Contributors

Clair S. Wylie, BSMary Coleman, MS

Hematology & HemostasisMedical Laboratory Technician

I. Normal hematopoietic systemA. Define hematopoiesis (Level 1)

1. Theory of pluripotent stem cell development2. Apoptosis

B. Identify phases and site of origin for cellular development of active hematopoietic tissue (Level 1)

1. Embryo and fetusa) Yolk sacb) Mesoblastic phasec) Hepatic phase (extramedullary)d) Medullary/myeloid phase

2. Infant and young childa) All red marrow spaces (all cell lines)b) Thymus fully developed (T lymphs)c) Secondary lymphoid tissue (B-cell, T- cell and NK-cell)

3. Adulta) Red marrow (axial skeleton and proximal ends of long

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

and NK-cell)C. Identify the role of other organ systems in hematopoiesis (Level 1)

1. Mononuclear phagocyte system2. Spleen

a) Structure and blood flowb) Function

3. Livera) Structureb) Function

4. Lymph nodesa) Structureb) Function

5. Thymusa) Structureb) Function

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D. Associate physical findings with the presence of hematologic disease (Level 1)

1. Splenomegaly2. Hypersplenism3. Hepatosplenomegaly4. Lymphadenopathy

E. Process bone marrow tissue1. Describe collection techniques (Level 1)

a) Aspirationb) Core biopsy

2. Prepare and stain smears with Romanowsky polychrome stain (Level 2)

3. Prepare and stain smears with Prussian blue (iron) stain (Level 2)

F. Prepare peripheral blood for routine hematologic procedure and smear analysis

1. Determine specimen acceptabilitya) 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)2. Stain smears using Romanowsky dyes and techniques

according to established procedures (Level 2)a) Manualb) Automated

3. List and define components of stain (Level 1)4. Judge the acceptability of blood smears through microscopic

evaluation and established criteria (Level 3)a) Random distribution of cellsb) Good stain qualityc) Absence of artifact

5. Troubleshoot staining problems (Level 3)6. Correlate peripheral blood evaluation with automated cell

analysis7. Enumerate and morphologically evaluate blood cells on

Romanowsky stained smearsII. Erythropoiesis

A. Identify distinctive features used to characterize developing cells

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(Level 1)1. Overall cell diameter or volume2. Nucleus

a) Shapeb) Relative diameter or volumec) Staining reactiond) Chromatin patterne) Presence or absence of nucleoli

3. Cytoplasma) Relative amountb) Staining reaction

4. Nuclear:cytoplasmic ratioB. List the maturation sequence and identify stages of developing

normal erythrocytes given Romanowsky stained smears, photographs, electronic images, (Level 2)

C. Categorize red cells (Level 2)1. Diameter or volume2. Shape3. Color4. Inclusions5. Distribution patterns

D. Associate nutritional and regulatory factors with erythropoiesis (Level 1)

1. Erythropoietin (EPO)2. Iron3. B12 and folate

E. Describe components of the mature red cell that are essential for survival and function (Level 1)

1. Membrane composition and functiona) Lipidsb) Integral proteinsc) Peripheral proteins

2. Functiona) Maintain RBC shape, deformability, and permeabilityb) Support system for surface antigensc) Transport and exchange of gases and ions (cationic

pumps)3. Metabolic pathways for production of adequate energy

a) Embden-Meyerhof

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b) Hexose monophosphate shuntc) Methemoglobin reductased) Luebering-Rapoport

F. Summarize mechanisms by which normal hemoglobin is structured and synthesized in the developing red cell (Level 1)

1. Iron transport, uptake, and supply2. Protoporphyrin IX (heme) formation3. Globin synthesis and genetic control

a) Embryonic hemoglobinsb) Hb Ac) Hb Fd) Hb A2

G. Describe normal hemoglobin-oxygen function using the oxygen dissociation curve (ODC) (Level 1)

1. Identify factors that contribute to shifts to the curve a) pH (Bohr effect)b) Temperaturec) CO2

d) 2,3-DPGe) Hb F and other variants

2. Cite factors that may affect the optimal level of hemoglobina) Age and genderb) Altitudec) Smokingd) Associated diseasee) Altered hemoglobin derivatives

(1) Carboxyhemoglobin(2) Sulfhemoglobn (3) Methemoglobin

H. Summarize the general mechanism by which red cells are catabolized (Level 1)

1. Identify phasesa) Extravascularb) Intravascular

2. Trace the basic steps associated with each phase3. Define terms

a) Biliverdinb) Bilirubin

(1) Unconjugated

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(2) Conjugatedc) Urobilinogend) Urobiline) Haptoglobinf) Hemoglobinemiag) Hemoglobinuriah) Hemosiderinuria

I. Describe and perform standard operational procedures to evaluate erythrocytes and their physical properties using patient blood and quality control samples

1. State the principles of method analysis and histogram/ scatterplot/scattergram review (Level 1)

2. 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 calculatedd) 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 morphology3. List reference values for variations in gender and age (Level

1)4. Correlate and verify automated hemogram parameters and

calculated indices with each other and with peripheral smear

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exams (Level 3)5. Calibrate and perform preventive maintenance on

instruments used to evaluate erythrocytes and their physical properties (Level 2)

6. Recognize and troubleshoot pre-analytical, analytical and post-analytical causes of problems or unexpected results (Level 3)

7. Notify supervisor for the resolution of results or events (Level 2)

III. LeukopoiesisA. Cite reference values for variations in gender and age for the

leukocyte counts in peripheral blood (Level 1)1. Total leukocyte count2. Relative and absolute values for neutrophil, lymphocyte,

eosinophil, basophil and monocyte countsB. Identify and recognize factors that may alter values (Level 1)

1. Physiologic variation2. Pathologic abnormalities

C. Enumerate and calculate leukocyte cell types (Level 2)1. Relative values2. Absolute values

D. Characterize morphologic features used to differentiate developing leukocytes (Level 1)

1. Overall cell diameter or volume2. Nucleus

a) Shapeb) Relative diameter or volumec) Nuclear to cytoplasmic ratio (N:C)d) Staining reactione) Chromatin patternf) Presence or absence of nucleoli

3. Cytoplasma) Relative amountb) Staining properties c) Presence or absence of granules and staining reaction

E. 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)

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1. Neutrophils2. Eosinophils3. Basophils

F. Identify general mechanisms that modulate granulopoiesis (Level 1)1. Kinetics

a) Life spanb) Circulation

2. Biochemistrya) Granule contentb) Energy metabolism

3. Functiona) Chemotaxisb) Phagocytosis and killingc) Allergic response (eosinophils and basophils)d) Host defense against parasites (eosinophils)e) Hypersensitivity mediator (basophils and mast cells)

G. List features that characterize monocytes-macrophages (Level 1)1. Identify morphology of developing cells2. Kinetics

a) Life spanb) Circulationc) Tissue phase

3. Functiona) Phagocytosisb) Antigen-presenting cells (APC)

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

a) Lymphocytes and precursorsb) Plasma cells

2. Sites of formation and productiona) Bone marrowb) Thymusc) Lymph nodes and secondary lymphoid tissue

3. Kineticsa) Life spanb) Migration

4. Functiona) Humoral immunity (B lymphs and subsets) b) Cell mediated immunity (T lymphs and subsets)

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c) Natural killing and antibody dependent cellular cytotoxicity

I. Perform commonly used methods to evaluate leukocytes 1. State the principles of method analysis and

histogram/scatterplot review (Level 1)2. 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)

3. Calibrate and perform preventive maintenance on instruments used to evaluate white cells (Level 2)

4. Determine differential cell counting using automated methods (Level 2)

5. Evaluate white cell histograms and scatterplots for diagnostic and quality control (Level 3)

6. Identify and classify white cells on a properly prepared Romanowsky stained blood smear (Level 2)

7. Correlate and verify automated cell counts and differentials with established criteria and/or peripheral smear exam (Level 3)

8. Estimate the total white blood count from a smear (Level 2)9. Correct leukocyte counts for the presence of nucleated red

cells (Level 2)10. Recognize and troubleshoot pre-analytical, analytical and

post-analytical causes for problems or unexpected results (Level 3)

11. Take corrective action to resolve unexpected results and/or events (Level 2)

IV. Hematologic disordersA. Red blood cell disorders

1. General conceptsa) 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

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(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 cellsd) 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 criteria that defines poikilocytosis (Level 1) and relate the morphologic changes in erythrocytes to clinical conditions (Level 2)

(1) Acanthocyte (spur cell)(2) Codocyte (target cell)

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(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) and correlate the possible pathologic conditions (Level 2)

(1) Basophilic stippling(2) Cabot rings(3) Heinz bodies(4) Howell-Jolly bodies(5) Malarial and other blood parasites(6) Pappenheimer bodies/siderotic granules(7) Hemoglobin crystals (S,C and SC)(8) Hemoglobin H inclusion bodies

2. 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)

3. 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

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(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)4. Megaloblastic anemias

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

b) Describe clinical features (Level 1)c) Explain megaloblastic 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

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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

5. Hypoproliferative anemiasa) Acquired aplastic anemia

(1) Define aplastic anemia (Level 1)(2) Identify common factors associated with the

development (Level 1)(3) Describe the general 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’s anemia (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)

6. 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

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(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 heterozygous thalassemia (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)

7. Hemolytic anemiasa) Intracorpuscular/intracellular defects

(1) RBC membrane abnormalities(a) Describe the etiology, general

pathophysiology, clinical features, and laboratory findings (Level 1)

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i. Hereditary spherocytosisii. 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 deficiencyii. 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 reactionii. Delayed hemolytic transfusion

reactioniii. 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

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(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 agentsiii. Chemicals

(b) Describe the hematologic findings (Level 1)i. Malaria

ii. Babesiosisiii. Bartonellosisiv. Bacterial sepsis v. Cardiac prosthetic devices

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

vii. Chemicals and venomsviii. Thermal injury

8. Acute blood lossa) 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)

9. Anemias associated with systemic disordersa) Describe the etiology, general pathophysiology (Level

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1), and identify significant laboratory findings (Level 2)(1) Chronic renal disease(2) Liver disease(3) Endocrine diseases(4) Systemic lupus erythematosus

b) Identify significant laboratory findings (Level 2)B. White blood cell disorders

1. Nonmalignant leukocyte disordersa) 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

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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)

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(a) Lymphocytopenia(b) Leukopenia(c) Anemia(d) Thrombocytopenia

2. Neoplastic disorders of leukocytesa) 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(b) Myeloproliferative neoplasms(c) Myelodysplastic/myeloproliferative

neoplasms(2) Lymphoproliferative disorders

(a) Precursor lymphoid neoplasms (B and T)(b) Mature B-cell neoplasms(c) Mature T and NK cell neoplasms

d) Observe and/or perform procedures, apply appropriate quality control procedures, recognize and follow up, within pre-established reporting guidelines, laboratory procedures used in the identification, classification and differentiation of neoplastic disorders (Level 2)

(1) Complete blood count(a) Hemograms(b) Scatterplots and histograms

(2) Morphologic evaluation of peripheral blood on Romanowsky stained smears

e) Describe the use of cytochemistry, immunophenotyping, cytogenetics, and molecular genetics

f) Apply knowledge and skills in interpreting laboratory results (Level 3)

3. Myelodysplastic syndromes (MDS)

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a) Define cellular features that characterize the MDS in general (Level 1)

(1) Dyserythropoiesis(2) Dysgranulopoiesis(3) Dysmegakaryocytopoiesis

b) Name key morphologic features on permanently stained blood and bone marrow smears, photographs or electronic images (Level 1)

c) List subgroups recognized by WHO for the MDS classification (Level 1)

(1) Refractory anemia (RA)(2) Refractory anemia with ringed sideroblasts

(RARS)(3) Refractory cytopenia with multilineage dysplasia

(RCMD)(4) Refractory anemia with excess blast (RAEB)(5) Myelodysplastic syndrome, unclassified (MDS-U)(6) Myelodysplastic syndrome with isolated del (5q)

d) Describe characteristics of MDS (Level 1)(1) Epidemiology(2) Clinical course with associated hematologic

changes4. Myeloproliferative neoplasms MPN

a) List subtypes (Level 1)(1) Chronic myelogenous leukemia (CML)(2) Polycythemia vera (PV)(3) Essential thrombocythemia (ET)(4) Primary myelofibrosis (PMF) (5) Chronic neutrophilic leukemia (CNL)(6) Chronic eosinophilic leukemia not otherwise

specified (CEL, NSO) b) Compare and contrast features commonly shared by

(MPN)(Level 2)(1) Clinical manifestations(2) General pathophysiologic mechanisms(3) Blood and bone marrow findings(4) Disease evolution with potential for blastic

transformation(5) Presence or absence of Philadelphia chromosome

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and BCR/ABL fusion c) Identify (Level 1) key morphologic features on

permanently stained blood smears, photographs, or electronic images and apply (Level 3) diagnostic criteria to these findings for the differential identification

(1) Chronic myelogenous leukemia (CML)(a) Leukocytosis with absolute neutrophilia

and left shift maturation(b) Absolute basophilia and eosinophilia(c) Thrombocytosis

(2) Polycythemia vera (PV)(a) Increased red blood cell (RBC) mass(b) Leukocytosis with mild left shift maturation

and basophilia(c) Thrombocytosis(d) Red cell morphology

(3) Essential thrombocythemia (ET)(a) Marked thrombocytosis with platelet

aggregates(b) Abnormal forms of megakaryocytes and

platelets(4) Primary myelofibrosis (PMF)

(a) Leukoerythroblastosis with teardrop-shaped red cells

(b) Leukocytosis with left shift maturation micromegakaryocytes

d) Recognize the effects of treatment options on peripheral blood white cells, red cell parameters, and platelets (Level 1)

5. Myelodysplastic/myeloproliferative neoplasms (MDS/MPN)a) List subgroups recognized by WHO for the

myelodysplastic/myeloproliferative classification (Level 1)

(1) Chronic myelomonocytic leukemia (CMML)(2) Atypical chronic myeloid leukemia (aCML)(3) Juvenile myelomonocytic leukemia (JMML)(4) MDS/MPN unclassifiable

b) Discuss the rational used for the classification (Level 2)6. Acute myeloid leukemias (AML) and related precursor

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neoplasmsa) Apply general criteria to classify leukemias (Level 1)

(1) Cell maturity(a) Acute(b) Chronic

(2) Cell lineage(a) Myeloid(b) Lymphoid

b) Describe for each leukemia (Level 1)(1) Clinical findings and symptoms(2) Incidence and epidemiology(3) Risk factors associated with the development of

leukemia(a) Hereditary abnormalities(b) Environmental(c) Viral infections

i. Immunologic disordersii. Therapy related

(d) Stem cell clonality as applied to the pathophysiology of leukemia

(e) Survival rates(f) Treatment options and correlation with

hematologic complicationsi. Chemotherapy

ii. Bone marrow/stem cell transplantiii. Targeted molecular/genetic therapy

(4) List (Level 1) and compare (Level 2) the FAB with the WHO acute leukemia subgroups and apply diagnostic blood and bone marrow findings to the differential identification (Level 3)

(a) FAB classificationi. M0--acute myeloid leukemia with

minimal differentiation ii. M1--acute myeloid leukemia without

maturation iii. M2--acute myeloid leukemia with

maturationiv. M3--acute promyelocytic leukemiav. M4--acute myelomonocytic leukemia

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vi. M5--acute monoblastic leukemiavii. M6--acute erythroleukemia

viii. M7--acute megakaryoblastic leukemia(b) WHO classification

i. AML with recurrent genetic abnormalities

ii. AML with myelodysplasia-related changes

iii. Therapy-related myeloid neoplasmsiv. AML, not otherwise specified

c) Precursor lymphoid neoplasms(1) List (Level 1) the WHO acute leukemia subgroups

(a) WHO classification:i. B lymphoblastic leukemia/lymphoma,

not otherwise specifiedii. T lymphoblastic leukemia/lymphoma

(2) Apply diagnostic blood and bone marrow findings to the differential identification (Level 3)

d) Mature B-cell neoplasms(1) Name and classify the neoplasms

(a) Chronic lymphocytic leukemia (CLL)(b) B-cell prolymphocytic leukemia (PLL)(c) Hairy cell leukemia (HCL)(d) Plasma cell neoplasms(e) Plasma cell leukemia

(2) Chronic lymphocytic leukemia (CLL)(a) List diagnostic features (Level 1)

i. Median age of onsetii. Symptoms and clinical findings

iii. Blood findings(a) Peripheral blood absolute

lymphocytosis(b) Leukemic cell line of mature, small

lymphocytes with monotonous morphology and smudge/basket cells

(b) Recognize and describe features associated with aggressive forms of the disease (Level 1)

(3) Prolymphocytic leukemia (PLL)

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(a) List diagnostic features (Level 1)i. Median age of onset and gender

ii. Clinical findings of severe splenomegaly(b) Review blood findings (Level 1)

i. Markedly elevated white blood cell count with absolute lymphocytosis

ii. White cell differential of greater than 55% prolymphocytes

(4) Hairy cell leukemia (HCL)(a) List diagnostic features (Level 1)

i. Median age of onset and genderii. Clinical finding of severe splenomegaly

(b) Review blood findings (Level 1)i. Pancytopenia

ii. Leukemic cell line of “hairy” cells iii. “Dry” tap; marrow fibrosis and

infiltrates(5) Plasma Cell neoplasms

(a) Name disorders (Level 1) and discuss classification based on proliferation of plasma cells and abnormal production of immunoglobulins (Level 2)

i. Multiple myeloma ii. Waldenström macroglobulinemia

iii. Plasma cell leukemiaiv. Heavy chain diseasev. Monoclonal gammopathy of

undetermined significance (MGUS)(b) Compare and contrast the following for

plasma cell disorders (Level 2)i. General pathophysiology

ii. Clinical findingsiii. Laboratory findings

(a) Complete blood count (CBC) and peripheral smear review

(b) Bone marrow biopsy (c) Blood and urine protein

electrophoresis and immunoelectrophoresis

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(d) Quantitative immunoglobulins(e) Chemistry panels--blood urea

nitrogen, creatinine, calcium, lactic dehydrogenase

(f) Serum viscosity(g) Beta-2-microglobulin(h) Radiologic studies of bones

(c) Identify key morphologic features for plasma cell disorders on permanently stained blood and bone marrow smears, photographs, electronic images (Level 2)

i. Plasma cells and variants ii. Rouleaux formation of red blood cells

(6) Mature T- and NK-cell neoplasms(a) T-cell large granular lymphocytic leukemia

(LGL) (T-cell)i. List diagnostic findings (Level 1)

ii. Review blood findings (Level 1)(b) Adult T-cell leukemia/lymphoma (ATLL)

i. List diagnostic features (Level 1)(a) Human T-cell lymphotropic virus

(HTLV-1)(b) Endemic areas

ii. Review blood findings (Level 1)(c) Sézary syndrome

i. List diagnostic features (Level 1)ii. Review blood findings (Level 1)

(7) Hodgkin lymphoma(a) Define lymphoma (Level 1)(b) Recall approaches used to diagnose and stage

Hodgkin lymphoma (Level 1)i. Physical examination and clinical history

ii. Radiologic studies iii. Lymph node biopsy--Reed Sternberg

cellsiv. Laboratory tests

(c) Describe (Level 1) and recognize (Level 2) the presence of lymphoma cells on permanently stained blood and body fluid smears,

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photographs, or electronic imagesV. Thrombopoiesis/megakaryopoiesis

A. List the maturation sequence and identify distinguishing morphology for stages of developing megakaryocytes using Romanowsky stained smears, photographs, electronic images, or slides (Level 2)

B. Cite reference values for peripheral blood platelet counts (Level 1) C. Correlate quantitative variations with disease manifestations (Level

3) 1. Thrombocytopenia2. Thrombocytosis

D. Correlate functional or qualitative variations with disease manifestations (Level 3)

E. Perform platelet counts on patient and control specimens using manual and automated methods in accord with prescribed criteria for accuracy and precision (Level 2)

1. State the principles of method analysis and histogram review (Level 1)

2. Compare automated count with those estimated from smear exam (Level 2)

3. Calibrate and perform preventive maintenance on instruments used to evaluate platelets (Level 2)

4. Evaluate automated hemogram parameters such as MPV and PPF with the peripheral blood film morphology (Level 2)

5. Evaluate platelet histograms and scatterplots for diagnostic and quality control purposes (Level 2)

6. Identify and recognize factors that may alter values (Level 1)a) Platelet satellitismb) Platelet aggregatesc) Giant plateletsd) Cell fragmentse) Extreme microcytosis

7. Troubleshoot and apply corrective action to resolve unexpected results (Level 2)

VI. Hemostasis/coagulationA. Hemostasis (Level 1)

1. Describe the general interaction of systems involved in maintaining hemostasis (Level 1)

a) Vasculature

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b) Plateletsc) Plasma coagulation factorsd) Fibrinolytic system

2. Differentiate between primary and secondary hemostasis (Level 1)

B. Vasculature1. Describe the functions of the vascular system in maintaining

hemostasis (Level 1)2. Describe metabolic functions of the endothelium in

hemostasis (Level 1)C. Platelets

1. Review the production of platelets by describing the ultra-structure components of a platelet (Level 1)

2. State the average time in circulation, normal peripheral count, and total body distribution of platelets (Level 1)

3. Summarize the physiological role of platelets in hemostasis (Level 1)

a) Platelet plug formationb) Maintaining normal vascular integrity

4. Describe the series of morphologic changes that occur in platelets following physiologic stimulation (Level 1)

a) Adhesionb) Aggregationc) Activation/secretion

5. Describe the effect of aspirin and other platelet inhibiting substances on platelet function (Level 1)

a) Biochemical mechanismb) Duration of the effect

6. Platelet aggregometry and platelet function analyzersa) Describe the principle of light transmittance, whole

blood impedance and lumiaggregometry (Level 1)b) Perform (Level 2) procedurec) Describe appropriate quality control procedures and

sources of error (Level 1)D. Plasma coagulation factors

1. List the coagulation factors (Level 1)a) Roman numeralsb) Common namesc) Synonyms

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2. Review the physiological role of the coagulation phase within the hemostatic process (Level 1)

3. Review characteristics of the coagulation factors (Level 1)a) Contact groupb) Prothrombin groupc) Fibrinogen group

4. List and describe the vitamin K-dependent factors (Level 1)5. Compare and contrast the plasma-based (in vitro) and cell-

based (in vivo) mechanisms of coagulation (Level 2)a) Plasma-based (in vitro) mechanism

(1) Intrinsic(2) Extrinsic(3) Common

b) Cell-based (physiologic, in vivo) mechanism(1) Initiation(2) Amplification(3) Propagation

6. Identify substances that are contact activators in vitro (Level 1)

7. Summarize the interaction of the coagulation system with the vascular and platelet systems to form a hemostatic plug (Level 1)

8. Describe the physiologic controls of hemostasis (Level 1)a) Blood flowb) Feedback inhibitionc) Liver clearanced) Inhibitors

(1) Antithrombins (2) Tissue factor pathway inhibitor (TFPI)(3) Protein C(4) Protein S(5) Z-dependent protease inhibitor (ZPI)

9. Identify the special precautions that must be taken in the collection and subsequent handling of specimens for coagulation testing (Level 1)

a) Anticoagulantb) Ratio of blood to anticoagulantc) Patient hematocrit valuesd) Centrifugation

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e) Storagef) Transportg) Phlebotomy procedure (e.g., time tourniquet is on arm,

needle gauge, probing, etc.)10. Identify and describe tests that are used to monitor the

coagulation phase of hemostasisa) Prothrombin time test

(1) State principle (Level 1)(2) Correlate clinical significance (Level 2)(3) Describe procedure (Level 1)(4) Perform procedure (Level 2)(5) Apply appropriate quality control procedures

(Level 2)(6) Interpret results (Level 3)

(a) Describe the International Normalized Ratio (INR)

(b) Calculate an INR given the international sensitivity index of the thromboplastin

b) Activated partial thromboplastin time(1) State principle (Level 1)(2) Correlate clinical significance (Level 2)(3) Describe procedure (Level 1)(4) Perform procedure (Level 2)(5) Apply appropriate quality control procedures

(Level 2)(6) Interpret results (Level 3)

c) Activated clotting time(1) State principle (Level 1)(2) Correlate clinical significance (Level 1)(3) Perform (Level 2) or describe (Level 1) procedure(4) Apply appropriate quality control procedures

(Level 2)(5) Interpret results (Level 3)

d) Thrombin clotting time(1) State principle (Level 1)(2) Correlate clinical significance (Level 1)(3) Perform (Level 2) or describe (Level 1) procedure(4) Apply appropriate quality control procedures

(Level 2)

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(5) Interpret results (Level 3)e) Fibrinogen assay

(1) State principle (Level 1)(2) Correlate clinical significance (Level 1)(3) Perform (Level 2) or describe (Level 1) procedure(4) Apply appropriate quality control procedures

(Level 2)(5) Interpret results (Level 3)

f) Factor assays(1) State principle of clot-based and chromogenic

assays (Level 1)(2) Correlate clinical significance (Level 1)(3) Perform (Level 2) or describe (Level 1) procedure(4) Apply appropriate quality control procedures

(Level 2)g) Given an established protocol, identify technical

conditions that cause inaccurate coagulation testing results (Level 1)

E. Fibrinolytic system1. Define fibrinolysis (Level 1)2. Describe the physiological role of the fibrinolytic system

(Level 1)3. Identify the major components of the fibrinolytic system

(Level 1)4. List the major fragments of fibrinogen/fibrin degradation

(Level 1)5. Identify and describe laboratory procedures that are used to

evaluate the fibrinolytic systema) D-dimer assay

(1) State principle (Level 1)(2) Correlate clinical significance (Level 2)(3) Perform (Level 2) or describe (Level 1) procedure(4) Apply appropriate quality control procedures

(Level 2)(5) Interpret results (Level 3)

b) Given an established protocol, identify technical conditions that cause unexpected coagulation testing results (Level 1)

F. Disorders of primary hemostasis

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1. Differentiate between inherited and acquired disorders of the vasculature (Level 1)

2. Define (Level 1)a) Thrombocytopeniab) Thrombocytosisc) Thrombocythemia

3. Describe the etiology, pathophysiology, clinical features, and laboratory findings of quantitative defects of platelets (Level 1)

a) Immunologic thrombocytopenic purpurasb) Microangiopathic hemolytic anemias

(1) Thrombotic thrombocytopenic purpura(2) Disseminated intravascular coagulation(3) Hemolytic uremic syndrome(4) HELLP syndrome

c) MYH9 inherited thrombocytopenias, e.g. May-Hegglin anomaly

d) Thrombocytosis(1) Myeloproliferative neoplasms(2) Secondary (reactive) conditions

4. Describe the etiology, general pathophysiology, clinical features, and laboratory findings of qualitative defects of platelets (Level 1)

a) Bernard-Soulier syndromeb) Glanzmann’s thrombastheniac) Storage pool deficienciesd) Acquired platelet disorders

G. Disorders of secondary hemostasis1. Describe the inheritance pattern, pathophysiology, clinical

features, and laboratory findings (Level 1)a) Hypofibrinogenemiab) Rare autosomal recessive coagulopathies: II, V, VII, Xc) Factor VIII deficiency (Hemophilia A)d) Factor IX deficiency (Hemophilia B)e) Factor XI deficiency

2. Describe clinical features and laboratory findings of acquired coagulation disorders (Level 1)

a) Vitamin K deficiencyb) Liver disease

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c) Renal disease3. Describe the significance and clinical implications of the

development of inhibitors (Level 1)a) Specific factor inhibitorsb) Lupus anticoagulant (LA), antiphospholipid antibodiesc) Global inhibitors

4. Identify and describe laboratory procedures that are used to evaluate inhibitors (Level 1)

a) APTT screening with moderate-high LA responsive reagent (LA-sensitive, low phospholipid)

(1) Discuss principle (Level 1)(2) Perform (Level 2) or describe (Level 1) procedure(3) Apply appropriate quality control procedures

(Level 2)(4) Interpret results (Level 3)

b) APTT based mixing study using pooled normal plasma(1) Discuss principle (Level 1)(2) Perform (Level 2) or describe (Level 1) procedure(3) Apply appropriate quality control procedures

(Level 2)(4) Interpret results (Level 3)

c) Tests to determine if inhibitor is phospholipid-dependent (low-phospholipid (LA-sensitive) vs high-phospholipid)

(1) Discuss principle (Level 1)(2) Perform (Level 2) or describe (Level 1) procedure(3) Apply appropriate quality control procedures

(Level 2)(4) Interpret results (Level 3)

d) Dilute Russell viper venom time (DRVVT) (1) State principle (Level 1)(2) Perform (Level 2) or describe (Level 1) procedure(3) Apply appropriate quality control procedures

(Level 2)(4) Interpret results (Level 3)

e) Low-phospholipid LA-sensitive vs. high-phospholipid APTT

(1) State principle (Level 1)(2) Perform (Level 2) or describe (Level 1) procedure

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(3) Apply appropriate quality control procedures (Level 2)

(4) Interpret results (Level 3)f) Factor assays with dilutions for detection of nonparallel

resultsg) Bethesda titer for factor VIII or IX inhibitorsh) Describe interferences and sources of error (Level 2)

H. Disorders of fibrinolysis1. Define disseminated intravascular coagulation (DIC) (Level

1)2. Identify mechanisms by which clotting is initiated during DIC

(Level 1)3. Describe the effect of DIC on laboratory procedures (Level 1)

a) Prothrombin time (PT)b) Activated partial thromboplastin time (APTT)c) Thrombin clotting time (TT)d) Platelet count e) D-dimerf) Fibrinogeng) Peripheral blood film

I. Describe conditions that are predisposing to recurrent thrombosis (Level 1)

1. Antithrombin deficiency2. Protein C deficiency3. Protein S deficiency4. Activated Protein C resistance and factor V mutation5. Prothrombin gene mutation (G20210A)6. Hyperhomocysteinemia7. Primary antiphospholipid antibody and lupus anticoagulant

J. Describe laboratory tests for used to assess thrombophilia and recurrent thrombosis (Level 2)

1. State principle (Level 1)2. Perform (Level 2) or describe (Level 1) procedure3. Apply appropriate quality control procedures (Level 2)4. Indicate sources of error due to timing of testing and

interference from anticoagulants (Level 1)5. Interpret results (Level 3)

K. Describe the action of anticoagulant therapy (Level1)1. Vitamin K antagonist (warfarin)

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2. Heparina) Low molecular weightb) High molecular weight

3. Antiplatelet agentsL. Identify laboratory tests used to monitor anticoagulant therapy,

indicate therapeutic intervals and sources of error (Level 1)1. Vitamin K antagonist (warfarin)2. Heparin

a) Low molecular weightb) Unfractionated heparinc) Pentasaccharide

3. Antiplatelet agentsVII. Instrumentation

A. Automated hematology cell counting systems1. Identify basic concepts of electrical impedance, optical

detection, radio frequency, light scatter, cytochemical stains, selective lysing agents, and fluorescence activated flow cytometry systems

a) Identify the principle (Level 1)b) List components (Level 1)c) Describe (Level 1) the operation and/or perform (Level

2) an analysisd) Describe (Level 1) and/or perform the maintenance and

basic troubleshooting (Level 2)e) Identify basic concepts of quality assurance for

automated hematology cell counting systems(1) Describe acceptable practice (Level 1)(2) Perform basic quality assurance (Level 2)(3) Assess data to ensure quality (Level 3)

f) Describe the limitations and list interfering substances (Level 1)

2. Identify and describe hemogram parameters (Level 1)3. Evaluate patient data

a) Describe the flagging system (Level 1)b) Correlate scatter plots, histograms and data plots with

the peripheral smear (Level 3)c) Evaluate findings generated by automated imaging

systems (Level 3)4. Describe the mathematical calculations used to monitor

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instruments (Level 1)5. Recognize unexpected results and take corrective action

(Level 2)B. Automated reticulocyte counting

1. Identify the principle (Level 1)2. List components (Level 1)3. Describe (Level 1) the operation and/or perform (Level 2) an

analysis 4. Describe (Level 1) and/or perform the maintenance and basic

troubleshooting (Level 2)5. Describe the limitations and list interfering substances (Level

1)6. Evaluate and correlate patient data with other test results

(Level 3)7. Recognize unexpected results (Level 1) and take corrective

action (Level 2)C. Automated coagulation instruments

1. Identify basic concepts of electromechanical, spectrophotometric, and chromogenic substrate assays

a) Discuss the principle (Level 1)b) List components (Level 1)c) Describe (Level 1) the operation and/or perform (Level

2) an analysisd) Describe (Level 1) and/or perform the maintenance and

basic troubleshooting (Level 2)e) Identify basic concepts of quality assurance

(1) Describe acceptable practice (Level 1)(2) Perform basic quality assurance (Level 2)(3) Assess data to ensure quality (Level 3)

2. Describe the limitations and list interfering substances (Level 1)

3. Evaluate and correlate patient data with other test results (Level 3)

4. Recognize unexpected results (Level 1) and take corrective action (Level 2)

D. Identify basic concepts of platelet aggregation and the platelet function analyzer (PFA) (Level 1)

1. Discuss the principle (Level 1)2. List components (Level 1)

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3. Describe (Level 1) the operation and/or perform (Level 2) 4. Describe the limitations and list interfering substances (Level

1)5. Recognize unexpected results (Level 1) and take corrective

action (Level 2)6. Evaluate patient data (Level 3)

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