Events during September 2023

The cellular pathology of clots and cell blocks

Meet your Haematology Portfolio examiners

Antimicrobial resistance (AMR) in anaerobic bacteria varies greatly between institutions and countries. It is crucial that we have robust and widely available methods and perform regular surveillance to raise awareness of AMR amongst laboratory and clinical teams.

The UKARU offers a UK-wide service for the identification and antimicrobial susceptibility testing (AST) of anaerobic clinical isolates. Since 2016, this service has included weekly AST by agar dilution. The MIC population distributions for isolates referred are presented in real time via the ARUMIC platform, facilitating continuous monitoring of the development of resistance and valuable data for the review and development of epidemiological cut-offs (ECOFFs) and species-specific breakpoints, alongside the European Committee for Antimicrobial Susceptibility Testing (EUCAST).

During 2017 – 2021 EUCAST and the UKARU reviewed the AST methodology and breakpoints for anaerobes and developed a standardised disk diffusion method. Fastidious Anaerobe Agar with horse blood (FAA-HB) was used to test the most commonly isolated anaerobic bacteria including Bacteroides spp (n=170), Prevotella spp. (n=49), Fusobacterium necrophorum (n=51), Clostridium perfringens (n=58) and Cutibacterium acnes(n=54). The antimicrobials included for the initial phase were benzylpenicillin, piperacillin-tazobactam, meropenem, metronidazole and clindamycin with vancomycin included for the Gram positive organisms. Breakpoints for additional agents have just been published on the EUCAST website.

This lecture will provide insights into the development of AMR in anaerobic bacteria, the available AST methodologies and the importance of surveillance for this important group of pathogens.

The debate about performance and sustainability of our healthcare services is often reduced to a questions of money and beds are there enough of either? Both are back ups to the more important question - are there enough staff?

The size and complexity of the workforce challenge means there will need to be concerted and sustained action across the system on workforce planning, training, retention, productivity, job roles and creating workplace cultures - that demonstrates staff are valued. For our sector, action is needed both in the short term and the long term to support the workforce and meet the needs of our service and how this will meet the wider healthcare service for patients.

This presentation will look at how leaders at all levels need to work collectively to address our workforce challenge and how we can together take action at a local, regional and national level.

Head and Neck cancers account for approximately 3% of new cancer incidence in the United Kingdom (UK). The use of ultrasound guided fine needle aspirations within head and neck ultrasound, has become a vital resource for cancer diagnosis. Historically, it was common for head and neck patients requiring a fine needle aspiration, to have an insufficient tissue sample from their initial examination, leading to patient re-call for repeat investigation. Subsequently, this negatively impacted upon the patient pathway by delaying cancer diagnosis and treatment.

The utilisation of Rapid on-site Evaluation (ROSE) has proven to transform the diagnostic pathway by negating the need for repeat examinations and therefore improving the rate at which patients are diagnosed and treated.

This presentation focuses on the achievements that have been accomplished through great collaborative working between radiology and cytology within head and neck and the consequent patient benefits. It includes a summary of how the ROSE service has grown at Royal Cornwall Hospital to include the Cornwall ROSE research pilot and the values this has brought to the population.

Case studies will be included as examples of where ROSE has been paramount to a swift diagnosis.

Additionally, the advantages and disadvantages of working with ROSE will be discussed from a sonographer's viewpoint, highlighting the potential pitfalls.



References

1. Head and neck cancers statistics | Cancer Research UK [Internet]. [cited 2023 May 26]. Available from: https://www.cancerresearchuk.org/health-professional/cancer-statistics/statistics-by-cancer-type/head-and-neck-cancers#heading-Zero

2. Breeze J, Poller DN, Gibson D, Tilley EA, Cooke L, Soar E, et al. Rapid on-site assessment of specimens by biomedical scientists improves the quality of head and neck fine needle aspiration cytology. Cytopathology. 2013 Oct;n/a-n/a.

3. Medina Chamorro FM, Calle JA, Stein JE, Merchancano L, Mendoza Briñez AM, Pulido Wilches AA. Experience of the Implementation of Rapid On-Site Evaluation in Ultrasound-Guided Fine-Needle Aspiration Biopsy of Thyroid Nodules. Curr Probl Diagn Radiol. 2018 Jul;47(4):220–4.

4. Aly AK, Ali MA, Sharma A, Gubbels MA, Zhao X, Ahmed A, et al. Rapid On-site Evaluation (ROSE) for Fine Needle Aspiration of Thyroid: Is It Helpful? SciMed J. 2021 Mar 1;3(1):1–7.

In recent years, healthcare policy has been moving towards the concept of patients being able to receive their pathology test results directly, it is likely that pathology providers may need to consider the communication of some laboratory test results directly to patients.

This is a very different group of people to what pathology providers are used to. Expansion of concepts such as reference intervals and what is significant need to be explored in the context of a more general audience.

Coagulation tests can be confusing, but correct interpretation is crucial to guide transfusion of blood products and haemostatic agents. Advantages and limitations of these tests will be discussed, using a variety of examples to demonstrate potential pitfalls.

Learning outcomes:

Understand appropriate use and limitations of coagulation tests
Interpretation of abnormal results
How results can guide transfusion of blood products
Recognise alternatives to blood products for haemostatic support

Blood Transfusion follows binary guidelines designed to protect against the formation of allo red cell antibodies capable of causing Haemolytic Disease of the Foetus and Newborn. For the first time, in 2021, the England and Wales Census included a gender identity question, ‘Is the gender you identify with the same as your sex registered at birth?’. 0.5% of respondents answered ‘No’ (262 000 people) of which 48 000 identified as a trans man, 30 000 as non-binary and 18 000 as another gender identity. Thus, there is a small, but significant, population of Transgender and Gender Diverse (TGD) individuals in society.

What are the implications for Blood Transfusion? There are several scenarios:

The lab could receive a sample labelled male and issue blood components which fail to meet the requirements of Kell negative and, if applicable, CDE negative red cells to someone with childbearing potential.

The lab could receive an antenatal sample labelled male and the LIMS does not allow staff to perform all the same testing and product issuing as it would for a female.

Some TGD individuals who have transitioned may get a new NHS number. Lab staff may be unaware and lab records are not merged which means all future transfusion requests are relying solely on antibody screening results with no historical transfusion information.

The clinical consequences of these errors are missed incompatibilities, special requirements not met (SRNM) errors and immediate or delayed transfusion reactions with a potential for major morbidity or mortality.?All the circumstances described above illustrate that provision of healthcare is not uniform?for?all patients in the UK and could be described as indirect discrimination - a policy or practice that is identical for all people but has an unfair or disproportionate effect on a people with a protected characteristic.

Coagulopathy has been shown to play an important role in COVID 19 infection. Reported abnormal coagulation laboratory values in severe COVID-19 are most notably a 3-to-4-fold increase in D-Dimer (Yao et al., 2020).

Several studies showed that elevated D-dimer in COVID-19 patients is associated with higher mortality. A retrospective cohort study carried out by Zhou, et al. (2020) also associated D-Dimer > 1000ng/ml with higher odds of in-patient death.

At the onset of the COVID 19 pandemic, there was no consensus as to how D-Dimer levels should be used for the management of COVID-19 patients. In April 2020, PAHT decided to use a D-Dimer cut-off of 1000 ng/ml to determine anticoagulation dosage. The source of reference used by PAHT in their decision making employed a D-Dimer assay with a cut off value of 500 ng/ml for the exclusion of venous thromboembolism (VTE). This raised an issue as the source of reference used by PAHT at the time employed a D Dimer assay with a cut-off value of 230 ng/ml for the exclusion of VTE. This meant the trust was unable to implement the new COVID 19 care bundle at the time. The haematology laboratory wanting to do whatever possible to assist patient care agreed to change the current D-Dimer methodology immediately to support the trust COVID 19 care bundle.

The verification and implementation of the new D-Dimer assay with cut of 500 ng/ml for the exclusion of VTE was completed within four weeks. A risk assessment and a change control were put in place to ensure users were made aware of the change in cut-off limit.

This verification and implementation of the new assay was possible through the hard and collaborative work of the haematology technical team with shared vision, motivation coupled with team engagement and strong leadership.

This presentation will outline the content of Paola's Clincal Case Study from her Higher Specialist Portfolio in Medical Microbiology. Here she will present the initial clinical presentation, diagnosis and treatment of a case of neonatal sepsis that linked to a previous unusual maternal screening swab. She will also outline her experience of the Higher Specialist Diploma and her plans for developing a training plan within Microbiology QMC, Nottingham for future candidates within their trust.