Sunday, April 12, 2015

While my guitar gently weeps (Musings on the seduction of technology)

Updated: 13 April 2015
April's blog focuses on news items from TraQ's latest newsletter that have a commonality. 
  • The main item deals with a molecular assay to identify 35 red cell antigens from 11 blood groups. 
  • The other, included to illustrate the blog's theme but mainly here for fun, focuses on the clinical uses of platelet-rich plasma (PRP). 
I'll leave it to readers to ascertain what the stories have in common. The blog's title derives from a 1968 George Harrison ditty in the Beatles 'White Album'. 

 NEWS ITEMS
MUSINGS on MOLECULAR BLOOD TYPING 
Typing of blood group antigens at the molecular level has been in the works for years. Now it's moving beyond its original special uses because of technological advances, decreasing costs, and lobbying by vested interests. 

However, its cost-effectiveness is still unproven. Immucor's PreciseTypeTM HEA test costs ~$350 USD but that likely varies significantly depending on individual contracts. And any cost study I've read in journals like AABB's Transfusion is so dependent on assumptions as to be almost meaningless and needs to be read carefully and critically.

Also, molecular blood typing is not the be-all, end-all for the 100s of blood group antigens that exist, since not all are DNA-defined. But the list of antigens covered is impressive and includes nearly all clinically important blood group systems (see Further Reading). 

Regardless, molecular blood typing has no end of proponents, mild and strong. For example:
I wrote a blog on this topic years ago: 
  • Snip, snip the party's over (Dec. 2010) 
    • Suggest you read it later, if the mood strikes. My predictions have come true but they were no-brainers. 

Me Medicine
Now molecular blood typing is being marketed as personalised medicine, ie., the tailoring of medical treatment to individual characteristics of each patient. The idea derives from the 13-year, $3 billion Human Genome Project. For example, Immucor advertises PreciseType this way:
Makes it seem that anything less is substandard. Get with the program, health care providers, because it's all about me.

But many experts like Donna Dickenson, emeritus professor of medical ethics and humanities at the University of London and research associate at the HeLEX Centre, University of Oxford caution that
MUSINGS: PLATELET-RICH PLASMA (PRP) 
I'd read several news items over the years about PRP's use in orthopedics, particularly for athletes:
And recently the owner of a local restaurant I frequent mentioned that she had her own plasma injected into her knee but had to pay for it as it wasn't covered by Canada's universal health care system, at least for her. She said her knee caused a lot of pain (she's a 50-something server in the restaurant) but apparently it wasn't bad enough to be operated on yet. 

With that as background, recent news items on PRP's expanding clinical uses caught my attention. Medical tourism grows daily, at least for the rich. Seems Dubai now has more plastic surgeons per capita than any other city in the world and hopes to attract half a million medical tourists by 2020. 

The penis and vagina PRP nonsense was included just for fun. But really, Academy Award nominees got a coupon for a Priapus Shot? You cannot make this stuff up. 

BOTTOM LINE 
Okay, I lied because I'm sure you've gotten the blog's theme by now:
  • Where there's a buck to be made or an agenda to be advanced, clinical uses of diagnostic tests and products will inevitably expand well beyond what's evidence-based. 
TM poster-child for phenomenon? Intravenous immunoglobulin (IVIg). 

But what's surprising, at least to me, is how few voices, especially in the TM community, question the *expanded use* of innovations like molecular typing of red blood cell antigens under the guise of me-medicine. Particularly since our so-called 'thought leaders' are so into evidence-based these days. 

I understand why advances that help solve real TM problems are celebrated. But why the uncritical approach? Is it because blood typing at the molecular level is 
  • A marvelous innovation and all want to be seen as 'with-it' hipsters on DNA's bandwagon? Versus being old-fogeys who resist change? 
  • Way to develop a business line and maximize earnings in a shrinking field like TM in age of 'blood conservation '├╝ber alles', e.g., AABB? 
  • Outright self-interest for those who specialized in molecular technology and need to maximize their career's life-span?  
  • Seen as eliminating humans from the equation, such as interpreting serological test results, thus must be good? 
  • High-throughput automated innovation, another way to decrease costs by eliminating those pesky creatures, aka staff, with their costly salaries, benefits, and pensions? 
    • Better to give money to international companies than keep staff, aka tax payers and community builders, employed at home?
    • Plus many staff are probably contemplating retirement anyway and eliminating their jobs will help make that decision easier? 
  • Viewed as best thing since sliced bread, not just a significant innovation with specific uses, motivating proponents to abandon whatever critical thinking skills they ever had?  
BOTTOM LINE 
Personally, I wholeheartedly agree that molecular blood typing is a useful, indeed marvelous, advancement that will make blood transfusion safer for many. Celebrate its potential but please don't promote it beyond clear clinical uses so that anything else seems sub-standard, as in this over-the-top headline: 
  • 'Boston Children’s Hospital ends BAD BLOOD between donors, patients' (Emphasis is mine)
FOR FUN 
'While My Guitar Gently Weeps':
  • #136 on Rolling Stone's "The 500 Greatest Songs of All Time"
  • #7 on its list of 100 Greatest Guitar Songs of All Time
  • #10 on its list of The Beatles 100 Greatest Songs. 
While my guitar gently weeps (Paul McCartney and Eric Clampton tribute to George Harrison, Queen's Golden Jubilee, London 2002) 
I don't know why nobody told you 
How to unfold your love 
I don't know how someone controlled you 
They bought and sold you. 

I look at the world and I notice it's turning 
While my guitar gently weeps 
With every mistake we must surely be learning 
Still my guitar gently weeps 

As always the views are mine alone and comment are most welcome.

FURTHER READING 
References for those who want to delve further into the blog's topics. 
Molecular blood typing
Nice overview: Denomme GA. Prospects for the provision of genotyped blood for transfusion. Brit J Haem 2013 Oct;163(1):3-9.

For molecular blood typing in detail, see these papers from 2009. Info overload but fascinating insight into predicting the future (All papers free full text): 

Molecular blood group diagnostics.Transfus Med Hemother. 2009 Jun; 36(3): 154–155.(editorial) 

Five expert opinions on the question ‘Will genotyping replace serology routine blood grouping in the future?’ 
Interpretations are mine. (Author origins refer to where they worked then, not necessarily nationality.) 
  • Opinion 1: Only partly. Unlikely unless... (Germany) 
  • Opinion 2: Probably (Switzerland) 
  • Opinion 3: For some applications (Austria) 
  • Opinion 4: Personalized versus Universal Blood Transfusions – Combining the Efforts: Probably but in combination with enzymatic conversion (ECO) to remove A and B antigens (Sweden) 
  • Opinion 5: Yes (Netherlands) 
Platelet-rich Plasma