6 August 2016 (Saturday) - Transfusion Evidence Library Update

My regular update from the Transfusion Evidence Library arrived in my inbox this morning – here’s ten of the latest 7188 evidence-based publications based on the areas and topics of interests I selected.

·         Roxadustat (FG-4592) versus epoetin alfa for anemia in patients receiving maintenance hemodialysis: a phase 2, randomized, 6- to 19-week, open-label, active-comparator, dose-ranging, safety and exploratory efficacy study
Provenzano R; Besarab A; Wright S; Dua S; Zeig S; Nguyen P; Poole L; Saikali KG; Saha G; Hemmerich S; Szczech L; Yu KH; Neff TB
American Journal of Kidney Diseases : the Official Journal of the National Kidney Foundation. 2016
·         Misoprostol for primary versus secondary prevention of postpartum haemorrhage: a cluster-randomised non-inferiority community trial
Raghavan S; Geller S; Miller S; Goudar SS; Anger H; Yadavannavar MC; Dabash R; Bidri SR; Gudadinni MR; Udgiri R; Koch AR; Bellad MB; Winikoff B
Bjog : an International Journal of Obstetrics and Gynaecology. 2016;123(-1):120-7
·         Comparison of combined hormonal vaginal ring with ultralow-dose combined oral contraceptive pills in the management of heavy menstrual bleeding: a pilot study
Agarwal N; Gupta M; Kriplani A; Bhatla N; Singh N
Journal of Obstetrics and Gynaecology : the Journal of the Institute of Obstetrics and Gynaecology. 2016;36(-1):71-5
·         The impact of tissue glue in wound healing of head and neck patients undergoing neck dissection
Huang CW; Wang CC; Jiang RS; Huang YC; Ho HC; Liu SA
European Archives of Oto-Rhino-Laryngology : Official Journal of the European Federation of Oto-Rhino-Laryngological Societies (Eufos) : Affiliated With the German Society for Oto-Rhino-Laryngology - Head and Neck Surgery. 2016;273(-1):245-50
·         Does tourniquet use in TKA affect recovery of lower extremity strength and function? A randomized trial
Dennis DA; Kittelson AJ; Yang CC; Miner TM; Kim RH; Stevens-Lapsley JE
Clinical Orthopaedics and Related Research. 2016;474(-1):69-77
·         Prevention of bleeding in orthognathic surgery - a systematic review and meta-analysis of randomized controlled trials
Olsen JJ; Skov J; Ingerslev J; Thorn JJ; Pinholt EM
Journal of Oral and Maxillofacial Surgery : Official Journal of the American Association of Oral and Maxillofacial Surgeons. 2016;74(-1):139-50
·         Double-blind randomized controlled trial: injection of autologous blood in the treatment of chronic patella tendinopathy - a pilot study
Resteghini P; Khanbhai TA; Mughal S; Sivardeen Z
Clinical Journal of Sport Medicine : Official Journal of the Canadian Academy of Sport Medicine. 2016;26(-1):17-23
·         Sublingual misoprostol is as effective as intravenous oxytocin to reduce intra-operative blood loss during cesarean delivery in women living at high altitude
Gavilanes P; Morales MF; Velasco S; Teran E
The Journal of Maternal-Fetal & Neonatal Medicine : the Official Journal of the European Association of Perinatal Medicine, the Federation of Asia and Oceania Perinatal Societies, the International Society of Perinatal Obstetricians. 2016;29(-4):559-61

Loads of stuff…

5 August 2016 (Friday) - Normal ?

Here’s an interesting case. To quote from the article in question: “I had been exhibiting speech and gait issues.  I was stumbling when I walked, slurring my speech and having trouble remembering what I wanted to say.  I went to my doctor, who ordered a series of tests, including x-rays, MRIs and a comprehensive panel.   My hemoglobin and hematocrit levels were “normal,” but not really normal for me.  And my ferritin (iron) level at 5 nanograms per milliliter of blood, while technically within range (5 to 300 ng/m for males and 5 to 150 ng/mL for females), was exceptionally low for me.  I consulted with a hematologist, who prescribed an iron supplement, but to which I had a bad reaction.   Meanwhile, my health problems continued to worsen, and I began to experience sleep apnea and even hemorrhaging issues.

I finally showed my results to some chemistry department colleagues, who confirmed that even though I was testing in range, because of my prolonged use of nonsteroidal anti-inflammatory drugs (NSAIDS) to alleviate my symptoms, I was literally blocking my body’s ability to absorb iron, which was triggering my symptoms (iron levels should be around 50 before the body can begin to absorb it properly).

I no longer have these symptoms, but the lesson here is to really know what is normal for your body chemistry and to have things checked out if you deviate from that baseline.  Additional laboratory testing was able to give me the answers I needed.”

I’m reminded of the senior chief MLSO when I first started working all those years ago. Having had TB at one stage he would always use himself as a case study – his ESR was always between fifty to seventy. Fort him that was “normal

Normal” or “reference” ranges are only applicable to some people…

1 August 2016 (Monday) UKAS Newsletter

The UKAS Newsletter came this morning. Loads of information; all good CPD, free just there for the taking:

As a UKAS customer, you are receiving this email to notify you that there has been an update to the following UKAS Publication(s):
A full list of UKAS publications is available from the UKAS website.

It’s all rather dry though…

30 July 2016 (Saturday) - IBMS Newsletter

The IBMS newsletter appeared in my inbox this morning.

Perhaps the thing which really caught my eye was the fact that the IBMS is doing away with its on-line discussion forums. On-line discussion forums are usually just one big argument, so getting shot of them will probably be a good thing.

There was also something about doing more work for less money. Surely there must come a point where all the possible economies have been made?

And some killjoy or other was griping that bringing cakes in to the departmental tea-rooms is a bad thing.

Interestingly much of the newsletter was directing the reader to entries on the IBMS Facebook page. That’s a sign of the times…

29 July 2019 (Friday) - Mistakes

The HCPC writes a blog. All the best people do, you know… Today I read something on their blog which made me think.
Standard Eight of the standards under which we all practice says that registrants need to be open and honest when something has gone wrong with the care, treatment or other services that we provide. This includes letting service users and carers know; apologising; and taking action to put matters right if we can.
The standard also says that registrants need to support service users and carers to raise concerns and be helpful and honest in their responses to complaints.

This is a very noble sentiment and *in theory* is all very well.

Mistakes in healthcare are by their very nature terrible. However one needs to bear in mind that mistakes are that – mistakes. Nobody goes into healthcare with the intention of deliberately harming patients.
And one also needs to bear in mind the harm done by ambulance-chasing lawyers looking to sue at the slightest provocation.

If mistakes become learning experiences then practitioners are going to be more inclined to report them.

If they become thinly-veiled witch-hunts then they are not…

25 July 2016 (Monday) - BloodMed Email

This morning I got the regular email from the Bloodmed people. The news items were quite interesting:

I found the first article particularly interesting; when I first started working morphology was everything. The technology used for investigating genetic variants was in its infancy.

Now all that we knew has been turned on its head…

23 July 2016 (Saturday) - Green Neutrophil Inclusions

Here’s something new to me. Two references on the matter – Pubmed  and Blood – both respected publications.

Apparently green neutrophil inclusions have been reported as a sign of impending patient death. In a series of twenty patients in whom green inclusions were identified in neutrophils or monocytes thirteen died within days of the detection of the inclusions.
A common feature to almost all patients was ischaemic or hypoxic hepatitis which, in fatal cases, was associated with lactic acidosis.

What are the inclusions?

Light and electron microscopy indicated that the inclusions were lipid-rich, probably derived from lipofuscin-like material released from necrotic liver parenchymal cells.

It is recommended that that the detection of green inclusions, referred to as 'critical green inclusions', is acknowledged and reported by laboratories and correlated with clinical findings.

I’ve never seen them…

21 July 2016 (Thursday) - A Podcast

An interesting podcast – you can hear it by clicking here. I suppose I’m rather used to the way I work here in the UK where patients go to their doctor and I effectively work for the doctor. This podcast clearly is aimed at parts of the world where labs work directly for patients.
Could we *really* improve what we do by communicating directly with patients? Perhaps I’m rather old-school but I’m not sure we can. Mind you I’m sre I’m wrong. I usually am….

20 July 2016 (Wednesday) - NHSBT Newsletter

The e-newsletter from NHSBT arrived this morning. It followed its usual format
For Action
1.1 “Save one O D Neg a week” campaign and O D Neg Toolkit
For Information
2.1 SHOT Annual Report for events reported in 2015
2.2 Patient Information Leaflets and Educational Resources
2.3 National Paediatric Conference
2.4 Haemoglobinopathy Genotyping Initiative – close of project
2.5 New genotype tests and pricing at IBGRL
2.6 Replacement of 3 part paper issue note and OBOS Development
For Training
3.1 Training & Education Events and Courses

Whilst it was all quite interesting (for once!) I found myself intrigued by the need for more O Neg blood. Being O Neg myself perhaps I might become a donor again…

18 July 2016 (Monday) - NEQAS Morphology

The latest NEQAS morphology scheme report came through this morning:

General Digital Morphology CPD Scheme
Report and Certificate
Participant Me !
Case Number: 1403DM
CPD Date: 2014-05-07 14:53:07

Consensus of morphological features recorded:
Total number of participants: 986
Group's top 5 observations:
Rank Morphological Feature Participants that selected this feature(%)
1 Thrombocytopenia 57.7
2 Myelocytes 42.1
3 Monocytosis 36.8
4 Promyelocytes 34.5
5 Blast cells 29.2

Your observations:
Rank Morphological Feature Participants that selected this feature(%)
1 Blast cells 29.2
2 Auer rods 1.5
3 Promyelocytes 34.5
4 RBC Fragments/Schistocyte.. 28.3

Reviewing your findings what action would you take?
Urgent - film requires immediate referral to clinician and renal unit should be

Considering your morphological findings, what is your suggested
myelodysplastic transformation

Actual pathological diagnosis:
Renal Failure with Chronic Myelomonocytic Leukaemia.

Of those offering a diagnosis, more than two-thirds suggested that this was a neoplastic condition: 20% suggested MDS, 10% suggested acute myeloid leukaemia (AML or AMML, noting the primitive monocytoid cells), and 10% suggested CML. Congratulations to the 25% who accurately pinpointed the final diagnosis.
This was a difficult and unusual case. Initially the increased white cell count could easily have been interpreted as reactive due to sepsis, but on closer inspection, the lack of toxic granulation in the neutrophils and the primitive and abnormal morphology of the monocytes should lead to this film being referred for clinical review.
It was encouraging to see that >90% of participants would have taken this action. Monocytosis and blast cells were among the top 5 selections made by participants, with an additional 26% correctly noting that agranular neutrophils were present. The platelet count in this case was 160 x 10^9/L; interestingly 58% of participants recorded the film as showing thrombocytopenia.

I don’t think I did that badly. Mind you I’d welcome the chance to discuss blood films with someone (anyone) on a regular basis…

17 July 2016 (Sunday) - Transfusione Evidence Library

This morning I got an email from the Personal Transfusion Evidence Library people. I must admit I was rather disappointed with what they sent through. Whilst what they suggested was all very interesting (albeit a tad dry), none of it was actually of any practical use to me.
I’m wondering if what I’m assuming to be useful sources of CPD actually isn’t…

7 July 2016 (Thursday) - Curing Sickle Cell Disease

Here’s an interesting article. Sickle cell disease can be cured by bone marrow transplant, but more often than not the patients are not up to the rigours of a transplant.

A new transplantation technique is now available… perhaps this might soon be happening in the DGH environment?

6 July 2016 (Wednesday) - BBTS Conference email

An email from the BBTS arrived in my inbox today. The focus of the thing was on the upcoming BBTS conference which will cover all sorts of subjects including

·         Transfusing Wisely
·         Blood Safety
·         Education
·         Quality
·         Donors and Blood Donation

Whilst it is all most interesting part of me wonders if the BBTS might be better off moving its focus away from a conference which can only be attended by a minority of members and moving it toward an on-line system accessible by all. Perhaps the seminars might be filmed and be available on-line? That might be useful

5 July 2016 (Tuesday) - Anti-K

Here’s an interesting case – a case study of HDN due to anti-K. the sort of thing that occurs in the lab from time to time, and this is a rather concise summary of all the salient features.

4 July 2016 (Monday) - AHP Mandate for Change

The morning’s haul of emails included one with an update from the Allied Health Profession’s Mandate for Change. You can read the update by clicking here.
I know I should really take this more seriously; I realise this will have far-reaching implications for me. But it is dull. The article runs to several pages without seeming to say very much.

Maybe it might become more comprehensible as the project goes on. I shall keep a weather eye on it and see how things progress…

4 July 2016 (Monday) - BloodMed Newsletter

The weekly BloodMed newsletter came in today. Whilst there were several articles that interested me including

None of the articles were really of immediate use or relevance for me. I suppose this illustrates a point; it is easy to find any old scientific paper and feel I’m doing CPD when in fact I am not…