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Optimization of laboratory workflow in clinical hematology
laboratory with reduced manual slide review: comparison
between Sysmex XE-2100 and ABX Pentra DX120M. HUR*, J.-H. CHO*, H. KIM*, M.-H. HONG*, H.-W. MOON*, Y.-M. YUN*, J. Q. KIM
INTRODUCTION
The complete blood count (CBC) with leukocyte dif-
ferential counts (LDC) is one of the most frequently
requested tests in clinical laboratories. Technical evo-
lutions in automated hematology analyzers have
improved the analytic performance greatly and have
broadened the range of information provided (Buttarello
*Department of Laboratory
Medicine, Konkuk University
School of Medicine, Seoul, KoreaKonkuk University, Seoul, Korea
Correspondence:
Mina Hur, Department of
Laboratory Medicine, Konkuk
University School of Medicine,
Konkuk University Hospital, 4-12,
Hwayang-dong, Kwangjin-gu,
Seoul 143-729, Korea.
Tel.: +82 2 2030 5581;
Fax: +82 2636 6764;
E-mail: [email protected]
This work was supported by
Konkuk University in 2010.
doi:10.1111/j.1751-553X.2011.01306.x
Received 24 September 2010;
accepted for publication 21
December 2010
Keywords
Slide, review, Sysmex XE-2100,
ABX Pentra DX120, hematology
SUMMARY
Introduction: The validation of automated hematology analyzer results
by manual slide review (MSR) is currently an inevitable work process
in clinical hematology laboratories. The laboratory workload wouldbe optimized if the requirement for MSR could be reduced without
compromising patient care. We investigated whether slide-making
rates would be different between two hematology analyzers, which
were paired with their own automated slide makers/stainers: Sysmex
XE-2100 with SP-1000i (Sysmex, Kobe, Japan) and ABX Pentra
DX120 with SPS evolution (ABX-Horiba, Montpellier, France).
Methods: A total of 943 samples were run in parallel on the Sysmex
XE-2100 and ABX Pentra DX120. Reflex slides were automatically
made in each analyzer according to its own criteria, which reflected
the criteria of MSR in our laboratory. The slide-making rates were
compared, and the results were further confirmed using the criteriaof MSR.
Results: The slide-making rates in Sysmex XE-2100, ABX Pentra
DX120, and manual review were 22.5% (212/943), 15.91% (150/
943), and 11.5% (108/943), respectively. In 774 (82.1%) samples,
the three methods showed concordant results, and all made slides in
82 samples. Using the manual method as a standard, the sensitivity
and specificity were 86.1% and 85.8% in Sysmex XE-2100 and
89.8% and 93.7% in ABX Pentra DX120.
Conclusion: Our data show that the slide-making rates are variable in
different hematology analyzers. It also implies that although MSRcannot be fully substituted by modern hematology analyzers, it can
be effectively reduced to optimize laboratory workload.
ORIGINAL ARTICLE INTERNATIONAL JOURNAL OF LABORATORY HEMATOLOGY
434 2011 Blackwell Publishing Ltd, Int. Jnl. Lab. Hem. 2011, 33, 434440
International Journal of Laboratory HematologyThe Official journal of the International Society for Laboratory Hematology
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RESULTS
The comparison data of slide preparation by Sysmex
XE-2100, ABX Pentra DX120, and manual review
are presented in Table 2. The slide-making rates in
Sysmex XE-2100, ABX Pentra DX120, and MSR were
22.5% (212/943), 15.91% (150/943), and 11.5%
(108/943), respectively. All the three methods showed
concordant results in 774 (82.1%) samples: all posi-
tive in 82 samples and all negative in 692 samples.
Discrepant results were observed in 169 samples. No
case showed a positive result by manual review but
Figure 2. Workflow of slide review with Sysmex XE-2100 and SP-1000i.
Figure 1. The decision-making criteria for manual slide review.
2011 Blackwell Publishing Ltd, Int. Jnl. Lab. Hem. 2011, 33, 434440
436 M. HUR ET AL. REDUCED SLIDE REVIEW IN HEMATOLOGY LABORATORY
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negative results by both Sysmex XE-2100 and ABX
Pentra DX120. However, there were discrepant results
between the Sysmex XE-2100 and ABX Pentra DX120
in 26 samples with positive MSR results: 15 were Sys-
mex negative and Pentra positive and the other 11were Sysmex positive and Pentra negative. Using
MSR as a reference method, the sensitivity and speci-
ficity were 86.1% (95% confidence interval (CI),
78.192.0%) and 85.8% (95% CI, 83.288.0%) in
Sysmex XE-2100 and 89.8% (95% CI, 82.594.8%)
and 93.7% (95% CI, 91.895.2%) in ABX Pentra
DX120, respectively (Table 3). Significant differences
in the specificity and specificity of the analyzers were
observed, with a difference of 3.7% (95% CI, 0.69
6.71; P = 0.0165) for sensitivity and 8.0% (95% CI,
5.210.8; P < 0.0001) for specificity (chi-square test).
The causes of false-positive and false-negative
results were analyzed (Table 4). In the 119 samples
with false-positive results by Sysmex XE-2100, slide
flag was the most frequent cause followed by delta
check and department; slide flag and/or delta check
comprised three-quarters (75.7%) of the total false-
positive causes. In ABX Pentra DX120, the two causes
of false-positive results were slide flag (64.2%) and
monocytosis with large immature cells (35.8%).
Regarding false-negative results, the causes were
department (n = 11) and absence of result (n = 4) in
Sysmex XE-2100, and absence of flag (n = 11) in ABX
Pentra DX120. The quantitative values or flags in 11
samples with false-negative results by ABX PentraDX120 are presented in Table 5. The Sysmex XE-2100
also showed flags and/or quantitative abnormalities
that triggered MSR in these 11 samples. However,
these did not correspond to our criteria for the
manual confirmation, except for one sample with 3%
basophils (sample 8).
DISCUSSION
The manual examination of blood smears is time-con-
suming and expensive and may not be always neces-
sary. To increase the clinical sensitivity, most
laboratories tend to develop less strict criteria so as
not to miss potentially important abnormalities. This
would be more conspicuous especially when a hospi-
tal has a large pool of hemato-oncological patients.
According to the College of American Pathologists
Q-Probes Study with 263 participating institutions,
the rates of MSR varied considerably among partici-
pants (26.7% in the median, 9.9% in the 10th per-
centile, and 50.0% in the 90th percentile institutions)
and were elevated with increased numbers of hospital
beds (Novis et al., 2006). That study showed that therates of MSR were directly related to the efficiency in
generating CBC results. Most of the MSR were trig-
gered by hematology analyzer flags, and these thresh-
old limits also varied widely among participants.
Recently, the use of automated slide makers and
stainers has increased in large-sized clinical laborato-
ries. They are used in combination with their multipa-
rameter hematology analyzers, and their performances
are reported to be comparable to well-prepared man-
ual processes (Simson, Gascon-Lema & Brown, 2009).
Compared with manual procedures, the introduction
of automated slide makers and stainers has signifi-
cantly reduced the workload of slide preparation as
well as the turn-around-time of the final CBC report.
On the other hand, not all the automatically prepared
slides are reviewed manually. If slide-making rules of
the instrument do not perfectly match the slide-review
criteria of the laboratory, there may be a discrepancy
between the prepared slides and reviewed slides. Con-
sidering the general policy of laboratories not to miss
Table 1. The rules for slide making in Sysmex XE-2100
Quantitative abnormalities
Leukocytopenia/leukocytosis: WBC < 2.0 109/l or
WBC > 20 109/l
Neutropenia/neutrophilia: neutrophils < 30% or
neutrophils > 85.5%
Lymphocytopenia/lymphocytosis: 70%
Monocytosis: monocytes > 15.5%
Eosinophilia: eosinophils > 20%
Basophilia: basophils > 2%
Nucleated RBCs > 2/100 WBCs
Thrombocytopenia/thrombocytosis: PLT < 100 109/l or
PLT > 600 109/l
Flags
PLT clumps or abnormal distribution
Fragments
Blasts
Immature granulocytesLeft shift
Atypical lymphocytes
Abnormal lymphocytes/lymphoblasts
WBC, white blood cell count; RBC, red blood cell count;
PLT, platelet count.
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M. HUR ET AL. REDUCED SLIDE REVIEW IN HEMATOLOGY LABORATORY 437
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any possible pathologic samples, the presence of these
unnecessarily prepared slides might be regarded as
inevitable. However, construction of the rules to
reflect the laboratories own criteria may be variable in
each hematology analyzer, and consequently, the gap
between the prepared and reviewed slides may be dif-
ferent. To the best of our knowledge, no study has
focused on this practical issue in routine hematology
laboratory so far.
This study investigated whether the slide-making
rates would be different between two hematology
analyzers when paired with their own automated slide
Figure 3. Workflow of the rules for slide making in Pentra DX120. PDX, ABX Pentra DX120; SPS, SPS evolution;
PML, Pentra multilink data management system.
Table 2. Slide preparation by Sysmex XE-2100, ABX
Pentra DX120, and manual review
Sysmex
XE-2100
ABX Pentra
DX120
Manual
review
Number
(%)
Positive Positive Positive 82 (8.7)
Positive Negative Positive 11 (1.2)
Negative Positive Positive 15 (1.6)
Negative Negative Positive 0 (0)
Negative Negative Negative 692 (73.4)
Positive Negative Negative 90 (9.5)
Negative Positive Negative 24 (2.5)
Positive Positive Negative 29 (3.1)
Positive means the slide preparation, and negative vice
versa.
Table 3. Comparison of the results between Sysmex
XE-2100, ABX Pentra DX120, and manual review
Sysmex XE-2100 ABX Pentra DX120
Positive Negative Positive Negative
Manual review
Positive
(n = 108)
93 15 97 11
Negative
(n = 835)
119 716 53 782
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makers/stainers: Sysmex XE-2100 with SP-1000i and
ABX Pentra DX120 with SPS evolution. Our data
showed that the sensitivity and specificity of slide
preparation were different between these two systems
and that the performance of ABX Pentra DX120
with SPS evolution was superior to that of Sysmex
XE-2100 with SP-1000i (Table 3). In particular, the
number of false-positive samples was decreased in
ABX Pentra DX120, and the main causes of difference
were attributable to delta check and department,
which could not be included in the rules for Sysmex
XE-2100 (Table 4). Department was also the main
cause of false-negative results in Sysmex XE-2100,
and in the routine practice of our laboratory, this was
one of the main causes of extra workload.
Eleven samples showed false-negative results by
ABX Pentra DX120 with no flags. In contrast, they
mostly showed flags of blasts, atypical lymphocytes, or
immature granulocytes and/or quantitative abnormali-
ties by Sysmex XE-2100 (Table 5). According to our
decision-making criteria for slide review, MSR was
triggered by the results of Sysmex XE-2100, and the
Table 4. Causes of false-positive and false-negative results by Sysmex XE-2100 and ABX Pentra DX120
Sysmex XE-2100 ABX Pentra DX120
False-positive Total (n = 119, 100%) Total (n = 53, 100%)Slide flag (n = 46, 38.7%) Slide flag (n = 34, 64.2%)
Delta check (n = 34, 28.6%) Mono + Lic (n = 19, 35.8%)
Department (n = 21, 17.6%)
Slide flag and delta check (n = 10, 8.4%)
Department and delta check (n = 8, 6.7%)
False-negative Total (n = 15, 100%) Total (n = 11, 100%)
Department (n = 11, 73.3%) No flag (n = 11, 100%)
No result (n = 4, 26.7%)
Mono + Lic, monocytosis and large immature cells.
Table 5. Quantitative values or flags in samples with false-negative results by ABX Pentra DX120
Dep
Quantitative values (%) or flags
ABX Pentra DX120 Sysmex XE-2100 Manual differential count (%)
1 IM Lic: 1.0 Abn L/L-Blasts N: 67, Nb: 2, L: 25, M: 6
2 IM E: 16.9 Eosinophilia, Blasts N: 65, L: 8, M: 8, E: 19
3 IM No flags Abn L/L-Blasts N:73, L:16, M:6, E:3, B:2
4 IM Lic: 1.0 Aty L N: 73, Nb: 2, L: 17, M: 4, E: 1, B: 2, Aty L: 1
5 IM Lic: 2.2 Immature Granulocytes N: 78, Nb: 2, L: 12, M: 4, E: 2, B: 1, Mm: 1
6 IM M:13.6, Lic: 0.4, Aty L: 1.5 Abn L/L-Blasts N: 43, Nb: 1, L: 39, M: 13, E: 3, B: 1
7 IM nRBC, platelet aggregates,
monocytosis, (M: 11.4,
Lic: 0.6, Aty L: 1.4)
Basophilia N: 65, Nb: 1, L: 22, M: 7, E: 4, B: 1
8 IM Lic: 0.8, Aty L: 0.9 Blasts N: 46, Nb: 2, L: 43, M: 6, B: 3
9 PED Neutropenia (M: 10.2,
Lic: 0.8, Aty L: 2.2)
Neutropenia,
Abn L/L-Blasts
N: 15, Nb: 4, L: 64, M: 11, E: 3, B: 2, Aty L: 1
10 IM Lic: 2.0, Aty L: 1.7 Aty L N: 79, Nb: 4, L: 10, M: 5, B: 1, Aty L: 1
11 IM M: 12.8, Lic: 0.9, Aty L: 1.4 Aty L N: 61, L: 25, M: 9, E: 2, Aty L: 3
Dep, department; IM, internal medicine; PED, pediatrics; Lic, large immature cells; Aty L, atypical lymphocytes; Abn L,
abnormal lymphocytes; nRBC, nucleated RBCs; L-Blasts, lymphoblasts; N, neutrophils; Nb, band-form neutrophils; L,
lymphocytes; M, monocytes; E, eosinophils; B, basophils; Mm, metamyelocytes; My, myelocytes.
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