3 December 2025 (Wednesday) - NEQAS 2507 BF

I got hold of the results of NEQAS 2507 BF today…

 

2507BF1

 

I wrote

 

Hypochromic (consensus 1^st)

Microcytic      (consensus 3^rd)

Pencil cells    (consensus 4^th)

Target cells   (consensus 2^nd)

Tear drop cells (consensus 6^th)

 

I wrote ?? Fe def. The expert opinion said “2507BF1 was the blood film from a 23-year-old woman with iron deficiency anaemia,”

 

 

25007BF2

 

Macrocytosis (consensus 4^th)

HJB

Tear drop cells (consensus 6^th)

Hypersegmented neut (consensus 1^st)

Low plts (consensus 3^rd)

 

I wrote ?? B12 def The expert opinion said “2507BF2 was the blood film from a 56-year-old man with nutritional megaloblastic anaemia”

 

I’ll take that…

 

3 December 2025 (Wednesday) - NEQAS 2504 PA

I got hold of the results of NEQAS 2504 PA today…

2504 PA1

This was “the thin blood film from a patient of unspecified age and sex and with an unknown travel history. It showed a heavy (2.1%) infestation with Plasmodium knowlesi malaria”.  

I wrote “P falciparum - rings, trophozoites & shizonts 5% parasitaemia”. I got the species wrong and overestimated the parasitaemia, but I spotted malaria.

2504 PA2

The expert opinion said “There were no parasites to see on this thick film” 

I wrote “Think it's negative. Saw one iffy thing”

 

I’ll take that…

3 December 2025 (Wednesday) - Westgard QC Update

The nice people at Wesgard QC sent out their newsletter today. You can read it by clicking here. Much of it was rather dry; much of it went over my head. But one article gave me a wry smile. A bit of a diatribe about how people are using QC terms to blag their way, safe in the knowledge that no one knows what they are talking about.

 

I’m not the only one who finds QC matters rather esoteric.

2 December 2025 (Tuesday) - Mild Neutropenia

People can be very quick to get incredibly over-excited about mild neutropenia. It can have several causes which don’t require massive over-reaction. Here’s one such:

2 December 2025 (Tuesday) - Fritsma Factor Newsletter

The Fritsma Factor newsletter appeared in my in-box today. You can see it by clicking here. This month there was quite a bit more than there usually is, Underfilled samples, anticoagulation, the PT, haemophilia…

Loads of stuff.

 

2 December 2025 (Tuesday) - Exchange Transfusions

There’s a phrase that is in common use – “exchange transfusion”. It implies that you take out all of someone’s blood because it is in some way sub-standard and exchange it for “decent” stuff. But you can’t just hoik it all out before putting in the good stuff as that would be fatal. Similarly putting the good stuff in one arm whilst taking out the bad from the other will lead to a degree of mixing.

Here’s an article examining the logistics of how it might best be done…

1 December 2025 (Monday) - BTLP-TACT Exercise

Last month I did thirteen BTLP-TACT cases, and still I’m getting emails about not doing enough… so here we go.

I was presented with one case – an eleven year old girl in ITU with burns needing two units of blood.

 

She grouped as A Rh(D) Positive with a negative antibody screen. I selected two units of A Rh(D) Positive K-Negative blood

 

I got the thumbs-up.

1 December 2025 (Monday) - Learning Monday

I won’t lie. I don’t know. It’s AML. Back in the day we’d do a Sudan Black stain and that was good enough.  Things have massively changed in the understanding and diagnosis of leukaemia.

 

Here’s the answer:

 

“Correct answers are A and B. This case illustrates a discrepancy between the two AML classification systems and underscores the complexity of diagnosis in the presence of multiple genetic alterations. An integrated diagnostic approach, including flow cytometry, cytogenetics, and molecular genetics, is necessary to reach a final diagnosis. The patient would be classified as an AML with mutated TP53 according to ICC 2022 and as an AML myelodysplasia-related according to WHO 2022. In the ICC 2022 classification, AML with mutated TP53 is recognized as a separate entity, including Pure Erythroid Leukemia, if morphologic criteria for this entity are respected.  According to WHO 2022, 5q deletion is included in the cytogenetic abnormalities defining AML-MR.  In both systems, the diagnosis of AEL (WHO 2022) or PEL (ICC 2022) requires ≥30% immature erythroid cells (proerythroblasts) and a bone marrow with erythroid predominance (≥80% of cellularity). The case of this patient doesn't comply with the criteria of the >30% proerythroblasts (he does have 45% of erythropoiesis in the BM, but not 30% or proerythroblasts)”.

 

Here’s a link to an article on the matter from an expert panel. I’ll make the observation that it wasn’t that long ago that we were all far more knowledgeable on the matter as we used to do a lot of the testing in-house and not send it off to reference labs…

27 November 2025 (Thursday) - BTLP-TACT Exercise

Time for another BTLP-TACT exercise. I had one case – a ninety-three year old chap who was bleeding with liver disease who needed four units of FFP

 

He grouped as B Rh(D) Positive with a negative antibody screen.

FFP is recommended for bleeding with a liver disease so I issued four units of B Rh(D) Positive FFP

 

I got it right.

26 November 2025 (Wednesday) - Competency Assessments

With pretty much a full house at work with nearly everyone in I was at something of a loose end today, so I took the opportunity to update my competencies. Over the last couple of weeks I’ve been gathering specific evidences and toady I wrote up little exercises for performing and reporting

• Blood counts
• Coagulation investigations
• D-Dimer assays
• Fibrinogen assays
• Infectious mononucleosis testing

Back in the day the boss would just blithely announce that someone was competent, or they were not and leave them to it. But today I spent a little while concentrating my mind on some of what it is that I do at work and reviewing it with a colleague.

I found it surprisingly useful…

26 November 2025 (Wednesday) - Transfusion Evidence Library Update

The nice people at the Transfusion Evidence Library sent their update today… Does it matter what ABO group of platelets you give someone? Transfusions and brain injuries, for the first time in a long time tranexamic acid wasn’t mentioned…

 ARTICLE OF THE MONTH

The effect of intravenous iron supplementation compared to oral iron supplementation during pregnancy on neonatal outcomes-a systematic review of randomized controlled trials.
Kuitunen, I., et al. (2025). European Journal of Pediatrics.
PICO SUMMARY

 

 

TOP ARTICLES

ABO matching for platelet transfusions for prevention or treatment of bleeding: a systematic review with meta-analysis.
Cain, L., et al. (2025). Transfusion Medicine Reviews. [Record in progress].

Clinical prediction models for postoperative blood transfusion after total knee arthroplasty: a systematic review and meta-analysis.
Chen, J., et al. (2025). BMC Musculoskeletal Disorders.

One versus five days of octreotide infusion for acute esophageal variceal bleeding: a randomized controlled trial.
Chirapongsathorn, S., et al. (2025). The American Journal of Gastroenterology. [Record in progress].

Rapid update and revision of: thromboelastography or rotational thromboelastometry guided algorithms in bleeding patients-an updated systematic review with meta-analysis and trial sequential analysis.
Kvisselgaard, A.D., et al. (2025). Acta Anaesthesiologica Scandinavica.

Restrictive transfusion in acute brain injury: a meta-analysis of randomized clinical trials.
Machado, M.F., et al. (2025). Journal of Critical Care. [Record in progress].  

Immunoglobulin for myasthenia gravis.
Manolopoulos, A., et al. (2025). The Cochrane Database of Systematic Reviews.

BiZact versus cold steel for post-tonsillectomy hemorrhage: a multicenter randomized trial.
M lhave, M., et al. (2025). European Archives of Oto-rhino-laryngology. [Record in progress].

Transfusion of amustaline/glutathione pathogen-reduced red blood cells in cardiac surgery: a randomized phase 3 clinical trial.
Sekela, M.E., et al. (2025). Anesthesiology. 

A pilot experimental study of cold-chain management, haemolysis and oxidative stress of packed red blood cells in early blood transfusion: toward a blood viability model in the out-of-hospital setting.
Zeenat, A., et al. (2025). Scientific Reports.

 

25 November 2025 (Tuesday) - BTLP-TACT Exercise

Time for another BTLP-TACT exercise. 

I had one case – a sixty-four year-old woman needing group and save.

She grouped as A Rh(D) Positive with a negative antibody screen. 

I got it right…  so flushed with success I tried again. This time I was presented with a fifty-year-old chap needing two units of blood for TURP. He too grouped as A Rh(D) Positive but with an antibody screen positive in cell 2.

I performed antibody panels.

The enzyme and IAT panels were positive in cells 2 and 6 corresponding with anti-K.

I selected two units of A Rh(D) Positive K-negative blood.

I got that right too.

 
Whilst I was logged in I had a look at the performance dashboard. I am currently at over double the rate of performance it thinks I should be… I wonder how long it will be before I get another email telling me I’m not doing enough. 

 

24 November 2025 (Monday) - Frozen Platelets (!)

One criticism which is often levelled at me is that I am too flippant. Perhaps I appear that way when I tell the trainees that the golden rule of blood transfusion is “don’t kill anyone”. But as golden rules go, in my considered professional opinion I think it’s a good one. One way of not killing anyone was to make sure that platelets are stored at room temperature (between twenty and twenty-four degrees Celsius) and gently agitated. And to make sure they didn’t get cold.

Now not only is it being suggested that they might be kept in the fridge, but that they might even be kept frozen prior to use.

 

If there’s one thing I’ve found in blood transfusion is that opinion changes. What used to be absolutely a no-no becomes a possibility, and then is standard practice. 

 

23 November 2025 (Sunday) - BTLP-TACT Exercise

It’s pouring hard with rain and I’ve half an hour before I have to go to the late shift… so I might as well do a BTLP-TACT exercise, mightn’t I?

I was given two cases:

 

40336 – a seventy-five year old chap who had been over-anticoagulated who needed a group and save.

He grouped as O Rh(D) Positive with a negative antibody screen.

 

02559 – a forty-two year-old woman in the ante-natal clinic also needing group and save.

She grouped as AB Rh(D) Negative with a negative antibody screen

 

I got it right.

 

21 November 2025 (Friday) - UKAS Update

The nice people at the UK Accreditation service sent their update today. You can read it by clicking here. I always do. Some people have criticized me for not taking the whole UKAS thing seriously, which is unfair. I take it very seriously as doing so is a legal requirement. However I question how any of its requirements improve what I do on a daily basis. I can remember asking the same question about its predecessor organisations Clinical Pathology Accreditation and Investors in People.

I am very open to being shown the error of my ways. I wish I could be shown the error of my ways; clearly thousands of people feel the entire accreditation process to be a very worthwhile endeavour. It’s just that every single person with whom I’ve spoken about it approaches accreditation from the perspective of “doing accreditation” for its own sake.

I’m sure I’m missing something. I *wish* I knew what.

20 November 2025 (Thirsday) - BTLP-TACT Exercise

Time for another BTLP-TACT exercise.

I was given two cases:

 

24870 – a thirty-four year-old woman in the maternity unit needing group and save.

She grouped as O Rh(D) Negative with antibody screen positive in cells 1 and 2. I performed antibody panels.

The enzyme and IAT panels were positive in cells 1, 2, 3 and 5 corresponding with anti-D and anti-E but not excluding anti-Cw

 

90078 – an eighty year old woman in the medical out-patients also needing group and save.

She grouped as A Rh(D) Positive with antibody screen positive in cells 1 and three. I performed antibody panels.

The IAT panel was positive in cells 1, 3, 6, 9 and 10 corresponding with anti Fy(a)

The enzyme panel was negative throughout.

 

I got it right…

 

20 November 2025 (Thursday) - T.A.C.O.

Back in the day it was widely accepted that the potential hazards of the transfusion of a single unit of blood greatly outweighed the advantages, and so it would be at least two units of blood or nothing.

Back in the day pretty much everyone would be transfused until their haemoglobin level was over 10 (or 100 in new currency).

And back in the day a lot of people would get pneumonia whilst in hospital for no adequately explored reason.

Nowadays we are more aware of transfusion associated circulatory overload, and today (despite being on a day off) I tuned in to a rather interesting talk on the subject presented over Microsoft Teams.

I listened to a couple of very interesting case studies… and found myself wondering just what can you do for the best. Someone’s anaemia is causing fluid retention, but trying to alleviate the anaemia by transfusing blood is just giving more fluid…

18 November 2025 (Tuesday) - Smouldering Myeloma

 

17 November 2025 (Monday) - Getting the BTLP-TACT Wrong (again)

Time for another BTLP-TACT exercise…

I was presented with two cases:

 

57466 – a forty-two year-old woman needing group and save for a PV bleed.

She grouped as O Rh(D) Negative with a negative antibody screen.

24369 – a sixty-eight year-old chap with hypofibrinogenaemia needing two units of cryo as he was bleeding.

He grouped as A Rh(D) Positive with antibody screen positive in all three cells. I performed antibody panels. The IAT panel was positive in cells 1, 2, 3, 5, 6, 7, 9 and 10 but the enzyme panel was negative throughout. Ideally I’d want to send this off, but from what I could see this was probably anti- S with anti-Fy(a) but I couldn’t exclude anti-K

Cryo *is* recommended in hypofribrinogenaemia so I issued two units of cryo.

 

I got the thumbs down… supposedly a clinically significant antibody was masked by not noted… I’d love to know what it was.

16 November 2025 (Sunday) - Chronic Eosinophilic Leukaemia

 

12 November 2025 (Wendesday) - HCPC Update

The HCPC sent their monthly update today. You can read it by clicking here.

It started off by trying to attract new people to its council. That can only be a good thing; it is so easy for such vital positions to become an “in-crowd”.

Three was also talk about the importance of retention – one in ten of all registrants (across all the HCPC’s professions) less last than four years before packing up.   

Sadly I can’t say I blame them… and sadly the HCPC doesn’t seem to have any suggestions to encourage people to stay.

11 November 2025 (Tuesday) - IBMS Update

The IBMS sent their monthly update today. You can read it by clicking here…

Every month I make mention of the thing; every month I am very disparaging about it… and sadly there’s no change this month.

It started off by asking for nominations for its annual awards. There’s loads of us who do all sorts of sterling things every day, and singling one out for praise (in my honest opinion) lessens the efforts of everyone else.

There was then talk about a statement on quality assurance which had been issued. A vital aspect of our everyday round; such a shame the focus of our professional body isn’t on what is required but what committees will quarrel about it.

The rest followed in much the same vein… really good ideas strangled by committee.

 

I find fault with it every month… I don’t know what I want from my professional body, but it isn’t this.

10 November 2025 (Monday) - Warm AIHA

I got that right…not that I will ever be deciding on the therapies, but it really helps if I know what the drugs are, what conditions they are for, and how they work.

Here’s the first reference, and here’s the second.

10 November 2025 (Monday) - BTLP-TACT Exercise

It’s pouring hard; the dog walk was a washout, and so with not a lot else on the agenda I thought I might as well do a BTLP-TACT exercise.

I was presented with one case – a thirty-eight year-old woman in theatre with a ruptured ectopic pregnancy needing six units of blood. She grouped as A Rh(D) Positive with a negative antibody screen. I selected six units of A Rh(D) Positive K Negative blood

I got it right.

8 November 2025 (Saturday) - A Quiz

Just done an on-line morphology quiz. I got it right…

6 November 2025 (Thursday) - BTLP-TACT Exercise

I suppose I should really do a BTLP-TACT exercise…  

I had one case – a seventy year old woman supposedly needing FFP for reversal of warfarin therapy.

Her ABO group was indeterminate (cell group A, no reaction in reverse group) but her Rh(D) group was negative.

The antibody screen was weakly positive in cells 1 and 2 so I performed antibody panels.

The IAT and enzyme panels were positive in cells 1, 2 and 3 corresponding with anti-D but not excluding anti-Cw.

Bearing in mind warfarin isn’t recommended for the reversal of warfarin therapy, I didn’t issue any.

I got it right this time…

5 November 2025 (Wednesday) - TACO-Related Fever

Here’s something to think about… back in the day transfusion trigger limits were a *lot* higher than they are these days. We’d give three or four units of blood where these days we’d only give one. And back in the day we were investigating quite a few alleged transfusion reactions which were characterized by post transfusion fevers. We’d do blood cultures… but nothing ever grew.

Were we seeing fevers related to transfusion associated circulatory overload?

4 November 2025 (Tuesday) - Fritsma Factor Newsletter

The Fritsma Factor newsletter appeared in my in-box this morning. As always it’s a rather useful source of information on matters haemostatic…

4 November 2025 (Tuesday) - Information Governance

I did my e-learning on information governance today. Governance… it’s a simple concept really. I have access to confidential information. I only discuss it with those who have a bona-fide reason to know what I know, and I keep my trap shut to everyone else. I make sure that no one could accidentally find out what I know… simple, really.

3 November 2025 (Monday) - A.P.L.

 

Acute promyelocytic leukaemia…  There’s some pictures here and an article about how the condition is best treated here.

 

Oh… Statements 1, 3, and 4 are correct.

The images given show dumbbell-shaped blasts consistent with acute promyelocytic leukemia (APL), a subtype of AML known for its aggressive presentation and high risk of bleeding and/or thrombosis due to coagulopathy. Unlike other AML variants, APL often leads to disseminated intravascular coagulation (DIC), supported by lab findings such as elevated INR, prolonged aPTT, low fibrinogen, and high D-dimer.

Despite its favorable long-term prognosis, APL is a hematologic emergency requiring urgent treatment.  The coagulopathy in APL is primarily driven by tissue factor (TF) released during promyelocyte destruction, triggering excessive activation of the coagulation cascade. With the advent of all-trans retinoic acid (ATRA) and arsenic trioxide (ATO) as frontline therapy, APL has become the most curable AML subtype. APL blasts are typically negative for HLA-DR and CD34, distinguishing them from other AML variants.

2 November 2025 (Sunday) - Slide Saturday Challenge

Strange-looking cells…. Obviously derived from basophils… or are they? The nuclei aren’t right.

This is a case of systemic mastocytosis. Here’s some information on the condition.

2 November 2025 (Sunday) - BTLP-TACT Exercise

It’s raining, I’m sulking… Might as well do another BTLP-TACT exercise until the rain stops.

I was presented with two cases:

 

76896 – a fifty-one year old chap needing four units of FFP for bleeding varices.

The control well was weakly positive so the entire group was invalidated and would need referral to NHSBT. The antibody screen was negative.

FFP is NOT recommended for bleeding varices https://pubmed.ncbi.nlm.nih.gov/33969607/  so I didn’t issue any.

 

45944 – a seventy-five year old chap with beta thalassemia needing two units of blood

He grouped as A Rh(D) Positive with antibody screen positive in cells 2 and 3, so I performed antibody panels. The IAT and enzyme panels were positive in cells 2, 3, 7, 8 and 9 corresponding with anti-Le(b) but not excluding anti-Lu(a) or anti-Kp(a)

https://pmc.ncbi.nlm.nih.gov/articles/PMC11747971/ says anti-Le(b) is not clinically significant, and bearing in mind that there were no units available which were Le(b)-negative I treated it as not significant. But there wasn’t any units at all that were Kp(a) negative so I didn’t issue any.

 

I got the thumbs down. Apparently anti-Lu(a) and anti-Kp(a) could be excluded…

I’d like to know how.

1 November 2025 (Saturday) - Daratumumab - Remember That Stuff?

Seven years ago I wrote something on here about daratumumab and how it gives false positive results in antibody screening, and what we do about it.  Somewhat ironic that the entire matter slipped my mind and I wasted a couple of hours messing around on completely unnecessary antibody panels this evening…

31 October 2025 (Friday) - BTLP-TACT Exercise

I’ve done six separate BTLP-TACT exercises (ten individual cases) this month and *still* I’m getting emails saying “you may need to complete further TACT participations to improve your engagement target with the system”. So I logged in again…
I was presented with two more cases:
 

51898 – an eighty-nine year old chap with beta thalassaemia needing two units of blood

He grouped as A Rh(D) Positive with a negative antibody screen. I selected two units of A Rh(D) Positive blood.

 

54334 – a twenty-six year old woman needing two units of irradiated blood prior to a stem cell transplant. She grouped as O Rh(D) Positive, but with a weak D reaction. In this world that counts as indeterminate.

The antibody screen was positive in cell 2 so I performed antibody panels.

The IAT panel was positive in cells 2, 3, 5 and 6 corresponding to anti-E and anti-K

The enzyme panel was strongly positive in cells 3 and 5 corresponding with anti-E, and it was weaker with cells 2 and 6 corresponding with anti-K. I selected two units of O Rh(D) Negative K-Neg E-Neg irradiated blood

 
I got it right…

30 October 2025 (Thursday) - Westgard QC Update

The nice people at Westgard QC sent their update today. You can read it by clicking here, but be warned – it’s not an easy read.

There was an interesting line in there – Are CLIA labs better than ISO 15189 labs?

The answer is… they didn’t actually give a straight answer. As there probably isn’t one.

29 October 2025 (Wednesday) - Post Transfusion Purpura

Here’s an interesting (if rather obscure) condition – post transfusion purpura.

28 October 2025 (Tuesday) - Transfusion Training Hub

A colleague was talking about a case study in a podcast which she had been watching on the National Blood Transfusion Committee’s Transfusion Training Hub.

I’d not heard of that one – you can access it by clicking here. It looks rather useful. The trouble is that having made a mention today, time will pass and I will forget it… I shall add it to my “Sources of CPD” page listed at the top of this page…

It needed updating…