A Dull Day At Work...?: 2026

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…

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.