Phlebotomy, a bridge between laboratory and patient

A survey on the practice of phlebotomy in Lithuania and adherence to the EFLM-COLABIOCLI recommendations: continuous training and clear standard operating procedures as tools for better quality

Introduction

The aim of this study was to determine the level of compliance of venous blood sampling (VBS) in Lithuania with the joint recommendations of the European Federation of Clinical Chemistry and Laboratory Medicine and the Latin American Confederation of Clinical Biochemistry (EFLM-COLABIOCLI) and to analyse possible causes of errors. A survey was conducted between April and September 2022.

Materials and methods

A self-designed questionnaire was distributed to the Lithuanian National Societies. Error frequencies and compliance score were computed. Differences between groups were analysed using Pearson's chi-square, Fisher's exact criterion, Mann-Whitney U (for two groups), or Kruskal-Wallis (for more than two groups) for categorical and discrete indicators. The association between ordinal and discrete variables was assessed using Spearman's rank correlation coefficient. Statistical significance was determined at P < 0.05.

Results

A total of 272 respondents completed the questionnaire. Median error rate and compliance score were 31.5% and 13/19, respectively. Significant differences were found among professional titles, standard operating procedures availability, training recency, and tourniquet purpose opinions. A negative correlation was noted between compliance and time since training (rs = - 0.28, P < 0.001).

Conclusions

The findings of this study indicate that there is a significant need for improvement in compliance with the EFLM-COLABIOCLI recommendations on VBS among specialists in Lithuania. Essential measures include prioritizing ongoing phlebotomy training and establishing national guidelines. Harmonisation of blood collection practices across healthcare institutions is crucial.

Effect of the 35 nm and 70 nm Size Exclusion Chromatography (SEC) Column and Plasma Storage Time on Separated Extracellular Vesicles

The technical difficulty of separating extracellular vesicles (EVs) from plasma proteins in human blood presents a significant hurdle in EV research, particularly during nano ultra-high-performance liquid chromatography-tandem mass spectrometric (UHPLC-MS/MS) analysis, where detecting "vesicular" proteins among abundant plasma proteins is challenging. Standardisation is a pressing issue in EV research, prompting collaborative global efforts to address it. While the MISEV guidelines offer valuable recommendations, unanswered questions remain, particularly regarding sample storage. We compared size exclusion chromatography (SEC) columns with pore sizes of 35 nm and 70 nm to identify fractions with minimal contaminating proteins and the highest concentration of small EVs (sEVs). Following column selection, we explored potential differences in the quality and quantity of sEVs isolated from platelet-free plasma (PFP) after long-term storage at -80 °C (>2.5 years) compared to freshly drawn blood. Our methodologically rigorous study indicates that prolonged storage, under correct storage and processing conditions, does not compromise sEV quality. Both columns effectively isolated vesicles, with the 70 nm column exhibiting a higher abundance of "vesicular" proteins. We propose a relatively rapid and moderately efficient protocol for obtaining a comparatively pure sEV fraction from plasma, facilitating sEV processing in clinical trials.

Beware of little expenses: Low-value endocrinological blood tests in geriatric medical inpatients

OBJECTIVES

Blood tests for endocrinological derangements are frequently requested in general medical inpatients, in particular those in the older age group. Interrogation of these tests may present opportunities for healthcare savings.

METHODS

This multicentre retrospective study over a 2.5-year period examined the frequency with which three common endocrinological investigations [thyroid stimulating hormone (TSH), HbA1c, 25-hydroxy Vitamin D3] were performed in this population, including the frequency of duplicate tests within a given admission, and the frequency of abnormal test results. The Medicare Benefits Schedule was used to calculate the cost associated with these tests.

RESULTS

There were 28,564 individual admissions included in the study. Individuals ≥65 years old were the majority of inpatients in whom the selected tests were performed (80% of tests). TSH was performed in 6730 admissions, HbA1c was performed in 2259 admissions, and vitamin D levels were performed in 5632 admissions. There were 6114 vitamin D tests performed during the study period, of which 2911 (48%) returned outside the normal range. The cost associated with vitamin D level testing was $183,726. Over the study period, 8% of tests for TSH, HbA1c, and Vitamin D were duplicates (where a second test was performed within a single admission), which was associated with a cost of $32,134.

CONCLUSIONS

Tests for common endocrinological abnormalities are associated with significant healthcare costs. Avenues by which future savings may be pursued include the investigation of strategies to reduce duplicate ordering and examining the rationale and guidelines associated with ordering tests such as vitamin D levels.

Blood alcohol concentration in the clinical laboratory: a narrative review of the preanalytical phase in diagnostic and forensic testing

The analysis of blood alcohol concentration (BAC), a pivotal toxicological test, concerns acute alcohol intoxication (AAI) and driving under the influence (DUI). As such, BAC presents an organizational challenge for clinical laboratories, with unique complexities due to the need for forensic defensibility as part of the diagnostic process. Unfortunately, a significant number of scientific investigations dealing with the subject present discrepancies that make it difficult to identify optimal practices in sample collection, transportation, handling, and preparation. This review provides a systematic analysis of the preanalytical phase of BAC that aims to identify and explain the chemical, physiological, and pharmacological mechanisms underlying controllable operational factors. Nevertheless, it seeks evidence for the necessity to separate preanalytical processes for diagnostic and forensic BAC testing. In this regard, the main finding of this review is that no literature evidence supports the necessity to differentiate preanalytical procedures for AAI and DUI, except for the traceability throughout the chain of custody. In fact, adhering to correct preanalytical procedures provided by official bodies such as European federation of clinical chemistry and laboratory medicine for routine phlebotomy ensures both diagnostic accuracy and forensic defensibility of BAC. This is shown to depend on the capability of modern pre-evacuated sterile collection tubes to control major factors influencing BAC, namely non-enzymatic oxidation and microbial contamination. While certain restrictions become obsolete with such devices, as the use of sodium fluoride (NaF) for specific preservation of forensic BAC, this review reinforces the recommendation to use non-alcoholic disinfectants as a means to achieve "error-proof" procedures in challenging operational environments like the emergency department.

HyperVein: A Hyperspectral Image Dataset for Human Vein Detection

HyperSpectral Imaging (HSI) plays a pivotal role in various fields, including medical diagnostics, where precise human vein detection is crucial. HyperSpectral (HS) image data are very large and can cause computational complexities. Dimensionality reduction techniques are often employed to streamline HS image data processing. This paper presents a HS image dataset encompassing left- and right-hand images captured from 100 subjects with varying skin tones. The dataset was annotated using anatomical data to represent vein and non-vein areas within the images. This dataset is utilised to explore the effectiveness of dimensionality reduction techniques, namely: Principal Component Analysis (PCA), Folded PCA (FPCA), and Ward's Linkage Strategy using Mutual Information (WaLuMI) for vein detection. To generate experimental results, the HS image dataset was divided into train and test datasets. Optimum performing parameters for each of the dimensionality reduction techniques in conjunction with the Support Vector Machine (SVM) binary classification were determined using the Training dataset. The performance of the three dimensionality reduction-based vein detection methods was then assessed and compared using the test image dataset. Results show that the FPCA-based method outperforms the other two methods in terms of accuracy. For visualization purposes, the classification prediction image for each technique is post-processed using morphological operators, and results show the significant potential of HS imaging in vein detection.

Artificial intelligence in the pre-analytical phase: State-of-the art and future perspectives

The use of artificial intelligence (AI) has become widespread in many areas of science and medicine, including laboratory medicine. Although it seems obvious that the analytical and post-analytical phases could be the most important fields of application in laboratory medicine, a kaleidoscope of new opportunities has emerged to extend the benefits of AI to many manual labor-intensive activities belonging to the pre-analytical phase, which are inherently characterized by enhanced vulnerability and higher risk of errors. These potential applications involve increasing the appropriateness of test prescription (with computerized physician order entry or demand management tools), improved specimen collection (using active patient recognition, automated specimen labeling, vein recognition and blood collection assistance, along with automated blood drawing), more efficient sample transportation (facilitated by the use of pneumatic transport systems or drones, and monitored with smart blood tubes or data loggers), systematic evaluation of sample quality (by measuring serum indices, fill volume or for detecting sample clotting), as well as error detection and analysis. Therefore, this opinion paper aims to discuss the state-of-the-art and some future possibilities of AI in the preanalytical phase.

Validation of the Hem-Col capillary blood collection system for routine laboratory analyses

At home collection of capillary blood using Hem-Col tubes (Labonovum) could offer a solution to patients with chronic conditions, who require frequent laboratory analyses. The collection tubes contain a conservation buffer to stabilize analytes for up to 5 days. In this validation study it was investigated whether analytes are measured accurately in Hem-Col tubes 5 days after collection. Forty-six healthy volunteers donated blood via venepuncture as well as capillary blood by finger prick using Hem-Col tubes. The analytes were measured within 2 h for the venepuncture and after 120 h for the Hem-Col method. The results of each analyte were analysed using Passing-Bablok regression analyses. The analytes that met the predefined acceptance criteria were total cholesterol, LDL-cholesterol, thyroid stimulating hormone (TSH) and glycated haemoglobin (HbA1c). HDL-cholesterol, C-reactive protein (CRP), ferritin, bilirubin total, creatinine, gGT and triglycerides met two out of three acceptance criteria. All other analytes did not meet the predefined criteria. The Hem-Col method is suitable for the measurement of total cholesterol, LDL-cholesterol, thyroid stimulating hormone (TSH) and glycated haemoglobin (HbA1c). However, due to this limited set of valid tests and practical limitations, routine application of this novel collection system in daily practice is limited.

Comparison of outcomes of an 18-gauge vs 16-gauge ultrasound-guided percutaneous renal biopsy: a systematic review and meta-analysis

Background: The needle size used in ultrasound-guided percutaneous renal biopsy significantly influences the efficacy and safety of the procedure. The aim of this study is to perform a comparative analysis of 16-gauge and 18-gauge needles for ultrasound-guided percutaneous renal biopsy.Methods: This systematic review and meta-analysis included randomized controlled trials and observational studies that compared the outcomes of using 18-gauge and 16-gauge needles for ultrasound-guided percutaneous renal biopsy. The efficacy parameters included a mean number of glomeruli obtained and the number of passes, while the safety parameters focused on the rate of complications. We searched multiple databases, assessed the risk of bias, and conducted statistical analyses using appropriate models.Results: Fifteen studies were included. Compared to the 18-gauge needle, the use of 16-gauge needle for the biopsy was associated with the significantly higher mean number of glomeruli obtained (pooled SMD 0.61, 95%CI: 0.32 to 0.89; p < 0.001) and fewer required passes (pooled SMD -0.57, 95%CI: -0.97 to -0.18; p = 0.004). No significant difference was observed in the individual safety parameters, including pain, hematuria, need for blood transfusion, major, and minor complications. However, the use of 16-gauge needle was associated with higher odds of total complications (pooled OR 1.57, 95%CI: 1.16 to 2.13; p = 0.004).Conclusion: While the 16-gauge needle for ultrasound-guided percutaneous renal biopsy offers improved efficacy in terms of a higher mean number of glomeruli and fewer required passes, it is associated with higher total complications. A judicious needle size selection that would consider patient-specific factors and risk-benefit ratio, is crucial for optimizing patient outcomes.

A Case of Axillary Web Syndrome Caused by Venous Blood Sampling

Axillary web syndrome (AWS) occurs after breast cancer surgery, sentinel lymph node dissection, or sentinel lymph node biopsy. Here, cord-like structures from the axilla to the forearm limit the range of motion of the shoulder joint and cause pain. Although the etiology is unknown, AWS has been attributed to the blockage of normal lymphatic flow. Here, we report a novel case of AWS after venous blood sampling in a patient. A healthy, 31-year-old male patient experienced pain with a limited range of motion of the shoulder joint the day after venous blood was collected from the left upper extremity for a medical checkup, and he presented to an orthopedic outpatient clinic on the day. Palpation of the axillary region disclosed a cord-like structure in the axillary region of the shoulder joint during abduction, and the patient was diagnosed with AWS. The cord-like structure was noted to be a hypoechogenic luminal structure on ultrasound (US) examination of the axilla, extending from the axilla to below the ulnar cutaneous vein from which the blood was drawn. In patients with pain and a limited range of motion of the shoulder joint, only the shoulder joint is examined during an orthopedic examination. It is important to obtain appropriate physical findings for possible AWS.

Blood microsampling technologies: Innovations and applications in 2022

With the development of highly sensitive bioanalytical techniques, the volume of samples necessary for accurate analysis has reduced. Microsampling, the process of obtaining small amounts of blood, has thus gained popularity as it offers minimal-invasiveness, reduced logistical costs and biohazard risks while simultaneously showing increased sample stability and a potential for the decentralization of the approach and at-home self-sampling. Although the benefits of microsampling have been recognised, its adoption in clinical practice has been slow. Several microsampling technologies and devices are currently available and employed in research studies for various biomedical applications. This review provides an overview of the state-of-the-art in microsampling technology with a focus on the latest developments and advancements in the field of microsampling. Research published in the year 2022, including studies (i) developing strategies for the quantitation of analytes in microsamples and (ii) bridging and comparing the interchangeability between matrices and choice of technology for a given application, is reviewed to assess the advantages, challenges and limitations of the current state of microsampling. Successful implementation of microsampling in routine clinical care requires continued efforts for standardization and harmonization. Microsampling has been shown to facilitate data-rich studies and a patient-centric approach to healthcare and is foreseen to play a central role in the future digital revolution of healthcare through continuous monitoring to improve the quality of life.

Metabolomics for biomarker discovery in schistosomiasis: A systematic scoping review

Background

Metabolomic based approaches are essential tools in the discovery of unique biomarkers for infectious diseases via high-throughput global assessment of metabolites and metabolite pathway dysregulation. This in-turn allows the development of diagnostic tools and provision of therapeutics. In this review, we aimed to give an overview of metabolite biomarkers and metabolic pathway alterations during Schistosoma haematobium and Schistosoma mansoni infections.

Methods

We conducted the review by systematically searching electronic databases and grey literature to identify relevant metabolomics studies on schistosomiasis. Arksey and O’Malley methodology for conducting systematic scoping reviews was applied. A narrative summary of results was conducted following the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for scoping review guidelines.

Results

Twelve articles included in the review identified 127 metabolites, whose concentrations were considerably altered during S. mansoni and S. haematobium infections. The metabolites were assigned to metabolic pathways involved in energy (34.6%), gut microbial (11.0%), amino acid (25.2%), nucleic acids (6.3%), immune proteins (8.7%) hormones (2.4%) and structural proteins/lipids (11.8%). Energy related metabolic pathways were the most affected during schistosome infections with metabolites such as succinate, citrate, aconitate and fumarate of the tricarbocylic acid cycle being significantly altered in organ, serum and plasma samples. Amino acid metabolism was also impacted during schistosome infections as phenylacetylglycine, alanine, taurine, 2-oxoisocaproate and 2-oxoisovalerate emerged as potent biomarkers. Elevated structural proteins such as actin, collagen and keratin concentrations were identified as biomarkers of liver fibrosis, a common pathological feature in chronic schistosomiasis infections. Hippurate was a major metabolite biomarker in the gut microbial related pathway.

Conclusions

The analysis of the literature revealed that energy related metabolic pathways are considerably altered during S. mansoni and S. haematobium infections. Therefore, their metabolites may provide biomarkers for diagnosis and prognosis in addition to providing therapeutics for parasitic infections. This scoping review has identified a need to replicate more schistosomiasis metabolomic studies in humans to complement animal-model based studies.

Standard Venipuncture vs a Capillary Blood Collection Device for the Prospective Determination of Abnormal Liver Chemistry

Background

Abnormal liver function is a common manifestation of human disease and may also occur in approved and investigational medications as drug-induced liver injury (DILI). Capillary blood collection devices may allow for more frequent and convenient measurement outside of the clinic. Validation of such approaches is lacking.

Methods

This prospective, biospecimens collection study evaluated the Tasso+ in patients with abnormal liver tests (NCT05259618). The primary objective was to define the concordance of alanine aminotransferase (ALT) obtained via Tasso+ compared to standard venipuncture. Secondary objectives included measurement of 14 other analytes and patient surveys. At the time of venipuncture, 2 Tasso+ samples were collected: one was centrifuged and shipped, and the other was refrigerated and shipped as whole blood.

Results

Thirty-six patients with elevated ALT values were enrolled. In total, 100 venipuncture, 50 Tasso+ centrifuged, and 48 Tasso+ whole blood samples were obtained. Tasso+ centrifuged samples demonstrated concordance correlation coefficients (CCC) of &gt;0.99 for ALT, alkaline phosphatase (ALP), aspartate aminotransferase (AST), and total bilirubin and CCC &gt;0.95 for albumin, chloride, enzymatic creatinine, serum glucose, magnesium, and phosphorus. Tasso+ whole blood showed CCC of &gt;0.99 for AST, bilirubin total, and enzymatic creatinine and CCC &gt;0.95 for ALT, ALP, albumin, magnesium, and phosphorus. Hemolysis was comparable across the 3 sample types, but its impact was reflected in the Tasso+ potassium data. Patient feedback indicated a very favorable patient experience.

Conclusions

The capillary blood collection device, Tasso+, showed substantial to almost perfect concordance to standard venipuncture for measurement of abnormal liver function. Studies are ongoing to validate longitudinal sampling outside of the clinic.

Clinicaltrials.gov Registration Number: NCT05259618

The societal impact of implementing an at-home blood sampling device for chronic care patients: patient preferences and cost impact

BACKGROUND

Diabetes mellitus, cardiovascular diseases, chronic kidney disease, and thyroid diseases are chronic diseases that require regular monitoring through blood tests. This paper first investigates the experiences of chronic care patients with venipuncture and their expectations of an at-home blood-sampling device, and then assesses the impact on societal costs of implementing such a device in current practice.

METHODS

An online survey was distributed among chronic care patients to gain insight into their experience of blood sampling in current practice, and their expectations of an at-home blood-sampling device. The survey results were used as input parameters in a patient-level monte carlo analysis developed to represent a hypothetical cohort of Dutch chronically ill patients to investigate the impact on societal costs compared to usual care.

RESULTS

In total, 1311 patients participated in the survey, of which 31% experience the time spent on the phlebotomy appointment as a burden. Of all respondents, 71% prefer to use an at-home blood-sampling device to monitor their chronic disease. The cost analysis indicated that implementing an at-home blood-sampling device increases the cost of phlebotomy itself by €27.25 per patient per year, but it reduces the overall societal costs by €24.86 per patient per year, mainly due to limiting productivity loss.

CONCLUSIONS

Patients consider an at-home blood-sampling device to be more user-friendly than venous phlebotomy on location. Long waiting times and crowded locations can be avoided by using an at-home blood-sampling device. Implementing such a device is likely cost-saving as it is expected to reduce societal costs.

Hematology and coagulation preanalytics for clinical chemists: Factors intrinsic to the sample and extrinsic to the patient

In hematology and coagulation, diligence in the preanalytical phase of testing is of critical importance to obtaining reliable test results. If the sample used for testing is unsuitable, even outstanding analytical procedures and technology cannot produce a clinically-reliable result. Therefore, the intent of this manuscript is to review preanalytical factors intrinsic to the sample that affect the hematology and coagulation testing. Factors intrinsic to the sample (excluding in vivo anomalies) can be controlled, theoretically, by phlebotomists (including nurses) and laboratorians in the preanalytical phase of testing. Furthermore, the management and prevention of such factors is highlighted. Erroneous control of preanalytical factors can produce laboratory errors.

Feasibility of 830 nm laser imaging for vein localization in dark skin tissue-mimicking phantoms

Accessing blood vessels by medical professionals has been a challenge in healthcare centers worldwide. The main objective of this work is to investigate the localization of blood vessels in dark skin based on near infrared laser imaging. An 830 nm diode laser was used as a light source to irradiate dark skin mimicking optical phantoms. Phantoms were constructed to simulate dark skin with embedded polymer tubes filled with human blood to mimic subcutaneous veins. Appropriate image processing techniques were also used to enhance the detection and depth resolved differentiation of the vein phantoms. Results show that a linear regression model can represent the relation between the grey level in subcutaneous vein images and the depth of vessels down to 3 mm or deeper (n = 15, R² = 0.88, P < 0.001). The effect of laser power on the system performance is also discussed. Analysis of the collected images demonstrates the feasibility of 830 nm laser imaging for differentiating vein depths under dark skin surface. The proposed method would enhance the localization of invisible subcutaneous veins. This, in turn, would further improve the success rate of related medical procedures such as blood sampling, drawing, in the dark skin population.

Diagnosis and treatment of nerve injury following venipuncture - A report of two cases

BACKGROUND

Venipuncture is one of the one of the most commonly performed, minimally-invasive procedures; however, it may lead to peripheral nerve injury. Here, we describe the diagnosis, treatment, and prognosis of two self-reported cases of nerve injury during venipuncture with the aim of drawing attention to possible needle-related nerve injuries.

CASE

Two anesthesiologists in our hospital experienced an injury of the lateral antebrachial cutaneous branch of the musculocutaneous nerve during venipuncture. Immediately, they underwent ultrasound examinations and nerve blocks with oral medication, resulting in full recovery.

CONCLUSIONS

Ultrasonography is important for the early and confirmative diagnosis of a nerve injury during venipuncture, and for immediate treatment with a nerve block. Moreover, it is imperative for both the practitioner and the patient to be aware of the possible complication of nerve injury after venipuncture.

Microneedle-Based Potentiometric Sensing System for Continuous Monitoring of Multiple Electrolytes in Skin Interstitial Fluids

Electrolytes play a pivotal role in regulating cardiovascular functions, hydration, and muscle activation. The current standards for monitoring electrolytes involve periodic sampling of blood and measurements using laboratory techniques, which are often uncomfortable/inconvenient to the subjects and add considerable expense to the management of their underlying disease conditions. The wide range of electrolytes in skin interstitial fluids (ISFs) and their correlations with those in plasma create exciting opportunities for applications such as electrolyte and circadian metabolism monitoring. However, it has been challenging to monitor these electrolytes in the skin ISFs. In this study, we report a minimally invasive microneedle-based potentiometric sensing system for multiplexed and continuous monitoring of Na⁺ and K⁺ in the skin ISFs. The potentiometric sensing system consists of a miniaturized stainless-steel hollow microneedle to prevent sensor delamination and a set of modified microneedle electrodes for multiplex monitoring. We demonstrate the measurement of Na⁺ and K⁺ in artificial ISFs with a fast response time, excellent reversibility and repeatability, adequate selectivity, and negligible potential interferences upon the addition of a physiologically relevant concentration of metabolites, dietary biomarkers, and nutrients. In addition, the sensor maintains the sensitivity after multiple insertions into the chicken skin model. Furthermore, the measurements in artificial ISFs using calibrated sensors confirm the accurate measurements of physiological electrolytes in artificial ISFs. Finally, the skin-mimicking phantom gel and chicken skin model experiments demonstrate the sensor's potential for minimally invasive monitoring of electrolytes in skin ISFs. The developed sensor platform can be adapted for a wide range of other applications, including real-time monitoring of nutrients, metabolites, and proteins.

Mean Platelet Ratio, Neutrophil to Lymphocyte Ratio, and the Risk of Febrile Seizures in Children Aged 6–59 Months

BACKGROUND: The occurrence of febrile seizure is affected by numerous factors, but some studies indicated that inflammatory cytokines might contribute to the development of febrile seizure. In resource limited settings, complete blood count (CBC) might serve as potential indices for inflammatory response. AIM: The aim of the present study was to determine the role of mean platelet ratio and neutrophil to lymphocyte ratio (NLR) on the risk of febrile seizures in children aged 6–24 months and 25–59 months at S.K. Lerik Regional Public Hospital in Kupang City, East Nusa Tenggara, Indonesia. METHODS: A case-control study was carried out in 104 patients (52 in the case group and 52 in the control group) aged 6–59 months. The CBC tests were taken on the first visit in the emergency room at S.K. Lerik Regional Public Hospital. RESULTS: Our study found that the odds for experiencing febrile seizure in younger children aged 6–24 months were 3.281 (95% confidence interval 1.470, 7.324) times as large as the odds for older children aged 25–59 months. There was a significant but weak correlation between the types of febrile seizure or fever and age of children (r = 0.279; p = 0.012). CONCLUSIONS: Children aged 6–24 months had higher risk of developing febrile seizure, compared to children aged 25–59 months. Further, for each unit decrease in NLR, we expected a 0.883 decrease in the odds for febrile seizures in the case group, compared to control group.

Order of draw of blood samples affect potassium results without K-EDTA contamination during routine workflow

Introduction

A specific sequence is recommended for filling blood tubes during blood collection to prevent erroneous test results due to carryover of additives. However, requirement of this procedure is still debatable. This study was aimed to investigate the potassium ethylenediaminetetraacetic acid (K-EDTA) contamination in blood samples taken after a tube containing the additive during routine workflow. The study was also carried out to examine the effect of order of draw on potassium results, regardless of K-EDTA contamination.

Materials and methods

In 388 outpatients, to determine the probability of K-EDTA cross-contamination, blood was drawn sequentially into a serum tube, followed by a tube containing K-EDTA, and by another serum tube. In another 405 outpatients, to evaluate the effect of order of draw blood unrelated to K-EDTA contamination, two serum tube were successively collected. Potassium was measured on Cobas 6000 c501 analyser (Roche Diagnostic GmbH, Mannheim, Germany) by indirect ion selective electrode method.

Results

Of paired samples collected before and after a K-EDTA tube, 24% had a potassium difference of above 0.3 mmol/L. However, no EDTA contamination was detected in these samples as well as 95% confidence intervals (CI) of limits of agreement for calcium were within the allowable error limits based on reference change values. Interestingly, of blood samples drawn successively, 24% had also a difference greater than 0.3 mmol/L for potassium.

Conclusion

Incorrect order of draw using closed blood collection system does not cause K-EDTA contamination, even in routine workflow. However, regardless of K-EDTA contamination, order of draw has significant influence on the potassium results.

Verification of technical characteristics and performance of VeinViewer Flex, ICEN IN-G090-2 and AccuVein AV400 transillumination devices

BACKGROUND AND AIM

Transilluminator device allow healthcare professionals to visualize peripheral veins without using tourniquet. Aim of the study was to test the ability of three devices (Christie VeinViewer Flex (Christie, Lake Mary, Florida, USA), ICEN IN-G090-2 (ICEN Technology Company Limited, Guangdong, China) and AccuVein AV400 (AccuVein, New York, USA)) to present quality images thought defined criterion.

MATERIALS AND METHODS

Study was designed as a comparison of technical characteristics, evaluation of image quality and assessment of applicability in different conditions (different viewing angels, conditions of lightning and image visibility under interference of humidity and body lotions) in reference person on two venipuncture sites.

RESULTS

Devices have different technical characteristics and vary in optimal distance for good quality image (18-30 cm), number of presented veins (1-4), image dimension (6.0-90.3 cm²), length (1.5-8.0 cm) and thickness (2-5 mm) of the dominant blood vessel. Devices present different image visibility under different viewing angels, conditions of lightning and interference of humidity and body lotions (from good quality to unusable images).

CONCLUSION

Transillumination devices differ in their technical characteristics and performance. The choice of the device should be based on the needs of the particular patient population and the intended use of the device.

Competitive Real-Time Near Infrared (NIR) Vein Finder Imaging Device to Improve Peripheral Subcutaneous Vein Selection in Venipuncture for Clinical Laboratory Testing

In this study, near-infrared (NIR) technology was utilized to develop a low-cost real-time near infrared (NIR) guiding device for cannulation. A portable device that can be used by medical practitioners and also by students for their skills development training in performing cannulation. Methods. First, is the development of a reflectance type optical vein finder using three (3) light emitting diode (LED) lights with 960 nm wavelength, complementary metal-oxide-semiconductor-infrared (CMOS-IR) sensor camera with 1920 × 1080 UXGA (1080P), IR filter set for the given wavelength, and an open-source image processing software. Second, is the actual in-vitro human testing in two sites: the arm and dorsal hand of 242 subjects. The following parameters were included, such as gender, age, mass index (BMI), and skin tone. In order to maximize the assessment process towards the device, the researchers included the arm circumference. This augmented subcutaneous vein imaging study using the develop vein finder device compared the difference in the captured vein images through visual and digital imaging approaches. The human testing was performed in accordance with the ethical standards of the Trinity University of Asia—Institutional Ethics Review Committee (TUA—IERC). Results. The NIR imaging system of the developed vein finder in this study showed its capability as an efficient guiding device through real-time vein pattern recognition, for both sites. Improved captured vein images were observed, having 100% visibility of vein patterns on the dorsal hand site. Fourteen (5.79%) out of 242 subjects reported non-visible peripheral subcutaneous veins in the arm sites. Conclusions. The developed vein finder device with the NIR technology and reflected light principle with low-energy consumption was efficient for real-time peripheral subcutaneous vein imaging without the application of a tourniquet. This might be utilized as a guiding device in locating the vein for the purpose of cannulation, at a very low cost as compared to the commercially available vein finders. Moreover, it may be used as an instructional device for student training in performing cannulation.

Design and Applicability of a Mechanical Impedance Sensor for Vein Penetration Detection

Intravenous needle insertion is typically conducted manually, with needles guided into vessels by feel while looking for a brief flash of blood. This process is imprecise and leads to mispositioned needles, multiple reinsertion attempts, increased procedure time and higher costs for the hospital. We present a method for indicating that the needle has reached the vein by measuring the change in mechanical impedance of the needle as it passes through different tissue layers. Testing in a phantom indicated that this has the potential to identify transitions through tissue boundaries.

Unlocking the Value of White Blood Cells for Heart Failure Diagnosis

Cardiovascular disease (CVD) is the single greatest cause of mortality and morbidity worldwide. Inciting 85% of CVD fatalities is heart failure, often resulting in or from a myocardial infarction. Early detection along with pharmacological treatment and lifestyle adaptation can result in better prognosis. Biomarkers are molecular or physiological measures that indicate disease presence, status, and severity. However, not all forms of heart failure are created equal. Current mainstay biomarkers for heart failure, including NT-pro-BNP and ejection fraction, lack sensitivity for many patients. Circulating white blood cells and peripheral blood mononuclear cells (PBMCs) are emerging as surrogate biopsies, reflecting molecular changes in the heart. We discuss the advantages of PBMCs over other sources, as well as limitations and considerations. We urge medical center biobanks to collect, isolate and store circulating white blood cells as a rich source of biomarkers to catalyze the discovery of novel diagnostic tools for heart failure.

Acceptability of external jugular venepuncture for patients with liver disease and difficult venous access

BACKGROUND

Difficult venous access (DVA) is common in liver patients requiring blood collection using traditional peripheral approaches. This study aimed to understand the experience of DVA for liver patients and the acceptability of peripheral venepuncture versus external jugular venepuncture (EJV). A secondary aim was to explore the impact of EJV on local resource utilization.

METHODS

Semistructured interviews with liver outpatients with DVA (n = 10) requiring venepuncture were firstly themed inductively. We then deductively applied the acceptability framework of Sekhon et al. as a further analytic lens. Audit data from DVA encounters (n = 24) allowed analysis of issues from multiple perspectives. The Consolidated Criteria for Reporting Qualitative Research reporting checklist guides this report.

RESULTS

Peripheral venepuncture had poor prospective, concurrent, and retrospective acceptability, requiring significant mental and physical preparation. Fear, stigma, pain and distress, poor continuity of care, and poor effectiveness led to service disengagement. While EJV caused initial trepidation, it had high concurrent and retrospective acceptability. The significant improvement in patient experience was corroborated by audit data for both procedure duration (5 versus 15 minutes) and first attempt success (100 versus 28.5%) for EJV versus peripheral venepuncture, respectively. While EJV required a recumbent position, it required less staff.

CONCLUSIONS

EJV is highly acceptable to patients, using less time and staff resources. EJV protocols and staff training should be considered where DVA presentations are common. Individualized care plans and careful care coordination could divert DVA patients needing venepuncture to services that use EJV preferentially. HIGHLIGHTS Peripheral venepuncture results in fear, stigma, pain, & distress for those with DVA. This poor acceptability of traditional venepuncture leads to service disengagement. External jugular venepuncture is highly acceptable & improves resource utilization.

Improving Patient Experience of Wait Times and Courtesy Through Electronic Sign-in and Notification in the Phlebotomy Clinic

Context.—

The phlebotomy clinic, which sees on average 900 patients a day, was faced with issues of congestion and noise due to inefficient workflow and processes. The staff called each patient name for his or her turn, and patients were unsure of wait time and position in line. These factors led to unfavorable patient satisfaction regarding wait times and courtesy of the staff.

Objective.—

To improve patients' experience of wait times and courtesy in the phlebotomy clinic through an electronic sign-in and notification system, redesign of the area, and training of employees.

Design.—

An electronic sign-in and notification system was implemented in the phlebotomy clinic. Several sign-in stations and whiteboard wall monitors were installed in the clinic, along with a redesign of the patient flow. A Press Ganey survey was given to patients after their visit which included 3 questions related to wait times, courtesy, and information about delays, respectively. The mean responses for each month between March 2016 and December 2018 were aggregated and compared for each measure.

Results.—

Overall, wait time saw a 7.7% increase in satisfaction score, and courtesy saw a 1.0% increase in satisfaction score during the course of the several interventions that were introduced. The operational efficiency of the clinic also saw a veritable increase because the percent of patients processed within 20 minutes increased by 27%, from 62% (8212 of 13 245 blood draws) to 89% (11 703 of 13 143 blood draws).

Conclusions.—

The interventions implemented proved to increase the patient satisfaction in each of the measures. The electronic sign-in and whiteboards provided valuable information to both patients and staff.

Vein Pattern Locating Technology for Cannulation: A Review of the Low-Cost Vein Finder Prototypes Utilizing near Infrared (NIR) Light to Improve Peripheral Subcutaneous Vein Selection for Phlebotomy

One of the most common means for diagnosis is through medical laboratory testing, which primarily uses venous blood as a sample. This requires an invasive method by cannulation that needs proper vein selection. The use of a vein finder would help the phlebotomist to easily locate the vein, preventing possible pre-analytical error in the specimen collection and even more discomfort and pain to the patient. This paper is a review of the scientific publications on the different developed low-cost vein finder prototypes utilizing camera assisted near infrared (NIR) light technology. Methods: Electronic databases were searched online, these included PubMed (PMC), MEDLINE, Science Direct, ResearchGate, and Institute of Electrical and Electronics Engineers (IEEE) Xplore digital library. Specifically, publications with the terms vein finder prototype, NIR technology, vein detection, and infrared imaging were screened. In addition, reference lists were used to further review related publications. Results: Cannulation challenges medical practitioners because of the different factors that can be reduced by the utilization of a vein finder. A limited number of publications regarding the assessment of personnel performing cannulation were observed. Moreover, variations in methodology, number of patients, type of patients according to their demographics and materials used in the assessment of the developed prototypes were noted. Some studies were limited with regard to the actual human testing of the prototype. Conclusions: The development of a low-cost effective near infrared (NIR) vein finder remains in the phase of improvement. Since, it is being challenged by different human factors, increasing the number of parameters and participants/human for actual testing of the prototypes must also be taken into consideration for possible commercialization. Finally, it was noted that publications regarding the assessment of the performance of phlebotomists using vein finders were limited.

Perceptions on the feasibility of decentralizing phlebotomy services in community anti-retroviral therapy group model in Lusaka, Zambia

BACKGROUND

The focus of the community anti-retroviral therapy Group model is on drug refill, adherence and support groups. However, laboratory services are completely neglected in this model, and stable patient still have to go to the clinic for blood draws after drugs refills from the community. Due to the introduction of new ART drugs, the guidelines now recommend the use of viral loads to guide decision in switching all patients from NNRTI to dolutegravir based first line ART regimens. But the national viral load testing coverage stands at 37% and and falls short of meeting the global UNAIDS and phlebotomy delivery system is congested. The purpose of this study was to identify the perceptions in decentralizing phlebotomy services into the community anti-retroviral therapy Group model.

METHOD

A qualitative case study design was used. Data were collected through ten Focused group discussions among community anti-retroviral therapy Group members, community and health care workers at anti-retroviral therapy clinics and in-depth interviews with five key informants. Data were managed with the help of Nvivo version 10 and analyzed using thematic method.

RESULTS

Positive perceptions were identified as those which contributed to decongesting phlebotomy rooms, reduced missing phlebotomy appointments, work Load, and lost results. Improved quality of phlebotomy service delivery and testing coverage, innovative access to laboratory services and encouraged patient's accountability. The negative perceptions were compromised sample integrity, inability to perform prevention control and patients less contact with clinicians.

CONCLUSION

The study has demonstrated that decentralizing phlebotomy services within the CAG model has greater potential to improve the quality of services delivery for patients. In addition, it has perceived threats on the quality of specimen collected, patient's safety, and health care.

A Way to Avoid Muscular Fibrosis in the First Dorsal Interosseous Muscle after Acupuncture Injection Therapy

Fibrosis of skeletal muscle following acupuncture is an iatrogenic disorder. The present case illustrates a patient with a unilateral fibrotic formation on a thumb muscle after acupuncture injection therapy with red sage. The patient in the present case was a counter-terrorism police officer with right-handedness; he noted a palpable nodule three months after injection therapy at his left first dorsal interosseous in which the acupuncture point LI4 (He Gu) is located. He also found a reduction in the strength of his left pinch grip that noticeably affected his left handgun marksmanship. However, being ambidextrous in single-hand pistol shooting is an essential requirement for counter-terrorism police officers. Based on the patient’s medical history and claims, no underlying disease or trauma was found to be associated with his current complaint. During physical examination, a fibrotic formation in his left first dorsal interosseous muscle was visualized by using diagnostic ultrasound; also, as confirmed with dynamometry, the strength of his left pinch grip was significantly lower than that of the right counterpart. Because acupuncture injection therapy has three components, antiseptic practices, the mechanical action of syringe insertion, and the pharmacological effect of the sterile herb extract, any one of the components may have contributed to the present adverse event. The first dorsal interosseous muscle is small in dimension and rather vascular; thus, it is not an ideal site for intramuscular injection. When a clinician needs to treat a patient by performing acupuncture at the LI4 acupoint and injecting a herbal extract simultaneously, the clinician should only mechanically stimulate the LI4 acupoint while injecting the herbal medicine into the LI14 (Bi Noe) acupoint on the same meridian, the LI14 acupoint being located in the distal portion of the deltoid muscle and being fairly close to the universally agreed upon site on the upper arm for safe administration of an injection.

Preanalytical investigations of phlebotomy: methodological aspects, pitfalls and recommendations

Phlebotomy is often addressed as a crucial process in the pre-analytical phase, in which a large part of laboratory errors take place, but to date there is not yet a consolidated methodological paradigm. Seeking literature, we found 36 suitable investigations issued between 1996 and 2016 (April) dealing with the investigation of pre-analytical factors related to phlebotomy. We found that the largest part of studies had a cohort of healthy volunteers (22/36) or outpatients (11/36), with the former group showing a significantly smaller median sample size (N = 20, IQR: 17.5-30 and N = 88, IQR: 54.5-220.5 respectively, P < 0.001). Moreover, the largest part investigated one pre-analytical factor (26/36) and regarded more than one laboratory test (29/36), and authors preferably used paired Student’s t-test (17/36) or Wilcoxon’s test (11/36), but calibration (i.e. sample size calculation for a detectable effect) was addressed only in one manuscript. The Bland-Altman plot was often the preferred method used to estimate bias (12/36), as well as the Passing-Bablok regression for agreement (8/36). However, often papers did assess neither bias (12/36) nor agreement (24/36). Clinical significance of bias was preferably assessed comparing to a database value (16/36), and it resulted uncorrelated with the size of the effect produced by the factor (P = 0.142). However, the median effect size (ES) resulted significantly larger if the associated factor was clinically significant instead of non-significant (ES = 1.140, IQR: 0.815-1.700 and ES = 0.349, IQR: 0.228-0.531 respectively, P < 0.001). On these evidences, we discussed some recommendations for improving methodological consistency, delivering reliable results, as well as ensuring accessibility to practical evidences.

Urinary free cortisol assessment by liquid chromatography tandem mass spectrometry: a case study of ion suppression due to unacquainted administration of piperacillin

Introduction

Liquid chromatography coupled to atmospheric pressure ionization tandem mass spectrometry (LC-ESI-MS/MS) is currently considered the reference method for quantitative determination of urinary free cortisol (UFC). One of the major drawbacks of this measurement is a particular form of matrix effect, conventionally known as ion suppression.

Materials and methods

We describe here the case of a 66-year-old-patient referred to the daily service of general medicine for intravenous antibiotic administration due to a generalized Staphylococcus aureus infection and for routine 24 hours UFC monitoring in the setting of glucocorticoid replacement therapy.

Results

The observation of 10-fold decrease of internal standard of cortisol signal led us to hypothesize the presence of an ion suppression effect due to a co-eluting endogenous compound. Screening analysis of tandem mass spectrometry (MS/MS) spectra of the interfering molecule, along with in vitro confirmation analyses, were suggestive of the presence of high concentration of piperacillin. The problem was then easily solved with minor modifications of the chromatographic technique.

Conclusions

According to our findings, antibiotic therapy with piperacillin/tazobactam should be regarded as an important interference in UFC assessment, which may potentially affect detection capability, precision and accuracy of this measurement. This case report emphasizes that accurate anamnesis and standardization of all phases of urine collection are essential aspects for preventing potential interference in laboratory testing.

Novel Opportunities for Improving the Quality of Preanalytical Phase. A Glimpse to the Future?

The preanalytical phase is crucial for assuring the quality of in vitro diagnostics. The leading aspects which contribute to enhance the vulnerability of this part of the total testing process include the lack of standardization of different practices for collecting, managing, transporting and processing biological specimens, the insufficient compliance with available guidelines and the still considerable number of preventable human errors. As in heavy industry, road traffic and aeronautics, technological advancement holds great promise for decreasing the risk of medical and diagnostic errors, thus including those occurring in the extra-analytical phases of the total testing process. The aim of this article is to discuss some potentially useful technological advances, which are not yet routine practice, but may be especially suited for improving the quality of the preanalytical phase in the future. These are mainly represented by introduction of needlewielding robotic phlebotomy devices, active blood tubes, drones for biological samples transportation, innovative approaches for detecting spurious hemolysis and preanalytical errors recording software products.

The alcohol used for cleansing the venipuncture site does not jeopardize blood and plasma alcohol measurement with head-space gas chromatography and an enzymatic assay

Introduction

This study aimed to establish whether an alcoholic antiseptic, wiped or not before venipuncture, may jeopardize alcohol testing with a commercial enzymatic assay and a reference head-space gas chromatography (GC) technique.

Materials and methods

Venous blood was collected from 23 healthy volunteers, with two sequential procedures. In the first blood collection, 2 mL of alcoholic antiseptic (0.5% chlorhexidine, 70% ethanol) were place on a gauge pad, the venipuncture site of right arm was cleaned but the antiseptic was not let to dry before phlebotomy. In the second blood collection, 2 mL of the same alcoholic antiseptic were placed on another gauge pad, the venipuncture site of left harm was cleaned and the antiseptic was accurately cleansed before phlebotomy. Ethanol was measured with a reference GC technique in whole blood and EDTA plasma, and a commercial enzymatic assay in EDTA plasma.

Results

No subject complained about feeling a particular itchy sensation when the alcohol was not wiped before puncturing the vein. The concentration of alcohol in all EDTA plasma samples was always lower than the limit of detection of the enzymatic assay (i.e., 2.2 mmol/L; 0.1 g/L). Similarly, alcohol concentration was also undetectable using a reference GC technique (i.e., < 0.22 mmol/L; 0.01 g/L) in EDTA plasma and whole blood.

Conclusion

It seems reasonable to conclude that using ethanol-containing antiseptics before venipuncture may not be causes of spurious or false positive results of alcohol measurement at least when ideal venipunctures can be performed.

Acutely developing, spurious anaemia without actual blood loss. A paradigmatic case report

We describe the case of a 55-year old women admitted at night to the emergency department (ED), complaining for acute abdominal pain lasting for nearly 5 hours. A first blood testing, performed immediately after admission, revealed mild anaemia. A second blood sample, drawn two hours after admission, revealed a considerable decrease of haemoglobin, haematocrit, total white blood cell and platelet counts (between 10-15% reduction). Abdominal ultrasonography was normal and the patient had no signs or symptoms of internal or external haemorrhage. Pre-analytical and analytical errors were accurately excluded. No infusion therapy was administered. After thoughtful discussing the sequence of events, it was ascertained that the first set of blood samples was drawn with the patient in seated position, immediately after ED admission (i.e., approximately 1 min passed from standing to seated position before venipuncture), whereas the second set of blood samples was drawn with the patient lying for two hours in supine position. This case report highlights the importance of standardizing patient position before venous blood collection, along with the crucial role played by cooperation and communication between laboratory and clinical wards for identifying and troubleshooting potential causes of spurious results of in vitro diagnostic testing.

Evaluation of Pain and Specimen Quality by Use of a Novel 25-Gauge Blood Collection Set With Ultra-Thin Wall Cannula and 5-Bevel Tip Design

BACKGROUND

Phlebotomy has significant impact on overall patient satisfaction. Smaller gauge needles, such as a 25 gauge, may lessen patient discomfort but increase hemolysis and tube-filling times. Our studies evaluated the effect of a 5-bevel, 25-gauge blood collection set (BCS) with ultra-thin wall cannula [BD Vacutainer® UltraTouch™ Push Button BCS (UltraTouch)] on patient pain and anxiety compared with two 3-bevel, thin-wall, 23-gauge BCSs [BD Vacutainer® Safety-Lok™ (Safety-Lok) and Greiner Bio-One Vacuette® (Vacuette)]. Our studies also evaluated the 25-gauge UltraTouch for sample quality and tube filling compared with the 3-bevel, thin-wall, 23-gauge BD Vacutainer Push Button BCS.

METHODS

We conducted 2 studies with 214 subjects to compare pain and anxiety regarding future phlebotomy with the 3 aforementioned devices. Another study with 52 subjects assessed hemolysis in specimens collected with the UltraTouch and Push Button BCS; bench testing evaluated tube-filling times with these devices. A questionnaire captured pain upon needle insertion, overall pain, and anxiety regarding future phlebotomy. Hemolysis was evaluated visually, by Hemolysis Index and hemolysis-sensitive indicators potassium (K) and lactate dehydrogenase (LDH).

RESULTS

A statistically significant decrease was noted for overall pain with UltraTouch compared with Vacuette and with insertion pain compared with Safety-Lok. There was no significant difference in anxiety regarding future phlebotomy. No increase was observed in Hemolysis Index, K or LDH. Tube-filling times were comparable for each device.

CONCLUSIONS

The 25-gauge UltraTouch provided less overall pain compared with the 23-gauge Vacuette, less pain upon needle insertion than the 23-gauge Safety-Lok, and no compromise in specimen quality or flow rate.

Blood venous sample collection: Recommendations overview and a checklist to improve quality

The extra-analytical phases of the total testing process have substantial impact on managed care, as well as an inherent high risk of vulnerability to errors which is often greater than that of the analytical phase. The collection of biological samples is a crucial preanalytical activity. Problems or errors occurring shortly before, or soon after, this preanalytical step may impair sample quality and characteristics, or else modify the final results of testing. The standardization of fasting requirements, rest, patient position and psychological state of the patient are therefore crucial for mitigating the impact of preanalytical variability. Moreover, the quality of materials used for collecting specimens, along with their compatibility, can guarantee sample quality and persistence of chemical and physical characteristics of the analytes over time, so safeguarding the reliability of testing. Appropriate techniques and sampling procedures are effective to prevent problems such as hemolysis, undue clotting in the blood tube, draw of insufficient sample volume and modification of analyte concentration. An accurate identification of both patient and blood samples is a key priority as for other healthcare activities. Good laboratory practice and appropriate training of operators, by specifically targeting collection of biological samples, blood in particular, may greatly improve this issue, thus lowering the risk of errors and their adverse clinical consequences. The implementation of a simple and rapid check-list, including verification of blood collection devices, patient preparation and sampling techniques, was found to be effective for enhancing sample quality and reducing some preanalytical errors associated with these procedures. The use of this tool, along with implementation of objective and standardized systems for detecting non-conformities related to unsuitable samples, can be helpful for standardizing preanalytical activities and improving the quality of laboratory diagnostics, ultimately helping to reaffirm a "preanalytical" culture founded on knowledge and real risk perception.