British Committee For Standards In Haematology Research Articles

Comparison of diagnostic criteria for polycythaemia vera

Three sets of diagnostic criteria for polycythaemia vera (PY); the Polycythaemia Vera Study Group (PVSG) criteria (1975), the British Committee for Standards in Haematology (BCSH) criteria (1996) and the World Health Organisation (WHO) criteria (2001) have been described. We compared the ability of each set of criteria to accurately diagnose PV and differentiate it from secondary, apparent and idiopathic erythrocytosis. A cohort was drawn from a clinical database of erythrocytosis patients currently attending the Belfast City Hospital and the relevant information from the time of diagnosis for each patient was assessed according to each set of criteria, with the BCSH criteria used as a comparator.Sufficient data was available on 71 patients: 46 PV, 8 idiopathic, 8 apparent and 9 secondary erythrocytosis. The BCSH criteria classified 34 of 46 patients (73.9%) as PV and the WHO criteria had a sensitivity and specificity of 100% for classifying PV. For idiopathic and apparent erythrocytosis, the specificity of the WHO criteria, compared to the BCSH criteria, declined to 66.7 and 87.5%, respectively. The PVSG criteria were limited by the unavailability of required data for some patients resulting in a sensitivity and specificity of 50% for PV and specificity of 100% for all other groups. The Janus kinase 2 (JAK2) V617F mutation was present in 34 (85.3%) PV, 2 (50%) IE, 1 (50%) apparent and no secondary erythrocytosis cases.We concluded that the BCSH criteria were the most accurate diagnostic criteria for PV as they had an acceptable level of sensitivity and could differentiate between PV and other erythrocytoses.

Recommendations from the British Committee for Standards in Haematology and National Patient Safety Agency

The British Committee for Standards in Haematology (BCSH) published its third edition of Guidelines on Oral Anticoagulation in 1998 (British Committee for Standards in Haematology, 1998) with an update in 2006 (Baglin et al, 2006). These recommendations on safety indicators compliment those guidelines. Risks and recommendations are accompanied by lists of safety indicators for patients starting oral anticoagulant therapy and for patients established on oral anticoagulant therapy. Not all indicators will necessarily be adopted by every service; rather a selection is provided from which to choose those considered most useful for local circumstances and needs. It is envisaged that indicators will be used to set standards for service development and for controls assurance, either by monitoring or audit (see section on Governance). As in the previous guidelines the term ‘oral anticoagulant’ refers to oral vitamin K antagonists (VKA), such as warfarin. Initial drafts of the guideline were produced by the writing group and modified in accordance with comments from a multidisciplinary sounding board, the BCSH and the British Society for Haematology (BSH ) and comments incorporated where appropriate. Criteria used to quote levels and grades of evidence are as in appendix 3 of the Procedure for Guidelines Commissioned by the BCSH (http://www.bcshguidelines.com). The target audience for this guideline is healthcare professionals involved in the management of patients receiving oral anticoagulant therapy.

Guidelines on the management of massive blood loss

The guideline group was selected to be representative of UKbased medical experts and included the authors of previous recommendations. Preparation of the guidelines included a review of key literature, including Cochrane Database and MEDLINE and consultation with representatives of relevant specialties. Recommendations are based on appraisal of the relevant literature and expert consensus. The writing group produced the draft guideline, which was subsequently revised by consensus by members of the Transfusion Task Force of the British Committee for Standards in Haematology. The guideline was then reviewed by a sounding board of approximately 100 UK haematologists, the British Committee for Standards in Haematology (BCSH) and the British Society for Haematology Committee and comments incorporated where appropriate. Criteria used to quote levels and grades of evidence are as outlined in appendix 3 of the Procedure for Guidelines Commissioned by the BCSH (http:// www.bcshguidelines.com/process1.asp#App3). The objective of this guideline is to provide healthcare professionals with clear guidance on the management of massive blood loss. They do not address the specific problems associated with major obstetric haemorrhage; these are being addressed by the Royal College of Obstetricians. In all cases individual patient circumstances may dictate an alternative approach.

Hospital admissions for acute painful crisis in Trinidad and Tobago. Are the British Committee for Standards in Haematology (BCSH) guidelines applicable?

We observed consecutive hospital admissions for acute painful crisis (APC) among adults with Sickle Cell Disease (SCD) over a 6-month period in Trinidad and Tobago. Episodes (111) of APC resulted in 82 admissions of 59 patients. The most common site for pain was the trunk. Patients ranged in age from 17 to 53 years (median: 25). Median length of hospital stay was 4 days. Total dose of Pethidine given per admission ranged from 100 to 1650 mg (median: 525). The mean dose of morphine was 70 mg. Six (7%) of patients were readmitted within 10 days of discharge. Twenty-five (30%) of patients had chest pain at presentation of whom 10 (12%) had consolidation on chest X-ray, defining the acute chest syndrome (ACS). There was one death caused by biliary sepsis. The study revealed seemingly low opiate usage for in-hospital treatment of APC with acceptable rates of readmission. The BCSH 2003 guidelines seemed applicable apart for the choice and route of fluid for rehydration and opiate analgesia.

P12 An Audit of Fresh Frozen Plasma Transfusion Use in the Royal Hospitals Trust (RGHT)

Allogeneic fresh frozen plasma (FFP) transfusions have increased in recent years, in the Royal Group of Hospitals Trust and in the UK as a whole. In the 2003 Serious Hazards of Transfusion report, FFP was the blood product most commonly attributed to the development of transfusion associated acute lung injury and a leading cause of transfusion related mortality. In the British Committee for Standards in Haematology (BCSH) guidelines there are few indications for FFP transfusion. Stainsby found that appropriateness of FFP transfusion in England varied from 62–92%.Audit objectives (i) To assess the appropriateness of FFP transfusions in the RGHT against BCSH guidelines ‐ 100% standard; and (ii) To assess the adequacy of documentation for FFP transfusion episodes re indication for transfusion and clinical effectiveness ‐ 100% standard.Method Data relating to FFP transfusion episodes between October 2004 and January 2005 inclusive, was extracted retrospectively from available patient notes by an SpR in haematology and a consultant anaesthetist. Anonymously completed proformas were jointly assessed for appropriateness of transfusion by the same investigators. FFP transfusion episodes Appropriate Inappropriate 137 episodes (114 patients) 93 (68%) 44 (32%) Reversal of warfarin effect, bleeding not severe or absent 16 Hepatic disease induced coagulopathy, no bleeding 6 Heparin/antiplatelet induced coagulopathy, with bleeding 4 Other causes of coagulopathy without bleeding 13 Ongoing blood loss, normal coagulation screen 4 Normal coagulation screen, no evidence of bleeding 1 Clinical documentation Present Absent Statement re indication for FFP transfusion 73 (53%) 64 (47%) Statement re clinical effectiveness of transfusion 52 (38%) 85 (62%) Conclusion and Recommendations A significant number of FFP transfusions are inappropriate, based on recent BCSH guidance. Documentation in clinical notes concerning the indication and response to FFP transfusion is frequently lacking. Appropriateness of FFP transfusion and associated clinical documentation should be improved by staff education and greater awareness of BCSH guidelines. Education should also include appropriate monitoring and management of bleeding secondary to warfarin or antiplatelet therapy. FFP transfusions should be re‐audited 1 year hence. Guidelines for the use of fresh‐frozen plasma, cryoprecipitate and cryosupernatant. The British Society for Haematology 2004, 126: 11–28 Stainsby D. Audit of the Appropriate Use of Fresh Frozen Plasma, National Blood Service, May 2002.

Guidelines on use of vena cava filters

Summary of key recommendations • VC filters are indicated to prevent pulmonary embolus(PE) in patients with venous thromboembolism (VTE)who have a contraindication to anticoagulation (grade B,level III).• Anticoagulation should be considered in patients with aVC filter when a temporary contraindication to antico-agulant therapy is no longer present. Insufficient dataexists to support a recommendation that all filter recip-ients should be treated with indefinite anticoagulationregardless of their risk of recurrent thrombosis (grade C,level IV). The decision as to whether or not to introduceanticoagulant therapy should be based on the perceivedunderlying thrombotic risk of the condition and thelikelihood of anticoagulant therapy-related bleeding.• VC filters are not indicated in unselected patients withVTE who will receive conventional anticoagulant therapy(grade A, level Ib).• VC filter insertion may be considered in selected patientswith PE despite therapeutic anticoagulation. Alternativetreatment options, such as long-term high-intensity oralanticoagulant therapy [international normalised ratio(INR) target 3AE5] or low molecular weight heparin(LMWH), should be considered prior to VC filterplacement, particularly in patients with thrombophilicdisorders (e.g. antiphospholipid syndrome) or cancer(grade C, level IV).• VC filter insertion may be considered in pregnantpatients who have contraindications to anticoagulationor develop extensive VTE shortly before delivery (within2 weeks). Retrievable filters should be considered (gradeC, level IV).• Free-floating thrombus is not an indication for insertionof a VC filter (grade B, level III).• Thrombolysis is not an indication for filter insertion. If afilter is used a retrievable filter should be used if available(grade C, level IV).• VC filters should be considered in any pre-operativepatient with recent VTE (within 1 month) in whomanticoagulation must be interrupted. Retrievable VCfilters should be considered in this situation where atemporary contraindication to anticoagulation exists(grade C, level IV).• No particular filter appears superior to others. Removablefilters should be used, if available, for patients with ashort-term contraindication to anticoagulant therapy(e.g. approximately 2 weeks) (grade C, level IV).

An audit of thrombophilia screens: results from the National Pathology Alliance benchmarking review

Aims: The National Pathology Alliance benchmarking review has completed six years of data collection and analysis of the workload and organisation of haematology laboratories in the UK. This study audits...

Guidelines on the diagnosis and management of multiple myeloma 2005

In 2001, guidelines for the diagnosis and management of myeloma were published by the Guidelines Working Group of the UK Myeloma Forum (UKMF) on behalf of the British Committee for Standards in Haematology (BCSH) (UK Myeloma Forum; British Committee for Standards in Haematology, 2001). That same year, the second edition of guidelines prepared by the Nordic Myeloma Study Group (NMSG) in 1995 was issued (in the Scandinavian languages; http:// www.myeloma-nordic.org). As both sets of guidelines were intended to be evidence based, it was reassuring to note that the recommendations were similar. Subsequently, informal contact between members of the two groups led to the decision to prepare these common, updated guidelines. These revised and updated guidelines include new sections on imaging and the management of skeletal disease, cover new developments in disease classification and staging and the use of new therapeutic approaches, such as thalidomide, bortezomib and reduced-intensity allogeneic transplantation. The guidelines are presented in specific sections as follows:

Guidelines on oral anticoagulation (warfarin): third edition – 2005 update

The British Committee for Standards in Haematology (BCSH) published its third edition of Guidelines on Oral Anticoagulation in 1998 (British Committee for Standards in Haematology, 1998). Most of the recommendations made in 1998 remain unchanged and a fourth edition of the guideline is considered unnecessary at the time of writing (June 2005). However, we draw attention to those areas where new informative data have been published. As in the original guideline, the term ‘oral anticoagulant’ used in this update refers to oral vitamin K antagonists (VKA), such as warfarin. New oral non-VKA are currently being evaluated in clinical trials but are not yet licensed for use in the UK. When these drugs become available new guidance will be issued specifically for the use of those drugs. The guideline group was selected to be representative of UKbased medical experts. The drafting group met and communicated by email. MEDLINE was searched systematically for publications in English from 1998. The writing group convenor (T. Baglin) produced the draft guidelines which were subsequently revised by consensus. The guideline was reviewed by a multidisciplinary sounding board, the BCSH and the British Society for Haematology (BSH) and comments incorporated where appropriate. Criteria used to quote levels and grades of evidence are as in Appendix 3 of the Procedure for Guidelines Commissioned by the BCSH (http://www.bcshguidelines.com/process1.asp#App3). The target audience for this guideline is healthcare professionals involved in the management of patients receiving oral anticoagulant therapy.

Response to van Veen et al

We note the retrospective report by van Veen et al on children with acute lymphoblastic leukaemia (ALL) with interest. When Task Forces of the British Committee for Standards in Haematology (BCSH) prepare guidelines for good practice, all available information is taken into account. It is accepted that the best evidence comes from randomized controlled clinical trials, but unfortunately there is often a dearth of such data in many areas of transfusion practice, for both children and adults. The Task Forces therefore have to refer to such information and studies as are available, which are mostly case reports and retrospective uncontrolled surveys. Among such reports is the account from Howard et al (2000), which evaluated 5223 lumbar punctures in 958 children with ALL at diagnosis and during treatment, and to which reference was made in the Guidelines for the Transfusion of Neonates and Older Children (BCSH, 2004). The relevant section in the BCSH Guidelines for the Transfusion of Neonates and Older Children (BCSH, 2004) (5.2.2. Platelets) includes the following statements (reference details are given in BCSH (2004): ‘In the absence of evidence-based guidelines for children, Table V reflects current recommended practice in children (Hume, 1996: level IIb evidence, grade B recommendation; Cahill & Lilleyman, 1998: level IV evidence, grade C recommendation; Ancliff & Machin, 1998: level IV evidence, grade C recommendation; Howard et al, 2000: level III evidence, grade B recommendation)…In children with aplasia, a restrictive policy with platelet transfusion is safe for long-term management (Sagmeister et al, 1999: level IV evidence, grade C recommendation). However, children with aplastic anaemia during and following treatment with ALG (antilymphocyte globulin) in particular may require intensive platelet support. In contrast, some paediatricians are prepared to conduct follow-up lumbar punctures on children with counts as low as 20 × 109/l, having not experienced unduly high adverse effects’. Table V of these Guidelines lists the indications for prophylactic platelet transfusion in children with thrombocytopenia as a result of reduced production (from any cause) and includes patients with a platelet count of 20–40 × 109/l prior to lumbar puncture (or central venous line insertion). It should be noted that this recommendation refers to a lumbar puncture performed in any setting. The BCSH Guidelines for the use of Platelet Transfusions (BCSH, 2003) state that there is a lack of evidence to guide decisions regarding platelet transfusions to cover invasive procedures, and that it is unlikely that comprehensive studies could be carried out because of the large number of variables involved. The BCSH guidelines indicate that work in this area is reviewed in the American Society of Clinical Oncology guidelines on platelet transfusion (Schiffer et al, 2001), including the papers by Edelson et al (1974) and Howard et al (2000). Schiffer et al (2001) pointed out that lumbar puncture is often more technically difficult in adults than in children, and that it is unclear whether the exemplary safety reported by Howard et al (2000) in children with ALL could be duplicated in adults. Guidance in the BCSH Guidelines for the use of Platelet Transfusions (BCSH, 2003) was given on the basis of this information and expert opinion, and included the recommendation that the platelet count should be raised to at least 50 × 109/l for lumbar puncture, epidural anaesthesia, gastroscopy and biopsy, insertion of indwelling lines, transbronchial biopsy, liver biopsy, laparotomy or similar procedures (grade B, level III). We do not demur from the advice from van Veen et al, given the specific circumstances affecting their patients, and we have acknowledged similar practice. We also acknowledge that transfusion of any blood component or product must be prescribed with the utmost care and consideration of long-term effects, especially in younger patients. Nevertheless, we do feel that the advice in the BCSH guidelines is founded on the best current information available.

Erratum

British Journal of HaematologyVolume 126, Issue 4 p. 625-625 Free Access Erratum First published: 19 July 2004 https://doi.org/10.1111/j.1365-2141.2004.05063.xAboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat In Marsh et al (2003), the following error was published on page 792. 3. Administration A test dose (1 mg in 100 ml Nsaline as an intravenous infusion over 1 h) must be given beforehand, and, if a severe systematic reaction or anaphylaxis occurs, further doses of that preparation of ATG must not be given. The text was incorrect and should have read: A test dose of one–tenth of a vial (10 mg for horse ATG or 2·5 mg for rabbit ATG), diluted in 100 ml of Nsaline and infused intravenously over 1 h, must be given beforehand, and, if a severe systematic reaction or anaphylaxis occurs, further doses of that preparation of ATG must not be given. We apologize for this error. Reference Marsh, J.C.W., Ball, S.E., Darbyshire, P., Gordon-Smith, E.C., Keidan, A.J., Martin, A., McCann, S.R., Mercieca, J., Oscier, D., Roques, A.W.W., Yin, J.A.L. on behalf of the British Committee for Standards in Haematology (BCSH) (2003) General Haematology Task Force. Guidelines for the diagnosis and management of acquired aplastic anaemia. British Journal of Haematology, 123, 782– 801.Wiley Online LibraryCASPubMedWeb of Science®Google Scholar Volume126, Issue4August 2004Pages 625-625 ReferencesRelatedInformation

Current performance of patient sample collection in the UK.

Collection of the patient sample for pretransfusion testing begins a complex chain of events in the transfusion process. Hospitals in England and North Wales were surveyed to compare local policies against recommendations of the British Committee for Standards in Haematology (BCSH). Hospitals also measured the frequency of rejected and miscollected samples [designated as wrong blood in tube (WBIT)]. 185 of 360 (51.4%) hospitals returned questionnaires and 182 of 185 (98%) hospitals reported that a policy for sample collection existed. Apart from frequent omission of the gender of the patient, there was 96% compliance with all mandatory identifiers of the BCSH guidelines. Practice allowing additions or changes to labelling on sample tubes and request forms varied. 3.2% (14 114/445 726) of samples submitted were rejected for various reasons, the most frequent being incomplete or missing information (49.5% of the total rejected samples). The corrected mean frequency for WBIT in the 27 hospitals with one or more observed WBIT was 1 in 1501 samples (95% CI: < or =1129.09 to < or =1872.91), and the median corrected frequency for WBIT was 1 in 1303 samples. This study has identified great variation in the policy and practice for sample collection for pretransfusion testing. Regular tracking of the rates of sample rejection and WBIT could be used to identify poor performance in individual hospitals requiring investigation and action.

Viral inactivation of fresh frozen plasma.

Viral inactivation of fresh frozen plasma.