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Thonon H, Van Nieuwenhove M, Thachil J, Lippi G, Hardy M, Mullier F. Hemostasis Testing in the Emergency Department: A Narrative Review. Semin Thromb Hemost 2024. [PMID: 38897223 DOI: 10.1055/s-0044-1787661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2024]
Abstract
Routine laboratory screening is typically performed at initial evaluation of the vast majority of presentations to the emergency department (ED). These laboratory results are crucial to the diagnostic process, as they may influence up to 70% of clinical decisions. However, despite the usefulness of biological assessments, many tests performed are inappropriate or of doubtful clinical relevance. This overutilization rate of laboratory testing in hospitals, which represents a significant medical-economic burden, ranges from 20 to 67%, with coagulation tests at the top of the list. While reviews frequently focus on nonintensive care units, there are few published assessments of emergency-specific interventions or guidelines/guidance to date. The aim of this review is to highlight current recommendations for hemostasis evaluation in the emergency setting with a specific analysis of common situations leading to ED admissions, such as suspected venous thrombosis or severe bleeding. We revisit the evidence related to the assessment of patient's hemostatic capacity based on comprehensive history taking and physical examination as well as best practice recommendations for blood sample collection to ensure the reliability of results. This review also includes an examination of various currently available point of care tests and a comprehensive discussion on indications, limitations, and interpretation of these tests.
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Affiliation(s)
- Henri Thonon
- Emergency Department, Université catholique de Louvain, CHU UCL Namur, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS), Yvoir, Belgium
| | | | - Jecko Thachil
- Department of Haematology, Manchester University Hospitals, Manchester, United Kingdom
| | - Giuseppe Lippi
- Section of Clinical Biochemistry, University of Verona, Verona, Italy
| | - Michael Hardy
- Department of Anesthesiology, Université catholique de Louvain, CHU UCL Namur, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS), Yvoir, Belgium
| | - François Mullier
- Université catholique de Louvain, CHU UCL Namur, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS), Hematology Laboratory, Yvoir, Belgium
- Institut de Recherche Expérimentale et Clinique (IREC), Pôle Mont, Université catholique de Louvain (UCLouvain), Yvoir, Belgium
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2
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Mahto M, Kumar V, Banerjee A, Kumar S, Kumar A. Pre-analytical errors in coagulation testing: a case series. Diagnosis (Berl) 2024; 11:114-119. [PMID: 38154060 DOI: 10.1515/dx-2023-0110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 12/11/2023] [Indexed: 12/30/2023]
Abstract
OBJECTIVES Prevention of pre-analytical issues in coagulation testing is of paramount importance for good laboratory performance. In addition to common issues like hemolysed, icteric, or lipemic samples, some specific pre-analytical errors of coagulation testing include clotted specimens, improper blood-to-anticoagulant ratio, contamination with other anticoagulants, etc. Prothrombin time (PT) and activated partial thromboplastin time (aPTT) are very commonly affected tests due to pre-analytical variables. The impact these parameters possess on surgical decision-making and various life-saving interventions are substantial therefore we cannot afford laxity and casual mistakes in carrying out these critical investigations at all. CASE PRESENTATION In this case series, a total of 4 cases of unexpectedly deranged coagulation profiles have been described which were reported incorrectly due to the overall casual approach towards these critical investigations. We have also mentioned how the treating clinician and lab physician retrospectively accessed relevant information in the nick of time to bring back reassurance. CONCLUSIONS Like every other critical investigation, analytical errors can occur in coagulation parameters due to various avoidable pre-analytical variables. The release of spurious results for coagulation parameters sets alarm bells ringing causing much agony to the treating doctor and patient. Only a disciplined and careful approach taken by hospital and lab staff towards each sample regardless of its criticality can negate these stressful errors to a large extent.
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Affiliation(s)
- Mala Mahto
- Department of Biochemistry, All India Institute of Medical Sciences, Patna, India
| | - Visesh Kumar
- Department of Biochemistry, Mahamaya Rajkiya Allopathic Medical College, Ambedkarnagar, India
| | - Ayan Banerjee
- Department of Biochemistry, All India Institute of Medical Sciences, Patna, India
| | - Sushil Kumar
- Department of Biochemistry, All India Institute of Medical Sciences, Patna, India
| | - Anurag Kumar
- Department of Biochemistry, All India Institute of Medical Sciences, Patna, India
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3
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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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4
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Negaard BJ, Hobbs R, Frye JR, Merrill AE. Propofol-induced interference with activated partial thromboplastin time-based monitoring of therapeutic heparin anticoagulation. Am J Health Syst Pharm 2023; 80:445-451. [PMID: 36370416 DOI: 10.1093/ajhp/zxac337] [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: 11/10/2022] [Indexed: 11/13/2022] Open
Abstract
PURPOSE The activated partial thromboplastin time (aPTT) is a coagulation assay commonly utilized for monitoring therapeutic heparin anticoagulation. aPTT methods based on optical detection are vulnerable to spectral interference from hemolysis, icterus, lipemia, and other substances. Intravenous lipid emulsions of primarily 20% have been shown to interfere with multiple clinical laboratory assays, including those measuring aPTT by optical methods, but there is limited data on propofol's effect. The primary objective of this study was to determine the rate of interference of propofol with aPTT measurements in patients receiving both propofol and intravenous heparin. METHODS A retrospective observational cohort study of intensive care unit patients who received concomitant propofol and heparin infusions (N = 38 patients) and whose heparin therapy was monitored by aPTT (N = 531 aPTTs) was conducted. Review of the electronic medical record was completed to obtain relevant clinical and laboratory data, while the laboratory information system was queried for analytical interference with the aPTT assay. RESULTS A total of 109 aPTTs (21%) spanning 21 patients (55%) had documented aPTT interference. All 21 patients had at least one aPTT requiring ultracentrifugation prior to reporting, and 12 aPTTs from 4 patients were unreportable due to interference. Patients with and without aPTT interference received similar doses of propofol. None of the cases of aPTT interference were caused by hemolysis or hyperbilirubinemia. CONCLUSION A potential medication-assay interaction was observed in approximately half of patients who received concomitant propofol and heparin infusions and had aPTT measured for anticoagulation management. Sample ultracentrifugation removes the optical interference in most cases but significantly prolongs aPTT reporting and delays appropriate adjustments to heparin dosing.
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Affiliation(s)
- Briana J Negaard
- Department of Pharmacy, Indiana University Health Methodist Hospital, Indianapolis, IN, USA
| | - Ryan Hobbs
- Department of Pharmaceutical Care, University of Iowa Hospitals & Clinics, Iowa City, IA, USA
| | - Jared R Frye
- Department of Pharmaceutical Care, University of Iowa Hospitals & Clinics, Iowa City, IA, USA
| | - Anna E Merrill
- Department of Pathology, University of Iowa Hospitals & Clinics, Iowa City, IA, USA
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5
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Sachs UJ. Pitfalls in Coagulation Testing. Hamostaseologie 2023; 43:60-66. [PMID: 36807821 DOI: 10.1055/a-1981-7939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023] Open
Abstract
Assays in the coagulation laboratory are affected by numerous variables. Variables which have impact on the test result can lead to incorrect results, and potentially to consequences for further diagnostic and therapeutic decisions made by the clinician. The interferences can be separated into three main groups: biological interferences, with an actual impairment of the patient's coagulation system (congenital or acquired); physical interferences, which usually occur in the pre-analytical phase; and chemical interferences, because of the presence of drugs (mainly anticoagulants) in the blood to be tested. This article discusses some of these interferences in seven instructive cases of (near) miss events as an approach to generate more attention to these issues.
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Affiliation(s)
- Ulrich J Sachs
- Department of Thrombosis and Haemostasis, Giessen University Hospital, Giessen, Germany.,Institute for Clinical Immunology, Transfusion Medicine, and Haemostasis, Justus Liebig University, Giessen, Germany
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6
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Favaloro EJ, Gosselin RC, Pasalic L, Lippi G. Post-analytical Issues in Hemostasis and Thrombosis Testing: An Update. Methods Mol Biol 2023; 2663:787-811. [PMID: 37204753 DOI: 10.1007/978-1-0716-3175-1_53] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
There are typically three phases identified as contributing to the total testing process. The preanalytical phase starts with the clinician and the patient, when laboratory testing is being considered. This phase also includes decisions about which tests to order (or not), patient identification, blood collection, blood transport, sample processing, and storage to name a few. There are many potential failures that may occur in this preanalytical phase, and these are the topic of another chapter in this book. The second phase, the analytical phase, represents the performance of the test, which is essentially covered in various protocols in this book and the previous edition. The third is the post-analytical phase, which is what occurs after sample testing, and is the topic of the current chapter. Post-analytical issues are generally related to reporting and interpretation of test results. This chapter provides a brief description of these events, as well as guidance for preventing or minimizing post-analytical issues. In particular, there are several strategies for improved post-analytical reporting of hemostasis assays, with this providing the final opportunity to prevent serious clinical errors in patient diagnosis or management.
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Affiliation(s)
- Emmanuel J Favaloro
- School of Medical Sciences, Faculty of Medicine and Health University of Sydney, Westmead Hospital, Westmead, NSW, Australia.
- School of Dentistry and Medical Sciences, Faculty of Science and Health, Charles Sturt University, Wagga, Wagga, NSW, Australia.
| | - Robert C Gosselin
- Hemostasis & Thrombosis Center, University of California, Davis Health System, Sacramento, CA, USA
| | - Leonardo Pasalic
- Department of Haematology, Sydney Centres for Thrombosis and Haemostasis, Institute of Clinical Pathology and Medical Research (ICPMR), NSW Health Pathology, Westmead Hospital, Westmead, NSW, Australia
- Westmead Clinical School, University of Sydney, Westmead, NSW, Australia
| | - Giuseppe Lippi
- Section of Clinical Biochemistry, University of Verona, Verona, Italy
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7
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Wauthier L, Favresse J, Hardy M, Douxfils J, Le Gal G, Roy P, van Es N, Ay C, ten Cate H, Lecompte T, Lippi G, Mullier F. D-dimer testing: A narrative review. Adv Clin Chem 2023. [DOI: 10.1016/bs.acc.2023.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/31/2023]
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8
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D-dimer Testing in Pulmonary Embolism with a Focus on Potential Pitfalls: A Narrative Review. Diagnostics (Basel) 2022; 12:diagnostics12112770. [PMID: 36428830 PMCID: PMC9689068 DOI: 10.3390/diagnostics12112770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 11/08/2022] [Accepted: 11/09/2022] [Indexed: 11/15/2022] Open
Abstract
D-dimer is a multifaceted biomarker of concomitant activation of coagulation and fibrinolysis, which is routinely used for ruling out pulmonary embolism (PE) and/or deep vein thrombosis (DVT) combined with a clinical pretest probability assessment. The intended use of the tests depends largely on the assay used, and local guidance should be applied. D-dimer testing may suffer from diagnostic errors occurring throughout the pre-analytical, analytical, and post-analytical phases of the testing process. This review aims to provide an overview of D-dimer testing and its value in diagnosing PE and discusses the variables that may impact the quality of its laboratory assessment.
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9
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Uncommon defibrinogenation and coagulopathy caused by Trimeresurus stejnegeri stejnegeri envenomation in a patient with swelling above the ankle. Toxicon 2022; 217:143-147. [PMID: 35987354 DOI: 10.1016/j.toxicon.2022.08.011] [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: 06/08/2022] [Revised: 07/27/2022] [Accepted: 08/11/2022] [Indexed: 11/22/2022]
Abstract
In Taiwan, Trimeresurus stejnegeri stejnegeri (Stejneger's Bamboo pitviper) is responsible for more than half of all venomous snakebites annually. This species often causes local envenoming characterized by tissue swelling and pain, occasional local ecchymosis, bullae and blister formation, and lymphangitis and lymphadenitis. The pathophysiology and treatment of potentially life-threatening coagulopathy and defibrinogenation induced by T. s. stejnegeri systemic envenoming have not been specifically addressed. Here, we describe the case of a man who was bitten by T. s. stejnegeri on his right first toe, which later developed into swelling above the ankle. It was found that there was severe hypofibrinogenemia, prolonged prothrombin time, and reduced activities of factors V and XI, plasminogen, and α2-antiplasmin. Even though a favorable outcome was achieved after repeatedly administering specific antivenom, fresh frozen plasma, and cryoprecipitate, probably low effectiveness of antivenom against the coagulopathy and prodigious amounts of replacement products were observed. To control coagulopathy early and avoid the needless replacement of coagulation factor, which are associated with inherent adverse reactions, more frequent serial blood assessment (e.g., every 6 h) and higher initial antivenom doses may be helpful. Knowledge of the specific coagulation factor deficiencies may improve our understanding of the relationship between hemotoxins and the resulting envenoming syndromes in this snakebite.
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10
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Sehgal T, Nanda A, Prakash S, Subramanian A. Use of modified-citrate tube to rectify spurious coagulopathy in smoker's polycythaemia: medical resolution of a dentist's dilemma. BMJ Case Rep 2022; 15:e246102. [PMID: 35039357 PMCID: PMC8768459 DOI: 10.1136/bcr-2021-246102] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/05/2021] [Indexed: 11/03/2022] Open
Affiliation(s)
- Tushar Sehgal
- Laboratory Medicine, All India Institute of Medical Sciences, New Delhi, Delhi, India
| | - Aditi Nanda
- Prosthodontics, CDER, All India Institute of Medical Sciences, New Delhi, Delhi, India
| | - Shyam Prakash
- Laboratory Medicine, All India Institute of Medical Sciences, New Delhi, Delhi, India
| | - Arulselvi Subramanian
- Laboratory Medicine, All India Institute of Medical Sciences, New Delhi, Delhi, India
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11
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Gaudard M, Boissier E, Talon L, Douxfils J, Sapin AF, Sinegre T, Lebreton A. Stability of coagulation parameters in plasma samples at room temperature after one freeze/thaw cycle. Int J Lab Hematol 2022; 44:610-618. [PMID: 35029031 DOI: 10.1111/ijlh.13794] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 12/16/2021] [Accepted: 12/23/2021] [Indexed: 12/01/2022]
Abstract
INTRODUCTION Sample freezing is a part of routine laboratory tasks because some coagulation parameters are analysed in batches to optimize reagent consumption. The coagulation parameter stability in fresh and frozen samples has been described, but data are scarcer after thawing. This study objective was to determine the stability of the main coagulation parameters (from blood withdrawn on siliconized CTAD tubes and double-centrifuged) after one freeze/thaw cycle to generate procedures for appropriate handling, storage and testing. METHODS Prothrombin time (PT), activated partial thromboplastin time (aPTT), fibrinogen, D-dimers, clotting factors (F), protein C, protein S, antithrombin, lupus anticoagulant (LA)-sensitive aPTT and diluted-Russel's viper venom time (dRVVT) were assessed in 60 plasma samples (n=30, normal range and n=30, outside the normal range). Thirty samples from anticoagulated patients [unfractionated heparin (UFH), low-molecular weight heparin (LMWH), apixaban or rivaroxaban] were assessed using specific anticoagulant assays. Frozen samples were thawed, and assays were performed at 15 min, 2, 4 and 6 h after thawing. The coagulation parameter stability was assessed with the method of rejection limit. RESULTS After thawing, aPTT, PT, fibrinogen, D-dimers, FII, FV, FX, FIX, FXI, FXII, PC and UFH anti-Xa activity remained stable for at least 6 h, FVII for 5 h, PS, AT, dRVVT screen assay and LMWH anti-Xa activity for 4 h, and LA-sensitive aPTT and apixaban-specific anti-Xa activity for 3 h. FVIII, dRVVT confirm assay and rivaroxaban specific anti-Xa activity were stable for 2 h. CONCLUSION These results suggest that sample stability for some haemostasis assays is limited after thawing.
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Affiliation(s)
- Marion Gaudard
- Service d'hématologie biologique, Centre hospitalier universitaire de Clermont-Ferrand, Clermont-Ferrand, France
| | - Elodie Boissier
- Service d'hématologie biologique, Centre hospitalier universitaire de Nantes, Nantes, France
| | - Laurie Talon
- Service d'hématologie biologique, Centre hospitalier universitaire de Clermont-Ferrand, Clermont-Ferrand, France
| | - Jonathan Douxfils
- Department of Pharmacy, Namur Research Institute for Life Sciences, Namur Thrombosis and Haemostasis Center, University of Namur, Namur, Belgium.,Qualiblood sa, Namur, Belgium
| | - Anne-Françoise Sapin
- Service d'hématologie biologique, Centre hospitalier universitaire de Clermont-Ferrand, Clermont-Ferrand, France
| | - Thomas Sinegre
- Service d'hématologie biologique, Centre hospitalier universitaire de Clermont-Ferrand, Clermont-Ferrand, France.,INRA UMR 1019, Université Clermont Auvergne, Clermont-Ferrand, France
| | - Aurélien Lebreton
- Service d'hématologie biologique, Centre hospitalier universitaire de Clermont-Ferrand, Clermont-Ferrand, France.,INRA UMR 1019, Université Clermont Auvergne, Clermont-Ferrand, France
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12
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Kaurav H, Sharma A, Upadhyay NK, Kapoor DN. Long term delivery of glibenclamide from in situ forming microparticles for the treatment of ischemic stroke. J Drug Deliv Sci Technol 2021. [DOI: 10.1016/j.jddst.2021.102860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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13
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Denessen EJS, Van Den Kerkhof DL, Jeurissen MLJ, Wetzels RJH, Verhezen PWM, Henskens YMC. Determining the Optimal Storage Time and Temperature for Performing Platelet Function Assays and Global Hemostasis Assays. Platelets 2021; 33:416-424. [PMID: 34115551 DOI: 10.1080/09537104.2021.1934666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Platelet function assays and global haemostasis assays are essential in diagnosing bleeding tendencies, with light transmission aggregometry (LTA) as golden standard. The Multiple Electrode Aggregation (Multiplate), platelet function assay (PFA) and rotational thromboelastometry (ROTEM) are mostly used as whole-blood screening tests. Currently, patients have to travel to specialized laboratories to undergo these tests, since specific expertise is required. Pre-analytical variables, like storage time and temperature during transport, are still considered to be the most vulnerable part of the process and may lead to discrepancies in the test results. We aim to give a first impression on the stability of blood samples from healthy volunteers during storage and investigate the effect of storage time (1, 3, 6 and 24 hours) and temperature (4°C, room temperature and 37°C) on the Multiplate, PFA, ROTEM and LTA test results. Our data indicated that, for the PFA, whole blood can be stored for 3 hours at room temperature. Whole blood used for the Multiplate and ROTEM can be stored for 6 hours of storage. For LTA, PRP and whole blood were stable up to 3 hours at 4°C or room temperature and 6 hours at room temperature, respectively.
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Affiliation(s)
- E J S Denessen
- Central Diagnostic Laboratory, Cluster for Haemostasis and Transfusion, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - D L Van Den Kerkhof
- Central Diagnostic Laboratory, Cluster for Haemostasis and Transfusion, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - M L J Jeurissen
- Central Diagnostic Laboratory, Cluster for Haemostasis and Transfusion, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - R J H Wetzels
- Central Diagnostic Laboratory, Cluster for Haemostasis and Transfusion, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - P W M Verhezen
- Central Diagnostic Laboratory, Cluster for Haemostasis and Transfusion, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Y M C Henskens
- Central Diagnostic Laboratory, Cluster for Haemostasis and Transfusion, Maastricht University Medical Centre+, Maastricht, The Netherlands
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14
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Quirke W, Toomey S, Sheikhi A. The stability of 'add-on' coagulation assays in refrigerated citrated plasma stored on a packed cellular fraction. Int J Lab Hematol 2021; 43:779-785. [PMID: 33991057 DOI: 10.1111/ijlh.13576] [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: 01/01/2021] [Revised: 03/14/2021] [Accepted: 04/22/2021] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Haematology laboratories are increasingly faced with requests for add-on coagulation testing. This study explores extending the specimen storage proposals by examining coagulation parameters on refrigerated citrated plasma retained on a cellular fraction over a 24-hour period. METHODS Sodium citrate (Sarstedt® S-Monovette 3.2%) specimens from 206 patients in University Hospital Limerick, Ireland were refrigerated immediately post-analysis and re-analysed in the centrifuged primary container at 4, 8 and 24-hour intervals using the Diagnostica Stago coagulometer and reagent combination. Coagulation assays examined for statistically and clinically significant differences included PT, APTT, D-Dimer, fibrinogen and Protein C. RESULTS PT, APTT and Protein C values displayed statistical significance from 4 hours. Fibrinogen differences were statistically significant from 8 hours. D-Dimer differences were not statistically significant at any interval over the 24-hour period. The refrigerated storage limit for PT and APTT results was determined to be 4 hours. D-Dimer was the only test parameter to report a mean percentage variance >10%. However, result changes at the threshold region of 0.5 µg/mL FEU were found to be within assay precision limits and desirable bias up to 8 hours. Maximum mean differences for Protein C (-1.3%) and fibrinogen (2.3%) were within assay precision limits and desirable biases up to 24 hours. CONCLUSION PT and APTT results are stable in refrigerated citrated plasma maintained on a cellular fraction up to 4 hours post-phlebotomy. D-Dimers results are reliable up to 8 hours, while fibrinogen and Protein C results are stable for at least 24 hours.
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Affiliation(s)
- William Quirke
- Haematology laboratory, University Hospital Limerick, Dooradoyle, Ireland
| | - Siobhan Toomey
- Haematology laboratory, University Hospital Limerick, Dooradoyle, Ireland
| | - Ali Sheikhi
- University of Limerick, Castletroy, Limerick, Ireland
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15
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Ninivaggi M, de Laat-Kremers R, Tripodi A, Wahl D, Zuily S, Dargaud Y, Ten Cate H, Ignjatović V, Devreese KMJ, de Laat B. Recommendations for the measurement of thrombin generation: Communication from the ISTH SSC Subcommittee on Lupus Anticoagulant/Antiphospholipid Antibodies. J Thromb Haemost 2021; 19:1372-1378. [PMID: 33880866 DOI: 10.1111/jth.15287] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Revised: 02/27/2021] [Accepted: 03/02/2021] [Indexed: 01/17/2023]
Abstract
Thrombin generation (TG) assay is an overall assay to assess the functionality of the hemostatic system and may be a useful tool in diagnosing patients with hyper- and hypocoagulability. Lack of standardization in performing the assays contributes largely to poor correlation between assays and study results. The current lack of standardization remains a major issue in the setting of TG, as illustrated in a recent survey of the ISTH/SSC indicating differences in pre-, analytical, and post-analytical factors among users. These factors may considerably affect the between-laboratory reproducibility of results. Based on the results of the survey and a current review of the literature, along with insights and strong consensus of key investigators in the field, we present guidance for measurement of TG in a clinical setting. Recommendations on blood drawing, handling, processing, and sample storage; reagent concentration and source; analytical conditions on dilution of samples and temperature; calibration and replicate testing; calculation and interpretation of results; and reference values are addressed to help in reducing interlaboratory variation. These recommendations aim at harmonization between methods and laboratories to support the application of TG in patient diagnosis and management.
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Affiliation(s)
| | - Romy de Laat-Kremers
- Synapse Research Institute, Maastricht, the Netherlands
- Departments of Internal medicine and Biochemistry, CARIM, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Armando Tripodi
- Fondazione IRCCS Ca' Granda Ospedale Maggiore, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione Luigi Villa, Milan, Italy
| | - Denis Wahl
- Université de Lorraine, Inserm UMRS 1116 DCAC; and Centre Hospitalier Régional Universitaire de Nancy, Vascular Medicine Division and Regional Competence Centre for Rare Vascular And Systemic Autoimmune Diseases, Nancy, France
| | - Stéphane Zuily
- Université de Lorraine, Inserm UMRS 1116 DCAC; and Centre Hospitalier Régional Universitaire de Nancy, Vascular Medicine Division and Regional Competence Centre for Rare Vascular And Systemic Autoimmune Diseases, Nancy, France
| | - Yesim Dargaud
- Unité d'Hémostase Clinique, Hôpital Cardiologique Louis Pradel, Université Lyon 1, Lyon,, France
| | - Hugo Ten Cate
- Departments of Internal medicine and Biochemistry, CARIM, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Vera Ignjatović
- Department of Paediatrics, Haematology Research, Murdoch Children's Research Institute, The University of Melbourne, Parkville, Australia
| | - Katrien M J Devreese
- Coagulation Laboratory, Department of Laboratory Medicine, Department of Diagnostic Sciences, Ghent University Hospital, Ghent University, Ghent, Belgium
| | - Bas de Laat
- Synapse Research Institute, Maastricht, the Netherlands
- Departments of Internal medicine and Biochemistry, CARIM, Maastricht University Medical Center, Maastricht, the Netherlands
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16
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Pillai S, Davies G, Lawrence M, Whitley J, Stephens J, Williams PR, Morris K, Evans PA. The effect of diabetic ketoacidosis (DKA) and its treatment on clot microstructure: Are they thrombogenic? Clin Hemorheol Microcirc 2021; 77:183-194. [PMID: 32925001 DOI: 10.3233/ch-200957] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Diabetic ketoacidosis (DKA) is a medical emergency with a high mortality rate and is associated with severe metabolic acidosis and dehydration. DKA patients have an increased risk of arterial and venous thromboembolism, however little is known about this metabolic derangement in the first 24 hours of admission and to assess its effect on coagulation. We therefore utilised a novel functional marker of clot microstructure (fractal dimension - df) to assess these changes within the first 24 hours. METHODS Prospective single centre observational study to demonstrate whether the tendency of blood clot formation differs in DKA patients. RESULTS 15 DKA patients and 15 healthy matched controls were recruited. Mean df in the healthy control group was 1.74±0.03. An elevated df of 1.78±0.07 was observed in patients with DKA on admission. The mean pH on admission was 7.14±0.13 and the lactate was 3.6±2.0. df changed significantly in response to standard treatment and was significantly reduced to 1.68±0.09 (2-6& h) and to 1.66±0.08 at 24& h (p < 0.01 One-way ANOVA). df also correlated significantly with lactate and pH (Pearson correlation coefficient 0.479 and -0.675 respectively, p < 0.05). CONCLUSIONS DKA patients at presentation have a densely organising less permeable thrombogenic clot microstructure as evidenced by high df. These structural changes are due to a combination of dehydration and a profound metabolic acidosis, which was reversed with treatment. These changes were not mirrored in standard clinical markers of thromboge-nicity.
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Affiliation(s)
- Suresh Pillai
- Welsh Centre for Emergency Medicine Research, Emergency Department, Morriston Hospital, Swansea, UK.,Morriston Hospital, Swansea, UK.,Swansea University, Swansea, UK
| | - Gareth Davies
- Welsh Centre for Emergency Medicine Research, Emergency Department, Morriston Hospital, Swansea, UK
| | - Matthew Lawrence
- Welsh Centre for Emergency Medicine Research, Emergency Department, Morriston Hospital, Swansea, UK.,Swansea University, Swansea, UK
| | - Janet Whitley
- Welsh Centre for Emergency Medicine Research, Emergency Department, Morriston Hospital, Swansea, UK.,Swansea University, Swansea, UK
| | - Jeffrey Stephens
- Morriston Hospital, Swansea, UK.,Swansea University, Swansea, UK
| | | | | | - Phillip Adrian Evans
- Welsh Centre for Emergency Medicine Research, Emergency Department, Morriston Hospital, Swansea, UK.,Morriston Hospital, Swansea, UK.,Swansea University, Swansea, UK
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17
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Brown L, Jennings I, Kitchen S, Kitchen DP, Woods TAL, Walker ID. Pre-analytical variables in haemostasis: Findings from the United Kingdom National External Quality Assessment scheme for Blood Coagulation (UK NEQAS BC) haemolysis exercise. Int J Lab Hematol 2021; 43:1198-1206. [PMID: 33605545 DOI: 10.1111/ijlh.13468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 12/15/2020] [Accepted: 12/27/2020] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Haemolysis is considered one of the major contributors of nonconformities and sample rejection in coagulation testing. MATERIALS AND METHODS Two lyophilized plasmas were distributed to 800 centres registered for prothrombin time (PT), activated partial thromboplastin time (APTT) and either Clauss fibrinogen or thrombin time (TT) in the UK NEQAS BC programme. The same pool of normal plasma was used to prepare both samples, to one of which red blood cell haemolysate was added to mimic haemolysis at 3 g/L haemoglobin concentration. Participants were asked to complete a questionnaire about their laboratory approach to dealing with haemolysed samples, including strategies used to deal with different levels of haemolysis. RESULTS Results for tests performed did not show great differences between the two samples. It should be noted that artificially constructed haemolysed samples may not behave in the same way as patient samples (ie, may not be commutable). However, the possibility of carrying out a large multicentre study for detection of haemolysis was demonstrated. Inconsistency in practice was observed with 226/551 (41%) of centres indicated they reject haemolysed samples solely on visual checks, and 163 (30%) using initial visual checks with further sample rejection evaluation by analyser flags. Furthermore, 333 (72%) of centres indicated that the level of haemolysis affects sample rejection decisions, while 132 (28%) stated it did not. CONCLUSION Variability of responses for dealing with haemolysed samples reflects a lack of clear consistency in the pre-analytical area of sample processing.
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Affiliation(s)
- Lilia Brown
- UK NEQAS for Blood Coagulation, Sheffield, UK
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18
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Waller AP, Troost JP, Parikh SV, Wolfgang KJ, Rovin BH, Nieman MT, Smoyer WE, Kretzler M, Kerlin BA. Nephrotic syndrome disease activity is proportional to its associated hypercoagulopathy. Thromb Res 2021; 201:50-59. [PMID: 33636573 DOI: 10.1016/j.thromres.2021.02.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 01/19/2021] [Accepted: 02/01/2021] [Indexed: 12/01/2022]
Abstract
INTRODUCTION Nephrotic syndrome (NS) is associated with an acquired hypercoagulopathy that drives its strong predilection for life-threatening thrombosis. We previously demonstrated that hypercoagulopathy is proportional to NS disease severity in animal models. Therefore, hypercoagulopathy and disease severity may inform thrombosis risk and better guide therapeutic decision making. The objective of this study was thus to establish the relationship between disease severity and hypercoagulopathy in human NS. MATERIALS AND METHODS Thrombin generation assays (TGA) were performed on biorepository plasma samples from a prospective longitudinal NS cohort study. TGA was also determined on a separate cohort of incident NS patients. Multivariable regression was used to build NS-hypercoagulopathy relationship models. RESULTS Endogenous thrombin potential (ETP) was the TGA parameter most strongly correlated with NS severity and was proportional to conventional measures of NS disease activity including proteinuria, hypercholesterolemia, and hypoalbuminemia. The overall disease activity model was well correlated with ETP (R2 = 0.38). The relationship with disease activity was confirmed in the second cohort. These models further revealed that ETP is related to disease activity in a manner dependent on remission status. CONCLUSION Consistent with our previously reported animal model observations, we found that the combination of proteinuria, hypercholesterolemia, and hypoalbuminemia correlated with ETP-defined hypercoagulopathy. Hypercoagulopathy improved significantly with partial or complete NS remission. These data are expected to inform studies designed to stratify thrombotic risk for patients with NS.
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Affiliation(s)
- Amanda P Waller
- Center for Clinical and Translational Research, Abigail Wexner Research Institute at Nationwide Children's, Columbus, OH, USA
| | - Jonathan P Troost
- Michigan Institute for Clinical and Health Research, University of Michigan, Ann Arbor, MI, USA
| | - Samir V Parikh
- Division of Nephrology, Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Katelyn J Wolfgang
- Center for Clinical and Translational Research, Abigail Wexner Research Institute at Nationwide Children's, Columbus, OH, USA
| | - Brad H Rovin
- Division of Nephrology, Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Marvin T Nieman
- Department of Pharmacology, Case Western Reserve University, Cleveland, OH, USA
| | - William E Smoyer
- Center for Clinical and Translational Research, Abigail Wexner Research Institute at Nationwide Children's, Columbus, OH, USA; Division of Nephrology, Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Matthias Kretzler
- Departments of Internal Medicine and Computational Medicine and Bioinformatics, University of Michigan School of Medicine, Ann Arbor, MI, USA
| | - Bryce A Kerlin
- Center for Clinical and Translational Research, Abigail Wexner Research Institute at Nationwide Children's, Columbus, OH, USA; Division of Hematology/Oncology/Blood & Marrow Transplantation, Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA.
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Tritten L, Gillis-Germitsch N, Kockmann T, Schnyder M. Quantitative proteomics analysis of Angiostrongylus vasorum-induced alterations in dog serum sheds light on the pathogenesis of canine angiostrongylosis. Sci Rep 2021; 11:283. [PMID: 33431914 PMCID: PMC7801463 DOI: 10.1038/s41598-020-79459-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 12/09/2020] [Indexed: 12/22/2022] Open
Abstract
Blood contains hundreds of proteins, reflecting ongoing cellular processes and immune reactions. Infections with the blood-dwelling cardiopulmonary nematode Angiostrongylus vasorum in dogs manifest with a broad spectrum of clinical signs including respiratory distress, bleeding diathesis and neurological signs, and are associated with a perturbed blood protein profile in dogs. However, current knowledge does not completely explain the observed pathologies induced by A. vasorum infections, including bleeding disorders. Using sera from experimentally infected dogs, dog serum proteome was analysed by quantitative mass spectrometry methods over several time points before and after inoculation. Following computational analysis, we identified 139 up- and downregulated proteins after infection (log2 ratio cut-off ≥ 1.0; q-value ≤ 0.05). Among upregulated proteins were chitinase 3-like 1 and pulmonary surfactant-associated protein B (log2 fold-changes ≥ 5). Pathway enrichment revealed the complement (especially the lectin pathway) and coagulation cascades as significantly affected upon analysis of downregulated proteins. Among them were mannan-binding lectin serine peptidases, ficolin, and coagulation factor XIII-B. These results bring new elements towards understanding the underlying pathomechanisms of bleeding diatheses observed in some A. vasorum-infected dogs.
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Affiliation(s)
- Lucienne Tritten
- Institute of Parasitology, Vetsuisse Faculty, University of Zurich, Zurich, Switzerland.
| | - Nina Gillis-Germitsch
- Institute of Parasitology, Vetsuisse Faculty, University of Zurich, Zurich, Switzerland
- Graduate School for Cellular and Biomedical Sciences, University of Bern, Bern, Switzerland
| | - Tobias Kockmann
- Functional Genomics Center Zurich, ETH/UZH Zurich, Zurich, Switzerland
| | - Manuela Schnyder
- Institute of Parasitology, Vetsuisse Faculty, University of Zurich, Zurich, Switzerland.
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20
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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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21
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Jo SY, Kim IS, Kim H. Potential misdiagnosis of von Willebrand disease caused by insufficient mixing after thawing frozen plasma. Int J Lab Hematol 2020; 43:831-836. [PMID: 33369143 DOI: 10.1111/ijlh.13445] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 12/08/2020] [Accepted: 12/09/2020] [Indexed: 10/22/2022]
Abstract
INTRODUCTION von Willebrand disease (vWD) is a common inherited bleeding disorder caused by a deficiency in von Willebrand factor (vWF), but many laboratories and clinicians continue to struggle with diagnosing or excluding vWD. Its diagnosis requires laboratory testing, which may be compromised by preanalytical events, including poor specimen quality. This study assessed 17 different preanalytical conditions as potential causes of vWD misdiagnosis. METHODS Specimens from healthy controls (N = 21) were obtained. vWF antigen and vWF activity were analyzed using a newly developed automatic coagulation analyzer according to various preanalytic conditions such as centrifugation conditions, storage room temperature before centrifugation, cold storage temperature after centrifugation, thawing conditions, and inadequate mixing of thawed citrated plasma following the recommendations of the Clinical and Laboratory Standards Institute (CLSI) H21-A5 guidelines. RESULTS The only condition that was significantly different from the reference condition was lack of mixing after thawing frozen citrated plasma (vWF activity and antigen were reduced by 58.7% and 49.6%, respectively). Our study showed that mixing after thawing was more important than the chosen method of mixing. CONCLUSION Thawed plasma should be mixed because of the risk of misdiagnosing vWD. Further education regarding the importance of appropriate mixing is warranted to achieve results comparable to those of freshly centrifuged samples.
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Affiliation(s)
- Su-Yeon Jo
- Department of Laboratory Medicine, Pusan National University School of Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - In-Suk Kim
- Department of Laboratory Medicine, Pusan National University School of Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Hyerim Kim
- Department of Laboratory Medicine, Pusan National University Hospital, Busan, Korea
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22
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Determining the maximal storage time of centrifuged citrated samples for performing add-on routine coagulation tests. Thromb Res 2020; 196:54-62. [DOI: 10.1016/j.thromres.2020.08.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 07/21/2020] [Accepted: 08/03/2020] [Indexed: 11/18/2022]
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23
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Jesting A, Jacobsen KK, De Cock A, De Preester H, Jensen KOF, Frank Joergensen S. Influence of sample centrifugation on plasma platelet count and activated partial thromboplastin time using patient samples. Clin Biochem 2020; 83:74-77. [DOI: 10.1016/j.clinbiochem.2020.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 04/22/2020] [Accepted: 05/14/2020] [Indexed: 10/24/2022]
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Condrey JA, Flietstra T, Nestor KM, Schlosser EL, Coleman-McCray JD, Genzer SC, Welch SR, Spengler JR. Prothrombin Time, Activated Partial Thromboplastin Time, and Fibrinogen Reference Intervals for Inbred Strain 13/N Guinea Pigs ( Cavia porcellus) and Validation of Low Volume Sample Analysis. Microorganisms 2020; 8:microorganisms8081127. [PMID: 32726969 PMCID: PMC7463423 DOI: 10.3390/microorganisms8081127] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 07/22/2020] [Accepted: 07/23/2020] [Indexed: 11/17/2022] Open
Abstract
Inbred strain 13/N guinea pigs are used as small animal models for the study of hemorrhagic fever viruses. Coagulation abnormalities, including prolonged clotting times and bleeding, are characteristic of hemorrhagic fever in humans; patients often meet criteria for disseminated intravascular coagulation (DIC). Comprehensively evaluating coagulation function is critical in model development and studies of viral pathogenesis and therapeutic efficacy. Here, using the VetScan VSpro veterinary point-of-care platform, we developed reference intervals in both juvenile and adult strain 13/N guinea pigs for three coagulation parameters: prothrombin time (PT), activated partial thromboplastin time (aPTT), and fibrinogen. In addition, for situations or species with limited availability of blood for clinical analysis, we investigated the validity of a modified collection approach for low-volume (0.1 mL) blood sample analysis of PT and aPTT.
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Affiliation(s)
- Jillian A. Condrey
- Comparative Medicine Branch, Division of Scientific Resources, Centers for Disease Control and Prevention, Atlanta, GA 30329, USA; (J.A.C.); (K.M.N.); (E.L.S.); (S.C.G.)
| | - Timothy Flietstra
- Viral Special Pathogens Branch, Division of High-Consequence Pathogens and Pathology, Centers for Disease Control and Prevention, Atlanta, GA 30329, USA; (T.F.); (J.D.C.-M.); (S.R.W.)
| | - Kaitlyn M. Nestor
- Comparative Medicine Branch, Division of Scientific Resources, Centers for Disease Control and Prevention, Atlanta, GA 30329, USA; (J.A.C.); (K.M.N.); (E.L.S.); (S.C.G.)
| | - Elizabeth L. Schlosser
- Comparative Medicine Branch, Division of Scientific Resources, Centers for Disease Control and Prevention, Atlanta, GA 30329, USA; (J.A.C.); (K.M.N.); (E.L.S.); (S.C.G.)
| | - JoAnn D. Coleman-McCray
- Viral Special Pathogens Branch, Division of High-Consequence Pathogens and Pathology, Centers for Disease Control and Prevention, Atlanta, GA 30329, USA; (T.F.); (J.D.C.-M.); (S.R.W.)
| | - Sarah C. Genzer
- Comparative Medicine Branch, Division of Scientific Resources, Centers for Disease Control and Prevention, Atlanta, GA 30329, USA; (J.A.C.); (K.M.N.); (E.L.S.); (S.C.G.)
| | - Stephen R. Welch
- Viral Special Pathogens Branch, Division of High-Consequence Pathogens and Pathology, Centers for Disease Control and Prevention, Atlanta, GA 30329, USA; (T.F.); (J.D.C.-M.); (S.R.W.)
| | - Jessica R. Spengler
- Viral Special Pathogens Branch, Division of High-Consequence Pathogens and Pathology, Centers for Disease Control and Prevention, Atlanta, GA 30329, USA; (T.F.); (J.D.C.-M.); (S.R.W.)
- Correspondence: ; Tel.: +1-404-639-1136; Fax: +1-404-639-1509
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Moore GW, Meijer D, Griffiths M, Rushen L, Brown A, Budde U, Dittmer R, Schocke B, Leyte A, Geiter S, Moes A, Cutler JA, Binder NB. A multi-center evaluation of TECHNOSCREEN ® ADAMTS-13 activity assay as a screening tool for detecting deficiency of ADAMTS-13. J Thromb Haemost 2020; 18:1686-1694. [PMID: 32239643 DOI: 10.1111/jth.14815] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 02/26/2020] [Accepted: 03/23/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Quantifying A disintegrin-like and metalloprotease with thrombospondin type 1 motif, member 13 (ADAMTS-13) activity enhances thrombotic thrombocytopenic purpura (TTP) diagnosis but most assays are time consuming, technically demanding, and mainly available in reference centers. OBJECTIVE Evaluate a simple, semiquantitative ADAMTS-13 activity screening test for early identification/exclusion of TTP. PATIENTS/METHODS Plasma from 220 patients with suspected thrombotic microangiopathy at three reference centers were tested with TECHNOSCREEN® ADAMTS13 activity screening test in comparison with TECHNOZYM® ADAMTS-13 activity ELISA at two centers, and in-house fluorescence resonance energy transfer assay at the third center. The screening test indicates if ADAMTS-13 activity is at one of four level-indicator points: 0, 0.1, 0.4, or 0.8 IU/mL. RESULTS Screen results were interpreted as binary data in that ADAMTS-13 activity was above or below the 0.1 IU/mL TTP clinical threshold. Combining all sites' data, the screen exhibited 88.7% sensitivity, 90.4% specificity, 74.6% positive predictive value, and 96.2% negative predictive value, comparable to published data for quantitative assays. Five samples with quantitative results below the threshold gave screen readings of 0.1 IU/mL and seven marginally above the threshold gave screen readings of zero. All would warrant plasma exchange while the level is quantified. Nine samples with normal/near normal results gave screens of zero and confirmatory quantifications would prompt early treatment withdrawal, as is current practice. One sample generated screen/quantitative results of 0.4/0.00 IU/mL respectively and was the only clear false-negative. CONCLUSIONS The screening test provides more rapid ADAMTS-13 level evaluation than most currently available assays. Its simple operation renders it suitable for adoption in routine or specialist laboratory environments.
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Affiliation(s)
- Gary W Moore
- Diagnostic Haemostasis and Thrombosis, Viapath Analytics, Guy's & St. Thomas' Hospitals, London, UK
- Specialist Haemostasis Unit, Addenbrooke's Hospital, Cambridge, UK
| | - Daniëlle Meijer
- Immune Pathology and Haemostasis Laboratories, Sanquin Diagnostics BV, Amsterdam, The Netherlands
| | | | - Lucy Rushen
- Diagnostic Haemostasis and Thrombosis, Viapath Analytics, Guy's & St. Thomas' Hospitals, London, UK
| | - Alice Brown
- Diagnostic Haemostasis and Thrombosis, Viapath Analytics, Guy's & St. Thomas' Hospitals, London, UK
| | - Ulrich Budde
- Department of Hemostaseology, MEDILYS Laborgesellschaft mbH, Hamburg, Germany
| | - Rita Dittmer
- Department of Hemostaseology, MEDILYS Laborgesellschaft mbH, Hamburg, Germany
| | - Barbara Schocke
- Department of Hemostaseology, MEDILYS Laborgesellschaft mbH, Hamburg, Germany
| | - Anja Leyte
- Immune Pathology and Haemostasis Laboratories, Sanquin Diagnostics BV, Amsterdam, The Netherlands
- OLVG Lab BV, Amsterdam, The Netherlands
| | | | - Anneke Moes
- Immune Pathology and Haemostasis Laboratories, Sanquin Diagnostics BV, Amsterdam, The Netherlands
| | - Jacqueline A Cutler
- Diagnostic Haemostasis and Thrombosis, Viapath Analytics, Guy's & St. Thomas' Hospitals, London, UK
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Banković Radovanović P. Quality improvement project: Reducing non-conformities of the samples for haemostasis testing in a secondary healthcare centre through the nurses' education in phlebotomy. Biochem Med (Zagreb) 2020; 30:020708. [PMID: 32550816 PMCID: PMC7271753 DOI: 10.11613/bm.2020.020708] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Accepted: 04/13/2020] [Indexed: 12/28/2022] Open
Abstract
Introduction Poor compliance to the current guidelines and lack of knowledge among nurses about proper blood sampling is set as the study hypothesis. Here is presented a quality improvement project with following aims: a) to identify the most prevalent non-conformity of the samples for haemostasis testing, b) to identify the cause of sample non-conformity, c) to perform corrective action(s) and d) to assess the effectiveness of the corrective action(s). Materials and methods The rate of non-conformity of samples collected for haemostasis tests was established for hospital wards with inpatients. Phlebotomy practice was audited throughout anonymous questionnaire among hospital’s nurses who perform phlebotomy. Education about blood sampling was performed as a 1-hour lecture in different small groups each working day within one month. Education effectiveness was assessed through the evaluation of sample quality and is considered effective if more than half of the hospital wards significantly reduced their sample non-conformities rate. Results Clotted sample constituted 84% of sample non-conformities. The questionnaire revealed nurses’ poor knowledge in phlebotomy. There was no difference in nurses’ knowledge regarding the level of education or work experience. Reduction in sample non-conformities was observed in 7 out of 9 wards 4 months after education; this improvement was statistically significant for 5 wards. Conclusion Clotted sample as the most prevalent non-conformity of the samples for haemostasis testing is caused by the lack of knowledge of the nurses in several parts of the phlebotomy process. Specific education of the motivated personnel in small groups was successful and long-term effective.
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Rade A, Đuras A, Kocijan I, Banković Radovanović P, Turčić A. Simple thrombin-based method for eliminating fibrinogen interference in serum protein electrophoresis of haemodialysed patients. Biochem Med (Zagreb) 2020; 30:020705. [PMID: 32292283 PMCID: PMC7138005 DOI: 10.11613/bm.2020.020705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2019] [Accepted: 02/21/2020] [Indexed: 11/10/2022] Open
Abstract
Introduction Serum samples of haemodialysed patients collected through vascular access devices, e.g. central venous catheter (CVC) can contain residual heparin, which can cause incomplete clotting and consequently fibrinogen interference in serum protein electrophoresis (SPE). We hypothesized that this problem may be overcome by addition of thrombin and aimed to find a simple thrombin-based method for fibrinogen interference removal. Materials and methods Blood samples of 51 haemodialysed patients with CVC were drawn through catheter into Clot Activator Tube (CAT) and Rapid Serum Tube Thrombin (RST) vacutainers (Becton Dickinson, New Jersey, USA) following the routine hospital protocols and analysed with gel-electrophoresis (Sebia, Lisses, France). Samples were redrawn in the CAT tubes and re-analysed after being treated with thrombin using two methods: transferring CAT serum into RST vacutainer and treatment of CAT serum with fibrinogen reagent (Multifibren U, Siemens, Marburg, Germany). Results Direct blood collection in RST proved to be slightly more efficient than CAT in removing the interfering band in beta fraction (CAT removed 6/51 and RST removed 12/51, P = 0.031). Transferring CAT serum into the RST vacutainer proved to be more efficient for subsequent removal of interfering band from CAT serum than the addition of fibrinogen reagent (39/45 vs. 0/45 samples with efficiently removed interfering band, P < 0.001). Conclusion Fibrinogen interference caused by incomplete clotting because of residual heparin can be overcome by addition of thrombin. Transferring CAT serum into the RST vacutainer was the most efficient method.
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Affiliation(s)
- Anamarija Rade
- Medical biochemistry laboratory, General Hospital Varaždin, Varaždin, Croatia
| | - Anamarija Đuras
- Medical biochemistry laboratory, General Hospital Varaždin, Varaždin, Croatia
| | - Irena Kocijan
- Medical biochemistry laboratory, General Hospital Varaždin, Varaždin, Croatia
| | | | - Ana Turčić
- Department of Laboratory Diagnostics, University Hospital Centre Zagreb, Zagreb, Croatia
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Grama A, Burac L, Aldea CO, Bulata B, Delean D, Samasca G, Abrudan C, Sirbe C, Pop TL. Vitamin D-Binding Protein (Gc-Globulin) in Acute Liver Failure in Children. Diagnostics (Basel) 2020; 10:E278. [PMID: 32375318 PMCID: PMC7278011 DOI: 10.3390/diagnostics10050278] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 04/28/2020] [Accepted: 05/01/2020] [Indexed: 02/05/2023] Open
Abstract
This study aimed to analyse vitamin d-binding protein (Gc-globulin) serum levels in acute liver failure (ALF) in children in relation to disease outcomes and correlations with other known markers used to evaluate the severity of ALF. Our study included 34 children (mean age 4.87 ± 5.30 years) with ALF of different causes (metabolic, 26.47%; autoimmune, 23.53%; toxic, 20.59%; infection, 17.65%; unknown, 11.76%) and 30 children without any liver injury (mean age 6.11 ± 4.26 years). The outcome was poor in 14 patients (41.18%), including one child with liver transplantation (2.94%). Serum Gc-globulin levels were significantly lower in ALF patients compared to the control group (151.57 ± 171.8 mg/L vs. 498.63 ± 252.50 mg/L; p < 0.000001), with an optimum cut-off of 163.5 mg/L (Area Under the Curve, AUC, 0.8921; sensitivity, 76.50%; specificity, 100%). Levels were also lower in patients with poor outcomes compared to survivors (59.34 ± 33.73 mg/L vs. 216.12 ± 199.69 mg/L; p < 0.0001), with an optimum cut-off 115 mg/L (AUC, 0.7642; sensitivity, 100%; specificity, 50%). Gc-globulin serum levels were variable according to ALF aetiology, i.e., lower in metabolic, infectious, or unknown causes compared to autoimmune and toxic causes. Gc-globulin serum levels were decreased in children with ALF and lower in those with poor outcomes compared with survivors. Gc-globulin serum levels were correlated with other known parameters used to evaluate the severity of ALF and could help to identify patients at high risk for poor outcomes.
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Affiliation(s)
- Alina Grama
- 2nd Paediatric Clinic, University of Medicine and Pharmacy “Iuliu Hatieganu”, 400177 Cluj-Napoca, Romania; (A.G.); (L.B.); (C.S.)
- Centre of Expertise in Paediatric Liver Rare Diseases, 2nd Paediatric Clinic, Emergency Clinical Hospital for Children, 400177 Cluj-Napoca, Romania
- University of Medicine and Pharmacy “Carol Davila”, 050474 Bucharest, Romania
| | - Lucia Burac
- 2nd Paediatric Clinic, University of Medicine and Pharmacy “Iuliu Hatieganu”, 400177 Cluj-Napoca, Romania; (A.G.); (L.B.); (C.S.)
- Centre of Expertise in Paediatric Liver Rare Diseases, 2nd Paediatric Clinic, Emergency Clinical Hospital for Children, 400177 Cluj-Napoca, Romania
| | - Cornel Olimpiu Aldea
- Paediatric Nephrology, Dialysis and Toxicology Clinic, Emergency Clinical Hospital for Children, 400177 Cluj-Napoca, Romania; (C.O.A.); (B.B.); (D.D.)
| | - Bogdan Bulata
- Paediatric Nephrology, Dialysis and Toxicology Clinic, Emergency Clinical Hospital for Children, 400177 Cluj-Napoca, Romania; (C.O.A.); (B.B.); (D.D.)
| | - Dan Delean
- Paediatric Nephrology, Dialysis and Toxicology Clinic, Emergency Clinical Hospital for Children, 400177 Cluj-Napoca, Romania; (C.O.A.); (B.B.); (D.D.)
| | - Gabriel Samasca
- Laboratory of Medical Analysis, Emergency Clinical Hospital for Children, 400177 Cluj-Napoca, Romania; (G.S.); (C.A.)
| | - Carmen Abrudan
- Laboratory of Medical Analysis, Emergency Clinical Hospital for Children, 400177 Cluj-Napoca, Romania; (G.S.); (C.A.)
| | - Claudia Sirbe
- 2nd Paediatric Clinic, University of Medicine and Pharmacy “Iuliu Hatieganu”, 400177 Cluj-Napoca, Romania; (A.G.); (L.B.); (C.S.)
| | - Tudor Lucian Pop
- 2nd Paediatric Clinic, University of Medicine and Pharmacy “Iuliu Hatieganu”, 400177 Cluj-Napoca, Romania; (A.G.); (L.B.); (C.S.)
- Centre of Expertise in Paediatric Liver Rare Diseases, 2nd Paediatric Clinic, Emergency Clinical Hospital for Children, 400177 Cluj-Napoca, Romania
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Banković Radovanović P, Živković Mikulčić T, Simović Medica J. Unexpected abnormal coagulation test results in a 2-year-old child: A case report. Biochem Med (Zagreb) 2020; 30:011002. [PMID: 31839729 PMCID: PMC6904964 DOI: 10.11613/bm.2020.011002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Accepted: 10/24/2019] [Indexed: 11/01/2022] Open
Abstract
Rejection of the sample with repeated blood withdrawal is always an unwanted consequence of sample nonconformity and preanalytical errors, especially in the most vulnerable population - children. Here is presented a case with unexpected abnormal coagulation test results in a 2-year-old child with no previously documented coagulation disorder. Child is planned for tympanostomy tubes removal under the anaesthesia driven procedure, and preoperative coagulation tests revealed prolonged prothrombin time, activated partial thromboplastin time and thrombin time, with fibrinogen and antithrombin within reference intervals. From the anamnestic and clinical data, congenital coagulation disorder was excluded, and with further investigation, sample mismatch, clot presence and accidental ingestion of oral anticoagulant, heparin contamination or vitamin K deficiency were excluded too. Due to suspected EDTA carryover during blood sampling another sample was taken the same day and all tests were performed again. The results for all tests were within reference intervals confirming EDTA effect on falsely prolongation of the coagulation times in the first sample. This case can serve as alert to avoid unnecessary loss in terms of blood withdrawal repetitions and discomfort of the patients and their relatives, tests repeating, prolonging medical procedures, and probably delaying diagnosis or proper medical treatment. It is the responsibility of the laboratory specialists to continuously educate laboratory staff and other phlebotomists on the correct blood collection as well as on its importance for the patient's safety.
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30
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Balboni F, Barbui S, Gallo M, Berardi M, Vezzosi M, Lippi G. Routine coagulation testing in Vacutainer® Citrate Plus tubes filled at minimum or optimal volume. Diagnosis (Berl) 2020; 7:55-60. [PMID: 31421038 DOI: 10.1515/dx-2019-0052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Accepted: 07/31/2019] [Indexed: 11/15/2022]
Abstract
Background Filling of citrate tubes with appropriate amount of blood is essential for obtaining reliable results of coagulation testing. This study aimed to verify whether results of routine coagulation tests are comparable when the new Becton Dickinson Vacutainer® Citrate Plus tubes are filled at minimum or optimal volume. Methods The study population consisted of 133 patients (40 on oral anticoagulant therapy), who had blood collected for routine coagulation testing. Two sequential Vacutainer® Citrate Plus tubes of the same type and lot were drawn. The first tube was collected after a butterfly needle was inserted into the vein, so that the air in the tubing was aspirated into the tube before blood (minimum fill volume), whilst the second was drawn at optimal fill volume. Experiments were repeated using 2.7-mL (n = 86) and 1.8-mL (n = 47) tubes. Results Prothrombin time (PT) and fibrinogen values were slightly but significantly decreased in tubes with minimum than in those with optimal fill volume. The activated partial thromboplastin time (APTT) was slightly prolonged in tubes with minimum than in those with optimal fill volume, but the difference was not statistically significant. An identical trend was noted in separate analyses for the 2.7-mL and 1.8-mL tubes. Spearman's correlations between the two fill volumes were always >0.94 and bias was always within the quality specifications. Conclusions Blood drawing into Vacutainer® Citrate Plus tubes at minimum fill volume does not clinically bias routine coagulation testing.
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Affiliation(s)
- Fiamma Balboni
- Service of Laboratory Medicine, Istituto Fiorentino Cura e Assistenza (IFCA), Florence, Italy
| | - Stefania Barbui
- Pre-hospital Admission Service, Istituto Fiorentino Cura e Assistenza (IFCA), Florence, Italy
| | - Marco Gallo
- Hemodialysis Unit, Istituto Fiorentino Cura e Assistenza (IFCA), Florence, Italy
| | - Margherita Berardi
- Service of Laboratory Medicine, Istituto Fiorentino Cura e Assistenza (IFCA), Florence, Italy
| | - Marco Vezzosi
- Service of Laboratory Medicine, Istituto Fiorentino Cura e Assistenza (IFCA), Florence, Italy
| | - Giuseppe Lippi
- Section of Clinical Biochemistry, University Hospital of Verona, Piazzale LA Scuro, 37134 Verona, Italy
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31
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Dopsaj V. Practical issues in measuring the anticoagulant effect of direct oral anticoagulants. ARHIV ZA FARMACIJU 2020. [DOI: 10.5937/arhfarm2005297d] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
The classical oral anticoagulants are increasingly being replaced in clinical practice by new antithrombotic drugs, which act by enabling direct inhibition of coagulation factor IIa (FIIa) or factor Xa (FXa). These drugs have multiple acronyms, including NOACs (new, non-vitamin K antagonist) or DOACs (direct oral anticoagulants), and currently include dabigatran (FIIa inhibitor), and rivaroxaban, apixaban, and edoxaban (FXa inhibitors). These drugs are approved for stroke prevention in patients with non-valvular atrial fibrillation and the prevention and treatment of venous thromboembolism. The "mantra" that DOACs do not require laboratory monitoring is not entirely correct because laboratory testing for drug effects is needed in many situations, because they influence hemostasis tests and in situations in which urgent measurement of DOACs is required. This should be very important to consider in the clinical situation for numbers of indications and increasing numbers of patients on DOACs therapy. The main aim of this article is to provide practical issues to general laboratory testing for DOACs, as well as to help avoid diagnostic errors associated with hemostasis testing. The assays for DOAC quantification must be available in medical centers on a whole day basis, to facilitate optimal drug management in conditions when things go wrong or in urgent cases of immediate reversal of anticoagulation or appropriate administration of a specific antidote.
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Motum P, Just S, Zebeljan D, Nicholls C, Kershaw G, Oliver S, Mohammed S, Favaloro EJ. A diagnosis of von Willebrand disease despite normal test results for factor VIII and von Willebrand factor antigen and activity. Am J Hematol 2019; 94:1425-1432. [PMID: 31423628 DOI: 10.1002/ajh.25618] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Revised: 08/08/2019] [Accepted: 08/13/2019] [Indexed: 11/08/2022]
Affiliation(s)
- Penelope Motum
- Haematology, NSW Health Pathology Liverpool Hospital New South Wales Australia
| | - Sarah Just
- Haematology, NSW Health Pathology Liverpool Hospital New South Wales Australia
| | - Diane Zebeljan
- Haematology, NSW Health Pathology Liverpool Hospital New South Wales Australia
| | - Catherine Nicholls
- Department of Genetic Pathology SA Pathology Adelaide South Australia Australia
| | - Geoffrey Kershaw
- Haematology, NSW Health Pathology Royal Prince Alfred Hospital New South Wales Australia
| | - Susan Oliver
- Department of Haematology Institute of Clinical Pathology and Medical Research (ICPMR), NSW Health Pathology, Westmead Hospital Westmead New South Wales Australia
| | - Soma Mohammed
- Department of Haematology Institute of Clinical Pathology and Medical Research (ICPMR), NSW Health Pathology, Westmead Hospital Westmead New South Wales Australia
| | - Emmanuel J. Favaloro
- Department of Haematology Institute of Clinical Pathology and Medical Research (ICPMR), NSW Health Pathology, Westmead Hospital Westmead New South Wales Australia
- Department of Haematology Sydney Centres for Thrombosis and Haemostasis Westmead New South Wales Australia
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Bronić A, Coen Herak D, Margetić S, Milić M. Croatian Society of Medical Biochemistry and Laboratory Medicine: National recommendations for blood collection, processing, performance and reporting of results for coagulation screening assays prothrombin time, activated partial thromboplastin time, thrombin time, fibrinogen and D-dimer. Biochem Med (Zagreb) 2019; 29:020503. [PMID: 31223257 PMCID: PMC6559624 DOI: 10.11613/bm.2019.020503] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Accepted: 08/07/2018] [Indexed: 12/20/2022] Open
Abstract
A modern diagnostic laboratory offers wide spectrum of coagulation assays utilized in the diagnosis and management of patients with haemostatic disorders, preoperative screening and anticoagulation therapy monitoring. The recent survey conducted among Croatian medical biochemistry and transfusion laboratories showed the existence of different practice policies in particular phases of laboratory process during coagulation testing and highlighted areas that need improvement. Lack of assay standardization together with non-harmonized test results between different measurement methods, can potentially lead to incorrect decisions in patient’s treatment. Consequently, patient safety could be compromised. Therefore, recommended procedures related to preanalytical, analytical and postanalytical phases of prothrombin time, activated partial thromboplastin time, thrombin time, fibrinogen and D-dimer testing are provided in this review, aiming to help laboratories to generate accurate and reliable test results.
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Affiliation(s)
- Ana Bronić
- Department of Clinical Chemistry, Sestre milosrdnice University Hospital Center, Zagreb, Croatia
| | - Desiree Coen Herak
- Department of Laboratory Diagnostics, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Sandra Margetić
- Department of Clinical Chemistry, Sestre milosrdnice University Hospital Center, Zagreb, Croatia
| | - Marija Milić
- Department of Clinical Laboratory Diagnostics, Osijek University Hospital, Osijek, Croatia.,Faculty of Medicine, University of Osijek, Osijek, Croatia
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Favresse J, Lippi G, Roy PM, Chatelain B, Jacqmin H, Ten Cate H, Mullier F. D-dimer: Preanalytical, analytical, postanalytical variables, and clinical applications. Crit Rev Clin Lab Sci 2019; 55:548-577. [PMID: 30694079 DOI: 10.1080/10408363.2018.1529734] [Citation(s) in RCA: 104] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
D-dimer is a soluble fibrin degradation product deriving from the plasmin-mediated degradation of cross-linked fibrin. D-dimer can hence be considered a biomarker of activation of coagulation and fibrinolysis, and it is routinely used for ruling out venous thromboembolism (VTE). D-dimer is increasingly used to assess the risk of VTE recurrence and to help define the optimal duration of anticoagulation treatment in patients with VTE, for diagnosing disseminated intravascular coagulation, and for screening medical patients at increased risk of VTE. This review is aimed at (1) revising the definition of D-dimer; (2) discussing preanalytical variables affecting the measurement of D-dimer; (3) reviewing and comparing assay performance and some postanalytical variables (e.g. different units and age-adjusted cutoffs); and (4) discussing the use of D-dimer measurement across different clinical settings.
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Affiliation(s)
- Julien Favresse
- a CHU UCL Namur, Namur Thrombosis and Hemostasis Center, Hematology Laboratory , Université Catholique de Louvain , Yvoir , Belgium
| | - Giuseppe Lippi
- b Section of Clinical Biochemistry , University Hospital of Verona , Verona , Italy
| | - Pierre-Marie Roy
- c Département de Médecine d'Urgence, CHU d'Angers, Institut MITOVASC , Université d'Angers , Angers , France
| | - Bernard Chatelain
- a CHU UCL Namur, Namur Thrombosis and Hemostasis Center, Hematology Laboratory , Université Catholique de Louvain , Yvoir , Belgium
| | - Hugues Jacqmin
- a CHU UCL Namur, Namur Thrombosis and Hemostasis Center, Hematology Laboratory , Université Catholique de Louvain , Yvoir , Belgium
| | - Hugo Ten Cate
- d Department of Internal Medicine, Cardiovascular Institute , Maastricht University Medical Center , Maastricht , the Netherlands
| | - François Mullier
- a CHU UCL Namur, Namur Thrombosis and Hemostasis Center, Hematology Laboratory , Université Catholique de Louvain , Yvoir , Belgium
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Sua LF, Amézquita MA, Hernández DE, Alcalá-Flores M, Leib CS, Aguirre-Rojas M, Fernández-Trujillo L. Estaciones automatizadas preanalíticas en el laboratorio de hemostasia. Estudio observacional descriptivo prospectivo, realizado en un hospital universitario de referencia entre el 15 de abril y 15 de julio de 2017. IATREIA 2019. [DOI: 10.17533/udea.iatreia.12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Introducción: los errores del proceso de análisis de las muestras del laboratorio clínico, impactan negativamente a la práctica médica, la seguridad del paciente e incrementan los costos de atención en la salud. El uso de estaciones automatizadas demostró una disminución de los errores en los laboratorios clínicos de inmunoquímica y hematología. Se propone comparar las primeras estaciones automatizadas de hemostasia con el método manual para determinar los interferentes en las muestras de cinco servicios del hospital durante tres meses.Métodos: estudio observacional descriptivo prospectivo de corte trasversal. Las muestras que ingresaron al laboratorio clínico fueron analizadas por la estación automatizada y el método manual. Las interferentes bilirrubinas, hemoglobina, lipemia, volumen de llenado del tubo y obstrucción fluídica-coágulo se estudiaron con ambos métodos. Se realizó el análisis estadístico y se calculó el índice kappa para determinar la fuerza de la concordancia entre los métodos.Resultados: de 8.970 muestras analizadas, 29 % provinieron del servicio de urgencias. Las muestras aportadas por la unidad de cuidado intensivo reportaron más interferentes con ambos métodos; la estación automatizada reportó más interferentes que el método manual, con un índice kappa 0,52; la bilirrubina fue el interferente más detectado por ambos métodos. El método manual no evidenció el interferente volumen de llenado del tubo ni obstrucción fluídica-coágulo, los cuales fueron detectados por la estación automatizada.Conclusiones: la estación automatizada detectó más interferentes en comparación con el método manual. Los interferentes son errores preanalíticos en el laboratorio de hemostasia y son detectados con poca frecuencia de forma visual, especialmente los interferentes volúmenes de llenado del tubo y obstrucción fluídica-coágulo.
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Calcoen B, Desmet K, Vermeersch P. An abrupt rise of coagulation error messages on ACL TOP automated analysers. Biochem Med (Zagreb) 2019. [DOI: 10.11613/bm.2018.021002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Calcoen B, Desmet K, Vermeersch P. An abrupt rise of coagulation error messages on ACL TOP automated analysers. Biochem Med (Zagreb) 2019; 29:021002. [PMID: 31223268 PMCID: PMC6559622 DOI: 10.11613/bm.2019.021002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 04/12/2019] [Indexed: 11/18/2022] Open
Abstract
Introduction Blood coagulation tests (BCT) are very important for clinicians to diagnose bleeding or thrombotic disorders and to monitor anticoagulant therapy. Case description On a Saturday morning, a laboratory technician noted an abrupt rise in the number of coagulation error messages on our ALC TOP analysers. Visual inspection revealed the presence of partially and/or fully clotted citrate tubes and prompted the clinical biologist to further investigate a potential preanalytical cause. Considered causes Partially or fully clotted blood in citrate tubes can have multiple causes including improper mixing of the tube, under- or overfilling or combining blood samples from different tubes into one citrate tube. What happened The affected citrate tubes originated mostly from the same clinical departments. Moreover, all the affected tubes shared the same lot number (1 of 7 in use at the time). Visual inspection of 7 unopened boxes of 100 citrate tubes of this lot number revealed one box with nine completely empty and two partially filled tubes and one box with two partially filled tubes. No under-filled tubes were found in the other 5 boxes. Discussion The blood to additive ratio is crucial for BCT. A sudden rise in clot errors should trigger a thorough investigation to identify the cause. Main lesson Laboratories should regularly monitor and evaluate the percentage of clotted samples as a quality indicator at scheduled time points. A problem with the volume of additive in citrate tubes should be considered as a possible cause.
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Affiliation(s)
- Bas Calcoen
- Department of Laboratory Medicine, UZ Leuven, Leuven, Belgium
| | - Koen Desmet
- Department of Laboratory Medicine, UZ Leuven, Leuven, Belgium
| | - Pieter Vermeersch
- Department of Laboratory Medicine, UZ Leuven, Leuven, Belgium.,Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
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Padoan A, Sciacovelli L, Zhou R, Plebani M. Extra-analytical sources of uncertainty: which ones really matter? ACTA ACUST UNITED AC 2019; 57:1488-1493. [DOI: 10.1515/cclm-2019-0197] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Accepted: 04/23/2019] [Indexed: 12/27/2022]
Abstract
Abstract
Since the endorsement by ISO15189:2012 of measurement uncertainty (MU) for the estimation of error in measurement procedures, the debate has been ongoing with questions concerning which method should be used for estimating MU and the benefits of using MU over other error methods. However, only limited attention has been given to extra-analytical sources of uncertainty and, currently, a clear standpoint is still missing. This opinion paper aims to evaluate whether extra-analytical variables could be included in MU. Considering coagulation tests as an example, the possible sources of preanalytical variations are evaluated by using a fishbone diagram. After excluding preanalytical errors, additional sources of uncertainty are divided into amenable to standardization/harmonization and/or possible random sources, which are not standardizable nor harmonizable. Finally, sources of uncertainty are evaluated for a possible inclusion into MU. In addition, postanalytical uncertainty is discussed, particularly considering the laboratory results calculated through a mathematical equation, derived from one or more quantities affected by their specific uncertainty.
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Affiliation(s)
- Andrea Padoan
- Department of Laboratory Medicine , University-Hospital of Padova , Padova , Italy
- Department of Medicine – DIMED , University of Padova , via Giustiniani 2 , 35128 Padova , Italy , Phone: +390498212801, Fax: +390498211981
| | - Laura Sciacovelli
- Department of Laboratory Medicine , University-Hospital of Padova , Padova , Italy
| | - Rui Zhou
- Department of Laboratory Medicine, Beijing Chao-yang Hospital , Capital Medical University , Beijing , P.R. China
- Beijing Center for Clinical Laboratories , Beijing , P.R. China
| | - Mario Plebani
- Department of Laboratory Medicine , University-Hospital of Padova , Padova , Italy
- Department of Medicine – DIMED , University of Padova , Padova , Italy
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Kristoffersen AH, Stavelin AV, Ajzner E, Kristensen GB, Sandberg S, Van Blerk M, Kitchen S, Kesseler D, Woods TA, Meijer P. Pre-analytical practices for routine coagulation tests in European laboratories. A collaborative study from the European Organisation for External Quality Assurance Providers in Laboratory Medicine (EQALM). ACTA ACUST UNITED AC 2019; 57:1511-1521. [DOI: 10.1515/cclm-2019-0214] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2019] [Accepted: 04/01/2019] [Indexed: 11/15/2022]
Abstract
Abstract
Background
Correct handling and storage of blood samples for coagulation tests are important to assure correct diagnosis and monitoring. The aim of this study was to assess the pre-analytical practices for routine coagulation testing in European laboratories.
Methods
In 2013–2014, European laboratories were invited to fill in a questionnaire addressing pre-analytical requirements regarding tube fill volume, citrate concentration, sample stability, centrifugation and storage conditions for routine coagulation testing (activated partial thromboplastin time [APTT], prothrombin time in seconds [PT-sec] and as international normalised ratio [PT-INR] and fibrinogen).
Results
A total of 662 laboratories from 28 different countries responded. The recommended 3.2% (105–109 mmol/L) citrate tubes are used by 74% of the laboratories. Tube fill volumes ≥90% were required by 73%–76% of the laboratories, depending upon the coagulation test and tube size. The variation in centrifugation force and duration was large (median 2500 g [10- and 90-percentiles 1500 and 4000] and 10 min [5 and 15], respectively). Large variations were also seen in the accepted storage time for different tests and sample materials, for example, for citrated blood at room temperature the accepted storage time ranged from 0.5–72 h and 0.5–189 h for PT-INR and fibrinogen, respectively. If the storage time or the tube fill requirements are not fulfilled, 72% and 84% of the respondents, respectively, would reject the samples.
Conclusions
There was a large variation in pre-analytical practices for routine coagulation testing in European laboratories, especially for centrifugation conditions and storage time requirements.
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Affiliation(s)
- Ann Helen Kristoffersen
- Department of Medical Biochemistry and Pharmacology , Haukeland University Hospital , Bergen , Norway
- Norwegian Quality Improvement of Laboratory Examinations (Noklus) , Haraldsplass Deaconess Hospital , Bergen , Norway
| | - Anne V. Stavelin
- Norwegian Quality Improvement of Laboratory Examinations (Noklus) , Haraldsplass Deaconess Hospital , Bergen , Norway
| | - Eva Ajzner
- Central Laboratory , Jósa University Hospital , Nyíregyháza , Hungary
| | - Gunn B.B. Kristensen
- Norwegian Quality Improvement of Laboratory Examinations (Noklus) , Haraldsplass Deaconess Hospital , Bergen , Norway
| | - Sverre Sandberg
- Department of Medical Biochemistry and Pharmacology , Haukeland University Hospital , Bergen , Norway
- Norwegian Quality Improvement of Laboratory Examinations (Noklus) , Haraldsplass Deaconess Hospital , Bergen , Norway
- Department of Global Public Health and Primary Care , University of Bergen , Bergen , Norway
| | | | - Steve Kitchen
- UK NEQAS for Blood Coagulation , Sheffield , UK
- Sheffield Haemophilia and Thrombosis Centre , Sheffield , UK
| | - Dagmar Kesseler
- Quality Control Center Switzerland (CSCQ) , Chêne-Bourg , Switzerland
| | | | - Piet Meijer
- ECAT foundation , Voorschoten , The Netherlands
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Seregina EA, Poletaev AV, Bondar EV, Vuimo TA, Ataullakhanov FI, Smetanina NS. The hemostasis system in children with hereditary spherocytosis. Thromb Res 2019; 176:11-17. [PMID: 30763822 DOI: 10.1016/j.thromres.2019.02.004] [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: 09/11/2018] [Revised: 01/31/2019] [Accepted: 02/04/2019] [Indexed: 10/27/2022]
Abstract
INTRODUCTION Patients with hereditary spherocytosis (HS) are characterized by having an increased risk for thrombosis. An early manifestation of thrombotic complications can occur even in childhood, especially after surgery. Hypercoagulability can be associated with hemolytic crises. AIM The aim of this study was to investigate the hemostatic state in children with HS using global hemostasis assays. METHODS The hemostatic status of 62 children (38 boys and 24 girls; age range: 0.5 to 17 years) with HS during and without hemolytic crisis was assessed using clotting times (APTT, TT, and PR), fibrinogen and D-dimer levels, and global hemostasis, thromboelastography (TEG) and thrombodynamics (TD) assays. One hundred and two healthy children undergoing annual medical examination were enrolled as a control group. RESULTS TEG and TD parameters were increased in the children with HS compared to the control group (60 ± 5 mm vs. 53 ± 4 mm, p < 0.05 for TEG maximum amplitude; 28 ± 3 μm/min vs. 24 ± 2 μm/min, p < 0.05 for TD clot growth rate), while APTT, TT and PR were not significantly different between the two groups. Patients with HS were divided into 2 groups: those during hemolytic crisis (28 patients) and those without hemolytic crisis (34 patients). TEG and TD parameters were increased in those during hemolytic crisis compared to the steady state HS group (62 ± 5 mm vs. 57 ± 4 mm, p < 0.05 for TEG maximum amplitude; 31 ± 4 μm/min vs. 26 ± 3 μm/min, p < 0.05 for TD clot growth rate). The D-dimer levels were increased in 4 HS patients, for whom the activation of blood clotting was noted. Fibrinogen levels were decreased in patients with HS compared to the control group (2.1 ± 0.4 mg/ml vs. 2.6 ± 0.4 mg/ml, p < 0.05). Other tests were within the reference ranges for both groups. CONCLUSIONS The global hemostasis tests TEG and TD revealed hypercoagulability in patients with HS. More dramatic changes were observed in patients experiencing a hemolytic crisis.
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Affiliation(s)
- E A Seregina
- Dmitry Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia; Center for Theoretical Problems of Physicochemical Pharmacology RAS, Moscow, Russia.
| | - A V Poletaev
- Dmitry Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - E V Bondar
- Dmitry Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - T A Vuimo
- Dmitry Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - F I Ataullakhanov
- Dmitry Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia; Center for Theoretical Problems of Physicochemical Pharmacology RAS, Moscow, Russia; Department of Physics, Moscow State University, Moscow, Russia; The Faculty of Biological and Medical Physics, Moscow Institute of Physics and Technology, Dolgoprudniy, Russia
| | - N S Smetanina
- Dmitry Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia; Pirogov Russian National Research Medical University, Moscow, Russia
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Saksena D, Mishra YK, Muralidharan S, Kanhere V, Srivastava P, Srivastava CP. Follow-up and management of valvular heart disease patients with prosthetic valve: a clinical practice guideline for Indian scenario. Indian J Thorac Cardiovasc Surg 2019; 35:3-44. [PMID: 33061064 PMCID: PMC7525528 DOI: 10.1007/s12055-019-00789-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
PURPOSE Valvular heart disease (VHD) patients after prosthetic valve implantation are at risk of thromboembolic events. Follow-up care of patients with prosthetic valve has a paramount role in reducing the morbidity and mortality. Currently, in India, there is quintessential need to stream line the follow-up care of prosthetic valve patients. This mandates the development of a consensus guideline for the antithrombotic therapy in VHD patients post prosthetic valve implantation. METHODS A national level panel was constituted comprising 13 leading cardio care experts in India who thoroughly reviewed the up to date literature, formulated the recommendations, and developed the consensus document. Later on, extensive discussions were held on this draft and the recommendations in 8 regional meetings involving 79 additional experts from the cardio care in India, to arrive at a consensus. The final consensus document is developed relying on the available evidence and/or majority consensus from all the meetings. RESULTS The panel recommended vitamin K antagonist (VKA) therapy with individualized target international normalized ratio (INR) in VHD patients after prosthetic valve implantation. The panel opined that management of prosthetic valve complications should be personalized on the basis of type of complications. In addition, the panel recommends to distinguish individuals with various co-morbidities and attend them appropriately. CONCLUSIONS Anticoagulant therapy with VKA seems to be an effective option post prosthetic valve implantation in VHD patients. However, the role for non-VKA oral therapy in prosthetic valve patients and the safety and efficacy of novel oral anticoagulants in patients with bioprosthetic valve need to be studied extensively.
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Gavva C, Johnson M, De Simone N, Sarode R. An Audit of Thrombophilia Testing in Patients with Ischemic Stroke or Transient Ischemic Attack: The Futility of Testing. J Stroke Cerebrovasc Dis 2018; 27:3301-3305. [DOI: 10.1016/j.jstrokecerebrovasdis.2018.07.032] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Revised: 07/14/2018] [Accepted: 07/19/2018] [Indexed: 01/11/2023] Open
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Sarkar MK, Botz CM, Laposata M. An assessment of overutilization and underutilization of laboratory tests by expert physicians in the evaluation of patients for bleeding and thrombotic disorders in clinical context and in real time. ACTA ACUST UNITED AC 2018. [PMID: 29536907 DOI: 10.1515/dx-2016-0042] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Diagnostic error is extremely common in the USA and likely around the world. A major reason for the diagnostic error is both the overutilization and the underutilization of laboratory tests. Using a panel of two to four experts in coagulation, test selection was reviewed in clinical context and in real time, and consensus determinations were made to derive conclusions about the extent of overutilization and underutilization. METHODS Two hundred cases of patients being evaluated for bleeding or thrombotic issues were presented at each daily meeting of the diagnostic management team, and a review of each case for appropriate utilization of tests was completed. RESULTS Two hundred randomly selected cases revealed 77.5% diagnostic errors (155 cases). Sixteen percent were associated with overutilization of laboratory tests, 44% were associated with underutilization, and 17.5% were associated with both. The annual cost burden estimated for overutilization alone in one institution of 450 beds was on the order of $20,000. The cost burden for the delay in diagnosis or the misdiagnosis in cases with underutilization is orders of magnitude greater ($200,000 or more), but it is impossible to determine the cost of a misdiagnosis in an individual case because it can produce many different clinical outcomes. CONCLUSIONS This was a rare opportunity for experts in a given field to review cases in real time and in clinical context and provide immediately a consensus answer about test utilization. The results of this study show errors in test selection in nearly 75% of the cases evaluated.
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Affiliation(s)
- Mayukh K Sarkar
- 1Department of Clinical Laboratory Sciences, University of Texas Medical Branch, Galveston, TX, USA
| | - Chad M Botz
- 2Department of Pathology, University of Texas Medical Branch, Galveston, TX, USA
| | - Michael Laposata
- 2Department of Pathology, University of Texas Medical Branch, Galveston, TX, USA
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Favaloro EJ, Mohammed S, Lippi G. Postanalytical considerations that may improve the diagnosis or exclusion of haemophilia and von Willebrand disease. Haemophilia 2018; 24:849-861. [PMID: 30024638 DOI: 10.1111/hae.13587] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Accepted: 06/17/2018] [Indexed: 01/07/2023]
Abstract
von Willebrand disease (VWD) and haemophilia represent the most common inherited or acquired bleeding disorders. However, many laboratories and clinicians may be challenged by their accurate diagnosis or exclusion. Difficulties in diagnosis/exclusion may include analytical issues, where assays occasionally generate an incorrect result (ie representing an analytical error) or have limitations in their measurement range of and/or low analytical sensitivity. Also increasingly recognized is the influence of preanalytical issues on the diagnosis of VWD or haemophilia. Unfortunately, postanalytical considerations are often not well considered in the diagnostic process. Therefore, this narrative review aims to provide an overview of some important postanalytical considerations that may help improve the diagnosis of VWD and haemophilia. This review primarily discusses aspects around reporting of test results. However, we also discuss other less well-recognized postanalytical considerations, including the use of assay ratios to help identify differential diagnoses and then guide further investigation.
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Affiliation(s)
- Emmanuel 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
| | - Soma Mohammed
- Diagnostic Haemostasis Laboratory, Department of Haematology, Institute of Clinical Pathology and Medical Research (ICPMR), NSW Health Pathology, Westmead Hospital, Westmead, NSW, Australia
| | - Giuseppe Lippi
- Section of Clinical Biochemistry, University of Verona, Verona, Italy
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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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Fitzgerald SD, Martinez J, Buchweitz JP. An apparent case of brodifacoum toxicosis in a whelping dog. J Vet Diagn Invest 2017; 30:169-171. [PMID: 29145778 DOI: 10.1177/1040638717741664] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
A 7-y-old Weimaraner bitch was presented to emergency service after 3 h of active labor with no puppies produced. Hemoabdomen and hemothorax were present at the time of surgery; prothrombin time (PT) and activated partial thromboplastin time (aPTT) were both found to be within normal ranges. Surgical cesarean section was performed; 4 dead puppies and 5 live puppies were delivered. Because hemostasis was difficult to achieve, a hysterectomy was performed; however, the dog died as the operation was being completed. At autopsy, the pleural cavity contained 1.5 L of unclotted blood; the peritoneal cavity was relatively normal, and no obvious hemorrhage was associated with the surgical sites. All 4 dead fetuses were opened, and their pleural cavities were filled with unclotted blood. An anticoagulant screen was performed, and brodifacoum was identified in the liver of the bitch. This case is unusual in that the PT and aPTT were within reference intervals, but brodifacoum was present in sufficient amounts to potentially result in this dog bleeding to death, and also is suspected to have crossed the placenta and caused hemothorax and death in 4 of 9 puppies in utero.
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Affiliation(s)
- Scott D Fitzgerald
- Department of Pathobiology and Diagnostic Investigation, College of Veterinary Medicine, Michigan State University, E. Lansing, MI (Fitzgerald, Buchweitz).,Diagnostic Center for Population and Animal Health, Michigan State University, Lansing, MI (Fitzgerald, Buchweitz).,Small Animal Clinical Sciences, College of Veterinary Medicine, University of Florida, Gainesville, FL (Martinez)
| | - Jennifer Martinez
- Department of Pathobiology and Diagnostic Investigation, College of Veterinary Medicine, Michigan State University, E. Lansing, MI (Fitzgerald, Buchweitz).,Diagnostic Center for Population and Animal Health, Michigan State University, Lansing, MI (Fitzgerald, Buchweitz).,Small Animal Clinical Sciences, College of Veterinary Medicine, University of Florida, Gainesville, FL (Martinez)
| | - John P Buchweitz
- Department of Pathobiology and Diagnostic Investigation, College of Veterinary Medicine, Michigan State University, E. Lansing, MI (Fitzgerald, Buchweitz).,Diagnostic Center for Population and Animal Health, Michigan State University, Lansing, MI (Fitzgerald, Buchweitz).,Small Animal Clinical Sciences, College of Veterinary Medicine, University of Florida, Gainesville, FL (Martinez)
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Bhushan R, Sen A. Quantitative assessment of prevalence of pre-analytical variables and their effect on coagulation assay. Can intervention improve patient safety? Med J Armed Forces India 2017; 73:152-158. [PMID: 28924316 DOI: 10.1016/j.mjafi.2016.12.005] [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: 02/27/2016] [Accepted: 12/04/2016] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND Very few Indian studies exist on evaluation of pre-analytical variables affecting "Prothrombin Time" the commonest coagulation assay performed. The study was performed in an Indian tertiary care setting with an aim to assess quantitatively the prevalence of pre-analytical variables and their effects on the results (patient safety), for Prothrombin time test. The study also evaluated their effects on the result and whether intervention, did correct the results. METHODS The firstly evaluated the prevalence for various pre-analytical variables detected in samples sent for Prothrombin Time testing. These samples with the detected variables wherever possible were tested and result noted. The samples from the same patients were repeated and retested ensuring that no pre-analytical variable is present. The results were again noted to check for difference the intervention produced. RESULTS The study evaluated 9989 samples received for PT/INR over a period of 18 months. The prevalence of different pre-analytical variables was found to be 862 (8.63%). The proportion of various pre-analytical variables detected were haemolysed samples 515 (5.16%), over filled vacutainers 62 (0.62%), under filled vacutainers 39 (0.39%), low values 205 (2.05%), clotted samples 11 (0.11%), wrong labeling 4 (0.04%), wrong vacutainer use 2 (0.02%), chylous samples 7 (0.07%) and samples with more than one variable 17 (0.17%). The comparison of percentage of samples showing errors were noted for the first variables since they could be tested with and without the variable in place. The reduction in error percentage was 91.5%, 69.2%, 81.5% and 95.4% post intervention for haemolysed, overfilled, under filled and samples collected with excess pressure at phlebotomy respectively. CONCLUSION Correcting the variables did reduce the error percentage to a great extent in these four variables and hence the variables are found to affect "Prothrombin Time" testing and can hamper patient safety.
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Affiliation(s)
- Ravi Bhushan
- Graded Specialist (Pathology), Military Hospital Bhopal, MP, India
| | - Arijit Sen
- Associate Professor, Department of Pathology, Armed Forces Medical College, Pune 411040, India
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Hernaningsih Y, Akualing JS. The effects of hemolysis on plasma prothrombin time and activated partial thromboplastin time tests using photo-optical method. Medicine (Baltimore) 2017; 96:e7976. [PMID: 28930835 PMCID: PMC5617702 DOI: 10.1097/md.0000000000007976] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Hemolysis is the most common reason why coagulation test samples are rejected. However, the effects of hemolysis on plasma prothrombin time (PPT) and activated partial thromboplastin time (APTT) are rarely investigated and the results are controversial. This research aims to analyze the effects of hemolysis on PPT and APPT using the photo-optical method.Nonhemolyzed citrate blood samples (n = 30) with normal PPT and APTT underwent 2-step mechanical lysis and then hemoglobin level measurement was carried out at each step. The first lysis was mild to moderate resulting in a hemoglobin level of <0.8 g/dL. These samples were labeled as group 1. The second step showed more severe lysis, which resulted in a plasma hemoglobin level of ≥0.8 g/dL. These samples were labeled as group 2. Analysis was carried out on the PPT and APTT differences between the 2 groups and baseline, as well as between group 1 and group 2 using repeated-measures analysis of variance (ANOVA). The effects of hemolysis were analyzed using linear regression. Receiver operating characteristic (ROC) curve analysis was performed to determine the cut-off value in PPT and APTT.Significantly shorter APTT was measured for group 1 than baseline, (P = .000), group 2 than baseline (P = .000), and group 2 than group 1 (P = .003). With regard to PPT results, those for group 1 were significant shorter than baseline (P = .002), while those for group 2 were significantly longer than group 1 (P = .000). In the correlation assay, the level of hemolysis revealed a mildly significant correlation to APTT (R = 0.245; P = .02). Cut-off value for PPT was 1.55 g/dL (100% sensitivity and 87.9% specificity), while the value for APTT was 0.95 g/dL (75% sensitivity and 62.5% specificity).Not all hemolyzed samples should be rejected for PPT and APTT tests using photo-optical methods.
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Affiliation(s)
- Yetti Hernaningsih
- Department of Clinical Pathology, Faculty of Medicine Universitas Airlangga, Dr. Soetomo General Hospital, Surabaya, Jawa Timur
| | - Jeine Stela Akualing
- Clinical Pathology Laboratory, Tobelo General Hospital, North Halmahera, Indonesia
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Favaloro EJ, Oliver S, Mohammed S, Ahuja M, Grzechnik E, Azimulla S, McDonald J, Lima-Oliveira G, Lippi G. Potential misdiagnosis of von Willebrand disease and haemophilia caused by ineffective mixing of thawed plasma. Haemophilia 2017; 23:e436-e443. [DOI: 10.1111/hae.13305] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/12/2017] [Indexed: 12/15/2022]
Affiliation(s)
- E. J. Favaloro
- Department of Haematology; Institute of Clinical Pathology and Medical Research; NSW Health Pathology; Westmead Hospital; Westmead NSW Australia
- Sydney Centres for Thrombosis and Haemostasis; Westmead Hospital; Westmead NSW Australia
| | - S. Oliver
- Department of Haematology; Institute of Clinical Pathology and Medical Research; NSW Health Pathology; Westmead Hospital; Westmead NSW Australia
| | - S. Mohammed
- Department of Haematology; Institute of Clinical Pathology and Medical Research; NSW Health Pathology; Westmead Hospital; Westmead NSW Australia
| | - M. Ahuja
- Department of Haematology; Institute of Clinical Pathology and Medical Research; NSW Health Pathology; Westmead Hospital; Westmead NSW Australia
| | - E. Grzechnik
- Department of Haematology; Institute of Clinical Pathology and Medical Research; NSW Health Pathology; Westmead Hospital; Westmead NSW Australia
| | - S. Azimulla
- Department of Haematology; Institute of Clinical Pathology and Medical Research; NSW Health Pathology; Westmead Hospital; Westmead NSW Australia
| | - J. McDonald
- Department of Haematology; Institute of Clinical Pathology and Medical Research; NSW Health Pathology; Westmead Hospital; Westmead NSW Australia
| | - G. Lima-Oliveira
- Section of Clinical Biochemistry; University of Verona; Verona Italy
| | - G. Lippi
- Section of Clinical Biochemistry; University of Verona; Verona Italy
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