16 February 2025 (Sunday) - Slide Staurday Challenge

Slide Saturday challenge… it comes out on the Saturday but I wait until the Sunday before the expert comment comes out so I can be sure that I’m right or wrong.
 
Well – I was right this time. Blister cells. You see those in G6PD deficiency. Having confidently announced this, I’ve only ever seen two cases of G6PD deficiency outside of NEQAS exercises.
Am I being a reactionary old fart in suggesting that morphology is all about remembering obscure things that you never actually see in actual practice?
 

16 February 2025 (Sunday) - BTLP-TACT Exercise

Time for a BTLP-TACT exercise. I was presented with one case – a fifteen year-old lad with liver disease needing group and save.

He grouped as O Rh(D) Negative with antibody screen positive in cells 1 and 2. I requested antibody panels. The IAT panel was positive in cells 2, 3, 5, 7 and 9 corresponding with anti-S, but not excluding anti-E or anti Lu(a). But the enzyme panel was negative, so that did exclude them. In this world…
I got the thumbs up.

Whilst I was logged in I had a look at my performance dashboard. I’ve copied a screenshot here.


I’m doing enough to meet my engagement targets… so why is it continually sending me emails saying “You may need to complete further TACT participations to improve your engagement target with the system. Please visit TACT and log in at your earliest convenience”?
Probably for the same reason that it thinks that in today’s case anti-E and anti Lu(a) were both excluded…

14 February 2025 (Friday) - ITP

The nice people at TouchHaematology sent me this link today. The latest thinking on the treatment of ITP.
This is why I need to do CPD. Back in the day the patients either had a massive dose of steroids, and if that didn’t work, out came the spleen. Both were rather effective; as I remember my mate’s mother was rather ill with ITP but soon recovered.
Treatment these days is a lot less like taking a sledgehammer to crack a nut.

13 February 2025 (Thursday) - Transfusion Evidence LIbrary Update

The Transfusion Evidence Library sent its update today. Am I imagining it, or is the move against having blood transfusions gathering momentum?

Top article

Selected articles

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.

Effect of minimization of early blood sampling losses among extremely premature neonates: a randomized clinical trial.
Balasubramanian, H., et al (2024). The Journal of Pediatrics.

Luspatercept versus epoetin alfa in erythropoiesis-stimulating agent-naive, transfusion-dependent, lower-risk myelodysplastic syndromes (COMMANDS): primary analysis of a phase 3, open-label, randomised, controlled trial.
Della Porta, M.G., et al. (2024). The Lancet Haematology.

Effects of individualized anemia therapy on hemoglobin stability: a randomized controlled pilot trial in patients on hemodialysis.
Fuertinger, D.H., et al. (2024). Clinical Journal of the American Society of Nephrology. [Record in progress].

Standard of care versus octreotide in angiodysplasia-related bleeding (the OCEAN Study): a multicenter randomized controlled trial.
Goltstein, L.C.M.J., et al. (2024). Gastroenterology.

Effect of preoperative recombinant human erythropoietin on the need for blood transfusion and surgical outcomes in adult patients undergoing cardiac surgery: a systematic review and meta-analysis with trial sequential analysis.
Hakim, S.M., Ahmad, A.H.M., and Amer, A.M., (2024). Journal of Cardiothoracic and Vascular Anesthesia.

Interventions for reducing red blood cell transfusion in adults undergoing hip fracture surgery: an overview of systematic reviews.
Lewis,  S.R., et al. (2023). Cochrane Database of Systematic Reviews.

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.

Pharmacotherapy for reducing RBC transfusion for patients in the ICU: a systematic review and network meta-analysis
Yoshihiro, S., et al. (2024). Critical Care Medicine.

11 February 2025 (Tuesday) - Westgard Update

Hot on the heels of the IBMS’s newsletter was the update from Westgard. As always it was rather dry and heavy going, but relevant to what I do on a daily basis.
It’s a shame that when it specifically tackles compliance with the various regulations governing medical laboratories it is looking at the American ones, but there are all sorts of transferable snippets in there.

11 February 2025 (Tuesday) - IBMS Update

The IBMS sent its newsletter today. I’m usually rather disparaging about the IBMS. I don’t want to be. I suspect that my grievances are actually evidence of how out of touch I am with the current state of the profession…
Having admitted that…
 
IBMS congress was always seen as a chance to get paid to go on a booze up with youe current and old colleagues. The sooner that thing is moved to being entirely virtual the sooner it can shake off that reputation.
There was concerns that enterprising students might be blagging their portfolio work using AI. But there was also talk of how AI might be used to assess students’ work.
And tere was no end of support for managers but absolutely nothing that would help those doing the job do their daily round. Again.

 

9 February 2025 (Sunday) - BTLP Exercise

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

39634 – a twenty-six year-old woman in the maternity department requiring group and save prior to a caesarian section.

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

 

07685 – an eight year old boy having haematemesis requiring two units of blood.

He grouped as B Rh(D) Negative with a negative antibody screen.

I selected two units of B Rh(D) Negative blood

 
I got the thumbs-up.

9 February 2025 (Sunday) - Slide Saturday Challenge

Slide Saturday Challenge – looks like a Cabot ring to me.
It was.
Here’s a rather good little write-up on them. Mind you it has to be said that Cabot rings are rather obscure. In over forty years of peering down microscopes, apart from QC exercises I’ve only ever seen one.

 

6 February 2025 (Thursday) - BTLP-TACT

Finding myself at a bit of a loose end I thought I might do a BTLP-TACT exercise.
 
I was presented with one case – a seventy-two year-old chap in A&E needing six units of blood for an AAA. Sadly neither the NHS number nor the hospital number on the ample agreed with that on the request form, so I rejected the request.
If it was truly urgent a repeat sample could have been in my hands in minutes. That sample is only as good as its labelling, and if the information on it comes from two different patients I have no way of knowing from which sample it comes.
Giving six units of the wrong blood group is not quite as sure a way of killing someone as letting them bleed to death… but with a little effort both eventualities might be avoided.

6 February 2025 (Thursday) - What if...

Here’s a couple of random thoughts that occurred to me whilst walking the dogs round the woods this morning.
I made a mistake at work yesterday. The mistake was that I thought I got something wrong. I hadn’t.
We had a phone call querying someone’s blood group. Last week our analyser wasn’t happy with a blood group so I did it manually and reported it as Rh(D) Positive. However records from way back when said she was Rh(D) Negative. I felt physically sick… but after a little to-ing and fro-ing it turned out that samples had gone to the National Blood Service and she was known to be Rh(D) Positive, albeit with a weak D. I’d actually got it right.
Back in the day when we did Rh groups we used to do a DAT on all negative reactions, and if that came out positive they were called Rh Du Positive. We now know there’s (effectively) a spectrum of positivity, and the modern antisera pick up more of the weak reacting D.
Which made me think… Back in the day had we been giving prophylactic anti-D to D-positive people during pregnancy? If so demonstrably it hadn’t been an issue. Had it?
 
My second thought was about how I’d worried yesterday. I had felt physically sick. Fourteen years ago I made a serious mistake at work. I never did get to the bottom of what happened. All I can say is that having made a mistake it was used as a way of getting rid of someone who didn’t always toe management’s line. Without going into details, what followed that mistake was stressful in the extreme.
But does this mean I am not allowed to make a mistake ever? Look at any hospital mistake that is ever made. No newspaper ever reports on tragic mistakes made by overworked staff who are racked with remorse. But they often talk about the incompetence of bungling medics.
I can remember a discussion about this very subject when I was doing my IBMS Special exam course in 1987 (MSc equivalent). Our tutor, the much-missed Pete Chopping asked us how many babies a midwife could drop.
Obviously he was being facetious, but it is a valid point.
This is where quality management should come in to play… I did a course on that last year.
 
I know I’m worrying over what-if. I should stop doing that. It does my blood pressure no good.

5 February 2025 (Wednesday) - Comments

Two days ago I wrote about vitamin B12 injections... Someone took offence and made the above comment...
I've tweaked the settings so that anonymous comments can't be made any more. If someone wants to make death threats they can put their name to it from here on in.
Was that post of two days ago *that* offensive?

3 February 2025 (Monday) - Fritsma Factor Newsletter

The latest Fritsma Factor newsletter appeared in my in-box today.

Proteins S and C, platelet clumping… all useful stuff.


3 February 2025 (Monday) - Stopping Vitamin B12 Injections?

Monday - #LearningMonday.  I got it right – answer three.
 
Tina has not consumed her vitamin B12 reserves built up by injections over the years. 
Large quantities of cobalamin are retained in the liver after absorption, as a result, any decline in the intake of cobalamin may take five to ten years to show clinically.  
Even if intake would stop altogether, normal liver supplies account for approximately two years of normal cobalamin consumption.  
Although sporadic reports of spontaneous remission of pernicious anemia are present in the literature, such events are very rare.    
Reference:
Jajoo SS et al. Etiology, Clinical Manifestations, Diagnosis, and Treatment of Cobalamin (Vitamin B12) Deficiency. Cureus. 2024 Jan 12;16(1):e52153.”   

2 February 2025 (Sunday) - BTLP-TACT Exercise

Time for another BTLP-TACT exercise. Eventually it gave me two cases:

81592 – a fifty-five year-old woman in the haematology clinic needing four units of FFP for a factor V deficiency

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

According to https://www.ncbi.nlm.nih.gov/books/NBK580494/ FFP *is* recommended for factor V deficiency so I issued four units of group O FFP.

81731 – a twenty-nine year-old woman on ITU needing six units of blood following a stabbing.

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

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

 
I got the thumbs-up

2 February 2025 (Sunday) - H.E.

Slide Saturday Challenge – well, those are elliptocytes. But the expert answer does leave a little to be desired… whilst *some* elliptocytes are seen in iron deficiency and MDS, the amount seen here would rather indicate hereditary elliptocytosis (H.E.).
 
I can distinctly remember being told of the Palek and Lux classification of H.E. with seven distinct categories ranging from totally non-symptomatic microscopic anomaly through to severe transfusion dependent anaemia. But that would seem to have fallen into disuse – nothing came up in Google when I looked.
 
H.E. isn’t *that* common really. I’ve identified maybe half a dozen over the years. One in an eighty-six year-old chap who had gone though his entire life with no issues from the condition which only came to light as a chance finding when I looked at a blood film when he’d developed a chest infection after he’d had a heart attack.
 
Here’s a rather detailed dissertation on the matter.