30 November 2024 (Saturday) - BTLP-TACT Exercise

BTLP-TACT time. I was presented with one case – a fifty-four year-old woman in ITU needing six units of blood right away following a stabbing.

 

She grouped as A Rh(D) Positive with a negative antibody screen. I selected six units of A Rh(D) Positive blood.

 

I got it right…

29 November 2024 (Friday) - Myeloid Cells Revisited

The other day I was pondering on the difference between promyelocytes and myelocytes…

But where do you draw the line between myelocytes and metamyelocytes. Or promyelocytes and blast cells…

Here’s a little diagram of the entire myeloid lineage..

 

And here’s some articles on the matter:

 

https://pmc.ncbi.nlm.nih.gov/articles/PMC6635720/

 

27 November 2024 (Wednesday) - AML DIagnostics

Oh, I am so out of date… look at this article from the nice people at Oncology Central about the latest genetic testing in making the diagnosis and assessing the prognosis in cases of AML.

Back in the day we’d go to the patient’s bedside with the consultant haematologist who would bore a hole in their chest and suck out some bone marrow. They’d give us a syringe full of the stuff. We’d make smears of it, and (once it was dry) we’d run two through the staining machine twice, and do a sudan black stain on another.

 

I suppose that realizing I’m out of date is a good thing… now I know where to direct myself.

26 November 2024 (Tuesday) - Transfusion Evidence Alert Update

The nice people at the Transfusion Evidence Alert sent their update today. There were two articles about the use of whole blood…

We used to issue that stuff years ago. Then red cell concentrates (packed cells) came in vogue. So much so that we would take the plasma off of units of whole blood to make red cell concentrates. Recently qualified colleagues have never seen a unit of whole blood.

 

But what was standard practice forty years ago and was largely dropped twenty years ago is now coming back…

ARTICLE OF THE MONTH Liberal versus restrictive transfusion strategies in acute myocardial infarction: a systematic review and comparative frequentist and Bayesian meta-analysis of randomized controlled trials. Braïk, R., et al. (2024). Annals of Intensive Care. PICO Summary available +++++

TOP ARTICLES Effect of perioperative erythropoietin on postoperative morbidity and mortality after cardiac surgery: a meta-analysis of randomized controlled trials. Abraham, D., et al. (2024). Anaesthesia, Critical Care & Pain Medicine. [Record in progress]. A randomized controlled trial comparing effectiveness of different fibrinogen preparations in restoring clot firmness. Baryshnikova, E., et al. (2024). Anesthesia and Analgesia. [Record in progress]. Early intervention of 5% albumin shown superior control of vascular integrity and function compared to ringer's lactate in hospitalized adult with grade I & II Dengue hemorrhagic fever: a multicenter randomized controlled trial in Indonesia. Bur, R., et al. (2024). Tropical Diseases, Travel Medicine and Vaccines. Mapping the landscape of machine learning models used for predicting transfusions in surgical procedures: a scoping review. Duranteau, O., et al. (2024). BMC Medical Informatics and Decision Making. Randomized controlled trials assessing continuous outcomes for the use of platelet-rich plasma in knee osteoarthritis are statistically fragile: a systematic review. Lameire, D.L., et al. (2024). Arthroscopy: The Journal of Arthroscopic & Related Surgery. [Record in progress]. Effect of preoperative autologous blood storage in major hepatectomy for perihilar malignancy: a randomized controlled trial. Onoe, S., et al. (2024). Annals of Surgery. [Record in progress]. Review of low titer group O whole blood (LTOWB) transfusion in initial resuscitation of pediatric trauma patients: assessing potential benefits. Park, S.M., et al. (2024). Journal of Pediatric Surgery. [Record in progress]. Does early transfusion of cold-stored whole blood reduce the need for component therapy in civilian trauma patients? a systematic review. Risha, M., et al. (2024). The Journal of Trauma and Acute Care Surgery. Assessment of hepatitis E virus transmission risks: a comprehensive review of cases among blood transfusion recipients and blood donors. Singson, S., et al. (2024). Infection Ecology & Epidemiology.

23 November 2024 (Saturday) - BTLP-TACT

Time for a BTLP-TACT exercise. I was presented with one case – a thirty-nine year-old chap in out-patients needing two units of irradiated blood tomorrow.

 

He grouped as B Rh(D) Positive with antibody panel positive in cells 2 & 3. I requested antibody panels. The IAT and enzyme panels were negative in cells 1 & 2 and positive in all other cells which was consistent with anti-c but didn’t exclude anti-E, anti-Kp(a) or anti-Lu(a)

There was only one c- E- unit, and that had no mention of its Kp(a) or Lu(a) status. I selected it working on the principle that the guidelines say that Kp(a) and Lu(a) are crossmatch compatible and I would be doing a wet crossmatch

 

Amazingly I got the thumbs-up. I don’t think I should have done – this was another no-win scenario. With only one unit that might be of any use I couldn’t have got the right answer.

This thing really is a work in progress. Such a shame no progress is being made.

22 November 2024 (Friday) - Low Platelets?

A massive drop in the platelet count… cell fragments… in a small child with pancreatitis…

Here’s a case study from the nice people at the American Society of Hematology.

20 November 2024 (Wednesday) UKAS Update

The nice people at UKAS sent their update today. They’ve set up a series of webinars about what they do. Sadly a podcast would be a better idea. Webinars are all very well if you are free at the time. You can listen to a podcast whenever you like…

19 November 2024 (Tuesday) - BTLP-TACT Exercise

Time for another BTLP-TACT exercise. Having got six right I must be due a thumbs-down…

I was presented with an eighty-five year old chap in theatre having a TURP needing two units of blood as soon as possible.

He grouped as O Rh(D) Positive with a negative antibody screen.

I selected two units of O Rh(D) Positive blood

That’s now seven green lights in a row…

 

19 November 2024 (Tuesday) - Westgard QC Newsletter

 Well, there’s no denying it is dull… But the Westgard newsletter is something for nothing, and no one ever pretended that statistics was riveting.

Speaking as someone with a degree in mathematics some branches of mathematics are beautiful and elegant - look at fractal geometry. Some are amazing – look at group theory. Some are just “wow” – look at differential calculus. And some are mind-blowing – look at complex numbers.

But statistics…  Sadly dull. But the good people at Westgard come up trumps with whaty they do.

18 November 2024 (Monday) - Horiba Update

The Horiba newsletter appeared in my in-box today. Just lately I’ve been rather derogatory about the CPD material that people are good enough to give me for free… but this one is setting the standard to which all others really should aspire. A case study, morphology tips, science, and technology updates…

Here’s hoping this continues in the same vein…

16 November 2024 (Saturday) - Another use for FFP

The other day I was ranting about the BTLP-TACT simulator. I do that a lot; I really shouldn’t. That particular rant prompted me to write up when fresh frozen plasma and cryoprecipitate are useful and when they are not.

Here’s another use of fresh frozen plasma. The stuff can be useful in extreme cases of angioedema.

https://pmc.ncbi.nlm.nih.gov/articles/PMC5298931/

14 November 2024 (Thursday) - BTLP-TACT Exercise

Time for another BTLP-TACT exercise. I was given two cases:
 

85624 – a sixty-nine year old chap in A&E needing four units of blood as soon as possible

He grouped as O Rh(D) Positive with a negative antibody screen.

I selected four units of O Rh(D) Positive blood

 

12582 – a forty-three year old woman needing four units of FFP and two units of cryo for a liver transplant

She grouped as O Rh(D) Negative with antibody screen positive I 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 does not exclude anti Lu(a) and anti Cw. The enzyme panel was negative which (in this plane of existence) does exclude anti Lu(a) and anti Cw.

I selected four units of FFP and two units of cryo

 

I got the thumbs-up

13 November 2024 (Wednesday) - Spot the Difference

Had an interesting conversation today which made me think. What *exactly* is the difference between a myelocyte and a promyelocyte?

They can be rather tricky to tell apart…

So I’ve had a think and done some Googling…

 

• Promyelocytes are bigger.
• Promyelocytes have prominent nucleoli and Golgi apparatus.
• Myelocytes do not have nucleoli and Golgi apparatus.
• Compared to the myelocyte, much more of the promyelocyte is nucleus
• Promyelocytes have huge, dark purple, primary (azurophilic) granules both in the cytoplasm and overlying the nucleus.
• Promyelocytes do NOT have secondary (specific,to neutrophil, eosinophil or basophil) granulation – not even the beginnings of it!  If you see any of that secondary granulation (even just a little blush of it in the cytoplasm) then it’s a myelocyte. The promyelocytes of the three granulocytic lineages cannot be distinguished by routine light microscopy.

 

Here’s some references…

 

https://www.sciencedirect.com/topics/medicine-and-dentistry/promyelocyte

https://www.pathologystudent.com/how-to-tell-apart-promyelocytes-and-myelocytes/

https://imagebank.hematology.org/image/60399/promyelocyte?type=upload

12 November 2024 (Tuesday) - IBMS Update

The IBMS sent their monthly newsletter today. It was on the dull side; it usually is. I was going to write about how their focus is on people and management and science is of peripheral interest, but I say that every month don’t it?

11November 2024 (Monday) - T.T.P.

“The correct answer is plasma exchange (PE). 

The treatment of choice for patients with thrombotic thrombocytopenic purpura (TTP) is plasma exchange. 

Although fresh frozen plasma infusion might be of limited impact, it is not the definitive treatment since it does not help removing the autontibodies from circulation. 

Platelets are thought to be contraindicated in TTP because of the theoretical possibility of worsening the TTP. 

Gamma globulin is ineffective in increasing the platelet count in TTP. 

Caplacizimab is an adjunct to PE but cannot replace it.”   

Reference:  Scully M, et al. Caplacizumab Treatment for Acquired Thrombotic Thrombocytopenic Purpura. N Engl J Med. 2019;380:335-346.

 

Plasma exchange? Haven’t done one of those for years…

Thursday 7 November 2024 (Thursday) - BTLP-TACT Exercise

Whenever I sit down to write up some CPD I always feel obliged to end it with a BTLP-TACT session. And so here we go.
 
I was presented with two cases:
 

27841 – a fifty-four year old woman in outpatients with ITP requiring group & save.

She grouped as O Rh(D) Positive with a negative antibody screen.

 

99755 – a forty-four year old chap under the medics requiring group & save, FFP (4) and cryo (2) for liver transplant.

He grouped as A Rh(D) Positive with a negative antibody screen.

I selected four units of A FFP and two units of A cryo as they *are* indicated

https://emedicine.medscape.com/article/431573

https://pmc.ncbi.nlm.nih.gov/articles/PMC2967283/

 
I got the thumbs up. Which is just as well. I get wound up when I get the thumbs down. Not because I got it wrong. I get wound up because it is a wasted learning opportunity. Being told “you got it wrong for the following reasons” and having a discussion on the matter is useful. That’s how we learn.
Just being told “you stuffed it up” helps no one.

5 November 2024 (Tuesday) - Fritsma Factor Newsletter

Inhibitors, lupus, haemophilia… as ever the Fritsma Factor newsletter is an invaluable resourse.

4 November 2024 (Monday) - NEQAS 2405DM

Having looked at NEQAS 2405DM on 12 September I get the resuts today.
 
“A previously fit 34-years old female attended her GP feeling tired. Her Haemoglobin was found to be 70g/l with normal white cell count and platelets – a blood film was prepared. What is your impression?”
 
I said:

 

Red cells   Anisopoikilocytosis Fragmented cells Polychromasia Marcrocytosis Target cells Tear drop cells

White cells   Hypersegmented neutrophil Toxic granulation Vacuolated monocyte with cleft nucleus

Platelets   Unremarkable

 
“Something haemolytic, but what are those vacuoles in the white cells. And what's the hypersegmented neutrophil all about?”
 
 
The expert comments were:
 
This blood film shows a severe deficiency of vitamin B12. The features quite distinct with the expected combination of oval macrocytes and hypersegmented neutrophils. If you have not seen a case like this before however, you may be surprised by the features of red cell fragility (fragments and misshapen cells) which can sometimes be mistaken for a fragmentation syndrome or even for microcytes. Also remember that the packed marrow can lead to many typical tear-drop forms being present.  
 
Well… I spotted the salient features but I did mistake them for a fragmentation syndrome. Just as well it’s not up to me to make a diagnosis. I’ve always said it’s unfair to judge us on something we don’t actually do.
And again I’ll make the comment that it is a shame that it took two months to get the result.

3 November 2024 (Sunday) - Slide Saturday Challenge

The American Society of Hematology sent out their “Slide Saturday Challenge” yesterday. There’s a hypersegmented neutrophil and macrocytosis. There’s also anisopoikilocytosis and tear drop cells seen.

My gut feeling is that this is a case of megaloblastic anaemia caused by a deficiency of vitamin B12 or folate.

But…

If that were the case wouldn’t there be Howell-Jolly bodies? Was it a case of myelodysplasia? In the end I thought that a case of myelodysplasia wouldn’t have that neutrophil and I went for megaloblastic anaemia.

I was right to do so.

 

For all that this is Slide Saturday Challenge I shall continue posting this on Sunday once the proper answer has come up. As I have said before, on-line morphology does tend to attract those who really haven’t got a clue. No matter what the case presented answers usually range from piles through to dead for three weeks, and the more clueless and wrong the suggestion, the more aggressively it is posted.

1 November 2024 (Friday) - Still Resentful...

This appeared on my Facebook feed today posted from the IBMS’s official Facebook account. A harmless joke… maybe.

 

Howe times have changed. Twelve years ago whilst on a night shift I posted a selfie saying I was tired. It wasn’t possible to see any of the background in that selfie, but I still got a formal disciplinary warning for bringing the profession into disrepute.

I was told at the time that any mention of work whatsoever on Facebook was immediate grounds for formal disciplinary action.

The manager at the time would have laid an egg over what our professional body today see as rather amusing.

 

I was tempted to tag him in a comment on that post but thought better of it. Twelve years have passed; I doubt he’d remember.

I do though…