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Blood Banking/Transfusion Medicine (BB/TM) specialists oversee all aspects of blood component transfusions and are often involved with apheresis, coagulation, and cellular therapy services as well. This study characterizes the BB/TM workforce to determine the scholarly productivity in the first 3 to 5 years after obtaining board certification and the impact of job type, job location, and academic rank on scholarly productivity. Academic productivity was assessed among individuals passing the American Board of Pathology BB/TM board exam between 2016 and 2018 using the National Institutes of Health (NIH) Office of Portfolio Analysis tool, iCite. One hundred and 28 BB/TM specialists were included in the analysis. The majority of BB/TM specialists work in academia, are located in the Great Lakes and Mid-Atlantic regions, and have a rank of Assistant Professor. Since passing the board exam, 76.5% (98/128) of BB/TM specialists have published papers, with 4.0 (IQR = 1-8) total number of published papers per individual, and 791 total papers amongst the group. The median publications per individual per year since passing boards is 0.9 (IQR = 0.2-2.3) the number of publications per year since passing boards for BB/TM specialists in academia is significantly higher compared to other jobs at 1.33 (IQR, 0.5-2.89, Kruskal-Wallis P = .03) per individual Assistant Professors and Associate Professors (1.3, IQR= 0.4-2.7 and 1.4, IQR = 0.6-3.3, Mann-Whitney test P.99). BB/TM specialists who passed the board exam between 2016 and 2018 are highly academically productive, especially those working in academia where publications are necessary for promotion. BB/TM physicians are an extensively trained and academically-minded group of practitioners.

The IL-3-pSTAT5 assay, a new, rapid, and standardized flow-cytometry-based assay may compensate for several limitations of the colony-forming unit (CFU) assay typically used for stem cell potency assessments of cord blood units (CBU). We performed an inter-laboratory evaluation of the performance of this new assay.This Biomedical Excellence for Safer Transfusion (BEST) Collaborative multicenter, international study included 15 participants from public cord blood banks (CBBs), CBB-supporting research laboratories, and stem cell laboratories. To perform the IL-3-pSTAT5 assay, participating centers received reagents, instructions, and 10 blind CBU samples, including eight normal samples and two samples exposed to a transient warming event. We measured inter-laboratory agreement qualitatively (proportion of correctly classified samples) and quantitatively (coefficient of variation [CV], correlation coefficients, receiver operating characteristics (ROC) curve, and intraclass correlation coefficient [ICC]).The qualitative agreement was 97.3% (i.e., 107/110; Fleiss' kappa = 0.835). The average CV on a per-sample basis was 11.57% among all samples, 8.99% among normal samples, and on a per-center basis was 9.42% among normal samples. In a correlation matrix that compared results across centers, the mean Pearson's correlation coefficient was 0.88 (standard deviation = 0.04). The ICC was 0.83 (95% confidence interval = 0.68-0.95). The area under the curve (AUC) from the ROC curve was 0.9974.Excellent qualitative and quantitative agreement was exhibited across laboratories. The IL-3-pSTAT5 assay may therefore be implemented in flow cytometry laboratories to rapidly and reliably provide standardized measures of stem cell potency in CBUs.

Background Entrustable professional activities (EPAs) are well-defined, executable, observable, and measurable activities that are performed by a trainee and can be performed independently as training progresses. The purpose of this study is to develop EPAs specific for the practice of apheresis medicine (AM). Methods Members of the American Society for Apheresis Graduate Medical Education subcommittee developed a list of 28 apheresis medical activities linked to Accreditation Council for Graduate Medical Education milestones and competencies in five areas: (a) consultation, (b) clinical care for therapeutic apheresis, (c) clinical care for donor collections, (d) test optimization, and (e) vascular access. Ten AM experts using a validated tool to measure the quality of the EPAs (QUEPA) evaluated these activities with use of a Likert scale. Per group consensus, an activity was considered acceptable for each domain if it had received an average score greater than 3.7, and it was rated 4 or 5 (agree or strongly agree) by at least 70% of experts. Results Of the 28 activities, 11 did not have acceptable QUEPA scores: 7 activities were rated as unobservable, 4 were rated unfocused, 2 were rated unrealistic and not generalizable, and 2 were rated as not addressing multiple competencies. Four activities had unacceptable scores in more than one domain. Subcommittee members edited these 11 activities over two review cycles to produce a final list of 26 activities. Conclusion A set of practical, focused, and observable EPAs in AM were systematically developed. These EPAs can be used to assess and support trainee performance in AM.

Red blood cell (RBC) transfusions are necessary to increase a patient's oxygen carrying capacity. The optimal transfusion trigger remains elusive, but a restrictive transfusion trigger of 7 g/dL has been shown in studies to reduce RBC transfusions without adversely affecting patient outcomes. Patient blood management programs have been shown effective at reducing RBC transfusions. Hemoglobin-based oxygen carriers and induced pluripotent stem cell derived RBCs are being developed to help mitigate RBC shortages and RBC transfusion limitations. Numerous challenges still exist that need to be overcome before they can have widespread clinical use.

Gene therapy will soon become the dominant modality for treating of sickle cell disease (SCD). Currently, three technologies are the most promising: expression of transgenic globin genes via a lentiviral vector, controlled mutation of the β-globin control cluster by transgenic CRISPR-based ribonucleoprotein, and suppression of BCL11a mRNA by shRNA. In this review, we discuss the mechanism of each technology and how they correct the SCD pathology at the molecular level. We conclude by discussing potential directions future therapy may take.

INTRODUCTION Obtaining vascular access (VA) is a critical part of the therapeutic apheresis (TA) treatment plan. Currently, there are no guidelines for VA decision-making and maintenance related to TA procedures. MATERIALS AND METHODS A 28-question survey to gather qualitative information regarding VA practices was distributed to the American Society for Apheresis (ASFA) 2018 Annual Meeting attendees and all ASFA members for voluntary participation. The descriptive analyses were reported as the number and frequency of responses for each question. RESULTS Total participation was 206 with 147 (71.4%) answering some or all 16 VA focused questions. The majority of respondents were nurses or physicians (89.0%) at sites providing ≥100 procedures. The most common TA procedures were plasma exchange, red cell exchange, and leukocytapheresis. The VA evaluation was predominantly performed by the TA service (80.3%, 118/147). The majority of TA physicians and/or providers do not insert (91.7%, 132/144) or remove (81.2%, 117/143) VA catheters. When an emergent TA procedure is needed, the majority of respondents felt

Background The COVID‐19 pandemic has placed additional stressors on physician lives. In this study, we report findings from a survey conducted among attending physician (AP) members of the American Society for Apheresis (ASFA) to elucidate the status of their well‐being during the COVID‐19 pandemic as well as resources provided or actions taken by their institutions and themselves personally to maintain or improve their well‐being. Study Design and Methods A 17‐question, voluntary, IRB‐approved survey regarding well‐being was distributed to the ASFA AP members between August 26, 2020 and September 16, 2020. The descriptive analyses were reported as number and frequency of respondents for each question. Non‐parametric chi‐square tests, ANOVA, and paired t‐tests were performed to determine differences in categorical variables, changes in well‐being scores, and compare time points, respectively. Results Based on the responses of 70 attending level physicians representing the United States (U.S., 53, 75.7%) and outside the U.S. (17, 24.3%), the following were observed: (1) COVID‐19 negatively affects the well‐being of a sub‐population of APs, (2) neither institutional nor individual measures to improve well‐being completely resolved the problem of decreased AP well‐being during the pandemic, and (3) personal actions may be superior to institutional resources. Conclusion There is a widespread decline in AP well‐being during the COVID‐19 pandemic that was not adequately improved by institutional or personal resources/actions taken. Institutions and physicians must work together to implement strategies including resources and actions that could further improve AP physician well‐being during a public health crisis.

The severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) has led to a major pandemic. While vaccine development moves forward, optimal treatment continues to be explored. Efforts include an ever‐expanding number of clinical trials along with newly proposed experimental and off‐label investigational therapies; one of which is therapeutic plasma exchange (TPE). There have been a number of publications on TPE use as adjunctive therapy for coronavirus disease 2019 (COVID‐19), but no prospective randomized controlled trials (RCTs) have been completed. This article critically appraises the current available evidence on TPE as a treatment modality for SARS‐CoV‐2 infection.

New York is at the epicenter of the coronavirus disease 2019 (COVID‐19) pandemic caused by the SARS‐CoV‐2 virus. Columbia University Irving Medical Center/NewYork‐Presbyterian Hospital (CUIMC/NYPH) had to make changes to its cellular therapy operations to ensure patient, donor, and staff safety and well‐being. In this article, we discuss the process changes we instituted for cellular therapy clinical care, collection, processing, and cryopreservation to cope with the rapidly evolving pandemic.

Introduction Red cell exchange (RCE) therapy is increasingly used to treat patients with acute or chronic manifestations of sickle cell disease (SCD). However, little is known regarding the most safe and effective practice parameters associated with this particular therapy. Methods A SCD subcommittee of members of the American Society for Apheresis (ASFA) developed a 122-question survey and administered it via email to other ASFA members. The survey inquired about clinical indications for treatment, practice patterns, and transfusion policies for RCE when used for patients with SCD. Results Ninety-nine distinct institutions completed the survey. Twenty-one (21%) were from outside of the US. Twenty-two (22%) provided chronic transfusion therapy to >10 patients, and both adult (25%) and pediatric-focused services (20%) were represented. Common acute indications for RCE included acute chest syndrome, acute ischemic stroke, and pre-surgical prophylaxis. Common chronic indications included primary stroke prophylaxis, secondary stroke prophylaxis, and recurrent acute chest syndrome. Respondents most commonly set a post-RCE treatment target of 30% for the hematocrit and hemoglobin S levels, regardless of the therapeutic indication. Units for RCE were phenotypically matched in 95% of cases. About 40% of respondents reported using isovolemic hemodilution. Conclusions This survey solicited the current practice variations in RCE from a diverse range of practice sites. Many sites reported similar practice patterns and challenges but some variations emerged. To our knowledge, this survey represents the largest and most in-depth investigation of the use of RCE for patients with SCD, and could inform future studies in the field.

To ensure optimal clinical outcomes for patients while retaining adequate protection for donors, the National Marrow Donor Program developed guidelines specifying that up to 20 mL/kg of bone marrow can be harvested from donors. These guidelines, originally developed for unrelated adult donors, are followed in children as well. We studied the impact of granulocyte colony-stimulating factor (G-CSF) priming on the cellular composition of harvested bone marrow, sought to develop an algorithm to optimize bone marrow harvest volume from pediatric matched sibling donors, and studied the impact of CD34+ cell dose on clinical outcomes. We analyzed data from 92 bone marrow harvests and clinical outcomes for 69 sibling recipient-donor duos, The mean age of recipients was 9.85 ± 5.90 years, and that of donors was 11.85 ± 6.36 years. G-CSF priming was not associated with higher yield of CD34+ cells/µL. The median CD34+ cell count obtained from donors was 700 cells/µL (range, 400-1700 cells/µL) in donors age 12 years (P

Purpose of review Acquired thrombotic thrombocytopenic purpura is an immune-mediated thrombotic microangiopathy caused by antibodies to ADAMTS13 (A Disintegrin And Metalloproteinase with a ThromboSpondin type 1 motif, member 13). Standard treatment with therapeutic plasma exchange and immunosuppression with steroids results in high remission and low mortality rates. However, a number of patients remain refractory to frontline therapy and/or experience multiple relapses. This study reviews emerging therapies for thrombotic thrombocytopenic purpura. Recent findings Studies indicate that reducing anti-ADAMTS13 antibody levels through B-cell depletion or proteasome inhibition is effective for the management of refractory disease. Preliminary reports examining anti-CD20 therapy for the treatment of initial disease or as maintenance therapy for seropositive patients suggest the addition of immunosuppression in other disease phases may delay relapse. Exciting developments in targeted therapies to von Willebrand Factor and recombinant ADAMTS13 hold promise for transforming disease management. Summary Approximately half of patients diagnosed with acquired thrombotic thrombocytopenic purpura experience refractory and/or relapsing disease. For these patients, a hematologic remission may be an insufficient therapeutic goal. With recent developments, it is now possible to envision a multifaceted approach targeting disease mechanisms that may dramatically improve outcomes for this otherwise debilitating disease.

Patients with the hemoglobinopathies, sickle cell disease (SCD), and thalassemia may require lifelong red blood cell (RBC) transfusion support. In SCD, deoxygenated sickle hemoglobin (Hb) forms rigid polymers within the erythrocyte, leading to vasoocclusion, intravascular hemolysis, and subsequent anemia. Patients suffer acute and chronic organ damage over time. RBC transfusions improve oxygen delivery and suppress erythropoiesis, and reduce vasoocclusion, hemolysis, and blood viscosity by decreasing the fraction of HbS-containing RBCs. The type of transfusion utilized, simple or exchange, depends on clinical indication and feasibility. Thalassemia results from mutations in the β-globin (β-thalassemia) or α-globin (α-thalassemia) genes that reduce synthesis of that globin, leading to ineffective erythropoiesis, iron hyperabsorption, RBC membrane damage, and extravascular hemolysis. Transfusions increase oxygen delivery and suppress erythropoiesis, thereby decreasing extramedullary hematopoiesis, hypersplenism, erythroid bone marrow expansion, bone fractures/osteopenia, and gastrointestinal absorption of iron. Transfusion may result in alloimmunization and iron overload.

Beta hemoglobinopathies such as sickle cell disease (SCD) and β-thalassemia (BT) are the most common monogenic diseases worldwide. Both diseases are associated with significant morbidity and mortality. Because patients require lifelong follow-up and care, it also poses a serious burden in health services. Blood transfusions and/or drug therapy ameliorate the signs and symptoms of the disorders but are not curative. Allogeneic hematopoietic cell transplantation (HCT) is currently the only cure but it has several limitations including the paucity of human leukocyte antigen-matched related donors and a high risk of adverse events. Recent advances in hematopoietic stem cell based-gene therapy has made autologous HCT (auto-HCT) a reality. Clinical trials are underway using different gene transfer vectors and cassettes. Data obtained so far with a short-term follow-up has been very encouraging. Patients with SCD engrafted, had sustained production of the transgene and a decreased number of vaso-occlusive crises. Patients with BT were able to decrease the amount of transfusions required or stop transfusions all together. Adverse events observed were mostly associated with the myeloablative conditioning regimen. Long term data on gene persistence and toxicities are still needed. This review focuses on the current state of auto-HCT with gene therapy for SCD and BT. Current clinical trials and their outcome results are summarized.

Background In sickle cell disease (SCD), red blood cells (RBCs) containing hemoglobin S can be denser than RBCs containing wild-type hemoglobin, especially when dehydrated. We hypothesize that targeting denser RBCs during red blood cell (RBC) exchange for SCD could result in more efficient removal of dehydrated, sickled RBCs and preservation of non-sickled RBCs. Study design and methods Waste products from RBC exchanges for SCD were used as “simulated patients”. One RBC volume was exchanged using ABO-compatible blood. The apheresis instrument was programmed to exchange the entire RBC layer by indicating the hematocrit (control), or the bottom half by indicating the hematocrit was half the hematocrit (experimental), with or without subsequent transfusion. Hemoglobin S levels, and complete blood counts were measured. Results Hemoglobin S levels were lower after the modified versus control RBC exchange (post-RBC exchange mean 4.96% and 11.27%); total hemoglobin S amounts were also lower (mean 19.27 and 58.29 mL of RBCs). Mean RBC density decreased after the modified RBC exchange by 8.86%. Hematocrit decreased in the modified RBC exchange by 36.37%, with partial correction by direct transfusion following a truncated RBC exchange. Conclusions Targeting denser RBCs in RBC exchange enhanced hemoglobin S removal and decreased RBC density. Further development of this ex vivo model could potentially allow for: 1) improved reduction in hemoglobin S levels (allowing for longer periods between RBC exchange or maintained lower levels), or 2) achievement of previous goal hemoglobin S levels with fewer donor units (reducing alloimmunization risk and improving blood utilization).

The Choosing Wisely campaign has stimulated clinicians to think about the appropriateness of various tests and procedures, compelling physicians to make smarter, safer and more effective choices for high quality patient care and to reduce healthcare cost. The American Society for Apheresis (ASFA) strives to advance apheresis medicine through education, evidence-based practice, research and advocacy. To complement these shared missions, ASFA created a working group, consisting of representatives from the various ASFA committees, to produce recommendations for apheresis medicine that reflect the Choosing Wisely guiding principles. A diverse group of ASFA physician and allied health members reviewed, rated and ranked 9 original draft proposals. Additional revisions and refinements were made prior to external review and adoption of five final recommendations by the ASFA Board of Directors. The ASFA Choosing Wisely recommendations encourage apheresis practitioners, patients and donors to discuss and prioritize best clinical practices that avoid harm and waste while optimizing clinical benefit.

The standard therapy for patients with chronic pancreatitis (CP) and severe abdominal pain is total pancreatectomy (TP) followed by islet autotransplantation (IAT) to prevent the development of brittle diabetes. In adult patients, narcotic independence is achieved in up to 73% of patients 1 to 5 years after transplantation whereas insulin independence is achieved in up to 40% of patients 1 to 2 years after transplantation. Pediatric patients have shown similar outcomes for narcotic independence (up to 79%) but better outcomes for insulin independence (up to 56% 1 year after transplantation). The quality of life of both adult and pediatric patients improved significantly after TP-IAT using the Medical Outcomes Study SF-36 survey. IAT after pancreatectomy is also performed for patients with benign and malignant disease of the pancreas. The limited studies in this patient population suggest that IAT may be potentially beneficial for carefully selected patients when sufficient numbers of islet cells can be isolated. Further studies involving a larger number of patients are needed to determine the risks and benefits of IAT in patients with malignancy. The feasibility of IAT depends on the availability of a laboratory that can isolate the pancreatic islet cells. An on-site laboratory is the traditional model; however, remote processing of pancreatic islets has been reported to result in successful outcomes. This review discusses the outcomes of adult and pediatric autologous pancreatic islet cell transplantation for CP and pancreatic tumors as well as laboratory processing of pancreatic islet cells.

The thrombotic microangiopathy (TMA) Registry Network of North America (TRNA) is a collaborative network organized for the purpose of developing a multi-institutional registry and network to conduct clinical studies in a rare patient population. The TRNA was founded in 2013 by four academic medical centers (Columbia University Medical Center, Duke University Medical Center, University of Alabama at Birmingham, and University of Pennsylvania) to develop a national and demographically diverse dataset of patients with TMA. A clinical database was developed by network members using REDCap (Research Electronic Data Capture), a web-based database developed for clinical research. To facilitate rapid Institutional Review Board (IRB) approval at multiple sites, the TRNA utilized IRBshare, a streamlined IRB process to allow patient recruitment and enrollment into the TMA registry. This article reviews the process used to establish the TRNA network and discusses the significance of the first multi-institutional clinical apheresis network developed in the United States. J. Clin. Apheresis 31:448-453, 2016. © 2015 Wiley Periodicals, Inc.

Cellular therapy products are highly regulated in the United States both at the state and federal levels. The Food and Drug Administration (FDA) and Centers for Medicare and Medicaid Services (CMS) are the main governing bodies that provide federal oversight. State health departments may also have local regulations for processing laboratories. Individuals and institutions involved in cellular therapy processing must be familiar with the requirements of these agencies. Cellular therapy processing laboratories may also be accredited by organizations such as the Foundation for the Accreditation of Cellular Therapy (FACT), Joint Accreditation Committee-ISCT and EBMT (JACIE), or American Association of Blood Banks (AABB). While regulations have the force of law, accreditation standards are not legally binding. Accreditation allows an organization or institution to be officially recognized as being highly qualified to perform cellular therapy activities and to have a high quality of operations. The federal government has granted deemed status to certain accreditation organizations that have standards and a survey process that meets or exceeds Medicare and Medicaid requirements. Laboratories that achieve accreditation through an organization’s “deemed status” survey are determined to meet or exceed federal requirements. In this chapter we discuss the regulations and accreditation steps of cellular processing laboratories by various organizations.

Background Heparin-induced thrombocytopenia (HIT) develops as a result of platelet (PLT) activation by anti-platelet factor 4 (PF4)/heparin complex antibodies. Despite repeated exposure to heparin, patients undergoing chronic intermittent hemodialysis (HD) rarely develop HIT. We investigated the possibility that HD decreases/removes PF4 from PLT surfaces and/or plasma, thereby disfavoring immune complex formation as a mechanism of protection against HIT. Materials and methods We enrolled 20 patients undergoing chronic HD at the Penn Presbyterian Medical Center. Blood samples were drawn before, during and after treatment in the presence and absence of heparin. PF4, anti-PF4/heparin antibody, heparin, and P-selectin levels were measured. Results No patients demonstrated clinical symptoms of HIT. PLT surface PF4 levels decreased and plasma PF4 levels increased concurrently with the increase in plasma heparin concentration. In the absence of heparin, PLT surface and plasma PF4 levels were unchanged. Anti-PF4/heparin antibodies, which were non-functional by the serotonin release assay, were detectable in 8 patients. PLT surface P-selectin levels did not change during treatment. Conclusions Removal of PLT surface and/or plasma PF4 as a mechanism of protection against HIT in patients undergoing HD is not supported by the results of our study, although the transient decrease in PLT surface PF4 in the presence of large amounts of heparin remains a candidate mechanism. The small sample size, single type of dialyzer membrane, and early sampling time points may have led to the inability to detect changes in PF4 levels. Future studies should explore other potential protective mechanisms.

Prior to the introduction of recombinant human erythropoietin (EPO), red blood cell (RBC) transfusions were frequently required when iron and anabolic steroids failed to improve the clinical symptoms of anemia associated with hemoglobin (Hb) levels that were commonly less than 7 g/dl. After the approval of EPO in the United States in 1989, the Hb levels of patients on hemodialysis dramatically improved and the need for RBC transfusions decreased significantly. The need for RBC transfusion remains for patients who require an immediate increase in their RBC mass due to symptomatic anemia and is likely to increase due to changes in the management of anemia in dialysis patients resulting from clinical trials data, regulatory changes, and new reimbursement policies for EPO. The safety of the blood supply has greatly improved over the last few decades, and the risk of transfusion-transmitted diseases has now been dramatically reduced. Noninfectious complications of transfusion currently cause the majority of morbidity and mortality associated with transfusion in the United States. Transfusion also brings a risk of alloimmunization, a particular concern for dialysis patients waiting for kidney transplantation. Knowledge of the risks of RBC transfusions will help clinicians better assess the risks and benefits of transfusing patients with ESRD. This article reviews the modern day infectious and noninfectious risks of allogeneic RBC transfusions.

BACKGROUND: Heparin-induced thrombocytopenia and thrombosis (HITT) is characterized by thrombocytopenia due to the formation of antibodies against heparin : platelet factor 4 (PF4) complexes. Despite the exposure to heparin during treatment and predisposition of patients with atherosclerosis to HITT, HITT in patients undergoing low-density lipoprotein (LDL) apheresis is rare. We investigated the possibility that LDL apheresis decreases PF4 on platelet (PLT) surfaces and/or plasma HITT antibody levels, either of which would disfavor HITT. STUDY DESIGN AND METHODS: We enrolled 25 patients undergoing LDL apheresis at the Hospital of the University of Pennsylvania. Blood samples were drawn before and after treatment. Plasma samples were drawn proximal and distal to the LA-15 treatment column. PF4, HITT antibodies, heparin levels, and P-selectin were measured. RESULTS: No patient had clinical symptoms of HITT. The LA-15 column was found to efficiently remove PF4. PF4 levels in peripheral blood plasma did not change significantly after LDL apheresis. However, PLT surface PF4 significantly decreased after treatment. HITT antibodies were found in only two patients and were nonfunctional. PLT surface P-selectin did not change during treatment. CONCLUSIONS: We have demonstrated that LDL apheresis via dextran sulfate absorption removes plasma PF4 and reduces the amount of PF4 on the surface of circulating PLTs. Reduced surface PF4 may decrease antibody formation and/or recognition by HITT antibodies. These data provide a potential explanation for the near lack of HITT in hypercholesterolemic patients undergoing LDL apheresis. They also suggest the possibility that LDL apheresis using dextran sulfate adsorption may have therapeutic value in the treatment of HITT.

Plerixafor (Mozobil, AMD3100) with granulocyte-colony stimulating factor (G-CSF) mobilizes more CD34+ cells/kg compared to G-CSF alone. Given that plerixafor enhances mobilization of multiple white blood cell lineages, we determined if more storage space is required for products collected from patients mobilized with plerixafor.A review of the medical records of 15 patients mobilized with chemotherapy and G-CSF (control) and 14 patients mobilized with plerixafor plus G-CSF (plerixafor) was performed. Data on demographics, baseline characteristics, CD34+ cells/kg, total nucleated cells, total mononuclear cells, total apheresis sessions, and total bags for storage were collected. Mean values were determined and compared using Student's t-test.We found that the proportion of CD34+ cells among total nucleated cells was less in the plerixafor group compared to the control group (P = 0.0427). More nucleated cells (10.7 x 10(10) vs. 7.1 x 10(10), P =0.0452) and mononuclear cells (9.7 x 10(10) vs. 5.9 x 10(10), P = 0.0059) were mobilized with plerixafor plus G-CSF. However, there was no significant difference in CD34+ cells/kg, total CD34+ cells or the proportion of mononuclear cells among total nucleated cells between the two groups. More storage bags were required for the plerixafor group compared to the control group (15 vs. 9, P = 0.0299).Mobilization with plerixafor plus G-CSF resulted in a smaller proportion of CD34+ cells collected and a greater number of storage bags. An increase in the number of bags required for stem cell storage may be logistically problematic and will also lead to increased costs for storage of stem cells.

We investigated the possibility of using a pharmacologic agent to modulate viral gene expression in order to target radiotherapy to tumor tissue. In a murine xenograft model, we had previously shown targeting of [125I]2'-fluoro-2'-deoxy-beta-D-5-iodouracilarabinofuranoside ([125I]FIAU) to tumors engineered to express the Epstein-Barr virus (EBV)-thymidine kinase (TK). Here we extend those results to targeting of a therapeutic radiopharmaceutical [131I]FIAU to slow or stop tumor growth or to achieve tumor regression. These outcomes were achieved in xenografts with tumors that constitutively expressed the EBV-TK, as well as with naturally-infected EBV tumor cell lines. Burkitt's lymphoma and gastric carcinoma required activation of viral gene expression by pretreatment with bortezomib. Marked changes in tumor growth could also be achieved in naturally-infected Kaposi's sarcoma herpesvirus (KSHV) tumors following bortezomib activation. Bortezomib-induced enzyme-targeted radiation (BETR) therapy illustrates the possibility of pharmacologically modulating tumor gene expression to effect targeted radiotherapy.

Purpose: EBV and other herpesviruses are associated with a variety of malignancies. The EBV thymidine kinase (TK) is either not expressed or is expressed at very low levels in EBV-associated tumors. However, EBV-TK expression can be induced in vitro with several chemotherapeutic agents that promote viral lytic induction. The goal of this study is to image EBV-associated tumors by induction of viral TK expression with radiolabeled 2′-fluoro-2′-deoxy-β-d-5-iodouracil-arabinofuranoside (FIAU). Experimental Design: Immunoblot, luciferase reporter assay, and in vitro assay with [14C]FIAU were used to show the effects of bortezomib on the induction of lytic gene expression of EBV-associated tumor cells. In vivo imaging and ex vivo biodistribution studies with [125I]FIAU on EBV-associated tumors were done to visualize and confirm, respectively, the EBV(+) tumor–specific effects of bortezomib. Results: In vitro assays with [14C]FIAU and ex vivo biodistribution studies with [125I]FIAU showed that uptake and retention of radiolabeled FIAU was specific for cells that express EBV-TK. Planar gamma imaging of EBV(+) Burkitt's lymphoma xenografts in severe combined immunodeficient mice showed [125I]FIAU localization within tumors following treatment with bortezomib. Conclusions: These results indicate the feasibility of imaging chemotherapy-mediated viral lytic induction by radiopharmaceutical-based techniques such as single photon emission computed tomography and positron emission tomography.

The thrombotic microangiopathy (TMA) Registry Network of North America (TRNA) is a collaborative network organized for the purpose of developing a multi-institutional registry and network to conduct clinical studies in a rare patient population. The TRNA was founded in 2013 by four academic medical centers (Columbia University Medical Center, Duke University Medical Center, University of Alabama at Birmingham, and University of Pennsylvania) to develop a national and demographically diverse dataset of patients with TMA. A clinical database was developed by network members using REDCap (Research Electronic Data Capture), a web-based database developed for clinical research. To facilitate rapid Institutional Review Board (IRB) approval at multiple sites, the TRNA utilized IRBshare, a streamlined IRB process to allow patient recruitment and enrollment into the TMA registry. This article reviews the process used to establish the TRNA network and discusses the significance of the first multi-institutional clinical apheresis network developed in the United States. J. Clin. Apheresis 31:448-453, 2016. © 2015 Wiley Periodicals, Inc.

Context: Formal training in pediatric transfusion medicine is often centered on education of Clinical Pathology and Hematology/Oncology Fellows. The Children's Hospital of Philadelphia (CHOP) accepts nine fellows annually into a Pediatric Anesthesiology and Critical Care Medicine (PACCM) Fellowship Training Program. Training requirements include the appropriate ordering and utilization of blood products for pediatric patients, which many fellows have limited prior experience. Objective: To design, implement, and review a teaching curriculum for PACCM Fellows to introduce these physician trainees to the unique features of pediatric TM and hospital specific policies. Design: Starting in 2006, two fellows per session were assigned a full day in the blood bank. The schedule included "hands-on" learning and lectures. Each fellow received lecture handouts and TM literature. They were asked to submit a pre- and post-test, an evaluation form and give oral feedback. Additional lectures were given during morning conferences as part of their overall educational training during their fellowship. Results: Twenty-eight fellows have completed this rotation to date of this curriculum review period. Most fellows demonstrated knowledge of the definition of clinically significant antibodies and proper labeling of blood samples. Fewer fellows demonstrated knowledge of CHOP specific policies prior to the rotation. Twenty-three written evaluations with ratings of outstanding to good were received. As a result of the teaching curriculum, there is less miscommunication, fewer customer complaints and occurrence reports (safety net reports) documented involving TM and PACCM departments. There has also been a steady overall improvement in client satisfaction. Conclusion: We report the development of a pediatric TM curriculum designed for anesthesiology fellows. The curriculum will continue to evolve as additional feedback is received. We will continue to monitor the curriculum in terms of an improvement in pre and post testing results, overall physician satisfaction and safety net reports.

The identity of the cells responsible for the initiation and maintenance of multiple myeloma (MM) remains unclear largely because of the difficulty growing MM cells in vitro and in vivo. MM cell lines and clinical specimens are characterized by malignant plasma cells that express the cell surface antigen syndecan-1 (CD138); however, CD138 expression is limited to terminally differentiated plasma cells during B-cell development. Moreover, circulating B cells that are clonally related to MM plasma cells have been reported in some patients with MM. We found that human MM cell lines contained small (< 5%) subpopulations that lacked CD138 expression and had greater clonogenic potential in vitro than corresponding CD138+ plasma cells. CD138- cells from clinical MM samples were similarly clonogenic both in vitro and in nonobese diabetic/severe combined immunodeficiency (NOD/SCID) mice, whereas CD138+ cells were not. Furthermore, CD138- cells from both cell lines and clinical samples phenotypically resembled postgerminal center B cells, and their clonogenic growth was inhibited by the anti-CD20 monoclonal antibody rituximab. These data suggest that MM “stem cells” are CD138- B cells with the ability to replicate and subsequently differentiate into malignant CD138+ plasma cells.

The presence of Epstein-Barr virus (EBV) in the tumor cells of some EBV-associated malignancies may facilitate selective killing of these tumor cells. We show that treatment of an EBV + Burkitt's lymphoma cell line with 5-azacytidine led to a dose-dependent induction of EBV lytic antigen expression, including expression of the viral thymidine kinase (TK) and phosphotransferase (PT). Azacytidine treatment for 24 h modestly sensitized the cell line to all nucleosides tested. To better characterize EBV TK with regard to various nucleoside analogues, we expressed EBV TK in stable cell clones. Two EBV TK-expressing clones were moderately sensitive to high doses of acyclovir and penciclovir (PCV) (62.5 to 500 μM) and to lower doses of ganciclovir (GCV) and bromovinyldeoxyuridine (BVdU) (10 to 100 μM) compared to a control clone and were shown to phosphorylate GCV. Similar experiments in a transient overexpression system showed more killing of cells transfected with the EBV TK expression vector than of cells transfected with the control mutant vector (50 μM GCV for 4 days). A putative PT was also studied in the transient transfection system and appeared similar to the TK in phosphorylating GCV and conferring sensitivity to GCV, but not in BVdU- or PCV-mediated cell killing. Induction of EBV kinases in combination with agents such as GCV merits further evaluation as an alternative strategy to gene therapy for selective killing of EBV-infected cells.

Induced pluripotent stem cells (iPSCs) are adult cells that have been genetically reprogrammed to an embryonic stem cell (ESC)–like state by being forced to express genes such as Oct4 , Sox2 , c-Myc , and Klf4 . iPSCs have been made from skin cells, immune cells, and other stem cells, such as mesenchymal stem cells and mobilized CD34+ hematopoietic stem cells (HSCs). However, iPSCs have not been made from nonmobilized CD34+ HSCs in the peripheral blood until now. Merling et al. derived iPSCs from a small volume of fresh or cryopreserved peripheral blood by reprogramming with an excisable loxP-flanked polycistronic lentiviral or nonintegrating Sendai viral vector. The loxP-flanked lentiviral vector resulted in 1 to 10 iPSC colonies from 20 mL of blood that were almost completely (>95%) reprogrammed. The Sendai viral vector gave variable colony yields (6 to >500) that were variably reprogrammed (10 to 80%). These iPSCs were capable of differentiating into all three germ layers in vitro and in vivo in teratoma assays. After excision of the loxP vectors by use of a transiently expressed Cre recombinase, the iPSCs retained the pluripotency markers, capacity for three germ layer formations, and their sample identity and origin. They also exhibited a normal karyotype and similar DNA methylation profiles to reference human ESC lines. Importantly, Merling and colleagues found that these iPSCs were not derived from lymphocytes or monocytes in the blood because they do not have the characteristic markers of these cells. The authors described an efficient method of generating transgene-free iPSCs from nonmobilized CD34+ HSCs in peripheral human blood using two different viral vector systems. HSCs are attractive targets for iPSC reprogramming because they may maintain greater genomic stability than that of mature cells and may be predisposed to redifferentiate to HSCs via epigenetic memory, which would be a useful alternative source of stem cells for treating leukemias and lymphomas. Furthermore, the small number of CD34+ HSCs needed to use this method is an advantage over other methods that require mobilization to obtain a larger number of CD34+ HSCs. R. Merling et al. , Transgene-free iPSCs generated from small volume peripheral blood non-mobilized CD34+ cells. Blood , published online 5 February 2013 (10.1182/blood-2012-03-420273). [[Abstract]][1] [1]: http://www.ncbi.nlm.nih.gov/pubmed/23386128?dopt

The introduction of plerixafor as a peripheral blood stem cell mobilization agent has allowed more patients with multiple myeloma, non-Hodgkin's lymphoma, and Hodgkin's disease to mobilize sufficient hematopoietic progenitor cells (HPCs) to proceed to autologous transplantation. Because of the high cost of plerixafor, it is not routinely used in all patients undergoing HPC mobilization. If cost were not an issue, an argument could be made that plerixafor could be added to every mobilization regimen, but cost is an issue so in an attempt to be more cost-effective, many centers have limited plerixafor use to patients who have failed or who are predicted to fail collection of adequate numbers of cells by other methods. Additionally, plerixafor is now under investigation both for HPC collection of healthy donors for allogeneic stem cell transplantation and as an adjunct therapy (i.e., chemosensitizing agent) for acute leukemias. This article briefly reviews the role of plerixafor in autologous and allogeneic transplantation as well as its emerging role in the treatment of acute leukemias. Emphasis is placed on the choice of appropriate patients for plerixafor use to assure an adequate stem cell yield while maximizing the cost effectiveness of using plerixafor. The role of prophylactic collections and future areas of research are also presented.

Signal transducer and activator of transcription 3 (STAT3), a transcription factor present in both malignant and nonmalignant tumor–associated cells, is critical for the survival of many types of blood cancers. Development of a STAT3-specific inhibitor is a promising therapeutic approach for the treatment of hematologic malignancies but has been difficult to achieve so far. A recently reported strategy promises to overcome these difficulties by targeting Toll-like receptor 9 (TLR9), a pathogen-recognition receptor found on immune cells, for cell-specific delivery of small interfering RNA (siRNA) against STAT3. To do this, the authors coupled their siRNA with CpG oligonucleotides, the natural ligand of TLR9, producing conjugates called CpG(A)- STAT3 and CpG(B)- STAT3 siRNA (the A type normally stimulates interferon production, whereas the B type activates B cells). Zhang et al. demonstrated in a mouse model of B cell lymphoma that CpG(B)- STAT3 siRNA treatment combined with local radiotherapy can prevent the growth of TLR9-positive lymphomas and provide long-term protective immunity against the primary cancer. They also showed that human cell–specific CpG(A)- STAT3 siRNA was quickly and efficiently internalized by cultured dendritic cells and primary B cells, but not by monocytes, which express almost undetectable levels of TLR9. Once inside the cells, the siRNA activated TLR9 and reduced STAT3 expression, without any evidence of toxic side effects. The inhibition of STAT3 mRNA expression, however, was transient and faded after prolonged cell culture. In vivo experiments in immunodeficient mice bearing subcutaneous grafts of TLR9-positive human leukemia showed that CpG(A)- STAT3­ siRNA reduced STAT3 protein expression and was directly cytotoxic to the tumors. CpG(A)-siRNA targeting BCL-XL (another protein that promotes tumor survival) had a similar effect. Aside from its tumoricidal effects, CpG(A)- STAT3 siRNA also activated plasmacytoid dendritic cells and increased tumor infiltration by innate immune cells such as neutrophils, which could contribute to the overall antitumor effect. In summary, Zhang and coauthors developed a promising method of using RNA interference to decrease the survival of TLR9-positive cancer cells by attacking them from within, while simultaneously activating human dendritic cells in the tumor microenvironment to restore antitumor immunity. Further studies are needed to optimize the serum stability and circulatory half-life of the new siRNA conjugates before this Trojan horse approach can be used to treat hematologic malignancies. Q. Zhang et al. , TLR9-mediated siRNA delivery for targeting of normal and malignant human hematopoietic cells in vivo. Blood , published online 3 January 2013 (10.1182/blood-2012-07-442590). [[Abstract]][1] [1]: http://bloodjournal.hematologylibrary.org/content/early/2013/01/03/blood-2012-07-442590.abstract