A Dull Day At Work...?: 2026

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…

1 September 2026 (Tuesday) - A.I.

The latest missive from the United Kingdom Accreditation Service arrived in my in-box today. You can read it by clicking here.

Good luck.

I actually laughed out loud when I read the bit about using artificial intelligence. I actually use that with any UKAS publications with which I come into contact. Seriously. I really do.

Last month I mentioned on here that I found one of their articles to be incomprehensible so I emailed UKAS to ask for it to be translated into words that I could understand. No one replied so I copied the lot into Microsoft Copilot and asked it to translate it into everyday English, and it did.

So that’s what I do with stuff from UKAS nowadays. I want to understand it, and here’s one way that I can…

31 August 2026 (Monday) - Learning Monday

The correct answer is option 3. Matched sibling donor transplantation using bone marrow. For younger patients with severe or very severe aplastic anemia who have an available HLA-identical sibling donor, upfront allogeneic transplantation is the preferred first-line treatment.
The priority order of donor source for bone marrow transplantation is: (1) HLA-identical sibling, (2) HLA-matched unrelated donor, and (3) HLA-haploidentical donor if an HLA-matched unrelated donor is not rapidly available. Each of these donor marrow sources may be preferable to nontransplant IST.
Upfront transplantation from an HLA-identical sibling donor is preferred in eligible patients because immunosuppressive therapy is associated with a continued risk of relapse and clonal evolution to MDS or AML, whereas allogeneic transplantation offers a potentially curative treatment.  

30 August 2026 (Sunday) - Lymphoblasts

27 August 2026 (Thursday) - BTLP-TACT Exercise

I’ve got a day off… and it’s hossing down outside. I suppose I might as well do a BTLP-TACT exercise.

I was presented with one case – a thirty-year-old woman in labour needing group and save.

She grouped as A Rh(D) Positive with a weak reaction in the D. I called that indeterminate as that is what the software likes to see.

The antibody screen was positive in cell 2 so I performed antibody panels. The enzyme and IAT panels were positive in cells 2 and 6 corresponding with anti-K

I got the thumbs-up

26 August 2026 (Wednesday) - Westgard QC Update

The nice people at Westgard QC sent their update today. You can read it by clicking here, but it is rather hard going… Don’t get me wrong – I’m very grateful for this free resource. But it is rather hard going.

25 August 2026 (Tuesday) - Unexpected Drop

DIFF Blood Film Review Diagnosis

--------------------------------------------------------------------------------

HBM WBCM PLT HCT RBCM MCVM MCHM MCHCM RDW N

251125 142 5.68 278 0.415 4.86 85.4 29.2 342 12.7 3.04

101225 133 5.31 221 0.391 4.50 86.9 29.6 340 12.5 2.59

020426 F 126 6.58 267 0.364 4.28 85.0 29.4 346 12.5 4.13

240826 137 6.05 134 0.384 4.28 89.7 32.0 357 14.0 4.01

L M E B RETP RETA IRF NUC GF ESR

251125 1.54 0.51 0.56 0.03

101225 1.52 0.92 0.25 0.03

020426 F 1.70 0.51 0.21 0.03 NA

240826 1.38 0.60 0.05 0.01

Here’s an interesting case - an unexplained finding of a low platelet count. The patient was on lamotrigine. This stuff can cause that.

https://pubmed.ncbi.nlm.nih.gov/15741138/

One lives and learns…

24 August 2026 (Monday) - Learning Monday

Well... the staining isn't perfect But they look like prolymphocytes to me...

The correct answer is option 3. T-cell prolymphocytic leukemia.

The blood film shows abnormal lymphoid cells with nucleoli that are CD4+ T-cells by immunophenotype. Abnormal karyotype with t(X;14)(q28;q11) involving TRA/D-locus at 14q11 and MTCP1 at Xq28 confirms the diagnosis of T-PLL.

Reference:

GONZáLEZ-RODRíGUEZ LM, JUáREZ-Salcedo LM, Loscertales J, et al. T-cell prolymphocytic leukemia, a case report and review of the literature. Oncol Res. 2025;33(3):505-517. Published 2025 Feb 28. doi:10.32604/or.2025.058175

23 August 2026 (Sunday) - Slide Saturday Challenge

Polychromatic red cells... I thought I was missing something...

21 August 2026 (Friday) - Information Governance

I did information governance e-learning today. It’s a simple enough concept… in the course of your job you will see all sorts of confidential information.

Keep your trap shut and MAKE SURE that you don’t let anything slip.

That’s it.

However there’s quite a few ways that you might let slip. A little refresher never hurts

19 August 2026 (Wednesday) - Transfusion Evidence Library Update

The nice people at the Transfusion Evidence Library sent their update today. I know I keep banging on about the stuff, but tranexamic acid really is *the* stuff, isn’t it?
Two more mentions…

ARTICLE OF THE MONTH

Avatrombopag versus placebo for persistent chemotherapy-induced thrombocytopenia in GI cancers: the phase II ACT-GI trial.
Al-Samkari, H., et al. (2026). Journal of Clinical Oncology. [Record in progress].
PICO SUMMARY

TOP ARTICLES

Barriers and enablers to non-remunerated plasma donation: a meta-synthesis of the qualitative literature using the theoretical domains framework.
Etherington, C., et al. (2026). Vox Sanguinis. [Record in progress].

The efficacy of tranexamic acid for the prevention of postpartum hemorrhage among women at high risk of postpartum hemorrhage undergoing cesarean section: a meta-analysis.
Gao, Q., et al. (2026). BMC Pregnancy and Childbirth. [Record in progress].

Optimal route of tranexamic acid administration in total knee arthroplasty: a Bayesian network meta-analysis with decision-analytic cost evaluation.
Hershfeld, B.E., et al. (2026). The Journal of Arthroplasty. [Record in progress].

Efficacy and safety of different doses of intravenous immunoglobulin combined with phototherapy in neonatal hemolytic disease: a systematic review and meta-analysis.
Huang, M., et al. (2026). European Journal of Pediatrics.

HLA selected red cell transfusions to prevent HLA sensitisation: a prospective, double-blinded, randomised controlled trial.
McComish, J.S., et al. (2026). Transplant Immunology.

Mortality effect of albumin fluid resuscitation in adults with septic shock: a systematic review and dual frequentist-bayesian meta-analysis of randomised trials.
Mendes, H., et al. (2026). Critical Care.

Adjuvant intravenous immunoglobulin in elderly sepsis: a randomized controlled study of mortality, organ function, and inflammation.
Miao, X., et al. (2026). Frontiers in Medicine.

Effect of blood donation in the glycemic control of prediabetic donors: a blinded randomized controlled trial.
Mora-Gonzalez, D., et al. (2026). Endocrine Practice. [Record in progress].

Comparative efficacy of intranasal, intramuscular, and intravenous vitamin B12 therapy for hematological recovery in vitamin B12 deficiency anemia: a randomized controlled trial.
Singh, S.K., et al. (2026). American Journal of Hematology.

Diagnostic accuracy of reticulocyte haemoglobin content in detecting iron deficiency without anaemia in blood donors: a systematic review and meta-analysis.
Yanyiam, P., et al. (2026). Vox Sanguinis. [Record in progress].

19 August 2026 (Wednesday) - NEQAS 2603DM

I finally got the result of 2603DM today… “a 43-year-old man who regularly attends Haematology outpatients. The blood film was prepared after new features were noticed in his blood count. Your opinion is requested”.

I can’t remember it at all, but at the time I said: “I’d say he regularly attends haematology outpatients because of a haemoglobinopathy. There’s target cells, sickle cells, nucleated red cells, polychromasia and Howell-Jolly bodies there.

And there’s blast cells and smear cells.
And there’s an eosinophilia too.

The platelet count is down as well

I’d say this is someone with sickle cell disease (possibly HbSC or with a co-existing thalassaemia because of the target cells) who has suddenly developed leukaemia”.

The expert opinion was “This is a case of sickle cell disease (HbSS) with typical red cell features including sickle cells, boat-shaped cells, hyposplenic features and nRBCs. However, in this case there are also blast cells which should not be present and indicate the additional presence of an acute leukaemia. The important principle here is to recognise that we like to consolidate all features of a diagnostic blood film into a single diagnosis (e.g. sickle cell anaemia with reactive/hyposplenic features, or an acute leukaemia or myelofibrosis with associated red cell change). The key is sometimes to focus on the really key findings – in this case the blast cells, thrombocytopenia and typical sickle cells. Then ask whether this is really compatible with a single disorder”.

So… I’d spotted all the salient features. I got it right.

18 August 2026 (Tuesday) - QC on the TOP

Still sulking about the BTLP-TACT debacle I had a look at the Werfen academy.

I had a go at one of the courses – “ACL TOP Family 50 Series - Running QC”.

I passed. That cheered me up a bit…

18 August 2026 (Tuesday) - Getting the BTLP Wrong (Again)

I had a little time on my hands this morning so I did a BTLP-TACT exercise.

I was presented with two cases:

47778 – a ninety-nine year-old woman in out patients needing group and save prior to hip replacement surgery.
She grouped as AB Rh(D) Positive with a negative antibody screen.

36230 – a twenty-nine year-old woman in the maternity unit needing group and save prior to induction of labour.
She grouped as A Rh(D) Negative with antibody screen positive in all three cells. I performed antibody panels.
The enzyme panel was negative throughout.
The IAT panel was positive in cells 1, 2, 3, 5, 6, 7, 9 and 10 corresponding with anti-S and anti-Fy(a)

I got it wrong. Apparently anti-K could not be excluded. I’m not happy about this. In previous exercises I was told that a negative reaction in the enzyme panel *did* rule out anti-K in the simulator (I know it don't in real life).

17 August 2026 (Monday) - Sounds Like Sezary's Syndrome...

The LEAST recommended diagnostic test is option 1. Bone marrow aspirate and biopsy

The patient shows the typical clinical picture of Sézary syndrome (cutaneous T-cell lymphoma, likely stage T4NxB2M0), characterized by erythroderma (erythema involving >80% of the body surface area), generalized lymphadenopathy and lymphocytosis with a TCR rearrangement shared between the skin and the blood. Skin biopsies, PET-CT and lymph node biopsies are indicated for diagnosis and staging. In the absence of unexplained cytopenia, a bone marrow study is generally not necessary.

First-line therapies include low-dose methotrexate, extracorporeal photopheresis, retinoids and interferon. Mogamulizumab (an anti-CCR4 monoclonal antibody) is the treatment of choice for relapsed/refractory disease. Allogeneic transplantation should be considered in selected cases.

Reference:

Dummer R, et al. Cutaneous T cell lymphoma. Nat Rev Dis Primers. 2021;7(1):61. Published 2021 Aug 26.

Latzka J, et al. EORTC consensus recommendations for the treatment of mycosis fungoides/Sézary syndrome - Update 2023. Eur J Cancer. 2023;195:113343.

Olsen E, et al. Revisions to the staging and classification of mycosis fungoides and Sezary syndrome: a proposal of the International Society for Cutaneous Lymphomas (ISCL) and the cutaneous lymphoma task force of the European Organization of Research and Treatment of Cancer (EORTC). Blood. 2007;110(6):1713-1722.

16 August 2026 (Sunday) - I've Heard Of It...

Well, I’ve heard of Chediak-Higashi syndrome, but don’t think I’ve actually seen it in real life.. Here’s as good a place as any to start with it.

It’s not restricted to humans…

15 August 2026 (Saturday) - DOAC

I finally got round to signing up to the Werfen Academy today, and got full marks on my first course “Introduction to Direct Oral Anticoagulants (DOACs)”.

Go me…

14 August 2026 (Friday) - Seriously?

I’m not quite old enough to remember the first Moon landings, but I remember the Apollo 13 disaster and Skylab. I remember Dolly (the first cloned sheep) and Louise Brown (the first test-tube baby).

I had such high hopes for the future… it turned out to be such a disappointment.

12 August 2026 (Wednesday) - BTLP-TACT Exercise

It’s too hot outside. I’ll do a BTLP-TACT exercise… I was presented with one case – a forty-nine year-old woman who claimed to be tired all the time. A group and save was required.

She grouped as A Rh(D) Positive, but it was one of those supposedly weak reactions so I called it A Rh indeterminate with the proviso that I would send it to NHSBT.

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

The enzyme panel was 2+ in cells 2 and 6 corresponding to anti-K, and 4+ in cells 3 and five corresponding to anti-E.

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

I got the thumbs-up.

9 August 2026 (Sunday) - Slide Saturday Challenge

Well, it’s hereditary elliptocytosis, isn’t it? This one looks particularly extreme with a lot of very bizarre red cells.

Clinically this one would be severe, some not so bad. I always remember discovering a case of H.E. in an eighty year old chap who had an infection after a prostatectomy. Morphologically loads of elliptocytes, clinically not a problem… he’d lived eighty years before anyone had any cause to put his blood under a microscope… and even then it wasn’t actually because of his red cells.

Here’s an article on the matter…

7 August 2026 (Friday) - ABO Groups

ABO groups aren’t quite as straightforward as we might like them to be…

Here’s a little article on the subject…

4 August 2026 (Tuesday) - BTLP-TACT Exercise

Time for a BTLP-TACT exercise. I had two cases:

15626 – a fifty-six year-old chap needing two units of cryo to treat Factor VIII deficiency.

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

According to https://pmc.ncbi.nlm.nih.gov/articles/PMC4627369 Cryo is not recommended for Factor VIII deficiency so I didn’t issue any

73726 – a seventy-eight year old chap needing four units of FFP for a pre-operative reversal of warfarin.

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

According to https://pmc.ncbi.nlm.nih.gov/articles/PMC9362864/ FFP is not the treatment of choice for the reversal of warfarin pre-operatively so I didn’t issue any.

I got it right.

4 August 2026 (Tuesday) - Fritsma Factor Newsletter

The nice people at the Fritsma Factor sent their update today. You can read it by clicking here.

There was quite a bit to take in…

3 August 2026 (Monday) - Learning Monday

The correct answer is option 3. Mixed phenotype acute leukemia with KMT2A rearrangement

Immunophenotypic properties of MPAL can change over time: both variable proportions of different lineages and phenotypic alterations have been described as lineage switch. Most cases of lineage change involve a switch from ALL to AML. A retrospective review can often reveal the presence of an unrecognized or underappreciated malignant subclonal population present in the initial specimen. This may represent a minor population which displayed more chemoresistance and emerged after eradication of the chemosensitive dominant clone. This kind of lineage switch is most common in MPALs with KMT2A rearrangement where a small myeloid/monocytic population can be difficult to appreciate due to hyperleukocytosis with a dominant B-precursor population at diagnosis.

Reference:

Weinberg OK, Arber DA, Döhner H, et al. The International Consensus Classification of acute leukemias of ambiguous lineage. Blood. 2023;141(18):2275-2277.

2 August 2026 (Sunday) - Something New

Emperipolesis – that’s a new one on me… apparently it’s a rare biological process where an intact, living cell enters and moves inside the cytoplasm of another cell without getting harmed or destroyed. It differs from phagocytosis because the engulfed cell stays alive and can leave and does…

Here’s a reference about it.

29 July 2026 (Wednesday) - UKAS Update

The nice people at UKAS sent their update today. You can read it by clicking here. I did, and struggled, as did the colleagues with whom I discussed it. I often whinge about the UKAS newsletter, but this time I’ve done something more than whinge. I’ve emailed them… Here’s what I wrote:

“Dear sir or madam
I just received your latest newsletter. I was intrigued to hear about the Pathology Transformation Review 2026 but when I clicked on the link I found the article incomprehensible.
The article in question is https://www.ukas.com/resources/latest-news/ukas-welcomes-the-pathology-transformation-review-2026/
I showed it to some colleagues, and none of us understand what it means. I don’t want to appear confrontational or reactionary. I seriously want to understand what is going on with my profession and its regulator… But I don't.
Could one of your experts paraphrase it in such a way that a semi-retired old dinosaur could understand it… (sorry)”

I wonder if they will get a reply? My request is a serious one. Despite having done a formal course of study in quality management I didn’t understand any of what that article was saying.

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