Performance evaluation of the new hematology analyzer Sysmex XN-series

A comparative study of blood cell count in four automated hematology analyzers: An evaluation of the impact of preanalytical factors

Differential white blood cell counts are frequently used in diagnosis, patient stratification, and treatment selection to optimize therapy responses. Referral laboratories are often used but challenged with use of different hematology platforms, variable blood shipping times and storage conditions, and the different sensitivities of specific cell types. To extend the scientific literature and knowledge on the temporal commutability of blood samples between hematology analyzers, we performed a comparative ex-vivo study using four of the most utilized commercial platforms, focusing on the assessment of eosinophils given its importance in asthma management. Whole blood from healthy volunteers with and without atopy (n = 6+6) and participants with eosinophilic asthma (n = 6) were stored under different conditions (at 4, 20, 30, and 37°C, with or without agitation) and analyzed at different time points (3, 6, 24, 48 and 72h post-sampling) in parallel on the Abbott CELL-DYN Sapphire, Beckman Coulter DxH900, Siemens ADVIA 2120i and Sysmex XN-1000V. In the same blood samples, eosinophil-derived neurotoxin (EDN), eosinophil activation and death markers were analyzed. All platforms gave comparable measurements of cell differentials on fresh blood within the same day of sampling. However, by 24 hours, significant temporal and temperature-dependent differences were observed, most markedly for eosinophils. None of the platforms performed perfectly across all temperatures tested during the 72 hours, showing that handling conditions should be optimized depending on the cell type of interest and the hematology analyzer. Neither disease status (healthy vs. asthma) nor agitation of the sample affected the cell quantification result or EDN release. The eosinophil activation markers measured by flow cytometry increased with time, were influenced by temperature, and were higher in those with asthma versus healthy participants. In conclusion, hematology analyzer, time window from sampling until analysis, and temperature conditions must be considered when analyzing blood cell differentials, particularly for eosinophils, via central labs to obtain counts comparable to the values obtained in freshly sampled blood.

Performance evaluation the new automated Atellica Hema 580 hematology analyzer

INTRODUCTION

The Atellica Hema (Siemens Healthineers, Tarrytown, NY, USA) is a new generation multi-parameter analyzer for full blood count, 6-part differential and reticulocyte testing by impedance variation and fluorescence flow cytometry. In this study, we verified the whole blood and limited body fluid modes of the Atellica Hema 580.

METHODS

We evaluated precision, linearity, carry-over, throughput and performed a method comparison to assess the performance of the Atellica Hema 580. For comparison of the Atellica Hema 580 with the Sysmex XN-1000 (Sysmex, Kobe, Japan), 140 samples from adult and pediatric patients including both normal and abnormal hematology profiles were analyzed in parallel.

RESULTS

The Atellica Hema 580 demonstrated acceptable imprecision within the manufacturer's specifications for whole blood and body fluid modes, good linearity for high and low ranges and no significant carryover. The full blood count, differential and reticulocyte correlated well with the Sysmex XN-1000, except for mean cell hemoglobin concentration, basophil and large immature cells. The optical platelet count, reflexed in 34 samples with a platelet count <150 × 109 /l, showed a strong correlation with the fluorescent platelet count on the Sysmex XN-1000. The morphology flagging efficiency was 92% for white blood cells, 95% for red blood cells and 87% for platelets.

CONCLUSION

The Atellica Hema 580 showed good analytical performance and workflow efficiency for a wide range of patient samples.

Incomplete filling of spray-dried K2EDTA evacuated blood tubes: impact on measuring routine hematological parameters on Sysmex XN-10

OBJECTIVES

Because there is little published evidence on the effects of incomplete filling of K2EDTA evacuated blood tubes on routine hematological testing, this original study aimed to provide updated information on this preanalytical aspect.

METHODS

The study population consisted of 17 ostensibly healthy volunteers. Blood was drawn by venipuncture with a 10 mL syringe and dispensed in varying amounts (0.2, 0.5, 1.0, 2.0, and 3.0 mL) into 3.0 mL blood tubes containing spray-dried 5.4 mg K2EDTA. All tubes were gently mixed and used to perform routine hematology tests on the Sysmex XN-10. Clinically significant variations were defined when the limits of desirable specifications of bias derived from biologic variation were exceeded.

RESULTS

The desirable bias was exceeded in 33 % filled tubes (1.0 mL) for hematocrit and MCV (increased values) and for MCHC (decreased values), while it was exceeded in 17 % filled tubes (0.5 mL) for hemoglobin, hematocrit and MCV (increased values), and for MCHC (decreased values). Finally, the variation of values was higher than the desirable bias for RBC, hemoglobin, hematocrit and MCV (increase), and for MCHC and MPV (decrease) in 7 % filled tubes (0.2 mL). No clinically significant variations were observed in tubes filled up to 67 % of their nominal volume (i.e., 2.0 mL).

CONCLUSIONS

Consideration should be given to reject spray-dried K2EDTA blood tubes that contain a blood volume <67 % of the nominal fill volume, as biased laboratory data in these samples may interfere with clinical decision making and care management.

Performance of the Sysmex XN-V hematology analyzer in determining the immature platelet fraction in dogs: A preliminary study and reference values

BACKGROUND

Immature platelets (IPs) are newly formed platelets released into circulation that have been demonstrated as good markers of thrombopoiesis. Although many flow cytometric and fully automated-based methods are available, the latest Sysmex XN-V hematology analyzer for veterinary use is equipped with a specific fluorescent platelet channel (PLT-F) that detects platelets using a platelet-specific dye.

OBJECTIVES

The aims of this study were to evaluate the performance of the Sysmex XSN-1000 V in determining the IPF (immature platelet fraction) and other selected PLT-F channel parameters and to propose IPF reference intervals (RIs) for canine blood samples.

METHODS

Canine EDTA blood samples were analyzed on the Sysmex XN-1000 V to assess linearity, imprecision, carryover, stability, and the effect of platelet clumping on selected platelet parameters from the PLT-F channel. We also reported the de novo generated RIs for the IPF in dogs.

RESULTS

Imprecision was acceptable (CV <10%) for all parameters except for the absolute IPF values (IPF#), in which the reproducibility was 12.15% for the normal-low concentration samples. Linearity and carryover were excellent for all variables. Relative IPF values (IPF %) and IPF# remained stable for both storage conditions for up to 48 hours; however, a nonsignificant progressive increase in these parameters was observed from 12 hours at 4°C. We observed a statistical increase in IPF% and IPF# and a statistically significant decrease in PLT-F counts after intentional in vitro platelet aggregation. RIs were generated for all reference samples (n = 69) and for samples with (n = 25) or without (n = 44) platelet clumps.

CONCLUSIONS

The performance of the new PLT-F channel-derived variables for dogs was excellent. Specific RIs for IPF should be used when platelet aggregates are present.

Pre-analytical and analytical variability of reticulocyte counts in dogs

BACKGROUND

Automated fluorescence-based haematology analysers are now available for reticulocyte enumeration in veterinary medicine, but manual counting is still largely used. This study aimed to evaluate potential sources of analytical and pre-analytical errors when performing automated and manual counts.

METHODS

Automated and two-operator double-blind manual reticulocyte counts were performed on 15 blood samples. The intra-assay variation of the automated and manual counts and the interoperator variation in the manual counts were then calculated. In addition, the effects of storage were evaluated using samples refrigerated at 4°C or stored at room temperature for 2, 4, 12, 24, 48 or 72 hours after sampling.

RESULTS

Intra-assay coefficients of variation were lower for automated counts than for manual counts. Comparison between automated and mean total manual reticulocyte count showed no significant differences. In both refrigerated samples and those stored at room temperature, an increase in reticulocyte count was recorded only after 72 hours. Staining artefacts occurred only in one stored sample counted manually.

LIMITATIONS

The presence of cytoplasmic particles other than RNA can cause misinterpretation of cells, leading to an erroneous reticulocyte count.

CONCLUSION

The use of an automated analyser is preferable for reticulocyte enumeration in dogs. Common storage conditions seem to minimally affect reticulocyte evaluation; however, it is recommended to perform the analysis as soon as possible after sampling.

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.

Application of the Fluorescence Method on Sysmex XN9000 Hematology Analyzer for Correcting Platelet Count in Individuals with Microcytosis

OBJECTIVE

Although small red blood cells are a well-known analytical pitfall that could cause artifactual increase of the platelet count, limited information is available on the accuracy of impedance platelet counting in cases with microcytosis. The aim of this study is to assess the accuracy of impedance platelet counting in the presence of small red blood cells, and to establish the optimal mean corpuscular volume (MCV) cutoff to endorse fluorescence platelet counting.

METHODS

In this study, platelet counts estimated by the impedance method on the Sysmex XN9000 analyzer (Sysmex, Kobe, Japan) were compared with those provided by the fluorescence method. The accuracy of impedance platelet counting was assessed. Receiver operating characteristic curve was used to evaluate the performance of MCV in predicting falsely increased platelet counts.

RESULTS

There was a tendency for the impedance method to overestimate the platelet count in samples with 70 fL < MCV ≤ 80 fL, 60 fL < MCV ≤ 70 fL, MCV ≤ 60 fL. Receiver operating characteristic curve analysis showed that a 73.5fL cutoff of MCV was highly sensitive in predicting falsely increased platelet counts.

CONCLUSION

In cases with MCV < 73.5 fL, we strongly suggest that the platelet counts obtained by the impedance method on the Sysmex XN9000 analyzer should be checked and corrected by fluorescence counting.

Development and Performance Evaluation of a Clinical Predictive Model to Estimate the Risk of Red Blood Cell Requirements in Brain Tumor Surgery

BACKGROUND

The identification of factors associated with perioperative red blood cell (RBC) transfusion provides an opportunity to optimize the patient and surgical plan, and to guide perioperative crossmatch and RBC orders. We examined the association among potential bleeding risk factors and RBC requirements to develop a novel predictive model for RBC transfusion in patients undergoing brain tumor surgery.

METHODS

This retrospective study included 696 adults who underwent brain tumor surgery between 2008 and 2018. Multivariable logistic regression with backward stepwise selection for predictor selection was used during modeling. Model performance was evaluated using area under the receiver operating characteristic curve, and calibration was evaluated with Hosmer-Lemeshow goodness-of-fit χ 2 -estimate.

RESULTS

Preoperative hemoglobin level was inversely associated with the probability of RBC transfusion (odds ratio [OR]: 0.50; 95% confidence interval [CI]: 0.39-0.63; P <0.001). The need for RBC transfusion was also greater in patients who had a previous craniotomy (OR: 2.71; 95% CI: 1.32-5.57; P =0.007) and in those with larger brain tumor volume (OR: 1.01; 95% CI: 1.00-1.02; P =0.009). The relationship between number of planned craniotomy sites and RBC transfusion was not statistically significant (OR: 2.11; 95% CI: 0.61-7.32; P =0.238). A predictive model for RBC requirements was built using these 4 variables. The area under the receiver operating characteristic curve was 0.79 (95% CI: 0.70-0.87; P <0.001) showing acceptable calibration for predicting RBC transfusion requirements.

CONCLUSIONS

RBC requirements in patients undergoing brain tumor surgery can be estimated with acceptable accuracy using a predictive model based on readily available preoperative clinical variables. This predictive model could help to optimize both individual patients and surgical plans, and to guide perioperative crossmatch orders.

Automated and manual microscopic analyses for leukocyte differential counts in exudative pleural effusions: Real-world disagreement and clinical application

Differential leukocyte counts of pleural fluid are routinely recommended for the early diagnosis and management of exudative pleural effusions. Rapid automated cellular analysis agrees strongly with standard manual microscopic counts and has become a reality in many clinical laboratories. However, discordant results sometimes observed between automated and manual analyses raise concern about using automated analysis to aid prompt differential diagnosis. This study aimed to evaluate the real-world disagreement between automated and manual leukocyte analyses in exudative pleural effusions and to investigate whether the discordant results occur in specific cellular ranges or randomly. We conducted a retrospective study of patients who were diagnosed with parapneumonic pleural effusions (PPE), tuberculous pleural effusions (TPE), and malignant pleural effusions (MPE) between September 2018 and December 2020. Differential and predominant leukocyte counts were performed using an automated XN-350 analyzer with a two-part differential count consisting of polymorphonuclear (PMN) and mononuclear (MN) leukocytes and a manual method with Wright-stained cytospin slides. We compared the two methods on cases of 109 PPEs, 50 TPEs, and 116 MPEs. Although the overall correlation between the two methods for differential leukocyte counts was excellent, there were etiologic variations; MPEs showed a lower correlation compared to PPEs and TPEs. Automated-PMN predominance almost corresponded to manual cytospin-neutrophilic predominance. In contrast, ~10% of the automated-MN predominance did not correspond with the cytospin-lymphocytic predominance. These discrepancies occurred most in the automated-MN% range of 51% to 60%, followed by 61% to 70%. The PMN% range ≥50% and <30% on the automated analysis reliably corresponds to the neutrophilic and lymphocytic predominance, respectively. However, the MN% range of 51% to 70% may not coincide with lymphocytic predominance on manual cytospin analysis. This range leaves the potential cause of exudative pleural effusions open.

Technological features of blast identification in the cerebrospinal fluid: A systematic review of flow cytometry and laboratory haematology methods

BACKGROUND

Involvement of the central nervous system (CNS) by acute leukemias (ALs) has important implications for risk stratification and disease outcome. The clinical laboratory plays an essential role in assessment of cerebrospinal fluid (CSF) specimens from patients with ALs at initial diagnosis, at the end of treatment, and when CNS involvement is clinically suspected. The two challenges for the laboratory are 1) to accurately provide a cell count of the CSF and 2) to successfully distinguish blasts from other cell types. These tasks are classically performed using manual techniques, which suffer from suboptimal turnaround time, imprecision, and inconsistent inter-operator performance. Technological innovations in flow cytometry and hematology analyzer technology have provided useful complements and/or alternatives to conventional manual techniques.

AIMS

We performed a PRISMA-compliant systematic review to address the medical literature regarding the development and current state of the art of CSF blast identification using flow cytometry and laboratory hematology technologies.

MATERIALS AND METHODS

We searched the peer reviewed medical literature using MEDLINE (PubMed interface), Web of Science, and Embase using the keywords "CSF or cerebrospinal" AND "blasts(s)".

RESULTS

108 articles were suitable for inclusion in our systematic review. These articles covered 1) clinical rationale for CSF blast identification; 2) morphology-based CSF blast identification; 3) the role of flow cytometry; 4) use of hematology analyzers for CSF blast identification; and 5) quality issues. 9 /L, which is much lower than the original machine count and platelet transfusion was warranted.

DISCUSSION

1) Clinical laboratory testing plays a central role in risk stratification and clinical management of patients with acute leukemias, most clearly in pediatric ALs; 2) studies focused on other patient populations, including adults and patients with AML are less prevalent in the literature; 3) improvements in instrumentation may provide better performance for the classification of CSF specimens.

CONCLUSION

Current challenges include: 1) more precisely characterizing the natural history of AL involvement of the CNS, 2) improvements in automated cell count technology of low cellularity specimens, 3) defining the role of flow MRD testing of CSF specimens and 4) improved recognition of specimen quality by clinicians and laboratory personnel.

In-Depth Immunological Typization of Children with Sickle Cell Disease: A Preliminary Insight into Its Plausible Correlation with Clinical Course and Hydroxyurea Therapy

Sickle cell disease (SCD) is a condition of functional hypo-/a-splenism in which predisposition to bacterial infections is only a facet of a wide spectrum of immune-dysregulation disorders forming the clinical expression of a peculiar immunophenotype. The objective of this study was to perform an in-depth immunophenotypical characterization of SCD pediatric patients, looking for plausible correlations between immunological biomarkers, the impact of hydroxyurea (HU) treatment and clinical course. This was an observational case−control study including 43 patients. The cohort was divided into two main groups, SCD subjects (19/43) and controls (24/43), differing in the presence/absence of an SCD diagnosis. The SCD group was split up into HU+ (12/19) and HU− (7/19) subgroups, respectively receiving or not a concomitant HU treatment. The principal outcomes measured were differences in the immunophenotyping between SCD patients and controls through chi-squared tests, t-tests, and Pearson’s correlation analysis between clinical and immunological parameters. Leukocyte and neutrophil increase, T-cell depletion with prevalence of memory T-cell compartment, NK and B-naïve subset elevation with memory and CD21low B subset reduction, and IgG expansion, significantly distinguished the SCD HU− subgroup from controls, with naïve T cells, switched-memory B cells and IgG maintaining differences between the SCD HU+ group and controls (p-value of <0.05). The mean CD4+ central-memory T-cell% count was the single independent variable showing a positive correlation with vaso-occlusive crisis score in the SCD group (Pearson’s R = 0.039). We report preliminary data assessing plausible clinical implications of baseline and HU-related SCD immunophenotypical alterations, which need to be validated in larger samples, but potentially affecting hypo-/a-splenism immuno-chemoprophylactic recommendations.

Automated Microfluidic System with Active Mixing Enables Rapid Analysis of Biomarkers in 5 μL of Whole Blood

We developed a microfluidic device for the rapid analysis of biomarkers in small volumes of whole blood. This device includes an onboard plasma separation module connected to a downstream bioanalysis module in which plasma mixes with reagents and the results of a colorimetric assay are recorded. Actuation of onboard microvalves within a bioanalysis module creates active mixing conditions that allowed us to achieve solution homogeneity within 5 min. To demonstrate utility, we carried out glucose detection in our device. With 5 μL of whole blood as an input, our microfluidic device enabled a time-to-answer of 10 min with a limit of detection of 0.21 ± 0.04 mM for glucose. This device has immediate applications for rapid and sensitive monitoring of hypoglycemia at the point of care (POC). Furthermore, our automated microfluidic device represents a platform technology that may be used to detect other biomarkers in whole blood.

Evaluation of immature granulocyte parameters in myeloid neoplasms assayed by Sysmex XN hematology analyzer

Immature granulocytes (IGs) have significance for the diagnosis of myeloid neoplasms (MNs). The current study aims to use a hematology analyzer to evaluate the accuracy of IG parameters in MNs. Blood specimens from 388 patients with MN, 524 with non-hematological neoplasms (non-HNs), including 109 patients with inflammation and 68 undergoing G-CSF administration, and 500 healthy control subjects were analyzed. IG parameters was assayed by Sysmex XN-9000 (XN) and compared with manual assessments. A high level of agreement between IG% derived from XN and manual measurements for MN patients (r = 0.828, p < 0.0001) was revealed but only a moderate correlation for acute myeloid leukemia patients (AML; r = 0.597; p < 0.0001). Bland-Altman bias analysis was conducted, and the results showed that differences in IG% from XN and manual analysis for MN patients were considered clinically insignificant. ROC analysis demonstrated a good performance of IG# (AUC = 0.842) and IG% (AUC = 0.885) assessed by XN for MN patients with cut-off values of 0.200 × 109/L and 1.95%, respectively. IG parameters from Sysmex XN analyzer are helpful for screening of MNs even though granulocyte morphological abnormalities may interfere with IG parameter accuracy.

Interchangeability of multiple Sysmex XN10 and XN20 modules for six types of leukocytes

INTRODUCTION

Differential counts of leukocytes are frequent, and often several automated blood cell counters are needed in contemporary laboratories. However, these modules are often individually quality assured. Our aim was therefore to validate the interchangeability of five hematology modules in a large modern laboratory and to compare them with our gold standard (GS) manual white blood cell differential count.

METHODS

At Copenhagen University Hospital, we compared five Sysmex XN-modules for neutrophils, lymphocytes, monocytes, eosinophils, basophils, and immature granulocytes (IG). We analyzed control samples in three levels to evaluate intra- and intermodular precision. Bias between modules was evaluated by analyzing 93 random patient samples within reference intervals. XN-modules' mean counts were compared with GS.

RESULTS

We found acceptable intramodular CV% (0.92%-8.76%), only neutrophils and eosinophils exceeded state-of-the-art imprecision or desirable specifications for medium control levels. Intermodular CV% showed significance difference for only monocytes (ANOVA, P < .0001). For patient samples, there were significant differences between XN-modules regarding four WBC types (ANOVA); however, proportional bias ranged from 1.7% to 3.8%, being within desirable specifications except basophils and IG (bias = 13.3% and 24.9%, respectively). Comparisons with GS, XN-modules exceeded desirable bias for basophils (lower than GS); monocytes and IG (higher than GS).

CONCLUSION

This multimodule comparison shows acceptable intermodular imprecision and bias for clinical purposes, which is important for patient safety. Similar multimodule study should be performed with samples out of reference range in large-scale laboratories to confirm the interchangeability.

Evaluation of the New Beckmann Coulter Analyzer DxH 900 Compared to Sysmex XN20: Analytical Performance and Flagging Efficiency

Efficiency and accuracy in automated hematology analyzers are very important for clinical laboratories. The purpose was to evaluate the flags and results reported by the newest Beckman Coulter analyzer DxH 900 compared to the Sysmex XN20 system. Samples were analyzed on the XN20 (Sysmex, Kobe, Japan) and on the Beckman Coulter DxH 900 (Beckman Coulter, Miami, Florida, USA). Slide reviews were performed microscopically. Morphologic criteria were used to identify abnormal cells as recommended by International Consensus Group for Hematology (ICSH): blasts, immature granulocytes (IG%), abnormal lymphocytes (ALs) and plasma cells. Results: there was a strong correlation between the analyzers in almost all clinical parameters tested. Both DxH 900 and XN20 showed an excellent degree of association for the leukocyte differential compared to the reference method (manual microscopy). When it comes to IG%, XN20 showed a positive bias for higher results. Related to platelets, there are no differences between the two methods for PLT count. For mean platelet volume (MPV), DxH 900 provided 100% results of the samples analyzed while XN20 while in the XN20 analyzer, 16% of the results were missing. From our results we came to the conclusion that both analyzers, DxH 900 and XN20 were clinically accurate and efficient. Abnormal Lymphocyte detection highlighted the differences between the two technologies as only minimal agreement was obtained. DxH 900 demonstrated higher sensitivity in detecting IG with good correlation with microscopic review. The DxH 900 for platelet clumps identification provides an excellent flag (PLT Clumps) with the highest sensitivity observed in our evaluation.

Evaluation of automated hematology analyzer DYMIND DH76 compared to SYSMEX XN 1000 system

Background

DYMIND DH76 (DYMIND BIOTECH, China) is a new automated hematology system designed to provide CBC count, including a 5-part WBC differential count, and its analytical performance should be assessed before adoption for clinical use.

Methods

The analyzer was evaluated according to the International Council for Standardization in Haematology guideline. The purposes of this study were to assess its analytical performance in comparison to SYSMEX XN 1000 hematology analyzer currently used in our laboratory, as well as to compare the automated and manual WBC differential.

Results

Within-run precision in all concentration ranges was very good with coefficients of variation (CVs) between 0.02% and 2.5% except for platelets over 500×109/L (CV 9.5%). Within-batch imprecision showed CVs lower the declared deviation ranges. Accuracy (defined as trueness) was excellent for all CBC and white cell differential parameters, compared with the state of the art%. Linearity was confirmed with excellent regression coefficients (0.999-1.000), even in the lowest values, and carryover was ≤ 1%. Comparison between DYMIND DH76 and SYSMEX XN 1000 was also very good with correlation coefficients (R2) for WBC (1.000), RBC (0.999), hemoglobin (0.999) and PLT over 50×10⁹/L (0.994) and R2 was lower but still acceptable (0.910) for PLT<50×10⁹/L. R2 for neutrophils, lymphocytes, eosinophils, basophils, and monocytes were 0.974, 0.982, 0.957, 0.625, and 0.836, respectively, in the comparison between the manual and DYMIND DH76 automated differential WBC counts.

Conclusions

With excellent analytical performance and acceptable comparative analysis, DYMIND DH76 hematology analyser covered the predefined international standards and requirements and is fully appropriate for clinical application.

A sample-preparation-free, automated, sample-to-answer system for cell counting in human body fluids

While many clinical laboratory tests are now highly automated, body fluid cell counting, particularly in low-cellularity samples such as cerebral spinal fluid (CSF), is often performed manually. Here, we report a simple, cost-effective method to obtain white and red blood cell counts from human body fluids such as CSF. The method consists of a compact, automated, and low-cost fluorescence microscope system, coupled to a sample chamber containing all of the necessary reagents in dry form to stain and prepare the sample. Sample focus and scanning are handled automatically, and the acquired multimodal images are automatically analyzed to extract cell counts. Comparison with manual counting on over 200 clinical samples shows excellent agreement. As the system counts a substantially larger image region than a standard manual cell count, we find our sensitivity to extremely low cellularity samples to potentially be higher than the manual gold standard, evidenced by our system recording images of cells in samples whose cell count was registered as "0" by a trained user. Thus, our system holds promise for routine, automated, and sensitive analysis of body fluids whose cellularity extends across a wide dynamic range.

Pseudothrombocytosis in a Case of Beta-thalassaemia Intermedia Masquerading as Myeloproliferative Neoplasm

Finding of spurious thrombocytopenia is a common occurrence in clinical practice whereas pseudothrombocytosis is very uncommon event. Despite several technical advancements in automated haematology analysers, a careful peripheral smear examination remains standard examination in cases of discrepancy of platelet counts. We are presenting a case of beta thalassaemia intermedia who had pseudothrombocytosis, which was falsely labelled as myeloproliferative neoplasm before the patient visited our haematology clinic.

Performance evaluation of the new hematology analyzer UniCel DxH 900

INTRODUCTION

UniCel DxH900 (Beckman Coulter, Miami, Florida, USA) is a quantitative, multi-parameter, automated hematology analyzer for in vitro diagnostic use in clinical laboratories. The aim of this study was to evaluate the analytical performance of the new DxH900 analyzer to verify its diagnostic and clinical utility in the hematology laboratory of a tertiary care hospital in Spain. The most important and novel feature offered by DxH900 analyzer is providing MDW (monocyte distribution width), a new hematologic parameter which is being clinically validated as an early sepsis indicator with promising results.

METHODS

We evaluated imprecision (including MDW), linearity, and carryover of DxH900. Method comparison for cell blood count (CBC) was performed in relation to DxH800 with 100 samples. We compared leukocyte differential (DIFF) from DxH900 with manual 400-cell differential. 390 samples were assessed for flag performance.

RESULTS

Results obtained for between days and within-run imprecision were good. DxH900 showed excellent linearity (R = 1.00) over analytical range for white blood cells, red blood cells, hemoglobin, platelets, and reticulocyte count (RET) (R = 0.96) and no significant carryover effect. CBC and RET on the DxH900 correlated well with DxH800 (R ≥ 0.99). Comparison with manual differential showed excellent correlation (R ≥ 0.88), except for basophils. Flagging performance exhibited sensitivity over 90% for majority of alarm messages and very high negative predictive value (over 95%).

CONCLUSION

UniCel DxH900 Coulter analyzer provides reliable results and fully comparable to DxH800. DxH900 is an accurate, highly precise analyzer with good analytical performances to be used effectively in high-volume laboratories.

Basophil counting in hematology analyzers: time to discontinue?

Basophils (basophilic granulocytes) are the least abundant cells in blood. Nowadays, basophils are included in the complete blood count performed by hematology analyzers and therefore reported in practically all patients in whom hematologic investigations are requested. However, hematology analyzers are not reliable enough to report clinically useful results. This is due to a combination of very high analytical imprecision and poor specificity, because the chemical and physical methods used for basophil counting in hematology analyzers are ill-defined and thus basophils are not well recognized by the analyzers. As a result, false basophil counts are quite common. In view of increasing analytical performance demands, hematology laboratories should stop reporting basophil counts produced by hematology analyzers. Suggestions for alternative pathways are presented for those situations where basophils are of clinical relevance.

Short-term biological variation of differential count in healthy subjects in a South Asian population

Estimates of Within-Subject and between subject biological variation for the white blood cell differential count (DC) have not been reported in South Asia. Therefore, we attempted to measure the short-term biological variation estimates for DC. The study was conducted on 28 healthy volunteers (15 males and 13 females). Blood from the volunteers was collected in the morning in K3-EDTA vials and analyzed in triplicate on the Sysmex XN-1000 analyzer, for six consecutive days. The Within subject, between subject and analytical coefficient of variation of the DC was calculated from the results by nested repeated measures ANOVA after outlier exclusion. The Reference change values (RCV) were also calculated. The within-subject variation for eosinophil Count and between subject variation for basophils in our study from South Asia was greater than the published European and American studies. Males and females showed similar biological variation for DC. The within-subject variation of other parameters (Neutrophils, Lymphocytes, Monocytes and Basophils) were similar or showed only mild differences to the published studies. The markedly different within-subject variation for Eosinophil counts suggest that the RCV for DC in South Asians need to be different from the published data in order to have clinical relevance. The Within-subject variation values of the other parameters seem transportable from the published European and American studies, but the small differences found mean that further regional estimates need to be reported for robust evidence of the same.

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.

The Sysmex XN-L (XN-350) hematology analyzer offers a compact solution for laboratories in niche diagnostics

INTRODUCTION

In 2015, Sysmex launched a new series of hematology analyzers (XN-L Series) designed to fulfill the needs of niche laboratories in areas such as pediatrics, dialysis, neurology, and oncology while providing a compact solution. In this study, we evaluate the whole blood and body fluid modes of one of these analyzers, the XN-350.

METHODS

A total of 300 residual EDTA samples were measured on the XN-350 in whole blood mode and the XN-1000 to evaluate method comparison, flagging sensitivity, repeatability, reproducibility, linearity, carryover, and stability. In addition, 191 samples were obtained and processed in body fluid mode which included, cerebrospinal fluid (CSF), continuous ambulatory peritoneal dialysis (CAPD), ascites, synovial, and pleural fluid to perform method comparison, repeatability, reproducibility, linearity, limit of quantitation, and carryover studies.

RESULTS

Strong agreement was shown between the XN-350 and XN-1000 for both whole blood and body fluid modes in results and flagging. Linearity results in both modes on the XN-350 showed a high R² value (>.99). For WBC, RBC, HGB, and PLT, the carryover results were well within the predetermined criteria of ≤0.5% for whole blood and ≤0.3% for CSF. Repeatability and reproducibility were acceptable for both modes, and there were no significant deviations present in stability for whole blood. In addition, there was high agreement in all body fluid types evaluated.

CONCLUSION

The performance of the XN-350 is comparable to the XN-1000 in both whole blood and body fluid modes, making it a reliable alternative to larger analyzers for smaller, niche laboratories.

Influence of different methods and anticoagulants on platelet parameter measurement

Platelets are the smallest and perhaps the most versatile components of human blood. Besides their role in coagulation and the maintenance of vascular integrity, they are involved in many physiological processes, ranging from immune response and leukocyte recruitment to the production of antimicrobial peptides and immune-suppressive factors like TGF-β. These versatile abilities make platelets interesting for researchers from different disciplines. However, beside profound investigation into platelets’ physiological role, there is a need for correct, standardized and thus reproducible quantification of platelet parameters. Mean platelet volume (MPV) is a widespread prognostic marker for several conditions, such as, acute coronary syndrome, chronic kidney disease and liver cirrhosis. Platelet activation is regarded as a marker for inflammatory processes, for example in autoimmune diseases such as type-1 diabetes, systemic lupus erythematosus and rheumatoid arthritis. The monitoring of platelet function is relevant for patients receiving antiplatelet medication. Platelet parameter measurement is affected by the choice of in vitro anticoagulant, the measurement technology and the time delay after sampling. This review focuses on the pre-analytical variability that arises as a result of the use of different in vitro anticoagulants and analyzer technologies when determining platelet parameters, since, even approximately 180 years after the discovery of platelets, there is still no standardized procedure.

Preliminary assessment of the new Sysmex XN parameter Iron-Def for identifying iron deficiency

BACKGROUND

Although the clinical assessment of iron status is usually based on iron stores, a rapid and accurate diagnosis of iron deficiency is challenging since ferritin is often unavailable as an urgent test and its value is frequently increased in acute phase conditions. This study was therefore aimed at evaluating the diagnostic performance of the new Sysmex XN "Iron Deficiency?" (Iron-Def) parameter for identifying patients with iron deficiency.

MATERIALS AND METHODS

The study population consisted of 688 consecutive patients (median age: 71 years; 341 women and 347 men), referred for routine diagnostics to the Laboratory of Clinical Pathology of Lecco Hospital, Italy. A complete clinical chemistry profile and haematological testing were performed for identifying iron deficiency anaemia.

RESULTS

A significant negative correlation was found between Sysmex XN Iron-Def and ferritin, serum iron, mean cell haemoglobin concentration, mean cell haemoglobin, mean corpuscular volume and age, while a positive correlation was noted with transferrin, percentage of microcytic red cell, red blood cell count and red blood cell distribution width. The diagnostic accuracy of Iron-Def for identifying patients with a percentage of saturation of transferrin <15% (n=104) was 84%, with a sensitivity of 0.952 and specificity of 0.538. A sub-analysis of 71 patients with ferritin <20 ng/dL yielded an even better diagnostic performance (86%, with a sensitivity of 0.935 and specificity of 0.620).

DISCUSSION

Although additional confirmatory investigations would be needed, the preliminary findings of our study attest that Iron-Def may be an easy, inexpensive, rapid and reliable parameter for screening iron deficiency anaemia.

Performance of the Sysmex White Precursor Channel to discover circulating leukemic blast cells

INTRODUCTION

Circulating immature precursor cells indicate malignant diseases like acute myeloid or lymphoid leukemia, and blast cells are key finds for disease management. Automatized cell counters are an essential contemporary appliance for blast detection, but false-positive samples remain challenging in terms of time and resources. To reduce this issue, the White Precursor Channel (WPC) was introduced to Sysmex XN series; however, sensitivity may reduce when accommodating low specificity. Therefore, our aim was to evaluate WPC blast alarm flag performance with regard to detecting blast cells.

METHODS

At two major Danish hospitals, random blood samples were collected from the routine setting   in a four-week period and analyzed on WPC XN20 (Sysmex, Japan). Results were compared with manual differential white blood cell count (Manual WBCC) assisted by CellaVisionDM96.

RESULTS

In 117 samples, we found 0.2 to 34.4% blasts, WPC blast flag specificity = 82% and a low sensitivity = 40%. However, other XN alarm flags forwarded samples to Manual WBCC, so blast cells were detected despite missing a specific blast flag: With all alarm flags, combined sensitivity increased to 88%. Overall, the WPC application stopped 18% of the 117 samples going to Manual WBCC (three false negatives). Q values are arbitrary probability measurements for the blast flag, and in five samples (0.5 to 47.3% blasts) imprecision ranged from 5.3 to 122 CV%.

CONCLUSIONS

WPC blast alarm flags are imprecise and inaccurate, especially when blast counts are low. However, the XN20 will alarm samples with other flags so that most samples containing blast cells will be manually reviewed after all. Hence, the presented flag types should not bias the decisions of manual reviewers.

Reticulated platelets – clinical application and future perspectives

Reticulated platelets are immature platelets freshly released from the bone marrow into the circulation and contain vestigial amounts of ribonucleic acid. Thus, they can serve as an indicator for the activity of thrombopoiesis. Despite the current lack of a standardized reference method, two types of hematology analyzers have incorporated a fully automated measurement of reticulated platelets. The “immature platelet fraction” (IPF; Sysmex XE-/XN-series) has some clinical utility in the differential diagnosis of thrombocytopenia. This is less clear for “reticulated platelets” (retPLT; Abbott CELL-DYN Sapphire/Alinity HQ). The usefulness of these parameters in the prediction of platelet recovery after chemotherapy or stem cell transplantation and as a decision aid for platelet transfusions has not been unequivocally confirmed. Recent findings have shown an association of reticulated platelets with an adverse risk in patients with coronary artery disease and stroke as well as resistance to anti-platelet therapy. Furthermore, a role of reticulated platelets for the prediction of sepsis was indicated. However, validation in larger prospective trials is necessary to establish the clinical benefit of reticulated platelets in these conditions. This review gives an overview of the available analytical methods and summarizes the current knowledge regarding the clinical application of reticulated platelets.

Immature platelet fraction related parameters in the differential diagnosis of thrombocytopenia

The pathogenesis of thrombocytopenia can be divided into increased destruction (ID) of platelets in the peripheral blood and decreased production (DP) of platelets in the bone marrow. This study aimed to analyze the efficacy of immature platelet fraction (IPF) related parameters, including the IPF count (IPF#), IPF percentage (IPF%) and highly fluorescence IPF percentage (H-IPF%), measured by XN-9000, in the differential diagnosis of thrombocytopenia. One hundred and twenty healthy volunteers were enrolled in the healthy control (HC) group, and 180 thrombocytopenia patients were grouped into either the increased destruction (ID) group or the decreased production (DP) group according to their final diagnosis. IPF# was significantly lower in the DP group than in the ID and HC groups (P < .01). Among the three groups, the ID group had the highest IPF% and H-IPF%, and the HC group had the lowest IPF% and H-IPF%. The differences between the three groups were all statistically significant (P < .01). In differentiating the ID patients from the DP patients, the areas under the operating characteristics curve of IPF#, IPF% and H-IPF% were 0.859, 0.944 and 0.930, respectively. False positive rates were below 0.04 when IPF#, IPF% and H-IPF% were above 2.65, 7.55 and 2.35, respectively. IPF related parameters showed high efficacy in the differential diagnosis of thrombocytopenia. However, due to the small numerical values of the IPF related parameters in some thrombocytopenia patients, the fluctuations of IPF% and H-IPF% should also be taken into consideration. Though H-IPF% is a new parameter, its effectiveness in the differential diagnosis of thrombocytopenia is not better than IPF%'s.

A novel automated image analysis system using deep convolutional neural networks can assist to differentiate MDS and AA

Detection of dysmorphic cells in peripheral blood (PB) smears is essential in diagnostic screening of hematological diseases. Myelodysplastic syndromes (MDS) are hematopoietic neoplasms characterized by dysplastic and ineffective hematopoiesis, which diagnosis is mainly based on morphological findings of PB and bone marrow. We developed an automated diagnostic support system of MDS by combining an automated blood cell image-recognition system using a deep learning system (DLS) powered by convolutional neural networks (CNNs) with a decision-making system using extreme gradient boosting (XGBoost). The DLS of blood cell image-recognition has been trained using datasets consisting of 695,030 blood cell images taken from 3,261 PB smears including hematopoietic malignancies. The DLS simultaneously classified 17 blood cell types and 97 morphological features of such cells with >93.5% sensitivity and >96.0% specificity. The automated MDS diagnostic system successfully differentiated MDS from aplastic anemia (AA) with high accuracy; 96.2% of sensitivity and 100% of specificity (AUC 0.990). This is the first CNN-based automated initial diagnostic system for MDS using PB smears, which is applicable to develop new automated diagnostic systems for various hematological disorders.

Influence of ferritin levels and inflammatory markers on HbA1c in the Type 2 Diabetes mellitus patients

Objective:

Diabetes Mellitus (DM) is a significant public health issue worldwide due to the associated comorbidities. Recent studies have demonstrated a strong relationship between blood glucose levels and serum ferritin levels in patients with type 2 DM. The aim of the study was to investigate the association between Ferritin Levels and Inflammatory Markers on HbA1c in the Type 2 Diabetes Mellitus Patients.

Methods:

This single-center, cross-sectional, controlled study included patients who were admitted to the Endocrine and Metabolic Disorders outpatient clinics of the Private Kütahya Hospital in the province of Kutahya in the Western Turkey. The study included a total of 172 patients, 84 of whom had type 2 DM and 88 without diabetes and constituted the control group. A total of 190 patients with DM were admitted to the Adult Endocrine and Metabolic Diseases Outpatient Clinics of the hospital between July 1, 2018 and September 1, 2018, and among these, the study was conducted on 172 volunteer patients who met the study inclusion criteria and who did not have any missing data. The HbA1c levels, serum ferritin, hemoglobin (Hb), insulin, Homeostatic Model Assessment of Insulin Resistance (HOMA-IR), C-Reactive Protein (CRP), lipid profiles, and uric acid levels were compared between the groups.

Results:

The serum ferritin levels of the patients with type 2 DM significantly increased with increasing HbA1c levels (p<0.01). A strong positive correlation was found between serum ferritin levels and HbA1c and fasting blood glucose (FBG) levels (p<0.01).

Conclusions:

Our study results show a significant relationship between HbA1c levels and serum ferritin and CRP levels, suggesting that serum ferritin and CRP levels can be used as a routine screening tool for the early diagnosis of DM. However, further large-scale, prospective studies are needed to confirm these findings.

Atypical lymphocyte count correlates with the severity of dengue infection

INTRODUCTION

The early identification of patients at risk of severe dengue infection (DI) is critical to guide clinical management. There is currently no validated laboratory test which can predict severe complications of DI. The Atypical lymphocyte count (ALC) is a research parameter generated at no extra cost when an automated Full Blood Count (FBC) is performed. The purpose of this study was to assess the association of ALC with the severity of DI.

METHODS

We prospectively collected data on patients admitted to Nawaloka Hospital Sri Lanka (NH) with DI between December 2016 and November 2017. DI was diagnosed based on a positive Non-structural antigen 1 (NS1) or dengue IgM antibody. ALC (absolute ALC and percentage) data were extracted from the Sysmex XS500i automated full blood count (FBC) analyzer (Sysmex Corporation Kobe, Japan). Clinical data was recorded from medical records and the computerized data base maintained by NH.

RESULTS

530 patients were enrolled. Patients with clinical manifestations of severe dengue have a significantly higher AL % compared to dengue without warning signs. Patients who presented with respiratory compromise had statistically significantly higher AL% compared to those without. (AL%; 8.65±12.09 vs 2.17±4.25 [p = 0.01]). Similarly, patients who developed hypotension had higher AL% compared to those who did not suffered from shock (AL%; 8.40±1.26 vs 2.18±4.25 [p = 0.001]). The AL% of dengue patients presenting with bleeding, at 4.07%, is also higher than those without bleeding complications, at 2.15%. There was a significant negative association between platelet count and AL% (p = 0.04).

CONCLUSIONS

Clinical manifestations of severe dengue have a significantly higher AL % compared to dengue without warning signs. AL % at presentation may be predictive of severe DI and future larger prospective longitudinal studies should be done to determine if AL % on admission is predictive of the complications of DI.

Monocytes-neutrophils-ratio as predictive marker for failure of first induction therapy in AML

INTRODUCTION

Acute myeloid leukemia (AML) is, if untreated, a fatal hematologic neoplasia. Failure of the first induction chemotherapy is a hallmark for a poor prognosis. Early recognition of therapy failure is crucial for planning further therapies. Therefore, international guidelines recommend a bone marrow biopsy around day 14 after the beginning of induction therapy. Hypocellular bone marrow on day 14 is still gold standard for therapy assessment and further therapy strategy. Despite this, non-invasive ways for the evaluation of induction therapy were looked for in the past years.

METHODS

We collected peripheral blood cell counts and routine laboratory values of patients treated with "7 + 3" induction therapy. Ratios of absolute cell counts of monocytes and neutrophils (MNR) were calculated daily, and the values were compared in patients with failure of the first induction therapy and patients with therapy response.

RESULTS

54 patients were included, 12 of which had failure of first induction therapy. The MNR following therapy was highly correlated with the bone marrow results. With the right cut-off, the MNR provides a valid and reliable tool for identification of patients with failure of first induction therapy with a sensitivity of 83.3% and a specificity of 87.8% on day 18.

CONCLUSIONS

We propose a novel and non-invasive method for detection of failure of first induction therapy in patients with de novo AML and "7 + 3" induction therapy. The MNR is free of cost since the required cell counts are performed routinely for each patient undergoing intensive chemotherapy.

Performance evaluation of the white cell precursor channel on the Sysmex XN hematology analyzer in HIV specimens

BACKGROUND

Automated hematology analyzers generate white blood cell (WBC) suspect flags to indicate smears requiring manual review. In a human immunodeficiency virus (HIV) patient population with a high frequency of abnormal specimens, the usefulness of these flags depends on their sensitivity and specificity. The white cell precursor (WPC) channel on the Sysmex XN-9000 analyzer (Sysmex Corporation, Kobe, Japan) has recently been introduced in order to distinguish immature cells such as blasts and abnormal lymphocytes.

METHODS

The efficiency of the flags generated by WPC reflex testing was compared to the white cell differential (WDF) on the Sysmex XN-9000 in 400 routine HIV samples.

RESULTS

A flag was generated by the WDF channel in 346 (86.50%) samples. Addition of the WPC to the WDF resulted in a 20.99% reduction in the smear review rate. WPC analysis correctly identified the initial WDF flag in 59 (60.82%) samples with 'blasts?' or 'abnormal lympho?' flags. WPC showed an excellent sensitivity of 100%. However, the specificity remained poor. On investigation, samples with chronic infection/inflammation (35.00%) and lymphopenia (63.25%) were associated with a high false positive rate of 76.32% and 55.56%, respectively. WPC analysis removed 45 (51.72%) coexisting 'atypical lympho?' false positive WDF flags. The 'atypical lympho?' flag showed an increased sensitivity and specificity of 88.46% and 74.67%, respectively.

CONCLUSION

White cell precursor reflex testing showed improved flagging efficiency for the 'atypical lympho?' flag, which was a good indicator of reactive lymphocytes during chronic infection/inflammation. Nevertheless, the false positive rate for 'abnormal lympho/blasts?' was high in the presence of lymphopenia and infection.

Evaluation of the Flagging Performance of the Hematology Analyzer Sysmex XN Series on the Basis of “Q Values”

Context.—

In the XN series of hematology analyzers (Sysmex, Kobe, Japan), the probability of the presence of abnormal cells is indicated by flags based on Q values.

Objective.—

To evaluate the Q value performance of the Sysmex XN-20 modular analyzer.

Design.—

The interinstrumental concordance, intrainstrumental precision, and diagnostic accuracy of Q values, with tested flags of “blasts/abnormal lymphocytes,” “atypical lymphocytes,” and “blasts,” were investigated.

Results.—

Absolute concordance rates in flagging between 2 analyzers ranged from 69.8% to 80.8%, and κ values ranged from 0.43 to 0.61. In samples with absolute related cell counts lower than 100/μL, the values ranged from 0.31 to 0.52. For intrainstrumental precision, standard deviations ranged from 4.8 to 23.9 for the blasts/abnormal lymphocytes, from 18.7 to 59.1 for the blasts, and from 11.0 to 23.0 for the atypical lymphocytes. Using a default Q value cutoff, diagnostic accuracy values based on the area under the curve, sensitivity, and specificity were, respectively, 0.910, 90.9%, and 72.2% for blasts/abnormal lymphocytes; 0.927, 84.9%, and 89.8% for blasts; and 0.865, 74.4%, and 84.9% for atypical lymphocytes. The diagnostic accuracy of Q values was much lower in samples with absolute related cell counts lower than 100/μL than in those 100/μL or higher.

Conclusions.—

Q values of the Sysmex XN-20 analyzer were found to be imprecise and irreproducible, especially with samples containing a small number of pathologic cells. Adjustments in the Q value threshold may help in the detection of these cells.

Evaluation of Sysmex XN-1000 hematology analyzer for cell count and screening of malignant cells of serous cavity effusion

Over the years, with the advancement in hematology analyzer technology, the use of fluid analysis method has seen a drastic increase in clinical examinations. Cell counting and classification in independent body fluid analysis method are conducted by semiconductor laser flow cytometry and nucleic acid fluorescence staining techniques. This study is to evaluate the efficacy of Sysmex XN-1000 hematology analyzer in cell counting and to screen malignant cells with serous cavity effusion. Specimens (N = 206) with serous cavity effusion from our hospital were included in this study. Manual and instrumental methods for cell counting, nucleated cell classification, and high-fluorescent cells (HFC) were used in this study. The correlation between RBC, nucleated cell count (NUC), the percentages of polymorphonuclear cell (PMN%), and mononuclear cells (MN%) was statistically analyzed using manual and instrumental methods. The regression equations of RBC, NUC, PMN%, and MN% in the manual and instrumental methods were RBC y = 0.88x + 426.4; NUC y = 0.85x + 33.4; PMN% y = 0.91x + 4.2; and MN% y = 0.91x + 5.1. Correlation coefficient R was 0.99, 0.98, 0.90, and 0.90 (P < .001). ROC curve analysis showed that when the cut-off value of HFC% was 4.4% and HFC# was 24.5/μL, area under curve (AUC), sensitivity, specificity, and 95% confidence interval were 0.707, 0.792, 0.558, 0.637-0.777; 0.708, 0.753, 0.550, 0.635-0.780, respectively. XN-1000 hematology analyzer body fluid method can accurately and rapidly count cell and nucleated cell classification with serous cavity effusion. HFC can indicate the possible existence of malignant cells; however, further investigations are required to validate its efficacy.

Investigation of morphological changes for the discrimination of nucleated red blood cells and other leukocytes in Sysmex XN hematology analyzer scattergrams using transmission electron microscopy

Background

The WNR channel of the XN-Series automated hematology analyzer (Sysmex) counts white blood cells (WBCs) and simultaneously performs a differential counting of basophils and nucleated red blood cells (NRBCs). The detection process involves exposing the cells to WNR-specific reagents containing an acidic detergent and a fluorescent dye and measuring the intensity of the forward scattered light (FSC) and side fluorescence light (SFL).

Method

We treated isolated peripheral WBCs and NRBCs with specific reagents and assessed the morphological changes in NRBCs and each leukocyte type using transmission electron microscopy (TEM).

Results

The results from a flow cytometer (FCM) showed that, after exposure to the reagents, basophils appeared on the highest FSC and SFL areas compared to other leukocytes on the WNR scattergram. Owing to the hemolysis of reticulocytes and erythrocytes, NRBCs that survived the reagent treatment could be distinguished by their lower intensity than those of the other leukocytes on the WNR scattergram. We investigated the significance of the relationship between the TEM and FCM results after the reagent treatment.

Conclusion

We confirmed that the WNR channel differentiates the blood cells on the WNR scattergram based on differences in the amount of residual cytoplasm and nucleic acids.

•

The WNR channel of the XN-Series counts WBCs and simultaneously performs a differential count of basophils and NRBCs.

•

Basophils had the highest scattered light and fluorescent intensities after WNR treatment on a flow cytometer scattergram.

•

NRBCs survived treatment with the WNR reagents had a lower intensity on the FCM scattergram than those of other leukocytes.

•

TEM revealed that the WNR channel can differentiate blood cells based on the amount of residual cytoplasm and nucleic acids.

Performance Evaluation of Automated Impedance and Optical Fluorescence Platelet Counts Compared With International Reference Method in Patients With Thalassemia

CONTEXT

- Spurious platelet counts from automated methods have been reported in patients with abnormal red blood cells. However, there is no specific study regarding performance of platelet counts by automated methods in patients with thalassemia.

OBJECTIVE

- To investigate the performance of automated platelet counts, including impedance (PLT-I) and optical fluorescent (PLT-O and PLT-F) methods, and compare them with the international reference method (IRM) for platelet counting in patients with thalassemia.

DESIGN

- Two hundred forty-nine thalassemia specimens from various subtypes were examined. PLT-I, PLT-O, and PLT-F from a Sysmex XN analyzer were evaluated and compared against the IRM. Demographic data, platelet counts, and red blood cell parameters are shown. Comparability between evaluated methods and IRM, as well as test characteristics, is presented. Factors involving inaccurate PLT-I were analyzed.

RESULTS

- Specimens with platelet counts ranging from 31 × 10³/μL to 932 × 10³/μL were included. Most patients were patients with thalassemia major. Correlation between PLT-I and IRM was lower than that of the other methods in overall patients. PLT-O and PLT-F were correlated to IRM when classifying patients according to clinically significant platelet ranges. All automated methods had acceptable sensitivities; however, specificity of PLT-I was low for diagnosis of thrombocytopenia. High RDW-CV (red blood cell distribution width-coefficient of variation) was an independent factor of inaccurate PLT-I measurement.

CONCLUSIONS

- Among the evaluated methods, PLT-I was the method least correlated to IRM, with PLT-O and PLT-F comparable to IRM in patients with thalassemia. Optical platelet counts and careful blood smear examination are recommended alternative platelet counting methods, depending on the clinical setting.