Chromosomes      peripheral blood cells


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Telephone Extensions

Consultant Clinical Haematologist

Dr Malcolm Hamilton 

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2226

Medical Secretary

Christine Smith 

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2202

Consultant Clinical Haematologist

Dr Matthew Lumley 

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2196

Medical Secretary

Karen Hughes  

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2204

Medical Secretary

Julie Stanier 

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2203

Associate Specialist Haematologist

Dr Nuri Alfasi 

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2541
Head Biomedical Scientist

David Clayton   

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2200
Phlebotomy Manager

Jane Pemberton 

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6079  Bleep 779
Main Laboratory

 

  

2205
Blood Transfusion     

2208
NEQAS Haematinics

 

  

2201
Customer Service Direct Line 

 

  

0121-378 6015

Representative

Christine Clift

  

 
Anticoagulant Clinic :

 

  

 

        Clinic Clerk

Pauline Scott

  

2224/2312

        Clinic Clerk

Julie Moran

  

2224/2312 

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.

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 – small sample size will result in prolonged results (increase in anticoagulation of the blood). The laboratory may not always detect this.

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 6 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

 2 ml EDTA

 

 Daily

Plasma Viscosity

 4 ml EDTA

Daily

D-Dimer
(as a negative predictor for PE and DVT)

 2.7 ml Citrate

 

 Daily

 

Test Specimen/Volume TubeCap Performed/Reported

Coagulation Tests :
Coagulation screen (PT, APTT, Fibrinogen) 2.7 ml Citrate

 

Daily
International Normalised Ratio (INR)
(Control of Warfarin therapy)		 2.7 ml Citrate

Daily
Activated Partial Thromboplastin Time (APTT)
(Control of Heparin therapy)		 2.7 ml Citrate

Daily
Lupus Anticoagulant Screening Tests 2.7 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 		 4.5 ml clotted

Weekly
Thyroid Peroxidase antibody 4.5 ml clotted

Fortnightly

Test Specimen/Volume TubeCap Performed/Reported

Miscellaneous tests
Semen analysis (infertility) and
Tests for reversal of vasectomy		 By arrangement with Pathology Reception ext. 2215
Semen analysis
(post-vasectomy)		 Arranged by the Surgeon
(send Blue form to Haematology)
Glandular Fever screen 4.5 ml clotted

Daily

RA Latex test

 4. 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)

 4.5 ml EDTA

 

As required

Red Cell Folate

 4.5 ml EDTA

 

Weekly

Bone marrow

 By arrangement with a Consultant Haematologist

Dicopac and Blood Volume

 Send referral letter to Consultant Haematologist

PNH screening

 By arrangement with Laboratory

Platelet Antibodies

Leucocyte Alkaline Phosphatase

 

 

Paediatric Haematology Samples

Full Blood Count 0.5 ml Paediatric EDTA tube
(Sufficient for film and retics if indicated)
ESR 0.5 ml Paediatric EDTA tube
Coagulation Screen :  PT, APTT, Fibrinogen 1.0 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 4.5 ml EDTA blood from the mother
Crossmatch (age >6 months) 4.5 ml EDTA blood from the child

 

Anticoagulant Clinics

Clinics are held at the following Centres:

Good Hope Hospital
Clinical Haematology Unit
(Sheldon Block) 		Monday New patients 1.30pm
Thursday Regular patients 8.30-10.30am
Thursday New patients 10.45am
Stockland Green Health Centre Tuesday   9.30am
Sir Robert Peel Hospital Monday   9.00am
Lichfield Victoria Hospital Friday   9.00am
Warren Farm Wednesday   9.30am

When a patient continuing on anticoagulants is discharged, an appointment for the appropriate clinic must be made with the Anticoagulant Clinic Clerk (ext. 2211) 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 <80 g/L 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
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.
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guidelines on the interpretation of D-Dimer in the diagnosis of DVT or PE

 

Auto-immune Testing

The Haematology Department performs a small repertoire of tests concerned with auto immune diseases. Clinical advice, where necessary, is available from :-

Mike Smith (Principle Immunologist) : Biochemistry Ext. 2247

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.