26 January 2024 (Friday) - Enrolled on a Course

I’m always whinging about what a load of meaningless nonsense that I consider quality management to be… probably because I don’t know that much about it. So I’ve enrolled in a course about it. I might learn something.

I’ve passed the first week with a score of eighty per cent, but I achieved that by remembering certain figures that were given during the (frankly rather dull) video lectures.

 

I know it is early days for this course, but I enrolled because I’ve always considered “Quality Management” to be a load of blah-blah-blah that gets in the way of doing my job, and for years I’ve been wondering just what I’m missing. I must be missing something.

So far the course has been nothing but blah-blah-blah, and all it is doing is confirming my preconceptions.

So… engaging “reflective mode”. Why do I consider this Quality Management course to be a load of blah-blah-blah? Because there are loads of words and loads of talk and very little practical example of improvement.

Bearing in mind this was an introductory week, the course might perk up. I hope so.

25 January 2024 (Thursday) - Transfusion Evidence Update

The Transfusion Evidence Alert update arrived today. Quite a lot to take in. The article about conservative vs liberal transfusions (see below) made me think. Back in the day no one’s haemoglobin was allowed to be below 100 g/l. It would seem we were massively over-transfusing back then, and may well be doing so now?

And tranexamic acid? That's the stuff...

Darbepoetin alfa to reduce transfusion episodes in infants with haemolytic disease of the fetus and newborn who are treated with intrauterine transfusions in the Netherlands: an open-label, single-centre, phase 2, randomised, controlled trial. Ree, I.M.C., et al. (2023). The Lancet. Haematology. PICO Summary available +++++

TOP ARTICLES Evaluation of the safety and effectiveness of topical intrapleural application of tranexamic acid in thoracic surgery: a systematic review and meta-analysis of randomized controlled trials. Alzahrani, A., et al. (2023). Clinical and Applied Thrombosis/Hemostasis. Effectiveness of tranexamic acid in the postoperative period in body contour surgery: randomized clinical trial. Bayter-Marín, J.E., et al. (2023). Plastic and Reconstructive Surgery. Global Open. Red cell transfusion thresholds in outpatients with myelodysplastic syndromes: combined results from two randomized controlled feasibility studies. Buckstein, R., et al. (2023). American Journal of Hematology. [Record in progress]. Volume replacement in the resuscitation of trauma patients with acute hemorrhage: an umbrella review. Gianola, S., et al. (2023). International Journal of Emergency Medicine. Meta-analysis and metaregression of the treatment effect of intravenous iron in iron-deficient heart failure. Martens, P., et al. (2023). JACC. Heart Failure. [Record in progress] Orthopaedic trauma and anemia: conservative versus liberal transfusion strategy: a prospective randomized study. Mullis, B.H., et al. (2024). Journal of Orthopaedic Trauma. A randomized controlled trial to explore the safety and efficacy of irradiated buffy-coat granulocytes in pediatric patients with febrile neutropenia. Ramachandran, M., et al. (2023). American Journal of Blood Research. Intravenous albumin in cardiac and vascular surgery: a systematic review and meta-analysis. Skubas, N.J., et al. (2023). British Journal of Anaesthesia. [Record in progress] The incidence of transfusion-related acute lung injury using active surveillance: a systematic review and meta-analysis. White, S.K., et al. (2023). Transfusion. [Record in progress]

24 January 2024 (Wednesday) - Westgard QC Update

The Westgard QC update arrived in my in-box today. Useful stuff…

23 January 2024 (Tuesday) - NEQAS 2308

The boss was talking about the results of the most recent NEQAS microscopy exercise today. I’d looked at the parasitology that came with it, but had somehow missed this one. So I had a quick look.

The first film was from someone with hypereosinophilic syndrome and I got that right.

The second one – I’m claiming shenanigans on that. There were parasites inside the red cells. Tucked up close to the edges of the red cells. Plasmodium falciparum? Had we been given the information that the patient had been in the sticks in North America I might have considered babeosis. As might pretty much every other participant of the scheme who also had plumped for malaria… because we don’t see babeosis in the UK, and if we do see parasites we ask for the patient’s history.

Again I’ll make the observation that these NEQAS microscopy exercises aren’t always a fair assessment of what we do.

18 January 2024 (Thursday) - UKAS Update

UKAS sent its newsletter today. You can read it by clicking here. There was one article which caught my eye about the benefits of accreditation to a laboratory. You can read it by clicking here. I read it… and read it again. It might as well be written in Greek for all the sense it made to me.

This is a failing on my part… Must do something about it.

17 January 2024 (Wednesday) - BTLP-TACT Exercise

Bearing in mind the last time I tried to do a BTLP TACT exercise the software totally failed, and then tried to blame me, I wasn’t keen on giving it another go, but so far this moth there has been very slim picking for CPD.

It actually gave me a case this time. One case. A twenty-two year-old woman in the haematology clinic needing two units of irradiated blood as soon as possible. Mind you it didn’t give me the case with any alacrity. It could probably have gone slower if it had tried…

 

She had an indeterminate ABO group, but was Rh (D) Negative. I told the software this, but it crashed. I got back in to it and saw the antibody screen was positive in all three cells.

I managed to request antibody panels.

The enzyme panel was positive in cells 1, 3, 4, 6 and 7 which corresponded with anti Jk(a) but didn’t exclude anti-Cw

The IAT panel was positive in cells 1, 3, 4, 6, 7, 9 and 10 which corresponded with anti Jk(a) and anti- Fy(a) but didn’t exclude anti-Cw.

I tried to tell the software but it crashed again.

I wanted to issue two irradiated units of O Rh(D) Negative which were negative for both Jk(a) and Fy(a), but there was only one of these units…

Amazingly I got the thumbs up…

17 January 2024 (Wednesday) - Coagulation Case Study

One of our trainees was given some questions to answer for his portfolio. The answers were circulated to all of us, and so I’ve shamelessly blagged them.

After all, why not? This is a really good example of where I’ve learned something…

A male patient in his 20s attends A&E after experiencing excessive bleeding during a routine dental procedure. The patient does not take any anticoagulants and has no past history of haemorrhages. In A&E, an FBC and clotting screen were requested. The results of the FBC were unremarkable.  
 
Q1: From which derivative curve shown above would the APTT value determined? 

APTT would be determined from the peak of the second derivative curve, where the rate of conversion of fibrinogen to fibrin is represented. 

The patient’s APTT result resembled the plot shown above. 

Q2: Which abnormal feature is present in this curve? What could this feature indicate? 

A biphasic curve (or double-peak) is shown in the plot above. These are often associated with coagulation disorders such as positive lupus anticoagulant, FVIII and FIX deficiency, and Von Willebrand Disease. 

The results from the patient’s clotting screen are: 

	Patient’s Result	Reference Range
PT (s)	13.0	11.0-15.0
APTT (s)	44.0	23.0-37.0
Fibrinogen (g/L)	3.68	1.50-5.00

 
The APTT was found to prolonged. Following this, a mixing study was performed. 

Q3: If the mixing study does not correct the prolonged APTT, what could this mean is causing the prolonged APTT? 

If the APTT does not correct in a mixing study this means that there is no factor deficiency, and the cause of the prolonged APTT is likely the result of an inhibitor in the patient’s plasma. 

Q4: Why is a lupus anticoagulant performed in cases of unexplained prolonged APTT? 

Patient’s with antiphospholipid syndrome may produce lupus anticoagulant antibody. These autoantibodies target the epitopes of phospholipids bound in cell membranes. This leads prothrombotic effects in vivo but prolonged APTT results in vitro. 

The mixing study corrected the APTT value therefore the sample was sent to be tested for intrinsic pathway factors: FVIII, FIX, FXI, and FXII. The results are shown below: 

	Patient’s Result	Reference Range
FVIII (IU/dL)	52	50-200
FIX (IU/dL)	136	60-150
FXI (IU/dL)	144	70-160
FXII (IU/dL)	144	50-200

 

Q5: Do these results explain the patient’s bleeding episode? What role does FVIII have in haemostasis? 

These results show the patient’s FVIII level is borderline. FVIII is a coenzyme responsible for accelerating the generation of FXa and subsequently thrombin (which cleaves fibrinogen to fibrin). FVIII is also responsible for stabilising VWF. Reduced FVIII is associated with bleeding tendency. 

Q6: Based on these results and clinical history, is Haemophilia A or Von Willebrand Disease more likely? What tests could be performed to differentiate Haemophilia A from Von Willebrand Disease? 

This case may suggest VWD as patients with VWD often receive a diagnosis later in life than compared to Haemophilia A patients. This is due to most cases of VWD causing only mild disease. The following tests are often required to diagnose VWD:  

• FVIII:C – a measure of the functional FVIII as FVIII activity is reduced in some VWD types. 

• VWF Ag – the level of functional (and non-functional) VWF. VWF concentration and functionality is reduced in VWD. 

• VWF:GPIbB – a measure of platelet glycoprotein activity, decreased activity represents the failure of VWF to bind to glycoproteins present on platelet membranes.