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Background With the goal of labeling and manipulating the zebrafish hypothalamus, we sought to target a green fluorescent protein (gfp) transgene to the expression domains of nkx2.4b, a gene expressed during hypothalamic and thyroid development. We combined transcription activator-like effector nucleases (TALENs)-mediated mutagenesis with a targeting construct to enable insertion of a gfp transgene into the endogenous nkx2.4b genomic locus. Results Injection of TALENs targeted to the first exon of nkx2.4b created a predicted null allele, and homozygous mutant embryos displayed loss of thyroid markers. From embryos injected with both TALENs and a targeting construct carrying a gfp transgene, we recovered a line in which GFP was expressed specifically in the hypothalamus and thyroid. Fish homozygous for this allele lacked exon 1 of nkx2.4b and exhibited hypothyroid phenotypes. Conclusions By combining TALENs injections with a targeting construct that contained a gfp transgene, we were able to recover an allele in which GFP is expressed in the nkx2.4b expression domains, with homozygous phenotypes suggesting the creation of a loss-of-function transgenic line. These results demonstrate the creation of a useful tool for studying hypothalamus and thyroid development.

Donor-derived T-cells mediate graft-versus-leukemia effect, immune reconstitution, and graft-versus-host-disease (GvHD) after allogeneic hematopoietic cell transplantation (HCT). We examined the association of donor cell subsets with outcomes in recipients of myeloablative allogeneic HCT using bone marrow (BM, N = 359) grafts from 2002 to 2014 with related or unrelated donors. Analysis considered pre-infusion graft total nucleated cell (TNC), CD34+ CD3+, CD4+, CD8+ doses. Most patients received busulfan-cyclophosphamide or etoposide-total body irradiation conditioning for acute leukemia or myelodysplastic syndrome. Calcineurin inhibitor-mycophenolate mofetil (CNI-MMF) (49%) or calcineurin inhibitor-methotrexate (CNI-MTX) (47%) were used for GvHD prophylaxis. In multivariable analysis, higher CD34+ dose was associated with platelet engraftment (P

Background Human induced pluripotent stem cell (hiPSC)-derived neuronal cultures are a useful tool for studying the mechanisms of neurological disorders and developing novel therapeutics. While plating hiPSC-derived neuronal progenitors onto glial feeder layers prepared from rodent cortex has been reported to promote functional differentiation of neuronal networks, this has not been examined in detail. New method Here we describe a method of using cryopreserved cells from primary cultures for generation of mouse astrocyte-enriched, neuron-free feeder layers that grow from 10% to 100% confluence in 1 week. Results Electrophysiological analysis demonstrated that compared to biochemical substrates alone, astrocyte-enriched feeder layers support more rapid differentiation of hiPSC-derived progenitors into excitable neurons that form spontaneously active networks in culture. There was a positive correlation between the degree of astroglial confluence at the time of progenitor plating and the average frequency of postsynaptic currents 3 weeks after plating. One disadvantage to plating on 100% confluent feeder layers was a high incidence of the astroglial layer with the overlying neurons detaching from the coverslips during transfer to the recording chamber. Comparison with existing method(s) Prevailing methods using primary glial feeder layers can result in possible contamination with rodent neurons and an unpredictable rate of growth. We provide a reliable method of generating mouse astroglial feeder layers from cryopreserved primary cultures to support differentiation of hiPSC-derived neurons. Conclusions The ability to make astrocyte-enriched feeder layers of defined confluence from cryopreserved primary cultures will facilitate the use of human stem cell derived neuronal cultures for disease modeling.

Summary Background No randomised trials have addressed whether exposure to red blood cells (RBCs) stored longer than 35 days is associated with harm in patients. We aimed to assess the risk of in-hospital mortality associated with transfusing blood stored longer than 35 days. Methods We did a secondary analysis of the INforming Fresh versus Old Red cell Management (INFORM) trial, a pragmatic, multicentre, randomised controlled trial of patients (≥18 years) admitted to one of six hospitals in Australia, Canada, Israel, and the USA and expected to need RBC transfusions. Patients were randomly assigned (2:1) to receive blood in inventory stored for the longest time (standard care) or the shortest time, using a random allocation schedule and stratified by centre and patient ABO blood group. The primary objective of the INFORM trial was to assess all-cause in-hospital mortality in patients with blood group A and O who were transfused. For our exploratory secondary analysis, we classified individuals into one of three mutually exclusive exposure categories on the basis of the maximum storage duration of any blood unit patients had received on each day in hospital: exclusively exposed to RBCs stored no longer than 7 days, exposed to at least one unit of RBCs stored 8–35 days, and exposed to least one unit of RBCs stored longer than 35 days. Our primary objective was to determine the effect on risk of in-hospital death of time-dependent exposure to RBCs stored longer than 35 days compared with exclusive exposure to RBCs stored no longer than 7 days, both in patients of blood groups A and O and all patients. The INFORM trial is registered as an International Standard Randomised Controlled Trial, number ISRCTN08118744. Findings Between April 2, 2012, and Oct 21, 2015, 31 497 patients were recruited, and 24 736 patients were eligible for inclusion in this analysis. We excluded nine patients for whom information about the storage duration of transfused blood was missing and one patient whose sex was unknown. 4480 (18%) patients were exposed to RBCs with longest storage, 1392 (6%) patients were exposed exclusively to RBCs with shortest storage, and 18 854 (76%) patients were exposed to RBCs stored 8–35 days. Median follow-up was 11 days (IQR 6–20). Exposure to RBCs stored longer than 35 days was not associated with increased risk of in-hospital death compared with exclusive exposure to the freshest RBC units after adjusting for demographic variables, diagnosis category, and blood product use history (in patients with blood group A or O: hazard ratio 0·94, 95% CI 0·73–1·20, p=0·60; in all patients: 0·91, 0·72–1·14, p=0·40). The risk of in-hospital death also did not differ between patients exposed to blood stored 8–35 days and patients exposed to blood stored 7 days or less (in patients with blood group A or O: 0·92, 0·74–1·15, p=0·48; in all patients: 0·90, 0·73–1·10, p=0·29). Interpretation These data provide evidence that transfusion of blood stored for longer than 35 days has no effect on in-hospital mortality, which suggests that current approaches to blood storage and inventory management are reasonable. Funding Canadian Institutes for Health Research, Canadian Blood Services, and Health Canada.

Background Although observational studies suggest an association between transfusion of older red blood cell (RBC) units and increased postoperative risk, randomized trials have not supported this. The objective of this randomized trial was to test the effect of RBC storage age on outcomes after cardiac surgery. Methods From July 2007 to May 2016, 3835 adults undergoing coronary artery bypass grafting, cardiac valve procedures, or ascending aorta repair, either alone or in combination, were randomized to transfusion of RBCs stored for ≤14 days (younger units) or for ≥20 days (older units) intraoperatively and throughout the postoperative hospitalization. According to protocol, 2448 patients were excluded because they did not receive RBC transfusions. Among the remaining 1387 modified intent-to-treat patients, 701 were randomized to receive younger RBC units (median age, 11 days) and the remaining 686 to receive older units (median age, 25 days). The primary endpoint was composite morbidity and mortality, analyzed using a generalized estimating equation (GEE) model. The trial was discontinued midway owing to enrollment constraints. Results A total of 5470 RBC units were transfused, including 2783 in the younger RBC storage group and 2687 in the older RBC storage group. The GEE average relative-effect odds ratio was 0.77 (95% confidence interval [CI], 0.50-1.19; P = .083) for the composite morbidity and mortality endpoint. In-hospital mortality was lower for the younger RBC storage group (2.1% [n = 15] vs 3.4% [n = 23]), as was occurrence of other adverse events except for atrial fibrillation, although all CIs crossed 1.0. Conclusions This clinical trial, which was stopped at its midpoint owing to enrollment constraints, supports neither the efficacy nor the futility of transfusing either younger or older RBC units. The effects of transfusing RBCs after even more prolonged storage (35-42 days) remains untested.

BackgroundRandomized, controlled trials have suggested that the transfusion of blood after prolonged storage does not increase the risk of adverse outcomes among patients, although most of these trials were restricted to high-risk populations and were not powered to detect small but clinically important differences in mortality. We sought to find out whether the duration of blood storage would have an effect on mortality after transfusion in a general population of hospitalized patients. MethodsIn this pragmatic, randomized, controlled trial conducted at six hospitals in four countries, we randomly assigned patients who required a red-cell transfusion to receive blood that had been stored for the shortest duration (short-term storage group) or the longest duration (long-term storage group) in a 1:2 ratio. Only patients with type A or O blood were included in the primary analysis, since pilot data suggested that our goal of achieving a difference in the mean duration of blood storage of at least 10 days wo...

Although red blood cell transfusion is a potentially lifesaving intervention in severely anemic and acutely bleeding patients, some observational studies have suggested that prolonged red cell storage before transfusion is associated with harm. INFORM is a large, pragmatic, randomized controlled trial comparing the effect of the shorter storage with longer storage red blood cell transfusions on inhospital mortality in hospitalized patients who require a blood transfusion. The trial is being conducted in centers in Australia, Canada, Israel, and the United States and is expected to enroll 31497 patients. If the results of INFORM indicate that shorter storage red blood cell transfusion is associated with superior outcomes compared with standard issue red blood cell transfusion, consideration may be given to shortening blood storage times. If, in contrast, the INFORM trial provides no evidence of harm from longer storage red blood cells, clinicians and patients may be reassured that current blood inventory management strategies are appropriate.

Donor-derived T-cells mediate graft-versus-leukemia effect, immune reconstitution, and graft-versus-host-disease (GvHD) after allogeneic hematopoietic cell transplantation (HCT). We examined the association of donor cell subsets with outcomes in recipients of myeloablative allogeneic HCT using bone marrow (BM, N = 359) grafts from 2002 to 2014 with related or unrelated donors. Analysis considered pre-infusion graft total nucleated cell (TNC), CD34+ CD3+, CD4+, CD8+ doses. Most patients received busulfan-cyclophosphamide or etoposide-total body irradiation conditioning for acute leukemia or myelodysplastic syndrome. Calcineurin inhibitor-mycophenolate mofetil (CNI-MMF) (49%) or calcineurin inhibitor-methotrexate (CNI-MTX) (47%) were used for GvHD prophylaxis. In multivariable analysis, higher CD34+ dose was associated with platelet engraftment (P 0.001) and lymphocyte recovery (P = 0.006). There was no association of donor cell subsets with donor chimerism or overall survival. In conclusion, BM graft composition is associated with myeloablative allogeneic HCT outcomes and future studies to evaluate optimal graft composition are needed.

Background During cold storage, some red blood cell (RBC) units age more rapidly than others. Yet, the Food and Drug Administration has set a uniform storage limit of 42 days. Objectives of this review are to present evidence for an RBC storage lesion and suggest that functional measures of stored RBC quality—which we call real age—may be more appropriate than calendar age. Methods During RBC storage, biochemical substances and byproducts accumulate and RBC shape alters. Factors that influence the rate of degradation include donor characteristics, bio-preservation conditions, and vesiculation. Better understanding of markers of RBC quality may lead to standardized, quantifiable, and operationally practical measures to improve donor selection, assess quality of an RBC unit, improve storage conditions, and test efficacy of the transfused product. Results The conundrum is that clinical trials of younger versus older RBC units have not aligned with in vitro aging data; that is, the units transfused were not old enough. In vitro changes are considerable beyond 28 to 35 days, and average storage age for older transfused units was 14 to 21 days. Conclusions RBC product real age varies by donor characteristics, storage conditions, and biological changes during storage. Metrics to measure temporal changes in quality of the stored RBC product may be more appropriate than the 42-day expiration date. Randomized trials and observational studies are focused on average effect, but, in the evolving age of precision medicine, we must acknowledge that vulnerable populations and individuals may be harmed by aging blood.

Our understanding of the pathogenesis of idiopathic thrombotic thrombocytopenic purpura (TTP) has increased, but remains incomplete, particularly with respect to cases of suspected TTP that are either unresponsive to therapeutic plasma exchange (TPE) or have normal ADAMTS13 (a disintegrin-like and metalloprotease with thrombospondin type 1 motif 13) activity. A 53-year-old woman presented with severe anemia (hemoglobin 1.8 g/dL) and clinical and laboratory findings consistent with TTP in conjunction with acute cocaine use. The patient was treated with TPE until the pre-treatment ADAMTS13 activity was reported as normal without evidence of an inhibitor. TPE was stopped and the patient continued to improve without treatment. This patient's microangiopathic hemolytic anemia (MAHA) appeared to be secondary to cocaine use. The proposed pathogenesis is likely a combination of cocaine-induced vasoconstriction, vascular damage, platelet activation, and procoagulation. This is the fifth published report of cocaine-induced MAHA and to our knowledge the first with ADAMTS13 testing.

Red blood cells (RBCs) undergo biochemical and structural changes during storage, commonly referred to as the "storage lesion." Evidence suggests that the longer the RBC product is stored, the less effective is the transfused blood. Many studies linking morbidity to transfusion have not considered duration of RBC storage as a variable that may modulate the effect. In addition, the effects of supply and demand and RBC inventory management strategies have been incompletely investigated. It is possible to envision a blood management system based on modern inventory management strategies that could greatly reduce storage duration.

BACKGROUND More than 5 million patients receive erythrocyte transfusions in the United States every year. Previous studies linked the storage duration of allogeneic erythrocytes to the risk of severe postoperative complications, especially after cardiac or trauma surgery. Limited data are available for noncardiac surgical patients. We therefore evaluated the association between storage duration of transfused erythrocytes and postoperative all-cause mortality among general surgery patients. METHODS Perioperative data corresponding to 63,319 adult, general surgery patients were obtained from our registry and merged with blood product data. Patients receiving solely leukocyte-reduced, allogeneic erythrocyte transfusions were included. Multivariable Cox proportional hazards regression was used to characterize the relationship between median erythrocyte storage duration and postoperative mortality rate, adjusting for characteristics plausibly influencing the storage duration of erythrocytes. RESULTS Of the 6,994 patients included in the final analysis, 23, 44, 11, 9, and 13% received 1, 2, 3, 4, and ≥5 erythrocyte units, respectively. The authors found no evidence that increasing median storage duration was associated with a difference in the risk of postoperative mortality (hazard ratio, 0.99 [0.94-1.04]; P = 0.64). Analyzing the mean storage duration of erythrocyte units as a function of year of transfusion, the authors demonstrate a relevant decrease in utilization of the oldest blood units, whereas young blood storage duration remains nearly unchanged. CONCLUSION The authors' study supports the recent literature in surgical and medical patients and underlines the importance of sufficiently powered randomized trials to finally resolve the erythrocyte storage duration debate.

Objectives: Cold antibodies (CAs) are rarely significant for transfusion, but they can cause complications under the hypothermic conditions of cardiovascular surgery. The purpose of this study was to determine the incidence of such complications. Methods: Patients with CAs who underwent cardiovascular surgery were identified, and their records were reviewed for intraoperative complications attributable to CAs. Results: Over 14.5 years, of the 47,373 patients who underwent cardiovascular surgery, 99 had CAs before or within 30 days after surgery. Ninety-seven patients had hypothermic surgery, and intraoperative agglutination was noted in four; two of these cases were never reported to the transfusion service. Conclusions: The incidence of intraoperative complications among our patients with CAs was only 4%; therefore, the use of special testing protocols for the preoperative identification of CAs is neither necessary nor justified. Patient risk is best managed by preoperative clinical evaluation for potentially pathogenic CAs and intraoperative vigilance for agglutination.

Blood management is a concept that adopts a principle of improving patient outcome by integrating all available techniques to ensure safety, availability, and appropriate allocation of blood products. This constitutes a model of multidisciplinary care where the changes in culture are system directed on the basis of evidence-based medicine. There are about 14% US hospitals where any kind of blood management program exists, although the idea remains the same but the programs vary in their execution, implementation, and ultimately providing the value to patients. In this article, we have described our experience of creating a patient-centric, cost-effective, evidence-based, and multipronged program creation with scalable results. The use of data, education, process improvement, engagement, and accountability of caregivers have resulted in sustained results and helped in creating a comprehensive blood management program.

Early and reliable prediction of the likelihood of achieving adequate stem cell collection for autologous stem cell transplantation (ASCT) in patients with multiple myeloma (MM) would improve collection efficiency, prevent unnecessary aphereses, and permit appropriate treatment alterations. No previous study has reported a threshold CD34+ cell collection quantity on Day 1 or 2 of leukapheresis that could predict successful stem cell collection. We performed a retrospective analysis of all MM patients undergoing first attempt of stem cell collection at our institution from 2001 through 2008. Recursive partitioning analysis was used to identify Day 1 or Day 1+2 CD34+ collection quantity that predicted failure to reach target ≥ 2 × 10(6) CD34+ cells/kg within five days of collection. Totally, 172 patients were included in the analysis. Patients underwent mobilization with G-CSF or G-CSF+ chemotherapy. 23 of 172 patients (13.4%) failed to collect sufficient (≥ 2 × 10(6) CD34+ cells/kg) CD34+ cells after five days of apheresis: 22 of 29 who collected ≤ 0.70 × 10(6) CD34+ cells/kg and 1 of 143 who collected0.70 × 10(6) CD34+ cells/kg (75.9% vs. 0.7%, P0.001) on Day 1. Collection failure occurred in 23 of 30 patients who collected ≤ 1.54 × 10(6) CD34+ cells/kg and 0 of 142 who collected1.54 × 10(6) CD34+ cells/kg (76.7% vs. 0%, P0.001) on Days 1 + 2. Day 1 CD34+ cell collection quantity identifies patients unlikely to achieve adequate collection for ASCT. Patients who collect ≤ 0.70 × 10(6) CD34+ cells/kg on day 1 could be considered for treatment modifications to improve CD34+ collection, such as early administration of plerixafor or large volume apheresis.

To determine the sensitivity and specificity of tests for hepatitis B surface antigen (HbsAg), hepatitis C virus (HCV), and syphilis conducted by laboratories of 3 blood collection organizations in a rural area of China.From October to December 2003, 1068 samples were collected from blood donors presenting to the 3 collection centers. All samples were tested twice using 2 different test kits for HBsAg, HCV, and syphilis. An aliquot was sent to the China National Center for Clinical Laboratories to confirm the local test results. Sensitivities and specificities of the 3 local blood centers/banks were calculated using the results of the National Center for Clinical Laboratories as the gold standard.The sensitivity of the 3 blood collection center/banks ranged from 0% to 63.2% for HBsAg. For HCV, the sensitivity was 0%, and for syphilis, ranged from 0% to 85.7%. There were no HBsAg positives in one of the blood center/banks, and no syphilis positives in the other. Thus, sensitivity could not be measured for these tests in these 2 facilities. Combining all 3 tests, the overall sensitivity was 55.6%. The specificity was 100%.The sensitivity of the local laboratories was inadequate and could cause possible infection for an unacceptable number of blood recipients. Action needs to be taken to improve the quality of testing to ensure the safety of the rural blood supply.

Background Platelet transfusion has been reported to confer increased morbidity after cardiac surgery but prior studies were limited by confounding variables including red blood cell (RBC) transfusions. Our objective was to examine the impact of platelet transfusion on outcomes in cardiac surgery controlling perioperative risk factors. Methods A total of 32,298 patients underwent on-pump isolated coronary artery bypass grafting (CABG), an isolated valve, or a combined CABG and valve procedure between January 1, 1993 and January 1, 2006. Regression analysis and propensity methodology was employed to assess the association between platelet transfusion and morbidity. Results Univariate comparisons demonstrated that patients who received platelet transfusions had increased morbidity. After risk adjustment with both multivariable regression and propensity methods, platelet transfusion was not significantly associated with in-hospital mortality: odds ratio (OR) 0.74 confidence limits 0.58, 0.95, p = 0.017 and 2.05% vs 3.06%, p = 0.017, respectively. Among 2,774 propensity matched-pairs, platelet transfusion was associated with similar or reduced morbidity, platelets versus no platelets: cardiac 2.42% vs 1.77%, p = 0.09; pulmonary 8.94% vs 9.88%, p = 0.23; renal 1.33% vs 1.48%, p = 0.65; neurologic 2.27% vs 3.21%, p = 0.033; serious infection 4.15% vs 5.34%, p = 0.037; and composite outcome 15.0% vs 17.2%, p = 0.024. Among a propensity-matched subgroup of patients never administered a concomitant RBC transfusion, platelet transfusion was not associated with increased morbidity: 4.49% vs 2.99%, p = 0.31. Conclusions Platelet transfusion was not found to increase morbid risk after cardiac surgery. Our results should not be interpreted as advocating platelet transfusions in cardiac surgery; rather, platelet transfusion empirically in the setting of persistent microvascular bleeding is not associated with increased morbid risk.

Background Stored red cells undergo progressive structural and functional changes over time. We tested the hypothesis that serious complications and mortality after cardiac surgery are increased when transfused red cells are stored for more than 2 weeks. Methods We examined data from patients given red-cell transfusions during coronary-artery bypass grafting, heart-valve surgery, or both between June 30, 1998, and January 30, 2006. A total of 2872 patients received 8802 units of blood that had been stored for 14 days or less (“newer blood”), and 3130 patients received 10,782 units of blood that had been stored for more than 14 days (“older blood”). Multivariable logistic regression with propensity-score methods was used to examine the effect of the duration of storage on outcomes. Survival was estimated by the Kaplan–Meier method and Blackstone's decomposition method. Results The median duration of storage was 11 days for newer blood and 20 days for older blood. Patients who were given older units had hig...

Allogeneic HCT is a crucial tool for the treatment of hematologic malignancies, immune-deficiencies, and metabolic disorders. Donor-derived T-cells are critical for the graft-versus-leukemia effect, assist in engraftment, and protect against infections; however, they are also involved in the development of graft-versus-host-disease (GVHD). Although total nucleated cell (TNC) dose and CD34 cell doses have previously been correlated with post-transplant outcomes, there are limited data on the role of donor T-cell subsets in engraftment and post-HCT complications including GVHD. We examined the association of donor cell subset data with outcomes in myeloablative allogeneic HCT recipients from 2002 to 2014 in our single-center retrospective cohort study. Analysis was restricted to recipients of BM (N=359) or G-CSF mobilized PBSC (N=61) grafts from HLA-identical sibling and unrelated donors. Total nucleated cell (TNC), CD34, CD3, CD4, CD8, and CD56 (PBSC only) doses from the pre-infusion graft were analyzed for association with disease and outcome data prospectively collected by our institution's HCT database. Multivariable Fine and Gray or Cox regression analyses adjusted for clinical variables and evaluated association of donor cell subset with the following outcomes: neutrophil engraftment (>500/uL x 3 days), platelet engraftment (>20,000/uL x 3 days), lymphocyte recovery (>500/uL x 1 day), any infection, donor chimerism (≥95% by day 100), grade 2-4 acute GVHD, chronic GVHD, non-relapse mortality (NRM) and overall survival. Analyses were performed separately for BM and PBSC groups. In the BM cohort, median recipient age was 47 years; 77% patients had acute leukemia/MDS; 58% had HLA-identical sibling donor. Most patients received ablative Bu-Cy (63%) or etoposide-TBI (19%) conditioning, with CNI-MMF (49%) or CNI-MTX (47%) as GVHD prophylaxis. Donor median age was 42 years and 39% were CMV positive. The mean graft (/kg) TNC and CD34 doses were 2.29x108 and 2.52x106, and mean T-cell subset doses were 32.19x108 CD3, 17.92x108 CD4, and 12.75x108 CD8, respectively. Among patients receiving a PBSC graft, median age was 48 years, 82% had acute leukemia/MDS, and 64% had an unrelated donor. Similar to BM, most patients received ablative Bu-Cy (67%) or etoposide-TBI (15%) conditioning, and CNI-MMF (33%) or CNI-MTX (61%) for GVHD prophylaxis. Median donor age was 40 years and 36% were CMV seropositive. The mean graft cell doses (/kg) were 9.51x108 TNC, 5.50x106 CD34, 2.74x108 CD3, 1.75x108 CD4, 0.88x108 CD8, and 0.36x108 CD56, respectively. Median time to neutrophil, lymphocyte and platelet recovery was 15, 27 and 23 days, respectively in the BM cohort, and 12, 19 and 16 days, respectively in the PBSC cohort. The table shows significant associations between donor cell subsets and post-HCT outcomes from the multivariable analysis. In summary, among myeloablative allogeneic HCT patients receiving BM grafts, earlier neutrophil engraftment was seen with higher TNC dose, while platelet engraftment and lymphocyte recovery was seen with higher CD34 dose. Among PBSC grafts, higher CD8 dose was associated with earlier lymphocyte recovery, higher CD4 dose with lower risk of infection, and higher CD34 dose with greater risk of acute GVHD but lower risk of NRM. The relative contribution of each donor cell subset between BM and PBSC grafts can impact outcomes. We did not observe any association of donor cell subsets with donor chimerism, chronic GVHD, or overall survival in this population. BM and PBSC graft composition can impact myeloablative allogeneic HCT outcomes and future studies to evaluate optimal graft composition are needed. Disclosures No relevant conflicts of interest to declare.

Our understanding of the pathogenesis of idiopathic thrombotic thrombocytopenic purpura (TTP) has increased, but remains incomplete, particularly with respect to cases of suspected TTP that are either unresponsive to therapeutic plasma exchange (TPE) or have normal ADAMTS13 (a disintegrin-like and metalloprotease with thrombospondin type 1 motif 13) activity. A 53-year-old woman presented with severe anemia (hemoglobin 1.8 g/dL) and clinical and laboratory findings consistent with TTP in conjunction with acute cocaine use. The patient was treated with TPE until the pre-treatment ADAMTS13 activity was reported as normal without evidence of an inhibitor. TPE was stopped and the patient continued to improve without treatment. This patient's microangiopathic hemolytic anemia (MAHA) appeared to be secondary to cocaine use. The proposed pathogenesis is likely a combination of cocaine-induced vasoconstriction, vascular damage, platelet activation, and procoagulation. This is the fifth published report of cocaine-induced MAHA and to our knowledge the first with ADAMTS13 testing.

Immune thrombocytopenic purpura (ITP) and thrombotic thrombocytopenic purpura (TTP) have each been associated with HIV infection. Sequential occurrence of these two diseases with a disease-free interval has been occasionally reported in the literature, whereas simultaneous manifestations of these two diseases have not been described. Here, we report an AIDS patient who was initially diagnosed as having TTP and showed an apparent partial response to plasmapheresis but was found to have a clinical course similar to ITP. Although precise mechanisms for the development of TTP and ITP in these patients are unclear, we offer several hypotheses. It is important to recognize that these two processes may be seen concurrently.

We sought to determine whether patients requiring more aphereses to obtain adequate numbers of CD34+ cells had delayed hematopoietic recovery following autologous transplantation. We identified 496 consecutive individuals with lymphoma who underwent hematopoietic stem cell mobilization using etoposide and G-CSF and first autologous transplantation. In multivariate analysis, increased apheresis days as a continuous and as a categorical variable at ⩾5/

Perioperative vasoplegia is associated with increased morbidity. Red blood cell (RBC) transfusion increases plasma concentrations of inflammatory mediators, possibly contributing to the development of vasoplegia. We investigated the prevalence of mild and profound postoperative vasoplegia, identified factors associated with its development, and examined the role of RBC and component transfusion on the occurrence of postoperative vasoplegia.Between January 1, 2000, and January 1, 2007, 25,960 patients underwent on-bypass cardiac surgical procedures. The incidence of vasoplegia was defined as (1) mild vasoplegia requiring norepinephrine infusion for blood pressure support on the day of operation and postoperative day 1, and (2) profound vasoplegia requiring vasopressin, with or without concomitant norepinephrine infusion, on the day of operation and postoperative day 1. Separate logistic regression models were used to model risk factors for development of mild and profound vasoplegia.RBC transfusion increased risk-adjusted odd ratios (ORs) of developing mild vasoplegia (1.07 [95% confidence limits (CL), 1.05, 1.10]; p0.001) and profound vasoplegia (1.38 [1.31, 1.46] p0.001). The risk-adjusted ORs (95% CL) for mild vasoplegia and profound vasoplegia were similarly increased by fresh-frozen plasma (OR, 1.24 [1.10, 1.41], p0.001; and OR, 1.20 [1.13, 1.29], p0.001) and platelet transfusion (OR, 1.39 [1.25, 1.54], p0.001; and OR, 1.22 [1.14, 1.31], p0.001), respectively.Red blood cells, fresh-frozen plasma, and platelet transfusion increased the prevalence of vasoplegia. RBC transfusion exhibited a dose-dependent response for developing vasoplegia with each RBC unit transfused. Further investigation is necessary to determine whether prophylactic use of vasopressor support in the setting of transfusion can ameliorate risk and effect outcomes.

BACKGROUND More than 5 million patients receive erythrocyte transfusions in the United States every year. Previous studies linked the storage duration of allogeneic erythrocytes to the risk of severe postoperative complications, especially after cardiac or trauma surgery. Limited data are available for noncardiac surgical patients. We therefore evaluated the association between storage duration of transfused erythrocytes and postoperative all-cause mortality among general surgery patients. METHODS Perioperative data corresponding to 63,319 adult, general surgery patients were obtained from our registry and merged with blood product data. Patients receiving solely leukocyte-reduced, allogeneic erythrocyte transfusions were included. Multivariable Cox proportional hazards regression was used to characterize the relationship between median erythrocyte storage duration and postoperative mortality rate, adjusting for characteristics plausibly influencing the storage duration of erythrocytes. RESULTS Of the 6,994 patients included in the final analysis, 23, 44, 11, 9, and 13% received 1, 2, 3, 4, and ≥5 erythrocyte units, respectively. The authors found no evidence that increasing median storage duration was associated with a difference in the risk of postoperative mortality (hazard ratio, 0.99 [0.94-1.04]; P = 0.64). Analyzing the mean storage duration of erythrocyte units as a function of year of transfusion, the authors demonstrate a relevant decrease in utilization of the oldest blood units, whereas young blood storage duration remains nearly unchanged. CONCLUSION The authors' study supports the recent literature in surgical and medical patients and underlines the importance of sufficiently powered randomized trials to finally resolve the erythrocyte storage duration debate.

Conventional pretransfusion testing uses hemagglutination to ensure donor-recipient compatibility for ABO/D status and recipient alloantibodies. While screening large numbers of donor units for multiple antigens by hemagglutination is impractical, novel methods of DNA analysis permit the rapid determination of an extended human erythrocyte antigen (xHEA) phenotype. A prospective observational study was conducted at four hospital transfusion services to test an alternative paradigm of identifying xHEA-typed units for patients in three cohorts by utilizing DNA analysis and a novel inventory management model.xHEA typing of recipient samples and donor units of known ABO/D status was performed by HEA analysis (BeadChip, BioArray Solutions). xHEA-typed units were assigned to pending transfusion requests using an inventory management system designed to simulate blood order processing. The fraction of requests fulfilled, or "fill fraction" (FF) was determined at four levels of matching stringency.For alloimmunized patients, all but one participating site observed an FF of more than 95% when matching for ABO, D, and known alloantibodies and an FF of more than 90% when additionally matching for C, c, E, e, and K; the site handling the most challenging requests still observed FFs of 62 and 51%, respectively. FF was found to correlate positively with the ratio of available donor units to units requested and negatively with the degree of recipient alloimmunization.This study demonstrates that substantial fill fractions can be achieved by selecting existing donor units for xHEA analysis and operating an inventory management system for efficient allocation of units to recipients.

True lung injury is among the leading causes of transfusion-related mortality. Pulmonary morbidity after cardiac surgery has been related to damaging effects of cardiopulmonary bypass and transfusion, but is confounded by cardiac-related events that may not reflect true lung injury. Thus, cardiac surgery poses unique challenges to criteria-specific diagnosis of transfusion-related acute lung injury (TRALI). Our objective was to determine the prevalence of pulmonary morbidity related to transfusion and whether TRALI consensus-criteria are applicable to cardiac surgery.A total of 16,847 patients underwent on-pump, coronary artery bypass grafting (CABG), valve, or CABG-valve surgery from September 1998 to February 1, 2006. We performed four propensity-score-matching analyses with logistic regression on probability of receiving a transfusion: total hospital red blood cell (RBC) and fresh frozen plasma (FFP) transfusion and intraoperative RBC and FFP transfusion. Outcomes included traditional cardiac-surgery-defined pulmonary morbidity and ratio of arterial partial pressure of oxygen to fractional inspired oxygen concentration (PaO(2)/FiO(2)), a criterion for TRALI.Patients receiving RBC transfusion had more risk-adjusted pulmonary complications: respiratory distress 4.8% vs 1.5%, p0.001; respiratory failure 2.2% vs 0.39%, p0.0001; longer intubation times, 9.9 hours vs 7.5 hours, p0.0001; acute respiratory distress syndrome, 0.64% vs 0.21%, p = 0.015; and reintubation, 5.6% vs 1.3%, p0.0001. The FFP was similarly related to more pulmonary complications after surgery. By TRALI criteria, the majority manifested "lung injury" (PaO(2)/FiO(2) ratio300) but unrelated to transfusion (65% vs 64%).Transfusion is associated with many measures of postoperative pulmonary morbidity. Yet the PaO(2)/FiO(2) ratio as important criterion of TRALI is unrelated to transfusion. Thus, due to the nature of cardiac surgery, application of consensus guided diagnosis of TRALI is problematic.

Introduction: The multidisciplinary nature of modern health care makes it susceptible to disruptions, waste and errors. These problems are potentially preventable by improving the systems, processes and environment of care, an approach described as quality improvement (QI). The need for resident education in QI is recognized by the Accreditation Council for Graduate Medical Education (ACGME), which requires competence in practice-based …

To detect miscollected (wrong blood in tube [WBIT]) samples, our institution requires a second independently drawn sample (check-type [CT]) on previously untyped, non-group O patients who are likely to require transfusion. During the 17-year period addressed by this report, 94 WBIT errors were detected: 57% by comparison with a historic blood type, 7% by the CT, and 35% by other means. The CT averted 5 potential ABO-incompatible transfusions. Our corrected WBIT error rate is 1 in 3,713 for verified samples tested between 2000 and 2003, the period for which actual number of CTs performed was available. The estimated rate of WBIT for the 17-year period is 1 in 2,262 samples. ABO-incompatible transfusions due to WBIT-type errors are avoided by comparison of current blood type results with a historic type, and the CT is an effective way to create a historic type.

Abstract 1178 Background: Effectively cryopreserving hematopietic peripheral blood progenitor cells (HPC(A)) until time of transplant is critical for successful autologous stem cell transplant. It is important to demonstrate long-term HPC(A) viability and recovery and also to identify patient characteristics that may influence this. We evaluated HPC(A) products cryopreserved over 16 year period. We analyzed potential correlations between total nucleated cell (TNC) and CD34+ recovery and viability and patient age, initial collection, and impact of stem cell mobilization regimen. Method: Samples were obtained from expired patients, chosen based on storage duration but randomly selected in regard to patient and product characteristics; 23 samples were obtained from 18 patients. Five patients had 2 samples each; for duplicate samples, data were averaged (collection dates and thaw dates were similar). All HPC(A) products were frozen in autologous plasma and 10% DMSO, then stored in liquid phase or vapor phase nitrogen. Products were uniformly thawed and washed to remove DMSO. Analysis included 7-Amino-actinomycin D viability, TNC and CD34+ cell counts and recovery. Some samples had post-thaw CD34+ cell counts that exceeded pre-thaw count; for these, the recovery was set to 100%. Spearman rank correlations were used to analyze association between the different parameters. Wilcoxon rank sum test and analysis of covariance were used to compare patient groups. Result: Median patient age at time of stem cell collection was 54 (range 2–75) years. A majority of patients had lymphoma (61%) or multiple myeloma (22%). Most (56%) were mobilized using G-CSF+VP16, 33% with G-CSF alone, and 11% other. Samples were cryopreserved for a median of 8 years (range 1–16). Median (range) for total CD34+ × 106 collected was 547 (43-5845). Median (range) for CD34+/kg × 106 was 8 (1-59). Median (range) count/bag for TNC × 108 was 144 (37-285) and for CD34+ × 106 was 105 (8-805). Median (range) recovery and viability were 85% (32-213%), and 70% (46-85%) respectively for TNC; and 97% (16-359%) and 80% (61-98%), respectively for CD34+ cells. Pre- and post- thaw TNC and CD34+ counts were both highly correlated (r=0.95, p Age did not significantly impact TNC or CD34+ recovery (r=-0.05, p=0.86, and r=-0.26, p=0.29, respectively); however there was suggestion of negative impact on viability (r=-0.45, p=0.06 and r=-0.42, p=0.08, respectively, figures 1a and 1b). Overall, there did not appear to be a correlation between the initial TNC count/bag or total CD34+ cell dose on recovery or viability (r=0.29, r=-0.22, r=0.18, r=-0.38, respectively; all p>0.12). However, when patients were stratified according to total collection >25×106 CD34+ cells/kg or ≤25 × 106 CD34+ cells/kg, there was better %CD34+ cell count recovery between groups (p = 0.07, median recovery 81% for 13 patients with ≤25 × 106 CD34+ cells/kg and 100% for 5 patients with >25×106 CD34+ cells/kg). For mobilization regimen, there was no significant difference in TNC recovery or viability (p = 0.19 and p=0.76, respectively) or CD34+ viability (p = 0.53), however there was suggestion that CD34+ recovery was greater with G-CSF+VP16 (p=0.06, see figure 2), independent of storage time. Conclusion: Products cryopreserved for 16 years retain acceptable recovery and viability. Unexpectedly, storage duration positively correlated with TNC recovery, and CD34+ cell recovery of >100% was noted in several samples. Reasons for this are unclear, but are likely related to changes in enumeration method or use of methods validated for counting fresh cells. Patient age was suggested to negatively impact post-thaw HPC(A) viability. Our data also suggested that the mobilization regimen or the CD34+ cell collection yield may affect the CD34+ cell recovery, possibly reflecting differences in graft characteristics. The number of patients included is relatively small and these findings warrant further studies for validation. Disclosures: No relevant conflicts of interest to declare.

Abstract 2151 Poster Board II-128 The number of CD34+ cells alone is used to determine the adequacy of mobilized pheresis products for autologous hematopoietic stem cell transplantation. The quantity of CD34+ cells infused predicts the speed of hematopoietic recovery following transplantation. To investigate the extent to which the number of days of pheresis required to collect the minimum number of CD34+ cells (i.e. 2 ×106 cells/kg) might influence the speed of hematopoietic recovery, we analyzed the speed of neutrophil and platelet recovery following autologous transplantation of 496 consecutive individuals transplanted for Hodgkin or non-Hodgkin lymphoma from 1998-2008. All had undergone mobilization using 2g/m2 of etoposide and 10μg/kg/day of G-CSF. Recovery for neutrophils was defined as PMN > 500 k/μl and for platelets >20,000 k/μl independent of transfusion. Recursive partitioning analysis (RPA) with a log-rank splitting method was used to identify cutpoints in days of pheresis that predict neutrophil or platelet engraftment. The cutpoints of Disclosures: No relevant conflicts of interest to declare.