S Holme

Dartmouth–Hitchcock Medical Center, LEB, New Hampshire, United States

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Publications (102)319.52 Total impact

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    ABSTRACT: Leukoreduced blood components are commonly manufactured via filtration. There are specifications for the residual leukocyte content of any final cellular blood component but not for residual clotting factors. Leukoreduced and nonleukoreduced platelet-poor plasma products were manufactured from filtered vs unfiltered platelet-rich plasma, respectively, using platelet leukoreduction filters. The leukoreduced plasma showed lower levels of factor VIII (75% ± 16% vs 88% ± 18%, P ≤ .05), factor XI (86% ± 9% vs 96% ± 10%, P ≤ .01) and factor VII (87% ± 14% vs 98% ± 11%, P ≤ .01). No difference was seen with factor X, factor V, or fibrinogen. Plasma filtered through a whole blood filter showed a reduction in factor V (105% ± 12% vs 124% ± 10%, P ≤ .01) but a minimal reduction in factor VIII (80% ± 5% vs 82% ± 6%, P = .04). Filtration can alter the residual levels of clotting factors to a variable extent in manufactured plasma, most noticeably factors V, VII, VIII, and XI.
    Preview · Article · Jan 2013 · American Journal of Clinical Pathology
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    ABSTRACT: The processing of whole blood-derived platelet-rich plasma (PRP) to a platelet concentrate and platelet-poor plasma is currently performed within 8 hours to comply with the requirements to manufacture fresh frozen plasma. Maintaining PRP at room temperature for a longer period can have the advantage of shifting the completion of component manufacture onto day shifts. Pairs of ABO-identical prepooled platelets were manufactured by the PRP method, using the current approach with platelet storage in a CLX HP container (Pall Medical, Covina, CA) and plasma, or a novel approach with an 18- to a 24-hour room temperature hold of the PRP and the manufacture of pooled platelets in a glucose-containing additive solution (AS) and storage in a new ELX container (Pall Medical). Standard in vitro assays were performed on days 2, 5, and 7. The results showed that the AS platelets in ELX have in vitro characteristics that are equivalent or superior to those of the standard product.
    Preview · Article · Oct 2011 · American Journal of Clinical Pathology
  • C Saunders · G Rowe · K Wilkins · S Holme · P Collins
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    ABSTRACT: The non-paired two-arm study compared the in vitro storage characteristics of platelets suspended as concentrates in either 100% plasma or a mixture of additive solution (SSP+™, MacoPharma, Mouveaux, France) and autologous plasma in a 70:30 ratio over a 14-day storage period. The buffy coat-derived pooled platelet concentrates were sampled on days 1, 2, 3, 6, 8, 10 and 14 and tests performed to determine platelet morphology, function, metabolism, activation and apoptosis-like activity. Swirling remained strong (score=3) in SSP+™, whilst scores of 1 and 0 were noted for plasma units by end of storage. In contrast to units in plasma, pH levels remained above seven in SSP+™ units, increasing after day 10. Percent positive expression of CD62P was similar in both groups on day 1 (median of 54% and 56% for plasma (n=13) and SSP+™ (n=12), respectively), with SSP+™ units showing a more moderate increase in activation after day 10. A progressive decrease in mitochondrial membrane potential was evident in both groups from day 1, whilst annexin V binding was relatively stable from days 1 to 3, with median values remaining below 6%. Subsequent to this, the percentage of platelets binding annexin V increased to approximately 30% by day 14. Platelets suspended in a medium of 70:30 SSP+™ to plasma ratio performed at least as well as platelets in 100% autologous plasma for up to 10 days of storage. Further, results are suggestive of an apoptosis-like process being involved in the platelet storage lesion.
    No preview · Article · Mar 2011 · Vox Sanguinis
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    ABSTRACT: The capability of holding whole blood (WB) units at ambient temperature, overnight, should help in platelet (PLT) concentrate preparation logistics. We summarize the results of a study conducted in the early 1990s that compared, in particular, PLT and red blood cell (RBC) in vivo viability properties following storage after preparation after 8- and 24-hour WB hold periods. Individuals donated units of WB on two occasions. Centrifugation at 20 to 24°C to separate PLTs and additive system RBC placement at 1 to 6°C was completed 8 hours after phlebotomy or after 24 hours in randomized order. Components were not leukoreduced. Studies including in vitro biochemical and hematologic analyses and autologous in vivo RBC and PLT evaluations were conducted at two sites. RBC 24-hour in vivo (mean ± SD) recoveries (single-label approach), after 35 days of storage, were 79.2 ± 4.3 and 79.4 ± 3.9% (n = 9; p > 0.05), with WB holding periods of 8 and 24 hours, respectively. With 42 days of storage, recovery after a 24-hour hold was slightly less than with an 8-hour hold (72.9 ± 6.5% vs. 76.0 ± 5.4%; n = 17; p < 0.05). RBC 2,3-diphosphoglycerate acid levels were substantially less after the 24-hour hold compared to after the 8-hour hold (n = 18; p < 0.05). PLT recovery after 5 days of storage with 8- and 24-hour hold periods were similar, 51.1 ± 14.9 and 50.6 ± 17.7%, respectively (n = 18; p > 0.05). The PLT survival variable and in vitro properties reflecting storage quality also showed no significant difference. RBC and PLT in vivo variables, and most in vitro variables, were not significantly different after storage with WB holding times of 8 and 24 hours except for a slight diminution of RBC recovery with the 24-hour hold after 42 days of storage.
    No preview · Article · Jan 2011 · Transfusion
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    ABSTRACT: The manufacture of fresh-frozen plasma (FFP) requires that plasma be frozen within 8 hours of collection and 24-hour frozen plasma requires 1 to 6°C refrigeration before freezing. Manufacture of plasma after a room temperature hold for 24 hours, while convenient, could compromise clotting factor levels. Pairs of FFP and 24-hour room temperature-frozen plasma (PLT-rich plasma [PRP]-24HRTFP) were manufactured from PRP after a room temperature hold for 8 and 24 hours, respectively. Additional whole blood (WB) donations were kept at room temperature for 24 hours before plasma manufacture (WB-24HRTFP). The frozen plasma products were stored at -18°C, thawed, and then stored at 1 to 6°C, with coagulation factor assays performed for up to 7 days. On the day of thaw, Factor (F)VIII was lower in PRP-24HRTFP by 13% (p = 0.002) but not in WB-24HRTFP (p = 0.3) compared to FFP. All other clotting factors were within normal range. During the postthaw period FVIII and FV declined 25 and 6%, respectively, in WB-24HRTFP and 23 to 50% in the paired products; however, the difference between both types of 24HRTFP and FFP is insignificant by Day 7 (p > 0.05). Other clotting factors either were unchanged or showed minimal reduction (< 15%). Plasma manufactured after a 24-hour room temperature hold contains coagulation factors comparable to FFP except for a possible reduction of up to 20% in FVIII. This plasma appears suitable as a transfusable product and extension of liquid storage to 7 days merits consideration.
    No preview · Article · Apr 2010 · Transfusion
  • Joseph D. Sweeney · Stein Holme · Andrew Heaton
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    ABSTRACT: Despite the current emphasis in transfusion medicine on regulatory compliance and cost containment, there is continuing activity in quality improvement of blood products. Quality can be assessed by measuring both benefit and risk. High quality products are those in which the benefit is maximized and the risk minimized. Risk, in the context of platelet transfusions, is minimized by reducing infectious agents, sources of allergic reactions, and other factors likely to cause adverse reactions in recipients. Benefit can be better described as potency. Potency is the ability to produce a desired effect. For platelet concentrates, potency has both quantitative [platelet yield] and qualitative [platelet viability, survival, and function] components. There are many activities which may influence the potency of the final transfused platelet product and these are summarized in Figure 1. It is helpful to review each step in order to assess the potential impact on the potency of the final transfused product.
    No preview · Article · Jul 2009 · Immunological investigations
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    ABSTRACT: In Europe, buffy-coat processing allows for the use of platelet additive solutions (PAS). These solutions, however, have long been questioned for their lack of glucose, a potentially essential nutrient for platelet storage. Using a novel, practical, two-part system for incorporation of glucose into an additive solution (PAS-G), this study compares platelet storage in plasma to storage in PAS-G. Study A paired study design of platelet concentrates (PC) were prepared from leucoreduced pools of eight buffy coats (BCP) split into two equal pools, with suspension in autologous plasma, or PAS-G. On days 2, 5, 7 and 9 of storage, samples were tested using standard in vitro platelet parameters. Data were analysed by paired Student's t-tests. During storage, PCs in PAS-G maintain a quality profile that is strikingly similar to PCs stored in plasma in terms of platelet activation (CD62) morphology score, swirl, glucose metabolism and pH. However, PCs in PAS-G perform lower (P < 0.05) in the %ESC and %HSR assays. PAS-G's novel presentation allows incorporation of glucose into the additive solution so that it is roughly equivalent to plasma for the maintenance of buffy-coat PCs.
    No preview · Article · May 2009 · Vox Sanguinis
  • Gary Moroff · Stein Holme · Thais Keegan · Andrew Heaton
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    ABSTRACT: Previous studies with CPDA-1 and Nutricel preserving solutions indicated that red cell properties were affected by small differences in storage temperature. The influence of a 3°C differential on the preservation of the in vitro properties of ADSOL-preserved (AS-1) red blood cells was investigated in a paired study. AS-1 red blood cells were stored at 2.5 and 5.5°C for 42 days. Extent of hemolysis, glucose consumption and pH levels were comparable at the two storage temperatures. Lactate levels were slightly, but significantly higher at 5.5°C. ATP levels were slightly but significantly higher at 2.5°C, only during the later part of the storage period. 2.3-DPG levels were slightly better retained at 2.5°C after 7 days of storage. Holding units of whole blood for either 1 or 8h at ambient temperature after phlebotomy prior to processing did not influence the types of temperature-dependent changes. The differences as a function of storage temperature were small and appear to be of no practical importance in connection with the storage of AS-1 red blood cells.
    No preview · Article · Mar 2009 · Vox Sanguinis
  • Stein Holme
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    ABSTRACT: There have been reports on platelet storage studies that have demonstrated little or no correlation of in vitro parameters with in vivo parameters of viability such as CCI, and % recovery and survival by radio labeling. However, this does not mean that the in vitro parameters necessarily are poor predictor of in vivo viability, but may be related to the fact that in the vivo parameters, as absolute values, do not precisely reflect the viability of the platelets due to uncertainty in the splenic uptake and inaccuracy of the estimated blood volume of the recipient. A more informative way to examine the predictability of the in vitro parameters is to examine whether processing and storage conditions associated with loss or improvement in vivo viability are also associated with corresponding changes to the in vitro parameters and vice versa.
    No preview · Article · Sep 2008 · Transfusion and Apheresis Science
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    ABSTRACT: The Pall eBDS uses oxygen consumption as a surrogate marker for bacterial detection in platelet (PLT) products. This article describes the evaluation of eBDS to detect bacterial contamination in inoculated fresh and stored leukoreduced red cell (RBC) units. Field studies were conducted at three sites to establish eBDS pouch incubation time and the pass/fail threshold. RBC units were inoculated with each of 12 bacterial species known to cause sepsis at target inocula of either 1 to 15 or 100 colony-forming units (CFUs) per mL. Units were mixed and stored at 2 to 6 degrees C. Samples were taken for culture and eBDS testing weekly from 0 hour to 42 days and incubated for 35 degrees C for 24 to 30, 48, and 72 hours, followed by measurement of percent oxygen content. The studies showed growth of five bacterial species (including Yersinia enterocolitica) in RBC units, while seven bacterial species showed no growth or autosterilized. A pass/fail oxygen threshold of 14.4 percent was determined based on results from noninoculated controls (n = 633) and from inoculated samples (n = 884) after 48 hours of incubation. Detection was 100 percent at all sampling times during refrigerated storage with both 48 and 72 hours of pouch incubation. With incubation of eBDS pouches for 48 and 72 hours, 100 percent detection was obtained in 884 samples with bacterial levels of at least 1 CFU per mL, and no false-positive samples were obtained. Based on the bacterial growth patterns, RBC units may be sampled 1 to 3 days after collection for optimal efficacy and read after 48 to 72 hours of incubation of the eBDS sample pouches at 35 degrees C. The Pall eBDS is suited for detection of typical bacterial contaminants in fresh and stored RBCs.
    No preview · Article · Jun 2008 · Transfusion
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    ABSTRACT: Currently used formulas for estimation of a person's red cell volume (RCV) by weight and height are decades old and were based on the use of 51Cr isotopes and on a sample population, which may not be reflective of today's population. In this study, the accuracy and precision of the use of 99mTc RCV measurements in volunteers more typical of today's population were evaluated. The subjects were volunteers who met the requirements for a standard blood donation. The mean +/- standard deviation (SD) 99mTc RCV for 127 males (mean weight, 83.2 kg; height, 180 cm) was 2062 +/- 339 mL, and for 101 females (mean weight, 69.5 kg; height, 166 cm) it was 1320 +/- 201 mL. These results were highly correlated with RCV results with the standard extrapolation 51Cr method with stored red blood cells (RBCs) and highly consistent (within +/-10%) by repeated measurements with the same 22 donors over a 3.5-year period. The RCV results correlated with estimates from the current formulas, but were on average 11 to 14 percent lower. The studies demonstrated that 99mTc is a reproducible and precise method for determination of a person's RCV and that current formulas may significantly overestimate the RCV of today's population. This is likely the result of a shift in population characteristics over the past four decades as reflected by an increased mean body mass index (from 25 to 28 kg/m2), which has not resulted in a proportionally increased RCV.
    No preview · Article · Jun 2008 · Transfusion
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    ABSTRACT: Current FDA regulations allow the prestorage pooling of whole blood-derived platelet concentrates (PCs) of identical ABO type in a recently cleared platelet (PLT) pooling bag (Acrodose, Pall Medical). It is unclear how ABO-mixed PC pools would store if pooled before storage. Pools consisting of ABO-identical PLTs and mixed A and O PLTs in varying proportions were evaluated on Days 1, 5, and 7 of storage with measures of the PLT storage lesion, lymphocyte activation, and activation of the complement and coagulation system. Data were analyzed by analysis of variance. Pools did not differ on Day 7 in pH (p = 0.63), hypotonic shock response (p = 0.25), extent of shape change (p = 0.26), morphology score (p = 0.18), or white cell count (p = 0.79), but surface P-selectin expression was more evident in the ABO-mixed pools (p = 0.02). Small microscopic clumps of PLTs were observed in all pools, but were more prominent in the ABO-mixed pools (p < 0.01). PLT counts, however, did not differ between pools (p = 0.93), indicating that only a small proportion of PLTs were clumped. Surface A-antigen expression was proportional to the number of A PCs in each pool and did not vary between study days. Anti-A(1) titers were either unchanged or decreased by one dilution. Complement and coagulation activation markers did not differ between pools. Pooling A and O PCs is associated with evidence of increased microscopic PLT clumping and activation, but these differences are not exacerbated with 7-day storage. Other major measures of PLT quality do not differ, and there was no evidence of a mixed lymphocyte reaction.
    No preview · Article · Aug 2007 · Transfusion
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    ABSTRACT: The pH environment of stored platelet (PLT) products is recognized as an important factor and is generally used as a key surrogate measure of PLT viability. It is the only in vitro measurement that has been translated into industry standards and regulatory rules or specifications for storage of PLT products. The objective of this study was to evaluate the effect of in vitro pH on the in vivo recovery and survival of autologous PLT products. Data from individual autologous radiolabeled PLT kinetic studies were solicited from independent laboratories. PLTs stored for at least 5 days in 100 percent autologous plasma with a pH(22 degrees C) of at least 6.2 were analyzed. Data were fit to a mixed-effects regression model with fixed effects of pH(22 degrees C), time of storage, and preparation method-storage bag combination. Eight research laboratories reported 476 individual recovery and survival results with associated pH before labeling from a variety of autologous, radiolabeled PLT kinetic studies from September 1999 to March 2005. These results are from 254 individual subjects who donated a total of 386 PLT units, with up to nine collections per subject reported. The effect of pH on either PLT recovery (p = 0.86) or survival (p = 0.55) was not significant. Time of storage and the method-bag combination both had significant effects on these outcomes (p < 0.0001). These data suggest that there is no relationship between in vitro pH at a pH(22 degrees C) of at least 6.2 and in vivo PLT viability as measured by radiolabeled recovery and survival of autologous PLTs.
    No preview · Article · Sep 2006 · Transfusion
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    ABSTRACT: Prestorage pooling of platelet (PLT)-rich plasma (PRP)-derived PLT concentrates (PCs) and storage in either plasma (PS) or an additive solution (AS) is logistically feasible and would result in a product similar to buffy-coat or apheresis PLTs. On Day 0, PS PRP PCs were pooled with a sterile connecting device into a new 1.3-L storage container (ELX, PALL Medical). AS-PCs were prepared by addition of a new low-pH glucose-containing AS to the PLT sediment. AS-PCs were pooled into a 1.3-L ELX bag containing four tablets of NaHCO3. PC pools were sampled on Days 1, 5, and 7. PS pools containing 5 units had a mean PLT yield similar to the AS pools (39 x 10(10) +/- 3 x 10(10) vs. 37 x 10(10) +/- 6 x 10(10); p = 0.25). All pools had WBC counts of less than 1 x 10(6). pH and HCO3 decreased in PS pools with storage, but either increased or remained constant in the AS pools. On Day 7, no differences were seen in morphology score or extent of shape change. Hypotonic shock response was better preserved in the plasma pools (71 +/- 12% vs. 56 +/- 13%, p < 0.01); however, surface P-selectin was expressed less in the AS pools (6 +/- 4% vs. 18 +/- 10%, p < 0.01). Manufacture and storage of PRP-PCs in pools either in plasma or in a glucose-containing AS in this new container are feasible, and there is good preservation of PLT quality to Day 7.
    No preview · Article · May 2006 · Transfusion
  • J D Sweeney · S Holme

    No preview · Article · Nov 2005 · Vox Sanguinis
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    ABSTRACT: Extension of platelet (PLT) storage and concomitant use of a bacterial detection system would provide logistical advantages by reducing outdating and improving patient care through promotion of the use of sensitive detection systems. This study evaluated the in vitro characteristics and in vivo viability of leukoreduced PLT units derived from PLT-rich plasma stored for 5 days (control) versus 7 days (test) in CLX plastic containers. Two whole-blood units were collected from each subject into a leuko-reduction filtration system (Leukotrap RC-PL system, Pall Medical) in a paired design, the second 2 days after the first. These were leukoreduced (Leukotrap PL) and stored for 7 and 5 days. Poststorage samples from test and control units were randomly labeled with (51)Cr or (111)In and simultaneously infused autologously to determine recovery and survival. Small but significant (p < 0.05, paired t test) differences between 5 and 7 days of storage were seen in in vitro variables such as extent of shape change, hypotonic shock response, morphology, and P-selectin expression. In vivo recovery declined on average 11 percent with the two additional days of storage from 54.4 +/- 13.6 to 48.7 +/- 15.0 percent (p < 0.002); survival decreased on average 19 percent from 6.7 +/- 1.0 to 5.4 +/- 1.7 days (p < 0.002). Storage for 7 days was associated with reduced recovery and survival and in vitro variables, suggestive of extension of the storage lesion. These differences, however, were small in magnitude and unlikely to have significant clinical effects. Current collection and storage systems provide PLTs that are as functional at 7 days as those licensed for 7-day storage two decades ago.
    No preview · Article · Sep 2005 · Transfusion
  • Stein Holme
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    ABSTRACT: This paper reviews some current issues related to the quality of red cells processed and stored for transfusion. These include the storage lesion, use of gamma irradiation, and storage of red cells in containers of plastic made with non-leachable plasticizers.
    No preview · Article · Sep 2005 · Transfusion and Apheresis Science
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    ABSTRACT: An enhanced bacterial detection system (Pall eBDS) was developed that distinguishes itself from its predecessor (Pall BDS) by removal of the platelet (PLT)-retaining filter allowing for optimal bacterial transfer, modification of the culture tablet to reduce the confounding effects of respiring PLTs while enhancing bacterial growth, and facilitation of nutrients and gas exchange by agitating the sample pouch during incubation at 35 degrees C. The objective was to evaluate the performance of the new eBDS. Leukoreduced whole blood-derived PLT concentrates (LR-PCs) and LR single-donor PLTs (LR-SDPs) were inoculated with 1 to 15 colony-forming units (CFUs) of bacteria per mL in studies of each of 10 bacterial species associated with fatal transfusion-transmitted bacterial infection. Immediately after inoculation and after 24 hours of storage at 22 degrees C, samples of inoculated LR-PCs were aseptically transferred into the eBDS pouches. Pouches were then incubated for 24 hours at 35 degrees C with agitation and oxygen concentration was then measured. Median inoculation levels ranged from 5 to 13 CFUs per mL for each species studied. No significant differences in oxygen concentration were found when comparing LR-PCs with LR-SDPs. When sampling occurred from the PLTs 24 hours after inoculation, all 280 cases (24-33 replicates of each species) were detected as contaminated by the device (100% sensitivity). No false-positives were obtained with 713 uninoculated PLT units. The eBDS demonstrated improved detection sensitivity in the range of 1 to 15 CFUs per mL with no observed false-positives compared to the original BDS (detection range 100 to 500 CFUs/mL) with no false-positives.
    No preview · Article · Jul 2005 · Transfusion
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    ABSTRACT: Prestorage pooling of whole-blood-derived PCs (WBD-PCs) would be advantageous to transfusion services in that it would make the product available in a more timely manner, reduce wastage of untransfused pools, and simplify bacterial screening by allowing testing of the pool rather than each single PLT concentrate (PC). Four to six individual leukoreduced PCs were pooled into a 1.5-L CLX-HP PLT storage bag using a sterile connecting device. Controls were individual prestorage leukoreduced PCs that were stored as single products. Products were sampled on Days 5 and 7 for measures of PLT quality; coagulation, fibrinolytic and complement activation; and for evidence of a mixed lymphocyte reaction. The pH level was well maintained to Day 7 with no prestorage pool having a pH below 6.7. Day 7 studies showed no evidence of coagulation or difference in complement activation. F1.2 levels did not differ between Days 5 and 7, but a 10- to 15-percent increase in C3a des-Arg was observed between these days in all product types. Day 7 activated lymphocyte surface markers (CD69, CD71, HLA-DR) were all at lower limits of detection in the prestorage pooled products, and levels of supernatant cytokines were either not different between product types on either study day or, if different, were lower in the prestorage pooled products. There is no evidence of a deterioration in quality, activation of coagulation or complement, or a mixed lymphocyte reaction attributable to the prestorage pooling process with up to 7 days of storage.
    No preview · Article · Sep 2004 · Transfusion
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    ABSTRACT: Random-donor PLTs (RDPs) are functional at 7 days. Nevertheless, since the mid-1980s, concern for bacterial contamination has caused the storage period to be reduced to 5 days. The ability of a bacteria detection system (BDS, Pall) to determine bacterial contamination and permit extension of the PLT shelf life to 7 days was assessed. Blood was collected into CP2D and leukoreduced RDPs were prepared. Upon arrival at the hospital, a 2- to 3-mL aliquot was removed from each RDP and introduced into the Pall BDS pouch with a sterile docking device. The pouch was incubated at 37 degrees C for 24 hours and then the oxygen content was measured to determine bacterial contamination. Additionally, the RDPs were pooled and an aliquot was removed for culture with standard manual techniques. CCIs were calculated 1 hour after infusion. A total of 12,062 individual RDPs were tested. The Pall BDS detected bacteria in 5 units. All of these were positive on repeat sampling. Propionibacterium acnes, coagulase-negative Staphylococcus, and Bacillus species were confirmed by manual technique in 3 units, one could not be identified, and one was negative. Aliquots from PLT pools were positive in 80 of 2201 pools when tested by manual methods. Of these, 79 were false-positives and 1 unit contained coagulase-negative Staphylococcus. The Pall BDS was easy to use and required less than 5 minutes for all manipulations. After 7 days of storage, the PLTs gave an average CCI of 16 x 10(11)+/- 3.39 x 10(11) 1 hour after transfusion (n = 9). The Pall BDS permits evaluation of RDPs for bacterial contamination. Culture-negative PLTs were successfully transfused in our institution up to and including 7 days after storage with good CCIs.
    No preview · Article · Apr 2004 · Transfusion

Publication Stats

3k Citations
319.52 Total Impact Points


  • 2006-2011
    • Dartmouth–Hitchcock Medical Center
      LEB, New Hampshire, United States
  • 1994-2011
    • Providence Hospital
      Mobile, Alabama, United States
    • National Institutes of Health
      베서스다, Maryland, United States
  • 1988-2009
    • Red Cross
      Washington, Washington, D.C., United States
  • 1987-2009
    • Eastern Virginia Medical School
      Norfolk, Virginia, United States
  • 2008
    • Case Western Reserve University School of Medicine
      Cleveland, Ohio, United States
  • 2005-2008
    • Pall Life Sciences
      Ann Arbor, Michigan, United States
    • Case Western Reserve University
      Cleveland, Ohio, United States
  • 2004
    • The Ottawa Hospital
      • Department of Pathology and Laboratory Medicine
      Ottawa, Ontario, Canada
  • 2003
    • Albert Einstein College of Medicine
      New York City, New York, United States
  • 2001
    • University of North Carolina at Chapel Hill
      North Carolina, United States
  • 1984-1994
    • Thomas Jefferson University Hospitals
      Philadelphia, Pennsylvania, United States
  • 1991
    • Biomedical Research Institute, Rockville
      Maryland, United States
  • 1983-1986
    • University of Tromsoe
      • Department of Clinical Medicine (IKM)
      Tromsø, Troms, Norway
  • 1978-1983
    • Thomas Jefferson University
      • Division of Hospital Medicine
      Filadelfia, Pennsylvania, United States