College of American Pathologists
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CAP Today




June 2012
Feature Story

Jan Bowers

Laboratorians working in hematology have long had a wealth of resources to help them identify what they see through the microscope, including the CAP’s Color Atlas of Hematology and the Hematology and Clinical Microscopy Glossary. What they haven’t had, until recently, is “something at the bench, that doesn’t require you to go to the supervisor’s office and check out their locked-up copy of the atlas, something that was going to work whether the computers were up or down,” says Tracy I. George, MD, director of the clinical hematology laboratory at Stanford University Medical Center and assistant professor of pathology, Stanford University School of Medicine.

Dr. George, chair of the CAP Hematology/Clinical Microscopy Resource Committee, says ease of use and image quality were guiding principles as six committee members brainstormed and created the Hematology Benchtop Reference Guide: An Illustrated Guide for Cell Morphology. Available since February, the user-friendly guide appears to have struck a chord with laboratories, with more than 2,000 copies having been sold to date.

The concept evolved from a committee discussion of unmet needs in the laboratory. After deciding to create a resource for quick reference, the committee identified the qualities that would make a printed guide ideal for use at the bench. The result: a compact, spiral-bound book whose pages are sturdy and coated to withstand coffee spills (and worse). “I’ve got an office filled with beautiful textbooks, but I’m very reluctant to loan them out to staff on the bench, given what’s going to happen to them there,” Dr. George says with a laugh. She credits Georganne Bradshaw, CAP senior technical specialist, and other CAP staff for helping the group pinpoint the characteristics that would make the book user-friendly: “its small size, the fact that it stays open on the image you want and stands up to wear and tear.”

Though intended for medical technologists, the guide could also be useful for medical technology and medical students, clinical laboratory scientists, residents, fellows, and physicians who come to the laboratory to look at smears, Dr. George says. Hematopathologists could use it too, notes co-author Lydia C. Contis, MD, medical director of the hematology laboratories of UPMC Presbyterian-Shadyside, Magee Women’s Hospital, and Children’s Hospital of Pittsburgh, “but for resident trainees especially, and maybe pathologists who don’t specialize in hematology, it might be a very handy quick reference guide.” Dr. George envisions the purchase of multiple copies: “In my laboratory, my supervisor’s going to have a copy, as well as all the labs that are looking at hematology and are performing peripheral blood smears.”

The quality of the images, and the stringent vetting process applied to each one, is a point of pride for the authors. When Dr. George asked the committee members for new ideas for resources a few years ago, Dr. Contis proposed a reference guide for medical technologists. “The CAP has a large archive of digitized and Kodachrome images. I said, ‘Why don’t we pull images we already have and put them in a book?’” In the archive are slides and photos submitted by members of the Hematology/Clinical Microscopy Resource Committee. Bradshaw gathered multiple images for each cell, microorganism, and artifact described in the guide, and “we pathologists chose the image that was the most clear, focused, and representative,” Dr. Contis explains. One of the guide’s strengths is that “these images have all been reviewed by multiple laboratories and agreed upon,” Dr. George says. “We’re using images that have been refereed and reviewed by participants of proficiency testing.”

In selecting content for the guide, the authors focused less on the obscure and more on what medical technologists would commonly encounter in their day-to-day work, Dr. George says, noting that “common” doesn’t necessarily mean “easy to identify.”

“Things like reactive lymphocytes—we all see them, it’s a very common problem, yet sometimes you really want a guide,” she says. “Some of these cases of infectious mononucleosis or EBV infection can look quite scary. And I find it’s very reassuring, especially for students who are training, or relatively new staff, to be able to picture it.”

Co-author Joan E. Etzell, MD, director of the clinical hematology laboratory at the University of California at San Francisco and professor of clinical laboratory medicine, UCSF School of Medicine, singled out the guide’s illustration of white cell morphology as particularly useful for the less experienced technologist. “Identification of blasts as well as promyelocytes, myelocytes, and metamyelocytes—all of those types, at least as indicated on our proficiency Surveys, can be difficult to get a consensus on,” she says. For Dr. Contis, the image of the microorganism Anaplasma stands out: “You don’t see a lot of images of that in the literature. It’s really quite helpful.”

The guide is divided into six sections, each with a tab for easy access: erythrocytic cells, erythrocytic cell inclusions, granulocytic (myeloid) and monocytic cells, lymphocytic cells, platelets and megakaryocytic cells, and microorganisms and artifacts. A 3½- by 2¼-inch image tops each page, followed by a description of appearance and special features.

The writing process began with CAP staff members who pulled descriptions from the glossary and distributed them to the pathologists working on the relevant sections of the guide, Dr. Etzell says. Those subject experts condensed the copy to fit the guide’s compact format and circulated it to the group of six co-authors. Says Dr. George, “I was involved more in the final review to make sure it was exactly what we wanted, the pictures were of high quality, and the copy was appropriate.”

The guide is divided into six sections, with tabs for each. Images have been refereed and reviewed by Surveys participants. To order ($64, code HBRG), call 800-323-4040 or 847-832-7000 option 1.
The guide is divided into six sections, with tabs for each. Images have been refereed and reviewed by Surveys participants. To order ($64, code HBRG), call 800-323-4040 or 847-832-7000 option 1.
The other co-authors are Kyle Thomas Bradley, MD, of Emory University Hospital; Sherrie L. Perkins, MD, PhD, of ARUP Laboratories; and Kathryn A. Rizzo, DO, PhD, of Professional Pathology Services, Columbia, SC.

In the committee’s view, a benchtop guide for hematology is just the beginning. “We also thought this would be fantastic for urinalysis, for body fluids, for microbiology—situations where you’re looking at a slide and you just want a simple guide,” says Dr. George. Dr. Etzell is already reviewing text for a benchtop guide to body fluids. “I think these benchtop guides will be a wonderful resource across hematology and potentially other areas of the laboratory going forward,” she says. “I certainly hope labs find them as useful as I think they’ll be.”

Jan Bowers is a writer in Evanston, Ill.