말초혈액도말 보고서의 표준화

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1 말초혈액도말보고서의표준화 박건 조선대학교의학전문대학원

2 구성 말초혈액도말보고서표준화의목표 말초혈액도말보고서표준화관련작업

3 Goals of PBS Report Standardization Communicable Guidable Flexible Databasable Integratable

4 Communicable features

5 Communicable Whole Informome Clinical informations Graphical Informations Textual Informations Numerical Informations Knowledge-based Interpretation

6 Definitions of Terms Communicable

7 Unremarkable Communicable

8 Communicable Asymmetric informations Unremarkable? Unremarkable!

9 Communicable Unremarkable 관찰항목 : RBC, WBC, PLT, Others Count, Size, Morphology, Color Distribution, Maturation, Inclusion 적절핚기술은? 임상적의의 : 말초혈액의세포학적변화가관찰되지않으나이소견만으로는혈액학적및혈액소견변화를유발하는질환과의연관성을배제핛수없다.

10 Guidable features

11 자주찾지않는길은사라집니다.

12 PBS Worksheet Guidable

13 Guidable 기본필수항목? RBC 1) Size/Color/Number 2) Shape 3) Variation(size/color) 4) Clump 5) Inclusion 6) Count(Schistocyte, N-RBC, Parasite) 7) Others WBC 1) Number 2) Distribution 3) Morphology: Nucleus, Granule 4) Count(Diff) 5) Inclusion 6) Clump 7) Others PLT 1) Number 2) Morphology 3) Clump 4) Others Others 1) Quality (optional)?

14 Guidable Basic Items: RBC Size: microcytic/normocytic/macrocytic/dimorphic; grading? Color: hypochromic/normochromic/hyperchromic; grading? Count: anemia/appearance/erythrocytosis; grading? Anisocytosis: grading? RDW~! poikilocytosis: types; grading or count Inclusion body: types, count? Clump

15 Guidable Basic Items: WBC Count: leukopenia/normal number/leukocytosis; Grading? Distribution: -penia/normal distribution/-philia or cytosis; Grading? Morphology: atypical(reactive/stress/activated?)/abnormal/dysplastic Differential count (if abnormal distribution): percent(%) 1) blast: type, count, description(size, N/C ratio, nuclear shape, chromatin pattern, color of cytoplasm, granularity)? 2) atypical lymphocyte: count(%), type? 3) abnormal cell: count, description(size, N/C ratio, nuclear shape, chromatin pattern, color of cytoplasm, granularity)? Maturation(if neutrophilia/-penia): Left shift/normal maturation/right shift Granulation: toxic granulation(neutrophil), increased/decreased, dysplastic Inclusion Clump

16 Guidable Basic Items: PLT Count: thrombocytopenia/normal in number/thrombocytosis Morphology: abnormal/normal Size: tiny/normal/large/giant Color/Granule: Gray/Pink Clump Normal platelet size = 1-2 microns and 7-9fL (about 1/7 to 1/5 size of a RBC)

17 Guidable 중요소견별필수항목? Eosinophilia 1) Absolute eosinophil count > 1,500/uL 2) Grade? (mild, moderate, severe or marked) 3) features related to cancer?(all, lymphoma) 4) Blast percent? CEL diagnostic criteria 5) Morphology & Maturation? 6) Dysplastic features? MDS or overlap r/o From

18 Flexible features

19 RBC: normocytic normochromic anemia with anisopoikilocytosis (elliptocyte) Flexible 적혈구에서정적혈구정색소성빈혈이적혈구부동증및타원적혈구등과동반되어관찰됩니다. RBC: size(nl), color(nl), number( ), size variation( ), shape variation( ): elliptocyte RBC RBC Findings Size normal Color normal Number decreased Aniso increased Poikylo increased (elliptocyte)

20 Flexible 난이결혼반델세 행복하다면찬성일세

21 Flexible

22 Flexible RBC WBC 1) Size/Color/Number 1) Number 2) Shape 2) Distribution 3) Variation(size/color) 3) Morphology: Nucleus, Granule 4) Clump 4) Count(Diff) 5) 기본 Inclusion 및특수필수항목에 5) Inclusion 대핚정보가 6) Count(Schistocyte, N-RBC, Parasite) 6) Clump 7) 임상의에게 Others 잘전달될7) Others 수만있다면?? PLT 1) Number 2) Morphology 3) Clump 4) Others Others 1) Quality (optional)? Special: Eosinophilia

23 Databasable

24 Databasable Left Shift 는한 달에몇건일까?

25 RBC: normocytic normochromic anemia with anisopoikilocytosis (elliptocyte) Databasable 적혈구에서정적혈구정색소성빈혈이적혈구부동증및타원적혈구등과동반되어관찰됩니다. RBC: size(nl), color(nl), number( ), size variation( ), shape variation( ): elliptocyte RBC RBC Findings Size Color Number Aniso Poikylo KeyWords normal normal decreased increased Codes increased (elliptocyte)

26 Code Standardization Databasable

27 Integratable features Automatic Data Incorporations & Data Interpretation & Optimal Description Selecting

28 말초혈액도말검사보고서표준화관련작업 1. Reference ranges 설정 : 나이별, 성별, 특수상황별 임신, 태아, 탯줄혈액 2. Terminology 정의 3. Grading system 구축 ( 정의 ) 및 4. 임상적의의에대한임상연구및메타분석 5. 중요소견별필수판독 ( 입력 ) 항목정리 ex) Eosinophilia??? 6. 보고서형태및구성요소분석 최적형태, 구성요소? 7. 보고서기술문구제안 8. 말초혈액도말검사에대한교육 : 진검전문의, 전공의, 임상의 9. 말초혈액도말검사프로그램및웹기반공유프로그램

29 1. Reference Ranges 설정

30 Reference Ranges 1st work From Hematology: Clinical principles and applications 2 nd Ed. by Rodak

31 2. Definitions & Terminology

32 2nd work Definitions & Terminology: RBC RBC 1) Number: anemia, erythrocytosis 2) Size: microcytic, normocytic, macrocytic, dimorphic 3) Color: hypochromic, normochromic, hyperchromic, polychromic 4) Variation: (1) size variation: anisocytosis (2) shape variation: poikilocytosis, poikilocytes 5) Clump (1) Rouleaux formation (2) Autoagglutination 6) Inclusion bodies

33 2nd work Hypochromia Definition: the RBC with central pale area which is greater than one-third the diameter Method: HPF(X1,000) 에서 10 fields 의평균

34 2nd work Rouleaux formation The term rouleaux is used to describe the appearance of red cells (four or more) aligned in a linear fashion, simulating a stack of coins. Rouleaux formation as an artifact is generally seen in the thick area of virtually all blood smears. However, true rouleaux formation is due to hyperproteinemia (primarily fibrinogen and globulins) and is recognized in the thinly spread area of the smears, where normally the red cells barely touch one another. It is often associated with proteinaceous (blue staining) background

35 Burr cells vs Crenated cells 2nd work

36 Spiculated RBC 2nd work

37 2nd work

38 2nd work Definitions & Terminology: WBC WBC 1) Number: leukocytopenia, leukocytosis 2) Distribution: neutropenia, neutrophilia, lymphocytosis, monocytosis, eosinophilia, basophilia 3) Atypical lymphocyte/atypical lymphocytosis 4) Dysplastic features 5) Maturation (1) Left shift: Band form (2) Right shift: Hypersegmented neutrophil (3) Blast 6) Toxic granulation 7) Clump 8) Inclusion bodies

39 Left shift 2nd work 전혈 μl 당 band neutrophil 700 개이상 Total WBC 중 band neutrophil 10% 이상 5% 12% Band or metamyelocytes(%) > 6% or total band neutrophil count >= 1,500 cells/μl

40 2nd work Definitions & Terminology: PLT PLT 1) Number: thrombocytopenia, thrombocytosis 2) Size: small, large, giant 3) Morphology 4) Clump

41 2nd work Giant platelet Reference 1) normal: 1.5 ~ 3 μm 2) small: less than 1.5 μm 3) large: 4~7 μm 4) giant: larger than 7 μm

42 3. Grading System

43 3rd work Grading system Spherocyte 2+?

44 Grading System Spherocyte 2+? Clinical Significances?

45 Grading System % 단위의 Grading system 은 실제로이용하기어렵다.

46 ISCH Grading System

47 Grading System Poikilocyte 언급최소개수? 한개라도보이면언급 ~! VS HPF 당 5 개이상보이는경우에만! X 개이하는임상적의의가없고비특이적인소견일수있으므로임상에보고하지않는것이좋다.

48 Grading System

49 Grading System poikilocytosis Definition : the presence of poikilocytes that are abnormally shaped red blood cells Methods : HPF(X1,000) 에서 10 fields 의 poikilocytes 의평균 Normal Slight Moderate Marked poikilocytes

50 Grading System

51 Grading System

52 4. 임상연구및메타분석

54 4th work Schistocyte 정량보고 X schistocytes / 1,000 RBCs What? (Triangular cell, Helmet cell) Not? (Bite cell, spherocyte, RBC remnants)

55 4th work Schistocyte-related disorders Microangiopathic hemolytic anemia Disseminated intravascular coagulation(dic) Thrombotic thrombocytopenic purpura(ttp) Hemolytic uremic syndrome(hus) Post-BMT Renal graft rejection Glomerulonephritis Prosthetic valve Eclampsia Vasculitis Giant hemangioma Scleroderma March hemoglobinuria (Marathon runners)

56 4th work Count: the number of fragmented red cells per 1000 re cells expressed as a percentage Grade: mild(<1%), moderate(1~1.9%), severe(>=2%) Clinical significances : mild red cell fragmentation is a common morphologic finding after transplantation with no clinical significance in the absence of other clinical and laboratory findings suggestive of thrombotic microangiopathy, although patients with moderate or severe fragmentation should be monitored closely.

57 4th work Count: the number of fragmented red cells per 1000 re cells expressed as a percentage Grade: not mentioned Clinical significances : Despite this, schistocytes were seen in 58% of the normal individuals with a mean of 0.05% and a range of % of all red cells; 93% of chronic renal failure patients had schistocytes with a mean of 0.21% and a range of 0 0.6% (P < 0.01) of all red cells; 80% of the preeclamptic women had schistocytes with a mean of 0.25% of all red cells and a range of % (P < 0.01). All of the patients with normally functioning prosthetic cardiac valves had schistocytes with a mean of 0.18% and a range of % of all red cells. The TTP patients had considerably more schistocytes than all of the other groups, with a mean of 5% and a range of % (P < 0.001, Table I). In addition, 100% of the TTP patients had schistocytes.

58 4th work

60 5. 중요소견별필수판독항목

62 5th work 중요소견별필수항목? Eosinophilia 1) Absolute eosinophil count > 1,500/uL 2) Grade? (mild, moderate, severe or marked) 3) features related to cancer?(all, lymphoma) 4) Blast percent? CEL diagnostic criteria 5) Morphology & Maturation? 6) Dysplastic features? MDS or overlap r/o From

63 5th work Eosinophilia 분류 Idiopathic eosinophilia Reactive eosinophilia (transient/persistent) Idiopathic hypereosinophilic syndrome Chronic eosinophilic leukemia, not otherwise specific (NOS) Myeloid and lymphoid neoplasms with eosinophilia and abnormalities of PDGFRA, PDGFRB, or FGFR1

64 5th work

65 5th work The eosinophil count in a normal adult ranges from /l (20 500/μl) [7]. Eosinophilia is classified as 1) mild ( /l), 2) moderate ( /l) and 3) severe [8] when the eosinophil count is more than 5 109/l. Although, the patient presented with severe eosinophilia ( /l), there was no organ involvement, as shown by normal ECG, echocardiography, chest X-Ray, and no evidence of nervous system dysfunction or skin rash. 7. Lewis M: Reference ranges and normal values. In Dacie and Lewis Practical Haematology 10th edition. Edited by: Lewis SM, Bain BJ, Bates I. Churchill Livingstone; 2006: Rothenberg ME: Eosinophilia. N Eng J Med 1998, 338:

66 5th work Keys of Description Absolute eosinophil count > 1,500/uL Grading? (mild, moderate, severe) Related cancer?(all, lymphoma) Blast percent? CEL diagnostic criteria Morphology & Maturation? Dysplastic features? MDS or overlap r/o

67 5th work Keys of Recommendation Eosinophilia duration > 6 months End organ damage? HES 진단기준 ~! Secondary causes workup? vasculitits, lymphoma, ALL, systemic mastocytosis, granulomatous disorder

68 Hypereosinophilic syndrome 5th work 1. Eosinophil count of > 1,500/uL & persistenting for at least 6 months 2. Reactive eosinophilia is excluded by appropriate thorough investigation 3. AML, MPN, MDS, MPN/MDS and systemic mastocytosis are excluded 4. A cytokine-producing, immunophenotypically-aberrant, T-cell population is excluded 5. And there is tissue damage as a result of hypereosinophilia. If no tissue damage idiopathic hypereosinophilia

69 5th work Example 57 yr/male C/C:?? CBC(Hgb/WBC/PLT): 9.5/5.9/237/Eo: 22% Morphology

70 5th work

71 5th work Description RBC: Normocytic normochromic anemia with anisocytosis and spherocyte(trace) WBC: Moderate eosinophilia (mature form) without blast and dysplastic features PLT: Normal in number with normal morphology

72 Recommendations F/U, spherocyte panel, eosinophilia panel

73 6. 보고서형태및구성요소분석

74 보고서구성요소 1. Informations of test: Name 2. Patient s informations: Hosp. No, Age, Sex, Diseases 3. Goals of Request 4. Slide informations: Smear, Stain 5. Findings (details) 6. Summary of findings 7. Interpretation 8. Suspicious disorders 9. Recommendation 10. Laboratory data 11. Images 12. Date & Time at reporting 13. Making technician & Reporting doctor 14. Informations of laboratory and hospital

75 6th work 병원별구성정리 1. Summary & Comments : 2 개병원 2. Summary & Comments & Lab. Data : 5 개병원 3. Findings & Summary & Comment : 5 개병원 4. Findings & Summary & Comment & Lab. Data : 3 개 5. With Image : 1 개병원? (Findings & Summary & Comment)

76 7. 기술문구제안?

77 Communicable Unremarkable 관찰항목 : RBC, WBC, PLT, Others Count, Size, Morphology, Color Distribution, Maturation, Inclusion 적절핚기술은? 임상적의의 : 말초혈액의세포학적변화가관찰되지않으나이소견만으로는혈액학적및혈액소견변화를유발하는질환과의연관성을배제핛수없다.

78 7th work Basic descriptions instead of Unremarkable

79 7th work RBC Size Color Count Anisocytosis poikilocytosis normocytic normochromic appearance without anisocytosis and poikilocytosis

80 7th work WBC Count Distribution Morphology Differential count (if abnormal distribution) Maturation (if abnormal distribution) Normal in number, maturation and morphology

81 7th work PLT Count Morphology normal numbers with normal morphology

82 7th work Summary of findings RBC: normocytic normochromic appearance without anisocytosis and poikilocytosis WBC: Normal in number, maturation and morphology PLT: normal numbers with normal morphology

83 8. 말초혈액도말검사에대핚교육

85 9. 말초혈액도말검사보고서프로그램

86 9th work PBS report 프로그램 웹기반프로그램 병원및개인정보의보안 PBS 정보의손쉬운공유 데이터베이스로편리핚활용 ( 통계, 아틀라스 ) 기존 EMR 과손쉬운호환 입력구조의손쉬운변경 출력형태의손쉬운변경 새로운필드값생성가능 [ 중앙에서관리필요 ] 기본적인입력및출력형태 ( 기술문구 ) 를제공하여선택에따라사용핛수있도록...

87 9th work 진단혈액학회 Database & Homepage Hospital 1. 말초혈액도말보고서프로그램제공 2. 말초혈액도말과관련된정보의코드관리 ( 생성및조정 ) 3. 말초혈액도말과관련된정보의데이터베이스화 4. 말초혈액도말검사와관련된정보를중앙서버로업로드 5. 통합된정보를분기별 ( 연별 ) 분석결과제공 6. Atlas 등정보를웹기반으로제공 7. 웹기반교육프로그램

88 9th work EMR Patients Informations Program Request Program Main server PBS Interpretation Program Sharing Program Database Program Clinicians Database servers in a hospital Integrating Program Worksheets Program Image upload Program CBC instruments Printer Microscopy & Image capture

89 Image upload Anemia & Spherocyte? Default description Report the modified description Worksheets Automatic integration & Suggested description

91 PBS Worksheet

92 PBS Worksheet: Part I

93 PBS Worksheet: Part II Automatic interpretation & select normocytic normochromic anemia form RBC : normocytic normochromic anemia with anisocytosis and polychromatophilia WBC: neutrophilia without left shift PLT: normal in number

94 PBS Worksheet: Part III

95 Report Summary of findings RBC: normocytic normochromic anemia with anisocytosis, polychromatophilia, dimorphic feature, and spherocyte(1+) WBC: neutrophilia without left shift and toxic granulation PLT: normal in number and morphology Recommendations RBC: serum haptoglobin, LDH, total/direct bilirubin, Coombs test, transfusion history, bleeding history WBC: CRP, r/o drug effect

97 끝이아닌시작 결롞이아닌열린제안

99 Web-based hematologic atlas

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012임수진

012임수진 Received : 2012. 11. 27 Reviewed : 2012. 12. 10 Accepted : 2012. 12. 12 A Clinical Study on Effect of Electro-acupuncture Treatment for Low Back Pain and Radicular Pain in Patients Diagnosed with Lumbar