Haematology Home

Consultant Clinical Haematologist	Dr Matthew Lumley	47196
Medical Secretary (Dr M.Lumley's secretary)	Sarah Hennessy	49280
Haematologist		49310
Medical Secretary	Liz Haycock	49707
Medical Secretary	Kerry Brown	49707
Associate Specialist Haematologist	Dr Nuri Alfasi	49294
Head Biomedical Scientist	David Clayton	47271
Phlebotomy Manager	Jane Pemberton	49079 Bleep 8266
Main Laboratory		47279/49286
Blood Transfusion		49290/49213
Customer Service Direct Line		0121-424-7279
Representative	Christine Clift
Anticoagulant Clinic :
Anticoagulant Secretary	Heather Vincent	49342
Anticoagulant Secretary	Janet Mackinnon	49342

Clinical Advice

For clinical advice the Consultant Haematologist can be contacted via the laboratory (normal working hours) or the switchboard (out of hours).

24 Hour Service

The Department operates a 24 hr service, 7 days a week.
To ensure that immediate attention is given to emergency requests, particularly crossmatches, doctors must phone the laboratory to ensure that staff are aware of the priority. It is the responsibility of the requesting doctor to ensure the sample is sent to the Department.

Core Hours (08:30 - 17:30 Monday to Friday) telephone Ext 49290/49213

Out of hours bleep 8779

Key factors known to affect Haematology tests

Preanalytical variation

Factors that may influence test results include phlebotomy, anticoagulant used, specimen transport and storage of samples.

Phlebotomy
Difficulty in taking blood from the patient may result in the sample clotting in the blood tube. This can result in fully clotted samples at one extreme to tiny fibrin ‘clots’ that can be difficult for the laboratory to detect at the other.

Affect on Full Blood Count (FBC) – reduced platelet count due to activation. All parameters can be affected if the clot is removed from the tube before sending to the laboratory.

Affect on Coagulation tests – increased results due to the reduction in available fibrinogen / or decreased results due to activation of the coagulation factors.

Affect on ESR – elevated results

Taking blood from a patients drip arm can result in a dilution of all tests results. Taking blood for coagulation tests from a patient heparin drip arm will result in falsely elevated results.

Anticoagulant
EDTA can cause platelet clumping in approximately 1% of patient samples. The affect is variable and can be detected on examination of the blood film. The problem can be overcome by repeating the FBC and taking both and EDTA and Trisodium Citrate tubes (platelets do not clump in citrate, but this anticoagulant is unsuitable for routine use as blood films are poor made from this anticoagulant).

Incorrect sample volume to anticoagulant is another common problem.

Affect on FBC – causes ‘storage changes’ affecting the White Blood Cell count (reduces count and get a false neutropenia).

Affect on Coagulation tests – samples not filled to the correct volume will result in prolonged analysis time and delays in reporting results (increase in anticoagulation of the blood).

Specimen Transport and Storage

If the specimens are subjected to excessive heat when transported (left in the window of a car in direct sunlight) then the laboratory will reject the FBC, as the results will be bizarre. Coagulation tests will be falsely elevated.

Storage of samples is not recommended before testing.

Coagulation samples – should be tested within 8 hours of phlebotomy or results will be increased.

ESR’s – should not be stored at 4C as this will increase the result even more than if they are left overnight at room temperature.

FBC – Should be kept at 4C overnight if cannot be analysed on the same day. Will still result in ‘storage changes’ as above.

Biological variation

Haemoglobin, Packed Cell Volume and Red Blood Cell count fluctuations usually repeat on a regular diurnal basis, the morning values typically being the highest. Mean WBC counts are usually highest in the afternoon.

Analytical variation

As modern fully automated analysers have replaced manual test procedures, analytic variation has become a relatively minor cause of test variation compared with biological variation. Generally, it is expected to contribute half, or less than half as much, to the total test variation as does biologic variation.

Routine Tests Available

See separate Paediatric instructions

Test	Specimen/Volume	TubeCap	Performed/Reported
Routine Haematology Screen
Full Blood Count inc. platelets, Blood film, Reticulocyte count (where appropriate)	4 ml EDTA		Daily
ESR	4 ml EDTA		Daily
Plasma Viscosity	4 ml EDTA		Daily
D-Dimer (as a negative predictor for PE and DVT)	3.5 ml Citrate		Daily

Test	Specimen/Volume	TubeCap	Performed/Reported
Coagulation Tests :
Coagulation screen (PT, APTT, Fibrinogen)	3.5 ml Citrate		Daily
International Normalised Ratio (INR) (Control of Warfarin therapy)	3.5 ml Citrate		Daily
Activated Partial Thromboplastin Time (APTT) (Control of Heparin therapy)	3.5 ml Citrate		Daily
Lupus Anticoagulant Screening Tests	3.5 ml Citrate		Monthly
Coagulopathy problems should be discussed with the Duty Consultant Haematologist (available through switchboard)

Test	Specimen/Volume	TubeCap	Performed/Reported
Haemoglobinopathy Screening Tests
Hb S (solubility screen)	1 x 4 ml EDTA		As required
Hb Electrophoresis
Hb A₂ Assay
G6 PD Assay

Haemolytic Anaemia Screening Tests
Red cell osmotic fragility	by arrangement with the Laboratory

Test	Specimen/Volume	TubeCap	Performed/Reported
Immunology Tests
Autoantibody screen (ANA) Consists of : Antibodies to nuclear components Mitochondria Smooth muscle Gastric parietal cells dsDNA (If appropriate) plus RA latex	3.5 ml clotted		Weekly

Test	Specimen/Volume	TubeCap	Performed/Reported
Miscellaneous tests
Semen analysis (infertility) and Tests for reversal of vasectomy	By arrangement with Pathology Reception ext. 49298
Semen analysis (post-vasectomy)	Arranged by the Surgeon (send Blue form to Haematology)
Glandular Fever screen	3.5 ml clotted		Daily
Pregnancy test	Early morning urine in sterile container		Daily
Sensitive pregnancy test ( 25 IU/L ) (gynaecological emergencies)	Random urine in sterile container		As required
Malarial Parasites (State country of travel)	4 ml EDTA		As required
Bone marrow	By arrangement with a Consultant Haematologist
PNH screening	By arrangement with Laboratory
Platelet Antibodies	By arrangement with Laboratory
Leucocyte Alkaline Phosphatase

Paediatric Haematology Samples

Full Blood Count	0.5 ml (minimum) Paediatric EDTA tube (Sufficient for film and retics if indicated)
ESR	0.5 ml Paediatric EDTA tube
Coagulation Screen : PT, APTT, Fibrinogen	1.3 ml Citrate tube
Hb Electrophoresis Screen	0.5 ml Paediatric EDTA tube
Autoantibody Screen	1.0 ml Clotted blood

Paediatric Blood Transfusion Samples

Group and Coombs 0.5 ml clotted blood

Crossmatch (age <6 months) 0.5 ml clotted blood from the child
and 4 ml EDTA blood from the mother

Crossmatch (age >6 months) 4 ml EDTA blood from the child

Completion of Request forms

Instructions for clinicians on how to complete Haematology and Blood Transfusion, Immunology and Andrology request forms.

Also refer to Blood Transfusion page for more specific information on completing Blood Transfusion request forms.

All forms should be hand written, legible and with an indelible pen. If pre- printed labels are used please check all details stated below are complete.

Detail	In-patient	GP patient
Registration number	Write the registration number in the box provided, including the prefix.	Leave blank.
Surname/Family name	Write the complete patient’s surname/family name in the box provided.
Forename/Given name	Write the complete patient’s forename in the box provided.
Date of Birth	Write the patient’s Date of Birth in the box provided.
NHS Number	If known write the patient’s NHS number in the boxes provided.
Gender	Complete this box with M or F.
Address	Write the patient’s full address in the box provided if on the request form
Post Code	Write the patient’s full Post Code in the box provided.
Hospital	Write in the code or full name of the hospital the report is to be returned to.	Leave blank
Clinician	Write in the full name of consultant.	Write in the full name of the GP. If using a stamp ensure the details are clear.
Location	Write in the ward, unit or out-patient department.	Write in the full address or known GP code.
Category	Section not on the request form.	Circle if patient is NHS, Cat 2 or Private Patient.
Copy to	Section not on the request form.	Write in the Dr’s name and location where a copy is required in the box provided.
Clinical details	Write all relevant details and medication.
Date requested	Write in the date in the box provided.
Requesters signature	Sign the form in the box provided.
Contact/bleep number	Write in bleep number.	Section not on request form
Date and time collected	Write in the date and time sample was collected in the box provided. The time can be in 12 or 24 hours.
Urgent	Tick this box if the sample is urgent. Remember to put in a contact number.
Sample collected by	This must be signed by the person obtaining the sample.
Specimen type	Write in the sample type e.g. blood, urine, etc.
Tests required	Tick boxes of tests required. For tests not stated write clearly the name of the test in ‘Other Investigations’.

Anticoagulant Clinics

Clinics are held at the following Centres:

Monday	Sir Robert Peel Hospital, Tamworth	9:00am - 12:45pm
Monday	Good Hope Hospital Treatment Centre 1st Floor	New and Review patients 1:15pm - 3:15pm
Tuesday	Good Hope Hospital Treatment Centre 1st Floor	Review patients 8:45am - 10:15am
	Stockland Green Health Centre, Erdington	9:30am - 11:30am
	Holy Cross Church Hall, Chapel lane, Lichfield	2:00pm - 3:15pm
Wednesday	Warren Farm Heath Centre, Kingstanding	9:30am - 10:45am
Wednesday	Good Hope Hospital Treatment Centre 1st Floor	Review patients 2:00pm - 3:15pm
Thursday	Good Hope Hospital Treatment Centre 1st Floor	Review patients from 8:30am - 10:15am New patients from 8:45am - 10:15am
Thursday	Belwell Lane, Four Oaks	2:00pm - 3:15pm
Friday	Good Hope Hospital Treatment Centre 1st Floor	Review patients from 9:00am - 11:00am
	Samuel Johnson Community Hospital, Lichfield	9:00am - 11:45am

When a patient continuing on anticoagulants is discharged, an appointment for the appropriate clinic must be made with the Anticoagulant Clinic Clerk (ext. 49342) 9.00 am - 5.00 pm, and the appropriate yellow form completed and sent to Pharmacy without delay. The Ward staff must inform the patient of the relevant details and arrange transport. It is essential that the dose of Warfarin, at the time of discharge, is stated on the form.
A yellow anticoagulant record book will be issued by Pharmacy to the patient together with their Clinic appointment date.

Warfarin dosing cannot be carried out without a fully completed referral.
The patient should be given sufficient Warfarin to last until at least the first visit to the Clinic and should be told to obtain further supplies promptly from their GP.
Note : Warfarin cannot be supplied at the Clinic.

GP Practices
Anticoagulant control can be arranged directly between the GP surgery and the laboratory, after patients have been stabilised at one of the above clinics. Suitable patients will be chosen at anticoagulant clinic and referred back to their GP.

Guidelines for using the Haematology Services

Users are advised to regard the haematology results as a guide to the assessment and management of an individual patient. It is helpful to indicate appropriate clinical details on the request form, e.g. 'on chemotherapy', 'post-transfusion', '? Anaemic' etc. There is 24-hour availability of consultant advice to assist in the interpretation of laboratory results. Where results appear inconsistent with the clinical condition, users are advised to discuss this with the laboratory and if necessary submit a repeat specimen.
There are no absolute thresholds for urgent action in the light of laboratory results as the clinical condition is in general of greater importance than the laboratory data. Usually, however, adult patients will be symptomatic with a Hb of <8.0 g/dL unless this anaemia has developed extremely gradually to allow for compensation. A further generalisation is that patients will not develop spontaneous bleeding unless the platelet count drops to <50x10⁹/L as an isolated phenomenon, naturally a coagulation screen would provide additional useful information in a bleeding patient. In practice, persistent leucopenia is not too uncommon and in the absence of infectious symptoms, this finding should not generate undue alarm.
There follows a brief description of some frequently used morphological terms and interpretative comments in relation to red cell, white cell and platelet numbers.

Red Cells
Anisocytosis	i.e. Variation In size
	? Anaemia responding to treatment
	? Post transfusion
Dimorphic	i.e. Two populations of cells
	? Anaemia responding to treatment
	? Post transfusion
Poikilocytosis	i.e. Variation in shape
Poikilocytosis	Teardrop cells may suggest marrow fibrosis
Elliptocytosis	Consider iron deficiency
Spherocytes	Consider haemolysis
Target cells	Consider liver disease, splenectomy,HbC , thalassaemia
Macrocytosis	Consider Liver disease (+ alcohol), B12 +/- folate deficiency
Howell-Jolly bodies	Lack of spleen, splenic atrophy
Microcytosis	Consider Iron deficiency, thalassaemia
Hypochromia	Consider iron deficiency, thalassaemia
Polychromasia	Indicates reticulocytosis e.g. in response to bleeding, haemolysis, haematinics

White Cells
Neutrophilia	Consider bacterial infection, inflammation, neoplasm, steroid treatment. A normal finding in pregnancy
Hypersegmented	Right shifted neutrophils. Consider B12 +/- folate deficiency
Left shifted Neutrophils	Consider bacterial infection, myelodysplasia
Neutropenia	Consider B12 +/- folate deficiency. Normal variant especially Afro-Caribbean. Autoimmune disease. Drugs (especially chemotherapy)
Lymphocytosis	Normal in children. Consider viral infection & TB. Chronic Lymphocytic Leukaemia (smear cells typically seen)

Platelets

Reduced Marrow failure, ITP, drugs (often platelet anisocytosis or giant platelets)

Increased Response to bleeding, inflammation, neoplasm, infection.
If persistent, consider myeloproliferative disease

D-Dimer

Click on the Word document icon below for guidelines on the interpretation of D-Dimer in the diagnosis of DVT or PE.
After viewing the guidelines, click on your browser 'back' button to exit from the document and return to this page.

Auto-immune Testing

With the merger of Good Hope Hospital and Heartlands Hospital, immunology tests are now performed at Heartlands Hospital, Immunology Department (0121 424 2105). Samples received at Good Hope Hospital for immunology tests will be processed and then forwarded to Immunology Department for analysis.
Anti-Nuclear Antibodies (ANA)
Indicated in the investigation of suspected connective tissue diseases and rheumatic diseases. They are present in elevated titres (>100) and are usually of IgG class in 95% of untreated cases of SLE, their absence virtually excludes this diagnosis. Hence it is a good screening test for SLE. However, these antibodies are not specific for SLE, as a positive ANA may occur in a number of conditions other than SLE including Juvenile Chronic Arthritis, Sjogrens Syndrome, Fibrosing Alveolitis, Chronic Active Hepatitis, viral infections (EBV, CMV) and in drug reactions. The frequency of low titre ANA in normal individuals rises with increasing age.
Anti DNA Antibodies (dsDNA)
The test is designed to pick up anti double stranded DNA Antibodies. This test is currently performed on any serum with a positive ANA, or when specifically requested by the clinician (indications for the test may alter as a result of laboratory audit). Their presence is strongly suggestive of SLE although they are present in only 40-60% of patients with this disease.

Anti Gastric Parietal Cell Antibodies (GPC)
Are present in 95% of patients with Pernicious Anaemia. They also occur in 3% of the normal population and the incidence rises with increasing age. If there is a suspicion of Pernicious Anaemia (e.g. a macrocytic anaemia) then Intrinsic Factor Antibodies should also be requested as 75% of patients with PA have this antibody.

Anti Mitochondrial Antibody (AMA)
High titres occur in 95% of patients with Primary Biliary Cirrhosis but low titres may also be found in Chronic Active Hepatitis.

Anti-Smooth Muscle Antibodies (SMA)
High titres are associated with Autoimmune Chronic Active Hepatitis. Low titres may occur in a number of conditions including viral infections especially EBV and Hepatitis A.

Group and Coombs	0.5 ml clotted blood
Crossmatch (age <6 months)	0.5 ml clotted blood from the child and 4 ml EDTA blood from the mother
Crossmatch (age >6 months)	4 ml EDTA blood from the child

Platelets
Reduced	Marrow failure, ITP, drugs (often platelet anisocytosis or giant platelets)
Increased	Response to bleeding, inflammation, neoplasm, infection. If persistent, consider myeloproliferative disease