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Hematology Section - Final Draft
Hematology Section - Final Draft
1EMT - Group #4
Aquitania, Mary Christelle
Donato, Anna Katrina
Galope, Jerrica Charlene
Leachon, Sofia Marie
Manalastas, Keen
Mendoza, Jose Paulo
Nabong, Krizel Ann Therese
Samorano, Kathryn Chemaine
Whaley, Kristen Therese
September 2008
Table of Contents
I. Introduction .......................................................................................................................................... 3
II. Definition of Terms ............................................................................................................................... 4
III. Function of the Section ......................................................................................................................... 6
Laboratory Floor Plan of Hematology Section .......................................................................................... 7
IV. Lists of Tests .......................................................................................................................................... 8
1. Routine Tests..................................................................................................................................... 8
COMPLETE BLOOD COUNT (CBC) .................................................................................................. 8
About MANUAL DIFFERENTIAL COUNT ...................................................................................... 19
2. Special Tests .................................................................................................................................... 20
Prothombin Time (PT) ................................................................................................................. 20
Partial Thromboplastin Time (PTT) ............................................................................................. 20
Diascopy ...................................................................................................................................... 21
D-dimer ....................................................................................................................................... 21
V. Flow of Specimen ................................................................................................................................ 22
VI. Quality Assurance & Quality Control .................................................................................................. 23
VII. Updates & Automation ....................................................................................................................... 25
References ................................................................................................................................................. 27
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I. Introduction
Blood is the most important fluid in our body which is being pumped by the heart through a
network of arteries and veins. It transports nutrients and oxygen throughout our body, removes
waste materials such as carbon dioxide, urea and lactic acid, regulates pH and body temperature.
Furthermore, and provides immunological, messenger and hydraulic functions.
Hematology is a part of the clinical laboratory which studies the blood, blood-forming organs
and the diseases related to it. It is a unique subdivision of internal medicine. This department is both
completely different but at the same time actually overlapping with the subspecialty, medical
oncology. The study of etiology, diagnosis, treatment, prognosis, and prevention of blood diseases
are also included in this division.
The physicians assigned to this section of clinical laboratory are called hematologists. These
physicians are usually board-certified interns who have managed to complete additional years of
training in hematology. Their work basically includes caring and treating patients with hematological
diseases. They are the ones assigned to view blood films and bone marrow slides under the
microscope, and then interpret the various hematological test results.
There are also physicians that are referred to as hemapathologists. These are pathologists who
specialize in diagnosing diseases that are related to hematology. Almost similar to a hematologist,
they manage and work in the hematology laboratory. Both physicians work closely together in order
to draw out an accurate diagnosis and dispatch the most appropriate treatment or therapy required.
Figure 1 Complete Blood Count by a hematologist in East Avenue Hospital (From left to right)
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II. Definition of Terms
Page 4
19. Leukocytes – A type of Blood Cell that
defend the body against both infectious
disease and foreign material. Also known as
white blood cells.
20. Magtration – A simple, patented separation
method in which magnetic particles on the
inner wall of the pipette tip are washed and
separated.
21. Mean – It is the arithmetic average of a Figure 4 Spherocytes
group of data points.
22. Median – It is the middle value of a dataset.
23. Mode – It is the value occurring most frequently.
24. Precision – This relates to reproducibility and repeatability of test samples using the
same methodology.
25. PRP - A special blood concentrate known as platelet-rich plasma (PRP) that can promote
healing in different aspects of medical and surgical situations.
26. Reticulocytes – Immature red blood cells. These are non-nucleated and that contain
remnant RNA material, reticulum.
27. Rouleaux – The stacking up of red blood cells, caused by extra or abnormal proteins in
the blood that decrease the normal distance red cells maintain between each other.
28. Smear - A blood sample or specimen spread on a slide for microscopic examination or
on the surface of a culture medium
29. Spherocytes – A spherical red blood cell.
30. Thrombocytes – A small cytoplasmic bodies derived from cells. They circulate in the
blood of mammals and are involved in homeostasis. Also known as platelets.
31. Transudate – A fluid substance that has passed through a membrane or has been
extruded from a tissue; it is characterized by high fluidity and a low content of protein,
cells or solid matter derived from cells.
32. Trephine Biopsy – Removal of a small core of bone marrow under local anesthetic. It is
used to assess bone marrow structure, the number and distribution of all the blood cell
types.
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III. Function of the Section
The hematology section is a section of a clinical laboratory which applies molecular, cellular and
morphological techniques to the study of blood, blood-forming tissues, and blood diseases. This section
of the laboratory is particularly involved in areas such as hemostasis, thrombosis, metabolism, and
morphology, and concentrated on the study of blood coagulation, fibrinolysis and the use of hemostatic
tests as markers of diseases. It performs routine and special tests on blood such as complete blood
count (CBC), peripheral smear and malarial parasite examination, and tests for hemostasis and
coagulation studies. The section also performs cell counts and microscopic examination of cerebrospinal
fluid (CSF) and other body fluids. The Hematology section counts and differentiates the types of cells in
blood. Tests performed in this area are used to check for anemia, leukemia, mononucleosis and
indications of viral or bacterial infection. They also observe the cells in other body fluids, such as
synovial (joint) fluid or spinal fluid, examine bone marrow aspirations and perform semen analyses.
Figure 6 Hematology laboratory: Test result analyzing Figure 7 CBC test using hematology analyzer
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Laboratory Floor Plan of Hematology Section
Courtesy of East Avenue Medical Center
Page 7
IV. Lists of Tests
1. Routine Tests
This test is also known as Full Blood Count (FBC) and hemogram.
Page 8
Figure 10 White Blood Cell
Hemoglobin (Hgb) Measures the constituent Male: Diagnose for anemia (low
of iron-containing 13 – 18 gm/dL hemoglobin)
respiratory pigment in red 2.1 – 2.7 mmol/L[1]
blood cells of vertebrates, 132 – 162 g/L[2]
consisting of about 6 135 – 175 g/L[1]
percent heme and 94
percent globin. Female:
12 – 16 gm/dL
1.9 – 2.5 mmol/L[1]
120 – 160 g/L
Figure 11 Hemoglobin
Hematocrit (Hct) Measures how much space Male: Very useful in diagnose for
in the blood is occupied by 0.41 – 0.53 [1] anemia
red blood cells. 0 – 15 mm/hr
Female:
0.36 – 0.46 [1]
0 – 20 mm/hr
Child:
0.31 – 43 [2]
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Figure 12 Hematocrit of the Blood Sample
Mean Corpuscular The average volume of red Male: Detection in deficiency in
Volume (MCV) cells in erythrocyte indices, 82 – 102 fL vitamin B12
calculated from the Detecting
hematocrit and the red Female: hemochromatosis
blood cell count. 78 – 101 fL Useful diagnostic
haematological parameter
Normal RBC Indices for detection of α-
Value: thalassaemia at birth
80 – 96 fL
Page 10
Figure 13 Platelets in 100x magnification (pointed by the arrow)
Red blood cell Measure of the variation of 11.5 – 14.5 % Diagnose for anemia (low
Distribution Width red blood cell volume (coefficient of hemoglobin)
(RDW) variation)
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Figure 15 Reticulocyte in peripheral smear
Erythrocytes A nonspecific screening test Male: 1 - 13 mm/hr Used to assess blood
Sedimentation Rate indicative of inflammation content through blood
(ESR) which is used as an initial Female: 1 - 20 mm/hr sedimentation
screening tool and follow-
up test to monitor therapy Hemoglobin in
and progression or plasma:
remission of disease. This 0.16 – 0.62 μmol/L
test is reported in 1 – 4 mg/dL
millimeters.
Page 12
Figure 17 Rouleaux Formation of RBC
Any condition that will increase rouleaux formation will usually increase the
settling of red cells.
Bone Marrow This test refers to (refer to the Normal Range Used in the diagnosis a
Examination pathologic analysis of bone of the 9 Components of
number of conditions,
CBC)
(See image in Figure 19) marrow samples obtained including leukemia,
by trephine biopsy and anemia, multiple myeloma
bone marrow aspiration. It and pancytopenia
is sometimes necessary to
examine the source of
blood in the bone marrow
to obtain information about
hematopoiesis.
Page 13
Figure 19 Bone Marrow Examination
Table 2 Factors in Erythrocyte Sedimentation Rate, from Practice in Hematology by Ciesla, B., page 300-301
Factors Affecting ESR
Red cell shape and size: Specimens containing sickle cells, acanthocytes, or spherocytes will
settle slowly and give a decreased ESR
Plasma fibrinogen and globulin levels:
o Increased fibrinogen or globulin levels will cause increased settling and give an
increased ESR
Mechanical and technical conditions: Surfaces that are not level will influence red cell
settling. Specimens that are not properly anticoagulated will also affect red cell settling. EDTA
is the recommended anticoagulant.
Blood Fluid Cell A CSF cell count is a test to Normal white blood Increase of white blood cells
Count/Cerebrospinal measure the number of red cells: indicates infection,
Fluid Cell Count and white blood cells that 0 and 5. inflammation or bleeding into
(CSF) are in CSF. CSF is a clear the cerebrospinal fluid that
(See image in Figure 20) fluid that circulates in the Normal red blood cell may cause, such Abscess,
space surrounding the count: 0 Acute infection, Encephalitis,
spinal cord and brain.It is Hemorrhage, Meningitis,
used to evaluate body Multiple sclerosis, Stroke and
fluids, differential diagnosis Tumor.
of exudates and transudate. Red blood cells may indicate a
Cell counts and cell sign of bleeding
morphology (refer to Figure
14) are key elements in
identifying abnormalities
within each of these
systems.
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Figure 20 CSF (cerebrospinal fluid) is a clear fluid that circulates in the space surrounding the spinal cord and
brain.
Differential Count A test based on the 4.3-10.8 × 103/mm3 Differentiate the different
percentage of each variety types of leukocytes and
of leukocytes in the blood, infection involve due to
usually based on counting varied results
100 leukocytes. Also known Diagnose viral and
as leukocyte count. parasitological infection in
blood
(Refer to Table 4: Peripheral
Smear Preparation)
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Table 3 Leukocyte Count Identification
WBC Components
Type Assessment Normal Range Image
Neutrophils Can increase in response to Adults:
bacterial infection or 50% to 70%
inflammatory disease
Severe elevations in
Infants:
neutrophils may be caused
by various bone marrow 37% to 67%
disorders, such as chronic
myelogenous leukemia
Decreased neutrophil levels
may be the result of severe
infection or other conditions,
such as responses to various
medications, particularly
chemotherapy.
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Basophils Can increase in cases of Adults:
leukemia, chronic 0% to 2%
inflammation, the presence
of a hypersensitivity reaction
to food, or radiation therapy Infants:
0% to 2%
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Monocyte Can increase in response to Adults:
all kinds of infection as well 4% to 10%
as to inflammatory disorders
Increases in certain
malignant disorders, Infants:
including leukemia. 1% to 12%
Decreases monocyte levels
indicate bone marrow injury
or failure and some forms of
leukemia.
Note 1 Reference Range Based on Three Different Sources:
1. Last page of Deepak A. Rao; Le, Tao; Bhushan, Vikas (2007). First Aid for the USMLE Step 1 2008 (First Aid for the
Usmle Step 1). McGraw-Hill Medical. ISBN 0-07-149868-0.
2. Normal Reference Range Table from The University of Texas Southwestern Medical Center at Dallas. Used in
Interactive Case Study Companion to PATHOLOGIC BASIS of DISEASE.
Page 18
About MANUAL DIFFERENTIAL COUNT
When automated differentials do not meet specified criteria programmed into the automated
hematology instrument, the technologist/technician must perform a manual differential count from a
prepared smear. There are two types of blood smears: the wedge smear and the spun smear. Usually,
wedge smear is done because it is easy to prepare and more reliable in terms of cell counting. A good
counting area is an essential ingredient in a peripheral smear for evaluating the numbers of and types of
white cells present and evaluating red cell and platelet morphology.
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2. Special Tests
Table 5 Prothrombin Time extends time due to different factors listed below.
Table 6 Obtain information from Practice in Hematology by Ciesla, B., page 315
Page 20
Diascopy
Diascopy is a medical approach used to differentiate between certain types of hematologic lesions. This
is divided in two general types of hematologic lesions: Vascular and Non-vascular lesions. This test relies
on the principle, difference in which it entails through the use of a thin plate of transparent to depress a
hematologic lesion. If the lesion blanches and no longer appears with the same bloodlike color, the
lesion is deemed vascular, as the glass or plastic has effectively blocked the circulatory flow of or about
the lesion, causing a momentary ischemia or the lesion. If the lesion is non-vascular, pressing it with the
plate will merely press on the collection of blood, but the area will not blanch.
D-dimer
D-dimer is a performed test to diagnose thrombosis. Its primary objective is to exclude thromboembolic
disease where the probability is low. This use when there is a suspicion of deep venous thrombosis
(DVT) or pulmonary embolism (PE). In its range reference, values exceeding 250-500 ng/ml and above
are considered positive.
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V. Flow of Specimen
Blood samples undergo series of procedure that ensures the accuracy and precision of results. The
Hematology section follows standardization and quality assurance for a quality service. The figure below
shows a step-by-step method on how blood samples are process within the premises of the laboratory.
BLOOD SPECIMEN
taken from the
patient
Record
Label the test
information of
tube in Number
the patient
BLOOD
Reticulocyte
CSF Differential Count CBC
Count
Test is repeated
until it satisfies
the requirement
Test Result
Clarification
Chief MT checks
the results
Pathologist
supervise and
checks the results
for finalization
RELEASE OF
RESULT
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VI. Quality Assurance & Quality
Control
Table 8 Quality Assurance Indicators, from Practice in Hematology by Ciesla, B., page 8
Short List of Quality Assurance Indicators
• Number of patient redraws
• Labeling errors
• Patient and specimens properly identified
• Critical values called
• Pass rate on competency testing
• Test cancellation
• Integrity of send-out samples
• Employee productivity
• Errors in data entry
• Testing turnaround times
• Delays due to equipment failures or maintenance
• Performance on proficiency testing
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The analytical component (actual measurement of the analyte in body fluids) is monitored in the
laboratory by quality control, a component of the laboratory quality assurance plan. Control materials
are assayed concurrently with patient samples, and the analyte value for the controls is calculated from
the calibration data in the same manner as the unknown or patient’s results are calculated. Control
materials are commercially available as stable or liquid materials that are analyzed concurrently with the
unknown samples. The control material measured values are compared with their expected values or
target range.
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VII. Updates & Automation
Retacrit is a biosimilar erythropoietin
approved in Europe3 for subcutaneous
administration in the treatment of anemia
associated with chemotherapy. Efficacy,
safety and tolerability in this indication
were evaluated from an open-label Phase III
trial involving 216 patients with solid
tumors, malignant lymphoma or multiple
myeloma who were undergoing
chemotherapy. Analysis of the safety of the Figure 26 Hematology-Analyzer-URIT-3300 used in CBC and other blood
data showed that, in almost all cases, examinations
patients and investigators reported tolerability as good or excellent.
"This study confirms that treatment with Retacrit has real benefits for cancer patients with anemia, a
common side-effect of chemotherapy. The data showed a high hemoglobin response rate, which means
a reduced need for blood transfusions during treatment and an improvement in patients' quality of life",
commented principal study investigator Valentina Tzekova, University Hospital Queen Joanna, Sofia,
Bulgaria.
‘Intelligent’ molecules are the new discovery of Professor A. Prasanna de Silva, a scientist from Queen’s
University. The discovery is based on previous pioneering research by Professor De Silva and his
colleagues at Queen's, which created 'Catch and tell' sensor molecules that send out light signals when
they catch chemicals in blood. This technology help create blood diagnostic cassettes, which are being
used in hospitals, ambulances, and veterinary offices nowadays to quickly monitor blood for levels of
common salt components such as sodium, potassium and calcium. The new research at Queen's also
shows as feasible 'ID tags' for very small objects the size of biological cells. It enables the on-the-spot
analysis of salt levels and blood type during accidents. Such ID tags can also help track infection and
highlight vulnerable people during disease outbreaks. An extension of the same design has also
developed molecules which can act as simple 'logic gates': more complex versions of which what drive
current computers.
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The Cedars-Sinai Medical Center recently purchased a blood mobile,
which helps to keep a steady and sufficient supply of blood and
blood products on hand. The blood mobile functions to transport all
of the equipment necessary to hold an off-site blood drive involving
up to 120 donors. The blood mobile is about the size of a city bus,
equipped with donor beds, two private screening rooms, automated
red-cell collection capabilities and a comfortable refreshment area
where donors can relax after giving blood. Designed to handle
smaller blood drives or locations that lack set-up space, the blood
mobile can accommodate up to 50 donors in one day.
Von Willebrand disease is a bleeding disorder caused by a defect or deficiency of a blood clotting protein
called von Willebrand factor. Von Willebrand factor is a protein necessary in the initial stages of blood
clotting. Through Alphanate(R), which is the first and only dual inactivated (solvent detergent and heat
treatment) and affinity chromatography purified antihemophilic factor/von Willebrand factor complex
VWD can be treated. This has been proven safe and effective for the treatment of hemophilia
Page 26
References:
Tzekova V, Mihaylov G, Koytchev R., Epoetin zeta: efficacy data from an open-label, Phase III
trial in patients with chemotherapy-induced anaemia. 33rd European Society of Medical
Oncology (ESMO) Congress; 12-16 September 2008; Stockholm, Sweden. Poster 906P.
Mihaylov G, Tzekova V, Koytchev R., Epoetin zeta: safety data from an open-label, Phase III trial
in patients with chemotherapy-induced anaemia. 33rd European Society of Medical
Oncology (ESMO) Congress; 12-16 September 2008; Stockholm, Sweden. Poster 907P.
European Medicines Agency (EMEA) European Public Assessment Report: Retacrit®. Available at
http://www.emea.europa.eu. Accessed September 2008.
Bohlius J, Wilson J, Seidenfeld J, et al. Recombinant human erythropoietins and cancer patients:
updated meta-analysis of 57 studies including 9353 patients. J Natl Cancer Inst 2006;
98:708-714.
Blood News & Hematology News from Medical News Today. Available at
http://www.medicalnewstoday.com/sections/blood/. Accessed September 2008.o
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