What's it all about, Alfie?

This month's blog is about how we spend our time in the context of transfusion medicine research. The title comes from the song What’s it all about Alfie? and the movie of the same name starring Michael Caine (and a later version with Jude Law). Perhaps you have pondered the meaning of this oldie-goldie from the 60s?

It's a cliche to say that to get the right answers you must ask the right questions, which is the researcher's equivalent of the techno-geek's GIGO.

But even more important is to know what questions of all the questions that could be asked are worthwhile spending time trying to answer. I would not call myself a researcher, although I have done applied research, but will not let that stop me from commenting or spouting off.

Two articles caught my attention in recent issues of Transfusion and Vox Sanguinis, both out of personal historical interest.

The first paper by a College of American Pathologists committee concerns blood bank serology, something at risk of becoming obsolete but nonetheless dear to my heart.

1. AuBuchon JP, de Wildt-Eggen J, Dumont LJ for the Biomedical Excellence for Safer Transfusion Collaborative and the Transfusion Medicine Resource Committee of the College of American Pathologists. Reducing the variation in performance of antibody titrations. Vox Sang 2008 Jul;95 (1):57–65.

Summary: Because antibody titration is difficult to standardize, the CAP proficiency testing program decided to investigate whether a detailed, uniform titration procedure would reduce variation in both tube-based and gel card titres (see abstract for details). Based on results from 35 laboratories, the U.S. authors concluded that a uniform method for antibody titration at 37°C and read at the antiglobulin phase in a tube-based method with a w+ end-point (compared to a 1+ end-point) reduced inter-laboratory variability.

Related reading:

• van Dijk BA, Dooren MC, Overbeeke MA. Red cell antibodies in pregnancy: there is no 'critical titre'. Transfus Med. 1995 Sep;5(3):199-202.

• CBBS e-Network Forum. In performing titration studies for NON-Rh antibodies in pregnant women, what is the practice regarding selection of reagent red cells that are heterozygous vs homozygous for the antigen in question? (in particular, see John Judd's comments at the end)

MUSINGS
Titrations - a blast from the past! Long ago I performed many a titration while working in Winnipeg with Dr. John Bowman - titrations on the plasma of women with anti-D who were candidates for intrauterine transfusion and on the plasma of women whose potent anti-D was used to manufacture Rh immune globulin.

One thing I know from working in a lab that used titrations as an adjunct to assess hemolytic disease of the newborn due to anti-D is that titre is an unreliable indicator of disease severity. Historically, it was used as a poor tool to assess whether invasive procedures such as amniocentesis and later PUBS were warranted.

Depending on the method, the red cell phenotype used, and operator technique, titres can vary significantly. Technically that's a 2-tube difference (or more) in a titration that uses a doubling dilution, e.g., titres of 4 and 8 are not considered significant but those of 4 and 16 would be.

While an anti-D (or anti-K) with a high titre (however that is defined) can alert us to the need to monitor current and future pregnancies, can getting more consistent inter-laboratory endpoints significantly influence clinical management?

Obtaining more reliable titres among labs is a good thing, but how important is it practically and clinically?

A second paper that makes the point:

2. Seltsam A, Agaylan A, Grueger D, Meyer O, Blasczyk R, Salama A. Rapid detection of JMH antibodies with recombinant Sema7A (CD108) protein and the particle gel immunoassay. Transfusion 2008 Jun;48(6):1151–5.

Summary: The German authors describe a method to detect anti-JMH with particles coated with recombinant semaphorin 7A, the protein that carries the JMH blood group antigens, presumably thus making identification of anti-JMH possible without having rare JMH-negative red cells.

MUSINGS
Another blast from the past - John Milton Hagen. Was there a patient by this name like Mrs. Kellacher whose ani-K led to the discovery of the antiglobulin test by Coombs? I've forgotten.

Anti-JMH was once considered a high-titer, low-avidity (HTLA) antibody, now an outdated term. The phenomenon is caused by the low number of antigen sites on red cells, not by antibody avidity, and not all antibodies classified as HTLA have a high titre.

JMH antibodies are usually harmless, although they can cause serologists problems by hiding clinically significant antibodies, since they react with most red cells. Rare cases of people with a variant JMH phenotype producing a clinically significant alloantibody have been reported.

While it would be useful to be able to identify anti-JMH without having rare JMH-negative red cells, how important is it practically and clinically?

Related reading

• CBBS e-Netrwork Forum. Is it necessary to determine the specificity of HTLA antibodies?

• J.M. Moulds (PDF file). A review of the Knops blood group:separating fact from fallacy. Immunohematology 2002;18(1)

BOTTOM LINE
Granted that these articles are cherry picked to serve a point, they do illustrate that sometimes research, even applied research, may have questionable technical or clinical relevance.
By happenstance, the June issue of Transfusion features the status of transfusion medicine in developing countries. Particularly noteworthy is this review paper:

• Tagny CT, Mbanya D, Tapko J-B, Lefrère J-J. Blood safety in Sub-Saharan Africa: a multi-factorial problem. Transfusion 2008 Jun; 48 (6):1256–61.

The paper's conclusion begins by noting, Blood safety remains an issue of concern in Africa and especially in countries of Sub-Saharan Africa where the key factor to most transfusion-related problems is the lack of financial resources.
It ends with these words: .... this is one of the unfortunate paradoxes of the history of humanity: it is those regions most in need of the means to fight prevalent diseases that have least access to them.

Yet we in developed counties continue to spend resources on ways to improve titration reliability and identification of antibodies such as anti-JMH. Those who do such investigations are respected researchers who have devoted their professional lives to improving transfusion medicine. But how important are some of these initiatives in the grand scheme of things?

An earlier blog discussed this issue of the discrepancy between them and us:

• Signs you live in the 21st century

The next time you read an article in a scientific journal - or if you are a researcher who is contemplating spending your valuable time and finite resources on investigating a problem, and you can choose from issues A, B, or C - I encourage you to ask, What's it all about Alfie?

• Dionne Warwick's version

The opening lyrics:
What's it all about, Alfie?
Is it just for the moment we live?
What's it all about when you sort it out, Alfie?
Are we meant to take more than we give.....
ADDENDUM- The nature of research

Unfortunately, research is often many tedious rounds of slogging it out with nothing working - until it does - should that happen. It may not. You cannot predict the result.

We can also differentiate between basic ("pure") research and applied research.

Pure research, as historically done at universities, is typically driven by the curiosity of the researcher with no practical application in mind. The reason is to create new knowledge by following the researcher's interests and passions. Although sometimes denigrated as a waste of time and money by anti-intellectuals, basic research has often resulted in incredible, if unforeseen, benefits to mankind. For a fun peek into the lives of researchers see

• The Nature of Research (PDF)

Applied research, becoming predominant at universities (which some would argue is unfortunate) is more focused on solving particular problems. For example, medical research is typically applied research and compares various treatments or drugs to investigate which gives better patient outcomes. In a prospective experimental study, the researcher creates a null hypothesis (treatment A and treatment B are the same and will result in similar patient outcomes) and tests it by conducting experiments.

SERENDIPITY
Often, research, regardless of its original purpose, results in unexpected, happy outcomes. For example, in the 1960s Baruch Blumberg was a geneticist (not a virologist) who was studying the genetic variation of proteins in blood. He and his colleagues decided to test the hypothesis that patients who received many transfusions might develop antibodies against polymorphic serum proteins which they had not inherited, but which the blood donors had.

Using double diffusion in agar gel they did find sera in multi-transfused patients that contained precipitating antibodies and in 1963 unexpectedly hit magic. When testing the sera of American hemophilia patients against that of an Australian aborigine, they found a precipitin band unlike any others and called it the Australia antigen.

Eventually, the Australia antigen was shown to be the HBsAg. In the process, one of Blumberg's technologist contacted hepatitis B. From this serendipitous discovery came tests for HBV infection and a vaccine. For the entire fascinating story, see

• Blumberg's 1976 Nobel lecture (PDF)

Unfortunately, HBV infection remains one of mankind's major diseases and killers.

Summary: Blumberg did not know if he would find antibodies in transfused patients stimulated by serum proteins in donor blood. Most particularly, he did not know that one of those proteins would be the hepatitis B surface antigen. And when he found it, no one knew what it was. My favorite quote about research is by Carl Sagan:

• “Somewhere, something incredible is waiting to be known.”