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Hematology Studies and Lab Reports Hematology Studies and Lab Reports

Normal Blood Cells: 2 Normal Blood Cells: 2

THE WBC Identify the segmented neutrophil, band neutrophil, lymphocyte, monocyte, eosinophil, basophil, and platelet THE WBC Identify the segmented neutrophil, band neutrophil, lymphocyte, monocyte, eosinophil, basophil, and platelet in the image 3

Neutrophil – targets bacteria/fungi. Fine, faintly pink granules when stained. Have many lobes within Neutrophil – targets bacteria/fungi. Fine, faintly pink granules when stained. Have many lobes within which can look like one single lobe (banded) or several (segmented). First responders, main component in pus. Eosinophil – targets larger parasites, modulates allergic rsvp. Pink orange granules. Have 2 lobes. Basophil – releases histamine for inflamm rsvp. Large and blue. Can be bi or tri lobed, but hard to see because of the multitude of dark granules. Lymphocyte – Bcells release antibodies and assist in activating T cells. Also are T cells and NK cells. Stain deeply, “eccentric. ” Monocyte – migrate from blood stream to tissues then change into macrophages or dendritic cells (which also help activate T cells). Kidney bean shaped lobes. Macrophages – phagocytes that engulf debris and pathogens. Stimulate lymphocytes and other cells that rsvp to pathogens. 4

band neutrophil, eosinophil, segmented neutrophil lymphocyte, basophil, monocyte, 5 band neutrophil, eosinophil, segmented neutrophil lymphocyte, basophil, monocyte, 5

6 6

Bone Marrow Cellularity: Normal Hypercellular Hypocellular 7 Bone Marrow Cellularity: Normal Hypercellular Hypocellular 7

Normal RBC §The red blood cells here are normal, happy RBC's. They have a Normal RBC §The red blood cells here are normal, happy RBC's. They have a zone of central pallor about 1/3 the size of the RBC. The RBC's demonstrate minimal- variation in size (anisocytosis) and shape (poikilocytosis). A few small fuzzy blue platelets are seen. In the center of the field are a band neutrophil on the left and a segmented neutrophil on the right. 8

Steps in Erythropoisis Early Proerythroblast (Pronormoblast) Intermediate Late Polychromatophilic Normoblast Basophilic Normoblast Reticulocyte Orthochromatophilic Steps in Erythropoisis Early Proerythroblast (Pronormoblast) Intermediate Late Polychromatophilic Normoblast Basophilic Normoblast Reticulocyte Orthochromatophilic Normoblast Erythrocyte 9

HCT (Hematocrit) (114) §The packed cell volume (HCT) is the percentage of total volume HCT (Hematocrit) (114) §The packed cell volume (HCT) is the percentage of total volume occupied by packed red blood cells when a given volume of whole blood is centrifuged at a constant speed for constant period of time. The HCT is one of the most precise methods of determining the degree of anemia or polycythemia. Plasma (55% of whole blood Buffy coat: leukocyctes and platelets(<1% of whole blood Erythrocytes (45% of whole blood) 10

MCH (149) § (Mean Corpuscular Hemoglobin): Indicates the weight of hemoglobin in a single MCH (149) § (Mean Corpuscular Hemoglobin): Indicates the weight of hemoglobin in a single red blood cell. §MCH increase or decrease along with an increase or decrease in MCV is a significant finding if there is a need for folic acid and/or B 12 §A decrease in MCH with a decrease in MCV indicates a need for iron, copper, or B 6. 11

MCV (150) § (Mean Corpuscular Volume): This measurement indicates the volume in cubic micron MCV (150) § (Mean Corpuscular Volume): This measurement indicates the volume in cubic micron occupied by an average single red blood cell. MCV increase or decrease along with an increase or decrease in MCH is a significant finding for folic acid and/or B 12 need (increase) or iron, copper or B 6 need (decrease). MCV and MCH should always be viewed together. 12

Complete Blood Count (85) §WBC: Total and differential counts §RBC: §HGB (Hemoglobin): §HCT (Hematocrit): Complete Blood Count (85) §WBC: Total and differential counts §RBC: §HGB (Hemoglobin): §HCT (Hematocrit): §MCV (Mean Corpuscular Volume): §MCH (Mean Corpuscular Hemoglobin): §MCHC (Mean corpuscular hemoglobin concentration): §PLATELETS: Platelets are concerned with the clotting of the blood and also clot retraction. 13

WBC : Differential Count (220) §SEG : A type of neutrophil, its primary function WBC : Differential Count (220) §SEG : A type of neutrophil, its primary function is phagocytosis. §BANDS: Non-segmented neutrophils (metamylocytes) the youngest forms that are normally found in the peripheral blood. These forms increase in the presence of acute infections with or without an absolute increase in the total WBC. 14

WBC : Differential Count §LYMPH : Lymphocytes help to destroy the toxic products of WBC : Differential Count §LYMPH : Lymphocytes help to destroy the toxic products of protein metabolism. Lymphocytes originate from lymphoblasts in the spleen, lymph glands, tonsils, thymus, bone marrow, and possibly the appendix. §NK cell 15

WBC : Differential Count §MONO : monospot test (125) EBV antibodies (95) Monocytes phagocytize WBC : Differential Count §MONO : monospot test (125) EBV antibodies (95) Monocytes phagocytize some bacteria, particulate matter, and protozoa. The monocytes remain to phagocytize fragments of cells, etc; hence, the reason for an elevation of the monocytes during the recovery phase of infection. 16

The WBC's seen here are The WBC's seen here are "atypical" lymphocytes. They are atypical because they are larger (more cytoplasm) and have nucleoli in their nuclei. The cytoplasm tends to be indented by surrounding RBC's. Such atypical lymphocytes are often associated with infectious mononucleosis. 17

WBC : Differential Count EOS : Eosinophils have an important role in detoxification, disintegration WBC : Differential Count EOS : Eosinophils have an important role in detoxification, disintegration and removal of protein. Eosinophils are commonly elevated in allergy sensitivity and parasites. 18

WBC : Differential Count §BASO : §With inflammation, basophils deliver heparin to the effected WBC : Differential Count §BASO : §With inflammation, basophils deliver heparin to the effected tissue to prevent clotting. 19

The nucleated RBC in the center contains basophilic stippling of the cytoplasm. This suggests The nucleated RBC in the center contains basophilic stippling of the cytoplasm. This suggests a toxic injury to the bone marrow, such as with lead poisoning. 20

Differential diagnosis of Anemia (397) Differential diagnosis of Anemia (397)

Sickle Cell Disease: 22 Sickle Cell Disease: 22

This is sickle cell anemia in sickle cell crisis. The abnormal hemoglobin SS is This is sickle cell anemia in sickle cell crisis. The abnormal hemoglobin SS is prone to crystallization when oxygen tension is low, and the RBC's change shape to long, thin sickle forms that sludge in capillaries, further decreasing blood flow and oxygen tension. Persons with sickle cell trait (Hemoglobin AS) are much less likely to have this happen. 23

Hereditary Spherocytosis: 24 Hereditary Spherocytosis: 24

Hypochromic Microcytic RBC 25 Hypochromic Microcytic RBC 25

Microcytic Anemia (IDA) 26 Microcytic Anemia (IDA) 26

VITAMIN B-12: (216) FOLIC ACID: (105) §Pernicious anemia is the megaloblastic anemia caused by VITAMIN B-12: (216) FOLIC ACID: (105) §Pernicious anemia is the megaloblastic anemia caused by malabsorption of Vitamin B 12. This is usually caused by decreased production of intrinsic factor, a substance essential to Vitamin B 12 absorption, in the stomach. This test may also be performed as part of the testing to determine the cause of nervous system disorders. §Folic acid (folate) is one of the "B" vitamins needed to metabolize homocysteine. Vitamin B 12, another B vitamin, helps keep folate in its active form, allowing it to keep homocysteine levels low. 27

Megaloblastic anemia: §Vitamin B 12/Folic acid deficiency §Second most common type of anemia. §Multi Megaloblastic anemia: §Vitamin B 12/Folic acid deficiency §Second most common type of anemia. §Multi System disease – All organs with increased cell division. §Macrocytic anemia, pancytopenia. §Pernicious anaemia – §autoimmune, Gastric atrophy, Vit. B 12 def. 28

Macrocytic Anemia (Megaloblastic): 29 Macrocytic Anemia (Megaloblastic): 29

Vitamin B 12 Absorption B 12 Stomach B 12 IF IF B 12 Parietal Vitamin B 12 Absorption B 12 Stomach B 12 IF IF B 12 Parietal cells produce Intrinsic Factor IF B 12 Ileum IF receptors B 12 absorption 30

SCHILLING TEST §Assesses ability of terminal ileum to absorb vitamin B 12 §Oral preparation SCHILLING TEST §Assesses ability of terminal ileum to absorb vitamin B 12 §Oral preparation of vitamin B 12 tagged with Co-57 §Prior to this ‘normal vitamin B 12 injection is given to facilitate excretion of oral B 12 administered §Test measures how much of this radioactive isotope is excreted in urine §May be given with Inrinsic factor as well to see if excretion in urine increases. §In pernicious anemia patients §Without Intrinsic factor the excretion is less than 7% §When given intrinsic factor tagged B 12 is given the excretion rate is greater then 7 -20% §If both are low then it may suggest other cause for malabsorption 31

Anemia with high Reticulocyte counts (186) §Differential diagnosis: §Bleeding – blood loss internal/external §Hemolysis Anemia with high Reticulocyte counts (186) §Differential diagnosis: §Bleeding – blood loss internal/external §Hemolysis – immune, mechanical, toxic, inf. §Laboratory evaluation §Blood film, n. RBC, spherocytes, Parasites, Retics. §Hemolysis – indirect Bilirubin, Haptoglobin, §Direct and indirect Coombs test §Hemoglobin electrophoresis, G 6 PD screen etc. 32

Anemia with Low MCV and Low Retics §Differential diagnosis §Iron deficiency §Anemia of chronic Anemia with Low MCV and Low Retics §Differential diagnosis §Iron deficiency §Anemia of chronic disease §Laboratory evaluation §Serum Iron levels, iron-binding capacity, and ferritin §Blood smear – Micro/hypo, Pencil cells. 33

C. B. C §Haemoglobin - 15± 2. 5, 14 ± 2. 5 - g/d. C. B. C §Haemoglobin - 15± 2. 5, 14 ± 2. 5 - g/d. L §PCV - 0. 47 ± 0. 07, 0. 42 ± 0. 05 - l/d. L (%) §Haematocrit, effective RBC volume - better §RBC count - 5. 5 ± 1, 4. 8 ± 1 x 1012/L §MCHC - Hb/PCV - 30 -36 - g/d. L §Hb synthesis within RBC §MCH - Hb/RBC - 29. 5 ± 2. 5 pg/L §Average Hb in RBC §MCV - PCV/RBC 85 ± 8 - f. L 34

automated instrument data 35 automated instrument data 35

Microcytic Hypochromic Report (398, 400) 36 Microcytic Hypochromic Report (398, 400) 36

The CBC here shows a markedly increased MCV, typical for megaloblastic anemia. The MCV The CBC here shows a markedly increased MCV, typical for megaloblastic anemia. The MCV can be mildly increased in persons recovering from blood loss or hemolytic anemia, because the newly released RBC's, the reticulocytes, are increased in size over normal RBC's, (399) 37

Anemia Screen (398 -400) §IRON: §IRON BINDING CAPACITY: §PERCENT OF IRON SATURATION: Measurement of Anemia Screen (398 -400) §IRON: §IRON BINDING CAPACITY: §PERCENT OF IRON SATURATION: Measurement of iron in serum. §FERRITIN: §TRANSFERRIN: §VITAMIN B-12: §FOLIC ACID: 38

Management of Oral Anticoagulant Therapy Principles & Practice (98 -99, 488) Management of Oral Anticoagulant Therapy Principles & Practice (98 -99, 488)

Coagulation and Fibrinolysis Coagulation Factors t-PA, Urokinase Fibrinogen Plasminogen PAI-1 Fibrin Plasmin Fibrinolysis Lp(a) Coagulation and Fibrinolysis Coagulation Factors t-PA, Urokinase Fibrinogen Plasminogen PAI-1 Fibrin Plasmin Fibrinolysis Lp(a) Homocysteine Cysteine Glutathione 40

Prothrombin Time (PT) (182) §Historically, a most reliable and “relied upon” clinical test However: Prothrombin Time (PT) (182) §Historically, a most reliable and “relied upon” clinical test However: §Proliferation of thromboplastin reagents with widely varying sensitivities to reduced levels of vitamin K-dependent clotting factors has occurred §Concept of correct “intensity” of anticoagulant therapy has changed significantly (low intensity) §Problem addressed by use of INR (International Normalized Ratio) 41

INR: International Normalized Ratio §A mathematical “correction” (of the PT ratio) for differences in INR: International Normalized Ratio §A mathematical “correction” (of the PT ratio) for differences in the sensitivity of thromboplastin reagents §Relies upon “reference” thromboplastins with known sensitivity to antithrombotic effects of oral anticoagulants §INR is the PT ratio one would have obtained if the “reference” thromboplastin had been used §Allows for comparison of results between labs and standardizes reporting of the prothrombin time 42 J Clin Path 1985; 38: 133 -134; WHO Tech Rep Ser. #687 983.

INR Equation ( ) Patient’s PT in Seconds ISI INR = Mean Normal PT INR Equation ( ) Patient’s PT in Seconds ISI INR = Mean Normal PT in Seconds INR = International Normalized Ratio ISI = International Sensitivity Index 43

How Different Thromboplastins Influence the PT Ratio and INR Blood from a single patient How Different Thromboplastins Influence the PT Ratio and INR Blood from a single patient Patient’s Mean Thromboplastin PT Normal Reagent (Seconds) PTR A 16 12 18 12 1. 5 C 21 13 1. 6 D 24 11 2. 2 E 38 14. 5 INR 1. 3 B ISI 2. 6 44

How Different Thromboplastins Influence the PT Ratio and INR Blood from a single patient How Different Thromboplastins Influence the PT Ratio and INR Blood from a single patient Patient’s Mean Thromboplastin PT Normal reagent (Seconds) PTR ISI INR A 16 12 1. 3 3. 2 2. 6 B 18 12 1. 5 2. 4 2. 6 C 21 13 1. 6 2. 0 2. 6 D 24 11 2. 2 1. 2 2. 6 E 38 14. 5 2. 6 1. 0 2. 6 45

Bone Marrow Maturation 46 Bone Marrow Maturation 46

47 47

Blood Group Antigens Antibodies Can give blood Can receive to blood from AB A Blood Group Antigens Antibodies Can give blood Can receive to blood from AB A and B None AB AB, A, B, 0 A A B A and AB A and 0 B B A B and AB B and 0 0 None A and B AB, A, B, 0 0 48

Bleeding Disorders (408 -409) Hemophilia Von Willebrand Disease (v. WD) Bleeding Disorders (408 -409) Hemophilia Von Willebrand Disease (v. WD)

Coagulation Process §Stage 1: Release of platelet factors to initiate clotting §Stage 2: Generation Coagulation Process §Stage 1: Release of platelet factors to initiate clotting §Stage 2: Generation of Thromboplastin by other factors §Stage 3: Conversion of prothrombin to thrombin §Stage 4: Formation of fibrin from fibrinogen 50

Hemophilia §Hemophilia : Affects 18, 000 in US §caused by deficiencies of either clotting Hemophilia §Hemophilia : Affects 18, 000 in US §caused by deficiencies of either clotting factor VIII or IX §Hemophilia A (factor VIII deficiency), which affects about 80% of hemophilic patients, and hemophilia B (factor IX deficiency) > 30% normal value §Elevated PTT and §Normal PT and §Normal platelet count; §it is confirmed by specific factor assays Von Willebrand Disease (v. WD) §Most common bleeding disorder affects 1 -2% (more common in women) §causes platelet dysfunction §Screening coagulation tests reveal : §normal platelet count; §normal INR; §prolonged bleeding time; and, §normal PTT §Diagnosis is based on low levels of VWF antigen and abnormal ristocetin cofactor activity. §. 51

PTT (168) §Partial thromboplastin time (PTT) screens plasma for abnormalities in factors of the PTT (168) §Partial thromboplastin time (PTT) screens plasma for abnormalities in factors of the intrinsic and common pathways §A normal range of 28 to 34 sec is typical. §A normal result indicates that at least 30% of all coagulation factors in the pathway are present in the plasma §prolongs the PTT, and the PTT is often used to monitor heparin 52

PT/INR §The PT screens for abnormalities in the extrinsic and common pathways of coagulation PT/INR §The PT screens for abnormalities in the extrinsic and common pathways of coagulation §A typical normal range for the PT is between 10 and 13 sec. An INR > 1. 5 or a PT ≥ 3 sec longer than a laboratory's normal control value is usually abnormal and requires further evaluation. 53

§A patient with a prolonged a. PTT and a normal PT is considered to §A patient with a prolonged a. PTT and a normal PT is considered to have a defect in the "intrinsic" coagulation pathway. §A patient with a prolonged PT and a normal a. PTT has a defect in the "extrinsic" coagulation pathway (tissue factor is "extrinsic" to the plasma). §Prolongation of both the a. PTT and the PT suggests that the defect lies in a common pathway. 54