Flagging

CD Ruby Application Training

CD Ruby Flagging

For WBCs For RBCs For PLTs

DFLT NRBC URI
BAND RRBC LRI
IG MCHC LURI
BLAST RBC MORPH NO MPV
VAR LYM
NWBC
FWBC
ATYPDEP

Flagging ACS Hematology

Ruby Application Training October 2008
DFLT (NLMEB)
One or more of the following conditions are true:

Fragile cells may be present. (When If the DFLT (NLMEB) flag is accompanied
1. the FWBC flag is triggered, DFLT with the FWBC flag, repeat in CBC+NOC
(NLMEB) flag is always set.) test selection.

An abnormally low number of cells Review scatter plot for clear separation of
2.
available to calculate differential. cell cluster.

The mono-poly cut has too much Review a stained smear to verify the
3.
interference. differential values.

Flagging ACS Hematology

Ruby Application Training October 2008
Acute Myelomonocytic Leukaemia (FAB M4)

Extreme leucocytosis is
observed in this patient
with FAB type M4
myelomonocytic
leukaemia.

The instrument has

recognised the
monocytoid
character of a large
number
of the Blast cells.

Flagging ACS Hematology

Ruby Application Training October 2008
BAND

The BAND flag is triggered if any of the following conditions are met:

The CV of the neutrophil cluster on the 0

1.
axis exceeds expected criteria.
Review a stained smear for the
presence of bands and follow your
laboratory’s review criteria.
2. %BAND > 12.5% of the total WBC count. NOTE: When bands are present,
they are included in the total
neutrophil count.

The ratio of suspected bands to mature

3.
neutrophils is >50%.

Flagging ACS Hematology

Ruby Application Training October 2008
Vitamin B12 Deficiency

In addition to the increased MCV, this patient also shows a high degree of Neutrophil
lobularity. This equates with the hypersegmentation which is typical in megaloblastic anaemia.
Flagging ACS Hematology
Ruby Application Training October 2008
IG (Immature Granulocyte)

The IG flag is triggered if the following condition is met:

Review a stained smear for the presence of

immature granulocytes and follow your
laboratory’s review criteria.
1. %IG  3% of the total WBC count
NOTE: When IGs are present, they are
included in the total neutrophil count.

Flagging ACS Hematology

Ruby Application Training October 2008
Chronic Myelomonocytic Leukaemia

Results from a patient

with CML who is
undergoing
blast cell transformation.

The instrument has

correctly detected the
presence of blast cells,
immature granulocytes
and band cells.

Flagging ACS Hematology

Ruby Application Training October 2008
BLAST – displayed next to LYM%
The BLAST flag is triggered if any of the following conditions are met:

Review a stained smear for the

The count in the region of scatter (on the presence of blasts and follow your
1. 90°/0° plot) where blasts are typically laboratory’s review criteria.
located is > 1% of the total WBC count.
NOTE: When blasts are present,
they are included in the monocyte
count.
The MONO% is > 20 % of the total WBC
2.
count

The MONO% is > 3% of the total WBC

count and the standard deviation of the
3.
monocytes on the 0° axis exceeds expected
criteria.

Flagging ACS Hematology

Ruby Application Training October 2008
Chronic Myeloid Leukaemia

In addition to detecting blast cells and immature granulocytes, the instrument has also
found an increased number of basophils and eosinophils.
Flagging ACS Hematology
Ruby Application Training October 2008
Acute Myelomonocytic Leukaemia (FAB M4)

Extreme leucocytosis is
observed in this patient with
myelomonocytic leukaemia.

The instrument has

recognised the monocytoid
character of a large number
of the Blast cells.

Flagging ACS Hematology

Ruby Application Training October 2008
VAR LYM – displayed next to the LYM%
When the FWBC flag is triggered, VAR LYM flag is always set.
Position of the lymphocyte cluster on the
1.
0°/10°scatter plot.
2. If the ratio NEU% / LYMPH% < 0.2
If abs. lymph count > 6.0 x 109/L
3 VLYM/BLAST.
If abs. Lymph + Mono + Baso > 7.0 x 109/L
Flagging ACS Hematology
Ruby Application Training October 2008
Review a stained smear for the
presence of variant lymphocytes and
follow your laboratory’s review
criteria.
NOTE: When variant lymphocytes
are present, they are included in the
lymphocyte count.
NOTE: This flag may be displayed
singly or in combination with the
blast flag. If the flag is displayed with
the blast flag, it is displayed as
B-Cell Chronic Lymphocytic Leukaemia

CBC mode
In the patient mode the Ruby
has identified the presence of
fragile lymphocytes and given
an FWBC alert.

CBC+NOC mode When the sample is run in the

CBC+NOC mode both the
WBC and lymphocyte counts
are increased, reflecting the
loss of the fragile WBCs from
the WOC count.

Flagging ACS Hematology

Ruby Application Training October 2008
NWBC – Non White Blood Cells

Review smear for platelet clumps, giant

A non-WBC population is present in the N1 platelets or low levels of NRBC and follow
region below the dynamic WBC threshold on your laboratory’s review criteria.
the 0°/10° scatter plot.
If no other suspect parameter flags are
The count in the N1 region is greater than present, the WBC and differential may be
2.9% of the total WBC and there is no reported.
declining count rate

CLL
Normal

0 1 2 3 4 5 6 7 8 9 10 11 12

Flagging ACS Hematology

Ruby Application Training October 2008
Myelodysplastic Syndrome

Despite showing leucopenia,

the Ruby is able to produce a
good differential in this patient
with refractory pancytopenia.

In addition the platelet

scattergram highlights the
presence of giant platelets.

Flagging ACS Hematology

Ruby Application Training October 2008
FWBC – Fragile White Blood Cells

Repeat in CBC+NOC test selection.

Cellular debris interference is low but a
1. NOC result will be reported as WBC
declining WOC kinetic rate is detected.
result.

Cellular debris interference is low and there

Review smear to confirm lymph count
2. is no declining WOC kinetic rate, but
and presence of fragile WBC.
WOC>4.1 x 10e3/μL and LYM%>80%.

CLL
Normal

0 1 2 3 4 5 6 7 8 9 10 11 12

Flagging ACS Hematology

Ruby Application Training October 2008
B-Cell Chronic Lymphocytic Leukaemia
CBC mode
In the patient mode the Ruby
has identified the presence of
fragile lymphocytes and
given an FWBC alert.

CBC+NOC mode
When the sample is run in the
CBC+NOC mode both the
WBC and lymphocyte counts
are increased, reflecting the
loss of the fragile WBCs from
the WOC count.

Flagging ACS Hematology

Ruby Application Training October 2008
ATYPDEP – Atypical depolarization

Atypical depolarization events detected in Review a stained blood film to detect a

the lobularity (90°), granularity possible morphologic correlate (situation),
(90°depolarizing) scatter data with cross and follow your laboratory's review criteria.
check done using size (0°) and complexity
(10°)scatter data.

Flagging ACS Hematology

Ruby Application Training October 2008
ATYPDEP – Atypical depolarization

Flagging ACS Hematology

Ruby Application Training October 2008
NRBC and RRBC

The count in the area below the WBC

threshold on the 0°/10° scatter plot is >
2.9% of the total WBC count, A: Repeat in CBC+RRBC test mode.

AND B: If the flag persists, review a smear for

presence of NRBC and verify Lymph value
There is a declining count rate (due to the
presence of RRBCs if they are present

CLL
Normal

0 1 2 3 4 5 6 7 8 9 10 11 12

Flagging ACS Hematology

Ruby Application Training October 2008
Neonate blood sample

The Ruby has identified the

presence of a population of
NRBCs and RRBCs.

The instrument warns of their

presence and also alerts the
operator of their potential
interference in both the WBC
count and differential.

Flagging ACS Hematology

Ruby Application Training October 2008
RBC MORPH & MCHC
One or more of the following parameters
exceeds expected limits:
MCH < 25pg or >34pg
MCHC < 29g/dL or >37g/dL
RDW >18.5%
MCHC < 24 g/dL or > 40 g/dL
Flagging
Ruby Application Training
Review a stained smear for abnormal RBC or
PLT morphology and follow your lab review
criteria.
If NRBC or RRBCs are suspected to be
present, run the specimen in the CBC+RRBC
test selection.
Verify that the specimen was properly mixed.
Check the specimen for lipids or cold
agglutination
ACS Hematology
October 2008
RBC MORPH & MCHC

Flagging ACS Hematology

Ruby Application Training October 2008
LRI – Lower Region Interference

1: Interference in the lower threshold region

(2fL–3fL) > 25% of PLT count.
2: Too much interference between noise
region and PLT population.
Repeat the specimen. If the flag persists,
3: Too much noise in the 0-low threshold review a smear and verify the platelet count.
region.
If the flag persists on subsequent samples,
check the platelet background count. If the
background count exceeds the specification,
NOTE: LRI may be caused by:
troubleshoot accordingly.
Debris
Contaminated reagent
Microbubbles
Dirty Diluent/Sheath filter

Flagging ACS Hematology

Ruby Application Training October 2008
LRI – Lower Region Interference

Flagging ACS Hematology

Ruby Application Training October 2008
URI – Upper Region Interference

Repeat the specimen. If the flag persists,

review a smear and verify the platelet count.
If the flag persists on subsequent samples,
check the platelet background count. If the
background count exceeds the specification,
troubleshoot accordingly.

Flagging ACS Hematology

Ruby Application Training October 2008
URI – Upper Region Interference

1. Interference in the upper threshold region

(15–35fL) > 25% of PLT peak.
2. PLT aggregate count (PLT clumps)
A. Review MCV, platelet histogram and
> 15% of PLT count. scatterplot.

NOTE: URI may be caused by: B. If the scatterplot shows overlap in the RBC
or platelet populations or a population is
Microcytic RBC
present above the platelet scatter, review
Schistocytes a smear to determine the cause and
confirm the platelet count.
Giant Platelets
Sickle Cells
Platelet Clumps

Flagging ACS Hematology

Ruby Application Training October 2008
URI

Flagging ACS Hematology

Ruby Application Training October 2008