3 April 2015 (Friday) - Dabigatran

BARNES, HEDWARD                                      06:38 MR      20/08/1940   Male   654321            Emergency Care Centre 185 Eaton Place                   Dr Foley Specimen No : AK564330X    Haematology & Chemistry         03/04/2015 06:38  Citrated Blood  Request Reason :     chest pain  PT                        20.4   s         (    12 to 16    ) Auth  APTT                      51.3   s         (  22.0 to 35    ) Auth  APTT Ratio                ^1.8                                Auth  I.N.R.                     1.4                                Auth   Coag Screen   LTG Comments :     Patient is on dabigatran

Dabigatran (Pradaxa or Prazaxa) is an oral anticoagulant acting as a direct thrombin inhibitor. It is being trialled for various clinical indications and is claimed to offer an alternative to warfarin as the preferred orally administered anticoagulant since it does not require INR monitoring while offering similar results in terms of efficacy.

There is no specific way to reverse the anticoagulant effect of dabigatran in the event of a major bleeding event unlike warfarin although a potential dabigatran antidote (pINN: idarucizumab) is undergoing clinical studies.

It was developed by the pharmaceutical company Boehringer Ingelheim… on July 26, 2014, the British Medical Journal (BMJ) published a series of investigations that accused Boehringer of withholding critical information about the need for monitoring to protect patients from severe bleeding, particularly in the elderly.

Reviews of internal communications between Boehringer researchers and employees, the FDA and the EMA revealed that Boehringer researchers found evidence that serum levels of dabigatran vary widely. The BMJ investigation suggested that Boehringer had a financial motive to withhold this concern from regulatory health agencies because the data conflicted with their extensive marketing of dabigatran as an anticoagulant that does not require monitoring.

I can’t help but wonder how many other “wonder drugs” aren’t quite so wonderful. Perhaps if they weren’t quite so lucrative…? 

2 April 2015 (Thursday) - HCPC Newsletter

The HCPC newsletter came out today.

http://www.hcpc-uk.org/assets/documents/10004B57HCPCInFocus-Issue58.pdf

At the risk of being saying something rather brave, the newsletter rarely has anything which I find directly relevant to me personally, and this one was no exception.

Mind you whilst I can’t say I found it relevant, it was (in places) interesting.  I didn’t realise that all of the HCPC’s activities are funded entirely out of the fees paid by registrants such as me.

Is that *really* any way to run such a body?

26 March 2015 (Thursday) - Thick Films

Whilst I’m confident that I can spot blood bourne parasites if they are there; I’ve always been somewhat iffy about my abilities on thick films. Mind you I think it’s fair to say I’m not alone in this.

Today I had a little one-to-one session on a NEQAS thick film.

Speaking with someone a little more experienced than I am has left me a little more confident in examining thick films.

The key feature is the malarial dots. Don’t try to see the same sort of thing you see in a thin film; look for definite distinct dots. If these are parasites, then attached to them will be the wispy remains of the parasites. Having now seen them I know what to be looking for…

23 March 2015 (Monday) - Bright Yellow

This case made me think

HUDSON,ANGUS                                             23/03/2015 12:45       03/04/2013 1 yrs   F  1234567              Infirmary 185 Eaton Square                    Dr Foley Specimen No : AC654321D    Haematology & Chemistry        <PgDn> for later ------------------------------------------------------------------------------ 23/03/2015 12:45  Serum/Plasma  Request Reason :     YELLOW   MOTHER GIVES A LITER OF CAROT JUOCE EVERY 24 HOURS  Sodium                         138    mmol/L          (   133 to 146   ) Auth  Potassium                      4.7    mmol/L          (   3.5 to 5.3   ) Auth  Creatinine                     24     umol/L          (    21 to 36    ) Auth  GFR (estimated)                Inappropriate to calculate                Auth  Total Protein                  69     g/L             (    56 to 75    ) Auth  Albumin                        41     g/L             (    30 to 50    ) Auth  Globulin                       28     g/L             (    20 to 35    ) Auth  Total Bilirubin                6      umol/L          (     0 to 22    ) Auth  Alkaline Phosphatase           304    U/L             (    60 to 425   ) Auth  ALT                            11     U/L             (     5 to 45    ) Auth  Haemolysis-Integra             ^1.0                                      Auth  Icterus-Integra                ^70                    (     0 to 85    ) Auth  Lipaemia-Index                 ^0.1                                      Auth

Leaving aside all arguments about use of the word “normal” these results are pretty much “normal”. Bilirubin within acceptable levels, icteric index is fine. Despite the fact the child is bright yellow.

However look at the diagnosis. Sometimes the answer to clinical conditions doesn’t need extensive laboratory investigations

21 March 2015 (Saturday) - To Give, or Not To Give

Here’s an interesting article.

http://www.nejm.org/doi/pdf/10.1056/NEJMoa1403612

Whether to give blood or not after heart surgery is arguable. Where’s MSBOS now…?

20 March 2015 (Friday) - Lab in a Bag

Here’s a possibly worrying article.

http://www.england.nhs.uk/2015/03/20/lab-in-a-bag/?utm_source=feedburner&utm_medium=email&utm_campaign=Feed%3A+NHSCBoard+%28NHS+England%29

“Lab in a Bag” is a “groundbreaking mobile diagnostics service that will deliver laboratory standard test results outside of hospital and allow patients to be diagnosed and treated at the point of care”

In theory it sounds like a good thing, and *if* it works it will clearly be essential in inmproving the patient experience and outcome.

In practice the entire “near patient thing” hasn’t really impacted on my personal workload. Will this one? I don’t know. But in all of this near patient testing I always remember the works of a paediatric sister who was once telling me about a ward-based bilurubin-measuring device. She would only allow the machine to be used if it was being done “just for fun”. If the result was to be used in patient treatment the sister refused to allow the machine to be used; for that she insisted the hospital lab produce the result.

11 March 2015 (Wednesday) - Myeloid Maturation

After looking at a recent NEQAS morphology exercise this website struck me as being particularly relevant

http://allaboutblood.com/2011/06/04/morphology-of-myeloid-precurssors/

It’s a rather good walkthrough of the myeloid maturation process.