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  2. 2. What is Immature Granulocyte ? Thymus Lymph nodes and spleen Pluri potent Stem Cell Lymphatic T0-Lymphocyte stem cell Makrophage T1-Lymphocyte B1-Lymphocyte Myeloblast Megakaryoblast Basophil in tissue Proerythroblast Promyelocyte T-Immuno- Centro- B-Immuno- Reticulum cell blast blast blast Megakaryocyte Polychr. Myelocyte Erythroblast Baso- Eosino 0 phil Neutrophil phil Monoblast Plasmoblast Reticulocytes Orthochr. Centrocyte Plasma cell 1 Erythroblast Blood-bone marrow barrier Metamyelocyte 2 Plasma cell Plasma 3 Bands B22-Lymphocyte B -Lymphocyte T -Lymphocyte T22-Lymphocyte 4 Monocyte Monocyte Peripheral Blood Thrombocytes Erythrocytes Segmented Cells SegmentedJuli Soemarsono SURAMADE I - 2011
  3. 3. 3 MANUAL MICROSCOPIC IMMATURE GRANULOCYTE Text1 Text1 Text1 Text1Juli Soemarsono SURAMADE I - 2011
  4. 4. 4Diana Aulia, Arief I. Sanjaya, and Ina S. Timan ;J. Lab. Med. & Quality Assurance 2003:25:237-242 MANUAL / MICROSCOPIC IMMATURE GRANULOCYE Text1 Text1 Text1 Text1Juli Soemarsono SURAMADE I - 2011
  5. 5. 5 HEMATOLGY ANALYZER IMMATURE GRANULOCYE Text1 Text1 Text1Juli Soemarsono SURAMADE I - 2011
  7. 7. 7Diana Aulia, Arief I. Sanjaya, and Ina S. Timan ; J. Lab. Med. & Quality Assurance 2003:25:237-242 •Ratio between immature neutrophyls to total neutrophils (IT ratio) is the ratio between the amount of immature neutrophils against the amount of total neutrophils in a blood smear preparation. •Immature neutrophils are cells at younger stage than neutrophil bands metamyelocytes, myelocytes, promyelocytes myeloblast).Juli Soemarsono SURAMADE I - 2011
  8. 8. 8 Clinical utility of the band count. has a long clinical tradition as a diagnostic test for bacterial infection imprecise BAND inaccurate COUNT required to calculate an immature to total neutrophil ratioJuli Soemarsono (I:T ratio) SURAMADE I - 2011
  9. 9. 9 Diagram neutrophils more immature than bands DETECTION absolute neutrophil count of INFECTION I / T RATIO Ardron MJ, Westengard JC, Dutcher TF. Am J Clin Pathol. 1994 Nov;102(5):646-9Juli Soemarsono SURAMADE I - 2011
  10. 10. 10 Immature granulocyte Reference ValueJuli Soemarsono SURAMADE I - 2011
  11. 11. Immature granulocyte Reference Value Samples size: • 156 healthy blood donors • Male: 80 • Female: 76 Reference values Male 0.03X109/L 0.5% Female 0.03X109/L 0.4% ** No age dependencyJuli Soemarsono SURAMADE I - 2011
  12. 12. 12Juli Soemarsono SURAMADE I - 2011
  13. 13. 13Correlation with flow cytometric reference method & manual reference method Flow cytometric method: • Anti-CD16, aniti-CD11b & anti-CD45 • Epics XL-MCL (BC) Manual Differential Count •400 WBC count (NCCLS protocol)Correlation Tests: XE-IG count vs flow cytometric ref. method using monoclonal antibodies demonstrated excellent results (r=0.96 on data without asterisks) XE-IG count vs. manual ref. count was lower (r=0.78). Reasons being Smaller number of cells counted with manual method Subjectivity involved in morphological classification of IGBriggs et al. ;Hematology. 2003;9:117-124Juli Soemarsono SURAMADE I - 2011
  14. 14. 14Clinical Significance Positive sample rate in samples with high IG (2.0% or higher). Good correlation • CRP • ESR • CD64 • IL-6 Conclusion: IG count can highlight a potential acute infectious inflammatory response at a relatively early stage of development of clinical features when other blood count parameters (e.g. Neutropils) are in the overall normal range and are generally non-specific as indicators. Reference: Briggs et al. Evaluation of Immature Granulocyte Counts by the XE-IG Masrer: Upgraded software for the XE-2100 Automated Hematology Analyzer. Laboratory Hematology. 2003;9:117-124 Juli Soemarsono SURAMADE I - 2011
  15. 15. 15IG count in infection and sepsisJuli Soemarsono SURAMADE I - 2011
  16. 16. 16 IG as a predictor of infections and sepsis • IG% is higher in infected patients and positive blood cultures • IG % is better predictor of infection than WBC count • IG % is comparable to the absolute neutrophil count • High IG helps direct molecular testing, leading to a more rapid diagnosis of severe infection • Low sensitivity as a screening tool, but prediction of infection / bacteremia may be improved by incoporating IG measurement with other tests to help in early detection of infection in patients. • > 3% IG is a very specific predictor of sepsis (>90%) (Ansari-Lari et al, 2003)Reference:Ansari-ari et al. Immature Immature Granulocyte Measurement using the Sysmex XE-2100: Relationship of Infectionand Sepsis. Am J Clin Pathol. 2003;120:795-799Juli Soemarsono SURAMADE I - 2011
  17. 17. 17IG ratio & IT ratio inSepsis Study objectives: To determine if IG, IG ratio and IT ratio can be used as a early indicator of sepsis To determine If IG count can provide a fast, reliable and more cost effective method of diagnosis in comparison with other diagnostic tools such as blood culture or CRPJuli Soemarsono SURAMADE I - 2011
  18. 18. 18 Comparison of IG ratio and IT ratio with blood culture All 7 patients with negative blood culture showed IT ratio > 0.65 6 of the 7 patients with negative blood culture having a raised IG ratio IT ratio provides a useful tool in diagnosing those sepsis patients who have a negative blood cultureJuli Soemarsono SURAMADE I - 2011
  19. 19. 19IT ratio vs IG ratio as indicator of Sepsis • IG Ratio of 0.35 gives the best sensitivity & specificity IT Ratio of 0.65 gives the best sensitivity & specificityJuli Soemarsono SURAMADE I - 2011
  20. 20. 20 IT ratio vs IG ratio as indicator of Sepsis• IT ratio though has the same sensitivity & specificity as IG ratio, it gives a better overall positive and negative predictive values than IG ratio.• IT ratio provides a useful tool in diagnosing those sepsis patients who have a negative blood culture (100 PPV). Juli Soemarsono SURAMADE I - 2011
  21. 21. 21 IT ratio and the day of Diagnosis • 12 (71%) of 17 patients studied showed an IT ratio > 0.65 in samples taken on 3 days pre diagnosis • => IT ratio can be used as early indicator of sepsis 29% 71% 18 (72%) of 25 septic patients studied 3 days post diagnosis showed an IT ratio > 0.65 in samples on 3 days post diagnosis => post sample detected 1 more patient => IT ratio can be used throughout the course of disease => may be used to monitor patient recoveryJuli Soemarsono SURAMADE I - 2011
  22. 22. 22 How to measure IG ? XE-seeries (5 +1) part diff automated hematology analyzer! XE-5000 XE-2100 (w/ XE IG Master) XE-2100L (w/ XE IG Master) XE -2100D (w/ XE IG Master)Juli Soemarsono SURAMADE I - 2011
  23. 23. 23IG count Measure in Diff Channel and report in IG # (103/µl) IG % Detect in IMI channel and display as flags Constitute of Promyelocytes, Myelocytes & MetamyelocytesJuli Soemarsono SURAMADE I - 2011
  24. 24. 24Benefits of quantitative IG count Using Sysmex XE “Anti-smear campaign”• Automated enumeration of IG using proprietary Fluorescent Flow Cytometery, eliminates – immature granulocyte flag – false positives – the need to perform unneccessary manual smear reviews• Improved sensitivity & accuracy compared to manual Diff-Count – Small no of IG, particularly in leukopenic sample are often missed in a std 100-cell DC – Wide inter-examiner and inter-laboratory variation• Reduce manual reviews – saves times & effort of MT – allow results to be delivered to physicians sooner -> reduce TAT• User defineable setting for Diff Review: (IG > 2%, 3%, 4% or 5%)• Fast, simple and inexpensive method Juli Soemarsono SURAMADE I - 2011
  25. 25. 25 Clinical Utilities of XE’s IG Count 1. provides an rapid, accurate and inexpensive method to detect inflammation and diagnosis of sepsis 2. early indicator of inflammation and sepsis to facilitates timely treatment.Juli Soemarsono SURAMADE I - 2011
  26. 26. Juli Soemarsono SURAMADE I - 2011