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. 

November 1 2010 (Monday) - The R.D.W.

Last Wednesday I gave a talk on anaemia, and when we were discussing the iron deficiency anaemias I was asked about the use of red cell distribution widths.
The RDW is a parameter I have felt we should be reporting for some years, but various inertias have prevented getting this test into routine use. Which is a shame – our analysers routinely produce this parameter with every blood count we do. Reporting them wouldn’t incur any extra expense. And they clearly would be useful. After all, as a trainee (at a hospital long since bulldozed) I was reporting these way back in 1983.

On the other hand, since I moved to my current lab in 1984, we’ve only ever once (to my recollection) been asked to report an RDW. Are they really *that* useful…?