Asian Journal of Transfusion Science
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   Table of Contents - Current issue
January-June 2019
Volume 13 | Issue 1
Page Nos. 1-78

Online since Thursday, June 13, 2019

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Greenish discoloration of plasma: Is it really a matter of concern? Highly accessed article p. 1
Anila Mani, AP Poornima, Debasish Gupta
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Reducing delivery times of emergency blood products through pneumatic tube systems p. 3
Jian Hao Jaryl Kok, Choong Weng Leslie Lam, Mee Yin Joanne Lee
Objectives: Recent advances in damage control resuscitation have advocated a push for early transfusion to maintain circulating volume and minimization of crystalloid use. While measures such as using rapid-matched group specific blood or uncrossmatched blood have been implemented to shorten this wait, delivery times can still be improved. We explored reducing delivery times by use of a pneumatic tube delivery system already built in our hospital. Few studies have evaluated this using fresh blood samples for one-way transport. We modified and evaluated our pneumatic tube delivery system for delivery timings and quality parameters; designing a robust protocol that also tested aged blood for simulated returns unlike other previous studies. Methods: Delivery timings of emergency blood products by our present portering system were collected and compared against that of products sent through the pneumatic tube system (PTS). The samples sent through the PTS were also tested and analyzed for temperature, quality, and hemolysis in accordance with established blood banking quality guidelines. Results: Blood products delivered by our PTS showed satisfactory conformance with all parameters of temperature, timing, and hemolysis. We showed a significant reduction in transport delivery times from mean of 8 min 43 s to 2 min 23 s. Conclusions: Delivery of blood products by our modified PTS is safe and significantly reduces delivery time. This time savings could be clinically significant in resuscitation. Usage of the PTS could also cut down on workforce utilization of porters, freeing them up for other tasks in the hospital.
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Effect of plateletpheresis on postdonation serum thrombopoietin levels and its correlation with platelet counts in healthy voluntary donors p. 10
Rekha Hans, Ratti Ram Sharma, Neelam Marwaha
Background: Thrombopoietin (TPO) is regulated by a feedback mechanism between megakaryocytes and platelets. This is important in plateletpheresis donors to compensate for donation-associated platelet loss. Aims and Objectives: The aim and objective of this study were to investigate changes in serum TPO levels in healthy plateletpheresis donors and its correlation with platelet recovery pattern. Materials and Methods: Out of 50 plateletpheresis donors recruited in the study over 1 year, only 29 completed follow-up and were further analyzed. Plateletpheresis procedures were performed on two types of cell separators (TRIMA ACCEL®, Terumo BCT Lakewood Colorado and AMICUS®, Fresenius Kabi, Germany). Platelet parameters were estimated pre- and post-platelet donation, at 3rd- and 5th-day postdonation. Serum TPO levels were determined using quantitative sandwich enzyme-linked immunosorbent assay technique (Raybiotech, USA) as per the protocol of the manufacturer. Results: The majority of donors (72%) in our study were first-time donors. The baseline platelet count was 226 ± 44 × 103/μl with a significant decline (30%; P < 0.001) in postdonation phase and remained below baseline on the 3rd and 5th day. The serum TPO levels increased significantly (P < 0.001) from a baseline of 227.81 (interquartile range [IQR]: 176.06) pg/ml to 269.94 (IQR: 110.68) pg/ml postdonation and remained elevated from baseline levels on the 3rd and 5th day. An inverse relation was observed between change in serum TPO levels and platelet count during postdonation phase which was not statistically significant (P > 0.05). Conclusion: Serum TPO levels increase significantly post plateletpheresis donation corresponding to decrease in platelet counts showing that TPO plays a vital role in compensatory mechanism after platelet loss.
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Impact of stored red cells on clinical outcome in critically ill p. 17
Aaditya Shivhare, Shamee Shastry, Mohandoss Murugesan, Karishma Ashwin Doshi, B Poornima Baliga
Background: The use and benefit of fresh blood and leuco-reduced blood for critically ill patients has been inconclusive. In this study we have tried to observe the same, in patients admitted to intensive care unit. Study Design and Methods: Prospective study was done to observe the effect of transfusion in critically ill patients in a tertiary care hospital. Clinical condition in cases and controls was assessed with the help of Simplified Acute Physiology Score II scoring tool. Clinical outcome among patients who received blood was compared using two cutoffs, 14 and 21 days of shelf life to delineate fresh from old blood. Length of hospital stay, length of stay in ICU, number of days on ventilator and number of hospital acquired infections were used as the surrogate markers for morbidity. Results: Of the 558 critically ill patients admitted during the study period, 427 received (cases) while 131 did not receive the transfusion (controls). Mean SAPS II scores of cases and controls were comparable. We observed a significantly higher rate of mortality among patients who received RBC units over 21 days. However morbidity parameters were affected even when the cutoff of 14 days is considered. Buffy-coat reduced blood did not influence the outcome in the study group. Conclusion: Critically ill patients may be prioritized for receiving fresher units of packed red cells preferably less than 21 days old. Transfusion is an independent risk factor for morbidity. Hence the risk to benefit ratio should be carefully assessed for every red cell transfusion in critically ill patients.
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A study on factors influencing the hemostatic potential of fresh frozen plasma p. 23
Lalit Dhantole, Anju Dubey, Atul Sonker
Background: Fresh frozen plasma (FFP) is administered to correct deficiencies of various coagulation factors. The level of these factors in FFP varies with donor demographics and ex-vivo processing of plasma. In this study we have compared the quality control parameters of FFP collected from donors of different genders, age groups, ABO blood groups, smoking and alcohol intake habits. Materials and Methods: Four ABO group matched plasma units were pooled, split and further processed by four different freeze-thaw algorithms: frozen by contact shock freezer; thawed at 37°C, frozen by contact shock freezer; thawed at 45°C, frozen by mechanical freezer; thawed at 37°C, frozen by mechanical freezer; thawed at 45°C. The coagulation factor levels in plasma units were compared. Results: There were no significant differences in the quality parameters with donor age, gender and alcohol intake. Factor VIII levels were significantly lower in O group FFP (P < 0.05). Smokers had significantly higher levels of fibrinogen (P < 0.05). There were no significant differences in PT, fibrinogen and factor VII levels of FFP processed through various algorithms. Plasma frozen rapidly through contact shock freezer had significantly lower aPTT and higher levels of factor V and VIII compared to mechanical freezing. There were no significant differences between PT, aPTT, fibrinogen, factor V, factor VII and factor VIII levels of FFP thawed at 37°C and 45°C. Mean thawing time was 28 minutes at 37°C and 17 minutes at 45°C. Conclusion: Rapid freezing is recommended for optimum preservation of coagulation factors. Thawing may be done at 45°C in cases of emergency, without compromising hemostatic potential.
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High thermal amplitude auto-anti-“N” complicating pretransfusion compatibility tests on a patient with malaria and bladder cancer p. 30
Sanmukh R Joshi, Ankita Sheladiya, Vijaykumar N Agrawal
Background: Antigen “N” is a high-frequency antigen of the MNS blood groups and carried on glycophorin B that is resistant to enzymatic cleavage by trypsin, and provides differential diagnosis of its antibody specificity to N being present of glycophorin A. Naturally occurring IgM antibodies to N are known to be clinically insignificant, as against the IgG counterpart with clinical relevance. Aim: Auto-anti-“N” association with the bladder cancer was explored for its clinical significance as well as its interference in grouping anomaly. Materials and Methods: A warm environment was created while blood sampling for the laboratory work up as the patient had a high-titer auto-cold agglutinin causing spontaneous hemagglutination. The antibody was tested by standard serological methods with the red cell, antisera, and enzymes prepared in house or obtained commercially. Results: The case was admitted to hospital with high fever and hematuria; he was diagnosed with malaria and bladder cancer. He required transfusions in the face of severe anemia. His blood sample posed problems in compatibility tests due to autoantibody present. Serological workup revealed its specificity as anti-“N.” Conclusion: Auto-anti-“N” as a cause of severe anemia could not be attributed to, for concurrent malarial infection. However, its presence may have some association with the underlying malignant condition.
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Antibody screening and identification in donors and general patients at a tertiary care teaching hospital in Western India Highly accessed article p. 34
Kamini Parshuram Gupta, Maitrey D Gajjar, Tarak Ramesh Patel, Nidhi Manish Bhatnagar, Nihar Chaudhari, Mamta Chintan Shah
Background and Objectives: The aim of the blood transfusion service should be to provide effective blood and blood components, which are as safe as possible and adequate to meet patient's need. To achieve safe blood transfusion practice, many blood transfusion center in India follow routine type and screen protocol for all patient's and donor's blood samples to detect unexpected alloantibodies. The present study is aimed at assessing the frequency and type of unexpected red cell alloantibodies in general patient population and donors at a tertiary care teaching hospital in western India. Materials and Methods: In this prospective study, samples of patients as well as blood donors were processed for ABO and Rh “D” grouping as well as antibody screening with three cell screening panel on fully automated immunohematology analyzer. Positive sample in three cell screening panel was further evaluated for identification of specific alloantibody with eleven cell identification panel by column agglutination technique. Results were recorded, and data were analyzed to calculate the frequency of unexpected alloantibody. Results: A total of 74,214 patient samples and 80,173 donor samples were processed for type and screen. Out of which, 512 patients and 11 donors were identified with alloantibody. Most common alloantibody found in the present study is anti-D (0.075%), followed by anti-E (0.041%), anti-c (0.021%), anti-K (0.0205%) in Rh and Kell blood group system. Conclusion: Antibody screening and identification of specific alloantibody help in identifying most appropriate blood unit that lacks the corresponding antigen and prevent alloimmunization.
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A guide to organize voluntary stem cell donors recruitment drive for hematopoietic progenitor stem cell transplant p. 39
Vikash Chandra Mishra, Aseem K Tiwari, Pranav Dorwal, Vimarsh Raina, Girish Sharma
Background: Hematopoietic progenitor cell transplantation (HPCT) is used as a definitive treatment in hematological malignancies. For a successful HPCT, the donor and recipient should have matching human leukocyte antigens (HLAs). About 25% of patients have a chance of finding matching HLA within family, while rests 75% are dependent on voluntary stem cell donor. Globally, there are 75 stem cell registries with more than 30 million donors registered among which India represents 0.36 million. Therefore, finding a stem cell donor for Indian patient is quite difficult. The aim of the present study is to discuss the significance of voluntary stem cell donor recruitment drive and also to guide the drive organizers and their team for effectively organizing the drive to increase the database of such donors. Materials and Methods: Voluntary stem cell donor recruitment drives are conducted to spread awareness among the people and motivate them to register as a donor. Once the donors have given their consent, the sample is taken and sent to laboratory for HLA typing and the result is uploaded in World Marrow Donor Association, an international association of member to find the best possible matches for patients with hematological disorders. Results: Genebandhu has organized over 127 recruitment camps since 2012 and recruited 13,000 voluntary stem cell donors. HLA typing of 7446 donors has been completed. Out of this small number of typed donors, 11 lifesaving HPCTs have been successfully facilitated. Conclusions: Here, we have demonstrated guidelines along with steps to organize voluntary stem cell donors recruitment drive that is needed to increase number of donors, thus increasing significantly the chances of saving many vital lives.
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Flow cytometric enumeration of CD34+ hematopoietic stem cells: A comparison between single- versus dual-platform methodology using the International Society of Hematotherapy and Graft Engineering protocol p. 43
Mohandoss Murugesan, Chandran K Nair, Sangeetha K Nayanar, Kalyana Chakravarthy Pentapati
Background: Flow cytometric enumeration of CD34+ hematopoietic stem cells (HSC) is the reference point for undertaking apheresis and evaluation of adequacy for peripheral blood stem cell (PBSC) engraftment. Aims: To determine whether single platform correlates with dual platform methods in CD34+ enumeration using ISHAGE protocol. Methods: Retrospective analysis of CD34 Enumeration assays on both peripheral blood and PBSC product samples using Beckman Coulter FC500 Flow Cytometer. The t test and correlation study was used to study the difference between single and dual platform methods in CD34+ enumeration. Results: We present our data on 152 samples comprising 41 peripheral blood samples collected before apheresis procedure and 111 samples collected from PBSC product. We observed strong positive correlation between single and dual platform methods for CD34+ counts in peripheral blood sample (r = 0.92; P < 0.001) and PBSC product sample (r = 0.85; P < 0.001). Conclusion: In our study, both single versus dual platform had similar results in CD34+ cell counts. The single platform provides rapid results with ease of procedure. Errors with dual platforms are relatively common with respect to denominator. We recommend to use mean of total leukocyte count from two different hematology analyzer to minimize variation in dual platform.
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Effect of autologous PRP on wound healing in dental regenerative surgeries and its correlation with PDGF levels p. 47
Rahul Verma, Gita Negi, Abhishek Kandwal, Harish Chandra, Dushyant Singh Gaur, Meena Harsh
Introduction: Autologous platelet-rich plasma (PRP) is the fraction of blood plasma, with increased concentration of platelets, from baseline serum level. Growth factors (GFs) in PRP expedite the soft tissue and bony healing. However, estimation of their levels and role in healing had not been studied extensively. This study gives an insight to the quantification of platelet-derived GF-BB (PDGF-BB) present in PRP and its correlation with the clinical wound healing and bone regeneration. Aims: This study aims to quantify PDGF-BB levels in PRP with its subsequent correlation with healing in dental regenerative surgeries. Settings and Design: This was an experimental study including patients undergoing various dental regenerative surgeries. Subjects and Methods: Autologous thrombin-activated PRP in the form of PRP gel was used in study group (n = 39) whereas no such intervention was given in control group (n = 30). PDGF-BB quantification was done in PRP samples using enzyme-linked immunosorbent assay. Clinicoradiological evaluation of healing was done in both the groups. Statistical Analysis Used: Descriptive analysis, independent Z-test, Correlation regression analysis, and ANOVA. Results: Mean platelet concentration achieved in PRP was 5.79 times the baseline count. Mean PDGF-BB concentration in PRP was 31.92 ± 10.47 ng/ml which significantly correlated (P < 0.05) with the PRP platelet count. Study group showed significant healing clinically (P < 0.05). Significant bone fill observed in study group at 3 and 6 months when compared to the baseline as well as control group. Furthermore, bone fill at 6 months showed linear correlation with PGDF-BB levels (r = 0. 80). Conclusions: PRP led to enhanced bone regeneration and soft-tissue healing with former being directly related to higher concentration of PDGF-BB.
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A case of rare anti-Hro alloantibody in a tertiary care center in India p. 54
Mohit Chowdhry, Soma Agrawal, Uday Kumar Thakur
Anti-Hro is an alloantibody produced in individuals with -D- phenotype after a sensitizing event. Owing to the rarity of this antigen negative unit, registration in rare donor registries helps in procuring blood components at the earliest. We had a patient of -D- with anti-Hro antibody who required 7 units of red cells which was unavailable at our center. The patients near relatives were typed in search of a similar phenotype blood. Search was made for the rare units and Japanese Red Cross Society, American Red Cross Society, and International Blood Group Reference Laboratory, United Kingdom was contacted. Patient's brother and mother were typed as -D- and one unit from each of them was collected, irradiated, and transfused to the patient. Five units were imported from the Japanese Red Cross Society, Japan. Accessibility for identification and confirmation of rare blood groups and provision of the same can be centralized and liaison with the international registries can go a long way in the provision of blood components at the earliest.
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Incompatible crossmatch: First sign of a hemolytic transfusion reaction due to out-of-group platelet transfusion p. 57
Debapriya Basu, Sabita Basu, Joydeep Roy, Mahua Reddy, Mammen Chandy, Jaydeep Bhaumik
Platelet (PLT) transfusion is undertaken in a variety of clinical settings with thrombocytopenia, with or without bleeding. Since PLTs are most often stored in donor plasma, group-specific PLT transfusions are preferred to out-of-group transfusions. PLTs adsorb ABO antigens over their surface from the plasma. In major ABO-incompatible PLT transfusions, anti-A/B from the patient plasma react with the ABO antigens on transfused PLTs and can potentially cause adverse reactions or PLT refractoriness. Transfusion of PLTs with major ABO incompatibility, though effective in preventing clinical bleeding, is associated with reduced posttransfusion PLT count increments. In minor incompatible PLT transfusion transfused, anti-A/B can cause hemolytic transfusion reaction (HTR) which is not always related to a high titer of anti-A/B in the donor. Although attempts are made to practice ABO identical PLT transfusion, most centers practice out-of-group random donor platelets (RDPs) as well as single-donor-platelets (SDP) transfusion. The limited PLT shelf life does not always permit ABO identical PLT transfusion. At our center, ABO-specific PLT transfusions are practiced where possible, and in case of minor ABO-incompatible transfusions, antibody titers are not done. Here, we report a case of HTR due to out-of-group SDP transfusion, detected in the laboratory after an incompatible red blood cell (RBC) crossmatch.
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A case of severe donor reaction leading to grievous injury p. 60
Vinu Rajendran, Revathy Nair, George Paul Thaliath, Debasish Gupta
Adverse events of variable severity may occur occasionally following whole blood donation. We are reporting a case of severe donor reaction leading to grievous injury. A first-time male voluntary blood donor donated blood in our blood donation camp. The donation was uneventful, and he left the premise after 20 min of postdonation observation and advice. Several minutes later, he fell on the road and injured himself complicated with severe delayed vaso-vagal reaction. The donor had lacerated wound over the chin, fracture neck of the left mandible, fracture left lower incisor and left lower molar tooth. Appropriate medical care was catered to the donor with full medical support from Department of Transfusion Medicine and was fully recovered from the injury. Blood collection team must take up the responsibility of the management of all complications related to blood donation.
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Intraoperative acute hematuria: Sole clue to mismatch transfusion p. 63
Priya Rudingwa, Muthapillai Senthilnathan, Srinivasan Suganya, Sakthirajan Panneerselvam
Hemolytic transfusion reactions (HTRs) remain one of the dreaded complications of transfusion-related morbidity and mortality. Here, we describe the diagnosis and management of acute HTR following transfusion of ABO-incompatible packed red blood cell under general anesthesia which manifested solely as acute intraoperative hematuria. A 65-year-old, diabetic male was scheduled for emergency re-explorative laparotomy in view of suspected anastomotic leak following subtotal gastrectomy. One unit of packed cell was transfused intraoperatively. Toward the end of surgery, hematuria was noted by the attending anesthesiologist, and the accidental bladder injury was ruled out by the surgeon. Transfusion of ABO-incompatible blood was spotted; direct Coombs test became positive. To mitigate the impact of incompatible blood, 1 L of 0.9% normal saline was administered. Mannitol 0.5 g/kg and furosemide 20 mg were administered every 8th hourly, and 1 ml/kg/h of urine output was targeted. Sodium bicarbonate (7.5%) 20 meq was administered intravenously to alkalinize the urine.
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Successful treatment of Sezary syndrome with extracorporeal photopheresis – The first attempt in India p. 66
Aseem K Tiwari, Dinesh Arora, Pratibha Dhiman, Sheilly Kapoor, Geet Aggarwal, Ravi C Dara, Ashok Vaid
Sezary syndrome (SS) is more aggressive leukemic variant of cutaneous T-cell lymphoma in which a significant number of circulating malignant (Sezary) cells are observed in peripheral blood. Although single-agent or combination chemotherapy regimens have produced moderately high response rates in patients with advanced-stage SS, these responses are invariably not durable. Extracorporeal photopheresis (ECP) is recommended as an immunomodulator treatment, offering better life quality for patient. We would like to present the first SS case treated successfully with low-dose methotrexate and ECP in India. A 50-year-old male presented with rash and severe pruritus all over the body for 2 years. He had received various treatment regimens but without any symptomatic improvement. He underwent detailed examination and diagnosis of SS was established. Peripheral smear revealed total leukocyte count of 14900/μ l with 55% cells reported as Sezary cells. Contrast-enhanced computerized tomography revealed few insignificant (<1.5 cm) bilateral nodes in the axillary and inguinal region. The patient's disease stage was determined IVA1, and grade was T4N0M0B2. He received six cycles of CHOP, which led to a short-term remission of <3 months, and he was started on single-agent methotrexate along with skin supportive treatment. He did not respond to low-dose methotrexate alone, and therefore, ECP was added to treatment regimen. This was possibly the first such treatment for SS patient in India. The patient had very good response after six cycles of ECP with pruritus and itching diminishing and scaly lesions down to <10% of body surface area. There was regrowth of hair all over affected area. Sezary cell counts also came down to 35%. The patient continues to do well post-ECP, with single-agent gemcitabine. ECP either as monotherapy or in combination with other immunotherapies offers a good treatment option to otherwise resistant cases of SS.
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Critical evaluation of donor direct antiglobulin test positivity: Implications in cross-matching and lessons learnt p. 70
Vandana Puri, Aruna Chhikara, Geetika Sharma, Shivali Sehgal, Sunita Sharma
Direct Antiglobulin Test is a method of demonstrating the presence of antibody/ complement bound to red cell membrane by using AHG to form a visible agglutination reaction. DAT positivity is seen in immune mediated haemolytic anaemias, however rarely non immune mediate haemolytic anaemias also show DAT positivity. DAT positivity predictive of 83% of autoimmune haemolytic anaemia and 1.4% cases without haemolytic anaemia. Screening of blood donors for DAT is usually not recommended traditionally by any guidelines. However DAT positivity is reported in 0.008% of donors. On extensive search of literature we could find only very few studies on DAT positivity in donors. We report two cases of DAT positive donors with no clinical or laboratory evidence of hemolysis.
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Successful therapeutic plasma exchange in a patient with Morvan syndrome p. 73
Rounak Dubey, Rajeev S Mallhi, Bhushan Asthana, Neerja Kushwaha, Arvind Yadav
Morvan syndrome is a rare autoimmune disorder, characterized by hyperexcitability of both central and peripheral nervous systems, accompanied by autonomic dysfunction and hallucinations.[1] Therapeutic plasma exchange (TPE) has been found to be an effective mode of treatment for this disease, but there is limited literature supporting the same.[2] A 26-year-old male was admitted to our hospital and diagnosed with a case of Morvan syndrome, based on the clinical picture and laboratory findings. When standard drug therapy failed to show any improvement, a decision to carry out TPE was taken. The case presented with many peculiar challenges, mostly due to autonomic instability and hyperkinesia experienced by the patient while carrying out the procedure. All these challenges were diligently addressed and managed promptly. Clinical signs of improvement were evident from the 2nd TPE and by the time fifth TPE had finished, the patient was able to perform activities such as walking with support. His autonomic dysfunction and behavioral abnormalities had significantly subsided. This case report highlights the possible effectiveness of TPE in the management of a rare disease such as Morvan syndrome and appropriate application of basic principles and criteria for the use of TPE in cases where limited literature is available.
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Hemolytic events during therapeutic plasma exchange: Root cause analysis p. 76
Sachan Deepti, Saha Suryatapa, Kaliamoorthy Ilankumaran, Rela Mohamed
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2006 - Asian Journal of Transfusion Science | Published by Wolters Kluwer - Medknow
Online since 10th November, 2006