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Alat-Alat Hematologi
Alat-Alat Hematologi
ematology analyzers are the workhorses of the Laboratories at the University of Michigan. “They’re evolving
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clinical laboratory. High-end, high-volume toward flow cell-based technologies, where cells are interrogated
analyzers deliver reliable red blood cell counts, cell by cell by optical systems that can then measure lots of
platelet counts, and 5-part differentials of things we never used to measure. The problem is that manufac-
white blood cells, identifying lymphocytes, turers appropriately want to take their own proprietary step to
monocytes, neutrophils, eosinophils, and ba- have their own identity. So they become very good at one thing,
sophils. Nucleated red blood cell counts and and maybe not as good at another.”
immature granulocytes are emerging as sixth and seventh param- Bruce H. Davis, MD, of the Maine Medical Center Re-
eters. While electrical impedance still has a firm foothold in de- search Institute in Scarborough, ME, said all of the analyzers on
termining the overall number and size of cells, flow cytometry the market are generally reliable. “The differences are really
techniques have proven their worth in differentiating white minor in terms of bells and whistles that may appeal to one per-
blood cells and identifying abnormal cells. son or another,” he said. “The decision typically comes down to
The increasing sophistication of flow techniques on the cost or someone is in a buying group so the decision has already
to perform a white count and red count on body fluid samples is The line between hematology analyzers and flow cytometers
a labor-intensive activity in the lab,” he said. “It’s usually done will probably continue to shift for the foreseeable future as tech-
manually on a hemocytometer, and is time-consuming and re- nologies or methodologies evolve, Davis predicted. “The reticu-
quires a skilled member of the laboratory staff to perform the locyte count is a good example,” he said. “First it was manual,
count, and labs are looking to reduce manually performed tests.” then it was done on a flow cytometer, then it swung back to the
The next big step in hematology is the extended differen- automated hematology instrument once the methodologies were
tial, Taylor said. “While today’s analyzers flag for suspect blast made in an automated way.”
cells, suspect immature granulocytes and atypical lymphocytes, Patricia K. Kotylo, MD, FASCP, of Pathology Associates,
now the next step will be to count those parameters instead of Indianapolis, IN, thinks it would be possible to adapt some of
just flagging. You will find a lot of analyzers today report them the simpler tests to the hematology analyzer. “Routine T-cell
in some shape or form on an RUO parameter—research use subsets, maybe eventually a very obvious, forthright chronic or
only. But it’s not too far away. Most of the major companies are acute leukemia where all the cells are uniform with a very clear
working on it. That’s where their focus is going.” phenotypic profile you could do as well,” she said. “If they can
control and standardization of your instrument and your instruments can do that. That’s what I think labs are looking for:
reagents,” Kotylo said. “If you don’t do that, you can get some ease of use, efficiency, and reduced microscopic review rate.”
erroneous results. You have to have someone who is trained, Finn is concerned that some pathologists and laboratory
knows what they are doing, knows what they are looking at. It’s professionals may focus too much on getting the best technology
pretty sophisticated. Your best techs are the ones working with rather than optimizing the technology to improve medical deci-
this technology.” sion-making. “You can buy the fanciest analyzer in the world,
At Trillium, Davis is working on an assay based on CD64 but if you are repeating every abnormal result, you have instantly
expression on neutrophils to detect infection or sepsis that can negated the power of your technology,” he said. “That assumes
be integrated into a high-end hematology analyzer. that abnormal results are innately more likely to be incorrect
“Within 3 to 5 years we’re going to see a new set of param- than normal results, which isn’t true actually. I’ve heard of labo-
eters that’s going to somewhat revolutionize lab hematology or at ratories auto-validating only normal results, and there’s no logic
least wake us up out of the doldrums which in my mind has to that whatsoever.”
been going on for 10 or 15 years with little change,” he said. Finnegan said that every laboratory has to determine the
every CBC that isn’t normal,” he said. “You have just negated that “Most of the techs in my lab really don’t have that much of
investment by one silly lapse in medical decision-making.” an understanding of the technology of the instrument,” she said.
“Also, their understanding of the graphic displays is very limited,
so as part of our continuing education in the lab, we try to em-
Optimizing the Automated Analyzer phasize correlating the graphic displays with their morphologic
Finn said there is too much emphasis on how good the findings, so they can get more out of that information.”
analyzers are getting, and not enough on optimizing the use of Even the CBC batteries have become overly complex, said
automated and manual technologies. Part of the problem is Sandhaus. “There’s just a ton of data that’s produced on every
that pathologists in charge of hematology laboratories trained CBC analysis,” she said. “We’ve got all these numbers that are
as residents in anatomic pathology and did not learn about produced, all these indices, graphic displays, and interpretive
laboratory medicine. comments. All of that information in some way needs to be in-
“There is not a culture of training residents to be medical tegrated into that laboratory’s algorithm for which results they’re
decision-makers in the clinical laboratory,” he said. “That’s going to review and which ones they’re going to auto-validate. If
where you have to start. A lot of pathologists are performing you make that process more complex, you’re going to be slowing
validation functions when they should be performing interpre- down your lab considerably. You have to weigh the benefits of
tive functions. The concepts aren’t firm with them. There are 2 more information against the additional complexity that it intro-
functions in the laboratory: One is to stand by the numbers duces into your whole operation.”
you release, and the other is to interpret the results you release.” To be fair, Finn said, it would take a biophysicist to un-
The next step is to practice evidence-based medicine, says derstand everything the analyzers are doing to cells. “We can
Finn. “If you look at the last 10,000 cases that you released and let the manufacturers be the biophysicists,” he added. “But we
see no evidence that they could not have been auto-verified with are all smart enough to run the instruments right if we get the
the exact same results, then you should be auto-verifying,” he right medical attitude to doing it. Medical decision-making
said. “If you look at the last 10,000 blood smears that a patholo- really has to take hold in the application of high-throughput
gist reviewed and there was no medical value added to that, then laboratory hematology. The first step is to have a medical di-
you shouldn’t be doing that. At the same time, if you released rector who is devoted to the practice of laboratory medicine
10,000 results that could have had medical value added, you and is not just a spectator.”
should have been reviewing those. We are very poor on Finn said medical directors should use the technology to free
evidence-based practice.” up technologists to do more interpretive work of cells that are in-
Another challenge is to help the technologists understand terrogated by methods other than microscopes, to teach them how
the information coming off the hematology analyzer. Sandhaus, to read the flow-based histogram data and the distributions on the
who teaches ASCP CMLE courses on preventing errors in the cells that have been manipulated with different reagents.
hematology laboratory and on diagnostic hematopathology, said “The potential is basically accumulating behind this wave of
that technologists’ understanding is variable. technology,” he said. “The technology is advancing rapidly, and
we should be grateful for that and encouraged by that, but be- That’s not to say that hematology laboratories should not
hind this wave, there is accumulating so much potential for the embrace the technological advances. “It doesn’t have to be
appropriate utilization of the technology, and I just don’t see the either/or,” Finn said. “You can get new technology and improve
mindset of clinical pathology evolving as quickly as the technol- your attitude about medical practice.”
ogy, and that’s unfortunate. The rate-limiting steps are really the In the end, said Kotylo, emerging technology is going to
attitudes toward medical practice in the clinical laboratory. People come no matter what. “You can’t keep hanging on to the way it
have to start leading and defining how we practice medicine with was,” she said. “I think what you’ll see in the future is that flow
tools that include automated platforms. There are smart ways to will be less isolated, and it’s going to be more a part of morphol-
use smart technology and we’re not always using them.” ogy and molecular diagnostics.” LM