December 22 2010 (Wednesday) - Wednesday Talks

There was no lunchtime talk scheduled for today: so today I reflected on how this year's program of Wednesday talks has gone so far.

We started with minor hiccups where people were preparing presentations at home and were using .pptx format documents which wouldn't open on the trust's software. We have a work-around for that now.
We had minor hiccups when speakers weren't available because of night shift commitments, but I was able to re-schedule.
The biggest problem (that the punters would have seen) was the decision by management to unilaterally cancel one seminar's second session. I have been asked to re-schedule that showing. I will so at some point.

For myself I feel there is still a problem with the talks having to be attended in people's own time. Management allow speakers to speak in work's time. And management allow me to prepare the room, tidy up afterwards and prepare certificates of attendance in works time. However people prepare and attend seminars in their own time. Which is fair enough - it's an established point of law that the onus is on the registered biomedical scientist to do CPD, not on the employer to provide facilities for them to do so.
However I then have a problem when management ask me for a list of attendees so's they can impress the CPA with the in-house CPD program. So far I've refused to provide information on specific attendances at the lunchtime sessions. I feel I am right to do so.

But all things considered, the sessions are going well. We've a program up till next April. I'll see how it goes...

December 21 2010 (Tuesday) - Post Transfusion

An interesting case. Clearly microscopically there is a dimorphic population from a blood transfusion in November

TRANS, FUSION                                       A+      
DOB  28/02/1960 Sex F Pat No 173985       Source    GP    
Address    FOLKESTONE,                    Clinician WHO  

  Date 20/12/2010 09/12/2010 11/11/2010 17/08/2009 05/08/2009 19/02/2009
  Time 15:30      14:45      15:30      14:50      15:25      u/k     
  Spec AW269253P  AM982778X  AW140608Q  AW219311R  AW183817E  AW279932C
       BIO        BIO        BIO        BIO        BIO        BIO

HB     9.9        9.6        7.4        12.2       12.0       12.3
WBC    5.5        5.3        5.7        5.4        4.0        11.7
PLT    335        353        568        346        288        242
RBC    4.82       5.06       4.57       4.31       4.07       4.06
HCT    0.350      0.352      0.280      0.390      0.400      0.380
MCV    72.8       69.6       61.3       91.2       97.1       93.6
MCH    20.5       19.0       16.2       28.3       29.5       30.3
MCHC   28.2       27.3       26.4       31.0       30.4       32.4
NEUH   2.9        3.3        3.2        3.4        1.5        9.1
LYMPH  1.9        1.5        2.0        1.5        1.9        1.7
MONO   0.4        0.4        0.4        0.4        0.5        0.9
EOS    0.2        0.1        0.1        0.1        0.1        0.0

I’m well aware of the vagaries of haematological analysis following blood transfusions, but know nothing of how biochemistry is affected. From a conversation with a consultant clinical chemist, it would seem that there is little information available in scientific literature.

Given that any parameter’s post transfusion level is similar to the pre-transfusion level, then it’s safe to say there’s been no effect.
Given that there is a difference, then how much is due to the fact that the patient is critically ill (after all, they needed a blood transfusion!) and how much is due to the transfusion itself would seem to be a matter of conjecture.
One lives and learns…

December 20 2010 (Monday) - The Future...?

The government’s education and workforce consultation paper has just been published: Developing the Healthcare Workforce.

I am told by my superiors that this will have serious implications for my place of work, my colleagues, and for me personally. I don’t doubt it will, but despite my best efforts, I can’t make head or tail of it, nor can I find anyone who can explain (in English rather than gobbledegook) what it is all about.

December 18 2010 (Saturday) - A Useful Link

One of my colleagues suggested this website to me. She warned me that it was rather basic, but having had a look round, I think that she’s wrong about the site's perceived simplicity. There are some very silly pictures which give the impression of simplicity, but the topics mentioned are covered in quite some detail.

I shall be adding this website to my list of recommended resources for students. And I shall learn a lot from it myself….

December 15 2010 (Wednesday) - Xmas Quiz

Normally on Wednesday we have a lunchtime lecture. Today we had an Xmas quiz, with questions from all walks of pathology. I was rather flummoxed by the acronym round. What do CAPA, NICE, IBMS stand for? And they didn’t get any easier. When was haemoglobin first discovered? I don’t know. What is the most common blood group in Kent?
But after all was said and done I didn’t do too badly. With twenty one points out of a possible forty, I ended up in joint third place, and only lost out on a prize after I failed the tiebreaker, which was of a festive nature. How many of Santa’s reindeer can you name? I got Rudolph, Donner, Blitzen, Sneezy, Grumpy, Dave, Dee, Dozy, Beaky, Mick and Titch. But it would seem I missed some out.

December 14 2010 (Tuesday) --Thalassaemia

An interesting case: From the consistent hypochromic microcytic erythrocytosis  together with target cells and stippled cells we clearly have an undiagnosed case of thalassaemia. Being nearly sixty years old, and with a diagnosis of “chest pains” the thalassaemia has clearly not affected the patient’s life overly.

THALASSAE, MICK                                               
DOB  26/07/1954 Sex M Pat No 654321       Source    WAE     
Address   13 FAECES BOULEVARD   Clinician KCMARY          

  Date 14/12/2010 14/01/2010 29/11/2006 10/01/2005 21/04/1998 02/04/1998
  Time u/k        u/k        u/k        u/k        12:51      13:24    
Spec AW246341N  AW156879P  AW186358Q  AW377685L  AW010664S  AW094786B
HB     12.6       13.2       12.5       12.9       11.3       10.3
WBC    12.0       15.2       7.2        8.6        7.1        5.7
PLT    218        283        260        293        255        223
RBC    5.96       6.40       6.26       6.31       5.76       5.36
HCT    0.380      0.400      0.389      0.406      0.367      0.324
MCV    64.3       63.0       62.1       64.3       63.8       60.5
MCH    21.1       20.6       20.0       20.4       19.6       19.2
MCHC   32.9       32.8       32.1       31.8       30.7       31.8
NEUH   7.6        11.6       4.36       5.19       3.97       2.94
LYMPH  3.6        2.8        2.30       2.83       2.43       2.01
MONO   0.8        0.7        0.42       0.42       0.24       0.21
EOS    0.1        0.1        0.09       0.15       0.32       0.27

The consultant will comment, and then family studies will ensue. Or that is they would have done back in the days before the fact that genetically transmissible conditions such as this affect one’s life assurance.

December 13 2010 (Monday) - A Letter

I read an interesting article in "Pathology in Practice" today. So interesting in fact that I wrote to the magazine’s editor.


I must admit to a wry smile over the article in "Pathology in Practice" Volume 11 Issue 4 entitled "Microscopes and imaging: a brief independent guide". Specifically the paragraph on page 127: "A good  quality digital micrscope camera with imaging software can be attached to any microscope for as little as £1500".

I have recently obtained a Bresser USB Electronic Microscope Eyepiece from Scopes 'n' Skies for my department:

This gadget has produced excellent quality photographs which students and senior staff alike have used, and far from costing over a thousand pounds, only costs £34.99. It comes with software, but can produce photographs with software as simple as MicroSoft Paint.

Yours faithfully

Adullday Atwork BA CSci FIBMS
Senior Biomedical Scientist
Blood Sciences Department
Saint Swithin’s Hospital

(I feel I should mention that I have no commercial connection with the companies in question here, I merely wish to share what I consider to be a serious economy that can be made)

I wonder if I will get a response…?

December 12 2010 (Sunday) - An Article

Here's something I found on line:

Making Medical Lab Quality Relevant: The Science of Qualitology: "I like the ASQ’s Quality Management Journal because it publishes articles in a science and experimental structure that I understand and expe..."
(click on the above to read the article)

An interesting article. Medical laboratories around the world are concerned with "Quality". But internationally the definition of the word "Quality" is different to that used here in the UK.
Internationally the concept of the  "Quality" of a laboratory reflects the standard of the blood test reports that are produced by that laboratory. 
A novel concept....

December 9 2010 (Thursday) - Chediak-Higashi Syndrome (?)

An interesting case. An eleven year old child, septic, with marked pancytopenia. And the few neutrophils she does have all show these odd granules. I have no idea what they are, and we are waiting for the expert opinion from the referral centre.

I’ve a vague idea it might possibly be a case of Chediak-Higashi syndrome, a rare autosomal recessive disorder in which there is a microtubule polymerization defect. This compromises the phagocytic ability of the neutrophil, resulting in recurrent infections, partial albinism and peripheral neuropathy.
It has been reported in humans, cattle, white tigers, blue Persian cats and albino orcas.

I wonder if today I might use my blog to ask if any of my readers might have any idea what this might be.

December 8 2010 (Wednesday) - Blood Films Revisited

Today’s lunchtime session was a refresher on blood film morphology. Whilst it was something I do on a regular basis, there’s a lot to be learned from taking a step back and reviewing practice.

And it was good to see our new web-cam has been put to use.

December 7 2010 (Tuesday) - Malaria Training

Today I had an in-house training session on malaria. I say "training session", it was more of a refresher and reminder. But we don't see that many cases of malaria, so I found it useful. I started off with an on-line tutorial, then had a go on some slides. One thing which became clear is that there is a world of difference between a microscope and a PC screen.

P. malariae is fairly easy to get right – it looks hideous. P Falciparum is (usually) the only one with multiple infestations in one red cell, or with “blister” forms. I have trouble distinguishing between P Vivax and P Ovale. From the depths of my memory came some old ditties:

  • Vivax-to-the-max (P. Vivax causes large infested red cells)
  • Vivax – Asia (two syllables)
  • Ovaly Ovale (P. Ovale causes oval infested red cells)
  • Ovale – Africa (three syllables)
I have done my test; the results will come out in a week or so. I wonder how badly I did? I’m not the worlds best at malaria. 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.
Is that being lazy?

December 6 2010 (Monday) - Queues Revisited

A while ago I rigged the lab computer so that samples with a one hour turnaround would be instantly accessible via a queue, and so that samples with a four hour turnaround would be instantly accessible via a different queue. I think that I can claim this idea as having been a success as the chemistry people have copied my idea.

                                 Queue Summary

    Queues requiring attention :-

 Queue   Queue name                 No. of specimens  Date      Time  User
Urgent  - General Queues
 B1HOUR  One hour samples (Biochem)       7       04/12/2010  11:03   0
 B4HOUR  Four hour samples (Biochem)      2       04/12/2010  11:03   0
 HCONS   Haematology consultant queue     22      04/12/2010  10:49   0
 URGENT  One-hour samples  (Haem WHH)     7       04/12/2010  10:57   0
 WARDS   Four hour samples (Haem WHH)     10      04/12/2010  10:51   0
Routine - General Queues
 BROUT   Biochemistry Routine General     17      04/12/2010  10:54   0
 GF      GF tests to be done              5       03/12/2010  16:58   0
 VITP    B12s awaiting authorisation      19      03/12/2010  22:12   0
 ZHB1    Hb-opathies awaiting analysis    6       03/12/2010  18:15   0
 ZHB2    Hb-opathies sent to Dartford     54      02/12/2010  18:31   0


This scheme had a minor hiccup in that should a consultant referral be necessary, then these samples would remain on the queue, even though there was no need for them to be there by this stage.

Today I added a minor tweak to the computer so that the presence of the flag we use to when consultant intervention is required would move such samples to a separate queue.

                             Rule Table Definition
  Rule Code : CONS           Description   : Haematology consultant queue
 [2 ]

 If   ~F1    CO  REF    OR  ~F2    CO  REF    OR  ~F3    CO  REF    OR        
~F4    CO  REF    OR  ~F5    CO  REF    OR  ~F6    CO  REF OR ~F7   CO
 REF   OR  ~F8    CO  REF    OR  ~F9    CO  REF    OR  ~F10   CO  REF                                                             
 Then QUEUE Else QUIT                                                                        
} Dialogue -----------------------------------------------------------{

Time will tell if it is advantageous…

December 3 2010 (Friday) - HPC Newsletter

On October 1st I mentioned that I wasn’t overly impressed with the HPC’s newsletter. I received the latest one today, and was (quite frankly) equally disappointed. There was half a page about some new publications concerning fitness to practice and raising concerns which I might incorporate into evidences for pre registration portfolio evidence suggestions. But other than that, there wasn’t much I felt to be relevant to me.

The term “biomedical scientist” wasn’t mentioned once…

December 2 2010 (Thursday) - The Pelger-Huet Anomoly

I saw something down the microscope you don’t see every day. And now I have a webcam, I can record what I saw on this blog using my own pictures, rather than blagging from Google Images.

The above picture has three neutrophils, all demonstrating the Pelger–Huet anomaly. Originally observed in Europeans, the Pelger-Huet anomaly has been seen in most racial groups of all ages with an equal gender ratio.
Pelger-Huet cells survive normally in circulation and demonstrate normal phagocytosis and normal ability to kill microorganisms. The defect (if that is the correct term) is in the terminal differentiation of neutrophils. PHA is inherited in an autosomal dominant pattern. Effectively the cells look left-shifted, but are functionally normal.
Eosinophils are also affected but monocytes and lymphocytes are normal in appearance.

There’s plenty of on-line references about this - is as good as most of them.

December 1 2010 (Wednesday) - Meningitis

Last week one of my colleagues spotted a cloudy CSF sample and immediately recognised it as being contaminated with bacteria. A rip-roaring case of meningitis immediately diagnosed by an experienced biomedical scientist, and today she presented the case.
I was able to contribute by using our newly acquired web-cam to obtain the CSF photo above…

November 29 2010 (Monday) - The R.D.W. Revisited

On November 1 I reflected on the use of the R.D.W. as a useful laboratory result.It’s since been pointed out to me that many labs report R.D.W. in place of M.C.H.C. since the R.D.W. is of far more diagnostic importance, and on pre-printed lab reports there is only so much space. Adding an R.D.W> result would mean that something else would have to go.

I thought about that for a bit, but today found something of interest. Consider this set of results:

                             Specimen Results Entry

Mouse, Mickey                                               
DOB  01/01/1930 Sex F Pat No 123456       Source    CJ2     
Address   EuroDisney                  Clinician HOSJ     
Diagnosis ?pe.....
Specimen No   :  AW198831V               Selected Auth Level : S
 HB     10.4   F000 |MONO   0.9    F000 |~F8   ^            |
 WBC    8.4    F000 |EOS    0.0    F000 |~F9   ^            |
 PLT    408    F000 |BASO   0.0    F000 |~F10  ^            |
 RBC    2.70   F000 |~F1   ^TURB   F008 |                   |
 HCT    0.260  F000 |~F2   ^FILMW  F008 |                   |
 MCV    95.9   F000 |~F3   ^            |                   |
 MCH    38.5   F000 |~F4   ^            |                   |
 MCHC   40.2   F000 |~F5   ^            |                   |
 NEUH   4.9    F000 |~F6   ^            |                   |
 LYMPH  2.5    F000 |~F7   ^            |                   |
LTG comments : F,FR

From the M.C.H.C. this is clearly a case of cold agglutinins. For information the RDW – SD  was 44.9 fl and the RDW – CV was 15.6 %. On warming the sample, the following (far more plausible) results were obtained:

                             Specimen Results Entry

Mouse, Mickey                                               
DOB  01/01/1930 Sex F Pat No 123456       Source    CJ2     
Address   EuroDisney                  Clinician HOSJ     
Diagnosis ?pe.....
Specimen No   :  AW198831V               Selected Auth Level : S
 HB     10.3   S000 |MONO   1.0    S000 |                   |
 WBC    9.7    S000 |EOS    0.1    S000 |                   |
 PLT    399    S000 |BASO   0.0    S000 |                   |
 RBC    3.42   S000 |~F2   ^FR     S008 |                   |
 HCT    0.310  S000 |                   |                   |
 MCV    89.5   S000 |                   |                   |
 MCH    30.1   S000 |                   |                   |
 MCHC   33.7   S000 |                   |                   |
 NEUH   5.6    S000 |                   |                   |
 LYMPH  2.9    S000 |                   |                   |
LTG comments : F,FR

RDW – SD was 45.5 fl and RDW – CV was 14.4 %. The M.C.H.C. is significantly improved, but the R.D.W. parameters are effectively unchanged. Bear in mind that the Sysmex XE Aniso flag doesn’t kick in until RDW – SD >65fl and/or  RDW - CV >20.

So were we to replace M.C.H.C. with R.D.W. then I think we would have the potential to miss cases of cold agglutinins. Current practice is (again) vindicated….

November 25 2010 (Thursday) - BCSH

The British Committee for Standards in Haematology emailed me to say they had re-vamped their website, so I had a peruse. Whilst the information is now somewhat more readily available, there’s not a terrific lot of recommendations for the laboratory.

It strikes me that in this age of CPA compliance, having everything written down (in triplicate) and everything being done purely by the book (with no leeway for personal flair), surely national Standard operating procedures must be an obvious next step. And if the BCSH aren’t going to provide them, then who will…?

November 24 2010 (Wednesday) - Hypoglycaemia

A case study – hypoglycaemia caused by an insulinoma: a rather obscure tumour occurring in (about) four times in every million people. I refreshed my memory of glucose metabolism and learned loads from the case study. I didn’t know that people used insulin as a murder weapon.

And I didn’t know that insulinomas are very common in ferrets…

November 22 2010 (Monday) - Fundoplication

Fundoplication – a new word. There’s various sorts of it. Nissen fundoplication is a surgical procedure to treat gastroesophageal reflux disease (GERD) and hiatus hernia. In GERD it is usually performed when medical therapy has failed, but with paraesophageal hiatus hernia, it is the first-line procedure. The Nissen fundoplication is total (360º), but partial fundoplications known as Belsey fundoplication (270º anterior transthoracic), Dor fundoplication (anterior 180-200º) or Toupet fundoplication (posterior 270º) are also alternative procedures with somewhat different indications.

One lives and learns…

November 19 2010 (Friday) - A Microscopical Camera

(I’ll allow myself a little rant today as well…)

For some time I’ve wanted the ability to photograph what I see down my microscope. The logical people to speak to about this would be the people who service the microscopes. I’ve been chasing them about this for two years: they just don’t get back to be.
The histology people have a wonderful system for photographing what they see down their microscopes, but it’s not cheap (five thousand pounds!).

 I knew exactly what I wanted, it only costs thirty five quid, and so I tried to obtain one through the proper channels. The supplies department were very loathe to buy anything from an Internet supplier. The I.T. department made all sorts of complications about security implications (?) After a month’s squabbling and beating my head against (virtual) brick walls, on Monday I got the go-ahead to buy one. I ordered it on Monday, it arrived Wednesday, and we had the software installed today. I only hope I can get my thirty five quid back from petty cash…

So far I’ve only photographed the neutrophil above. But it proves a point, and from now on students are no longer dependent on blagging pictures from Google Images and hoping no one can tell where the picture came from.
And once I’ve made the various updates and changes to the websites of advice for pre-registration and specialist portfolios, I’ve half a mind to put together my own on-line atlas of haematology…

November 18 2010 (Thursday) - CPA, NICE and Politics...

When I started this diary I resolved that it would *not* be a vehicle for my ranting, but I feel I need to get something off my chest…

In my thirty years in the NHS I’ve seen some changes. The way the NHS is run changes all the time. The latest plan is to re-organise so that the entire NHS is commanded by the GPs. But this isn’t a new idea - am I the only one who can remember that this has already been tried. Does the phrase “GP Fundholders” ring any bells?
Did it work when it was introduced in 1991?
I don’t know. It’s been shown that there was absolutely no evidence as to whether it might have worked or not. Instead the decisions to implement the scheme and the decision (under a different government seven years later) to abolish it were taken purely on political and ideological grounds.

It’s rather strange that if I want to make the slightest change to how I perform my professional duties I have to fulfil a myriad of regulations to prove beyond any doubt that the proposed change is for the better. If researchers have ideas for new treatments, these must be radically tested to destruction before they can even reach the clinical trials stage. But the entire structure of the NHS can be reformed on the whim of current political opinion with no evidence whatsoever as to whether or not the idea is good, bad or just plain stupid…

How many other decisions in government are made this way? How are the police, the armed forces, schools, the nation’s transport infrastructure organised? Are they subject to sensible management? Are they run on sound financial principals? Or are they run at the whim of political ideology too…?

November 17 2010 (Wednesday) - Using the Laboratory....

Our clinical director spoke at today's lunchtime session. She based her talk on one she gives to GPs and junior hospital doctors on how best to use the laboratory.  We started off with the role of laboratory medicine, and good and bad ways to use a path lab. Confirmation of diagnosis, ruling out diagnosis, and the need for useful clinical information to be provided were discussed.
We then touched on the various forms of results the lab gives out; wordy descriptive opinions, positives and negatives, and then (what we do mostly) numerical results. We discussed how often reference ranges are rather irrelevent, and the need to spot obvious duff results - clotted samples, drip arms, etc.
In many ways the talk was "back to basics", but that's not always a bad thing...

November 16 2010 (Tuesday) - A Magazine Rack

I get various magazines delivered to me at work. I read them, and leave them for colleagues to share. Invariably they are thrown away within the hour by people who think that they are helping by tidying up. Today we had a magazine rack installed. 
A small thing, but now magazines will survive long enough for people to be able to share them. C.P.D. in action !!

November 15 2010 (Monday) - Specialist Portfolio Questions

A week ago I mentioned that I needed to re-write the questions I’ve set on my website of advice for students tacking the IBMS specialist portfolio. Today I re-vamped questions for sections 7.1a, 7.1b and 7.1c.
Three sections took half an hour. Doing all forty is going to take a while…

November 10 2010 (Wednesday) - Glandular Fever

Today’s lunchtime seminar was on glandular fever. A useful refresher, and a comparison between what we do and what the microbiology department does. It was good to see some people from the microbiology department at the session.
The speaker had volunteered to give the talk as a practice run for her presenting at the university in a couple of weeks, and I think it’s fair to say that she got a lot of useful feedback too.

I’m quite pleased with how well the talks are going this year…

November 5 2010 (Friday) - The Specialist Portfolio

Over the last few weeks I’ve had success with students having pre registration portfolios passing assessment. However I’m painfully aware that I’ve been concentrating on pre-registration portfolio students at the expense of specialist portfolio students and my foundation degree student. Today I spent some time with my specialist portfolio students.
About eighteen months ago my plan was that I would give them a website to work from, so they wouldn’t need so much regular input from me. And since that time I have periodically worked on that website, including a major face-lift and re-vamp a month or so ago.

This idea has had some limited success. Whilst the students have access to questions and information, in retrospect I've not been fair to them by leaving them to get on with it. They do need input from a supervisor/mentor/me(!). Probably not much input, but more than I've been giving them.

Also on re-reading what I’ve put on that website, I’m not entirely happy with the questions I’ve set. When I wrote them I did so with the required competences in mind. However from my experiences of pre-registration portfolio examinations (in which assessors can’t see what I thought was painfully obvious(!)) I shall revisit my set questions for each section and make them more in line with the required competences.

However, bearing in mind this is over forty sets of questions to re-write, this may take some time….

November 3 2010 (Wednesday) - C.R.P.

Today’s lunchtime seminar was on c-reactive protein. I realised that acute phase proteins went up in inflammatory conditions. I didn’t realise that they don’t all go up by the same amounts. An interesting seminar and a very good chat afterwards. Especially good, bearing in mind the multi-disciplinary nature of the subject.
Why do we measure ESRs when a CRP is probably easier and quicker?

November 2 2010 (Tuesday) - Another Success

On 12 October I mentioned that I’d overseen the qualification of eighteen trainees. Today’s success made that figure nineteen.
The inspector who visited a month ago was absolutely ecstatic with what he saw. Today’s assessor (from the same place of work) was not so impressed.  I’ll accept that I am probably wrong in using the same evidences to both “observe the trainee” and to show that they have “answered questions…”. It’s a valid point, and I shall bear it in mind.

Also suggesting that certificates of achievement are not enough on their own (and that they should be backed up with reflection) is a new (to me) idea. I suppose it is a valid idea, and easy enough to do.

I could whinge more, but it would not be right to do so here, bearing in mind I’ve taken the (somewhat brave!) decision to publish my reflective diary. And seeing this is a reflective diary (of sorts), on reflection I need to be more receptive to criticism.
But I will say that this is now the seventh portfolio assessment that I’ve been on the receiving end of, and whilst there are other assessors who agree with me (in part), there are those who don’t seem to agree very much either with me or with each other. Perhaps we need stricter guidelines? I shall also get on to the IBMS in the morning.
But after all was said and done, the chap passed. Which is the main thing.