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Introduction The athlete biological passport monitors blood variables over time to uncover blood doping. With the phasing in of a new series of blood analyzers, the Sysmex XN series, it was necessary to examine the comparability of results with the previously employed XT/XE series. A previous comparison between XN and XT/XE series suggested a small but significant bias between the two instruments in the measurements of RET%. Here, we examined the comparability of RET% on the XN and XT/XE platform using data collected over the first year since the transition. Methods The comparability of results obtained from XN and XT/XE instruments was assessed using three datasets: (i) 767 blood samples measured on both instrument series in 22 WADA-accredited laboratories, (ii) 27 323 samples measured on either instrument across 31 laboratories, and (iii) 119 clinical samples and 110 anti-doping samples measured on both instruments in a single laboratory. Results Analysis of the three datasets confirms the previous observation of a bias toward higher RET% values for samples measured on Sysmex XN instruments compared with the XT/XE series. Using data across a larger number of XN instruments and a larger athlete population, the current work suggests that the bias is proportional and slightly higher than previously observed across most of the range RET% values. Conclusion A model is proposed for the comparison of data across XN and XT/XE technologies whereby the instrument bias increases proportionally with RET% measured on Sysmex XN Series, but where the rate of increase is negatively related to IRF%.

The extraordinary advances in clinical hematology, biology, and oncology in the last decades would not have been possible without discovering how to identify and count the cells circulating in the blood. For centuries, scientists have used slides, counting chambers (hemocytometers), and diluting and staining solutions for this task. Then, automated hemocytometry began. This science, now linked to the daily routine of laboratory hematology, has completed an overwhelming path over a few decades. Our laboratories today operate with versatile multiparameter systems, ranging from complex single-channel instruments to bulky continuous flow machines. In terms of clinical information obtained from a simple routine blood test, the full exploitation of their potential depends on the operators' imagination and courage. A comprehensive review of the scientific publications that have accompanied the development of hemocytometry from the 1950s to today would require entire volumes. More than seven hundred contributions that authors worldwide have published in Clinical and Laboratory Haematology until 2007 and then the International Journal of Laboratory Hematology are summarized. Such journals have represented and hopefully will continue to represent the privileged place of welcome for future scientific research in hemocytometry. Improved technologies, attention to quality, new reagents and electronics, information technology, and scientist talent ensure a more profound and deeper knowledge of cell properties: current laboratory devices measure and count even minor immature or pathological cell subpopulations. Full-field hemocytometry includes the analysis of nonhematic fluids, digital adds to the microscope, and the development of effective point-of-care devices.

Importance of reporting quality: An assessment of the COVID-19 meta-analysis laboratory hematology literature

Objectives In 2019 The Croatian Working Group for Laboratory Hematology, on behalf of the Croatian Society of Medical Biochemistry and Laboratory Medicine, wanted to explore the background in field of laboratory hematology routine practice among Croatian laboratories in order to develop future strategies for producing national recommendations, if needed. Methods During April and May 2019, a comprehensive survey covering all main parts of the total testing process within the field of laboratory hematology among Croatian medical laboratories was conducted. The survey comprised 49 inquiries. Data was collected using Survey Monkey (Palo Alto, CA, USA). All collected data was anonymized. Results The response rate was 72%. There is still a substantial number of laboratories that have only three-part differential hematology analyzers (9%). Furthermore, a very high number of laboratories did not perform analyzer verification prior to implementation into routine work (31%). Out of those who have verified their analyzers, a diversity of guidelines and recommendations were used. Nearly 10% of the laboratories do not have a defined policy regarding specimen rejection. The majority of the participants perform internal quality control daily (83%), however, only 51% of respondents evaluate the agreement between different hematology analyzers on daily basis. Although more than 90% of Croatian laboratories have a defined policy regarding specimen rejection, only 61% of respondents continuously monitor quality indicators in routine practice. Conclusions The survey revealed substantial differences in all aspects of laboratory hematology practices among Croatian medical laboratories, indicating the need for universal recommendations at the national level.

The first decade of capture-based targeted whole exome sequencing (WES) has now passed, while the sequencing modality continues to find more widespread usage in clinical research laboratories and still offers an unprecedented diagnostic assay in terms of throughput, informational content and running costs. Until quite recently, WES has been out of reach for many clinicians and molecular biologists, and it still poses issues or is met with some reluctance with regards to cost versus benefit in terms of effective assay costs, hands-on laboratory work and data analysis bottlenecks. Although WES is used more than ever, it may also be argued that the usage is peaking and that new implementations, or relevance in its current state, will likely be leveling off during the following decade as the price on whole genome sequencing continues to drop. In this review, we focus on the past decade of targeted whole exome sequencing in malignant hematology. We thematically revisit some of the significant discoveries and niches that use next-generation sequencing, and we outline what and how WES has contributed to the field - from clonal hematopoiesis of the aging bone marrow to profiling malignancies down to the single cell.

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.

Background: Many medical decisions in hospital are based on hematology examination results. We must be aware about their method performance. Sigma-metric is an excellent way to evaluate analytical performance quality. We will display the performance of our laboratory hematology analyzer, Cell Dyne Ruby, by sigma-metric analysis.Method: sigma analysis was calculated by a formula, sigma = (TEa – CV)/ Bias. Total Error Allowable (TEa) was specified by the CLIA proficiency testing criteria. The coefficien of variant (CV) and bias data were supplied from analyzer running three levels of control low (L), normal (N), and high (H) include following analytes: hemoglobin (Hb), Red Blood Cell count (RBC), Hematocrit (HCT), White Blood Cell count (WBC), and Platelet count (PLT).Results : Sigma value as follows Hb(L:4,33 N:6,68 H:2,62), RBC(L:3,43 N:3,84 H:3,46), HCT(L:2,52 N:1,73 H:2,27), WBC (L:7,14 N:8,44 H:6,38),and PLT (L:2,46 N:8,75 H:7,84). Average sigma value for all parameters were 4,75. Minimum sigma value for any business or manufacturing process was 3. More than 6 sigma value was world class performance.Conclusion: Hematology Analyzer Cell Dyne Ruby provides "Good” performance by sigma-metric.

INTRODUCTION: The percentage of circulating reticulocytes (RET%) is a useful marker of blood doping in the context of the Athlete Biological Passport (ABP). The viability of the ABP depends on the comparability of sample data obtained across multiple laboratories for a given athlete. With the recent introduction of a different technology for the measurement of reticulocytes, the goal of this study was to compare currently employed Sysmex XT/XE analyzers to the recently introduced Sysmex XN analyzer. METHODS: RET% differences were searched in two independent data sets, the first consisting of 95 369 RET% values coming from 29 laboratories located in five continents as part of routine testing for the ABP, the second from a targeted study involving 510 samples analyzed on both a Sysmex XT and XN analyzers by two different laboratories. RESULTS: A relatively small but significant bias of 0.27 ([0.22-0.35] 95% CI) for the first data set and 0.19% ([0.16-0.22] 95% CI) for the second data set was observed with Sysmex XN analyzers returning higher values than Sysmex XT/XE analyzers. This bias appears constant over most of the range of RET% measured in elite athletes. CONCLUSION: When RET% values are obtained for the same athlete with different technologies (XT/XE vs XN), an adjustment of RET% emanating from the XT/XE instruments through a decrease of 0.22% within the ABP calculated ranges appears to be sufficient to integrate the results from the two technologies.

Background The automated hematology analyzer Celltac G (Nihon Kohden) was designed to improve leukocyte differential performance. Comparison with analyzers using different leukocyte detection principles and differential leukocyte count on wedge film (Wedge‐Diff) shows its clinical utility, and comparison with immunophenotypic leukocyte differential reference method (FCM‐Ref) shows its accuracy performance. Methods For method comparison, 598 clinical samples and 46 healthy volunteer samples were selected. The two comparative hematology analyzers (CAAs) used were XN‐9000 (Sysmex) and CELL‐DYN Sapphire (Abbott). The FCM‐Ref provided by the Japanese Society for Laboratory Hematology was selected, and a flow cytometer Navios (Beckman‐Coulter) was used. In manual differential, two kinds of automated slide makers were used: SP‐10 (Sysmex) for wedge technique and SPINNER‐2000 (Lion‐Power) for spinner technique. The spinner technique avoids the issue of Wedge‐Diff smudge cells by removing the risk of breaking cells and non‐uniformity of blood cell distribution on films (Spinner‐Diff). Results The Celltac G showed sufficient comparability (r = 0.67–1.00) with the CAAs for each leukocyte differential counting value at 0.00–40.87(109/L), and sufficient comparability (r = 0.73–0.97) with FCM‐Ref for each leukocyte differential percentage at 0.4–78.5. The identification ratio of the FCM‐Ref in CD45‐positive cells was 99.7% (99.4% to 99.8%). Differences were found between FCM‐Ref/Celltac G/XN‐9000/Spinner‐Diff and Wedge‐Diff for monocytes and neutrophils. The appearance ratio of smudge cells on wedge and spinner film was 12.5% and 0.5%. Conclusion The Celltac G hematology analyzer's leukocyte differential showed adequate accuracy compared with the CAAs, FCM‐Ref, and two manual methods and was considered suitable for clinical use., Leukocyte differential in two hematology analyzers and a manual leukocyte differential method on spinner film showed consistency compared with the reference flow cytometry method provided by an immunophenotypic leukocyte differential reference method, whereas in a manual leukocyte differential method on wedge film for percentages of monocytes and neutrophils showed inconsistency. Abbreviatons: TAA, Test automated analyzer; CAA: Comparative automated analyzer; BA, basophil; EO, eosinophil; LY, lymphocyte; MO, monocyte; NE, neutrophil; 5diff, number of identified normal five‐part leukocyte WBC cell differential events; CD45+, number of CD45‐positive cell events.

Starting from the discussion topics triggered by Hoffmann about the past and current basophil counting, a broader view of the role and future of laboratory hematology, passing through some general considerations concerning the idea of laboratory medicine in the healthcare pathway between technology and professionalism, is here provided.

Objective: The golden standard for measuring erythrocyte sedimentation rate (ESR) is the Westergren method. Some other methods for measuring ESR have become available in the recent decades. They differ from a modest modification of the Westergren method to very different methodologies. Even though the methodologies of these tests are different the results of them are assessed as the same test by clinicians. Therefore the bias reasoned by different methodology has caused misinterpretation of the patients by clinicians. The comparison and harmonization of this method will provide a standardization and same interpretation for ESR.Methods: The golden standard method for measuring ESR which is called Westergren Method and two prototypes of the remaining methods were chosen for comparison. Three different group of patients were were assessed with three different methods in this study. Results: The monitorization of three samples were observed for 60 minutes. There was no correlation detected depending on the time after the monitorization had started. Hence the adjustment of the results were collected after 20 or 30 minutes for simulating 60 minutes were found significantly different than the classical Westergren method. The detected bias between the adjustment of the earlier result to one hour and the classical method is not always different than the classical method. The sample results were found significantly different in comparison to two methods for all selected patient groups. Conclusion: There is no sedimentation algorithm detected in ESR monitorization process. Therefore the observed bias is thought to be caused by the adjustment of the earlier results to one hour. The adjusted results of 30 minutes were found to be significantly similar compared to the adjusted results of 20 minutes. The results of the capillary photometric kinetic method were found unbiased with the classical Westergren method and compatible with the clinical observations.

The goal of harmonizing laboratory testing is contributing to improving the quality of patient care and ultimately ameliorating patient outcome. The complete blood and leukocyte differential counts are among the most frequently requested clinical laboratory tests. The morphological assessment of peripheral blood cells (PB) through microscopic examination of properly stained blood smears is still considered a hallmark of laboratory hematology. Nevertheless, a variable inter-observer experience and the different terminology used for characterizing cellular abnormalities both contribute to the current lack of harmonization in blood smear revision. In 2014, the Working Group on Diagnostic Hematology of the Italian Society of Clinical Chemistry and Clinical Molecular Biology (WGDH-SIBioC) conducted a national survey, collecting responses from 78 different Italian laboratories. The results of this survey highlighted a lack of harmonization of interpretative comments in hematology, which prompted the WGDH-SIBioC to develop a project on “Harmonization of interpretative comments in the laboratory hematology report”, aimed at identifying appropriate comments and proposing a standardized reporting system. The comments were then revised and updated according to the 2016 revision of the World Health Organization classification of hematologic malignancies. In 2016, the Working Group on Diagnostic Hematology of the Italian Society of Clinical Chemistry and Clinical Molecular Biology (WGDH SIBioC) published its first consensus based recommendation for interpretative comments in laboratory hematology reporting whit the purpose of evaluating comments and the aim to (a) reducing their overall number, (b) standardizing the language, (c) providing information that could be easily comprehended by clinicians and patients, (d) increasing the quality of the clinical information, and (e) suggesting additional diagnostic tests when necessary. This paper represents a review of the recommendations of the former document.

Introduction Recent automated hematology analyzers (HAs) can identify and report nucleated red blood cells (NRBC) count as a separate population out of white blood cells (WBC). The aim of this study was to investigate the analytical performances of NRBC enumeration on five top of the range HAs. Methods We evaluated the within-run and between-day precision, limit of blank (LoB), limit of detection (LoD), and limit of quantitation (LoQ) of XE-2100 and XN-module (Sysmex), ADVIA 2120i (Siemens), BC-6800 (Mindray), and UniCel DxH 800 (Beckman Coulter). Automated NRBC counts were also compared with optical microscopy (OM). Results The limits of detection for NRBC of the BC-6800, XN-module, XE-2100, UniCel DxH 800, and ADVIA 2120i are 0.035×109/L, 0.019×109/L, 0.067×109/L, 0.038×109/L, and 0.167×109/L, respectively. Our data indicated excellent performance in terms of precision. The agreement with OM was excellent for BC-6800, XN-module, and XE-2100 (Bias 0.023, 0.019, and 0.033×109/L, respectively). ADVIA 2120i displayed a significant constant error and UniCel DxH 800 both proportional and small constant error. Conclusion Regards to NRBC counting, the performances shown by BC-6800, XN-module, and XE-2100 are excellent also a low count, ADVIA 2120i and UniCel DxH 800 need to be improved.

Introduction Morphological assessment of the blood smear has been performed by conventional manual microscopy for many decades. Recently, rapid progress in digital imaging and information technology has led to the development of automated methods of digital morphological analysis of blood smears. Methods A panel of experts in laboratory hematology reviewed the literature on the use of digital imaging and other strategies for the morphological analysis of blood smears. The strengths and weaknesses of digital imaging were determined, and recommendations on improvement were proposed. Results By preclassifying cells using artificial intelligence algorithms, digital image analysis automates the blood smear review process and enables faster slide reviews. Digital image analyzers also allow remote networked laboratories to transfer images rapidly to a central laboratory for review, and facilitate a variety of essential work functions in laboratory hematology such as consultations, digital image archival, libraries, quality assurance, competency assessment, education, and training. Different instruments from several manufacturers are available, but there is a lack of standardization of staining methods, optical magnifications, color and display characteristics, hardware, software, and file formats. Conclusion In order to realize the full potential of Digital Morphology Hematology Analyzers, pre-analytic, analytic, and postanalytic parameters should be standardized. Manufacturers of new instruments should focus on improving the accuracy of cell preclassifications, and the automated recognition and classification of pathological cell types. Cutoffs for grading morphological abnormalities should depend on clinical significance. With all current devices, a skilled morphologist remains essential for cell reclassification and diagnostic interpretation of the blood smear.

Francesco Lo-Coco speaks to Sebastian Dennis-Beron, Commissioning Editor: Francesco Lo-Coco is currently a full professor of hematology and head of the Laboratory of Integrated Diagnosis of Oncohematologic Diseases at the Department of Biomedicine and Prevention of the University Tor Vergata of Roma. He obtained his MD degree from the University of Pisa in 1981, and his specialization in clinical and laboratory hematology is from the University La Sapienza of Rome in 1985. From 1992 to 1994, he has trained on molecular genetics of lymphomas at Columbia University, New York. His main scientific interest and research activities include genetic characterization, monitoring and treatment of hematologic tumors, particularly acute myeloid leukemia and acute promyelocytic leukemia (APL). He has published over 390 internationally peer-reviewed articles, mainly focused on molecular diagnosis and follow-up of leukemia as well as on treatment of APL. He chairs at present the APL subcommittee of the Italian National Cooperative Group, GIMEMA. He served as president of the Italian Society of Experimental Hematology, chairman of the Education Committee of the European Hematology Association, board member of the Italian Foundation for Cancer Research, member of the Committe on Health Research of the Italian Ministry of Health and member of the Editorial Board of the journals Leukemia, Journal of Clinical Oncology and Haematologica.

// Jahangir Abdi 1,2 , Hou Jian 3 and Hong Chang 1,2,4 1 Division of Molecular and Cellular Biology, Toronto General Research Institute, Toronto, Ontario, Canada 2 Department of Laboratory Medicine & Pathobiology, University of Toronto, Toronto, Ontario, Canada 3 Department of Hematology, Shanghai Chang Zheng Hospital, Shanghai, China 4 Department of Laboratory Hematology and Medical Oncology, University Health Network, Toronto, Ontario, Canada Correspondence to: Hong Chang, email: // Keywords : miRNA, drug resistance, multiple myeloma Received : May 18, 2016 Accepted : July 19, 2016 Published : August 02, 2016 Abstract While novel therapeutic approaches have profoundly improved survival of multiple myeloma (MM) patients, drug resistance and treatment refractoriness still persists. This obstacle highly demands thorough investigation into the root and underlying molecular mechanisms to develop more effective strategies. The advent of micro-RNAs (miRNAs) in the study of cancer biology and pathogenesis in recent years has revolutionized therapy in this field and particularly opened new windows to further understanding of tumor drug resistance. However; in spite of the fact that miRNAs involvement in MM pathogenesis and progression has been substantially evidenced, miRNA investigation in MM drug resistance is still in its infancy. Our knowledge of the potential role of miRNAs in MM drug resistance comes from few recent reports confirming that some miRNAs including miR-137/197, miR-21 and miR-221/222 could negatively modulate drug sensitivity of MM cells. Further continuous researches are required to exploit miRNAs to elucidate the critical mechanisms controlling drug resistance in MM. In this review, we will highlight the most recent observations on the role of miRNAs in MM drug resistance. Moreover, approaches and insights into clinical application of miRNAs to overcome MM drug resistance will be discussed.

Introduction:Quality Assurance comprising External Quality Assessment Scheme (EQAS) and Internal Quality Control (IQC) is an indispensible part of the laboratory analytical process to ensure reliable results from the laboratories. However, due to various challenges in many developing countries such as limitations in resources and manpower, EQAS samples are often given less importance at laboratories. The objective of this study istoassessperformanceonhematologyEQASsamplesreceivedfromPacific Paramedical Training Center- External Quality Assesment Scheme (PPTC-EQAS) and International External Quality Assesment Scheme-United Kingdom (IEQAS-UK)since 2007 and 2008 respectively.The findings from this study will be helpful to establish an effective system to ensure timely follow up and corrective actions to improve the quality of laboratory services. Methods:The feedback of the EQAS results submitted thrice a year to the PPTC-EQAS and six times a year to the IEQAS-UK since 2007 and 2008 respectively were reviewed to assess the laboratory’s performance and to determine the effectiveness of EQAS participation for improving the performance of laboratory hematology in Bhutan. Results:For PPTC-EQAS, the average yearly scores were 69.00%, 75.00%, 87.66%, 87.50%, 70.00%, 80.33%, 80.50%, 85.00% for the years 2007-2014. For IEQAS-UK, the average yearly scores were 76.66%, 75.95%, 77.91%, 85.83%, 92.50%, 63.88% and 98.14% for the years 2008-2014. Our results show inconsistent performances on both EQAS samples despite gradual improvement over the last seven years. Conclusions:We conclude that, strengthening the system for regular follow up and implementing corrective actions for the outlying results in addition to replacement of the equipment could improve the trend and ensure consistency of the performance. Keywords: Corrective action; Quality assurance.

The difficulties in establishing and delivering reliable clinical hematology and laboratory services in resource-limited settings are well recognized. However, much can be achieved by better use of existing resources through a concerted quality improvement approach. The recommendations of this article are based in part upon work in the thalassemias, inherited disorders of hemoglobin that are widely prevalent in Asia, which may serve as a model that is applicable to other common, chronic disorders in resource-poor settings. Available resources are highlighted and recommendations made regarding approaches to improving services. Over the last few years, a number of low and middle-income countries, obtaining support from appropriate governmental sources, have identified and overcome difficulties and significantly improved clinical services for patients with thalassemia.

Objective We compared hemoglobin results from manually mixed blood gas (BG) Portex syringes (Smiths Medical) and automatically mixed safePICO BG syringes (Radiometer Medical) measured on the ABL90 FLEX blood gas analyzer at the Point of Care with a laboratory hematology analyzer (XN-series, Sysmex) to determine whether automatic mixing improved the accuracy and precision of hemoglobin measurement relative to the standardized method. Methods Ninety-nine lithium heparin tubes and EDTA tubes were collected simultaneously from selected patients at five participating institutions. The lithium heparin tubes were then split between the Portex ABG syringe and the safePICO aspirator. The Portex syringe was mixed manually according to routine procedures, while the safePICO syringe was mixed automatically on the ABL90 FLEX using the automatic mixing ball. The two syringes were mixed and run on the ABL90 FLEX analyzer by the same lab personnel. Total hemoglobin results obtained from the EDTA tubes on the Sysmex XN hematology analyzer were used as the reference values. Results Manual mixing demonstrated a larger scatter of hemoglobin values (R2 ​= ​0.515 and Mean diff.: -0.9 ​g/dL) while automatic mixing at the point of care yielded a significantly better correlation (R2 ​= ​0.986 and Mean diff.: -0.2 ​g/dL) when compared to a reference hematology analyzer. Conclusion Using the safePICO syringe with automatic mixing at the point of care results in a significantly better correlation of hemoglobin with the standardized method., Highlights • Variation in manual mixing techniques for syringes can lead to false results. • Automatic mixing ensures sample homogeneity. • Automatic mixing improved accuracy and precision of hemoglobin measurements.

As technology advances, recently developed automated hematology analyzers (HA) determine routine CBC parameters with better accuracy. In addition, they yield novel parameters also called Advanced Clinical Parameters (ACP) whose clinical utility is being assessed by several researchers in the field of laboratory hematology. Many of these ACP have been found to enhance clinical information and are now integrated into the routine Complete Blood Count (CBC) report.

Flow cytometry is a technique of cell analysis commonly used in laboratory hematology and immunology. The basic operational principles of a flow cytometer are reviewed, and its uses in diagnostic hematology and immunology are discussed.

Summary Introduction Practice guidelines provide helpful support for clinical laboratories. Our goal was to assemble an inventory of publically listed guidelines on hematology laboratory topics, to create a resource for laboratories and for assessing gaps in practice-focused guidelines. Methods PubMed and website searches were conducted to assemble an inventory of hematology laboratory-focused guidelines. Exclusions included annual, technical, or collaborative study reports, clinically focused guidelines, position papers, nomenclature, and calibration documents. Results Sixty-eight guidelines were identified on hematology laboratory practice topics from 12 organizations, some as joint guidelines. The median year of publication was 2010 and 15% were >10 years old. Coagulation topics had the largest numbers of guidelines, whereas some areas of practice had few guidelines. A minority of guidelines showed evidence of periodic updates, as some organizations did not remove or identify outdated guidelines. Conclusions This inventory of current practice guidelines will encourage awareness and uptake of guideline recommendations by the worldwide hematology laboratory community, with the International Society for Laboratory Hematology facilitating ongoing updates. There is a need to encourage best guideline development practices, to ensure that hematology laboratory community has current, high-quality, and evidence-based practice guidelines that cover the full scope of hematology laboratory practice.

The Japanese Society for Laboratory Hematology (JSLH) was launched in 2000 and has been developed by a mutual collaboration of hematologists, medical technologists, and the companies involved in hematological laboratory testing. The aim of JSLH is the progress and development of laboratory hematology by academic conferences, periodic publication of academic journal, training and education (in the meeting, the journal, or the website), promotion of the standardization of laboratory hematology, and certification of the laboratory hematology specialists. Among 3 specialized committees organized for the standardization of laboratory hematology, the standardization committee on blood cell morphology has been dealing with the various projects on peripheral/bone marrow blood cells and normal/abnormal morphology. Another independent organization, the Japanese National Research Group on idiopathic bone marrow failure syndromes (BMF), has raised the importance of the dysplasia of myelodysplastic syndromes (MDS) and has been conducting the prospective registration, central review, and follow-up study of MDS. This group recently proposed the grading system for diagnostic accuracy of MDS, and the detailed procedure of morphological diagnosis of MDS is presented in the specialized color atlas with typical photographs of various dysplasia. JSLH has also approved the grading system for diagnostic accuracy of MDS and adopted this standardized diagnostic system to the educational item for certification of the laboratory hematology specialists, aiming at a nationwidely expanding morphological evaluation of myelodysplasia. Further and significant progress in the standardization of blood cell morphology will be expected in Japan through the activity of JSLH.

Although the diagnosis of anemia is a relatively simple and straightforward endeavor, since it is mostly based on the measurement of hemoglobin in whole blood, the accurate characterization of red blood cell (RBC) disorders has emerged as a mainstay in the era of precision (laboratory) medicine. The many technological advances occurred in laboratory medicine over recent times have enabled the introduction of a vast array of innovations also for RBC diagnostics, mostly represented by modular automation, digital hematology, innovative erythrocyte parameters and adaptation of disruptive technologies to laboratory hematology, especially mass spectrometry and molecular biology. These important breakthroughs have enormously contributed to broadening the diagnostic armamentarium and making more efficient and sustainable the diagnostics of RBC disorders. Some on these important innovations will be discussed in this article.

Background We evaluated the efficacy of white blood cell (WBC) differential counts in severely leukopenic samples by the Hematoflow method and by automated hematology analyzers and compared the results with manual counts. Methods EDTA-anticoagulated blood samples (175 samples) with WBC counts of 40-990/µL were selected. Hematoflow differential counts were performed in duplicates employing flow cytometry using the CytoDiff reagent and analysis software. Differential counts were also performed using the DxH 800 (Beckman Coulter) and XE-2100 (Sysmex) automated hematology analyzers. The sum of the manual counts by a hematology technician and a resident were used as the manual counts. Results The total analysis time and hands-on time required by the Hematoflow method were shorter than those required by manual counting. Hematoflow counts were reproducible, showed a good correlation with automated analyzers, and also showed strong correlation with manual counts (r > 0.8) in neutrophils, lymphocytes, and monocytes. None of the cases containing less than 4% blasts as analyzed by the Hematoflow method had blasts in the manual counts, but 8 cases of 21 cases (38.1%) with over 4% blasts by Hematoflow had blasts in manual counts. Conclusion Hematoflow counts of severely leukopenic samples were reproducible and showed a good correlation with manual counts in terms of neutrophil, lymphocyte, and monocyte counts. The Hematoflow method also detected the presence of blasts. Manual slide review is recommended when over 4% blasts are found by Hematoflow.

Background: Thrombotic microangiopathic anemia (TMA) is a hematological emergency that requires prompt review of a peripheral blood smear for the presence of schistocytes. Within our institution, we had concern for lack of consistency in identifying schistocytes, lack of consistency in reporting methods, possible variation in schistocyte quantitation due to microscope differences, and the threshold for which our laboratory had been reporting increased schistocytes. The objective of our quality improvement project was to implement published practice standards for morphological identification, quantitation, and reporting of schistocytes across different groups at the University of Cincinnati Medical Center (UCMC). Methods: The International Council for Standardization in Haematology (ICSH) recommendations for the identification, diagnostic value, and quantitation of schistocytes (Zini et. al. International Journal of Laboratory Hematology 2012) were reviewed prior to designing this project. We next conducted a survey of groups that were reviewing peripheral blood smears for schistocytes on a routine basis: medical technologists (n=9), pathology residents (n=10) and hematology-oncology fellows (n=13). The survey included questions about schistocytes, including desire for standardization and normal reference values, desire for pathologist instruction, and reporting patterns. One question included 8 images of various red cell morphologies, and participants were asked to select ones they would classify as schistocytes. The microscopes were compared for objective and field diameter measurements. Six (6) peripheral blood smears with previously reported schistocytes were re-reviewed. Schistocytes were identified per ICSH guidelines and counted as a percentage (%) of 1000 total red blood cells using a Miller optical disc and also as an average number per field for a total of 10 high power fields. The results were plotted on a linear X-Y axis graph (Fig 1) and compared to the ICSH guidelines (Fig 2) and the policy for reporting schistocytes in our laboratory. Results: Survey results showed that the majority of each group desired standardization, normal reference values, and pathologist instruction. For reporting of schistocytes, residents answered present/absent (50%) or average per high power field (HPF) (50%), whereas 92% of fellows answered average per HPF. No participants reported a percentage of 1000 red blood cells, the current ICSH recommendation. For the morphological identification, 50% of residents, 62% of fellows and 67% of technologists correctly identified keratocytes as schistocytes. Fifteen (15%) of fellows misidentified bite cells as schistocytes, whereas one fellow (8%) and one technologist (11%) misidentified acanthocytes as schistocytes. Only 70% of technologists correctly identified helmet cells as schistocytes, whereas all residents and fellows chose them correctly. Almost all participants failed to recognize microspherocytes as schistocytes. The microscopes all showed the same objective and field diameter measurements. The schistocyte percentage plotted versus the number of schistocytes per HPF showed a 0.99% correlation co-efficient (R=0.99%) (Fig 1). The results were compared to the ICSH threshold of 1%, above which the ICSH reports is a robust morphologic indicator for the diagnosis of TMA (Fig 2), and to the current reporting policy at UCMC. Two (2) schistocytes per HPF correlated with 1% schistocytes on the linear plot. At UCMC, policy had been to report 2-8 schistocytes per HPF as present and >8 per HPF as increased. These findings indicated that the threshold for reporting increased schistocytes should be lowered from >8 per HPF to >2 per HPF. The above data were reviewed with each survey group. A process was also initiated to change the laboratory schistocyte reporting policy. Conclusion: All survey groups needed and desired education on schistocyte identification and reporting per ICSH guidelines. All microscopes showed the same measurements and were therefore expected to produce the same quantitation results. Schistocyte percentage correlated with the number of schistocytes per HPF. By implementing the ICSH guidelines, we aimed to decrease inter-observer bias and to standardize the quantitation and reporting of schistocytes at UCMC, thereby assisting in timely and accurate diagnosis of thrombotic microangiopathic anemia. Disclosures No relevant conflicts of interest to declare.

Introduction The gold standard for the determination of the erythrocyte sedimentation rate (ESR) is the Westergren method. Other methods to measure the ESR have become available. They range from modest modifications of the Westergren method to very different methodologies. The ICSH therefore established a Working Group to investigate these new approaches and compile recommendations for their validation and verification. Methods A panel of six experts in laboratory hematology examined the peer-reviewed literature and EQA surveys from over 6000 laboratories on four continents performing ESR testing. This information was used to create lists of ESR instrument manufacturers and their methods. Results Only 28% of laboratories surveyed used the unmodified Westergren method, while 72% of sites used modified or alternate methods. Results obtained with the new instruments could differ from results obtained with the Westergren method by up to 142%. Different non-Westergren methods showed differences from each other of up to 42%. The new methods were often significantly faster, safer, and less labor-intensive. They reduced costs and often used standard EDTA tubes, eliminating the need for a dedicated ESR tube. Conclusion Based on the consensus of the Working Group, recommendations for manufacturers for the validation of new ESR methods were developed. In addition, a list of recommendations for laboratories that are moving to modified or alternate methods was compiled, addressing instrument performance verification and communications of results to clinical users.

Background Morphological characteristics of blood cells are still qualitatively defined. So a texture analysis (Tx) method using gray level co-occurrence matrices (GLCMs; CM-Tx method) was applied to images of erythrocyte precursor cells (EPCs) for quantitatively distinguishing four types of EPC stages: proerythroblast, basophilic erythroblast, polychromatic erythroblast, and orthochromatic erythroblast. Methods Fifty-five images of four types of EPCs were downloaded from an atlas uploaded by the Blood Cell Morphology Standardization Subcommittee (BCMSS) of the Japanese Society of Laboratory Hematology (JSLH). Using in-house programs, two types of GLCMs-(R: d=1, θ=0°) and (U: d=1, θ=270°)-and nine types of texture distinction index (TDI) were calculated with images removed outer part of cell. Results Three binary decision trees were sequentially divided among four types of EPC with the sum average of GLCM (U), the contrast of GLCM (R), and the sum average of GLCM (U). The average concordance rate (sensitivity) of CM-Tx method with the judgments of eleven experts in the BCMSS of the JSLH was 95.8% (87.5-100.0), and the average specificity was 97.6% (92.5-100.0). Conclusions The CM-Tx method is an effective tool for quantitative distinction of EPC with their morphological features.

SummaryIntroduction To provide target values for the manufacturers’ survey of the Japanese Society for Laboratory Hematology (JSLH), accurate standard data from healthy volunteers were needed for the five-part differential leukocyte count. To obtain such data, JSLH required an antibody panel that achieved high specificity (particularly for mononuclear cells) using simple gating procedures. We developed a flow cytometric method for determining the differential leukocyte count (JSLH-Diff) and validated it by comparison with the flow cytometric differential leukocyte count of the International Council for Standardization in Haematology (ICSH-Diff) and the manual differential count obtained by microscopy (Manual-Diff). Methods First, the reference laboratory performed an imprecision study of JSLH-Diff and ICSH-Diff, as well as performing comparison among JSLH-Diff, Manual-Diff, and ICSH-Diff. Then two reference laboratories and seven participating laboratories performed imprecision and accuracy studies of JSLH-Diff, Manual-Diff, and ICSH-Diff. Simultaneously, six manufacturers’ laboratories provided their own representative values by using automated hematology analyzers. Results The precision of both JSLH-Diff and ICSH-Diff methods was adequate. Comparison by the reference laboratory showed that all correlation coefficients, slopes and intercepts obtained by the JSLH-Diff, ICSH-Diff, and Manual-Diff methods conformed to the criteria. When the imprecision and accuracy of JSLH-Diff were assessed at seven laboratories, the CV% for lymphocytes, neutrophils, monocytes, eosinophils, and basophils was 0.5~0.9%, 0.3~0.7%, 1.7~2.6%, 3.0~7.9%, and 3.8~10.4%, respectively. More than 99% of CD45 positive leukocytes were identified as normal leukocytes by JSLH-Diff. Conclusions When JSLH-Diff method were validated by comparison with Manual-Diff and ICSH-Diff, JSLH-Diff showed good performance as a reference method.

A microscopic examination of an appropriately prepared and well-stained blood smear by a knowledgeable laboratory professional is necessary and clinically useful in a number of circumstances and for a variety of reasons. In this article, an attempt is made to delineate the purpose and criteria for blood smear examination in a variety of circumstances that are encountered in everyday laboratory hematology practice. A blood smear scan serves to at least (a) verify the flagged automated hematology results and (b) determine if a manual differential leukocyte count needs to be performed. Blood smear examination/manual differential leukocyte count with complete blood count (CBC) provides the complete hematologic picture of the case, at least from the morphologic standpoint. Blood smear review with or without interpretation serves to ensure that no clinically significant finding is missed, besides providing diagnosis or diagnostic clue(s), particularly if and when interpreted by a physician.

Background: For the occasion of the 50th anniversary of the journal Clinical Chemistry and Laboratory Medicine (CCLM), an historic overview of papers that the journal has published in the field of laboratory hematology (LH) is presented. Methods: All past volumes of CCLM were screened for papers on LH and these were categorized. Bibliographic data of these papers were also analyzed. Results: CCLM published in total 387 LH papers. The absolute number of LH papers published annually showed a significant increase over the years since 1985. Also the share of LH papers demonstrated a steady increase (overall mean 5%, but mean 8% over the past 4 years). The most frequent category was coagulation and fibrinolysis (23.5%). Authors from Germany contributed the most LH papers to the journal (22.7%), followed by the Netherlands and Italy (16.3 and 13.2%, respectively). Recent citation data indicated that other publications cited LH review papers much more frequently than other types of papers. Conclusions: The history of the journal reflects the emergence and development of laboratory hematology as a separate discipline of laboratory medicine.

Outsourcing or sending out of patients' samples to other laboratories for hematologic investigations is a common practice these days. Preanalytic variables that alter cellular parameters and levels of analytes in transit and on storage can significantly and adversely affect interpretation of test results in hematology. Awareness of these changes is necessary to avoid misinterpretation of results that in turn could influence medical management decisions.

Summary Introduction Given the importance of evidence-based guidelines in health care, we surveyed the laboratory hematology community to determine their opinions on guideline development and their experience and interest in developing clinical hematology laboratory practice guidelines. Methods The study was conducted using an online survey, distributed to members of the International Society for Laboratory Hematology (ISLH) in 2015, with analysis of collected, anonymized responses. Results A total of 245 individuals participated. Most worked in clinical and/or research laboratories (83%) or industry (11%). 42% felt there were gaps in current guidelines. The majority (58%) recommended that ISLH engages its membership in guideline development. Participants differed in their familiarity with, and use of, different organizations’ guidelines. Participants felt it was important to follow best practice recommendations on guideline development, including engagement of experts, statement about conflict of interests and how they were managed, systematic review and grading evidence for recommendations, identifying recommendations lacking evidence or consensus, and public input and peer review of the guideline. Moreover, it was considered important to provide guidelines free of charge. Industry involvement in guidelines was considered less important. Conclusions The clinical laboratory hematology community has high expectations of laboratory practice guidelines that are consistent with recent recommendations on evidence-based guideline development.

The authors of this article formulate a strategy to guide residents and faculty in laboratory hematology. The authors build upon the recommendations of the Academy of Clinical Laboratory Physicians and Scientists (ACLPS) published earlier as well as draw from their own experiences, in discussing principles that should be considered when implementing a program that effectively trains residents to be competent pathologists in the various settings that they may encounter once they complete training.

Hematological laboratory diagnostics of platelets is faced with technical difficulties and requires preanalytical considerations. The handling of platelet agglutination needs to be addressed in the daily routine. This article summarizes the current state of platelet counting and subsequent differential diagnosis.