Hematological and coagulation parameters as predictors of death by Coronavirus disease in hospitalized patients: a Brazilian follow-up study

Abstract This study aimed to evaluate the hematological and coagulation parameters according to the clinical outcomes of coronavirus disease (COVID-19). We analyzed the hematological and coagulation parameters of hospitalized patients with COVID-19 at admission, and two and three weeks during hospitalization. To assess the performance of these parameters in predicting poor outcomes, receiver operating characteristic (ROC) curves were created. We studied 128 patients with COVID-19 (59.2±17.7 years, 56% male). Non-survivors (n=54, 42%) presented significant alterations in hematological and coagulation parameters at admission, such as increased in white blood cells (WBC), neutrophil, and band cell counts, as well as elevated prothrombin time (PT), activated partial thromboplastin time, and D-dimer levels. During follow-up, the same group presented a gradual increase in D-dimer and PT levels, accompanied by a reduction in PT activity, hemoglobin, and red blood cell count (RBC). ROC curves showed that WBC, neutrophil, and band cell counts presented the best area under the curve (AUC) values with sensitivity and specificity of >70%; however, a logistic regression model combining all the parameters, except for RBC, presented an AUC of 0.89, sensitivity of 84.84%, and specificity of 77.41%. Our study shows that significant alterations in hematological and coagulation tests at admission could be useful predictors of disease severity and mortality in COVID-19.

Quality control validation for a veterinary laboratory network of six Sysmex XT-2000iV hematology analyzers.

BACKGROUND: Quality control (QC) validation is an important step in the laboratory harmonization process. This includes the application of statistical QC requirements, procedures, and control rules to identify and maintain ongoing stable analytical performance. This provides confidence in the production of patient results that are suitable for clinical interpretation across a network of veterinary laboratories. OBJECTIVES: To determine that a higher probability of error detection (Ped ) and lower probability of false rejection (Pfr ) using a simple control rule and one level of quality control material (QCM) could be achieved using observed analytical performance than by using the manufacturer's acceptable ranges for QCM on the Sysmex XT-2000iV hematology analyzers for veterinary use. We also determined whether Westgard Sigma Rules could be sufficient to monitor and maintain a sufficiently high level of analytical performance to support harmonization. METHODS: EZRules3 was used to investigate candidate QC rules and determine the Ped and Pfr of manufacturer's acceptable limits and also analyzer-specific observed analytical performance for each of the six Sysmex analyzers within our laboratory system using the American Society of Veterinary Clinical Pathology (ASVCP)-recommended or internal expert opinion quality goals (expressed as total allowable error, TEa ) as the quality requirement. The internal expert quality goals were generated by consensus of the Quality, Education, Planning, and Implementation (QEPI) group comprised of five clinical pathologists and seven laboratory technicians and managers. Sigma metrics, which are a useful monitoring tool and can be used in conjunction with Westgard Sigma Rules, were also calculated. RESULTS: The QC validation using the manufacturer's acceptable limits for analyzer 1 showed only 3/10 measurands reached acceptable Ped for veterinary laboratories (>0.85). For QC validation based on observed analyzer performance, the Ped was >0.94 using a 1-2.5s QC rule for the majority of observations (57/60) across the group of analyzers at the recommended TEa . We found little variation in Pfr between manufacturer acceptable limits and individual analyzer observed performance as this is a characteristic of the rule used, not the analyzer performance. CONCLUSIONS: An improved probability of error detection and probability of false rejection using a 1-2.5s QC rule for individual analyzer QC was achieved compared with the use of the manufacturers' acceptable limits for hematology in veterinary laboratories. A validated QC rule (1-2.5s) in conjunction with sigma metrics (>5.5), desirable bias, and desirable CV based on biologic variation was successful to evaluate stable analytical performance supporting continued harmonization across the network of analyzers.

Identification of parameters and formulation of a statistical and machine learning model to identify Babesia canis infections in dogs using available ADVIA hematology analyzer data.

BACKGROUND: Canine babesiosis is an important tick-borne disease in endemic regions. One of the relevant subspecies in Europe is Babesia canis, and it can cause severe clinical signs such as hemolytic anemia. Apart from acute clinical symptoms dogs can also have a more chronic disease development or be asymptomatic carriers. Our objective was to identify readily available ADVIA hematology analyzer parameters suggestive of B. canis parasitemia in dogs and to formulate a predictive model. METHODS: A historical dataset of complete blood count data from an ADVIA hematology system with blood smear or PCR confirmed parasitemia cases was used to obtain a model by conventional statistics (CS) methods and machine learning (ML) using logistical regression and tree methods. RESULTS: Both methods identified that important parameters were platelet count, mean platelet volume and percentage large unstained cells. We were able to formulate a CS model and ML model to screen for Babesia parasitemia in dogs with a sensitivity of 84.6% (CS) and 100% (ML), a specificity of 97.7% (CS) and 95.7% (ML) and a positive likelihood ratio (LR+) of 36.78 (CS) and 23.2 (ML). CONCLUSIONS: This study introduces two methods of screening for B. canis parasitemia on readily available data from ADVIA hematology systems. The algorithms can easily be introduced in laboratories that use these analyzers. When the algorithm marks a sample as 'suggestive' for Babesia parasitemia, the sample is approximately 37 times more likely to show Babesia merozoites on blood smear analysis.

Educational cost-effective intervention to reduce pathologist's peripheral blood smears reviews with non-contributory findings: an academic institution experience.

Peripheral blood smear (PBS) review by a pathologist is a necessary and invaluable diagnostic tool. However, innovative highly sophisticated haematology analysers that flag peripheral blood abnormalities have decreased the need for a PBS review. Ordering practices including PBS reviews lumped as part of an 'order set' or with complete blood count (CBC) constituted most PBS requests at our institution. A retrospective review of all PBS review orders from 1 April 2016 to 31 January 2017 was performed to investigate the ordering practices at our institution. A total of 2864 PBS were ordered during the above study period. In many cases, the PBS report did not add any significant clinical information beyond that acquired by the CBC and differential count. These findings inspired policy changes within our institution for pathologist PBS reviews. Within the electronic order system, all PBS orders for inpatients were linked to a pop-up window with criteria for peripheral smear review and instructions on the approval policy. Outpatient orders required clinicians to request pathology approval. This implementation reduced total number of PBS orders by 42.5% with no adverse effect on patient management. Empowering pathologists and clinicians with guidelines on PBS review orders is a beneficial educational exercise of resource utilisation. Discussion with physicians regarding clinical indications reduces non-contributory PBS reviews, provides guidance to appropriate testing, and aptly allocates pathologist and laboratory staff time and resources.

Measurement of hematopoietic progenitor cells using XN2000 hematology analyzer.

INTRODUCTION: Stem cell enumeration by the hematopoietic progenitor cells (HPC) mode is a novel method available from Sysmex XN2000 hematology analyzer. A small amount of blood (190 µL) is required, and the results are available in a few minutes without manual gating or presample treatment. The present study compares stem cell measurements using XN2000 analyzer HPC mode and FC500 flow cytometry analyzer using peripheral blood (PB) specimens and apheresis products. METHODS: In this prospective study, CD34-positive cell counts were enumerated using an FC500 flow cytometry analyzer and compared with XN2000 Sysmex analyzer (XN-HPC mode) in the same samples. Results were compared using Bland-Altman plots. RESULTS: A total of 103 samples were used. In the PB samples, the median HPC count and CD34-positive cells were 83.5 × 106 /L and 78.0 × 106 /L, respectively. The mean Bland-Altman difference was 4.5 × 106 /L (Limits: -51.7 to 60.7 × 106 /L), with a Pearson's correlation of 0.79. In the apheresis products, the median HPC count and CD34-positive cells were 1468 × 106 /L (IQR: 1049 - 1960 × 106 /L) and 1327 × 106 /L (IQR: 910 - 2001 × 106 /L), respectively. The mean Bland-Altman difference was 179.0 × 106 /L (Limits: -2022.2 - 2380.2 × 106 /L), with a Pearson's correlation of 0.58. CONCLUSION: The XN-HPC mode has an excellent correlation and minimal disagreement for stem cell enumeration in PB compared with flow cytometry and could replace it. There is high disagreement in apheresis products, and therefore, the XN-HPC mode cannot be recommended.

Colocating Wound Care for Patients with Sickle Cell Ulcers in a Hematology Clinic.

OBJECTIVE: Leg ulcers affect 15% of people with sickle cell disease. However, wound centers typically treat few people with this condition, which makes it difficult to concentrate clinical expertise or support the scientific study of this orphan disease. This article describes an initiative to increase engagement in care through a partnership between wound healing and hematology leadership that led to colocating wound services within a sickle cell clinic. METHODS: Via a retrospective chart review, the authors collected records of all adult patients with sickle cell disease who received wound care in the last decade, including 7 years of wound center data and 3 years of data from the colocated services. Patient and visit characteristics were analyzed using descriptive analytics. RESULTS: The general wound center had previously treated 35 patients with sickle cell ulcers over 7 years. In contrast, colocated services engaged 56 patients within 3 years, including 20 who transferred care and 36 new patients. The majority of patients at the colocated site were women, unlike at the wound center (58% vs 47%, P = .07). Results indicated that 36% of patients healed initial wounds, and 45% had new wound occurrences. CONCLUSIONS: Colocation successfully increases the number of patients with sickle cell ulcers who will engage in wound care at a single site, laying the foundation for clinical studies to improve the evidence base for this difficult-to-treat condition.

Leukocyte differential and reactive lymphocyte counts from Sysmex XN analyzer in the evaluation of SARS-CoV-2 infection.

BACKGROUND: Leukocyte differential present certain features in COVID 19 patients. RE-LYMP (reactive lymphocytes) is an extended inflammation parameter (EIP) reported by XN analyzer (Sysmex Corporation, Kobe, Japan) reflect the activation of lymphocytes triggered by infections. We aimed to assess the clinical utility of these parameters as biomarkers for the rapid detection of COVID 19. METHODS: The study group included 200 COVID 19 and 167 patients with other infections at admission. Differences of leukocyte differential, neutrophil/lymphocyte ratio (NLR) and EIP among groups were assessed with the Kruskal-Wallis test; parameters statiscally different in the groups were tested with Receiver operating characteristic (ROC) curve analysis to assess their diagnostic performance in distinguishing SARS-CoV-2 infections. The reliability of the selected parameters was evaluated in a validation group of 347 patients (160 COVID 19 and 187 other infections). RESULTS: NLR performed well to discard viral infections, area under curve (AUC) 0.988 (95%CI 0.973 - 0.991) and RE-LYMP was useful to distinguish COVID 19 and bacterial infections AUC 0.920 (95%CI 0.884 - 0.948); the two conditions NLR> 3.3 RE-LYMP> 0.6% was applied to the validation group and 153 out of 160 COVID 19 patients were correctly distinguished (95.6%). CONCLUSIONS: Early diagnosis of SARS-CoV-2 infection is critical for better caring of patients and to reduce the threat of nosocomial infection for professionals. Leukocyte differential and RE-LYMPH could assist in a preliminary differential diagnosis of the disease.

The hematology laboratory's response to the COVID-19 pandemic: A scoping review.

The ongoing COVID-19 pandemic has had a profound worldwide impact on the laboratory hematology community. Nevertheless, the pace of COVID-19 hematology-related research has continued to accelerate and has established the role of laboratory hematology data for many purposes including disease prognosis and outcome. The purpose of this scoping review was to assess the current state of COVID-19 laboratory hematology research. A comprehensive search of the literature published between December 1, 2019, and July 3, 2020, was performed, and we analyzed the sources, publication dates, study types, and topics of the retrieved studies. Overall, 402 studies were included in this scoping review. Approximately half of these studies (n = 202, 50.37%) originated in China. Retrospective cohort studies comprised the largest study type (n = 176, 43.89%). Prognosis/ risk factors, epidemiology, and coagulation were the most common topics. The number of studies published per day has increased through the end of May. The studies were heavily biased in favor of papers originating in China and on retrospective clinical studies with limited use of and reporting of laboratory data. Despite the major improvements in our understanding of the role of coagulation, automated hematology, and cell morphology in COVID-19, there are gaps in the literature, including biosafety and the laboratory role in screening and prevention of COVID-19. There is a gap in the publication of papers focused on guidelines for the laboratory. Our findings suggest that, despite the large number of publications related to laboratory data and their use in COVID-19 disease, many areas remain unexplored or under-reported.

COVID-19 and hematology findings based on the current evidences: A puzzle with many missing pieces.

In December 2019, a new type of coronavirus was detected for the first time in Wuhan, Hubei Province, China. According to the reported data, the emerging coronavirus has spread worldwide, infecting more than fifty-seven million individuals, leading to more than one million deaths. The current study aimed to review and discuss the hematological findings of COVID-19. Laboratory changes and hematologic abnormalities have been reported repeatedly in COVID-19 patients. WBC count and peripheral blood lymphocytes are normal or slightly reduced while these indicators may change with the progression of the disease. In addition, several studies demonstrated that decreased hemoglobin levels in COVID-19 patients were associated with the severity of the disease. Moreover, thrombocytopenia, which is reported in 5%-40% of patients, is known to be associated with poor prognosis of the disease. COVID-19 can present with various hematologic manifestations. In this regard, accurate evaluation of laboratory indicators at the beginning and during COVID-19 can help physicians to adjust appropriate treatment and provide special and prompt care for those in need.

Lysercell M enhances the detection of stage-specific Plasmodium-infected red blood cells in the automated hematology analyzer XN-31 prototype.

The automated hematology analyzers XN-30 (for research) and XN-31 prototype (for diagnosis support) can easily and rapidly detect Plasmodium-infected red blood cells (iRBCs) and distinguish the developmental stages of the parasite in approximately 1 min. Two dedicated reagents, Lysercell M and Fluorocell M, are available with the analyzers. Lysercell M plays an indispensable role in enhancing the fluorescence intensity of the nucleic acid staining dye in Fluorocell M and altering cell morphology. These effects of Lysercell M have been empirically determined but insufficiently analyzed. In this study, the properties of Lysercell M were analyzed using two flow cytometers and a fluorescence microscope. First, the fluorescence intensity emitted by iRBCs treated with Lysercell M or phosphate-buffered saline (PBS) was evaluated. Second, the size of RBCs treated with Lysercell M or PBS was measured. Finally, the morphology of individual parasites was observed after reconstruction of an M scattergram, a cytogram of the XN-31 prototype system, using an imaging flow cytometer. These analyses showed that treatment of iRBCs with Lysercell M increased the fluorescence intensity of stained parasite nucleic acids by approximately 10-fold and reduced the size of iRBCs in a stage-specific manner, facilitating the identification and quantification of ring form, trophozoite, and schizont stage iRBCs. These properties suggest that Lysercell M is useful for rapidly detecting iRBCs and accurately distinguishing the parasite developmental stages, thereby contributing to the usability of the XN-30 and XN-31 prototype analyzers.

A meta-analysis of SARS-CoV-2 patients identifies the combinatorial significance of D-dimer, C-reactive protein, lymphocyte, and neutrophil values as a predictor of disease severity.

BACKGROUND: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), known to be the causative agent of COVID-19, has led to a worldwide pandemic. At presentation, individual clinical laboratory blood values, such as lymphocyte counts or C-reactive protein (CRP) levels, may be abnormal and associated with disease severity. However, combinatorial interpretation of these laboratory blood values, in the context of COVID-19, remains a challenge. METHODS: To assess the significance of multiple laboratory blood values in patients with SARS-CoV-2 and develop a COVID-19 predictive equation, we conducted a literature search using PubMed to seek articles that included defined laboratory data points along with clinical disease progression. We identified 9846 papers, selecting primary studies with at least 20 patients for univariate analysis to identify clinical variables predicting nonsevere and severe COVID-19 cases. Multiple regression analysis was performed on a training set of patient studies to generate severity predictor equations, and subsequently tested on a validation cohort of 151 patients who had a median duration of observation of 14 days. RESULTS: Two COVID-19 predictive equations were generated: one using four variables (CRP, D-dimer levels, lymphocyte count, and neutrophil count), and another using three variables (CRP, lymphocyte count, and neutrophil count). In adult and pediatric populations, the predictive equations exhibited high specificity, sensitivity, positive predictive values, and negative predictive values. CONCLUSION: Using the generated equations, the outcomes of COVID-19 patients can be predicted using commonly obtained clinical laboratory data. These predictive equations may inform future studies evaluating the long-term follow-up of COVID-19 patients.

Evaluation and comparison of the new Mindray BC-6200 hematology analyzer with ADVIA 2120i.

BACKGROUND: The Mindray BC-6200 is a new automatic hematology analyzer that quantifies the parameters of blood morphology and leukocyte differential in five populations (5-Diff). The aim of the study was to evaluate the BC-6200 and compare it with the Siemens ADVIA 2120i analyzer. MATERIALS AND METHODS: The comparison between BC-6200 and ADVIA 2120i analyzers was performed using 390 whole blood samples collected on K3 EDTA. For the BC-6200, the carryover effect, precision, and linearity were evaluated. 138 samples were used to assess the sensitivity and flag ability, suggesting the presence of abnormal cells such as blasts, immature granulocytes, or atypical lymphocytes. Flagging results were compared with microscopic evaluation of blood smears. RESULTS: The BC-6200 analyzer showed a high correlation (r ≥ .97) with ADVIA 2120i for most of the compared parameters except RDW (r = .8350), MPV (r = .7634), Mon# (r = .8366), Baso# (r = .9205), and NRBC (r = .3768). The BC-6200 had better correlation with microscopic evaluation for NRBC (r = .8902) compared with ADVIA 2120i (r = .5677). The BC-6200 has shown high efficiency for flagging blasts (80.4%), immature granulocytes (80.5%), and atypical lymphocytes (69.0%). CONCLUSION: The new Mindray BC-6200 hematology analyzer provides high measurements precision and good correlation with ADVIA 2120i for most of the morphology and 5-diff parameters.

Standardization and harmonization in hematology: Instrument alignment, quality control materials, and commutability issue.

INTRODUCTION: In the hub and spoke laboratory network, the number of hematology analyzers (HAs) within each core center has increased, and the control of HAs alignment is becoming necessary requirement to ensure analytical quality. In this scenario, HA alignment can be assessed by analyzing the same control material used for internal quality control on multiple HAs, assuming its commutability. The aim of the study was to verify the applicability of a protocol for the alignment of HAs based on control material rather than on fresh whole-blood samples. METHODS: The alignment of five HAs was evaluated for red (RBC, Hb, MCV, RET), white (WBC, NE, LY, MO, EO, BA, IG), and platelet (PLT) series parameters, following a protocol by SIBioC, using human sample (HS) and quality control material (QC), after the verification of commutability, according to the IFCC protocol. Maximum bias was derived from biological variation data. RESULTS: A complete alignment between instruments was confirmed for the majority of the parameters investigated both for HS and QC material. Partial misalignments or inconcludent results were instead evident for MCV, MO, EO, BA, and IG. Interestingly, QC material was found to be not commutable for LY, MO, and BA. CONCLUSION: The alignment of hematologic analyzers for main cell population parameters may be verified with both QC and HS, displaying consistent results and interpretation. The evaluation for some white series parameters (EO, BA, and IG) is critical, and particular attention must be paid to the values of the material used for the alignment.

The importance of manual white blood cell differential counts and platelet estimates in elephant hematology: blood film review is essential.

Unique features of elephant hematology are known challenges in analytical methodology like two types of monocytes typical for members of the Order Afrotheria and platelet counts of the comparatively small elephant platelet. To investigate WBC differential and platelet data generated by an impedance-based hematology analyzer without availability of validated species-specific software for recognition of elephant WBCs and platelets, compared to manual blood film review. Blood samples preserved in ethylenediaminetetraacetic acid (EDTA) of 50 elephants (n = 35 Elephas maximus and n = 15 Loxodonta africana) were used. A Mann-Whitney test for independent samples was used to compare parameters between methods and agreement was tested using Bland-Altman bias plots. All hematological variables, including absolute numbers of heterophils, lymphocytes, monocytes, eosinophils, basophils, and platelets, were significantly different (p < 0.0001) between both methods of analysis, and there was no agreement using Bland-Altman bias plots. Manual review consistently produced higher heterophil and monocyte counts as well as platelet estimates, while the automated analyzer produced higher lymphocyte, eosinophil, and basophil counts. The hematology analyzer did not properly differentiate elephant lymphocytes and monocytes, and did not accurately count elephant platelets. These findings emphasize the importance of manual blood film review as part of elephant complete blood counts in both clinical and research settings and as a basis for the development of hematological reference intervals.

[Digital morphology analyzers in hematology: a French survey]. / État des lieux des pratiques d'utilisation du microscope automatisé en hématologie en France.

Digital morphology hematology analyzers are becoming more prevalent in laboratories Aims: investigate practices and assess the benefits and limits of digital automated microscopy in hematology. METHODS: questionnaire sent by e-mail in 2018 to French public and private laboratories. RESULTS: out of 118 responses (56 private, 62 public), 117 participants had a CellaVision® microscope, 1 had a West Medica®. Practices were sometimes different, especially in the choice of smears to be digitized or for quality controls (16.1% had internal quality controls, 48.3% external quality controls); 62.1% never used the red blood cell (RBC) characterization tool; the number of cells counted varied from 100 to 400. The study reported a high rate of agreement for these benefits: traceability (95.7%), staff training (94.1%), eye strain (91.4%), risk of error (87.2%), time saving (83.6%). Among the disadvantages, apart from the inadequate search for platelets clumps (93.2%), the agreement rates were often lower: adaptation to digital images (61.2%), difficult assessment of atypical morphologies (49.6%) or RBC morphology (49.6%). CONCLUSION: despite well-established benefits, standardization of practices and technical improvement are still needed.

False-positive flag of WBC and change of mean platelet volume (MPV) caused by K3-EDTA on the DxH 900 hematology analyzer.

During the evaluation of the DxH 900 hematology analyzer (Beckman Coulter, Miami, FL), we noted that some patient samples produced a false positive white blood cell (WBC) flag, neutrophil blasts (NE-blast), despite the absence of abnormal cells. We investigated whether storage time or anticoagulants such as K2- or K3-ethylenediaminetetraacetic acid (EDTA) would affect complete blood count (CBC) tests on the DxH 900. Sixty-four whole blood samples were collected in K3-EDTA tubes, and 44 were simultaneously drawn in K2-EDTA tubes. Samples were tested at the following two intervals: within 30 min of collection (0 min) and after an additional 30 min of roller-mixing at room temperature (30 min). WBC differential dataplots in 0-min K3-EDTA tubes showed a mixed cell population between lymphocytes and neutrophils in 22 patients presenting the NE-blast flag. All 22 samples revealed normal WBC differential dataplots after 30 min of roller-mixing. The significantly lower mean neutrophil volume in specimens of 0-min K3-EDTA tubes than those of 0-min K2-EDTA, 30-min K2-EDTA and 30-min K3-EDTA tubes appear to be the cause of the false flag. Unlike blood cell counts, mean platelet volume (MPV) was significantly higher at 30 min using both EDTA tubes than that at 0 min. In conclusion, K3-EDTA can produce a false positive flag, NE-blast, on the DxH 900. MPV increases over time irrespective of EDTA salt type.

Precision and accuracy of the Mindray BC-5000Vet hematology analyzer for canine and feline blood.

BACKGROUND: The Mindray BC-5000Vet hematology analyzer is a flow cytometry-based automated hematology analyzer that generates a complete blood count with a five-part white blood cell (WBC) differential count. OBJECTIVES: We aimed to validate reliability results of the Mindray BC-5000Vet for use in dog and cat blood. METHODS: Imprecision was performed using the manufacturer's quality control material at low, normal, and high levels. Blood sample results of healthy and ill dogs and cats were studied for comparability between manual methods and the Mindray BC-5000Vet analyzer. Forty dogs and 40 cats were included in the study. RESULTS: Precision for red blood cell (RBC) parameters was excellent, with a coefficient of variation within-run (%CVw ) and between-run (%CVb ) of <2%. WBC count and differential count showed %CVw and %CVb <8%; however, %CVw and %CVb of low-level control material gave >9% eosinophils. The correlation between the BC-5000 Vet and manual methods in normal and abnormal canine and feline blood samples showed excellent correlations for the RBC counts, hemoglobin concentrations, hematocrits, and WBC counts (r > .93). The differential WBC analysis of canine blood showed good correlation (r = .80-.92). Feline blood samples showed excellent correlations for neutrophils and lymphocytes, with a good correlation for monocytes and eosinophils. CONCLUSIONS: The Mindray BC-5000Vet hematology analyzer proved a suitable instrument for routine analysis in dogs and cats with various hematologic abnormalities.