Detection of dysplasia in peripheral blood: Proposal of an algorithm to detect myelodysplastic syndromes and chronic myelomonocytic leukemias on a high-speed technical platform using the Sysmex XN™ analyser

INTRODUCTION

Chronic Myelomonocytic Leukemia (CMML) and Myelodysplastic Syndromes (MDS) are increasingly represented in the general population. We propose a screening strategy based on algorithms calculated from quantitative and analytical data from the XN analyser.

MATERIALS AND METHODS

We tested the performance of previously published MDS and CMML scores on an evaluation cohort of 749 individual eligible patients over 50 years of age. These patients were classified into 3 groups as follows: 713 patients without MDS or CMML, 18 patients with MDS, and finally 18 patients with CMML. In a second step, a routine cohort of 37 828 samples was studied to evaluate the impact of this approach.

RESULTS

The concordance rate between cytology and the two scores is 92.1%. The sensitivity and specificity of the CMML score are 100% and 96.2%, respectively. For the MDS score, they are 83.3% and 89.6% respectively. The ratio of platelets measured by fluorescence on board (PLT-F) as reflex tests generated is 1.5% after 6 months. The additional smear ratio for suspected MDS is calculated at 0.6%.

CONCLUSION

We propose a flowchart using embedded artificial intelligence to help the cytologist in an optimized smear review and thus improve guidance to the clinician and the patients in the diagnosis process. This strategy permits a more comprehensive approach to MDS and CMML detection fitting with the new definition of CMML according to the recommendations of the World Health Organization (WHO) published in 2022.

Comparison of Sysmex XN-V body fluid mode and deep-learning-based quantification with manual techniques for total nucleated cell count and differential count for equine bronchoalveolar lavage samples

BACKGROUND

Bronchoalveolar lavage (BAL) is a diagnostic method for the assessment of the lower respiratory airway health status in horses. Differential cell count and sometimes also total nucleated cell count (TNCC) are routinely measured by time-consuming manual methods, while faster automated methods exist. The aims of this study were to compare: 1) the Sysmex XN-V body fluid (BF) mode with the manual techniques for TNCC and two-part differential into mononuclear and polymorphonuclear cells; 2) the Olympus VS200 slide scanner and software generated deep-learning-based algorithm with manual techniques for four-part differential cell count into alveolar macrophages, lymphocytes, neutrophils, and mast cells. The methods were compared in 69 clinical BAL samples.

RESULTS

Incorrect gating by the Sysmex BF mode was observed on many scattergrams, therefore all samples were reanalyzed with manually set gates. For the TNCC, a proportional and systematic bias with a correlation of r = 0.79 was seen when comparing the Sysmex BF mode with manual methods. For the two-part differential count, a mild constant and proportional bias and a very small mean difference with moderate limits of agreement with a correlation of r = 0.84 and 0.83 were seen when comparing the Sysmex BF mode with manual methods. The Sysmex BF mode classified significantly more samples as abnormal based on the TNCC and the two-part differential compared to the manual method. When comparing the Olympus VS200 deep-learning-based algorithm with manual methods for the four-part differential cell count, a very small bias in the regression analysis and a very small mean difference in the difference plot, as well as a correlation of r = 0.85 to 0.92 were observed for all four cell categories. The Olympus VS200 deep-learning-based algorithm also showed better precision than manual methods for the four-part differential cell count, especially with an increasing number of analyzed cells.

CONCLUSIONS

The Sysmex XN-V BF mode can be used for TNCC and two-part differential count measurements after reanalyzing the samples with manually set gates. The Olympus VS200 deep-learning-based algorithm correlates well with the manual methods, while showing better precision and can be used for a four-part differential cell count.

Agreement between one stage and chromogenic assays in samples from patients receiving recombinant porcine FVIII (Obizur, Susoctocog-alfa)

INTRODUCTION

Recombinant porcine FVIII (rpFVIII) (Obizur, Susoctcog-alfa, Takeda, Japan) is licensed for the treatment of bleeding in acquired Haemophilia A (AHA). The summary of product characteristics state that monitoring should be by one stage assay (OSA) rather than chromogenic assay (CSA). CSA have been shown to underestimate activity when rpFVIII is added to plasma in vitro.

METHODS

Samples from three AHA patients (n = 21) (pre- and post rpFVIII) were assessed using FVIII:C assays; OSA methods: Actin, Actin FS, Actin FSL and Pathromtin SL performed on CS5100i (Sysmex, Kobe, Japan); APTT-SP, SynthASil and SynthAFax performed on ACL TOP (Werfen, Barcelona, Spain). CSA methods on CS5100i: Siemens Chromogenic Assay, Biophen FVIII:C, Technochrom FVIII:C; on ACL TOP: Rox Factor VIII, Coamatic Factor VIII and CRYOcheck Factor VIII.

RESULTS

OSA and CSA varied according to reagent used median OSA 61 IU/dL (range 41.5-81 IU/dL (ANOVA p < 0.0001)) median CSA 46.5 IU/dL (range of method specific medians 36.5-84 IU/dL (ANOVA p < 0.0001)). Amongst OSA, Actin FS was associated with the highest FVIII:C, APTT-SP was associated with the lowest. Variation in CSA results by different methods was also seen with highest FVIII:C levels obtained using the Technochrom FVIII:C and the lowest levels obtained with Siemens Assay.

CONCLUSION

The relationship between OSA and CSA was not consistent between method or patient. Previously there has been reports of underestimation by CSA in in vitro spiked samples. Investigation into concentration of phospholipids in the APTT reagents may explain some of these variations.

Repeat patient testing-quality control with canine samples shows promise as an alternative to commercial quality control material for a network of four Sysmex XT-2000iV hematology analyzers

BACKGROUND

Repeat patient testing-quality control (RPT-QC) uses retained patient samples as an alternative to commercial quality control material (QCM). We elected to calculate and validate RPT-QC limits for red blood cell count (RBC), hemoglobin (HBG), hematocrit (HCT), and white blood cell count (WBC).

OBJECTIVES

(1) To validate RPT-QC across a network of four harmonized Sysmex XT-2000iV hematology analyzers and determine the total error that can be controlled with RPT-QC. (2) To generate quality control (QC) limits using the standard deviation (SD) of the duplicate measurement differences and determine a suitable simple QC rule with a probability of error detection >0.85 and probability of false rejection <0.05. (3) Monitor RPT-QC using sigma metrics as a performance indicator and (4) to challenge RPT-QC to ensure acceptable sensitivity.

METHODS

Fresh adult canine EDTA samples with results within reference intervals were selected and run again on days 2, 3, and 4. QC limits were generated from the SD of the duplicate measurement differences. The QC limits were challenged using interventions designed to promote unstable system performance. The total error detectable by RPT-QC was determined using EZRULES 3 software.

RESULTS

In all, 20-40 data points were needed for RPT-QC calculations and validated using 20 additional data points. The calculated limits differed among the network of analyzers. The total error that could be controlled was the same or better than that of the manufacturer's commercially available quality control material using the same analyzer for all measurands except hematocrit, which required a higher total error goal than that proposed by ASVCP guidelines to achieve an acceptable probability of error detection. The challenges designed to mimic unstable system performance were successfully detected as out-of-control QC.

CONCLUSIONS

The challenges for RPT-QC resulted in acceptable detection of potential unstable system performance. This initial study demonstrates that RPT-QC limits differ among the network of Sysmex XT-2000iV analyzers, indicating a requirement to customize for the individual analyzer and laboratory conditions. RPT-QC could achieve ASVCP total allowable error goals for RBC, HGB, and WBC, but not for HCT. Sigma metrics were consistently >5.5 for RBC, HGB, and WBC, but not for HCT.

Repeat patient testing-quality control compared to commercial quality control material for the Sysmex XT-2000iV hematology analyzer in a multi-site veterinary laboratory

BACKGROUND

Quality control material (QCM) for hematology in veterinary laboratories is limited, and repeat patient testing quality control (RPT-QC) is an alternative method using excess matrix-specific samples.

OBJECTIVES

This study aimed to determine if median differences between RPT-QC analyses for each time interval for RBC, HGB, HCT, and WBC were the same, determine if unified RPT-QC limits can be applied to a network of veterinary laboratories, compare the performance of RPT-QC to commercial QCM for the reference analyzer and evaluate the experience over a 4 month period and design, improve and implement an automated spreadsheet for RPT-QC data management.

METHODS

The potential to unify individual analyzer RPT-QC limits for red blood cells (RBC), hematocrit (HCT), hemoglobin (HGB), and white blood cells (WBC) on multi-site Sysmex XT-2000-iV analyzers was explored by a difference of means test and confidence interval determination for the median difference for each network analyzer in comparison to the network reference analyzer. User experience of an automated RPT-QC data management Excel spreadsheet was collected by user feedback during monthly meetings. Numbers of out-of-control results and the root causes for these for RPT-QC were compared against those of a commercial QCM over a 4-month period.

RESULTS

Differences between individual analyzer RPT-QC limits were too large to allow for unification of network limits. The automated spreadsheet successfully highlighted out-of-control events for RPT-QC. Trends or shifts were more frequent for commercial QCM based on observed performance and a 1-2.5 s QC rule than for RPT-QC. Following routine troubleshooting, RPT-QC out-of-control events were resolved with an alternative RPT-QC sample indicating random error associated with excessive deterioration. Use of an automated spreadsheet for recording RPT-QC, documentation and troubleshooting of out-of-control events, and collating monthly summary calculations were considered an asset in laboratory quality management.

CONCLUSIONS

RPT-QC can be successfully implemented and integrated into a multi-site veterinary laboratory. Individual analyzer RPT-QC limit generation is recommended. The deterioration of commercial QCM caused shifts or trends in QC results, which initiated more repeat analyses and investigations than did RPT-QC.

Analytical errors in nucleated red blood cell enumeration

BACKGROUND

Enumeration of nucleated red blood cells (NRBCs) in peripheral blood of dogs and cats is performed by manual counting during blood film evaluation. Automated methods have increased precision and accuracy; however, most analyzers cannot distinguish leukocytes and NRBCs. The Sysmex XN-V Series may distinguish NRBCs and leukocytes; however, analytical errors occur.

OBJECTIVES

We aimed to investigate cases with discrepant automated and manual NRBC counts, and to evaluate reasons for analytical errors.

METHODS

Data from samples with increased NRBCs were collected retrospectively and compared with manual counts performed on blood films using Spearman's correlation, Passing-Bablok agreement analysis, and Bland-Altman comparisons. Precision of the automated method and interobserver agreement of manual counts were evaluated. Cases with discrepant results were investigated.

RESULTS

Agreement between the methods was good at ≤1NRBC ×109 /L in dogs and cats, and inadequate at ≥1NRBC ×109 /L. The automated method demonstrated a negative proportional difference to the manual method. Precision was good for the automated method (overall CV 7.1%) and interobserver agreement for the manual method was poor overall (mean CV 27.3%, range 0%-106.1%). Inaccuracies in NRBC enumeration by the automated method occurred with high hematocrits, the mergence of the cell fragments and leukocyte clouds, and the presence of earlier erythroid precursors.

CONCLUSIONS

NRBC enumeration by the WNR channel on the Sysmex XN-1000 V is precise and has good agreement with manual counts in canine and feline blood samples at ≤1NRBC ×109 /L. Manual film review is indicated for samples with ≥1NRBC ×109 /L, earlier erythroid precursors, samples from greyhounds and dehydrated patients, and if gating errors are noted.

Differential diagnosis of lymphocytosis in routine laboratory practice: Contribution of lymphocyte parameters using the Sysmex-XN9000 haematology analyzer

INTRODUCTION

This study investigates the potential contribution of structural and dispersion parameters, as well as alarms provided by Sysmex XN9000 haematology analyzer. The objective was to assess the need for a microscopic examination in the context of lymphocytosis. It also aims to contribute in differentiating rapidly lymphoproliferative disorders such as chronic lymphocytic leukaemia (CLL), non-chronic lymphocytic leukaemia (NON-CLL) and non-infectious reactive lymphocytosis (REAC).

METHODS

We prospectively assessed lymphocyte parameters (Ly-X, Ly-Y, Ly-Z, Ly-WX, Ly-WY, Ly-WZ) provided by the Sysmex XN9000 analyzer; they were measured in the white blood cell differential (WDF) channel which also provides alarms via the precursor/pathological cellular channel (WPC). Blood samples from 71 subjects with CLL, NON-CLL lymphoproliferative and REAC non-infectious reactive lymphocytosis, as well as a control (NORM) group of 12 subjects without any abnormalities were analyzed.

RESULTS

The most discriminating parameters to distinguish the different groups were Ly-X, Ly-Z and Ly-WZ. The lymphoid structural parameters Ly-X and Ly-Z significantly discriminated the CLL group from the other groups (p < 0.001), and the CLL group from the REAC group (p < 0.01), respectively. The Ly-WZ parameter discriminated the CLL group from the NON-CLL, REAC (p < 0.001) and NORM (p < 0.01) groups. Alarms were higher in all study groups compared to the NORM group. An algorithm integrating these structural and alarm parameters is proposed.

CONCLUSION

This study demonstrated that Ly-X, Ly-Z, and Ly-WZ lymphocyte parameters are useful for detecting morphological changes in lymphocytes; they provide useful information for the differential diagnosis of lymphocytosis, and this before the examination of the blood smear. An algorithm combining the WDF (parameters) and the WPC (alarms) makes it possible to decide whether or not to use a microscopic examination or flow cytometry immunophenotyping.

Reticulocyte Hemoglobin Equivalent (Ret-He) as a Potential Diagnostic Marker of Iron Deficiency Anemia among Bangladeshi Adults

Anemia involving a variety of etiological sources constitutes a common side effect of long-term liver diseases. Anemia caused by an iron deficiency (IDA) is a prominent kind of anemia among various other types. Blood ferritin levels and other iron-related indicators can be used to identify anemia. On the other hand, it is now possible to quantify reticulocyte hemoglobin equivalent (Ret-He), which indicates the reticulocyte iron concentration. It would be useful to diagnose IDA immediately if Ret-He could evaluate the ID. The effectiveness of Ret-He to diagnose ID in Bangladeshi patients was investigated in an ongoing study. Whole bloodstream numbers, blood ferritin phases, and Ret-He concentrations were measured in a cohort of 215 Bangladeshi people. Hemoglobin (Hb) values less than 12 gm/dL were considered anemia. An individual was classified as iron deficient if their blood ferritin concentration was below 12 ng/mL. Participants were split into four groups for this study: non-ID groups with anemia, IDA, ID, and control groups. In comparison to patients with IDA and ID, the concentrations of Ret-He showed a downward tendency. Serum Ret-He levels were correlated with ferritin levels in the subjects. The measurement of the area around the intercept (AUC) for Ret-He on the ROC curve was 0.906, suggesting a correlation with diagnosis. The study's results provide optimism for the therapeutic use of Ret-He value as an indicator for identification in Bangladeshi patients.

How to cite this article

Miah MMZ, Pramanik MEA, Rafi MA, et al. Reticulocyte Hemoglobin Equivalent (Ret-He) as a Potential Diagnostic Marker of Iron Deficiency Anemia among Bangladeshi Adults. Euroasian J Hepato-Gastroenterol 2023;13(2):128-132.

Usefulness of New Neutrophil-Related Hematologic Parameters in Patients with Myelodysplastic Syndrome

Myelodysplastic syndromes (MDS) are common malignant disorders with a poor prognosis. It is necessary to search for new rapid diagnostic methods to detect MDS patients with cytogenetic changes. The aim of the study was to assess new hematological neutrophil- and monocyte- related parameters I then bone marrow of MDS patient with and without cytogenetic changes. A total of 45 patients with MDS, including 17 patients with cytogenetic changes, were examined. The study was conducted using the Sysmex XN-Series hematological analyzer. New neutrophil and monocyte parameters, such as immature granulocytes (IG), neutrophil reactivity intensity (NEUT-RI), neutrophil granularity intensity (NEUT-GI), neutrophil size (NE-FSC) and neutrophil/monocyte data relating to granularity, activity and volume (NE-WX/MO-WX, NE-WY/MO-WY, NE-WZ/MO-WZ, MO-X, MO-Y, MO-Z) were evaluated. We observed higher median proportions of NE-WX, NE-WY, NE-WZ, and IG counts in MDS patients with cytogenetic changes than in patients without cytogenetic changes. The NE-FSC parameter was lower in MDS patients with cytogenetic changes than in patients without cytogenetic changes. The combination of new neutrophil parameters was found to be a new successful approach in distinguishing MDS patients with cytogenetic changes from patients without cytogenetic changes. It appears that there may be unique neutrophil parameter signatures associated with an underlying mutation.

Evaluation of bone marrow aspirates using the automated hematology analyzer Sysmex XN-3000

INTRODUCTION

This study evaluated the feasibility of the Sysmex XN-3000 automated hematology analyzer for the assessment of total nucleated cells (TNC) and bone marrow (BM) cell density in routine bone marrow aspiration (BMA) samples.

METHODS

A total of 54 BMA samples from 39 hematological patients were evaluated. The number of megakaryocytes was calculated by a specific gating algorithm using the body fluid mode of the WBC differential (WDF) channel. Lipid contents were calculated through a newly developed algorithm utilizing the WDF channel. The ratio of lipid particles over TNCs by the WNR channel was compared with the BM cellularity assessed by the BM biopsy. The myeloid/erythroid (M/E) ratio was calculated by measuring the number of myeloid cells in the WDF channel and the number of nucleated red blood cells (NRBCs) in the WNR channel.

RESULTS

XN-3000 counts and microscopic results showed a linear correlation in TNC (R²  = .98, p < .001), megakaryocytes (R²  = .59, p = .002), NRBC (R²  = .84, p < .001), and M/E ratio (R²  = .59, p < .001). There were significant differences in the lipid/TNC ratios of hypercellular, normocellular, and hypocellular BMs measured by XN-3000 (p < .001). Receiver-operating characteristic analysis detected cut-off values of the lipid/TNC ratio of >0.4054 for hypoplasia and <0.157 for hyperplasia. The sensitivity and specificity for hypoplasia were 100% and 88%, and for hyperplasia were 89% and 86%, respectively.

CONCLUSION

XN-3000 provides a quantitative assessment of BM cellularity, supporting the qualitative assessment by myelogram and BM biopsy.

Comparison of platelet count results on the Sysmex XN between citrate or MgSO4 and K2 EDTA anticoagulants

INTRODUCTION

The aim of this study performed on Sysmex XN is to compare platelet values on citrate and MgSO₄ (TBX) in patients with K2EDTA-induced platelet clusters and to identify platelet biases of these matrices compared to K2EDTA.

METHODS

Sixty patients with K2EDTA-induced platelet clusters were re-sampled with K2EDTA, citrate and TBX. Platelet results were then compared, and smears were analysed for clumping. Platelet results from 120 patients without K2EDTA-induced platelet clusters were compared between K2 EDTA, citrate, and MgSO₄ with impedance and fluorescence modes. Biases from regressions were analysed.

RESULTS

Out of the 60 patients with K2EDTA-induced platelet clusters, none showed platelet clusters with MgSO₄ whereas 50% still showed clusters with citrate. Among those without platelet clusters on citrate, the mean relative difference between (citrate- MgSO₄ )/MgSO₄ was -12.7% in impedance and -9.8% in fluorescence. Among the 120 patients without K2EDTA-induced platelet clusters, in fluorescence the mean relative bias with respect to K2EDTA was -2.06% for MgSO₄ and -10.3% for Citrate. For the MgSO₄ versus K2 EDTA regressions, the maximum absolute values of the 95% CI of the relative biases at 150 × 10⁹ /L (5.45%) and 450 × 10⁹ /L (3.56%) were below the desirable analytical objectives of the EFLM.

CONCLUSION

In patients with K2EDTA-induced platelet clusters, MgSO₄ is preferable to citrate. MgSO₄ provides a bias with XN in fluorescence when compared to EDTA which is within analytical tolerance.

The diagnostic accuracy of Sysmex XN for identification of pseudothrombocytopenia using various thresholds for definition of platelet aggregation

INTRODUCTION

The aim of this study was to investigate the diagnostic accuracy of the flag PLT-Clumps from the WNR/WDF and the PLT-F channels from Sysmex XN and to study how different cut-offs for investigation for pseudothrombocytopenia (PTCP) and the definition of platelet aggregation affected the diagnostic accuracy.

METHODS

A smear review was performed for samples with platelet count <150 × 109 /L and samples flagged for platelet aggregation by Sysmex XN-20. The samples were investigated for platelet aggregation in 30 fields using 40× objective. Findings were classified by size and quantity using two definitions of aggregation: the Norwegian quality improvement of laboratory investigations (Noklus) and the Groupe Francophone de'Hematologie Cellulaire (GFHC). The Q-values for the PLT-Clumps flag from the WNR/WFD channel and the PLT-F channel were compared with smear findings.

RESULTS

ROC analysis showed that the diagnostic accuracy of the PLT-clumps flags increased with increasing stringency of the definition of platelet aggregation and when only samples with thrombocytopenia were investigated. With the most stringent PTCP definitions, the diagnostic accuracy of the PLT-Clumps flag from PLT-F was very high (AUC 0.97-0.98) and markedly better than for WNR/WDF.

CONCLUSION

The diagnostic accuracy of PLT-F from Sysmex XN-20 for identification of PTCP was very good and superior to the WNDR/WDF channel in samples with platelet count <150 × 109 /L and a moderate to high number of aggregates in the smear. There is a need for a more precise definition of platelet aggregation.

Automated Complete Blood Cell Count Using Sysmex XN-9000(®) in the Diagnosis of Newborn Infection

The early identification of septically infected newborn infants is important for ensuring good outcomes. Blood cell differentiations are helpful, but they are often time consuming and inaccurate. In this study, we evaluated the use of automatic white blood cell differentiations by flow cytometry for the diagnosis of neonatal sepsis. Episodes of suspected infection in neonates were retrospectively classified into two groups, unlikely infection (UI, levels of Interleukin-6 < 400 pg/mL or CRP within 48 h < 10 mg/L), n = 101 and probable infection (PI, Interleukin-6 ≥ 400 pg/mL or CRP within 48 h ≥ 10 mg/L), n = 98. Complete blood cell counts were performed by Sysmex XN-9000® using flow cytometry. Relative and absolute proportions of immature granulocytes were evaluated. Unexpectedly, the absolute count of immature granulocytes was significantly lower in the group of PI compared to UI neonates. Similar results were found when analysing the relative proportion of immature granulocytes among all neutrophil granulocytes. On the other hand, manually counted immature to total (I/T) ratios of granulocytes were higher in PI than in UI infants. Therefore, we conclude that differentiations of granulocytes by Sysmex XN-9000® can be used to distinguish between infected and uninfected neonates if the results are interpreted according to our findings. A low count of immature granulocytes as determined by Sysmex XN-9000® may indicate neonatal infection.

Automated analysers underestimate atypical basophil count in myeloid neoplasms

INTRODUCTION

Recent data suggest basophils can adopt an atypical appearance in myeloid disorders including myeloproliferative neoplasms (MPNs) and myeloproliferative/myelodysplastic disease. We hypothesized that automated analysers may not accurately quantitate basophils in myeloid neoplasms based on scatter properties. This study examined basophil counts and properties in myeloid disorders by automated cell analyser, manual differential, and flow cytometry.

METHODS

Patients with myeloid neoplasms and control patients with no myeloid disorder diagnosis at a tertiary care centre were identified. Basophil percentage was compared for automated analyser counts (Sysmex XN9000), manual differential, and flow cytometry. Basophil scatter properties in MPNs were examined using flow cytometry.

RESULTS

Thirty-one patients with myeloid neoplasms were included: 58% were male, mean age was 70.2 (±20.7) years, 32% had a diagnosis of chronic myeloid leukaemia with the remaining patients divided among various other forms of myeloid disease (including: essential thrombocythemia, polycythemia vera, unclassifiable MPN, myelodysplastic syndromes). For these patients, mean basophil percentage by automated analyser was significantly lower than manual differential (2.7 ± 2.9 vs. 7.1 ± 4.6, respectively, p < 0.001). No significant difference was found between automated versus manual differential for basophils in control subjects (p = 0.373). For myeloid neoplasm patients, mean basophil percentage was not significantly different between manual differential and flow cytometry (p = 0.116); mean basophil percentage by automated analyser was significantly lower than flow cytometry (2.7 ± 2.9 vs. 5.3 ± 3.7, respectively, p = 0.003).

CONCLUSION

Automated analysers underestimate basophil counts in patients with myeloid neoplasms. Manual differential and flow cytometry are recommended for more accurate quantitation and characterization of aberrant basophils.

Evaluation of Sysmex XT-2000iV analyzer performance across a network of five veterinary laboratories using a commercially available quality control material

BACKGROUND

Laboratory and instrument harmonization is seldom reported in the veterinary literature despite its advantages to clinical interpretation, including the use of interchangeable results and common reference intervals within a system of laboratories.

OBJECTIVES

A three-step process was employed to evaluate and optimize performance and then assess the appropriateness of common reference intervals across a network of six Sysmex XT-2000iV hematology analyzers at 5 commercial veterinary laboratory sites. The aims were to discover if harmonization was feasible in veterinary hematology and which quality parameters would best identify performance deviations to ensure a harmonized status could be maintained.

METHODS

The performance of 10 measurands of a commercially available quality control material (Level 2-Normal e-CHECK (XE)-Hematology Control) was evaluated during three 1-month time periods. Precision and bias were assessed with Six Sigma, American Society of Veterinary Clinical Pathology (ASVCP) total error quality goals and biologic variation (BV)-based quality goal approaches to performance measurement.

RESULTS

Instrument adjustments were made to 1 analyzer twice and 3 analyzers once between evaluations to improve performance and achieve harmonization. Sigma metrics improved from 37/50 > 6 to 58/60 > 6 and to all >5 over the course of the harmonization project. BV-based quality goals for desirable bias and for laboratory systems of 0.33 × CV_I (within-subject biologic variation) were more sensitive and useful for assessing performance than the ASVCP total error goals.

CONCLUSIONS

Optimization and harmonization were achieved, and because BV-derived bias goals were achieved, common reference intervals could be implemented across the network of analyzers.

Measurement of hematopoietic progenitor cells using XN2000 hematology analyzer

INTRODUCTION

Stem cell enumeration by the hematopoietic progenitor cells (HPC) mode is a novel method available from Sysmex XN2000 hematology analyzer. A small amount of blood (190 μL) is required, and the results are available in a few minutes without manual gating or presample treatment. The present study compares stem cell measurements using XN2000 analyzer HPC mode and FC500 flow cytometry analyzer using peripheral blood (PB) specimens and apheresis products.

METHODS

In this prospective study, CD34-positive cell counts were enumerated using an FC500 flow cytometry analyzer and compared with XN2000 Sysmex analyzer (XN-HPC mode) in the same samples. Results were compared using Bland-Altman plots.

RESULTS

A total of 103 samples were used. In the PB samples, the median HPC count and CD34-positive cells were 83.5 × 10⁶ /L and 78.0 × 10⁶ /L, respectively. The mean Bland-Altman difference was 4.5 × 10⁶ /L (Limits: -51.7 to 60.7 × 10⁶ /L), with a Pearson's correlation of 0.79. In the apheresis products, the median HPC count and CD34-positive cells were 1468 × 10⁶ /L (IQR: 1049 - 1960 × 10⁶ /L) and 1327 × 10⁶ /L (IQR: 910 - 2001 × 10⁶ /L), respectively. The mean Bland-Altman difference was 179.0 × 10⁶ /L (Limits: -2022.2 - 2380.2 × 10⁶ /L), with a Pearson's correlation of 0.58.

CONCLUSION

The XN-HPC mode has an excellent correlation and minimal disagreement for stem cell enumeration in PB compared with flow cytometry and could replace it. There is high disagreement in apheresis products, and therefore, the XN-HPC mode cannot be recommended.

Complete Blood Count as point of care testing QBC STAR™: Preliminary evaluation

INTRODUCTION

Point of care testing (POCT) represents a valuable option when laboratory data shall be urgently available for timely clinical management, with a turnaround time (TAT) that is unfeasible using conventional laboratory instrumentation. This study was aimed to compare the performance of QBC STAR™ compared to Sysmex XN-module and the reference optical microscopy (OM) assessment.

MATERIAL AND METHODS

One hundred peripheral blood samples, collected in K₃ EDTA tubes, and 50 capillary blood samples obtained by finger stick were analyzed with QBC STAR™, Sysmex XN-module, and OM. Data were compared with Passing-Bablok regression and Bland-Altman plots.

RESULTS

The Passing-Bablok regression analysis (QBC STAR™ capillary sample vs XN-module) yielded slopes comprised between 0.30 and 1.37, while the intercepts ranged between -17.57 and 232.6. Bland-Altman plots yielded relative bias comprised between -4.87% (for MN QBC STAR™ capillary sample vs XN-module) and 27% (PLT QBC STAR™ capillary sample vs XN-module). A significant bias was found for all parameters except MN and WBC, RBC in all and pediatric samples, and HB in adults samples.

CONCLUSION

The results of this analytical evaluation suggest that QBC STAR™ may not be the ideal tool for performing complete blood count analysis for diagnostic purposes, while it could be more useful in urgent/emergent conditions, such as for rapid monitoring of some hematological parameters (eg, WBC and HB).

The integration of Sysmex XN-9100' WPC channel reflex testing in the detection of reactive versus malignant blood samples

INTRODUCTION

Sysmex XN-9100^™ (Sysmex, Kobe, Japan) system has an optional White Progenitor Cell (WPC) channel. While the White Differentiation (WDF) channel reports a combined flag for blasts/abnormal lymphocytes, WPC channel specifies flagging into a separate flag for each cell type or removes the flag entirely. Aim of this study was to evaluate the added value of this WPC channel in the detection of malignant samples.

METHODS

Routine blood samples analyzed on Sysmex XE-5000 with flagging for either blasts, abnormal lymphocytes, or atypical lymphocytes (n = 630) were selected for testing on Sysmex XN-9100, resulting in a reflex WPC analysis in 420 samples. All samples were microscopically evaluated with DI-60 digital cell imaging analyzer.

RESULTS

WPC reflex testing resulted in a suspect flag ("blasts" and/or "abnormal lymphocytes") in 334 samples, which was confirmed microscopically in 38% (128/334). In all true positive samples, WPC correctly classified the initial WDF flag in either "blasts" flag or "abnormal lymphocytes?" flag in 75%. Only 12% (50/420) of WDF "blasts/abnormal lymphocytes" positive samples became negative after WPC reflex testing. Subgroup analysis showed differences between the "pediatric" versus "adult" groups and the "hematological/chemotherapy" versus "nonhematological/nonchemotherapy" groups in specificity and smear reduction.

CONCLUSION

Overall, WPC reflex testing showed good sensitivity (99%); however, the specificity remains poor (29%). Using reflex WPC to the WDF channel resulted in a 12% reduction of the smear review rate. Although the WPC channel offers different interesting advantages, additional topics and a specific workflow should be applied to optimize the use of this channel.

Application of Sysmex XN-Series Automated Haematology Analyser in the Rapid Detection of Malaria

Malaria, an important parasitic disease worldwide, still has diagnostic challenges in the laboratory. Many studies have been conducted on the detection ability of haematology analysers for malaria. We evaluated the Sysmex XN-series analyser as a tool for detection of malaria by analysing the leukocyte cell population data (LCPD), scattergrams and associated Flow Cytometry Standard (FCS) data from both the WNR (white cell nucleated) and WDF (white cell differential) channels. 1281 clinically suspected cases of malaria were screened for malaria by peripheral blood smear examination and were run in the Sysmex XN-1000 for analysis of haematological parameter data, LCPD, all the scattergrams and FCS data. 1281 clinically suspected cases of malaria were screened for malaria by peripheral blood smear examination and were run in the Sysmex XN-1000 for analysis of haematological parameter data, LCPD, all the scattergrams and FCS data. 48 cases had malarial parasite on microscopy; of which, 41 cases were of Plasmodium vivax, 6 cases of Plasmodium falciparum and 1 case of mixed infection. 46 malaria-positive samples showed certain patterns of clusters in the scattergrams of both WDF and WNR channels. A case with only a few ring forms of P. vivax and another with very low parasite load having only gametocyte of P. falciparum didn't show the distinctive cluster. The most distinctive clusters for all other cases were seen in WNR (SFL-SSC) and WNR (SSC-FSC) scattergrams. FCS data for the same were analysed to gate for those events. The gated events correlated (Spearman ρ = 0.77, p < 0.01) with the parasite load of the patients. By observing the scattergrams and different parameters in the Sysmex XN-series analyser, malaria can be detected from the analyser itself.

Spurious, marked leukocytosis in 2 cats with Heinz body hemolytic anemia

Two domestic shorthair cats were presented with anorexia and dehydration following ingestion of caramelized onions. Shared key findings from a CBC (ADVIA 2120), serum biochemistry, and urinalysis included a spurious, marked leukocytosis with discordant basophil (BASO) channel and peroxidase channel WBC counts, normal manual leukocyte counts, mild, non-regenerative anemia with discrepancies between automated and manual reticulocyte counts, an abundance of large Heinz bodies (HBs), and highly irregular scattergrams. Case 1 also demonstrated a markedly elevated mean corpuscular hemoglobin concentration (MCHC) and discrepancies between RBC hemoglobin indices. Spurious leukocyte results were confirmed through re-analysis of samples (including the acquisition of a new sample, use of an alternate analyzer (Sysmex XT-2000iV; Case 1 only), and evaluation of scattergrams and blood films (Cases 1 and 2). Repeatedly discrepant reticulocyte counts were also identified. In both cases, the erroneous BASO WBC counts, discrepancies in reticulocyte counts and RBC indices, and atypical scattergrams were interpreted to result from various effects of the HBs. These cases emphasize the importance of reviewing blood films, interpreting scattergrams, and the usefulness of duplicate methods for determining various measurands on hematology analyzers.

NEUTROPHIL SCATTERING DATA DRIVEN PRE-MICROSCOPIC FLAGGING OF ACUTE LEUKEMIC CASES

Background

The hematology analyzer, Sysmex XN-1000, generates white blood cell count with varying scattering intensities during a complete blood count (CBC) analysis.

Objectives

The objectives of the study were to study the predictive role of median and coefficient of variation of neutrophil scattering items in blood samples for differentiation of leukemic subjects.

Methods

We evaluated six neutrophil scattering parameters: neutrophil side scatter mean intensity, neutrophil side fluorescence light (SFL) mean intensity, neutrophil forward scatter mean intensity, neutrophil side scatter area distribution width (NE-WX), neutrophil SFL area distribution width (NE-WY), and neutrophil forward scatter area distribution width (NE-WZ), measured in white blood cell differential scattergram generated by the hematology analyzer (Sysmex XN-1000) at an academic medical center.

Results

We collected 433 blood samples from acute myeloid leukemia (AML) and acute lymphoid leukemia (ALL) cases and normal controls. AML group showed highly significant differences in the mean values compared with the control group. Out of six neutrophil scattering items, NE-WX, NE-WY, and NE-WZ showed high efficiency, with area under the curve (AUC) values of 0.764, 0.748, and 0.757, respectively, to differentiate AML from ALL cases and control groups. When comparing combined acute leukemia cases (AML plus ALL) with the control group, NE-WX, NE-WY, and NE-WZ generated highly significant AUC values (0.840, 0.884, and 0.801, respectively).

Conclusion

The neutrophil scattering parameters generated during CBC analysis provide a new tool for the prediction of acute leukemia and its lineage.

Use of the reticulocyte channel warmed to 41°C of the XN-9000 analyzer in samples with the presence of cold agglutinins

OBJECTIVES

The purpose of this study was to compare data obtained from the reticulocyte channel (RET channel) heated to 41°C with those obtained from impedance channel (I-Channel) at room temperature in the samples with the mean corpuscular hemoglobin concentration (MCHC)<370g/L and in samples with the MCHC>370g/L, in the presence of cold agglutinins.

METHODS

In this study, 60 blood samples (group 1) with the MCHC<370g/L (without cold agglutinins) and 78 blood samples (group 2) with the MCHC>370g/L (with cold agglutinins) were used to compare the two analytical channels of the XN-9000 analyzer in different preanalytical conditions. The parameters evaluated in both groups were the following: red blood cell (RBC), hemoglobin (HGB), hematocrit (HCT), mean cell volume (MCV), RBC-most frequent volume (R-MFV), mean hemoglobin concentration (MCH) and mean cellular hemoglobin concentration (MCHC).

RESULTS

The results of this study showed an excellent correlation with both channels of the XN-9000 analyzer in samples with and without cold agglutinins, except for the MCHC. The bias between the values obtained in the I-channel and those obtained in the RET channel of both groups was insignificant and remained within the limits of acceptability, as reported by Ricos et al. for all considered parameters, except for MCHC.

CONCLUSIONS

The presence of cold agglutinins in blood samples can be detected by a spurious lowering of the RBC count and by a spurious increase in the MCHC. The RET channel represents a great opportunity to correct the RBC count in a rapid manner without preheating. However, neither methodology can completely solve the residual presence of cold agglutinins in all samples, despite the MCHC values being < 370g/L.

Preliminary evaluation of a new flow cytometry method for the routine hematology workflow

Background In a generalist laboratory, the integration of the data obtained from hematology analyzers (HAs) with those from multiparametric flow cytometry (FMC) could increase the specificity and sensitivity of first level screening to identify the pathological samples. The aim of this study was to perform a preliminary evaluation of a new simple hybrid method (HM). The method was obtained by integration between HAs reagents into FCM, with a basic monoclonal antibodies panel for the leukocytes differential count. Methods Eighty-one peripheral blood samples, collected in K3EDTA tubes, were analyzed by XN-module, and CyFlow Space System, using both standard MoAbs and HM method analysis, and with the optical microscopy (OM). Within-run imprecision was carried out using normal samples, the carryover was evaluated, data comparison was performed with Passing-Bablok regression and Bland-Altman plots. Results The within-run imprecision of HM methods ranged between 1.4% for neutrophils (NE) and 10.1% for monocytes (MO) always equal or lower to the OM. The comparison between HM methods vs. OM shows Passing-Bablok regression slopes comprised between 0.83 for lymphocyte (LY) and 1.14 for MO, whilst the intercepts ranged between -0.18 for NE and 0.25 for LY. Bland-Altman relative bias was comprised between -12.43% for NE, and 19.77% for eosinophils. In all 11 pathological samples the agreement between the methods was 100%. Conclusions The new hybrid method generates a leukocytes differential count suitable for routine clinical use and it is also useful for identifying morphological abnormalities with a reduction in cost and improvement of screening for first level hematology workflow.

Reliable assessment of bone marrow and bone marrow concentrates using automated hematology analyzer

Aim: A limiting factor in advancement of bone marrow based cell therapies is the lack of characterization of cell products delivered to patients. Methods: Using an automated hematology analyzer that can be implemented in clinical setting, the composition of bone marrow aspirates (n = 17 patients) and bone marrow concentrates (n = 12 patients) were assessed. ICC estimates were calculated for measuring reliability. Results: Bone marrow aspirates assessment resulted in excellent reliability for determining white blood cells (ICC - 0.96; 95% CI: 0.92-0.99), red blood cells (ICC - 0.9; 95% CI: 0.77-0.96), platelets (ICC - 0.93; 95% CI: 0.85-0.97) composition. Bone marrow concentrate assessment resulted in excellent reliability for determining white blood cells (ICC - 0.97; 95% CI: 0.93-0.99), platelets (ICC - 0.95; 95% CI: 0.89-0.99) and moderate reliability for red blood cells (ICC - 0.66; 95% CI: 0.36-0.87) composition. Conclusion: Modern automated hematology analyzers could assist to better characterize the cell therapy products to provide reliable and consistent outcomes.

Insignificant interference of Elevit in pregnant women serum samples with HBsAg immunoassay on Sysmex

BACKGROUND

The pregnant women often take Elevit as the multivitamin supplement which has a substantial amount of biotin that might potentially interfere with the HBsAg immunoassay performed by the prevalent Sysmex system in clinical laboratories. We therefore wanted to determine this, so that the therapeutic intervention on the hepatitis B virus infection during pregnancy and birth would not be missed.

METHODS

Elevit was both serially diluted in vitro and orally taken by healthy volunteers whose blood samples were then taken at different time points. All samples were added to a serum sample with a known result of HBsAg and then measured by Sysmex. The Abbott immunoassay system was used as the control as it involves no streptavidin-biotin binding in the reagent set. Besides, the HBsAg results were compared between the pregnant women taking or not taking Elevit.

RESULTS

Biotin at 25 ng/mL in the Elevit started to suppress the HBsAg and reached about 50% suppression at 100 ng/mL on Sysmex. In the volunteers, biotin reached the peak concentration at 2 hours. However, their blood samples showed no suppression on the HBsAg detection by Sysmex. In samples from pregnant women who took Elevit, the HBsAg results by Sysmex were highly correlated with those by Abbott (R²  = 0.96). Comparison of the results from Sysmex between the age- and pregnancy-matched females with and without Elevit intake showed no difference.

CONCLUSION

Elevit intake in pregnant women shows no significant interference with HBsAg immunoassay on Sysmex.

Usefulness of the lymphocyte positional parameters in the Sysmex XN haematology analyser in lymphoproliferative disorders and mononucleosis syndrome

INTRODUCTION

The lymphocyte positional parameters included in Sysmex XN have been suggested as useful means to differentiate lymphoproliferative disorders (LPD), mononucleosis syndrome (MNS) and other lymphocytoses.

METHODS

We evaluated Sysmex XN analysers, which supply 6 lymphocyte positional parameters that can be measured in the WDF scattergram: LY-X, LY-Y, LY-Z, LY-WX, LY-WY and LY-WZ.

RESULTS

We collected 301 samples from normal controls, polyclonal lymphocytosis, MNS and LPD. MNS and monoclonal expansion of T granular lymphocyte (T-GL) diagnostic groups accumulated higher numbers of significant differences in the mean values in comparison with the other groups. We propose a new algorithm that can differentiate T-GL cases from other diagnostic groups with an SE of 67.5%, an SP of 98.2%, a PPV of 87.1% and an NPV of 94.3%. Another algorithm showed its efficiency to differentiate MNS cases from other diagnostic groups with an SE of 63.6%, an SP of 97.5%, a PPV of 70.0% and an NPV of 96.7%. In 38.5% of all cases, the analyser did not generate any morphologic flag. Abnormal results in lymphocyte positional parameters were useful to detect 72.5% of these samples.

CONCLUSION

The lymphocyte positional parameters provided by Sysmex XN analysers are useful to differentiate expansions of T-GLs from other LPD and to differentiate MNS cases from other diagnostic groups. In addition, these parameters are very useful for detecting changes in the lymphocytes that make it necessary to review blood smears in samples without morphological flagging.

Two-site evaluation of the diagnostic performance of the Sysmex XN Body Fluid (BF) module for cell count and differential in Cerebrospinal Fluid

INTRODUCTION

Cellular analysis in cerebrospinal fluid (CSF) provides important diagnostic information in many pathological settings. The aim of this two-site study was to evaluate the Sysmex XN Body Fluid mode (XN-BF) for cell analysis of CSF compared to light microscopy (LM).

METHODS

Two hundred and seven consecutive CSF samples were analyzed in parallel with XN-BF and LM. The study also included the estimation of the limit of blank (LoB), limit of detection (LoD), limit of quantitation (LoQ), carry-over and linearity of XN-BF module.

RESULTS

LoQ of white blood cells (WBC) was 3×10⁶  cells/L; linearity was good and carry-over negligible. XN-BF parameters were compared to LM for the following cell classes: total cells, WBC, polymorphonuclear (PMN), and mononuclear (MN) cells. The bias ranged from 1.3 to 15.2×10⁶  cells/L. The receiver operating characteristics curve analysis for WBC showed an area under the curve of 0.98, and the global diagnostic agreement was 95% at a cutoff of 5×10⁶  cells/L.

CONCLUSIONS

XN-BF provides rapid and accurate counts in clinically relevant ranges of CSF values, thus providing a valuable alternative to conventional LM analysis. However, microscopic review remains advisable in samples with abnormal cell counts or high fluorescent (HF-BF) cell parameter exceeding 5×10⁶  cells/L.

Evaluation of the Sysmex XN-550, a Novel Compact Haematology analyser from the XN-L® series, compared to the XN-20 system

INTRODUCTION

The XN-550 is a new, automated, compact, haematology analyser designed to generate a full blood count with a standard five-part white blood cell differential and an immature granulocyte count, as well as an optional reticulocyte and optical platelet (PLT) counts. The aim of the study was to evaluate the performance of the XN-550 and compare it to the established XN-20 system.

METHODS

We evaluated the basic parameter and special measurement channels of the XN-550, using the XN-20 (which has a similar operating system), as a reference analyser. Precision, carry-over and throughput evaluations were performed. In addition, a total of 202 samples including normal controls and various pathological samples were studied for comparability.

RESULTS

Good correlations with the reference analyser were obtained for all parameters except basophils. The XN-550 offers impedance and optical PLT counts and the latter showed a better correlation and less scatter than the impedance count and was comparable to the XN-20 fluorescent count at PLT counts ≤40×10⁹ /L. Precision was good, and no significant carry-over was detected.

CONCLUSIONS

The XN-550 was simple and easy to use, while maintaining the good diagnostic sensitivity seen with high-range systems such as the XN-20, making this compact device suitable for near-patient services and smaller satellite laboratories.

Relationship between conventional culture and flow cytometry for the diagnosis of urinary tract infection

BACKGROUND

Urine culture is the gold standard for the diagnosis of urinary tract infections (UTI). The use of flow cytometry analyzers (FCA) prior to culture allows for the quantification and recognition of cell components in urine to be automated and makes it possible to relate these data to the urine pathogens subsequently identified in cultures.

METHODS

Urine samples were assessed with the Sysmex UF-1000i analyzer. Those that met the criteria for culture (> 25 leukocytes/μL or > 385 bacteria/μL) were subjected to quantitative urine culture on chromogenic agar. Counts of red blood cells (RBC), white blood cells (WBC), epithelial cells (EC), and the kind of microorganisms identified in cultures were evaluated.

RESULTS

A total of 17,483 samples were processed by FCA. Of these, 9057 met the criteria for culture. Urine cultures were reduced by 48.2%. The most common urine pathogen was Escherichia coli (60.3%). Negative urine cultures were significantly (p < 0.001) associated with a lower WBC count than urine with E. coli, Klebsiella spp. and Proteus spp., but urine with Enterococcus spp. had a lower WBC than negative urine. Contaminated urine had a significantly (p < 0.001) lower WBC than urine with E. coli, Klebsiella spp. and Proteus spp., but no differences were found for Enterococcus spp. (p = 0.729). Negative urine cultures had significantly (p < 0.05) higher EC than all positive urine samples. Contaminated urine was associated (p < 0.001) with higher EC than cultures with E. coli and Klebsiella spp., in comparison with cultures with Enterococcus spp. (p = 0.091) and Proteus spp. (p = 0.251).

CONCLUSION

The use of the Sysmex UF-1000i flow cytometer for screening urine samples allows for a reduction in the number of urine cultures. WBC values correlate well with the main urine pathogens related to UTI. The results observed for Enterococcus spp. suggest a low impact of these pathogens as a cause of UTI.

Comparison of the Sysmex XT-2000iV with microscopic differential counts of canine bone marrow

Canine bone marrow is frequently assessed in the advanced preclinical research environment. Automated analysis provides time savings and objectivity over the gold standard of microscopic (cytologic) evaluation. We compared the analysis of 90 canine bone marrow samples by the Sysmex XT-2000iV hematology analyzer (Sysmex Corp., Kobe, Japan) with cytologic evaluation. Gates for cell populations were created in the system's WBC/BASO channel. Variables "total nucleated red blood cells" (total_NRBC), "poly- and orthochromatic nucleated red blood cells" (poly_orth_NRBC), "total neutrophils" (total_NEUT), "mature neutrophils" (mature_NEUT), and myeloid-to-erythroid (M:E) ratio were compared with cytologic evaluation. Intra-assay repeatability and total error (TE) were calculated for both methods. Intra-assay repeatability was 0.95-2.48% for the XT-2000iV and 8.32-23.23% for cytology. Observed TE for the automated measurement was 5.16-46.8% and for cytology 22.70-76.74%. Spearman rank correlation was excellent for M:E ratio (0.91) and fair for the other populations (0.65-0.71). Absolute bias for M:E ratio was low (-0.114). A negative absolute bias of -7.71% for the XT-2000iV was found for poly_orth_NRBC, whereas the bias was positive for total_NEUT (7.10%) and mature_NEUT (14.67%). M:E ratio of canine bone marrow samples can be precisely determined using the Sysmex XT-2000iV WBC/BASO channel. Total_NRBC, poly_orth_NRBC, total_NEUT, and mature_NEUT can be estimated rapidly. With distinctly lower coefficient of variation and observed TE compared with cytology, automated measurement provides advantages in terms of standardization, and it is suited to the advanced preclinical research environment where large numbers of samples are investigated.

Clinical significance of cell population data (CPD) on Sysmex XN-9000 in septic patients with our without liver impairment

BACKGROUND

This study evaluated the clinical significance of cell population data (CPD) parameters obtained on Sysmex XN-9000 in septic patients admitted to intensive care unit (ICU) and stratified according to liver function.

METHODS

The study population consisted in 84 patients, 44 of whom did not develop sepsis (NS), whereas the remaining 40 developed sepsis (SE) (n=24) or septic shock (SS) (n=16). Two hundred ostensibly healthy blood donors [healthy subjects (HS)], undergoing routine blood testing before a regular blood donation, were studied.

RESULTS

Except for neutrophils and lymphocytes cell size (NE-FCS and LY-Z), all other CPD values were significantly different in ICU patients compared to HS. Neutrophils and monocytes fluorescence intensity (NE-SFL and MO-X) values were significantly higher in SS compared to sepsis and not develop sepsis patients. The value of many parameters was also different according to liver function. Overall, MO-X and neutrophils fluorescence intensity (NE-SFL) exhibited the best performance for diagnosing sepsis in all patients (AUC, 0.75 and 0.72), as well as in those with (AUC, 0.95 and 0.89) or without (AUC, 0.72 for both) liver impairment. These parameters were also significantly correlated with Sequential Organ Failure Assessment (SOFA) score.

CONCLUSIONS

This study suggested that some novel CPD parameters (namely NE-SFL and MO-X) may provide useful information for diagnosis and management of sepsis.

Algorithms utilizing peripheral blood hematopoietic progenitor cell counts in lieu of some CD34+ cell counts predict successful peripheral blood stem cell collections with substantial time and cost savings

Background and Objectives

Hematopoietic progenitor cell (HPC) counts from Sysmex hematology analyzers have been shown to correlate with peripheral blood (PB) CD34+ cell counts by flow cytometry. Algorithms utilizing HPC counts to guide stem cell collections have been proposed but rarely tested. This study describes the development and validation of algorithms utilizing HPC and PB CD34+cell counts to predict adequate peripheral blood stem cell (PBSC) collections for chemomobilized and cytokine-mobilized individuals.

Materials and Methods

Utilizing a test set of 83 PB samples from chemomobilized or cytokine-mobilized PBSC collection patients, PB CD34+ counts were correlated with HPC counts and a receiver operating characteristic curve was constructed. Cut-offs of ≤0.5 HPC/μl and ≥7 HPC/μl were established to maximize sensitivity and specificity for using HPC to predict PB CD34+ ≥ 10 cells/μl. These cut-offs were subsequently validated using a separate prospective validation set of 88 HPC/CD34+ cell sample pairs.

Results

Using the algorithms, all patients in the prospective validation data set achieved adequate collections of ≥1 × 10⁶ CD34⁺ cells/kg, and a 67% reduction in the number of CD34⁺ cell counts performed was achieved. This lead to a direct cost savings of at least $18,700 USD over a 21-month period (88% reduction in direct costs).

Conclusion

Use of the algorithms provides significant time and cost savings for the laboratory while accurately predicting (i) timing of PBSC collections to obtain adequate CD34⁺ product yields for chemomobilized patients and (ii) when to administer plerixafor to cytokine-mobilized patients to improve the likelihood of achieving adequate collections.

Optimization of Cellular analysis of Synovial Fluids by optical microscopy and automated count using the Sysmex XN Body Fluid Mode

BACKGROUND

This study was planned to assess the impact of pre-treating synovial fluid (SF) samples with hyaluronidase (HY), defining the best procedure for optical microscopy (OM) analysis and evaluating the performance of Sysmex XN-9000 Body Fluid module (XN-BF).

METHODS

The cell count by OM was carried out both with and without HY pre-treatment, and using 3 different types of staining reagents. The evaluation of XN-BF included data comparison with OM (100 SFs), carryover, Limit of Blank (LoB), Limit of Detection (LoD), Limit of Quantitation (LoQ) and linearity.

RESULTS

Unlike cell count in Burker's chamber and staining with Stromatol, pre-treatment with HY and staining with Methylene Blue and Turk's promoted cell clustering. The SF samples pre-treated with HY displayed excellent morphological quality, contrary to samples without HY pre-treatment. Excellent correlation was found between total cells counting with both OM and XN-BF. Satisfactory agreement was also observed between polymorphonuclear neutrophils compared to XN-BF parameter, whereas mononuclear cell count on XN-BF had suboptimal agreement with OM. The carryover was negligible. The LoB, LoD, LoQ and linearity were excellent.

CONCLUSION

XN-BF displays excellent performance, which makes it a reliable and practical alternative to OM for SF samples analysis in clinical laboratories.

Local verification between the hematological analyzers Sysmex XN-series and XE-5000

INTRODUCTION

The aim of this study was to perform a verification of the hematology analyzer Sysmex XN-2000 by comparing with the previous XE-5000. This study assessed the precision and carryover on the XN-2000 and the systematic error between the both counters according to desirable biological variability criterion and a flag comparison study.

METHODS

Within-run precision and between-batch precision were measured according to the ICSH guidelines. A comparative study was performed analyzing two hundred and six samples of peripheral blood from patients. The statistical study was conducted using the Passing-Bablok and Bland-Altman analyses. The leucocyte flag comparison was made by measuring the efficiency rate.

RESULTS

Between-batch precision was lower than that recommended by the biological variability criterion and manufacturer specifications. The comparison gave nonagreement results for neutrophil and basophil counts according to the criterion of biological variability. Erythroblasts and immature granulocytes showed nonagreement, but there is no available biological variation database for these parameters to compare with. Nevertheless, excellent absolute agreement was found for red blood cell parameters, and for platelet, lymphocyte, monocyte, and eosinophil counts.

CONCLUSIONS

The global results obtained for the precision, comparability, and efficiency provide a satisfactory integration of the XN-2000 in the core laboratory routine and accomplish an optimal reliability.

Microcentrifuge or Automated Hematological Analyzer to Assess Hematocrit in Exercise? Effect on Plasma Volume Loss Calculations

The assessment of plasma volume loss (∆PV) induced by exercise can be estimated from changes in hematocrit (Htc) and hemoglobin (Hb), and it is essential when investigating the metabolic or biologic response to exercise of circulating biomarkers. We aimed to ascertain whether the estimation of ∆PV may differ when Hb and Htc are determined by automated hematological analyzer (AHA) versus manual methods. Twenty-five healthy male subjects performed a maximal running incremental exercise. Blood samples were taken before exercise, immediately after exercise, and after a 30-min recovery. Hb and Htc (Htc-AHA) were determined by an AHA. Htc was also determined by microcentrifugation (Htc-M). The ∆PV immediately after exercise and after recovery was calculated. The serum concentrations of several specimens were determined and corrected for ∆PV derived from Htc-AHA (∆PVAHA) and from Htc-M (∆PVM). Htc-M was found to be higher than Htc-AHA at all time points (p < 0.001). However, no differences were observed between ∆PVM and ∆PVAHA either post exercise (∆PVM -12.43% versus ∆PVAHA -12.41%, p = 0.929) or after recovery (∆PVM 1.47% versus ∆PVAHA 1.97%, p = 0.171). No significant differences were found between both ∆PV corrected concentrations of any biomarker (p ≥ 0.076). In conclusion, both AHA and the microcentrifuge may be reliably used to estimate ∆PV during exercise.

Performance analysis of newly developed point-of-care hemoglobinometer (TrueHb) against an automated hematology analyzer (Sysmex XT 1800i) in terms of precision in hemoglobin measurement

INTRODUCTION

The aim of this study was to evaluate the performance of the newly developed handheld hemoglobinmeter (TrueHb) by comparing its performance against and an automated five-part hematology analyzer, Sysmex counter XT 1800i (Sysmex).

METHODS

Two hundred venous blood samples were subjected through their total hemoglobin evaluation on each device three times. The average of the three readings on each device was considered as their respective device values, that is, TrueHb values and Sysmex values. The two set of values were comparatively analyzed. The repeatability of the performance of TrueHb was also evaluated against Sysmex values.

RESULTS

The scatter plot of TrueHb values and Sysmex values showed linear distribution with positive correlations (r = 0.99). The intraclass correlation (ICC) values between the two set of values was found to be 0.995. Regression coefficients through origin, β, was found to be 0.995, with 95% confidence intervals (CI) ranging between 0.9900 and 1.0000. The mean difference in Bland-Altman plots of TrueHb values against the Sysmex values was found to be -0.02, with limits of agreement between -0.777 and 0.732 g/dL. Statistical analysis suggested good repeatability in results of TrueHb, having a low mean CV of 2.22, against 4.44, that of Sysmex values, and 95% confidence interval of 1.99-2.44, against 3.85-5.03, that of Sysmex values.

CONCLUSION

These results suggested a strong positive correlation between the two measurements devices. It is thus concluded that TrueHb is a good point-of-care testing tool for estimating hemoglobin.

Breed-specific hematologic reference intervals in healthy adult Dogues de Bordeaux

BACKGROUND

There is an increasing interest for breed-specific reference intervals in veterinary medicine. In a previous study, breed-specific biochemical reference intervals (RIs) have been established for Dogues de Bordeaux (DDBs). This breed is predisposed to familial juvenile glomerulonephropathy and hypothyroidism, and would benefit from hematologic RI.

OBJECTIVE

The purpose was de novo establishment of breed-specific hematologic RIs for the DDB in accordance with the International Federation of Clinical Chemistry and Clinical and Laboratory Standards Institute guidelines.

METHODS

One hundred and twenty DDBs from France and Belgium were recruited. CBCs were determined with the Sysmex XT-2000iV analyzer within 12 hours of blood collection. RIs were determined using the nonparametric method. Effects of sex, age, and face mask color were studied.

RESULTS

RIs were determined in 58 healthy dogs. DDBs had higher RIs for HGB, HCT, MCV, MCHC, and mean platelet volume, and lower RIs for reticulocytes counts, platelets by impedance (PLT-I) and optical count (PLT-O), and plateletcrit when compared with generic canine RIs. Age significantly affected RIs for HGB, HCT, MCHC, WBC, neutrophil, lymphocyte, and monocyte counts.

CONCLUSION

The generic canine RIs established in the same laboratory with analogous preanalytical and analytical variations did not differ significantly from breed-specific RIs, and thus have no significant impact on clinical decision making; however, breed-specific RIs are advised for some RBC and all platelet-related variables to avoid erroneous suspicion of polycythemia and thrombocytopenia when using general canine RIs for evaluation of DDB.

Immature platelet fraction levels in a variety of bone marrow pathologies in South African HIV-positive patients with thrombocytopenia

OBJECTIVES

Thrombocytopenia is common in HIV-infected individuals and often requires a diagnostic bone marrow examination. Interpretation may, however, be limited due to the multifactorial nature of HIV-associated thrombocytopenia and the difficulty in assessing megakaryocyte function morphologically. The immature platelet fraction (IPF) is a parameter which reportedly reflects megakaryocyte activity, with an IPF >7.7% suggesting increased platelet production. The aim of this study was to correlate the IPF with the bone marrow findings as well as other clinical variables of interest in South African patients with HIV-associated thrombocytopenia.

METHODS

Seventy-eight HIV-positive patients with thrombocytopenia were enrolled from the Charlotte Maxeke Johannesburg Academic Hospital. The IPF levels were measured using a Sysmex XE-5000 haematology analyzer and were correlated with bone marrow and other findings.

RESULTS

The median IPF was 7.6%, ranging from 1.3 to 44%. It was raised in 78% of patients with immune thrombocytopenia (ITP) (median = 16.3%) and low in 79% of patients with hypocellular marrow (median = 6.5%). Surprisingly, it was highly variable among patients with malignant marrow infiltration and mycobacterial infection of the bone marrow (BMTB) (median = 8.4 and 7.1%, respectively). Multivariate linear regression analysis confirmed a significant independent inverse relationship between the IPF and hypocellular marrow (P < 0.0001), a marginally significant positive association with ITP (P = 0.059), and the absence of any relationship with malignant infiltration or BMTB. The IPF had a significant inverse association with the platelet count (P = 0.0006), but was unrelated to the CD4 count and exposure to anti-retroviral therapy. Unexpectedly, it showed a significant positive association with the HIV viral load (P = 0.005). We speculate this to reflect increased megakaryocyte activity in compensation for accelerated platelet clearance due to HIV-driven platelet activation.

CONCLUSION

This study investigates the role of the IPF in HIV-associated thrombocytopenia, and emphasizes the limitations of morphological analysis in determining megakaryocyte function.