A Dull Day At Work...?: September 2016

29 September 2016 (Thursday) - JBL - Iron deficiency

Talk is cheap…. I’ve put my money where my mouth is and done some JBL from the IBMS web site.

I read the specified paper https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4451195/ about iron deficiency in blood donors, and then answered some questions.

I got seventeen right out of twenty. Ok so I passed… I could have done better. Mind you I did learn quite a bit from it. Hepcidin, whilst not entirely new, is something I need to refresh myself about.

I might do one or two more of these. They didn’t take that long; I got to learn something, and from a CPD-evidence point of view I get a certificate to show I’ve done something…

29 September 2016 (Thursday) - IBMS Newsletter

The IBMS newsletter arrived today. It had a lot of interest. There is a new-look IBMS website. It invited me to create a user account. Eventually I managed to do that and I then had a look round the site.

I really should use the journal based learning section more often.

Mind you I won’t be using the discussion forums. From bitter experience in all walks of life everyone wants to set up a discussion forum, and they *always* descend into petty bickering.

This time the “links of the month” didn’t seem that relevant to me… but I’m going to have another look at that JBL bit…

28 September 2016 (Wednesday) - Digital Morphology NEQAS

I had a look at the NEQAS on-line digital morphology 1604DM today. The case was:

"A 39 year old female presents unwell at the emergency department. Hb 120g/L, WBC 6.5 x 10*9/L, platelets 150 x 10*9/L. The analyser fails to produce a differential so a blood film is examined"

What did I see… I shan’t post my thoughts just yet (in case anyone else might try to copy)…

26 September 2016 (Monady) - BloodMed Newsletter

The BloodMed email arrived this morning. Not as much as sometimes it has:

· Organizations join forces in pediatric cancer research
· Anniversary celebrates stem cell donors and transplants
· Hope for CML treatment

Sometimes there is reams of stuff; other times not so much…

17 September 2016 (Saturday) - Text Messages

Apparently blood donors in Sweden now receive a text message when their blood is given to a patient.

(From the Independent’s website)

“People who donate initially receive a 'thank you' text when they give blood, but they get another message when their blood makes it into somebody else’s veins.

“We are constantly trying to develop ways to express [donors'] importance,” Karolina Blom Wiberg, a communications manager at the Stockholm blood service told The Independent.

“We want to give them feed back on their effort, and we find this is a good way to do that.”

The service says the messages give donors more positive feedback about how they’ve helped their fellow citizens – which encourages them to donate again.

But the new policy has also been a hit on social media and has got people talking about blood donation amongst their friends.”

This is an excellent idea in theory. In practice such an automated system could work *if* the I.T. was up to it. However I worry that this might just end up being more work for us…

16 September 2016 (Friday) - Anticoagulation

Here’s an interesting article. It investigates how various medical specialists coordinate anticoagulation bridging decisions for certain patients with atrial fibrillation.

Long-term anticoagulant therapy is essential for stroke prevention among patients with atrial fibrillation, but increasing evidence also points to substantial risk for adverse events, especially when anticoagulation is even only temporarily interrupted.

A recently published Effectiveness of Bridging Anticoagulation for Surgery Trial confirmed prior observational evidence that using short-acting anticoagulants periprocedurally increases bleeding risk without any reduction in stroke risk.

Little is known about how medical specialists coordinate the complex decision of which patients to bridge…

15 September 2016 (Thursday) - Worth While !

I’ve been feeling a tad negative about work lately. There are all sorts of reasons for this that I won’t go into details about. But here’s an article which has re-invigorated me. (Admittedly American, but I’m sure this goes across the Atlantic)

As part of their 2015 – 2016 College Salary Report, Payscale.com asked survey respondents if they feel that their job “makes the world a better place,” using the percentage of respondents in each field who said they derived a “high” level of meaning from their work to rank the associated 319 college majors accordingly.

At the top of the list this year is Medical Laboratory Science. A staggering 97% of respondents found their work in fields associated with this major to be meaningful.

Taking second place, down one rung from last year, is Pastoral Ministry.

I would have thought that pastoral ministry would have been far more rewarding. Perhaps not.

14 September 2016 (Wednesday) - Pugh Scoring

Whilst authorising some coagulation results today I saw a diagnosis of “for Pugh score”. This was a new one to me. So I had a look at that font of all wisdom; Wikipedia.

Apparently the Child-Pugh score (sometimes the Child-Turcotte-Pugh score) is used to assess the prognosis of chronic liver disease, mainly cirrhosis. Although it was originally used to predict mortality during surgery, it is now used to determine the prognosis, as well as the required strength of treatment and the necessity of liver transplantation.

The score employs five clinical measures of liver disease. Each measure is scored 1-3, with 3 indicating most severe derangement.

Measure	1 point	2 points	3 points
Total bilirubin, μmol/L (mg/dL)	<34 (<2)	34-50 (2-3)	>50 (>3)
Serum albumin, g/dL	>3.5	2.8-3.5	<2.8
INR	<4.0	4.0-6.0	> 6.0
Ascites	None	Mild (or suppressed with medication)	Moderate to Severe (or refractory)
Hepatic encephalopathy	None	Grade I-II	Grade III-IV

Chronic liver disease is classified into Child-Pugh class A to C, employing the added score from above.

Points	Class	One year survival	Two year survival
5-6	A	100%	85%
7-9	B	81%	57%
10-15	C	45%	35%

One lives and learns…. Which is why we do CPD…

14 September 2016 (Wednesday) - CPD Talk

We had a lunchtime presentation from a visiting dignitary from the NBS today. I can remember that she brought along a box of chocolates and that I gave up my lunch break for the talk. But now when I come to write up my notes (two weeks later) I find I cannot remember a single thing about the session.

Does this have any place in a CPD diary? Clearly I got nothing from the session. But I was willing. I’d given up an hour for it. Surely the good intention should be credited.

I suppose this is actually true of a lot of CPD activities; the intention outstrips the achievement…

12 September 2016 (Monday) - Rh(D) genotyping from maternal plasma

Is this the future? We had a CPD talk at work today. It won’t be long before the blood groups of the unborn babies of pregnant women are determined by PCR on maternal blood samples.

This will save a lot of time and trouble. Mothers requiring anti-D post-delivery will be identified before the baby is born. There will be no need to send cord samples to the lab for labour-intensive cord blood grouping. Anti-D can be issued far quicker than it currently is.

Win-win all round… How soon can we start doing this?

11 September 2016 (Sunday) - Target cells/Stomatocytes

I found this picture on a Facebook group which I follow

Comparing and contrasting is always a useful little way of clarifying things in my mind.

TARGET CELLS – so called because they look like a shooting target with a bullseye. In optical microscopy, these cells appears to have a dark centre (a central hemoglobinzed area) surrounded by a white ring (an area of relative pallor) followed by dark outer second ring containing a band of haemoglobin. Target cells are associated with following conditions.

· Liver disease
· Iron deficiency
· Alpha & beta thalassemia
· Haemoglobin C disease
· Post splenectomy & auto splenectomy.

STOMATOCYTES - characterized by the red cells taking on an abnormal shape resembling a mouth or stoma. There are a number of variants:

· Over hydrated hereditary stomatocytosis
· Dehydrated hereditary stomatocytosis.
· Dehydrated with perinatal ascities.
· Cryohydrocytosis
· Blackburn variant
· Familial pseudohyperkalkaemia.

9 September 2016 (Friday) - NEQAS Return

The most recent blood film NEQAS (1605BF and 1603PA) results became available today:

· 1605 BF1 was a case of megakaryoblastic transformation of primary myelofibrosis

· 1605 BF2 was haemoglobin E with beta thalassaemia that had recently been transfused showing a dual red cell population

· 1603 PA1 had P.falciparum gametocytes

· 1603 PA2 was negative

I think it’s fair to say I spotted all the salient features even if I didn’t arrive at a comprehensive diagnosis in the first one. Mind you I’m not sure that it is realistic to expect me to; the information given in these exercises isn’t quite as much as it might be.

7 September 2016 (Wednesday) - Neutrophil Disorders

I came across this article today

“Neutrophil disorders are an uncommon yet important cause of morbidity and mortality in infants and children. This article is an overview of these conditions, with emphasis on clinical recognition, rational investigation, and treatment.

A comprehensive list of references is provided for further reading”.

The full article is on-line here

6 September 2016 (Tuesday) - Surprise Finding

This appeared on one of the Facebook groups I follow - a chap was just doing a routine manual differential on a patient complaining of weakness. They didn't even order a parasite screen.

Totally unexpected Plasmodium falciparum with 20% parasitaemia . Patient was in kidney failure.

Moral of the story - expect the unexpected...

5 September 2016 (Monday) - BloodMed Newsletter

The regular bloodmed email came in today. This one was focussing rather heavily on the more clinical stuff, but there was a rather good case study about a haemoglobinopathy with a nutritional anaemia. I would have shamelessly blagged it but for some reason the pictures wouldn’t come up on the PC.

Probably to stop me blagging them...

4 September 2016 (Sunday) - Who Reads This Drivel?

Why do I write this little blog? I can’t pretend I do it for fun. On re-reading it the thing is rather dull.

I write it because I feel it is the easiest way for me to perform a legal obligation. I am required to keep a record of my CPD activities, and this seems as good a way as any to do so. However I’m perhaps a little lax in keeping it up to date. I tend to make notes as I go along, but only update this blog once a month or so.

When I first set the thing up I thought I would make it public just in case anyone else was interested. It would seem people are. This morning after I caught up with writing up my notes I saw that some ninety people then logged in and had a look-see at what I’d written. (The Blogger software has a hit counter you know).

Ninety people in one day! Who are all you people? Why not leave a comment and say hello.

And if you find this site interesting, you’ll love my diary… Mind you that gets hundreds of hits every week and I’ve no idea why that is so popular either…

1 September 2016 (Thursday) - UKAS e-newsletter

The UKAS e-newsletter came today; there has been an update to the following UKAS Publication(s):

· 1110-LAB 12 - Edition 2 - August 2016.pdf

· 1111-TPS 62 - Edition 2 - August 2016.pdf

· 1112-NHSS 6 9001_2015 - Issue 1 July 2016.pdf

· 1113-LAB 22 - Edition 2 - August 2016 - Draft for consultation.pdf

· 1114-LAB 22 - Edition 2 - August 2016 - Comments on draft for consultation.docx

· 1115-TPS 57 - Edition 3 - August 2016 - Draft for consultation.pdf

· 1116-TPS 57 - Edition 3 - August 2016 - Comments on draft for consultation.docx

· 1117-TPS 65 - Edition 1 - August 2016 - Draft for consultation.pdf

· 1118-TPS 65 - Edition 1 - August 2016 - Comments on draft for consultation.docx

· 1119-TPS 47 - Edition 3 - August 2016 - Draft for consultation.pdf

· 1120-TPS 57 - Edition 3 - August 2016 - Comments on draft for consultation(2).docx

· 1121-2016.08 Printable Publications List.pdf

· 1122-Edition 206 Publications - changes since the previous edition - August 2016.pdf

· 1123-TPS 47 - Edition 3 - August 2016 - Comments on draft for consultation.docx

I won’t pretend I’ve read the lot. The ones I skimmed were rather dry. But the e-newsletter is a useful resource. If nothing else it reminds me about the whole UKAS process. And is a useful first place to go to look for anything UKAS-related.

31 August 2016 (Wednesday) - BCSH Guidelines

An email from the British Committee for Standardisation in Haematology. They don’t come through that often. They’ve published four new guidelines:

1. Investigation and Management of Eosinophilia
2. Diagnosis, investigation and management of primary Autoimmune Haemolytic Anaemia
3. Management of drug induced immune and secondary Autoimmune Haemolytic Anaemia
4. Peri-Operative Management of Anti-Coagulation and Anti-Platelet Therapy

Interestingly this lot operate on Facebook. I didn’t realise that. I’ve signed up to follow them. Hopefully that might provide some useful CPD…

31 August 2016 (Wednesday) - IBMS e-newsletter

The IBMS newsletter came in this morning. All actually rather interesting; however some was irrelevant.

· Parkinson's Disease Risk Indicators Found in Diverse Tissues

· Novel MRI technique distinguishes healthy prostate tissue from cancer using zinc

· Smartphone app may help improve antiretroviral therapy adherence

· Should we be Concerned about Biohacking?

· DNA database brings scientists closer to pinpointing genes for disease

· Pop Culture Dissections You Won’t See in Any Medical Books

· The Lonely Life of a Clinical Pathologist: Rounding in the Lab

· What's Your Hemolysis Quotient? Test your knowledge of hemolysis and steps labs take to deal with it

· Obstacles in transgender pathology healthcare

· Optimising pathology services: improvement throgh effectiveness not efficiency

· Microbiology Case Study: A 61 Year Old Male with Productive Cough and Altered Mental Status

· Noble’s 11 Rules: How to NOT DIE working in your laboratory

· Antibiotic resistance: 'Snot wars' study yields new class of drugs

It is so easy to get engrossed in histological dissections or antibiotic discussions, or the ethics of LBGT. CPD is supposed to help me improve what I do. I need to focus. I’m not entirely sure the IBMS e-newsletter isn’t too generalist for its own good…

31 August 2016 (Wednesday) - Pipettes

Some might feel this article a tad basic, it does rather point out the obvious, but for a basic refresher on pipettes it concentrates the mind on a topic which is usually taken for granted…

30 August 2016 (Tuesday) - Cholera

This article looked interesting at first sight – why do people with blood type O often get more severely ill from cholera than people of other blood types?

The article discussed how cholera attaches to various intestinal antigens, and explained that ABO antigens appear on the intestinal cells. But the article actually said “the blood group antigens – A, B, AB and O” and that is where I rather became sceptical. “A, B, AB and O” are phenotypes. A and B are antigens.

Do they actually mean “O antigen” Do they actually mean H substance and precursor substance?

I can’t help but feel that the terminology in this article leaves a lot to be desired…

29 August 2016 (Monday) - BloodMed Newsletter

Another BloodMed e-mewsletter. Whilst these aren’t immediately applicable to what I do, I often wonder if they are harbingers of things to come. Take today’s one - A new test for childhood leukemia which could have major implications for diagnosis and treatment. The test for acute lymphoblastic leukemia involves the measurement of extracellular vesicles released by cancer cells into the blood.

The article was rather vague about how one goes about detecting these vesicles, but I’m sure this is the way forward…

Blood 21 July 2016; doi:10.1182/blood-2015-12-688051

25 August 2016 (Thursday) - Bagpipe Lung

I read in the news today that players of brass wind instruments are at risk of an obscure disease called “bagpipe lung”. Apparently sufferers develop a bad reaction to mould and fungi lurking inside the moist interior of bagpipes. This was rather an article of academic interest until I saw that it has been reported in saxophonists.

However I was always under the impression that one blew the instrument, not sucked it. Certainly that is how I play my saxophone…

I suppose this isn’t really that relevant to my professional practice, but after thirty-plus years I’ve found a disease of which I’d previously never heard…

23 August 2016 (Tuesday) - Haemolysis

I found this little quiz today. Somewhat twee…. Only five questions, but some of them made me think.

As for my score… 4/5 – could do better…

22 August 2016 (Monday) - Hairy Cells

An interesting case; A 63-year-old woman being followed for splenomegaly presented with lymphocytosis

· haemoglobin, 14 g/dL

· neutrophils, 2.5 × 10^9/L

· lymphocytes, 8.5 × 10^9/L

· monocytes, 0.7 × 10^9/L

· platelets, 200 × 10^9/L.

A blood smear showed 40% medium-sized lymphocytes with abundant cytoplasm with circumferential projections, similar to those of classic hairy cells. The nucleus had condensed chromatin with a conspicuous nucleolus (see the piccie above).

Now here’s the rub - flow cytometry showed 45% clonal B lymphocytes that expressed CD19 / CD20 / CD22 / CD103 / CD11c and a lack of CD5 / CD10 / CD123 / CD25 / CD200. The BRAFV600E mutation was negative, confirming the diagnosis of hairy cell leukemia-variant (HCL-v).

The article actually says “Despite morphologic similarities, HCL-v is not biologically related to classic HCL (cHCL).” How things have changed. Morphology is not the be-all and end-all which once it was. Immunophenotyping is clearly the way forward. How long will it be before this is a technique available in all district general hospitals?

22 August 2016 (Monday) - BloodMed e-Newsletter

This morning saw the arrival of this week’s BloodMed e-newsletter. Sometimes these are really relevant and useful; other times they just get deleted. Today’s had three snippets which were rather interesting:

The article about diagnosing MDS piqued my interest. However it advocates gene sequencing as the technique of choice for diagnosis. I wonder how long it will be until such techniques are used in the routine labs by the likes of me.

I doubt it will be long…

21 August 2016 (Sunday) - Zika virus

Food for thought… for all that the media is alive with panic about zika virus here’s something of direct relevance. Can zika be passed on by blood transfusions? I expect so – other viruses such as hepatitis can be.

It would seem there is a test which might be used; although it is still in the experimental phase. Screening out the likely carriers will be the way forward for the time being…

However I wonder if this will be a realistic problem, or just media generated hype?

17 August 2016 (Thursday) - SHOT Report

The SHOT report came through today. It made for rather worrying reading. However for all of the doom and gloom I was pleased to see the emphasis on education. And when considering mistakes in blood transfusions we should really bear in mind the operative word is “mistake”. No one deliberately gives the wrong blood component.

16 August 2016 (Wednesday) - Mosquitoes

When I think of mosquitos I think of malaria. I suppose that is because that is what I do. However I do see (relatively) a lot of negative malarial screens. The immediate reaction to those is “what a waste of my time”, but here’s an article which has reminded me that mosquitos carry far more than just malaria.

· Chikungunya
· Dog Heartworm
· Dengue
· Yellow Fever
· Eastern Equine Encephalitis
· St. Louis Encephalitis
· LaCrosse Encephalitis
· Western Equine Encephalitis
· West Nile Virus
· Zika Virus

So many conditions… not just malaria. It is so easy to get blinkered by my own narrow specialty.

Pages