Impact of Automated Blood Culture Systems on the Management of Bloodstream Infections: Results from a Crossover Diagnostic Clinical Trial

Bloodstream infections are associated with high rates of morbidity and mortality. Blood culture remains the gold standard for the diagnosis of BSIs. We report a prospective crossover diagnostic clinical trial comparing the performances of two blood culture incubation systems: Virtuo and Bactec FX. The primary outcome was the time to detection (TTD) (from the loading of the sample into the incubator to the positivity signal). Patients over 16 years old suspected of having bacteremia/fungemia were included. They were divided into two strata with a total of 9,957 blood extractions. Initially, each stratum was randomly assigned to one of the incubators and then alternated every 2 weeks for 6 months. Each sample was inoculated into an aerobic bottle and an anaerobic bottle. All bottles were processed equally according to the laboratory's standard procedures after they were flagged positive. We analyzed 4,797 samples in the Virtuo system and 5,160 in the Bactec FX system. The median TTD was significantly lower for the Virtuo group (Virtuo, 15.2 h; Bactec FX, 16.3 h [P < 0.0001]). The turnaround time (TAT) (from sample loading to the Gram stain report) was also reduced with Virtuo (Virtuo, 26.2 h; Bactec FX, 28.3 h [P < 0.004]). When considering only samples from patients with antimicrobial treatment prior to blood culture extraction, the TTD was shorter for Virtuo (median differences in the TTD of 4.5 h for all bottles and 8.7 h for aerobic bottles only [P = 0.0001]). In conclusion, virtuo provided shorter TTD and TAT than Bactec FX. The difference in the median TTD was increased when considering samples incubated in aerobic bottles from patients with antimicrobial treatment. This could have an important effect on the faster diagnosis of BSIs. IMPORTANCE Bloodstream infections are associated with high rates of morbidity and mortality. Blood culture remains the gold standard for its diagnosis. While the identification of the pathogen and its antibiotic susceptibility is required to confirm the optimal antimicrobial regimen, reductions in the times to the detection of positivity and reporting of Gram stain results may be important and time-saving to reduce inappropriate antimicrobial use, improve patient outcomes, and decrease health care costs. We report the first clinical diagnostic study of this scale in a "real-world" setting with a crossover design, comparing two automatic blood culture incubators using samples from patients with a suspected diagnosis of bacteremia/sepsis, as opposed to spiked vials. Our study design mimics that of clinical trials performed for drug marketing authorization, but patient randomization was replaced with the crossover design. A shorter time to detection could have an important effect on the faster identification of causative microorganisms of BSIs and antimicrobial stewardship.

Turnaround time prediction for clinical chemistry samples using machine learning

OBJECTIVES

Turnaround time (TAT) is an essential performance indicator of a medical diagnostic laboratory. Accurate TAT prediction is crucial for taking timely action in case of prolonged TAT and is important for efficient organization of healthcare. The objective was to develop a model to accurately predict TAT, focusing on the automated pre-analytical and analytical phase.

METHODS

A total of 90,543 clinical chemistry samples from Erasmus MC were included and 39 features were analyzed, including priority level and workload in the different stages upon sample arrival. PyCaret was used to evaluate and compare multiple regression models, including the Extra Trees (ET) Regressor, Ridge Regression and K Neighbors Regressor, to determine the best model for TAT prediction. The relative residual and SHAP (SHapley Additive exPlanations) values were plotted for model evaluation.

RESULTS

The regression-tree-based method ET Regressor performed best with an R² of 0.63, a mean absolute error of 2.42 min and a mean absolute percentage error of 7.35%, where the average TAT was 30.09 min. Of the test set samples, 77% had a relative residual error of at most 10%. SHAP value analysis indicated that TAT was mainly influenced by the workload in pre-analysis upon sample arrival and the number of modules visited.

CONCLUSIONS

Accurate TAT predictions were attained with the ET Regressor and features with the biggest impact on TAT were identified, enabling the laboratory to take timely action in case of prolonged TAT and helping healthcare providers to improve planning of scarce resources to increase healthcare efficiency.

Sepsis among Neonates in a Ghanaian Tertiary Military Hospital: Culture Results and Turnaround Times

In this study, we described the bacterial profile, antibiotic resistance pattern, and laboratory result turnaround time (TAT) in neonates with suspected sepsis from a tertiary-level, military hospital in Accra, Ghana (2017-2020). This was a cross-sectional study using secondary data from electronic medical records. Of 471 neonates clinically diagnosed with suspected sepsis in whom blood samples were collected, the median TAT from culture request to report was three days for neonates who were culture-positive and five days for neonates who were culture-negative. There were 241 (51%) neonates discharged before the receipt of culture reports, and of them, 37 (15%) were culture-positive. Of 471 neonates, twenty-nine percent (n = 139) were bacteriologically confirmed, of whom 61% (n = 85) had late-onset sepsis. Gram-positive bacterial infection (89%, n = 124) was the most common cause of culture-positive neonatal sepsis. The most frequent Gram-positive pathogen was coagulase-negative Staphylococcus (55%, n = 68) followed by Staphylococcus aureus (36%, n = 45), of which one in two were multidrug resistant. The reasons for large numbers being discharged before the receipt of culture reports need to be further explored. There is a need for improved infection prevention and control, along with ongoing local antimicrobial resistance surveillance and antibiotic stewardship to guide future empirical treatment.

Understanding how physician perceptions of job demand and process benefits evolve during CPOE implementation

We examine how physicians' perceptions of two computerized provider order entry (CPOE) capabilities, standardisation of care protocols and documentation quality, are associated with their perceptions of turnaround time, medical error, and job demand at three phases of CPOE implementation: pre-go-live, initial use, and continued use. Through a longitudinal study at a large urban hospital, we find standardisation of care protocols is positively associated with turnaround time reduction in all phases but positively associated with job demand increase only in the initial use phase. Standardisation also has a positive association with medical error reduction in the initial use phase, but later this effect becomes fully mediated through turnaround time reduction in the continued use phase. Documentation quality has a positive association with medical error reduction in the initial use phase and this association strengthens in the continued use phase. Our findings provide insights to effectively manage physicians' response to CPOE implementation.

Strategies to shorten turnaround time in outpatient laboratory

BACKGROUND

Turnaround time (TAT) is one of the most important indicators of laboratory quality. For the outpatient routine chemistry tests whose results are checked by clinicians on the same day, we set a quality goal that >90% of these samples should be reported within 60 min. As more than 20% of the samples failed to achieve this goal in 2020, we introduced an additional autoanalyzer and a real-time monitoring system to improve this rate.

METHODS

As the TAT of the pre-analytical phase is the greatest contributor to TAT, we divided it into sampling, sample transport, and sample preparation times. An additional autoanalyzer was introduced, and its effect on TAT improvement was evaluated with the TAT data of June and July 2020. A real-time monitoring system was introduced to sort delayed samples, and its effect was assessed with the TAT data of June and July 2021. TAT data from December 2019 to January 2020 were set as baseline controls.

RESULTS

The preparation time comprised the largest proportion of TAT. Although there was a slight decrease in overall TAT after the introduction of the above two strategies, the target TAT achievement rate increased significantly from 78.5% to 88.7% (p < 0.001).

CONCLUSIONS

We checked the cause of TAT prolongation and introduced new strategies to improve it. The addition of an autoanalyzer per se was not so effective but was better when combined with the real-time monitoring system. Such strategies would increase the quality of the laboratory services.

Setting Up an Ultra-Fast Next-Generation Sequencing Approach as Reflex Testing at Diagnosis of Non-Squamous Non-Small Cell Lung Cancer; Experience of a Single Center (LPCE, Nice, France)

The number of genomic alterations required for targeted therapy of non-squamous non-small cell lung cancer (NS-NSCLC) patients has increased and become more complex these last few years. These molecular abnormalities lead to treatment that provides improvement in overall survival for certain patients. However, these treated tumors inexorably develop mechanisms of resistance, some of which can be targeted with new therapies. The characterization of the genomic alterations needs to be performed in a short turnaround time (TAT), as indicated by the international guidelines. The origin of the tissue biopsies used for the analyses is diverse, but their size is progressively decreasing due to the development of less invasive methods. In this respect, the pathologists are facing a number of different challenges requiring them to set up efficient molecular technologies while maintaining a strategy that allows rapid diagnosis. We report here our experience concerning the development of an optimal workflow for genomic alteration assessment as reflex testing in routine clinical practice at diagnosis for NS-NSCLC patients by using an ultra-fast-next generation sequencing approach (Ion Torrent Genexus Sequencer, Thermo Fisher Scientific). We show that the molecular targets currently available to personalized medicine in thoracic oncology can be identified using this system in an appropriate TAT, notably when only a small amount of nucleic acids is available. We discuss the new challenges and the perspectives of using such an ultra-fast NGS in daily practice.

Evaluation of a cardiac troponin process flow at the chest pain center with the shortest turnaround time

BACKGROUND

Early diagnosis of myocardial infarction is crucial in chest pain management and cardiac troponin (cTn) test is an important step in it. Process improvement to shorten the test turnaround time (TAT) may improve patients' outcomes. The cTn test at chest pain center (CPC) of Zhongshan Hospital had the shortest TAT ever reported, but its process flow was not fully evaluated.

METHODS

We performed a stepwise evaluation of CPC cTn TAT and explored the potential factor that might cause delay. The performance of CPC cTn test was also compared with cTn test and human chorionic gonadotropin (HCG) test ordered from emergency department (ED).

RESULTS

At least 95% of CPC cTn tests were completed in 60 min, while 62% in 30 min. The medians of monthly order-to-collect time, collect-to-received time, and received-to-result time were ~7 min, ~3 min, and ~13 min, respectively. The samples collected at the bedside had longer collect-to-received time than the ones collected at the blood draw site next to the laboratory. Compared to ED cTn test and ED HCG test, CPC cTn test took less time in each step. A combination of the sample type switch and the centrifugation time reduction contributed the most to the shortening of TAT, which was reflected in the received-to-result time.

CONCLUSIONS

The current process flow of CPC cTn test satisfied the requirements of chest pain management, giving an example of how to implement process improvement for emergency medicine to shorten TAT of laboratory tests.

Current State of Laboratory Automation in Clinical Microbiology Laboratory

BACKGROUND

Although it has been 30 years since the first automation systems were introduced in the microbiology laboratory, total laboratory automation (TLA) has only recently been recognized as a valuable component of the laboratory. A growing number of publications illustrate the potential impact of automation. TLA can improve standardization, increase laboratory efficiency, increase workplace safety, and reduce long-term costs.

CONTENT

This review provides a preview of the current state of automation in clinical microbiology and covers the main developments during the last years. We describe the available hardware systems (that range from single function devices to multifunction workstations) and the challenging alterations on workflow and organization of the laboratory that have to be implemented to optimize automation.

SUMMARY

Despite the many advantages in efficiency, productivity, and timeliness that automation offers, it is not without new and unique challenges. For every advantage that laboratory automation provides, there are similar challenges that a laboratory must face. Change management strategies should be used to lead to a successful implementation. TLA represents, moreover, a substantial initial investment. Nevertheless, if properly approached, there are a number of important benefits that can be achieved through implementation of automation in the clinical microbiology laboratory. Future developments in the field of automation will likely focus on image analysis and artificial intelligence improvements. Patient care, however, should remain the epicenter of all future directions and there will always be a need for clinical microbiology expertise to interpret the complex clinical and laboratory information.

A snapshot of U.S. IRB review of COVID-19 research in the early pandemic

Background/Objective:

Along with the greater research enterprise, Institutional Review Boards (IRBs) had to quickly adapt to the COVID-19 pandemic. IRBs had to review and oversee COVID-related research, while navigating strict public health measures and a workforce largely relegated to working from home. Our objectives were to measure adjustments to standard IRB review processes, IRB turnaround time and document and any novel ethical issues encountered.

Methods:

Structured data requests were sent to members of the Consortium to Advance Effective Research Ethics Oversight directing Human Research Protection Programs (HRPP).

Results:

Fourteen of the 32 HRPP director members responded to a questionnaire about their approach to review and oversight during COVID-19. Eleven of the 14 provided summary data on COVID-19-specific protocols and six of the 11 provided protocol-related documents for our review. All respondents adopted at least one additional COVID-19-specific step to their usual review process. The average turnaround time for convened and expedited IRB reviews was 15 calendar days. In our review of the documents from 194 COVID-19-specific protocols (n = 302 documents), we identified only a single review that raised ethical concerns unique to COVID-19.

Conclusions:

Our data provide a snapshot of how HRPPs approached the review of COVID-19-specific protocols at the start of the pandemic in the USA. While not generalizable to all HRPPs, these data indicate that HRPPs can adapt and respond quickly response to a pandemic and likely need little novel expertise in the review and oversight of COVID-19-specific protocols.

Direct Rapid Identification from Positive Blood Cultures by MALDI-TOF MS: Specific Focus on Turnaround Times

Early availability of pathogen identification in bloodstream infections has critical importance in patients' management. This study investigated the accuracy and feasibility of the direct rapid identification (RID) method from positive blood cultures (BCs) by MALDI-TOF MS and its impact on the turnaround time (TAT) compared to the short-term incubation routine identification (SIRID) method. Pellets prepared from 328 BCs using a serum separator tube in the RID method and colonies on agar plates in the SIRID method were identified with MALDI Biotyper. BCs on weekdays from 6 a.m. to 4 p.m. were defined as the daytime signal group (DSG); BCs from 4 p.m. to 6 a.m. were defined as the night signal group (NSG). Comparison between the two methods was performed with 310 monomicrobial BCs. Two hundred ninety-five (95.2%) monomicrobial BCs yielded an identification result with the RID method. Of the 295 BCs, 289 (97.9%) were identified correctly at the species level, 4 (1.4%) were at the genus level, and 2 (0.7%) were misidentified. In the RID method, at score cutoff values of 1.2, 1.3, 1.4 and 1.5, the rates of correct identifications at the species level were 97.9%, 98.9%, 99.3%, and 100%, respectively. The mean TAT in the DSG was significantly lower (P < 0.001) in the RID method (mean: 2.86 h; 95% CI: 2.65 to 3.07) compared to the SIRID method (mean: 19.49 h; 95% CI: 18.08 to 20.89). Correct identification rates at the species level were 100% in Gram-negative bacteria, 88.9% in Gram-positive bacteria, and 93.2% of all BCs isolates with the RID method. The TAT was improved remarkably in DSG, which might contribute to empirical antibiotic therapies of patients.

IMPORTANCE Using MALDI-TOF MS directly from BCs reduces the time required for pathogen identification, and the TATs for final identification have been compared with overnight incubation from solid media in previous studies. However, identification from a short incubation of agar plates has been increasingly accepted and successfully implemented in routine laboratories, but there is no data comparing direct MALDI-TOF MS with the short-term incubated agar plates. Our study showed that the TAT improved remarkably by applying a RID method by MALDI-TOF MS twice a day periodically when compared to the SIRID method.

Total Laboratory Automation and Three Shifts Reduce Turnaround Time of Cerebrospinal Fluid Culture Results in the Chinese Clinical Microbiology Laboratory

Background

Total laboratory automation (TLA) has the potential to reduce specimen processing time, optimize workflow, and decrease turnaround time (TAT). The purpose of this research is to investigate whether the TAT of our laboratory has changed since the adoption of TLA, as well as to optimize laboratory workflow, improve laboratory testing efficiency, and provide better services of clinical diagnosis and treatment.

Materials and Methods

Laboratory data was extracted from our laboratory information system in two 6-month periods: pre-TLA (July to December 2019) and post-TLA (July to December 2020), respectively.

Results

The median TAT for positive cultures decreased significantly from pre-TLA to post-TLA (65.93 vs 63.53, P<0.001). For different types of cultures, The TAT of CSF changed the most (86.76 vs 64.30, P=0.007), followed by sputum (64.38 vs 61.41, P<0.001), urine (52.10 vs 49,57, P<0.001), blood (68.49 vs 66.60, P<0.001). For Ascites and Pleural fluid, there was no significant difference (P>0.05). Further analysis found that the incidence of broth growth only for pre-TLA was 12.4% (14/133), while for post-TLA, it was 3.4% (4/119). The difference was statistically significant (P=0.01). The common isolates from CSF samples were Cryptococcus neoformans, coagulase-negative Staphylococcus, Acinetobacter baumannii, and Klebsiella pneumonia.

Conclusion

Using TLA and setting up three shifts shortened the TAT of our clinical microbiology laboratory, especially for CSF samples.

Understanding Constraints and Enablers of Turnaround Time for Ethics Review: The Case of Institutional Review Boards in Tanzania

Background. Independent ethics review of research is required prior to the implementation of all health research involving human participants. However, ethics review processes are challenged by protracted turnaround times, which may negatively impact the implementation of socially valuable research. Previous research has documented delays in ethics review in developed and developing countries. This study aimed to determine the extent of variability in turnaround times for protocol review among different institutional review boards (IRBs) within Tanzania. Methods. This descriptive cross-sectional study employed a mixed-method approach, with qualitative and quantitative components. Seven IRBs were purposively sampled from the 15 accredited IRBs operational in Tanzania during the study period, April 2017-April 2018. Quantitative data were analysed using STATA software and qualitative data were analysed thematically. Results. The median time for review across all IRBs was 32 days, with a range of 1-396 days. Qualitative results identified five key themes related to turnaround time from interviews with participants. These included: (1) procedures for receiving and distribution of protocols, (2) number of reviewers assigned to protocols, (3) duration of reviewing protocols, (4) reasons for delayed feedback, and (5) training of research ethics committee members. Conclusion. The study showed that the median days for ethical approval in Tanzania was 32 days. We observed from this study that electronic submission systems facilitated faster turnaround times. Failure to adhere to the submission checklists and guidelines was a major obstacle to the turnaround time.

An Overview of King Hussein Cancer Center Institutional Review Board Over 12 Years (2009-2020), Successes and Challenges, Including Those Imposed by the COVID-19 Pandemic

The problem: Running an efficient institutional review board (IRB) can be challenging. The research subjects: To ensure an efficient committee, our IRB adopted several operational metrics. Methods: Analysis of retrospective data from the IRB records, database, and annual reports over 12 years. Results: The IRB roster comprises 11 members. The average medical to nonmedical member ratio is 5:6, and the male to female ratio is 4:7, which has not been consistent over the years. One thousand three hundred and twenty-four proposals were reviewed including 1077 exempt (81.3%), 126 expedited (9.5%), and 121 full board (9.2%) with a median turnaround time to approval of 4.0, 35.0, and 68.0 days, respectively. Training of the IRB members was conducted to enhance their knowledge and skills. IRB at King Hussein Cancer Center has managed to stay abreast and efficient during the COVID-19 pandemic, by working remotely. Conclusion: Running an efficient IRB mandates implementing a number of operational metrics.

Real-world data on NGS using the Oncomine DxTT for detecting genetic alterations in non-small-cell lung cancer: WJOG13019L

Considering the increasing number of identified driver oncogene alterations, additional genetic tests are required to determine the treatment for advanced non-small-cell lung cancer (NSCLC). Next-generation sequencing can detect multiple driver oncogenes simultaneously, enabling the analysis of limited amounts of biopsied tissue samples. In this retrospective, multicenter study (UMIN ID000039523), we evaluated real-world clinical data using the Oncomine Dx Target Test Multi-CDx System (Oncomine DxTT) as a companion diagnostic system. Patients with NSCLC who were tested for a panel of 46 genes using the Oncomine DxTT between June 2019 and January 2020 were eligible for enrollment. Patients from 19 institutions affiliated to the West Japan Oncology Group were recruited. The primary endpoint of the study was the success rate of genetic alteration testing in four driver genes (EGFR, ALK, ROS1, and BRAF) using the Oncomine DxTT. In total, 533 patients were enrolled in the study. The success rate of genetic alteration testing for all four genes was 80.1% (95% CI 76.5%-83.4%). Surgical resection was associated with the highest success rate (88.0%), which was significantly higher than that for bronchoscopic biopsy (76.8%, P = .005). Multivariate analysis revealed a significant difference for surgical resection alone (P = .006, 95% CI 1.36-6.18, odds ratio 2.90). Although the success rate of genetic alteration testing immediately after Oncomine DxTT induction was not sufficient in this study, optimizing specimen quantity and quality may improve the use of driver gene testing in clinical settings.

A Real-World Application of Liquid Biopsy in Metastatic Colorectal Cancer: The Poseidon Study

BACKGROUND

First-line decision making is the key to the successful care of mCRC patients and RAS/BRAF status is crucial to select the best targeted agent. In hub centers, a relevant proportion of patients referred from small volume centers may not have standard tissue-based (STB) molecular results available at the time of the first visit (T0). Liquid biopsy (LB) may help circumvent these hurdles.

METHODS

A monoinstitutional prospective head-to-head comparison of LB versus (vs.) STB testing was performed in a real-world setting. Selection criteria included: mCRC diagnosis with unknown RAS/BRAF status at T0, tumoral tissue archived in external centers, no previous treatment with anti-EGFR. At T0, patients underwent plasma sampling for LB testing and procedure for tissue recovery. RAS/BRAF genotyping was carried out by droplet digital PCR on circulating-tumoral (ct) DNA. The primary endpoint was the comparison of time to LB (T1) vs. STB (T2) results using the Mann-Whitney U test. Secondary endpoints were the concordance between LB and STB defined as overall percent agreement and the accuracy of LB in terms of specificity, sensitivity, positive and negative predictive value. We also performed an exploratory analysis on urinary (u) ctDNA.

RESULTS

A total of 33 mCRC patients were included. Mean T1 and T2 was 7 and 22 days (d), respectively (p < 0.00001). T2 included a mean time for archival tissue recovery of 17 d. The overall percent agreement between LB and STB analysis was 83%. Compared to STB testing, LB specificity and sensitivity were 90% and 80%, respectively, with a positive predictive value of 94% and negative one of 69%. In detail, at STB and LB testing, RAS mutation was found in 45% and 42% of patients, respectively; BRAF mutation in 15%. LB results included one false positive and four false negative. False negative cases showed a significantly lower tumor burden at basal CT scan. Concordance between STB and uctDNA testing was 89%.

CONCLUSIONS

Faster turnaround time, high concordance and accuracy are three key points supporting the adoption of LB in routinary mCRC care, in particular when decision on first-line therapy is urgent and tissue recovery from external centers may require a long time. Results should be interpreted with caution in LB wild-type cases with low tumor burden.

Microwave-Based Rapid Tissue Processing Technique: A Novel Aid in Histopathologic Laboratory

Introduction:

Conventional tissue processing takes a lot of time, but microwave processing method though rapid, its quality of tissue texture and staining properties is still questionable. Therefore, we conducted this study to find out the reliability of histological sections in the microwave method.

Aim and Objectives:

The aim is to assess whether microwave tissue processing, which is a rapid technique, is comparable to conventional tissue processing in terms of quality and reliability of histological sections.

Materials and Methods:

A total of 80 formalin-fixed tissue samples were taken and were divided into two pieces. One subjected to conventional tissue processing and the other subjected to microwave tissue processing. The slides were coded and evaluated by three independent observers using various parameters. All the data were subjected to Chi-square test.

Results:

Both the process did not differ in their efficiency in overall nuclear details, overall cytoplasmic detail, occurrence of artifact and tissue architecture, nuclear staining, cytoplasmic staining, and red blood cell staining. Although the other observers did not find any statistical significance, according to observer 3, conventional processing proved to have marginally significantly better epithelial connective tissue interface than microwave processing (P = 0.047).

Conclusion:

The microwave method of tissue processing is an economical procedure which reduces the obnoxious chemicals as well as the turnaround time.

Effectiveness of a Cloud-Based Telepathology System in China: Large-Sample Observational Study

BACKGROUND

Whole-slide imaging allows the entire slide to be viewed in a manner that simulates microscopy; therefore, it is widely used in telepathology. However, managing the large digital files needed for whole-slide imaging is difficult. To solve this problem, we set up the Chinese National Cloud-Based Telepathology System (CNCTPS). CNCTPS has been running for more than 4 years and has accumulated a large amount of data.

OBJECTIVE

The main purpose of this study was to comprehensively evaluate the effectiveness of the CNCTPS based on a large sample. The evaluation indicators included service volume, turnaround time, diagnosis accuracy, and economic benefits.

METHODS

Details of 23,167 cases submitted to the CNCTPS from January 2016 to December 2019 were collected to analyze the service volume, turnaround time, and economic benefits. A total of 564 patients who visited the First Affiliated Hospital of Zhengzhou University and obtained final diagnoses were followed up to analyze the diagnostic accuracy of the CNCTPS.

RESULTS

From 2016 to 2019, the service volume of the CNCTPS increased from 2335 to 9240, and the number of participating hospitals increased from 60 to 74. Consultation requests from county-level hospitals accounted for 86.57% (20,287/23,167). A total of 17,495 of 23,167 cases (75.52%) were confirmed, including 12,088 benign lesions, 5217 malignant lesions, and 190 borderline lesions. Of the cases, 3.85% (893/23,167) failed to be diagnosed for reasons such as poor slice quality and incomplete sampling. The median turnaround time was 16.93 hours and was shortened yearly (between 2018 and 2019: adjusted P=.01; other groups: adjusted P<.001); 82.88% cases were diagnosed in 48 hours. There was a discrepancy between the diagnosis and final diagnosis for 11 cases, including 4 false-positive cases and 7 false-negative cases. The sensitivity and specificity were 97.66% and 98.49%, respectively. The diagnostic accuracy of the system was 98.05%, with no statistical difference from the final diagnosis in the hospital (P=.55). By using this system, a total of US $300,000 was saved for patients every year.

CONCLUSIONS

The novel cloud-based telepathology system has the potential to relieve the shortage of pathologists in primary hospitals. It can also simultaneously reduce medical costs for patients in China. It should, therefore, be further promoted to enhance the efficiency, quantity, and quality of telepathology diagnoses.

Comparison between tube test and automated column agglutination technology on VISION Max for anti-A/B isoagglutinin titres: A multidimensional analysis

BACKGROUND AND OBJECTIVES

VISION Max (Ortho Clinical Diagnostics, Raritan, NJ) measures anti-A/B isoagglutinin titres using automated column agglutination technology (CAT). We compared tube test (TT) and CAT of VISION Max comprehensively, including failure mode and effect analysis (FMEA), turnaround time (TAT) and cost, and suggested modified CAT (MCAT).

MATERIALS AND METHODS

For 100 samples (each 25 for blood type A, B and O with anti-A and anti-B), anti-A/B isoagglutinin titres were measured by TT and CAT (1:2-1:1024 dilution), as well as by MCAT (with agglutination at 1:32 dilution, then perform additional testing from 1:64 to 1:1024). We assessed the agreement and correlation between TT and CAT and compared FMEA (risk priority number [RPN] score), TAT (h:min:sec) and cost (US dollar, US $) among TT, CAT and MCAT.

RESULTS

TT and CAT showed overall substantial agreement (k = 0.73) and high correlation (ρ ≥ 0.75) except blood type O with anti-A (ρ = 0.68). Compared with TT, CAT showed lower RPN scores in FMEA and similar TAT and cost (FMEA, 33,700 vs. 184,300; TAT, 15:23:00 vs. 14:26:40; cost, 1377.4 vs. 1312.4, respectively). Regarding FMEA, TAT and cost, MCAT was superior to CAT or TT (43,810; 13:28:00; 899.2, respectively).

CONCLUSION

This is the first multidimensional analysis on VISION Max CAT for measuring anti-A/B isoagglutinin titres. The results of anti-A/B isoagglutinin titres by CAT were comparable with those of TT. MCAT would be a safe, time-saving and cost-effective alternative to TT and CAT in high-volume blood bank laboratories.

Audit in surgical histopathology at a tertiary healthcare center: Study of preanalytical and analytical phase

Context

An audit aims to verify conformance to required processes, assess their implementation, and define the targets of quality control.

Aims

To evaluate preanalytic and analytic phases of surgical histopathology in a tertiary healthcare center.

Setting and Design

An observational retrospective and prospective study over 3 months each of year 2013 and 2014.

Materials and Methods

Biopsy, small resections, large organ resections, bone marrow aspirate/biopsy (BMA/BMB), and frozen section samples received in surgical histopathology were categorized as I to V, respectively. A manual audit was done for preanalytical phase (adequacy of clinical information and grossing adequacy) and analytical phase [turnaround time (TAT) and tissue section quality].

Statistical Analysis

Qualitative data was assessed by Chi-Square test. Quantitative data was assessed using One-Way Analysis of Variance.

Results

Among 3179 total cases, category I to V had 1558 (49%), 1099 (34.6%), 342 (10.8%), 124 (3.8%), and 56 (1.8%) cases, respectively. Category I had shortest TAT but maximum number of inadequately sent specimens and recuts. Category III had maximum cases with inadequate clinical history, grossing errors, additional sections, and longest TAT. Category IV had maximum cases with poor quality sections. Category V had maximum cases with inadequate demographic details and clinical investigations. BMB (114, 91.9%) was more useful than BMA for diagnosis. Mean TAT for fixed tissues and frozen tissues was 3.6 ± 1.8 days and 26.6 ± 11.2 min, respectively.

Conclusions

Total 25% of annual workload was studied by an observational, manual audit. Quality indicators were achieved as per international norms despite limited resources. Remedial actions were suggested for technicians, clinicians, and pathologists to minimize errors.

Evaluation of the postal service for referral of specimen of drug resistance tuberculosis in Amhara region, Ethiopia; mixed method

BACKGROUND

In Ethiopia, specimens of presumptive drug resistant tuberculosis cases are transported by courier system from district sample collection centers to reference laboratories. It is essential to track the effectiveness of the referral system and identify challenges in order to take timely and appropriate actions. We assessed turnaround time and quality of specimens, and explored challenges of the specimen referral system in Amhara region, Ethiopia, 2017.

METHODS

With mixed methods, we retrospectively examined 385 randomly selected presumptive drug resistance TB specimens, and interviewed 53 purposively selected key informants from laboratories and post offices. We calculated median TAT and proportion of acceptable quality. We analyzed qualitative data thematically.

RESULTS

Of the 385 specimens, 94.5% (364/385) had acceptable quality at arrival in the reference laboratories. All the 364 specimens had result. Three - fourth (76.1%) of results were dispatched to the referring health facilities within the recommended turnaround time. Ineffective communication and lack of feedback among institutions were mentioned as challenges.

CONCLUSION

The postal service was effective in keeping quality and majority of test results were timely delivered. Yet, there were operational challenges. Therefore, effective communication, using dedicated vehicle for specimen shipment and awareness creation on specimen collection and handling are recommended.

A reduction of the number of assays and turnaround time by optimizing polymerase chain reaction (PCR) pooled testing for SARS-CoV-2

Early detection of the severe acute respiratory syndrome coronavirus 2 infection can decrease the spread of the disease and provide therapeutic options promptly in affected individuals. However, the diagnosis by reverse‐transcription polymerase chain reaction is costly and time‐consuming. Several methods of group testing have been developed to overcome this problem. The proposed strategy offers optimization of group testing according to the available resources by decreasing not only the number of the assays but also the turnaround time. The initial classification of the samples would be done according to the intention of testing defined as diagnostic or screening/surveillance, achieving the best possible homogeneity. The proposed stratification of pooling is based on branching (divisions) and depth (levels of re‐pooling) of the original group in association with the estimated probability of a positive sample. The dilutional effect of the grouped samples has also been considered. The margins of minimum and maximum conservation of assays of pooled specimens are calculated and the optimum strategy can be selected in association with the probability of positive samples in the original group. This algorithm intends to be a useful tool for group testing offering a choice of strategies according to the requirements.

Long Turnaround Times in Viral Load Monitoring of People Living with HIV in Resource-Limited Settings

Introduction

Routine viral load (VL) testing is fraught with challenges in resource-limited settings which lead to longer turnaround times for the return of VL results. We assessed the turnaround times for VL testing and factors associated with long turnaround (>30 days) in Marondera, Zimbabwe, between January and September 2018.

Methods

This was an analytical study of routine program data. Data were extracted from electronic records and paper-based reports at two laboratories and at antiretroviral therapy (ART) facilities. The unit of analysis was the VL sample. Duration (in days) between sample collection and sample testing (pre-test turnaround time), duration between sample testing and receipt of VL result at ART the site (post-test turnaround time), and duration between sample collection and receipt of result at the ART site (overall turnaround time) were calculated. Days on which the VL testing machine was not functional, and workload (number of tests done per month) were used to assess associations. We used binomial log models to assess the factors associated with longer turnaround time.

Results

A total of 3348 samples were received at the two VL testing laboratories, and 3313 were tested, of these, 1111 were analyzed for overall turnaround time. Pre-test, post-test, and overall turnaround times were 22 days (interquartile range (IQR): 11-41), 51 days (IQR: 30-89), and 67 days (IQR: 46-100), respectively. Laboratory workload (relative risk [RR]: 1.12, 95% confidence interval [CI]: 1.10-1.14) and machine break down (RR: 1.15, 95% CI: 1.14-1.17) were associated with long turnaround time.

Conclusions

Routine VL turnaround time was long. Decentralizing VL testing and enhancing laboratory capacity may help shorten the turnaround time.

Viral infection neutralization tests: A focus on severe acute respiratory syndrome-coronavirus-2 with implications for convalescent plasma therapy

Viral neutralization tests (VNTs) have long been considered old-fashioned tricks in the armamentarium of fundamental virology, with laboratory implementation for a limited array of viruses only. Nevertheless, they represent the most reliable surrogate of potency for passive immunotherapies, such as monoclonal or polyclonal antibody therapy. The recent interest around therapy with convalescent plasma or monoclonal antibodies for the Covid-19 pandemic has paralleled the revival of VNTs. We review here the available methods by dissecting variations for each fundamental component of the VNT (i.e., virus type and dose, replication-competent cell line, serum, and detection system).

Improving turnaround time of molecular diagnosis of Middle East respiratory syndrome coronavirus in a hospital in Saudi Arabia

Background

There have been 2562 laboratory-confirmed cases of Middle East respiratory syndrome coronavirus (MERS-CoV) in 27 countries, with a case fatality rate of 34.5%. Data on the turnaround time (TAT) are lacking. We report TAT for MERS-CoV samples over time.

Methods

This is a monocentric study and the TAT for the reporting of 2664 MERS-CoV polymerase chain reaction (PCR) results were calculated in hours from the time of the receipt of respiratory samples to the reporting of the results.

Results

The mean TAT±standard deviation was significantly lower in 2018 compared with previous years (19.25±13.8). The percentage of samples processed within 24 h increased from 42.3% to 73.8% in 2015 and 2018, respectively (p<0.0001). The mean TAT was 19.2 h in 2018 and was significantly lower than previous years.

Conclusions

The TAT for the MERS-CoV results decreased during the study period. Timely reporting of MERS-CoV PCR results may aid in further enhancing infection control measures.