A Dull Day At Work...?: 2024

26 July 2024 (Friday) - At A Loose End

With my car in for service and what was supposed to be a two-hour service now taking all day, and everything I had planned for the day needing a car I thought I might as well do a BTLP-TACT exercise.

I was presented with two cases.

93476 – a sixty-year-old chap in A&E needing group & save for a fractured neck of femur.
He grouped as AB Rh(D) Negative with antibody screen positive in cells 1 and 2. I requested antibody panels. The IAT and enzyme panels were positive in cells 1, 2, 3 and 4 which corresponded with anti-C and anti-D but didn’t exclude anti-Cw

86139 – a thirty-two year-old chap in the haematology clinic needing two units of irradiated blood within the hour.
He grouped as O Rh(D) Positive with antibody screen positive in cell 2. I requested antibody panels. The IAT and enzyme panels were positive in cells 3 and 5 corresponding to anti-E.
I selected two units of irradiated O Rh(D) Positive E Negative blood

I got the green light.

23 July 2024 (Tuesday) - BTLP-TACT Exercise

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

28671 – a forty-six year-old woman in the maternity unit needing four units of CMV-negative blood for tomorrow. She grouped as A Rh(D) Positive with a negative antibody screen. I selected four units of A Rh(D) Positive K-Neg CMV-Neg.

98423 a fifty-five year-old chap in the orthopaedic department. Recently transfused he needed four units of blood for today. He had an inconclusive ABO group presumably an AB person having been given O blood, and his Rh group was negative. However his antibody screen was negative. I selected four units of O Rh(D) Negative

I got the green light.

22 July 2024 (Monday) - Learn Haem

Whilst rummaging about on the Internet whilst I should really have been doing proper work I discovered this web site. There’s all sorts of tutorials and lectures on there, complete with quizzes.

I did one, and learned quite a bit. Hepcidin was only discovered twenty years ago.

I shall do more of these.

22 July 2024 (Monday) - NEQAS 2403 DM

The results of NEQAS DM 2403 became available today. I thought the case was a case of Hb SC disease with an utterly unrelated lymphoproliferative condition – probably a myeloma.

I would seem to be in agreement with the consensus. I’ll take that.

21 July 2024 (Sunday) - In The Future

Here’s something that made me think. What will the effect of AI be on what we do?

When I first started in this game forty-three years ago I spent a few months in each part of pathology to get a feel for what I might like to do.

At the time I was told that clinical chemistry was ripe for automation but it would never happen with haematology. I’m reminded of Arthur C Clarke’s comments about the failure of imagination; the people with whom I worked all those years ago wouldn’t recognize where I now work.

I’m not saying that AI will wipe out biomedical scientists.

I’m not saying that biomedical scientists will be safe from AI.

I am saying that the future won’t turn out anything like we imagine it will.

As the Hitch Hiker’s Guide to the Galaxy said about grammar in the future, “the term "Future Perfect" has been abandoned since it was discovered not to be.”

18 July 2024 (Thursday) - BTLP-TACT Exercise

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

87818 – a fifty-year-old chap in the outpatient department needing group & save.
The ABO group was inconclusive, but the RH(D) group was negative.
The antibody screen was positive in cells 1 & 2 so I requested antibody panels. The IAT and enzyme panels were positive in cells 1, 2 and 3 corresponding with anti-D but not excluding anti-Cw.

48596 – a fifty-one-year-old woman also in the outpatient department needing two units of blood. Sadly the NHS number on the blood sample was completely different from that on the accompanying form so I rejected the request.

I got the green light.

Mind you, I find myself wondering just how much use this simulator is to me. It doesn’t really simulate what I do at work on a daily basis. If I make a mistake at work (which we all do from time to time) I would be mortified, and fret about it for weeks. However I get this thing right with a sense of serious achievement and amazement.

18 July 2025 (Thursday) - Oncology Central Update

The most recent Oncology Central newsletter appeared in my in-box this morning. You can read it by clicking here. I had a wry smile at the bit about acupuncture having a role in modern medicine. Back in the day this would have been laughed out. Nowadays people would seem to be doing what science should be about – seeing that something happens and finding out why rather than just laughing because it doesn’t fit the theory.

To be honest this is something of which I am guilty. We all know that dowsing is a load of rubbish and has absolutely no basis in science… it really annoys me that I can do it.

17 July 2024 (Wednesday) - Auer Rods

I was mooching about on the Facebook Haematology Interest Group when I found their archive of case studies. Here’s an interesting one – a particularly strange case of AML with Auer rods in the mature neutrophils.

15 July 2024 (Monday) - BTLP-TACT Exercise

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

62583 – a forty-nine year-old woman in out-patients needing a pre-operative group & save.She grouped as A Rh(D) Positive with a negative antibody screen
11943 – a twenty-four year-old chap in A&E needing two units of blood within the hour. He 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 & 10 corresponding with anti-Fy(a) but not excluding anti Cw or anti-Lu(a). The enzyme panel was negative throughout. According to BTLP-TACT this excludes anti Cw or anti-Lu(a)

I selected two units of ORh(D) blood that were Fy(a) negative

I got the green light.

15 July 2024 (Monday) - Gaucher's Disease

#LearningMonday… continuing being a reactionary old fart, I hate hashtags. But I do like the Learning Monday idea. This one was a good one… which is the most unlikely diagnosis. Initially I plumped for PNH as it is a disease of older people.

But… Gaucher’s disease… what’s that?

There’s a Wikipedia entry on the condition here. I know that proper science sneers at Wikipedia, but as a starting point it is hard to beat. Apparently Gaucher’s disease is one in which glucocerebroside accumulates in cells and certain organs… one of the places it accumulates is in macrophages which have a distinctive appearance in bone marrow smears… and to complicate the issue there are also pseudo-Gaucher cells.

I learned something here…

12 July 2024 (Friday) - UKAS Update

The nice people at the UK Accreditation Service sent their update today. You can read it by clicking here. On the one hand the reactionary old fart in me thinks it is a load of blah-blah-blah. On the other hand I realise that regardless of what I might think, UKAS has a bigger bearing on my professional life than any other body. Like it or lump it, this is the way forward. And like it or lump it I am better off being aware of what they are up to and what they are suggesting.

The biggest problem with their updates is that they say a lot without saying very much. What exactly is an ISO standard, and what is a mistaken interpretation of an overworked assessor?

The cynic in me would take them far more seriously if they openly published their standards rather than demanding one hundred and sixty quid for a copy of them.

10 July 2024 (Wednesday) - IBMS Update

The IBMS sent their newsletter for members today. You can read it by clicking here.

It made me think. Though not about that which CPD should make me think. The whole point of CPD is that I learn something new, or find that what I thought was good practice isn’t.

Over the years I’ve come to realise that I *don’t* get this from my professional body. Again the IBMS newsletter was all about what people have done and who is on what committee. This month the IBMS sent out all sorts of awards, and as I have said many times before, singling one out for praise cheapens the efforts of thousands who have done the same but gone unrecognized.

My first on-line rant about this subject was nearly eighteen years ago – click here and look up 13 September 2006, and I ranted along similar lines on 4 January 2007.

My thoughts right now are that it costs me sixteen quid a month to be a member of the IBMS and now that they don’t offer professional indemnity insurance I really have to ask what I get for my money.

There’s reflection, eh?

9 July 2024 (Tuesday) - Redeeming Myself

After yesterday’s little balls-up I thought I’d better see if I might redeem myself. I was presented with two cases:

68506 – a fifty-nine year-old woman in theatre requiring two units of blood for tomorrow.
She grouped as A Rh(D) Positive with a negative antibody screen.
I issued two units of A Rh(D) Positive blood.

54326 – a seventy-nine year-old woman with haematemesis also requiring two units of blood tomorrow.
She grouped as B Rh(D) Positive also with a negative antibody screen.
I issued two units of B Rh(D) Positive blood.

I got the green light. I suppose if nothing else this made me sit up and take notice about one feature of the software – to which patient the units are being allocated.

8 July 2024 (Monday) - Getting the BTLP-TACT Wrong (Again!)

Time for a BTLP-TACT exercise. I was presented with two cases:

54995 – a twenty-one year-old chap needing four units of FFP for the next morning

The ABO group was indeterminate being B in the cells and AB in the serum, but was Rh(D) Positive, and had a positive antibody screen in cells 1 & 2. I selected antibody panels. The IAT and enzyme panels were positive in cells 1, 2, 3 and 4 corresponding to anti-C and anti-D but not excluding anti-Cw… even though the patient was Rh(D) Positive.

I selected four units of B FFP. The guidelines said to give it

https://www.nature.com/articles/s41598-024-54379-0, and methylene blue inactivated is no longer needed for someone of that age.

https://rightdecisions.scot.nhs.uk/m/dbjpyafg/fresh-frozen-plasma.pdf

53685 – an eighty-six year-old woman needing four units of FFP and two units of cryo prior to a liver transplant.

They grouped as A Rh(D) Positive with an antibody screen positive in cell 2. I selected antibody panels. The IAT and enzyme panels were positive in cells 2 & 6 corresponding with anti-K.

I selected four units of A FFP and two units of A cryo. The guidelines that I could find on the spur of the moment seemed rather vague so I thought I’d rather be wrong for doing something than be wrong for not doing something.

I got the thumbs down. Apparently I selected all the plasma products for the second patient.

8 July 2024 (Monday) - Learning Monday

Thrombophilia wasn't something I ever formally studied so in my mind it is one of theise "new fangled" things... Which is exactly why I (and we all) need to do CPD.

I got the answer right. Which was something of a result...

5 July 2024 (Friday) - BTLP-TACT Exercise

Time for another BTLP-TAXT exercise. I was presented with one case – a nineteen year old woman in theatre.

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

I got the green light.

2 July 2024 (Tuesday) - Fritsma Factor Update

The Fritsma Factor update appeared in my in-box today. You can read it by clicking here. Unlike previous instalments this one was rather dull, but all good background reading if nothing else.

2 July 2024 (Tuesday) - BTLP TACT Exercise

Time for another BTLP-TACT exercise. I had one case – a forty-four year-old chap with appendicitis requiring group and save.

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

I got the green light.

1 July 2024 (Monday) - Learning Monday

Learning Monday…. Thrombocytopenia with apparently normal megakaryocytes in the bone marrow? Immune thrombocytopenia.

I quite like these little exercises. Especially when I get them right…

26 June 2024 (Wednesday) - Westgard QC Update

The nice people at Westgard sent their update today. You can read it by clicking here. It’s a tad dry, but it’s the sort of thing that is relevant to what we do every day.

25 June 2024 (Tuesday) - Transfusion Evidence Alert

The Transfusion Evidence Alert email arrived in my in-box this morning.

Back in the day the worst thing that you could do with a bag of platelets was to stick it in the fridge. Now this is being encouraged.

And transfusion volumes – one unit transfusions were a no-no. Now one unit is the amount most people seem to have.

One thing I’ve found over the years is that what is terrible practice at one moment becomes standard practice the next.

ARTICLE OF THE MONTH

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

+++++

24 June 2024 (Monday) - Schistocytes

Clare’s done some science again. She’s rather good at it. Schistocyte counts… You can see the ICSH recommendations on the matter by clicking here.
I won’t repeat what Clare has said – she’s said it far better than I could, and you can read it by clicking here anyway.

But I will make an observation… what is an acceptable measurement of uncertainty? Am I being utterly unreasonable in thinking that in numerical terms a schistocyte count won’t be a million miles from a parasitaemia count? Look at the most recent malaria NEQAS – we made the answer 0.2. Plenty of other people made the answer double or triple that number. What is an acceptable measurement of uncertainty?

24 June 2024 (Monday) - Porphyria

Monday – “learning Monday” and I learned something today. What I thought was probably a case of haemochromatosis wasn’t.

I suppose the clue was the photosensitivity. This was a case of porphyria – a range of conditions caused by abnormally high levels of porphyrins and porphyrin precursors due to deficiency of certain enzymes essential to the synthesis of haem.

These are rather obscure…

This is what CPD should be about. I’ve been reminded of something I used to know, and having been prompted I’ve given myself a little refresher.

18 June 2024 (Tuesday) - Mindray

There’s a new kid on the block. Back in the day every blood counter in the country was made by Coulter. And I mean *every* one.

Then Technicon launched the H1. With a five-part differential that (at the time) Coulter could not compete, it wasn’t long before Technicon made serious in-roads into the market.

Then along came Sysmex with faster smaller machines…

Mindray looks interesting. Particularly with their platelet de-aggregation capability. I doubt they will have their machines in at work before I retire, but maybe a year or two after…

17 June 2024 (Monday)- Learning Monday

Should I worry about this strange looking cell? At first sight I laid an egg. Then I looked again and read the words that came with it.

It’s bone marrow – that’s an osteoclast, isn’t it?

Panic over.

13 June 2024 (Thursday) - Oncology Central Update

The nice people at Oncology Central sent their update today. As always most of it went over my head, but one article made me think.

Quadruplet therapy – four drugs where once three were used. There was a lot of talk about avoiding side effects… I can remember my grandmother having a spate of “funny turns” when it turned out that for every medication she’d been prescribed she’d been prescribed another because of the side effects of the first. In the end the consultant in charge of her care stopped all of the tablets and she was suddenly fine.

This was fifty years ago – some things never chage…

10 June 2024 (Monday) - BTLP-TACT Exercise

Time for another BTLP-TACT exercise… I was presented with one case – a ninety-year-old chap in theatre needing two units of blood for a TURP. Back in the day we did two units of blood for every TURP… they never used any. Ever.

But I digress.

He grouped as O Rh(D) Positive with antibody screen positive in cell 2 so I requested antibody panels. The IAT and enzyme panels were positive in cells 2 & 6 corresponding with anti-K.

I selected two units of O Rh(D) Positive K Negative blood

I got the green light.

10 June 2024 (Monday) - Fritsma Factor Newsletter

Threshold limits for platelet transfusions, factor assays (remember those?) and poking about in samples with wooden sticks to check for clots. This month’s Fritsma Factor newsletter is a tad old-skool… but then, so am I.

I’ll just make the observation that in this high-tech age of science there is still a place for getting hold of a snake, milking its venom and using that as a reagent. Back in the day (early to mid 1980s) there was a very active haematology group which met at St Thomas’s hospital on Thursday evenings. People would do round trips of over a hundred miles to be there (I did) and back then people were sneering at the rough and ready use of snake venom in haemostasis.

Has nothing been developed in the meantime to replace Russell’s viper?

7 June 2024 (Friday) - NEQAS 2403 BF

I got hold of the NEQAS results today…

2403 BF1

Anisopoikilcytosis
Polychromasia
NRBC
Fragments

Thrombocytopenia

eosinophilic myelocytes
Blast cells
Neutropenia
Auer rod

?? AML

2403 BF2

Target cells
Rouleaux

Neutrophilia
Toxic granulation
Monocytosis

? infection

I got these right too…

7 June 2024 (Friday) - NEQAS 2402 PA

I got hold of the NEQAS results today…

2402PA1
P falciparum 0.2%
2402 PA2
microfilaria ?? loa loa

I got it right…

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