Frequent blood transfusion to treat chronic hematopoietic dysfunctions, such as aplastic anemia and myelodysplastic syndrome, causes iron overload and leads to failure of various organs in patients with anemia. After administration of Deferasirox, an oral iron-chelating agent, as part of iron chelation therapy, increased evidence of the efficacy of iron chelation therapy in treating transfusional iron overload has been reported. The medical guideline for transfusional iron overload in Japan was announced in July 2008, indicating diagnostic criteria for transfusional iron overload and criteria for iron chelation therapy. To assess the implementation of iron chelation therapy, we examined actual data on transfusional iron overload during a five-year period from January 2007 to December 2011 at Saga University Hospital. A total of 419 patients who received over 20 units of annual total erythrocyte transfusion were analyzed. Fifteen people received chelation therapy with Deferasirox during the study period, but only four had chelation therapy initiated in accordance with the medical guide for transfusional iron overload, likely due to both a difficulty in understanding precisely the total units of erythrocyte transfusion in a patient and delayed recognition of iron overload status. Taking these findings into account, we established a new system of electronic medical recording in our hospital. The program consists of three phases: calculation of total units of erythrocyte transfusion in a patient, automatic ordering of a ferritin test, and displaying the results of serum ferritin level to the attending physician. We describe here this integrated program for managing transfusional iron overload based on an electronic medical record system.

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Human T-cell leukemia virus type I (HTLV-1) is estimated to have infected 15-20 million worldwide, and over 1 million in Japan. HTLV-1 is well-known as the cause of several severe diseases, such as adult T-cell leukemia and HTLV-1-associated myelopathy/tropical spastic paraparesis. A screening test for the antibody to HTLV-1 was implemented to test all donated blood samples in the Japanese Red Cross Blood Center in 1986. The examination is carried out using chemiluminescence enzyme immunoassay (CLEIA). Western blotting (WB), instead of indirect immunofluorescence assay (IF), has been adopted as a confirmatory process following CLEIA since September 2012. However, numerous cases have been deferred in which serum samples, positive on CLEIA, displayed indeterminate patterns on subsequent WB. To clarify the specificity of these WB indeterminate patterns, 239 serum samples deferred on WB were examined using particle agglutination assay, chemiluminescence immunoassay (CLIA), IF, line immunoassay, and PCR for HTLV-1 provirus detection, with findings for the differences in reactivity for antibody tests compared on the basis of the kinds and origins of immobilized antigens in each examination. Results from PCR showed that 89 (37.2%) of the 239 deferred samples in WB were positive for HTLV-1 provirus. In contrast, specific antibodies were detected in 19 (12.7%) of 150 PCR-negative cases. While 83 (93.3%) were positive for all antibody tests, anti-Gag antibody was predominantly observed in only 2 (2.2%) of 89. Only anti-Env antibody was detected in 1 (1.1%) case, which was positive only on CLIA. These findings indicate that genuine HTLV-1 carriers are included among individuals with indeterminate patterns on WB and suggest the existence of occult HTLV-1 carriers, indicating a much higher incidence of HTLV-1 in Japan than previously reported.

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The establishment of an outpatient clinic for preoperative autologous blood donation (PABD) is a useful measure for the promotion of preoperative autologous blood transfusion (PABT). However, in hospitals without a transfusion department, the establishment of such outpatient clinics is difficult, due to the complexity of the office work, time restrictions, and limited human resources. For the establishment of a PABD outpatient clinic in our hospital, in an attempt to guarantee the efficient management, we developed a novel computer system (the " PABT Management System" ). This system facilitates requesting and planning PABD and the registration and provision request of autologous blood products, as well as the registration of autologous blood usage or wastage. In addition, information on PABT, the clinical pathways, and product labels can be printed in this system, which contributes to the safe and efficient management of the outpatient clinic. We concluded that development of an efficient PABT computer system allows for the establishment of a PABD outpatient clinic, even in hospitals with limited human resources.

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The indirect antiglobulin test (IAT) often registers as a false positive with enhancing reagents in screening test for irregular antibodies and cross-match test in response to the presence of cold antibodies. Since cold antibodies do not cause a transfusion reaction, IAT without enhancing reagents, 60-min IAT is useful in distinguishing clinically significant antibodies. We recently experienced a rare case in which 1×and 2×-diluted samples showed negative results, while 4×-diluted samples showed positive results on 60-min IAT. IgM type anti-M was produced at a patient's first pregnancy, and IgM+IgG type anti-M was produced after the first child delivery. At the third pregnancy, anti-M titer was monitored every two weeks until the day before delivery. Titer of anti-M increased to 1: 64, but findings for 1: 1-2 dilution serum of the patient were negative on 60-min IAT at 37 weeks into the pregnancy. Flow cytometry analysis revealed that IgM type anti-M reacted more strongly at 37°Cthan at lower temperatures. These findings suggested that anti-IgG globulin serum was unable to be used to build bridges, resulting in the negative results on IAT because IgM type anti-M, which reacted at 37°C, inhibited the binding of IgG type anti-M. The present case has shown the importance of using dithiothreitol or 2-mercaptoethanol, which destroys IgM type antibody, for the detection of clinically significant antibodies.

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[in Japanese]

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