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Transfusion of blood products is a common medical procedure, and maintaining adequate blood supply depends on the unpaid donation of a small share of the general population. The absence of pre-donation testing for iron status allows many donors with iron deficiency to donate blood. This dissertation seeks to enhance our understanding of the causes of iron deficiency among blood donors, the resultant symptoms, and the likely effectiveness of alternate strategies for reducing the risk of iron deficiency. In Study 1, we used data from the REDS-II RISE prospective cohort study, over a 2-year follow-up period, to evaluate whether higher levels of dietary iron protect against incident iron deficiency in blood donors. Responses to a brief checklist of consumption of animal proteins were combined into an Iron Composite Score weighted for iron content and reported frequency. We found that donors reporting the lowest levels of iron consumption were more likely to develop advanced iron depletion during follow-up. In Study 2, we performed an analysis of observational data from the STRIDE study, a randomized trial, to evaluate whether improvements in iron status were associated with improvements in reported fatigue levels. Using linear regression, we found that many donors had sizable changes in both reported levels of fatigue and in measures of iron status, but neither iron status nor changes in iron status was associated with fatigue at the end of 20–24 months follow-up. In Study 3, we conducted a simulation study to evaluate the range of outcomes of different strategies that might be adopted by blood centers to reduce the prevalence of iron depletion in blood donors. Using inputs primarily from the REDS-II program, we simulated approaches that extended the minimum interval between donations, that promoted use of iron supplementation by blood donors, and that performed ferritin testing to determine donor iron stores and extended the donation interval to those with iron depletion. Only extending the current 8-week interval to 26 weeks approached a reduction by half of the proportion of blood donors who were iron deficient, but the estimated impact on blood supply was a 21% drop in blood availability. Those interventions impacting supply less were also less effective in reducing iron depletion.

<p>Xenotransplantation, i.e. transplantation between different species, could be a possible solution to the present shortage of organ donors. The immunological response to a xenograft is strong and difficult to suppress. It is driven both by the humoral and cellular part of the immune system. The aim of this thesis was to characterise and modulate this response in a concordant mouse-to-rat model, using both vascularised and non-vascularised grafts.</p><p>Exposure of mouse cells or tissue to the circulation of a rat, either through transplantation or transfusions, easily evoked an immune response, consisting of IgM antibodies. A response that was aimed both at antigens present on mouse mononuclear cells and on erythrocytes. A non-immunosuppressed rat rejected a mouse heart graft within three days. The combined use of cyclosporine A (CyA) and deoxyspergualin (DSG) as immunosuppression prevented the rejection of vascularised heart transplants as well as of non-vascularised pancreatic islet grafts. This acceptance was sustained for the heart transplant also after the termination of DSG treatment, but not for the pancreatic islet graft. Furthermore, a second heart graft was accepted when transplanted under monotherapy with CyA 56-154 days after the first transplantation. This finding was interpreted as a humoral unresponsiveness, which could not be reproduced when the primary heart was substituted with a cellular graft, consisting of pancreatic islets or heart cells, or by blood transfusions. However, the rejection of a mouse heart after blood transfusions occurred in the absence of antibodies directed against mouse erythrocytes, in contrast to the observations in non-transfused animals. This indicates that a partial humoral tolerance restricted to the response against erythrocytes can be induced. This mechanism may offer a possibility to induce total humoral tolerance against a xenograft if the appropriate antigens are administered in conjunction with CyA and DSG.</p>

Xenotransplantation, i.e. transplantation between different species, could be a possible solution to the present shortage of organ donors. The immunological response to a xenograft is strong and difficult to suppress. It is driven both by the humoral and cellular part of the immune system. The aim of this thesis was to characterise and modulate this response in a concordant mouse-to-rat model, using both vascularised and non-vascularised grafts. Exposure of mouse cells or tissue to the circulation of a rat, either through transplantation or transfusions, easily evoked an immune response, consisting of IgM antibodies. A response that was aimed both at antigens present on mouse mononuclear cells and on erythrocytes. A non-immunosuppressed rat rejected a mouse heart graft within three days. The combined use of cyclosporine A (CyA) and deoxyspergualin (DSG) as immunosuppression prevented the rejection of vascularised heart transplants as well as of non-vascularised pancreatic islet grafts. This acceptance was sustained for the heart transplant also after the termination of DSG treatment, but not for the pancreatic islet graft. Furthermore, a second heart graft was accepted when transplanted under monotherapy with CyA 56-154 days after the first transplantation. This finding was interpreted as a humoral unresponsiveness, which could not be reproduced when the primary heart was substituted with a cellular graft, consisting of pancreatic islets or heart cells, or by blood transfusions. However, the rejection of a mouse heart after blood transfusions occurred in the absence of antibodies directed against mouse erythrocytes, in contrast to the observations in non-transfused animals. This indicates that a partial humoral tolerance restricted to the response against erythrocytes can be induced. This mechanism may offer a possibility to induce total humoral tolerance against a xenograft if the appropriate antigens are administered in conjunction with CyA and DSG.

Sammanfattning   Bakgrund: Sedan början på förra århundrandet är blodtransfusioner en av de främsta livräddande medicinska behandlingarna. Sjuksköterskan är ansvarig under hela arbetsprocessen vid administrering av blodprodukter. Sjuksköterskans arbete utgör en livsviktig uppgift som innefattar patientsäkerhet genom att sjuksköterskan övervakar patienten för att tidigt kunna upptäcka symtom och därmed förhindra att allvarliga och livshotande komplikationer uppstår. Syfte: Syftet var att belysa blodtransfusioner utifrån sjuksköterskans och patientens erfarenheter. Metod: Metoden som användes var en litteraturbaserad studie enligt Friberg. Datainsamlingen utfördes i databaserna Cinahl with full text och Pubmed with full text med sökorden nursing, nursing care, blood transfusion, transfusion, patient care och patient experience. Resultatet baserades på sex vetenskapliga publikationer med både kvalitativ och kvantitativ design. Resultatet diskuterades utifrån begreppet patientsäkerhet. Resultat: Resultatet belyste vikten av sjuksköterskans kompetens, utbildning och patientens delaktighet vilket bidrar till  möjliggöra ökad säkerhet vid blodtransfusioner. Två övergripande teman framkom: patientutbildning främjar patientsäkerhet och sjuksköterskans kompetens inverkar på patientsäkerhet. Diskussion: Resultatet belyser sjuksköterskans strävan att uppnå patientsäkerhet vid blodtransfusioner och diskuteras utifrån lagar och riktlinjers påverkan. Sjuksköterskans vårdrelation till patienten utgör en central roll vid arbetet med blodtransfusion och som genom professionellt arbete kan åstadkomma patientsäker vård. / Background: Since the beginning of the previous decade blood transfusions are one of the most important lifesaving medical treatments. The nurse is responsible for the whole process with administrating blood components. The nurse´s work is an essential task involving patient safety through monitoring the patient in order to detect symptoms and prevent serious and life- threatening complications. Aim: The purpose was to illuminate blood transfusions from the experience of the nurse and the patient. Method: The methodology was based on a literature study according to Friberg. The data collection was performed in the databases Cinahl with full text and Pubmed with full text with the search terms nursing, nursing care, blood transfusion, transfusion, patient care and patient experience. The result was based on six original articles with both qualitative and quantitative design. The notion of patient safety was discussed according to the results. Results: The results illuminate the importance of the competence and education of the nurse and the patient participation leading to increased patient safety.  Two head themes were generated: patient education increases patient safety and the competence of the nurse influences patient safety. Discussions: The results illuminate the nurse´s endeavor for patient safety during blood transfusion and is discussed according to laws and guidelines. The nurse´s caring relation with the patient is crucial for achieving patient safety during blood transfusion.

Although blood products are a great deal safer these days than in the past, patients receiving allogeneic blood transfusions are still exposed to potential hazards such as infectious diseases and immunomodulatory reactions. Therefore it is important to consider alternatives to allogeneic blood use. This can be done by means of blood conservation alternatives. A successful blood conservation program consists of three integrated phases, namely pre-operative, intra-operative and post-operative stages of patient care. The main objective of this study was to create a transfusion medicine database in order to evaluate the effect of a blood conservation program on the length of hospital stay of patients and the costs incurred in such a program. Five pilot hospitals who had implemented a blood conservation program were compared to five non-pilot hospitals (no blood conservation program). The results show that the average cost related to allogeneic blood usage in pilot hospitals amounted to R 473 274.13, compared to R 777 646.22 for the non-pilot hospitals. Length of hospital stay was also significantly lower in patients receiving blood conservation alternatives compared to patients receiving allogeneic blood. The total costs related to patients of blood conservation was lower, although not significantly, than the total costs of patients using allogeneic blood or both. In this study it was seen that the outcomes were positively associated with the implementation of blood conservation techniques. The efficacy of two leukodepletion methods for allogeneic blood products namely pre-storage and post-storage filtration, were evaluated. The results revealed that the mean leukocyte count of pre-storage leukodepleted blood samples (n = 30) was 0.12 cells/μl. The mean leukocyte count of the post-storage filtered blood samples (n = 20) was 0.05 cells/μl. Both methods were shown to be successful in the efficient removal of leukocytes. Copyright / Dissertation (MSc)--University of Pretoria, 2011. / Immunology / unrestricted

Maternell immunisering är ett sjukdomstillstånd där moderns försvarsmekanism förstör fostrets röda blodkroppar och orsakar anemi hos fostret. Den primära behandlingsmetoden är intrauterina blodtransfusioner. Undersökning av foster under graviditeten utförs i stor utsträckning med hjälp av ultraljud. Ultraljudsundersökning begränsas av att fostret rör på sig och har en hög hjärtfrekvens. Målet med arbetet var att undersöka deformationen av myokardiet hos två grupper av foster. Den ena bestod av nio foster som genomgår intrauterina blodtransfusioner, den andra bestod av nio normala foster i motsvarande graviditetsvecka. Mätningar utfördes i programmet EchoPAC med 2D STE metoden, en tvådimensionell metod där speckle från myokardiet markeras och observeras över tid för att studera förändringen i hjärtats segment, hjärtdeformationen. Detta gjordes som en pilotundersökning primärt i syfte att bedöma genomförbarheten samt möjliga svårigheter med undersökningarna samt undersöka om metoden skulle kunna påvisa skillnader i deformationen mellan foster som behandlas med intrauterina blodtransfusioner och normala foster. Metoden visades vara genomförbar. Resultaten visar att deformationen i hjärtat hos foster som genomgår intrauterina blodtransfusioner är en aning högre än hos normala foster. Skillnaden i hjärtdeformationen mellan grupperna har visat sig vara signifikant. / Maternal immunization is a condition in which the mother's defense mechanism destroys the red blood cells in the fetus, which causes anemia. The primary treatment method is intrauterine blood transfusions. Ultrasound is one of the most common tools used to assess fetuses. Examination with ultrasound is limited by the fetal movements and a high fetal heart rate. The aim of this project was to pilot an investigation of myocardial strain within two groups of fetuses. One group consisted of nine fetuses undergoing intrauterine blood transfusions, the other consisted of nine normal fetuses in the corresponding week of pregnancy. Measurements were performed in the program EchoPAC with the 2D STE method, a two-dimensional method where speckles from the myocardium are marked and observed over time to study the change in the heart segment, the strain. This was done primarily to investigate if measurements were feasible and what problems could occur, and secondarily whether the method could show a difference in strain between fetuses treated with intrauterine blood transfusions and normal fetuses. The results show that the measurements were feasible. Results show that the strain of the heart in fetuses undergoing intrauterine blood transfusions is higher than in normal fetuses. The difference in the strain between the groups has shown to be significant

Aim: The aim of this study was to explore the attitudes and perceptions of health care professionals to alternatives to blood transfusion for Jehovah's Witnesses patients in a critical care setting. Methodology: Quantitative and qualitative approaches were used to explore the attitudes and perceptions of health care professional to alternatives to blood transfusion, in a critical care setting. The study was conducted in four largest hospitals in the Durban Metropolitan area, of which two were public and two private. A questionnaire was used as tool for collecting data. Space was provided to accommodate comments from the respondents in the questionnaire. Analysis of findings was done quantitatively by using a computer programme called SPSS (Statistical Packages for the Social Sciences), version 11.5. Themes that emerged from the participant's responses were classified under categories in the conceptual framework and analysed qualitatively. Findings: Most of the respondents had mixed feelings about using alternatives to blood transfusion. The study revealed, however, that although alternatives to blood transfusions were commonly used in a critical care setting, some of the respondents did not know about the different types of alternatives available. Furthermore, it was evident from the respondent's comments that most of them had a positive attitude to people who refused blood transfusion and preferred alternatives. Research into suitable alternatives to blood transfusion was encouraged by most of the respondents. However, transfusion transmitted diseases emerged as a current concern over and above the religious concerns. Recommendations for the future were made for the health care professionals working in critical care setting, nurse educators and nursing management. / Thesis (M.N.)-University of Natal, Durban, 2004.

L’utilisation de stratégies transfusionnelles restrictives (pas de transfusion de globules rouges si hémoglobine > 70 g/L) a été démontrée comme étant sécuritaire en aiguë et celles-ci sont maintenant largement utilisées aux soins intensifs pédiatriques (SIP). En conséquence, plus de patients quittent les SIP en étant anémiques. L’anémie chronique, plus spécifiquement l’anémie ferriprive, est associée à des issues neurodéveloppementales défavorables. Peu d’études sont disponibles pour caractériser la prévalence de l’anémie au congé des SIP. Les études présentées dans ce mémoire s’intéressent à cette question en examinant d’abord le problème de l’anémie aux SIP et son traitement (revue narrative), puis sa prévalence au congé chez tous les patients ayant survécu aux SIP sur une période de 5 ans et pour finir, la prévalence de ce problème chez les nourrissons admis pour une chirurgie cardiaque (via 2 études de cohorte rétrospectives). Nous avons démontré que 50,9% des patients survivant à un séjour aux SIP sont anémiques au congé. Cette proportion varie en fonction du type d’admission (44,8% médicale, 70,3% chirurgicale non-cardiaque et 53,3% chirurgicale cardiaque). Le fait d’être anémique à l’admission aux SIP est le facteur de risque le plus souvent associé à l’anémie au congé des SIP (rapport des cotes, RC : 14,41). Chez les nourrissons ayant subi une chirurgie cardiaque, la prévalence d’anémie au congé est de 27,7%. La proportion de patients quittant les SIP anémiques est alarmante : il est primordial de déterminer la trajectoire et l’impact de ce problème chez les patients survivant à une maladie critique. / It is now clear that restrictive transfusion strategies (no red blood cell transfusion if the hemoglobin level is > 70 g/L) are safe in acute settings. Therefore, these strategies are widely being used in Pediatric Intensive Care Unit (PICU) and as a consequence, numerous children leave the PICU anemic. Prolonged anemia, especially iron-deficiency anemia, is associated with worst neurocognitive outcomes. Data regarding the true prevalence of anemia at PICU discharge is lacking. This thesis addresses this question. Etiology and management of anemia in the PICU is explored through a narrative review. Prevalence of anemia at PICU discharge is examined through two retrospective cohort studies: the first describes the prevalence of this complication in PICU survivors over a five-year period and the second one, the prevalence of anemia in infants admitted to the PICU after cardiac surgery. Through our studies, we established that the prevalence of anemia at PICU discharge was 50.9% in PICU survivors. This proportion varied depending on the type of admission (44.8%, 70.3%, and 53.3% for medical, non-cardiac surgery, and cardiac surgery respectively). Anemia at PICU admission was the most important risk factor associated with anemia at PICU discharge (odds ratio, OR 14.41). In newborns less than 6 weeks old who underwent cardiac surgery, the prevalence of anemia at PICU discharge was 27.7%. Given the alarming proportion of PICU survivors that are anemic at discharge, it is paramount that we determined the trajectory and impact of this problem in critically ill survivors.