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Vetgirl Cytology Webinar 11/10/16 All# you#need#to#know# about# hematology# and#cytology* Tracy#Stokol,#BVSc,#PhD,#DACVP Ashleigh# Newman,#VMD,#DACVP *Well,&not&everything,&but&as&much&as&we&can&teach&you&in&2&hours!& Blood Handling Blood Handling As It was Intended Seals Automatically The SAFE-TEC ® PCV/TP System is designed Prevents Centrifuge Blowouts to improve your blood handling procedure by ensuring technicians’ safety and saving Protects Technicians from Glass Shards valuable time 142 Railroad Drive Ivyland, PA 1-215-364-5582 www.safe-tecllc.com 142 Railroad Drive Ivyland, PA 1-215-364-5582 www.safe-tecllc.com As It was Intended FREE SAMPLES Simplifies Sample Transfer See the difference for yourself! Eliminates Snapping Tubes The first 100 Veterinary Professionals to contact us will receive 10 free samples of Preserves Refractometers SAFEC AP®. E-MAIL: [email protected] CALL: 1-215-364-5582 142 Railroad Drive Ivyland, PA 1-215-364-5582 www.safe-tecllc.com 142 Railroad Drive Ivyland, PA 1-215-364-5582 www.safe-tecllc.com 1 11/10/16 Introduction Introduction Garret# Pachtinger,# VMD,# Justine-A.-Lee,- DVM, DACVECC DACVECC,- DABT CEO,-VETgirl COO,# VETgirl VETgirl…OnFTheFRun VETgirl#ELITE • The#techFsavvy# way#to#get#online#veterinary# CE! • A#subscriptionFbased# podcast# and#webinar# service# offering# veterinary# RACEFapproved# CE 50F60# podcasts/year# plus&24+#hours#of#webinars! • $199/year • 40+#hours#of#RACEFCE New#and#improved#video! Up$to$5$members:$ $599/year Up$to$10$members:$ $999/year >$10$members: Ping$us 2 11/10/16 New#and#improved#video! Download#our#iTunes#podcasts#free! Social#media#and#our#blog! Introduction Logistics:#CE#Certificates ! Type-in-questions Dr.-Tr ac y - Stokol BVSc,- PhD,-DACVP ! EmaileD- to-you 48-hours after-the-webinar ! Active-participation-=-no-quiz Professor-Department-of- ! Watching- viDeo-later,-must- complete- quiz Population-MeDicine-anD- ! ELITE- members- only Diagnostic-Sciences-College- ! Email-/-contact- with-ANY-questions of-Veterinary-MeDicine- Cornell-University ! [email protected] ! [email protected] 3 11/10/16 Introduction www.eclinpath.com Dr.-Ashleigh- Newman,- VMD,-DACVP Instructor-in-Clinical- Pathology-at-Cornell- University Outline Make#a#fresh#blood#smear! • Hematology • Crucial! • Tips# on# smear#preparation • ASAP,#ideally#<#4#hours • How# to# examine#a#blood# smear • Fact#or#fiction? • Delays#can#result#in: • Why# look# at#a#blood# smear? • WBC: • Cases:# Approach# to#anemia,# diagnostic# conundrums • Nuclear#swelling#and#smoothing:##PseudoFleft#shift • Prominent#Dohle • Cytology bodies:#PseudoFtoxic# • Tips# on# smear#preparation change • How# to# examine#a#cytologic# smear • Apoptosis:#Mimic#nRBC • Fact#or#fiction? • Cases:# Skin#lumps# and# bumps# (the#tip# of#the#iceberg) fresh stored Make#a#fresh#blood#smear! Making#a#smear • Delays#can#result#in: • RBC: • Crenation#and#lysis • Detachment#Mycoplasma&(c ats) • Platelets: • Clumping#and#degranulation Image:& Orsini &&Divers.& Equine& Emergencies:& Treatment& anD&ProceDures 4 11/10/16 Blood#smear#examination Blood#smear#examination • Check#that#feathered#edge#(10x) • Find#and#scan#the#monolayer#(10x) Blood#smear#examination Blood#smear#examination • Perform#a#differential#count# • Identify#and#classify#leukocytes#(40x#or#50x) (40x#or#50x) • Note#obvious#abnormalities Segmented#neutrophils Lymphocyte Monocyte Blood#smear#examination Blood#smear#examination • Evaluate#WBC#morphologic#features#(100x) • Evaluate#RBC#morphologic#features#(100x) Toxic#band Iron#deficiency# anemia# (hypochromic# fragmented#RBCs)# pos t#trans fus ion# (dual# population) Reactive# lymphocyte 5 11/10/16 Blood#smear#examination Fact#or#fiction? • Estimate#platelets#(1#per#100x# OIF#=#15,000/μL) • Which#one#is#the#infectious# agent? • Evaluate#morphologic#features#(100x) Anaplasmaplatys Stain# precipitate Phagocytized# bacteria Fact#or#fiction? Fact#or#fiction? • Which#one#is#the#infectious# agent? • Which#one#is#the#infectious# agent? Mycoplasma& haemofelis Water# artifact Birman granules Mast# cell# granules Fact#or#fiction? Why#look#at#a#blood#smear? • Is#the#arrowed#cell#a#nucleated#RBC? • Our#eyes#are#better#than#a#machine • Verify#results#(e.g.#platelet#count) • Morphologic#clues#to#underlying# disease • RBC#changes No:# • Left#shift,#toxic#change Pyknotic WB C in# a#dog#with# • Abnormal#cells Acute#leukemia heatstroke • Infectious#agents • Assess# critical#patients#when# analyzer/lab#is# unavailable# (e.g.#after#hours) 6 11/10/16 Case#1:#Taffy Is#Taffy#anemic? • 4#year#old#MN#Golden#Retriever • One#week#history#of#lethargy • Exposed# to#wasp#insecticide • Drugs • Revolution#2#weeks#prior • Intranasal#Bordetella#and#parainfluenza 3#months#prior • Examination • Quiet,#alert,#responsive • Pallor • Tachycardia,#tachypnea • Grade#II/VI#heart#murmur How#severe#is#the#anemia? Severity#of#anemia • Based#on#Hct Anemia Dog Cat None ≥#41 ≥#31 Mild 30F40 25F30 Moderate 15F30 15F25 Severe <15 <15 Transfusion2 trigger Clinical# and# laboratory# evidence# of# hypoxia# (not# Hct)! Tachypnea,#tachycardia Decreased#percent#oxygen#saturation Hypotension,#etc. Is#the#anemia#regenerative? Response#to#an#anemia • Erythroid#hyperplasia:#Takes#3F5#days • Release#of#immature#anuc leate RBC • Polychromatophi ls (Wright’s,# DiffFquik) • Reticulocytes# (vital# or# fluorescent# dyes):# Aggregate# in# cats P P N P A P Has#the#bone#marrow#had#time#to#respond? Polychromatophils (P),#nRBC (N) A:# Aggregate;#P:#Punctate 7 11/10/16 How#good#is#the#regeneration? Test Taffy Reference2interval Hct (%) 13 42F57 • Quantify# via#absolute#reticulocyte#count MCV#(fL) 73 63F74 MCHC#(g/dL) 33 32F37 Degree2of2 Dog2 Cat2 RDW#(%) 16.7 11.3F14.0 regeneration Reticulocyte2 Aggregate2reticulocyte2 Retic (%) 1.0 0.2F1.1 count2(thou/μL) count2(thou/μL) Retic (thou/uL) 19 10F76 None <92 <60 WBC#(thou/uL) 10.3 6.2F14.4 Mild 92F150 60F100 Seg neut (thou/uL) 8.2 3.4F9.7 Moderate 150F300 100F200 Band neut (thou/uL) 0 0F0.1 Severe ≥#300 ≥#200 PLAT#(thou/uL) 189 179F483 Plasma Normal NonFregenerative#anemia Are#there#clues? • Problem#with#effective bone#marrow#production • Decreased,#ceased,#or#defective#production • Can#occur#with#hemorrhage#or#hemolysis • Many#mechanisms#and#causes • Ask#these#questions: • Are#there#any#clues#as#to#the#cause? • Drugs,#toxins,#infectious#agents? • Is#there#a#disease#preventing#the#marrow#from# responding? • Is#the#problem#in#the#marrow? Elliptocyte /#ovalocyte:#Fibrosis Concept:#RBC#changes Ask#these#questions • Clinical# relevance#of#RBC#changes? • Drugs,#toxins,#infectious#agents? • Revolution#2#weeks#prior • NumberFdependent • Intranasal#Bordetella and#parainfluenza 3# months# • CONTEXTFdependent prior • Exposed#to#wasp#insecticide • Judgment# call#by#you# • Is#there#a#disease#preventing#the#marrow#from# and#your#clinical# responding? • Anemia#of#inflammatory#disease:#Evidence#of#another# pathologist disease#(chemistry#panel,#examination,#imaging) • Lack#of#erythropoietin:#CKD#(chemistry#panel) • Endocrine#disease:#Hypothyroidism,#Addison’s • CLUE:#Anemia#is#mild#to#moderate Acanthocytes • Taffy’s#anemia# is#SEVERE 8 11/10/16 Taffy:#Chemistry#and#urinalysis Is#the#marrow#the#problem? • Severity#of#anemia:#SEVERE in#Taffy Test Taffy Reference2interval • Other#cytopenias:#No#in#Taffy ALT#(U/L) 120 25F106 • Normal#neutrophil#and#platelet#count AST#(U/L) 74 16F50 • Abnormal#cells#in#circulation:#No#in#Taffy Total# bilirubin#(mg/dL) 0.3 0F0.3 Iron#(μg/dL) 250 98F220 Saturation#(%) 100 28F62 Urinalysis:##no#abnormalities What#additional#tests#should#we# Taffy’s#bone#marrow perform#in#Taffy? E 1. Bone#marrow#aspirate" M E E 2. Coombs " Negative 3. 4Dx#plus#SNAP#test " Negative 4. Abdominal#ultrasound" NSF 5. Thoracic#radiographs " NSF M E:#Early#erythroid,#M:#Myeloid,#arrow:#Late#erythroid Let’s#recap#Taffy Taffy’s#diagnosis… • Ill#for#7#days#at# least • Severe#normocytic# normochromic# nonF NonNRegenerative2 ImmuneN regenerative# anemia Mediated2 Anemia2 (NRIMA)2 • Increased# hepatocellular# injury#enzymes# (hypoxia) or2 • No# other# cytopenias PrecursorNdirecte d2 ImmuneN • Bone#marrow:# Ineffective# erythropoiesis Mediated2 Anemia2 (PIMA) • Erythroid# hyperplasia# with# leftFshifted# maturation • Increased# iron# and# %#saturation • No#identifiable# cause# with#diagnostic# testing 9 11/10/16 NRIMA NRIMA • Any#age#or#breed • Pure# red#cell# aplasia# (most#severe):#Young# FeLVFnegative# cats# (<3# • Coombs# test:# Negative# or#weak#positive years#of#age) • Chemistry • Severe#nonFregenerative#anemia:#Hct <15%# • High# iron# and# %#saturation • Usually# normocytic# normochromic • ± Increases# in#liver#leakage#enzymes#(hypoxic# • No#other# cytopenias injury) • Stable#clinical#signs,#i.e.#chronic • Usually#not#cholestatic,#unless#concurrent#destruction • • Clues#on#blood#smear Normal#total#protein • Dogs:#No#spherocytes or# “partial”# spherocytes,# elliptocytes • Bone# marrow:# Needed#for#diagnosis • Cats :#No#aggregate# and# few#to#no#punctate# reticulocytes • Determine# severity • No#underlying#disease#or#drugs • Caution:# May#not# obtain# in# some# dogs# due# to# fibrosis#(dry#tap) Bone#marrow#from#cat#with#PRCA The#IMHA#spectrum No#RBC#precursors,#increased#small#lymphocytes#(arrows) Smear#comparison Taffy#followFup Classic2IMHA NRIMA/PIMA • Treatment:#Blood#transfusions,# Spherocytes# (s upport# for# immunosuppressive# drugs,#gastroprotectants extravascular# hemolysis) Elliptocyte (s ugges ti ve# of# fibros is ) • Progress:# Day Hct Retic (%) (thou/μL) 1 13 19 Normal# canine# 5 19* 6 RBC# wi th# c entral# pallor 14 14 30 21 25 176 Polychromatop hil 28
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