- Email: [email protected]
International trends in transfusion therapy 2011
Transfusion and Apheresis Science 46 (2012) 5–6
Contents lists available at SciVerse ScienceDirect
Transfusion and Apheresis Science journal homepage: www.elsevier.com/locate/transci
International trends in transfusion therapyI Names and places Names, and word choice, can tell us something about trends. In 2004, I was invited to Sapporo from Sacramento, California to speak at the 52rd annual meeting of the Japan Society of Blood Transfusion (JSBT). Returning in 2007 to speak at the 55th annual meeting in Nagoya, I was a guest of the newly renamed Japan Society of Transfusion Medicine and Cell Therapy (JSTMCT). About the same time, the American Association of Blood Banks stopped using its full name, and began to identify itself simply as AABB, with the slogan, ‘‘Advancing Transfusion and Cellular Therapies Worldwide.’’ Community-based donor recruitment and laboratory-based blood banking are still very much a part of our specialty, but a renewed focus on the patient is emerging. In English, blood transfusion seems to be about a product, whereas transfusion medicine is clearly about medical care of patients. Transfusion has always been a form of cell therapy, but modern cell therapy has expanded greatly beyond the transfusion of cellular products with finite in vitro and in vivo life spans. Progenitor cells, whether harvested from bone marrow or collected by apheresis from peripheral blood, are intended to become an integral and persistent part of a patient’s physiology after infusion. Considering that unintended persistence and proliferation of donor white cells is associated with transfusion-associated graft-versus-host disease (TA-GVHD), any permanent effect of what we give to patients should weigh heavily on the minds of professionals involved in the collection, testing, preparation, and infusion of such products.
Names and faces The meetings in 2004 and 2007 were memorable for bringing me face-to-face with famous names in transfusion medicine, including Dr. Hisami Ikeda, convenor of the 52rd meeting, Professor Shigeru Takamoto, convenor of the 55th meeting, and Professor Hitoshi Ohto, president of JSTMCT, 2007-2011. Internationally published manuscripts from Professor Ohto and colleagues, concerning transfusionI
Published in Japanese by the Medical & Test Journal, 2011-08-01, p3.
doi:10.1016/j.transci.2011.11.008
associated graft-versus-host disease, were essential reading when I trained at the Mayo Clinic [1–3]. Even today, a 1993 manuscript by Yasuda et al., published in the Fukushima Journal of Medical Science, is cited internationally [4]. It may be impolite to call attention to these manuscripts, because I now have the privilege of working at Fukushima Medical University with Professor Ohto, Mr. Yasuda, and a delightful cohort of other diligent and innovative colleagues. Independence and interdependance I joined Fukushima Medical University in 2008, when our group was still a division. In April, 2010, we became a full department. This, too, reflects an international trend in transfusion medicine. Early hospital-based blood banks and transfusion services were often subordinated under departments of anesthesia, pathology, or surgery. I believe the trend will continue, in which transfusion services will be full departments, administratively independent of other specialties, but certainly cooperative with everyone involved in patient care. We are specialists, but patients are special In America, doctors who sub-specialize in transfusion medicine are most often those who have already specialized in pathology or laboratory medicine. Thus, the American Board of Pathology is responsible for examining and credentialing transfusion medicine sub-specialists. My training and credentialing follows this pattern. I moved from Sacramento, California to Brisbane, Queensland in 2004. In Australia I was surprised to find that transfusion sub-specialists came mostly from the ranks of hematologists rather than pathologists. Here in Japan, a diversity of specialists work in transfusion medicine. This seems to be a good thing. We, as caregivers, may be specially trained in some branch of internal medicine, surgery, nursing, or laboratory technology, but modern transfusion therapy is not about us. It is about the patient. Another important trend in this regard is that more and more specialists concern themselves with patients who refuse blood transfusion. Japan has the distinction of developing and publishing national guidelines
6
K.E. Nollet / Transfusion and Apheresis Science 46 (2012) 5–6
for the care of such patients [5]. These guidelines are endorsed by the Japan Society of Transfusion Medicine and Cell Therapy, the Japanese Society of Anesthesiologists, the Japan Pediatric Society, the Japan Society of Obstetrics and Gynecology, and the Japan Surgical Society. The historically common religious refusal of blood transfusion is being reframed in modern times as part of a broader concept, conscientious objection in patient blood management [5,6]. Once again, word choice is indicative of important trends. Risk reduction Preventing transfusion-transmitted disease remains a high priority. Japanese conference speakers still mention the case of US Ambassador Edwin O. Reischauer, who contracted hepatitis after a transfusion in 1964. Ambassador Reischauer himself was grateful for the live-saving transfusion, and spoke of feeling even closer to the Japanese people after having Japanese blood in the veins. In modern times, nucleic acid testing has all but eliminated the risk of contracting hepatitis B or C, and HIV, from blood transfusion. Human mobility and climate change have shifted concern to other agents: West Nile virus came to North America in 1999, prompting the rapid introduction of new screening protocols. Chagas disease, caused by Trypanosoma cruzi, is endemic in many parts of South America, and came to North America through immigration. US FDA-approved screening tests are now available for Chagas disease, whose carriers may be asymptomatic for years. Spongiform encephalopathies, including variant Creutzfeldt-Jacob disease, also have asymptomatic phases, but screening tests have yet to be licensed for blood bank use. Some manufacturers are developing filters to reduce the risk of transmitting infectious doses of causative prions by blood transfusion. Pathogen inactivation is another way to address transfusion-transmitted infection risk. Non-cellular products can be partially pathogen-inactivated through a solventdetergent process. For cellular blood products, various ways to photochemically cross-link nucleic acids have been developed. France rapidly deployed photochemical pathogen inactivation on Reunion Island in response to a major outbreak of Chikungunya virus [7]. During my time in Australia (2004-2007), mosquito carriers of Dengue virus were identified every summer in small areas of Queensland, prompting various donor deferral criteria. Dengue risk areas expanded to cover much of Queensland in subsequent years, and projections suggest that human adaptation to climate change may spread Dengue to all of Australia’s major population areas [8–10]. As risk trends make donor deferral impractical, decisions will have to be
made to deploy more infectious disease screening, or implement some form of pathogen inactivation. Each has advantages and disadvantages. The main point Let me close with a final thought. Point of care testing was an emerging trend when I was still a trainee in laboratory medicine. Now, it is an everyday fact that while many tests are still performed in laboratories, the availability of compact and reliable equipment allows more and more tests to be performed at or near the patient, i.e., the point of care. Something that should never change, however, can be described by turning the phrase around. Whether we see the patient, or not, every sample we handle represents a human life. Thus, we should redouble our efforts to practice point of test caring. What we do matters, and our state of mind should always reflect this. References [1] Ohto H, Yasuda H, Noguchi M, Abe R. Risk of transfusion-associated graft-versus-host disease as a result of directed donations from relatives. Transfusion 1992;32(7):691-3. [2] Ohto H, Anderson KC. Posttransfusion graft-versus-host disease in Japanese newborns. Transfusion 1996;36(2):117-23. [3] Ohto H, Anderson KC. Survey of transfusion-associated graft-versushost disease in immunocompetent recipients. Transfus Med Rev 1996;10(1):31-43. [4] Gorlin JB, Mintz PD. Transfusion-associated graft-vs-host disease. In: Mintz PD, ed. Transfusion Therapy: Clinical Principles and Practice. Bethesda, Maryland: AABB Press, 2005:579-96. [5] Ohto H, Yonemura Y, Takeda J, et al. Guidelines for managing conscientious objection to blood transfusion. Transfus Med Rev 2009;23(3):221-8. [6] Nollet KE, Ohto H. Conscientious Objection in Patient Blood Management. In: Bettati S, Mozzarelli A, eds. Chemistry and Biochemistry of Oxygen Therapeutics: From Transfusion to Artificial Blood: John Wiley & Sons, Ltd., 2011:205-11. [7] Rasongles P, Angelini-Tibert MF, Simon P, et al. Transfusion of platelet components prepared with photochemical pathogen inactivation treatment during a Chikungunya virus epidemic in Ile de La Reunion. Transfusion 2009;49(6):1083-91. [8] Beebe NW, Cooper RD, Mottram P, Sweeney AW. Australia’s Dengue Risk Driven by Human Adaptation to Climate Change. PLoS Negl Trop Dis 2009;3(5):e429. [9] Seed CR, Kiely P, Hyland CA, Keller AJ. The risk of dengue transmission by blood during a 2004 outbreak in Cairns, Australia. Transfusion 2009;49(7):1482-7. [10] Dunstan RA, Seed CR, Keller AJ. Emerging viral threats to the Australian blood supply. Aust N Z J Public Health 2008;32(4):35460.
Kenneth E. Nollet Department of Blood Transfusion and Transplantation Immunology, Fukushima Medical University, Hikarigaoka 1, Fukushima 960-1295, Japan E-mail addresses: [email protected], [email protected]
Contents lists available at SciVerse ScienceDirect
Transfusion and Apheresis Science journal homepage: www.elsevier.com/locate/transci
International trends in transfusion therapyI Names and places Names, and word choice, can tell us something about trends. In 2004, I was invited to Sapporo from Sacramento, California to speak at the 52rd annual meeting of the Japan Society of Blood Transfusion (JSBT). Returning in 2007 to speak at the 55th annual meeting in Nagoya, I was a guest of the newly renamed Japan Society of Transfusion Medicine and Cell Therapy (JSTMCT). About the same time, the American Association of Blood Banks stopped using its full name, and began to identify itself simply as AABB, with the slogan, ‘‘Advancing Transfusion and Cellular Therapies Worldwide.’’ Community-based donor recruitment and laboratory-based blood banking are still very much a part of our specialty, but a renewed focus on the patient is emerging. In English, blood transfusion seems to be about a product, whereas transfusion medicine is clearly about medical care of patients. Transfusion has always been a form of cell therapy, but modern cell therapy has expanded greatly beyond the transfusion of cellular products with finite in vitro and in vivo life spans. Progenitor cells, whether harvested from bone marrow or collected by apheresis from peripheral blood, are intended to become an integral and persistent part of a patient’s physiology after infusion. Considering that unintended persistence and proliferation of donor white cells is associated with transfusion-associated graft-versus-host disease (TA-GVHD), any permanent effect of what we give to patients should weigh heavily on the minds of professionals involved in the collection, testing, preparation, and infusion of such products.
Names and faces The meetings in 2004 and 2007 were memorable for bringing me face-to-face with famous names in transfusion medicine, including Dr. Hisami Ikeda, convenor of the 52rd meeting, Professor Shigeru Takamoto, convenor of the 55th meeting, and Professor Hitoshi Ohto, president of JSTMCT, 2007-2011. Internationally published manuscripts from Professor Ohto and colleagues, concerning transfusionI
Published in Japanese by the Medical & Test Journal, 2011-08-01, p3.
doi:10.1016/j.transci.2011.11.008
associated graft-versus-host disease, were essential reading when I trained at the Mayo Clinic [1–3]. Even today, a 1993 manuscript by Yasuda et al., published in the Fukushima Journal of Medical Science, is cited internationally [4]. It may be impolite to call attention to these manuscripts, because I now have the privilege of working at Fukushima Medical University with Professor Ohto, Mr. Yasuda, and a delightful cohort of other diligent and innovative colleagues. Independence and interdependance I joined Fukushima Medical University in 2008, when our group was still a division. In April, 2010, we became a full department. This, too, reflects an international trend in transfusion medicine. Early hospital-based blood banks and transfusion services were often subordinated under departments of anesthesia, pathology, or surgery. I believe the trend will continue, in which transfusion services will be full departments, administratively independent of other specialties, but certainly cooperative with everyone involved in patient care. We are specialists, but patients are special In America, doctors who sub-specialize in transfusion medicine are most often those who have already specialized in pathology or laboratory medicine. Thus, the American Board of Pathology is responsible for examining and credentialing transfusion medicine sub-specialists. My training and credentialing follows this pattern. I moved from Sacramento, California to Brisbane, Queensland in 2004. In Australia I was surprised to find that transfusion sub-specialists came mostly from the ranks of hematologists rather than pathologists. Here in Japan, a diversity of specialists work in transfusion medicine. This seems to be a good thing. We, as caregivers, may be specially trained in some branch of internal medicine, surgery, nursing, or laboratory technology, but modern transfusion therapy is not about us. It is about the patient. Another important trend in this regard is that more and more specialists concern themselves with patients who refuse blood transfusion. Japan has the distinction of developing and publishing national guidelines
6
K.E. Nollet / Transfusion and Apheresis Science 46 (2012) 5–6
for the care of such patients [5]. These guidelines are endorsed by the Japan Society of Transfusion Medicine and Cell Therapy, the Japanese Society of Anesthesiologists, the Japan Pediatric Society, the Japan Society of Obstetrics and Gynecology, and the Japan Surgical Society. The historically common religious refusal of blood transfusion is being reframed in modern times as part of a broader concept, conscientious objection in patient blood management [5,6]. Once again, word choice is indicative of important trends. Risk reduction Preventing transfusion-transmitted disease remains a high priority. Japanese conference speakers still mention the case of US Ambassador Edwin O. Reischauer, who contracted hepatitis after a transfusion in 1964. Ambassador Reischauer himself was grateful for the live-saving transfusion, and spoke of feeling even closer to the Japanese people after having Japanese blood in the veins. In modern times, nucleic acid testing has all but eliminated the risk of contracting hepatitis B or C, and HIV, from blood transfusion. Human mobility and climate change have shifted concern to other agents: West Nile virus came to North America in 1999, prompting the rapid introduction of new screening protocols. Chagas disease, caused by Trypanosoma cruzi, is endemic in many parts of South America, and came to North America through immigration. US FDA-approved screening tests are now available for Chagas disease, whose carriers may be asymptomatic for years. Spongiform encephalopathies, including variant Creutzfeldt-Jacob disease, also have asymptomatic phases, but screening tests have yet to be licensed for blood bank use. Some manufacturers are developing filters to reduce the risk of transmitting infectious doses of causative prions by blood transfusion. Pathogen inactivation is another way to address transfusion-transmitted infection risk. Non-cellular products can be partially pathogen-inactivated through a solventdetergent process. For cellular blood products, various ways to photochemically cross-link nucleic acids have been developed. France rapidly deployed photochemical pathogen inactivation on Reunion Island in response to a major outbreak of Chikungunya virus [7]. During my time in Australia (2004-2007), mosquito carriers of Dengue virus were identified every summer in small areas of Queensland, prompting various donor deferral criteria. Dengue risk areas expanded to cover much of Queensland in subsequent years, and projections suggest that human adaptation to climate change may spread Dengue to all of Australia’s major population areas [8–10]. As risk trends make donor deferral impractical, decisions will have to be
made to deploy more infectious disease screening, or implement some form of pathogen inactivation. Each has advantages and disadvantages. The main point Let me close with a final thought. Point of care testing was an emerging trend when I was still a trainee in laboratory medicine. Now, it is an everyday fact that while many tests are still performed in laboratories, the availability of compact and reliable equipment allows more and more tests to be performed at or near the patient, i.e., the point of care. Something that should never change, however, can be described by turning the phrase around. Whether we see the patient, or not, every sample we handle represents a human life. Thus, we should redouble our efforts to practice point of test caring. What we do matters, and our state of mind should always reflect this. References [1] Ohto H, Yasuda H, Noguchi M, Abe R. Risk of transfusion-associated graft-versus-host disease as a result of directed donations from relatives. Transfusion 1992;32(7):691-3. [2] Ohto H, Anderson KC. Posttransfusion graft-versus-host disease in Japanese newborns. Transfusion 1996;36(2):117-23. [3] Ohto H, Anderson KC. Survey of transfusion-associated graft-versushost disease in immunocompetent recipients. Transfus Med Rev 1996;10(1):31-43. [4] Gorlin JB, Mintz PD. Transfusion-associated graft-vs-host disease. In: Mintz PD, ed. Transfusion Therapy: Clinical Principles and Practice. Bethesda, Maryland: AABB Press, 2005:579-96. [5] Ohto H, Yonemura Y, Takeda J, et al. Guidelines for managing conscientious objection to blood transfusion. Transfus Med Rev 2009;23(3):221-8. [6] Nollet KE, Ohto H. Conscientious Objection in Patient Blood Management. In: Bettati S, Mozzarelli A, eds. Chemistry and Biochemistry of Oxygen Therapeutics: From Transfusion to Artificial Blood: John Wiley & Sons, Ltd., 2011:205-11. [7] Rasongles P, Angelini-Tibert MF, Simon P, et al. Transfusion of platelet components prepared with photochemical pathogen inactivation treatment during a Chikungunya virus epidemic in Ile de La Reunion. Transfusion 2009;49(6):1083-91. [8] Beebe NW, Cooper RD, Mottram P, Sweeney AW. Australia’s Dengue Risk Driven by Human Adaptation to Climate Change. PLoS Negl Trop Dis 2009;3(5):e429. [9] Seed CR, Kiely P, Hyland CA, Keller AJ. The risk of dengue transmission by blood during a 2004 outbreak in Cairns, Australia. Transfusion 2009;49(7):1482-7. [10] Dunstan RA, Seed CR, Keller AJ. Emerging viral threats to the Australian blood supply. Aust N Z J Public Health 2008;32(4):35460.
Kenneth E. Nollet Department of Blood Transfusion and Transplantation Immunology, Fukushima Medical University, Hikarigaoka 1, Fukushima 960-1295, Japan E-mail addresses: [email protected], [email protected]