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    wbc, celulas blancas, boodcell, morph, balance,

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    White Blood Cell Morphology in the Balance

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    wbc, celulas blancas, boodcell, morph, balance,

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    © All Rights Reserved
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    15 views4 pages

    White Blood Cell Morphology in The Balance

    Uploaded by

    Gaby Gómez
    wbc, celulas blancas, boodcell, morph, balance,

    Copyright:

    © All Rights Reserved
    Download as PDF or read online from Scribd
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    Laboratory Hematology 11:79-82 (© 2008 Carden Jennings Publishing Co. Led doi 10.1532/LH96.05015 Editorial fic! Pabteaton White Blood Cell Morphology in the Balance ‘New demands by clinicians may be challenging laboratorians' assumptions about the clinical utility of WBC morphology and other hematology test resus BEREND HOuWEN Reccved Mare 22,2005) nesepted Marah 29, 2005 Sometimes reflection on things unchanged for a long time can lead to sarding conclusions. Like many in the hetnatol- ogy laboratory profession, I have spent countess hours read- ing blood films, bone marrows, and body fluids. Bur did 1 ver ero ace if was making an impact on medical decision making with my morphology assessments? Years ago, prompted by the apparent anomaly of requests for blood samples to be tested simultaneously for iron defi- ciency, vitamin By2 and folate levels, I looked into how physicians were influenced by MCV data, specifically decreased MCV values in patients. The findings disturbed mmc, to say the least. Half of the physicians were not influ enced in their test ordering patterns, and a significant por- tion of patients left the hospital with an apparent diagnosis of iron deficicney snemia but no resolution of is cause or even a prescription ‘While chs was many years ago, the situation still serves as an example of the differences in how lahoratarians and clini- cians perceive the importance of WBC morphology and ‘other hematology test results, prompting the question, “Are WBC morphology findings even relevant o physicians? ‘At frst, such a question might sound strange ~ even shocking. Highly qualified technologists spend large Berend Houwen MD, PAD, Founder ISLH, 1941-2004, De. Houwen ‘was working on this paper atthe time he pased sway in February few minor changes and additions by Stefanie L. McFadden |MT(ASCD)SH ina few small clay unfinished areas, i has ben le ashe wrote it Ie will probably be the last work of Dr. Houses to be publihed Correspondence and reprint requests: Stephanie L. MePadden, MT (ASCP) SH, Laboratory Consultan, 104 S. Westmoor Ave, Colum: bus, OH 43204, USA (emi: 5441 @yahoo.com) 7 amounts of time and a significant portion of the lb’s budgee fon manual mleroscopy; several laborarortes I know do tis fon every specimen passing through the lab. Buc while there are certain “quality aspect” inherent in these efforts, ic i, worth inquiring whether such activity adde diagnostic value to the analyzer report. In an effor 19 answer my own question, I conducted my own assesment. I studied WBC morphology statements, creat- ing table with eel counts and flags for WBCs, and cross tabu- lated these against laboratory and medical relevance. Factors considered included those critical for patient safery (vital), ‘whether the ndings were specie or not, and with which con ditions these were commonly asociated. From such an exercise, I discovered tha there are often better ot alternative methods to reach the stme conclusion, as by counting cells or fagging. morphological abnormalities, and that there are more fictive ‘ways for laboratorians and clinicians to work together. ‘TRANSFORMING DATA INTO INFORMATION ‘This effort is personal and arbitrary, and I invite you to chink aboue ean oie your opinion, Bue fst, eis por ‘anc to make several generalizations. If one reviews a blood film, fully informed about the patients history, and takes into account physieal findings and additional information such as X-rays, cultures, ete, then the information one obtains is often highly relevant aad focused. In the al soseatle, clinicians hove ccowe to this extensive information. Unfortunately, the average bench ‘technologist docs not ‘This contrasts sharply with the roe ofthe laboratory sev- cra decades ago. In those days, technologists went outside the lb to do phlebotomy and often obtained valuable infor- imation about patients whose blood specimens they analyzed facet. Despite today’s huge improvements in informatics in the hospital and laboratory setting, in most cases there is no cy B.Houwen transparency of esental patient information forthe technol- ‘gist. Even atthe pathologist level, that information is not readily avalable for blood film analysis. The conclusion is that most morphological interpretation of che blood film is generated in an information vacuum. This limits che power of the microscopic analysis and it ‘may alo generate information that nox needed by the rest ordering physician, Similar to the MCV example referenced calir, physicians may not be interested in the presence of Doble bodies in a patient they are erying to prevent from going into circulatory shock from sepsis. : $0 what are labs to do? Should they continue to operate in silos and generate information thar they think is techn cally exace ye is actually viewed as clinically irrelevant by physicians? Or is there a beter way—pethaps an opporcu- nity for laboratorians to collaborate more effectively with clinicians and transform data into information? Take morphology fags, for example. As laboratorians, we must ak ourselves, “What are we trying to do?” The physi dan wants information that will help with the diagnore or ‘monitoring of his or her patients, And they would like that information to reach them in an uncluctered way. Instead, however, we often provide the entire dataset generated by an automated analyze, plus morphology information in instu- :ment, lagged or otherwise abnormal samples. That slot to absorb if all you wanted to know is whether the Hb level was stable in your patient. Random access testing can, of course help reduce this “data overload,” but, in genera, i is time we reconsider how swe use morphology findings and whether che thinking inthe laboratory is in alignment with clinical needs. Thac will require changing perceptions, both in the laboratory and in the physician setting DIFFERENCES IN PERCEPTION ‘Within the lab, white and red cells and platelets can dis- play a wide range of morphological features. Laboratorians hhave been taught to record these abnormalities and score them in terms oftheir aeverity: Bue sometimes clinieiane who make the medical decisions do not pay attention to those abnormalities, even though some of them may be associated ‘with significant diseases Often, it is because, obviously, clinicians base their diag noses and treatment decisions on other information, not pr vided by the laboratory: The finding that the patient has lef-shfted” cells or increased band cells may or may not be very significane co a physician who is seeing a patient with fever and other symptoms: “Ac other times, clinicians may not be “up to dats" on che clinical significance of this lab data. These-older opinions ‘may be difficule co change. Take, for example. 2 2002 study involving University Hospitals of Cleveland and che Case Western Reserve Uni versity [1]. The study surveyed more than 2000 physicians and sought to determine how useful CBC and reciculocyte reports are t clinicians. Ir found that only 4 (WBC, HB, HICCT, and PLT) of the 11 parameters routinely reported in the CBC battery were selected as frequendly or always useful by mote than 90% of physicians. “The study also found that physteans who had been in practice for fewer than 10 years indicated higher use of red call distribution informacion than physicians who had been practicing for more than 10 years. ‘These results are shocking in light of the fact that retcu- logyte measurements ean help clinicians diagnose and teat a ‘wide range of conditions, from anemia and nutritional def- ciency 0 bone marrow failure. The study illustrates that i is more important than ever for laboratorians and clinicians to ‘work cogether to find alignment on which lab information is import, and which isnot. “Thas, che importance of morphology information can be overestimated in situations when ic is mor required or, even ‘worse, ignored in situations when it required Unforcunately, chese differing ideas of “perceived value” and lack of communication are not optimizing patient care. Bue these barriers and communication deficits can be easily rectified by bringing both disciplines closer together and understanding each other’s capabilites and needs. More importantly, simple economics—the need 10 do more with less—is making this « necessity, CIVILIZATION AND THE HEMATOLOGY LAB Indeed, simple economics is forcing laboratories to rethink their srategy and make changes to how they deliver hematol- ‘ogy results. For example, the identification and enumeration of cell gypes, normally nor present in blood type or present in very small numbers, is shifting feom microscopic to auco- rated electronic analysis. Meanwhile, additional forms of automation—such as instrument flagging of abnormalities and the applicaon of decision rules—are helping labs post addicional guns in efficiency o give physicians more relevant information and deliver that information much more quieldy Tehas been said tha che stone ages ended not because peo- ple ran out of rocks, but because of advancements in human Civilization. In many way, this is analogous to the elfors of the modern lab co automate process and meet new demands In other words, we are not automating WBC analysis because ‘ve ae running out of microscopes. Rather, we are auromating this analysis because 11s more efficient and allows analysis in areater detail such as the extended differential. And this deaaled analysis is more in tune with physicians needs. ‘Automated blood cell analysis certainly has come a long way from its earliest applications in the 1960s. Back hen, automated image analysis systems could identify most blood cells in normal specimens, but ehey failed in preparations from patients with significant diseases. This meant that che operator had co interact with the system to identify the remaining difficult-to-clasify cell. The reality was tht image analysis systems were slow, even compared with manual ‘microscopy, and they were not truly "walk-away” systems. ‘Automating manual steps did noe really stare moving for ‘ward until the 1980s when the flow through five-ell dif otal Became evailable, Then « hey sdvancement same in 1990, when the fivecell differential became available on many automated analyzes, This important shift has greatly impacted routine operations in the clinical lab. Tike the electronic analysis of normally appearing white cell types, performing the recently extended differenial— and using i ealir—

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