Contributors

Clair S. Wylie, BS

Mary Coleman, MS

MLT Hem1

HematologyHemostasis

Medical Laboratory Technician

  1. Normal hematopoietic system
  2. Define hematopoiesis (Level 1)
  3. Theory of pluripotent stem cell development
  4. Apoptosis
  5. Identify phases and site of origin for cellular development of active hematopoietic tissue (Level 1)
  6. Embryo and fetus

a)Yolk sac

b)Mesoblastic phase

c)Hepatic phase (extramedullary)

d)Medullary/myeloid phase

  1. Infant and young child

a)All red marrow spaces (all cell lines)

b)Thymus fully developed (T lymphs)

c)Secondary lymphoid tissue (B-cell, T- cell and NK-cell)

  1. Adult

a)Red marrow (axial skeleton and proximal ends of long bones)

b)Primary and secondary lymphoid tissue(B-cell, T-cell and NK-cell)

  1. Identify the role of other organ systems in hematopoiesis (Level 1)
  2. Mononuclear phagocyte system
  3. Spleen

a)Structure and blood flow

b)Function

  1. Liver

a)Structure

b)Function

  1. Lymph nodes

a)Structure

b)Function

  1. Thymus

a)Structure

b)Function

MLT Hem1

  1. Associate physical findings with the presence of hematologic disease (Level 1)
  2. Splenomegaly
  3. Hypersplenism
  4. Hepatosplenomegaly
  5. Lymphadenopathy
  6. Process bone marrow tissue
  7. Describe collection techniques (Level 1)

a)Aspiration

b)Core biopsy

  1. Prepare and stain smears with Romanowsky polychrome stain(Level 2)
  2. Prepare and stain smears with Prussian blue (iron) stain (Level 2)
  1. Prepare peripheral blood for routine hematologic procedure and smear analysis
  2. Determine specimen acceptability

a)List appropriate anticoagulants (Level 1)

b)Identify acceptable ratio of anticoagulant to blood for specimens obtained from venipuncture and skin puncture (Level 1)

c)List reasons for rejecting specimens (Level 1)

  1. Stain smears using Romanowsky dyes and techniques according to established procedures (Level 2)

a)Manual

b)Automated

  1. List and define components of stain (Level 1)
  2. Judge the acceptability of blood smears through microscopic evaluation and established criteria (Level 3)

a)Random distribution of cells

b)Good stain quality

c)Absence of artifact

  1. Troubleshoot staining problems (Level 3)
  2. Correlate peripheral blood evaluation with automated cell analysis
  3. Enumerate and morphologically evaluate blood cells on Romanowsky stained smears
  1. Erythropoiesis
  2. Identify distinctive features used to characterize developing cells (Level 1)
  3. Overall cell diameter or volume
  4. Nucleus

a)Shape

b)Relative diameter or volume

c)Staining reaction

d)Chromatin pattern

e)Presence or absence of nucleoli

  1. Cytoplasm

a)Relative amount

b)Staining reaction

  1. Nuclear:cytoplasmic ratio
  1. List the maturation sequence and identify stages of developing normal erythrocytes given Romanowsky stained smears, photographs, electronic images, (Level 2)
  2. Categorize red cells (Level 2)
  3. Diameter or volume
  4. Shape
  5. Color
  6. Inclusions
  7. Distribution patterns
  8. Associatenutritional and regulatory factors with erythropoiesis (Level 1)
  9. Erythropoietin (EPO)
  10. Iron
  11. B12 and folate
  12. Describe components of the mature red cell that are essential for survival and function (Level 1)
  13. Membrane composition and function

a)Lipids

b)Integral proteins

c)Peripheral proteins

  1. Function

a)Maintain RBC shape, deformability, and permeability

b)Support system for surface antigens

c)Transport and exchange of gases and ions (cationic pumps)

  1. Metabolic pathways for production of adequate energy

a)Embden-Meyerhof

b)Hexose monophosphate shunt

c)Methemoglobin reductase

d)Luebering-Rapoport

  1. Summarize mechanisms by which normal hemoglobin is structured and synthesized in the developing red cell (Level 1)
  2. Iron transport, uptake, and supply
  3. Protoporphyrin IX (heme) formation
  4. Globin synthesis and genetic control

a)Embryonic hemoglobins

b) Hb A

c) Hb F

d) Hb A2

  1. Describe normal hemoglobin-oxygen function using the oxygen dissociation curve (ODC) (Level 1)
  2. Identify factors that contribute to shifts to the curve

a)pH (Bohr effect)

b)Temperature

c)CO2

d)2,3-DPG

e)Hb F and other variants

  1. Cite factors that may affect the optimal level of hemoglobin

a)Age and gender

b)Altitude

c)Smoking

d)Associated disease

e)Altered hemoglobin derivatives

(1)Carboxyhemoglobin

(2)Sulfhemoglobn

(3)Methemoglobin

  1. Summarize the general mechanism by which red cells are catabolized (Level 1)
  2. Identify phases

a)Extravascular

b)Intravascular

  1. Trace the basic steps associated with each phase
  2. Define terms

a)Biliverdin

b)Bilirubin

(1)Unconjugated

(2)Conjugated

c)Urobilinogen

d)Urobilin

e)Haptoglobin

f)Hemoglobinemia

g)Hemoglobinuria

h)Hemosiderinuria

  1. Describe and perform standard operational procedures to evaluate erythrocytes and their physical properties using patient blood and quality control samples
  2. State the principles of method analysis and histogram/ scatterplot/scattergram review (Level 1)
  3. Determine results in accord with prescribed criteria for accuracy and precision (Level 2)

a)Automated hemogram parameters for red cell count, hemoglobin, hematocrit, mean cell volume (MCV), mean cell hemoglobin (MCH), mean cell hemoglobin concentration (MCHC), and red cell distribution width (RDW)

b)Microhematocrit (centrifuged)

c)MCV, MCH, MCHC calculated

d)Erythrocyte sedimentation rates

(1)Westergren and its modifications

(2)Automated

e)Reticulocytes

(1)Supravital smear method with Miller disc

(2)Supravital smear method without Miller disc

(3)Automated methods

(4)Calculations

(a)Corrected

(b)Absolute

(c)Production index (RPI), immature reticulocyte fraction (IRF),reticulated hemoglobin

f)Peripheral smear examination for red cell morphology

  1. List reference values for variations in gender and age (Level 1)
  2. Correlate and verify automated hemogram parameters and calculated indices with each other and with peripheral smear exams (Level 3)
  3. Calibrate and perform preventive maintenance on instruments used to evaluate erythrocytes and their physical properties (Level 2)
  4. Recognize and troubleshoot pre-analytical, analytical and post-analytical causes of problems or unexpected results (Level 3)
  5. Notify supervisor for the resolution of results or events (Level 2)
  1. Leukopoiesis
  2. Cite reference values for variations in gender and age for theleukocyte counts in peripheral blood (Level 1)
  3. Total leukocyte count
  4. Relative and absolute values for neutrophil, lymphocyte, eosinophil, basophil and monocyte counts
  5. Identify and recognize factors that may alter values (Level 1)
  6. Physiologic variation
  7. Pathologic abnormalities
  8. Enumerate and calculate leukocyte cell types (Level 2)
  9. Relative values
  10. Absolute values
  11. Characterize morphologic features used to differentiate developing leukocytes(Level 1)
  12. Overall cell diameter or volume
  13. Nucleus

a)Shape

b)Relative diameter or volume

c)Nuclear to cytoplasmic ratio (N:C)

d)Staining reaction

e)Chromatin pattern

f)Presence or absence of nucleoli

  1. Cytoplasm

a)Relative amount

b)Staining properties

c)Presence or absence of granules and staining reaction

  1. List the maturation sequence and identify distinguishing morphology for stages of developing blood granulocytes using Romanowsky stained smears, photographs, electronic images, or slides or other visual means of representation(Level 2)
  2. Neutrophils
  3. Eosinophils
  4. Basophils
  5. Identify general mechanisms that modulate granulopoiesis (Level 1)
  6. Kinetics

a)Life span

b)Circulation

  1. Biochemistry

a)Granule content

b)Energy metabolism

  1. Function

a)Chemotaxis

b)Phagocytosis and killing

c)Allergic response (eosinophils and basophils)

d)Host defense against parasites (eosinophils)

e)Hypersensitivity mediator (basophils and mast cells)

  1. List features that characterize monocytes-macrophages (Level 1)
  2. Identify morphology of developing cells
  3. Kinetics

a)Life span

b)Circulation

c)Tissue phase

  1. Function

a)Phagocytosis

b)Antigen-presenting cells (APC)

  1. List features that characterize lymphopoiesis (Level 1)
  2. Identify morphology of developing cells

a)Lymphocytes and precursors

b)Plasma cells

  1. Sites of formation and production

a)Bone marrow

b)Thymus

c)Lymph nodes and secondary lymphoid tissue

  1. Kinetics

a)Life span

b)Migration

  1. Function

a)Humoral immunity (B lymphs and subsets)

b)Cell mediated immunity (T lymphs and subsets)

c)Natural killing and antibody dependent cellular cytotoxicity

  1. Perform commonly used methods to evaluate leukocytes
  2. State the principles of method analysis and histogram/scatterplot review (Level 1)
  3. Determine relative and absolute white cell counts on patient and control specimens using manual and automated methods in accord with prescribed criteria for accuracy and precision (Level 1)
  4. Calibrate and perform preventive maintenance on instruments used to evaluate white cells (Level 2)
  5. Determine differential cell counting using automated methods (Level 2)
  6. Evaluate white cell histograms and scatterplots for diagnostic and quality control (Level 3)
  7. Identify and classify white cells on a properly prepared Romanowsky stained blood smear (Level 2)
  8. Correlate and verify automated cell counts and differentials withestablished criteria and/or peripheral smear exam (Level 3)
  9. Estimate the total white blood count from a smear (Level 2)
  10. Correct leukocyte counts for the presence of nucleated red cells (Level 2)
  11. Recognize and troubleshoot pre-analytical, analytical and post-analytical causes for problems or unexpected results (Level 3)
  12. Take corrective action to resolve unexpected results and/or events (Level 2)
  1. Hematologic disorders
  2. Red blood cell disorders
  3. General concepts

a)Define anemia (Level 1)

(1)Clinical signs and symptoms

(2)Hematologic findings

(a)Hemoglobin

(b)Hematocrit

(c)Red blood cell count

(d)RBC indices

(e)RDW

(f)Reticulocyte count

(g)Peripheral smear

b)Describe the categories used in a morphological classification of the anemias (Level 1)

c)Describe the pathophysiologic classification of the anemias (Level 1)

(1)Decreased red cell production

(a)Bone marrow failure

(b)Ineffective hematopoiesis

(c)Myelophthsic

(2)Increased red cell destruction, hemolytic processes

(3)Loss of red cells

d)Define (Level 1) and calculate (Level 2) RBC indices and explain sources of errors (Level 1)

e)Interpret values of the RBC indices (Level 2) and relate results to physiologic conditions (Level 3)

f)Use the RBC indices as a quality control mechanism for assessing the validity of the erythrocyte count, hemoglobin, and hematocrit values(Level 2)

g)Define (Level 1), recognize and correlate (Level 2) variations in red blood cell diameter or volume

(1)Normal diameter or volume erythrocytes

(2)Anisocytosis

(3)Microcytes

(4)Macrocytes

h)Define polychromatophilia and describe clinical significance(Level 1)

(1)Normal

(2)Increased

i)Define hypochromia and describe clinical significance (Level 1)

j)Describe the morphologic change in erythrocyte shape(Level 2)

k)State the criteriathat defines poikilocytosis (Level 1) and relate the morphologic changes in erythrocytes to clinical conditions (Level 2)

(1)Acanthocyte (spur cell)

(2)Codocyte (target cell)

(3)Dacryocyte (tear drop cell)

(4)Drepanocyte (sickle cell)

(5)Echinocyte (burr cell)

(6)Elliptocyte (oval cell)

(7)Keratocyte (helmet cell)

(8)Schistocyte (fragmented cell)

(9)Spherocyte

(10)Stomatocyte (mouth cell)

l)Microscopically, identify alterations in red cell distribution (Level 2)

(1)Rouleaux

(2)Agglutination

m)Describe the composition and morphology ( Level 1)andcorrelate the possible pathologic conditions (Level 2)

(1)Basophilic stippling

(2)Cabot rings

(3)Heinz bodies

(4)Howell-Jolly bodies

(5)Malarial and otherblood parasites

(6)Pappenheimer bodies/siderotic granules

(7)Hemoglobin crystals (S,C andSC)

(8)Hemoglobin H inclusion bodies

  1. Erythrocytosis (Polycythemia)

a)Define (Level 1) and differentiate between absolute polycythemia and relative polycythemia (Level 2)

b)Compare and contrast secondary polycythemia, and relative erythrocytosis (Level 2)

(1)Etiology

(2)Clinical features

(3)Laboratory findings

c)Identify changes in the peripheral blood with polycythemia vera (Level 2)

  1. Anemias due to disordered iron metabolism or heme synthesis

a)Identify the etiology and general pathophysiology (Level 1)

(1)Iron deficiency anemia

(2)Sideroblastic anemia

(3)Anemia of chronic disease/inflammation

(4)Porphyrias

(5)Lead intoxication

b)Define (Level 1)

(1)Transferrin

(2)Siderocyte

(3)Sideroblast

(4)Ringed sideroblast

c)Compare and contrast laboratory findings in iron deficiency anemia and anemia of chronic disease/inflammation(Level 2)

(1)Serum ferritin

(2)Serum iron

(3)Total iron binding capacity (TIBC)

(4)Percent transferrin saturation

(5)Free erythrocyte protoporphyrin (FEP)/zinc protoporphyrin (ZPP)

(6)Hepcidin

d)Indicate expected result in sideroblastic anemia (Level 1)

(1)Serum ferritin

(2)Serum iron

(3)TIBC

(4)Percent transferrin saturation

(5)Free erythrocyte protoporphyrin (FEP)/zinc protoporphyrin (ZPP)

  1. Megaloblastic anemias

a)Recall the normal absorption and general metabolism of vitamin B12 and folate (Level 1)

b)Describe clinical features (Level 1)

c)Explainmegaloblastic transformation (Level 2)

(1)General mechanism

(2)Cellular changes

d)Identify the hematologic abnormalities(Level 2)

(1)Peripheral blood changes

(2)Bone marrow morphological changes

e)Compare and contrast pernicious anemia to the other types of vitamin B12 deficiency (Level 2)

f)Differentiate nonmegaloblastic macrocytosis from megaloblastic anemia in terms of peripheral blood characteristics (Level 2)

g)Compare and contrast lab testing for serum B12 and folate acid deficiency (Level 2)

h)Differentiate nonmegaloblastic macrocytosis from megaloblastic anemia (Level 2)

(1)Peripheral blood characteristics

(2)Serum vitamin B12 level

(3)Serum folate level

(4)Red cell folate level

(5)Reticulocyte findings

  1. Hypoproliferative anemias

a)Acquired aplastic anemia

(1)Define aplastic anemia (Level 1)

(2)Identify common factors associated with the development (Level 1)

(3)Describe thegeneral pathophysiology (Level 1)

(4)Describe the clinical features (Level 1)

(5)Describe the laboratory findings (Level 1)

(a)Peripheral blood changes

(b)Bone marrow changes

b)Fanconi’sanemia (Level 1)

(1)Define Fanconi’s anemia

(2)Describes the laboratory findings (Level 1)

c)Congenital pure red cell aplasia

(1)Define pure red cell aplasia (Level 1)

(2)Describe the clinical features (Level 1)

(3)Describe the laboratory findings (Level 1)

d)Anemia caused by myelophthisis

(1)Define (Level 1)

(2)Describe the clinical features (Level 1)

(3)Describe the laboratory findings (Level 1)

  1. Hemoglobinopathies

a)Define hemoglobinopathy (Level 1)

b)Distinguish between qualitative and quantitative hemoglobin defects (Level 1)

c)Describe the physiologic abnormalities and clinical findings (Level 1)

(1)Hb SS

(2)Hb AS

(3)Hb CC

(4)Hb AC

(5)HB SC

(6)Hb EE

d)Identify the amino acid substitutions associated with sickle cell anemia and hemoglobin C disease (Level 1)

e)Describe the physiologic abnormality (Level 1)

(1)Hemoglobin variants with altered oxygen affinity

(2)Unstable hemoglobins

(3)Methemoglobinemia

f)Define the hemoglobin defect in thalassemia (Level 1)

g)Identify the characteristic laboratory findings associated with thalassemia (Level 1)

h)Describe the peripheral blood morphology associated with homozygous and heterozygousthalassemia (Level 1)

(1) Alpha thalassemia

(2) Beta thalassemia

i)Describe the principle and clinical significance (Level 1)

(1)Solubility test for sickling hemoglobin

(2)Hemoglobin electrophoresis and capillary electrophoresis

(a)Cellulose acetate

(b)Citrate agar

(3)Hemoglobin quantitation

(a)Hb A2

(b)Hb F

j)Perform the solubility test for sickling hemoglobin (Level 2)

(1)Quality control

(2)Sources of error

(3)Interpret results (Level 3)

  1. Hemolytic anemias

a)Intracorpuscular/intracellular defects

(1)RBC membrane abnormalities

(a)Describe the etiology, general pathophysiology, clinical features, and laboratory findings (Level 1)

i.Hereditary spherocytosis

ii.Hereditary elliptocytosis

iii.Paroxysmal nocturnal hemoglobinuria (PNH)

(b)Identify and describe laboratory tests that are used to diagnose RBC membrane abnormalities(Level 2)

(c)Describe disorders of membrane cation permeability (Level 1)

(2)RBC enzyme abnormalities

(a)Describe the etiology, general pathophysiolgy, and clinical features (Level 1)

i.Glucose-6-phosphate dehydrogenase (G6PD) deficiency

ii.Pyruvate kinase (PK) deficiency

(b)Identify laboratory test results (Level 1)

i.G6PD deficiency

ii.PK deficiency

b)Extracorpuscular/extracellular defects

(1)Alloimmune hemolytic anemia

(a)Identify mechanisms of immune hemolytic anemias (Level 1)

(b)Define and describe the etiology and clinical features

i.Acute hemolytic transfusion reaction

ii.Delayed hemolytic transfusion reaction

iii.Hemolytic disease of the fetus and newborn (HDN)

(a)ABO

(b)Rh

(c)Identify laboratory findings

i.Acute hemolytic transfusion reaction

ii.Delayed hemolytic transfusion reaction

iii.Hemolytic disease of the fetus and newborn (HDN)

(a)ABO

(b)Rh

(2)Autoimmune hemolytic anemia (AIHA)

(a)Define and describe the etiology and clinical features

i.Warm autoimmune hemolytic anemia (WAIHA)

ii.Cold autoimmune hemolytic anemia

(a)Cold agglutinin syndrome

(b)Paroxysmal cold hemoglobinuria

(b)Identify laboratory findings

i.Warm autoimmune hemolytic anemia (WAIHA)

ii.Cold autoimmune hemolytic anemia

(a)Cold agglutinin syndrome

(b)Paroxysmal cold hemoglobinuria

(3)Nonimmune hemolytic anemia

(a)Identify the etiology

i.Infectious organisms

ii.Mechanical agents

iii.Chemicals

(b)Describe the hematologic findings (Level 1)

i.Malaria

ii.Babesiosis

iii.Bartonellosis

iv.Bacterial sepsis

v.Cardiac prosthetic devices

vi.Microangiopathic hemolytic anemia (HUS, TTP, DIC, HELLP)

vii.Chemicals and venoms

viii.Thermal injury

  1. Acute blood loss

a)Describe the etiology of anemia of acute blood loss (Level 1)

b)List the clinical symptoms (Level 1)

c)Identify the laboratory findings (Level 1)

  1. Anemias associated with systemicdisorders

a)Describe the etiology, general pathophysiology (Level 1), and identify significantlaboratory findings (Level 2)

(1)Chronic renal disease

(2)Liver disease

(3)Endocrine diseases

(4)Systemic lupus erythematosus

b)Identify significant laboratory findings (Level 2)

  1. White blood cell disorders
  2. Nonmalignant leukocyte disorders

a)Identify the criteria used to classify nonmalignant leukocytic disorders (Level 1)

(1)Quantitative changes

(2)Qualitative changes

(a) Inherited

(b) Acquired

b)Characterize granulopoietic alterations

(1)Calculate and compare absolute values with relative values (Level 2)

(a)Neutrophilia

(b)Neutropenia

(c)Eosinophilia

(d)Eosinopenia

(e)Basophilia

(2)List causes and conditions (Level 1)

(3)Identify on Romanowsky stained smears, photographs, electronic images, or slides morphologic changes in neutrophils that may accompany nonmalignant neutrophilic disorders (Level 2)

(a)Shift to the left

(b)Toxic granulation

(c)Döhle bodies

(d)Vacuolization

(e)Leukemoid reaction

(f)Leukoerythroblastic reaction

(g)Agranulation, hypogranulation

(h)Hyposegmentation

(i)Hypersegmentation

(j)Intracellular microorganisms

(4)Correlate characteristic abnormalities and clinical features for the major qualitative/functional disorders of neutrophils (Level 3)

(a)Pelger-Hüet anomaly

(b)Alder-Reilly anomaly

(c)Chédiak-Higashi anomaly

(d)May-Hegglin anomaly

(e)Chronic granulomatous disease (CGD)

(f)Myeloperoxidase deficiencies

c)Define and describe alterations of monocytes

(1)Calculate and compare absolute values with relative values (Level 2)

(2)Identify causes and conditions of reactive monocytosis (Level 1)

d)Appraise non-neoplastic disorders of lymphocytes and plasma cells

(1)Define (Level 1)

(a)Lymphocytopenia

(b)Lymphocytosis

(2)Calculate and compare lymphocyte absolute values with relative values (Level 2)

(3)Recognize and compare morphologic features that characterize reactive/variant lymphocytes from normal lymphocytes (Level 2)

(a)Diameter or volume

(b)Nucleus

(c)Cytoplasm

(d)Heterogeneity

(4)Identify reactive/variant lymphocytes on Romanowsky stained smears, photographs, electronic images, or slides of peripheral blood (Level 2)

(5)Describe infectious mononucleosis and other infectious diseases that cause reactive and nonreactive lymphocytosis(Level 1)

(a)Presence of reactive/variant lymphocytes

(b)Positive serologic tests

(6)Recognize hematologic alterations associated with Acquired Immune Deficiency Syndrome (AIDS) (Level 1)

(a)Lymphocytopenia

(b)Leukopenia

(c)Anemia

(d)Thrombocytopenia

  1. Neoplastic disorders of leukocytes

a)Recall the theoretical basis for identifying neoplastic leukocyte disorders (Level 1)

b)Identify major systems used to classify neoplastic disorders of leukocytes

(1)French, American-British (FAB) Cooperative Group (1976)

(2)World Health Organization (WHO) (2001)

c)Group neoplastic disorders into distinct categories(Level 1)

(1)Non-lymphoid

(a)Myelodysplastic syndromes