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The Value of the Peripheral Blood Smear in Anemic Inpatients: The Laboratory's Reading v a Physician's Reading

The Value of the Peripheral Blood Smear in Anemic Inpatients: The Laboratory's Reading v a... Abstract • Since physicians are routinely taught to review the peripheral blood smear results of all anemic patients, we analyzed the diagnostic value of the laboratory's blood smear reading and the incremental value of a physician's personal reading in anemic inpatients. Blood smear abnormalities, as reported by the laboratory and two hematologists, were poorly reproducible, with only five of the 11 types of abnormalities being more reproducible than could be expected by chance. The blood smear performed no better than RBC indices in detecting probable iron deficiency or low serum levels of folate or vitamin B12. In anemias not caused by deficiency states, the blood smear reading performed by the hospital laboratory provided unique information in 6% of the cases and helpful information in another 25%, but the additional reading performed by a hematologist never provided unique information and provided incremental helpful information in only 4% of the cases. The peripheral blood smears of all anemic inpatients should be read by the hospital laboratory, but in our hospital, a routine additional personal reading by a physician had limited incremental value and could be reserved for selected cases. (Arch Intern Med 1983;143:1120-1125) References 1. Isselbacher KJ, Adams RD, Braunwald E, et al: Pallor and anemia , in Harrison's Principles of Internal Medicine , ed 9. New York, McGraw-Hill Book Co, 1980, pp 269. 2. Wintrobe MM, Lee GR, Boggs DR, et al: Approach to the patient with anemia , in Clinical Hematology , ed 8. Philadelphia, Lea & Febiger, 1981, p 537. 3. Williams WJ, Beutler E, Ersler AJ, et al: Examination of the peripheral blood , in Hematology , ed 2. New York, McGraw-Hill Book Co, 1977, p 22. 4. Beeson P, McDermott W, Wyngaarden J: The anemias: Introduction , in Textbook of Medicine , ed 15. Philadelphia, WB Saunders Co, 1979, p 1718. 5. Woo B, Jen P, Rosenthal PE, et al: Anemic inpatients: Correlates of house officer performance. Arch Intern Med 1981;141:1199-1202.Crossref 6. Banton DF, Finch CA: The diagnosis of iron deficiency anemia. Am J Med 1964;37:62-70.Crossref 7. Cohen J: Weighted kappa: Nominal scale agreement with provision for scaled disagreement or partial credit. Psychol Bull 1968;70:213-220.Crossref 8. Fleiss JL, Cohen J, Everett BS: Large sample standard errors of kappa and weighted kappa. Psychol Bull 1969;72:323-327.Crossref 9. McNeil BJ, Keeler E, Adelstein SJ: Primer on certain elements of medical decision making. N Engl J Med 1975;293:211-215.Crossref 10. Koran LM: The reliability of clinical methods, data and judgments. N Engl J Med 1975;293:642-646, 695-701.Crossref 11. Norden C, Philipps E, Levy P, et al: Variation in interpretation of intravenous pyelograms. Am J Epidemiol 1970;91:155-160. 12. Wright EC, Acheson RM: New Haven survey of joint diseases: XI. Observer variability in the assessment of x-rays for osteoarthritis of the hands. Am J Epidemiol 1970;91:378-392. 13. Taranta A, Spagnuolo M, Snyder R, et al: Auscultation of the heart by physicians and by computer , in Enslein E (ed): Data Acquisition and Processing in Biology and Medicine . New York, Macmillan Publishing Co Inc, 1964, vol 3, pp 23-52. 14. Meade TW, Gardner MJ, Cannon P, et al: Observer variability in recording the peripheral pulses. Br Heart J 1968;30:661-665.Crossref 15. Light RJ: Measures of response agreement for qualitative data: Some generalizations and alternatives. Psychol Bull 1971;76:365-377.Crossref 16. Fairbanks VF: Is the peripheral blood film reliable for the diagnosis of iron deficiency anemia? Am J Clin Pathol 1971;55:447-451. 17. Paine CJ, Polk A, Eichner ER: Analysis of anemia in medical inpatients. Am J Med Sci 1974;268:37-44.Crossref 18. Croft RF, Streeter AM, O'Neill BJ: Red cell indices in megaloblastosis and iron deficiency. Pathology 1974;6:107-117.Crossref 19. Lessels S, Davidson RJL: The low mean cell volume in routine haematology. Clin Lab Haematol 1979;1:291-298.Crossref 20. Beutler E: The red cell indices in the diagnosis of iron-deficiency anemias. Ann Intern Med 1959;50:313-322.Crossref 21. Beutler E, Robson MJ, Buttenwieser E: A comparison of the plasma iron, iron-binding capacity, sternal marrow iron and other methods in the clinical evaluation of iron stores. Ann Intern Med 1958;48:60-82.Crossref 22. McPhedran P, Barnes MG, Weinstein JS, et al: Interpretation of electronically determined macrocytosis. Ann Intern Med 1973;78:677-683.Crossref 23. Davidson RJL, Hamilton PJ: High mean red cell volume: Its incidence and significance in routine haematology. J Clin Pathol 1978;31:493-498.Crossref 24. Cooper BA, Whitehead VM: Evidence that some patients with pernicious anemia are not recognized by radiodilution assay for cobalamin in serum. N Engl J Med 1978;299:816-818.Crossref 25. Kolhouse JF, Kondo H, Allen NC, et al: Cobalamin analogues are present in human plasma and can mask cobalamin deficiency because current radioisotope dilution assays are not specific for true cobalamin. N Engl J Med 1978;299:785-792.Crossref 26. Ransohoff DF, Feinstein AR: Problems of spectrum and bias in evaluating the efficacy of diagnostic tests. N Engl J Med 1978;299:926-930.Crossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Internal Medicine American Medical Association

The Value of the Peripheral Blood Smear in Anemic Inpatients: The Laboratory's Reading v a Physician's Reading

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References (28)

Publisher
American Medical Association
Copyright
Copyright © 1983 American Medical Association. All Rights Reserved.
ISSN
0003-9926
eISSN
1538-3679
DOI
10.1001/archinte.1983.00350060042005
Publisher site
See Article on Publisher Site

Abstract

Abstract • Since physicians are routinely taught to review the peripheral blood smear results of all anemic patients, we analyzed the diagnostic value of the laboratory's blood smear reading and the incremental value of a physician's personal reading in anemic inpatients. Blood smear abnormalities, as reported by the laboratory and two hematologists, were poorly reproducible, with only five of the 11 types of abnormalities being more reproducible than could be expected by chance. The blood smear performed no better than RBC indices in detecting probable iron deficiency or low serum levels of folate or vitamin B12. In anemias not caused by deficiency states, the blood smear reading performed by the hospital laboratory provided unique information in 6% of the cases and helpful information in another 25%, but the additional reading performed by a hematologist never provided unique information and provided incremental helpful information in only 4% of the cases. The peripheral blood smears of all anemic inpatients should be read by the hospital laboratory, but in our hospital, a routine additional personal reading by a physician had limited incremental value and could be reserved for selected cases. (Arch Intern Med 1983;143:1120-1125) References 1. Isselbacher KJ, Adams RD, Braunwald E, et al: Pallor and anemia , in Harrison's Principles of Internal Medicine , ed 9. New York, McGraw-Hill Book Co, 1980, pp 269. 2. Wintrobe MM, Lee GR, Boggs DR, et al: Approach to the patient with anemia , in Clinical Hematology , ed 8. Philadelphia, Lea & Febiger, 1981, p 537. 3. Williams WJ, Beutler E, Ersler AJ, et al: Examination of the peripheral blood , in Hematology , ed 2. New York, McGraw-Hill Book Co, 1977, p 22. 4. Beeson P, McDermott W, Wyngaarden J: The anemias: Introduction , in Textbook of Medicine , ed 15. Philadelphia, WB Saunders Co, 1979, p 1718. 5. Woo B, Jen P, Rosenthal PE, et al: Anemic inpatients: Correlates of house officer performance. Arch Intern Med 1981;141:1199-1202.Crossref 6. Banton DF, Finch CA: The diagnosis of iron deficiency anemia. Am J Med 1964;37:62-70.Crossref 7. Cohen J: Weighted kappa: Nominal scale agreement with provision for scaled disagreement or partial credit. Psychol Bull 1968;70:213-220.Crossref 8. Fleiss JL, Cohen J, Everett BS: Large sample standard errors of kappa and weighted kappa. Psychol Bull 1969;72:323-327.Crossref 9. McNeil BJ, Keeler E, Adelstein SJ: Primer on certain elements of medical decision making. N Engl J Med 1975;293:211-215.Crossref 10. Koran LM: The reliability of clinical methods, data and judgments. N Engl J Med 1975;293:642-646, 695-701.Crossref 11. Norden C, Philipps E, Levy P, et al: Variation in interpretation of intravenous pyelograms. Am J Epidemiol 1970;91:155-160. 12. Wright EC, Acheson RM: New Haven survey of joint diseases: XI. Observer variability in the assessment of x-rays for osteoarthritis of the hands. Am J Epidemiol 1970;91:378-392. 13. Taranta A, Spagnuolo M, Snyder R, et al: Auscultation of the heart by physicians and by computer , in Enslein E (ed): Data Acquisition and Processing in Biology and Medicine . New York, Macmillan Publishing Co Inc, 1964, vol 3, pp 23-52. 14. Meade TW, Gardner MJ, Cannon P, et al: Observer variability in recording the peripheral pulses. Br Heart J 1968;30:661-665.Crossref 15. Light RJ: Measures of response agreement for qualitative data: Some generalizations and alternatives. Psychol Bull 1971;76:365-377.Crossref 16. Fairbanks VF: Is the peripheral blood film reliable for the diagnosis of iron deficiency anemia? Am J Clin Pathol 1971;55:447-451. 17. Paine CJ, Polk A, Eichner ER: Analysis of anemia in medical inpatients. Am J Med Sci 1974;268:37-44.Crossref 18. Croft RF, Streeter AM, O'Neill BJ: Red cell indices in megaloblastosis and iron deficiency. Pathology 1974;6:107-117.Crossref 19. Lessels S, Davidson RJL: The low mean cell volume in routine haematology. Clin Lab Haematol 1979;1:291-298.Crossref 20. Beutler E: The red cell indices in the diagnosis of iron-deficiency anemias. Ann Intern Med 1959;50:313-322.Crossref 21. Beutler E, Robson MJ, Buttenwieser E: A comparison of the plasma iron, iron-binding capacity, sternal marrow iron and other methods in the clinical evaluation of iron stores. Ann Intern Med 1958;48:60-82.Crossref 22. McPhedran P, Barnes MG, Weinstein JS, et al: Interpretation of electronically determined macrocytosis. Ann Intern Med 1973;78:677-683.Crossref 23. Davidson RJL, Hamilton PJ: High mean red cell volume: Its incidence and significance in routine haematology. J Clin Pathol 1978;31:493-498.Crossref 24. Cooper BA, Whitehead VM: Evidence that some patients with pernicious anemia are not recognized by radiodilution assay for cobalamin in serum. N Engl J Med 1978;299:816-818.Crossref 25. Kolhouse JF, Kondo H, Allen NC, et al: Cobalamin analogues are present in human plasma and can mask cobalamin deficiency because current radioisotope dilution assays are not specific for true cobalamin. N Engl J Med 1978;299:785-792.Crossref 26. Ransohoff DF, Feinstein AR: Problems of spectrum and bias in evaluating the efficacy of diagnostic tests. N Engl J Med 1978;299:926-930.Crossref

Journal

Archives of Internal MedicineAmerican Medical Association

Published: Jun 1, 1983

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