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C-reactive protein question
|
|
| stryped@hotmail.com 2005-05-05, 11:53 am |
| As you know I am being tested for lymphoma next week. My c reactice
protein was high last week, a 54. It was in the normal range this week.
Does that mean it might not be lymphoma?
| |
| stryped@hotmail.com 2005-05-05, 11:53 am |
| But, with it being normal, a 1.1, would that mean the infection is
gone?
I went to see the doctor for recurrent fevers I have been having every
3 months or so. They come quickly with flu like symptoms and go
quickly.
My bloodwork initially showed a high c reactive protein level while I
was sick. It also should my Lymphocytes to be 14.1 which was low
according to the range on the test.
I was refered to an infectious disease doctor this week. She took more
blood and scheduled me for a Gallium scan.
I just found out my c reactive protein was 1.1 with normal being 0.0 to
4 something. She did not do another cbc.
On the first test pretty much everythign was normal but the lymphocytes
as i said and something that says "GR" was high.
White blood cells were 9.8 which was in range and red blood cells were
4.78 which was in range.
The first doctor checked me for Rocky Mountain Spotted fever,
EBV,CMV,liver function, thyroid, etc. All were fine.
| |
|
|
<stryped@hotmail.com> wrote in message
news:1115308444.454025.186360@o13g2000cwo.googlegroups.com...
> But, with it being normal, a 1.1, would that mean the infection is
> gone?
It would *seem* so.
But, I don't know your full history. I have not examined you. And, I have
not seen your all your lab results.
I don't even know if you had an infection.
I think seeing an infectious disease doctor is a very good idea. And the
test she has ordered seems appropriate.
Jeff
> I went to see the doctor for recurrent fevers I have been having every
> 3 months or so. They come quickly with flu like symptoms and go
> quickly.
>
> My bloodwork initially showed a high c reactive protein level while I
> was sick. It also should my Lymphocytes to be 14.1 which was low
> according to the range on the test.
>
> I was refered to an infectious disease doctor this week. She took more
> blood and scheduled me for a Gallium scan.
>
>
> I just found out my c reactive protein was 1.1 with normal being 0.0 to
> 4 something. She did not do another cbc.
>
> On the first test pretty much everythign was normal but the lymphocytes
> as i said and something that says "GR" was high.
>
> White blood cells were 9.8 which was in range and red blood cells were
> 4.78 which was in range.
>
> The first doctor checked me for Rocky Mountain Spotted fever,
> EBV,CMV,liver function, thyroid, etc. All were fine.
>
| |
| Jason 2005-05-05, 11:54 am |
| In article <1115304415.677446.21100@g14g2000cwa.googlegroups.com>,
stryped@hotmail.com wrote:
> As you know I am being tested for lymphoma next week. My c reactice
> protein was high last week, a 54. It was in the normal range this week.
> Does that mean it might not be lymphoma?
It could mean several things. You should see your doctor within the next
couple of weeks and get retested. It takes several tests and various types
of tests for a doctor to determine whether or not a person has lymphoma.
Tell your doctor your concerns.
--
NEWSGROUP SUBSCRIBERS MOTTO
We respect those subscribers that ask for advice or provide advice.
We do NOT respect the subscribers that enjoy criticizing people.
| |
| J. Davidson 2005-05-05, 5:58 pm |
| Have you had a TB skin test?
J. Davidson
<stryped@hotmail.com> wrote in message
news:1115304415.677446.21100@g14g2000cwa.googlegroups.com...
> As you know I am being tested for lymphoma next week. My c reactice
> protein was high last week, a 54. It was in the normal range this week.
> Does that mean it might not be lymphoma?
>
| |
| stryped@hotmail.com 2005-05-05, 5:58 pm |
| No, should I?
| |
| stryped@hotmail.com 2005-05-05, 5:58 pm |
| If one's c reactive protein level was high due to lymphoma, wouldnt it
stay high as long as the lymphoma was present?
| |
| stryped@hotmail.com 2005-05-05, 5:58 pm |
| What types of tests are required for lymphoma?
Guys and Gals, I really appreciate your advice. Is there any other
information I could provide?
| |
| Manky Badger 2005-05-05, 5:58 pm |
|
<stryped@hotmail.com> wrote in message
news:1115308444.454025.186360@o13g2000cwo.googlegroups.com...
> But, with it being normal, a 1.1, would that mean the infection is
> gone?
>
> I went to see the doctor for recurrent fevers I have been having every
> 3 months or so. They come quickly with flu like symptoms and go
> quickly.
>
> My bloodwork initially showed a high c reactive protein level while I
> was sick.
As it should. High CRP means you're sick !
> It also should my Lymphocytes to be 14.1 which was low
> according to the range on the test.
14.1 what ? Grams per litre ? Pints ? Pence per gallon ?
> I was refered to an infectious disease doctor this week. She took more
> blood and scheduled me for a Gallium scan.
Lymphoma isn't considered an infectious disease.
> I just found out my c reactive protein was 1.1 with normal being 0.0 to
> 4 something. She did not do another cbc.
C reactive protein isn't part of a cbc
> On the first test pretty much everythign was normal but the lymphocytes
> as i said and something that says "GR" was high.
>
> White blood cells were 9.8 which was in range and red blood cells were
> 4.78 which was in range.
If your white cell count is 9.8 I think it's rather unlikely that your
lymphocytes would be 14.1. Again, what are the units.
I'm reminded of the apochrypal tale of the medical student with Hodgkin's
lymphoma who committed suicide for fear of the lymphome. At post mortem it
transpired there was nothing wrong with him.
Talk to your doctor.
| |
| TwitteringOne 2005-05-05, 5:58 pm |
|
Manky Badger wrote:
> <stryped@hotmail.com> wrote in message
> news:1115308444.454025.186360@o13g2000cwo.googlegroups.com...
every[vbcol=seagreen]
I[vbcol=seagreen]
>
> As it should. High CRP means you're sick !
>
>
> 14.1 what ? Grams per litre ? Pints ? Pence per gallon ?
>
more[vbcol=seagreen]
>
> Lymphoma isn't considered an infectious disease.
>
0.0 to[vbcol=seagreen]
>
> C reactive protein isn't part of a cbc
>
lymphocytes[vbcol=seagreen]
were[vbcol=seagreen]
>
> If your white cell count is 9.8 I think it's rather unlikely that
your
> lymphocytes would be 14.1. Again, what are the units.
>
> I'm reminded of the apochrypal tale of the medical student with
Hodgkin's
> lymphoma who committed suicide for fear of the lymphome. At post
mortem it
> transpired there was nothing wrong with him.
>
> Talk to your doctor.
Gnostic nonsense.
Pungent fragrance.
Slathered sandwish.
Mayonaise.
Grey Poupon.
Pampered pillow.
| |
| stryped@hotmail.com 2005-05-05, 5:58 pm |
| This is what the cbc looks like:
Patient Limits 3
Wbc 9.8 x10^3/uL 4.5-10.5
LY 14.1 L % 20.5-51.1
MO 2.7 3 % 1.7-9.3
GR 83.2 3H % 42.2-75.2
LY# 1.4 x10^3/UL 1.2-3.4
MO# 0.3 3 x10^3/uL 0.1-0.6
GR# 8.2 3H x10^3/uL 1.4-6.5
RBC 4.78 x10^6/uL 4.0-6.0
Hgb 14.1 g/dl 11.0-18.0
Hct 42.1 % 35.0-60.0
MCV 87.9 fl 80.0-99.9
MCH 29.5 pg 27.0-31.0
MCHC 33.5 g/dl 33.0-37.0
RDW 13.7 % 11.6-13.7
PLT 171 x10^3/uL 150-450
MPV 7.9 fL 7.8-11.0
Any help is appreciated!
| |
| Twittering One 2005-05-05, 5:58 pm |
| Yes,
But what are standard ranges of norm,
For each measure?
| |
| stryped@hotmail.com 2005-05-05, 5:58 pm |
| I assume the range of numbers under "Patient limits". What is on there
is exactly as it is on my sheet.
| |
| Twittering One 2005-05-05, 5:58 pm |
|
stry...@hotmail.com wrote:
> I assume the range of numbers under "Patient limits". What is on
there
> is exactly as it is on my sheet.
You need a professionl to interpret those numbers, for norm range,
if you are not familiar with medical research, eg,
using a Merck Manual etc. Best to seek an expert.
| |
| stryped@hotmail.com 2005-05-05, 5:58 pm |
| Is there somewhere or someone online that could help me?
| |
| Norminn 2005-05-05, 5:58 pm |
|
stryped@hotmail.com wrote:
> Is there somewhere or someone online that could help me?
>
Here is a link to an article discussing CRP. CRP is only one indicator,
and not conclusive of anything. The article discusses issues which I
believe you have encountered before.
http://www.yourhealthbase.com/heart_CRP.htm
| |
| J. Davidson 2005-05-05, 10:56 pm |
| I don't think it should be ignored. (TB test)
Jackie Davidson
<stryped@hotmail.com> wrote in message
news:1115316852.015237.82310@o13g2000cwo.googlegroups.com...
> No, should I?
>
| |
| Jason 2005-05-05, 10:56 pm |
| In article <1115316995.794036.92810@o13g2000cwo.googlegroups.com>,
stryped@hotmail.com wrote:
> What types of tests are required for lymphoma?
>
> Guys and Gals, I really appreciate your advice. Is there any other
> information I could provide?
You need to discuss these issues with your doctor. There are lots of us on
this newsgroup that are NOT doctors. If you took advice from anyone that
is not a doctor--it could cause you harm. Your doctor knows MORE about
your medical problems than anyone in this newsgroup could possibly know
since none of us have examined you or taken a look at all of your medical
records. If you want to find out about lymphoma--visit these websites:
webmd.com
www.nlm.nih.gov/medlineplus
--
NEWSGROUP SUBSCRIBERS MOTTO
We respect those subscribers that ask for advice or provide advice.
We do NOT respect the subscribers that enjoy criticizing people.
| |
| J. Davidson 2005-05-05, 10:56 pm |
| Comparing to the lab norms for my drs. lab:
You seem to be in normal range for all but
GR# where you are apparently 8.2 and norm is 1.4 to 6.5
I do not know what this means.
Jackie
<stryped@hotmail.com> wrote in message
news:1115325928.445426.312460@o13g2000cwo.googlegroups.com...
> This is what the cbc looks like:
>
> Patient Limits 3
> Wbc 9.8 x10^3/uL 4.5-10.5
> LY 14.1 L % 20.5-51.1
> MO 2.7 3 % 1.7-9.3
> GR 83.2 3H % 42.2-75.2
> LY# 1.4 x10^3/UL 1.2-3.4
> MO# 0.3 3 x10^3/uL 0.1-0.6
> GR# 8.2 3H x10^3/uL 1.4-6.5
> RBC 4.78 x10^6/uL 4.0-6.0
> Hgb 14.1 g/dl 11.0-18.0
> Hct 42.1 % 35.0-60.0
> MCV 87.9 fl 80.0-99.9
> MCH 29.5 pg 27.0-31.0
> MCHC 33.5 g/dl 33.0-37.0
> RDW 13.7 % 11.6-13.7
> PLT 171 x10^3/uL 150-450
> MPV 7.9 fL 7.8-11.0
>
>
> Any help is appreciated!
>
| |
| stryped@hotmail.com 2005-05-05, 10:56 pm |
| I know and I plan to follow up with her. I just like hearing different
opinions. Could anyone answer this: the second time I had my crp tested
and it was normal I still had a fever. Wouldnt my crp have to be
abnormal to have a fever?
Also I still have a fever of 99 or so that comes and goes for some
reason. What could that be other than lymphoma?
| |
| OmManiPadmeOmelet 2005-05-05, 10:56 pm |
| In article <1115341186.445234.34990@o13g2000cwo.googlegroups.com>,
stryped@hotmail.com wrote:
> I know and I plan to follow up with her. I just like hearing different
> opinions. Could anyone answer this: the second time I had my crp tested
> and it was normal I still had a fever. Wouldnt my crp have to be
> abnormal to have a fever?
>
> Also I still have a fever of 99 or so that comes and goes for some
> reason. What could that be other than lymphoma?
>
_lots_ of things...
Google it.
Hopefully, you may be scaring yourself needlessly. ;-)
At least we hope so!!!!!
http://www.google.com/search?hl=en&...ined+periodic+f
evers
Blessings!!!
--
Om.
"My mother never saw the irony in calling me a son-of-a-XXXXX." -Jack Nicholson
| |
| JEDilworth 2005-05-06, 9:18 am |
| http://web2.iadfw.net/uthman/lab_test.html
Scroll down to the section on Hemoglobin/Hematocrit, etc. This website
is by a clinical pathologist and has lots of information regarding lab
testing.
Your total WBC (white cell count) is 9.8, which is on the high side, but
according to the lab normal posted, still in normal range.
LY = Lymphocytes, which are at 14.1%. That means that, of the 9.8 X
10^3, 14.1% of your white cells are lymphocytes. The percentages of each
type of cell should add up to 100%.
MO = Monocytes
GR = Granulocytes (which include segmented neutrophils, eosinophils, and
basophils. Most blood counting instruments lump these all together).
The numbers that follow are the ABSOLUTE counts of each, not
percentages. Dr. Uthman explains all this on this page of his:
http://web2.iadfw.net/uthman/blood_cells.html
Absolute counts are actually more diagnostic than percentage counts, and
can vary based on diseases. All of these parameters can help diagnose
different diseases that can present in a routine blood count. Hematology
is really really complicated. I know basic stuff, and that's about it.
The other numbers are red cell indices, indicating size of red cell.
They are calculations based on the hemoglobin. RDW is red cell
distribution width. If you have lots of different sizes of RBC's, your
RDW will be abnormal. PLT is platelet count. Yours is normal. I don't
know what MPV is.
The reason that you can't get anyone to commit to a diagnosis on this
group is that this group is peopled by LAB TECHNOLOGISTS. We run the
tests, but it is NOT OUR BUSINESS to make diagnoses. We furnish the
doctors the raw data from the tests ordered BY THE PHYSICIANS and then
the doc, based on lab results, his history, and physical exam, the
latter two of which the lab is NOT privy to, in most cases, makes a
diagnosis and a recommendation for treatment.
I am confused as to why you are assuming you have lymphoma. Are you
cashing in all your chips on one elevated CRP result? There must be
something in your history that prompted your seeing an ID doctor.
http://www.c-rptest.com/about_crp.asp
Here is some information on the different types of CRP testing. I have
been in microbiology exclusively since 1988, so don't know much about
this testing. I was always taught that CRP was an indicator of
inflammation. I know they are using it now with cardiac testing, but
don't know much about it.
http://www.questdiagnostics.com/hcp.../cardiocrp.html
We can only help you so much on this newsgroup, as we are, for the most
part, NOT physicians. Hope you do understand our predicament.
Judy Dilworth, M.T. (ASCP)
Microbiology
(but did some basic Chemistry/Hematology way back when for
awhile....:-))
<stryped@hotmail.com> wrote in message
news:1115325928.445426.312460@o13g2000cwo.googlegroups.com...
> This is what the cbc looks like:
>
> Patient Limits 3
> Wbc 9.8 x10^3/uL 4.5-10.5
> LY 14.1 L % 20.5-51.1
> MO 2.7 3 % 1.7-9.3
> GR 83.2 3H % 42.2-75.2
> LY# 1.4 x10^3/UL 1.2-3.4
> MO# 0.3 3 x10^3/uL 0.1-0.6
> GR# 8.2 3H x10^3/uL 1.4-6.5
> RBC 4.78 x10^6/uL 4.0-6.0
> Hgb 14.1 g/dl 11.0-18.0
> Hct 42.1 % 35.0-60.0
> MCV 87.9 fl 80.0-99.9
> MCH 29.5 pg 27.0-31.0
> MCHC 33.5 g/dl 33.0-37.0
> RDW 13.7 % 11.6-13.7
> PLT 171 x10^3/uL 150-450
> MPV 7.9 fL 7.8-11.0
>
>
> Any help is appreciated!
>
| |
|
| In article <NeGdnYVBtIeZYuffRVn-3Q@buckeye-express.com>,
"JEDilworth" <bactitech@nospamhortonsbay.com> wrote:
> http://web2.iadfw.net/uthman/lab_test.html
>
> Scroll down to the section on Hemoglobin/Hematocrit, etc. This website
> is by a clinical pathologist and has lots of information regarding lab
> testing.
>
> Your total WBC (white cell count) is 9.8, which is on the high side, but
> according to the lab normal posted, still in normal range.
>
> LY = Lymphocytes, which are at 14.1%. That means that, of the 9.8 X
> 10^3, 14.1% of your white cells are lymphocytes. The percentages of each
> type of cell should add up to 100%.
>
> MO = Monocytes
> GR = Granulocytes (which include segmented neutrophils, eosinophils, and
> basophils. Most blood counting instruments lump these all together).
His granulocyte count was high enough to call for a manual differential.
I don't understand why that lab did not do it. It would be interesting
to see if he had any immature neutrophils.
Many really modern instruments (including the new coulter series with
the laser flow cytometer) differentiate between Segs, eos, and baso's
now. The 3 dimentional scattergrams can also show you if there is a
population of immature cells and which cell line they are in.
The thing is, the reduced lymphocyte percentage does not necessarily
mean anything. The elevation of the granulacyte count and skew that and
may even indicate bacterial infection. The fever is low grade tho'.
He said he had some gastrointestinal problems earlier in his history.
There might be something going on there!
>
> The numbers that follow are the ABSOLUTE counts of each, not
> percentages. Dr. Uthman explains all this on this page of his:
>
> http://web2.iadfw.net/uthman/blood_cells.html
>
> Absolute counts are actually more diagnostic than percentage counts, and
> can vary based on diseases. All of these parameters can help diagnose
> different diseases that can present in a routine blood count. Hematology
> is really really complicated. I know basic stuff, and that's about it.
>
> The other numbers are red cell indices, indicating size of red cell.
> They are calculations based on the hemoglobin. RDW is red cell
> distribution width. If you have lots of different sizes of RBC's, your
> RDW will be abnormal. PLT is platelet count. Yours is normal. I don't
> know what MPV is.
Mean platelet volume. Indicates platelet size.
>
> The reason that you can't get anyone to commit to a diagnosis on this
> group is that this group is peopled by LAB TECHNOLOGISTS. We run the
> tests, but it is NOT OUR BUSINESS to make diagnoses. We furnish the
> doctors the raw data from the tests ordered BY THE PHYSICIANS and then
> the doc, based on lab results, his history, and physical exam, the
> latter two of which the lab is NOT privy to, in most cases, makes a
> diagnosis and a recommendation for treatment.
Very true. ;-) It's a standing joke in the lab field that we know just
enough to be dangerous. <lol>
Diagnosis cannot be made on the basis of lab results alone! A patient
history must also be considered along with other diagnostic tests
outside of the laboratory.
Has he been checked for malaria? How severe are the fevers? Has he ever
been outside of the country? What is his eosinophil count? There are
other blood parasites that can do this.
This is why I pointed him to google. There are dozens of possible causes
for intermittant fevers! (fever of unknown origin). I'd not panic about
Lymphoma until it was proven without a doubt to be the problem...
>
> I am confused as to why you are assuming you have lymphoma. Are you
> cashing in all your chips on one elevated CRP result? There must be
> something in your history that prompted your seeing an ID doctor.
>
> http://www.c-rptest.com/about_crp.asp
Wonder if they ran a sed rate...
Just kidding. ;-)
I think he is just scared. People tend to presume the worst.
I think the doctor that even told him of that possibility with no
absolute proof of it was, well, irresponsible at best.
>
> Here is some information on the different types of CRP testing. I have
> been in microbiology exclusively since 1988, so don't know much about
> this testing. I was always taught that CRP was an indicator of
> inflammation. I know they are using it now with cardiac testing, but
> don't know much about it.
>
> http://www.questdiagnostics.com/hcp.../cardiocrp.html
>
> We can only help you so much on this newsgroup, as we are, for the most
> part, NOT physicians. Hope you do understand our predicament.
>
> Judy Dilworth, M.T. (ASCP)
> Microbiology
> (but did some basic Chemistry/Hematology way back when for
> awhile....:-))
I read his CBC and I don't see how anyone can attempt to make a
diagnosis based on that alone. AFAIK, CRP is not specific for lymphoma
either?
I also wonder if anyone even looked at the peripheral smear, and was it
reviewed by a pathologist???
K. MT (ASCP) former hematology supervisor.....
>
> <stryped@hotmail.com> wrote in message
> news:1115325928.445426.312460@o13g2000cwo.googlegroups.com...
>
--
K.
Sprout the MungBean to reply
"I don't like to commit myself about heaven and hell‹you
see, I have friends in both places." --Mark Twain
| |
| stryped@hotmail.com 2005-05-06, 9:18 am |
| Thanks for the information. This is very educational and interesting.
Have not been out of the country. Not sure what eosinophil count is.
In December of 2003 I had 5 days of really bad flu. SInce then, I have
had fevers and flu like symptoms come suddenly every 3 months or so. My
fever goes up to about 100 to 102, I get chills and achs. I go to bed
and usually feel a little better when I get up and by the next day feel
fine.
Starting in December 2003 I have lost some weight but I also went on a
diet at this same time. I have lost abotu 30 lbs since 2003. I was on
Atkins for a long time. (Not the full blown atkins)
I have been off it for awhile and have gained some back but not much.
For the last week I have noticed in the afternoons my temperature goes
to around 99.2. In the morning it is 97.5 or so when I first get up.
It usually goes to 98.7 or so right before bed.
Two years ago I had a swollen lympth node under my arm that was
painless. Went to the family doctor, he did a cbc which was normal. The
node went back to normal in about a week.
I have had stomach bloating and constipation for the last 3 years. I
take 4 table spoons of Milk of Magnesia every night.
By the way, this low grade fever has lasted for about 2 weeks or so. It
used to go away but is kind of lingering. It is funny, It got up to
99.2 or so after work yesterday when I got home and I panicked because
I was sure it was lymphoma. I called my uncle and had a nice
conversation with him for about an hour on the phone untill bedtime. I
checked my temperature before going to bed and it was 98.6 or so.
| |
| JEDilworth 2005-05-06, 5:57 pm |
| I worked for a private laboratory at a small draw station years ago. We
had strict guidelines when a manual differential should be run, and when
the tube should be sent up to the "main lab" for more intensive review.
My guidelines were pretty strict, which was good, I think, as I was by
myself and had no one else to run questions by when diffs got weird. I
was pretty much limited to signing out extremely normal CBC's on my own.
This was good as my main background up until that point was microbiology
(although I think I could still recognize a good Dohle body :-)).
I would think the elevated granulocytes alone would flag. I'm also
surprised a manual differential wasn't done.
Stryped - eosinophils are lumped into the granulocyte count. Granulocyte
count is a total of neutrophils, eosinophils, and basophils. If grans
are elevated, usually a manual slide is made and looked at - but it
depends on your lab's guidelines for making manual slides, and the
scattergram results you get in the lab on your printout, along with lots
of other factors (that Katra knows about and I do not.)
Katra - where do the monos go on a three part diff? Just curious. I
never worked with one of these BIG :-) counters. My experience goes back
to some weirdo Corning instrument that was old in 1988 (last time I did
Hematology) and an old Coulter S I used in the mid-80's (a castoff they
brought to my draw station lab). The scattergram technology was just
starting in the mid-80's, and I never got to work with it.
Yes, I agree - how did we get to lymphoma from one CBC and CRP result?
Judy Dilworth, M.T. (ASCP)
Microbiology
| |
| JEDilworth 2005-05-06, 5:57 pm |
| Stryped, what you're describing is a classic "fever of unknown origin"
case. These are usually referred to infectious disease doctors, who
tailor their workup to your history.
The fact that you have repeated fevers indicate to me that you need to
visit one SOONER than later. Have your doc give you a referral. Family
docs and internal medicine people usually don't have the investigatory
skills to work out the many causes of this diagnosis. ID docs completed
internal medicine first - before they specialize in infectious disease.
Therefore, if your problem doesn't turn out to be caused by an
infection, they should be able to handle getting you to the correct
doctor.
Eosinophils are a type of blood cell (granulocyte) that can become
extremely elevated in parasitic infections, or mildly elevated in an
allergy situation.
In micro, we get the results of FUO workups. I'm sure Katra sees the
hematology part of the workup, but micro and serology sees the
serological and culture side. The ID doc will take a good history from
you (hope you have good insurance, because an FUO workup can cost some
bucks). He/she should include a detailed travel history, even if it was
not out of the country. Certain parts of the US (are you in the US???)
and I'm sure other countries are "notorious" for certain diseases and
they will want to know that.
Body temperatures cycle up and down during the day (ask any woman who's
checking temperatures for ovulation). A 99.2 temp down to a 98.6 isn't
really much. A temp of 100-102 is, however.
http://www.wrongdiagnosis.com/sym/fuo.htm
I don't know anything about this website (found it on Google) but this
should keep you busy for awhile....
This may be a better website, and includes an "official" definition of
FUO:
http://www.5mcc.com/Assets/SUMMARY/TP0341.html
Judy Dilworth, M.T. (ASCP)
Microbiology
<stryped@hotmail.com> wrote in message
news:1115383914.593526.164340@z14g2000cwz.googlegroups.com...
> Thanks for the information. This is very educational and interesting.
| |
| Robert 2005-05-06, 5:57 pm |
|
"JEDilworth" <bactitech@nospamhortonsbay.com> wrote in message
news:862dne1vbqb2f-bfRVn-iw@buckeye-express.com...
> I worked for a private laboratory at a small draw station years ago. We
> had strict guidelines when a manual differential should be run, and when
> the tube should be sent up to the "main lab" for more intensive review.
> My guidelines were pretty strict, which was good, I think, as I was by
> myself and had no one else to run questions by when diffs got weird. I
> was pretty much limited to signing out extremely normal CBC's on my own.
> This was good as my main background up until that point was microbiology
> (although I think I could still recognize a good Dohle body :-)).
>
> I would think the elevated granulocytes alone would flag. I'm also
> surprised a manual differential wasn't done.
Three part differentials are no less accurate then 5 part differentials. In
some instances they are more accurate meaning the problems associated with
getting an accurate basophil eos count with the 5 part is common.
Flags are important but if no flags are present than the mere presence of
increased granulocyte percent is not important. Bands are not important and
immature in the myelocte metamyeolocyte would generate a flag for manual
diff. The total WBC is often a better predictor of infection in many cases.
>
> Stryped - eosinophils are lumped into the granulocyte count. Granulocyte
> count is a total of neutrophils, eosinophils, and basophils. If grans
> are elevated, usually a manual slide is made and looked at - but it
> depends on your lab's guidelines for making manual slides, and the
When the granulocyte percent is very high in the 90% range with the three
part diff is common to generate a manual diff but usually the trigger is a
flag before it reaches that range.
> scattergram results you get in the lab on your printout, along with lots
> of other factors (that Katra knows about and I do not.)
>
> Katra - where do the monos go on a three part diff? Just curious. I
Granulocytes mononuclears lymphocytes.
LY 14.1 L % 20.5-51.1
MO 2.7 3 % 1.7-9.3
GR 83.2 3H % 42.2-75.2
> never worked with one of these BIG :-) counters. My experience goes back
These are not big counters. 2 ft by 2 1/2ft front view.
The 5 part ones are much larger.
> to some weirdo Corning instrument that was old in 1988 (last time I did
> Hematology) and an old Coulter S I used in the mid-80's (a castoff they
> brought to my draw station lab). The scattergram technology was just
> starting in the mid-80's, and I never got to work with it.
>
> Yes, I agree - how did we get to lymphoma from one CBC and CRP result?
My impression was the doctor told him the possibility of that as he was
referred to an infectious disease doctor and working down the differential
diagnosis. Work in progress.
>
> Judy Dilworth, M.T. (ASCP)
> Microbiology
>
| |
| Robert 2005-05-06, 10:51 pm |
|
"Twittering One" <twitteringone@aol.com> wrote in message
news:1115424150.366931.300130@o13g2000cwo.googlegroups.com...
> ~ * Work In Progress,
> Indeed ~ ! *
>
Sorry about the wording there as there is a working diagnosis until a
definitive diagnosis is reached after the studies to rule in or rule out the
working diagnosis.
I forgot to mention that any eosinophilia would be evident in a histogram of
the granulocytes as atypical and thus a flag would be generated even though
the percent granulocytes may be normal in a three part diff. The basophils
are also registered in the mononuclear fraction with the monocytes.
| |
| JEDilworth 2005-05-06, 10:51 pm |
| Thanks for catching me up on technology in the hematology department. I
forgot that many instruments are not nearly as huge as they were back in
the 80's.
I didn't realize that these instruments were that sensitive to abnormal
cells. It makes sense that eos would give a different scattergram than
other granulocytes. I received a cursory onceover with this technology
almost twenty years ago, so thanks for the review.
When I started working in labs back in 1971, I was a secretary for two
years before I went into MT training. I remember that they were working
with Coulter F's and my lab upgraded to an S right before I went into
training in June of 1973. This was a HUGE BIG DEAL back then, believe
me. The idea that you could hold a tube of blood up to an instrument and
it would spit out an entire hemogram was just an amazing thing. Platelet
counting didn't come until later, and the S did not include a platelet
count. It did include all the indices, though. When I was a secretary,
my tiny office was right off of the Hematology lab, so I could hear the
hematology conversation all day. It was quite interesting. They were
still doing platelets manually, and therefore only did them if one was
ordered, although we always reported a platelet estimate on every slide.
Reticulocyte counts were also done manually. Those are automated now,
aren't they?
My room was the file room, and I filed tons of reports, as we were not
computerized back then. Everything was on paper and charted by hand. I
still had to perform manual RBC and WBC counts and compare to the
Coulter when I was a student. I don't know how long they required that
to be done, but it sure was a waste of time (although it taught you to
hate manual counts - talk about tedious!). When I worked for a private
lab in the 80's, we had a small counter that was similar to a Coulter F
that required cup dilutions for the counts, then lysing for the
hemoglobins. It was a nice little counter, though - I don't remember the
brand name. They bought me that after the old Coulter S kind of died.
The latter ate a lot of expensive reagents.
Also sorry I didn't remember the first part of the thread. I have my
newsgroup reader set to only show new entries and didn't go back to
review before I wrote.
Thanks for all the great information.
Judy Dilworth, M.T. (ASCP)
Microbiology
"Robert" <Robertitsme@hotmail.com> wrote in message
news:yoadncPsqaEQcebfRVn-qg@got.net...
[lots of interesting stuff :-)]
| |
| stryped@hotmail.com 2005-05-06, 10:51 pm |
| But, with it being normal, a 1.1, would that mean the infection is
gone?
I went to see the doctor for recurrent fevers I have been having every
3 months or so. They come quickly with flu like symptoms and go
quickly.
My bloodwork initially showed a high c reactive protein level while I
was sick. It also should my Lymphocytes to be 14.1 which was low
according to the range on the test.
I was refered to an infectious disease doctor this week. She took more
blood and scheduled me for a Gallium scan.
I just found out my c reactive protein was 1.1 with normal being 0.0 to
4 something. She did not do another cbc.
On the first test pretty much everythign was normal but the lymphocytes
as i said and something that says "GR" was high.
White blood cells were 9.8 which was in range and red blood cells were
4.78 which was in range.
The first doctor checked me for Rocky Mountain Spotted fever,
EBV,CMV,liver function, thyroid, etc. All were fine.
| |
| Robert 2005-05-07, 8:55 am |
|
"JEDilworth" <bactitech@nospamhortonsbay.com> wrote in message
news:-LudnY-ez7r5reHfRVn-1Q@buckeye-express.com...
> Thanks for catching me up on technology in the hematology department. I
> forgot that many instruments are not nearly as huge as they were back in
> the 80's.
>
> I didn't realize that these instruments were that sensitive to abnormal
> cells. It makes sense that eos would give a different scattergram than
> other granulocytes. I received a cursory onceover with this technology
> almost twenty years ago, so thanks for the review.
>
> When I started working in labs back in 1971, I was a secretary for two
> years before I went into MT training. I remember that they were working
> with Coulter F's and my lab upgraded to an S right before I went into
> training in June of 1973. This was a HUGE BIG DEAL back then, believe
> me. The idea that you could hold a tube of blood up to an instrument and
> it would spit out an entire hemogram was just an amazing thing. Platelet
> counting didn't come until later, and the S did not include a platelet
> count. It did include all the indices, though. When I was a secretary,
> my tiny office was right off of the Hematology lab, so I could hear the
> hematology conversation all day. It was quite interesting. They were
> still doing platelets manually, and therefore only did them if one was
> ordered, although we always reported a platelet estimate on every slide.
> Reticulocyte counts were also done manually. Those are automated now,
> aren't they?
>
> My room was the file room, and I filed tons of reports, as we were not
> computerized back then. Everything was on paper and charted by hand. I
> still had to perform manual RBC and WBC counts and compare to the
> Coulter when I was a student. I don't know how long they required that
> to be done, but it sure was a waste of time (although it taught you to
> hate manual counts - talk about tedious!). When I worked for a private
> lab in the 80's, we had a small counter that was similar to a Coulter F
> that required cup dilutions for the counts, then lysing for the
> hemoglobins. It was a nice little counter, though - I don't remember the
> brand name. They bought me that after the old Coulter S kind of died.
> The latter ate a lot of expensive reagents.
>
> Also sorry I didn't remember the first part of the thread. I have my
> newsgroup reader set to only show new entries and didn't go back to
> review before I wrote.
>
> Thanks for all the great information.
>
> Judy Dilworth, M.T. (ASCP)
> Microbiology
>
> "Robert" <Robertitsme@hotmail.com> wrote in message
> news:yoadncPsqaEQcebfRVn-qg@got.net...
>
> [lots of interesting stuff :-)]
>
| |
| Robert 2005-05-07, 8:55 am |
|
"Robert" <Robertitsme@hotmail.com> wrote in message
news:3vSdnTGhjJ8y2-HfRVn-2Q@got.net...
>
Meant to say yes retics are automated and routinely used and some
instruments such as Cell dyn 4000 can be used in flow cytometry. The laser
instrument has been adapted from other flow cytometry for use in CD4 counts
for example or fetal cell detection for Rhogam testing or immunological
platelet counts with monoclonal antibodies.
| |
|
| In article <862dne1vbqb2f-bfRVn-iw@buckeye-express.com>,
"JEDilworth" <bactitech@nospamhortonsbay.com> wrote:
> I worked for a private laboratory at a small draw station years ago. We
> had strict guidelines when a manual differential should be run, and when
> the tube should be sent up to the "main lab" for more intensive review.
> My guidelines were pretty strict, which was good, I think, as I was by
> myself and had no one else to run questions by when diffs got weird. I
> was pretty much limited to signing out extremely normal CBC's on my own.
> This was good as my main background up until that point was microbiology
> (although I think I could still recognize a good Dohle body :-)).
<grins> I know what you mean...
It's nice to be able to run weird stuff by other co-workers!
Same goes for Gram stains, (especially on postive blood cultures) and
O&P's if you have a poor specimen...
>
> I would think the elevated granulocytes alone would flag. I'm also
> surprised a manual differential wasn't done.
Indeedy!
>
> Stryped - eosinophils are lumped into the granulocyte count. Granulocyte
> count is a total of neutrophils, eosinophils, and basophils. If grans
> are elevated, usually a manual slide is made and looked at - but it
> depends on your lab's guidelines for making manual slides, and the
> scattergram results you get in the lab on your printout, along with lots
> of other factors (that Katra knows about and I do not.)
Heh. When we got the Coulter LH-750, our lab was still doing manual
diffs on about 80% or more of CBC's. It was ridiculous! I was able to
work with the pathologist to re-set our standards based on nation wide
standards set by other LH users. We now are down to 20% to 25% of CBC's
which is why it ticks me off when some people get "lazy" on us. <sigh>
I finally discussed the issue with the new Hem. supervisor. I advised
her that if she and others chose to make "exceptions" to the rules, it
needed to be documented and approved by the medical staff, then signed
off by the path. in charge. I'm still training her it seems. If she does
not document the "exceptions" in the diff procedure, she is gonna get
nailed by CAP on the next inspection!
I can't help but wonder if someone got "lazy" on his CBC and chose not
to do a manual diff. when it should have been!
>
> Katra - where do the monos go on a three part diff? Just curious. I
> never worked with one of these BIG :-) counters. My experience goes back
> to some weirdo Corning instrument that was old in 1988 (last time I did
> Hematology) and an old Coulter S I used in the mid-80's (a castoff they
> brought to my draw station lab). The scattergram technology was just
> starting in the mid-80's, and I never got to work with it.
Oh my!
The new Coulter laser technology is a real DREAM! Even the last Sysmex
we had did a 5 part diff and flagged if there were bands/immature cells.
The newer 5 part diff technology is well over 10 years old now.
Unlike the Coulter, the Sysmex used lyse-specific reagents. The Coulter
uses Laser flow cytometry technology. Much better and fewer boxes to
move around <lol>
I'm not sure I understand your question? Are you asking about
Scattergrams or Histograms? They are on the lower part of the
scattergram and are well grouped. The new LH series has a 3 dimentional
scattergram and you can remove "cell groups" to visualize each one
separately. It's AWEsome! The cell groups are also different colors.
If you remove Eos, Baso's, Seg's, Lymph's and unlysed RBC groups, you
can see the Mono group by itself and look for a separate grouping for
immature cells. Pro-Monocytes and Mono-Blasts are rare unless you run
into the rare Monocytic Leukemias...
>
> Yes, I agree - how did we get to lymphoma from one CBC and CRP result?
>
> Judy Dilworth, M.T. (ASCP)
> Microbiology
:-)
>
--
K.
Sprout the MungBean to reply
"I don't like to commit myself about heaven and hell‹you
see, I have friends in both places." --Mark Twain
| |
|
| In article <dIGdnZduC6o6leHfRVn-1g@got.net>,
"Robert" <Robertitsme@hotmail.com> wrote:
> "Twittering One" <twitteringone@aol.com> wrote in message
> news:1115424150.366931.300130@o13g2000cwo.googlegroups.com...
> Sorry about the wording there as there is a working diagnosis until a
> definitive diagnosis is reached after the studies to rule in or rule out the
> working diagnosis.
> I forgot to mention that any eosinophilia would be evident in a histogram of
> the granulocytes as atypical and thus a flag would be generated even though
> the percent granulocytes may be normal in a three part diff. The basophils
> are also registered in the mononuclear fraction with the monocytes.
>
>
Uh, not on any Sysmex or Coulter instrument I've ever worked on!
Basophils are included in the 3 part diff granulocyte count.
3 part diff machines are primitive at best these days......... ;-)
Even the old Coulter HMX does a 5 part diff and it's considered OLD.
Don't you upgrade every 5 years????
Any ANY granulocyte count over 80% should get a manual diff!!!!!
To not do so it just sheer laziness.
And most MD's would NOT agree with you that bands are not important.
Depends on how many there are.......
--
K.
Sprout the MungBean to reply
"I don't like to commit myself about heaven and hell‹you
see, I have friends in both places." --Mark Twain
| |
| Manky Badger 2005-05-07, 8:55 am |
|
<stryped@hotmail.com> wrote in message
news:1115341186.445234.34990@o13g2000cwo.googlegroups.com...
>I know and I plan to follow up with her. I just like hearing different
> opinions. Could anyone answer this: the second time I had my crp tested
> and it was normal I still had a fever. Wouldnt my crp have to be
> abnormal to have a fever?
>
> Also I still have a fever of 99 or so that comes and goes for some
> reason. What could that be other than lymphoma?
Thank you for that paragraph above.
I shall use it, word for word, as an essay for my trainee staff.
I shall allow them only an hour to write that essay.
:o)
| |
| Robert 2005-05-07, 8:55 am |
|
"Katra" <KatraMungBean@Centurytel.net> wrote in message > > I forgot to
mention that any eosinophilia would be evident in a histogram of
though[vbcol=seagreen]
basophils[vbcol=seagreen]
> Uh, not on any Sysmex or Coulter instrument I've ever worked on!
>
> Basophils are included in the 3 part diff granulocyte count.
We used the Sysmex instrument several years back right after the coulter S
and I thought we called them mononuclear fraction instead of monocytes but I
might have messed that up as it has been years.
>
> 3 part diff machines are primitive at best these days......... ;-)
They are fine for low volumne.
>
> Even the old Coulter HMX does a 5 part diff and it's considered OLD.
Well it's not so much the machine as the flags and cuttoffs for smear review
that are important. If you have an overly sensitive machine that flags
everything including things that are not there then it becomes more of a
problem.
According to the technical reps any abnormal parameter and or flag present
should call for a smear review. So that doesn't change whether it is a three
part diff or 5. You also have the doctors who do not care for an auto diff
no matter what it is. They simply want a manual one so the machine is
worthless for that.
>
> Don't you upgrade every 5 years????
Not every five years, no. We have CD 4K and CD 3200's at our place. The 3200
gives band flags all the time when they are not there and the 4K doesn't see
them when they are there.
>
> Any ANY granulocyte count over 80% should get a manual diff!!!!!
That varies from institution to instiution and instrument.
We do not do smear reviews because of any granulocyte percentage on the Cell
Dyn's. We have smear reviews for Total WBC and white cell flags including
immature band blast atypical lymphs etc.
Years ago with the Sysmex three part diffs we did have on greater than 90%
granulocytes.
>
> To not do so it just sheer laziness.
We have smear reviews or scans on those above and if a manual diff is needed
then it is done otherwise the auto diff is reported with a comment that it
was smear reviewed.
We are a teaching hospital of 500 beds and yeah we are lazy.
The interns still order manual diffs and want them on all newborns and
elderly regardless of the autodiff.
>
> And most MD's would NOT agree with you that bands are not important.
> Depends on how many there are.......
I agree with you that most MD's would not agree with bands.
They have done many studies concerning the tech variation of scoring bands
and found CV's over 20% making it unreliable.
I might get 2 and somebody next to me gets 20%. The literature is out there
and it will go the way of the bleeding time. I bet the same doctors think
the bleeding time is great also.
The Mayo Clinic laboratories does not report bands for that reason. Because
of the unreliability of the counts the band is a poor predictor of anything
and like the PFA in replacing the bleeding time, if you can get a machine
that gives an accurate band percentage that is reproduceable then that might
be revisited.
> --
> K.
>
> Sprout the MungBean to reply
>
> "I don't like to commit myself about heaven and hell > see, I have friends
in both places." --Mark Twain
| |
| Robert 2005-05-07, 8:55 am |
|
"Katra" <KatraMungBean@Centurytel.net> wrote in message
news:KatraMungBean-15811D.01094807052005@corp.supernews.com...
> In article <862dne1vbqb2f-bfRVn-iw@buckeye-express.com>,
> "JEDilworth" <bactitech@nospamhortonsbay.com> wrote:
>
>
> <grins> I know what you mean...
> It's nice to be able to run weird stuff by other co-workers!
>
> Same goes for Gram stains, (especially on postive blood cultures) and
> O&P's if you have a poor specimen...
>
>
> Indeedy!
>
>
> Heh. When we got the Coulter LH-750, our lab was still doing manual
> diffs on about 80% or more of CBC's. It was ridiculous! I was able to
> work with the pathologist to re-set our standards based on nation wide
> standards set by other LH users. We now are down to 20% to 25% of CBC's
> which is why it ticks me off when some people get "lazy" on us. <sigh>
>
> I finally discussed the issue with the new Hem. supervisor. I advised
> her that if she and others chose to make "exceptions" to the rules, it
> needed to be documented and approved by the medical staff, then signed
> off by the path. in charge. I'm still training her it seems. If she does
> not document the "exceptions" in the diff procedure, she is gonna get
> nailed by CAP on the next inspection!
Maybe you can show me where in the CAP inspection it says that specimens
that have a greater than 80% granulocytes need a manual diff. That may be in
your lab but that in now way is a CAP standard. This is from the CAP website
checklist.
HEM.34200 Phase II N/A YES NO
Has the laboratory established criteria for checking and reviewing leukocyte
differential counter data, histograms, and/or blood films for clinically
important results flagged by the automated differential counter?
COMMENTARY:
The laboratory must have defined protocols for validation and review of
automated WBC differential counter results for clinically significant
findings. These include pathologic quantities of normal cell types and
abnormal cells. Flagging mechanisms include those within the particular
instrument, inspection of histographic/cytographic displays, laboratory
criteria based on local experience, and awareness of published evaluations.
REFERENCES: 1) Rümke CL. The statistically expected variability in
differential leukocyte counts. In: Differential leukocyte counting, CAP
conference/Aspen. Northfield, IL: CAP, 1977:39-45; 2) Payne BA, Pierre RV.
Using the three-part differential: part II. Implementation of the system.
Lab Med. 1986;17:517-522; 3) Kalish RJ, Becker K. Evaluation of the Coulter
S-Plus V three-part differential in a community hospital, including criteria
for its use. Am J Clin Pathol. 1986;86:751-755; 4) Ross DW, Bentley SA.
Evaluation of an automated hematology system (Technicon H-1). Arch Pathol
Lab Med. 1986;110:803-808; 5) NCCLS. Reference leukocyte differential count
(proportional) and evaluation of instrumental methods; approved standard
H20-A. Wayne, PA: NCCLS, 1991; 6) Miers MK, et al. White blood cell
differentials as performed by the Technicon H-1; evaluation and
implementation in a tertiary care hospital. Lab Med. 1991;22:99-106; 7)
Hallawell R, et al. An evaluation of the Sysmex NE-8000 hematology analyzer.
Am J Clin Pathol. 1991;96:594-601; 8) Cornbleet PJ, et al. Evaluation of
the Cell-Dyn 3000 differential. Am J Clin Pathol. 1992;98:603-614; 9)
NCCLS. Method comparison and bias estimation using patient samples;
tentative guideline EP9-T. Wayne, PA: NCCLS, 1993; 10) Krause JR. The
automated white blood cell differential. A current perspective. Hematol
Oncol Clin North Am. 1994;8:605-16; 11) Goyzueta FG, et al. Automated
differential white blood cell counts in the young pediatric population. Lab
Med. 1996;27:48-52; 12) Gulati GL, et al. Suspect flags and regional flags
on the Coulter-STKS. An assessment. Lab Med. 1999;30:675-680.
>
> I can't help but wonder if someone got "lazy" on his CBC and chose not
> to do a manual diff. when it should have been!
Each site performs a validation study on site with that equipment.
Come to our lab and expect to find an 80% cuttoff for manual diff and you
will be laughed at. We do not do manual diffs or even make a smear with a
patient who has a 14000 WBC count and there are no white cell flags and
nobody cares about the percent granulocytes as a flag. The autodiff contains
the granulocytes and diffs. It is a differential. They get a WBC and
autodiff. That is based on validation studies at our site.
I am curious to see what you would find in that smear, you being an ex
hematology supervisor and the all the techs in your present bench are lazy?
Please show me a published criteria that says manual diffs must be perfomed
when granulocytes are over 80%.
Let's see your hem supervisor is poor and the people who did that CBC above
should have done a manual diff to see what?
Please tell me what you are looking for in his blood smear with the above
CBC results.
| |
|
| In article <x66dnXOYm_696eHfRVn-sQ@got.net>,
"Robert" <Robertitsme@hotmail.com> wrote:
> "Katra" <KatraMungBean@Centurytel.net> wrote in message > > I forgot to
> mention that any eosinophilia would be evident in a histogram of
> though
> basophils
>
> We used the Sysmex instrument several years back right after the coulter S
> and I thought we called them mononuclear fraction instead of monocytes but I
> might have messed that up as it has been years.
No comment on that one. ;-)
Basophils are in the granulocytic cells... Trust me.
> They are fine for low volumne.
>
> Well it's not so much the machine as the flags and cuttoffs for smear review
> that are important. If you have an overly sensitive machine that flags
> everything including things that are not there then it becomes more of a
> problem.
I have to agree with you on that! Even then, Suspect flags still get
diffs. Talking with the Coulter hematology applications specialist, even
she, working with the medical staff and the pathologists on differential
review criteria, has only been able to get manual slide reviews to 20%
of CBC's at best in larger facilities. We are only a 120 bed hospital
with a large out patient population and OP surgical center.
I had the criteria from several different hospitals faxed to me to help
us decide on our numerical cutoffs. Those are combined with both/either
suspect or definitive flags.
Numbers alone are _far_ from the only criteria, but there are common
sense numerical settings AFAIK.
The thing is, if your machine is flagging things that are not there
_frequently_, you need to have a service rep. check the electronic
settings.
Keep a copy of the CBC's and the manual diff reviews (and do 200 cell
diffs since machines tend to be more accurate, especially if a tech is
counting the wrong area of the slide, or you are creating poorly
made/too thick slides). There are OH so many factors to winnowing out
problems!
But when it comes to patient care, it's better to be safe than sorry!
> According to the technical reps any abnormal parameter and or flag present
> should call for a smear review. So that doesn't change whether it is a three
> part diff or 5.
True.
> You also have the doctors who do not care for an auto diff
> no matter what it is. They simply want a manual one so the machine is
> worthless for that.
Heh. Glad to see THAT problem is universal! <lol>
>
> Not every five years, no. We have CD 4K and CD 3200's at our place. The 3200
> gives band flags all the time when they are not there and the 4K doesn't see
> them when they are there.
The LH sometimes flags bands or blasts too when they are not there...
Believe it or not, sometimes that is more of a problem with mixing and
stabilization of the cells with the EDTA anticoagulant. We see it more
in fresher specimens from the ER.
Additional mixing and a re-run often get rid of erroneous flags.
With morning run samples that sit in the phlebotomy tray for any length
of time, it's not usually as much of a problem.
>
> That varies from institution to instiution and instrument.
Yes, but, there are STILL national accepted standards.
When I had to set up the criteria, I got input (as suggested by both
Coulter and CAP) from several hospitals using the same instrument.
But, think about it! 80% segs is kinda high.
We are dealing with people's LIVES here!
Do you really want to take silly chances???
> We do not do smear reviews because of any granulocyte percentage on the Cell
> Dyn's. We have smear reviews for Total WBC and white cell flags including
> immature band blast atypical lymphs etc.
Indeed. :-)
> Years ago with the Sysmex three part diffs we did have on greater than 90%
> granulocytes.
Sorry. That is too high IMHO.
>
> We have smear reviews or scans on those above and if a manual diff is needed
> then it is done otherwise the auto diff is reported with a comment that it
> was smear reviewed.
> We are a teaching hospital of 500 beds and yeah we are lazy.
> The interns still order manual diffs and want them on all newborns and
> elderly regardless of the autodiff.
We do manual diff's as requested, and also ALL pedi's 12 and under get a
manual diff. Liability on pediatric patients is too much of an issue
with our litiginous society to take any risks.
And it keesp the pediatricians off of our backs. <lol>
It's really not that much trouble, even with a high workload.
>
>
> I agree with you that most MD's would not agree with bands.
> They have done many studies concerning the tech variation of scoring bands
> and found CV's over 20% making it unreliable.
C'mon dear!
CV values are MEANINGLESS on small cell populations!
Try doing CV calculations sometime on Digoxin control results. <lol>
The smaller the numerical value, the less reliable CV calculations are.
Ever looked at the CV's of a 5 part diff on Eos and Baso control numbers?
> I might get 2 and somebody next to me gets 20%.
That is an intralaboratory training issue!!!
With proper training and in-servicing, you can correct that problem.
I know. I had to work on it in our own lab to get better consistancy on
reporting. Annual tech reviews help a LOT on that, and it's a CAP
requirement.
> The literature is out there
> and it will go the way of the bleeding time. I bet the same doctors think
> the bleeding time is great also.
<grins>
For the vast majority of laboratories that do not posses a machine for
Platelet function studies, it's currently the simplest and most reliable
plt function test.
I'm not overly fond of it, but it's all we have for now. And it's not
ordered frequently thank goodness!
> The Mayo Clinic laboratories does not report bands for that reason. Because
> of the unreliability of the counts the band is a poor predictor of anything
> and like the PFA in replacing the bleeding time, if you can get a machine
> that gives an accurate band percentage that is reproduceable then that might
> be revisited.
Give Coulter time....... ;-)
The thing is, we still have to serve the physicians needs.
Not wanting to do manual slides.......... Well, I think I made my
feelings on that abundantly clear.
Thanks for the input!
This is fun!
--
K.
Sprout the MungBean to reply
"I don't like to commit myself about heaven and hell‹you
see, I have friends in both places." --Mark Twain
| |
| Robert 2005-05-07, 8:55 am |
|
"Manky Badger" <spam@puritanDOTfreeserve.FULLSTOPcoSPOTuk> wrote in message
news:d5hntu$hb9$1@newsg1.svr.pol.co.uk...
>
> <stryped@hotmail.com> wrote in message
> news:1115341186.445234.34990@o13g2000cwo.googlegroups.com...
>
> Thank you for that paragraph above.
> I shall use it, word for word, as an essay for my trainee staff.
> I shall allow them only an hour to write that essay.
>
> :o)
>
>
With all due respect Manky, I don't think he was or is interested in your
class especially seeing how you won't post their answers here anyway. I do
hope you donate your dead body to the local medical school after your
students get to see your autopsy of course.
| |
|
| In article <ZoOdnVHIxrK34uHfRVn-vA@got.net>,
"Robert" <Robertitsme@hotmail.com> wrote:
> "Katra" <KatraMungBean@Centurytel.net> wrote in message
> news:KatraMungBean-15811D.01094807052005@corp.supernews.com...
>
>
> Maybe you can show me where in the CAP inspection it says that specimens
> that have a greater than 80% granulocytes need a manual diff. That may be in
> your lab but that in now way is a CAP standard. This is from the CAP website
> checklist.
NO NO NO!!!
You mis-understood me!!!
Some of the tech's were deciding when and when not to do manual diff's
based on the type of patient (most commonly labor and post-partum
patients) and NOT following the written review criteria! ;-)
THAT is a CAP violation, randomly not following written protocal!
IF you are going to have exceptions to your written, documented
criteria, then those exceptions must be decided on, approved by the lab
director and documented in the procedure.
>
> HEM.34200 Phase II N/A YES NO
>
> Has the laboratory established criteria for checking and reviewing leukocyte
> differential counter data, histograms, and/or blood films for clinically
> important results flagged by the automated differential counter?
> COMMENTARY:
> The laboratory must have defined protocols for validation and review of
> automated WBC differential counter results for clinically significant
> findings. These include pathologic quantities of normal cell types and
> abnormal cells. Flagging mechanisms include those within the particular
> instrument, inspection of histographic/cytographic displays, laboratory
> criteria based on local experience, and awareness of published evaluations.
Like I said, you obviously mis-read my commentary.
Your laboratory is free to set your references as you see fit based on
your population. Are other local hospitals with the same
instrumentation set as loose?
Whether I agree or disagree with your numbers is a personal opinion and
I believe I stated it as such. ;-)
<snipped references>
What was your 90% value based upon?
You must have the documentation for CAP inspectors in your
implementation manual. You can't just randomly select numbers.
I does not work that way.
We based our 80% on a number of factors, AND it had to be approved by
the hospital medical staff as well. We are not allowed to arbitrarily
set numbers to reduce our workload.
>
> Each site performs a validation study on site with that equipment.
> Come to our lab and expect to find an 80% cuttoff for manual diff and you
> will be laughed at. We do not do manual diffs or even make a smear with a
> patient who has a 14000 WBC count and there are no white cell flags and
> nobody cares about the percent granulocytes as a flag. The autodiff contains
> the granulocytes and diffs. It is a differential. They get a WBC and
> autodiff. That is based on validation studies at our site.
Whatever works for you. ;-)
Just hope a defense lawyer never gets ahold of you in a lawsuit.
> I am curious to see what you would find in that smear, you being an ex
> hematology supervisor and the all the techs in your present bench are lazy?
> Please show me a published criteria that says manual diffs must be perfomed
> when granulocytes are over 80%.
Let's just say that the majority of diff's that we do are positive, (we
keep track of that to monitor over-flagging by the machine), so at this
point, the 80% appears to be justified.
Oh, and I was not fired as supervisor. For a number of complicated
reasons, I resigned the position.
Something to do with being forced to change shifts if I kept it, for a
$7,000 per year paycut. :-P
Lab politics.
I was supervisor for over 12 years thru 3 different instruments.
> Let's see your hem supervisor is poor and the people who did that CBC above
> should have done a manual diff to see what?
> Please tell me what you are looking for in his blood smear with the above
> CBC results.
Left shift and immature cells.
They seem to be significant enough to our medical staff, and we are
there to serve THEIR needs.
Not our own.
From the reviews I've done, we are only having a laziness problem with 3
out of the 20 people performing CBC's
It's being dealt with.
Cheers!
--
K.
Sprout the MungBean to reply
"I don't like to commit myself about heaven and hell‹you
see, I have friends in both places." --Mark Twain
| |
| JEDilworth 2005-05-07, 11:54 am |
| While I'm reading the discussions on Hematology methods between Katra
and Robert, it is very interesting to see that Hematology has lots of
different viewpoints, just like micro. I come from a very anal retentive
lab background, and now am working in a lab where things are much more
laissez faire with regards to interpretation. I think it's good,
however, that I came from a "rules" background as it helps me make
better decisions in this looser environment.
With all due respect, I as a patient would like someone to look at my
slide if I were running 80% granulocytes. :-)
Small story: my mother-in-law, who is now deceased, presented at my
little outpatient lab back in 1985 for her "yearly" blood work (yes they
did that stuff back then). She hadn't been feeling that great, but
otherwise was supposed to be in good health. I sent her CBC up to the
main lab as I really didn't want to get involved in her reporting. Good
thing I did. She had a "normal" (in the 8-9000 range) WBC count, but her
absolute lymphocytes were extremely elevated. The hematologist looked at
her slide (yes, it must have been flagged) and referred it to the
pathologist. Diagnosis was probable early CLL, confirm with bone marrow
examination. Of course, my mother-in-law called me for the results (back
in pre-HIPAA days) and I hedged and said they weren't back yet. I got
the printout and called her physician with the results. He reordered
another count a week later that came back the same. She went on to have
a bone marrow biopsy which confirmed the CLL diagnosis. She didn't
really have lots of problems with it until around 1995, when her
platelets went haywire (down) and she had to have open heart surgery to
replace a damaged heart valve. Apparently it was damaged when she had
had rheumatic fever in childhoos and just wore out. She had a massive
stroke right after surgery, ended up in a nursing home, and passed away
from a bowel obstruction in March, 1997.
The point of this story is that flags and absolute counts in hematology
are everything. With a normal WBC count, many labs without the advanced
technology that was available at the "big lab" at the time would never
have caught this diagnosis at such an early date. We owed a lot to the
astute Hematology supervisor at our reference lab. I have no idea
whether I would have caught this if I had done just a hemogram and
manual diff at my little lab, as my limited hematology background would
probably have missed the smudge cells and the "look" of the diff.
Gotta go to work.
Judy Dilworth, M.T. (ASCP)
Microbiology
| |
| Twittering One 2005-05-07, 5:53 pm |
| Several points, actually,
Not least ~ Privacy & Respect & Bereavement & Dignity.
Back later,
Gotta spin,
Gotta shower,
Gotta get outta here ...
CRP, or peptide marker?
See me? Hey ~ Please
Hold my hand,
Swim with me, and O, so much more ~ !
Come, lovely
Capsicum ...
| |
| Robert 2005-05-07, 5:53 pm |
|
"JEDilworth" <bactitech@nospamhortonsbay.com> wrote in message
news:OOmdnQD0bOUlQ-HfRVn-iw@buckeye-express.com...
> While I'm reading the discussions on Hematology methods between Katra
> and Robert, it is very interesting to see that Hematology has lots of
> different viewpoints, just like micro. I come from a very anal retentive
> lab background, and now am working in a lab where things are much more
> laissez faire with regards to interpretation. I think it's good,
> however, that I came from a "rules" background as it helps me make
> better decisions in this looser environment.
>
> With all due respect, I as a patient would like someone to look at my
> slide if I were running 80% granulocytes. :-)
Include that in your protocol but don't assume everybody else is doing it
and that the tech messed up or missed it because it wasn't done. That was
the whole point I was making.
It is the abosolute count that is important and not the relative percent
that is important. You also have machines that have flags. If you don't
trust the machine then there is no need in reporting out autodiffs or there
is something wrong with the protocols or the doctor considers it important
enough that a manual diff be performed.
As far as who looks at blood smears, I have never seen in all my years in
doing this an infectious disease specialist go look at a blood smear. If
they thought that seeing bands or immatures are important they would look at
the smear or order a manual diff regardless of what the diff shows. That
doesn't happen.
Clinical hematologist are always there and required to look at the blood
smear regardless of what is reported on the differential by the tech.
>
> Small story: my mother-in-law, who is now deceased, presented at my
> little outpatient lab back in 1985 for her "yearly" blood work (yes they
> did that stuff back then). She hadn't been feeling that great, but
> otherwise was supposed to be in good health. I sent her CBC up to the
> main lab as I really didn't want to get involved in her reporting. Good
> thing I did. She had a "normal" (in the 8-9000 range) WBC count, but her
> absolute lymphocytes were extremely elevated.
Again you mention absolute count and not relative percent so that is in the
right direction. We do scan a slide with an absolute lymph count greater
than 6 K or a variant lymph flag or a fragile cell percentage.
The hematologist looked at
> her slide (yes, it must have been flagged) and referred it to the
> pathologist. Diagnosis was probable early CLL, confirm with bone marrow
> examination. Of course, my mother-in-law called me for the results (back
> in pre-HIPAA days) and I hedged and said they weren't back yet. I got
> the printout and called her physician with the results. He reordered
> another count a week later that came back the same. She went on to have
> a bone marrow biopsy which confirmed the CLL diagnosis. She didn't
> really have lots of problems with it until around 1995,
They did nothing for her early on and the clinical implications would have
been the same if it had been missed back then. Like any progression she
probably had it for years before it was flagged.
when her
> platelets went haywire (down) and she had to have open heart surgery to
> replace a damaged heart valve. Apparently it was damaged when she had
> had rheumatic fever in childhoos and just wore out. She had a massive
> stroke right after surgery, ended up in a nursing home, and passed away
> from a bowel obstruction in March, 1997.
Well sorry to hear about that but her clinical course was not effected by
when it was discovered she had CLL.
>
> The point of this story is that flags and absolute counts in hematology
> are everything.
Not everything as you can never catch all the abnormals based on above. It
is not sensitive enough as I mentioned all hematologist look at smears for
very minute clues not mentioned on reports.
Blood smear interpretation is different from doing and reporting a
differential.
With a normal WBC count, many labs without the advanced
> technology that was available at the "big lab" at the time would never
> have caught this diagnosis at such an early date.
You said it was the absolute lymphs that sent it in for review so it wasn't
really the technology. If it had been done by a machine without a autodiff
and a manual diff performed then it would still have the same abnormal
morphology and sent in for review.
The treatment protocols for CLL are very poor and the course is indolent so
in the case of CLL the early aspects of diagnosis does not apply. Treatment
guidelines require A and B symptoms some of which include parameters of the
CBC.
We owed a lot to the
> astute Hematology supervisor at our reference lab. I have no idea
> whether I would have caught this if I had done just a hemogram and
> manual diff at my little lab, as my limited hematology background would
> probably have missed the smudge cells and the "look" of the diff.
In the case of CLL I think you worried needlessly as the platelet count etc
would have manifested itself and treatment rendered then.
Good luck
>
> Gotta go to work.
>
> Judy Dilworth, M.T. (ASCP)
> Microbiology
>
| |
| Robert 2005-05-07, 5:53 pm |
|
"Katra" <KatraMungBean@Centurytel.net> wrote in message
news:KatraMungBean-D29F95.03442107052005@corp.supernews.com...
> In article <x66dnXOYm_696eHfRVn-sQ@got.net>,
> "Robert" <Robertitsme@hotmail.com> wrote:
>
S[vbcol=seagreen]
but I[vbcol=seagreen]
>
> No comment on that one. ;-)
> Basophils are in the granulocytic cells... Trust me.
That wasn't the point I was making. I am aware that basophils are
granulocytes. I am also aware that machines think that blast are sometimes
basophils or that blast are monocytes. You need to talk to the machine about
that. Trust me on that one the machines don't always get it right. Sometimes
you don't even know what the machine is looking at.
>
review[vbcol=seagreen]
>
> I have to agree with you on that! Even then, Suspect flags still get
> diffs.
At your place maybe. I suggest you look at scan criteria. Me thinks you do
not do scans but manual diffs on everything. We have criteria on when to
reject the autodiff and scan the smear to see if the autodiff is valid and
if not then a manual diff is done or accept the autodiff or criteria in
rejecting the autodiff all together and only reporting a manual
differential. Two sets of criteria.
Talking with the Coulter hematology applications specialist, even
> she, working with the medical staff and the pathologists on differential
> review criteria, has only been able to get manual slide reviews to 20%
> of CBC's at best in larger facilities. We are only a 120 bed hospital
> with a large out patient population and OP surgical center.
At a 120 bed hospital you don't even need a autodiff.
I am sure the Coulter specialist can put all the medical staff in one room
and talk to them. That's good.
>
> I had the criteria from several different hospitals faxed to me to help
> us decide on our numerical cutoffs. Those are combined with both/either
> suspect or definitive flags.
They all have coulters and the same machine?
We don't have the same criteria for the CD 3200 and CD 4K. How could you as
they are different machines and different technology lasers. Are you using
their same reference range also.
>
> Numbers alone are _far_ from the only criteria, but there are common
> sense numerical settings AFAIK.
>
> The thing is, if your machine is flagging things that are not there
> _frequently_, you need to have a service rep. check the electronic
> settings.
They do frequently and we reset frquently and we recalibrate frequently.
These are high volumne output regardless of the instrument used they take a
beating.
The whole arguement on their side is that you want it sensitive so you don't
miss anything.
> Keep a copy of the CBC's and the manual diff reviews (and do 200 cell
> diffs since machines tend to be more accurate, especially if a tech is
The number of cells counted on the manual count is WBC count dependent with
a 300 count in the very high range.
> counting the wrong area of the slide, or you are creating poorly
> made/too thick slides). There are OH so many factors to winnowing out
> problems!
I am saying that not all autodiffs are accurate and not all autodiffs are
inaccurate. That all depends on reliance of validation studies that take
into account all the stuff.
>
> But when it comes to patient care, it's better to be safe than sorry!
>
Nobody is implying otherwise.
present[vbcol=seagreen]
three[vbcol=seagreen]
>
> True.
>
>
> Heh. Glad to see THAT problem is universal! <lol>
That really isn't a problem. There are clincial situations where not only
the white cell diff is important to them but the red cell morphology is also
and we have to scan a smear to be able to enter the RBC morph.
>
3200[vbcol=seagreen]
see[vbcol=seagreen]
>
> The LH sometimes flags bands or blasts too when they are not there...
> Believe it or not, sometimes that is more of a problem with mixing and
> stabilization of the cells with the EDTA anticoagulant. We see it more
> in fresher specimens from the ER.
We have our own ER lab and that is true sometimes but the technology is
different for both instruments in not only diffs but in H and Hs MCHC also.
> Additional mixing and a re-run often get rid of erroneous flags.
>
> With morning run samples that sit in the phlebotomy tray for any length
> of time, it's not usually as much of a problem.
>
>
> Yes, but, there are STILL national accepted standards.
> When I had to set up the criteria, I got input (as suggested by both
> Coulter and CAP) from several hospitals using the same instrument.
THat is your national standard. Then I misunderstood your national
standards. CAP inspections are regional. You can set anything you want as
long as you have validation studies.
If those are not working well then you can reset to diffenent levels with
validation studies.
>
> But, think about it! 80% segs is kinda high.
> We are dealing with people's LIVES here!
> Do you really want to take silly chances???
So a 79% is OK and a 81% is not OK. Do you really have confidence in your
autodiffs? I don't think so when you talk like that. It is not the relative
percent that is important and you seem to make a mistake made by many non
professionals over the intenet and that is look solely at the relative
percent and not the absolute count. Penias and philias are defined
clinically by the absolute counts. Please look up and show me where you see
an 84% granulocytes as clinical neutrophilia? You are not going to save any
lives by making that mistake.
>
Cell[vbcol=seagreen]
including[vbcol=seagreen]
>
> Indeed. :-)
>
90%[vbcol=seagreen]
>
> Sorry. That is too high IMHO.
Just trying to remember but I think that was right or maybe 85% not really
sure now but other criteria would have caught any significant abnormalities.
bands[vbcol=seagreen]
>
> C'mon dear!
> CV values are MEANINGLESS on small cell populations!
Those are clinical studies of CAP interests. The range of reporting is the
problem. It is a problem and that problem like any test that is not
performed properly is worthless clinically. Again the hallmark of any test
is it's use clinically. Take one person from every state in the union and
you will see a spread on reporting bands. That's a fact out there.
>
> Try doing CV calculations sometime on Digoxin control results. <lol>
>
> The smaller the numerical value, the less reliable CV calculations are.
There are clinical studies out there in sepsis and markers for sepsis and
you will find that absolute white cell count vs granulocyte count vs band
count that bands show poorly. Not only clinically but in performance.
>
> Ever looked at the CV's of a 5 part diff on Eos and Baso control numbers?
>
>
> That is an intralaboratory training issue!!!
Yes. It is an intralaboratory, interlaboratory and more importantly a
clinical issue that has not gone away.
> With proper training and in-servicing, you can correct that problem.
CAP has been trying to do it for years and has failed.
> I know. I had to work on it in our own lab to get better consistancy on
> reporting. Annual tech reviews help a LOT on that, and it's a CAP
> requirement.
>
>
think[vbcol=seagreen]
>
> <grins>
> For the vast majority of laboratories that do not posses a machine for
> Platelet function studies, it's currently the simplest and most reliable
> plt function test.
Again the way a test is appraised is not on how simple a test is but it's
clinical utility. It is not reliable clinically which is why CAP has pretty
much clamped down on when to order one to the point that they are rarely
down anymore.
>
| |
| Manky Badger 2005-05-07, 5:53 pm |
|
"Robert" <Robertitsme@hotmail.com> wrote in message
news:BoydnWQaObemHOHfRVn-1w@got.net...
>
> "Manky Badger" <spam@puritanDOTfreeserve.FULLSTOPcoSPOTuk> wrote in
> message
> news:d5hntu$hb9$1@newsg1.svr.pol.co.uk...
> With all due respect Manky, I don't think he was or is interested in your
> class especially seeing how you won't post their answers here anyway.
However he might get the idea that what he is asking is, quite frankly, a
stupid question in both the way it is phrased and the medium in which it is
set. To answer his question properly would involve writing an essay taking
at least an hour to do.
If anyone is interested, and if the students use a PC to do their essays, I
could post them here.
In any event, as was pointed out by someone else in this thread,
sci.med.laboratory is lab people. If he must use the internet rather than
talk to his own physician, he'd be better off talking to a doctors' group.
> I do
> hope you donate your dead body to the local medical school after your
> students get to see your autopsy of course.
Is this supposed to be some sort of threat, insult or joke ?
| |
|
| In article <OOmdnQD0bOUlQ-HfRVn-iw@buckeye-express.com>,
"JEDilworth" <bactitech@nospamhortonsbay.com> wrote:
<snipped>
>
> The point of this story is that flags and absolute counts in hematology
> are everything. With a normal WBC count, many labs without the advanced
> technology that was available at the "big lab" at the time would never
> have caught this diagnosis at such an early date. We owed a lot to the
> astute Hematology supervisor at our reference lab. I have no idea
> whether I would have caught this if I had done just a hemogram and
> manual diff at my little lab, as my limited hematology background would
> probably have missed the smudge cells and the "look" of the diff.
>
> Gotta go to work.
>
> Judy Dilworth, M.T. (ASCP)
> Microbiology
>
Thanks and have a great day! :-)
And condolences on the loss of your grandmother...
It's been a bit scary. I don't know whether it's just the increase in
workload and older patient population, but has anyone else seen a real
rise in cancers and leukemias at their labs over the past several years?
--
K.
Sprout the MungBean to reply
"I don't like to commit myself about heaven and hell‹you
see, I have friends in both places." --Mark Twain
| |
|
| In article <2vSdncRphPFgkeDfRVn-1w@got.net>,
"Robert" <Robertitsme@hotmail.com> wrote:
> "JEDilworth" <bactitech@nospamhortonsbay.com> wrote in message
> news:OOmdnQD0bOUlQ-HfRVn-iw@buckeye-express.com...
> Include that in your protocol but don't assume everybody else is doing it
> and that the tech messed up or missed it because it wasn't done. That was
> the whole point I was making.
> It is the abosolute count that is important and not the relative percent
> that is important. You also have machines that have flags. If you don't
> trust the machine then there is no need in reporting out autodiffs or there
> is something wrong with the protocols or the doctor considers it important
> enough that a manual diff be performed.
> As far as who looks at blood smears, I have never seen in all my years in
> doing this an infectious disease specialist go look at a blood smear. If
> they thought that seeing bands or immatures are important they would look at
> the smear or order a manual diff regardless of what the diff shows. That
> doesn't happen.
> Clinical hematologist are always there and required to look at the blood
> smear regardless of what is reported on the differential by the tech.
>
> Again you mention absolute count and not relative percent so that is in the
> right direction. We do scan a slide with an absolute lymph count greater
> than 6 K or a variant lymph flag or a fragile cell percentage.
> The hematologist looked at
> They did nothing for her early on and the clinical implications would have
> been the same if it had been missed back then. Like any progression she
> probably had it for years before it was flagged.
> when her
>
> Well sorry to hear about that but her clinical course was not effected by
> when it was discovered she had CLL.
> Not everything as you can never catch all the abnormals based on above. It
> is not sensitive enough as I mentioned all hematologist look at smears for
> very minute clues not mentioned on reports.
> Blood smear interpretation is different from doing and reporting a
> differential.
>
>
> With a normal WBC count, many labs without the advanced
>
> You said it was the absolute lymphs that sent it in for review so it wasn't
> really the technology. If it had been done by a machine without a autodiff
> and a manual diff performed then it would still have the same abnormal
> morphology and sent in for review.
> The treatment protocols for CLL are very poor and the course is indolent so
> in the case of CLL the early aspects of diagnosis does not apply. Treatment
> guidelines require A and B symptoms some of which include parameters of the
> CBC.
>
<lol> But the total WBC count was normal...
Ok, try this one Robert.
WBC count, 4.5
Neutrophil % 45%
Lymphocyte % 50%
Monos 5%
Patient age: 27
Presents with high fever, vomiting and diarrhea.
Based on the numbers, would you have done a diff?
Machine was too primitive at the time to flag immature/band cells
I'll tell you her diagnosis after I see your answer. ;-)
>
> In the case of CLL I think you worried needlessly as the platelet count etc
> would have manifested itself and treatment rendered then.
> Good luck
Later. MUCH later.
Usually, the earlier CLL gets treated, the better chances of recovery.
But, since CLL can often go on for years without showing symptoms,
elderly patients are often left untreated. I once saw a 92 year old in
the ER that had a CLL. Her WBC cound was running around 12,000.
I was told that yes, she had a history of it and she had not even been
told! They felt that old age would kill her before the CLL would.
>
>
--
K.
Sprout the MungBean to reply
"I don't like to commit myself about heaven and hell‹you
see, I have friends in both places." --Mark Twain
| |
| Robert 2005-05-07, 5:53 pm |
|
"Katra" <KatraMungBean@Centurytel.net> wrote in message
news:KatraMungBean-305C65.15371407052005@corp.supernews.com...
> In article <2vSdncRphPFgkeDfRVn-1w@got.net>,
> "Robert" <Robertitsme@hotmail.com> wrote:
>
retentive[vbcol=seagreen]
it[vbcol=seagreen]
was[vbcol=seagreen]
percent[vbcol=seagreen]
there[vbcol=seagreen]
important[vbcol=seagreen]
in[vbcol=seagreen]
If[vbcol=seagreen]
look at[vbcol=seagreen]
they[vbcol=seagreen]
Good[vbcol=seagreen]
her[vbcol=seagreen]
the[vbcol=seagreen]
marrow[vbcol=seagreen]
(back[vbcol=seagreen]
have[vbcol=seagreen]
have[vbcol=seagreen]
to[vbcol=seagreen]
away[vbcol=seagreen]
by[vbcol=seagreen]
hematology[vbcol=seagreen]
It[vbcol=seagreen]
for[vbcol=seagreen]
wasn't[vbcol=seagreen]
autodiff[vbcol=seagreen]
so[vbcol=seagreen]
Treatment[vbcol=seagreen]
the[vbcol=seagreen]
>
> <lol> But the total WBC count was normal...
As Judy mentioned her abosolute lymphs were high.
I think you are over thinking there. Doctors are able to distinguish between
all the CBC results.
Do you want to be diagnosed early with CLL? Not me thank you as they won't
do anything different.
>
> Ok, try this one Robert.
>
> WBC count, 4.5
> Neutrophil % 45%
> Lymphocyte % 50%
> Monos 5%
>
> Patient age: 27
>
> Presents with high fever, vomiting and diarrhea.
I don't really make decisions on who gets a smear review based on symptoms
etc. There are procotols established that people follow. People should not
assume that those protocols are universal. What one lab scans another might
not. What others consider as signficant such as bands there are others who
do not.
I report out bands in our lab but other labs do not. Some labs report out
percentage of reactive lymphs and others only use few mod etc. Some call
them reactive lymphs other places call them atypical lymphs. Some labs count
mesothelial cells in their WBC count cell counts and others do not.
So to answer your question I would follow the protocols of that lab and
expect the doctors who are familiar with that lab to evaluate all the
results. You age going under the assumption that doctors do not know how to
interpret a diff.
>
> Based on the numbers, would you have done a diff?
It is never decided that way. We do not make individual decisions on
cuttoff. IF it meets the criteria then it will have a scan.
>
> Machine was too primitive at the time to flag immature/band cells
Not important with the same answer.
>
> I'll tell you her diagnosis after I see your answer. ;-)
We don't make the diagnosis only perform the laboratory testing according to
accepted practices.
I have worked in many laboratories and each has pretty much differing
procedures for everything. I basicly follow procedures.
>
would[vbcol=seagreen]
etc[vbcol=seagreen]
>
> Later. MUCH later.
And treatment usually follows later MUCH later.
> Usually, the earlier CLL gets treated, the better chances of recovery.
Recovery? Oh really. Why don't we ask Judy if she was treated early?
> But, since CLL can often go on for years without showing symptoms,
> elderly patients are often left untreated.
?? Most are elderly and treatment rarely works.
I once saw a 92 year old in
> the ER that had a CLL. Her WBC cound was running around 12,000.
>
> I was told that yes, she had a history of it and she had not even been
> told! They felt that old age would kill her before the CLL would.
Twain
| |
| Robert 2005-05-07, 10:52 pm |
|
"Katra" <KatraMungBean@Centurytel.net> wrote in message
news:KatraMungBean-FB4CB2.04023507052005@corp.supernews.com...
> In article <ZoOdnVHIxrK34uHfRVn-vA@got.net>,
> "Robert" <Robertitsme@hotmail.com> wrote:
>
does[vbcol=seagreen]
be in[vbcol=seagreen]
website[vbcol=seagreen]
>
> NO NO NO!!!
> You mis-understood me!!!
>
> Some of the tech's were deciding when and when not to do manual diff's
> based on the type of patient (most commonly labor and post-partum
> patients) and NOT following the written review criteria! ;-)
So you assumed that the lab in this case did the same. I prefer to assume it
was performed properly until proven otherwise.
>
> THAT is a CAP violation, randomly not following written protocal!
That is a lab problem that should be monitored by reviewing printouts. Most
patients have multiple CBC's and deltas on diffs can be seen.
>
> Like I said, you obviously mis-read my commentary.
>
> Your laboratory is free to set your references as you see fit based on
> your population. Are other local hospitals with the same
> instrumentation set as loose?
We have a hospital chain so we have the same criteria.
>
> Whether I agree or disagree with your numbers is a personal opinion and
> I believe I stated it as such. ;-)
>
> <snipped references>
>
> What was your 90% value based upon?
> You must have the documentation for CAP inspectors in your
> implementation manual. You can't just randomly select numbers.
> I does not work that way.
Never said it wasn't validated but as I said I thought it was 90 and it
might have been lower.
>
> We based our 80% on a number of factors, AND it had to be approved by
> the hospital medical staff as well. We are not allowed to arbitrarily
> set numbers to reduce our workload.
??? If validation studies have been done to "validate" those results without
flags etc that 85% granulocytes are in fact granulocytes than where is the
problem?
The medical staff is consulted but what does that mean with a large
institution?
Last I heard doctors were able to see a differntial and tell if it was a
three part differential or a manual diff. They were and aren't prevented
from ordering a manual diff in the first place. If they didn't like the
autodiff they can order a manual one afterward. It happens all the time. I
think you are over reacting on the cuttoffs. If it is valid and the medical
chiefs agree and the doctors always have a right to use clinical judgements
to overide, I don't see where you say that people are dying because of the
85 or 90% cuttoff. Just to let you know that bands, metas and myelos are
granulocytes. They don't report out neutrophils but granulocytes.
The abnormal valleys on the graph would flag any substantial immatures via
validation studies.
This is the instrument we are using and see what you think about flags.
Notice they said that its performance is insufficient for detecting
clinically relevant abnormal lymphocytes.
Clin Lab Haematol. 2004 Feb;26(1):9-13. Related Articles, Books, LinkOut
Diagnostic performance of the variant lymphocyte flag of the Abbott Cell-Dyn
4000 haematology analyser.
Hoffmann JJ, Hoedemakers RM.
Department of Clinical Laboratories, Catharina Hospital, Eindhoven, The
Netherlands. hans.hoffmann@cze.nl
BACKGROUND: In addition to differential cell counts, modern haematology
analysers generate suspect flags if abnormal cells are detected. Reports on
validation of suspect flags are scarce. We have routine experience with the
Abbott Cell-Dyn 4000 analyser for over 5 years and have previously
demonstrated the utility of the blast flag. Here we report a similar study
on the performance of the analyser's Variant Lymphocyte (VL) flag. AIM OF
THE STUDY: Evaluation of the diagnostic performance of the Cell-Dyn 4000 VL
flag, as compared with lymphocyte morphology in blood smears. In addition,
we investigated the usefulness of the numerical VL flag confidence index as
provided by the analyser. MATERIALS AND METHODS: All samples generating a VL
flag were reviewed over a 5-month period. We also reviewed smears from
patients with known lymphoid disorders, even if the analyser did not flag
the sample. Two experienced investigators assessed lymphocyte morphology
independently. RESULTS: In total, 187 samples were included in the study, of
which 183 had a VL flag and four had not. Of the 183 flagged samples, 83
appeared to have abnormal lymphocyte morphology and 100, normal lymphocyte
morphology. The sensitivity of the VL flag for detecting abnormal
lymphocytes was 0.95 and the positive predictive value was 0.44. Using ROC
analysis of the VL flag confidence index, the area under the R | | |