusion into 7 groups (

Abstracts of the XXXI Annual Scientific Meeting of the British Blood Transfusion Society. October 16-18, 2013. Birmingham, United Kingdom.

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