21 October 2024 (Monday) - Learning Monday

I wasn’t sure but wondered if it was Sezary syndrome.

It wasn’t.

"The clinical presentation, the morphology, the immunophenotype and the positive finding for HTLV-1 were all consistent with adult T-cell leukemia lymphoma.

All the other T-cell disorders are HTLV-1 negative.

In addition, the patient was of African descent and central and West Africa have been shown to be endemic for the virus and the associated diseases".

Reference: Cook LB, Phillips AA. How I treat adult T-cell leukemia/lymphoma. Blood. 2021;137:459-470.

Well – I learned something there…

20 October 2024 (Sunday) - BTLP-TACT Exercise

Time for another BTLP-TACT exercise... it's not as though there's anything worth watching on the telly.
It gave me two cases:

40274 – A sixty eight year old woman needing two units of blood tomorrow for surgery.
The ABO group was indeterminate but the Rh(D) group was negative. Fortunately the antibody screen was negative. I selected two units of O Rh(D) Negative blood.

97135 – a sixty nine year old chap from the renal clinic needing group & save. My heart sank when I saw this one. It’s O Rh(D) positive, but with a weak D. But the BTLP-TACT does odd things, so I called it O with an indeterminate D group. Even though it wasn’t.
The antibody screen was negative… I was grateful for small mercies.

I got the green light. I was pleased about that. However…

The first case was implausible. It was clearly an AB patient who had received O blood in a transfusion… just like the one I’d set up for them. Such a case would be known to the blood bank.

Similarly someone of that age not having had a weak D previously identified? And given that there was why hasn’t the software got an option for weak D?

This BTLP-TACT simulator is a work in progress in which (sadly) no progress is being made.

19 October 2024 (Saturday) - Slide Saturday Challenge

The American Society of Hematology have started something new – “Slide Saturday Challenge”. I shall have to remember to tune in every Saturday…

Well, it’s a myeloblast with an auer rod. Mostly indicative of AML, but also seen in MDS, CMML, and other conditions.

As always just giving one cell in isolation isn’t perhaps the best way to assess morphology, but (quite frankly) this is something for nothing, and if they are going to give me the answer tomorrow (as they claim) then that is streets ahead than the schemes for which my employer pays a small fortune.

17 October 2024 (Thursday) - DIC Case Study

The nice people at Lablogatory sent a rather good case study about DIC today. You can read it by clicking here.

It was a rather good refresher…

17 October 2024 (Thursday) - Transfusion Evidence Library Update

The nice people at the Transfusion Evidence Library sent their update with World Trauma Day 2024 in mind. If one thing has changed over the last forty years it is how little blood is used in trauma cases these days compared to the bad old days.

Is that because of tranexamic acid?

Top article

Pelvic packing or endovascular interventions: Which should be given priority in managing hemodynamically unstable pelvic fractures? A systematic review and a meta-analysis. Zhang, D., et al. (2024). Surgery Open Science.
PICO SUMMARY

Selected articles

The efficacy and safety of pre-hospital plasma in patients at risk for hemorrhagic shock: an updated systematic review and meta-analysis of randomized controlled trials. Abuelazm, M., et al. (2024). European Journal of Trauma and Emergency Surgery. [Record in progress].

Prehospital tranexamic acid in trauma patients: a systematic review and meta-analysis of randomized controlled trials.
Acharya, P., et al. (2023). Frontiers in Medicine.

Management of non-compressible torso hemorrhage of the abdomen in civilian and military austere environments: a scoping review.
Adams, D., et al. (2024). Trauma Surgery & Acute Care Open.

Efficacy and safety of early administration of 4-factor prothrombin complex concentrate in patients with trauma at risk of massive transfusion: the PROCOAG randomized clinical trial.
Bouzat, P., et al. (2023). JAMA.

Prothrombin complex concentrate (PCC) for treatment of trauma-induced coagulopathy: systematic review and meta-analyses.
Hannadjas I., et al. (2023). Critical Care.

Emergency department resuscitative endovascular balloon occlusion of the aorta in trauma patients with exsanguinating hemorrhage: the UK-REBOA randomized clinical trial.
Jansen J.O., et al. (2023). JAMA.

Predicting blood transfusion following traumatic injury using machine learning models: a systematic review and narrative synthesis.
Oakley W., et al. (2024). The Journal of Trauma and Acute Care Surgery.

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

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.

16 October 2024 (Wednesday_ - BTLP-TACT Success

Having had endless disasters with the BTLP-TACT recently I thought I might have another go…

It presented me with two cases:

13323 – a forty year old woman in the ante-natal clinic needing group & save.
She grouped as O Rh(D) Positive with a negative antibody screen.

89767 – a sixty eight year old woman requiring six units of blood for AAA.
She grouped as A Rh(D) Positive with a negative antibody screen.
I selected six units of A Rh(D) Positive blood

I got the green light which, bearing in mind my track record with BTLP-TACT, I felt was frankly amazing.

14 October 2024 (Monday) - BTLP-TACT

Time for another BTLP-TACT exercise… it’s pouring hard outside and I’m a tad bored.
I asked it if I might have a go. The spinny wheel thingy spun and spun. Eventually it crashed. I started it again and it told me to process any samples in the in-tray. There weren’t any. After a lot of fiddling about I came out of the thing and went back in again. It gave me the thumbs down for that.
I tried again.
Again the spinny wheel thingy spun and spun. Finally it gave me two cases.

34385 – a twenty-five year old woman needing group and save.
She grouped as O Rh(D) Positive with antibody screen positive in all three cells. I requested antibody panels. The IAT panel was variable. It was 3+ in cells 3 and 9 and 1+ in cells 1, 2, 5, 6, 7 and 10. Being negative in only cells 4 and 8 I could only really exclude anti-C, anti-c, anti-e, anti-N, anti-s, anti-P1, anti-Fya,
The enzyme screen was negative in everything therefore excluding all Rh antibodies and anti-Lu(a).
So heaven only knows what’s going on here… it could be an unholy combination of anti-S and Fy(a) from which I couldn’t exclude anti-K. I don’t know – I would refer this. I’d appreciate going through this with someone…

08821 – a fifty-seven year old chap also needing group and save.
He grouped as A Rh(D) Positive with antibody screen positive in cell 2. I requested antibody panels. The IAT panel was positive in cells 2 and 6 corresponding to anti-K, as was the enzyme panel.

I got it wrong… apparently there was a clinically significant antibody masked but not noted in case 34385. Was there? I’d like to know what it was.

11 October 2024 (Friday) NEQAS 2406BF

Got the results of NEQAS 2406BF today. I saw…

BF1

Sickle cells (consensus #2)

Eosinophilia (consensus #1)

Nucleated red cells (consensus #3)

Target cells (consensus #4)

Howell-Jolly bodies (consensus #6)

I felt this was a haemoglobinopathy with something setting off the eosinophils.

The expert opinion was that this was sickle cell disease with an unexplained eosinophilia

BF2

Target cells (consensus #1)

Tear drop cells (consensus #2)

Fragments (consensus #8)

Basophilic stippling (consensus #5)

Polychromasia (consensus #4)

I felt this was a haemolytic condition. It was haemoglobin H disease…

The expert opinion started off with “this case indicates how difficult it can be to think of the possibility of the correct diagnosis in the absence of clinical history and ethnic origin”

I think this just shows we should be given a lot more information in these cases

I saw the salient features, didn’t miss anything, and would have dealt with each appropriately. That'll do...

11 October 2024 (Friday) - NEQAS 2403DF

Got the results of NEQAS 2403DF today

Neutrophils 7.9 - 10.9 10.2
Lymphocytes 3 4 - .7 3 3.4
Monocytes 0.6 - 2.0 0.9
Eosinophils 2.4 - 4.8 3.7
Basophils 0.0 - 0.1 0.0
Metamyelocytes 0.0 0.1 0.0
Myelocytes 0.0 - 0.3 0.0
Promyelocytes 0.0 - 0.0 0.0
Blast cells 0.0 - 0.0 0.0
Smear cells 0.0 - 0.0 0.0
Neoplastic cells 0.0 - 0.0 0.0

That’ll do…

10 October 2024 (Thursday) - UKAS Newsletter

The nice people at the UK Accreditation Service published their quarterly newsletter today. You can read it by clicking here.

I read it.

It is all very interesting from a theoretical hypothetical point of view. It would men so much more (and grab my interest so much more) if they would give specific examples of professional practice and explain how that is directly relevant to their standards.

But, bearing in mind that they expect me to pay to see what their standards are, that ain’t going to happen.

A missed opportunity

9 October 2024 (Wednesday) - Little Bit of Politics

The IBMS have published their response to Lord Darzi’s review of the NHS. I’m reminded of my grandmother listening to a cousin jabbering on at great length loudly and ostentatiously about the failings of the committee of the local fishing club whilst doing nothing himself other than sitting on his bum and finding fault. Gran listened patiently, then announced “fine words butter no parsnips” and this is true of both what Lord Darzi has found and the IBMS’s response.

Lord Darzi’s report highlights the rising number of people living with multiple long-term conditions and the strain this places on hospitals. To address these challenges he says that immediate action and a strengthened diagnostic infrastructure are needed to ensure early detection, continuous monitoring, and better management of chronic diseases.

Can’t disagree there.

He goes on to say that a shift in focus from hospitals to community-based care is essential, and expanding the reach of diagnostics into community settings will enable earlier interventions and reduce pressure on hospitals.

We can’t argue with that in theory, can we?

But in practice? Lord Darzi has done reviews of the NHS before. He feels (probably rightly) that the NHS is too big, and would work better in smaller units. However at the time pathology service were reviewed by Lord Carter of Coles and he said “big is better”.

It’s no secret that path labs struggle to recruit. It wasn’t that long ago that an NHS Trust not a million miles away from where I live was seriously considering closing one of its three laboratories because it (probably) had enough staff to run two labs, but three was a stretch.

And look at today’s trend for pathology networks in which individual labs are reducing their test repertoire and centralizing tests for economies of scale.

If Lord Darzi wants diagnostic testing out in the community and a massive increase in point of care testing he needs to staff it. So he can either de-skill the workforce, and we all saw what a shambles that was (on national TV!), or he can recruit a *lot* more biomedical scientists. And he can only do that by making the job more attractive. And that will cost.

Having said (ranted) that, personally I’m taking whatever Lord Darzi has to say with a pinch of salt. Whatever he says simply won’t happen. At the risk of appearing to be an old reactionary, I really have seen it all before. Many times.

There will be all sorts of meetings at the Department of Health. Meetings, meetings about meetings that have happened. Meetings about meetings that are to happen. Eventually NHS Trusts will get orders from these meetings… and at that very point where something might actually happen, Lord Darzi’s ideas will be superceded by the next great NHS shake-up.

Look at what Lord Darzi is suggesting… he feels that (effectively) community-based care will call the shots in the NHS. That’s been done before (at least twice) and abandoned both times because of political ideology rather than any tangible evidence.

What the NHS needs is a load more money to recruit and train staff. And having recruited and trained staff it needs to be left alone for whatever current review and shake-up to take effect. Then this current review and shake-up needs to be formally reviewed and assessed, and fine-tuned on the strength of verifiable objective data, not the whim of whatever politician is in vogue at the time.

9 October 2024 (Wednesday) - Turning Off Immunity?

Here’s something… two injured comb jellies have been seen to merge into one individual.

It’s been established that comb jellies do have an immune system, so what’s going on here. Clearly there is some mechanism in which the recognition of “non-self” is modified.

Could this have relevance to humans? Could this trick be used to increase the success rate of organ and bone marrow transplant? Will this herald a whole new era of lab tests for us to be doing?

7 October 2024 (Monday) - Learning Monday

It’s Monday – time to turn to the European Hematology Association’s “Learning Monday”.

Perhaps the start of learning is finding out what you don’t know.

Apparently Ruxolitinib is indicated in patients with symptomatic splenomegaly and/or constitutional symptoms due to IM-2 and HR PMF. Bearing in mind I don’t know what Ruxolitinib IM-2 or HR PMF are, there’s the start of today’s CPD…

6 October 2024 (Sunday) - BTLP-TACT Exercise

Well, it’s been a few days since I had a go at the BTLP-TACT, so I sparked it up. I was presented with one case – a twenty-seven year-old woman in maternity needing four units of blood.

The sample was completely unlabelled, so I rejected it. And I got the thumbs-up for doing so. Flushed with success I had another go.

I was presented with one case – a sixty year old woman needing two units of cryo for vitamin K deficiency.

She grouped as A Rh(D) Positive with a negative antibody screen, but with no more clinical information given I wasn’t going to waste valuable cryo when an injection of vitamin K would do the trick.

I got the thumbs-down. Apparently there was a labelling error. I didn’t spot it. I suppose that’s why two people check when we do this at work.

And so with one pass and one fail, I went on to see what two out of three would be. One more case – a ninety year old woman needing two units of blood.

She had an indeterminate ABO group but was Rh(D) Negative. The antibody screen was negative so I selected two units of O Rh(D) Negative.

And having got two right out of three I called that a day.

2 October 2024 (Wednesday) - Fritsma Factor Newsletter

Inhibitors, haemophilia and reptilase time (remember that?)… again the Fritsma Factor newsletter delivers. When you consider George is giving me something for nothing here, it is rather good value for money.

1 October 2024 (Tuesday) - More BTLP-TACT Frustration

Well… admittedly I’ve been off on holiday for a couple of weeks so I suppose that’s why I’ve been getting low participation warnings from the people at BTLP. Bearing in mind the debacle of the last exercise I’m not keen on doing any more… but if I am going to carry on in this line of work I have to do CPD.

Then again I’m not really keen on carrying on working at all. But for now…

I asked the BTLP-TACT software if I might have another go. It eventually presented me with one case – a forty-one year-old woman in the maternity department needing group & save.

I decided that the sample labelling was correct and told it so. After about five minutes it moved on to the next screen.

Actually requesting said group and save took another five minutes. Five more passed before I was able to see the result of the grouping

Both ABO and Rh group were indeterminate. It struck me that this was an AB Rh(D) Positive patient who had been transfused O Rh(D) Negative blood. In reality we would have this information.

And then the entire thing crashed in a server error.

I restarted it and eventually saw that the antibody screen was positive in cells 1 and 2.

I made a cuppa whilst I waited for it to allow me to request antibody panels, and drank the cuppa with a couple of biccies whilst waiting for it to show me the results of those panels.

The IAT panel was positive in cells 1, 2, 3 and 4 corresponding with anti-C and anti-D whilst not excluding anti-Cw. After another painfully long wait it again crashed in another server error.

I again restarted the thing and eventually saw that the enzyme panel was the same as the IAT panel. positive in cells 1, 2, 3 and 4 corresponding with anti-C and anti-D whilst not excluding anti-Cw. Once I’d given it the answer the software just hung.

After waiting for seemingly an age it gave me the thumbs-up.

1 October 2024 (Tuesday) - Westgard QC Update

The trouble with statistics in the lab is that the people using them aren’t mathematicians. I’ve got a degree in maths and often struggle with what the nice people from Westgard tell me…

Measurement of uncertainty for example. Surely common sense tells us that if you’re not measuring something very often then you will have more variability in your results than if you measure lots…

You can read the latest update from the nice people at Westgard QC by clicking here

23 September 2024 (Monday) - Transfusion Evidence Alert Update

Tranexamic acid features yet again… and an interesting article about transporting blood by drone. With the pitiful state of the road network round our way that could be the way forward?

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