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Abstract
We evaluated the UniCel DxH 800 Coulter Cellular Analysis System, the newest-generation hematologic analyzer from Beckman Coulter, Inc, for its accuracy and clinical sensitivity. We compared the accuracy of the complete blood count (CBC), differential counts, nucleated red blood cell (NRBC) counts, and reticulocyte parameters from the DxH 800 system to that of the Coulter LH 750 Hematology Analyzer, and to manual differentials.
The DxH 800 system provided accurate results for all analyzed parameters including the NRBC count, which correlated well with the manual NRBC count. With regard to flagged results, the DxH 800 was approximately 10% more efficient compared with the LH 750 analyzer. With our workload of more than 1500 samples per day, a 10% gain in overall efficiency will result in 30 fewer slides for review per day. The DxH 800 had a better negative predictive value (ie, 94% vs. 89%) and a better positive predictive value (ie, 40% vs. 34%).
The DxH 800 system accurately counts CBCs, as well as differential and reticulocyte parameters. In this evaluation, we observed better clinical sensitivity in comparison with the LH 750 analyzer.
Manual High School Jrotc
high-throughput hematology analyzers, complete blood count, NRBC, DxH 800, LH 750
The UniCel DxH 800 Coulter Cellular Analysis System (Beckman Coulter, Inc, Miami, FL; hereafter referred to as the DxH 800 system) (Figure 1) is a fully automated hematologic analyzer with a small footprint and a throughput of 100 samples per hour. It provides 28 hematologic parameters, including complete blood count (CBC) and differential count, corrected white blood cell (WBC) count, nucleated red blood cell (NRBC) count, and 4 reticulocyte (RET) parameters. Aspiration volume in the open or closed mode is 165 μL with a single aspiration pathway that eliminates the need for mode-to-mode calibration and quality control. The low sample volume required makes this analyzer ideal for pediatric samples. In addition to volume and conductivity measurements, 5 light-scatter measurements are performed to assess the granularity and lobularity characteristics of cells passing through the detector. The DxH 800 also provides total nucleated and red blood cell (RBC) counts in bodily fluids.
The Indiana University Health Pathology Laboratory performs CBCs and differential counts for more than 1500 samples daily, with 10% of samples derived from the pediatric population. The aim of this study was to evaluate the performance of the newest Beckman Coulter, Inc hematologic analyzer, the DxH 800, against that of its predecessor, the Coulter LH 750 Hematology Analyzer (hereafter referred to as the LH 750), to determine its efficiency and accuracy in a setting of a large clinical laboratory.
Materials and MethodsSpecimens
Blood samples were collected in ethylenediaminetetraacetic acid (EDTA) and stored at room temperature.
UniCel DxH 800 Coulter Cellular Analysis System (Beckman Coulter, Inc, Miami, FL) with a small footprint and a modular design providing for a continuous “load ‘n’ go” capability.
UniCel DxH 800 Coulter Cellular Analysis System (Beckman Coulter, Inc, Miami, FL) with a small footprint and a modular design providing for a continuous “load ‘n’ go” capability.
Range of WBC Counts Tested on the DxH 800 and the LH 750a
Range of WBC Counts Tested on the DxH 800 and the LH 750a
Samples from healthy individuals and patients with various hematological and non-hematological disorders were included. All specimens were analyzed, and smears stained with Wright stain within 4 hours of collection. In each case, 2 experienced medical technologists performed a 200-cell differential count in accordance with the reference method protocol specified by the Clinical and Laboratory Standards Institute (CLSI) outlined in Document H20-A.1 The morphologists were not provided with the results generated by the automated analyzer.
Accuracy of CBC and Differential Counts: DxH 800 vs. LH 750a
Accuracy of CBC and Differential Counts: DxH 800 vs. LH 750a
Instruments
The DxH 800 provides 28 hematology parameters, including CBC and differential count, corrected WBC count, NRBC count, and 4 RET parameters, and has a throughput of 100 specimens per hour. Initial testing of the DxH 800 for precision, linearity, and carryover were within the manufacturer’s specifications.
The LH 750 is a fully automated high-throughput hematology analyzer capable of testing as many as 110 samples per hour with a full 6-part differential, flagging of abnormal samples, enumeration of NRBCs, and automated correction for WBC counts when interfering substances are present.
Comparison Studies
The following parameters were evaluated: CBC (composed of WBC count, RBC count, hemoglobin, mean corpuscular volume, red blood cell distribution width, platelet count, and mean platelet volume, automated and manual differential counts, NRBC, and RET parameters. The results were evaluated by simple linear regression and correlation coefficients, including slope and intercept (Microsoft Office Excel 2003, Microsoft Corporation, Redmond, WA).
The accuracy of the WBC count was assessed for 327 samples. We compared the means of WBC counts on the DxH 800 and LH 750 within 3 ranges: 0 to <2.0, 2.0 to <100, and 100–400 × 109/L in 50, 275 and 2 samples, respectively. The accuracy of CBC parameters other than the WBC count was established by comparing the results from the DxH 800 with those from the LH 750 in 339 specimens. For specific parameters, specimens with suspect flags were excluded.
The automated differential counts were compared in 246 specimens. Also, we compared the accuracy of the DxH 800 results to those from the 400-cell manual differential in 158 samples (with all suspect and system-event flagged results excluded). The accuracy of the NRBC count was established by comparing the DxH 800 count with the manual morphological count in 276 samples. The accuracy of the RET percentage (RET %) and other RET parameters (namely, mean RET volume [MRV] and immature RET fraction [IRF]) was established by comparing 304 samples.
The clinical sensitivity of the DxH 800 and the LH 750 was compared with the manual differential assessment. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and overall efficiency were calculated. For comparison of the differential and flagging capabilities of the analyzers, 339 patient samples were selected at random from the daily workload.
ResultsComparison of CBC Accuracy
The comparison of CBC results from the DxH 800 and the LH 750 data are presented in Table 1 and Table 2. The WBC count, RBC count, hemoglobin, mean corpuscle volume, red blood cell distribution width, and platelet count were closely correlated (R values greater than or equal to 0.99). For most of these parameters, the slope and the y-intercept were close to 1 and 0, respectively. A slightly lower correlation coefficient (R = 0.88) was observed for mean platelet volume.
Accuracy of Automated and Manual Differential Counts
The accuracy of the automated differential counts was assessed by comparing the means of differential counts between the DxH 800 and the LH 750 (Table 2). The percentages of neutrophils, lymphocytes, monocytes, and eosinophils were closely correlated. The poorest correlation was between the basophil counts (R = 0.34).
We also compared the accuracy of the DxH 800 results to 400-cell manual differential counts (Table 3 and Figure 2). The R values ranged from 0.85 to 0.98 for neutrophils, lymphocytes, monocytes, and eosinophils. The comparison of basophil counts had an R value of 0.54.
Automated Differential Counts from the DxH 800 and the Manual Differential Counts in 158 Samplesa
Automated Differential Counts from the DxH 800 and the Manual Differential Counts in 158 Samplesa
Correlation between automated cell differential counts derived from the DxH 800 Coulter Cellular Analysis System and those derived from the manual differential count. A, Neutrophil (NE) percentage, r = 0.97. B, Lymphocyte (LY) percentage, r = 0.98. C, Monocyte (MO) percentage, r = 0.85. D, Eosinophil (EO) percentage, r = 0.91. E, Basophil (BA) percentage, r = 0.54.
Correlation between automated cell differential counts derived from the DxH 800 Coulter Cellular Analysis System and those derived from the manual differential count. A, Neutrophil (NE) percentage, r = 0.97. B, Lymphocyte (LY) percentage, r = 0.98. C, Monocyte (MO) percentage, r = 0.85. D, Eosinophil (EO) percentage, r = 0.91. E, Basophil (BA) percentage, r = 0.54.
Receiver operator curve (ROC) of the UniCel DxH 800 Coulter Cellular Analysis System for nucleated red blood cell (NRBC) count and the manual NRBC count.
Receiver operator curve (ROC) of the UniCel DxH 800 Coulter Cellular Analysis System for nucleated red blood cell (NRBC) count and the manual NRBC count.
The accuracy of the NRBC count was established by comparing the DxH 800 counts to the manual morphological counts in 276 samples; strong correlation was observed (R = 0.97). Further evaluation of the DxH 800-derived NRBC count using receiver operating characteristic (ROC) curve analysis (Figure 3) showed high sensitivity and specificity for this parameter (90.4% and 87.3%, respectively).
Analysis of RETs and Related Parameters
The RET %, IRF, and MRV results derived from the DxH 800 and LH 750 were compared. The following R values were received: RET % R = 0.94, IRF R = 0.71, and MRV R = 0.88 (Table 4).
Clinical Sensitivity
The clinical sensitivity of the DxH 800 was compared against the manual differential. The sensitivity was determined to be 88%; the specificity was 56%. The PPV was 40%; the NPV was 94%. The overall efficiency was 64%.
Investigation of 10 false-negative samples from the DxH 800 evaluation revealed that those samples could be categorized into 2 broad groups, the first of which included 3 samples showing only a mild left shift. Two samples had 7% and 13% bands, respectively, and one sample had 4% metamyelocytes and myelocytes in a low normal WBC count. An additional 7 samples were considered to have lymphocyte false-negative results. Four of these samples had low numbers (ie, less than 9%) of reactive or variant lymphocytes. One sample had 20% small reactive lymphocytes in an otherwise normal WBC count. An additional 2 samples were from patients with chronic lymphocytic leukemia who had a higher-than-normal WBC count (13.6 and 39.4 × 109/L) and small numbers of large variant lymphocytes. These cells were morphologically classified as prolymphocytes (11% and 6%, respectively). The latter samples would have been reviewed because of their elevated WBC count and lymphocytosis.
Accuracy of RET Parameters for DxH 800 vs. LH 750 in 304 Samplesa
Accuracy of RET Parameters for DxH 800 vs. LH 750 in 304 Samplesa
For comparison, we also evaluated the LH 750 for its clinical sensitivity against the manual differential. The sensitivity was determined to be 83%, with a specificity of 46%. The PPV was 34%, the NPV was 89%, and the overall efficiency was 56%. The DxH 800 performs considerably better than the LH 750 on all the clinical sensitivity parameters.
Discussion
In this study we compared the performance of the DxH 800 hematology analyzer to its predecessor, the LH 750, with specific attention to manual differential counts. Our findings demonstrated that the DxH 800 produces accurate CBCs, differential counts, and RET results. The only exception was the basophil percentage, which showed a systematic underestimation over the entire range of samples in comparison to the differential counts. The low accuracy of basophil enumeration has been reported previously for other analyzers2,3 and is related in part to the low basophil count in tested samples.
The automated NRBC count from the DxH 800 correlated well with the manual method; our results are similar to those reported for the LH 750 and the Sysmex XE-2100 (Sysmex Asia Pacific Pte Ltd, Singapore) and significantly better that those reported for other analyzers.4–6 The presence of NRBCs beyond the first week after full-term delivery is usually associated with generalized hypoxia or bone marrow disorders. Accurate enumeration of NRBCs is pivotal because there is increasing evidence that the NRBC count has prognostic significance in patients with burns, after stem cell transplantation, and in surgical intensive care patients.7–9
The productivity and efficiency of a hematology laboratory depends on the performance of the hematology analyzers; each new instrument must be thoroughly evaluated for its potential to improve laboratory workflow. The importance of increasing workflow efficiency cannot be underestimated. In previous reports,4,10–18 manual review of flagged samples has been found to be time consuming and labor intensive. Therefore, the greatest gains in productivity often can be found in improvements in clinical sensitivity and efficiency (ie, the slide-review rate). A number of publications4,10–13,15–18 have evaluated the accuracy of CBC, NRBC, and RET parameters, as well as the clinical sensitivity of the WBC count and differential flagging of the LH 750, confirming the low false-positive and false-negative rates of this instrument. The results of our study showed improved performance of the DxH 800 compared with that of the LH 750. The DxH 800 has a higher clinical sensitivity and efficiency rate for overall flagging and improved negative and positive predictive values. These results translate into an improvement of approximately 10% in clinical sensitivity (ie, a 10% lower slide-review rate). Only a few samples showed false-negative results. Detailed review of these cases showed mild abnormalities, namely, 3 samples with mild left shift and 7 with low numbers of variant or reactive lymphocytes.
The improvement of 10% in overall efficiency accomplished by the DxH 800 had a substantial positive effect on our laboratory productivity, equating to approximately 30 fewer slides per day that required review. On average, a scan of each slide takes 5 minutes; the manual differential including review and reporting takes approximately 8 minutes. Thus, the reduction in the total number of slides that require review results in a savings of 210 minutes (ie, 3.5 hours) of labor per day. In addition to the improvements noted herein, we observed a reduction in the number of incomplete differentials when using the DxH 800 system.
In conclusion, the new-generation automated hematology analyzer, the DxH 800, generates highly accurate results for all CBC, differential, and RET measurements. Our evaluation revealed a notable improvement of 10% in overall efficiency compared with its predecessor, the LH 750. In the large laboratory setting, this translates into a considerable improvement in productivity and better allocation of laboratory personnel for faster service delivery to our health care professionals and patients.
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Abbreviations
This instrument was field-tested in conjunction with this study.
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