Hot Topic: H1N1 Snapshot : BC September 14

14 September; school is back in, and infections begin to rise. BC stats for this week include:

• 865 confirmed H1N1 cases
• 48 hospitalized due to H1N1
• 5 deaths.

(facts found at BCCDC FluWatch, ILI Watch, and Authority Bulletins)

As one dives into the spreadsheets and graphs, a picture begins to make sense beyond the obvious. Although children between the ages of 10 and 19 have the highest number of positive cases, when taking into account they were also the most extensively tested this week (possibily due to parental concerns upon sickness following return to school), it makes sense that the most positives were found in this demographic. Remember, testing of mild cases is now discouraged in otherwise healthy adults.

What concerns me from this weeks picture is that those healthy adults(20-39) seem to be the hardest hit, and most hospitalized. Usually the flu preys on "weak" populations, those with other conditions, the old, the very young, or in vulnerable states such as pregnancy. H1N1 has almost been taking a spanish flu like approach instead; the majority of hospitalized patients in this bulletin were adults or young adults.

As well, new this week is the magic percent of known positive cases upon which WHO suggests schools are to close: *drum roll* The magic number is: one percent. That means if a school of 700 has seven ill students, WHO suggests closing. That said, the Public Health Agency of Canada promptly replied that unless the severity of the pandemic gets a lot worse, or massive numbers of children fall ill, it is unlikely they will activate school closures. (http://www.cbc.ca/health/story/2009/09/11/h1n1-school-close-who.html.

Still no vaccine available in Canada, not even for health care workers.

Hot Topic: H1N1 Basics

H1n1 Basics: Recognition

The following symptoms have been found in patients testing positive:

• 92% had fever
• 92% had a cough, mild to heavy
• 66% had a sore throat
• Only 25% had diarhoeae or vomiting/nausea.

(Note that in elderly patients, the fever can be absent, substiting instead with delirium or decreased level of consciousness.)

H1N1 has not been a nosocomial infection, but instead has been transmitted via the community(on your commute, in the workplace, in the schools, etc). You do not need to be around one of these hospitalized sick people, or someone who has been to Mexico, to contact the flu anymore.

H1n1: So I have the above symptoms.... What next?

DO NOT run to the emergency room for mild flu symptoms. This clogs up the system!

DO take a self inventory. Are your symptoms mild? moderate? debilitating?

If your symptoms are mild and you don't have underlying issues, the BCCDC is not even recommending you go and get tested at the moment. If your symptoms are moderate or if you are pregnant, have concerns about a newborn, or immunocompromised, testing and follow up are still recommended.

The BC Centre for Disease control is currently recommending people who have a fever and respiratory symptoms do the following:

1. Self Isolate for seven days after your symptoms first start. This will prevent spreading.
2. Practise Hand Hygiene (Wash your hands with a non antibacterial soap often)
3. Practise Cough Etiquette (Cough into your elbow, or into a handerchief).
4. If your newborn has H1n1, encourage breastfeeding; this will help.
5. If you DO go out in public, use a surgical mask to prevent spread to other people.
6. Do NOT go to work.

If your symptoms worsen, there are several medications that are effective, as well as the vaccine coming out later this year.

Blood Conservation Systems: BBCIM

It's obvious that the need for more blood is there, both from looking at our interhospital ledgers and the ads on television. The drive is already at maximum to inspire more blood donation (see PSA's here, here, and here), so how do we make what we have last longer, especially in this wavering economy? Each hospital is working on reducing the need for blood by being more stringent with requirements for transfusion already; "top-up" transfusions are nigh a thing of the past, and Which leaves end stage management, an area untouched before 2003: we can do our best to ensure the units we have aren't wasted.

Yes, outdating blood is a problem. Some of the precious blood supply does end up expiring before we use it, even with the high turnover of product and sometimes inappropriate indications given for transfusion. In fact, in 2001/2002, over 4500 units of blood expired without being used in British Columbia(over 98 hospitals); 30% of these were type O (the universal donor).

The main reasons given were as follows:

• wrong blood type for population (only 3% people have type AB blood),
• rural locale (no need for the unit, but it had to be on hand Just-In-Case),
• phenotyped units saved for special patients and then never used, and
• trauma's not needing the massive amounts of blood ordered (Some surgeries/traumas can take anywhere from 4 to over 30 units of red cells to patch back together, so ordering can be overestimated to ensure supply in emergency).

Base line alleviation of this loss is simply shipping the close-to-outdate units to the nearest larger hospital, in hopes they will use it. In the case of phenotyped units, rare blood, or even universal donor units, this method just doesn't fufill potential as is; so enters the British Columbia Blood Inventory Management Pilot.

BCBIM's goals are as follows: (from website)

1. Build a web-based provincial blood inventory communication system.
2. Monitor provincial RBC inventory status and provide early warnings on RBC shortages.
3. Guide Canadian Blood Service’ and hospitals’ ordering policies to correspond with provincial RBC inventory.
4. Establish appropriate medical rules and guidelines for hospitals in response to provincial RBC shortages or other contingencies.

Started in 1997, this program has grown to include over 60 hospitals, leaving only 26 of British Columbia's hospitals uninvolved. After one year of more stringent application of the program, the number of unused blood units in BC had been reduced to 3187. That's over 1000 units of blood saved for use, or at least $500,000 in health care budget, (base cost of replacing all those units). Even better, it brings the outdate percentage down by half for our province.

In plainer English, by documenting exactly how many units of blood (including specialized blood) each hospital has, and when they expire, this overseeing program can plot the logistics of getting blood to the place most needed. For instance, CMV neg and irradiated units, which have a shorter shelf life, to pediatric hospitals, or matched phenotyped units to appropriate donors. woot.

I would highly recommend hospitals to get on board with BCBIM, or their Canadian regional equivilent. At grass roots, it is simple: Just take your daily inventory down on a standardized form,(noting which of your units outdate within seven days), and send it off. The staff at BCBIM then work with the central blood provider to coordinate best allocation of blood to ensure use. Ship your units when requested to the central blood provider(or where they ask you to ship it), and its done.

Although I searched the internet high and low, I cannot seem to find an equivilent system in Washington, or California, the two more active online med lab states. Is this type of system only practical with socialized medicine, where the province is responsible for all blood distribution rather that individual hospitals? Closest I could get to the concepts were:

http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Blood+Management.htm

Endings

I heard today some bitter news; one of my friends and mentors in medlab has recently passed on.

Karen Morrison nee Sigvaldisen was one of my major inspirations to entering medical laboratory science. She was the mother of my best friend in high school, and we would have amazing conversations about current chemistry procedures and how they developed from what was happening when she was starting out; how safety standards back then were such things as "to not try and multitask when mouth pipetting" (see anecdote here for why).

She encouraged me all thoughout the intense medlab program, and explained things to me in high school when the textbooks just didn't cut it. I remember her easy chuckle at those who just hadn't been inspired to love science yet, and how much she loved bike riding and swimming and sailing with her family and friends.

Throughout her life Karen was many things; a teacher, a technologist, a tutor, a mother, a friend, a loving wife, and a charming lady all the way around. My sincere condolences go out to her three daughters and husband.

Pediatric Red Cell Tranfusion

Jargon warning: Present.

Let's talk a little about transfusions in children....

So, what are the top three indications for pediatric transfusion?

1. Acute hemmorhage
2. Bone Marrow Failure
3. Symptomatic chronic anemia (sickle cell anemia, diamond-blackfan anemia, or thallessemia)

Transfusion is something most doctors try and avoid, for two reasons:

1. Children are generally most robust than adults.... their systems can easily compensate for blood loss of up to 25% and remain asymptomatic. They tend to not have any of the underlying conditions that complicate adult cases. If the patient isn't symptomatic, why risk transfusion, and the associated risks of iron overload, and possible infection or reaction?
2. There tend to be other treatments available for most conditions with symptoms; EPO for renal insufficiency, colloid solution for blood volume problems, or oral iron for IDA. Other than acute hemmorhage, there tend to be other viable options instead of transfusion.

When you do transfuse pediatrics, special requirements of the products include either the traditional CMV negative, fresh packed cells(<7 days old), or the more modern choice of a CMV negative single designated donor, depending on your hospital procedures. Speaking of...

I've seen hospital procedure vary a lot, around those two golden principles. Some hospitals saline wash to remove preservative solution just before giving the unit, some do not. Some hospitals insist on across-the board irradiation of the units as well, to cover the special cases such as new oncology patients with unconfirmed diagnosis. Others treat older adolescents like adults. One endorsed method was to always have a fresh CMV negative unit available, that would be hand washed to remove the preservative and then given out with a form to denote how much of the unit was actually given. Another method was to divide the single PRBC unit into three or four bags, to be given out to the patient as needed over the twenty four hour period
(thus reducing the number of donors the child is exposed to, as well as enabling smaller transfusions.)

Both have solid reasons....Doctor's who choose to go with a single donor unit, are typically concerned about minimizing the amount of donor exposure. Aliquots are taken off the sterile unit and used for the amount of permitted storage. The rationale of the traditional choice of fresh packed cells involves trying to side step the possible buildup of potassium(during unit storage) being passed on to the patient(usually more of a concern when patient is in the first four months of life). Let's take a look at this concern.

After the full 42 days of storage, extracellular plasma potassium levels in a single unit of packed red blood cells are shown to be 50mEq/L. I agree that giving the whole unit at once on the last day of possible use would decidedly be too much of a system shock to a neonate, and therefore unsuitable. Thing is, most neonate transfusions we give 15mL/kg. For small amount transfusions(<15mL at a time), the age of the blood is not a concern, as maximum potassium levels would be only 0.015mEq/L (tiny amount) of potassium per transfusion. (See Nelson Pediatrics 18th Ed 2007, pg. 2057). Anything over 25mL of older blood is getting a bit more dicey, and shoule be avoided. That said, non-neonatal pediatrics
can handle the 50mEq/L maximum possible amount of potassium, as can adults.

In short, neonate transfusion requirements and pediatric transfusion requirement are different. Not all hospitals denote that, instead preferring to stick to the more stringent newborn guidelines for all. As blood banking protocols improve, we are working on tailoring out unnecessary product preparation while ensuring that the proper precautions are still in place.

AIDS Symptoms Causes: Part One of Three

Jargon warning: None

Okay, this is going to be a several parter, as I'm delving quite deeply into what is happening in several organs and the body as a whole to cause symptoms. Forgive the variety in assumed knowledge, b/c I'm not quite certain how much I need to go into the basics. This first post will be quite basic. Clear as mud?And it begins!
General AIDS facts:

• Transmitted through blood, sex, and blood products
• Usually targets immune cells called T cells that have a specific protein called CD4 present, although it can infect other types of cells
• Two types of the virus exist, HIV-1 and HIV-2
• The type of virus is the retrovirus, lentivirus sub-family.
• Four stages of AIDS:
  Initial Infection: Mono like illness with fever
  Asymptomatic Infection
  Asymptomatic Infection with Swollen Lymph Nodes
  AIDS - fever, weight loss, swollen lymph nodes, neurological symptoms, and a poor immune system

Basic Hematological changes in AIDS:

• Low platelet count - platelets make up the clot when you stop bleeding. So when you don't have many, you bleed longer, and bruise easier. Sometimes you can bleed from the nose or gums.
• Bone marrow changes - Your bone marrow stores the cells that make new cells to maintain your immune system. AIDS can change these momma cells, either to make your immune system ineffective, or to slow down the rate at which they reproduce.
• Low neutrophil count - Neutrophils are some of the cells in the blood that play important roles in the body's immune by fighting off infection. Low numbers of these mean you catch infections easier.
• Anemia - ie a low red blood cell count. If you don't have many red blood cells, you don't get the oxygen you need to your body as easily. This can make you tired, short of breath, dizzy, pale, or insomniacic, among other things.
  

Next post I'm going to look further into why the above happen. Look for Subject: AIDS, Hematological Changes

Children and Blood Draws

Jargon warning : None Present
Current Mood: relaxed

Lately I've been asked on what you can do to help a child's blood being taken go easier, and be less stressful on your child. Here are a few things that are helpful.

A. Before you come in:

If the child is old enough, explain what will happen when they get poked, or leave enough time that the person taking the blood can explain it to them when you get there. There are several online booklets that can help. See Here.

DO NOT tell your child that it will not hurt, because it will. Tell them its like being pinched or bitten by a mosquito, but the needle will be very small and it will be over quickly. If your child thinks it will not hurt, and then it does, the mismatched expectation often causes thrashing and panic during the procedure.

DO ensure you child has had plenty of water to drink before you come in. Even if a specimen is to be "fasting", you can still drink all the water you want. This will cause the veins to be more plump and visible, which equals an easier poke and no "digging" in the arm. This works for adults too!B. During the Collection

Decide beforehand if you as a parent are able to stay calm being in the same room during the blood draw. Either way is fine; its just if you think you will fuss or cry yourself during the procedure, this will upset your child. If you do stay in the room.....

B. During the phlebotomy:

You can hold your smaller child in your lap to help prevent squirming. A parents lap is a safe space for a young child.

You can help distract! Depending on the age of the child, there usually will be small stickers to give out after the draw, finger puppets, a stuffed animal, and/or comics on the walls, to look at.
Some of the more sucessful child phlebotomists I know have memorized a mountain of knock-knock jokes. Even asking questions that the child has to think about to answer is a good distraction from getting upset.

You can hold their other hand, for older children

Tell them its okay to make as much noise as they want, or cry, as long as they don't move their arm. (or hit the person with the needle ^^) Parent and child can sing a favorite song if they like; whatever distraction that enables the child to hold still, we're happy with.

If your child is not of an age to hold their arm still, often we have the parent and another helper immobilize the arm and torso. If the child is still, the chances of needing a second poke are much slimmer.

C. After the Collection :

Praise your child! Tell them they were brave, and did well. Positive association is important for next time.

Hope this helps!

Welcome

Welcome to the Scope And Needle. This blog will focus on anything and everything medical laboratory related, from the evaluation of the latest innovations and ethical problems in our field, to the late night musings I have about current practise or medlab culture.

Constructive comments are welcome, as are anecdotes. If you disagree with something I post, please be respectful and clear.

A little about me: I am a medical laboratory scientist working on the beautiful west coast of Canada. I've been in out in the field for five years now, and am working on my ART in Immunology and Hematology via classes at the University of British Columbia and CMSLS. I spent the first few years of working (and my practicum) in the centralized acute care and trauma centre of my region; I was excited to get to work with the state of the art neonatal ward there. I then moved to work at a tertiary care hospital while furthering my education, and have now settled on a position that integrates research with core lab functions, as I continue to take classes and figure out where I'm going.

Picture me as that co-worker with the large smile that has tremedous fun breaking down the immune system's cells into army analogies at the bar, and you've got me down pat.

~Dillen