19 October 2026 (Monday) - BTLP-TACT Exercise

 I thought I might do another BTLP-TACT exercise. I was presented with two cases

 

05898 – a sixty-one year-old chap in out-patients needing a pre-operative group and save.

His ABO group was uninterpretable as there was no reaction in anything. One for NHSBT. His Rh(D) group was negative.

His antibody screen was negative.

 

72428 – a fifty-two year-old chap also needing group and save following over-anticoagulation.

He grouped as A Rh(D) Positive and also had a negative antibody screen.

 

I got the thumbs-up which, bearing in mind my last few goes, came as something of a relief. 

19 October 2026 (Monday) - NEQAS 2606 BF & 2603 DF

I got the results of NEQAS 2606BF today

 

2606BF1 looked unremarkable to me, and the expert opinion couldn’t find anything amiss with it either.

 

In 2606 BF2 I saw Macrocytosis,  hypersegmented neutrophils, and thrombocytopenia. This was what the expert opinion found, but didn’t give any diagnosis

 

I’ll take that as a win…

 

I also got the results of 2603 DF. My results were (with expected range in brackets)

 

Neut      53% (43 – 63)

Lymph  40%  (27 – 47)

Mono      5%   (3 – 7)

Eos         2%   (0.7 – 1.4)

Baso       0%   (0 – 1.4)

 

My eosinophils were a tad high, but if I counted another two hundred cells… which is why we have automated this test.

16 October 2026 (Friday) - BTLP-TACT Exercise

Having failed the two previous BTLP-TACT exercises (together with an email telling me I’m not doing enough of them) I thought I might do another.

I was presented with two cases:

 

71741 – a child of less than two years of age with coffee ground vomit needing group and save

He grouped as A Rh(D) Negative with a negative antibody screen.

 

16621 – a ninety-four year-old chap needing four units of blood for a GI bleed.

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

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

 

I got it right…

16 October 2026 (Friday) - Sharing e-books

In amongst the puerile nonsense filling the work-related Facebook pages is (occasionally) a link to a text book in .pdf format. I’ve been downloading them when I see them, but it occurred to me that rather than just leaving them in my downloads folder (where I will never see them again) I might make a sharable folder on my Google drive. After all Google gives me a squillion plabtobytes of free webspace with which I’m not doing very much at all. It only took a minute to set up. I quite like e-books for the simple reason that they take up a whole lot less space than a real book. At the moment there’s only half a dozen e-books in there. In the fullness of time I might need to figure out something of a Dewey Decimal Classification system to sort them… 

15 October 2026 (Thursday) - It Knows, You Know

I’ve got bored with the dull picture I’ve been using for BTLP-TACT exercise so got Microsoft Copilot to generate a new one - a fun piccie of me at work in the blood bank.

In order to personalise it somewhat I asked it to include a poster featuring the two rules I always tell the trainees (which it did).

 

When I thanked Microsoft Copilot for this picture it commented: “I have to say, the final blood bank version with the "Two Rules. Don't balls it up. Don't kill no one" poster made me laugh. It feels exactly like the sort of unofficial quality-management statement that every transfusion laboratory secretly operates under, despite hundreds of pages of SOPs saying the same thing in a much more complicated way”.

 

Seeing it has this level of understanding is why I always thank it for anything I ask it to do.

 

15 October 2026 (Thursday) - BTLP-TACT Exercise

Bearing in mind I stuffed up on Monday (and also bearing in mind I’ve been playing with Microsoft Copilot) I thought I’d do another BTLP-TACT exercise…

 

I was presented with two cases:

 

18718 – a fifty year old woman in ITU needing two units of blood

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

I selected two units of B Rh(D) Positive blood for her.

 

37802 – a thirty-six year old woman in the haematology clinic needing two units of irradiated blood

She grouped as O Rh(D) Positive with antibody screen positive in cells 1 and 3.

I performed antibody panels. The IAT panel was positive in cells 1, 3, 6, 9 and 10 corresponding with anti-Fy(a) whilst the enzyme panel was negative throughout.

I selected two irradiated units of O (one Rh(D) Positive and one Rh(D) Negative) Fy(a) Negative which were also K-Negative.

I got the red light as it felf there were more antibodies there… I’d love to know which ones. Possibly anti-Kp(a)?

Rather ironic what with my new piccie courtesy of Microsoft Copilot, eh?

13 October 2026 (Tuesday) - NEQAS 2604DM

 

I got hold of the results of 2604DM today. When I looked at it I said:

 

• Neutrophilia – mature cells
• Howell Jolly Bodies
• Sickle cells
• Target cells
• Polychromasia
• Some Large platelets

 

Was this someone with sickle cell disease with some sort of myeloproliferation?

 

The expert final comment that I read today was:

 

“This film showed a G-CSF-induced neutrophilia in a patient with sickle cell disease (who was recovering from chemotherapy).

It is often easy to overlook a second disorder when there is a dominant abnormal feature on a blood film. In this case, there were clues to a red cell element: red cell appearances were very abnormal and nucleated red cells and Howell-Jolly bodies were present, but most of all there were clear sickle cells on the film. If you missed these, have another look.

Could you have known the neutrophilia was caused by G-CSF administration? Probably not, but given the high neutrophil count, it would be unusual for an infective cause not to have marked toxic features in the neutrophils! A chronic neutrophilic leukaemia could be considered if G-CSF had not been administered”.

 

Well, I spotted the salient features, but my final comment might not appear very professional, but what a load of bollox. It is utterly inconceivable that a patient with sickle cell disease who was receiving G-CSF following chemotherapy would be unknown to the haematology laboratory.

For these exercises to have any validity they need to have al least a passing relationship with reality.

13 October 2026 (Tuesday) - IBMS Update

The IBMS sent their update today – you can read it by clicking here. There wasn’t a lot that was directly relevant to me, but it did mention the recent publication of certain national standards to do with microbiology and sepsis.

That’s a step in the right direction.

There was still a lot of stuff about what individual committee members had been getting up to, but perhaps we are moving away from that sort of thing to what our professional body should be doing

(or what a semi-retired out of date old reactionary thinks it should be doing. A subtle difference…)

12 October 2026 (Monday) - BTLP-TACT Exercise

Time for a BTLP-TACT exercise. I was (eventually) presented with two cases:
 

51761 – a seventy-two year-old chap needing group and save

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

98771 – a fifty-nine year-old woman also needing group and save

She also grouped as O Rh(D) Positive but with antibody screen weakly positive in cells 2 & 3. I performed antibody panels. Both the enzyme and IAT panels were negative in cells 1 & 2 and positive in all other cells corresponding with anti-c, but I was unable to exclude anti – Lu(a) as it doesn’t feature on the antigram of the screen, and also unable to exclude anti-Kp(a)

 
I got the thumbs down… anti-E was also masked… I saw that - why didn't I write it down?

10 October 2026 (Saturday) - Platelet Refractoriness

Platelet transfusions don’t always do the trick. You gave a full adult dose, ABO-compatible, straight off the agitator, room temperature the whole way, and the post-transfusion count looks almost identical to the pre-transfusion count. So do you carry on stuffing in more platelets?

Here’s a treatise on the matter.

 

6 October 2026 (Tuesday) - Fritsma Factor Update

The latest update from the nice people at the Fritsma Factor arrived in my in-box today.

As always there was quite a bit of useful stuff.

Haemophilia in women… we don’t often think about that…

 

6 October 2026 (Tuesday)- -UKAS Update

Here’s the latest update from the UK Accreditation Service. It’s rather dry and at first sight might well (quite frankly) seem to be meaningless gibberish. I told them this (rather politely) a couple of months ago and they never even replied.

I’ve found that if you copy the entire lot into Chat GPT and ask it to translate into everyday English it becomes a tad more comprehensible. It actually becomes rather sensible.

That’s what winds me up about quality management. It is *such* a good idea but is couched in mystery. Why do people do this with it?

3 October 2026 (Saturday) - IgA Deficiency

The whole reason that we do CPD is to stay abreast of latest developments. And there is no field in which there are no end of developments quite like there is with blood transfusion.

Here’s the latest thinking on IgA deficiency…

 

30 September 2026 (Wednesday) - BTLP-TACT Exercise

As it is the end of the month I thought I might as well do a BTLP-TACT exercise if only to keep the engagement level up.

I had one case – a ninety-two year-old chap needing four units of blood prior to surgery. 

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

I selected four units of O Rh(D) Positive blood

 

I got it right. Having done six exercises this month the software says I’m currently meeting my engagement targets… I wonder why it keeps sending me emails saying that I’m not…

29 September 2026 (Tuesday) - IBMS Newsletter

It was with something of a sense of frustration that I received the IBMS newsletter today. Having received it in four different emails, the works IT refused to open it as it originated from outside its own domain.

I eventually got the thing open – you can read it by clicking here (hopefully). Much of it was irrelevant to me, but two items made me think.

There was an article about embracing automation… This is clearly the way forward, but when I first started people were fighting tooth and nail against automation. There was supposedly some merit by doing everything in the most laborious, time consuming, expensive and imprecise way possible (or so it was ranted at me by so many people).

But I saw red when I read about “Pathology Transformation: Building a sustainable workforce”. This is a standard management catchphrase which has been trotted out ever since we as a profession decided not to build a sustainable workforce but to hope to have a workforce educate and train itself, and then pretended to be surprised when in the large part it didn’t work. (I’ve ranted about this before).

24 September 2026 (Thursday) - BTLP-TACT Exercise

Time for another BTLP-TACT exercise. I was presented with one case – a twenty-eight year-old woman with a ruptured ectopic pregnancy needing six units of blood.
 

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

I selected two units of B Rh(D) Negative and four units of O Rh(D) Negative

 
I got the thumbs-up.

 

23 September 2026 (Wednesday) - Westgard QC Update

The nice people at Westgard QC sent their update today. It was rather heavy going, but that’s the nature of the subject…

 

22 September 2026 (Tuesday) - Transfusion Evidence Library Update

The nice people at the Transfusion Evidence Library sent their update today. Tranexamic acid and keeping platelets in the fridge featured again…

ARTICLE OF THE MONTH

Cold and room-temperature platelets in cardiac surgery: the CHIPS randomized clinical trial.
Spinella, P.C., et al. (2026). JAMA. [Record in progress].
PICO SUMMARY

 

 

TOP ARTICLES

Subcutaneous immunoglobulin for chronic inflammatory demyelinating polyradiculoneuropathy.
Bus, S.R., et al. (2026). The Cochrane Database of Systematic Reviews.

Perioperative albumin versus other fluids to prevent cardiac surgery-associated kidney injury: a systematic review and meta-analysis of randomized trials.
Darlison, P.R., et al. (2026). Critical Care Science.

AI and blood banking: predicting transfusion demand - a systematic review of forecasting approaches.
Engelke, M., et al. (2026). Transfusion Medicine and Hemotherapy. [Record in progress].

All-trans retinoic acid plus eltrombopag for refractory/relapsed immune thrombocytopenia.
Fu, H., et al. (2026). NEJM Evidence.

Recombinant human thrombopoietin reduces the need for platelet transfusion in patients with chronic liver disease and thrombocytopenia.
Han, Y., et al. (2026). American Journal of Hematology.

Eltrombopag plus cyclosporine A for moderate aplastic anemia (EMAA): a placebo-controlled, double-blind, phase 3 trial.
Höchsmann, B., et al. (2026). Blood. [Record in progress].

Impact of tranexamic acid on outcomes in early-admitted patients with aneurysmal subarachnoid hemorrhage: a systematic review and bayesian meta-analysis of randomized controlled trials.
Łajczak, P., et al. (2026). Journal of Thrombosis and Thrombolysis. [Record in progress].

Intravenous iron to treat anaemia before cardiac surgery (ITACS): international, double blind, placebo controlled randomised trial.
Myles, P.S., et al. (2026). BMJ.

Early red blood cell transfusion strategy in septic shock among patients with cancer: the TRANSPORT randomized controlled trial.
Pène, F., et al. (2026). Intensive Care Medicine. [Record in progress].

Larger versus smaller red blood cell volume per transfusion in hospitalized adults, children and preterm neonates.
Roumeliotis, N., et al. (2026). The Cochrane Database of Systematic Reviews.

Albumin for people with liver cirrhosis and bacterial infections.
Simonetti, R.G., et al. (2026). The Cochrane Database of Systematic Reviews.

 

 

21 September 2026 (Monday) - Hb D Punjab

 

The correct answer is option 1. HPLC of the husband should be advised.  

HbD Punjab is a structural hemoglobin variant that is usually clinically benign in the heterozygous state (HbAD). Therefore, identification of HbD Punjab in the mother alone is not an indication for termination of pregnancy. However, HbD Punjab is important because it can be inherited by the fetus, may interact with other haemoglobin variants, and can result in clinically significant disease when combined with certain hemoglobinopathies.  

The important next step is to evaluate the husband for an underlying hemoglobinopathy, particularly HbS or β-thalassaemia, as compound heterozygosity in the offspring may result in a clinically significant hemoglobin disorder. Based on the husband's results, the couple should receive appropriate genetic counselling and, if indicated, prenatal diagnostic testing. 

Although HbD Punjab is generally clinically silent, it can become clinically significant when inherited alongside other hemoglobin variants, such as sickle haemoglobin (HbS) or β-thalassaemia. In particular, HbSD Punjab disease can present with manifestations similar to sickle cell disease, including vaso-occlusive complications, while HbD Punjab/β-thalassaemia may produce a variable clinical phenotype ranging from mild to moderately severe anaemia 

Reference:

• Torres Lde S, Okumura JV, Silva DG, Bonini-Domingos CR. Hemoglobin D-Punjab: origin, distribution and laboratory diagnosis. Rev Bras Hematol Hemoter. 2015 Mar-Apr;37(2):120-6. 

I got that right...

20 September 2026 (Sunday) - Hedging Your Bets

 

Well… the initial Slide Saturday Challenge (yesterday) asked: “How would you describe the atypical cell in the centre of the field and what diagnosis would you consider”.
I see that the American Society of Hematology was as reluctant to commit themselves as I was…

18 September 2026 (Friday) - BTLP-TACT Exercise

 Time for another BTLP-TACT exercise. I had one case – a twenty-five year-old woman with sickle cell disease needing eight units of blood for an exchange transfusion.

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

I selected all the O Rh(D) Negative K Negative HbS Negative units I could scrape up.. two of them.

 

I got the green light, but I hardly got it right, did I? I supplied a quarter of what was required. In reality I would have got on to NHSBT and had more supplies sent.

But I got the green light and that was a result.

16 September 2026 (Wednesday) - Inspections

This appeared on one of the satirical work-related Facebook pages that I follow… but it illustrates something I’ve been banging on about for years. Back in the day the old CPA standards were for most people unobtainable for most of the time.

Everyone knew this, and everyone accepted this.

Back in the day when I was in charge our lab passed with only three (very) minor findings, but it was the result of a lot of hard work to reach a standard for one day which was frankly beyond anyone’s ability to maintain for more than a day. We would put on a show, breathe a sigh of relief when the inspectors went home, and put our feet up for the next four years. After four years we would get plenty of notice of our next inspection, and would again move heaven and Earth to be ready on the day.

The late Duke of Edinburgh unknowingly summed up the old CPA standards when he once remarked that everywhere he went smelled of paint. And the current ISO standards are in much the same vein.

 

As a lad our Boys Brigade entered a team into the fire brigade’s fire safety quiz competition. There we learned about industrial and commercial fire safety standards which were manageable and obtainable…  but the fire brigade would turn up unannounced to check that all was in order.

 

Surely we would be far better off with such a system. Manageable and achievable objectives which are inspected without prior notice.

14 September 2026 (Monday) - Hairy Cells

 

Looks like hairy cell leukaemia to me...

The correct answer is option 3. Hairy cell leukemia. 
The combination of neutropenia, thrombocytopenia, marked monocytopenia, splenomegaly, absence of lymphadenopathy, and a dry bone marrow aspirate is highly suggestive of classic hairy cell leukemia (HCL).
Cytopenias result from bone marrow infiltration and fibrosis, which commonly causes a dry tap. Marked monocytopenia is particularly characteristic of HCL, while splenomegaly without significant lymphadenopathy is a typical clinical pattern. Diagnosis should be confirmed by bone marrow biopsy, flow cytometry, and BRAF V600E testing. The presence of a BRAF V600E mutation supports the diagnosis of classic HCL and helps distinguish it from several HCL-like disorders. 
CLL is unlikely in the absence of lymphocytosis, whereas myelodysplastic syndrome and T-cell large granular lymphocytic leukemia do not typically produce this combination of findings.

Reference:

• Zent CS, et al. Updated consensus guidelines for the diagnosis and management of patients with HCL and HCL variant. Blood. 2026 Jul 2;148(1):31-42.
• Falini B, Tiacci E. Hairy-Cell Leukemia. N Engl J Med. 2024 Oct 10;391(14):1328-1341.
• Wotherspoon A, et al. Bone marrow and splenic histology in hairy cell leukaemia. Best Pract Res Clin Haematol. 2015 Dec;28(4):200-7.

10 September 2026 (Thursday) - BTLP-TACT Exercise

Time for another BTLP-TACT exercise. I had one case – a seventy year old woman needing six units of blood for an aortic aneurysm.

 

Her ABO group was indeterminate, but her Rh(D) group was negative.

The antibody screen was negative.

I selected six units of O Rh(D) Negative.

 

I got it right.

7 September 2026 (Monday) - NEQAS 2603 PA

I got the results of NEQAS 2603 PA today…

 

2603PA1

 

I saw some things that made me look twice, but nothing convincing. It was probably debris; certainly wasn’t a parasite.I don’t like thick films at the best of times.

The slide was actually negative and that’s what I said.

 

2603PA2

 

I saw some small worm-things. Was it  Leishmania donovani?

The expert opinion was that this was amastigotes of Leishmania. Bearing in mind I’ve never seen this outside of a NEQAS exercise I think I’m justified in saying “Go me” (!)

 

7 September 2026 (Monday) - BTLP-TACT Exercise

 

Time for a BTLP-TACT exercise… I was presented with one case – a thirty-two year-old chap in the haematology clinic with sickle cell disease needing eight units of blood for an exchange transfusion.

He grouped as O Rh(D) Positive with a negative antibody screen. I selected all the HbS negative units there were (four).

I got it right…   In reality that would be a resounding fail because I only came up with half the amount of blood needed. In reality I would get onto NHSBT and have them send some suitable blood. But this isn’t reality. It’s a simulator. Not a bad one, but quite obviously a work in progress on which no progress is being made. (That’s very ungrateful of me, isn’t it?)

6 September 2026 (Sunday) - CML

Well… it looks like CML to me. There’s nothing else that gives you quite such an assortment of myeloid cells.

4 September 2026 (Friday) - BTLP-TACT Exercise

Time for a BTLP-TACT exercise… I was presented with one case – a fifty-five year old chap in theatre needing six units of blood for gunshot wounds.

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

I selected six units of O Rh(D) Positive K Negative blood.

 

I got the thumbs-up.

2 September 2026 (Wednesday) - Fritsma Factor Update

The Fritsma Factor newsletter appeared in my in-box today. As always there was a lot to take in, but as a source of haemostasis-related CPD it can’t be bettered.

2 September 2026 (Wednesday) - NEQAS 2605BF

I got the results of NEQAS 2605 BF today
 
For 2065BF1 said
 

Thrombocytosis

Target cells

NRBC

Bizarre red cells

HJB (?)

Echinocytes

Rbc Fragments

Lymphocytosis

 

I wondered if this was heat changes, it was a case of congenital dyserythropoietic anaemia from the haematology clinic.

 
For 2065BF2 I said
 

NRBC

Target cells

Botyroid neutroohils

Lymphocytosis

Polychromasia

?? Occasional sickle cells???

 

I wondered if this was a case of heat stroke, it was a case of homozygous sickle cell disease three days after being treated for malaria. Interestingly the botroid neutrophils weren’t spotted by most people.

 
How did I do? Well, as I said to a colleague, this was a load of bollox. I spotted all of the salient features. However someone known to have haematological diseases which are being treated *aren’t* going to turn up as random chance findings.
The organization of NEQAS blood films leaves a lot to be desired…