Biological variations of leukocyte numerical and morphologic parameters determined by UniCel DxH 800 hematology analyzer.inherency in·here
intr.v. in·hered, in·her·ing, in·heres
To be inherent or innate.
[Latin inhaer involved in the aging process. For example, the numbers of leukocytes change with age and during pregnancy. On the day of birth, a newborn has a high white blood cell (WBC WBC white blood cell; see leukocyte.
white blood cell
n stands for white
cell. ) count. This number falls to adult levels within 2 weeks. The percentage of neutrophils is high for the first few weeks after birth, but then lymphocyte lymphocyte: see blood; immunity.
Type of leukocyte fundamental to the immune system, regulating and participating in acquired immunity. Each has receptor molecules on its surface that bind to a specific antigen. predominance is seen. Until about 8 years of age, lymphocytes are more predominant than neutrophils. In the elderly, the total WBC count decreases slightly. Pregnancy results in leukocytosis Leukocytosis Definition
Leukocytosis is a condition characterized by an elevated number of white cells in the blood.
Leukocytosis is a condition that affects all types of white blood cells. , primarily due to an increase in neutrophils with a slight increase in lymphocytes. (1)
Two numerical measurements of WBCs commonly done in the hematology laboratory are the total number of WBCs in blood and the percentages of each of the 5 types of WBC, known as differentials. In addition to traditional numerical parameters measured, a Coulter hematology analyzer with VCS (1) (Verilog Computer Simulator) See Verilog.
(2) (Version Control System) See version control. technology, such as the UniCel DxH 800 (Beckman Coulter This article needs sources or references that appear in reliable, third-party publications. Alone, primary sources and sources affiliated with the subject of this article are not sufficient for an accurate encyclopedia article. Inc, Brea, California), uses 3 independent energy sources simultaneously to evaluate the intrinsic biophysical properties of more than 8000 leukocytes in their near-native states. Namely, it uses direct current impedance to measure cell volume for accurate size of all cell types; radio frequency opacity to characterize conductivity for internal composition of each cell; and a laser beam to measure light scatter for cytoplasmic cytoplasmic
pertaining to or included in cytoplasm.
include secretory inclusions (enzymes, acids, proteins, mucosubstances), nutritive inclusions (glycogen, lipids), pigment granules (melanin, lipofuscin, granularity and nuclear structure. It also measures the degree of cell size variation. These measurements of cellular morphologic properties are known as cell population data (CPD CPD citrate phosphate dextrose; see anticoagulant citrate phosphate dextrose solution, under solution.
Cephalopelvic disproportion (CPD) ).
The DxH 800 is the newest fully automatic hematology analyzer. In addition to volume and conductivity measurements, a new flow cell design supports multiple angles of light scatter measurements, enabling enhanced data acquisition for the WBC differentials. These multiple angles of light scatter measurements include median angle light scatter, lower median angle light scatter, and upper median angle light scatter, which detect granularity and membrane topography; axial light loss measurement, which analyzes cellular transparency; and low-angle light scatter, which is a cellular complexity index. This enhanced data collection allows the DxH 800 to collect 10 times more information on each sample when compared to other Coulter hematology analyzers, such as the LH 780, and give accurate determination of a WBC count even in the presence of interference. (2)
It has previously been demonstrated that neutrophil neutrophil /neu·tro·phil/ (noo´tro-fil)
1. a granular leukocyte having a nucleus with three to five lobes connected by threads of chromatin, and cytoplasm containing very fine granules; cf. heterophil.
2. morphologic parameters change significantly in septic patients. For example, the neutrophil CPD, such as mean neutrophil volume and neutrophil volume distribution width, are significantly increased not only in septic patients with high WBC, but also in those with normal or low WBC. (3-7) The mean neutrophil volume and/or neutrophil volume distribution width, which reflect respectively neutrophil size and size variations, show superior sensitivity and specificity for predicting sepsis compared to WBC, the percentage of neutrophils, band counts, C-reactive protein, or procalcitonin, proving to be promising indicators for the diagnosis of acute bacterial infection. (8,9) In addition, the mean neutrophil volume and neutrophil volume distribution width are significantly increased in postsurgical patients with bacterial infection compared with non infected patients, although WBC was increased in both groups. (9,10) Alterations of the lymphocyte CPD in viral infection viral infection,
n an infection by a pathogenic virus. A virus acts on the cell nucleus, taking over the genetic material within the nucleus and replicating itself. (11,12) and in chronic lymphocytic leukemia chronic lymphocytic leukemia
n. Abbr. CLL
Lymphocytic leukemia occurring mainly in older adults, characterized by slow onset and gradual progression of symptoms. and other chronic lymphoproliferative disorders (12) as well as the monocyte monocyte /mono·cyte/ (mon´o-sit) a mononuclear, phagocytic leukocyte, 13µ to 25µ in diameter, with an ovoid or kidney-shaped nucleus, and azurophilic cytoplasmic granules. CPD in malaria infection (13) have also been reported.
Although several previous studies have investigated biological variations of numerical parameters of leukocytes (14-17) and demonstrated hour-to-hour and day-to-day intraindividual fluctuation of WBC, (17) this study is the first to investigate the biological variations of morphologic parameters of leukocytes because of their increasing clinical significance. As we know, the variation can be described as random fluctuation around a homeostatic homeostatic
pertaining to homeostasis. setting point. The test results of any individual may vary over time, because of 3 factors: preanalytical variation, such as preparation of the individual for sampling and sample collection itself; analytical variation (precision), such as random error and possibly systematic error (changes in bias due to calibration); and inherent biological variation. (18) Using the newest analyzer, the DxH 800, with likely improved analytical precision, we attempted to reinvestigate biological variations of leukocyte leukocyte (l`kəsīt'): see blood.
or white blood cell or white corpuscle numerical parameters. The biological variations of morphologic parameters or CPD were also studied.
MATERIALS AND METHODS
The participants were 40 healthy volunteers of Chinese ethnicity (21 women and 19 men) with ages ranging from 20 to 40 years. None of the women were menstruating. All participants maintained their normal lifestyles, including no excess of alcohol, tea, or tobacco consumption, and did not engage in strenuous exercise during the study period.
The blood samples were drawn in duplicate at 8 am, noon, and 4 pm each day for 3 consecutive days. The participants were in sitting position for at least 15 minutes before drawing. All samples were collected in EDTA-anticoagulated tubes (BD Inc, Franklin Lakes, New Jersey Franklin Lakes is a borough in Bergen County, New Jersey, United States. The Franklin Lakes zip code is 07417. As of the United States 2000 Census, the borough population was 10,422. ) by a single experienced phlebotomist phle·bot·o·mist
1. One who practices phlebotomy.
2. One who draws blood for analysis or transfusion. and analyzed within 2 hours after specimen collection.
All samples were analyzed using a single DxH 800 hematology analyzer. Before each batch sample analysis, the instrument quality controls were performed using the same lots of Coulter SCAL SCAL Southern California
SCAL Steuben County American Legion Calibrator calibrator
an instrument for dilating a tubular structure or for determining the caliber of such a structure. (lot 112753780), and Coulter 6C Cell Control with 3 levels at different concentrations (for level 1, lot 122755170; for level 2, lot 132757540; and for level 3, lot 142755190) to allow consistent determination during the course of the study.
The study protocol was approved by the hospital ethics committee ethics committee A multidisciplinary hospital body composed of a broad spectrum of personnel–eg, physicians, nurses, social workers, priests, and others, which addresses the moral and ethical issues within the hospital. See DNR, Institutional review board. .
Automated Hematologic hematological, hematologic
pertaining to or emanating from blood cells.
total and differential white cell counts, hematocrit estimation, erythrocyte count. Data Collection
Data collected from the DxH 800 included total WBC, leukocyte differentials, and CPD, which were generated by each individual cell passing through the aperture and optically and electronically being measured by the analyzer. The CPD included volume, conductivity, and 5 different light scatters (median angle light scatter, lower median angle light scatter, upper median angle light scatter, axial light loss measurement, and low-angle light scatter) for neutrophils, lymphocytes, and monocytes.
Nested analysis of variance and coefficients of variation were performed using SPSS A statistical package from SPSS, Inc., Chicago (www.spss.com) that runs on PCs, most mainframes and minis and is used extensively in marketing research. It provides over 50 statistical processes, including regression analysis, correlation and analysis of variance. software, version 10.0 (SPSS, Chicago, Illinois) and Microsoft (Redmond, Washington Redmond is a city in King County, Washington, USA. It is situated on the eastern edge of the Seattle urban area, in what is known as the Eastside. In 2003 the Census Bureau estimated the city population was 46,391. ) Excel 2003. Analytical coefficient of variation Coefficient of Variation
A measure of investment risk that defines risk as the standard deviation per unit of expected return. was calculated from 10 independent tests using Coulter 6C Cell Control (Beckman Coulter). Comparison between 2 means was performed by Student t test. A P value less than .05 was considered significant.
Within-Subject and Between-Subjects Biological Variations
We initially studied within-subject (CVI CVI C (Language) Virtual Instrument
CVI Clinical and Vaccine Immunology (journal)
CVI Chronic Venous Insufficiency
CVI Coastal Vulnerability Index
CVI Canaan Valley Institute ) and between-subjects (CVG CVG Convergys Corp
CVG Corporación Venezolana de Guayana
CVG Clear Vertical Grain (woodworking)
CVG Carrier Group
CVG Corporacion Venezolana de Guyana
CVG Comprehensive Video Group (South Hackensack, NJ, USA) ) biological variations on both leukocyte numerical parameters and morphologic parameters. As shown in Table 1, although we achieved similar CVI (10.97% versus 10.9%) and CVG (19.3% versus 19.6%) values for total leukocyte counts compared with published data, (14,18) the CVI values for absolute neutrophil, monocyte, and lymphocyte differential counts were much smaller than previously reported (14,18). 6.7% versus 16.1%, 10.7% versus 17.8%, and 9.8% versus 12.3%, respectively. The CVG values for absolute neutrophil, monocyte, and lymphocyte counts were also smaller than previously reported (14,18): 13.8% versus 32.8%, 25.7% versus 49.8%, and 18.8% versus 21.3%, respectively. The smaller CVI and CVG values in this study are likely due to much improved analytical precision (analytical coefficient of variation) of the DxH 800 for leukocyte differential counts (0.93% versus 8.1% for neutrophil, (18) 0.9% versus 6.9% for lymphocyte, (1,4) and 2.9% versus 8.9% for monocyte (18)). Compared to numerical parameters, the morphologic parameters or CPD showed much smaller overall CVI and CVG (Table 2). The coefficients of variation for most parameters were less than 5%, suggesting that these parameters are less variable around the homeostatic set point intraindividually and interindividually. The index of individuality, calculated as the simple ratio of the [CV.sub.I]/[CV.sub.G], (18) for all morphologic parameters was low, ranging from 0.3 to 0.92 with a mean of 0.71 (Table 2). A low index of individuality indicates that conventional reference values ref·er·ence values
A set of laboratory test values obtained from an individual or from a group in a defined state of health. for these parameters may be of little utility, particularly when deciding whether changes in an individual have occurred. (18)
Intraday and Interday Biological Variations
The intraday and interday biological variations on both leukocyte numerical parameters and morphologic parameters were next investigated. As shown in Table 3, the biological coefficients of variation of total leukocytes and their differential counts are constant except for the 4 PM time point on day 3. We do not have explanations for this. The results are slightly different from the previous observation, which showed hour-to-hour variations and subject-specific diurnal diurnal /di·ur·nal/ (di-er´nal) pertaining to or occurring during the daytime, or period of light.
1. Having a 24-hour period or cycle; daily.
2. variation. (17) One explanation for this is that the current study uses a more advanced analyzer with likely improved precision, which may minimize the interference of likely analytical variation. On the other hand, all coefficients of variation for morphologic parameters or CPD are less than 10%, with most less than 5%, suggesting that these parameters are more constant in biological homeostatic conditions (Table 4).
Although several previous studies have investigated the biological variations of leukocyte numerical parameters, (14-17) such as total leukocytes and their differential counts, this carefully designed study is the first attempt to our knowledge to document the biological variations of leukocyte morphologic parameters, also known as CPD. The CPD are generated by Coulter hematology analyzers with VCS technology. Using the newest analyzer, the Coulter UniCel DxH 800, we have demonstrated that CVI and CVG for leukocyte numerical parameters are much smaller than previously reported, (14,18) likely because of improved analytical precision of the analyzer (analytical coefficient of variation = 0.93% versus 8.1% for neutrophils, (18) 0.9% versus 6.9% for lymphocytes, (14) and 2.99% versus 8.9% for monocytes (18)). We also evaluated the biological variations of leukocyte morphologic parameters or CPD, mainly because of an increasing number of publications (3-13) in recent years demonstrating the potential clinical utility of CPD in diagnosing many pathologic conditions, particularly in acute bacterial infection or sepsis. (3-10) We showed that the CPD have much smaller overall CVI and CVG compared to numerical parameters, suggesting that these morphologic parameters are less variable around the homeostatic set point intraindividually and interindividually. In addition, the index of individuality for all morphologic parameters was low. A low index of individuality suggests that these parameters may have marked individuality and the conventional reference values for these parameters may be of little utility. (18) We also show that intraday and inter day biological variations of leukocyte numerical parameters and CPD are fairly constant in the age group examined, although the study only spans the 3-day period and the population studied is limited to Chinese ethnicity. However, there was no previous report regarding biological variations on leukocyte numerical parameters using an Asian population. Further studies with a similar ethnic population or other ethnic groups may be warranted for validating the current findings.
These observations are clinically important. Data on CVI and analytical precision may be used to determine the change that occur in an individual's serial results before the change is significant, and to generate objective delta-check values for use in quality management. (18) Comparing [CV.sub.I] and [CV.sub.G] on CPD may allow us to decide the utility of traditional population-based reference ranges. (18) Data on biological variation may also be used for determining the number of samples needed to get an estimate of the homeostatic setting point within a certain percentage with a stated probability, and deciding the best way to report test results, the best sample to collect, and the test procedure of greatest potential use. (18) Lastly, documentation of CPD data on biological variations is an essential prerequisite in the development of any new application of CPD clinically. (18)
In summary, [CV.sub.I], [CV.sub.G], and intraday and interday biological variations measured by the DxH 800 for leukocyte numerical parameters in healthy adults are smaller than those previously reported. Biological variations for CPD show even less fluctuation at homeostatic set point, making them potentially more reliable parameters for clinical use. The index of individuality for CPD was low, indicating that reference values for these parameters may have little utility.
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(4.) Chaves F, Tierno B, Xu D. Neutrophil volume distribution width: a new automated hematologic parameter for acute infection. Arch Pathol Lab Med. 2006; 130(3):378-380.
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(6.) Mardi D, Fwity B, Lobmann R, Ambrosch A. Mean cell volume of neutrophils and monocytes compared with C-reactive protein, interleukin-6 and white blood cell count white blood cell count,
n a diagnostic clinical laboratory test to determine the number and types of leukocytes present in a measured sample of blood. Overall the normal number of leukocytes ranges from 5000 to 10,000/mm3. for prediction of sepsis and nonsystemic bacterial infections. Int J Lab Hematol. 2010; 32(4):410-418.
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(8.) Bagdasaryan R, Zhou ZR, Tierno B, Rosenman D, Xu D. Neutrophil VCS parameters are superior indicators for acute infection. Lab Hematol. 2007; 13(1):12-16.
(9.) Charafeddine KM, Youssef AM, Mahfouz RA, Sarieddine DS, Daher RT. Comparison of neutrophil volume distribution width to C-reactive protein and procalcitonin as a proposed new marker of acute infection. Scand J Infect Dis. 2011; 43(10):777-784
(10.) Zhu Y, Cao X, Chen Y, Wang Y, Yuan K, Xu D. Neutrophil cell population data: useful indicators for post-surgical bacterial infection [published online ahead of print December 29, 2011]. Int J Lab Hematol. doi: 10.1111/j.1751553X.2011.01394.x.
(11.) Zhu Y, Cao X, Xu D. Detection of morphologic changes of peripheral mononuclear mononuclear /mono·nu·cle·ar/ (-noo´kle-er)
1. having but one nucleus.
2. a cell having a single nucleus, especially a monocyte of the blood or tissues.
adj. cells in Hepatitis B Hepatitis B Definition
Hepatitis B is a potentially serious form of liver inflammation due to infection by the hepatitis B virus (HBV). It occurs in both rapidly developing (acute) and long-lasting (chronic) forms, and is one of the most common chronic virus infection using Coulter LH750. Lab Hematol. 2011; 17(3):22-26.
(12.) Silva M, Fourcade C, Fartoukh C, et al. Lymphocyte volume and conductivity indices of the haematology analyser Coulter GEN.S in lymphoproliferative disorders and viral diseases. Clin Lab Haematol. 2006; 28(1):1-8.
(13.) Briggs C, DaCosta A, Freeman L, Aucamp I, Ngubeni B, Machin SJ. Development of an automated malaria discriminant dis·crim·i·nant
An expression used to distinguish or separate other expressions in a quantity or equation. factor using VCS technology. Am J Clin Pathol. 2006; 126(5):691-698.
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(15.) Dot D, Miro J, Fuentes-Arderiu X. Within-subject biological variation of hematological hematological, hematologic
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(16.) Statland BE, Winkel P, Harris SC, Burdsall MJ, Saunders AM. Evaluation of biologic sources of variation of leukocyte counts and other hematologic quantities using very precise automated analyzers. Am J Clin Pathol. 1978; 69(1):48-54.
(17.) Winkel P, Statland BE, Saunders AM, Osborn H, Kupperman H. Withinday physiologic variation of leukocyte types in healthy subjects as assayed by two automated leukocyte differential analyzers. Am J Clin Pathol. 1981; 75(5):693700.
(18.) Fraser CG. Biological Variation: From Principles to Practice. Washington, DC: AACC Press; 2001.
Huqiang Tang, MS, MPH; Jiyong Jing, MS; Dandan Bo, BS; Dongsheng Xu, MD, PhD
Accepted for publication January 31, 2012.
From the Clinical Laboratory Center, the Second Affiliated Hospital, Zhejiang University School of Medicine, Zhejiang, China (Tang and Jing); the School of Medical Sciences and Laboratory, Jiangsu University, Jiangsu, China (Ms Bo); and the Hematopathology Program, CBLPath, Inc, Rye Brook, New York Rye Brook is a village in Westchester County, New York, United States. The population was 8,602 according to the 2000 census.
The Village of Rye Brook was established in 1982 and is in the Town of Rye. (Dr Xu).
The authors have no relevant financial interest in the products or companies described in this article.
Reprints: Dongsheng Xu, MD, PhD, CBLPath, Inc, 760 Westchester Ave, Rye Brook, NY 10573 (e-mail: email@example.com).
Table 1. Biological Coefficients of Variation of Numerical Parameters Analytes CVa, % CVi, % CVg, % II Leukocyte count 0.77 10.97 19.3 0.57 Neutrophil count 0.93 6.77 13.8 0.49 Lymphocyte count 0.9 9.85 18.85 0.52 Monocyte count 2.99 10.73 25.69 0.42 Abbreviations: CVa, analytical coefficient of variation; CVg, between/subjects biological variation; CVi, within/subject biological variation; II, index of individuality (CVi/CVg). Table 2. Biological Coefficients of Variation of Morphologic Parameters Analytes CVa, % CVi, % CVg, % II Neutrophils Volume Mean 0.44 1.71 2.93 0.58 SD 1.58 4.42 6.44 0.69 Conductivity 0.56 0.9 1.18 0.76 MALS 0.52 1.5 2.62 0.57 UMALS 0.73 0.78 2.63 0.3 LMALS 0.43 2.19 3.25 0.67 LALS 0.43 2.73 4.3 0.63 AL2S 0.61 0.73 1.73 0.42 Lymphocytes Volume Mean 1.26 1.47 2.84 0.52 SD 5.35 4.45 8.68 0.51 Conductivity 0.86 0.95 1.08 0.88 MALS 1.34 2.34 3.55 0.66 UMALS 1.74 3.95 5.66 0.7 LMALS 1.59 3.2 4.31 0.72 LALS 1.12 3.53 4.17 0.85 AL2S 2.87 3.52 3.92 0.89 Monocytes Volume Mean 1.38 1.41 2.28 0.62 SD 4.19 5.31 8.78 0.61 Conductivity 1.01 1.09 1.18 0.92 MALS 1.6 2.16 3.06 0.71 UMALS 1.43 1.49 2.65 0.56 LMALS 3.43 3.71 4.68 0.79 LALS 6.36 6.54 8.33 0.78 AL2S 2.76 3.16 3.61 0.88 Abbreviations: AL2S, axial light loss; CVa, analytical coefficient of variation; CVg, between-subject biological variation; CVi, within-subject biological variation; II, index of individuality (CVi/CVg); LALS, low angle light scatter; LMALS, lower median angle light scatter; MALS, median angle light scatter; UMALS, upper median angle light scatter. Table 3. Intraday and Interday Biological Coefficients of Variation of Numerical Parameters Analytes Day 1 Day 2 8 AM Noon 4 PM 8 AM Noon 4 PM Leukocyte count 19.1 17.92 20.18 16.55 16.74 19.17 Neutrophil count 13.52 14.16 13.63 12.97 13.94 14.71 Lymphocyte 18.07 18.83 18.23 17.65 17.88 19.39 count Monocyte count 28.85 31.45 31.7 23.39 25.46 22.82 Analytes Day 3 8 AM Noon 4 PM Leukocyte count 21.56 17.52 14 Neutrophil count 14.48 14.49 11.91 Lymphocyte 19.74 20.85 18 count Monocyte count 23.54 21.84 17.98 Table 4. Intraday and Interday Biological Coefficients of Variation of Morphologic Parameters Analytes Day 1 Day 2 8 AM Noon 4 PM 8 AM Noon 4 PM Neutrophils Volume Mean 3.09 2.76 3.10 2.39 2.82 2.69 SD 7.23 6.29 6.85 4.93 5.59 5.94 Conductivity 1.01 0.90 0.93 0.99 1.05 0.83 MALS 2.70 2.40 2.59 2.32 2.18 2.64 UMALS 2.71 2.59 2.75 2.64 2.49 2.51 LMALS 3.16 2.85 3.10 2.45 2.47 3.27 LALS 3.67 3.29 3.80 3.50 3.46 4.17 AL2S 1.75 1.83 1.91 1.40 1.81 1.61 Lymphocytes Volume Mean 2.93 2.89 2.86 2.84 2.80 2.57 SD 7.48 9.61 7.70 6.61 7.20 9.59 Conductivity 0.77 0.85 1.01 0.90 0.85 0.84 MALS 2.70 3.13 4.56 2.70 2.88 3.01 UMALS 4.23 4.87 6.17 4.50 4.76 5.90 LMALS 3.00 3.42 5.03 2.71 3.08 3.20 LALS 2.85 2.97 3.61 2.40 2.60 3.11 AL2S 2.34 2.59 3.11 2.25 2.46 2.17 Monocytes Volume Mean 2.15 2.00 2.61 1.87 1.98 2.11 SD 9.70 8.18 8.93 9.66 9.35 9.20 Conductivity 0.74 0.73 0.94 0.79 0.74 0.73 MALS 2.40 2.73 3.30 2.23 2.34 2.50 UMALS 2.53 2.35 2.90 2.43 2.24 2.90 LMALS 3.51 3.94 5.03 2.85 3.09 3.49 LALS 5.98 6.10 9.97 4.45 4.74 6.72 AL2S 2.00 2.18 3.76 1.80 1.72 2.66 Analytes Day 3 8 AM Noon 4 PM Neutrophils Volume Mean 3.00 2.85 3.01 SD 6.59 6.17 6.85 Conductivity 1.11 1.08 1.03 MALS 2.68 2.47 2.76 UMALS 2.54 2.56 2.69 LMALS 3.57 3.48 3.63 LALS 4.52 5.06 4.64 AL2S 1.52 1.78 1.75 Lymphocytes Volume Mean 2.59 2.71 2.49 SD 8.81 8.94 9.75 Conductivity 0.65 0.70 0.86 MALS 2.59 2.86 2.92 UMALS 4.32 4.66 5.80 LMALS 2.90 3.24 3.38 LALS 2.92 2.91 3.64 AL2S 2.46 2.20 2.16 Monocytes Volume Mean 1.95 2.13 2.17 SD 8.89 6.93 7.42 Conductivity 1.11 0.73 0.90 MALS 3.09 2.31 2.78 UMALS 2.52 2.42 2.51 LMALS 5.15 3.17 4.42 LALS 9.38 5.02 8.74 AL2S 3.58 1.83 2.91 Abbreviations: AL2S, axial light loss; LALS, low angle light scatter; LMALS, lower median angle light scatter; MALS, median angle light scatter; UMALS, upper median angle light scatter.
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|Author:||Tang, Huqiang; Jing, Jiyong; Bo, Dandan; Xu, Dongsheng|
|Publication:||Archives of Pathology & Laboratory Medicine|
|Date:||Nov 1, 2012|
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