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Favaloro EJ, Arunachalam S, Chapman K, Pasalic L. Continued harmonization of the international normalized ratio across a large laboratory network: Evidence of sustained low interlaboratory variation and bias after a change in instrumentation. Am J Clin Pathol 2024:aqae090. [PMID: 39024475 DOI: 10.1093/ajcp/aqae090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Accepted: 06/22/2024] [Indexed: 07/20/2024] Open
Abstract
OBJECTIVES Our objective was to maintain low interlaboratory variation and bias in international normalized ratio (INR) results following a network change in instrumentation and reagents, using a process of ongoing standardization and harmonization. METHODS Network-wide standardization to new common instrument and reagent platforms followed by network-wide application of a simple novel process of verification of international sensitive index and mean normal prothrombin time values for each new lot of prothrombin time (PT) reagent that does not require use of World Health Organization reference thromboplastin or INR calibration/certified plasma. RESULTS The network transitioned from mechanical hemostasis detection instruments with associated PT reagent (Diagnostica Stago; NeoPTimal) to optical detection (ACL TOPs) with associated PT reagent (Werfen; RecombiPlasTin 2G). Comparing 3 years of data for each situation, the network (n = 27 laboratories) maintained low INR variability and bias relative to general mechanical and optical groups and other laboratories. CONCLUSIONS Harmonized support for patient management of vitamin K antagonists such as warfarin was continuously maintained in our geography, with potentially positive implications for other coagulation laboratories and geographies. For the United States in particular, paucity of US Food and Drug Administration-cleared INR certified plasmas potentially compromises INR test accuracy; our novel approach may provide workable alternatives for other laboratories/networks.
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Affiliation(s)
- Emmanuel J Favaloro
- Department of Haematology, Institute of Clinical Pathology and Medical Research (ICPMR), Sydney Centres for Thrombosis and Haemostasis, NSW Health Pathology, Westmead Hospital, Westmead, New South Wales, Australia
- School of Dentistry and Medical Sciences, Faculty of Science and Health, Charles Sturt University, Wagga Wagga, New South Wales, Australia
- School of Medical Sciences, Faculty of Medicine and Health, University of Sydney, Westmead Hospital, Westmead, New South Wales, Australia
| | | | - Kent Chapman
- Department of Haematology, NSW Health Pathology, John Hunter Hospital, Newcastle, New South Wales, Australia
| | - Leonardo Pasalic
- Department of Haematology, Institute of Clinical Pathology and Medical Research (ICPMR), Sydney Centres for Thrombosis and Haemostasis, NSW Health Pathology, Westmead Hospital, Westmead, New South Wales, Australia
- Westmead Clinical School, University of Sydney, Westmead, New South Wales, Australia
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2
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Favaloro EJ. Evolution of Hemostasis Testing: A Personal Reflection Covering over 40 Years of History. Semin Thromb Hemost 2024; 50:8-25. [PMID: 36731486 DOI: 10.1055/s-0043-1761487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
There is no certainty in change, other than change is certain. As Seminars in Thrombosis and Hemostasis celebrates 50 years of publication, I felt it appropriate to reflect on my own 40-year plus scientific career. My career in the thrombosis and hemostasis field did not start until 1987, but the subsequent 35 years reflected a period of significant change in associated disease diagnostics. I started in the Westmead Hospital "coagulation laboratory" when staff were still performing manual clotting tests, using stopwatches, pipettes, test tubes, and a water bath, which we transported to the hospital outpatient department to run our weekly warfarin clinic. Several hemostasis instruments have come and gone, including the Coag-A-Mate X2, the ACL-300R, the MDA-180, the BCS XP, and several StaR Evolution analyzers. Some instruments remain, including the PFA-100, PFA-200, the AggRAM, the CS-5100, an AcuStar, a Hydrasys gel system, and two ACL-TOP 750s. We still have a water bath, but this is primarily used to defrost frozen samples, and manual clotting tests are only used to teach visiting medical students. We have migrated across several methodologies in the 45-year history of the local laboratory. Laurel gel rockets, used for several assays in the 1980s, were replaced with enzyme-linked immunosorbent assay assays and most assays were eventually placed on automated instruments. Radio-isotopic assays, used in the 1980s, were replaced by an alternate safer method or else abandoned. Test numbers have increased markedly over time. The approximately 31,000 hemostasis assays performed at the Westmead-based laboratory in 1983 had become approximately 200,000 in 2022, a sixfold increase. Some 90,000 prothrombin times and activated partial thromboplastic times are now performed at this laboratory per year. Thrombophilia assays were added to the test repertoires over time, as were the tests to measure several anticoagulant drugs, most recently the direct oral anticoagulants. I hope my personal history, reflecting on the changes in hemostasis testing over my career to date in the field, is found to be of interest to the readership, and I hope they forgive any inaccuracies I have introduced in this reflection of the past.
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Affiliation(s)
- Emmanuel J Favaloro
- Department of Haematology, Institute of Clinical Pathology and Medical Research (ICPMR), Sydney Centres for Thrombosis and Haemostasis, NSW Health Pathology, Westmead Hospital, Westmead, NSW Australia
- School of Dentistry and Medical Sciences, Faculty of Science and Health, Charles Sturt University, Wagga Wagga, New South Wales, Australia
- School of Medical Sciences, Faculty of Medicine and Health, University of Sydney, Westmead Hospital, Westmead, New South Wales, Australia
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3
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Favaloro EJ, Gosselin RC, Pasalic L, Lippi G. Hemostasis and Thrombosis: An Overview Focusing on Associated Laboratory Testing to Diagnose and Help Manage Related Disorders. Methods Mol Biol 2023; 2663:3-38. [PMID: 37204701 DOI: 10.1007/978-1-0716-3175-1_1] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
Hemostasis is a complex but balanced process that permit normal blood flow, without adverse events. Disruption of the balance may lead to bleeding or thrombotic events, and clinical interventions may be required. Hemostasis laboratories typically offer an array of tests, including routine coagulation and specialized hemostasis assays used to guide clinicians for diagnosing and managing patients. Routine assays may be used to screen patients for hemostasis-related disturbances but may also be used for drug monitoring, measuring efficacy of replacement or adjunctive therapy, and other indications, which may then be used to guide further patient management. Similarly, "specialized" assays are used for diagnostic purposes or may be used to monitor or measure efficacy of a given therapy. This chapter provides an overview of hemostasis and thrombosis, with a focus on laboratory testing that may be used to diagnose and help manage patients suspected of hemostasis- and thrombosis-related disorders.
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Affiliation(s)
- Emmanuel J Favaloro
- School of Medical Sciences, Faculty of Medicine and Health University of Sydney, Westmead Hospital, Westmead, NSW, Australia.
- School of Dentistry and Medical Sciences, Faculty of Science and Health, Charles Sturt University, Wagga, Wagga, NSW, Australia.
| | - Robert C Gosselin
- Hemostasis & Thrombosis Center, Davis Health System, University of California, Sacramento, CA, USA
| | - Leonardo Pasalic
- Department of Haematology, Sydney Centres for Thrombosis and Haemostasis, Institute of Clinical Pathology and Medical Research (ICPMR), NSW Health Pathology, Westmead Hospital, Westmead, NSW, Australia
- Westmead Clinical School, University of Sydney, Westmead, NSW, Australia
| | - Giuseppe Lippi
- Section of Clinical Biochemistry, University of Verona, Verona, Italy
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4
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Ashwell E. The basics of blood and associated disorders. BRITISH JOURNAL OF NURSING (MARK ALLEN PUBLISHING) 2022; 31:1096-1102. [PMID: 36416634 DOI: 10.12968/bjon.2022.31.21.1096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
The blood and its components are involved in a wide range of processes to support life, including fighting infection and providing the body's tissues with oxygen and nutrients. If any stage in the development of blood cells is disrupted, for example by genetic abnormalities or a lack of nutrients, disease may result. This article provides an overview of some of the blood's key components, blood cells and their formation and functions, blood groups and some of the problems that can arise from malfunctions. A case study on haemophilia A as a blood disorder is presented to consolidate knowledge.
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Affiliation(s)
- Emily Ashwell
- Community Case Manager Nurse, Buckinghamshire Healthcare NHS Trust
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5
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Selby R, Duffy ER, Berny-Lang MA, Andry CD, Lee AYY. Impact of specific preclinical variables on coagulation biomarkers in cancer-associated thrombosis. Thromb Res 2021; 191 Suppl 1:S26-S30. [PMID: 32736774 DOI: 10.1016/s0049-3848(20)30393-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Revised: 11/18/2019] [Accepted: 11/24/2019] [Indexed: 10/23/2022]
Abstract
Coagulation biomarkers are being actively studied for their diagnostic and prognostic value in patients with venous thromboembolism and cancer, as well as in the study of pathogenic mechanisms between cancer and thrombosis. For the results of such studies to be accurate and reproducible, attention must be paid to minimize sources of error in all phases of testing. The pre-analytical phase of laboratory testing is known to be fraught with the majority of errors. Coagulation testing is particularly susceptible to conditions during collection, processing, transport and storage of specimens which can lead to clinically significant errors in results. In addition, changes in pre-analytical conditions can impact different biomarkers differently. Therefore, research studies investigating coagulation biomarkers must carefully standardize not just the analytical phase, but also the pre-analytical phase of testing to ensure accuracy and reliability. We briefly review the impact of pre-analytical conditions on coagulation testing in general, and on specific biomarkers in cancer and thrombosis. In addition, we provide recommendations to reduce pre-analytical errors by developing and sharing standard operating procedures that specifically target standardization of methodologies for collecting specimens and measuring current and emerging coagulation biomarkers in cancer studies.
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Affiliation(s)
- Rita Selby
- Departments of Laboratory Medicine and Pathobiology & Medicine, University of Toronto, Toronto, ON, Canada
| | - Elizabeth R Duffy
- Department of Pathology & Laboratory Medicine, Boston University School of Medicine, Boston Medical Center, Boston, MA, USA
| | - Michelle A Berny-Lang
- Center for Strategic Scientific Initiatives, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Christopher D Andry
- Department of Pathology & Laboratory Medicine, Boston University School of Medicine, Boston Medical Center, Boston, MA, USA
| | - Agnes Y Y Lee
- University of British Columbia, British Columbia Cancer Agency, Vancouver, BC, Canada.
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6
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Jaarsma T, Strömberg A, Dunbar SB, Fitzsimons D, Lee C, Middleton S, Vellone E, Freedland KE, Riegel B. Self-care research: How to grow the evidence base? (reprint). Int J Nurs Stud 2021; 116:103903. [PMID: 33637295 DOI: 10.1016/j.ijnurstu.2021.103903] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 02/18/2020] [Accepted: 02/26/2020] [Indexed: 01/03/2023]
Abstract
BACKGROUND AND OBJECTIVE The number of studies in the area of self-care is growing and international researchers are increasingly developing self-care interventions to improve outcomes of individual patients and communities. However, growth of the evidence is still slow due to challenges with designing and testing self-care interventions. In this article we address major methodological challenges with regard to the definition of self-care, use of theory, and research design, intended to provide guidance to researchers in this field. METHOD During the inaugural conference of the International Center for Self-Care Research held in Rome, Italy in June 2019 we identified important issues in existing self-care research. Discussion and literature review lead to eight recommendation for future self-care research. RESULTS In preparation, begin with a theoretically sound definition of self-care. In planning the intervention, build on and extend previous studies. Use theory to develop self-care interventions and consider translational models to guide development, evaluation and implementation of complex self-care interventions. Employ a study design that fits the current phase and objectives of the research and measure self-care and related factors carefully. In reporting, describe the sample and setting sufficiently so that others can draw conclusions about generalizability and applicability to their practice and patient population. In interpretation, describe how the intervention is assumed to work (causal assumptions) and its key components. CONCLUSION Our review of existing self-care research clearly illustrates that the recommendations we provide are needed if we are to substantially grow the evidence base supporting self-care. Embracing a core set of principles will allow us to build on each other's work. Tweetable abstract: A core set of methodological principles is needed to substantially grow the evidence base supporting self-care.
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Affiliation(s)
- T Jaarsma
- Department of Health, Medicine and Caring Sciences, Linkoping University, 58381 Linköping, Sweden; Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia; Julius Center, University Medical Center Utrecht, the Netherlands.
| | - A Strömberg
- Department of Health, Medicine and Caring Sciences, Linkoping University, 58381 Linköping, Sweden; Department of Cardiology, Linkoping University, Sweden
| | - S B Dunbar
- Nell Hodgson Woodruff School of Nursing, Emory University, USA
| | - D Fitzsimons
- School of Nursing & Midwifery, Queen's University Belfast, UK
| | - C Lee
- William F. Connell, School of Nursing, Boston College, USA
| | - S Middleton
- Nursing Research Institute, St Vincent's Health Australia & Australian Catholic University, Australia
| | - E Vellone
- University of Rome "Tor Vergata", Italy
| | - K E Freedland
- Department of Psychiatry, Washington University School of Medicine, USA
| | - B Riegel
- Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia; School of Nursing, University of Pennsylvania, USA
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7
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Dorgalaleh A, Favaloro EJ, Bahraini M, Rad F. Standardization of Prothrombin Time/International Normalized Ratio (PT/INR). Int J Lab Hematol 2020; 43:21-28. [PMID: 32979036 DOI: 10.1111/ijlh.13349] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 09/02/2020] [Accepted: 09/07/2020] [Indexed: 01/02/2023]
Abstract
The prothrombin time (PT) represents the most commonly used coagulation test in clinical laboratories. The PT is mathematically converted to the international normalized ratio (INR) for use in monitoring anticoagulant therapy with vitamin K antagonists such as warfarin in order to provide test results that are adjusted for thromboplastin and instrument used. The INR is created using two major PT 'correction factors', namely the mean normal PT (MNPT) and the international sensitivity index (ISI). Manufacturers of reagents and coagulometers have made some efforts to harmonizing INRs, for example, by tailoring reagents to specific coagulometers and provide associated ISI values. Thus, two types of ISIs may be generated, with one being a 'general' or 'generic' ISI and others being reagent/coagulometer-specific ISI values. Although these play a crucial role in improving INR results between laboratories, these laboratories reported INR values are known to still differ, even when laboratories use the same thromboplastin reagent and coagulometer. Moreover, ISI values for a specific thromboplastin can vary among different models of coagulometers from a manufacturer using the same method for clot identification. All these factors can be sources of error for INR reporting, which in turn can significantly affect patient management. In this narrative review, we provide some guidance to appropriate ISI verification/validation, which may help decrease the variability in cross laboratory reporting of INRs.
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Affiliation(s)
- Akbar Dorgalaleh
- Department of Hematology and Blood Transfusion, School of Allied Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Emmanuel J Favaloro
- Department of Haematology, Sydney Centres for Thrombosis and Haemostasis, Institute of Clinical Pathology and Medical Research, NSW Health Pathology, Westmead Hospital, Westmead, NSW, Australia
| | - Mehran Bahraini
- Department of Hematology and Blood Transfusion, School of Allied Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Fariba Rad
- Cellular and Molecular Research Center, Yasuj University of Medical Sciences, Yasuj, Iran.,Blood Transfusion Research Center, High Institute for Research and Education in Transfusion Medicine, Tehran, Iran
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8
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Self-care research: How to grow the evidence base? Int J Nurs Stud 2020; 105:103555. [DOI: 10.1016/j.ijnurstu.2020.103555] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 02/18/2020] [Accepted: 02/26/2020] [Indexed: 02/06/2023]
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9
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Lippi G, Adcock D, Favaloro EJ. Understanding the "philosophy" of laboratory hemostasis. ACTA ACUST UNITED AC 2020; 6:223-226. [PMID: 30827079 DOI: 10.1515/dx-2018-0099] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2018] [Accepted: 11/30/2018] [Indexed: 02/06/2023]
Abstract
Unlike many other areas of laboratory medicine, laboratory hemostasis has some peculiarities, which makes it one of the most complex diagnostic domains in clinical medicine. The inherent complexity of the hemostasis process, the components of which have not yet been thoroughly unravelled, is mirrored by a large number of hemostasis disturbances, which can involve single or multiple components. Although laboratory diagnostics represents an unavoidable part of the diagnostic reasoning in patients with bleeding or thrombotic disorders, the basic concept beneath the assumption that in many human pathologies, one single test may be sufficient for the diagnosis, does not hold true in hemostasis. There are in fact many aspects that would lead us to conclude that laboratory hemostasis can be considered a very challenging arena for many clinicians and perhaps also for some laboratory professionals. The most challenging aspects typically include the following concepts; that hemostasis is an intricate and multifaceted process, that more than one test is typically needed to achieve a final diagnosis, that results of screening tests depend on many biological factors and do not allow making a final diagnosis, that harmonization of techniques is still an unmet target, and that the calculations used vary widely among laboratories. This article is hence aimed at discussing many of these aspects, with the hope of presenting a useful contribution to better understand the "philosophy" of laboratory hemostasis.
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Affiliation(s)
- Giuseppe Lippi
- Section of Clinical Biochemistry, University of Verona, P.le LA Scuro 10, Verona 37134, Italy
| | - Dorothy Adcock
- Laboratory Corporation of AmericaHoldings, Colorado Coagulation, Englewood, CO, USA
| | - Emmanuel J Favaloro
- Department of Haematology, Institute of Clinical Pathology and Medical Research (ICPMR), NSW Health Pathology, Westmead Hospital, Westmead, NSW, Australia
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10
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Bronić A, Coen Herak D, Margetić S, Milić M. Croatian Society of Medical Biochemistry and Laboratory Medicine: National recommendations for blood collection, processing, performance and reporting of results for coagulation screening assays prothrombin time, activated partial thromboplastin time, thrombin time, fibrinogen and D-dimer. Biochem Med (Zagreb) 2019; 29:020503. [PMID: 31223257 PMCID: PMC6559624 DOI: 10.11613/bm.2019.020503] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Accepted: 08/07/2018] [Indexed: 12/20/2022] Open
Abstract
A modern diagnostic laboratory offers wide spectrum of coagulation assays utilized in the diagnosis and management of patients with haemostatic disorders, preoperative screening and anticoagulation therapy monitoring. The recent survey conducted among Croatian medical biochemistry and transfusion laboratories showed the existence of different practice policies in particular phases of laboratory process during coagulation testing and highlighted areas that need improvement. Lack of assay standardization together with non-harmonized test results between different measurement methods, can potentially lead to incorrect decisions in patient’s treatment. Consequently, patient safety could be compromised. Therefore, recommended procedures related to preanalytical, analytical and postanalytical phases of prothrombin time, activated partial thromboplastin time, thrombin time, fibrinogen and D-dimer testing are provided in this review, aiming to help laboratories to generate accurate and reliable test results.
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Affiliation(s)
- Ana Bronić
- Department of Clinical Chemistry, Sestre milosrdnice University Hospital Center, Zagreb, Croatia
| | - Desiree Coen Herak
- Department of Laboratory Diagnostics, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Sandra Margetić
- Department of Clinical Chemistry, Sestre milosrdnice University Hospital Center, Zagreb, Croatia
| | - Marija Milić
- Department of Clinical Laboratory Diagnostics, Osijek University Hospital, Osijek, Croatia.,Faculty of Medicine, University of Osijek, Osijek, Croatia
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11
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Laboratory testing for lupus anticoagulant (LA) in patients taking direct oral anticoagulants (DOACs): potential for false positives and false negatives. Pathology 2019; 51:292-300. [DOI: 10.1016/j.pathol.2018.11.008] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 11/04/2018] [Accepted: 11/08/2018] [Indexed: 01/06/2023]
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12
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Favaloro EJ. Danger of false negative (exclusion) or false positive (diagnosis) for ‘congenital thrombophilia’ in the age of anticoagulants. ACTA ACUST UNITED AC 2018; 57:873-882. [DOI: 10.1515/cclm-2018-1041] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Accepted: 11/05/2018] [Indexed: 11/15/2022]
Abstract
Abstract
Background
Most guidelines and experts recommend against performance of thrombophilia testing in general, and specifically against testing patients on pharmacological anticoagulants, due to substantially increased risk of false positive identification. For example, vitamin K antagonist (VKA) therapy affects protein C (PC) and protein S (PS), as well as some clotting assays (e.g. as used to investigate activated PC resistance [APCR]). Although heparin may also affect clotting assays, most commercial methods contain neutralisers to make them ‘insensitive’ to therapeutic levels. Direct oral anticoagulants (DOACs) also affect a wide variety of thrombophilia assays, although most reported data has employed artificial in vitro spiked samples.
Methods
In the current report, data from our facility for the past 2.5 years has been assessed for all ‘congenital thrombophilia’ related tests, as evaluated against patient anticoagulant status. We processed 10,571 ‘thrombophilia’ related test requests, including antithrombin (AT; n=3470), PC (n=3569), PS (n=3585), APCR (n=2359), factor V Leiden (FVL; n=2659), and prothrombin gene mutation (PGM; n=2103).
Results
As expected, VKA therapy affected PC and PS, and despite manufacturer claims, also APCR. Most assays, as suggested by manufacturers, were largely resistant to heparin therapy. DOACs’ use was associated with falsely low APCR ratios (i.e. FVL-like effect) and somewhat unexpectedly, anti-Xa agents apixaban and rivaroxaban were also associated with lower AT and higher PS values.
Conclusions
It is concluded that ex-vivo data appears to confirm the potential for both false positive and false negative ‘thrombophilia’ events in patients on anticoagulant (including DOAC) treatment.
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Affiliation(s)
- Emmanuel J. Favaloro
- Haematology , Institute of Clinical Pathology and Medical Research, NSW Health Pathology, Westmead Hospital , Westmead, NSW 2145 , Australia
- Sydney Centres for Thrombosis and Haemostasis , Sydney, NSW , Australia , Phone: +612 8890 6618
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13
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Favaloro EJ, McVicker W, Mohammed S, Hamdam S. Mathematical rounding as a post-analytical issue in pathology reporting: generation of bias in INR resulting. Pathology 2018; 50:459-461. [PMID: 29731140 DOI: 10.1016/j.pathol.2017.11.090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Revised: 11/06/2017] [Accepted: 11/13/2017] [Indexed: 10/17/2022]
Affiliation(s)
- Emmanuel J Favaloro
- Department of Haematology, Institute of Clinical Pathology and Medical Research, NSW Health Pathology, Westmead Hospital, Westmead, NSW, Australia; Sydney Centres for Thrombosis and Haemostasis, Westmead, NSW, Australia.
| | - Wendy McVicker
- Department of Haematology, Institute of Clinical Pathology and Medical Research, NSW Health Pathology, Westmead Hospital, Westmead, NSW, Australia
| | - Soma Mohammed
- Department of Haematology, Institute of Clinical Pathology and Medical Research, NSW Health Pathology, Westmead Hospital, Westmead, NSW, Australia
| | - Sayed Hamdam
- NSW Health Pathology, Blacktown Hospital, Blacktown, NSW, Australia
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Favaloro EJ, Lippi G. On the complexity of hemostasis and the need for harmonization of test practice. ACTA ACUST UNITED AC 2018; 56:1568-1574. [DOI: 10.1515/cclm-2018-0174] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Affiliation(s)
- Emmanuel J. Favaloro
- Department of Haematology , Institute of Clinical Pathology and Medical Research (ICPMR), NSW Health Pathology, Westmead Hospital , Westmead, NSW, 2145 , Australia
- Sydney Centres for Thrombosis and Haemostasis , Westmead, NSW , Australia , Phone: +(612) 8890 6618, Fax: +(612) 9689 2331
| | - Giuseppe Lippi
- Section of Clinical Biochemistry , Department of Neurological, Biomedical and Movement Sciences , University of Verona , Verona , Italy
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15
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Replacing warfarin therapy with the newer direct oral anticoagulants, or simply a growth in anticoagulation therapy? Implications for pathology testing. Pathology 2017; 49:639-643. [DOI: 10.1016/j.pathol.2017.04.011] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Revised: 04/08/2017] [Accepted: 04/13/2017] [Indexed: 11/18/2022]
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16
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Favaloro EJ. Optimizing the Verification of Mean Normal Prothrombin Time (MNPT) and International Sensitivity Index (ISI) for Accurate Conversion of Prothrombin Time (PT) to International Normalized Ratio (INR). Methods Mol Biol 2017; 1646:59-74. [PMID: 28804818 DOI: 10.1007/978-1-4939-7196-1_4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
The Prothrombin Time (PT) assay is the most common test performed in hemostasis laboratories, most commonly as converted to an international normalized ratio (INR) to monitor anticoagulant therapy using vitamin K antagonists (VKAs) such as warfarin. Although the INR is meant to standardize PT values by taking into consideration reagent and instrument variability, substantial inter-laboratory variation in INRs still exists and suggests that this can be further improved. This paper describes the PT test, its conversion to an INR value, and methods to improve the accuracy of INRs by improving the determination of critical components to the INR, namely the mean normal prothrombin time (MNPT) and the international sensitive index (ISI).
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Affiliation(s)
- Emmanuel J Favaloro
- Haematology Department, Sydney Centres for Thrombosis and Haemostasis, Institute of Clinical Pathology and Medical Research (ICPMR), Westmead Hospital, NSW Health Pathology, Westmead, NSW, 2145, Australia.
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17
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Bonar RA, Lippi G, Favaloro EJ. Overview of Hemostasis and Thrombosis and Contribution of Laboratory Testing to Diagnosis and Management of Hemostasis and Thrombosis Disorders. Methods Mol Biol 2017; 1646:3-27. [PMID: 28804815 DOI: 10.1007/978-1-4939-7196-1_1] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Hemostasis is a complex and tightly regulated process whereby the body attempts to maintain a homeostatic balance to permit normal blood flow, without bleeding or thrombosis. When this balance is disrupted, due to trauma or underlying congenital bleeding or thrombotic disorders, clinical intervention may be required. To assist clinicians in diagnosing and managing affected patients, hemostasis laboratories offer an arsenal of tests, both routine (screening) and more specialized (diagnostic). In general, screening assays are used to screen for hemostasis-related disease or to monitor or measure the effect of anticoagulant therapy, which may be applied to treat patients with recent thrombosis or at risk of thrombosis. Diagnostic assays are used to diagnose or exclude specific hemostasis-related diseases, and in some cases, to monitor or measure the effect of anticoagulant therapy, or alternatively procoagulant therapy that may be applied to those at risk of bleeding. This chapter provides an overview of hemostasis and thrombosis with respect to laboratory tests that may be applied to affected patients.
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Affiliation(s)
- Roslyn A Bonar
- Royal College of Pathologists of Australasia Quality Assurance Program (RCPAQAP) Haematology, Suite 201, Level 2, 8 Herbert Street, St Leonards, NSW, Australia.
| | - Giuseppe Lippi
- Section of Clinical Biochemistry, University of Verona, Verona, Italy
| | - Emmanuel J Favaloro
- Haematology Department, Sydney Centres for Thrombosis and Haemostasis, Institute of Clinical Pathology and Medical Research (ICPMR), Westmead Hospital, NSW Health Pathology, Westmead, NSW, 2145, Australia
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