The enumeration of lymph nodes (LNs) from surgical specimens plays a critical role in the staging of patients with cancer. LN count (LNC) can affect prognosis, staging, adequacy of resection, and/or eligibility for clinical trials. However, there is no standard method for counting LNs. Most studies in the literature site the pathology report as the source of LN data, without discussion of the counting criteria. Four microscopic slides from separate pelvic LN dissections were digitally scanned and uploaded with their gross descriptions to an online library and an online survey. Respondents were asked how many LNs they would count per slide as part of a staging procedure. The survey was distributed to an international cohort of pathologists. A total of 122 surveys were returned: 79 from practicing pathologists and 43 from residents/fellows. There was no statistical difference between the groups. All slides showed significant individual variability. The LNC range for each slide was as follows: slide 1, 1-3; slide 2, 0-13; slide 3, 1-8; slide 4, 1-11. The intraclass correlation (ICC) for all responders was 0.26 (95% CI, 0.05

We report an asplenic patient who was infected with Babesia divergens–like/MO-1. The clinical course was complicated by multiorgan failure that required intubation and dialysis. The patient recovered after an exchange transfusion and antimicrobial drug therapy. Physicians should be alert for additional cases, particularly in asplenic persons.

Ipilimumab, nivolumab, and pembrolizumab represent a new class of immunotherapeutic drugs for treating patients with advanced cancer. Known as checkpoint inhibitors, these drugs act to upregulate the cellular and humoral immune response to tumor antigens by inhibiting T-cell autoregulation. As a consequence, they can be associated with immune-related adverse events (irAEs) due to loss of self-tolerance, including rare cases of immune-related cytopenias. We performed a retrospective clinical chart review, including serologic, hematology, and chemistry laboratory results, of two patients who developed red blood cell (RBC) autoantibodies during treatment with a checkpoint inhibitor. Serologic testing of blood samples from these patients during induction therapy with ipilimumab and nivolumab, respectively, showed their RBCs to be positive by the direct antiglobulin test (IgG+, C3+) and their plasma to contain panreactive RBC autoantibodies. Neither patient had evidence of hemolysis. Both patients developed an additional irAE during treatment. A literature review for patients who had developed immune-mediated cytopenia following treatment with a checkpoint inhibitor was performed. Nine other patients were reported with a hematologic irAE, including six with anemia attributable to autoimmune anemia, aplastic anemia, or pure RBC aplasia. Hematologic irAEs tend to occur early during induction therapy, often coincident with irAEs of other organs. In conclusion, checkpoint inhibitors can be associated with the development of autoantibodies, immune-mediated cytopenias, pure RBC aplasia, and aplastic anemia. Immunohematology reference laboratories should be aware of these agents when evaluating patients with advanced cancer and new-onset autoantibodies, anemia, and other cytopenias. Immunohematology 2017;33:15-21.

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This case of platelet transfusion in palliative care illustrates a common dilemma in transfusion medicine: approval of the use of a scarce, yet potentially life-saving, resource. As in this case, these decisions often involve seriously ill patients with acute needs and evolving goals of care. The use of resources to treat the patient at hand must be balanced against maintaining adequate resources to treat future patients. In this setting, the ethical principles of beneficence and social justice are in conflict. CaseDr. J, a second-year resident on the palliative care service, has become quite close to his patient, Emma, a 5-year-old girl with acute lymphoblastic leukemia. Two years ago, Emma completed successful chemotherapy and achieved remission, but a recent bone marrow biopsy showed lymphoblastic infiltration. She was started on a rescue therapy program with little response and underwent a bone marrow transplant. During this relapse, she has been hospitalized on multiple occasions for infections and bleeding, which required blood and platelet transfusions, and is now receiving palliative care for tumor lysis syndrome. It is Emma's medical team's opinion that there is no more that can be done to cure her leukemia, which prompted her transfer to the palliative care service. Shortly after transfer, Emma developed bright red blood per rectum, and Dr. J requested human leukocyte antigen (HLA)-matched platelet transfusion for her to help stop the bleeding.Dr. S, a third-year pathology resident, received Dr. J's request for HLA-matched platelets. Typically, pathologists oversee platelet distribution, since they are the physicians responsible for administering transfusion services in a hospital-maintaining an adequate blood supply, monitoring blood donor and patient-recipient safety, ensuring appropriate blood utilization, and directing the preparation and safe use of blood components according to a hospital's platelet distribution protocol. Since Dr. S oversees a busy transfusion service with many sick patients requiring blood and platelets, one of her duties is to carefully assess each request for these limited resources. She contacts Dr. J and asks for more information about his request. Dr. S explains that HLA-matched