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Sorry, I was muted. Um Can you see my, can you see my screen now? Yes, very clearly. Excellent. Oh, I'm a second. All right. Let me just get it. So that sorry, I'm just gonna stop shared to try and get it so I can see it properly as well. Okay, perfect. Right. Ok. Um So firstly, I um um using someone else's slides. So a big thank you to doctor proven for permission to use the slides and, and these slides were first used at a BMJ Masterclass, of course, but obviously this talk is sort of on behalf of me, it's not on behalf of BMJ Masterclass is. So I've been asked to talk about interpreting abnormal results, which is not something that is a particular expertise of mine, but obviously as a G P, um we do it all the time, we get results that are a bit odd and we have to think is this something significant? Is this not? So I'm going to talk you through largely interpreting hematology results. Um and a little bit at the end about abnormal LFTs and fatty liver, which is an increasing problem with the growth of obesity and metabolic syndrome. Um So the first just going a little bit sort of philosophically, um there are various definitions of health and if you think about the sort of bell curve with 2.5% outside the normal range at each end, and if you do 20 tests on a healthy person, you may well end up with one of them being abnormal. So I think always the first thing to look at when you get an abnormal test is, is this, is this actually relevant? How abnormal is it? If the normal range of something is 100 and 50 to 500 your patient has come back with a test of 501 is that actually significant or is it just um just, just, just, just out of the normal range? Do you want to think about repeating it before you actually do anything else? Um And we have certainly in the UK, we have a massive problem with private companies offering um, screens where they do a load of blood tests which aren't particularly indicated. And inevitably one of them comes around, comes back slightly outside the normal range and then they dump it on the G P to sort it out, you're going to have to excuse me because I have a bit of a cold at the moment. So it is just something to be aware of when you qualify. Um I'm always very keen on saying to our GP trainees don't do a test unless you know how the outcome of that test will influence your actions. If you, if the result of a test is not going to change your actions don't do it. And if, if you find yourself going tick, tick, tick, tick down the blood form, ticking all the boxes and stop and think, why am I actually requesting these tests? So, let's start with our deficiency anemia, which is very common. So we've got here a 43 year old woman with a low ferritin of three and a low hemoglobin of 6.5. It's not uncommon to see hemoglobin's down to six and sometimes lower in women for whom it ends up that the periods are the are the only issue. Um It gets remarkably low, the hemoglobin lower than you might think. So, I know you haven't got um I know you haven't got the boating pads, but just have a little think about what you might want to do, what test you might want to do if you were thinking about someone's um iron status when this talk was last given, that was the, that was how people voted. So most people went with a serum ferritin. Um Not very many people want with a transfer in saturation or, or hipaa chromic red cells. So we're thinking about a 46 year old woman with heavy periods hemoglobin of eight. In this case, MCV of 71 a ferritin of four. So that seems quite clearly to be an iron deficiency picture. And you can see there, obviously, we don't often get a film to actually look at in primary care, but we sometimes get the results of a film. So they get these hipaa chromic red cells are very pale in the middle. Um A low hemoglobin is a relatively late feature of iron deficiency. Um So this woman has been having heavy periods if that's what the causes for quite some time. And it always amazes me how women in particular who are losing blood gradually through their periods can walk around with a hemoglobin sometimes as low as four or five. Um And they're feeling absolutely fine because they're losing it so gradually. Whereas obviously, if you had a massive bleed, that took your hemoglobin down to four or five, you'd feel pretty unwell with it. Um And in what also surprises me is how quickly it comes up with iron. So, in previous years, I always used to prefer women with hemoglobins of five or six in for a transfusion. And then in COVID, they were often very reluctant to go, which was understandable. So I'd say we'll give you some iron and check it in a month and see what happens. And, and the hemoglobin would have come up from, from five or other from, from sort of 50 up to um you know, up to 100 and 10, up to up to nearly normal. So low hemoglobin is a late feature, the MCV tends to go down first. Um Ferritin is the main thing that we use. Um But I will come on to the next slide. The problems with using ferritin, if you need an extra indication, then generally speaking, transferring saturation is the best one to use. And depending on what system you work in, often, if you just request iron studies, you will get iron and total iron binding content and, and transparent saturation and, and everything together. The problem with ferritin is that it is an acute phase protein as well. So it goes up with inflammation. So if for example, you had a patient who you were concerned about iron deficiency, but they had inflammatory bowel disease at the same time and there was a bit of a flare going on at the moment. It may well be that they're ferritin was normal because the low ferritin of the iron deficiency is um sort of overridden by the increased ferritin of it being an acute phase protein. So if your ferritin is low, then then you know what you're looking at that, that there are the iron stores are absent. Um And often when, when you correct someone's hemoglobin, it takes some time after you correct the hemoglobin for the ferritin to come back to normal because it reflects the iron stores. If the ferritin is normal, that could mean the iron stores are normal or it could mean the iron stores are low and the ferritin is being put up as an acute phase protein. If as an acute pick phase protein, if the ferritin is high, then it is likely that the iron stores will be normal or high. So ferritin is most useful in a patient who is not unwell at the time. And if your patient is unwell, you're thinking about iron deficiency anemia, but the ferritin is normal, then wonder if that might be because of the acute phase reaction and think about looking at other measures of iron. That's basically the sort of take home message from this. What about if you do a ferritin and it's high. So this is a man with a normal hemoglobin and a raised ferritin above 1000. There are a variety of causes of raised ferritin, um including things like metabolic syndrome, which are extremely common these days. But obviously, the thing that we always immediately think if someone has a raised ferritin is um do they have hemochromatosis? Do they have um you know, excess iron, which actually needs proper investigation? So this is the British Society for Hematology um guidance as to whether we should think about hemochromotosis. Basically, what they want to know is the sex of the patient, the ferritin and the transparent saturation. And these are the points at which they think we should consider testing for hemochromatosis and depending on what system you're working in. Sometimes in primary care, you might be able to check for the genetic mutation or hemochromotosis. Um, and sometimes at this point, you might want to refer on to a hematologist. Um, it's, it's not a terribly common condition. Um, and it most often presents with common symptoms, fatigue, joint pain, depression, things that we see in primary care all the time. And so it's very, very easy to miss. It's worth thinking about in your patient's who have these sort of unexplained symptoms. It's worth checking a ferritin and a transparent saturation. Um The, the they call it um bronze diabetes that you read about in the textbooks of people who have increased pigmentation in the skin along with diabetes do to pancreas. Um problems from hemochromotosis is a very, very late sign and not one that is regularly seen. So this is something to think about. Um, we all have, you know, a group of patients who have vague symptoms over a long period of time that we haven't managed to get to the bottom of. And there are a group of conditions that do present vaguely. And so in, you know, in patient's with symptoms like this, I always think about hemochromotosis. Um with fatigue, things like celiac hepatitis C HIV. These conditions that don't always present with an obvious symptoms are worth thinking about and worth trying to test for if you're having a patient where you're really not getting on and you really can't work out what's going on. So this is a 58 year old man who is anemic with a very low MCB 58. So much lower than the iron deficiency ones that we were looking at which were in the seventies. So ever think for a second about which of these tests you would think about using to distinguish beta thalassemia from iron deficiency in this patient. I'll just let you have a think about that for a second. And these were the answers when this talk was first given. So, electric freezes, that is the correct answer that the majority of people have gone with. So be thalassemia trait is very easily confused with iron deficiency. And so probably the first thing when you get someone with a low MCV is to just have a quick look back through the old records if they're available to, to check if a thalassemia trait has ever been looked for in the past. And they're usually asymptomatic with a mild anemia. Um and these are the different types of, of, um, hemoglobin's that you find in the blood. So, yep. So this is sort of typical results. The MCV will be very low in the fifties as opposed to in the seventies with, with a mild anemia. So, you know, these people have a hemoglobin of 10 or so not, not a hemoglobin of, you know, a five. And obviously, I'll just say at the moment that um different depending on what, what, what uh units you're using, sometimes hemoglobin is measured as sort of, you know, 3456, up to 10, 12, 13. And sometimes it's measures 30 40 50 just depends what, what units you use. Um, so thalassemia trait is something to be aware of and to look, obviously, if it's been tested in the past, it's a genetic condition. So if the patient's have a test in the past and there's no reason to repeat it. Um You can do this quite neat thing of taking the MCV and dividing it by the red blood cell count. And if that is less than 13, it's more likely to be beat a thalassemia trait. And if that is more than 13, it's more likely to be iron deficiency. So people with the thalassemia have this very low MCV with a sort of relatively preserved red cell count. Whereas in iron deficiency, the MCV isn't. So hello. And the red cell count um is lower and therefore you get the difference in the ratio. So that's something that sometimes worth doing. But you usually have to do it manually because when we get results back from the lab and things, it tends not to be calculated for you. So here we have a 30 year old woman who has quite a good going anemia. So, hemoglobin 6.4, but her MCV is plum normal 92.6 fairly in the middle of the normal range of 80 to 96. So that doesn't suggest that this is an iron deficiency periods kind of thing. Um We can see it's been requested by an orthopedic clinic. So perhaps it's a pre operative blood test. So what sort of thing would be, be thinking about? Well, firstly, um this is what you would see if you had acute blood loss because obviously, if you lose a huge amount of blood straight away, then there is no time for the body to, to adjust and develop that microcytosis. So you might see that picture of someone was brought in after a trauma. You might see it with an anemia of chronic disease or account which cancel to produce cancer and you might see it with him pollicis. So let's talk a little bit about anemia of chronic disease. There tends to be a normal MCV. There's often a lower the ferritin, maybe low or normal or raised. But if you give this person iron, the hemoglobin is not going to get any any better. Um And it's, I don't, I don't propose, I don't assume to fully understand the mechanism, but it's to do with changes in cytokines. Um And often in these patient's, if you look back at the notes, you can see, oh yeah, I know that this person has got rheumatoid arthritis or I know that they've got renal failure. So I can see that there is a reason for their chronic disease. But if you're getting this picture in someone who does not have an obvious chronic disease, then we really should be going on a bit of a hunt for what the cause is. Um, so if you have a person with a consistently low hemoglobin, nothing else terribly exciting in the rest of the full blood counts of the white cells and platelets and all of that look fine, the hematinic look fine. Maybe you've given some iron, they're not better. Um And you don't have a chronic disease to pin it on, then you, you probably should be referring them probably to hematology in the first instance, who may refer them elsewhere. But also you do want to be seeing them and taking a decent history and asking some direct questions, make sure there aren't any symptoms that they've been just sort of stoically sitting on rather than coming to see you about. Right. So here we have a man who's 58 this has been taken in a and E this blood test and he has, you can see a normal hemoglobin but a significantly raised MCV. So he's got a macro cytosis, the normal range for the MCV. Here is 80 to 96 his is 105. So, what are we going to think about that? Um So a mild macro cytosis a bit less and that is quite common and it's not unusual that you investigate it and you don't actually find a cause at all. But that doesn't mean that we should invest, shouldn't investigate. So, the obvious things I do first is I ask about alcohol. I check for drugs. Um, often in primary care we have an increasing number of patient's who are on things like um azaTHIOprine hydroxyurea methotrexate. And quite often I see one of these and I think, oh, that's odd. And then I look back and it's been like that for you years and they're on methotrexate. But final, that's the cause. But I always do check liver function tests. Ask, ask about alcohol, check B 12 and folate. Think about checking immunoglobulins. And if the patient's well, then I would probably, when I get the result, I'll probably ring them up and, and if there's nothing particularly worrying, I'd probably say right here's a blood form for all these things and we'll repeat the full blood count, but don't do it now, do it in a month just so we can see if things are changing. Cause generally in medicine, it is very helpful to have an idea about whether something is a blip or a trend. So if you've got a few hemoglobins on file and suddenly you've got a low one, is that a blip? And it's the next one is going to be normal or is it a trend? And the next one is going to be even lower. So you can't tell whether it's B 12 and folate unless B 12 or folate unless you actually test for B 12 and folate, they both look the same low hemoglobin, raised MCV, often a low white cell count and platelets. And um if you do a blood film, you'll see these hyper segmented neutrophils or you'll get a report that sees them. I don't routinely check for lactate dehydrogenase, but if you do, you might see that it was increased. So, have a think about if you were based in the UK, what you think would be the commonest flaws of vitamin B 12 deficiency. And obviously this will vary from country to country. Um It's just, I mean female. Oh but, but in these are the the answers, these are the answers um given. So, um this is another person with a raised MCV. Um but in this case, it's slightly different. If you look at the rest of these results, this person, they're 66. So they're of an age where, you know, we're starting to more have our antennae pricked for, for pathology. Um The hemoglobin is 7.8. So they're significantly anemic total white count is low. Their neutrophils are low, their platelets are low. There's a slightly raised esr whether or not that significant the age of, of, of 66 they have hypergranular neutrophils and hypergranular neutrophils are a particular sign of myelodysplastic syndrome, which is something that does need a referral. So, thinking about MCV, when we should be referring, certainly, I'm more worried about an MCV, which is a macrocytic anemia. So, it's got associated with a low hemoglobin rather than just a macro cytosis on its own. With the hemoglobin being normal. If the white cells are abnormal in either direction, if the platelets are low, if there's a normal B 12 and folate, so you don't have that as a reason and if they're elderly because, um, these think like myelodysplasia are markedly more common in elderly people. And in general, most pathology is more common as you um as you get older and don't forget to check for B 12 and folate and check for hypothyroidism and think about referring for consideration of myelodysplasia. Um If you are concerned. So thinking again about anemia, this is the last side of anemia, just a sort of pragmatic classification. Obviously, hopefully you should get the MCV back when you get the low hemoglobin. So if it's low, you're thinking about iron deficiency thalassemia anemia of chronic disease. And don't forget that menstruating women really can drop their HB quite impressively low and feel completely fine. Um And don't forget of course, that if you want to run a bath, you have to put the plug in before you turn the taps on more. So, if you've got a woman who has a low hemoglobin due to her periods, don't forget to give her something for the periods rather than just giving her iron. So does she want some Tranexamic acid just with her periods or does she want something like the combined contraceptive pill or the implant or the intrauterine system to actually make her periods much lighter or possibly make them stop. And if that's outside your sphere of expertise, then referral to a colleague who can help a normal bleeding, normal MCV, you'd be thinking about a recent bleed. So that's not something we see so much in primary care. But obviously, if you're in an emergency department and then you'd be thinking about things like chronic disease or myelodysplasia for a high MCV. Um thinking about B 12 and folate alcohol, thyroid, liver disease and myelodysplasia. So talk about the hemoglobin being low. But what about if the hemoglobin is high? So we've got a patient here with a hemoglobin of 17.9. It's one of these things that, you know, from medical school, you would immediately go oh polycythemia rubra vera, you know, that is the sort of thing we learn about that is associated with a high hemoglobin and we kind of get a bit excited if we pick it up in someone. Um But at actually secondary polycythemia is vastly more common and you can see here all the different causes for secondary polycythemia against the sort of one cause of primary polycythemia rubra vera. And if you think about it, how many patient's do you have with polycythemia rule Rivera? Versus how many patients do you have, who are heavy smokers or have obesity or on direct exposure, that second group is going to be much, much bigger. So it's something you need to, to think about. Um, hematology will test patient's for the Jack to Gene, um which is very common in those who do have primary polycythemia rubra vera. And generally speaking, I would almost, I would, I would tend to repeat a high hemoglobin. Um And then I would refer if the hemoglobin is over 18 in a man or over 16 in a woman. Um And I'd be particularly concerned if there are sort of constitutional symptoms like weight loss, sweating or itching rate. And if there are other parameters of the full blood count are abnormal or if they have splenomegaly. So it's worth laying a hand on the abdomen so that you can document the presence or absence of splenomegaly, right, moving on to white cells. So I have so many patients in my practice who run at a neutrophil count that is lower than the normal range because I'm in a very diverse area of London. And if you are black or you come from the Middle East, then it may be entirely normal for you to have a lower neutrophil count. And that is your normal and it's not something to be worried about, but it is on the list of the British HIV associations indicator conditions for HIV. So it is something just to be aware of particularly because obviously, if you come maybe from Sub Saharan Africa, then you, um, you have the ethnicity reason to have a low neutrophil count. But you're also coming from a place where HIV prevalence is high. So when I see a neutral field count of maybe 1.5 or 1.7 of someone of this sort of ethnicity, um, then I would usually offer an HIV test if one hasn't been done. And otherwise I'm not terribly worried and often when you look back through the notes, you find that actually it's, it's been like that for years, sort of bumping along between maybe 1.5 and two below one. I'm starting to get a little bit more concerned and that does seem to be when hematology I'm more concerned. Um Also things to think about our hematinic deficiencies and obviously drugs, you know. Um So, well, as I said before, we have a large number of patient's on things like azaTHIOprine methotrexate. And if they drop their neutrophils having previously had a normal neutrophil count, then we do need to do something about that. We need to speak to their consultant because it maybe they need their dose of their methotrexate reducing or they even need to stop it for a bit. And when you're looking at white cell counts, neutrophils and lymphocytes in the context of having a patient who's taking something like methotrexate, a, the trend is important as well. So, you know, if your patient's got a neutral, a count of five. And then the next blood test is 4.5. The next blood test is four. Those are all plum normal in the normal range, but that is a trend of a decrease and their consultant will probably be increased interested in that trend. And they may want to do something in terms of adjusting their dose to catch it before it drops further to three and 22 and then to being abnormal. So when should we be particularly worried? Um as I said, people on Dimard disease modifying drugs will need to talk to their consultant, but certainly neutrophil count below 0.5. Definitely. And below one, I start to get a bit more concerned again, as with everything else, it's about the whole patient, not just the number. So if they are unwell, if they have a temperature, if they're losing weight, it goes without saying if they're on something like chemotherapy, then we get very concerned. But usually patient's on chemotherapy, get very clear advice from um from their oncology unit and they will usually present directly to hospital if they have, have a temperature. Do they have a liver or a spleen that's palpable or palpable lymph nodes and what's happening to the rest of their full blood count. And if you're concerned and you sat on it for a while and things aren't improving, then it is worth asking for help from, from a local consultant. If you're from the, from the point of your primary care. So the other, the other end of the scale hi neutrophils, these are pretty common actually. Um So obviously, uh an infection of bacterial infection, um if someone is postoperative, their neutrophils can go up as they can if they're taking steroids. Um and this is one of these things that often we never find a cause because we repeat it and it's got back to normal and we just sort of put it down to experience. But if neutrals over 15, then it's sensible to refer. And again, as always, look at the whole patient, not the number of the patient is unwell. If they have weight loss, if they're sweating, if they have splenomegaly, then you might want to have a lower threshold to refer. So here, what do we have here? We have a normal hemoglobin. Um and we have a raised lymphocyte count. So you can see lymphocyte count there, the normal range is 1.5 to 4 and this person has a lymphocyte count of 7.7. So, um lymphocytes can go viral infection. So I would always check for things like C M V and Epstein Barr virus and HIV. Um but in an elderly person, what I would be thinking of is chronic lymphocytic leukemia, um which is one of these conditions, you know, it's a cancer and it has the word leukemia in it, but it tends to be managed as a chronic condition. And many people actually don't end up needing any treatment. They just need keeping an eye on by a hematologist. You have uncontrolled growth of the B lymphocytes with a reduction in background antibodies. So these patient's even if they're not being treated, they are at risk of infections, they are relatively immune suppressed. Um And so if they're not already having things like flu vaccines, pneumococcal vaccines, COVID 19 vaccines, then they certainly should be having them. So it's really a disease mainly of elderly patients. It can occur in those younger, but it's much more common in those who are elderly. It's often found by chance. Um And they do need to be referred to hematology. Um Some will be treated, plenty will just be monitored on an annual basis, but they should be on the radar of the specialist. Um Again, this is another increased lymphocyte count, but this is in a man whose age 33. So although younger people can get cll, it would be much more unusual and CLL would certainly be lower down your differential list. Um So this is where you might be thinking about all the viral infections. So you wanting to take a clinical history, you know, why would the blood test done in the first place? It's always important to think that and um in these days of sometimes more fragmented healthcare, we're often looking at blood results that we didn't ourselves request. So it's important to look about why was the blood test done? Was there a reason? Was someone just getting a bit too keen on the tick, tick tick on the blood form? Um Was the patient unwell? So think about all these things. Um And if it does look like there's a transient viral infection, then it would be perfectly reasonable to hold on to this if the patient's well and maybe repeat it in six or eight weeks time. Um, but if there are other abnormalities in the full blood count or they're unwell losing weight, um, then you certainly would want to think about referring, um, raised here cinephiles. Um, I don't think I've ever found a course for any race here cinephiles and I would agree with through here when he says the investigation is often unrewarding. Um, it's not something that we routinely look for in the diagnosis of asthma, but actually, it is mentioned as a supporting factor in some of the guidelines on asthma. So that is worth thinking about ease your patient a topic. Um, have they actually never bothered to report to you that, you know, they get terrible hay fever and, um, they've got Isma but they just buy some creams over the counter and once or twice, they went into hospital with a bit of a wheeze and they're still, yeah, using the blue inhaler that they got given then. So, you know, I would investigate a two P, I think a lot of people don't treat, don't really go along with treatment for their asthma and eczema and, and so on that can have consequences. So, do they have a condition that maybe needs a little bit more attention for a primary care point of view? If they're extremely raised over five, then it is worth referring. There are a couple of very rare diagnoses, eosinophilic leukemia and hyper eosinophilic syn syndrome. Um yeah, they say about rare things when you hear hooves think horses not zebras, common things are common, but rare things do exist. A rare disease is defined as one that's under affects under one in 2000 people. But we know that actually in the UK, collectively one person in 17 is affected with a rare disease of some sort when you add them all together. So think about common things, but just always do you know, have your antennae twitching for the occasional rarity that you might find. So here you've got a raised platelet count and um and otherwise more or less, more or less normal, slightly low red cell volume, but otherwise more or less normal. Um So this is essential thrombocythemia. But I would counsel you to always think cancer when you see a raise platelet count, I think it is something we are becoming increasingly aware of that raise platelet count is a sort of soft sign for cancer. And in the UK are suspected cancer guidelines. One or two of them do now include a raise platelet count. So, it is worth seeing the patient doing a general sort of systems review. Have they had any, um, any things they're not, they haven't mentioned to you. Are they, are they a smoker? You know, they've got their regular smokers coffin every now and then. They've been coughing up a bit of blood and they haven't come to the doctor because they either can't be bothered to, or more likely, they're absolutely terrified and they don't want to tell you because if that tells you that it makes it a bit real. Um, so often it's just reactive and you test again and it comes down to normal. But if it's, um, you know, sort of theme of the theme of this talk, you know, if you keep testing something and it keeps being raised, then you need to take it a bit more seriously. And obviously the other theme is that if the patient is unwell, you need to take it a bit more seriously. So this is a child with a low plate, look at a very low platelet count 22. So I would be certainly, you know, not passing go and sending this child straight into my pediatric colleagues because I would be concerned as to whether she might have something very nasty going on there. Um, this is a man with, again a very low platelet count of three, but you can see that someone has written on the bottom that actually the platelet count was 269 in the past. So that has dropped. There is this thing with platelets that they can clump together. And sometimes the automated system will think that the platelet count is very low. And when an actual person looks down the microscope, they don't look so low. So sometimes you'll get a comment on it. Um But yeah, platelet counts um really below 100. I am starting to get concerned as to what's going to happen to that patient if they start to bleed. So below 100 I would certainly be thinking about referring. And again, if they're unwell, if they've got a palpable liver or palpable spleen, certainly, if they're bleeding, then that needs someone to take look at them the same day. Um And if they are pregnant, you can, you can get some, some conditions are called low platelet counts in pregnancy. If it's above 100. Um and the patient is well and there's nothing else for me to worry about. Then I would probably in the first instance, just repeat it um in a month or so. So high platelets. Um You're thinking about essential thrombocytosis. That's what PT stands for your thinking about malignancy. And it could also just be reactive to infection or something like that. Low platelets. You're thinking about immune conditions such as immune thrombocytopenia, purpura drugs infiltrations from cancer, viral illness or as I said, it can be spurious because of clumping. So below 100 below 100 I would be taking a low platelet count very seriously. And of course, as I said, a few times, it's important to look at the rest of the things. So this platelet count of eight um would worry me anyway. But then I see that this person's white count is only 1.7 and their hemoglobin is only 9.5. So now we're looking at a pancytopenia. So that's extremely concerning. Um And I don't know what the problem it turned out with this woman, this person. But, you know, I would be concerned that this might be a bone marrow malignancy or something like that. So I would certainly be wanting to get them in front of a human's. We'll just extremely quickly, don't forget about myeloma. It's another one of those conditions that can present with quite vague symptoms, tiredness, bit of aches and pains, bit of nausea, sometimes back pain, in particular. All these things are very common. Um But there is a reason why age is a red flag in black back pain. So I always take, always treat back pain seriously full stop. But I, I'm more concerned by antonia more pricked up when the person is older. So this person you can see is anemic. They have a low platelet count. They have a very high esr of 100 and 31. Um And they have multiple myeloma and you can see here some lytic lesion's um multiple myeloma is a sort of, is a hematological cancer. It's not generally curable, but it can be treated. People's length of lives can be increased as can there as can their quality of life. So it's important that they get referred and we saw if I just flick back this person haven't. Yes, are of 100 and 31 which is extremely high. Um So thinking about other causes of ESR it does rise with age. Um So you know, an ESR of 20 in a child or an adolescent would um would just make me make me look a bit. I wouldn't be so concerned about an ESR of 20 is someone who was very elderly. So think about inflammatory conditions like rheumatoid arthritis, think about acute or chronic infection, think about cancer like cancer, think about temporal arthritis. You don't want to miss temporal arthritis, early steroids and temporal arthritis can save site. So you really don't want to miss that, that typically presents with this temporal bone pain and a very high esr in an ideal world, someone with temporal arthritis would have a biopsy before you start steroids in the real world that's often unobtainable. And therefore you start steroids in order to save their site and then the rheumatology team sort of pick it up afterwards. And this was a question of who do you refer, who do you refer a raised esr when you don't know what's going on. Um, it's the same problem as who do you refer weight loss too when you don't know what's going on. And really all you can do is do your absolute best in primary care to take a good history to a thorough examination. Do any other tests, see if you can narrow it down. Um, but certainly now in the UK, we have a pathway called rapid diagnostic centers which are specifically set up for that situation when you know that there's something serious going on, but you can't quite pinpoint the body system and you don't want to waste time referring to one specialist consultant who will exclude disease in there um area of interest and then send the patient back to you. So we refer to these rapid diagnostic centers where they will take a very broad view and often they will run them head to toe through a scan, er which which is quite helpful. Um Obviously, depending on where you work, you will probably have a pathway for what I would call non specific badness, there's something going on and you just don't know wearing, you don't yourself have access to the tests to work it out. So when, if you are working in primary care is always worth knowing what, what uh what your pathway is for non specific concerns. M gus monoclonal gammopathy of undetermined significance is a sort of precursor condition to myeloma. And it's very common particularly with increasing age. So with the aging population, we're going to see more and more of it, it's completely asymptomatic. So you find it on chance and they have a paraprotein. But at a lower level of myeloma, low 11 than myeloma in about 10% of these people will develop myeloma. But the problem is we don't know which 10%. So they basically will need monitoring every six months or every year for life. And depending on your local set up that might be done in primary care if it's funded or it might be done in secondary care by a hematologist. So this is something that wasn't, it wasn't so much on our radio. I'm not even sure if I was taught about it in medical school. I qualified 23 years ago. Um, but it is going to be increasingly on our radar with an aging population as it gets more common. Um, monoclonal bands are concerning and need referring, particularly what always really, but particularly I'd worry if there's a reduction in other facets of the full blood count like hemoglobin or platelets or white cell count and often associated with renal impairment. So it's always worth checking the kidney function as well. Um, abnormal bleeding. Um, it is quite common. I mean, I've quite often get calls from someone saying that they're getting bruising for no obvious reason and I do a full blood count and I do a calculation screen and I must have done hundreds of them and I've never had anything come back normal and it just goes away in the end. Um, always, if someone is talking to you about unexplained bleeding, just unexplained bruising or indeed bleeding, just check that they're not being abused at home. Make sure you get to see them on their own because if you're talking to them on the phone, you don't know who else is in the room or if you're on a video call, make sure you see them physically in your room on your own without their partner present and just remind them reassure that that they are in a safe space. And is there anything that they want to tell you? Um And every now and then you'll find something significant that needs to be taken forward, um, bruises on the chest and the back and the abdomen. It the sort of soft abdomen, particular soft places, it's harder to get bruises there, sort of more significant, um, significant bleeds such as inter joints or muscles are concerning. And if you do a calculation screen, then you might find things like hemophilia, um and other, other coagulopathy. She's purpura. You know, we worry about patiki eye, obviously unwell Children. We really worry about meningitis. We don't want to be the doctor on the front page of the, of the newspaper because we sent a child home saying they've got a cold and then they go back five hours later to a and e, and they turn out to have meningitis but they are commoner in older people. Um, so you might want to do a full blood count and clotting screen if you're concerned. But if they've been there for years and it's just kind of like a while I'm here, I just thought I'd mention how long have you had that been there for years. I'm completely, well, it's not changed at all. Then I'm not going to be terribly worried. So moving on from hematology, I'm just going to briefly talk about raised liver transaminase is particularly in the context of fatty liver because this is something we're seeing increasingly commonly. We are much more aware of the issues of obesity, type two diabetes, hypertension, the metabolic syndrome and in lots of healthcare systems, a screen for diabetes and lipids will be offered to everyone at the age of say 40. And we usually do liver function tests at the same time because if someone is found to have raised lipids and they are going to need a statin, then we need to know their LFTs and quite often we find raised limit liver transaminations. So this is a diagram of the disease process. You can see it one side, you've got a healthy liver there and then you've got a nonalcoholic fatty liver and that can just stay as it is or it can revert to a healthy liver, particularly the significant life style change. But it can progress to non alcoholic, static, keep Stiolto hepatitis, which is inflammation and to fibrosis and then to cirrhosis, which is irreversible and potentially to hepatocellular cancer. So, our concern about this is not that it's going to cause a patient any symptoms because it's a symptomatic. But our concern is how do we find the people who are going to progress to the right hand side of those graph of that graph and stop that happening? So how do we find this? We might find an incidental finding of fatty liver on an ultrasound that was done. For another reason, we might find raised LFTs on bloods that we did for the work up of another condition or that we did because the patient had fatigue or something. We might have done it, as I said, for health screening, um in some areas, they do case case finding, checking liver function tests in everyone who has certain certain conditions, metabolic and so on. And um it is a risk factor for cirrhosis and it can reverse. I've got a few patient's who have lost masses of weight, made huge changes in their lifestyle and their fatty liver has completely reversed. So it is something to try and encourage people. And we do have a bit more now that we can do for people with obesity. We have a few more drugs coming along that can help. So it is something worth talking about. Um I always do a sort of liver screen. So hepatitis HIV, liver or two antibodies, thinking about things like primary biliary cirrhosis. Uh So that should say gamma GT. Um and I would usually, unless the liver transaminations were absolutely sky high. And I wanted to add urgently, my first thing would be to give them a form with a repeat of the LFTs and all these other things and tell them to do them in maybe 4 to 6 weeks. So I can see the trend on the original transaminases, abdominal examination just to make sure you're not missing a massive liver. Although it's generally normal, consider an ultrasound if you haven't got one already. But the key thing is your assessment of fibrosis risk. Um So if you are working as most people are in a system with limited resources, then you need to work out which of the patient's that you can just hang onto in primary care, check their liver function once a year and address their lifestyle factors and which of these patient's need to go and see a liver specialist. Now. So in some areas in the UK, we have elf blood test, which is a variety of different biomarkers or the intelligent LFT system. But if you don't have any of these, if you have liver function tests and a full blood count, then you can calculate a 54 which is the age times the A S T over the platelet count times a square root of the A L T. Um, and you don't need to get your calculator out the reloads online. Calculus is if you just put fibbed four into your search engine of choice, um, and most areas will have a cut off for referral, but certainly if it's less than 1.45, then that has quite a good negative predictive value for advanced fibrosis. And this might be someone who can just hang onto in primary care or as if your food four test is higher, then you need to be referring someone. Um And if I was talking to you about this 10, 15 years ago, then I'd have said you're probably referring in for them to do a liver biopsy. But these days, there are transient elastography scans which are non invasive way that they can do a scan to look for fibrosis. So they would usually do that first. So that is the end of those, I'm going to stop share. Um I'm happy to answer any questions with the caveat, but I'm not a hematologist, but as long as they're not too difficult, then I'm happy to answer any questions you said about the rapid diagnostic test. What was it about? Like uh when somebody doesn't like general hemoglobin, our general CBC is not giving any answers. Uh So did you mean sort of like non, non specific, if someone has a non specific something that you're worried about like a, you know, raised esr you can't find a reason or a weight loss or something that doesn't, um, doesn't fit with a body system, then hopefully there will be some sort of pathway where you can refer them to where they might be able to either do some, um, you know, sort of head to toe scanning or have the facilities to do more investigations to actually try and narrow it down to the body system that's affected. Okay. I think that's probably it. So I will leave you to it. Thank you very much. Thank you very much, Doctor Tony. It was a lovely lecture. You. Thank you again and thank every single person who attended today and if no one else has any questions, then I think we can end it there today. Ok. Cheers. Take a take care. Goodbye. Doctor. Right guys, I've uploaded the certificate and please do book for the next lecture in the link, which will be from 1 to 2 PM today with Doctor David Ellis. Just give it a few minutes for everyone to download. So I have one question. Can we write our name on certificate or? It's like this only? So what you do is once you download the certificate, you can insert your name where it says into your name and you can add your name. Okay, thanks. All right. No problem. All right. I think that's it. Thank you. Every single person who attended today. Hope you have a lovely day and hope to see you in the next lecture. Goodbye.