Alan Neal

Why not use an alternative methodology, i.e. a non-EDTA anticoagulant e.g. S-Monovette® ThromboExact tube*. Else, if using citrate tube, then take CBC at same time, then compare corrected RBC / Hb value on CBC, with corrected RBC / Hb on citrate tube. PS In my experience, many of the EDTA clumpers, also do the same in citrate - so blood film &/or analyzer flags important tools to ensure accurate platelet count provided. *If using this technique, then CBC analyser already calibrated etc, just need to verify performance of this collection tube.

We use a combination of CBC results, Plt count, ICT and DxH NRBC information to prioritise the review of malaria (Giemsa) blood film reviews (Morphologists not available 24/7). The DxH 800 NRBC plot can demonstrate the presence of malaria parasites, with a number of publications available. We have had limited experience (Have very few cases a year), but have found this additional tool useful.

Hi Why don't you try using the 1:5 dilution method on the DxH analyser - If WBC not to high, then both WBC interference with RBC count* & WBC turbidity with Hb measurement would be reduced / excluded. Also another question, if hyper leucocytosis, what so important about reporting the RBC & associated parameters? Surely WBC, Hb, Plts & WBC Diff the most important (this is what we do). *DxH software designed to minimise this effect, but I'm not convinced this very effective.

We have seen these in a number of very 'sick' patients - most recent case in a Gram Neg sepsis with DIC & 'bugs' in neutrophils! We do report with following comment - Neutrophils show green inclusions-indicates severe toxic state (& we would alert clinician).

We have seen this on a number of occasions - Usually a significant delta change MCV failure, with low MCHC. We don't do a correction, but make a comment: Note the discrepancy with previous MCV. Hyperglycaemia may interfere with RBC indices, esp. MCV. Suggest correlate with glucose levels

Agree - highly probably that the SD being used is not appropriate i.e. to large. Results should be distributed across the L-J chart, with approx. 1:20 results in the 2-3 SD space. Suggest review local and published SD for analytes

I'm currently trying to pull together some Paed Coag ranges for basic investigations - PT / INR, APTT, Fib + TCT. I have done a literature search and have a number of hits, but I also wondered if any local unpublished data available (Have info from Great Ormond St, London). Once data collated, I would be happy to share with all contributors. Many thanks Alan Neal NZ

A few comments: Beware of running strong Cold agg samples initially cold and the subsequently warm. Most Haematology analysers sample from the bottom of tube, with strong Cold Aggs (especially those anaemic) this may result in a significant volume of concentrated RBC's being removed from tube, when sample warmed and re-analysed then patient may become significantly more anaemic! (So we only allow 5 g/L difference between runs). We use Middleware rules to identify these known patients and prevent these samples to be run 'cold'. Why worry about not reporting RBC, MCV, MCH etc in this small set of patients, clinically they need accurate WBC / Diff, Hb & Plts. Beware of using warmed diluents, this will cause MCV shift (Dependant on analyser), so will need to validate procedure.

We use Mixrate 20 - semi-automatic system using dedicated ESR tubes (MONOSED), 30or 60 min ESR. System works well, relatively cheap to purchase, very few problems and easy to use. Other systems around - INVERSA, just seen evaluation data and in discussion with company MD, all previous system issues now addressed (Leaking seals). System mod to high capital cost with low to mod consumable costs. Cost per cycle more than the above, but much less hands on time. Other alternative use a ESR similar technology - Alifax TEST1 (RBC aggregation). Have used for many years, with no major analyser issues. In our hands correlation to ESR OK up to values of 40'ish. System easy to use, results in approx. 3-5 mins BUT need to understand limitations. Finally, why not additionally significantly reduce ESR volume - over used investigation with very limited value (See BPAC guidelines for Inflammatory response). If can reduce work load, then semi-automatic systems can easily support smaller workloads.

Hi Agree with other responses, need to find best fit for your lab. We have been using DxH 800 for almost two years, good performance, easy to use and more reliable than LH750's. If have small workload & perhaps also want backup then Beckman have recently released a new CBC analyser DxH 500 - CBC, Plts + 5 Pop Diff, from our limited experience looks like good instrument, with small sample volume. Initially wont have autoloader, but I believe this coming.

I would suggest read information about preacceptance testing. I would be VERY careful about the use of QC with every reagent change. My approach, if accreditated supplier with good history and performance, then I wouldn't amend QC frequency (Use internal tools xM & xB), unless reagent manufactured or criticial compenent i.e. Risk assessment. Suggest review: A review of current intervention guidelines, best practice guidelines and other relevant publications was performed, these included: JACHO – Quality system assessment for non-waived testing 20132CLIA – Brochure #4 2003, Facts 16E, 19CAP Standards: HEM 65850, 24575, 30070RCP(UK) 2005 – Code of practice haematology departments

We using Hurst Colour frost (very simular to BC, but much cheaper), good quality, very few breakages and little glass dust. Must avoid a few cheaper brands, thinner slides and more glass dust (We did use these of LH 750's & previously OK). Unlike Antie - we have good experience with 1601's (We have x 2) on outlet onshared Power express. Initial issue with timimg between DxH & SMS, now all resolved (Caused analyer to lock up). Re methanol, we use supply from commercial outlet (Provides methanol for car spraying, cleaning commercial world), cheap & works (Just need to get change frequency right - to ensure no water contamination). Just a few other tips - if using wright stain, we mature stain for 1 day off SMS (Fill bath and take /then leave off to evapour), also if using bath 4 for diluted stain, then using fill all baths command will result in only buffer placed into this bath (Get very poor stain) - so use diagnostics to fill bath 4 (Then OK).

Agree this practice has no value for MP's - havn't seen in any parctice guidelines. Only time used this techniques was for Microfilaria screening -but wouldnt do this routinely.

As above - we only release valid results to Clinicians - so any significantly abnormal (or flagged) WBC Diff is not released until manual review performed. If on manual review abnormal cells seen and previously WBC Diff released (No flags & within Technical limits), then we would amend report and ONLY report the manual WBC DIff.

WBC Differential /Band cell counts: Suggest review these publications: CAP survey 1995 Lab Hematol 1,89 - Inter and Intra observer consistency Eur J Haematol 2006:76: 251-254. Good article Re variation of WBC Diff with a number of morphologist review digital images ISLH recent publication June 2015: ICSH recommendations for the standardization of nomenclature and grading of peripheral blood cell morphological features - which recommends that band cells be counted with neutrophils (Also directs to an image library) I would question the value of this enumeration in the 21st cent., also consider the significant variation (LoU) of band cell counting.. Our local evaluation with digital images, gave a LoU of > 40% (Which is a good result!), hence we do not report bands cell counts, but will only make a comment.

We have been partialy validating / releasing results for many years. We automatically release all technically valid key parameters (WBC, Hb, MCV, RDW, Plts and WBC differential) and if not complete ly autovalidated, will review for Clinical review / commenting. We use Remisol, so have complete control over this process.

Suggest review recent BSCH Malaria parasite guideline,,also RCPA HAematology best practice guidleines. Essentially, we are compliant to these guidelines, in that we do: Malarial antigen screen Thick & thick films (Giesma stained), reviewed by two people. We only would consider refering positive cases ONLY, if difficult cases - images sent to CDC for confirmation (Now thinking about differentiation between Malariae and Knowlesi - may need to locate molecular technique & always notify clinicain if patient from area with Knowlesi & morphology Malariae like). Alan NZ

Hi We use a mixture of ACl 500 (x3), 700 LAS (x2) across 4 different locations and have recently validated the reference interval of new Lot No of Synthacil. We routinely will do min 20 normal samples each site, with collective group of 80+ pool of results (Aslo do heparin spiking each site, plus one site peform factor 8 & 9 sensitivity evaluation). We have found our reference range to be consistently 26 - 36 sec (& have not changed for the past 3 lot No's used) - very happy with Lot to Lot consistency for all aspects reviewed, We also initially did APTT V's anti-Xa assay results and information was very simular to IL information. Alan NZ

We use a product from sarstedt - see link below. http://www.medicalsearch.com.au/Blood-Collection-S-Monovette-ThromboExact-for-Pseudothrombocytopenia/p/69255 A limited validation has been done and we agree with product information. Hope this of help. Alan

I have never heard or used the votex method and would have concerns Re fragmentation of other blood cells giving rise to false platelet counts (As per previous comment). Re comment Re EDTA clumping phenomenon. We have recently reviewed the use of Amykacin to prevent this problem. We have used a commercial product and this seem to resolve the problem in the few cases to date (Out experience matches publications & product information). WE plan to use this methodology where platelet count is essential e.g. Chemotherapy patients, patients on warfarin or other situation where platelet estimate suggest platelet count redduced but unable to quantitfy.

Within NZ HAematology laboratory's we have an agreed standard on terminology and grading when reporting of Blood films- including grading of RBC morphology (Which is graded Increased or Marked Increased). If you would like a copy of information I can e-mail (or will locate web address when published). RE view rates (We are still fine tuning), within my lab approx. 1400 CBC's day, film review rate 6 % (of which approx 10 have manual differential - No diff available or immature cells >1%). We have fune tuned our system and utlise some research parameters to identify abnormal clusters (ing) of WBC information.