Bone marrow aspirate collection and preparation--a comparison of three methods.

PURPOSE: Preparing bone marrow smears using non-anticoagulated bone marrow aspirate is a traditional practice but many laboratories now use anticoagulated aspirate samples in K-EDTA. There are no published studies comparing the effectiveness of these two methods. This report compares the readability of slides, prepared using non-anticoagulated and anticoagulated methods, from three laboratories in Hamilton Ontario. METHODS: A blinded set of 129 aspirate slides prepared using anticoagulated and non-anticoagulated methodologies (using K-EDTA) was reviewed by three reviewers. Slides were classified as unreadable if two of the three observers rejected them based on a standardized survey. RESULTS: The proportion of slides classed as unreadable varied widely (5.0% to 46.9%) depending on collection and slide preparation methods. Degree of coagulation did not affect readability. CONCLUSION: A measurable advantage to using non-anticoagulated bone marrow was not demonstrated. Immediate anticoagulation of bone marrow samples, with laboratory personnel at the bedside to assess sample quality, followed by slide preparation in the laboratory provided the best results.

A multicenter trial of the effectiveness of zeta-globin enzyme-linked immunosorbent assay and hemoglobin H inclusion body screening for the detection of alpha0-thalassemia trait.

Routine laboratories use a hemoglobin H (HbH) screen to detect alpha-thalassemia carriers of fatal hemoglobin Bart's hydrops fetalis. This test is laborious and has sensitivity concerns. A commercial zeta-globin enzyme-linked immunosorbent assay (ELISA) is effective in detecting Southeast Asian (SEA) alpha-thalassemia. We present results of a study of the effectiveness of carrier detection of ELISA and a shortened HbH screen compared with gap polymerase chain reaction. ELISA was superior to the HbH screen for the SEA alpha0-thalassemia trait. The ELISA and H screen were equal for detection of all carriers encountered and combined were more effective than either test alone. A positive zeta-globin ELISA result is diagnostic of SEA alpha-thalassemia, and routine use of the zeta-globin ELISA in combination with a shortened HbH screen will improve the efficacy of prenatal screening for carriers of hemoglobin Bart's hydrops fetalis through improved detection and referral for follow-up DNA testing.

Prevalence of thalassemia in patients with microcytosis referred for hemoglobinopathy investigation in Ontario: a prospective cohort study.

In Ontario, Canada, beta-thalassemia is easily detected through measurement of hemoglobin A2, but most laboratories do not do exhaustive DNA investigations for alpha-thalassemia. Therefore, the prevalence of thalassemia in microcytic samples for hemoglobinopathy investigation in Ontario is unknown. To address this, we performed a prospective cohort study in which samples referred for hemoglobinopathy investigation were also evaluated for alpha-thalassemia by DNA testing. Of 800 samples submitted, 664 were evaluable. Of the 664 patients represented, 163 (24.5%) were beta-thalassemia major carriers, 68 (10.2%) were hemoglobin Bart's hydrops fetalis carriers and, in total, 361 (54.4%) had some form of thalassemia. We conclude that microcytosis due to thalassemia is common in Ontario and that major forms of thalassemia, including forms predisposing to hemoglobin Bart's hydrops fetalis and beta-thalassemia major, are frequent. This illustrates the importance of adequate prenatal and laboratory investigation for these abnormalities in Ontario and other similar multiethnic jurisdictions worldwide.

Good practice guidelines for laboratory investigation of hemoglobinopathies.

A review of the Quality Management Program-Laboratory Services (QMP-LS) hemoglobin fraction quantitation/hemoglobinopathy investigation surveys revealed recurrent errors in diagnosis of carrier genotypes for serious hemoglobinopathies. To address these concerns, QMP-LS developed guidelines for laboratory investigation of hemoglobinopathy syndromes. The guidelines are based on current practice in the province of Ontario, expert opinion in the field, and a review of recent literature. They include an overview of the clinical significance of the hemoglobinopathies, the indications for a hemoglobinopathy investigation, key components of a thorough laboratory hemoglobinopathy investigation, interpretation of investigation results, diagnosis of rare hemoglobin variants, and indications for DNA investigation of hemoglobinopathies. The guidelines present various tables and figures outlining mean cell volume reference intervals, recommended hemoglobinopathy investigative techniques, recommendations for further investigation of abnormal findings, and algorithms for interpretation of the various laboratory hemoglobinopathy investigative techniques. The guidelines are intended for use in the processing of specimens when a clinical or laboratory physician has ordered a hemoglobinopathy investigation (hemoglobin electrophoresis).

Beta-thalassemia in association with a new delta-chain hemoglobin variant [delta116(g18)Arg-->Leu]: implications for carrier screening and prenatal diagnosis.

We describe a complicated genetic counseling and prenatal diagnostic case involving an East Indian couple that had lost two consecutive pregnancies. Hemoglobinopathy screening was conducted to investigate the possibility of Hb Bart's hydrops fetalis or Hb H hydrops fetalis. The initial work-up indicated that alpha-thalassemia was not a contributing factor, with both parents being carriers of single gene deletions (-alpha(3.7)/alphaalpha). However, the Hb electrophoresis results indicated that the couple might be at risk for having children with Hb E/Hb Lepore disease. Subsequent DNA testing demonstrated that the father carried the Hb E mutation, but failed to confirm that the mother carries the Hb Lepore deletion. Sequence analysis revealed that the mother was heterozygous for a common East Indian beta(0)-thalassemia mutation, yet had a normal level of Hb A(2). The mother also carried a previously unreported missense mutation of the delta-globin gene, in cis with the beta(0)-thalassemia mutation, which gave rise to the minor Hb variant originally misidentified as Hb Lepore. This case illustrates the importance of comprehensive molecular analyses for accurate assessment of genetic risks for hemoglobinopathy syndromes.

Fetal-maternal hemorrhage detection in Ontario.

The results from fetal-maternal hemorrhage (FMH) detection and quantitation external quality assessment surveys conducted in Ontario indicate that the rosette test had a sensitivity and specificity for an FMH of more than 10 mL of 1.0 and 0.75, respectively, compared with 0.96 and 0.92, respectively, for acid elution. With FMH quantitation, the percentage error of the mean from the target FMH was 20% or more in 7 of 8 surveys, and coefficients of variation ranged from 39.5% to 71.8%. Inadequate Rho(D) immune globulin prophylaxis could have occurred in 19.4% of the challenges with an FMH of more than 10 mL. The rosette and acid elution techniques are both effective for the detection or exclusion of FMH, but acid elution lacks adequate accuracy and precision for reliable FMH quantitation. Furthermore, a strategy of prescribing an extra 1,500-IU Rho(D) immune globulin dose, in addition to the dose required to treat the volume of fetal blood detected, is an effective strategy to overcome the limitations of FMH quantitation by acid elution.

Evaluation of a dual hemoglobin A(2)/A(1c) quantitation kit on the bio-rad variant II automated hemoglobin analyzer.

CONTEXT: Quantitation of hemoglobin (Hb) A(1c) and investigation of hemoglobinopathy on the Bio-Rad Variant analyzers require a switch between 2 separate kits that is time consuming and causes errors. OBJECTIVE: Evaluation of a new Variant II HbA(2)/HbA(1c) Dual kit capable of both Hb A(1c) quantitation and hemoglobinopathy investigation on a single kit. DESIGN: We evaluated Hb A(1c), Hb A(2), and Hb F quantitation for precision, linearity, and correlation with current methodology. We also evaluated detection of Hb variants and correlation of Hb Barts quantitation. SETTING: Hamilton Regional Laboratory Medicine Program, Provincial Hemoglobinopathy Laboratory, St Joseph's Healthcare Site, Hamilton, Ontario. PATIENTS: Patient blood samples submitted for Hb A(1c) quantitation or hemoglobinopathy investigation. MAIN OUTCOME MEASURES: Precision, linearity, linear regression, and reference interval validation. RESULTS: We provide tables and figures illustrating precision, linearity, linear regression, and quantitation of Hb variants. We validated reference intervals for Hb A(1c), Hb A(2), and Hb F. CONCLUSIONS: The dual kit provides precise Hb A(1c), Hb A(2), and Hb F quantitation. The results show good linearity and correlate well with the results of current methods. We detected all clinically important Hb variants and a wide variety of rare variants. The dual kit has several advantages: it eliminates the need for extensive kit switch over; improves utility for newborn screening because of its quantification of Hb Barts; permits quantification of Hb A(1c) using the beta-Thal method; and eliminates the need for separate Hb A(2) reference intervals for patients with Hb S because of its accurate quantitation of Hb A(2) in the presence of Hb S.