A Dull Day At Work...?: 2025

3 July 2025 (Thursday) - BTLP-TACT Exercise

On the last day of last month (three days ago) I wrote on here: “That’s eight BTLP-TACT exercises I’ve done this month… I bet I get an email whinging about my low involvement by the end of the week”. That email came at two o’clock this afternoon…

So here we go again. I was presented with one case – a sixty-two year-old woman needing four units of blood right away for a GI bleed.
The ABO group was indeterminate. The cell group was B; the serum group AB. But the Rh group was negative. That’s one for NHSBT.
The antibody panel was positive in cells 1 and 2 so I requested antibody panels. The IAT and enzyme panels were positive in cells 1, 2 and 3 corresponding with anti-D but not excluding anti Cw
I issued four units of O Rh(D) Negative blood.

I got it right.

1 July 2025 (Tuesday) - Competency Assessment

I was asked if I might produce a series of slides for competency assessments. I was rather happy to do so… it’s easier said than done though.

How many slides do we need? I went for twenty, but at five minutes per slide that’s going to take two hours per assessment.

What cases should we cover? What cases have we got in the teaching slides… Has anyone sorted the teaching slides for a while?

Back in the day I compiled a series of teaching slides by sticking what I considered to be an interesting case into a slide tray with a plan to sort it later… and I would forget about it. So consequently when I came to sort the myriad of slides I’d piled up I had a few dozen cases of iron deficient anaemia, a few dozen cases of CLL, and a few dozen slides with frankly horrific looking blast cells. All of which were rather faded.

Fortunately we had quite a variety of cases in the teaching slides. I’ve managed to get eight different slides which are predominantly red cell issues, eight which are predominantly white cell issues, one thrombocytosis, one thrombocytopenia, one with clumps, and one unremarkable one.

Getting a selection was tricky. Now I’ve got to come up with standard (correct) answers…

I quite like making myself useful like this…

30 June 2025 (Monday) - BTLP-TACT Exercise

It’s a day off work. There’s no end of stuff I might be doing but there’s a heatwave. It’s over thirty degrees outside so I’m staying where it is relatively cool. And to pass the time I’m doing a BTLP-TACT exercise.

I was presented with two cases:

93507 – a twenty-six year-old woman requiring group and save following a miscarriage.
She grouped as A Rh(D) Positive with a negative antibody screen.

24778 – an eighty-five year-old chap with haemophilia also requiring group and save.
He also grouped as A Rh(D) Positive but with antibody screen positive in all three cells. I requested antibody panels.
The IAT panel was positive in cells 1, 3, 5, 6 9 and 10 corresponding to anti-E and anti-Fy(a) but not ruling out anti-Cw or anti Lu(a).
The enzyme panel was positive in cells 3 and 5 corresponding to anti-E and ruling out anti-Cw and anti Lu(a).

I got the green light. That’s eight BTLP-TACT exercises I’ve done this month… I bet I get an email whinging about my low involvement by the end of the week.,

30 June 2025 (Monday) - NHS Elect

I’ve signed up to NHS Elect; I had this idea that it might be a source of CPD… As I logged in the form asked me my interests. It listed such diverse topics as

Career planning

Communication and engagement

Customer care

Leadership training

Management fundamentals

Quality improvement

Strategy and systems

Wellbeing

Am I being hopelessly naïve in expecting to have seen topics such as “blood tests” or “doing an X-ray” or “giving a bed bath”? Perhaps NHS Elect might have some useful stuff?

The trouble with me is that I am a hopeless old reactionary and I am too dismissive of anything which I might describe as “management nonsense”. Am I being *that* unreasonable in hoping that they might offer a comprehensive series of webinars suited to the haematology BMS?

One of the courses they offer is on “growing your social media following”, and that always gets me going. Many years ago I posted a selfie to Facebook at six o’clock in the morning whilst on a night shift and commented that I was tired. I received a formal written warning for doing so. During the hearing I was formally told by a senior manager that there was a formal policy that any mention on social media whatsoever of where I worked at the time was seen as bringing it into disrepute. Whether or not it said good, bad or indifferent things about the place.

And now we are being encouraged to grow our professional following on-line on that same social media.

How times have changed

Was there a formal policy? Somehow I doubt it. I should really let it go…

Shortly after that episode the fellow who gave me the formal written warning had the cheek to add me as a Facebook friend…

29 June 2025 (Sunday) - Infection Control e-learning

I did my infection control e-learning today. All a tad dull, all a tad basic… all incredibly important. It’s so easy to belittle this sort of thing. I’m reminded of an old English teacher who fifty years ago insisted we all learned proverbs. One of them was “familiarity breeds contempt”. Something of which I should be aware.

29 June 2025 (Sunday) - Platelet Clumps

Not sure about the calculation though... it presupposes that the clumps are distributed evenly across the film.
Which they aren't.

27 June 2025 (Friday) - BTLP-TACT Exercise

Yet another email whinging about my low engagement with BTLP. I’m doing one a week on average. How many more do they want me to do?

Still… here we go…

I had one case – a sixty year old chap needing four units of FFP and two units of cryo prior to liver transplant.

He grouped as B Rh(D) Positive with antibody screen positive in cell 2. I requested antibody panels. The IAT and enzyme panels were positive in cells 3 and 5 corresponding with anti-E.

https://pmc.ncbi.nlm.nih.gov/articles/PMC2958698/ implies both FFP and cryo are indicated in liver transplants so I issued both.

I got the thumbs up.

25 June 2025 (Wednesday) - Westgard QC Update

The nice people at Westgard QC sent their update today. You can read it by clicking here. As always it was rather dry, but QC stuff usually is.

Here’s a question… It’s pretty much accepted that you’d expect that one in twenty QC results (of a given assay) will be outside 2sd limits if you are measuring something as a numerical result. What about if you are doing a positive/negative test? At what level is the difference between positive and negative? Would you still expect one in twenty to be out?

24 June 2025 (Tuesday) - BTLP-TACT Exercise

It’s been a week since I did a BTLP-TACT exercise. I was presented with two cases:

51288 – a forty-one year-old woman in theatre needing group and save prior to a caesarian section.
She grouped as A Rh(D) Positive with a negative antibody screen.

17439 – an eighty-year-old chap in A&E needing group and save following a head injury.
He grouped as A Rh(D) Positive with a negative antibody screen

I got it right.

24 June 2025 (Tuesday) - Transfusion Evidence Library Update

The nice people at the Transfusion Evidence Library sent their update today. As always quite a bit to take in, but all good stuff…

ARTICLE OF THE MONTH

Comparison of relaxed verses standard cut-offs of rotational thromboelastometry for guiding blood product use before invasive procedures in advanced cirrhosis: a randomized controlled trial.
Kumar, M., et al. (2025). Hepatology International. [Record in progress].
PICO SUMMARY

TOP ARTICLES

Bleeding definitions in pediatric extracorporeal membrane oxygenation (ECMO) studies: a systematic review and meta-analysis.
Atchison, C., et al. (2025). ASAIO Journal. [Record in progress].

Systematic vitamin K antagonist reversal with prothrombin complex concentrate in patients with mild traumatic brain injury: randomized controlled trial. Douillet, D., et al. (2025). European Journal of Emergency Medicine.

Liberal transfusion strategies reduce sepsis risk and improve neurological recovery in acute brain injury: an updated systematic review and meta-analysis.
Nguyen, N., et al. (2025). Critical Care.

Evaluating the necessity of pre-transfusion testing in primary total hip arthroplasty: a systematic review and meta-analysis.
Nuñez, J.H., et al. (2025). Hip International.

Darbepoetin, red cell mass, and neuroprotection in preterm infants: a randomized clinical trial.
Ohls, R.K., et al. (2025). JAMA Pediatrics. [Record in progress].

Methodological quality of systematic reviews on platelet-rich plasma therapy for osteoarthritis: a meta-research study.
Onuki, M.E.O., et al. (2025). Revista Brasileira de Ortopedia.

Boosting blood donations through Facebook engagement: randomized controlled field trial.
Ramondt, S., Kerkhof, P., and Merz, E.M., (2025). Journal of Medical Internet Research.

Prevention of rebleeding after primary haemostasis using haemostatic powder in non-variceal upper gastrointestinal bleeding: a multicentre randomised controlled trial.
Shin, J., et al. (2025). Gut. [Record in progress].

Estimating the incidence of transfusion-associated circulatory overload using active surveillance: a systematic review and meta-analysis.
White, S.K., et al. (2025). Transfusion.

22 June 2025 (Sunday) - Slide Saturday Challenge

It’s a reactive cell from someone with glandular fever. Downey cell? Never heard of that name before…

21 June 2025 (Saturday) - ASH Update

The American Society of Hematology sent their update today. There was a lot of stuff to take in; I might have taken something in…

20 June 2025 (Friday) - Fire Safety e-learrning

I did my fire safety e-learning today. A refresher is always useful…

17 June 2025 (Tuesday) - BTLP-TACT Exercise

Time for another BTLP-TACT exercise. I was presented with two cases

98137 – a thirty-one year-old woman in outpatients with “maternal alloantibody” requiring group and save
She grouped as A Rh(D) Positive with a negative antibody screen. Bearing in mind the diagnosis of “maternal alloantibody” this might warrant further investigation to find just how long ago this “maternal alloantibody” was identified.
47220 – a nineteen year old woman in theatre requiring group and save.
Her ABO group was indeterminate; cell group A, reverse group AB. But the Rh group was negative. This should be referred to NHSBT, but given that she was having a baby this would probably be a known case.
The antibody screen was negative.

I got it right.

16 June 2025 (Monday) - NEQAS 2502 PA

The results of NEQAS 2502 PA became available today. It gas to be said that I wasn’t overly confident on that survey.

2502 PA1 was a thick film. I said “Parasites present”. There were – P. Knowlesi. The expert opinion said “It is optimistic to hope to distinguish between different species of Plasmodium on a thick film unless you are working in a high prevalence area or have extensive experience”.

For 2502 PA2 I said “ring forms” and there was. The expert opinion said “This is an example of babesiosis, most likely due to Babesia microti. It was a difficult film to interpret. B. microti is mainly seen as small rings, so it is easily confused with Plasmodium sp”.

In both cases I spotted parasites present. Obscure ones that I rarely, if ever (never), see in practice. But I spotted them. Had this happened in reality the case would be referred to a specialist lab.

I’m taking this as a success

15 June 2025 (Sunday) - Slide Saturday Challenge

Babesia... carried by ticks. I've piulled a few of those off of the dogs over the last few months...

13 June 2025 (Friday) - BTLP-TACT Exercise

Having stuffed up the BTLP-TACT in the week I thought I’d best have another go. It presented me with two cases:

05245 – a thirty-one year-old woman needing four units of FFP for pre-operative reversal of warfarin therapy.
She grouped as O Rh(D) Positive with antibody screen positive in cell 2. I requested antibody panels. The IAT and enzyme panels were positive in cells 3 & 5 corresponding with anti-E.
PCC would be better than FFP for reversal of warfarin therapy, so I didn’t issue any

71170 – a thirty year old woman needing two units of cryo for factor VIIII deficiency.
She grouped as O Rh(D) Positive with a negative antibody screen.
Factor VIII concentrate would be a far better treatment, so I didn’t issue cryo.

I got it right… which was a result.

12 June 2025 (Thursday) - ASH Update

The American Society of Hematology sent their update today. You can read it by clicking here.

There’s a lot to take in, and I can’t pretend to understand very much of it… but te more of this sort of thing I read, the more of is seeps through my thick head…

11 June 2025 (Wednesday) - Getting the BTLP-TACT Wrong

Time for a BTLP-TACT exercise. It gave me two cases:

52493 – a fifty-two year-old chap in theatre needing four units of blood for a GI bleed

He grouped as A Rh(D) Positive with a negative antibody screen.
The software had presented me with IAT Ab ID which was negative throughout. What was that all about?

I issued four units of A Rh(D) Positive K Negative blood

72993 – a sixty-two year-old chap in out-patients with thalassaemia needing two units of blood tomorrow.

He grouped as B Rh(D) Positive with a negative antibody screen.
The software had also presented me with IAT Ab ID which was negative throughout. What was that all about?

I issued two units of B Rh(D) Positive K Negative blood

I got the thumbs-down. It claimed the D group of the second case was uninterpretable. Was it? Bearing in mind I can’t call it up, I’ll have to trust it… Possibly my attention was on the unwanted IAT screens it had randomly generated? It pays to stay alert…

9 June 2025 (Monday) - XbarM Analysis

The XbarM alarm is in theory an absolutely brilliant idea. Given that the population with which we are dealing remains constant then the average result of any given blood parameter will also remain constant. And so any serious change in the average of the measurements of that parameter will tell us (me!) that there’s something causing that result to change.

However there is one big assumption in there… if we take the day’s workload and compare it to yesterday’s or tomorrow’s then the population with which we are dealing probably does remain constant. However we aren’t comparing on a daily basis. We are comparing batches of twenty patients. And bearing in mind that the various clinics batch up their work and sent it to us in job lots, XbarM analysis effectively ends up comparing twenty ante-natal patients with twenty oncology patients.

And so the alarm goes off.

There’s an interesting article from Sysmex on the matter which you can read by clicking here.

8 June 2025 - Buffy Coats?

Intracellular bacteria... What I found interesting was the concept of preparing a buffy coat to examine. In this day and age this is exacttly the sort of thing from which we are moving away.

7 June 2025 (Saturday) - NEQAS 2503 BF

I got the results of NEQAS 2503BF today.

For NEQAS 2503 BF1 I felt the red cells were unremarkable. The white cells showed blast cells, folded nuclei, cytoplasmic blebbing/hairy cells and neutropenia. The platelet count was reduced.

I spotted the salient features – the patient had AML.

For NEQAS 2503 BF2 I felt the red cells showed anisopoikilocytosis with nucleated red cells, target cells and burr cells seen. The white cells showed neutrophilia and monocytosis (with vacuolation). Some cells showed cleft nuclei and clover leaf nuclei. I spent a while before deciding these were not Sezary cells. There were also smear cells there.

The platelet count was reduced.

I spotted the salient features – the patient had CMML.

6 June 2025 (Friday) - UKAS Update

The United Kingdom Accreditation Service sent their update today. You can read it by clicking here.

This time they were talking about how “training supports professional development in the conformity assessment sector”. However, as is always the case, they seemed to be talking in riddles. It is all very well referring to how something or other does or doesn’t fit in with their standards. But all the time you have to spend serious money to see what their standards actually are, there’s a large amount of guesswork going on.

I’m reminded of my days as a manager when another manager would always get his way by insisting that whatever he wanted was “an MHRA requirement”. As no one in the meetings ever knew what MHRA required, his demands were always met without argument.

Perhaps if the UKAS people were more open about their standards we might all learn something. After all their predecessor was quite open about what their standards were.

6 June 2025 (Friday) - BTLP-TACT Exercise

Time for another BTLP-TACT exercise. I was presented with one case – a forty-nine year-old woman needing four units of blood for a surgical procedure.

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

I selected four units of O Rh(D) Positive K – negative blood.

I got the thumbs-up.

4 June 2025 (Wednesday) - Warm Autoantibodies

Back in the day when presented with a patient who has warm-acting autoantibodies we would crossmatch half a dozen units and give those which seemed to be least incompatible.

These days we sent samples to NHSBT.

Here’s a little article on the matter.

3 June 2025 (Tuesday) - Fritsma Factor Newsletter

The Fritsma Factor newsletter appeared in my in-box today. You can read it by clicking here. As always it has some useful snippets… but bleeding time and whole blood clotting time? Seriously?

3 June 2025 (Tuesday) - BTLP-TACT Exercise

Time for another BTLP-TACT exercise. I was presented with one case – a twenty-nine year-old woman in the haematology clinic needing two units of cryo for Factor VIII deficiency

Their ABO group was indeterminate but the Rh(D) group was positive.

Their antibody screen was negative.

The guidelines say that cryo is NOT indicated when virus-inactivated factor concentrates are available.

And in my world they are.

So I didn’t issue any.

I got it right…

29 May 2025 (Thursday) - Oncology Central Update

The nice people at Oncology Central sent their update today. Much of it went over my head; much of it usually does. But just occasionally something sticks…

29 May 2025

OC - 2024 - Q1 - AstraZeneca vis Arc Bio - interview - LB

ASCO 2025 guide: breaking news and key themes

The world’s largest clinical oncology conference, the ASCO Annual Meeting (May 30–June 3, IL, USA), begins tomorrow! To help you maximise your experience at ASCO, we have compiled breaking news headlines and key conference themes in one handy article.