Where did platelets go in 2012? A survey of platelet transfusion practice in the North of England.

OBJECTIVES: To record the fate of transfused platelet doses in the North of England, and thereby assist with demand-planning and help target teaching on appropriate use. BACKGROUND: Platelet use has risen recently to the extent that donation practice has changed to meet demand. Two national comparative audits have shown inappropriate use and the 2010 audit concluded that current U.K. guidelines for platelet usage should be completely implemented at a local level. It is necessary to know how platelets are used and by whom in order to facilitate guideline concordance. METHODS: All hospital trusts in the North East and Cumbria recorded data on all platelet doses transfused in two separate 4-week periods in 2012. Data were entered onto an electronic survey tool. RESULTS: One thousand and five hundred and seventy-four reports were received, documenting 1937 transfused doses--96% of total issues for the study periods. One thousand and forty-five platelet doses (54%) were given for haematological indications. The second commonest indication was cardiac surgery (201 doses, 10% of the total) followed by non-haematological oncology (127 doses, 6.5%), critical care (106 doses, 5%) and liver disease (50 doses, 2.5%). The commonest haematological indication was acute myeloid leukaemia, 310 doses, (16% of all platelet use), followed by stem cell transplantation, 271 doses (14%). Seventy-two percent of platelet doses were given prophylactically, the majority without any planned procedure. CONCLUSION: The commonest indication for platelet use, where reinforcement of guidelines will be productive, is prophylaxis in haematological disease. Use of platelets in cardiac surgery is also worthy of close scrutiny.

Factors predisposing to wrong blood in tube incidents: a year's experience in the North East of England.

INTRODUCTION: Wrong blood in tube (WBIT) describes a transfusion sample collected from one patient but labelled with the identification details of a different patient. These incidents have the potential to result in catastrophic harm to patients. In 2011, the Serious Hazards of Transfusion (SHOT) organisation received 469 reports of WBIT across the UK. WHAT THIS STUDY ADDS: This was a prospective study of WBIT which collected information not only on the frequency of WBIT but also risk factors. METHOD: All hospitals in the North East region of England submitted details of known WBITs during a 12-month period starting from July 2011, including the time of day and location where samples were taken, the job title and competency of the sample taker, and how the WBIT was identified. Where possible, the sampler was interviewed to determine reasons for the WBIT. RESULTS: There were 48 WBITs, giving a corrected incidence of 1 : 2717 repeat transfusion samples. Doctors were responsible for 24 of 45 WBITs where the identity of the sampler was known. The rate as a proportion of samples was highest in medicine and paediatric specialties. The commonest risk factor for WBIT was labelling away from the bedside (44%). CONCLUSIONS: These findings support, and add to, the data collected by SHOT. If our figures are representative of the whole of the UK, then over 1160 WBITs will occur each year, justifying SHOT's concerns that WBITs are under reported. Interventions are needed to ensure labelling of transfusion samples is always carried out at the patient's side.

Antenatal monitoring of anti-D and anti-c: could titre scores determined by column agglutination technology replace continuous flow analyser quantification?

OBJECTIVE: To determine if column agglutination technology (CAT) for titration of anti-D and anti-c concentrations produces comparable results to those obtained by continuous flow analyser (CFA). BACKGROUND: Anti-D and anti-c are the two commonest antibodies that contribute to serious haemolytic disease of the foetus and neonate (HDFN). Current practice in the UK is to monitor these antibodies by CFA quantification, which is considered more reproducible and less subjective than manual titration by tube IAT (indirect antiglobulin test). CAT is widely used in transfusion laboratory practice and provides a more objective endpoint than tube technique. MATERIALS AND METHODS: Antenatal samples were (i) quantified using CFA and (ii) titrated using CAT with the reaction strength recorded by a card reader and expressed as a titre score (TS). RESULTS: The TS rose in accordance with levels measured by quantification and was able to distinguish antibody levels above and below the threshold of clinical significance. CONCLUSION: CAT titre scores provided a simple and reproducible method to monitor anti-D and anti-c levels. The method was sensitive to a wide range of antibody levels as determined by quantification. This technique may have the potential to replace CFA quantification by identifying those cases that require closer monitoring for potential HDFN.

Cryoprecipitate for transfusion: which patients receive it and why? A study of patterns of use across three regions in England.

BACKGROUND: Despite increasing interest in the use of fibrinogen concentrates, cryoprecipitate remains the major source of fibrinogen in England. OBJECTIVES: Understand patterns and indications for use of cryoprecipitate in hospitals from three English regions. METHOD/MATERIALS: Data collection over 3 months from adults, children and neonates receiving cryoprecipitate, including clinical scenario, indications, dose and levels of fibrinogen concentrations pre- and post-transfusion. RESULTS: Four hundred and twenty-three episodes of cryoprecipitate transfusion were analysed from 39 hospitals. Use varied from 0.1 to 4.9 units per 100 red cells transfused. The primary indication was haemorrhage [311 episodes (74%)]. The commonest clinical scenario in all age groups was cardiac surgery, followed by trauma in adults and critical/neonatal care for children. Pre-treatment fibrinogen levels were measured in 322 episodes. In 179 episodes, the level was ≥ 1.0 g L(-1) . CONCLUSION: Wide variation in practice and dose suggests inconsistent practice and uncertainty in the evidence informing optimal use of cryoprecipitate.

When and why is blood crossmatched? A prospective survey of transfusion laboratory practice in two regions in the north of England.

BACKGROUND AND OBJECTIVES: This study was undertaken to provide data relating to the timing of laboratory crossmatch procedures, and the source of requests for out of hours crossmatch, to support interpretation of error reports originating in the transfusion laboratory, received by the Serious Hazards of Transfusion haemovigilance scheme. MATERIALS AND METHODS: Data on the timing, origin and urgency of all crossmatch requests were collected in 34 hospitals in northern England over a 7-day period in 2008. Additional data on clinical urgency were collected on crossmatches that were performed out of hours. RESULTS: Data were obtained on 2423 crossmatches, including 610 (25.2%) performed outside core hours. 30.3% of out of hours crossmatch requests were for transfusions that were set up outside 4 h of completion of the crossmatch. CONCLUSION: 2008 Serious Hazards of Transfusion data showed that 29/39 (74%) of laboratory errors resulting in 'wrong blood' occurred out of hours whilst our audit shows that only 25% of crossmatch requests are made in that time period, suggesting that crossmatching performed outside core hours carries increased risks. The reason for increased risk of error needs further research, but 25 laboratories had only one member of staff working out of hours, often combining blood transfusion, haematology and coagulation work. A total of 25% of out of hours requests were not clinically urgent. Hospitals should develop policies to define indications for out of hours transfusion testing, empower laboratory staff to challenge inappropriate requests and ensure that staffing and expertise is appropriate for the workload at all times.

Where and when is blood transfused? An observational study of the timing and location of red cell transfusions in the north of England.

BACKGROUND AND OBJECTIVES: This study was undertaken to provide denominator data relating to the timing and location of transfusion, to support interpretation of reports of incorrect blood component transfused (IBCT) events to the UK Serious Hazards of Transfusion (SHOT) scheme. MATERIALS AND METHODS: The study was carried out in 29 hospitals in northern England. Data on the timing, location and specialty responsible for transfusion were collected retrospectively (usually the following day) for all red cell units transfused over a 7-day period in September 2005. The timing and location of transfusion of these units was compared with those IBCT reports to SHOT between 1 January and 31 December 2005 in which there was an error in blood collection from the hospital storage site and/or administration to the patient. RESULTS: Data were received on 3123 red cell units, 3118 of which were analysable. Individual hospitals returned data on between 1 and 279 units. The data showed that 888 out of 3118 (28.5%) of units were transfused between 20:00 and 08:00 hours, while 63 out of 169 (37%) of IBCT reports to SHOT where there was an error in blood collection/administration were recorded as occurring during this time period. CONCLUSIONS: Comparison of our data with those from SHOT suggests that transfusions that are given outside core hours are more likely to be associated with clinical errors.

An audit of delays in diagnosis and treatment of lymphoma in district hospitals in the northern region of the United Kingdom.

Prompt diagnosis and treatment of malignant disorders is generally regarded as improving outcomes. There is good evidence for this in the most common solid tumours, bronchus, breast and large bowel. It might be expected that delays in diagnosis of lymphoma could affect the outcome of treatment, as well as causing dissatisfaction among patients and relatives. However it would be difficult to obtain definite evidence for this as a randomised trial of delay is an unethical proposition. The recently introduced National Priorities Guidance (NPG) Cancer Targets require that all new patients with suspected cancer should see a specialist within two weeks of referral by their General Practitioner (GP). There is no good evidence to support this requirement in lymphoma, but we decided to audit delays at different stages of the process of diagnosis and initial treatment of lymphoma as a base line to assess current performance, identify possible shortcomings and set achievable standards amenable to further audit.

Primary treatment of low-grade non-Hodgkin's lymphoma using an all oral anthracycline-containing regimen, chlorambucil, idarubicin, dexamethasone (CID)--a phase II study.

PURPOSE: The majority of patients with low-grade non-Hodgkin's lymphoma (LGNHL) are in the older age groups and are thus less able to tolerate aggressive treatment. Chlorambucil, alone and in combination, has been widely accepted as the initial treatment of choice for many years. The availability of an anthracycline which could be given orally in combination with chlorambucil and steroid led us to investigate the efficacy and toxicity of this novel regimen. METHODS: Patients (age less than 70 years) with a histologically confirmed diagnosis of LGNHL (Kiel classification) were eligible for the study if they had no previous chemotherapy. Treatment consisted of chlorambucil 20 mg/ m2 daily for 3 days given on each day in three divided doses, idarubicin 10 mg/m2 for 3 days before breakfast, and dexamethasone 4 mg twice daily for 5 days. All drugs were given orally. Treatment was repeated every 21 days for a maximum of six courses. The regimen was assessed for toxicity and response. RESULTS: A total of 72 patients were registered, and 64 were eligible (median age 52 years). Toxicity was assessed for all cycles given (347). The predominant toxicity was haematological, but in only one course did grade 4 neutropenia (less than 0.5 x 10(9)) occur. Alopecia was not a problem. Full doses of the treatment were administered to 40% of the patients, with no delays or dose reductions. The overall response rate was 83%. Six patients had static disease and two progressed on treatment. Lactate dehydrogenase (LDH) was found to be a good predictor of response to treatment. Of 12 patients documented to have raised LDH, 5 failed to respond to treatment, compared to 1 of 32 patients who had a normal LDH (chi2 10.65, P < 0.002). With a minimum follow-up of 4 years for all patients actuarial 5-year event-free survival was 22% and overall survival was 65%. However, in patients with best and intermediate risk LGNHL (by the SNLG Prognostic Index for Low Grade Disease) overall survival are 88% and 64%, respectively. CONCLUSIONS: This novel regimen was effective and well tolerated.

Falsely prolonged prothrombin time due to an inhibitor to human thromboplastin.

A patient with nephrotic syndrome of unknown aetiology was found to have a grossly prolonged prothrombin time in the absence of any other coagulation abnormality and with no clinical bleeding problem. Subsequent investigations showed his plasma contained an inhibitor-like substance, directed against human but not animal thromboplastin.

The 5q--syndrome: an underdiagnosed form of macrocytic anaemia.

Since the description in 1974 of the 5q--syndrome, only 29 cases have been reported. Over a 3 1/2 year period cytogenetic culture of bone marrow submitted from 344 patients being investigated for a blood disorder revealed nine patients with anomalies of chromosome 5. In five of these patients (samples arising from 37 patients being investigated for refractory macrocytic or aplastic anaemia) the 5q-syndrome was diagnosed. The clinical and haematological findings of this syndrome are reviewed and attention is drawn to the importance of reviewing megakaryocytic numbers and morphology in refractory macrocytic anaemia if the diagnosis is to be considered. The diagnosis is compatible with prolonged survival and establishing it prevents repeated and unnecessary investigation.