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

13 November 2024 (Wednesday) - Spot the Difference

Had an interesting conversation today which made me think. What *exactly* is the difference between a myelocyte and a promyelocyte?

They can be rather tricky to tell apart…

So I’ve had a think and done some Googling…

Promyelocytes are bigger.
Promyelocytes have prominent nucleoli and Golgi apparatus.
Myelocytes do not have nucleoli and Golgi apparatus.
Compared to the myelocyte, much more of the promyelocyte is nucleus
Promyelocytes have huge, dark purple, primary (azurophilic) granules both in the cytoplasm and overlying the nucleus.
Promyelocytes do NOT have secondary (specific,to neutrophil, eosinophil or basophil) granulation – not even the beginnings of it! If you see any of that secondary granulation (even just a little blush of it in the cytoplasm) then it’s a myelocyte. The promyelocytes of the three granulocytic lineages cannot be distinguished by routine light microscopy.

Here’s some references…

https://www.sciencedirect.com/topics/medicine-and-dentistry/promyelocyte

https://www.pathologystudent.com/how-to-tell-apart-promyelocytes-and-myelocytes/

https://imagebank.hematology.org/image/60399/promyelocyte?type=upload

12 November 2024 (Tuesday) - IBMS Update

The IBMS sent their monthly newsletter today. It was on the dull side; it usually is. I was going to write about how their focus is on people and management and science is of peripheral interest, but I say that every month don’t it?

11November 2024 (Monday) - T.T.P.

“The correct answer is plasma exchange (PE).

The treatment of choice for patients with thrombotic thrombocytopenic purpura (TTP) is plasma exchange.
Although fresh frozen plasma infusion might be of limited impact, it is not the definitive treatment since it does not help removing the autontibodies from circulation.
Platelets are thought to be contraindicated in TTP because of the theoretical possibility of worsening the TTP.
Gamma globulin is ineffective in increasing the platelet count in TTP.
Caplacizimab is an adjunct to PE but cannot replace it.”
Reference: Scully M, et al. Caplacizumab Treatment for Acquired Thrombotic Thrombocytopenic Purpura. N Engl J Med. 2019;380:335-346.

Plasma exchange? Haven’t done one of those for years…

Thursday 7 November 2024 (Thursday) - BTLP-TACT Exercise

Whenever I sit down to write up some CPD I always feel obliged to end it with a BTLP-TACT session. And so here we go.

I was presented with two cases:

27841 – a fifty-four year old woman in outpatients with ITP requiring group & save.
She grouped as O Rh(D) Positive with a negative antibody screen.

99755 – a forty-four year old chap under the medics requiring group & save, FFP (4) and cryo (2) for liver transplant.
He grouped as A Rh(D) Positive with a negative antibody screen.
I selected four units of A FFP and two units of A cryo as they *are* indicated
https://emedicine.medscape.com/article/431573
https://pmc.ncbi.nlm.nih.gov/articles/PMC2967283/

I got the thumbs up. Which is just as well. I get wound up when I get the thumbs down. Not because I got it wrong. I get wound up because it is a wasted learning opportunity. Being told “you got it wrong for the following reasons” and having a discussion on the matter is useful. That’s how we learn.
Just being told “you stuffed it up” helps no one.

5 November 2024 (Tuesday) - Fritsma Factor Newsletter

Inhibitors, lupus, haemophilia… as ever the Fritsma Factor newsletter is an invaluable resourse.

4 November 2024 (Monday) - NEQAS 2405DM

Having looked at NEQAS 2405DM on 12 September I get the resuts today.

“A previously fit 34-years old female attended her GP feeling tired. Her Haemoglobin was found to be 70g/l with normal white cell count and platelets – a blood film was prepared. What is your impression?”

I said:

Red cells

Anisopoikilocytosis

Fragmented cells

Polychromasia

Marcrocytosis

Target cells

Tear drop cells

White cells

Hypersegmented neutrophil

Toxic granulation

Vacuolated monocyte with cleft nucleus

Platelets

Unremarkable

“Something haemolytic, but what are those vacuoles in the white cells. And what's the hypersegmented neutrophil all about?”

The expert comments were:

This blood film shows a severe deficiency of vitamin B12. The features quite distinct with the expected combination of oval macrocytes and hypersegmented neutrophils. If you have not seen a case like this before however, you may be surprised by the features of red cell fragility (fragments and misshapen cells) which can sometimes be mistaken for a fragmentation syndrome or even for microcytes. Also remember that the packed marrow can lead to many typical tear-drop forms being present.

Well… I spotted the salient features but I did mistake them for a fragmentation syndrome. Just as well it’s not up to me to make a diagnosis. I’ve always said it’s unfair to judge us on something we don’t actually do.
And again I’ll make the comment that it is a shame that it took two months to get the result.

3 November 2024 (Sunday) - Slide Saturday Challenge

The American Society of Hematology sent out their “Slide Saturday Challenge” yesterday. There’s a hypersegmented neutrophil and macrocytosis. There’s also anisopoikilocytosis and tear drop cells seen.

My gut feeling is that this is a case of megaloblastic anaemia caused by a deficiency of vitamin B12 or folate.

But…

If that were the case wouldn’t there be Howell-Jolly bodies? Was it a case of myelodysplasia? In the end I thought that a case of myelodysplasia wouldn’t have that neutrophil and I went for megaloblastic anaemia.

I was right to do so.

For all that this is Slide Saturday Challenge I shall continue posting this on Sunday once the proper answer has come up. As I have said before, on-line morphology does tend to attract those who really haven’t got a clue. No matter what the case presented answers usually range from piles through to dead for three weeks, and the more clueless and wrong the suggestion, the more aggressively it is posted.

1 November 2024 (Friday) - Still Resentful...

This appeared on my Facebook feed today posted from the IBMS’s official Facebook account. A harmless joke… maybe.

Howe times have changed. Twelve years ago whilst on a night shift I posted a selfie saying I was tired. It wasn’t possible to see any of the background in that selfie, but I still got a formal disciplinary warning for bringing the profession into disrepute.

I was told at the time that any mention of work whatsoever on Facebook was immediate grounds for formal disciplinary action.

The manager at the time would have laid an egg over what our professional body today see as rather amusing.

I was tempted to tag him in a comment on that post but thought better of it. Twelve years have passed; I doubt he’d remember.

I do though…

31 October 2024 (Thursday) - BTLP-TACT Exercise

Being at a loose end I did another BTLP-TACT exercise. It gave me two cases

37718 – a sixty-two year old woman in A&E with a CVA needing group & save
She grouped as O Rh(D) Positive with antibody screen positive in cells 1 & 3. I requested antibody panels. The IAT panel was positive in cells 1, 3, 6, 9 and 10 corresponding with anti-Fy(a) but not ruling out anti-Cw or anti-Lu(a). The enzyme panel was negative which did rule out anti-Cw and anti-Lu(a).
98389 – an eighty-seven year old woman in out-patients also needing group & save.
Her ABO and Rh(D) groups were both indeterminate, and the antibody screen was positive in cell 2. I requested antibody panels. The IAT and enzyme panels were positive in cells 2 and 6 corresponding to anti-K .

I got the thumbs-up

29 October 2024 (Tuesday) - GMP e-learning

I did my Good Manufacturing Practice e-learning today. A useful little refresher…

29 October 2024 (Tuesday) - Westgard QC Update

The nice people at Westgard sent their newsletter today. It was a tad dry and a tad heavy going, but as always was one of the better sources of CPD. When you consider that much of what we do in the lab at the most basic level is measure stuff, working out just how good our measuring is must be pretty much fundamental to what we do.

28 October 2024 (Monday) - Transfusion Evidence Library Update

The nice people at the Transfusion Evidence Alert sent their update today. Some of it was a tad clinical, some a tad specialized, and (again) tranexamic acid features (it does that a lot).

ARTICLE OF THE MONTH

Intravenous versus oral iron for anaemia among pregnant women in Nigeria (IVON): an open-label, randomised controlled trial.
Afolabi, B.B., et al. (2024). The Lancet. Global Health.
PICO Summary available

+++++

28 October 2024 (Monday) - Learning Monday

A normocytic anaemia with incredibly low ferritin? But stomach cancer… this is an anaemia due to a deficiency of both iron and vitamin B12.

I got it right.

27 October 2024 (Sunday) - Slide Saturday (!) Challenge

Saw this yesterday… Looks like haemoglobin C crystals to me…

Tuned in late today – it was. “The blood smear shows Hemoglobin C (HbC) crystals in a patient with hemoglobin C disease. HbC crystals form when a mutation in the beta-globin chain of hemoglobin replaces glutamic acid with lysine. This mutation makes HbC less soluble than HbA, forming hexagonal crystals (HbC crystals as seen in the peripheral smear). Individuals with one HbA gene and one HbC gene exhibit the HbC trait and are typically asymptomatic. In contrast, those with homozygous mutations for HbC have hemoglobin C disease, characterized by mild and chronic hemolytic anemia.”

26 October 2024 (Saturday) - FFP & Cryoprecipitate

Following on from the last BTLP-TACT exercise, I had a little look on Google to remind myself…

Fresh frozen plasma (FFP) is recommended for a variety of conditions, including:

· Bleeding

FFP is used to prevent or stop bleeding, or to replace coagulation factors in patients with abnormal coagulation tests. It can be used for patients with:

· Disseminated intravascular coagulation (DIC)

· Bleeding associated with acute blood loss

· Bleeding in patients with decompensated liver disease

· Warfarin overdose with life-threatening bleeding

· Surgery

FFP is used for patients with abnormal coagulation tests who are undergoing a planned surgery or invasive procedure.

· Plasma exchange

FFP is used for plasma exchange in patients with thrombotic thrombocytopenic purpura (TTP) or hyperviscosity syndrome.

· Factor deficiency

FFP is used to replace coagulation factors in patients with congenital or acquired factor deficiency.

· Trauma

FFP is used for trauma patients requiring massive transfusion.

Fresh frozen plasma (FFP) is NOT recommended in the following situations:

· When there are more effective treatments

FFP is not recommended when there are more effective treatments for the condition, such as vitamin K, cryoprecipitate, or factor VIII.

· When blood volume can be replaced

FFP should not be used as a volume expander unless there is active bleeding and coagulation deficiencies.

· To reverse anticoagulation

FFP should not be used to reverse anticoagulation caused by heparin, direct thrombin inhibitors, or direct factor Xa inhibitors.

· For disseminated intravascular coagulation

FFP is not recommended for disseminated intravascular coagulation without bleeding.

· For vitamin K deficiency

FFP should not be used to reverse vitamin K deficiency for neonates or patients in intensive care units.

· For patients with normal clotting

FFP should not be used for patients who are bleeding due to a surgical cause and who have normal clotting.

· As a circulating volume replacement

FFP should never be used as circulating volume replacement.

Cryoprecipitate is recommended for patients who have low levels of clotting proteins, especially fibrinogen, or who are bleeding or have a risk of bleeding:

· Bleeding

Cryoprecipitate can be used to prevent or control bleeding in patients whose blood doesn't clot properly.

· Invasive procedures

Cryoprecipitate can be used before an invasive procedure in patients with significant hypofibrinogenemia.

· Massive transfusions

Cryoprecipitate is often used when a patient needs a large number of blood components at once.

· Fibrinogen deficiency

Cryoprecipitate can be used to treat acquired fibrinogen deficiency or dysfibrinogenaemia.

· Disseminated intravascular coagulation (DIC)

Cryoprecipitate can be used to treat DIC.

Cryoprecipitate is NOT recommended for the following conditions:

· Hemophilia A

Cryoprecipitate should not be used to treat Hemophilia A unless other factor VIII preparations are not available.

· Von Willebrand disease

Cryoprecipitate should not be used to treat von Willebrand disease unless the patient does not respond to DDAVP.

· Factor XIII deficiency

Cryoprecipitate is not usually given for Factor XIII deficiency because virus-inactivated concentrates of this protein are available.

· Congenital afibrinogenemia or dysfibrinogenemia

Cryoprecipitate should not be used to treat these conditions.

· Factor deficiencies

Cryoprecipitate should not be used to treat factor deficiencies when specific factor concentrates are available

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