Review Of Peripheral Blood Smear Research Articles

Pseudo-NRBC in the Mindray BC-6800Plus analyzer: A clue for diagnostic anticipation of fungemia. Experimental and preliminary clinical reports.

Candidemia can be a significant cause of death in immunosuppressed or debilitated patients particularly. Abnormalities of the instrumental cytograms of some hematological analyzers, such as Mindray BC-6800Plus, can be related to circulating Candida. We studied the possible diagnostic usefulness of this information. A fungal bloodstream infection has been simulated by adding aliquots of Candida albicans, Candida parapsilosis, and Candida glabrata to 75 leftovers and anonymized peripheral blood samples. Cytographic abnormalities like those of experimental samples were used to select patients with possible fungemia. The microscopic review of peripheral blood smears constituted the confirmatory method. In all experimental samples, the various Candida types caused pseudo-NRBC and morphological abnormalities of WNB and DIFF cytograms. Circulating blastospores, free or engulfed by neutrophils, were the microscopic findings in the peripheral blood smears. In the clinical verification, 72 patients were recruited based on the presence of an evocative cluster in the WNB and DIFF cytograms. The microscopic review of 39 out of 72 samples was positive for NRBC. According to blood cultures, light microscopy revealed fungal forms of several Candida or non-Candida types in the remaining 33 samples. Nine of these cases were not yet known to suffer from bloodstream infection. Although further confirmatory clinical studies are required for these diagnostic abilities, the BC 6800Plus cytographic abnormalities related to fungemia have proven helpful in rapidly monitoring persistent fungemia in already diagnosed patients. In unknown or undiagnosed cases, they could be the trigger point for the subsequent diagnostic-therapeutic pathway.

Evaluating the effectiveness of pseudothrombocytopenia (PTCP) panel with alternative anticoagulants on clinically suspicious EDTA-dependent PTCP: a single tertiary hospital experience

Abstract EDTA is considered the most common anticoagulant to induce pseudothrombocytopenia (PTCP). PTCP panel with alternative anticoagulants (heparin and citrate) has been ordered by clinicians in our hospital for suspicious EDTA-dependent PTCP cases to obtain the correct platelet count (PC). In this study, we aimed to evaluate the effectiveness of alternative anticoagulants on clinically suspicious EDTA-PTCP. We retrospectively identified cases for which PTCP panel (EDTA, heparin, and citrate) was performed from June 2021 to March 2022 using the SAP business intelligence tool. PC was considered significantly different when the difference is more than 25% comparing heparin or citrate to EDTA tubes. Representative cases were chosen for chart review and/or peripheral blood smear review. 200 cases were included in the study. 76 cases had similar PCs in all 3 tubes which represent either true thrombocytopenia or PTCP in all 3 tubes. 17 cases had higher PC on heparin and/or citrate than EDTA which are EDTA-PTCP corrected by alternative anticoagulants (confirmed by smear review). Among those 17 cases: 6/17 had high PC on citrate only, 2/17 on heparin only and 9/17 had higher PC on citrate/heparin. 82 cases had lower PC on heparin only compared to EDTA and 62/82 had heparin exposure. There was 1 case with lower PC on citrate only (no heparin tube) compared to EDTA. 24 cases had lower PC in both heparin and citrate than EDTA tubes (lowest PC on Heparin) and 21/24 have heparin exposure. Peripheral blood smears were reviewed in 39 representative cases. Platelet clumps were identified in the corresponding tubes of all cases. Our study shows that heparin-PTCP is common in hospitalized patients and confirms that heparin is not a suitable alternative anticoagulant for EDTA-PTCP as shown by previous literature. However, many laboratories still use it for EDTA-PTCP. Heparin is known to promote platelet activation which may cause PTCP. The low PC in the heparin tube also seems to be associated with prior heparin exposure. Citrate is a better alternative to EDTA-PTCP. Among cases with low PCs on citrate, nearly all have low PCs on heparin as well. It is interesting to note those cases usually have lower PCs on heparin versus citrate and have prior exposure to heparin. The low PCs on citrate might be partially due to insufficient correction (110%) of PC by the dilution factor of the anticoagulant. Literature showed that a higher corrective factor of PCs is required for citrate. Therefore, a correlation study of PCs in EDTA versus citrate in each lab is needed to establish the corrective factor. Furthermore, delayed processing might be contributing as PCs on citrate are less stable and must be processed within 3 hours.

Targeting Complement Inhibition in Cold Hemolysis; A Multifaceted Approach Using Sutimlimab and Washed Red Cell Transfusions

Introduction: Cold agglutinin syndrome (CAS) is a transient disorder mediated by autoantibodies that cause red cell agglutination at cold temperatures. CAS is often associated with infections rather than malignant or autoimmune conditions. Sutimlimab, a monoclonal antibody directed against the complement component C1s, was previously shown to improve anemia and fatigue in cold agglutinin disease (CAD) in single-arm studies. However, its use in CAS has not yet been elucidated. Here, we describe a case where complement inhibition using the novel C1s inhibitor, as well as washed and warmed red cell transfusions, were used to treat CAS in the setting of a rare autoantibody directed toward the Pr antigen Case report: A healthy 46-year-old woman presented with severe acute hemolytic anemia: with nadir hemoglobin of 4.7, hematocrit of 13.4%, 0.2% of reticulocytes, total bilirubin of 9.8 mg/dL, and unconjugated bilirubin of 8.4 mg/dL. A peripheral blood smear review revealed severe anemia with agglutination of red blood cells. An extensive infectious workup was negative including COVID-19, Parvovirus B19, CMV, EBV, CMV, and HIV. Over a period of two weeks, she received three doses of IVIG, prednisone, and 17 transfusions units of warmed red blood cells in the setting of persistent hemolytic anemia. Despite the evidence of severe hemolysis, her reticulocyte count remained very low (<0.5%). A bone marrow biopsy showed trilineage hematopoiesis with erythroid hypoplasia and maturation arrest. A direct Coombs test was intermittently positive but probably confused by IgG infusions, with anti-I and anti-i titers of 1:64, and positive for C3. Thermal amplitude studies showed agglutination at 30°C, 37°C, and room temperature. Red blood cell antibodies were not identified in the eluate. The indirect antiglobulin test was negative for ficin-treated RBCs showing no agglutination. This led the reference laboratory to report that the cold agglutination was directed against the anti-pr antigen and that this patient had clinically significant anti-Pr antibodies. The patient was kept warm and started on Danazol and Sutimlimab. However, the patient continued to have hemolysis after transfusions. After receiving her second dose of Sutimlimab and in the context of persistent hemolytic anemia, she underwent another bone marrow biopsy on day 34 after presentation. The biopsy showed hypercellular bone marrow with erythroid hyperplasia and complete maturation. However, this was not reflected in reticulocytosis until day 44. The patient received her third dose of Sutimlimab, and red blood cell transfusions were washed in addition to being warmed, which resolved hemolysis after transfusion reactions. She received a total of 30 red blood cell transfusions since presentation. The patient's anemia improved, with a hemoglobin level of 8.8 mg/dL and a reticulocyte count of 13%, and she was discharged on Day 51 after presentation (figure 1). She received one more dose of Sutimlimab (total of four doses) with complete resolution of her anemia, a normal reticulocyte count, normal LDH, negative Coombs study, and negative cold agglutinin titers. Conclusion: Here, we describe a challenging case of CAS caused by a rare Pr autoantibody, with a failure of first-line treatments for CAS. This report is the first to describe the use of Sutimlimab as a treatment for CAS. After initiating Sutimlimab, the patient continued to experience significant hemolysis shortly after transfusions, exhibiting hemoglobinuria and an inadequate increase in hematocrit. Only when the red blood cell transfusions were washed to remove complement, the hemolytic reactions ceased and significant increases in hematocrit occurred. This finding may be a consideration in other cases of cold agglutinin anemia. As CAS is a transient disorder, Sutimlimab could ultimately be discontinued once the hemolysis resolved. This case illustrates the role of complement inhibition in CAS and the potential need to warm and wash red blood cells in severe cases of CAS.

Successful treatment with doxycycline monotherapy for human infection with Babesia venatorum (Babesiidae, Sporozoa) in China: a case report and proposal for a clinical regimen

BackgroundHuman babesiosis is a worldwide disease caused by intraerythrocytic protozoa of the genus Babesia. It is transmitted by bites from ixodid ticks, and mechanically transmitted by blood transfusion. It is primarily treated with quinine and/or atovaquone, which are not readily available in China. In this study, we developed a novel treatment regimen involving doxycycline monotherapy in a patient with severe Babesia venatorum infection as an alternative therapeutic medication. The aim of our study is to provide a guidance for clinical practice treatment of human babesiosis.Case presentationA 73-year-old man who had undergone splenectomy and blood transfusion 8 years prior, presented with an unexplained fever, headache, and thrombocytopenia, and was admitted to the Fifth Medical Center of the PLA General Hospital. He was diagnosed with B. venatorum infection by morphological review of thin peripheral blood smears, which was confirmed by multi-gene polymerase chain reaction (PCR), and sequencing of the entire 18s rRNA and partial β-tubulin encoding genes, as well as isolation by animal inoculation. The doxycycline monotherapy regimen (peros, 0.1 g bisindie) was administered following pharmacological guidance and an effective outcome was observed. The patient recovered rapidly following the doxycycline monotherapy. The protozoan load in peripheral blood samples decreased by 88% in hematocrit counts after 8 days, and negative PCR results were obtained after 90 days of follow-up at the hospital. The treatment lasted for 3 months without any side effects or sequelae. The nine-month follow-up survey of the patient did not reveal any signs of recrudescence or anti-babesial tolerance.ConclusionsWe have reported a clinical case of successful doxycycline monotherapy for human babesiosis caused by B. venatorum, which provides an optional medical intervention for human babesiosis.Graphical

Consensus recommendations on peripheral blood smear review: defining curricular standards and fellow competency.

Graduate medical education training in hematology in North America is accredited by the Accreditation Council for Graduate Medical Education (ACGME). Trainees routinely review peripheral blood smears (PBS) in providing clinical care. Competency in PBS review at graduation is required by the ACGME. However, there are no consensus guidelines on best practices surrounding PBS review, education, or competency. We describe the generation of proposed theory and the consensus recommendations developed through a multi-institutional focus group, developed using constructivist grounded theory and a modified nominal group technique. Eight academic hematologists, spanning classical and malignant hematology, enrolled and participated in 2 one-hour focus groups. All routinely worked with fellows and half had formally instructed trainees on PBS interpretation. Focus group data were analyzed using mixed-methods techniques. Tenets of emerging theory were identified through inductive coding. Consensus recommendations (CR) were generated. Participants reviewed CR in an iterative fashion until consensus was reached. Strong consensus was reached on multiple aspects of PBS education. All agreed that trainees should learn PBS review through a systematic approach. Group discussion focused on disorders of red and white blood cells. The diagnoses of acute leukemia and thrombotic microangiopathies were most commonly discussed, with specific emphasis on disorders in which prompt recognition was required to avert significant patient morbidity. These CR offer external validity to future research and curricular development for both PBS review and other visuospatial tasks in medical education.

Development of Consensus Guidelines for Hematology Fellow Competency in Peripheral Blood Smear Review Utilizing Nominal Group Technique

INTRODUCTION: Graduate medical education (GME) training in hematology in the United States is accredited by the Accreditation Council for Graduate Medical Education (ACGME). Trainees provide patient care that requires manual review and interpretation of peripheral blood smears (PBS). The ACGME milestones were developed with significant input from the American Society of Hematology (ASH) and mandate fellow competency in the interpretation of peripheral blood smears. However, there are currently no publications that define competency or propose consensus recommendations (CRs) for PBS review. The primary aim of this study was to establish CRs on PBS review with a focus at the GME level. METHODS: Nominal group technique (NGT) and constructivist grounded theory (CGT) were selected given the lack of existing published theory and consensus on the methodology of PBS review or other analogous visuospatial skills within GME. A convenience sample of hematologists with expertise in training and assessing fellows was recruited through the ASH Medical Educators Institute. Goal accrual was 5-10 hematologists. Participants were required to regularly review PBSs as part of their clinical practice and attend two 1-hour virtual focus group sessions. The facilitator guide for session 1 was developed a priori to prompt open discussion on PBS review. Dialogue was transcribed and organized into thematic concepts through inductive coding. Data from session 1 were analyzed using a mixed methods approach and were used to develop a facilitator guide for session 2. Draft CRs were created using CGT. Weak and strong consensus were pre-specified as 50 - 69%, and >70% agreement, respectively. CRs underwent iterative review which would continue for a pre-specified minimum of 2, but no more than 3 rounds. RESULTS: Eight academic hematologists (5 men, 3 women) enrolled in the focus group (Table 1). Duration of clinical practice ranged from 5 to 33 years. Clinical focus spanned classical and malignant hematologic conditions. Half had formally instructed trainees in course work on PBS morphology. All routinely worked with fellows. CRs were generated through CGT. Three rounds of review occurred. Participants provided a statement of agree vs. disagree and offered qualitative suggestions for each statement in which they disagreed. Response rates per round were 87.5%, 87.5%, and 100%. The most commonly identified themes included recognition of morphology suggestive of thrombotic microangiopathies and distinguishing between malignant vs. benign white blood cells (WBC), specifically as it pertains to acute leukemias. Strong consensus was reached on multiple aspects of PBS education, including curricular considerations, method of review, and morphology (Table 2). All agreed that trainees should learn PBS review through a systematic approach, although some agreed that this systematic approach is not always used in clinical practice. The group agreed that trainees should be educated through PBS review of patients under their clinical care as well as through formal slide "libraries". Many discussed the changing landscape of PBS education with the advent of digital microscopy, and formed strong consensus that trainees should understand the benefits and limitations of digital microscopy. Group discussion largely focused on disorders of WBCs and red blood cells (RBC) (43% and 48% of all coded statements respectively). Most discussion focused on disorders in which prompt recognition was imperative to avert significant patient morbidity or mortality. However, all agreed that trainees must also be competent in the identification of common conditions, regardless of the degree of clinical importance, including normal peripheral blood smear morphology. The group was unable to reach consensus on how to balance these competing philosophies. CONCLUSIONS: A formal theory of PBS education was systematically developed using CGT. Experts were able to form strong CRs on almost every aspect of PBS review at the GME level. FUTURE DIRECTIONS: We propose that these guidelines serve as a template for future research and curricular development for both PBS review and other visuospatial tasks in medical education. This framework can also be used by organizations, such as ACGME and ASH, when formally reviewing and codifying guidelines on PBS review. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Top Accurate Cell Detection and Segmentation Using A Pen, Agile Digital Image Processing for Deep Learning Models

Abstract Introduction/Objective The Hematopathology labs suffer from insufficient productivity, profitability and increased liability. The predicted shortage in the Hematopathologists in the USA is 25% by 2040. Medical errors and results variability due to fatigue and stress could also increase. At least 99% specificity or 99% sensitivity is required in automated visual review of peripheral blood and bone marrow smears to be generalizable and work-fit. Fortunately, the growing digital Hematopathology scanners market besides the vastly developed artificial intelligence (AI) and machine deep learning (DL) technologies could make this realized soon. The AI/DL production cycle includes (1) images collection, (2) image processing/data science, (3) technology, (4) engineering, (5) testing and validation. Methods/Case Report Integration with a Hematopathology lab using digital scanners and/or integrated cameras on microscopes is the mean for whole slide images (WSI) collection. Image processing refers to AI/DL spoon-feeding with accurate, diverse and highly-dissimilar materials for learning. This requires providing hundreds of thousands examples of (a) WSI context correction for stain and resolution normalization, (b) cellular dimensions on the WSI patches for detection, (c) cellular segmentation/boundaries determination for counting (d) cellular labels for classification. Comparing with the confirmatory testing results including flow cytometry and immunohistochemistry is essential in both image processing and validation. Currently, image processing resembles 80-90% of the AI/DL cycle/pipeline which may take years of hectic work. Our proposed developed tool enables the Hematopathologists to use pens and draw on the boundaries of each cell in a field/patch. 3-15 seconds are needed for each cell. The required ground truth/masks for segmentation and dimensions for detection are generated in real-time with no need for data scientists. Results (if a Case Study enter NA) NA Conclusion Similar to the automated agile development-operation loop concept (DevOps), enabling the Hematopathologists to perform image processing directly will reduce the production cycles from years to weeks. No technology can perform qualitatively better than the human eyes, the proposed pen-based cell detection and segmentation tool results in 10-50 fold increase in quality and quantity. Promisingly, there is a trend among the AI/DL platforms companies to automate the AI/DL coding.

Pseudothrombocytopenia – frequency, causes, and evaluation in a clinical lab.

Objective: To find out frequency, different causes of pseudothrombocytopenia andtheir further evaluation to reach a final diagnosisMethodology: This cross-sectional study was conducted at Muhammad MedicalHospital, Mirpurkhas between October 2021 to January 2022. All patients who hadan automated platelet count less than 100 were included in the study. While patients with a known cause of thrombocytopenia were excluded. Data was collectedwith the help of designed proforma. Complete blood count was performed by anautomated hematology analyzer. The samples with platelet count less than 100(flag on platelet counts) were selected for peripheral blood smear review for manual counting to ascertain the cause of thrombocytopenia.Results: A total of 1800 blood samples were analyzed. 95 patients (5.27%) had isolated platelet count < 100 with no previous history. Peripheral blood smear reviewwas done, 84 patients (88%) had true thrombocytopenia that is low platelet countby both automated and manual techniques. The incidence rate of pseudothrombocytopenia was 0.61%. Clumping due to EDTA was found in 0.27% cases followed byplatelet satellitism in 0.05% cases.Conclusion: Our study reported an incidence of pseudothrombocytopenia to be0.61%. Further breakdown revealed clumping due to EDTA to be the most commoncause. Platelet Satellitism was found to be the cause of pseudothrombocytopenia in0.05% cases.
 Keywords: pseudothrombocytopenia, PTCP, spurious, thrombocytopenia.

Evaluation of thrombocytopenia: A single-center experience

To evaluate the common etiologies and bleeding manifestations in patients of thrombocytopenia and its clinical presentation, methods of investigation, and impact of various modes of management. Total 104 patients with platelet count less than l00,000 per cu.mm. with age, more than 12 years admitted to hospital between January 2010 to October 2011 were included in this study. Platelet count on automated cell counter less than 100,000 per cu.mm. and confirmed in peripheral smear were included in the study. All EDTA samples were processed in Abacus junior 5 hematology Analyser. Peripheral blood smear review was done for all cases. Clinical history and physical examination were collected from patients and medical record files.The present study included 56 male patients and 48 female patients. The most common bleeding manifestation was petechial rash 8.6%, hemoptysis and traumatic bleeding account for 1.9 % each, whereas 74% of patients did not present with any bleeding issues. Total 66 patients presented with symptoms of fever, 73 had signs of pallor, 22 patients had splenomegaly, 16 patients had hepatomegaly. Total 37.5% of patients were diagnosed with malaria and 1 patient (0.96%) was diagnosed with plasma cell leukemia. Chronic liver disease, megaloblastic anaemia, ITP (Idiopathic thrombocytopenia) and chronic renal failure account for 9.6%, 13.4%, 5.7% and 3.8% respectively. Total 16 patients had platelet counts less than 20000/cu.mm. and 37 patients had platelet count between 60000-80000/cu.mm. Malaria (39 patients) was the major cause of thrombocytopenia. Out of 39 patients with malaria 10 patients had P. Falciparum, 27 had P. Vivax and 2 patients had both. Patients with a platelet count less than 100,000/cu.mm have very high chances of bleeding manifestation. Cutaneous bleed is the most common manifestation. Malaria can be present with signs of thrombocytopenia. Timely and accurate diagnosis is the key to the management of thrombocytopenia.

Pro-Platelet Formation Is Impaired in Megakaryocytes of MYH9 -Related Disease Patients

IntroductionThe MYH9 gene encodes myosin-IIA, a nonmuscle myosin heavy chain that facilitates shape changes in diverse cell types. The mutation of MYH9 may lead to the MYH9 -related disease (MYH9 -RD), an autosomal dominant disorder with macrothrombocytopenia and leukocyte inclusion bodies at birth and the risk of developing nephropathy, deafness and cataracts during infancy or adult life. Currently, at least 44 different MYH9 mutations in all 40 exons have been reported. Mutated MYH9 protein expression is reduced in megakaryocytes and is clumped in a few aggregates together with the wild-type protein in neutrophils, where they form the inclusion bodies. In a mouse model, myosin-IIA protein inhibits pro-platelet formation and is regulated by Rho-associated kinase (ROCK). However, how the mutated myosin-IIA influences the pro-platelet formation (PPF) of megakaryocytes in patients has not been explored. The aim of this study is to determine the function and regulation of mutated myosin-IIA in MYH9 -RD patients' megakaryocytes.MethodsOne kindred with inherited macrothrombocytopenia was identified and 5 healthy donors were enrolled as controls. Peripheral blood smear review, slit lamp examination, pure-tone audiometry, renal ultrasonography and examination of blood (urea, creatinine, electrolytes) and urine were performed for each family member to diagnose and evaluate the disease. Bidirectional polymerase chain reaction (PCR) amplification and DNA sequence analysis were performed on all 40 MYH9 exons for each patient. Platelets from peripheral blood and megakaryocytes from bone marrow were fractionated for electron microscopy. Bone marrow tissues from patients were stained with fluorescein-labeled antibodies against CD41 and CD144 to observe the distribution of mature megakaryocytes in the vascular niche by confocal fluorescence microscopy. CD34+ cells were isolated from bone marrow samples by cell sorting for in vitro culture with TPO. On day 8, megakaryocytes were enriched using an albumin density gradient and seeded onto 96-well plates in serum-free medium with or without Y27632, the ROCK inhibitor. At the same time every day for 5 days, the percentage of proplatelet-displaying megakaryocytes was quantified by inverted microscopy.ResultsFive patients in the kindred were diagnosed with MYH9 -RD based upon peripheral blood smear review, one of whom had severe renal failure. None of the patients suffered from deafness or cataracts. A pathogenic heterozygous sequence variant in exon 39 (c.5521G>A, p.E1841K) was detected, which substitutes glutamate at codon 1841 to lysine. This mutation is one of the 44 reported pathogenic mutations. Electron microscopic results showed that platelets from patients had increased diameters and irregular shapes while megakaryocytes from patients had smaller diameters and a disorganized demarcation membrane system (DMS). Immunofluorescence results of bone marrow tissues showed that proplatelet-displaying mature megakaryocytes in MYH9 -RD patients located distally to the vascular niche, compared with the control group. CD34+ cells from bone marrow differentiated into megakaryocytes after in vitro culture with TPO. However, the PPF of megakaryocytes from MYH9 -RD patients appeared much earlier than that from controls. At the same time point, PPF megakaryocytes in MYH9 -RD patients were significantly increased compared to those of the control group. When cultured with Y27632, the PPF appearance time and proplatelet-displaying megakaryocyte percentage in the control group were advanced, while the MYH9 -RD group was not influenced.ConclusionThe mutation in exon 39 of the MYH9 gene may lead to morphological abnormalities of megakaryocytes and platelets. The regulation of myosin-IIA function by ROCK in patients may be decreased when the MYH9 gene is mutated. As a result, the timing of PPF of megakaryocytes with mutated myosin-IIA in the bone marrow niche of MYH9 -RD patients may be advanced, and their mis-location away from the vascular niche may lead to reduced platelet production and increased platelet destruction. DisclosuresNo relevant conflicts of interest to declare.

The Development and Implementation of a Novel Electronic Consult System by a Laboratory Medicine Service: Experience From the First 2 Years of Use.

A novel electronic consult (e-consult) system for a pathology and laboratory medicine service (PLMS) was implemented in 2015 at a high-complexity Veterans Administration health care facility. Consults were previously made through direct provider communication without documentation in the medical record. To evaluate the utilization trends of the laboratory e-consult system at the Department of Veterans Affairs Connecticut facility during the first 2 years since inception. E-consultation involves pathology and laboratory medicine resident review followed by attending pathologist review and cosignature. E-consults to the pathology and laboratory medicine service from 2015 to 2017 were reviewed to record type of consult, requesting department, patient location, and turnaround time. The pathology and laboratory medicine service received 351 e-consults from 2015 to 2017. The volume varied by subsection: hematology and coagulation (215 of 351; 61%), chemistry (109 of 351; 31%), blood bank (19 of 351; 6%), and microbiology/virology (8 of 351; 2%). Hematology and coagulation consults were entirely for peripheral blood smear review (215 of 215; 100%). Chemistry consults were placed for toxicology/drugs of abuse (81 of 109; 74%), test utilization (17 of 109; 16%), or nontoxicology (11 of 109; 10%). Three services placed the majority of consults: primary care (279 of 351; 80%), hematology/oncology (39 of 351; 11%), and psychiatry (27 of 351; 8%). The median turnaround time for completion of e-consults was 1.2 days. Since e-consult implementation, the mean number of consults increased from 8.6/mo in 2015 to 18.1/mo in 2017, peaking in the last quarter of analysis in 2017 with a mean of 25.3 consults/mo. This novel e-consult system improved accessibility to and documentation of answers to laboratory questions and increased the visibility of the pathology and laboratory medicine service. Future goals include development of outcomes-based measures to better assess the clinical impact of e-consults.

Choosing Wisely: Optimizing Outpatient Cancer Care and Conserving Resources with a New Algorithm to Report Automated ANC Results in the Presence of Analyzer Flags

Background: The complete blood cell count (CBC) with white blood cell (WBC) differential is an essential laboratory test used to screen cancer patients prior to chemotherapy. WBC differential analysis is performed by automated hematology platforms in the clinical laboratory. However, automated results often require manual review if the analysis is associated with instrument flags that indicate the potential for inaccurate results. Review and confirmation of flagged results by laboratory technologists is time consuming and increases test result turnaround time (TAT), thereby prolonging patient appointments. Since chemotherapy administration requires an adequate absolute neutrophil count (ANC), we examined the reliability of the automated ANC in the presence of instrument flags, in outpatients with solid tumor malignancies, to determine if discrete ordering of a "CBC with ANC only" test could be used to replace the traditional CBC with full WBC differential and shorten patient wait times. Methods: We performed a retrospective analysis of ANC test results (N=1422) performed for patients with solid tumor malignancies across 5 outpatient sites, over the course of one month. The accuracy of automated ANC results (Sysmex XN) was assessed by comparison to the manual differential using Rumke statistics. Results: Of the 1422 CBC with WBC differential results evaluated, 74% (N= 1046) were flagged for manual review. Instrument flags included blasts/abnormal lymphocytes, nucleated red blood cells (NRBC), WBC abnormal scattergram, monocytosis, previous sample with blasts, lymphocytosis, atypical lymphoid cells, eosinophilia, basophilia, and new patients with leukocytosis. Peripheral blood smear review confirmed the automated ANC in 312/1046 (30%) cases. A full manual differential was performed in 734/1046 cases (70%) and confirmed the automated ANC in 604/1046 (58%) cases. Discordant automated and manual ANC results were identified in 130 cases. In the majority of these (N=113), the automated ANC was > 2000/µL, well above chemotherapy administration thresholds, and generally lower than the manual ANC (Figure 1). The automated ANC was ≤ 2000/µL in only 30/1046 (2.9%) flagged WBC differential results. Conclusion: These findings support the concept of creating a distinct test order for "CBC with ANC only," when the ANC is required for the initiation of chemotherapy in patients with solid tumors. The data demonstrate that the automated ANC performed by the Sysmex XN can be safely resulted, even in the presence of analyzer flags, when the automated ANC is greater than 2000/µL. This would reduce patient wait times, increase patient satisfaction, as well as conserve laboratory and clinical resources. In our institution, the TAT for an automated and manual ANC is 10-15 minutes and 30-60 minutes, respectively. A reduction in manual differential analysis from 734 to 30 would represent a laboratory labor savings of approximately 2 full time equivalents (FTE). Additional savings are expected based on more efficient management of chemotherapy appointments. Further studies are ongoing to extend this testing algorithm to other outpatient groups such as patients with lymphoma. Disclosures No relevant conflicts of interest to declare.

Unusual Presentation of Myeloid Sarcoma in a Patient With Usher Syndrome

Abstract A 45-year-old woman with Usher syndrome, associated congenital deafness, progressive blindness due to retinitis pigmentosa, and latent autoimmune diabetes presented to the emergency department with malaise, dizziness, and pelvic pain following removal of an intrauterine device. A posterior vaginal wall mass was found on examination. Laboratory values demonstrated anemia, thrombocytopenia, and an elevated white blood cell count, raising concern for infection and potential onset of diabetic ketoacidosis. This prompted a peripheral blood smear review, which showed 60% monocytic blasts. A subsequent vaginal mass biopsy showed a myeloid sarcoma. Molecular studies demonstrated an NPM1 mutation in exon 12 without FLT3 mutation or internal tandem duplication. While a diagnosis of acute myeloid leukemia with mutated NPM1 was considered, cytogenetics revealed a complex karyotype with evidence of clonal evolution, consistent with acute myeloid leukemia with myelodysplasia-related changes. In addition to an unusual presentation of myeloid sarcoma, this case posed significant questions regarding management and pursuit of hematopoietic stem cell transplantation. Usher syndrome is genetically and clinically heterogeneous. While it is not known to be associated with increased risk of malignancy, mutation of genes associated with Usher syndrome has been identified in acute leukemia. Our case raises the question as to whether potential germline predisposition should be considered in a patient with a previously unassociated congenital syndrome.

Assessment of International Consensus Group for Haematology smear review rules among patients with Plasmodium falciparum malaria in Johannesburg, South Africa.

A peripheral blood smear review is a useful but labour intensive adjunct to the full blood count and differential count. In this study, we retrospectively evaluated the performance of the International Consensus Group for Haematology smear review rules for detection of malaria in 153 samples with Plasmodium falciparum parasitaemia. Review rules were triggered in 132 (86.3%) samples, including all patients with severe malaria. Of the 21 false negative samples, 14 (66.7%) had haemoglobin values ≥ 10g/dl and platelets > 120x109/l.

Live remote digital microscopy in peripheral blood smear evaluation: Intraobserver concordance and experience.

Peripheral blood smear (PBS) review is a routine laboratory test which requires pathologist's interpretation when abnormal indices, atypical cells, or critical findings are identified. Real-time remote digital microscopy (DM) can potentially facilitate rapid review when an on-site pathologist is not available. Herein, we assess intraobserver concordance of PBS evaluation with light microscopy (LM) and DM using VisionTek M6 robotic DM and TeamViewer imaging software. Thirty-seven de-identified PBS slides were evaluated by five reviewers. Slides were loaded on a VisionTek M6 robotic microscope at an off-site laboratory and evaluated remotely via TeamViewer software. Reviewers recorded interpretation, time required for interpretation (in minutes), imaging quality (score 0-3), and confidence of interpretation (score 0-3). Other relevant information associated with DM evaluation was also documented. Slides were subsequently evaluated using LM after washout interval. The intraobserver variation of results for impression, digital slide quality, minutes to interpretation, and confidence of interpretation was compared between DM and LM. The intraobserver concordance between LM and DM was 93%, with nine discordant interpretations among 135 evaluations under each review modality, respectively. Although reviewers spent more time under DM mode (5min/slide) than LM mode (2.5min/slide), the reviewers felt the DM provided sufficient image quality and the confidence levels of reviewers on slide interpretation were comparable between DM (2.6/3) and LM (2.8/3). There was a high level of intraobserver concordance and comparable interpretation confidence between DM and LM. DM can be a useful methodology for off-site pathologist's review of PBS.

Pilot Study on the Performance of a New System for Image Based Analysis of Peripheral Blood Smears on Normal Samples.

Image analysis based automated systems aiming to automate the manual microscopic review of peripheral blood smears have gained popularity in recent times. In this paper, we evaluate a new blood smear analysis system based on artificial intelligence, Shonit™ by SigTuple Technologies Private Limited. One hundred normal samples with no flags from an automated haematology analyser were taken. Peripheral blood smear slides were prepared using the autostainer integrated with an automated haematology analyser and stained using May-Grunwald-Giemsa stain. These slides were analysed with Shonit™. The metrics for evaluation included (1) accuracy of white blood cell classification for the five normal white blood cell types, and (2) comparison of white blood cell differential count with the automated haematology analyser. In addition, we also explored the possibility of estimating the value of red blood cell and platelet indices via image analysis. Overall white blood cell classification specificity was greater than 97.90% and the precision was greater than 93.90% for all the five white blood cell classes. The correlation of the white blood cell differential count between the automated haematology analyser and Shonit™ was found to be within the known inter cell-counter variability. Shonit™ was found to show promise in terms of its ability to analyse peripheral blood smear images to derive quantifiable metrics useful for clinicians. Future enhancement should include the ability to analyse abnormal blood samples.

The utility of peripheral blood smear review for identifying specimens for flow cytometric immunophenotyping.

Laboratory professionals are in an ideal situation to identify CBC and peripheral blood smear findings that raise the possibility of a hematolymphoid neoplasm, and based on this information make recommendations for additional studies, such as flow cytometric immunophenotyping. In some circumstances a definitive diagnosis can be established from the combined peripheral blood morphologic and immunophenotypic findings obviating the need for bone marrow evaluation, such as for chronic lymphocytic leukemia. Occasionally flow cytometric studies are superior to morphologic assessment, such as in screening for hairy cell leukemia or identifying lymphocytic-variant hypereosinophilia. However, there is increasing recognition of small immunophenotypically unusual or abnormal populations of peripheral blood cells, particularly in older patients, which are of uncertain clinical significance, such as monoclonal B lymphocytosis and T-cell clonopathy. Therefore, it is important to integrate peripheral blood smear review findings with the clinical and other information before recommending flow cytometry. In addition, it is important to recognize situations where the results of peripheral blood smear review and flow cytometric immunophenotyping do not explain the clinical findings.

Does morphology matter in 2017? An approach to morphologic clues in non-neoplastic blood and bone marrow disorders.

Numerous non-neoplastic and neoplastic conditions manifest with distinctive features in blood. Although automated complete blood count (CBC) data are essential, CBC information alone is insufficient for diagnosis. Consequently, morphologic review of blood smears is still relevant in the era of sophisticated automated analyzer systems. Pathologist interpretation of the peripheral blood smear, in conjunction with CBC and clinical information, can provide rapid diagnostic information and guide cost-effective targeted laboratory testing. Pathologist review of blood smears can be used to diagnose cases in which the clinical findings are misleading or nonspecific. Here, we discuss a selection of cases in which the pathologist examination of the blood smear can aid in rapid and accurate diagnosis and guide appropriate treatment. Exemplary non-neoplastic disorders with distinctive morphologic blood features of RBC, neutrophils, monocytes, and lymphocytes will be highlighted. The differential diagnostic considerations in blood smears with RBC destruction will be presented, expanding beyond microangiopathic hemolytic anemia. Lymphocyte morphologic assessment guides differential diagnosis including the identification of rare germline disorders. In each case presented, the integration of morphologic features guided additional testing with confirmation of the diagnosis. Peripheral blood smear review is timely and cost effective, even in an era of sophisticated automated laboratory testing.

Utility of Peripheral Film Findings and its Correlation with Automated Analyzer - An Audit from Tertiary Care Hospital.

Background and Objective:With the advent of automated hematology analyzer, the use of traditional microscopy of blood film has become limited. The objective of our study was to determine the percentage of peripheral blood smear review in our institution in the era of automation and to identify reasons of manual review.Materials and Methods:This was a prospective audit from January 1, 2015, to January 15, 2015. Consecutive complete blood count (CBC) samples and peripheral smear requests made up the sample size. All age groups and genders were included. CBCs were performed on Sysmex XE-5000. The variables to be analyzed included inpatient and outpatient samples, frequency of peripheral film review, identifying reasons of smear review, and addition of information missed by the automated analyzer.Results:We analyzed 1200 consecutive CBC samples. Peripheral smear was reviewed in 500 (42%) of the cases of which, 241 were inpatient, and 259 were outpatient samples. In 384/500, the findings of hematology analyzer correlated with peripheral smear review. Flags identified included nucleated red blood cells (NRBCs) in 155 (40%), immature white blood cell (WBC) 129 (34%), and atypical lymphocytes 100 (26%). In 23% of the cases, the analyzer missed important findings. The sensitivity of abnormal histogram in our study was 91.3%, while the sensitivity of abnormal parameters was 100%.Conclusion:Peripheral smear review was performed in 42% of the cases. The analyzer identified NRBC, immature WBC precursors, and atypical lymphocytes as the most common abnormality. The information correlated in 77% of the cases.

Significant Variability in the Initial Workup of Thrombocytopenia in the Hematology Clinic - What Is the "Optimal" Workup?

BACKGROUNDThrombocytopenia is a common hematologic condition associated with multiple etiologies ranging from benign to malignant to potentially life-threatening disorders. Given the heterogeneity of clinical presentations, available clinical information, and pertinent clinical history, there are inter-physician variations in the approach to the workup of thrombocytopenia in the hematology clinic. While a limited test repertoire may be adequate for many cases, more extensive testing may be warranted in others. We were interested in analyzing the various tests performed and testing approaches in the initial workup of thrombocytopenia. METHODSWe reviewed the records of 69 patients who were referred to our center between 2010 and 2015 for an initial workup of thrombocytopenia. We collected epidemiologic data, laboratory testing results, and pathologic findings. Pathologic results were classified as "normal" or "abnormal" and further subcategorized on the basis of review by two clinicians. Quantitative data were analyzed using JMP Pro 10.0.2 software. RESULTSAt the time of thrombocytopenia diagnosis, the median age was 59 years (range: 17-90) and majority were males (65%). The median platelet count was 91,000/µL (range: 3,000-146,000). Isolated thrombocytopenia was present in 51 cases (74%). Forty-four patients (64%) had a peripheral blood smear review and 4 (9%) contained abnormalities including hypogranular neutrophils, rouleaux formation, and target cells. Autoimmune workup included anti-platelet antibody (APA) in 34 (49%), anti-nuclear antibody (ANA) in 21 (30%), lupus anticoagulant (LA) in 4 (6%) and rheumatoid factor (RF) in 13 (19%) of cases. Autoimmune testing was positive for APA in 2 (5.9%), ANA in 4 (19%), LA in 0 (0%), and RF in 1 (8%) of patients who underwent testing, respectively. Common infectious workups included human immunodeficiency virus in 23 (33%), hepatitis A virus in 2 (3%), hepatitis B virus in 11 (16%), hepatitis C virus in 22 (32%), Epstein-Barr virus in 5 (EBV, 7%), cytomegalovirus in 7 (10%) and Helicobacter pylori in 5 (7%) of patients, and were negative in all cases except for one patient with evidence of active EBV infection. Sixteen patients (23%) underwent bone marrow biopsy, and 2 (12.5%) were diagnosed with hematologic malignancies including myelodysplastic syndrome and hairy cell leukemia. Based on results of these tests, 28 (41%) patients were diagnosed with primary immune thrombocytopenia, 19 (27%) with thrombocytopenia secondary to another medical condition, and 22 (32%) with thrombocytopenia of undefined etiology. CONCLUSIONThrombocytopenia is a common laboratory finding, and workup involves significant inter-clinician variation, often involving multiple laboratory tests and in some cases invasive tests such as bone marrow biopsy. We found that autoimmune causes of thrombocytopenia were moderately common and infectious and malignant causes were rare. Our findings were based on a small cohort of patients but are likely to be representative of the clinical practice in a large tertiary care center. Large scale studies may be warranted to devise a protocol for a thorough yet cost-effective and stepwise initial workup of thrombocytopenia and to minimize unwarranted inter-clinician variation in such investigations. DisclosuresNo relevant conflicts of interest to declare.