A Dull Day At Work...?: August 2024

30 August 2024 (Friday) - BTLP-TACT Exercise

Time for another BTLP-TACT exercise as the thing has just sent me two emails saying I’m not doing enough of them…

It gave me two cases:

39326: A sixty-four year-old woman needing group and save with sepsis.
She grouped as B Rh(D) Positive with antibody screen positive in cells 1 and 3. I requested antibody panels.
The IAT panel was positive in cells 1, 3, 6, 9 and 10 corresponding with anti Fy(a) but not ruling out anti-Cw or anti Lu(a). However the enzyme panel was negative in all cells, so in this plane of reality anti-Cw and anti Lu(a) are ruled out.
78632: a seventy-seven year-old chap with liver disease and bleeding needing four units of FFP within two hours
He too grouped as B Rh)D) Positive but with a negative antibody screen.
https://www.ncbi.nlm.nih.gov/books/NBK513347 says FFP is recommended for treatment of bleeding in cases of liver disease. So I issued four units of B Rh(D) Positive FFP.

I got the green light.

27 August 2024 (Tuesday) - Transfusion Evidence Alert Update

The nice people at the Transfusion Evidence Alert sent their update today. For once there was no mention of tranexamic acid, but another article caught my eye. Universal irradiation of platelets…

Why not?

Bearing in mind that most recipients of platelets (in my world) need them to be irradiated, ordering non-irradiated ones is no good to me in that if the patient for whom I’ve ordered them no longer requires them I’ve no one who can use them.

However irradiated ones can be given to someone else…

ARTICLE OF THE MONTH

Luspatercept versus epoetin alfa in erythropoiesis-stimulating agent-naive, transfusion-dependent, lower-risk myelodysplastic syndromes (COMMANDS): primary analysis of a phase 3, open-label, randomised, controlled trial.
Porta, M.G.D., et al. (2024). The Lancet. Haematology. [Record in progress].
PICO Summary available

+++++

24 August 2024 (Saturday) - BTLP-TACT Exercise

It’s a bank holiday weekend and it is pouring hard with rain. I’m bored senseless so here we go…

I was given one case – a seventy-nine year-old haemophiliac needing group and save.

He grouped as A Rh(D) Positive with antibody screen positive in cells 1 and 2.

I requested antibody panels. The IAT panel was positive in cells 2, 3, 5, 7 and 9 which corresponded with anti-S but didn’t exclude anti-E or anti-Lu(a). However the enzyme screen was negative which did exclude anti-E and anti-Lu(a). Well… in reality it doesn’t but in this plane of reality it does.

I got the green light.

23 August 2024 (Friday) - Long Long Ago

As I peered into Facebook this morning there was something on one of the haematology-related pages that made me think. Someone was talking about LE cell preparations…

Compared to the technology of today, LE cell preparations were somewhat laughable.

Back in the day we would take ten millilitres of blood into a glass jar which contained several glass beads. We would then seal the jar with a tight cap and shake. I say “shake” – we would thrash the thing as vigorously as we could with all of our might. And at the point of exhaustion we would pass the jar to a colleague who would carry on thrashing the thing. And when they were worn out someone else would take over.

After fifteen minutes it would go into an incubator for half an hour or so. The contents would then be poured through a muslin cloth (which made a real mess and spilled blood everywhere) into a tube, gently spun, and a blood film prepared from the buffy coat.

We would then look under the microscope for neutrophils which had engulfed other cells – these were the LE cells. Seeing the cells was diagnostic of systemic lupus erythematosus, and not seeing them excluded the condition. In the three years that I did this procedure (whilst working in a long-since bulldozed hospital) we never had a positive result. Not one. And neither had anyone else with whom I spoke about them at day release college.

It would seem that lupus is on the rise. And has been for the last few decades Is this because the disease is really becoming more prevalent, or because nowadays there’s a much more involved diagnostic process which employs tests which are nowhere near so medieval.

Did we miss cases of lupus back in the day because they really were less common? Are we finding more these days because the condition is more prevalent. Or because the technology is better? I don’t know, but I can remember doing at least one LE cell preparation a week for three years and never getting a positive result. At the time I was only a trainee, and the frankly bullying atmosphere in which I worked actively discouraged comment, but surely someone would have thought there was something wrong in a test which was *always* negative.

Unless it really was always negative?

21 August 2024 (Wednesday) - Getting The BTLP-Tact Wrong (Yet Again)

Time for another BTLP-TACT exercise? Probably not but I had a go anyway. I pressed the “start new scenario” button and waited patiently. Last time I got impatient and got given two.

I was only given one case today – a twenty-seven year-old woman in the maternity unit requiring group & save. She grouped as A Rh(D) Negative. Admittedly a weak reaction with the anti-A. Certainly this one would go off to NHSBT for further investigation…but it was definitely positive and the reverse group concurred.

It was at this point that the software crashed…

I got back in. The antibody screen was positive in cell 2 so I requested antibody panels.

The IAT and enzyme panels were positive in cells 3 & 5 corresponding with anti-E

I got the thumbs down. Apparently the group was uninterpretable. Have a look at the piccie… I’d say that was interpretable, wouldn’t you?

Oh well… last week I put up a list of vagaries of the BTLP-TACT system in which it disagrees with reality. Here’s another example.

19 August 2024 (Monday) - Learning Monday

A pregnant woman with a thrombosis… what further tests should be done?

This case has me somewhat puzzled. Perhaps a little (lot) more information might have been useful. Is this a new case? Is there any history?

How can the neutrophil count be three times higher than the total white cell count.

Given that the neutrophil count features a missing decimal point I’d suspect that the massive platelet count is due to an ongoing chronic (albeit serious) bleed. Hence the microcytic blood picture and low ferritin.

How likely is myelofibrosis or essential thrombocythaemia in someone in their mid-twenties?

Going straight to bone marrow biopsy in a pregnant woman is a tad extreme?

15 August 2024 (Thursday) - BTLP-TACT Update

Last week I whinged about having a “no win scenario” on the BTLP-TACT. But I didn’t whinge here; I also whinged at the scheme’s organizer who said that “Under those circumstances, issuing a single unit would result in a correct mark”.

I shall add that snippet to the other vagaries of the system that I have picked up along the way.

So… in order to get the green light I must bear in mind that in the simulator

A control failure invalidates the entire group; not just the Rh group.
Rh antibodies work by both IAT and enzyme.
Lu(a) works by both IAT and enzyme. If negative in enzyme then anti-Lu(a) is not there.
If I’m unable to provide the correct amount of suitable blood (given antibody issues) I should issue what I can.

It is such a shame that the simulator can’t be brought in line with what happens in reality…

13 August 2024 (Tuesday) - Horiba Newsletter

The nice people at Horiba sent their update today. You can see it by clicking here.

In theory a rather good morphology resource; in practice I rarely mention this one since they have this annoying way of giving the photos of the slide in question in one newsletter and the commentary in another.

But this one had a rather good article on monocyte maturation.

13 August 2024 (Tuesday) - BTLP-TACT Exercise

The last time I did a BTLP-TACT exercise I had a no-win scenario. I emailed BTLP-TACT head office but have had no reply yet.

So with something of a sense of “why do I bother” I did another one… after all I usually do one before the night shift

I was presented with one case – a ninety-eight year old chap requiring six units of blood within the next two hours for an aortic aneurysm.
He grouped as A Rh(D) Positive with antibody screen positive in cell 2. I requested antibody panels. The IAT and enzyme panels were positive in cells 2, 3, 5 and 6 which corresponded to anti-E and anti-K.
I selected six units of A Rh(D) Positive E-negative K-negative

I got the green light… and it also suggested I might like to continue with another case. So I did. It gave me two more cases:

98610 – a sixty-two year old woman in ITU needing group and save
The control came up positive. In the past control failure invalidated the entire group. So I was unable to get a blood group. This would go off to NHSBT.
Mind you, in the past the control failure has only invalidated the RH group…
Fortunately the antibody screen was negative.
98546 – a forty-six year old woman on the medical ward needing group and save and two units of cryo for a vitamin K deficiency.
She has a cell group of B, but no reaction in the reverse group. The Rh group was positive though. Another one for NHSBT.
Fortunately the antibody screen was negative.
I’m pretty sure cryo isn’t recommended to correct vitamin K deficiency, so I didn’t prepare any.

I got the green light again. I was pleased about that.

12 August 2024 (Monday) - Learning Monday

An 82-year-old man presented with mild leucocytosis. On examination he had an 8cm spleen below the left intercostal margin and no palpable lymphadenopathy.

Hb 82 g/l

Wbc 63

Plt 75

Lymph 35

“Try and identify the cells our patient has in his blood film”.

Well… what a silly question. Bearing in mind there’s six neutrophils it can only be option 2… or is it option 3? Are a couple of those neutrophils immature?

The software said option 3. I suppose it is a UK thing that we lump band forms in with mature neutrophils and only count as separate when metamyelocytes?

Butu what a wasted opportunity – we might have had the option to learn something about those lymphoma cells. And the red cells – a tad hypochromic and microcytic?

I suppose this illustrates the difficulty of coming up with a simple yes or no question in morphology, doesn’t it?

10 August 2024 (Saturday) - Pre Eclampsia

The nice people at the Medical Laboratory Observer sent me a rather good little article about pre-eclampsia today, You can read it by clicking here.

It was a rather good refresher…

8 August 2024 (Thursday) - Kobayashi Maru

Time for another BTLP-TACT exercise. I was presented with one case – a thirty-one-year-old chap in the haematology clinic with sickle cell disease needing eight units of blood for an exchange transfusion tomorrow.

He had an indeterminate ABO group presumably from previous exchange transfusions, but his Rh(D) group was negative.

The antibody screen was positive in cells 2 and 3 so I requested antibody panels.

The IAT and enzyme panels were positive in cells 1, 3, 4, 6 and 7 corresponding with anti-Jk(a).

I didn’t issue any blood as there was only one suitable unit in the fridge. I got the thumbs down, but (to be blunt) what am I supposed to do when the software gives me this requirement but doesn’t give me eight units of O Rh(D) Negative Jk(a) Negative HbS Negative units to fulfill it?

8 August 2024 (Thursday) - HCPC Newsletter

The HCPC sent their update today. You can read it by clicking here.

As always I read it by clicking there, and as always I wonder just how my practice was improved by doing so. The trouble with the HCPC is that it covers such a wide range of professions that anything it comes up with can only be of peripheral interest to what we do.

Mind you its relevance to my daily round is probably on a par with that of the IBMS…

6 August 2024 (Tuesday) - Fritsma Factor Update

The Fritsma Factor newsletter appeared in my in-box today. As always it doesn’t overload with information, but what it has is useful.

Another good source of CPD…

5 August 2024 (Monday) - Learning Monday

Learning Monday was a tad different this week. Here’s a link to some previous cases.

Clinical cases with the relevance of the lab tests pointed out. If only I could find more CPD like this…

30 July 2024 (Tuesday) - Chief Scientific Officer's Update

The Office of the Chief Scientific Officer sent their update today. You can read it by clicking here.

As is always the way with this publication it can only be of peripheral interest and I would be unreasonable of me to expect anything of direct relevance. But like so much these days it rather wound me up.

It started off with Lord Darzi asking for submissions and suggestions for the latest shake-up fo the NHS. Here’s my contribution. NO MORE SHAKE-UPS. In (nearly) forty-three years of being part of the NHS I’ve lost count of the amount of shake-ups we’ve had. None have ever actually been seen through before being abandoned in favour of the next. And there has never been any review to look for the good or bad in what was tried before it was abandoned.

Let’s just stick with whatever the last one was, and give it a few years to actually take effect.

There was then a spotlight on a biomedical scientist being woman of the year. Is that so surprising? However by singling her out for praise it immediately cheapens the efforts of the thousands who (like I have done) have contributed so much and missed events with family and friends to keep the service going.

I originally wrote a rant about every single item in the newsletter. Perhaps I should stop following it as it only winds me up.

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