22 December 2024 (Sunday) - Historical Records

Just how believable are historic blood groups? There was a post on the Facebook “Blood Bank Professionals Group” about it today in which many people commented about the blood groups recorded on the history of patients grouped whilst on military service which were later found to be wrong.
Obviously you perform a confirmatory group…
 
What if there’s a historic antibody record? Do we trust that or are we sceptical of that too? With the passage of time it isn’t unusual for blood group antibodies to fall below the level of detection. Given that a patient turns up with a supposed history of (say) anti-S, anti-Jk(a) and anti-Jk(b) do we just crossmatch antigen-negative blood or do we phenotype the patient to see if the supposed antibody is plausible (leaving aside the entire concept of auto-antibodies)
 

18 December 2024 (Wednesday) - HCPC Newsletter

The HCPC sent their quarterly newsletter today. It started will with information about next year’s CPD week, but then for me it all went rather downhill with a whole load of stuff which wasn’t really of any interest to me.
Am I being unreasonable in expecting detailed information and updates on the specific areas in I work when the HCPC has such a diverse group with whom it works?
Probably.

17 December 2024 (Tuesday) -NEQAS 2406 DM

I got the results of NEQAS 2406 DM today.
 
When I looked at it I said
 

Rbc

Anisopoik
Polychromasia
echinocytes
NRBC

 

Wbc 

Blast cells
Vacuolated monocytes
Dysplastic neutrophils
Thing with strange protruberances – seen that before !!!!


Plts

 Low Plts
Giant plts

 

 
??? CMML
 

The expert opinion said a lot without saying anything “The cells in the circulation in this case are very abnormal with their shared morphological features predominantly of mature but abnormal monocytes, at least one “blast cell” form present. In a young adult the diagnosis in such cases is by far most likely to be an acute leukaemia with monocytic differentiation. This diagnosis is often difficult to make for morphologists since the monocytes appear predominantly mature, so it is important also to take into account the relatively young age of the patient and the very low likelihood of a predominantly monocytic response to severe infection. This is even more challenging in older patients where the possibility of a CMML should also be considered. If in doubt (particularly in the presence of cytopenias) the case should be alerted urgently to the clinicians as clinical and bone marrow evaluation may be vital”.
 
I’m claiming I got this right.


16 December 2024 (Monday) - Learning Monday

Learning Monday – how best to assess the progression of myeloma? Back in the day it was by bone marrow aspirate, and it still is. Admittedly these days we do different things with the marrow once it’s aspirated though.


14 December 2024 (Saturday) - Transfusion Evidence Alert Update

The nice people at the Transfusion Evidence Alert sent their update today. Well actually they sent it a few days ago and it went into my junk email…
Again tranexamic acid features, and again there’s talk of keeping platelets in the fridge.

Top article 2024

 

Selected articles

Andexanet for factor Xa inhibitor-associated acute intracerebral hemorrhage.
Connolly, S.J., et al. (2024). The New England Journal of Medicine.

Meta-analysis and metaregression of the treatment effect of intravenous iron in iron-deficient heart failure.
Martens, P., et al. (2023). JACC: Heart Failure.

Prehospital tranexamic acid is associated with a survival benefit without an increase in complications: results of two harmonized randomized clinical trials.
Mazzei, M., et al. (2024). The Journal of Trauma and Acute Care Surgery.    

Two-year outcomes following a randomised platelet transfusion trial in preterm infants.
Moore, C.M., et al. (2023). Archives of Disease in Childhood. Fetal and Neonatal Edition.

Darbepoetin alfa to reduce transfusion episodes in infants with haemolytic disease of the fetus and newborn who are treated with intrauterine transfusions in the Netherlands: an open-label, single-centre, phase 2, randomised, controlled trial.
Ree, I.M.C., et al. (2023). The Lancet. Haematology.

Early cold stored platelet transfusion following severe injury: a randomized clinical trial.
Sperry, J.L., et al. (2024). Annals of Surgery.

Liberal or restrictive transfusion strategy in patients with traumatic brain injury.
Turgeon, A.F., et al. (2024). The New England Journal of Medicine.   

A cost-effectiveness analysis of early detection and bundled treatment of postpartum hemorrhage alongside the E-MOTIVE trial.
Williams, E.V., et al. (2024). Nature Medicine.  

Efficacy and safety of tranexamic acid in acute traumatic brain injury: a meta-analysis of randomized controlled trials.
Zhang, M. and Liu, T., (2024). The American Journal of Emergency Medicine.

 

13 December 2024 (Friday) - The Great Big Biomedical Science Quiz

I must admit that I am very quick to find fault with the IBMS. I often rant about how they have lost their way. But this morning on their Facebook page they’ve announced their “Great Big Biomedical Science Quiz” – eight questions for each of the disciplies of biomedical science.

This is what I like to see… and I got seven out of the eight haematology questions right. I’d not heard of space anaemia before. I spent a few minutes looking up a few articles… and now I’ve learned something. Which is what CPD and my professional institute should be about.

11 December 2024 (Wednesday) - It's Important !!!


Sometimes it is easy to forget exactly what it is we do for a living. Not so much the aspect that people’s well-being depends on us getting the answer right, but what we actually do. What we test. And where it comes from.

Many years ago one of the young ladies with whom I went to college died of a brain tumour. A rather obscure one which accounts for less than one per cent of all types of brain tumours. And three of the people she worked with at the time died of exactly the same sort of tumour.

Nothing was ever proved – things were different back then. When asking for a pencil sharpener in my first place of work I was given a scalpel.

When I first started I was advised to take out the works pension but the chap advising me to do so openly admitted that he did so because he was under orders to do so. He implied a pension was a waste of money and claimed that (at that time) the average person doing the job died three years before collecting their pension from something nasty they contracted doing the job.

Was he right? I’ve never fact-checked what he said. But this brings today’s missive from the nice people at Lablogatory into focus. Don’t roll your eyes at health and safety. It’s important.

10 December 2024 (Tuesday) - Westgard QC Update

The nice people at Westgard QC sent their update today. I’ve got a degree in maths and spent five years studying the subject and still I struggle with the sort of thing that comes in their monthly update.
I saw this piccie on Facebook the other day and thought it particularly apposite

 

9 December 2024 (Monday) - Learning Monday

Bone marrow transplantation… who would be the best donor? I was right in choosing option 2.
Back in the day bone marrow was the future for the lab in the district general hospital. We did autologous transplants for a few years, but allogenic transplantation would be in our remit. HLA typing and all the testing…
Didn’t turn out that way, did it?


8 December 2024 (Sunday) - BTLP-TACT Exercise

Time for another BTLP-TACT exercise… I was presented with two cases:
 

93347 – a forty-three year-old woman needing group & save. 

She grouped as AB Rh(D) Positive with a negative antibody screen

 

17507 – a thirty-three year-old needing two units of blood for a surgical procedure.

He grouped as A Rh(D) Positive with a negative antibody screen

I selected two units of A Rh(D) Positive blood

 
I got the thumbs up.

6 December 2024 (Friday) - NEQAS 2407

I got hold of the results of NEQAS 2407 BF today…
 
2407 BF1
 
I said:
 

Rbc

 

Macrocytes

Anisopoik

Echinocytes

Rbc fragments

Nucleated Rbs

 

Wbc

 

Myelocytes (and pro-)

Dysplastic neutrophils

Bi-lobed neutrophils

Smear cells 

Vacuolation

Occasional blast

 

Plt

 

Low plts

Giant platelets

 

 
Top ten reported comments were
 
Nucleated RBCs
Thrombocytopenia
Blast Cells
Echinocytes/Crenated Cells
Left Shift
Promyelocytes
Myelocytes
Fragments/Schistocytes
Large/Giant Platelets
Acanthocytes
I felt this was a case of Myelodysplasia. It wasn’t – it was a case of severe sepsis. I spotted all the salient features, and can’t help but feel that (as is the case in all NEQAS exercises) we are deliberately hobbled by a total lack of clinical information and lack of blood count information.
 
 
2407 BF2
 

I said:
 

Rbc

 

Rouleaux

Tear drop cells

NRBCs

 

Wbc

 

Neutropenia

Blast cells

 

Plt

 

Low plts

 

 

Top ten reported comments were
 
Thrombocytopenia
Nucleated RBCs
Blast Cells
Neutropenia
Tear Drop Poikilocytes
Rouleaux
Polychromatic Cells
Poikilocytes
Hypochromic Cells
Macrocytes
 
I said this was “?? something nasty ? AML”.  
It was


3 December 2024 (Tuesday) - NEQAS 2404 PA

I got hold of the results of NEQAS parasitology survey 2402 today.
 
2404 PA1
"Returned from safari in Tanzania with suspected malaria"
 
I saw trypanosomes -  T. brucei
I was right
 
2404 PA2
"Fever on return from Thailand"
 
I said no parasites seen
I was right

2 December 2024 (Monday) - Fritsma Factor Newsletter

The Fritsma Factor newsletter appeared in my in=box today. You can read it by clicking here.
One article made me think…  how do you know if a sample has got a clot in it? Well, you pop it open and fish about with a wooden stick, don’t you? We’ve certainly been doing that since 1981. It would seem there’s no evidence that this doesn’t activate an otherwise decent sample…
So what are we supposed to do?

 

30 November 2024 (Saturday) - BTLP-TACT Exercise

BTLP-TACT time. I was presented with one case – a fifty-four year-old woman in ITU needing six units of blood right away following a stabbing.
 
She grouped as A Rh(D) Positive with a negative antibody screen. I selected six units of A Rh(D) Positive blood.
 
I got it right…

29 November 2024 (Friday) - Myeloid Cells Revisited

The other day I was pondering on the difference between promyelocytes and myelocytes…
But where do you draw the line between myelocytes and metamyelocytes. Or promyelocytes and blast cells…
Here’s a little diagram of the entire myeloid lineage..
 
And here’s some articles on the matter:
 

 

27 November 2024 (Wednesday) - AML DIagnostics

Oh, I am so out of date… look at this article from the nice people at Oncology Central about the latest genetic testing in making the diagnosis and assessing the prognosis in cases of AML.
Back in the day we’d go to the patient’s bedside with the consultant haematologist who would bore a hole in their chest and suck out some bone marrow. They’d give us a syringe full of the stuff. We’d make smears of it, and (once it was dry) we’d run two through the staining machine twice, and do a sudan black stain on another.
 
I suppose that realizing I’m out of date is a good thing… now I know where to direct myself.

26 November 2024 (Tuesday) - Transfusion Evidence Alert Update

The nice people at the Transfusion Evidence Alert sent their update today. There were two articles about the use of whole blood…
We used to issue that stuff years ago. Then red cell concentrates (packed cells) came in vogue. So much so that we would take the plasma off of units of whole blood to make red cell concentrates. Recently qualified colleagues have never seen a unit of whole blood.
 
But what was standard practice forty years ago and was largely dropped twenty years ago is now coming back…

ARTICLE OF THE MONTH

Liberal versus restrictive transfusion strategies in acute myocardial infarction: a systematic review and comparative frequentist and Bayesian meta-analysis of randomized controlled trials.
Braïk, R., et al. (2024). Annals of Intensive Care.
PICO Summary available

+++++

TOP ARTICLES

Effect of perioperative erythropoietin on postoperative morbidity and mortality after cardiac surgery: a meta-analysis of randomized controlled trials.
Abraham, D., et al. (2024). Anaesthesia, Critical Care & Pain Medicine. [Record in progress].

A randomized controlled trial comparing effectiveness of different fibrinogen preparations in restoring clot firmness.
Baryshnikova, E., et al. (2024). Anesthesia and Analgesia. [Record in progress].

Early intervention of 5% albumin shown superior control of vascular integrity and function compared to ringer's lactate in hospitalized adult with grade I & II Dengue hemorrhagic fever: a multicenter randomized controlled trial in Indonesia.
Bur, R., et al. (2024). Tropical Diseases, Travel Medicine and Vaccines.

Mapping the landscape of machine learning models used for predicting transfusions in surgical procedures: a scoping review.
Duranteau, O., et al. (2024). BMC Medical Informatics and Decision Making.

Randomized controlled trials assessing continuous outcomes for the use of platelet-rich plasma in knee osteoarthritis are statistically fragile: a systematic review.
Lameire, D.L., et al. (2024). Arthroscopy: The Journal of Arthroscopic & Related Surgery. [Record in progress].

Effect of preoperative autologous blood storage in major hepatectomy for perihilar malignancy: a randomized controlled trial.
Onoe, S., et al. (2024). Annals of Surgery. [Record in progress].

Review of low titer group O whole blood (LTOWB) transfusion in initial resuscitation of pediatric trauma patients: assessing potential benefits.
Park, S.M., et al. (2024). Journal of Pediatric Surgery. [Record in progress].

Does early transfusion of cold-stored whole blood reduce the need for component therapy in civilian trauma patients? a systematic review.
Risha, M., et al. (2024). The Journal of Trauma and Acute Care Surgery.

Assessment of hepatitis E virus transmission risks: a comprehensive review of cases among blood transfusion recipients and blood donors.
Singson, S., et al. (2024). Infection Ecology & Epidemiology.

23 November 2024 (Saturday) - BTLP-TACT

Time for a BTLP-TACT exercise. I was presented with one case – a thirty-nine year-old chap in out-patients needing two units of irradiated blood tomorrow.
 
He grouped as B Rh(D) Positive with antibody panel positive in cells 2 & 3. I requested antibody panels. The IAT and enzyme panels were negative in cells 1 & 2 and positive in all other cells which was consistent with anti-c but didn’t exclude anti-E, anti-Kp(a) or anti-Lu(a)
There was only one c- E- unit, and that had no mention of its Kp(a) or Lu(a) status. I selected it working on the principle that the guidelines say that Kp(a) and Lu(a) are crossmatch compatible and I would be doing a wet crossmatch
 
Amazingly I got the thumbs-up. I don’t think I should have done – this was another no-win scenario. With only one unit that might be of any use I couldn’t have got the right answer.
This thing really is a work in progress. Such a shame no progress is being made.

22 November 2024 (Friday) - Low Platelets?

A massive drop in the platelet count… cell fragments… in a small child with pancreatitis…
Here’s a case study from the nice people at the American Society of Hematology.

20 November 2024 (Wednesday) UKAS Update

The nice people at UKAS sent their update today. They’ve set up a series of webinars about what they do. Sadly a podcast would be a better idea. Webinars are all very well if you are free at the time. You can listen to a podcast whenever you like…


19 November 2024 (Tuesday) - BTLP-TACT Exercise

Time for another BTLP-TACT exercise. Having got six right I must be due a thumbs-down…

I was presented with an eighty-five year old chap in theatre having a TURP needing two units of blood as soon as possible.
He grouped as O Rh(D) Positive with a negative antibody screen.
I selected two units of O Rh(D) Positive blood

That’s now seven green lights in a row…

 

19 November 2024 (Tuesday) - Westgard QC Newsletter


 Well, there’s no denying it is dull… But the Westgard newsletter is something for nothing, and no one ever pretended that statistics was riveting.

Speaking as someone with a degree in mathematics some branches of mathematics are beautiful and elegant - look at fractal geometry. Some are amazing – look at group theory. Some are just “wow” – look at differential calculus. And some are mind-blowing – look at complex numbers.

But statistics…  Sadly dull. But the good people at Westgard come up trumps with whaty they do.

18 November 2024 (Monday) - Horiba Update

The Horiba newsletter appeared in my in-box today. Just lately I’ve been rather derogatory about the CPD material that people are good enough to give me for free… but this one is setting the standard to which all others really should aspire. A case study, morphology tips, science, and technology updates…

Here’s hoping this continues in the same vein…


16 November 2024 (Saturday) - Another use for FFP

The other day I was ranting about the BTLP-TACT simulator. I do that a lot; I really shouldn’t. That particular rant prompted me to write up when fresh frozen plasma and cryoprecipitate are useful and when they are not.

Here’s another use of fresh frozen plasma. The stuff can be useful in extreme cases of angioedema.

https://pmc.ncbi.nlm.nih.gov/articles/PMC5298931/

14 November 2024 (Thursday) - BTLP-TACT Exercise

Time for another BTLP-TACT exercise. I was given two cases:
 

85624 – a sixty-nine year old chap in A&E needing four units of blood as soon as possible

He grouped as O Rh(D) Positive with a negative antibody screen.

I selected four units of O Rh(D) Positive blood

 

12582 – a forty-three year old woman needing four units of FFP and two units of cryo for a liver transplant

She grouped as O Rh(D) Negative with antibody screen positive I cells 1 and 3. I requested antibody panels. The IAT panel was positive in cells 1, 3, 6, 9 and 10 corresponding with anti-Fy(a) but does not exclude anti Lu(a) and anti Cw. The enzyme panel was negative which (in this plane of existence) does exclude anti Lu(a) and anti Cw.

I selected four units of FFP and two units of cryo

 
I got the thumbs-up