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Tuesday, 6 March 2012

It may be however hoped that some major changes may happen in Blood Transfusion service in West Bengal, India, also in future, by next 15-20 years when and if synthetic blood will be available in market on coomercial basis at low price

*Professor Pranab kumar Bhattacharya MD(cal), Fic path(Ind.) –Professor and Head Department   of Pathology,  Now at School of Tropical Medicine Kolkata, 108 C.R Avenue Kol-73, W.B ; India & Ex Professor and Head, Department of Ophthalmic  pathology, RIO kolkata and of WBUHS, EX Professor Pathology, Institute of post Graduate Medical Education& Research, Technical adviser in charge Blood Bank IPGME&R/SSKM hospital and  of VCCTC *Miss Upasana Bhattacharya- Daughter of Prof.Pranab kumar Bhattacharya Mahamya apartments Mahamyatala, Garia kol-84;  **Mr. Rupak Bhattacharya Bsc(cal), Msc(JU), **Mr. Ritwik Bhattacharya B.Com(cal), ** Miss Rupsa Bhattacharya ,  ** MrSomayak Bhattacharya BHM(cal) MSc Student PUSHA Delhi  all  of residence  7/51 purbapalli; Po= Sodepur; Dist 24 parganas(north) Kol-110 W.B India, Mrs Dalia Mukherjee BA(hons) Cal and Mr. Miss Oaindrila Mukherjee –Student   Mr.Debasis Mukherjee Bsc (cal) of Residence swamiji Nagar South Habra ,West Bengal .

 Conflict of Interest
 Professor Pranab kumar Bhattacharya acted as  a chairperson & Technical supervisor In charge of state of art Blood Banks and Voluntary Confidential Counseling Center for HIV[VCCTC]of IPGME&R/SSKM Hospital kolkata-20 a state of art  Govt. run Tertiary care hospital and Post Graduate & Post Doctoral teaching Institute of Under  West Bengal University of Health Sciences(WBUHS) West Bengal-for long ten years(since 2002-2011)
Blood is a vital organ system that requires often to be transfused in patients as a life saving measures in emergency situations due to severe loss of Blood(> 1 liter of Blood loss leads to irreversible hypovolemic shock) from any cause or may be needed as an elective operational procedure or as a replacement therapy. Today many components are done in blood banks by aphaeresis or by cell separators like RBC concentrate, Platelet concentrate, Granulocyte concentrate Fresh frozen plasma and factor VIII (these five are mostly requisitioned by clinicians as  first authors long experience} lucodepleted blood, Granulocyte or WBC concentrate saline washed RBC concentrate etc .Today however the concept of Whole blood transfusion gradually being faded away as component therapy came into hospital based practice also in the developing counties. The transfusion of Blood component depends on many factors and today it is observed that blood requirement has come down in many elective surgical procedures, good example of which may be in some open heart surgery like valve replacement and in gastroenterology surgery like cholesystectomy. In spite of that requirement of Blood and its component in West Bengal is over 14-16 lacks units every years in population of 8.6 cores of the state. In West Bengal, Blood Banks are concentrated mostly in big towns and in metropolis. In West Bengal State Government Run Blood Banks are 58 in numbers, Private business run Blood Banks 32 in numbers and Central Government run Blood Banks are 16( total 106). The main source of Blood and components of Blood in Blood Banks in West Bengal is two types 1) voluntary Blood Donation &2) Replacement donation.

Year           Voluntary Donations             Replacement donation         Total Units
                   In blood Donation Camp          in Blood banks

1997-98           2,16,695                               1,,23113                          3,39,808

2005-06          4,44102                                 7,0759                            5,14,861

2006-07           5,53141                               7,8308                             6,31449
                                In Govt Run Blood banks

1997-98           1,89.869                               1,02,233                         2,92096

2005-06           4,03,309                                058,961                         4,62070
 2006-2007      4,13085                                  5,11,74                         5,64259
 District wise collection of Blood shows in the last year shows highest collections[ maintaining Blood donation & collection rules of Drug Controller of India) occur in Greater Kolkata (3,89,659 units) from suburb, followed by in Burdwan district( 4,1733 units) Mednapore (2,7845 units) when least collection is found in south 24 parganas, Purulia, Dinajpur districts, Birbhum and in Hoara districts( range of collection is 1000-3000 units a year). The above table shows that in spite of a very high level of governmental propaganda from the health department for population to donate his/her blood and to save a life, collection of blood units in the state of West Bengal is less than half what it requires [ In spite collection of units increases every years] and as such blood is not often available in regional or central blood banks and blood banks runs dry many a month of a year. The collection and donation of blood depends on  donors will. No person can force to donate his organ and blood is organ.
 The main source of blood in Blood Banks of the developing counties or in this state of West Bengal is voluntary blood Donation with a certificate or a token memento and it is dependent of motivation of people to donate his/her blood  mostly by younger generation of people( average blood donors age here 18-38 years old population as they have ideology in mind and  it is from distant suburb or villages blood camps). The metropolis educated people are less interested to donate his/her blood but  highly demanding when they require. It has been found that 80% of regular voluntary blood donors from village, suburban or urban areas are there anemic (Hb level<10 gm/dl) as anemia is highly prevalent in West Bengal state in village population. Blood Donation is a  no doubt a safe procedure and does not cause harm to donor when blood is collected maintaining strict Drug Controller of India Guide lines and SOP. The question plays in conscious people minds probably of metropolis “why shall I donate my blood to save life of others who are not related to mine, not known to myself and for a blood Bankers who will do business and make profit out of my donated blood in the open market? More over there remain donor psychological reactions of occurring some adverse blood donation reactions mostly Vasovagal shock, pain at phlebotomy site(9%) Giddiness and nausea(2-3%), Tingling & twitching (4%),hematoma at collection site, multiple pricking, very few incidences of tetany and transient seizure with loss of consciousness for few seconds, which symptoms can be reduced however prior consultation with donors. Many persons has fear of Blood donating can leads to AIDS(30%), leads to weakness(18%), afraid of needles(23%). city Population thinks they must not donate blood in spite of incentive tokens, memento certificates etc.
 In the field of blood banking, the main focus of our attention remains in making the transfusion therapy most safe. Scientists working in this field are making thus concreted efforts to improve methodologies and technologies and the journey began with very simple ABO  Rh, Du  Bombay blood grouping test[ agglutination], reverse group test and cross matching, microscopy for Malaria, filarial Parasites, serology for malarial antigens, agglutination reaction to confirm ABO group, Passive hemagglutination for VDRL reaction, to highly sensitive tests like nucleic acid tests. Efforts are also made for higher sensitivity of diagnostic tests to increase the detectable limit of pathogens ( Bacteria & virus like Hepatities B hepC ,TT, HIV1,HIV2 JCE ,prion). In spite of modern tests were included continuously emerging pathogens threats blood transfusions related transmitted infections rate and cost of unit of Blood is increasing in open market due to battery of tests.  In west Bengal rate of Transmission of HIV1 through donated blood is 2,7% in spite of donated blood is tested for HIV1 and discarded if equivocally positive & destroyed.. Total seropositive rate of HIV in VCTC of Blood banks is 8.5% in Male and 8.8% in female amongst population who donate bloods.
 In the last century, the blood banks not only dealt with patients sample but with blood donors and patients also and carry out simple procedures like screening , whole blood collection, component preparations, stem cell harvesting and stem cell banking.
Do we require Blood  substitute or engineered blood? According to first author myself Of course and yes.  My (first authors)  passed away(1925-2009) old father late. Bholanath Bhattacharya had sever bronchiactesis, chronic bronchitis and COPD who often in a years or two  used to bleed (massive haemoptosis) and required  then admissions at Panihati State General hospital  [a secondary level Care Hospital of state) at suburban village of West Bengal , Sodepur; Dist 24 parganas(north)- 30 km away from Kolkata central Blood Bank at Manik tala. There is one blood Bank at 20 km distance from sodepur at RG kar Medical college with component separation. Another at District town Barasat  District Hospital. In spite of the real fact that I was myself in charge of a hospital Blood Bank at state of art Post Graduate level teaching hospital, IPGMER/SSKM Hospital-kolkata-20, I feel so ashamed to say that I could not transfuse him even he went in a hyopovolemic shock from hemoptosis in  years1993,1995,1997,2002, 2006, whenever he was admitted in Panihati State General hospital with severe hemoptasis and he was immediately referred by visiting physician even in  hypovolumic shock stage at tertiary level hospital RG Kar Medical Colleges and within this 30- 35 km there is no human transfusable blood are still available. Why? Why no blood bank grew within Sodepur government secondary care  level state general hospital? More over in case of trivial street accidents[street accidents became a disease today in kolkata] patients often bleeds so profusely externally or internally from visceral injuries  pelvic injury or rupture of organs and die often out of hypo volemic, hypoxic shock and  simply due to want of blood transfusion. Numbers of blood banks are not sufficient for this state and mostly why concentrated in cities and metropolis I myself can not explain which can never satisfy needs of patients when in real emergency like  in severe haemoptosis,  severe varicial bleedings or severe malena or in PPH or in trivial accidental injuries or in soldiers when in a war which are real threats.  Question is why and how voluntarily donated human blood goes to private centers and private run business hospitals for treatment of upper middle class people and most time wasted for transfusion  not indicated and just to add in bill?. Most of these blood banks has no licensee from  The Drug controller of India to run such blood bank and it is criminal offence to sell blood privately and even to organize blood donation camp privately with aim to sell blood  in India ( under organ donation and sell prevention  act) .So questions of a substitute of blood/RBC/ Hb specially that can deliver Oxygen to issues to prevent  tissue hypoxia and shock and death is highly needed still.
 Ability to make unlimited quantities of RBC which can carry oxygen to vital organs and around the body is a  long dream yet for medical researchers for almost half a century. Few commercial companies, universities medical schools  are working so hard to find a substitute of RBC to carry oxygen to tissue. We authors do hypothesize that one of the solution may be- developing Hemoglobin solution. But to come up with substitute of RBC is still a question of  billion dollars and involvement of herculean tasks and brain. It involves complex molecular technologies and EC stem cell research.
 The good solution for this, may be according to first author, development of Universal RBC- O negative group RBCs that  must lacks both ABO & Rh antigens on their RBC cell surface as antigens or that are secreting an enzyme which can block antigenic sites of Recipient RBC. This can probably make RBC transfusion safer removing antigenecity of RBC.
 Stem cells are the cells that can both renews itself in unlimited numbers and can generate specialized functional differentiated lines progeny in unlimited numbers under certain environment and stimulus. Stem cells are classified by their development stages of origin and range of phenotypic potentials. Embryonic stem cells are derived from the inner cell layer mass of Blastocysts 4-5 days after conception and are pluripotent. Many scientist had shown that that it is possible to take a single stem cell from an early embryo left over IVF treatment and when stimulated with nutrient , other chemicals, growth factors and colony stimulated factors may they can one day successfully differentiate to any cell line. Then why not RBC? This technology  may be useful to multiply stem cells to supply RBC in unlimited numbers. If the stem cells are made  from a “O negative”  blood group parents early embryo blastocysts, called “ universal donor embryo”_ the O negative blood ,we may get Universal donor RBC- universal synthetic Blood

Problems-  our hypothesis has many problems too .Many question however remains to be solved with our Hypothesis. How much ethical the technology is? Universal synthetic blood of course will not have ABO or RhD antigen but of course and must will have other allo antigens like C c E e and Du antigens which are inherited from parents through genes of sperm or ova. So they may produce antibody for dCE, dce or dcE antigens in recipients other RBC alloimunization antigens may be present are  Mn  Le which are also clinically important.  There remains many other ethical questions also, as the embryo has to be destroyed and an embryo is life[?] has to be sacrificed and who will donate that embryo?. Can one kill a life when one can not give life? Institutional ethical committee of course will become a long standing problem behind such proposal and carry out the  real research. Another problem is fund to carry out the research.  FDA approval will be needed after phase I and II for human trial. One benefit is that these stem cell derived RBC will be free from any infections like Hepatitis B, Hep C, TT virus CJD virus, or HIV virus & prion proteins for mad cows diseases. The next questions remains whether the Hb solution or Universal stem cell derived RBC will be able to replace human RBC in Vivo? It might be helpful for immediate or some emergency treatment like use in street injuries or in soldiers amputation or bleedings. What will be biological life of these RBC or Hb solution? Will it be helpful for patients who needs chronic replacement of Hb or RBC support like patients of thalassemias, patients of refractory anemia? Or patients with leukemia or MDS or cancer after chemotherapy or radiotherapy? I, the first author personally belief that they will not be benefited. Another question remains what will be cost of therapy?. Cost may be a factor that will hinder in mass use specially for poors
 In future number of Blood Banks will come down and high capacity technically up sealed Central blood Bank will function rather in their place. Two types of blood transfusion service will then exist one will be large central or regional blood centers and there will be smaller hospital based blood banks having responsibilities limited to that hospital. Traditional blood banks will fade out. Stem cell production and dispensing them will be the main functions of Blood banks.

Copy Right of this article published in this Blogs  under following terms
Copy Right belongs to Prof. Pranab Kumar Bhattacharya and his first degree blood related relatives as per  IPR Copy Right Ac/t Rules of Intellectual Property Right and Protect Intellectual Property (PIP) act and laws of USA-2012. No Private blood bank, or person, or News paper. Journalists, Media personals, private Organizations, in the state of West Bengal or other states of country India  are not permitted by the first author to  use any word or scientifically meaning full  any sentences from this article as implementations in blood bank or laboratories or disseminate such the knowledge/hypothesis  or use of of stem cell for RBC production concept and if done will be considered as  infringement of copy right of  first author. It will be published as open access article in open access journal in due time and  can be viewed only with payment in internet issues.  Positive Comments are only  allowed from reasearchers.
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