In living color: new body fluids atlas

October 2006
Feature Story

Anne Ford

Before the CAP’s new Color Atlas of Body Fluids became available last month, one of its co-editors—Katherine A. Galagan, MD, chief of pathology and director of the clinical laboratory at Virginia Mason Medical Center, Seattle—shared a few preliminary pages with some of her colleagues. They were “kind of blown away,” she says. A microbiologist who caught sight of one of the atlas’ many illustrations exclaimed: “What is this? That’s the best drawing I’ve ever seen!”

Her words gratified Dr. Galagan, who, along with co-editors David Blomberg, MD, of Arrowhead Pathologists, Duluth, Minn.; P. Joanne Cornbleet, MD, PhD, associate professor emerita of pathology, Stanford University Medical Center; and Eric F. Glassy, MD, partner with Affiliated Pathologists Medical Group, Torrance, Calif., spent three years and an untold number of hours writing, compiling, editing, and (in Dr. Glassy’s case) designing and illustrating the 368-page book. “You just had to put your head down and push the plow,” Dr. Blomberg says.

The atlas is the third in a series of reference works created by the CAP Hematology and Clinical Microscopy Resource Committee, whose first atlas, the Color Atlas of Hematology, appeared in 1998. The committee had originally intended merely to expand an existing text-only hematology glossary, but, as Dr. Glassy told CAP TODAY at the time, “Somebody said, ‘Well, why not publish pictures?’ And we started to say, ‘Why don’t we add illustrations, and then maybe additional commentary, and turn it into a first-class book?’” Out of that discussion grew first the hematology atlas and then a second work, the Color Atlas of Hemoglobin Disorders, in 2003. Because those books were so well received, and because of the relative scarcity of body fluids textbooks on the market, Dr. Cornbleet proposed the latest book and came up with an outline and table of contents before the subcommittee began its work.

Dr. Glassy says the body fluids atlas most closely resembles the hematology atlas. “It differs in that there are many more illustrations” in the body fluids book, he says. “And there is more didactic text in this atlas. Otherwise, the idea and concept and layout are the same.”

Of the atlas’ scope, Dr. Blomberg says wryly: “Everybody calls it the hematology committee, because that’s how everybody thinks of it. However, we also do have this stuff called clinical microscopy—and that includes the evaluation of body fluids.”

The subcommittee responsible for the body fluids atlas consisted of the four co-editors as well as Amy Gewirtz, MD, associate clinical professor of pathology at Ohio State University, Columbus; David Hudnall, MD, professor and director of hematopathology at the University of Texas Medical Branch, Galveston; Robert Novak, MD, chair of the Department of Pathology and Laboratory Medicine at Akron Children’s Hospital, Ohio; Powers Peterson, MD, associate professor of pathology and laboratory medicine, Weill Cornell Medical College, Doha, Qatar and New York; and Patrick C.J. Ward, MD, professor and head of the Department of Anatomy, Microbiology, and Pathology at the University of Minnesota School of Medicine, Duluth. The subcommittee received assistance from seven other contributors as well.

What have many laboratories relied on as a body fluid reference until now? “Nothing recent,” Dr. Blomberg says. “There are a couple of very excellent books by Joseph Knight and Carl Kjeldsberg out of the University of Utah at Salt Lake City,” such as Body Fluids: Laboratory Examination of Amniotic, Cerebrospinal, Seminal, Serous & Synovial Fluids. “They’re about 10 years old. They’re also not quite as comprehensive as the [CAP] body fluid atlas. We’ve tried to include some things that weren’t so much in the picture at the time these [older] books were published, such as some stuff on infectious disease agents that can be identified as body fluids…[and] a table about lymphoid markers that are commonly used for lymphoma—not only what the name of the marker is, but actually what it represents functionally, what part of the cell structure it represents.” As evidence of the atlas’ up-to-date nature, he says: “There are references from 2006 in there.”

Dr. Blomberg refers to the atlas as “one-stop shopping.”

“For body fluids, I think it’s pretty comprehensive,” he says. “It not only talks about the cellular findings in abnormal states, but there’s a lot of information in there on anatomy and physiology of the body cavities that produce the body fluids. There’s a very extensive bibliography that not only uses the standard literature but also gives references to Web sites.”

What chiefly distinguishes the atlas, however, is its reliance on more than two decades’ worth of refereed material from the College’s proficiency testing program. Each slide that appears in the atlas has been reviewed first by a group of referees and then by the thousands of laboratories that participate in CAP Surveys. “That’s an unusual approach” for a book of this nature, Dr. Galagan says. “The beauty of it is, something like 3,000 labs have seen these slides. There’s a lot of power in that. That was the original idea with the hematology atlas—trying to get the power of that much peer review.”

The editors based the atlas’ organizational structure on the master list identifications from which the proficiency tests themselves stem and which are listed in one of the atlas’ appendices. Each identification includes a summary and overview of the cell or object and several photomicrographs, all of which have been used as actual proficiency tests. With each photomicrograph appears information such as its source, stain, and magnification, as well as common referee and participant responses and a description of the slide that often includes historical patient information and any relevant identifying features of the cell or object. Dr. Galagan says that while the information the atlas contains may be available elsewhere, “it’s not available in this kind of format, in the sense of a cell-by-cell breakdown of how to diagnose a particular cell. That kind of layout is unique to body fluid atlases.”

The atlas’ “How to Use This Book” feature contains a diagram that guides readers through a sample proficiency testing data interpretation, while the book’s index uses keywords to help readers find specific topics. The atlas contains 13 major sections: an introduction that includes technical considerations, followed by sections on cerebrospinal fluid; pericardial, pleural, and peritoneal fluid; synovial fluid; erythroid series; lymphoid series; myeloid series; mononuclear-phagocytic series; lining cells; miscellaneous cells; crystals; microorganisms; and miscellaneous findings. Six appendices provide directions for reviewing proficiency testing challenges, selected references, the body fluid master list, nonrefereed examples of master list identifications, and testing challenges listed by master list identification and year.

The atlas also contains 24 features (titled “A Closer Look”) on topics such as bronchoalveolar lavage, crystal-induced synovitis, Ehrlichia and tick-borne diseases, lymphoma markers, plasma cell disorders, and reactive lymphocytes. These in-depth discussions, Dr. Glassy says, “go into more specialized knowledge that the pathologist and technologist will find useful in terms of making a diagnosis or tying the findings into clinical situations.” Dr. Galagan adds, “It allows us to put information that’s hard to find or hard to explain into a one- to two- or three-page summary, and some of it is information you can spend a lot of time trying to dig up [elsewhere].” The subcommittee decided to use the “A Closer Look” format because it had proved effective in the hematology atlas, she says. Twenty-four additional pictorial discussions address body fluid cell counts, lumbar puncture technique, paracentesis, synovial fluid crystals, and other subjects.

Dr. Glassy says he and his co-editors take particular pride in several portions of the atlas. “Dr. Blomberg was responsible for the sections on crystal analysis and polarization, and he did a terrific job of explaining that,” he says. In addition, “there’s an excellent discussion of mesothelial cells—how to separate malignant from reactive cells. I’ve never seen that kind of description or discussion at such length, and with such excellent photographic examples.” Dr. Blomberg chimes in: “It was written by Joanne Cornbleet, who’s a real expert on this, and there’s not much written on it [elsewhere]. You can find it, but it’s hard to find.”

Another point of pride: the section on Wright-Giemsa staining. “That’s actually a modification of a publication by a woman I know, Kristine P. Woronzoff-Dashkoff, MD,” Dr. Blomberg says. “To do that, she had to go back into the old European literature—she’s fluent in Russian—to find some of this stuff. She pulled it together in one very, very good paper that was published in a journal that wasn’t widely read, and here it’s repackaged.”

Dr. Galagan, meanwhile, is a fan of the section on malignant cells, which Dr. Cornbleet conceived and Dr. Glassy expanded. “He compares characteristics of the nine malignant cells in a step-by-step way—nuclear, chromatin, nuclear cytoplasmic ratio, all sorts of things—and then he shows examples,” she says.

Like the hematology and hemoglobin disorders atlases before it, the Color Atlas of Body Fluids features scores of illustrations by Dr. Glassy, a mostly self-taught graphic designer who used computer programs such as Adobe Photoshop and Adobe Freehand to create the illustrations and Adobe InDesign to create the book’s layout. “I’ve always enjoyed graphic design,” he says, adding that he has been grateful for the chance to channel his creative energies into “what I think have been some excellent reference texts.”

The body fluids atlas contains more illustrations than either of its predecessors. Why? “I guess I just got better,” Dr. Glassy says, laughing. “I did the heme atlas in ’98, and that was a four- or five-year process. This time I just got faster at doing them, and the software’s gotten better along the way as well.” In addition, “the study of body fluids lends itself to more interesting illustrations. There’s more clinical information that’s associated with the cells, and that lent itself to a richer set of diagrams.”

“Dr. Glassy is not only a great pathologist and a great human being, but also an incredibly talented graphic artist,” Dr. Galagan says. “So many hematologists and pathologists are visual people,” making extensive, detailed illustrations all the more crucial to a resource such as this.

With four co-editors, five other subcommittee members, and seven additional contributors, managing a project this large sounds much like herding cats. But the process went fairly smoothly, Dr. Blomberg says. “It just took a lot of time. If we had put this together before all of this instant communication by e-mail, it would have been a terrible project, because Glassy is in L.A., Cornbleet’s at Stanford, Galagan is in Seattle, and I’m in Duluth—and I’m retired.” Retired or no, at one point Dr. Blomberg traveled to CAP headquarters in Northfield, Ill., to spend several days with Dr. Glassy “just trying to ferret out the last few slides we needed. That required a lot of digging by us and by the staff of the CAP,” he says.

An atlas on cytology is next in the series, Dr. Glassy says. “After that, if all goes well, we’ll start work on a color atlas of urinalysis. That one is really needed,” he adds. Dr. Blomberg will head up that effort. “We’ve got some terrific ideas that will make it one amazing book,” Dr. Glassy says.

Related Links

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