research topics on blood bank

Review of current transfusion therapy and blood banking practices

Affiliations.

• 1 Food and Drug Administration, USA. Electronic address: [email protected].
• 2 UCSF Department of Laboratory Medicine, Blood Systems Research Institute, USA. Electronic address: [email protected].
• 3 Department of Pathology, Case Western Reserve University, USA; Department of Clinical Microbiology, University Hospitals Cleveland Medical Center, USA. Electronic address: [email protected].
• 4 Department of Pathology and Laboratory Medicine, University of Kansas Medical Center, USA.
• 5 Verax Biomedical Incorporated, USA. Electronic address: [email protected].
• PMID: 31405535
• DOI: 10.1016/j.blre.2019.100593

Transfusion Medicine is a dynamically evolving field. Recent high-quality research has reshaped the paradigms guiding blood transfusion. As increasing evidence supports the benefit of limiting transfusion, guidelines have been developed and disseminated into clinical practice governing optimal transfusion of red cells, platelets, plasma and cryoprecipitate. Concepts ranging from transfusion thresholds to prophylactic use to maximal storage time are addressed in guidelines. Patient blood management programs have developed to implement principles of patient safety through limiting transfusion in clinical practice. Data from National Hemovigilance Surveys showing dramatic declines in blood utilization over the past decade demonstrate the practical uptake of current principles guiding patient safety. In parallel with decreasing use of traditional blood products, the development of new technologies for blood transfusion such as freeze drying and cold storage has accelerated. Approaches to policy decision making to augment blood safety have also changed. Drivers of these changes include a deeper understanding of emerging threats and adverse events based on hemovigilance, and an increasing healthcare system expectation to align blood safety decision making with approaches used in other healthcare disciplines.

Keywords: blood transfusion; cold stored platelets; cryoprecipitate; hemovigilance; lyophilized plasma; pathogen reduction; patient blood management; plasma; platelets; red blood cells.

Copyright © 2019 Elsevier Ltd. All rights reserved.

Publication types

• Blood Banking / methods*
• Blood Preservation / methods
• Blood Safety / methods
• Blood Transfusion / methods*
• Transfusion Medicine / methods

• Frontiers in Medicine
• Research Topics

Transfusion Medicine and Blood

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Transfusion medicine is in perpetual evolution and has faced several challenges from donors screening to clinical practices through blood preparation. Nowadays, blood is mainly processed in its different components that are red blood cells, platelets, plasma and some therapeutics. This incredible story ...

Keywords : Blood, blood products, donors, hematology, transfusion medicine

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Peer-reviewed

Research Article

A generic blood banking and transfusion process-oriented architecture for virtual organizations

Contributed equally to this work with: Anwar Rjoop, Shaima’ Elhaj

Roles Conceptualization, Formal analysis, Investigation, Methodology, Project administration, Supervision, Validation, Writing – original draft, Writing – review & editing

* E-mail: [email protected] (AR); [email protected] (MO)

Affiliation Department of Pathology and Microbiology, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan

Roles Data curation, Formal analysis, Project administration, Validation, Writing – original draft, Writing – review & editing

Affiliation Center for Cancer Care Informatics Research, King Hussain Cancer Center (KHCC), Amman, Jordan

Roles Formal analysis, Methodology, Supervision, Writing – original draft, Writing – review & editing

Affiliations Center for Cancer Care Informatics Research, King Hussain Cancer Center (KHCC), Amman, Jordan, College of Technological Innovation, Zayed University, Dubai, UAE, Information Science Department, University of Jordan, Amman, Jordan

Affiliations Center for Cancer Care Informatics Research, King Hussain Cancer Center (KHCC), Amman, Jordan, Software Engineering Department, Faculty of Science and Information Technology, Al Zaytoonah University of Jordan, Amman, Jordan

Roles Supervision, Writing – original draft, Writing – review & editing

Roles Conceptualization, Formal analysis, Investigation, Methodology, Supervision, Writing – original draft, Writing – review & editing

Affiliations Center for Cancer Care Informatics Research, King Hussain Cancer Center (KHCC), Amman, Jordan, College of Arts, Technology and Environment, University of the West of England, Bristol, United Kingdom, Global Academy for Digital Health, United Kingdom

• Anwar Rjoop, 
• Shaima’ Elhaj, 
• Dina Tbaishat, 
• Yousra Odeh, 
• Asem Mansour, 
• Mohammed Odeh

• Published: June 5, 2024
• https://doi.org/10.1371/journal.pone.0303970
• Peer Review
• Reader Comments

Blood banks are an important part of healthcare systems. They embrace critical processes that start with donor recruitment and blood collection, followed by blood processing to produce different types of blood components used in transfusions, blood storage, blood distribution, and transfusion. Blood components must be generated at high quality, preserved safely, and transfused in a timely manner. This can be achieved by operating interrelated processes within a complex network. There is no comprehensive blueprint of Blood Banking and Transfusion (BB&T) processes and their relationships; therefore, this study aims to develop and evaluate a BB&T process architecture using the Riva method.

Research design

This research adopts a design science research methodology process (DSRM) that aims to create artifacts for the purpose of serving humanity through six phases: identifying problems, identifying solutions and objectives, designing and developing artifacts, demonstrating and evaluating the artifacts, and communicating the work. The adapted DSRM process is used to build a process architecture in the BB&T unit to improve the quality and strategic planning of BB&T processes. Applying the adapted DSRM process generated four increments before the outcomes were communicated as a highly comprehensive BB&T process architecture (BB&TPA) blueprint for virtual organizations. Finally, the generated BB&TPA is tested and validated at a reference hospital.

A Riva-based process architecture diagram was successfully developed, acting as a reference model for virtual BB&T organizations. It is a novel output in the domain of BB&T and can also be considered as a reference model to evaluate the existing processes in BB&T real-world units. This assists domain experts in performing gap analysis in their BB&T units and paths for developing BB&T management information systems and can be incorporated in the inspection workflow of accreditation organizations.

Citation: Rjoop A, Elhaj S, Tbaishat D, Odeh Y, Mansour A, Odeh M (2024) A generic blood banking and transfusion process-oriented architecture for virtual organizations. PLoS ONE 19(6): e0303970. https://doi.org/10.1371/journal.pone.0303970

Editor: Stephen Emilio Njolomole, Kamuzu University of Health Sciences, MALAWI

Received: January 11, 2024; Accepted: May 3, 2024; Published: June 5, 2024

Copyright: © 2024 Rjoop et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are within the manuscript and its Supporting information files.

Funding: The author(s) received no specific funding for this work.

Competing interests: The authors have declared that no competing interests exist.

Introduction

Blood banks are mission-critical systems and an important part of healthcare systems. They embrace critical processes that start with donor recruitment and blood collection, followed by blood processing, storage, and distribution to produce different types of blood components used in transfusions. These blood components must be generated at high quality and preserved safely. Technicians, nurses, and physicians face various challenges in managing transfusion complications. Blood shortage is a major concern for stakeholders and has been exacerbated more in middle- and low-income countries [ 1 ]. This limits the timely administration of blood units when needed. According to Abderrahman and Saleh, this is a major concern, especially in developing countries such as Jordan and Saudi Arabia [ 2 ]. Identifying all processes in the blood bank and linking these processes together is essential for early monitoring of workflow and troubleshooting errors.

Business Process Architecture (BPA) is one of the most important methods utilized in business domains to blueprint a common understanding of running processes and their dynamic interactions from a high-level perspective. BPA can assist stakeholders in identifying process gaps and pitfalls [ 3 ]. To minimize risks, attain good blood banking and transfusion clinical and planning practices, and improve the quality of blood banking and transfusion (BB&T) products and services, it is worth looking at the existing processes more closely. Not only this, but we are also looking forward to digitizing this organization and making it virtually available to all stakeholders, namely the BB&T virtual organization.

In the literature, the Riva method has been employed to develop a BPA for various organizations in the healthcare sector, such as cancer care centers and cancer registries [ 4 – 9 ]. “Riva is a method for eliciting, analyzing, and designing the organizational architecture of business processes.” [ 3 ]. The resulting BPA of the Riva method is based on deriving essential business entities that have an important lifetime for the organization [ 3 , 5 , 10 , 11 ].

The remainder of this paper is structured to describe the following: background, research design used to develop Process Architecture PA, evaluation and reflections on BB&T PA, conclusion, and future work.

The BB&T unit at King Abdullah University Hospital (KAUH) is a division in the pathology and laboratory department that offers transfusion services by handling blood donations and producing various types of blood components such as packed red blood cells, fresh frozen plasma, platelets, and cryoprecipitate. In addition, it provides routine blood tests, such as blood genotyping, blood phenotyping, cross-matching, and direct and indirect Coombs testing [ 12 , 13 ]. It also provides infectious disease tests and blood component modifications (e.g., irradiation and leukoreduction) [ 13 ]. These services require the operation and coordination of many activities, starting from the blood bank reception, where a blood donor questionnaire is completed, followed by drawing blood in a donation room. Subsequently, blood storage, processing, and preparation take place in the designated rooms. Finally, a blood transfusion is performed in the inpatient department. The blood bank of KAUH receives approximately 10,000 regular donors annually and performs 193 single-donor procedures.

To understand business processes and their interactions in the big picture, a process architecture diagram is necessary for development and maintenance. In the literature, BPA are referred to as clusters [ 14 ], process maps [ 15 , 16 ], or process landscapes [ 17 – 19 ]. Despite the crucial role of blood banks and transfusion in health systems and services, the literature lacks a blueprint that presents the entire blood banking and transfusion processes and their relationships. Consequently, the development and application of BPA in this field have not yet been explored. The aim of this study is to develop and evaluate a generic Blood Banking and Transfusion Process Architecture (BB&TPA) designed using the Riva method.

Methods and design

Ethical considerations.

This study was conducted according to the principles expressed in the Declaration of Helsinki; no personal patient information was used, and the outcomes did not have a direct impact on patient treatment. This study was approved by the institutional ethics review board (IRB number 39/139/2021).

BB&T process architecture development (Research framework design).

The design of this research adopts the Design Science Research Methodology process (DSRM) that aims to create artifacts to serve humanity through six phases: identifying problems, identifying solutions and objectives, designing and developing the artifact, demonstration, evaluating the artifact, and communicating the work [ 20 ]. During the entire life cycle of the DSRM process, the phases iterate, overlap, and incrementally deliver the output to adjust the development of an artifact for the best benefit to address a solution to an identified problem [ 20 ]. The DSRM has been widely used in many health informatics studies in the literature [ 4 – 6 ]. It has also been used to design a Riva-object-based process architecture and evaluate the effectiveness of its heuristics [ 4 ].

The Riva method for identifying an organization’s business process architecture comprises seven steps:

• Identify the organization and its boundaries. This means identifying what we want to look at.
• Characterize an organization that can be specified abstractly through objectives. This is elaborated by eliciting a set of candidate essential business entities by answering a set of questions, such as “What do we make?”, “What services do we offer,” and so on [ 3 ]. The questions were customized to fit the domains.
• Find the essential business entities.
• Identify the units of work.
• Identify dynamic relationships between units of work.
• Transform the unit of work diagram into a first-cut process architecture.
• Transform the first-cut process architecture into a second-cut process architecture.

Step 1 and Step 2: The Riva BPA method has seven steps, as illustrated above: The first and second steps align well with the first and second phases of the adapted DSRM process for this research, related to problem identification and defining objectives; in this case, the problem is specified in the absence of a process architecture in the BB&T unit at KAHU to improve the quality and strategic planning of BB&T processes. This research gap was identified based on the literature. The rest of the Riva method steps were applied in the third, fourth, and fifth phases. As for steps 3–7 of the Riva method, they are considered a form of four iterations over phases 3 to 5 of the adapted DSRM process, generating four increments before the outcomes are communicated and publicized through the concerned stakeholders and publications in phase 6.

The BB&T Process Architecture (PA) is a virtual representation of this unit at KAUH, where its processes evolve with emerging changes in the domain and organization. Therefore, this study aims to develop a highly representative BB&T PA to enact as a lower boundary unit where all processes and their associated resources coordinate to achieve a lower boundary goal. BB&T PA allows similar BB&T units to reuse the resulting BB&T PA to specify whether it is fully or semi-virtual or not. Two research questions (RQ) were formulated to achieve the aims of this study.

• RQ1: How to design the BB&T unit at KAUH using the Riva method?
• RQ2: How to evaluate the representativeness of BB&T PA that involves processes and their relationships?

Phase 1: Define the Research Problem:

In this phase, the research problem was identified. Based on the literature, a notable absence of process architecture in the BB&T unit at KAUH for the purpose of improving the quality and strategic planning of BB&T processes is recognized.

Phase 2: Define the Objectives of the Solution:

This phase involves identifying the objective of this research: to develop and evaluate a comprehensive BB&T PA using the Riva method to act as a representative reference model for a process-oriented BB&T virtual organization. To enrich the specification of this objective, this phase involves applying the first and second steps of the Riva method [ 3 ]. The first step entails agreeing with an organization’s business boundary and the scope of interest that the organization is interested in [ 3 ]. In this regard, we are interested in examining the blood banking and transfusion domains at KAUH [ 12 , 13 ]. This indicates the boundary of the anticipated solution, namely, the BB&T PA at KAUH.

According to the Riva method, the second step entails characterizing the BB&T organization. This step enriches the description of the anticipated solution. A list of 14 heuristics in the form of questions should be answered to elicit Candidate Essential Business Entities (CEBEs). The questions were distributed to 20 key stakeholders ( S1 Appendix ) in the form of a questionnaire ( S2 Appendix ) in the period from 01.04.2021 to 30.04.2021 (the stakeholder is defined as a person with a vested interest, or stake, in the decision-making and activities of the blood bank and transfusion services). The adult participants provided informed consent. The authors contributed to the 14 heuristic questions by permitting stakeholders to score the degree of confidence for each CEBE, indicating the clarity of each heuristic (yes/no question), and suggesting rephrasing of each heuristic if needed. As the participants were extremely busy, getting them together in a brainstorming session was very difficult; therefore, each heuristic was explained in detail to each participant individually in a face-to-face meeting. The responses were submitted within one week, and as per the participants’ feedback, they believed that some open-ended questions required in-depth thinking. The questionnaire resulted in 150 CEBEs that were reduced to 136 after duplicates were removed.

Phases 3 to 5: Design, Development, Demonstration, and Evaluation

The Riva method steps from 3 to 7 are conducted in the form of iterations over phases 3 to 5 of the adapted DSRM process, generating four increments before the outcomes are communicated and publicized through the concerned stakeholders and publications in phase 6. Fig 1 summarizes the phases of the framework.

• PPT PowerPoint slide
• PNG larger image
• TIFF original image

https://doi.org/10.1371/journal.pone.0303970.g001

Step 3: Find the Essential Business Entities

Different filters were used to filter CEBEs into Essential Business Entities (EBEs). For example, one filter requires that “a” or “the” be prefixed to each CEBE in turn, and if the resulting phrase makes sense, then the CEBE is deemed to be an EBE [ 3 ]. The final number of EBEs was 80, as listed in Table 1 . It is worth mentioning that two meetings were held with domain experts to validate the filtration of the CEBEs into EBEs. In addition, a few EBEs have been renamed for ease of use [ 3 ]. For example, an EBE called “manage the transfusion reaction” is renamed to “post-transfusion,” which will include all activities happening after the initiation of the transfusion. In addition, the word “manage” will be added in front of the EBEs at some later steps, if needed, according to Riva method instructions [ 3 ].

Units of Work (UOW) are highlighted in bold font.

https://doi.org/10.1371/journal.pone.0303970.t001

Step 4: Identify the Units of Work (UOW):

In this step, EBEs were filtered into Units of Works (UOW), which are EBEs with an important lifetime. The total number of UOW resulting from this filtration process was 16, as highlighted in bold font in Table 1 .

As suggested by Ould [ 3 ], for unseen UOW that may not be derived through heuristics, the author scanned the department names. Moreover, UOW were examined by adding “change to “or “collection of” prior to the UOW, to reveal whether a candidate UOW creates another UOW. Three ‘unseen’ UOW were identified: blood unit, blood processing, and quality plan.

Deriving UOW from literature is a novel method developed by the authors. First, during the literature review, every term related to blood bank and blood transfusion was examined to see whether it was compatible with the specification of UOW. Subsequently, a list of candidates UOW was developed based on the literature review. Finally, the list was reviewed by both the authors and validated by a domain expert. Consequently, 20 UOW were extracted from the literature.

In comparison to those derived through the Riva method, 19 UOW were identical, in addition to a new UOW called “blood donor recruitment” derived from the literature. Hence, this denotes new information for the candidate process.

Step 5: Identify Dynamic Relationships Between Units of Work

To design the UOW diagram, the architect ought to determine all the ‘generate’ relationships among all the UOW that were identified in the previous step [ 3 ]. The ‘generate’ relationship means that if there are two units of work, i.e., one is called A and the other is called B, during the lifetime of UOW A, the UOW B is generated [ 3 ]. The ‘generate’ relationship covers other concepts such as ‘activate,’ ‘require’ and “call for” [ 3 ]. The UOW diagram is designed where each UOW is represented in a hexagonal shape, and the relationships are indicated by arrows with the titles of the relationships. If an outside relationship is found to generate a UOW, this outside party is represented as a cloud [ 3 ].

The 20 UOW extracted using the Riva method and literature review were ordered alphabetically. Each UOW was then selected separately, starting from the first UOW in the list, and its relationships with all the other 19 UOW were examined. The UOW diagram is shown in Fig 2 .

https://doi.org/10.1371/journal.pone.0303970.g002

Step 6: Transform the Unit of Work Diagram into a First-Cut Process Architecture

To develop the first-cut architecture diagram, three processes are hypothesized for each UOW as follows: the Case Process (CP) occurs during the lifetime of a single case of the UOW [ 3 ]. A Case Management Process (CMP) occurs when managing the flow of several cases of the same type of UOW [ 3 ]. The Case Strategy Process (CSP) occurs only for UOW that require maintenance or changes [ 3 ]. Next, each relationship should be classified into either a ‘service’ relationship, which means that the generated UOW is generated independently from the generating UOW, or a “task force” relationship, which means the generated UOW is generated dependently on the generating UOW [ 3 ]. There are general rules for designing ‘service’ and “task force” relationships [ 3 ].

The general rule for designing the ‘task force’ relationship states that if UOW (A) generates UOW (B), then (A) CP requests (B) CMP, (B) CMP negotiates (A) CP, (B) CMP starts and monitors, intervenes, or stops (B) CP, (B) CMP negotiates (A) CMP, and (B) CP delivers to (A) CP. The general rule for designing a “service” relationship is similar to the general rule for designing the ‘task force’ relationship, except that there is no CMP in the service type relationship.

The CPs, CMPs, and CSPs for BB&T organization UOW were determined. According to the domain expert, the UOW that have CSPs are “Funding Facilitation,” “Blood Donation Campaign,” “Blood Shortage Crisis,” “Blood Donation,” “Biomedical Waste,” “Blood Donor Recruitment,” “Data Pool for Research,” “Safety Measure,” and “Quality Control.” Then, all the relationships between the processes of the BB&T organization are classified as “service” relationships or “task force” relationships. The architecture of the first-cut process is shown in Fig 2 .

Step 7: Transform the First-Cut Process Architecture into a Second-Cut Process Architecture

In this step, Ould proposed five heuristics to transform the first-cut process architecture into a second-cut process architecture [ 3 ]. These heuristics include folding task force CMP into the requesting CP, dealing with 1:1 “generates” relationships, delivery interactions and delivery chains, collections, and empty CMPs [ 3 ]. These heuristics were applied to the first-cut BB&T organization diagram to generate the second-cut architecture, as shown in Fig 3 , resulting in 45 interrelated processes.

https://doi.org/10.1371/journal.pone.0303970.g003

The second-cut process architecture of the BB&T organization is the actual BB&T PA, as shown in Fig 4 . This is the first process architecture for the BB&T organization that links all BB&T processes into a coherent blueprint. This can be generalized as a reference process architecture (PA) for all similar BB&T organizations. Moreover, this resultant architecture is a “to-be” model that acts as a BPA blueprint for the business at this stage. Finally, the architecture was constructed based on inputs from both the BB&T industry and literature sources to make it as solid, comprehensive, and generic as possible.

https://doi.org/10.1371/journal.pone.0303970.g004

Phase 6: Communication

The resulting BB&TPA was communicated to domain experts to evaluate its representativeness. The output solution artifact from these phases, which is the deliverable point of this research, is a highly comprehensive BB&TPA blueprint for virtual organizations.

Results and discussion

Evaluating the blood banking and transfusion process architecture.

The purpose of this section is to evaluate the resulting BB&TPA by applying it to a real BB&T organization. This was conducted by testing it in the blood bank and transfusion section at KAUH [ 11 , 12 ]. The processes in the second-cut architecture were compared to real-world blood banking and transfusion processes. A comparison was performed on several dimensions. The first dimension relates to the process level, verifying whether all processes in the resulting BB&TPA are identified and are running at KAUH. Other comparison dimensions were conducted at the levels of activities, roles, data, Standard Operating Procedures (SOPs), guidelines, and policies for each process.

To manage this evaluation, domain experts divided the second-cut architecture into four function-based units (functional units): “Blood Component,” “Blood Donation,” “Quality Management,” and ‘Transfusion’ represented as the divisions of the BB&TPA, as shown in Figs 5 – 8 , respectively. Subsequently, a table of five columns demonstrating the evaluation was developed as an evaluation tool. The first column lists the functional unit. The second column represents the domain expert agreement regarding the presence of the functional unit at KAUH. The list of all related processes in each unit of BB&T PA is shown in the third column. The fourth column shows whether the processes in BB&T PA currently exist at KAUH. Finally, the fifth column presents the implications of the BB & T PA processes in a real-world example. The last column is divided into sub-columns to address issues related to relationships between processes, roles, data, policies, activities, and SOPs. Table 2 presents the evaluation results.

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https://doi.org/10.1371/journal.pone.0303970.g007

https://doi.org/10.1371/journal.pone.0303970.g008

https://doi.org/10.1371/journal.pone.0303970.t002

Reflections on the blood banking and transfusion process architecture

The work of this paper has made a significant contribution to the BB&T department at KAUH by designing its BPA. The key contributions of the PA diagram are represented in providing a blueprint of the current BB&T processes and their relationships that have already been absent, acting as a common communication ground for stakeholders, and raising awareness among staff about the current running processes and their dependencies, which would facilitate implementing changes starting at a higher level. Most importantly, the development of BPA revealed that 16 BB&T processes were missing at KAUH: three CPs, three CMPs, and all ten CSPs. The term “missing” is defined in two ways: either the process is totally absent in the hospital, and in this case, it is called “absolutely missed process,” or the process is formulated generally, not defined specifically, but can be extracted from the hospital or organization’s general processes, and, in this case, it is called “partially missed process.” These are mostly related to the strategic view of the blood bank processes; thus, they cannot be defined specifically in the blood bank, and can be extracted from the hospital/organization’s strategic view. It is important to highlight these partially missed processes to correlate their dependencies and improve these areas. Table 3 presents the missing BB&T processes at the KAUH.

https://doi.org/10.1371/journal.pone.0303970.t003

As shown in Table 3 , some processes were absent in all three basic forms (CP, CMP, and CSP), including processes related to “blood donor recruitment,” “pool for research,” and “funding facilitation.” The absence of these processes has implications for other processes. Starting with “blood donor recruitment,” the missing CSP (“maintain the strategic view of blood donors’ recruitments”) leads to a missing written strategic plan for blood donation marketing that aims to raise awareness about the benefits of blood donation through a society that encourages people to donate blood, as well as failing to have a plan to keep blood donors as regular ones. In addition, because of missing the CSP "maintain the strategic view of blood donors’ recruitments", both "Manage the flow of blood donors’ recruitments" (CMP) and "handle a blood donor recruitment" (CP) will be lost. This means that there is no “handle a blood donor recruitment” (CP) to request “manage the flow of blood donations” (CMP) and “manage the flow of blood donation campaigns” (CMP). Thus, there are no more blood units to replenish the blood stores that usually suffer from shortages. The loss of the negotiation between "manage the flow of blood donors’ recruitments" (CMP), which is the process that deals with prioritizing and managing targeted people to be retained as regular blood donors, "manage the flow of blood donations" and "manage the flow of blood donation campaigns" at KAUH, is another example of missing relationships between the BB&T processes. The absence of these relationships prevents replenishing the blood bank with the required blood volume.

The "data pool for research" is another significant example of how” basic processes (CP, CMP, and CSP) have been lost at KAUH. The absence of “maintain the strategic view of data pools for research” (CSP), which is responsible for preparing maintenance plans to keep the "manage the flow of data pools for research" (CMP) and "handle a data pool for research" (CP) for ongoing research, will lead to a lack of processes that are driven by it. According to the BB&TPA, “manage the flow of the data pool for research” (CMP) is requested by “prepare a transfusion” (CP), “handle an aphaeresis” (CP), and “handle a post-transfusion” (CP). This is to provide them with the necessary information about the appropriate dose for transfusion and recommendations for the best way to prevent, diagnose, and manage transfusion reactions or complications, such as transfusion-transmitted diseases. Consequently, the absence of “manage the flow of data pool for research” (CMP) means that there are no request and negotiation relationships with “prepare a transfusion” (CP), “handle an aphaeresis” (CP), and “handle a post-transfusion” (CP). This means that there will be no recommendation data to decrease transfusion reactions and other complications; hence, improving “handle a post-transfusion,” which is significant to raising the efficiency of “prepare a transfusion” (CP). Furthermore, failing to "handle a data pool for research" (CP), that is, failing to handle one data pool by collecting, analyzing, and representing the data, means there is no "report" relationship to produce a precise report to “manage the flow of the data pool for research" (CMP).

Furthermore, as for the missing basic processes (CSP, CMP, and CP) of “funding facilitation,” the absence of “maintain the strategic view of funding facilitations" (CSP) leads to missing both "manage the flow of funding facilitations" (CMP) and "handle a funding facilitation" (CP), because “maintain the strategic view of funding facilitations" (CSP) is responsible for establishing a maintenance plan to ensure the continuous operation of its related CMP and CP. Moreover, the "manage the flow of funding facilitations" (CMP) is required by four CPs: "handle a blood donor recruitment,” "handle a blood donation campaign,” "handle a blood donation,” and "handle a blood shortage crisis,” so the absence of "manage the flow of funding facilitations" (CMP) will directly or indirectly reduce the number of "run a donation campaign" (CP), "handle a donation recruitment" (CP) and "handle a blood donation” (CP), resulting in failure to replenish the volume of donated blood, which will exacerbate the shortage of blood volume, an already existing challenge for blood banks. On the other hand, “manage the flow of funding facilitations” (CMP) is requested by “handle a data pool for research” (CP) which could play a pivotal role in ameliorating the transfusion reaction. Consequently, failure to run the former process may result in failure to achieve the latter. It is highly recommended to look after the basic processes of “funding facilitation” at KAUH for its significant role in supporting several BB&T processes such as “handle a blood donor recruitment” (CP) and “run a blood donation campaign” (CP). This could alleviate the blood volume shortage and transfusion reactions, the main challenges that confront blood banks, transfusion stakeholders, and patients, especially those with cancer.

As mentioned at the beginning of this section, all CSPs appear to be missing at KAUH. Three of these were discussed above, as their related CMPs and CPs were missing. The absence of the other seven CSPs may lead to the absence of several related processes that may affect the sustainability of these critical processes. For example, missing “maintain the strategic view of blood donations” (CSP), “maintain the strategic view of blood donation campaigns” (CSP), and “maintain the strategic view of blood shortage crises” (CSP) may prevent the blood store from further replenishing, which is essential for overcoming the blood shortage. In addition, failing to “maintain the strategic view of safety measures” (CSP),“maintain the strategic view of quality controls (CSP),” “maintain the strategic view of data pools for research” (CSP), and “maintain the strategic view of funding facilitations (CSP)” will have an impact on the quality of the service delivered, such as the incidence and management of transfusion reactions. On the other hand, missing the “maintain the strategic view of biomedical wastes (CSP)” specific to the blood bank would have an impact on environmental safety.

Missing out on CSPs in the process architecture seems to be common, possibly because it is not deemed relevant to the organization or is neglected [ 21 ]. Even Martyn Ould, who pioneered the development of the Riva method, did not specify associated activities [ 22 ]. Ould stated that CSPs are generally omitted from the process architecture diagram (PAD) unless they are of specific interest [ 23 ].

Addressing these missing processes is important for a better understanding of how the BB&T organization performs and runs the business. CSPs, in particular, are crucial for determining future strategies for CPs and CMPs. Furthermore, they are significant in terms of incremental improvements and radical changes. Identifying the missing processes through this research has helped the blood bank at KAUH link the gaps and urged them to rework existing laboratory policies, procedures, and documents at both the departmental and hospital levels, although working on the strategic view of these processes is still in progress [ 11 , 12 ].

After conducting the research gap analysis, we found that there is no comprehensive blueprint for BB&T processes and their relationships; therefore, one product of this research was developed: the BB&T process architecture comprised 45 processes, as shown in Fig 4 . Following the evaluation of BB&TPA by applying it to a real BB&T organization at KAUH, the process architecture was validated to be impactful and was able to inform the correctness and completeness of the blueprint. This blueprint has been used at KAUH to improve BB&T services; one example of the impact of this BB&TPA is identifying “handle a blood donor recruitment” as a missed process, so the blood banking unit is working on adding a policy to facilitate recruitment of donors, especially those who have rare blood types, and also incorporating a mobile phone application to ease the reach to the recurring donors when they are needed based on their location and blood types. It was found that the blueprints of case processes, case management processes, and case strategy processes that have been identified are representative of the domain from a blueprint point-view of processes. The relationships between the processes were found to be correct after they were reviewed. This opens further directions for research to comprehensively examine the governance of BB&T, and thus, this has also inspired further research that is being developed to do with informing quality governance of BB&T processes through the process architecture. Attempts have been made to build intelligent management systems in BB&T services, but with a fragmented approach, largely focusing on parts of the complete operations, such as the blood donation process [ 24 ]. The implementation of BB&T.PArch would serve as a guide for the development of intelligent systems for blood banking and transfusion services in a comprehensive manner.

Finally, it is worth mentioning that the researchers observed shortcomings in the Riva method. Questionnaires were used to answer a set of questions, and the original Riva method does not necessarily suggest using questionnaires. As for strategic modeling, the Riva method also does not have enough guidance; researchers tend to employ the notion of strategic process modeling throughout the transition from the UOW diagram to the first cut and the second cut process architecture. This adds another dimension to the Riva process architecture and its impact on the strategic view of BB&T's virtual organization and opens a new research avenue. Having built the blueprint of processes and their relationships, the next step can be process-modeling of each of those processes.

In terms of study limitations, identifying Essential Business Entities and Units of Work required distinguishing overlapping technical terms, such as “post-transfusion” and “transfusion reaction.” Furthermore, despite the comprehensive review of transfusion processes using the Riva method and the literature review search, in which every term related to blood banks and transfusions was examined to see if it was compatible with the UOW specification, additional processes may emerge when the generated BB&TPA is employed in multiple blood centers for some time. The BB&T PArch has been validated in a regional hospital (KAUH) that is accredited by national and international bodies, including JCIA and HCAC ( https://www.kauh.edu.jo/Home ). Consequently, as this hospital implements and adheres to the generalized services of these accrediting bodies (which adhere to international standards in relation to blood banking and transfusion), the BB&T.PArch is one attempt that portrays a generalized (but not “the” generalized) blueprint of the processes of blood banking and transfusion and their interactions and relationships. However, every implementation of the BB&T PArch is subject to the legal, social, ethical, professional, and technical requirements of the local blood banking and transfusion center, let alone alignment with its healthcare information systems.

A Riva-based process architecture diagram was successfully developed, showing 45 BB&T interrelated processes that acted as a reference model for a virtual BB&T organization. It is a novel output in the domain of blood banking and transfusion and can also be considered as a reference model to evaluate the existing processes in real-world BB&T units. The DSRM process was adapted for the application of the Riva BPA, which seems to be well-aligned as it led to validating each Riva method step with domain experts. The generated BB&TPA artifact can serve as a knowledge repository for developing a shared understanding of BB&T processes and their linkages. As a result, domain experts can do gap analysis in their BB&T units, plan the development of BB&T management information systems, identify any flaws in their practice, and trace related processes back to the flaw to maximize the impact of improvement, saving time and effort.

Another reflection is the incorporation of these processes in the inspection workflow of accreditation organizations, in which spotting a deficiency in one process can draw attention to processes linked to the deficiency area, working as a map for the inspection team.

The main challenges encountered in this study include the limits of the Riva approach while employing questionnaires and applying strategic modeling. Furthermore, the generated BB&TPA was evaluated in one blood center and additional processes may emerge when it is employed on a wider scale. Further follow- up will be needed.

This work opens further directions for research to comprehensively examine the governance of BB&T, and thus, this has also inspired further research that is being developed to do with informing quality governance of BB&T processes through the process architecture. Finally, as we have developed the blueprint of processes and their relationships, the next stage can be process modeling of each of those processes.

Supporting information

S1 appendix. list of stakeholders’ title and number who responded to the research questionnaire..

https://doi.org/10.1371/journal.pone.0303970.s001

S2 Appendix. The research questionnaire form.

https://doi.org/10.1371/journal.pone.0303970.s002

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Blood is essential to life and health. Prolonging life and improving health are at the foundation of the NIH Clinical Center’s mission, so maintaining an adequate and safe blood supply is vital to so much of what happens in the hospital. The NIH Blood Bank is where it all begins

The NIH Blood Bank has two locations: one in the Clinical Center on the NIH campus in Bethesda, Md., with an additional donor center in nearby Rockville, Md. The Clinical Center focuses on whole blood donations, where all blood components are collected in a single visit. The Rockville location offers easy access for community donors and collects only platelet and ‘double red cell’ donations, the latter being a specialized process where one donor can provide two units of red blood cells at one time while sparing the other elements of blood compared to conventional single unit donations.

As a part of the Clinical Center’s Department of Transfusion Medicine (DTM), the Blood Bank manages blood donations from its generous donors. Many donors are recruited from the local community but NIH staff and some patients and families represent a substantial proportion of blood donors - in 2019, 55% of blood donors were either NIH staff or patient family members. DTM uses most of these donations for transfusions in support of patient care at the hospital. About 20% of all blood donations are used for research conducted in over 200 NIH and U.S. Food and Drug Administration (FDA) scientific laboratories. Additionally, the DTM collects cellular products for development of experimental therapeutics for various illnesses, from sickle cell disease to many cancers.

“The Blood Bank obtains the blood used in transfusions for both adults and pediatric NIH patients,” said Al Decot, the Blood Bank’s marketing coordinator.

“Red blood cells are frequently used to treat patients with anemia related disorders, platelets are needed for blood clotting for bleeding patients, and granulocytes - white blood cells - are needed for patients with infections.”

Many NIH Institutes and Centers need a reliable blood supply for experimental and routine treatments, as well as laboratory research. The Blood Bank remains in continuous communication with patient care teams in the Clinical Center to anticipate their needs. All blood products used for NIH patients must meet the same FDA regulations that other organizations, such as the Red Cross, must meet. Donations used for research purposes are categorized and inventoried differently, having less restrictive criteria for donor eligibility.

Recruiting new donors through NIH-based blood drives and cooperative efforts with external organizations is key to maintaining an adequate supply. This has become more challenging as the COVID-19 pandemic reduced the active donor pool by 25%.

Significant efforts are made to ensure a pleasant donation experience for new and returning donors. To ensure donating is safe for the donor, a detailed questionnaire is completed to identify risks for potential complications. People donating blood must be at least 17 years old, and the Blood Bank works hard to expand their pool of younger donors to help complement the roster of older donors who cannot donate as frequently. There is no upper age limited as long as donor health is stable and established criteria are met.

Other screening rules are applied to assure donated blood is free from many potential types of blood borne infections. The FDA sets the screening criteria, which evolve as ongoing studies provide new information regarding donor eligibility and infectious dangers to the blood supply.

“Blood banking historically started with donors being paid. Then about 50 years ago, screening became increasingly recognized as an absolute necessity and paid donations were phased out with screened voluntary donations replacing them as a way to begin ensuring the safety of donated blood,” stated Dr. Leonard Chen, Staff Clinician of the Blood Services Section in the Department of Transfusion Medicine.

“The FDA and CDC carefully monitor the blood supply - right down to geographic regions, where certain types of infections may be more prevalent, and even for pathogens that are more likely to occur in certain seasons of the year,” added Chen.

Collecting a variety of blood types is key to maintaining a healthy blood supply. There are eight main types of blood: A, B, AB and O which can be either RhD positive or RhD negative. Group O (positive and negative) can be used for most patients who need blood transfusions and is constantly in need, along with platelets, which only have a short, five-day shelf life.

Using a patient’s correct blood type is vitally important as transfusion of an incompatible type can cause damage to multiple organs or even death.

“The blood type really clues us into to what kind of cell donation will benefit the patient the most. Sometimes there’s lab work involved to find what tranfusable product will be best for a particular patient,” said Decot.

The Blood Bank has invested time and resources into screening to ensure donations are safe for the blood donor and recipient.

“Don’t automatically rule yourself out - potential first-time donors should not assume that age, a particular health condition or other concern will inevitably lead to not being accepted as a donor. If anyone has questions about eligibility, call us to find out if you can help save lives,” added Decot.

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• Review Article
• Published: 14 May 2019

Cord blood research, banking, and transplantation: achievements, challenges, and perspectives

• Hector Mayani 1 ,
• John E. Wagner 2 &
• Hal E. Broxmeyer 3  

Bone Marrow Transplantation volume  55 ,  pages 48–61 ( 2020 ) Cite this article

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• Haematopoietic stem cells
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The first hematopoietic transplant in which umbilical cord blood (UCB) was used as the source of hematopoietic cells was performed in October 1988. Since then, significant achievements have been reported in terms of our understanding of the biology of UCB-derived hematopoietic stem (HSCs) and progenitor (HPCs) cells. Over 40,000 UCB transplants (UCBTs) have been performed, in both children and adults, for the treatment of many different diseases, including hematologic, metabolic, immunologic, neoplastic, and neurologic disorders. In addition, cord blood banking has been developed to the point that around 800,000 units are being stored in public banks and more than 4 million units in private banks worldwide. During these 30 years, research in the UCB field has transformed the hematopoietic transplantation arena. Today, scientific and clinical teams are still working on different ways to improve and expand the use of UCB cells. A major effort has been focused on enhancing engraftment to potentially reduce risk of infection and cost. To that end, we have to understand in detail the molecular mechanisms controlling stem cell self-renewal that may lead to the development of ex vivo systems for HSCs expansion, characterize the mechanisms regulating the homing of HSCs and HPCs, and determine the relative place of UCBTs, as compared to other sources. These challenges will be met by encouraging innovative research on the basic biology of HSCs and HPCs, developing novel clinical trials, and improving UCB banking both in the public and private arenas.

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Umbilical cord blood transplants facilitated by the French cord blood banks network. On behalf of the Agency of Biomedicine, Eurocord and the French society of bone marrow transplant and cell therapy (SFGM-TC)

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Acknowledgements

Research in the Mayani laboratory is supported by grants from the Mexican Institute of Social Security (IMSS) and the National Council of Science and Technology (CONACYT), Mexico. Publications reported from the Broxmeyer lab were supported by Public Health Service Grants from the National Institutes of Health: R35 HL139599, R01 DK109188, R01 HL056416, R01 HL112669, and U54 DK106846.

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Mayani, H., Wagner, J.E. & Broxmeyer, H.E. Cord blood research, banking, and transplantation: achievements, challenges, and perspectives. Bone Marrow Transplant 55 , 48–61 (2020). https://doi.org/10.1038/s41409-019-0546-9

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On Medicine

Topics in blood transfusion

Today marks World Blood Donor Day and so we asked Deputy Editor for Journal of Intensive Care , Hiroshi Morisaki, to explain more about the importance of blood transfusion, and how research in this area is progressing.

Hiroshi Morisaki 14 Jun 2016

To date, humans have uncovered a number of natural principles and issues such as the origin and mysteries of the universe, the earth and even life. We have simultaneously developed innumerable non-natural products for human use.

However, we have not yet succeeded in creating a man-made, cost-effective alternative to red blood cells (RBCs) despite the performance of extensive research and numerous clinical trials.

A life-saving intervention

The cellular health of the host requires an oxygen (O 2 ) supply that matches the O 2 requirements of its tissue. An insufficient O 2 supply results in ischemia, subsequently inducing tissue and/or organ injury, frequently observed in critically ill patients.

RBC transfusion, first performed over 300 years ago, remains a fundamental life-saving intervention in medicine.

Hemoglobin, which is enclosed in RBCs as an O 2 carrier, plays the most important role in supplying O 2 to the tissues. Accordingly, RBC transfusion, first performed over 300 years ago, remains a fundamental life-saving intervention in medicine.

Until the early 1980s, RBC transfusion was considered to be practically risk-free and a truly effective intervention in patients with active bleeding or anemia due to a variety of reasons in the intensive care field.

However, the threat of potentially-fatal transfusion-related infections, i.e., human immunodeficiency virus, has led physicians throughout the world to obviate this conventional intervention to the extent that is possible.

Research in the literature

In 1999, Canadian investigators examined the effects of a restrictive RBC transfusion strategy in comparison to a liberal strategy in critically ill patients. They indicated that a restrictive strategy was at least as effective as and possibly superior to a liberal transfusion strategy in critically ill patients with some exceptions.

Although several debates are currently ongoing, most physicians now agree that a restrictive strategy to limit RBC transfusion is a valuable approach in the treatment of stable patients with anemia.

However, we need to be cautious when interpreting the results of the Canadian study as it indicated some exceptions.

Even though we have seen extraordinary advances in medical science and related technology over the last several decades, clinical practices have been determined based on the balance between the benefits and related risks of intervention.

They found that a restrictive transfusion strategy was significantly associated with reduced mortality in younger patients and in those with less severe conditions. In other words, a liberal RBC transfusion strategy might be more effective for older patients and patients with more severe conditions.

RBC transfusion by itself is not an exception. The level of hemoglobin that works in some patients may not work in others. Indeed, a previous cohort study of intensive care unit patients suggests that restrictive RBC transfusion policies may not be uniformly applicable in the clinical setting.

World Blood Donor Day

In 2012, the World Health Organization (WHO) released a document entitled, “ Blood donor selection – Guideline on assessing donor suitability for blood donation ”. In this guideline, the authors noted that a careful process to assess the suitability of donors is essential for protecting the safety and sufficiency of the blood supply, and safeguarding the health of both ‘recipients’ and ‘donors’. We should therefore understand that blood transfusion not only improves the recipients’ conditions but also affects the donors’ health.

Away from the discussion of whether restrictive or liberal RBC transfusion strategies should be applied, natural human blood is needed to save the lives in emergency and long-term treatment settings, even in the 21 st century.

If you believe yourself to be in good health, you should donate your blood to prove it and to save lives at the same time.

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Topics in Health Care Operations: Blood Banks, Hospitals and Patients, and Telemedicine

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Part of the book series: Springer Series in Supply Chain Management ((SSSCM,volume 19))

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In this chapter, we pursue two main objectives, both related to health care operations. The first objective is to provide an overview of Morris Cohen’s main contributions to health care operations research and of the current research trends on the related topics: blood bank inventory management, patient in-hospital flows, and patient choice of hospitals. The second objective is to review recent developments on the adoption of telemedicine, a rapidly growing component of the health care delivery system, and the related research literature in the field of operations.

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Agarwal N, Jain P, Pathak R, Gupta R (2020) Telemedicine in India: A tool for transforming health care in the era of COVID-19 pandemic. J Educ Health Promot 9:190. Accessed January 21, 2022. https://doi.org/10.4103/jehp.jehp_472_20

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American Medical Association Digital Health Research (2020a) Physicians’ motivations and requirements for adopting digital health. Adoption and attitudinal shifts from 2016 to 2019. Accessed January 21, 2022. https://www.ama-assn.org/system/files/2020-02/ama-digital-health-study.pdf

American Medical Association (2020b) COVID-19 Physician practice financial impact survey results. Accessed January 21, 2022. https://www.ama-assn.org/system/files/2020-10/covid-19-physician-practice-financial-impact-survey-results.pdf

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Savin, S. (2022). Topics in Health Care Operations: Blood Banks, Hospitals and Patients, and Telemedicine. In: Lee, H., Ernst, R., Huchzermeier, A., Cui, S. (eds) Creating Values with Operations and Analytics. Springer Series in Supply Chain Management, vol 19. Springer, Cham. https://doi.org/10.1007/978-3-031-08871-1_12

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Harvard-led study IDs statin that may block pathway to some cancers

Cholesterol-lowering drug suppresses chronic inflammation that creates dangerous cascade

Tracy Hampton

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Statins, commonly used cholesterol-lowering drugs, may block a pathway that leads to the development of cancer from chronic inflammation, according to a new study led by investigators from Harvard-affiliated  Mass General Cancer Center .

The team’s experiments showed that environmental toxins, such as those caused by exposure to allergens and chemical irritants, create a cascade effect that stimulates inflammation in the skin and pancreas that, when chronic, can result in cancer. Their findings suggest that using statins to suppress this pathway may have a protective effect.

The findings are published in Nature Communications.

In mice, pitavastatin suppressed environmentally induced inflammation in the skin and the pancreas and prevented the development of inflammation-related pancreatic cancers. 

“Chronic inflammation is a major cause of cancer worldwide,” said senior author Shawn Demehri, a principal investigator at the Center for Cancer Immunology and Cutaneous Biology Research Center of Massachusetts General Hospital and an associate professor of dermatology at Harvard Medical School and the Bob and Rita Davis Family MGH Research Scholar 2023-2028 .

“We investigated the mechanism by which environmental toxins drive the initiation of cancer-prone chronic inflammation in the skin and pancreas. Furthermore, we examined safe and effective therapies to block this pathway in order to suppress chronic inflammation and its cancer aftermath,” Demehri said.

The study relied on cell lines, animal models, human tissue samples, and epidemiological data. The group’s cell-based experiments demonstrated that environmental toxins (such as exposure to allergens and chemical irritants) activate two connected signaling pathways called the TLR3/4 and TBK1-IRF3 pathways. This activation leads to the production of the interleukin-33 (IL-33) protein, which stimulates inflammation in the skin and pancreas that can contribute to the development of cancer.

When they screened a library of U.S. Food and Drug Administration-approved drugs, the researchers found that the statin pitavastatin effectively suppresses IL-33 expression by blocking the activation of the TBK1-IRF3 signaling pathway. In mice, pitavastatin suppressed environmentally induced inflammation in the skin and pancreas and prevented development of inflammation-related pancreatic cancers. 

In human pancreas tissue samples, IL-33 was overexpressed in samples from patients with chronic pancreatitis (inflammation) and pancreatic cancer compared with normal pancreatic tissue. Also, in analyses of electronic health records data on more than 200 million people across North America and Europe, use of pitavastatin was linked to a significantly reduced risk of chronic pancreatitis and pancreatic cancer.

The findings demonstrate that blocking IL-33 production with pitavastatin may be a safe and effective preventive strategy to suppress chronic inflammation and the subsequent development of certain cancers.

“Next, we aim to further examine the impact of statins in preventing cancer development in chronic inflammation in liver and gastrointestinal tract and to identify other novel, therapeutic approaches to suppress cancer-prone chronic inflammation” said Demehri.

Research support was provided by the Burroughs Wellcome Fund, the LEO Foundation, the Sidney Kimmel Foundation, and the National Institutes of Health.

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Original research

Knowledge of blood donation and associated factors in ethiopia: a systematic review and meta-analysis, addisu getie.

1 Nursing, Woldia University, Woldia, Ethiopia

Adam Wondmieneh

Melaku bimerew, getnet gedefaw.

2 Midwifery, Woldia University, Woldia, Ethiopia

Asmamaw Demis

Associated data.

bmjopen-2020-044343supp001.pdf

All data relevant to the study are included in the article or uploaded as supplementary information.

To assess the level of knowledge about blood donation and associated factors in Ethiopia.

Systematic review and meta-analysis.

Both published and unpublished cross-sectional studies on the level of knowledge about blood donation in Ethiopia were included. Articles from different databases such as PubMed/MEDLINE, HINARI, EMBASE, Scopus, Google Scholar and African Journals Online were searched. Cochrane I 2 statistics were used to check for heterogeneity. Subgroup and sensitivity analyses of evidence of heterogeneity were carried out. Egger’s test with funnel plot was conducted to investigate publication bias.

Twenty cross-sectional studies with a total of 8338 study participants (4712 men and 3626 women) were included. The overall nationwide level of knowledge about blood donation was 56.57% (95% CI 50.30 to 62.84). Being in secondary school and above (adjusted OR=3.12; 95% CI 2.34 to 4.16) and being male (adjusted OR=1.81; 95% CI 1.44 to 2.28) were the factors associated with level of knowledge about blood donation.

More than half of the study participants were knowledgeable about blood donation. Sex and educational status were the factors significantly associated with level of knowledge about blood donation in Ethiopia. Therefore, there is a need for education and dissemination of information about blood donation among the general population to build adequate knowledge and maintain regular blood supply.

Strengths and limitations of this study

• This study highlights the nationwide level of knowledge about blood donation in Ethiopia.
• This study covers a wide area and investigates different articles, making the review more accurate.
• Subgroup and sensitivity analyses were carried out to investigate the heterogeneity of the included studies.
• All included studies were cross-sectional in design, which may limit investigation of the cause–effect relationship.

Introduction

Blood donation is life-saving for people in different emergency conditions, such as road traffic accidents, surgical procedures, pregnancy and delivery complications, chemotherapy, and diseases such as malaria, anaemia and intestinal parasites. 1 Blood donation is a noble practice of saving the life of millions of people. Donating safe and adequet blood can safe up to three lives of a patient who need blood. 2

Although the demand for adequate and safe blood is significantly increasing, there is a serious and critical shortage of blood stocks in low-income and middle-income countries. In low-income and middle-income countries, family replacement and paid blood donors are the most common sources of blood transfusion. 3 The availability of blood for transfusion in low-income countries is very limited due to the low level of knowledge, unwillingness to donate blood and poor blood donation practices. Meanwhile, patients suffer from lack of blood transfusion due to increased need from different medical and surgical conditions 4

While every blood donor is considered a hero, the amount of blood collected from donors and the average rate of blood collection in low-income countries including Ethiopia are low compared with the demand for blood. 5 The act of family replacement therapy is a common blood donation practice than collecting from volunteer blood donors, which is a common predisposing factor for misconception towards blood donation practice. 6

As different studies have shown, the prevalence of level of knowledge regarding blood donation ranged from 32.4% to 40.45%. 7 4 8 Education, sensitisation of blood donation, increasing public awareness, and campaign through the internet and media are recommended strategies to increase awareness, attitude and motivational practice of blood donation. 9–11 Fear of the different health risks after blood donation and lack of information on where, when and how to donate blood are the most common factors that hinder blood donation. 12 Even though beliefs, attitudes and behaviours regarding blood donation differ, adequate knowledge is needed among non-donors. There is a gap between willingness to donate blood and the number of donors in most populations around the world, which affects the practice of blood donation. 13 There is a need to spread awareness on blood donation among the general population to maintain an adequate and safe blood supply, which can be done through well-designed communication strategies to overcome the problem. 7

While there is a very high need for blood supply in Ethiopia, there is a serious shortage of blood stocks in the country. Thus, identifying the different factors that hinder knowledge about the practice of blood donation is essential. This systematic review and meta-analysis aims to review the different studies conducted so far on the level of knowledge about blood donation and associated factors in Ethiopia.

Methods and materials

Study protocol.

In this meta-analysis, the Preferred Reporting Items for Systematic Review and Meta-analysis guidelines for reporting of findings were used 14 ( online supplemental table S1 ).

Supplementary data

Databases and search strategy.

Different databases such as PubMed/MEDLINE, Hinari, EMBASE, Google Scholar and African Journals Online were used to search for available articles. Both published and unpublished articles from the repository of Ethiopian universities were also searched. The search date was from 1 January 2000 up to 1 May 2021. Articles reporting on knowledge about blood donation and associated factors in Ethiopia were included in the final analysis. The search items were “knowledge” OR “awareness” AND “blood donation” OR “volunteer blood donation” AND “associated factors” OR “determinant factors” AND “Ethiopia”. These search strings were developed using “AND” and “OR” Boolean operators ( table 1 ).

Search of different databases for studies about level of knowledge and associated factors regarding blood donation in Ethiopia

Search and eligibility of studies

All retrieved articles were exported to EndNote reference software V.8 citation manager (Thomson, Stamford, Connecticut, USA) to sort and delete duplicates. Two investigators (AG and AD) independently evaluated each article by title and abstract, assessed the eligibility of the articles, and critically reviewed the selected articles. Extraction was done by author name, publication year, region where the study was conducted, study subjects, sampling method, method of survey, study period, sample size, study design, level of education, level of knowledge regarding blood donation and factors associated with level of knowledge about blood donation.

Eligibility criteria

Both published and unpublished cross-sectional studies conducted on the level of knowledge about blood donation among populations in Ethiopia were included, whereas qualitative studies, different trials, case reports, review articles, updates and news were excluded from the analysis. Furthermore, articles not reporting on the outcome of the study and those without full texts were excluded.

Outcome measurement of the study

There are two main outcomes, namely level of knowledge about blood donation and the factors associated with it. Level of knowledge was measured using the mean score on the knowledge assessment questions. Study participants who scored with a mean score and above on the knowledge assessment items were considered knowledgeable about blood donation, whereas those who scored below the mean score were considered not knowledgeable.

Quality assessment

Two authors (AG and AD) independently assessed the quality of the studies using the Newcastle-Ottawa Scale for cross-sectional studies. 15 Methodological quality, comparability, outcome and statistical analysis of the studies were the main assessment tools used to determine quality. Studies that scored ≥7 out of 10 were considered to be of high quality. During quality appraisal of the articles, any discrepancies between the two authors were resolved. All authors independently assessed the eligibility of the articles to be considered in the final analysis.

Data processing and analysis

In this systematic review and meta-analysis, a weighted inverse variance random-effects model at 95% CI was used to calculate the pooled prevalence of level of knowledge about blood donation and the associated factors. 16 After extraction and cleaning using Microsoft Excel spreadsheets, the data were exported to STATA V.11 statistical software for analysis. The heterogeneity of the studies was assessed using the Cochrane Q-test and I 2 with the corresponding p value. I 2 values of 25%, 50% and 75% represent low, moderate and high heterogeneity, respectively. 17 The source of heterogeneity was examined through subgroup analysis based on region, study subjects, study setting and sample size. Sensitivity analysis was also carried out to confirm the presence or absence of influential studies. The presence of publication bias was evaluated using Egger’s test and presented with funnel plots. 18 For associated factors, log OR was used to decide on the association between the associated factors and the level of knowledge about blood donation. A statistical test with a p value of less than 0.05 was considered statistically significant. 19

Patient and public involvement

It was not appropriate or possible to involve the patients or the public in the design, conduct, reporting or dissemination plans of our research.

Six hundred and ninety-four articles were retrieved. Of these retrieved articles, 284 were excluded due to duplication. Three hundred and sixty-eight articles were further excluded after reviewing the titles and abstracts. Furthermore, 22 articles which did not fulfil the inclusion criteria were excluded. Finally, 20 articles were used in the analysis ( figure 1 ).

Flow chart of selection of studies for the systematic review and meta-analysis of the level of knowledge about blood donation and associated factors in Ethiopia.

Characteristics of the studies and study participants

Twenty cross-sectional studies with a total of 8338 study participants (4712 men and 3626 women) were involved. Of the included articles, eight were from the Amhara region, 1 12 20–25 five from the Oromia region, 4 26–29 two from the Addis Ababa city administration, 5 30 two from Southern Nations, Nationalities and Peoples Region, 31 32 two from Tigri region, 33 34 and the remaining was from the Afar region. 35 The sample size of the included studies ranged from 218 to 845 ( table 2 ).

Characteristics of studies included in the review and meta-analysis of knowledge about blood donation and associated factors in Ethiopia

SNNPR, South Nations, Nationalities and Peoples Region.

Knowledge about blood donation

The overall pooled prevalence of level of knowledge about blood donation in Ethiopia was 56.57% (95% CI 50.30 to 62.84) ( figure 2 ).

Forest plot of the pooled prevalence of knowledge about blood donation and associated factors in Ethiopia. ES, Effect Size.

Heterogeneity and publication bias

In this systematic review and meta-analysis, heterogeneity was identified within the studies (I 2 =97.3%, p<0.001). The funnel plot showed an asymmetrical distribution of studies included in the review and a statistically significant Egger’s test (p=0.02), suggesting the presence of publication bias ( figure 3 ).

Funnel plot with 95% confidence limits of the pooled prevalence of knowledge about blood donation and associated factors in Ethiopia. sep; standared error of prevalence.

Subgroup analysis

Subgroup analysis was done by region, study subjects, study setting and sample size. The highest pooled prevalence of level of knowledge about blood donation was reported by healthcare workers (65.28%, 95% CI 55.16 to 75.40). Similarly, the level of knowledge about blood donation was higher among studies done in institutions (institution-based) (60.45%, 95% CI 51.05 to 69.83) than studies conducted in the community ( table 3 ).

Subgroup analysis of the level of knowledge about blood donation and associated factors in Ethiopia (n=20)

Other: Addis Ababa, Eastern Ethiopia.

Sensitivity analysis

As shown in table 4 , all of the point’s estimates are within the overall 95% CI, which confirms that omission of any of the studies included in this systematic review and meta-analysis does not affect the overall prevalence of the level of knowledge about blood donation.

Sensitivity analysis of knowledge about blood donation and associated factors in Ethiopia

Factors associated with knowledge about blood donation

In this study, participants’ sex and level of education were significant factors associated with level of knowledge about blood donation. The odds of level of knowledge were 1.81 times more likely among men than women (adjusted OR (AOR)=1.81; 95% CI 1.44 to 2.28) ( figure 4 ). Similarly, the odds of level of knowledge were 3.12 times more likely among participants whose educational status was above secondary school than those who did not attend any formal education (AOR=3.12; 95% CI 2.34 to 4.16) ( figure 5 ).

Overall pooled OR of the association between sex and level of knowledge about blood donation in Ethiopia. AOR, adjusted OR.

Overall pooled OR of the association between educational status and level of knowledge about blood donation in Ethiopia. AOR, adjusted OR.

In this systematic review and meta-analysis, the pooled prevalence of good knowledge about blood donation is 56.57% (95% CI 50.30 to 62.84), which indicates that there is a lack of adequate knowledge about blood donation in the country. This might be due to the absence of regular blood donation programmes, less media coverage, limited campaign and limited educational access with regard to blood donation in the country.

The level of knowledge in this study is lower than the studies conducted in Malaysia (98%), 2 Barabanki, India (90%), 36 and Benin City, Nigeria (92.65 %). 37 This variation might be due to differences in study participants. In Malaysia, the study participants were nursing students; in Benin City, Nigeria the study participants were healthcare workers; and in Barabanki, India the study participants were undergraduate medical students. In contrast, this study targeted all populations in the country. This variation might also be due to the status and level of media coverage and the educational status of people in Ethiopia; Ethiopia is one of the low-income countries with very limited education coverage and media accessibility. There is an almost similar finding with regard to knowledge about blood donation with a study done among students of a tertiary institution in Nigeria. 9 However, the finding of this study is higher than the studies conducted in Kerala, India (35%) 7 and in Nepal (32%), 8 which may be due to time variations, where the previous studies were conducted before 7 and 5 years, respectively.

In the subgroup analysis, there was no significant variation with regard to the prevalence of knowledge about blood donation within the region where the studies were done. However, there were variations with regard to knowledge prevalence within study participants, study setting and sample size categories. Accordingly, the highest prevalence of knowledge was reported among healthcare workers. This is because healthcare workers have formal education on blood donation and know more about human physiology than others. Healthcare workers may also have experience with blood donation. This agreed with a study conducted in developing countries where regular donors had good knowledge compared with non-donors. 13 Studies conducted in institutions (institution-based) showed a higher prevalence of knowledge than studies conducted in the community (community-based). This is due to the populations in institutions having more access to information. 7

In this systematic review and meta-analysis, the odds of knowledge about blood donation were 1.81 times more likely among men than women. This might be due to women being more prone to different physiological conditions such as menstruation and bleeding during pregnancy and delivery, which deter them from donating blood. As a result they have poor blood donation practices when compared with men. This poor practice may indirectly affect women’s knowledge about blood donation. 3 Educational status also had a significant association with knowledge about blood donation. The odds of knowledge about blood donation were 3.12 times more likely among participants who had a level of education above secondary school compared with illiterates. 11 This is because formal education is the cornerstone of acquiring knowledge. Therefore, participants who reached secondary school and above have more access to information than participants who did not have any formal education.

Limitations of the study

All studies included in this systematic review and meta-analysis were cross-sectional studies, which may limit the generation of a cause–effect link between independent and dependent variables.

More than half of the study participants were knowledgeable about blood donation. Sex and educational status were significantly associated with level of knowledge about blood donation in Ethiopia. Therefore, there is a need for education and dissemination of information about blood donation among the general population to build adequate knowledge and maintain regular blood supply.

Supplementary Material

Contributors: AG and MB designed the study, as well as designed and run the literature search. AG, AW, MB, GG and AD acquired the data, screened the records, extracted the data and assessed the risk of bias. AG and AD did the statistical analyses and wrote the report. All authors provided critical conceptual input, analysed and interpreted the data, and critically revised the report. All authors read and approved the final manuscript.

Funding: The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Competing interests: None declared.

Provenance and peer review: Not commissioned; externally peer reviewed.

Supplemental material: This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

Data availability statement

Ethics statements, patient consent for publication.

Not required.

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New ultra-sensitive blood test predicts recurrence of breast cancer, months or years before relapse

by Institute of Cancer Research

A new type of blood test can predict the recurrence of breast cancer in high-risk patients, months or even years before they relapse, research has shown.

A team from The Institute of Cancer Research, London, used an ultra-sensitive liquid biopsy to detect the presence of tiny amounts of cancer DNA left in the body following treatment for early breast cancer.

The findings, presented at the American Society of Clinical Oncology ( ASCO ) annual meeting in Chicago on Sunday 2 June, involved analyzing blood samples from the ChemoNEAR sample collection study for circulating tumor DNA (ctDNA) that is released into the bloodstream by cancer cells.

The researchers, based at the Breast Cancer Now Toby Robins Research Center at The Institute of Cancer Research (ICR), were able to identify all patients from the study who later went on to relapse by detecting very low levels of cancer found in the blood—known as molecular residual disease.

Detecting larger numbers of cancer-related changes

By helping to spot the patients most likely to relapse, the ICR scientists hope the results will pave the way for a new strategy for treating recurrent breast cancer where treatment can be started much earlier, without waiting for incurable, advanced disease to develop and show up on a scan.

Although previous studies have shown that ctDNA blood tests can identify relapse long before it can be seen on a scan, most tests use a technique called whole exome sequencing (WES) as it focuses on the exons—the protein-coding regions of genes—which are directly related to diseases.

However, the approach in this study, involves sequencing the entire genome, known as whole genome sequencing (WGS). This enabled researchers to identify up to 1,800 mutations, which is much more sensitive and includes a larger number of cancer-related changes that could occur in a patient's DNA.

Blood samples from 78 patients with different types of early breast cancer (23 with triple negative breast cancer, 35 with HER2+ breast cancer, 18 with hormone receptor+ breast cancer and two with an unknown subtype) were screened for ctDNA.

The samples were collected from the women at diagnosis before their therapy, after the second cycle of chemotherapy, following their surgery and every three months during follow-up for the first year. After that, samples were collected every six months for the next five years.

Spotting which patients are most likely to relapse

The results showed that detection of ctDNA at any point after surgery or during the follow up period was associated with a high risk of future relapse and poorer overall survival.

Molecular residual disease was detected in all 11 patients who relapsed. The median lead time to clinical relapse in this group of patients was 15 months, an increase of over three months, compared with current tests in all types of breast cancer. The longest lead time to clinical relapse was 41 months.

None of the 60 women in whom ctDNA remained undetected, relapsed throughout the follow-up period. Three patients had ctDNA detected in follow-up but had not relapsed by the end of the study—the researchers didn't have samples to analyze beyond the study follow-up period. Median survival for ctDNA detected patients was 62 months and not reached for the patients in whom ctDNA was undetected.

"This proof-of-principle retrospective study lays the groundwork for better post-treatment monitoring and potentially life-extending treatment in patients."

First author, Dr. Isaac Garcia-Murillas, Staff Scientist in the Molecular Oncology Group at The Institute of Cancer Research, London, said, "Breast cancer cells can remain in the body after surgery and other treatments but there can be so few of these cells that they are undetectable on follow-up scans.

"These cells can cause breast cancer patients to relapse many years after their initial treatment. Ultra-sensitive blood tests could offer a better approach for the long-term monitoring of patients whose cancer is at high risk of returning.

"Most personalized liquid biopsies currently use whole exome sequencing to identify mutations. But this approach goes one step further and uses whole genome sequencing to identify up to 1,800 mutations in a patient's tumor DNA that could uniquely identify recurrence of the patient's cancer from a blood sample.

"A more sensitive test is very important for this group of early breast cancer patients as they tend to have a very low amount of cancer DNA in their blood. This proof-of-principle retrospective study lays the groundwork for better post-treatment monitoring and potentially life-extending treatment in patients."

Professor Nicholas Turner, Professor of Molecular Oncology at the ICR, and Consultant Medical Oncologist at The Royal Marsden NHS Foundation Trust, said, "Testing a patient's blood for ctDNA will allow clinicians to diagnose the return of cancer at the very earliest stage. However, further research and testing are needed before we can demonstrate whether detecting molecular residual disease could guide therapy in the future.

"The ongoing TRAK-ER trial at The Royal Marsden, for example, is using a different molecular test to identify circulating tumor DNA and predict relapse in ER positive breast cancer patients. This trial is looking at whether relapse in patients with residual disease could be prevented by altering their treatment."

Professor Kristian Helin, Chief Executive of the ICR, said, "Breast cancer is much easier to treat before it spreads to other parts of the body, so it is vital to be able to detect signs of recurrence of the disease as early as possible to give people the best chance of survival.

"It is very exciting to see advances in technology that can detect cancer cells and DNA with greater sensitivity to pick up residual disease or detect the early signs of breast cancer recurrence while a cure is still possible.

"These approaches are having a transformative effect on cancer diagnosis. They will help us exploit our knowledge of cancer risk to develop new strategies for targeted screening and detection."

Dr. Simon Vincent, director of research, support and influencing at Breast Cancer Now, said, "Early detection is one of our greatest weapons against breast cancer and these initial findings, which suggests new tests could be able to detect signs of breast cancer recurrence over a year before symptoms emerge, are incredibly exciting.

"While this research is still in its early stages, catching breast cancer recurrence earlier means treatment is much more likely to destroy the cancer and stop it spreading to other parts of the body, at which point it becomes incurable.

"With around 11,000 people dying every year in the U.K. from secondary breast cancer, breakthroughs like these are urgently needed so that we can stop people losing their lives to this devastating disease.

"We look forward to seeing further findings from this promising study and encourage anyone who is affected by breast cancer to contact our helpline by calling 0808 800 6000 for information and support from our expert nurses."

Dr. Richard Chen, chief medical officer and executive vice president of R&D at Personalis, said, "We are excited to work with Professor Turner, Dr. Garcia-Murillas and other breast cancer leaders at the ICR on this ground-breaking breast cancer study.

"The study shows the importance and promise of using an ultra-sensitive MRD test like NeXT Personal to detect the earliest traces of breast cancer recurrence, and more optimally guide management of breast cancer patients."

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Blood flow makes waves across the surface of the mouse brain

Researchers have, for the first time, visualized the full network of blood vessels across the cortex of awake mice, finding that blood vessels rhythmically expand and contract leading to "waves" washing across the surface of the brain. These findings, funded by the National Institutes of Health (NIH), improve the understanding of how the brain receives blood, though the function of the waves remains a mystery.

A network of elastic and actively pumping vessels carrying oxygenated blood span the surface of the brain before entering the cortex. There, they feed into a second network of capillaries that supply oxygen deeper into the tissue. Using physics-based experimental methods and analyses, the researchers saw that in addition to the pulses of blood flow that occur with each heartbeat, there are slower waves of blood flow changes that sweep across the brain and occur about once every ten seconds. The change in blood flow that occur with these slow waves was up to 20% of the entire brain blood supply. Surprisingly, this phenomenon was only weakly tied to changes in brain activity.

The waves produced visible bulges in the blood vessels, which will aid in mixing the fluid around the brain's cells. This has implications in how waste products and other materials are removed from the fluid surrounding brain cells. Because the waves of bulging blood vessels move in a variety of directions, the authors surmise that the pulses of dilation and contraction of the blood vessels are more likely to be involved in mixing the fluid around them rather than actively moving it in a given direction. Regardless, this mixing activity could aid in removing misfolded proteins and other components from the brain into the cerebrospinal fluid that surrounds it. This process is considered an important protective mechanism for a variety of neurological disorders, such as Alzheimer's disease and other related dementias, and is more active during sleep.

These findings may also affect current approaches to interpreting fMRI scans, which measure changes in blood oxygenation within brain structures as they are activated. Specifically, the finding that these waves of blood flow changes occur largely independent of brain activity suggests a new level of complexity complication that needs to be considered when interpreting the link between the fMRI data and brain activation.

This research was funded in part by the NIH's Brain Research Through Advancing Innovative Neurotechnologies ® (BRAIN) Initiative (U19NS123717, R01NS108472), the NIH's National Institute of Neurological Disorders and Stroke (R35NS097265), the NIH's National Institute of Mental Health (R01MH111438), and the NIH's National Institute of Biological Imaging and Bioengineering (U24EB028942, R01EB026936)

• Brain Injury
• Brain-Computer Interfaces
• Neuroscience
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• Blood vessel
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Story Source:

Materials provided by NIH/National Institute of Neurological Disorders and Stroke . Note: Content may be edited for style and length.

Journal Reference :

• Thomas Broggini, Jacob Duckworth, Xiang Ji, Rui Liu, Xinyue Xia, Philipp Mächler, Iftach Shaked, Leon Paul Munting, Satish Iyengar, Michael Kotlikoff, Susanne J. van Veluw, Massimo Vergassola, Gal Mishne, David Kleinfeld. Long-wavelength traveling waves of vasomotion modulate the perfusion of cortex . Neuron , 2024; DOI: 10.1016/j.neuron.2024.04.034

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