Diagnostic potential of Q-flags (RBC agglutination? and fragments?) in beta thalassemia carriers: a comparative analysis with nutritional anemias

INTRODUCTION: Beta thalassemia carriers have hereditary anemia marked by ineffective erythropoiesis and hemolysis, leading to considerable variation in red blood cell (RBC) morphology. Automated hematology analyzers equipped with quality flags (Q-flags) can identify abnormal RBC populations. This study evaluates the diagnostic performance of two Q-flags (RBC Agglutination? and Fragments?) in differentiating beta thalassemia from common nutritional anemias. METHODS: This study was conducted on complete blood count (CBC) data from 37 patients with beta thalassemia carriers and 3317 patients with nutritional anemias, including 2780 with iron deficiency anemia, 478 with vitamin B12 deficiency, and 59 with folate deficiency. All data were obtained using Sysmex hematology analyzers. The Shapiro-Wilk test assessed the distribution of data, and group comparisons were performed using the Mann-Whitney U test. Receiver operating characteristic (ROC) curve analysis was employed to determine the cutoff values of Q-flag parameters. RESULTS: Patients with beta thalassemia demonstrated significantly lower values for Q-flag (RBC Agglutination?) and significantly higher values for Q-flag (Fragments?) compared to those with nutritional anemias. The median (interquartile range) for Q-flag (RBC Agglutination?) was 40.0 (40.0-50.0), and for Q-flag (Fragments?) it was 40.0 (20.0-60.0). Significant differences were also noted in routinely reported hematological indices such as MCV, MCH, MCHC, and MicroR%. ROC analysis revealed that cutoff value of 60.0 for Q-flag (RBC Agglutination?) and 20.0 for Q-flag (Fragments?) had reasonable sensitivity and specificity for distinguishing beta thalassemia from nutritional anemias. CONCLUSION: There is a possibility that both Q-flags demonstrate strong discriminatory ability for beta thalassemia carriers in comparison to nutritional anemias and serve as useful screening tools within routine hematology workflows.