The Application of Digital Morphology in Haematology

Education

Barbara De la Salle Deputy Director

UK NEQAS General Haematology

8 November, 2011

UK National External Quality Assessment Service comprises a network of 144 schemes operating from 24 centres based at major hospitals, research institutions and universities throughout the UK

West Herts Hospitals Trust

Digital ‘Slides’

All view the same cell(s) Microscopy vs morphology skills Direct annotation: education/training Relatively low cost Viewable by ‘limitless’ numbers Easy to store

Hutchinson CV et al Clin Lab Haem (2005)

The five most commonly reported features were: Nucleated red cells Blast cells Macrocytic platelets Myelocytes Megakaryocyte fragments.

Patient Details Age (yrs) Sex Hb(g/l) WBC(x109/l) Platelets (x109/l)

55 f 8.7 76.7 114

Expert Comment (Dr J Parker-Williams, Scheme Director, UK NEQAS) This f ilm was prepared from a blood specimen taken from a fifty-five-year-old-lady, who was diagnosed with myelofibrosis in 1992. This is a f ilm with complex morphological abnormalities - too many to score as many stated! Myelofibrosis was diagnosed in 1992; a splenectomy was performed in 1996 for increasing splenomegaly; twenty percent of participants recorded features of hyposplenism. The majority felt that the features were those of a myeloproliferative/myelodysplastic disorder with transformation to AML-M7.

2004 Exercise: stitched images

2004: Rate the Exercise

With thanks to Michelle Brereton, Manchester Royal Infirmary

Feedback 2004:

High quality, large scale, stitched slides Easy to use software Educational content Access for more participants

Photograph single “high power” images

Take multiple “overlapping” fields

Computer software matches fields

While still retaining details that can be viewed at high power

2007: UK NEQAS / SlidePath ‘not for profit’ collaboration

UK NEQAS images

Digital Slidebox software

Secure, on-line, individual participation

Digital Morphology CPD Scheme

Launched April 2008 Individual participation Educational in purpose 6 cases per year 2000 individual licenses 1100 - 1300 returns per case Laboratory manager admin pages 2011 Additional educational content for 2012

Feedback from users “It is a relatively effortless way for my staff to create

evidence of CPD”

“This strengthens the knowledge of all of my staff and improves their validation knowledge”

“It’s more personal and removes some of the pressure of similar schemes. It is more comfortable for less experienced staff to participate”

Cases issued

First Case - 0801DM1

Previous UK NEQAS 0507BF2 37 year old, female, SE Asia Hepatosplenomegaly, transfused Hb 7.2 g/dL, RBC 4.36, MCV 55, MCH 17 DIAGNOSIS Complex haemoglobinopathy:

Hb A + Hb E + Hb Barts Disease

Top 5 Features 0801DM1

Glass slide Digital slide

1 Target cells Target cells

2 Hypochromic RBC Punctate basophilia

3 Tear drop poikilocytes Tear drop poikilocytes

4 Punctate basophilia RBC fragments etc

5 Poikilocytes Hypochromic RBC

Second Case - 0802DM1

Previous UK NEQAS 0505BF1 83 year old, female Transient ischaemic attack, angina,

hypertension Hb 11.2 g/dL, WBC 138, Platelets 7 DIAGNOSIS Lymphoproliferative disorder: T-PLL

Top 5 Features 0802DM1

Glass slide Digital slide

1 Thrombocytopenia Thrombocytopenia

2 Lymphocytosis Lymphocytosis

3 Smear/smudge cells Smear/smudge cells

4 Prolymphocytes Cleft nuclei

5 Cleft nuclei Neutropenia

Questionnaire 2009

411 completed survey Overall feedback was positive with several

good suggestions on improvement

Participant groups surveyed

11%

36%

35%

14%

2%

2%

Laboratory Manager

Chief or Senior BMS

Specialist BMS

Basic grade BMS Generic/ nonSpecialist BMS.

Trainee BMS

Other (please specify)

Type of organisation

26%

66%

2%6%

Teaching

District General

Private

Other (please specify)

Background

Haematology 37.7% Haematology/Transfusion 50.5% Blood transfusion 5.5% Combined Blood Sciences 4.5% Others 1.8%

Leukaemia diagnosis Stem Cell Laboratory Haemato-Oncology

Morphology Experience How much morphology experience do you have?

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

Series1 6.0% 59.3% 13.7% 16.2% 4.7%

Report under supervision

Regularly issue reports

Issue reports out of hours

Occasionally report films

Not currently practising

Quality of DM Process Very

good/good (%)

Very poor/poor

(%)

Range of cases

99.7 0.3

Quality of images

96.4 3.6

Stain quality

95.5 4.6

Case questions

96.5 3.4 0

20

40

60

80

100

120

Range ofcases

Quality ofimages

Stainquality

Casequestions

Good/Very Good (%) Poor/Very Poor(%)

Cases: viewed / completed

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%How many cases completed % How many cases viewed %

How many casescompleted %

3.9% 17.6% 23.0% 19.1% 17.9% 18.5%

How many cases viewed%

1.5% 15.7% 20.5% 19.3% 18.4% 24.5%

None 1-2 3-4 5-6 6-7 >7

Lab Managers: 87% - ‘Registration is easy’ 70% - ‘Want on-line management and to track staff participation’

UK NEQAS Digital Morphology Workshop 2010

75 participants, all DM users 95% rated the educative morphology

narrative as useful 76% liked comparison of their results

against others 70% felt the programme met their

expectations

Collaborative Activities

British Society for Haematology slide sessions Institute of Biomedical Science slide

sessions International Society for Laboratory

Haematology morphology workshop 2008 World Health Organisation photo-gallery

Conclusions

Novel educational programme for laboratory scientists High level of satisfaction with quality and

case mix Demonstrated increased confidence

amongst participants: 2008 – 30% offered a diagnosis 2011 – 90% offered a diagnosis

Finally…….. “I have just completed the first module of the

scheme and I must say that I have found it very informative and instructive, even for someone with my experience. The website was very clear to navigate around and the quality of the images was excellent. The teaching input was very comprehensive and has proved to be of great benefit and interest to all my staff taking part. Many thanks for what promises to be an innovative and instructive scheme.”

A participant’s comment

Manchester Royal Infirmary, UK Michelle Brereton, John Burthem, John Ardern

UK NEQAS General Haematology staff and advisors Zuotimi Eke, John Parker-Williams, Keith Patterson, Paul McTaggart, Mary West, Keith Hyde

Manchester Universities, UK Len Seal, Laura Tatum

UK NEQAS participants

Acknowledgements