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.