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Background Lebanon has a decentralized/fragmented transfusion system. The current blood supply does not meet the World Health Organization target of achieving 100% voluntary non-remunerated blood donation (VNRD). There are currently 3 types of donors/donations in Lebanon: replacement/family donations (70-75%), VNRD (20-25%), and compensated donations (5-10%). Remunerated donations are illegal. Aims This report summarizes the content of presentations given during the first World Blood Donor Day seminar in Lebanon in June 2017. The aim is to describe the current Lebanese blood supply system and the major road blocks and to suggest practical recommendations that may assist in achieving 100% VNRD. Methods The content of presentations given during the first World Blood Donor Day seminar in Lebanon in June 2017 were summarized. Results The seminar was attended by all major stakeholders involved in transfusion medicine (Lebanese National Committee of Blood Transfusion, Hospital Blood Banks directors, Lebanese Army Blood Bank, Lebanese Red Cross and Donner Sang Compter). Conclusions The Ministry of Public Health should focus on performing regular audits regarding the implementation of national guidelines. There is a need for a national blood supply committee, unifying all stakeholders in the transfusion and donation fields. Transfusion medicine should be declared by law as a public health issue and considered a priority for patient safety.

International audience; No abstract available

Context Outcomes of haplo-identical hematopoietic stem cell transplantation (haploSCT) have recently improved due to better control of allo-reactive reactions related to the major HLA mismatch between the recipient and the donor. Presence of pretransplant donor-specific anti-HLA antibodies (DSA) is associated with higher risk of graft failure. However, little is known regarding the association between the presence of these antibodies and platelet transfusion refractoriness (PTR) post-haploSCT that could predict poor transplant outcomes. Objective The aim of this study is to evaluate the association between DSA status of the recipient and the corrected platelet count increment (CCI) from day 0-100 post-haploSCT as an objective measure of PTR. Design This is a retrospective study that comprises chart review of patients who underwent haplo-SCT between June 2015 and January 2020 at the American University of Beirut medical center in Lebanon. Main outcome measures Pretransplant panel reactive antibodies (PRA) and DSA status at the time of transplant were collected, and the 24-hour CCI was calculated for every platelet donor transfusion. Results We identified 69 patients with a median age of 36 years (range: 16-77). 44 patients (64%) were males and 52 patients (75%) had myelodysplastic syndrome or acute leukemia. Median time from diagnosis to transplant was 13.8 months (range: 2.5-91.7), and 43 patients (62%) were in complete remission at transplant. Of all patients, only 6 patients (8.7%) were DSA+ at time of transplant, 14 (20.3%) were PRA+/DSA-, and the remaining 49 (71%) were PRA-. All 6 patients with DSAs underwent desensitization with a median MFI decrease of 375 (range: -541-1603). One of these 6 did not reach platelet nor leukocyte engraftment. Patients with persistent DSAs had lower mean CCI (9.27, range: 4.58-12.37) compared to those without DSAs (mean CCI: 11.93, range: 1.34-29.71; p=0.017). Statistical significance was maintained upon comparing PRA+DSA+ patients to PRA+DSA- and to PRA- patients with mean CCI of 14.04 (range: 1.39-29.71; p=0.005) and 11.38 (range: 1.34-28.00, p=0.024), respectively. Conclusions Presence of anti-HLA DSAs in haploSCT recipients, even at MFI lower than 1500, was associated with increased PTR. Larger number of patients is needed to evaluate its impact on survival outcomes.

Voluntary non-remunerated donations remain the cornerstone for a safe and sustainable blood supply. According to the World Health Organization and other international scientific committees, all nations must switch their system of blood collection to voluntary non-remunerated donation. Several other types of blood donations still exist nowadays that will be discussed. Lebanon, similarly to other developing countries, is struggling to achieve 100% voluntary non-remunerated donations for the many existing social, demographic, cultural and economic problems. Replacement donations remain the predominant type, which creates huge burden on both hospital blood banks and patient families. Despite the limited resources, some improvements have been made recently in this field and Lebanon seems to be on the road of achieving 100% voluntary non-remunerated blood donation as requested by the World Health Organization. The Lebanese experience is worth sharing so that neighbouring countries facing similar problems could benefit from it.

We explore the safety, and therapeutic benefit of intrathecal injection of ex-vivo expanded autologous bone marrow derived mesenchymal stem cells (BM-MSCs) in 10 patients with advanced multiple sclerosis (MS). Patients were assessed at 3, 6 and 12 months. Assessment at 3-6 months revealed Expanded Disability Scale Score (EDSS) improvement in 5/7, stabilization in 1/7, and worsening in 1/7 patients. MRI at 3 months revealed new or enlarging lesions in 5/7 and Gadolinium (Gd+) enhancing lesions in 3/7 patients. Vision and low contrast sensitivity testing at 3 months showed improvement in 5/6 and worsening in 1/6 patients. Early results show hints of clinical but not radiological efficacy and evidence of safety with no serious adverse events.

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A well-recognized complication of the transfusion of red blood cells (RBCs) is hyperkalaemia. This occurs in paediatric or adult patients receiving massive transfusion and can lead to cardiac arrest. Hyperkalaemia may follow the transfusion of 'stored' RBCs and/or haemolysed units, and depends on the quantity and rate of transfusion. We report on an unusual case of hyperkalaemia-induced cardiac arrest during transfusion of a 'fresh' blood unit. A 62-day-old baby girl was scheduled for a construction of a Blalock-Taussig shunt, after the completion of anastomosis, and upon release of vascular control, there was bleeding at the anastomotic site that was controlled with a suture placement. To compensate for the blood loss, a stat order was given for a push of 120 mL of RBCs over 10 min through the inferior vena cava central line. The blood unit was 6 days old and had been gamma-irradiated 48 h earlier. Shortly after the transfusion, the patient's electrocardiogram showed changes typical of hyperkalaemia; she then went into cardiac asystole. The blood unit potassium concentration was 55.3 mmol L-1, which flushed the atrioventricular node during transfusion. This is the first report of a high potassium level found in a 'fresh', less than 7 days old, nonhaemolysed RBC blood unit. The high concentration of potassium in this unit seems to be due to accelerated alterations of the RBC sodium/potassium adenosine triphosphatase pump (Na+/K+ pump), resulting in the release of intracellular potassium. This early and severe alteration of the pump and the unusually high potassium level may be due to as yet unexplained causes, warranting awareness, future investigation and routine saline washing of 'fresh' RBCs for paediatric patients who are candidates for central line transfusion.

Hemophagocytic lymphohistiocytosis (HLH) is characterized by fever, cytopenia, splenomegaly, and lymphohistiocytic proliferation with hemophagocytosis. Sporadic, familial, and reactive HLH varieties exist. The latter, also termed the reactive hemophagocytic syndrome (RHS), has been associated with a variety of infectious and noninfectious etiologies. Activation of monocytes in RHS is due to stimulation by high levels of activating cytokines. RHS has not been associated previously with thrombotic thrombocytopenic purpura (TTP). TTP is a multisystem disorder characterized by consumptive thrombocytopenia, microangiopathic hemolytic anemia, neurologic symptoms, renal impairment, and fever. We report on a 33 year old male patient with a classic picture of TTP who initially responded to therapeutic plasma exchange but then became refractory to treatment and developed RHS. It is likely that a specific pathophysiology involving the activation of neutrophils during TPE is present for the development of cytokine-induced hemophagocytosis during TTP treatment. The consequent development of RHS possibly caused early TTP relapse.

We report the rare complication of thrombotic thrombocytopenic purpura (TTP) in an elderly patient with the uncommon scleroderma renal crisis (SRC) at the advanced age of 85 years. Initially, she was treated by standard daily one and a half plasma volume therapeutic plasma exchange (TPE), in combination with steroid therapy. Due to an unsatisfactory clinical response, she was consequently, treated by an intensive twice-daily one and a half plasma volume TPE regimen. Although there was an increase in the platelet count, a 7-day course of the intensive regimen did not elicit further propitious laboratory test results or a clinical improvement and the patient expired secondary to the pulmonary and cardiac conditions related to SRC. Intensive TPE administration has been advocated in few specific patients who are refractory to standard daily treatment. The unfavorable outcome in this case may be attributed to the multiple complications associated with her primary disorder. In conclusion, we observed intensive twice-daily TPE to increase temporarily the platelet count, but not to be of benefit in a patient with SRC and multiple organ failure. The two TPE regimens and outcomes are compared and the pathogenesis of TTP and scleroderma are discussed.

Therapeutic plasma exchange (TPE) is a procedure performed on patients suffering from various disorders, including thrombotic thrombocytopenic purpura (TTP). As we noted a frequent transient deterioration in respiratory function when the procedure was performed on intensive care unit (ICU) patients, we studied retrospectively the incidence of respiratory deterioration during and shortly after TPE and looked for a probable correlation with a change in the white blood cell (WBC) counts. Over a period of 10 months six patients with TTP, five of whom had parenchymal lung disease due to different medical reasons, underwent TPE. The oxygen saturation was measured continuously before, during, and after TPE; additionally, the WBC and differential counts were measured pre- and post-TPE. The ratio of the oxygen saturation by pulse oxymetry (SpO2) to the fraction of inspired oxygen (FiO2) was calculated before, during and after TPE. In these five patients with lung disorders, there was a consistent trend of a decreasing SpO2/FiO2 quotient during and within 2 h post TPE compared to the pre-TPE value. The decrease in SpO2/FiO2 range was 0.20-0.89 with an average of 0.56. In the same 5 patients there was an increase in the WBC count in the range of 2.3-19.7 x 10(9)/L with an average increase of 9.3 x 10(9)/L. The percent neutrophils of the total WBC counts also increased following most of the sessions, this increase was in the range of 1-15 % with an average of 7%. The effect of TPE on the SpO2/FiO2 ratio and the correlation to the WBC count and to a possible neutrophil activation has not been previously reported. We postulate that TPE can accentuate respiratory deterioration in patients with TTP who already have acute lung injury. This may be due to the priming and activation of the leukocytes that could lead to the release of cytokines and inflammatory mediators during the procedure. Thus, it is important to be aware of the possible deterioration in respiratory function and gas exchange while administering TPE to patients with pre-existing parenchymal lung injury.

Quelle prise en charge de la douleur peut-on reellement developper dans un petit hopital general francais? Les auteurs presentent l’hopital d’Abbeville et ses realisations: Comite de Lutte contre la Douleur, Consultation de la douleur, enquete d’opinion parmi les soignants, generalisation de l’evaluation de la douleur, enquete d’assurance qualite, suivi de la consommation des antalgiques, developpement des protocoles d’antalgie, recherche, formation des soignants.

In transfusion medicine today, ‘zero risk’ has become a universal objective. Thus, we investigated whether the level of blood safety as defined by Lebanese legislation is satisfactory. Our work covered the period from September 2008 to June 2012. First, we studied each chapter in law and regulations, and compared them with the latest French regulations. The standards of Good Manufacturing Practice, characteristics of blood products and their storage, and the overall organization and haemovigilance for recipients and donors are not defined. Our analysis revealed numerous problems in today’s blood safety situation. There is, for example, no clear definition or identification of the different blood safety components. Then, we conducted a national survey of blood bank directors to assess their perception of blood safety in Lebanon. Our survey revealed a negative perception (52.4 per cent) of the current blood safety situation, with more than 90 per cent of respondents in favor of national regulatory improvements.

Thrombotic thrombocytopenic purpura (TTP)/Hemolytic-uremic syndrome (HUS) is a syndrome characterized by thrombocytopenia, microangiopathic hemolytic anemia, fever, renal failure and neurologic manifestation. Almost all cases are idiopathic. However, secondary TTP/HUS associated with viral, bacterial and mycobacterial infections, drugs, connective tissue disease, solid tumors, bone marrow transplantation and pregnancy have been described. Early relapse associated with infection is a rare occurrence. The patient we report had a classic case of postdiarrheal TTP/HUS that responded to plasmapheresis but relapsed during treatment as reflected by the increased schistocytosis, decreased hematocrit, increased lactate dehydrogenase, and decreased platelet counts. This relapse may be attributed to Acinetobacter anitratus bacteremia, secondary to central line infection. Administration of antimicrobial treatment resulted initially in a mild improvement. However, this was followed by a fatal relapse. The importance of monitoring the possible bacterial colonization of an indwelling catheter is thus emphasized.

To investigate the prevalence of Helicobacter pylori infection in Lebanon and the association between virulence factors (cytotoxin-associated gene A and vacuolating cytotoxin gene A), ABO blood groups, and disease phenotype.One hundred and thirty symptomatic patients with H. pylori-associated endoscopic findings and 104 healthy male donors (age range 18-55) were evaluated. Both, patients and donors underwent ABO blood typing and Western blot for cytotoxin-associated gene A and vacuolating cytotoxin gene A.The prevalence of H. pylori infection in healthy donors is 68.3%. Type I (cytotoxin-associated gene A- and vacuolating cytotoxin gene A-positive) was the predominant phenotype in all groups, though significantly less common in the asymptomatic population (46.5%) than in patients with benign disease (71.4%, p0.01) or malignancy (71.6%, p0.05). Type II (cytotoxin-associated gene A- and vacuolating cytotoxin gene A-negative) and vacuolating cytotoxin gene A-only strains were more common in the asymptomatic cohort. Overall, 35.2% of asymptomatic individuals and 10.8% of patients with benign disease were cytotoxin-associated gene A-negative (p0.01). There was no significant association between immunoserotypes, ABO groups or benign gastroduodenal disease. All gastric malignancies (lymphoma and adenocarcinoma) were cytotoxin-associated gene A-positive but this was not significantly different from patients with benign disease. We found a higher prevalence of blood group A in patients with gastric malignancy than in the general population [47.6% versus 25%, p=0.037; RR=2.73 (1.04-7.16; 95% CI)].The seroprevalence of H. pylori is moderately high in Lebanon. Phenotypic classification identifies a higher prevalence of Type I in symptomatic patients. A significant relationship between infection with a cytotoxin-associated gene A-positive strain in blood type A patients and the risk of gastric malignancy was noted.

Human T-cell lymphtropic virus type I (HTLV-I) is associated with certain hematologic and neurologic disorders. Seroprevalence studies demonstrated that the distribution of HTLV-I is heterogeneous worldwide and not specific to 1 region. Because blood is one of the major routes of transmission of the virus, blood banks of several countries routinely screen all blood donations for HTLV-I. The aim of the present study was to assess the seroprevalence rate of HTLV-I/II antibodies among Lebanese blood donors. Between August 2001 and March 2002, consecutive blood samples of 3529 blood donors were collected at blood banks of 4 major hospitals in Lebanon. Initial enzyme-linked immunosorbent assay (ELISA) screening resulted in 23 (0.7%) positive samples, of which 12 (0.3%) were reconfirmed positive by ELISA. Further analysis by Western blot resulted in 2 (0.06%) positive samples, of which 1 tested positive for HTLV-I by PCR (0.028%). Although its very low prevalence among Lebanese blood donors does not support routine screening of Lebanese blood donors for HTLV-I, screening of blood donors from other nationalities may be exercised, especially those from HTLV-I endemic areas.

The tumour suppressor p53 induces cell death by launching several pathways that are either dependent on or independent of gene transcription. Accumulation of the sphingolipid ceramide and reactive oxygen species are among these pathways. Crossregulation of these two pathways is possible owing to the demonstrated inhibition of neutral sphingomyelinase by glutathione, the predominant cellular antioxidant, and has been observed in some cytokine-dependent cell-death models. In a model of irradiation-induced cell death of Molt-4 leukaemia cells, it was found that ceramide accumulation and glutathione depletion were dependent on p53 up-regulation. The loss of p53 owing to expression of the papilloma virus E6 protein inhibited both pathways after irradiation. However, in this model, these two pathways appeared to be independently regulated on the basis of the following observations: (1) glutathione supplementation or depletion did not alter irradiation-induced ceramide accumulation, (2) exogenous ceramide treatment did not induce glutathione depletion, (3) glutathione depletion was dependent on new protein synthesis, whereas ceramide accumulation was independent of it and (4) caspase activation was required for ceramide accumulation but not for glutathione depletion. Furthermore, caspase 9 activation, which is dependent on the release of mitochondrial cytochrome c, was not required for ceramide accumulation. This suggested that a caspase, other than caspase 9, was necessary for ceramide accumulation. Interestingly, Bcl-2 expression inhibited these pathways, indicating a possible role for mitochondria in regulating both pathways. These findings indicate that these two pathways exhibit cross-regulation in cytokine-dependent, but not in p53-dependent, cell-death models.

Aim: An in-patient unit for supportive care in oncology (USSO) was created in 2011 in the Georges Pompidou European Hospital. Its primary objective is to improve patient care and manage the complications of cancer as well as their specific treatment. Patients are previously screened by a cross disciplinary team at an early stage before complication. Methods: A prospective observational study was performed through a yearly evaluation of the unit's activity from January 1st 2011 to December 31st 2013. Results: 594 patients were admitted in the unit during the three years period of study. Most of them (64.3%) came directly from home, with an increase of this rate along this period (59.4% to 67.6%). The early screening thereby rendered emergency admission from 17.7% (2011) to 6.5% (2013). The predominant diseases observed were head and neck cancer (42.4%) and lung cancer (23%), followed by breast (7.2%) and ovarian cancer (7.2%). The main grounds for hospitalization were state of health impairment 32%, pain 12.8%, and invasive procedures 11.8%, increasing from 2011 to 2013. Therefore, an interdisciplinary approach is the cornerstone of the unit with the daily collaboration of dieticians (for 90% of inpatients), social workers, psychologists, physiotherapists and pain specialists (34%, 46%, 56% and 50% of inpatients respectively). The average length of stay decreased from 2011 (10.2 days) to 2013 (8.3 days) and 58.4% of the patients were home discharged. With the help of a social worker, 12% of the patients were transferred to a recovery unit and 9.7% to a palliative care unit while 9% died in the unit. Conclusions: With the opening of the in-patient USSO, and the development of its interdisciplinary strategy, most of the patients recover faster and regain better health. Preventive care can accommodate a majority of patients coming from home and allows for ambulatory secured discharge. These positive results conducted to enhance the USSO's beds capacity and supportive care development in order to improve cancer care rganization in the hospital as well as patient's quality of life. Disclosure: All authors have declared no conflicts of interest.

Aim: The PROCHE [Programme for optimisation of the chemotherapy network] initiative is an innovative oncology-monitoring program designed to reduce patient waiting time and chemotherapy wastage, ultimately improving patient care. Laboratory test results and side effects data are collected for patients in the PROCHE monitoring program 2 days prior to scheduled chemotherapy visits, allowing oncologists to confirm or delay each patient's chemotherapy. Methods: This prospective study compared the program Data from patients entered in the PROCHE program with 513 control patients. Primary objective was to evaluate the evolution of delay between arrival and start of chemotherapy from 2008 to 2013. Secondary objectives were evolution of toxicity incidence and patient satisfaction along 4 years of activity. Incidence per year was compared using the Maentel-Haenszel Khi-2. Results: Between Oct 2008 and Dec 2013, 2 040 patients participated in the program, representing 21,920 scheduled chemotherapy. Results demonstrated significant reductions in mean hospital stay with a decrease of 53 min (116 min in 2008 compared to 63 min in 2013) allowing 30% activity enhancement to reach a 95% of patient satisfaction. Drug wastage was decreased by a factor 2 compared to another ambulatory chemotherapy department in the same hospital (5.4% vs 10.9%). Main adverse events (AE) incidence was collected on an ongoing basis (percentages are rounded to nearest integer). Fatigue was the most incident, with a decrease between 2009 and 2013, respectively 81% vs 54% (p Conclusions: the PROCHE initiative resulted in improved patient quality of care and improvement of hospital as well as pharmacy efficiency. Disclosure: All authors have declared no conflicts of interest.

We report and characterize a novel mutant of the hepatitis B virus surface antigen (HBsAg). The mutant was isolated from a symptomatic patient who was found to be persistently positive for both HBsAg and anti-hepatitis B surface antibody (anti-HBs) and a long-lasting anti-HBc (core) IgM. Due to the unusual immune serological profile, polymerase chain reaction and sequencing were performed and revealed a genotype D mutant HBV (LBN). Aligned with known HBsAg sequences from GenBank, the LBN variant matched to consensus subtype ayw2 and revealed five mutation positions. Interestingly, none of the mutations was found within the group-specific "a" determinant region (124-147) and, specifically, two of the five mutations, T118K and P120Q, were located only a few amino acids adjacent to the 124-147 region. Using a panel of six monoclonal antibodies and vaccine raised human neutralizing antibodies, the recombinant wild-type HBsAg and the novel variant LBN HBsAg were investigated for their immunological reactivity. Vaccine raised human anti-HBs showed less reactivity to the variant LBN HBsAg than to wild-type HBsAg in enzyme immune assays. Furthermore, our observations demonstrate the influence of adjacent residues on the group-specific "a" determinant structural configuration; this resulted in severe antigenic changes of the immunodominant region as well as in the subtype serology. The importance of the variant LBN lies in the observation that mutations close to the "a" determinant can change the immunodominant region structure and therefore alter the group specific determinant antigenicity even though no mutations are present within this region. Hence, the classical definition of the "a" determinant cluster may need to be extended to cover a broader region to include the requirement of adjacent amino acids to support its conformation. In conclusion, by understanding the HBsAg major immunodominant region structure and by using a combination of antibodies with specificity covering all key mutation locations, maximal anti-HBs-based protection, and highly sensitive diagnostic assays can be achieved.

Thrombotic thrombocytopenic purpura (TTP) is a multisystem disorder characterized by consumptive thrombocytopenia, microangiopathic hemolytic anemia, and neurologic symptoms. TTP is associated with many diseases and several therapeutic drugs. We report the rare case of a patient with rheumatoid arthritis who developed TTP that was not associated with drug therapy, 18 months after the onset of rheumatoid arthritis. She recovered from the TTP following daily sessions of therapeutic plasma exchange (TPE) with fresh frozen plasma replacement and glucocorticoid therapy. Recent pathogenic mechanisms are reviewed as they relate to von Willebrand factor. In this report of the rare association of TTP with rheumatoid arthritis, an immediate relationship is likely because both are of an immune nature. Awareness of the possible development of TTP in rheumatoid arthritis is important for early diagnosis and treatment.

Summary - Effect of cheese ripening on rheological properties of camembert and saint-paulin cheeses. The influence of ripening on the rheological properties of cheese has been evaluated by using 2 mechanical tests : the uniaxial compression and the stress relaxation. The calculated rheological parameters from an uniaxial compression test were the force of yield point, the relative deformation at yield point and the deformability modulus. From relaxation curves, 2 parameters were calculated : the half-relaxation time and the residual force/initial force ratio. Beside the latter parameters, an exploitation of the relaxation curves, according to the Maxwell generalized model, allowed to show that the 2 test cheese types exhibit a viscoelastic behaviour. It has been shown that these rheological properties change during ripening. Such evolutions are not always similar for the 2 investigated cheese types (camembert and saint-paulin). For example, from the beginning to the end of ripening, Ose varies from 70 to 40% for camembert, and trom 62 to 70% for saint-paulin. This can be explained by the more heterogeneous character of camembert paste. Conversely, the evolutions of the R1/2 are reverse for the 2 cheese types. An explanation can be given if we state that the stress relaxation (10 min) is probably incomplete for camembert cheese. The adjustment of the relaxation experimental curves to the generalized Maxwell model requires the use of 2 elements in the saint-paulin case, while 3 elements are required in the camembert case. From the multiple linear regression analysis, it could be demonstrated that many parameters are correlated with the ripening degree or the water content. Moreover, some important differences