HemoCue® Product Vita och diff – nyttan I primärvården Stellan Lindberg, M Sc Medical Director HemoCue AB Kuvettgatan 1 SE-262 71 Ängelholm Sweden Stellan.Lindberg@hemocue.se

Agenda Kort presentation av HemoCue WBC DIFF Hur den fungerar Prestanda Vad ska man ha den till Sammanfattning

HemoCue® WBC DIFF System - den första 5-part Diff räknaren för primärvården And now to the point of care instrument. It looks like this. It is very easy to handle. Just fill the microcuvette with about 10 µL capillary or EDTA blood. Put the cuvette in the analyzer and wait about 5 minutes for the result. 1. Fyll kuvetten med 10 µL blod 2. Tryck på knappen för patient test och placera kuvetten i kuvetthållaren. För in kuvetthållaren. 3. Resultaten visas inom 5 minuter

WBC DIFF Data Management Patient ID Avd/VC ID Operatörs ID QC ID Lab ID Datum och tid Ethernet För att mata in data i HemoCue WBC DIFF – använd barcode scanner eller ett externt tangentbord Resultaten kan skrivas ut på en skrivare Data transfer via Ethernet

Hur fungerar instrumentet under skalet?

Ett foto microskop som automatiskt räknar vita blodkroppar Reagens I kuvetten: Saponin – hemolyserar de röda blodkropparna Metylen Blått – färgar kärnorna i de vita blodkropparna A one-step procedure without any manual steps! The measuring principle is like a microscope, a simple digital camera chip, a lens that moves and the microcuvette. The measured volume is defined by the cavity depth of the cuvette, a patented repeated position mechanism of the cuvette making every image be at the same size. The red cells are hemolyzed and the white cells are stained by methylene blue. Volume ≈ appr. 0.2 µL Kuvettkammare med en bestämd tjocklek och en area som definieras av bildens storlek

För att göra det möjligt att differentiera de vita blodkropparna, analyseras kaviteten I många lager Kamerans lins flyttas i små steg och många bilder tas genom kaviteten Kavitetdjup 140 µm Alla celler i varje tagen bild klipps ut Programmet identifierar när en enskild cell är bäst i fokus Alla bäst fokuserade celler monteras tillsammans i en slutlig bild Inside the system, it works like this – The lens moves in step of 5 µm and takes more than 30 images through the cavity. All cells in all images will be cut out and will be compared with the cells in the same positions on the different images. The imaging software will identify when each a cell is best in focus. Those images with best focused cells will when be merged together into a final image. It is on this image the number of leukocytes are counted and differentiated. Vita räknas och diffrentieras

“Photoshoping” av varje cell I bilden Neutrofil Lymfocyt Monocyt When we developed the software we have identified more than 30 different characteristics on cells, size, number of nucleons etc. We have when transformed those features into mathematical algorithms by artificial network. As you can see on the slide, the cells does not look like on an ordinary manual diff count, but it is relative easy to learn how different cell types look. WBC DIFF använder mer än 30 olika egenskaper för att bestämma celltyp Eosinofil Basofil

WBC DIFF kan också identifiera and flagga patologiska vita blodkroppar! Sample with 87,5 % blast cells Sample with 25,0 % myelocytes and 4,3 % metamyelocytes Important in the development work has been to identify pathological cells like blast and immature granulocytes.

Inbyggt avancerat QC System Vid start up (“Self test”): Test av elektronik och mjukvara Blank test (Kvalitet på ljus, kontroll av smuts på optik) Mellan analyserna: Blank test För varje prov: Prov detektion ”Bad area” detektion ”Out of focus” detektion Luft bubbel detektion Dålig ljus intensitet Dålig cell distribution HemoCue has also built in an internal quality control. By imaging technology the analyzer check for correct filling, dirt, etc. The risk assessment has been to catch of all type of user errors.

Bra korrelation mot laboratoriernas cell räknare Total Leukocyter Neutrofila Lymfocyter Monocyter Eosinofila ADVIA® 2120 Siemens Beckman Coulter® LH750 This slide shows comparisons against three different common cell counters. I will not go into details. Small calibration different can be seen, and it seems like cell counters have some challenges in monocyte counting. HemoCue is calibrated against manual diff count and theoretical particle count, number of counts in a fixed volume. Sysmex® XS-1000i

Postrar vid AACC CPOCT meeting i Prag oktober 2012

Vad ska man ha den till?

Hb, vita och diff – de mest beställda testerna i primärvården

Differentialräkning av leukocyter När ska man testa? LPK Bestämning av total antalet vita har störst värde när man misstänker sänkt respektive ökat antal neutrofila Differentialräkning av leukocyter Om total antalet av vita är förhöjt eller sänkt bör komplettering ske för att utröna I vilket/vilka cellsystem en rubbning föreligger. Detsamma kan gälla vid normalt antal leukocyter, om klinisk misstanke föreligger om ett förändrat antal av något särskilt cellslag t. ex. Lymfocyter (som vid mononukleos) Eosinofila (överkänslighetsreaktioner, maskinfektioner) Basofila (polycytemia vera) Källa: Laurells Klinisk kemi I praktisk medicin

Patientnära vita - diff fyller ett kliniskt behov i flera olika vårdmiljöer och kliniska situationer Akutmottagning “We conclude that for clinicians who evaluate patients with a suspected severe infection in the ED, special attention should be directed to the RR, CRP, and WBC, and that low Hb may be an underestimated biomarker in this context” Gille-Johnson P., et al., Scand. Journal of Infectious Diseases (2012) “In an emergency care setting, both lymphocytopenia and NLCR are better predictors of bacteremia than routine parameters like CRP level, WBC count and neutrophil count. Attention to these markers is easy to integrate in daily practice and without extra costs.” de Jager C.P., et al., Crit Care 14 (2010) Vårdcentral “In conclusion, the NLCR (Neutrophil to Lymphocyte Count Ratio) may serve as a simple marker for discrimination between severe bacterial and viral infections.“ Holub M. et al., Cent. Eur. J. Med. (2012) Barnmottagning White blood cell count can aid judicious antibiotic prescribing in acute upper respiratory infections in children Casey, J. et al, Clin Pediatr 42 (2003) But before that talk a little bit of use of leukocyte counting with diff in point-of-care settings. The white blood cell count (WBC) and differential(diff) counting are well established tests and has been used in medicine for more than 100 years. It is not unusual that the practitioner or nurse have or had a microscope at his office. It is well known that result of WBC and diff is valuable tool in several clinical situations but as many different conditions could affect the result, the interpretation should always be within the context of patient history, clinical signs and physical examination. The art of medicine. The last years, it seems like more publications is coming describing situations where a point-of-care system would be suitable. The first one on the slide is in the emergency department(ED) done at the Karolinska University hospital in Stockholm. Gille-Johnson et al conclude that in patients with a suspected severe infection, special attention should be directed to the respiratory rate, CRP, WBC and neutrophils. New markers like Procalcitonin, IL-6, and lipopolysaccharide binding protein did not provide additional guidance on antibiotic decisions. Low hemoglobin concentration on the contrary may be an underestimated biomarker. Two groups, one in Rotterdam and one here in the Czech republic has shown that the ratio between neutrophils and lymphocytes is the best discriminator between a bacterial and viral infection. In US Case and Pichetechro has shown that they can decrease antibiotic prescription on children by having a POC WBC. An another interesting application is to monitor clozapine treatment on schizophrenic patients. It is mandatory to measure WBC and neutrophils due to the toxicity of the drug. The frequent visits to the laboratory cause inconvenience or anxiety for the patient about confrontation to the laboratory staff and venous sampling may have a deterrent effect. Monitoring of oncology patients could also be of interest due to avoid infections and inconvenience for the patients. Psykiatrisk klinik Monitoring total WBC and neutrophils (NEU) with a point-of-care device during Clozapine treatment on schizophrenic patients Nielsen, J., et al., Eur. Neuropsychopharmacol. (2011) Onkologimottagning Monitoring before next doze of chemotherapy Price CP, et al, Point-of-care testing; 2nd ed. (2004)

CRP, vita, RR och Hb bäst vid antibiotika beslut vid alvarliga infektioner Methods: The diagnostic value of clinical and laboratory variables in predicting infections that require antibiotic treatment was evaluated in a prospective observational study of 404 adult patients admitted from the emergency department (ED) with suspected severe infections. Results: increased levels of C-reactive protein (CRP) Procalcitonin (PCT) Interleukin 6 (IL-6) Lipopolysaccharide binding protein (LBP) White blood cell count (WBC) Neutrophils Respiratory rate (RR) ( p 0.001) and a decreased haemoglobin (Hb) level ( p 0.005) were associated with an indicated demand for antibiotics ( n 286). Conclusions: Special attention should be directed to CRP, WBC, RR, and Hb when selecting patients for antibiotic treatment in the emergency department. PCT, IL-6, and LBP did not provide additional guidance on antibiotic decisions

Patientnära vita - diff fyller ett kliniskt behov i flera olika vårdmiljöer och kliniska situationer Akutmottagning “We conclude that for clinicians who evaluate patients with a suspected severe infection in the ED, special attention should be directed to the RR, CRP, and WBC, and that low Hb may be an underestimated biomarker in this context” Gille-Johnson P., et al., Scand. Journal of Infectious Diseases (2012) “In an emergency care setting, both lymphocytopenia and NLCR are better predictors of bacteremia than routine parameters like CRP level, WBC count and neutrophil count. Attention to these markers is easy to integrate in daily practice and without extra costs.” de Jager C.P., et al., Crit Care 14 (2010) Vårdcentral “In conclusion, the NLCR (Neutrophil to Lymphocyte Count Ratio) may serve as a simple marker for discrimination between severe bacterial and viral infections.“ Holub M. et al., Cent. Eur. J. Med. (2012) Barnmottagning White blood cell count can aid judicious antibiotic prescribing in acute upper respiratory infections in children Casey, J. et al, Clin Pediatr 42 (2003) But before that talk a little bit of use of leukocyte counting with diff in point-of-care settings. The white blood cell count (WBC) and differential(diff) counting are well established tests and has been used in medicine for more than 100 years. It is not unusual that the practitioner or nurse have or had a microscope at his office. It is well known that result of WBC and diff is valuable tool in several clinical situations but as many different conditions could affect the result, the interpretation should always be within the context of patient history, clinical signs and physical examination. The art of medicine. The last years, it seems like more publications is coming describing situations where a point-of-care system would be suitable. The first one on the slide is in the emergency department(ED) done at the Karolinska University hospital in Stockholm. Gille-Johnson et al conclude that in patients with a suspected severe infection, special attention should be directed to the respiratory rate, CRP, WBC and neutrophils. New markers like Procalcitonin, IL-6, and lipopolysaccharide binding protein did not provide additional guidance on antibiotic decisions. Low hemoglobin concentration on the contrary may be an underestimated biomarker. Two groups, one in Rotterdam and one here in the Czech republic has shown that the ratio between neutrophils and lymphocytes is the best discriminator between a bacterial and viral infection. In US Case and Pichetechro has shown that they can decrease antibiotic prescription on children by having a POC WBC. An another interesting application is to monitor clozapine treatment on schizophrenic patients. It is mandatory to measure WBC and neutrophils due to the toxicity of the drug. The frequent visits to the laboratory cause inconvenience or anxiety for the patient about confrontation to the laboratory staff and venous sampling may have a deterrent effect. Monitoring of oncology patients could also be of interest due to avoid infections and inconvenience for the patients. Psykiatrisk klinik Monitoring total WBC and neutrophils (NEU) with a point-of-care device during Clozapine treatment on schizophrenic patients Nielsen, J., et al., Eur. Neuropsychopharmacol. (2011) Onkologimottagning Monitoring before next doze of chemotherapy Price CP, et al, Point-of-care testing; 2nd ed. (2004)

Neutrofil-lymfocyt kvot bäst på att prediktera pneumoni outcome

Patientnära vita - diff fyller ett kliniskt behov i flera olika vårdmiljöer och kliniska situationer Akutmottagning “We conclude that for clinicians who evaluate patients with a suspected severe infection in the ED, special attention should be directed to the RR, CRP, and WBC, and that low Hb may be an underestimated biomarker in this context” Gille-Johnson P., et al., Scand. Journal of Infectious Diseases (2012) “In an emergency care setting, both lymphocytopenia and NLCR are better predictors of bacteremia than routine parameters like CRP level, WBC count and neutrophil count. Attention to these markers is easy to integrate in daily practice and without extra costs.” de Jager C.P., et al., Crit Care 14 (2010) Vårdcentral “In conclusion, the NLCR (Neutrophil to Lymphocyte Count Ratio) may serve as a simple marker for discrimination between severe bacterial and viral infections.“ Holub M. et al., Cent. Eur. J. Med. (2012) Barnmottagning White blood cell count can aid judicious antibiotic prescribing in acute upper respiratory infections in children Casey, J. et al, Clin Pediatr 42 (2003) But before that talk a little bit of use of leukocyte counting with diff in point-of-care settings. The white blood cell count (WBC) and differential(diff) counting are well established tests and has been used in medicine for more than 100 years. It is not unusual that the practitioner or nurse have or had a microscope at his office. It is well known that result of WBC and diff is valuable tool in several clinical situations but as many different conditions could affect the result, the interpretation should always be within the context of patient history, clinical signs and physical examination. The art of medicine. The last years, it seems like more publications is coming describing situations where a point-of-care system would be suitable. The first one on the slide is in the emergency department(ED) done at the Karolinska University hospital in Stockholm. Gille-Johnson et al conclude that in patients with a suspected severe infection, special attention should be directed to the respiratory rate, CRP, WBC and neutrophils. New markers like Procalcitonin, IL-6, and lipopolysaccharide binding protein did not provide additional guidance on antibiotic decisions. Low hemoglobin concentration on the contrary may be an underestimated biomarker. Two groups, one in Rotterdam and one here in the Czech republic has shown that the ratio between neutrophils and lymphocytes is the best discriminator between a bacterial and viral infection. In US Case and Pichetechro has shown that they can decrease antibiotic prescription on children by having a POC WBC. An another interesting application is to monitor clozapine treatment on schizophrenic patients. It is mandatory to measure WBC and neutrophils due to the toxicity of the drug. The frequent visits to the laboratory cause inconvenience or anxiety for the patient about confrontation to the laboratory staff and venous sampling may have a deterrent effect. Monitoring of oncology patients could also be of interest due to avoid infections and inconvenience for the patients. Psykiatrisk klinik Monitoring total WBC and neutrophils (NEU) with a point-of-care device during Clozapine treatment on schizophrenic patients Nielsen, J., et al., Eur. Neuropsychopharmacol. (2011) Onkologimottagning Monitoring before next doze of chemotherapy Price CP, et al, Point-of-care testing; 2nd ed. (2004)

Primärvårdsstudie på Neutrofil-Lymfocyt kvot: Hög sensitivitet och specificitet för att skilja mellan en viral och bakteriell infektion! The NLCR cut-off value of 6.2 exhibited a sensitivity value of 0.91 and a specificity value of 0.96 for bacterial infection.

Patientnära vita - diff fyller ett kliniskt behov i flera olika vårdmiljöer och kliniska situationer Akutmottagning “We conclude that for clinicians who evaluate patients with a suspected severe infection in the ED, special attention should be directed to the RR, CRP, and WBC, and that low Hb may be an underestimated biomarker in this context” Gille-Johnson P., et al., Scand. Journal of Infectious Diseases (2012) “In an emergency care setting, both lymphocytopenia and NLCR are better predictors of bacteremia than routine parameters like CRP level, WBC count and neutrophil count. Attention to these markers is easy to integrate in daily practice and without extra costs.” de Jager C.P., et al., Crit Care 14 (2010) Vårdcentral “In conclusion, the NLCR (Neutrophil to Lymphocyte Count Ratio) may serve as a simple marker for discrimination between severe bacterial and viral infections.“ Holub M. et al., Cent. Eur. J. Med. (2012) Barnmottagning White blood cell count can aid judicious antibiotic prescribing in acute upper respiratory infections in children Casey, J. et al, Clin Pediatr 42 (2003) But before that talk a little bit of use of leukocyte counting with diff in point-of-care settings. The white blood cell count (WBC) and differential(diff) counting are well established tests and has been used in medicine for more than 100 years. It is not unusual that the practitioner or nurse have or had a microscope at his office. It is well known that result of WBC and diff is valuable tool in several clinical situations but as many different conditions could affect the result, the interpretation should always be within the context of patient history, clinical signs and physical examination. The art of medicine. The last years, it seems like more publications is coming describing situations where a point-of-care system would be suitable. The first one on the slide is in the emergency department(ED) done at the Karolinska University hospital in Stockholm. Gille-Johnson et al conclude that in patients with a suspected severe infection, special attention should be directed to the respiratory rate, CRP, WBC and neutrophils. New markers like Procalcitonin, IL-6, and lipopolysaccharide binding protein did not provide additional guidance on antibiotic decisions. Low hemoglobin concentration on the contrary may be an underestimated biomarker. Two groups, one in Rotterdam and one here in the Czech republic has shown that the ratio between neutrophils and lymphocytes is the best discriminator between a bacterial and viral infection. In US Case and Pichetechro has shown that they can decrease antibiotic prescription on children by having a POC WBC. An another interesting application is to monitor clozapine treatment on schizophrenic patients. It is mandatory to measure WBC and neutrophils due to the toxicity of the drug. The frequent visits to the laboratory cause inconvenience or anxiety for the patient about confrontation to the laboratory staff and venous sampling may have a deterrent effect. Monitoring of oncology patients could also be of interest due to avoid infections and inconvenience for the patients. Psykiatrisk klinik Monitoring total WBC and neutrophils (NEU) with a point-of-care device during Clozapine treatment on schizophrenic patients Nielsen, J., et al., Eur. Neuropsychopharmacol. (2011) Onkologimottagning Monitoring before next doze of chemotherapy Price CP, et al, Point-of-care testing; 2nd ed. (2004)

LPK på barn med övre luftvägsinfektioner för att undvika antibiotika förskrivning >38°C <38°C Med denna approach var återbesök inom 2 veckor ovanliga (13% av 737 patienter) och inga barn med signifikant bakteriell sjukdom missades. Med selektiv användning av LPK testning kan onödig antibiotika användning nästan uteslutas på barn med övre luftvägsinfektioner och med ospecifik feber utan negativa effekter på barnen. LPK <15x109/L n= 337 LPK >15x109/L n= 14 Prescription of antibiotics n= 13 Källa: Casey, J. et al, Clin Pediatr 42 (2003)

Patientnära vita - diff fyller ett kliniskt behov i flera olika vårdmiljöer och kliniska situationer Akutmottagning “We conclude that for clinicians who evaluate patients with a suspected severe infection in the ED, special attention should be directed to the RR, CRP, and WBC, and that low Hb may be an underestimated biomarker in this context” Gille-Johnson P., et al., Scand. Journal of Infectious Diseases (2012) “In an emergency care setting, both lymphocytopenia and NLCR are better predictors of bacteremia than routine parameters like CRP level, WBC count and neutrophil count. Attention to these markers is easy to integrate in daily practice and without extra costs.” de Jager C.P., et al., Crit Care 14 (2010) Vårdcentral “In conclusion, the NLCR (Neutrophil to Lymphocyte Count Ratio) may serve as a simple marker for discrimination between severe bacterial and viral infections.“ Holub M. et al., Cent. Eur. J. Med. (2012) Barnmottagning White blood cell count can aid judicious antibiotic prescribing in acute upper respiratory infections in children Casey, J. et al, Clin Pediatr 42 (2003) But before that talk a little bit of use of leukocyte counting with diff in point-of-care settings. The white blood cell count (WBC) and differential(diff) counting are well established tests and has been used in medicine for more than 100 years. It is not unusual that the practitioner or nurse have or had a microscope at his office. It is well known that result of WBC and diff is valuable tool in several clinical situations but as many different conditions could affect the result, the interpretation should always be within the context of patient history, clinical signs and physical examination. The art of medicine. The last years, it seems like more publications is coming describing situations where a point-of-care system would be suitable. The first one on the slide is in the emergency department(ED) done at the Karolinska University hospital in Stockholm. Gille-Johnson et al conclude that in patients with a suspected severe infection, special attention should be directed to the respiratory rate, CRP, WBC and neutrophils. New markers like Procalcitonin, IL-6, and lipopolysaccharide binding protein did not provide additional guidance on antibiotic decisions. Low hemoglobin concentration on the contrary may be an underestimated biomarker. Two groups, one in Rotterdam and one here in the Czech republic has shown that the ratio between neutrophils and lymphocytes is the best discriminator between a bacterial and viral infection. In US Case and Pichetechro has shown that they can decrease antibiotic prescription on children by having a POC WBC. An another interesting application is to monitor clozapine treatment on schizophrenic patients. It is mandatory to measure WBC and neutrophils due to the toxicity of the drug. The frequent visits to the laboratory cause inconvenience or anxiety for the patient about confrontation to the laboratory staff and venous sampling may have a deterrent effect. Monitoring of oncology patients could also be of interest due to avoid infections and inconvenience for the patients. Psykiatrisk klinik Monitoring total WBC and neutrophils (NEU) with a point-of-care device during Clozapine treatment on schizophrenic patients Nielsen, J., et al., Eur. Neuropsychopharmacol. (2011) Onkologimottagning Monitoring before next doze of chemotherapy or radiation Price CP, et al, Point-of-care testing; 2nd ed. (2004)

Är där ett behov av patientnära LPK och Diff ? Hjälp vid bedömning och uppföljning av infektioner och inflammationer Övre och nedre respiratoriska infektioner Appendicit Leukemi Allergier Screening av patienter vid akutmottagning och vårdcentraler Allmän hälsoindikator Monitorering av Onkologi patienter Clozapine patienter Liten provvolym Barn Dålig hållbarhet på kapillära prov Svar direkt

Sammanfattning Nya HemoCue® WBC DIFF är byggt på modern bild analys teknologi Resultaten är ackurata and precisa and korrelerar väl med sjukhuslaboratoriernas cellräknare Patientnära LPK med en 5-parts diff ger en förbättrad tillgång av redan väl etablerade och frekvent använda lab parametrar Snabb och lätt access av LPK och diff är ett värdefullt verktyg för läkaren att ge direkta och mer välunderbyggda beslut i många kliniska situationer. The conclusion is The novel POCT HemoCue® WBC DIFF technology is built on state-of-the art imaging technology The results from the system are accurate and precise and correlate well to laboratory cell counters both in the hands of lab technicians as well as untrained users A white blood cell count including a 5-part diff at the point of care will increase the availability of already well established and frequently used lab parameters Rapid and easy access will be a valuable tool for physicians in making direct and more well informed decisions in several clinical conditions