Bone Marrow Transplantation (2000) 25, 899–905  2000 Macmillan Publishers Ltd All rights reserved 0268–3369/00 $15.00 www.nature.com/bmt Development of a district Cord Bank: a model for cord blood banking in the

C Donaldson1, R Buchanan2, J Webster2, V Laundy1, H Horsley1, C Barron1, N Anderson3, B Bradley1 and J Hows1

1University of Division of Transplantation Sciences, 2Department of Women’s Health Services, Hospital and 3National Blood Service, Bristol Centre, Bristol, UK

Summary: personal communication).4 Transplants performed world- wide show that low cell dose significantly decreases post- The Bristol Cord was established as a pilot transplant survival.4,5 Therefore, to date, most cord blood project within existing health services to establish cost- transplant recipients have been small children under effective recruitment, collection and processing suitable the age of 10 years. for use in the NHS should cord blood become a routine The Bristol Cord Blood Bank (BCBB) was developed as source of haemopoietic stem cells for transplantation in a pilot research project to optimise recruitment, collection the UK. An important aim of the project was to evaluate and processing of cord blood donations, with future incor- the feasibility of establishing a midwifery-based collec- poration of cord blood banking into the NHS in mind. An tion network, thus utilising expertise already in place. important aim of the project was to evaluate the feasibility Collection was performed on the delivery suite immedi- of establishing a midwifery-based collection network, thus ately after the placenta was delivered. The clinical utilising expertise already in place within the NHS. experience of the midwife collector/counsellors allowed rapid pre-collection assessment of the condition of the cord and placenta. This prevented collection attempts Establishment of the Bristol Cord Blood Bank from diseased or otherwise damaged placentas, leading to conservation of resources by preventing collection of The district most small volume donations. The bank was established within the National Blood Service, Bristol Centre to The North Bristol NHS Trust provides community and hos- achieve Good Manufacturing Practice standards and pital services to 500 000 people living in north Bristol and ensure that processing was subject to the same strin- . Community midwives provide the gency required for other sources of haemopoietic stem majority of antenatal care in the community, with referral cells. Cord blood is an expensive resource. By utilising to the hospital antenatal assessment unit when necessary. existing expertise in district Obstetric and National During the 1997/1998 financial year there were 88 116 Blood Services, the Bristol Cord Blood Bank may serve community midwife/patient visits compared with 16 000 as a model for health economic evaluation of cord blood maternity-related admissions to Southmead Hospital, which banking of volunteer donations within the NHS. Bone included 5500 births. Marrow Transplantation (2000) 25, 899–905. The National Blood Service, Bristol Centre, provides Keywords: cord blood; collection; banking; obstetric processing and storage facilities for bone marrow and per- factors ipheral blood stem cell harvests. The cord blood bank was established within this facility to achieve Good Manufactur- ing Practice (GMP) standards and ensure that processing was subject to the same stringency and underlying prin- Haemopoietic stem cells from human umbilical cord blood ciples required for other sources of haemopoietic stem cells. can be transplanted in place of bone marrow to treat chil- dren with leukaemia and other potentially fatal marrow dis- eases.1–3 The future of cord blood as a practical source of Staffing haemopoietic stem cells for transplantation is uncertain and Central Delivery Suite (CDS) at Southmead has a core staff research is still ongoing. A cohort controlled study from the of 40 full-time equivalent midwives working in shifts, as International Bone Marrow Transplant Registry comparing well as four teams of community midwives on rotational banked cord blood with bone marrow donations from regis- attachment.There was concern that if all midwives were tered unrelated volunteers is still awaited (John Wagner, asked to collect cord blood, there would have to be constant retraining in the collection procedures and an increased possibility of small volume collections and higher bacterial Correspondence: Dr C Donaldson, University of Bristol, Division of Transplantation Sciences, Southmead Hospital, Westbury-on-Trym, contamination rates, as the frequency of collections perfor- Bristol BS10 5NB, UK med by any individual midwife would be low. Received 18 August 1999; accepted 15 December 1999 The collection system was therefore developed around Cord blood banking in the NHS C Donaldson et al 900 senior core midwifery staff. Two senior midwives were labour as previously described by the New York Cord seconded for 40% of their time to the cord blood bank as Blood Bank.7 Briefly, the obstetric team in charge of the midwife counsellors. Their role was to organise the recruit- delivery passed the placenta out of the delivery room to ment system, perform the collections, counsel and consent one of the midwife counsellors whose clinical experience mothers for donation and organise the collection of allowed rapid pre-collection assessment of the condition of maternal blood samples 6 months post partum for ‘follow- the cord and placenta. This assessment, which was based up’ virology screens. For the remaining 60% of their time on the findings of a pre-clinical study,8 took into account they were midwives in charge of CDS. Cord blood banking the size, health and condition of the placenta, the size of was therefore seen by all staff as a development within the infant, length of labour, and time of cord clamping. This midwifery services, not as an outside research project. With prevented collection attempts from diseased or otherwise this arrangement it was possible to build up expertise and damaged placentas, leading to conservation of resources by enthusiasm for the project within the obstetric department. preventing collection of most small volume donations. The placenta was placed on a collection stand with the Recruitment foetal surface positioned ventrally. The cord was cleaned with an alcohol spray. A venesection site was selected on A two-stage recruitment and counselling procedure was the umbilical vein as near to the distal cord clamp as poss- developed within National Blood Service guidelines6 antici- ible. The umbilical vein was cannulated with the needle of pating a central role for the NBS should cord blood become a standard Baxter Optipac triple blood collection pack a routine source of haemopoietic stem cells in the UK. (Baxter Healthcare Ltd, Newbury, UK); the volume of anti- Community midwives recruited healthy pregnant women coagulant having been reduced to 23 ml for cord blood col- during the third trimester by giving them information about lection by the removal of 40 ml by sterile technique. The the project and a leaflet highlighting lifestyle exclusion cri- cord blood drained into the collection bag which was placed teria. Certain aspects of the expectant mother’s health and on a blood collection mixer (Baxter Optimix) throughout lifestyle are routinely discussed between the midwife and the collection to prevent clotting. The donation was labelled the mother to enable the best management of the preg- in the collection room with a maternal hospital label and nancy, delivery and immediate care of the newborn. Com- placed in an insulated blood transport box on the delivery munity midwives performed an initial ‘pre-selection’ and suite until collected for processing. did not give the information to women whose known social By the end of the research period, 749 donations had history or personal and family would been collected for banking with a mean volume of 98 ml warrant exclusion. (s.d. 35), excluding the volume of anticoagulant. This com- After reading the leaflets women either gave written con- pares favourably with other reports. In one study, collection sent for cord blood to be collected after delivery of the by obstetricians during the third stage of labour was com- placenta, or were free to decline without giving a reason. pared with collections by cord blood bank technicians after Signed consent forms were placed in the mother’s ante- placental delivery.9 The mean volume collected during the natal notes. third stage of labour was 81 ml (n ϭ 293), and after pla- There were 8267 births on CDS between September cental delivery was 75 ml (n ϭ 41). In a smaller study of 1997, when clinical cord blood collection commenced, and 42 collections,10 a mean volume of 83 ml (s.d. 7.9) for 23 the end of the pilot research project in March 1999. In the donations collected during the third stage compared with first 6 months successful collections averaged 33% of those 48 ml (s.d. 4) for 19 donations collected after placental possible during the midwife counsellors’ shifts (Table 1). delivery. Therefore our decision to collect after placental Improvements were made to the recruitment and collection delivery did not obviously compromise the volume of procedures following an audit by the midwife counsellors donations. in February 1998. These changes, combined with greater Four hundred and sixty-four donations were from vaginal availability of processing facilities, enabled us to increase deliveries, mean volume 92 ml (s.d. 32), and 285 after Cae- the collection rate to 53% for the following year. sarean sections, mean volume 107 ml (s.d. 36), P Ͻ 0.001. In the pre-clinical observational study8 factors found to sig- Collection nificantly enhance total nucleated count of the donation included the total volume collected. Therefore we used Local hospital ethics committee approval was obtained for minimum volume as the most practical variable to decide cord blood collection for clinical banking. Collections were whether a donation was suitable for clinical banking. made from normal deliveries, defined as gestation greater Donations of less than 60 ml were excluded from the bank than 37 weeks, where the obstetric team was not aware of but, when applicable, were used for research. Of the 56 any potential complications. units discarded because they were below the defined mini- The midwife in charge of the delivery informed one of mum, 14 were after Caesarean deliveries, whilst 42 were the midwife counsellors if a mother had consented to cord post vaginal deliveries. These data indicate that donations blood collection and alerted them when delivery was immi- collected after both vaginal and Caesarean deliveries are nent. The midwife delivered the baby and placenta, having acceptable for clinical banking. However, if banking been instructed not to alter the routine clinical resources are limited, collection after delivery by Caesarean management of the delivery because cord blood was section should be chosen. being collected. The pre-clinical study identified other clinical factors Collections were performed following the third stage of influencing the quality of donations.8 Obstetric variables

Bone Marrow Transplantation Cord blood banking in the NHS C Donaldson et al 901 Table 1 Details of activity on the delivery suite

Month Total Targeted Number of % of total % of targeted deliveries deliveriesa collections deliveries deliveries collected collected

Pre-audit Sep 97 407 88 29 7 33 Oct 97 464 84 23 5 27 Nov 97 489 95 33 7 35 Dec 97 463 72 25 5 35 Jan 98 472 105 37 8 35 Feb 98 471 116 36 8 31 Total 2766 560 183 7 33 Post audit Mar 98 471 89 53 11 60 Apr 98 484 106 40 8 38 May 98 441 84 44 10 52 Jun 98 446 97 48 11 50 Jul 98 439 80 48 11 60 Aug 98 442 90 23 5 26 Sep 98 428 96 47 11 49 Oct 98 436 80 56 13 70 Nov 98 403 77 46 11 60 Dec 98 421 71 48 11 68 Jan 99 388 64 31 8 48 Feb 99 356 80 43 12 54 Mar 99 346 77 49 14 64 Total 5501 1091 576 11 53 aTargeted deliveries were the number of deliveries that occurred during the time that the midwife counsellors/collectors were on duty (08.00 to 16.00 Monday–Thursday during the study period). found to be significantly associated with high total for the reasons shown in Table 3. This rate compares nucleated cell count (TNC) were long gestation, long labour favourably with reports by other investigators. Data from and short time between delivery of the infant and cord Besanc¸on gives an overall discard rate of 55%,11 and from clamping. The mean total TNC of the 614 banked buffy Milan 51%,12 with 50% of the discards due to low volume. coat preparations was 10.2 ϫ 108 (s.d. 4.6), with a mean Cord blood banks in Mannheim13 and Leuven14 have of 4.3 ϫ 106 (s.d. 3.8) CD34ϩ cells. Table 2 shows the reported discard rates due to low volume of 18% and 29%, post-volume reduction nucleated cell count on the 644 units respectively. The main reason for the low discard rate processed to that stage, analysed with respect to parity. The reported here is the pre-collection assessment of the pla- mean cell count decreased from 11.18 ϫ 108 from prima- centas by the midwife collectors. This is an advantage over gravidae to 8.07 ϫ 108 from fifth parity deliveries. There the practice of employing technical collection staff to work is a significant difference between the nucleated cell count within the delivery ward 24 h a day collecting from all obtained from primiparous compared to multiparious deliveries. This latter approach, which has been used in the mothers (P Ͻ 0.001). This observation may be due to the New York and London Cord Blood Banks, may result in known association between shorter labour with increasing more collections, but wastes resources as more donations parity. Although these variables cannot be influenced, are discarded due to low volume.15,16 knowledge of their effect allows informed selection of ‘best Another factor contributing to the low discard rate achi- scenario’ collections when banking resources are limited. eved by the BCBB was the pre-selection of volunteer Overall 135 (18%) donations collected were discarded mothers by community midwives collaborating in the pro-

Table 2 Analysis of the total nucleated cell count (ϫ108) of cord blood donations with respect to parity

Parity 1 2 3 4 5 n 253 285 82 16 8 Median TNC 10.2 9.0 8.7 8.5 7.4 Minimum 2.6 2.8 1.9 3.6 3.0 Maximum 29.1 25.9 21.4 17.2 17.6 Mean 11.2a 9.7 9.5 8.7 8.1 s.d. 4.9 4.4 4.2 3.7 4.8 aThe mean TNC of donations obtained from primagravida was significantly higher than the mean TNC of donations from multiparous women, P Ͻ 0.001.

Bone Marrow Transplantation Cord blood banking in the NHS C Donaldson et al 902 Table 3 Reason for discard of cord blood donations

Reason for unit discard n % of total % of donations discarded collected donations

Low volumea 56 8 42 Donor selection 42 6 31 Body piercing 8 Withdrew consent 15 Medicationb 16 Communication difficulty 2 Medical history 1 Clots in sample 12 2 9 Controlled rate freezer failure 7 1 5 Infection 15 2 11 Bacterial contaminationc 6 Maternal virologyd 5 Malarial positive 3 Medical history of baby 1 Follow-upe 3 Ͻ12

aϽ60 ml. bIncluded eight donations where dexamethasone was administered to the mother before elective caesarean section. cThe identity of five positive cultures discarded were Peptostreptococcus asaccharolytica and diptheroids, alpha haemolytic streptococci, Staphylococcus aureus, Enterococcus sp, and coagulase-negative staphylococcus and bacteroids. A sixth culture negative unit was discarded because a maternal high vaginal swab taken pre-labour grew haem strep B. dTwo HbsAg false positive, one HCV confirmed positive and one HCV false positive. eThese donations were discarded at the 6-month follow-up because of suspected congenital malformation or disease.

ject. Exclusions were based on standard life-style and fam- Maternal consent ily history criteria routinely obtained from mothers by com- munity midwives to ensure the best possible management Written consent was obtained from the mother for the col- of the pregnancy, delivery and post-natal period. lected cord blood to be donated to the bank for clinical transplantation, research, or both. The donation was made on the understanding that the unit could not be reserved Donor interview and maternal virological for family use. Consent included permission to contact the If a successful collection was made, a midwife counsellor mother 6 months post partum for a repeat virological visited the mother soon after delivery to review and discuss screen, and their GP to enquire about the child’s general her original consent for cord blood collection. The midwife health. counsellor administered a medical history questionnaire, compliant with the NBS Medical Assessment of Donors 17 Processing and microbiological screening of the cord document and, if there were no reasons why the collection blood units should be excluded, ascertained if the mother was still wil- ling to donate. A sample of maternal blood was then taken Processing was performed within 24 h of collection of the for the mandatory virological screens cord blood. An aliquot was removed from each suitable (HIV 1 and 2, HBsAg, HCV, CMV and ).6 Forty- donation for HLA typing, white blood cell count (WBC) two units were discarded following the donor selection and CD34-positive cell count to quality control the volume interview (Table 3) and eight following the results of the reduction procedure. Aerobic and anaerobic microbiologi- maternal blood tests. cal cultures were performed on all donations. Although the There is still a debate in the cord blood banking com- incidence of bacterial contamination was 16 out of 749 munity as to whether or not re-testing for viral markers at (2.3%), 11 were positive for coagulase-negative staphylo- 6 months is practical.18 In the system employed at the coccus and the decision was taken to record their antibiotic BCBB initial recall was by letter to the mothers. Seventy- sensitivities and bank the donations. Seven additional units nine percent returned samples taken at their doctor’s sur- were discarded as indicated in Table 3. gery within 8 weeks (Table 4). The midwife counsellors Cord blood units were centrifuged to produce a buffy telephoned those who had not responded by 8 weeks. As coat layer and the volume reduced to 30 ml using a Baxter a result of proactive follow-up by the midwife counsellors, Optipress II automated blood component extractor.19,20 A 91% of all samples requested were obtained and tested. If WBC and CD34ϩ cell count were performed on every buffy a second sample for virological screening had not been coat fraction to assess the haemopoietic cell content of the received 1 year after the original donation, the unit processed donation. remained in the quarantine bank but could be made avail- Donations were cryopreserved in 6 ml of 50% DMSO in able for searches at the discretion of the requesting phys- autologous plasma, to give a final concentration of 10% ician and the cord blood bank Medical Director. DMSO. The processed blood is placed in a 50 ml cryocyte

Bone Marrow Transplantation Cord blood banking in the NHS C Donaldson et al 903 Table 4 Timing of receipt of maternal samples for repeat virology screens

Due Received % Received % Received % Ͻ8 weeks Ͻ12 weeks Ͼ12 weeks

March 16 16 100 16 100 16 100 April 13 11 85 13 100 13 100 May 30 27 90 28 93 29 97 June 22 21 96 21 96 22 100 July 32 23 72 26 82 30 94 August 36 31 86 31 86 33 92 September 49 34 70 37 76 41 84 October 33 22 67 23 70 29 88 November 38 29 76 31 82 34 90 December 44 35 80 36 82 39 89 January 36 27 75 32 89 February 18 13 72 March 39 34 87

The table shows the number and percentage of samples returned within 8 weeks, within 12 weeks and those returned more than 3 months after they had been requested. bag and frozen by controlled rate of Ϫ1°C/min down to Table 5 Costs of collecting one unit for the Bristol Cord Blood Bank Ϫ40°C followed by Ϫ5°C/min down to Ϫ160°C. This pro- cedure was based on optimal cryopreservation protocols Cost per unit evaluated previously.21 Units are stored in the vapour phase of liquid nitrogen Consumables cost per unit and are available for bone marrow donor searches through Activity Collection and processing £23 the British Bone Marrow Registry once the 6 month maternal QC (FBC and CD34) £5 follow-up virological screens have been performed. Laboratory servicesa HLA typing £55 Virology £12 Future role of cord blood banking Microbiology £9 6 month follow up £13 Pilot data on unrelated cord blood transplants using volun- Total £117 £117 2,4,22 teer donations have been published. Results in small Other costs per annum children with relatively good risk leukaemia are encour- Salariesb £55055 aging.3,23 In contrast, there are few data on unrelated cord Equipment capital chargesc £4768 blood transplants in adults because only 10–15% of cord Service contracts £6500 blood donations contain sufficient TNC, CD34ϩ cells and Liquid nitrogen £2688 Total £69010 £168 colony-forming cells for adult requirements.8,24 A recent review of the literature suggests that engraftment failure Total cost per unit £285 may be high after cord blood transplants in adults.25 a The BCBB was established with research funding utilis- HLA typing and virology screening were purchased from the Bristol Blood Centre. Microbiology screening was purchased from Southmead ing existing facilities and equipment. It also benefited from Hospital Department of Microbiology. the enthusiasm generated within the community midwifery bSalaries for two, 40% whole time equivalent, grade G midwives; one service by the midwife counsellors as all the recruitment research technician and one research fellow/Cord Blood Bank manager. of expectant mothers was performed voluntarily by the cEquipment purchased included two Espace 330 liquid nitrogen storage banks, one GT75 ampoule storage tank, one GT55 quarantine tank, one community midwives. Taking into account costs for staff, Baxter OptipressII blood component extractor. consumables and capital and revenue costs only on that Pre-existing facilities that are not costed include the processing laboratory equipment purchased specifically for the cord blood bank, at the Bristol Blood Centre, laminar flow hoods, two controlled rate freez- the cost of banking one unit was £285 (Table 5). It has ers and a flow cytometer. been calculated that if the bank had been established as a stand-alone facility, the cost of banking one unit would have been approximately £500. 1000 donations must be issued, or 5% of the units banked. In the UK the four operational cord blood banks in It is debatable if this release rate is attainable in the UK Belfast, Bristol, London and Newcastle, operating within unless cord blood transplantation becomes feasible for the Blood Transfusion Service, intend to maintain 20 000 adults. Although the NYCBB issued 676 out of 7705 units stored unrelated donations between them. It is difficult to (8.7%) by 30 June 1998,2 the release rate of the large Italian project the cost per unit supplied from the UK, as so far cord blood bank network, GRACE, is currently only only a small number has been supplied, however, following between 1 and 2%.26 Projected costs for provision of cord FDA guidelines a charge of $15 300 (£10 000) is suggested. blood donations in the UK to transplant centres must be To recover costs of establishing the combined UK CBB, compared with £7000 to provide an unrelated marrow

Bone Marrow Transplantation Cord blood banking in the NHS C Donaldson et al 904 donation from the British Bone Marrow Registry, The View Road, Keynsham; The , 38–42 Bradley Road, Patch- Anthony Nolan Trust or the Welsh Registry. Cord blood way; The Surgery, 40 Parsonage Street, Dursley; The Surgery, 42 is an expensive resource. Unrelated volunteer cord blood The Street, Uley, Dursley; The Surgery, 43 Gloucester Road, Fil- banking directed towards ethnic minority groups among ton; The Surgery, 43 Nevil Road, Bishopston; The Surgery, 58 whom there is a shortage of HLA-compatible unrelated vol- Pembroke Road, Clifton; The Surgery, 60 Falcondale Road, Westbury-on-Trym; The Surgery, 111 Pembroke Road, Clifton; unteer marrow donors may, however, be a valuable cost 15,27,28 The Surgery, 232 Milton Road, Weston-super-Mare; The Surgery, effective initiative. 269 Stapleton Road, Easton; The Surgery, 521 Avenue, In summary, we have described a system for setting up Northville; The Surgery, Abbotswood, Yate; The Surgery, Coron- and operating a district cord blood bank. We have utilised ation Road, Downend; The Surgery, Culverhay, Wotton-under- existing Obstetric and National Blood Service facilities and Edge; The Surgery, Mount Pleasant Park, Caldicot; The Surgery, expertise. The Bristol Cord Blood Bank may serve as a Northwick Road, Pilning; The Surgery, St Mary Street, model for health economic evaluation of cord blood bank- Thornbury; The Surgery, Sundays Hill, Lower Almondsbury; The ing of volunteer donations within the NHS. Surgery, Sunnyside Road, Clevedon; The Surgery, Wellington Road, Yate; Thornbury Health Centre; Vauxhall Surgery, Tutshill, Chepstow; Wells City Practice, Wells; Wells Health Centre Prac- tice; Whitchurch Health Centre; Whiteladies Family Practice, Acknowledgements Clifton; Whiteladies Medical Centre, Clifton; Whitney Mead, Frampton Cotterell; William Budd Health Centre, ; The Bristol Cord Blood Bank is funded by the Leukaemia Winscombe New Surgery; Wrington Vale Medical Practice, Research Fund grant 96/04, jointly with the Bristol Institute of Wrington; Yatton Family Practice. Transfusion Sciences; Director Professor D Anstee. We thank Dr D Pamphilon and staff at the Bristol Transfusion Centre for the use of laboratory facilities; Dr A MacGowan, Consultant Microbi- ologist, for advice throughout the project; the midwives on CDS References and other members of the Department of Obstetrics and Gynae- cology, Southmead Hospital, for their enthusiastic support of the 1 Gluckman E, Broxmeyer HA, Auerbach AD et al. Hematopo- project and all the mothers who donated cord blood to the bank. ietic reconstitution in a patient with Fanconi’s by means of umbilical-cord blood from an HLA-identical sibling. We would like to thank all the GPs and community midwives New Engl J Med 1989; 321: 1174–1178. from the following practices without whose help this project 2 Rubinstein P, Carrier C, Scaradavou A et al. Outcomes among would not have been possible: 2 Riverleaze Practice, Sea Mills; 33 562 recipients of placental-blood transplants from unrelated North Street Practice, Downend; 227 Lodge Causeway Practice, donors. New Engl J Med 1998; 339: 1565–1577. ; Air Balloon Surgery, St George; Medical 3 Locatelli F, Rocha V, Chastang C et al. Factors associated Centre; Berkley Health Centre; Bradgate Surgery, ; Brad- with outcome after cord blood transplantation in children with ley Stoke Surgery; Brockway Medical Centre, Nailsea; Brooklea acute leukemia. Blood 1999; 93: 3662–3671. Health Centre, ; Brunston Surgery, Cinderhill, Cole- 4 Gluckman E, Rocha V, Boyer-Chammard A et al. Outcome ford; Cadbury Health Centre; Cheddar Medical Centre; Chew of cord-blood transplantation from related and unrelated Magna Surgery; Coalpit Heath Surgery; Clevedon Health Centre; donors. New Engl J Med 1997; 337: 373–381. Close Farm Surgery, North Common; Coniston Medical Practice, 5 Wagner JE, DeFor T, Rubinstein P et al. Transplantation of ; Corbett House Clinic, Barton Hill; Courtside Surgery, unrelated donor umbilical cord blood (UCB): outcomes and Yate; Downland Surgery, Worle; Eastville Health Centre; Fish- analysis of risk factors. Blood 1997; 90 (Suppl. 1): 398 ponds Health Centre; Gable House Surgery, Malmesbury; Gay- (Abstr. 1767). wood House Surgery, Bedminster; Gloucester Road Medical 6 UKBTS/NIBSC. Guidelines for the Blood Transfusion Ser- Centre, Horfield; Graham Road Surgery, Weston Super Mare; vice, 3rd edn. HMSO: London, 1996. Surgery; Harptree Surgery, West Harptree; 7 Rubinstein P, Rosenfield RE, Adamson JW et al. Stored pla- Health Centre; Heywood Surgery, Pill; Horfield Health Centre; cental blood for unrelated bone marrow reconstitution. Blood Kennedy Way Surgery, Yate; Kingswood Health Centre; Lawr- 1993; 81: 1679–1690. ence Hill Health Centre, Easton; Lodgeside Surgery, Kingswood; 8 Donaldson C, Armitage WJ, Laundy V et al. Impact of Lydney Health Centre; Montpelier Health Centre; Nailsea Health obstetric factors on cord blood donation for transplantation. Centre Practice; Oldland Surgery Practice, ; Br J Haematol 1999; 106: 128–132. Portishead Health Centre; Riverbank Medical Centre, Worle; 9 Wall DA, Noffsinger JM, Mueckl KA et al. Feasibility of an Rowcroft Medical Centre, Stroud; St Augustines Practice, Keyn- obstetrician-based cord blood collection network for unrelated sham; St George Health Centre; St Johns Lane Health Centre, donor umbilical cord blood banking. J Matern-Fetal Med Bedminster; Health Centre; Surgery; 1997; 6: 321–323. Southmead Health Centre; Spence Group Practice, Redland; 10 Surbek DV, Scho¨nfeld B, Tichelli A et al. Optimizing cord Station Road Surgery, Congresbury; Health Centre; blood mononuclear cell yield: a randomized comparison of Medical Centre; Sussex Place Surgery, Bristol; The collection before vs after placenta delivery (letter). Bone Chipping Surgery, Wickwar; The Chipping Surgery, Wotton- Marrow Transplant 1998; 22: 311–312. under-Edge; The Malago Surgery, Bedminster; The Medical 11 Marchand P, Pellegrini N, Petit-Prost E et al. Experience of Centre, Ridingleaze, Lawrence Weston; The Orchard Medical the Besanc¸on cord blood bank. Bone Marrow Transplant Centre, Kingswood; The Stokes Medical Centre, ; The 1998; 21 (Suppl. 1): S22 (Abstr. 78). Surgery, 2 Back Lane, Pucklechurch; The Surgery, 8 Queens Par- 12 Lecchi L, Ratti I, Garcea F et al. Cord blood unit deferral ade, Bath; The Surgery, 11 Hayes Lane, Staple Hill; The Surgery, rate and causes. 3rd Eurocord Transplant Concerted Action 13 Fallodon Way, ; The Surgery, 14 Overnhill Road, Workshop, Annecy, France, 1998, (Abstr. 38). Staple Hill; The Surgery, 18 Fouracre Road, Downend; The Sur- 13 Richter E, Eichler H, Leveringhaus A et al. The Mannheim gery, 24 Avenue, Horfield; The Surgery, 37 West cord blood project: data on volume reduction by buffy coat

Bone Marrow Transplantation Cord blood banking in the NHS C Donaldson et al 905 preparation of 209 cord blood samples. Bone Marrow Trans- 22 Kurtzberg J, Laughlin M, Graham ML et al. Placental blood plant 1998; 21 (Suppl. 1): S22 (Abstr. 79). as a source of hematopoietic stem cells for transplantation into 14 Bries G, Uttebroek A, Spitz B et al. The Leuven cord blood unrelated recipients. New Engl J Med 1996; 335: 157–166. banking project: logistics and results. 3rd Eurocord Transplant 23 Wagner JE, Kernan NA, Steinbuch M et al. Allogeneic sibling Concerted Action Workshop, Annecy, France, 1998 (Abstr. umbilical-cord-blood transplantation in children with malig- 57). nant and non-malignant disease. Lancet 1995; 346: 214–219. 15 Armitage S, Warwick R, Fehily D et al. Cord blood banking 24 Migliaccio A, Addinson J, Rubinstein P et al. Correlation in London: the first 1000 collections. Bone Marrow Trans- between progenitor cell dose and time to myeloid engraftment plant 1999; 24: 139–145. in 79 unrelated placental/cord blood transplants. Exp Hematol 16 Rubinstein P, Dobrila L, Rosenfield RE et al. Processing and 1997; 25: 350 (Abstr. 356). cryopreservation of placental/umbilical cord blood for unre- 25 Gian VG, Moreb JS, Abdel-Mageed A et al. Successful sal- lated bone marrow reconstitution. Proc Natl Acad Sci USA vage using mismatched umbilical cord blood transplant in an 1995; 92: 10119–10122. adult with recurrent acute myelogenous leukemia failing auto- 17 UKBTS/NIBSC. Medical Assessment of Donors Document. logous peripheral blood progenitor cell transplant: a case his- HMSO: London, 1998. tory and review. Bone Marrow Transplant 1998; 21: 1197– 18 Engelfriet CP, Reesink HW, Wagner JE et al. Use of cord 1200. blood progenitor cells as an alternative for bone marrow trans- 26 Sirchia G, Rebulla P, Tibaldi S et al. Cost of umbilical cord plantation. Vox Sang 1998; 75: 156–172. blood units released for transplantation. Transfusion 1999; 39: 19 Ademokun JA, Chapman C, Dunn J et al. Umbilical cord 645–650. blood collection and separation for haematopoietic progenitor 27 Hows J, Downie T, Nunn A et al. Fate of patients undergoing cell banking. Bone Marrow Transplant 1997; 19: 1023–1028. unrelated donor (UD) searches in the UK. Bone Marrow 20 Armitage S, Fehily D, Dickinson A et al. Cord blood banking: Transplant 1996; 17: S56 (Abstr. 269). volume reduction of cord blood units using a semi-automated 28 Ko¨gler G, Callejas J, Hakenberg P et al. Hematopoietic trans- closed system. Bone Marrow Transplant 1999; 23: 505–509. plant potential of unrelated cord blood: critical issues. J Hema- 21 Donaldson C, Armitage WJ, Denning-Kendall PA et al. Opti- tother 1996; 5: 105–116. mal cryopreservation of human umbilical cord blood. Bone Marrow Transplant 1996; 18: 725–731.

Bone Marrow Transplantation