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…