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McCafferty R, Cembrowski G, de la Salle B, Peng M, Urrechaga E. ICSH review of internal quality control policy for blood cell counters. Int J Lab Hematol 2024; 46:216-226. [PMID: 38214063 DOI: 10.1111/ijlh.14220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Accepted: 11/24/2023] [Indexed: 01/13/2024]
Abstract
INTRODUCTION This paper is a report of an ICSH review of policies and practices for internal quality control (IQC) policy for haematology cell counters among regulatory bodies, cell counter manufacturers and diagnostic laboratories. It includes a discussion of the study findings and links to separate ICSH guidance for such policies and practices. The application of internal quality control (IQC) methods is an essential pre-requisite for all clinical laboratory testing including the blood count (Full Blood Count, FBC, or Complete Blood Count, CBC). METHODS The ICSH has gathered information regarding the current state of practice through review of published guidance from regulatory bodies, a questionnaire to six major cell counter manufacturers (Abbott Diagnostics, Beckman Coulter, Horiba Medical Diagnostic Instruments & Systems, Mindray Medical International, Siemens Healthcare Diagnostics and Sysmex Corporation) and a survey issued to 191 diagnostic laboratories in four countries (China, Republic of Ireland, Spain and the United Kingdom) on their IQC practice and approach to use of commercial IQC materials. RESULTS This has revealed diversity both in guidance and in practice around the world. There is diversity in guidance from regulatory organizations in regard to IQC methods each recommends, clinical levels to use and frequency to run commercial controls, and finally recommended sources of commercial controls. The diversity in practice among clinical laboratories spans the areas of IQC methods used, derivation of target values and action limits used with control materials, and frequency of running commercial controls materials. CONCLUSIONS These findings and their implications for IQC Practice are discussed in this paper. They are used to inform a separate guidance document, which proposes a harmonized approach to address the issues faced by diagnostic laboratories.
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McCafferty R, Cembrowski G, de la Salle B, Peng M, Urrechaga E. ICSH guidance for internal quality control policy for blood cell counters. Int J Lab Hematol 2024; 46:227-233. [PMID: 38189640 DOI: 10.1111/ijlh.14212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Accepted: 11/01/2023] [Indexed: 01/09/2024]
Abstract
This paper is a description of the ICSH guidance for internal quality control (IQC) policy for blood cell counters. It follows from and links to a separate ICSH review for such policies and practices. The ICSH has gathered information regarding the current state of practice through review of published guidance from regulatory bodies, a questionnaire to six major cell counter manufacturers and a survey issued to 191 diagnostic laboratories in four countries (China, the Republic of Ireland, Spain, and the United Kingdom) on their IQC practice and approach to the use of commercial IQC materials. This has revealed diversity both in guidance and in practice around the world. There is diversity in guidance from regulatory organizations in regard to IQC methods each recommends, clinical levels to use and frequency to run commercial controls, and finally recommended sources of commercial control materials. The diversity in practice among clinical laboratories spans the areas of IQC methods used, derivation of target values, and action limits used with commercial control materials, and frequency of running commercial controls materials. These findings and their implications for IQC Practice are addressed in this guidance document, which proposes a harmonized approach to address the issues faced by diagnostic laboratories.
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Affiliation(s)
| | | | | | | | - Eloisa Urrechaga
- Haematology Department, Hospital Galdakao Usansolo, Galdakao, Spain
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Tan H, Chen X, Huang X, Chen D, Qin X, Wang J, Chen J. Electrical micro flow cytometry with LSTM and its application in leukocyte differential. Cytometry A 2024; 105:54-61. [PMID: 37715355 DOI: 10.1002/cyto.a.24791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Revised: 07/13/2023] [Accepted: 09/04/2023] [Indexed: 09/17/2023]
Abstract
This paper developed an electrical micro flow cytometry to realize leukocyte differentials leveraging a constrictional microchannel and a deep neural network. Firstly, purified granulocytes, lymphocytes or monocytes traveled through the constrictional microchannel with a cross-sectional area marginally larger than individual cells and produced large impedance variations by blocking focused electric field lines. By optimizing key elements (e.g., normalization, learning rate, batch size and neuron number) of the recurrent neural network (RNN), electrical results of purified leukocytes were analyzed to establish a leukocyte differential system with a classification accuracy of 95.2%. Then the leukocyte mixtures were forced to travel through the same constrictional microchannel, producing mixed impedance profiles which were classified into granulocytes, lymphocytes and monocytes based on the aforementioned differential system. As to the classification results, two leukocyte mixtures from the same donor were processed, producing comparable classification results, which were 57% versus 59% of granulocytes, 37% versus 34% of lymphocytes and 6% versus 7% of monocytes. These results validated the established classification system based on the constrictional microchannel and the recurrent neural network, providing a new perspective of differentiating white blood cells by electrical flow cytometry.
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Affiliation(s)
- Huiwen Tan
- State Key Laboratory of Transducer Technology, Aerospace Information Research Institute, Chinese Academy of Sciences, Beijing, People's Republic of China
- School of Future Technology, University of Chinese Academy of Sciences, Beijing, People's Republic of China
| | - Xiao Chen
- State Key Laboratory of Transducer Technology, Aerospace Information Research Institute, Chinese Academy of Sciences, Beijing, People's Republic of China
- School of Future Technology, University of Chinese Academy of Sciences, Beijing, People's Republic of China
| | - Xukun Huang
- State Key Laboratory of Transducer Technology, Aerospace Information Research Institute, Chinese Academy of Sciences, Beijing, People's Republic of China
- School of Electronic, Electrical and Communication Engineering, University of Chinese Academy of Sciences, Beijing, People's Republic of China
| | - Deyong Chen
- State Key Laboratory of Transducer Technology, Aerospace Information Research Institute, Chinese Academy of Sciences, Beijing, People's Republic of China
- School of Future Technology, University of Chinese Academy of Sciences, Beijing, People's Republic of China
- School of Electronic, Electrical and Communication Engineering, University of Chinese Academy of Sciences, Beijing, People's Republic of China
| | - Xuzhen Qin
- Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Junbo Wang
- State Key Laboratory of Transducer Technology, Aerospace Information Research Institute, Chinese Academy of Sciences, Beijing, People's Republic of China
- School of Future Technology, University of Chinese Academy of Sciences, Beijing, People's Republic of China
- School of Electronic, Electrical and Communication Engineering, University of Chinese Academy of Sciences, Beijing, People's Republic of China
| | - Jian Chen
- State Key Laboratory of Transducer Technology, Aerospace Information Research Institute, Chinese Academy of Sciences, Beijing, People's Republic of China
- School of Future Technology, University of Chinese Academy of Sciences, Beijing, People's Republic of China
- School of Electronic, Electrical and Communication Engineering, University of Chinese Academy of Sciences, Beijing, People's Republic of China
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Vidali M, Carobene A, Apassiti Esposito S, Napolitano G, Caracciolo A, Seghezzi M, Previtali G, Lippi G, Buoro S. Standardization and harmonization in hematology: Instrument alignment, quality control materials, and commutability issue. Int J Lab Hematol 2020; 43:364-371. [PMID: 33174358 DOI: 10.1111/ijlh.13379] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Revised: 09/13/2020] [Accepted: 10/05/2020] [Indexed: 11/27/2022]
Abstract
INTRODUCTION In the hub and spoke laboratory network, the number of hematology analyzers (HAs) within each core center has increased, and the control of HAs alignment is becoming necessary requirement to ensure analytical quality. In this scenario, HA alignment can be assessed by analyzing the same control material used for internal quality control on multiple HAs, assuming its commutability. The aim of the study was to verify the applicability of a protocol for the alignment of HAs based on control material rather than on fresh whole-blood samples. METHODS The alignment of five HAs was evaluated for red (RBC, Hb, MCV, RET), white (WBC, NE, LY, MO, EO, BA, IG), and platelet (PLT) series parameters, following a protocol by SIBioC, using human sample (HS) and quality control material (QC), after the verification of commutability, according to the IFCC protocol. Maximum bias was derived from biological variation data. RESULTS A complete alignment between instruments was confirmed for the majority of the parameters investigated both for HS and QC material. Partial misalignments or inconcludent results were instead evident for MCV, MO, EO, BA, and IG. Interestingly, QC material was found to be not commutable for LY, MO, and BA. CONCLUSION The alignment of hematologic analyzers for main cell population parameters may be verified with both QC and HS, displaying consistent results and interpretation. The evaluation for some white series parameters (EO, BA, and IG) is critical, and particular attention must be paid to the values of the material used for the alignment.
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Affiliation(s)
- Matteo Vidali
- Clinical Chemistry Unit, Maggiore della Carità Hospital, Novara, Italy
| | - Anna Carobene
- Laboratory Medicine, Ospedale San Raffaele, Milan, Italy
| | | | - Gavino Napolitano
- Clinical Chemistry Laboratory, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | | | - Michela Seghezzi
- Clinical Chemistry Laboratory, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Giulia Previtali
- Clinical Chemistry Laboratory, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Giuseppe Lippi
- Section of Clinical Biochemistry, University of Verona, Verona, Italy
| | - Sabrina Buoro
- Clinical Chemistry Laboratory, Hospital Papa Giovanni XXIII, Bergamo, Italy
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van Rossum HH. An approach to selecting auto-verification limits and validating their error detection performance independently for pre-analytical and analytical errors. Clin Chim Acta 2020; 508:130-136. [PMID: 32416173 DOI: 10.1016/j.cca.2020.05.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 04/28/2020] [Accepted: 05/12/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Auto-verification limits are widely used to trigger confirmatory actions to enable detection of pre-analytical, analytical and post-analytical errors. An approach is presented for validating auto-verification limit performance in a laboratory-specific manner, independently for pre-analytical and analytical error detection. METHODS To evaluate this approach, MA Generator (www.huvaros.com) was used to run error-detection simulations using various upper-limit checks (ULC) and lower-limit checks (LLC). Pre-analytical error detection was defined as triggering of a limit check alarm within one erroneous result. Analytical error detection was defined as triggering a limit check alarm within the scheduled internal QC measurement interval, both with ≥97.5% probability. Furthermore, the limit check alarm rates were obtained. RESULTS Pre-analytical error detection and rapid detection of larger analytical errors by limit checks outperformed moving average quality control at the cost of a significantly larger number of alarms. A pre-analytical error detection by LLC and ULC of ≥-55% and >60%, ≥-10% and ≥20%, and ≥-40% and ≥50% and an analytical error detection of ≥-4% and ≥15%, ≥-3% and ≥4% and ≥-30% and ≥25% were obtained for hemoglobin, sodium and calcium, respectively. CONCLUSIONS The obtained ULC and LLC alarm rate and error detection performance, enabled substantiated selection of optimal auto-verification limits and validation thereof.
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Affiliation(s)
- Huub H van Rossum
- Department of Laboratory Medicine, The Netherlands Cancer Institute, Amsterdam, the Netherlands; Huvaros, the Netherlands.
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Kimura K, Tabe Y, Ai T, Takehara I, Fukuda H, Takahashi H, Naito T, Komatsu N, Uchihashi K, Ohsaka A. A novel automated image analysis system using deep convolutional neural networks can assist to differentiate MDS and AA. Sci Rep 2019; 9:13385. [PMID: 31527646 PMCID: PMC6746738 DOI: 10.1038/s41598-019-49942-z] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Accepted: 08/29/2019] [Indexed: 12/31/2022] Open
Abstract
Detection of dysmorphic cells in peripheral blood (PB) smears is essential in diagnostic screening of hematological diseases. Myelodysplastic syndromes (MDS) are hematopoietic neoplasms characterized by dysplastic and ineffective hematopoiesis, which diagnosis is mainly based on morphological findings of PB and bone marrow. We developed an automated diagnostic support system of MDS by combining an automated blood cell image-recognition system using a deep learning system (DLS) powered by convolutional neural networks (CNNs) with a decision-making system using extreme gradient boosting (XGBoost). The DLS of blood cell image-recognition has been trained using datasets consisting of 695,030 blood cell images taken from 3,261 PB smears including hematopoietic malignancies. The DLS simultaneously classified 17 blood cell types and 97 morphological features of such cells with >93.5% sensitivity and >96.0% specificity. The automated MDS diagnostic system successfully differentiated MDS from aplastic anemia (AA) with high accuracy; 96.2% of sensitivity and 100% of specificity (AUC 0.990). This is the first CNN-based automated initial diagnostic system for MDS using PB smears, which is applicable to develop new automated diagnostic systems for various hematological disorders.
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Affiliation(s)
- Konobu Kimura
- Department of Next Generation Hematology Laboratory Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan.,Sysmex Corporation, Kobe, Japan
| | - Yoko Tabe
- Department of Next Generation Hematology Laboratory Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan. .,Department of Clinical Laboratory Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan.
| | - Tomohiko Ai
- Department of Clinical Laboratory Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | | | - Hiroshi Fukuda
- Department of General Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Hiromizu Takahashi
- Department of General Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Toshio Naito
- Department of General Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Norio Komatsu
- Department of Hematology, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | | | - Akimichi Ohsaka
- Department of Next Generation Hematology Laboratory Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan.,Department of Transfusion Medicine and Stem Cell Regulation, Juntendo University Graduate School of Medicine, Tokyo, Japan
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Pai S, Frater JL. Quality management and accreditation in laboratory hematology: Perspectives from India. Int J Lab Hematol 2019; 41 Suppl 1:177-183. [PMID: 31069974 DOI: 10.1111/ijlh.13017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 03/04/2019] [Accepted: 03/06/2019] [Indexed: 11/29/2022]
Abstract
Quality management (QM), including quality assurance and quality control, was developed in clinical laboratories in North America and Western Europe, but must be implemented worldwide to ensure accurate, reproducible, and clinically useful results. India, a middle income country with a population of over 1.34 billion, has limited budget allotted to health care. As yet accreditation for clinical laboratories is not mandatory, which contributes to challenges in implementing good laboratory practice. This review provides a summary of internationally laid down QM principles and their application in a middle income country like India.
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Affiliation(s)
| | - John L Frater
- Department of Pathology and Immunology, Washington University, St. Louis, Missouri
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Gao X, Colicino E, Shen J, Kioumourtzoglou MA, Just AC, Nwanaji-Enwerem JC, Coull B, Lin X, Vokonas P, Zheng Y, Hou L, Schwartz J, Baccarelli AA. Impacts of air pollution, temperature, and relative humidity on leukocyte distribution: An epigenetic perspective. ENVIRONMENT INTERNATIONAL 2019; 126:395-405. [PMID: 30826618 PMCID: PMC6441628 DOI: 10.1016/j.envint.2019.02.053] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 02/15/2019] [Accepted: 02/21/2019] [Indexed: 05/20/2023]
Abstract
BACKGROUND Exploring the associations of air pollution and weather variables with blood leukocyte distribution is critical to understand the impacts of environmental exposures on the human immune system. OBJECTIVES As previous analyses have been mainly based on data from cell counters, which might not be feasible in epidemiologic studies including large populations of long-stored blood samples, we aimed to expand the understanding of this topic by employing the leukocyte distribution estimated by DNA methylation profiles. METHODS We measured DNA methylation profiles in blood samples using Illumina HumanMethylation450 BeadChip from 1519 visits of 774 Caucasian males participating in the Normative Aging Study. Leukocyte distribution was estimated using Houseman's and Horvath's algorithms. Data on air pollution exposure, temperature, and relative humidity within 28 days before each blood draw was obtained. RESULTS After fully adjusting for potential covariates, PM2.5, black carbon, particle number, carbon monoxide, nitrogen dioxide, sulfur dioxide, temperature, and relative humidity were associated with the proportions of at least one subtype of leukocytes. Particularly, an interquartile range-higher 28-day average exposure of PM2.5 was associated with 0.147-, 0.054- and 0.101-unit lower proportions (z-scored) of plasma cells, naïve CD8+ T cells, and natural killers, respectively, and 0.059- and 0.161-unit higher proportions (z-scored) of naïve CD4+ T cells and CD8+ T cells, respectively. CONCLUSIONS Our study suggests that short-term air pollution exposure, temperature, and relative humidity are associated with leukocyte distribution. Our study further provides a successful attempt to use epigenetic patterns to assess the influences of environmental exposures on human immune profiles.
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Affiliation(s)
- Xu Gao
- Department of Environmental Health Sciences, Mailman School of Public Health, Columbia University, New York, NY, USA.
| | - Elena Colicino
- Department of Environmental Medicine and Public Health, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jincheng Shen
- Department of Population Health Sciences, University of Utah, School of Medicine, Salt Lake City, UT, USA
| | | | - Allan C Just
- Department of Environmental Medicine and Public Health, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Brent Coull
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Xihong Lin
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Pantel Vokonas
- Veterans Affairs Normative Aging Study, Veterans Affairs Boston Healthcare System, Department of Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Yinan Zheng
- Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Lifang Hou
- Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Joel Schwartz
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Andrea A Baccarelli
- Department of Environmental Health Sciences, Mailman School of Public Health, Columbia University, New York, NY, USA
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La Gioia A, Fumi M, Fiorini F, Pezzati P, Balboni F, Bombara M, Marini A, Pancione Y, Solarino L, Marchese E, Sale S, Rocco V, Fiorini M. Short preheating at 41°C leads to a red blood cells count comparable to that in RET channel of Sysmex analysers in samples showing cold agglutination. J Clin Pathol 2018. [PMID: 29535214 DOI: 10.1136/jclinpath-2017-204954] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
AIMS The presence of cold agglutinin in blood samples can cause a spontaneous agglutination of red blood cells (RBCs) when low temperature occurs. This phenomenon causes a spurious lowering of RBC count on the automated haematological analysers that are detected by incongruous values (≥370 g/L) of the mean cellular haemoglobi concentration (MCHC). A preheating at 37°C can remove the RBC agglutination generally resulting in a reliable count. It has been reported that the same result can be reached by using the optical reticulocyte (RET) channel of Sysmex analysers where the RBC count is not influenced by the presence of cold agglutinin. This study aims to evaluate these data in a larger population, with regard to environmental conditions on Sysmex analysers. We have also evaluated the influence of different thermal pretreatments on the RBC count. METHODS This study was performed on 96 remnants of peripheral blood samples (48 with MCHC in normal range and 48 with MCHC>370 g/L) which have been analysed in different preanalytical conditions on the Sysmex analysers. RESULTS A preheating of samples at 41°C for 1 min leads to a reversibility of the cold agglutination comparable to the one observed in the RET channel and yields better results compared with 37°C for 2 hours. CONCLUSIONS None of described procedures assure the complete cold agglutination reversibility in every case. Consequently, since the haematological analysers not yet provide reliable parameters to confirm the complete resolution of agglutination, further verification of RBC count accuracy needs to be performed.
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Affiliation(s)
- Antonio La Gioia
- Docemus Onlus "Theoretical and Practical Training School for Improving Specialty Medicine", Torrevecchia Teatina, Italy
| | - Maurizio Fumi
- U.O. Patologia Clinica A.O.R.N. "G.Rummo", Benevento, Italy
| | - Fabiana Fiorini
- UOC Medicina di Laboratorio Azienda USL Toscana Nord Ovest, Pontedera, Italy
| | - Paola Pezzati
- Centro Regionale Controllo di Qualità AOU Careggi, Firenze, Italy
| | - Fiamma Balboni
- Laboratorio Analisi IFCA (Istituto Fiorentino di Cura ed Assistenza), Firenze, Italy
| | - Maria Bombara
- UOC Medicina di Laboratorio Azienda USL Toscana Nord Ovest, Livorno, Italy
| | - Alessandra Marini
- UOC Medicina di Laboratorio Azienda USL Toscana Nord Ovest, Versilia, Italy
| | | | - Leonardo Solarino
- UOC Laboratorio Analisi I - Policlinico Vittorio Emanuele, Azienda Universitaria Ospedaliera, Catania, Italy
| | - Elisa Marchese
- UOC Laboratorio Analisi I - Policlinico Vittorio Emanuele, Azienda Universitaria Ospedaliera, Catania, Italy
| | - Silvia Sale
- U.O. Patologia Clinica A.O.R.N. "G.Rummo", Benevento, Italy
| | - Vincenzo Rocco
- U.O. Patologia Clinica A.O.R.N. "G.Rummo", Benevento, Italy
| | - Marcello Fiorini
- UOC Medicina di Laboratorio Azienda USL Toscana Nord Ovest, Livorno, Italy
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Vis JY, Huisman A. Verification and quality control of routine hematology analyzers. Int J Lab Hematol 2016; 38 Suppl 1:100-9. [DOI: 10.1111/ijlh.12503] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/23/2016] [Indexed: 01/20/2023]
Affiliation(s)
- J. Y. Vis
- Department of Clinical Chemistry and Hematology; University Medical Center Utrecht; Utrecht The Netherlands
| | - A. Huisman
- Department of Clinical Chemistry and Hematology; University Medical Center Utrecht; Utrecht The Netherlands
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