Revolution (More musings on using artificial intelligence in transfusion medicine)

Updated: 3 Sept. 2020 (Added to Learning Point)

August's blog will discuss the issue of artificial intelligence (AI) & 'big data' in medicine and health.

The idea for the blog was stimulated by a fascinating article in The Economist of June 13-19 as part of its Technology Quarterly: 'Driverless cars illustrate the limits of today's AI.' (Further Reading)

The blog's title derives from a 1968 ditty by the Beatles written by John Lennon

LIMITATIONS OF AI

According to The Economist article, the following are some of AI's current limitations that I've chosen to highlight. Yes they relate to self-driving cars but most have broad applicability relevant to medicine:

1. Self-driving cars work similar to other applications of machine learning. Computers crunch huge piles of data to extract general rules, and in theory the more data, the better the systems perform.  

But deep-learning is statistical, linking inputs to outputs in ways specified by training data. That leaves them unable to cope with “edge cases” ­ unusual circumstances that are not common in those training data.

• You can imagine if this applies to driving cars how much it can apply to the complexities of human beings, their health, symptoms, medical needs, etc. Humans can cope with oddities much better than AI, which in some ways works with only half a brain. 

2. Google’s “Translate” often does a decent job at translating between languages. But in 2018 researchers noticed that, when asked to translate 18 repetitions of the word “dog” into a language spoken in parts of Nigeria and Benin and back into English, it came up with the following hilarious translations:

• “Doomsday Clock is at three minutes to twelve. We are experiencing characters and dramatic developments in the world, which indicate that we are increasingly approaching the end times and Jesus’ return.” 
• Fact: Google’s system doesn't understand language because concepts like verbs and nouns are alien. It's constructed using statistical rules linking strings of letters in one language with strings of letters in another and is baffled by questions a toddler would find trivial. 

3. Richard Sutton, AI researcher at the University of Alberta and DeepMind, published “The Bitter Lesson” (Further Reading) arguing that AI history shows that attempts to build human understanding into computers rarely work. The “bitter lesson” is that “the actual contents of [human] minds are tremendously, irredeemably complex…They are not what should be built in [to machines].” 

Christopher Manning of Stanford University’s AI Lab notes that biological brains learn from far richer data-sets than machines. 

4. About Big Data, which makes AI possible, see 'Big Data in Healthcare' (Further Reading). The conclusion: 'While big data provides great potential for improving healthcare delivery, it is essential that we consider the individual, social and organizational contexts of data use when implementing big data solutions.'  Personal note: 

* The lead author is one of my UAlberta Med Lab Science 'kids'. 

LEARNING POINT

AI has a long way to go before it can be safely used in self-driven cars. Despite the hype, AI has an even longer road to travel before it's as safe and reliable as human health care professionals. Feel free to disagree. 

The entire Technical Quarterly in The Economist, June 13-19, 2020 deals with AI and its limits. As its many proponents hype AI and Big Data, it's prudent to show their limitations too. Included articles:

1. Reality check: After yrs of hype,an understanding of AI's limitations is beginning to set in
2. Data - Not So Big: Data can be scarcer than you think and full of traps
3. Brain Scan | An AI for an eye: Pioneering ophthalmologist highlights the potential, and the pitfalls, of medical AI
4. Computing Hardware | Machine Learning: The cost of training machines is becoming a problem
5. Road Block: Driverless cars illustrate the limits of today's AI
6. The Future | Autumn is coming: As AI's limits become apparent, humans will add more

Note:  If you don't subscribe to The Economist, perhaps take a trial one? Or check if your hospital is affiliated with a university, college (or perhaps the public library) has it available.

As always, comments are most welcome. And there are some.

FOR FUN

I chose this song because pretty much everyone has hopped on Big Data and AI bandwagons as if they're a revolution that's going to sweep traditional medicine aside. Maybe but I suspect not for years.

• Revolution (by the Beatles)

FURTHER READING

Driverless cars illustrate the limits of today's AI - They, and many other such systems, still struggle to handle the unexpected (The Economist, June 13-19, 2020) 

Prior AI blog (30 Nov. 2019): I can see clearly now (Musings on using artificial intelligence in transfusion medicine)

The Bitter Lesson by Rich Sutton (19 Mar. 2019)

Rich Sutton, University of Alberta | Also see this bio

Kuziemsky CE, Monkman H, Petersen C, et al. Big Data in Healthcare - Defining the digital persona through user contexts from the micro to the macro. Contribution of the IMIA Organizational and Social Issues WG. Yearb Med Inform. 2014;9(1):82-9. Published 2014 Aug 15. 

The Sound of silence (Musings on transfusion professionals use of Twitter)

Updated: 25 Sept. 2016 

September's blog takes its theme from Twitter activity on my @transfusionnews Twitter account. The blog is shorter than usual (a good thing), but something I feel passionate about. 

The title is from a 1964 classic by Simon and Garfunkel.

For readers who choose not to read the full blog, here's the executive version. The blog's aims are to

• Showcase prolific transfusion-focused tweeps from the English-speaking world - those who clearly believe in the power of social media like Twitter to engage and educate about transfusion.

• Interest you in joining Twitter (even as a 'lurker' who reads but never posts, as so many were and are on mailing lists) or, if that's a bridge too far, at least bookmark one of the Twitter accounts (maybe mine?), and periodically read the latest. You can do so without being on Twitter. 

Bottom line: Being a transfusion professional is a career not a 9-5 job. Learning what's happening around the globe enriches and broadens our experience. And we can use Twitter tidbits to interest our students and inform our practice. That's a good thing. Note that I resisted saying we could leverage Twitter. 

Recently, while helping a friend with a project she did for the BC PBCO, international colleagues I met only on Twitter took time from their incredibly busy schedules to go away 'above and beyond' to assist. Being on Twitter is like having an amazingly diverse family whose members generously share knowledge and expertise.

TRANSFUSION TWEEPS OF NOTE
From my experience, here are the transfusion professionals, individuals who regularly distribute transfusion news via Twitter. I've not included blood suppliers like Canadian Blood Services (@itsinyoutogive) or professional associations like @aabb, @BritishBloodTS, and  @CanSocTransMed.

To my knowledge, these are transfusion medicine's prolific tweeps (number of tweets in brackets). The list is not all inclusive. I follow many valuable transfusion tweeps with fewer tweets and others with 1000s of posts but many unrelated to transfusion. 

AUSTRALIA (2)

Haemovigilance Guy @Haemovigilante (1300+) 

Dr Sandy Minck @DrSandyMinck (1,000+)

IRELAND (1)
Gerard Crotty @gmcrotty (18,000+)

GREAT BRITAIN  (8)

Sylvia Benjamin @Gogmum (6,500+) 

Tony Davies @Dobbysdad (1,800+) 

HarveysGang @Laird_Admiral (6,000+) 

Dr. Suzy Morton: @TransfusionWM (1,900+)

Kate Pendry @KatePendry  (4,000+)

TeamHaem @TeamHaem (6500+) 

Dan Smith @Dan1763 (3,900+)

CANADA (4)

Jenny Ryan @JRyanCS (5,300+) 

Elianna Saidenberg @ESaidenberg (2,600+) 

Cyber Bloodbanker @transfusion news (2,000+) - Me 

Ron Vezina @Vez_says (1300+)

SUMMARY
Did you notice that the Brits are the transfusion rock stars on Twitter? Why is that, I wonder? If I've missed any 'tweetaholics', please let me know. 

To discover who to follow on Twitter, use hashtags such as 

• #transfusion 
• #bloodeducation
• #blood

The last may produce unexpected results.
And when you find someone you like, see who they follow and who follows them.

FOR FUN
The blog's theme reminded me of a 1964 ditty by Simon and Garfunkel. Seems the transfusion twittersphere sadly suffers from the Sound of Silence, especially in Canada and the USA. Let's be disruptive and break the silence more, folks.

• Sound of Silence (Simon and Garfunkel) 

As always, comments are most welcome.

The In Crowd (Musings on the relevance of transfusion journals)

Stay tuned because updates will occur

May's blog was stimulated a long time ago but returned to me recently when I was cleaning house and tossed out (recycled) several thick issues of the AABB journal Transfusion, which were piled on my computer desk, largely unread after scanning content indices.

The blog's title derives from a 1965 jazz instrumental by the Ramsey Lewis Trio.

Musings focus on the articles I read in Transfusion's May 2016 issue and what this says about the journal's relevance to someone with a medical laboratory technology/science background (me). For context, traditional measures of a journal's relative importance and Transfusion's top 10 cited articles are also discussed. 

The questions I hope to answer: 

1. What value is the AABB journal to practicing transfusion professionals (as opposed to its value to authors/researchers)?
2. Why am I (and presumably everyone) getting a paper version of the journal and not being given an option for an e-journal only?
3. What would my AABB membership fee be if all the costs associated with a paper version of Transfusion were eliminated?
4. What factors should affect a journal's overall relevance and importance?

The blog is written from a medical laboratory technology perspective, as that's my background, but the issues also relate to nursing and physicians. Regardless of where you live, please ask similar questions of your professional association's journal. For example, 

• How many papers do you typically read in your transfusion-related professional journal and where - at work on breaks, at home? 
• Do you scan titles only or a combination titles, authors and abstracts? 
• Which criteria determine whether you will read a given article?
• In deciding what to read, how important is an article's direct relevance to your daily work?
• How many articles, if any, do you read just for curiosity or fun?

Sometimes I wonder of journals even matter anymore but of course they do. And I miss the days when transfusion services regularly held journal clubs during lunch hours, often based on journal articles or conferences, in which all staff participated.

To promote continuity of the blog's ideas, consider reading the blog in its entirety and then return to access linked resources. Bet you can't.

1. AABB JOURNAL 'TRANSFUSION' - BRAGGING RIGHTS

So to begin, here's how most journals measure their worth. On its homepage, Transfusion gives its ISI journal citation ranking under the medical specialty, hematology, as well as its Impact Factor. Both are intended to show the relative importance of individual journals. 

In 2014 Transfusion's ISI Journal Citation Reports^© Ranking was 23/68 and its Impact Factor was 3.225. 

So what do ISI Journal Citation Reports© (JCR) Ranking and Impact Factor (IF) mean?

• JCR Ranking claims to objectively critically evaluate the world's leading journals using statistics. Uh-oh! That's a red flag if there ever was one. Just kidding because, as with any statistical data, users need to use their noggins to assess validity. 
• With a JCR rank of 23/68, my guess is that Transfusion ranks no. 23 of 68 journals and is in the top third of most hematology journal citations (two-thirds of similar journals have fewer overall citations, whatever complicated statistics are used).

• Impact Factor is the average number of annual citations recent journal articles have and obviously the higher, the better. As such, it's a proxy for the relative importance of a journal in its field. 
• With an IF of 3.225, recent Transfusion articles were cited an average of just over 3 times in a year.

But similar to surrogate tests such as elevated ALT and anti-HBc used to screen blood donors for non-A, non-B hepatitis before HCV was identified, issues exist for how well Impact Factors measure relative importance.

For interest, The Impact Factor was devised by Eugene Garfield, who explains its history in a 2006 JAMA article.

As an aside,  I love Garfield, because in my early pre-Internet years in Medical Laboratory Science, MLS subscribed to Current Contents, which I always enjoyed and looked forward to reading. If my memory is correct, each issue began with a fascinating Garfield comments/editorial. [See Further Reading]

2. TRANSFUSION'S TOP 10 CITED ARTICLES
Since 1975 I've been an AABB member and once read 90%+ of Transfusion's articles, but mostly for interest, not because they directly related to my work. 

Most reading was done because I'm curious and love transfusion medicine. After becoming an educator, motivation included the potential to discover 'juicy' tidbits that would interest or amuse students, and Transfusion's articles often did. 

In today's hectic and understaffed work environment, I wonder which of Transfusion's top 10 articles would be read during leisure time, on breaks or after hours, by 

• Clin lab technologists/scientists in a blood supplier or transfusion service laboratory? 
• Transfusion and blood conservation RNs?
• Hematologists/hematopathologists?

I suspect that not many in these three professions would read 3, 7 and 9 below, which is good because only 30% un-read is excellent. As an experiment, please assess which of the following you would read. I've linked the PubMed abstract for each article. 

Please think about which criteria helped decide whether you would read an article or not.

Transfusion's Top Ten Cited Articles: [Author's work location/country]

1. Activity-based costs of blood transfusions in surgical patients at four hospitals. (Shander A, et al) 2010;50:753-65. [USA]

2. Transfusion of older stored blood and risk of death: A meta-analysis. (Wang D, et al) 2012;52:1184-95. [USA]

3. Pathogen inactivation and removal methods for plasma-derived clotting factor concentrates. (Klamroth R, et al) 2014; 54:1406-17. [Germany]

4. Is fresh-frozen plasma clinically effective? An update of a systematic review of randomized controlled trials. (Yang L, et al) 2012;52:1673-86. [UK]

5. Fibrinogen as a therapeutic target for bleeding: A review of critical levels and replacement therapy. (Levy JH, et al) 2014; 54:1389-1405. [USA]

6. Duration of red blood cell storage and survival of transfused patients. (Edgren G, et al) 2010;50:1185-95. [Sweden]

7. Storage lesion: Role of red blood cell breakdown (Kim-Shapiro DB et al) 2011;51:844-51. [USA]

8. The use of fresh frozen plasma in England: High levels of inappropriate use in adults and children. (Stanworth S et al) 2011;51:62-70. [UK]

9. Adoptive transfer and selective reconstitution of streptamer-selected cytomegalovirus-specific CD8+ T cells leads to virus clearance in patients after allogeneic peripheral blood stem cell transplantation. (Schmitt M et al) 2011;51:591-9. [Germany]

10. Transfusion-associated circulatory overload after plasma transfusion. (Narick C, et al) 2012;52:160-5. [USA]

So, what's your health profession and  how many of these top cited papers would you have read? Be honest. As both a lab technologist in the trenches and an educator, I'd have read all but #9.  

3. TRANSFUSION'S MAY 2016 ISSUE
Below are three papers I read in the May issue of Transfusion (Volume 56, Issue 5,pp. 1001–1249) that directly relate to my prior career as a med lab tech/scientist and educator. Yes, only three and I read them out of interest. These days,although retired from real work, my time is even more precious. 

The journal sections each paper is under are included. I've summarized each with a 'So What?' conclusion.

1. TRANSFUSION MEDICINE ILLUSTRATED (pp.1006–7)
Delayed hemolytic transfusion reaction captured by a cell phone camera.Margaret E. Gatti-Mays, S. Gerald Sandler [USA]

So what? The delayed hemolytic reaction was due to anti-Jk^a and shows a photo of the peripheral blood smear with multiple microspherocytes. Authors encourage physicians to use cell phone cameras to photograph peripheral blood smears and use them in clinical presentations. 

2. IMMUNOHEMATOLOGY (pp. 1182–4)
Anti-Mur as the most likely cause of mild hemolytic disease of the newborn. Sara Bakhtary, Anastasia Gikas, Bertil Glader, Jennifer Andrews [USA] 

So what? Full term infant had jaundice presumed to be due to anti-Mur, an antibody more commonly found in Asian patients in the USA, and one important to recognize since the Mur+ phenotype has a higher prevalence in this population.

3. LETTER TO EDITOR (pp.1247–8)
Sustained and significant increase in reporting of transfusion reactions with the implementation of an electronic reporting system. Rosanne St Bernard, Matthew Yan, Shuoyan Ning, Alioska Escorcia, Jacob M. Pendergrast, Christine Cserti-Gazdewich [Canada]

So what? In 2009 the authors transitioned from a paper-based to an electronic reporting system (ERS) for suspected transfusion reactions. The user-friendly process did not result in “junk inflations”. Instead reporter suspicions generally concurred with specialist conclusions. Accordingly, they endorse using an ERS for transfusion reaction reporting to improve hemovigilance.

ANSWERING THE QUESTIONS
Here are my answers  - conditioned by my professional experience and biases - to the questions posed about Transfusion. Your answers may differ and likely will.

Q1. What value is the AABB journal to practicing transfusion professionals (as opposed to its value to authors/researchers)?

A: Transfusion has value as a good read for anyone who's curious on current 'hot' clinical issues and to educators who must keep up-to-date with the latest and greatest, including esoteric research, which may or may not ultimately translate into something useful to practitioners.

The journal's relevance to the day-to-day working lives of medical laboratory technologists/scientists in laboratories is minimal. Most papers relate to clinical practice (MDs, RNs) or research (PhDs).

Q2. Why am I (and presumably everyone) getting a paper version of the journal and not being given an option for an e-journal only?

A: Transfusion is a glossy journal that costs many trees to produce, plus mailing costs, which are not insignificant. I don't need or want a paper copy.  

It's published monthly, plus has supplements of Annual Meeting abstracts and others such as conference proceedings. That's a lot of paper.

For May's issue I read only 7 of 248 pages, ~2.8%, which related directly to my work. And some issues have even fewer articles relevant to my needs and interests.

Q3. What would my AABB membership fee be if all the costs associated with a paper version of Transfusion were eliminated?

A: My 2016 AABB membership cost $124 USD, which at the time I paid was $170.27 CDN. Sure, membership is a good deal, less than 50 cents/day.

But how much of this does AABB pay per member to Transfusion's publisher, Wiley? Darned if I or any member knows.

Academic publishers such as Wiley and its subsidiaries, e.g., Wiley-Blackwell,  surely make most money from advertisers and libraries. It's interesting that they've been under pressure recently for being an oligarchy that gouges cash-strapped university and college libraries. [See Further Reading]

Q4. What factors should affect a journal's overall relevance and importance?

A. To me, Transfusion's relevance should relate not only to its citation ranking or impact factor. Rather, a key factor is how many articles in each issue busy transfusion professionals will actually read because they relate to their day-to-day jobs.   

Yes, it's easy to dismiss my views because immunohematology (beloved to med lab techs/scientists) is a dying art and increasingly irrelevant. But how many papers in the 2016 May issue would time-strapped nurses and physicians read in their spare time? You decide.

Transfusion comes with AABB membership. Shouldn't its content reflect the needs of ALL members, at least according to their membership percentage?

SUMMARY
Just a few of the many issues I'd love AABB to address:

1. AABB, please allow members to opt out of receiving a paper copy of Transfusion and please decrease membership fees accordingly. 

2. AABB seems an association mainly for physicians. Is it? Why does its journal offer only continuing MEDICAL education credits for reading select articles and successfully completing a test on the content? I think I know why...

Cannot help but wonder what percentage of AABB's membership constitutes physicians vs PhD researchers vs medical lab scientists vs nurses vs administrators. Transparency please. We'd love to know.

3. Never mind med lab technologists/scientists, how about more Transfusion articles relevant to nurses? They increasingly play a key role in our profession. 

Of course, I know from experience that asking AABB or any large organization such questions is pretty much useless and akin to pissing in the wind. Would love to be proven wrong.

FOR FUN
I decided to use 'The In Crowd' in the blog's title for these reasons:

1. It's a laid-back, simple tune that's easy to listen to. Indeed, over the years I've listened to it for many hours because I bought the Ramsey Lewis album of the same name many moons ago. 
2. Although it's an instrumental version, the lyrics fit with the blog's theme of promoting a journal based on its relative ranking and impact. Hey dude, don't ya wanna publish in the 'In Crowd' journal Transfusion?

I'm in with the in crowd.
I go where the in crowd goes.
I'm in with the in crowd.
And I know what the in crowd knows.

Tidbit: I've got this album somewhere if I could only recall where I stashed the few 33¹⁄3 rpm vinyl records I've kept.  

• The In Crowd (The Ramsey Lewis Trio vinyl album, recorded live at the Bohemian Caverns in Washington, D.C. in 1965)

As always, comments are most welcome. 

FURTHER READING

Academic publishers reap huge profits as libraries go broke (CBC, June 15, 2015) 

Larivière V, Haustein S, Mongeon P. The oligopoly of academic publishers in the digital era. PLoS ONE 10(6): e0127502. E-pub: June 10, 2015 (Free full text)

Just for fun
Confession: I've included these just so I have a record and can read on some long winter nights.

The writing of Eugene Garfield, including

Essays of an Information Scientist:1962 - 1973 

Essays of an Information Scientist:1974 - 1976 

Essays of an Information Scientist:1977 - 1978 

Ex:  Humor in Scientific Journals and Journals of Humor

Sweet dreams are made of this (Musings on personalized medicine)

Updated : 28 July 2020 (Fixed song's link)

September's blog derives from increased marketing of medical treatments and clinical laboratory tests as personalized medicine tailored to the individual characteristics and needs of each patient. Seems like a great idea, right?  

After all, in the age of 'selfies' it's all about me. 

The title is from a 1983 ditty by the British duo, the Eurythmics (Annie Lennox and David Stewart). 

PERSONALIZED MEDICINE
'Personalized medicine' is a term that drives me nuts.  This April I blogged about molecular blood typing being marketed as personalized medicine:

• While my guitar gently weeps (Musings on the seduction of technology) [Further Reading]

Five years ago I had sniffed its perfumed allure with the blog

• Snip, snip the party's over (Musings on the seductive rise of DNA typing of blood groups) [Further Reading]

WAIT, THERE'S MORE
Now a new variation has arisen, the latest and greatest 'term du jour' ('term d'année?') is Precision Medicine:

• Red blood cell transfusion. Precision vs imprecision medicine  [Further Reading]

One sentence in the article stood out as a red flag:

'Although currently not practical, providing extended antigen matching by molecular techniques to all patients should improve typing accuracy and reduce alloimmunization.'

If past is prologue, even if impractical and relatively expensive, eventually molecular genotyping will be done for all transfusion recipients. After all, who can resist the sales pitch of personalized and precision medicine?

BANDWAGON
Certainly the United States, with its private health care system, cannot resist and has jumped on the bandwagon. Similarly, so has Canada, UK and other industrialized nations. 

As to the developing world, well they're stuck making do with 20^thC medicine, un-personalized and un-precision.

Of course, a genuine case can be made to tailor tests and treatments to individuals, especially those with special needs such as blood group genotyping for sickle cell and thalassemia patients. 

But why the rush to personalized / precision medicine as embodied by molecular blood genotyping? It's likely because of the reasons cited in 'While my guitar gently weeps':

• To be seen as 'with-it' hipsters on DNA's bandwagon vs being old-fogeys who resist change; 
• Way for TM organizations to develop business lines and increase earnings in age of blood conservation; 
• Self-interest for those who specialized in molecular technology; 
• No humans interpreting serologic test results must be safer; 
• High-throughput automation decreases costs by eliminating staff, with their salaries, benefits, and pensions.

Plus it's good for private enterprises that develop and market test systems and health profession leaders who want to be seen as in the real world of business efficiency. 

ANATOMY OF A SALES PITCH 
Today, many businesses promote and sell stuff that we do not  need. The aim is to trick us into thinking we need the latest and greatest. 

Consider Apple's iPhone. The premise is that potential buyers don't even know what they want until Apple tells them. They don't really need to market it because all geeks know they must have one to be part of the in-crowd. 

• It's the same reason why all TM docs know their facilities must do molecular typing.

Apple builds beautiful products and justifies price with features and benefits no one else can match. Whether you need the features is another matter. But once you've seen them, Apple will make you think you do. 

• Similarly, serologic blood typing cannot match molecular typing. Whether you need the benefits of molecular typing is a moot point.

Apple built one of the most hardcore fan bases of any product, called Apple fanboys/fangirls and, before the iPod/iPad/iPhone revolution, macophiles. I was one and would show disdain for Windows every chance I got. 

• Today, molecular red cell genotyping fans abound and can barely suppress a sneer when mentioning serology and immunohematology. The fan base of influential TM leaders is hard to combat and develops a momentum all its own.

It's worth recalling that whether selling an iphone, tablet, used car or botox, a good sales rep will FOCUS ON

1. BENEFITS and VALUE, NOT PRICE
Some examples [My comments]: 

Before molecular genotyping transfusion service labs had to use inefficient, labor-intensive serologic assays. ²

[PL: Red cell serology is passé, based on inefficient testing that costs more because of paying laboratory technologists for their time.]

Now in the 21st century and with the emergence of precision medicine, inexpensive molecular typing paired with powerful bioinformatics has enabled mass-scale red blood cell genotyping. ²

[PL: Get with the 21^stC. Molecular typing is cheap (really?) and it's twinned with bioinformatics. Bioinformatics sounds pretty darn impressive. We've got datasets coming out the wazoo.]

Web-based data storage and analytics are revolutionizing the provision of antigen-negative blood with an efficiency scarcely conceived of just a decade ago. ²

[PL: You'll be on the bleeding edge and very, very efficient. Plus it's analytics, for gawd sake. And 'analytics leverage data in a particular functional process (or application) to enable context-specific insight that is actionable'.  

Wowsa! Leverage,data, process, context-specific, and actionable in the same sentence. I'm in jargon heaven. Gotta love analytics.]

2. EMOTIONS, NOT REASON
Blood incompatibility remains a significant problem with lifelong consequences that adds to the burden of healthcare delivery and may result in life-threatening delays in care.³

If an antigen-negative patient receives blood from an antigen-positive donor, it could trigger an immune reaction, where the blood recipient’s immune system develops antibodies that can attack and reject the donor RBCs.³

[PL: If you buy our product you will prevent the dreaded immune response and save patient lives. You don't wanna kill folks, do you buddy?]

With today’s dual focus on improving health outcomes and lowering healthcare costs, preventing alloimmunization is the ultimate goal in transfusion medicine. Accordingly, a best practice for the hospital or transfusion center is to create a patient phenotype profile with the PreciseType test before a patient receives his or her first-ever transfusion.³

[PL: Do you dig what TM's ultimate goal is? It's about preventing alloimmunization. (Who knew!) Are you into best practices, a thought leader? Because if you are, you better buy our kit right now, before some patient gets immunized!]

NAYSAYERS
There are those who question the orthodoxy of personalized / precision  medicine and caution against potential pitfalls.  Two examples that examine personalized medicine from a broad perspective:

1) 'Why you shouldn't know too much about your own genes.' [Further Reading] Sample quote: 

• Here is the under-appreciated corollary to the new age of personalized medicine: just because you can do a genetic test, doesn't mean you should.

2) Juengst ET, Flatt MA, Settersten RA, Jr. Personalized genomic medicine and the rhetoric of empowerment. Hastings Cent Rep. 2012 Sep-Oct; 42(5): 34­40. [Further Reading¹] Sample quote: 

• 70 million Baby Boomers, now or soon-to-be over age 60, seek to live not just longer, but healthier and more productive lives. 
• When they fully understand and embrace personalized medicine, it will create an unprecedented level of consumer demand. 
• When physicians feel they may incur liability for not offering a test that provides information on optimal care, the impetus toward adoption will be even greater.

LEARNING POINTS
Eventually, everywhere in the developed world, red cell matching of patient and donors will routinely be done by molecular blood typing. It will be precision medicine, personalized medicine done using kits supplied by foreign companies and performed by minimally trained, inexpensive local staff supervised by a well educated lab professional.

If employers plan wisely, staff can be hired part-time or casual so they won't need to worry about benefits and pensions. 

In Canada government health care money will flow abroad, giving sustenance to anonymous investors of Immucor, et al. They'll leverage our health care dollars where they WON'T do the most good for our communities, all in the name of efficiency and safety.

POSTSCRIPT
Am I similar to 19^thC Luddites, protesting against new labour-economizing technologies? Maybe, though I'm not against technology per se and have embraced computers and the Internet from the get-go.

But, hot damn! I'm gonna get my genome profile done because it's all about me. And I can get it done for $199 CDN by 23andme...not that I really want to know.

And if I ever need a blood transfusion, I'm not into being second class and will demand complete molecular antigen typing with donor blood. Not that I'll get it now but definitely one day. None of that passé serology for me!

FOR FUN
A great song, one of my favorites, that highlights the allure of molecular blood typing and personalized / precision medicine. 

• Sweet Dreams [are made of this] (Annie Lennox, Live 8, Hyde Park, London, 2005)

'Sweet dreams are made of this
Who am I to disagree?'

As always, comments are most welcome.

FURTHER READING

1. Juengst ET, Flatt MA, Settersten RA, Jr. Personalized genomic medicine and the rhetoric of empowerment. Hastings Cent Rep. 2012 Sep-Oct; 42(5): 34­40. (Free full text)
2. Klein HG, Flegel WA, Natanson C. Red blood cell transfusion. Precision vs imprecision medicine. JAMA. Pub online 10 Sept. 2015. (Free full text)
3. Immucor: PreciseType™ HEA Test 

Other
Carolyn Johnston. Why you shouldn't know too much about your own genes. (Washington Post, 11 Sept. 2015)

USA FDA: Paving the way for personalized medicine. FDA’s role in a new era of medical product development  

US News & World Report. Personalized medicine

USA White House. Next steps in developing the precision medicine initiative

Prior Related Blogs
While my guitar gently weeps (Musings on the seduction of technology) |  April 2015

Snip, snip the party's over (Musings on the seductive rise of DNA typing of blood groups) | Dec. 2010

You don't own me (Musings on TM professionals as industry's poodles)

Updated 1 Nov. 2012

This month's blog is about how much of the TM information we consume is meant to inform, how much is crafted to persuade, and how much info purveyors assume we’re owned by them, i.e., their poodles. The title is from a 1964 Lesley Gore song. 

The blog was stimulated by 3 items:
1. Supposed news from new-medical.net in its 'Insights from industry' section:

• Blood banks: an interview with Celia Tombalakian, Worldwide Group Director, Immunohematology at Johnson & Johnson's Ortho-Clinical Diagnostics, Inc. (OCD) 

2. The article motivated me to visit OCD's 'On Demand' website and register to see its offerings. 

3. Then I was reminded of a recent research paper by OCD staff published in AABB's Transfusion:

• South SF, Casina TS, Li L. Exponential error reduction in pretransfusion testing with automation. Transfusion. 2012 Aug;52(8):81S-87S.

BACKGROUND
Increasingly, I suspect that industry owns the transfusion medicine community. In a way, it's natural given that TM was healthcare but now is business and has been for awhile. Businesses depend on each other to survive. You scratch my back and I’ll scratch yours.

Today's AABB is more and more cosy with commercial interests, which is also natural given the reliance of the former on the latter for advertising revenues and conference support. Plus, as noted in earlier blogs, some AABB luminaries have close ties with industry. It's one big happy family.

The blog’s components  - industry promoting automation via 3 mechanisms - are akin to a full court press in basketball in which industry pressures TM staff from every angle to buy into their false assertions about automation.

The blog's theme is how much industry thinks it owns us and attempts to baffle our brains with BS. 

A common thread in industry’s automation initiative is to create false arguments. For example, manual methods have more processes than automation (true), therefore automated instruments have fewer chances for human errors to occur (true). 

BUT… here’s the logical fallacy (the BS, if you will): Where do most serious TM errors occur? Are they related to manual testing? 

Read and assess for yourself.

1. INTERVIEW
First note where this interview was published: news-medical.net

As with many so-called health sites, news-medical's business model is not immediately apparent without reading the fine print. And let's face it, that's the first thing we do when visiting a website, right?

Part of the 3239 word, 27 point,Terms and Conditions:

News-Medical hereby discloses that a commission or listing fee may be payable by Experts to News-Medical for any fees received by them as a result of an introduction of a client through the Website.  

Unsurprisingly, the site's underlying purpose is to sell stuff.

Besides industry news, news-medical, based in Australia, cheaply repackages health information from several sources, including a heavy reliance on Wikipedia under the Creative Commons Attribution-ShareAlike License.

Below is my summary of a few highlights of OCD’s Celia Tombalakian's interview with news-medical.net in question and answer format, with my comments, aka musings, in italics. Readers are directed to the full interview for exactly what she said. 

The report is selective and my approach is facetious in places. But is it off the mark? You be the judge.

QUESTION: How is the blood banking industry currently being transformed?

CT's ANSWER

CT: Current focus is to improve transfusion safety and efficiency through technology solutions.  

Ah, safety and efficiency, with safety mentioned first. Who can argue?

CT: Over past 20 yrs, the number of highly skilled technologists and scientists entering the global TM workforce has shrunk. 

CT: Therefore, automation is becoming a standard part of blood bank laboratories because it eliminates many of the labor-intensive, time-consuming manual testing that requires specialized skills and significant experience to master.  

Really? Her response implies that automation arose because of staff shortages, which misleads in a chicken and egg sort of way.  

Why has the highly skilled technical and scientific TM workforce shrunk? Many reasons around the globe, inc. poor compensation for education involved (mainly USA), decreased health care funding, leading to regionalization and centralized testing, all facilitated by automation.  Automated instruments continue to be marketed on their ability to decrease absolute numbers of highly skilled staff.

CT: Ultimately, automation can increase a lab’s capacity and help it operate more efficiently, even with a smaller staff. 

A case can be made for how instruments are more reliable than humans, at least for some things. But notice there's no more mention of safety, only efficiency.

QUESTION. Tell us about the new Bloodbanker App and its benefits over traditional blood banking tools.

CT's ANSWER

CT: ORTHO's Pocket Blood Banker app is an educational reference tool that combines genotyping and antibody indexing. Users can quickly determine genotypes based on results with Rh antisera via the Genotype Calculator and learn more about antibodies with the Antibody Index.

CT: Prior to the app, blood bankers used reference tools such as cardboard slide rules. 

You gotta be kidding. Cardboard slide rules? Maybe that's what Ortho supplied customers back in the Jurassic age, but for decades I and many others taught MLS students how to determine Rh genotypes using their ... wait for it ... inbuilt computers, aka brains.

Reminds me of this exquisite Danish humour on computers: Medieval helpdesk

CT: Drawing from a deep understanding of the importance of and need for innovation in blood banking, OCD identified the need for more advanced tools and developed this new technology. The app reinforces our commitment to providing innovative solutions to our customers. 

OMG, classic marketing and branding. We're wise, we're innovative, we're dedicated to helping clients. Please bring us cute babies to kiss. 

QUESTION: Could you introduce Ortho ON DEMAND and how it fits with OCDs overall focus?

CT's ANSWER

CT: ON DEMAND is an innovative virtual engagement platform that enables blood bankers to learn from and connect with experts on topics central to achieving science-driven safety and efficiency in the blood bank. 

Attempt to reinforce Ortho's brand as innovative, Also love 'virtual engagement platform' and 'science driven.' Buzzwords convey modernity and objectivity, respectively. And note re-introduction of the safety and efficiency double whammy.

CT: With OCD’s strong TM history, we understand the importance of supporting industry through education and awareness. 

We're the pros, we understand. Trust us.

CT: Because many of today’s blood bankers work longer hours with fewer financial resources, many laboratories have had to cut costs that previously supported career growth opportunities. Through our new platforms, we hope to help prepare blood bankers to address growing demands for TM expertise. 

Excuse me? Labs have had to cut CE and CPD funding because staff work longer hours with less money? Does not compute. Pure bafflegab.

As for helping a growing demand for expertise, is there a growing demand for expertise? If so, it's to address what automation created in the first place, namely a diminished demand for technical and scientific expertise with fewer positions for TM specialists.

Frankly, automation and apps both contribute to and help alleviate a 'dumbing down' of the profession. I acknowledge that 'dumbing down' is a harsh catch phrase for staffing with less qualified personnel, not that such staff are dumb. I use the term to emphasize that apps do not contribute to developing expertise, but rather exist to alleviate lack of it.

QUESTION. What impact do you think these initiatives will have on blood bankers?

CT's ANSWER

CT: Many of today’s blood bankers struggle to do more with less, working longer hours with fewer financial resources. Concurrently, instrumentation is more complex and the number of transfusions is increasing globally. 

Meaningless bafflegab. Yes, cost constraints force blood bankers to do more with less.  

But instrumentation is more complex? More complex than what? Earlier instruments? Manual testing? Do sales reps' spiels include these words?  "Hey, our instrumentation is more complex. You need better trained dudes to operate it."   

Also, in an age of blood conservation and a kazillion studies on real and unproven potential transfusion dangers, what evidence exists that transfusion numbers have increased? Does not compute.

CT: With reduced resources, many labs cut travel costs to learning events that could better prepare staff to address growing demands for TM expertise. Ortho ON DEMAND addresses this challenge by offering TM professionals free access to education according to their own schedules.

Offering free online education has merit. But it's not exactly true that today's over-worked TM professionals are clamouring to access education on their own schedules. Employers allot no time during work hours. Staff who are under-paid and feel under-appreciated are increasingly less motivated to take time away from families to further their careers.

QUESTION: How do you think the future of blood banks will develop?

CT's ANSWER

CT: While technology has made many routine BB tasks faster and easier, the demand for blood continues to rise and the pace of processing blood continues to accelerate.  

Demand for RBC transfusions (type that automated instruments process in transfusion service labs) is increasing? Where's the evidence? Surely all the efforts on blood management, blood conservation, and improved utilization are having an impact on RBC usage.

Pace of processing blood continues to accelerate? What does this mean? I could speculate but she doesn't explain.  

CT: Hemovigilance and ensuring efficiency is of utmost importance to blood banks in maintaining a safe and accessible blood supply while keeping pace with accelerating demand for blood processing. 

Sounds good but what has hemovigilance to do with OCD's automation and apps? And again the unexplained 'accelerated demand for blood processing.'

CT: The future of blood banks lies in technological solutions that will allow blood bankers to increase safety and efficiency in order to provide the best possible outcomes for patients. 

Motherhood statement. But where is the evidence that automated ABO and Rh group testing and automated antibody screening have improved outcomes for transfused patients? Or that apps that generate Rh genotypes and describe antibodies have made a difference? 

Surely, getting patient identification correct when drawing blood samples and correlating patient identity to crossmatched donor blood when administering blood remain THE hallmarks of safe transfusion practice, the 'right patient, right blood product, at right time' mantra. 

QUESTION: What are OCDs plans for the future? Would you like to comment further?

CT's ANSWER

OCD is the global leader in Transfusion Medicine, stemming from a 70-year history of protecting the safety of the worlds blood supply. We intend to continue our leadership of the market into the future, both with our products and through our service and support of the blood banking community. 

Forgive me, but I'm jaundiced. Although I've known, liked, and respected many Ortho reps, having just read Blood Medicine (aka Blood Feud) about Ortho Biotech and Amgen's marketing of EPO products, protecting patient safety as applied to J & J or any Big Pharma company rings hollow.
Author Q & A

2. WEBSITE

Simply put, Ortho ON DEMAND offers varied worthwhile educational talks by respected TM professionals, but promotes automation. To illustrate, the first 4 talks in its Presentation section are about automation. 

I'm reminded that Ortho and its competitors such as Immucor operate on a razor-blade business model: cheap razors (instruments), with the real money made on expensive blades (reagents).

3. RESEARCH PAPER
This paper by OCD employees further shows how industry treats TM professionals like poodles, hoping to baffle brains with BS. 

• South SF, Casina TS, Li L. Exponential error reduction in pretransfusion testing with automation. Transfusion. 2012 Aug;52(8):81S-87S.

Interestingly, one of the authors, TS Casina, an OCD marketing manager, also penned these 3 articles:

Casina TS. Technologies to improve the future of blood banking. Med Lab Obs 2011 Oct;43(10):32. Excerpt:

• 'As the labor force shrinks, the rapidly evolving field of laboratory medicine is struggling to keep pace with the growing demand for blood and its components. Automation is becoming a standard part of blood bank laboratories because it can help eliminate the labor-intensive, time-consuming manual testing processes that require specialized skills and significant experience to master.'

Casina TS. What's new in transfusion services. Advance for Med Lab Professionals. Posted online 19 Sept. 2012. Excerpt:

• Transfusion of incompatible blood has the greatest potential for severe adverse events and health complications, including death. Fortunately, due to advances in transfusion medicine (TM) practices -improved blood testing, donor screening and the advent of automated systems - the blood transfused to patients is safer today than it's ever been.

Casina TS. References for "transfusion medicine reactions. Advance for Administrators of the Laboratory 2012 Oct;21(10):20. This paper is a reworked version of the one above. Excerpt: 

• A study conducted by Ortho Clinical Diagnostics provides quantitative evidence of how automation could transform pretransfusion testing processes by dramatically reducing error potentials and thereby improve the safety of blood transfusion.  Evaluating the common testing methods above and leveraging failure modes and effects analysis (FMEA) to compare error potentials, the group concluded that automation significantly reduces defect opportunities in pretransfusion testing and could dramatically improve blood transfusion safety.

Can you see how marketing managers use a full court press and recycled material (with the help of willing publishers desperate for articles) to get their message out to industry's poodles, namely us?

Abstract Highlights (Transfusion paper)

BACKGROUND: Human error associated with manual pretransfusion testing is a cause of transfusion-related mortality and morbidity and most human errors can be eliminated by automated systems. 

STUDY DESIGN AND METHODS: Study’s goal was to compare error potentials of commonly used manual (e.g., tiles and tubes) vs automated (e.g., ID-GelStation and AutoVue Innova) group and screen (G and S) methods. G and S processes in 7 TS labs (4 with manual and 3 with automated methods) were analyzed to evaluate error potentials of each method.

Tiles?  Really? Well, they could be large welled plates. But who uses these in routine manual pretransfusion testing?  

RESULTS: Manual methods contained more process steps ranging from 22 to 39; automated methods contained 6 to 8 steps.  

Roughly 4-5 times more steps for manual methods. Authors then use ‘risk priority numbers’ (RPN)  - trust me, you don’t want to go there -  to show manual method RPNs ranged from 5304 to 10,976 vs 129 and 436 for automated methods, conveniently making manual tests away more than 4-5 times as risky as automation.

What the hey! Let's go there. A team (needed to reduce subjectivity) of OCD researchers and staff at 7 TS labs determined how many defects were likely at each process step (defect opportunities) and decided where failures could occur, the likelihood that the failure would be identified, how frequently the failures might occur, and what the effects of those failures (severity) were. The result was a 10 point scale. An example: 

Process Step 16 (tile or plate required tapping and rocking before reading reactions) had 18 defect opportunities. 18 represents 6 wells in the tile or plate in which it was possible to undertap reactants (6 defect opps), forget to tap the plate (6 defect opps), or overtap and splash reactants among wells (6 defect opps) for a total defect opportunity of 18 at that step (6 + 6 + 6 + = 18). The severity was rated 7 out of 10.

Wow! Talk about creative number crunching to get the results you want. The mind boggles....

CONCLUSION: This study provided quantitative evidence on how automation could transform pretransfusion testing processes by dramatically reducing error potentials and thus would improve the safety of blood transfusion.

Oh sure. Is I or is I not your poodle?

MORE MUSINGS
This study’s logical fallacy posits (love that word!) that most, or even many, serious transfusion errors result from manual testing of ABO and Rh groups and manual antibody screening. It's true that manual testing has potential to create more errors than automated testing.

The best evidence of where TM errors occur comes from the UK’s annual SHOT Reports. For example, consider 

• 2011 SHOT Report

I’ll not bore you with too many specifics  - you can read for yourself - but believe me, it’s NOT all about lab staff making technical errors when manually testing. 

'Adverse reactions caused by errors' lists these causes of cumulative cases reviewed 1996-2011 (n=9925):

• Anti-D errors 
• Inappropriate & unnecessary
• Handling & storage errors
• Incorrect blood component transfused (n>3000)

To quote SHOT: Key lesson from 2011 is an emphasis again on the importance of the essential steps of the transfusion process:

• Taking the blood sample from the correct patient 
• Correct laboratory procedures
• Issuing of the correct component
• Identification of the right patient at the bedside at the time of transfusion
• It is clear from the SHOT 2011 data that identification of the correct patient remains a key issue and that this must become a core clinical skill.

BOTTOM LINE
So, what's it all about? Yes, automation can increase efficiency and increase safety by reducing human error. But is automation the TM saviour that industry reps and some TM professionals make it out to be? 

When you examine the arguments of proponents, such as OCD's Celia Tombalakian or the research of OCD employees, their arguments do not stand up to scrutiny. They continually overstate how automated testing can improve safety and propose it as magic it is not. 

Companies have a vested interest in promoting automated testing since the business model of cheap razor (instrument) and expensive blades (reagents) is what makes their industry viable. 

Their multi-media advertisements are relentlessly promoted to TM professionals using flawed arguments that show they think they own us and we are their poodles. 

FOR FUN

Industry's seeming hold on so many TM professionals brings to mind:

• You Don't Own Me (1964 ditty by Lesley Gore; this version in Australia, 1989)

• You Don't Own Me (Same song re-worked for 2012 USA election - thoroughly partisan. ALERT: Depending on your politics, you may be offended.)

• You Don't Own Me (Diane Keaton, Bette Midler, Goldie Hawn in 1996 movie The First Wives Club)

Comments are welcome but due to excess spam this section is removed. Please send comments to me personally.