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Gosselin RC, Moore GW, Kershaw GW, Montalvão S, Adcock DM. International Council for Standardization in Haematology Field Study Evaluating Optimal Interpretation Methods for Activated Partial Thromboplastin Time and Prothrombin Time Mixing Studies. Arch Pathol Lab Med 2024; 148:880-889. [PMID: 38031817 DOI: 10.5858/arpa.2023-0030-oa] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/18/2023] [Indexed: 12/01/2023]
Abstract
CONTEXT.— The prothrombin time (PT) and activated partial thromboplastin time (APTT) are screening tests used to detect congenital or acquired bleeding disorders. An unexpected PT and/or APTT prolongation is often evaluated using a mixing test with normal plasma. Failure to correct ("noncorrection") prolongation upon mixing is attributed to an inhibitor, whereas "correction" points to factor deficiency(ies). OBJECTIVE.— To define an optimal method for determining correction or noncorrection of plasma mixing tests through an international, multisite study that used multiple PT and APTT reagents and well-characterized plasma samples. DESIGN.— Each testing site was provided 22 abnormal and 25 normal donor plasma samples, and mixing studies were performed using local PT and APTT reagents. Mixing study results were evaluated using 11 different calculation methods to assess the optimal method based on the expected interpretation for factor deficiencies (correction) and noncorrection (inhibitor effect). Misprediction, which represents the failure of a mixing study interpretation method, was assessed. RESULTS.— Percentage correction was the most suitable calculation method for interpreting PT mixing test results for nearly all reagents evaluated. Incubated PT mixing tests should not be performed. For APTT mixing tests, percentage correction should be performed, and if the result indicates a factor deficiency, this should be confirmed with the subtraction III calculation where the normal pooled plasma result (run concurrently) is subtracted from the mixing test result with correction indicated by a result of 0 or less. In general, other calculation methods evaluated that performed well in the identification of factor deficiency tended to have high misprediction rates for inhibitors and vice versa. CONCLUSIONS.— No single method of mixing test result calculation was consistently successful in accurately distinguishing factor deficiencies from inhibitors, with between-reagent and between-site variability also identified.
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Affiliation(s)
- Robert C Gosselin
- From the Hemostasis & Thrombosis Center, University of California, Davis Health System, Sacramento (Gosselin)
| | - Gary W Moore
- the Department of Haematology, Specialist Haemostasis Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom (Moore)
- the Department of Natural Sciences, Faculty of Science and Technology, Middlesex University, London, United Kingdom (Moore)
| | - Geoffrey W Kershaw
- the Institute of Haematology, Royal Prince Alfred Hospital, Sydney, NSW, Australia (Kershaw)
| | - Silmara Montalvão
- Laboratory Hemostasis and Thrombosis, Hematology and Hemotherapy Center, University of Campinas UNICAMP, Campinas-SP, Brazil (Montalvão)
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Adcock DM, Moore GW, Kershaw GW, Montalvao SAL, Gosselin RC. International Council for Standardization in Haematology (ICSH) recommendations for the performance and interpretation of activated partial thromboplastin time and prothrombin time mixing tests. Int J Lab Hematol 2024. [PMID: 39009028 DOI: 10.1111/ijlh.14344] [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: 03/20/2024] [Accepted: 06/27/2024] [Indexed: 07/17/2024]
Abstract
This guidance document has been prepared on behalf of the International Council for Standardization in Haematology (ICSH). The aim of the document is to provide guidance and recommendations for the performance and interpretation of activated partial thromboplastin time (APTT) and prothrombin time (PT) plasma mixing tests in clinical laboratories in all regions of the world. The following areas are included in this document: preanalytical, analytical, postanalytical, and quality assurance considerations as they relate to the proper performance and interpretation of plasma mixing tests. The recommendations are based on good laboratory practice, published data in peer-reviewed literature, and expert opinion.
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Affiliation(s)
- D M Adcock
- Retired Labcorp, Burlington, North Carolina, USA
| | - G W Moore
- Department of Haematology, Specialist Haemostasis Unit, Cambridge University Hospitals Foundation Trust, Cambridge, UK
- Department of Natural Sciences, Middlesex University, London, UK
| | - G W Kershaw
- Institute of Haematology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - S A L Montalvao
- Laboratory Hemostasis and Thrombosis, Hematology and Hemotherapy Center, University of Campinas UNICAMP, Campinas, Brazil
| | - R C Gosselin
- Hemostasis and Thrombosis Center, University of California, Davis Health System, Sacramento, California, USA
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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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Adcock DM, Moore GW, Montalvão SDL, Kershaw G, Gosselin RC. Activated Partial Thromboplastin Time and Prothrombin Time Mixing Studies: Current State of the Art. Semin Thromb Hemost 2023; 49:571-579. [PMID: 36055261 DOI: 10.1055/s-0042-1756196] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Mixing studies have long been in the clinical laboratory armamentarium for investigating unexpected, prolonged activated partial thromboplastin time (aPTT) or prothrombin time (PT). The purpose of the mixing study is to identify whether the aPTT/PT prolongation is secondary to a factor deficiency versus an inhibitor, which would present as a "corrected" and "noncorrected" mixing study, respectively. The differentiation between a factor deficiency and inhibitor may likely further direct clinical decisions, including additional diagnostic testing or factor replacement therapy. While aPTT/PT mixing studies are simple tests to perform, there is a lack of standardization for both the testing protocol and the interpretation of what is considered to be a corrected or noncorrected mixing study result. This review will describe the common indications for the mixing test, preanalytic variables that may affect mixing study performance, and describe several methods for interpreting the results of aPTT and PT mixing tests.
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Affiliation(s)
| | - Gary W Moore
- Specialist Haemostasis Unit, Department of Haematology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
- Department of Natural Sciences, Middlesex University London, London, United Kingdom
| | - Silmara de Lima Montalvão
- Laboratory Hemostasis, Hematology and Hemotherapy Center, University of Campinas (UNICAMP), Campinas-SP, Brazil
| | - Geoffrey Kershaw
- Institute of Haematology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Robert C Gosselin
- Davis Health System, Hemostasis and Thrombosis Center, University of California, Sacramento, California
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Meijer P, Peyvandi F, Young G, Pruthi R, de Lima Montalvão S, Kitchen S. International Council for Standardization in Haematology recommendations for laboratory measurement of factor VIII and FIX type I inhibitors. Int J Lab Hematol 2023; 45:413-424. [PMID: 37287431 DOI: 10.1111/ijlh.14109] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 05/12/2023] [Indexed: 06/09/2023]
Abstract
This guidance document has been prepared on behalf of the International Council for Standardisation in Hematology. The aim of the document is to provide guidance and recommendations on the measurement of factor VIII (FVIII) and factor IX (FIX) inhibitors. After an introduction on the clinical background and relevance of factor VIII and factor IX inhibitor testing, the following aspects of laboratory testing are included: screening for inhibitors, assay principle, sample requirements, testing requirements and interpretation, quality assurance, interferences and recent developments. This guidance document focusses on recommendations for a standardised procedure for the laboratory measurement of FVIII and FIX type I inhibitors. The recommendations are based on published data in peer-reviewed literature and expert opinion.
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Affiliation(s)
- Piet Meijer
- ECAT Foundation, Voorschoten, The Netherlands
| | - Flora Peyvandi
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Guy Young
- Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, California, USA
| | - Rajiv Pruthi
- Division of Hematology and Hematopathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Silmara de Lima Montalvão
- Laboratory Hemostasis, Hematology and Hemotherapy Center, University of Campinas UNICAMP, Campinas, São Paulo, Brazil
| | - Steve Kitchen
- Sheffield Haemophilia and Thrombosis Centre, Sheffield, UK
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Kitchen S, Adcock DM, Dauer R, Kristoffersen AH, Lippi G, Mackie I, Marlar RA, Nair S. International Council for Standardisation in Haematology (ICSH) recommendations for collection of blood samples for coagulation testing. Int J Lab Hematol 2021; 43:571-580. [PMID: 34097805 DOI: 10.1111/ijlh.13584] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 03/27/2021] [Accepted: 04/02/2021] [Indexed: 01/17/2023]
Abstract
This guidance document has been prepared on behalf of the International Council for Standardisation in Haematology (ICSH). The aim of the document is to provide guidance and recommendations for collection of blood samples for coagulation tests in clinical laboratories throughout the world. The following processes will be covered: ordering tests, sample collection tube and anticoagulant, patient preparation, sample collection device, venous stasis before sample collection, order of draw when different sample types need to be collected, sample labelling, blood-to-anticoagulant ratio (tube filling) and influence of haematocrit. The following areas are excluded from this document, but are included in an associated ICSH document addressing processing of samples for coagulation tests in clinical laboratories: sample transport and primary tube sample stability; centrifugation; interfering substances including haemolysis, icterus and lipaemia; secondary aliquots-transport and storage; and preanalytical variables for platelet function testing. The recommendations are based on published data in peer-reviewed literature and expert opinion.
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Affiliation(s)
- Steve Kitchen
- Sheffield Haemophilia and Thrombosis Centre, Sheffield, UK
| | | | | | - Ann-Helen Kristoffersen
- Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, Bergen, Norway.,Norwegian Organization for Quality Improvement of Laboratory Examinations (Noklus), Haraldsplass Deaconess Hospital, Bergen, Norway
| | - Giuseppe Lippi
- Section of Clinical Biochemistry, University of Verona, Verona, Italy
| | - Ian Mackie
- Research Department of Haematology, University College London, London, UK
| | - Richard A Marlar
- Department of Pathology, University of New Mexico, Albuquerque, NM, USA
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Batty P, Riddell A, Kitchen S, Sardo Infirri S, Walker I, Woods T, Jennings I, Hart DP. Factor VIII/IX inhibitor testing practices in the United Kingdom: Results of a UKHCDO and UKNEQAS national survey. Haemophilia 2021; 27:490-499. [PMID: 33650732 DOI: 10.1111/hae.14158] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 08/07/2020] [Accepted: 09/03/2020] [Indexed: 12/22/2022]
Abstract
INTRODUCTION Inhibitor formation is the greatest challenge facing persons with haemophilia treated with factor concentrates. The gold standard testing methodologies are the Nijmegen-Bethesda assay (NBA) for FVIII and Bethesda assay (BA) for FIX inhibitors, which are affected by pre-analytical and inter-laboratory variability. AIMS To evaluate inhibitor testing methodology and assess correlation between self-reported and actual methodology. METHODS Methodology was evaluated using a survey distributed alongside a UK National External Quality Assessment Service Blood Coagulation external quality assurance (EQA) exercise for FVIII and FIX inhibitor testing. RESULTS Seventy four survey and EQA exercise responses were received (response rate 63.2%), with 50 paired survey/EQA results. 47.1% (33/70) reported using the NBA and 42.9% (30/70) the BA for FVIII inhibitor testing. Review of FVIII inhibitor assay methodology demonstrated discrepancy (self-reported to actual) in 64.3% (BA reporting) and 27.6% (NBA reporting). Pre-analytical heat treatment was used by 32.4%, most commonly 56°C for 30 minutes. Assay cut-offs of 0.1-1.0 BU/mL were reported. EQA samples (acquired FVIII and congenital FIX) demonstrated titres and coefficients of variation (CV) of 3.1 BU/mL (0.7-15.4 BU/mL; CV = 43%) and 18.0 BU/mL (0-117 BU/mL; CV = 33%), respectively. No significant assay or laboratory factors were found to explain this variance, which could have resulted in change in management for 6 patients (5 misclassified high-titre FVIII inhibitors and 1 false negative for a FIX inhibitor). CONCLUSIONS Heterogeneity was seen at each stage of assay methodology. No assay-related factors were found to explain variation in inhibitor titres. Further standardization is required to improve inhibitor quantification to guide patient care.
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Affiliation(s)
- Paul Batty
- The Royal London Hospital Haemophilia Centre, Barts and The London School of Medicine and Dentistry, QMUL, London, UK
| | - Anne Riddell
- Katharine Dormandy Haemophilia Centre and Thrombosis Unit, Royal Free Hospital, London, UK
| | | | - Sofia Sardo Infirri
- The Royal London Hospital Haemophilia Centre, Barts and The London School of Medicine and Dentistry, QMUL, London, UK
| | | | - Tim Woods
- UK NEQAS (Blood Coagulation), Sheffield, UK
| | | | - Daniel P Hart
- The Royal London Hospital Haemophilia Centre, Barts and The London School of Medicine and Dentistry, QMUL, London, UK
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Delianu C, Moscalu M, Hurjui LL, Tărniceriu CC, Bădulescu OV, Lozneanu L, Hurjui I, Goriuc A, Surlari Z, Foia L. Chronometric vs. Structural Hypercoagulability. ACTA ACUST UNITED AC 2020; 57:medicina57010013. [PMID: 33379139 PMCID: PMC7823593 DOI: 10.3390/medicina57010013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 12/15/2020] [Accepted: 12/21/2020] [Indexed: 11/16/2022]
Abstract
Prolonged tourniquet stasis induced by venepuncture can lead to the release of the plasma of cell lysis products, as well as tissue factor (TF), impairing the quality of coagulation test results. The accidental presence of TF in vitro can trigger the coagulation mechanism, generating a false decrease in prothrombin time (PT). Background and Objectives: Identification of short PT tests below the normal reference value that could suggest a situation of hypercoagulability. The study aimed to compare the results of the shortened PT tests at their first determination with the eventual correction following duplication of the analysis from the same sample. Materials and methods: Identification of the shortened PT tests has been carried out for a period of 4 months, upon 544 coagulation samples referred to the Hematology department of Sf. Spiridon County Clinical Emergency Hospital from Iasi, Romania. Results: Out of the 544 samples of which the results indicated a state of hypercoagulability, by repeating the determination from the same sample, for 200 (36.76%) PT tests (p = 0.001) the value was corrected, falling within the normal reference range. For 344 (63.24%) tests, the results suggested a situation of hypercoagulability. Conclusions: In order to guarantee the highest quality of the laboratory services, a proper interpretation and report of the patients' results must be congruent and harmoniously associated to the actual clinical condition of the patient. Duplication of the PT determination from the same sample would exclude situations of false hypercoagulability and would provide significant improvement for the patient's safety.
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Affiliation(s)
- Carmen Delianu
- Department of Biochemistry, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (C.D.); (A.G.); (L.F.)
- Central Clinical Laboratory—Hematology Department, “Sf. Spiridon” County Clinical Emergency Hospital, 700111 Iasi, Romania
| | - Mihaela Moscalu
- Department of Preventive Medicine and Interdisciplinarity, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
- Correspondence: (M.M.); (L.L.H.)
| | - Loredana Liliana Hurjui
- Central Clinical Laboratory—Hematology Department, “Sf. Spiridon” County Clinical Emergency Hospital, 700111 Iasi, Romania
- Department of Morpho-Functional Sciences II, Discipline of Physiology, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania;
- Correspondence: (M.M.); (L.L.H.)
| | - Claudia Cristina Tărniceriu
- Department of Morpho-Functional Sciences I, Discipline of Anatomy, “Grigore T. Popa” University of Medicine and Pharmacy, Universității str. 16, 700115 Iasi, Romania;
- Hematology Clinic, “Sf. Spiridon” County Clinical Emergency Hospital, 700111 Iasi, Romania
| | - Oana-Viola Bădulescu
- Department of Morpho-Functional Sciences II, Discipline of Physiology, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania;
- Hematology Clinic, “Sf. Spiridon” County Clinical Emergency Hospital, 700111 Iasi, Romania
| | - Ludmila Lozneanu
- Department of Morpho-Functional Sciences I, Discipline of Histology, “Grigore T. Popa” University of Medicine and Pharmacy, Universității str. 16, 700115 Iasi, Romania;
- Department of Pathology, “Sf. Spiridon” Emergency County Hospital, 700111 Iasi, Romania
| | - Ion Hurjui
- Department of Morpho-Functional Sciences II, Discipline of Biophysics, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania;
| | - Ancuta Goriuc
- Department of Biochemistry, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (C.D.); (A.G.); (L.F.)
| | - Zinovia Surlari
- Department of Odontology and Parodontology, “Grigore T. Popa” University of Medicine and Pharmacy, Universității str. 16, 700115 Iasi, Romania;
| | - Liliana Foia
- Department of Biochemistry, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (C.D.); (A.G.); (L.F.)
- Central Clinical Laboratory—Biochemistry Department, “Sf. Spiridon” County Clinical Emergency Hospital, 700111 Iasi, Romania
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Favaloro EJ. Coagulation mixing studies: Utility, algorithmic strategies and limitations for lupus anticoagulant testing or follow up of abnormal coagulation tests. Am J Hematol 2020; 95:117-128. [PMID: 31674066 DOI: 10.1002/ajh.25669] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 10/24/2019] [Accepted: 10/28/2019] [Indexed: 01/08/2023]
Abstract
Coagulation testing underpins the investigation of hemostasis and/or monitoring of anticoagulation therapy for prevention and/or treatment of thrombosis related pathology. Assessment of coagulation results requires comparison against a normal reference range or interval (NRR/NRI). Results flagged as "abnormal" (ie, above the NRR/NRI for patients not on anticoagulant therapy), typically require further evaluation. eg, follow up or reflexive testing is used to identify the reason for prolongation, especially when supported by clinical context (eg, bleeding). Mixing tests may have utility to help identify the pathway of follow-up testing (ie, towards investigation of factor deficiencies, or else inhibitors), and are also useful for investigation of lupus anticoagulants (LA). In general, mixing tests that "correct" tend to suggest the presence of factor deficiencies, where as those that do not correct suggest the presence of "inhibitors". Various approaches can be used to identify correction/non-correction, and all have strengths and limitations. Furthermore, eventual identification of causal factor deficiencies or even "inhibitors" may (eg, factor VIII or IX deficiencies or inhibitors) or may not (eg, factor XII deficiency) be clinically important. Ultimately, mixing studies performed in view of appropriate clinical scenarios (eg, bleeding patient) and for LA investigations in symptomatic patients will have best utility.
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Affiliation(s)
- Emmanuel J. Favaloro
- Department of HaematologyInstitute of Clinical Pathology and Medical Research (ICPMR), Sydney Centres for Thrombosis and Haemostasis, NSW Health Pathology, Westmead Hospital Westmead New South Wales Australia
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Abstract
Analytical concerns within hemostasis and thrombosis testing are continuously decreasing. This is essentially attributable to modern instrumentation, improvements in test performance and reliability, as well as the application of appropriate internal quality control and external quality assurance measures. Pre-analytical issues are also being dealt with in some newer instrumentation, which are able to detect hemolysis, icteria and lipemia, and, in some cases, other issues related to sample collection such as tube under-filling. Post-analytical issues are generally related to appropriate reporting and interpretation of test results, and these are the focus of the current overview, which provides a brief description of these events, as well as guidance for their prevention or minimization. In particular, we propose several strategies for improved post-analytical reporting of hemostasis assays and advise that this may provide the final opportunity to prevent serious clinical errors in diagnosis.
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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.
| | - Giuseppe Lippi
- Section of Clinical Biochemistry, University of Verona, Verona, Italy
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Favaloro EJ, Lippi G. Preanalytical issues that may cause misdiagnosis in haemophilia and von Willebrand disease. Haemophilia 2017; 24:198-210. [DOI: 10.1111/hae.13396] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/27/2017] [Indexed: 12/16/2022]
Affiliation(s)
- E. J. Favaloro
- Diagnostic Haemostasis Laboratory; Department of Haematology; Institute of Clinical Pathology and Medical Research (ICPMR); NSW Health Pathology; Westmead Hospital; Westmead NSW Australia
- Sydney Centres for Thrombosis and Haemostasis; Westmead NSW Australia
| | - G. Lippi
- Section of Clinical Biochemistry; University of Verona; Verona Italy
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Batty P, Moore G, Platton S, Maloney J, Palmer B, Bowles L, Pasi J, Rangarajan S, Hart D. Diagnostic accuracy study of a factor VIII ELISA for detection of factor VIII antibodies in congenital and acquired haemophilia A. Thromb Haemost 2017; 114:804-11. [DOI: 10.1160/th14-12-1062] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Accepted: 05/19/2015] [Indexed: 11/05/2022]
Abstract
SummaryAntibody formation to factor VIII (FVIII) remains the greatest clinical and diagnostic challenge to the haemophilia-treating physician. Current guidance for testing for inhibitory FVIII antibodies (inhibitors) recommends the functional Nijmegen-Bethesda assay (NBA). A FVIII ELISA offers a complementary, immunological approach for FVIII antibody testing. It was the aim of this study to retrospectively evaluate the performance of a FVIII ELISA (index) for detection of FVIII antibodies, compared with the NBA (reference). All samples sent for routine FVIII antibody testing at two haemophilia Comprehensive Care Centres, were tested in parallel using the NBA and a solid-phase, indirect FVIII ELISA kit (Immucor). A total of 497 samples from 239 patients (severe haemophilia A=140, non-severe haemophilia A=85, acquired haemophilia A=14) were available for analysis. Sixty-THree samples tested positive by the NBA (prevalence 12.7 %, 95 % confidence interval [CI], 9.9–15.9 %), with a median inhibitor titre of 1.2 BU/ml (range 0.7–978.0). The FVIII ELISA demonstrated a specificity of 94.0 % (95 %CI, 91.3–96.0), sensitivity of 77.8 % (95 %CI, 65.5–87.3), negative predictive value of 96.7 % (95 %CI, 94.5–98.2), positive predictive value 65.3 % (95 %CI, 53.5–76.0), negative likelihood ratio 0.2 (95 %CI, 0.1–0.4), positive likelihood ratio 13.0 (95 %CI, 8.7–19.3) and a diagnostic odds ratio of 54.9 (95 %CI, 27.0–112.0). Strong positive correlation (r=0.77, p< 0.001) was seen between the results of the NBA (log adjusted) and FVIII ELISA optical density. In conclusion, FVIII ELISA offers a simple, specific, surveillance method enabling batch testing of non-urgent samples for the presence of FVIII antibodies.
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13
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Nonneutralizing antibodies against factor VIII and risk of inhibitor development in severe hemophilia A. Blood 2017; 129:1245-1250. [DOI: 10.1182/blood-2016-06-720086] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Accepted: 12/15/2016] [Indexed: 01/22/2023] Open
Abstract
Key Points
Nonneutralizing antibodies against FVIII are detected in untreated or minimally treated patients with hemophilia A. The presence of nonneutralizing antibodies is associated with a substantially increased risk of inhibitor development.
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Adcock DM, Favaloro EJ, Lippi G. Critical pre-examination variables in the hemostasis laboratory and their quality indicators. Clin Biochem 2016; 49:1315-1320. [DOI: 10.1016/j.clinbiochem.2016.08.022] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Revised: 08/30/2016] [Accepted: 08/31/2016] [Indexed: 10/21/2022]
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Doma SA, Hillarp A, Pajič T, Andoljšek D, Černelč P, Preldžnik Zupan I. Concurrent acquired inhibitors to factor VIII and IX, a laboratory artifact: a case report. Biochem Med (Zagreb) 2016; 26:279-84. [PMID: 27346976 PMCID: PMC4910271 DOI: 10.11613/bm.2016.033] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Accepted: 05/21/2016] [Indexed: 11/23/2022] Open
Abstract
Acquired inhibitors to coagulation factors other than factor VIII are extremely rare. We describe a case of a 59-year-old woman with abnormal bleeding, diagnosed with concurrent inhibitor antibodies to factor VIII and IX by Bethesda testing. We demonstrate that anti-FVIII antibodies of a very high titre are capable of disturbing the aPTT-based Bethesda assay, resulting in falsely-positive antibodies to factor IX. The case also illustrates the usefulness of the immunological assay (ELISA) in complementing the inhibitor diagnosis.
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Affiliation(s)
- Saša Anžej Doma
- Department of Hematology, University Medical Centre Ljubljana, Slovenia
| | - Andreas Hillarp
- Department of Clinical Chemistry and Transfusion Medicine, Halland Hospital, Halmstad, Sweden ; at the time of the investigation working at the Coagulation laboratory of Malmö Centre for Thrombosis and Haemostasis, Skane University Hospital, Malmö, Sweden
| | - Tadej Pajič
- Department of Hematology, University Medical Centre Ljubljana, Slovenia
| | - Dušan Andoljšek
- Department of Hematology, University Medical Centre Ljubljana, Slovenia
| | - Peter Černelč
- Department of Hematology, University Medical Centre Ljubljana, Slovenia
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Adcock DM, Favaloro EJ. Pearls and pitfalls in factor inhibitor assays. Int J Lab Hematol 2016; 37 Suppl 1:52-60. [PMID: 25976961 DOI: 10.1111/ijlh.12352] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2015] [Accepted: 03/10/2015] [Indexed: 12/30/2022]
Abstract
The proper performance and interpretation of factor inhibitor assays is a critical role for the hemostasis laboratory. Both false-positive and false-negative inhibitor assays may be reported, leading to serious patient mismanagement. Knowledge and recognition of common causes of both false-positive and negative-results can aid in the identification of these potential pitfalls. Safeguards to reporting accurate factor inhibitor assays include initial characterization of the sample, using the Nijmegen modification, properly performing and interpreting an incubated mixing test in conjunction, and performing two dilutions for each dependent dilution in the factor inhibitor assay.
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Affiliation(s)
- D M Adcock
- Colorado Coagulation, Laboratory Corporation of America® Holdings, Englewood, CO, USA
| | - E J Favaloro
- Department of Haematology, Institute of Clinical Pathology and Medical Research, Pathology West, NSW Health Pathology, Westmead Hospital, Sydney, NSW, Australia
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Mulliez SMN, Vantilborgh A, Devreese KMJ. Acquired hemophilia: a case report and review of the literature. Int J Lab Hematol 2014; 36:398-407. [PMID: 24750687 DOI: 10.1111/ijlh.12210] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2013] [Accepted: 02/24/2014] [Indexed: 11/27/2022]
Abstract
Acquired hemophilia A (AHA) is a rare bleeding disorder caused by autoantibodies against clotting factor VIII (FVIII). FVIII autoantibody is characterized as polyclonal immunoglobulin G directed against the FVIII procoagulant activity. This disease occurs most commonly in the elderly population and with preponderance of men in nonpregnancy-related AHA. There are well-established clinical associations with AHA such as malignancy, other autoimmune diseases and pregnancy. However, up to 50% of reported cases remain idiopathic. The clinical manifestation of AHA includes mostly spontaneous hemorrhages into skin, muscles and soft tissues, or mucous membranes. AHA should be suspected when a patient with no previous history of bleeding presents with bleeding and an unexplained prolonged activated partial thromboplastin time. The diagnosis is confirmed in the laboratory by the subsequent identification of reduced FVIII levels and FVIII inhibitor titration. There is a high mortality, making prompt diagnosis and treatment vitally important. The principles of treatment consist in controlling the bleeding and eradicating the inhibitor. Because of the overall high relapse rate (15-33%), it is also recommended to follow up these patients. The review summarizes what is currently known about the epidemiology, pathogenesis, clinical features, diagnosis, treatment and prognosis of AHA and starts with a case report.
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Affiliation(s)
- S M N Mulliez
- Coagulation Laboratory, Department of Clinical Chemistry, Microbiology and Immunology, Ghent University Hospital, Ghent, Belgium
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18
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Lima-Oliveira G, Salvagno GL, Danese E, Favaloro EJ, Guidi GC, Lippi G. Sodium citrate blood contamination by K2-ethylenediaminetetraacetic acid (EDTA): impact on routine coagulation testing. Int J Lab Hematol 2014; 37:403-9. [DOI: 10.1111/ijlh.12301] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2014] [Accepted: 09/15/2014] [Indexed: 01/12/2023]
Affiliation(s)
- G. Lima-Oliveira
- Laboratory of Clinical Biochemistry; Department of Life and Reproduction Sciences; University of Verona; Verona Italy
- Post-Graduate Program of Pharmaceutical Sciences; Department of Clinical Analyses; Federal University of Parana; Curitiba Parana Brazil
| | - G. L. Salvagno
- Laboratory of Clinical Biochemistry; Department of Life and Reproduction Sciences; University of Verona; Verona Italy
| | - E. Danese
- Laboratory of Clinical Biochemistry; Department of Life and Reproduction Sciences; University of Verona; Verona Italy
| | - E. J. Favaloro
- Department of Haematology; Institute of Clinical Pathology and Medical Research (ICPMR); Pathology West; Westmead Hospital; Westmead NSW Australia
| | - G. C. Guidi
- Laboratory of Clinical Biochemistry; Department of Life and Reproduction Sciences; University of Verona; Verona Italy
- Post-Graduate Program of Pharmaceutical Sciences; Department of Clinical Analyses; Federal University of Parana; Curitiba Parana Brazil
| | - G. Lippi
- Laboratory of Clinical Chemistry and Hematology; Academic Hospital of Parma; Parma Italy
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19
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Chang HH, Chiang BL. The diagnosis and classification of autoimmune coagulopathy: An updated review. Autoimmun Rev 2014; 13:587-90. [DOI: 10.1016/j.autrev.2014.01.032] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/13/2013] [Indexed: 10/25/2022]
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20
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Laboratory identification of factor inhibitors: an update. Pathology 2012; 44:293-302. [PMID: 22531341 DOI: 10.1097/pat.0b013e328353254d] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2011] [Revised: 01/19/2012] [Accepted: 01/29/2012] [Indexed: 11/26/2022]
Abstract
Coagulation factor inhibitors comprise antibodies that bind to and then neutralise specific pro-coagulant plasma proteins. Coagulation factor inhibitors can develop against any coagulation factor, although the most common are against factor VIII (FVIII). These can develop in individuals with inherited haemophilia A (HA) as an immune response to factor replacement therapy, or as auto-antibodies leading to the condition of acquired HA. Clinical suspicion for inhibitors may arise when individuals present with bleeding symptoms without any prior bleeding diathesis, or when a patient with known mild haemophilia presents with a bleeding diathesis more extreme to their usual presentation, or when there is failure of factor replacement therapy to arrest bleeding in a known haemophiliac. The laboratory identification of factor inhibitors requires a careful and systematic approach that excludes other possible causes of prolonged screening tests, most commonly the activated partial thromboplastin time (APTT), and sometimes prothrombin time (PT). Coagulation factor inhibitor studies, including the Bethesda assay, are then undertaken to measure inhibitor titre, which guides treatment. This paper overviews the laboratory investigation of factor inhibitors, and also briefly reviews recent cross-laboratory inhibitor studies and the most recent evidence related to differential inhibitor formation according to type of therapy.
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SAHUD M, ZHUKOV O, MO K, POPOV J, DLOTT J. False-positive results in ELISA-based anti FVIII antibody assay may occur with lupus anticoagulant and phospholipid antibodies. Haemophilia 2012; 18:777-81. [DOI: 10.1111/j.1365-2516.2012.02781.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Favaloro EJ, (Adcock) Funk DM, Lippi G. Pre-analytical Variables in Coagulation Testing Associated With Diagnostic Errors in Hemostasis. Lab Med 2012. [DOI: 10.1309/lm749bqetkypypvm] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
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Favaloro EJ, Wong RCW. Laboratory testing for the antiphospholipid syndrome: making sense of antiphospholipid antibody assays. Clin Chem Lab Med 2011; 49:447-61. [PMID: 21275808 DOI: 10.1515/cclm.2011.064] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
The antiphospholipid syndrome (APS) is an autoimmune condition characterised by a wide range of clinical features (primarily thrombosis and/or obstetric related), associated with the presence of antiphospholipid antibodies (aPL) as detected by a diverse range of laboratory tests. APS remains a significant diagnostic challenge for clinicians across a wide range of specialities, largely due to issues related to laboratory testing as well as the expanding range of reported clinical manifestations of APS. The laboratory issues include limitations in detailed knowledge by both clinical and laboratory personnel regarding the 'complete' range of available aPL tests, as well as ongoing problems with assay reproducibility and standardisation. aPL are identified using diverse laboratory procedures based on one of two distinct test processes, namely solid phase and liquid phase assays. The former includes anticardiolipin antibodies (aCL) and anti-β(2)-glycoprotein I antibodies (aβ(2)GPI). The latter are centred on clot-based tests that are used to identify the so-called lupus anticoagulant (LA). This article will discuss: (i) issues related to laboratory testing for APS in terms of the currently available solid-phase and liquid-phase assays, and identifiable biases resulting from these tests usually being performed in different laboratories; (ii) current problems with calibration, standardisation and reproducibility of these assays; (iii) pre-analytical, analytical and post-analytical considerations and ongoing initiatives for improvement; (iv) issues related to potential combinations/panels of available aPL tests; and (v) the entities of seropositive APS, seronegative APS and non-APS aPL-positivity. In doing so, this review will hopefully help bridge the two disciplines of haematology and immunology ('representing' liquid-phase and solid-phase aPL testing, respectively), by improving the understanding of those working in each of these disciplines of the merits and limitations of the assays performed in the other discipline, and encouraging inter-discipline cooperation in the reporting of aPL test results.
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Affiliation(s)
- Emmanuel J Favaloro
- Department of Haematology, Institute of Clinical Pathology and Medical Research (ICPMR), Westmead Hospital, NSW, Australia.
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Favaloro EJ, Lippi G. Laboratory reporting of hemostasis assays: the final post-analytical opportunity to reduce errors of clinical diagnosis in hemostasis? Clin Chem Lab Med 2010; 48:309-21. [PMID: 20014957 DOI: 10.1515/cclm.2010.061] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The advent of modern instrumentation, with associated improvements in test performance and reliability, together with appropriate internal quality control (IQC) and external quality assurance (EQA) measures, has led to substantial reductions in analytical errors within hemostasis laboratories. Unfortunately, the reporting of incorrect or inappropriate test results still occurs, perhaps even as frequently as in the past. Many of these cases arise due to a variety of events largely outside the control of the laboratories performing the tests. These events are primarily preanalytical, related to sample collection and processing, but can also include post-analytical events related to the reporting and interpretation of test results. The current report provides an overview of these events, as well as guidance for prevention or minimization. In particular, we propose several strategies for the post-analytical reporting of hemostasis assays, and how this may provide the final opportunity to prevent serious clinical errors in diagnosis. This report should be of interest to both the laboratory scientists working in hemostasis and clinicians that request and attempt to interpret the test results. Laboratory scientists are ultimately responsible for these test results, and there is a duty to provide both accurate and precise results to enable clinicians to manage patients appropriately and to avoid the need to recollect and retest. Also, clinicians will not be in a position to best diagnose and manage their patient unless they gain an appreciation of these issues.
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Affiliation(s)
- Emmanuel J Favaloro
- Department of Hematology, Institute of Clinical Pathology and Medical Research ICPMR, Westmead Hospital, SWAHS, Westmead, NSW, Australia.
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LIPPI G, SALVAGNO GL, ADCOCK DM, GELATI M, GUIDI GC, FAVALORO EJ. Right or wrong sample received for coagulation testing? Tentative algorithms for detection of an incorrect type of sample. Int J Lab Hematol 2010; 32:132-8. [DOI: 10.1111/j.1751-553x.2009.01142.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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FAVALORO EJ, BONAR R, KERSHAW G, MOHAMMED S, DUNCAN E, MARSDEN K. Laboratory identification of factor VIII inhibitors in the real world: the experience from Australasia. Haemophilia 2010; 16:662-70. [DOI: 10.1111/j.1365-2516.2009.02173.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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