January 31 2011 (Monday) - Anaemic?

An example of an ongoing problem….. Look at the second set of results from the left.

MOUSE,MICKEY                                     A+        DOB  06/04/1961 Sex M Pat No 501298       Source    KB Address   EURODISNEY                      Clinician HARM   Date 31/01     31/01      30/01       20/01     18/01 HB     10.5       5.2        11.5       11.9       12.0 WBC    13.8       20.0       15.8       19.1       17.6 PLT    283        389        253        218        263  RBC    3.16       1.56       3.45       3.53       3.61 HCT    0.310      0.150      0.330      0.340      0.360 MCV    97.2       97.4       96.8       97.2       98.9  MCH    33.2       33.3       33.3       33.7       33.2  MCHC   34.2       34.2       34.4       34.7       33.6  NEUH   11.3       16.7       13.4       16.5       15.5  LYMPH  1.2        1.4        1.0        1.2        0.9 MONO   1.2        1.8        1.4        1.3        1.2 EOS    0.1        0.1        0.0        0.1        0.0

Blood samples are collected using needle and syringe and having taken the blood, the syringe was left to stand before filling the blood bottles. We know this because the venesectionist who took the blood admitted doing so – they got distracted for a few minutes.

In the time the syringe was left standing, the blood settled remarkably fast, and the blood count bottle was filled last. Clearly the results are rubbish, as evidenced by the “normal” repeat sample.

This cause of spurious results should be borne in mind to avoid unnecessary and unwanted blood transfusions.

January 27 2011 (Thursday) - A Template

I’ve been recording my CPD on line for some months now. However there are still many people who prefer to record these things on paper. Many years ago I devised a template for doing exactly this.

Despite our living in a very on-line world, I still get asked for this paper template a lot. The template is available here, for anyone who might like to record CPD in this format.

January 26 2011 (Wednesday) - Distance Based Learning

Today’s talk was on the distance-based learning offered by the University of Greenwich. They offer modules on a range of topics including lung disease, renal disease, blood transfusion, quality issues, near patient testing…..

They also offer a scheme whereby if you complete four modules and a practical or theoretical project in the workplace within six years, then they’ll give you an MSc degree for it. Bearing in mind each module takes three months, obtaining an MSc suddenly becomes a much less painful proposition, both in terms of spreading out the academic effort, and in spreading out the cost.

I’m quite tempted to go for it myself, if it wasn’t for the fact that I can’t really make a case for my needing an MSc degree (and so getting work to pay for it) and the courses aren’t cheap…

January 25 2011 (Tuesday) - H.U.S.

Haemolytic-uraemic syndrome (HUS) is a disease characterized by hemolytic anemia, acute renal failure causing uremia and thrombocytopenia. Predominantly (but not exclusively) affecting children; most cases are preceded by an episode of diarrhea caused by E. coli O157:H7 acquired as a foodborne illness.

It carries a 5–10% mortality; of the remainder, the majority recover without major consequences but a small proportion develop chronic kidney disease and become reliant on renal replacement therapies

DUCK, DONALD DOB  06/03/2009 Sex F Pat No 99816806     Source    PAD  Received  19:51 Address   DISNEYLAND Diagnosis diarrhea, E.Coli 0157 POSITIVE.? HUS Specimen No   :  AW372191Z               Selected Auth Level : S  HB     5.8    Q000  MONO   2.9    Q000  WBC    26.7   Q000  EOS    0.2    Q000  PLT    86     Q000  BASO   0.1    Q000  RBC    2.37   Q000  ~F1   ^LS     Q008  HCT    0.170  Q000  ~F2   ^FILMW  Q008  MCV    73.0   Q000  MCH    24.5   Q000  MCHC   33.5   Q000  NEUH   10.6   Q000  LYMPH  12.9   Q000 LTG comments : F,FR

This case is a good example of the condition – note the anaemia and thrombocytopenia. The bldd film shows fragmented cells, poikilocytes and spherocytes

January 24 2011 (Monday) - Odd Cell Revisited

On Friday I posted a picture of a strange cell and asked for suggestions as to what it might be. I also mentioned about this blog entry on a pathology mailing list to which I subscribe. I cannot believe the response I have had, Normally this blog receives about dozen visits a day. On Friday it got thirty visits, on Saturday it got two hundred and seventy seven visits, on Sunday it got seventy three visits, and there have been one hundred and nine visits today (so far).

Furthermore the picture has been reposted on another blog and people have posted comments there too. In total I have received over thirty responses as to what the cell might be.

I don’t want to be dismissive of anyone’s suggestions, but some of the comments I’ve received aren’t very likely. Whilst the cell is definitely a white cell of some sort, it is certainly not an eosinophil or a basophil.

The most likely suggestions include:

• lymphocyte with cleaved nucleus, and cytoplasmic pseudopods
• micromegakaryocyte
• binucleated lymphocyte with cytoplasmic fragments
• degenerate cell.

There was only the one cell like it – we couldn’t find any others. A lot of people gave the sage advice that if there’s only one oddity then it can be ignored. Which is what we’ve actually done in practice.

But it would have been nice to have known what the thing was….

January 21 2011 (Friday) - What's This ?

This cell was found in the blood film of one of our patients. As is so often the case clinical details were somewhat lacking (it is enough that the doctor wants a blood count!!!).

The cell is unique in that I could find no others on the blood film, and I’ve never seen anything like it before. Might I ask my loyal readers if they have any ideas as to what it might be…

January 20 2011 (Thursday) - Malaria Revisited

On December 7 last year I mentioned that I had some malaria training. I say “training” – I had a look over an on-line atlas which features pictures which are probably computer enhanced. I then was set four slides to examine. I mentioned at the time that the slides weren’t particularly well stained, but was told to get on with them.

In retrospect I really could have done with having feedback at the time. Waiting for six weeks means that I have forgotten all about what I saw. In any event I’m told I didn’t do too well. I was given four sides to look at, none of which were of any particular quality – all were very blurred.

• The first one I correctly identified as not having any parasites
• The second one had no parasites, but I reported a P. falciparum infestation of 0.001%. I can vaguely remember not being happy with that slide and erring on the side of caution. In a real-life situation I would have asked for a second opinion.
• The third I correctly identified as having a P.vivax infestation.
• The fourth I spotted there was an infestation, but got the species wrong.

At the time I wrote “I can’t help but feel that if I can spot the fact that a patient has malaria, then that is good enough. Other people far more expert than I can identify the species and quantitate the parasitaemia.”

Enough sulking – what can I do too improve? I need training – and that isn’t immediately forthcoming. I’ve asked for a day’s secondment to the London School of Tropical Medicine. I wonder if I’ll get it.