This month, while Dr. Karon is on a short sabbatical, we dig into MLO's archives for some time-tested tips from two other experts.
A bit of history explains “stabs”
Q
Why are banded
neutrophils called “stabs”
?
A Early in the last century, Paul Ehrlich developed staining techniques for the examination of blood films. When these films were examined, a variety of nucleated cells were found, including what we now know as neutrophils (i.e., they did not stain very intensely with either the red or blue dyes). German scientist Victor Schilling (1883-1960) differentiated the neutrophils into several categories based upon their morphology which included “myelozyten, jugendliche, stabkernige, und segmentkernige.” The translations of these cells are myelocytes, metamyelocytes, bands, and segmented neutrophils.
Schilling also developed a reporting format in which increases in the more immature band cells were noted on the report sheet to the left of the segmented neutrophils. So, if there was an increase in stabs or bands, it was called a “left shift.”
To answer your question, band neutrophils were the stabkernige, (i.e., with stab nuclei). To Schilling, the “stab” nuclei looked like a shepherd's staff or crook with its curved end, the German word being “stab.” This term has more or less persisted since then. Dr. L.W. Diggs reviewed the history of neutrophil counts at the 1977 CAP Aspen Conference on Differential Leukocyte Counting and the interested reader will find his remarks informative.1
Since then, flow-cytometric methods have increasingly displaced the morphologic differentiation of leukocytes in hematology laboratories. But the classic left-shift of transitional neutrophils as an indicator of acute inflammation or infection has become somewhat problematic with these instruments. There is, therefore, a growing consensus to merge the immature neutrophils and report them together as “immature granulocytes.” So, now there is a debate on the best way to standardize differentials among these various methodologies in order to provide the best laboratory data as well as to avoid confusion for the clinicians.2
—John A. Koepke, MD
Professor Emeritus of Pathology
Duke University Medical Center
Durham, NC
Originally published July 2003
References
- Diggs, LW. Highlights in the history of neutrophil counts. In: Differential Leukocyte Counting, JA Koepke, editor. College of American Pathologists. Skokie, IL; 1978.
- Koepke, JA. How should neutrophil reactions be measured? (editorial) Laboratory Hematology 1: 87-88, 1995.
Erroneous reports
Q I have read that when submitting a corrected report that the original — the erroneous report — is to be left on the chart. The reasoning is that if the physician treated based on erroneous data, evidence of that data is needed to support the physician's treatment. The protocol in our lab states that erroneous data should be removed from the chart. Are there any references that I can cite to support this position?
A You are correct that erroneous reports must not be removed from a medical record. If this is a paper (non-computer) report, leave the report in the chart and mark it as “Erroneous, see corrected report.” The person marking the report should sign and date the change. If the report is computer-generated, be sure that the computer tags it as a corrected report. In either case, it is important to show both the original report (labeled as erroneous) and the corrected report (labeled as corrected).
The Laboratory General Checklist used for CAP accreditation inspections has several questions relating to this issue such as, “When a revised report is issued, is it clearly defined as such, and are the original information and changed information reported together?”
According to CLIA '88 guidelines, when a revised report is issued, the laboratory must have a mechanism to ensure that both the new result and previous incorrect result are reported together. As clinical decisions or actions may have been based on the previous report (data, interpretations, reference intervals), it is important to replicate previous information (clearly identified as such) together with the revised information (clearly identified as such). Ideally, these would occur in juxtaposition for easy comparison, but the precise format is at the discretion of the laboratory.
Unless specifically endorsed by the medical staff/clients, it is not acceptable to simply indicate that a result has been revised, with the expectation that the reader will look up the previous result somewhere in the laboratory chart. For extensive interpretive or textual data (e.g., surgical pathology reports), repeating the entire original and corrected pathology reports may be cumbersome and render the revised report format difficult to interpret. In such cases, a comment in the corrected report explaining both the previous information and the reason for the correction may be more appropriate than repeating the entire original report.
Data should never be removed from a medical record. Lawyers love to find deletions because they are evidence of chart tampering.
—Daniel M. Baer, MD (now deceased)
Professor Emeritus
Department of Pathology
Oregon Health and Science University
Portland, OR
Originally published October 2003
Brad S. Karon, MD, PhD, is associate professor of laboratory medicine and pathology, and director of the Hospital Clinical Laboratories, point-of-care testing, and phlebotomy services at Mayo Clinic in Rochester, MN.
MLO's “Tips from the Clinical Experts” provides practical, up-to-date solutions to readers' technical and clinical issues from a panel of experts in various fields. Readers may send questions to Brad S. Karon, MD, PhD, by e-mail at [email protected].
