Joint EFLM-COLABIOCLI Recommendation for venous blood sampling

Recommendations for blood sampling in emergency departments from the European Society for Emergency Medicine (EUSEM), European Society for Emergency Nursing (EuSEN), and European Federation of Clinical Chemistry and Laboratory Medicine (EFLM) Working Group for the Preanalytical Phase. Executive summary

AIM

Blood Sampling Guidelines have been developed to target European emergency medicine-related professionals involved in the blood sampling process (e.g. physicians, nurses, phlebotomists working in the ED), as well as laboratory physicians and other related professionals. The guidelines population focus on adult patients. The development of these blood sampling guidelines for the ED setting is based on the collaboration of three European scientific societies that have a role to play in the preanalytical phase process: EuSEN, EFLM, and EUSEM. The elaboration of the questions was done using the PICO procedure, literature search and appraisal was based on the GRADE methodology. The final recommendations were reviewed by an international multidisciplinary external review group.

RESULTS

The document includes the elaborated recommendations for the selected sixteen questions. Three in pre-sampling, eight regarding sampling, three post-sampling, and two focus on quality assurance. In general, the quality of the evidence is very low, and the strength of the recommendation in all the questions has been rated as weak. The working group in four questions elaborate the recommendations, based mainly on group experience, rating as good practice.

CONCLUSIONS

The multidisciplinary working group was considered one of the major contributors to this guideline. The lack of quality information highlights the need for research in this area of the patient care process. The peculiarities of the emergency medical areas need specific considerations to minimise the possibility of errors in the preanalytical phase.

Venous blood collection systems using evacuated tubes: a systematic review focusing on safety, efficacy and economic implications of integrated vs. combined systems

Venous blood collection systems (VBCSs) are combinations of in-vitro diagnostics and medical devices, usually available as integrated set. However, purchasing and using a combination of devices from different sets is considered by clinical laboratories as an option to achieve specific sampling tasks or reduce costs. This systematic review aimed to retrieve available evidence regarding safety, efficacy, and economic aspects of VBCSs, focusing on differences between integrated and combined systems. The literature review was carried out in PubMed. Cited documents and resources made available by scientific organisations were also screened. Extracted evidence was clustered according to Quality/Efficacy/Performance, Safety, and Costs/Procurement domains and discussed in the current European regulatory framework. Twenty documents published between 2010 and 2021 were included. There was no evidence to suggest equivalence between combined and integrated VBCSs in terms of safety and efficacy. Scientific society's consensus documents and product standards report that combined VBCS can impact operators' and patients' safety. Analytical performances and overall efficacy of combined VBCSs are not guaranteed without whole system validation and verification. EU regulatory framework clearly allocates responsibilities for the validation and verification of an integrated VBCS, but not for combined VBCSs, lacking information about the management of product nonconformities and post-market surveillance. Laboratory validation of combined VBCS demands risk-benefit and cost-benefit analyses, a non-negligible organisational and economic burden, and investment in knowledge acquisition. Implications in terms of laboratory responsibility and legal liability should be part of a comprehensive assessment of safety, efficacy, and cost carried out during device procurement.

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

Introduction

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

Materials and methods

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

Results

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

Conclusions

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

Assessing Non-Laboratory Healthcare Professionals' Attitude towards the Importance of Patient Preparation for Laboratory Tests

(1) Background: Various guidelines address patient preparation and its importance for venous blood sampling, such as the GP41 guideline issued by the Clinical Laboratory Standards Institute (CLSI) and the blood collection guidelines published by the World Health Organisation. Recommendations provided by national societies or international organisations in the field of radiology, such as The Contrast Media Safety Committee of the European Society of Urogenital Radiology, or in the field of laboratory medicine, such as the Working Group for Preanalytical Phase (WG-PRE) of the European Federation of Clinical Chemistry and Laboratory Medicine (EFLM) and the Latin American Working Group for Preanalytical Phase (WG-PRE-LATAM) of the Latin American Confederation of Clinical Biochemistry (COLABIOCLI), also guide this practice. There is a notable lack of understanding regarding the viewpoints held by non-laboratory healthcare professionals concerning the significance of patient preparation for laboratory testing and the impact of typical factors associated with patient preparation. This study endeavours to bridge this gap by assessing the attitude of non-laboratory healthcare professionals in Lithuania regarding these pivotal aspects. (2) Methods: A self-designed anonymous questionnaire was disseminated among 141 public healthcare institutions in Lithuania. The internal consistency of the questionnaire was evaluated by computing Cronbach's alpha. Descriptive statistics were utilised for the variables, while comparisons of attitude among groups were conducted using Mann-Whitney U (for two groups) or Kruskal-Wallis (for more than two groups) for categorical and discrete indicators. The Kruskal-Wallis post-hoc test was employed for pairwise comparisons. A significance level of p-Value < 0.05 was applied to establish statistical significance. (3) Results: A total of 158 respondents constituted two distinct groups of healthcare professionals: nurses and physicians. Most of the participants either agreed or strongly agreed that patient preparation could introduce bias into laboratory test results. Professionals with less than 20 years of work experience or those who attended training in patient preparation for sampling within a 5-year timeframe exhibited stronger agreement regarding different preanalytical factors in patient preparation and their impact on laboratory test results compared to their counterparts. (4) Conclusions: Non-laboratory healthcare professionals who participated in this survey consider proper patient preparation for laboratory testing to be a significant step towards obtaining accurate test results. They also recognize the commonly acknowledged preanalytical factors as important for ensuring reliable test results. However, attitudes towards the importance of several preanalytical factors vary depending on whether non-laboratory healthcare professionals have more or less than 20 years of work experience, as well as whether they have attended any training on this topic within the last five years or have never attended such training.

The impact of preanalytical variables on the analysis of cell-free DNA from blood and urine samples

Cell-free DNA (cfDNA), a burgeoning class of molecular biomarkers, has been extensively studied across a variety of biomedical fields. As a key component of liquid biopsy, cfDNA testing is gaining prominence in disease detection and management due to the convenience of sample collection and the abundant wealth of genetic information it provides. However, the broader clinical application of cfDNA is currently impeded by a lack of standardization in the preanalytical procedures for cfDNA analysis. A number of fundamental challenges, including the selection of appropriate preanalytical procedures, prevention of short cfDNA fragment loss, and the validation of various cfDNA measurement methods, remain unaddressed. These existing hurdles lead to difficulties in comparing results and ensuring repeatability, thereby undermining the reliability of cfDNA analysis in clinical settings. This review discusses the crucial preanalytical factors that influence cfDNA analysis outcomes, including sample collection, transportation, temporary storage, processing, extraction, quality control, and long-term storage. The review provides clarification on achievable consensus and offers an analysis of the current issues with the goal of standardizing preanalytical procedures for cfDNA analysis.

Determination of systemic inflammatory biomarkers in multiple sclerosis

Background

Multiple sclerosis (MS) is one of the most common demyelinating diseases of the central nervous system. We aimed to investigate serum and cerebrospinal fluid levels of different laboratory inflammatory biomarkers in patients with MS.

Methods

A total of 120 subjects participated in the study, 60 of whom were diagnosed with MS, 30 with the final diagnosis of non-inflammatory diseases of the central nervous system (CNS), and 30 healthy subjects representing the control group. Regarding the progression of radiological findings after 2 years from the initial diagnosis, the MS group was divided into stationary radiological findings (n=30) and radiologically proven disease progression (n=30). In all patients, we analyzed levels of laboratory inflammatory biomarkers: C reactive protein (CRP), Neutrophil-to-lymphocyte ratio (NLR), Growth differentiation factor 15 (GDF15) in serum samples, and neurofilaments (NFs) in cerebrospinal fluid (CSF). NFs and GDF15 were analyzed initially, while CRP and NLR values were analyzed initially and after two years.

Results

We found statistically lower GDF15 values and initial CRP values in the MS group regarding the group with non-inflammatory diseases of the CNS (p<0.0001). On the other side, we determined a significant elevation of laboratory markers CRP and NLR, initially and after a two-year period, in the MS subgroup with the progression of magnetic resonance imaging (MRI) findings (p<0.0001 and p=0.050, respectively). Also, we found a positive correlation between CRP and NFs (r=0.243, p=0.04), as well as a positive correlation between CRP and GDF15 in patients with MS (r=0.769, p<0.0001).

Conclusions

We found a significant elevation of laboratory markers of systemic inflammation, CRP, and NLR in MS patients who developed disease progression based on MRI findings. There is a need for further studies to validate current parameters to be considered as useful markers of MS activity and disability.

To disinfect or not to disinfect that is the question - Procedure when drawing blood for alcohol measurements in Denmark

Swabbing with ethanol to disinfect the skin before venipuncture does not bias measurements of blood ethanol, as previously suspected. International evidence-based theory may not always be successfully integrated into local practices, where old customs may remain. So how are the local protocols for swabbing in practice - if they even do swab? Not disinfecting may risk patient safety. We aim to put a focus on the venipuncture disinfection procedure in practice when measuring blood alcohol for clinical matters and if their procedure refers to a guideline. Specialized biomedical laboratory scientists (BLS) are typically responsible for the phlebotomy procedure in Denmark, thus questionnaires were sent to the relevant BLS in 2020 to map disinfection procedures in all Danish hospitals and affiliated blood draw clinics (n = 58). The response rate was 93% (54/58). We observed an inter-laboratory dissimilarity in swabbing procedures, when measuring blood alcohol: A quarter did not use any disinfectant (26%), while the remaining disinfected with ethanol 55%, isopropanol 13%, and 6% with ethanol/chlorhexidine. Of the five Danish regions, three had a regional guideline (3/5), otherwise the swabbing protocol was locally based. There was a regional difference in disinfecting or not (Chi2 p < 0,0001). Danish protocols do not always parallel international literature and international guidelines. Not applying disinfectant may jeopardize patient safety. Laboratories are encouraged to work with evidence-based practice or follow newest standardized international guidelines.

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

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

Identification of miR-30c-5p microRNA in Serum as a Candidate Biomarker to Diagnose Endometriosis

The diagnosis of endometriosis by laparoscopy is delayed until advanced stages. In recent years, microRNAs have emerged as novel biomarkers for different diseases. These molecules are small non-coding RNA sequences involved in the regulation of gene expression and can be detected in peripheral blood. Our aim was to identify candidate serum microRNAs associated with endometriosis and their role as minimally invasive biomarkers. Serum samples were obtained from 159 women, of whom 77 were diagnosed with endometriosis by laparoscopy and 82 were healthy women. First, a preliminary study identified 29 differentially expressed microRNAs between the two study groups. Next, nine of the differentially expressed microRNAs in the preliminary analysis were evaluated in a new cohort of 67 women with endometriosis and 72 healthy women. Upon validation by quantitative real-time PCR technique, the circulating level of miR-30c-5p was significantly higher in the endometriosis group compared with the healthy women group. The area under the curve value of miR-30c-5p was 0.8437, demonstrating its diagnostic potential even when serum samples registered an acceptable limit of hemolysis. Dysregulation of this microRNA was associated with molecular pathways related to cancer and neuronal processes. We concluded that miR-30c-5p is a potential minimally invasive biomarker of endometriosis, with higher expression in the group of women with endometriosis diagnosed by laparoscopy.

Five days serum glucose stability at room-temperature in centrifuged fast-clotting serum tubes and the comparability with glucose in heparin-plasma and plasma containing citrate-stabilizer

Glucose measurement plays a central role in the diagnosis of gestational diabetes mellitus (GDM). Because of earlier reports of overestimation of glucose in the widely used tubes containing granulated glycolysis inhibitor, the study assessed the performance of fast-clotting serum tubes as an alternative sample for the measurement of glucose. Glucose concentration in fast-clotting serum was compared to lithium-heparin plasma placed in an ice-water slurry after sample collection and glucose stability at room-temperature was studied. Blood samples from 30 volunteers were drawn in four different types of tubes (serum separator tubes, fast-clotting serum tubes, lithium-heparin tubes and sodium fluoride, EDTA and a citrate buffer (NaF-EDTA-citrate) tubes, all from Greiner Bio-One). Lithium-heparin tubes were placed in an ice-water slurry until centrifugation in accordance with international recommendations and centrifuged within 10 min. After centrifugation, glucose was measured in all tubes (timepoint T0) and after 24, 48, 72, 96 and 120 h of storage at 20-22 °C. NaF-EDTA-citrate plasma showed significant overestimation of glucose concentration by 4.7% compared to lithium-heparin plasma; fast-clotting serum showed glucose concentrations clinically equivalent to lithium-heparin plasma. In fast-clotting serum tubes, mean bias between glucose concentration after 24, 48, 72, 96 and 120 h and T0 was less than 2.4%. All individual differences compared to T0 were less than 6.5%. The results fulfill the acceptance criteria for sample stability based on biological variation. Fast-clotting serum tubes can be an alternative for the measurement of glucose in diagnosis and management of GDM and diabetes mellitus, especially when prolonged transportation is necessary.

Exploratory analyses on the effect of time since last meal on concentrations of amino acids, lipids, one-carbon metabolites, and vitamins in the Hordaland Health Study

PURPOSE

Dietary intake may have pronounced effects on circulating biomarker concentrations. Therefore, the aim was to provide a descriptive overview of serum metabolite concentrations in relation to time since last meal, focusing on amino acids, lipids, one-carbon metabolites, and biomarkers of vitamin status.

METHODS

We used baseline data from the observational community-based Hordaland Health Study, including 2960 participants aged 46-49 years and 2874 participants aged 70-74 years. A single blood draw was taken from each participant, and time since last meal varied. Estimated marginal geometric mean metabolite concentrations were plotted as a function of time since last meal, up to 7 h, adjusted for age, sex, and BMI.

RESULTS

We observed a common pattern for nearly all amino acids and one-carbon metabolites with highest concentrations during the first 3 h after dietary intake. Homocysteine and cysteine were lowest the 1st hour after a meal, while no patterns were observed for glutamate and glutamic acid. The concentrations of phylloquinone and triglycerides were highest 1 h after dietary intake. Thiamine and thiamine monophosphate concentrations were highest, while flavin mononucleotide concentrations were lowest within the first 2 h after a meal. No clear patterns emerged for the other fat-soluble vitamins, blood lipids, or B-vitamin biomarkers.

CONCLUSION

Our findings suggest that distinguishing between "fasting" and "non-fasting" blood samples may be inadequate, and a more granular approach is warranted. This may have implications for how to account for dietary intake when blood sampling in both clinical and research settings.

Consensus report on flow cytometry for platelet function testing in thrombocytopenic patients: communication from the SSC of the ISTH

BACKGROUND

Platelet count alone does not reliably predict bleeding risk, suggesting platelet function is important to monitor in patients with thrombocytopenia. There is still an unmet need for improved platelet function diagnostics in patients with low platelet count in many clinical situations. Flow cytometry is a promising tool allowing reliable platelet function study in this setting.

OBJECTIVES

The goal of this joint project between the International Society on Thrombosis and Haemostasis (ISTH) Scientific Standardization Committee (SSC) Subcommittees on Platelet Physiology and Platelet Immunology is to provide expert consensus guidance on the use of flow cytometry for the evaluation of platelet function, particularly activation, in patients with low platelet counts.

METHODS

A literature review was performed to identify relevant questions and areas of interest. An electronic expression of interest form was thereafter announced on the ISTH webpage, followed by a survey encompassing 37 issues regarding preanalytical, analytical, postanalytical, and performance aspects. Areas of disagreement or uncertainty were identified and formed the basis for 2 focus group discussions.

RESULTS

Consensus recommendations relative to patient sample collection, preanalytical variables, sample type, platelet-count cutoff, any potential specific modification of the standard flow cytometry protocol, and results expression and reporting are proposed based on the current practices of experts in the field as well as on literature review.

CONCLUSION

The proposed consensus recommendations would allow standardization of protocols in upcoming clinical studies. The clinical utility of platelet function testing using flow cytometry to predict bleeding risk still needs rigorous multicenter outcome studies in patients with thrombocytopenia.

Recommendation for the design of stability studies on clinical specimens

OBJECTIVES

Knowledge of the stability of analytes in clinical specimens is a prerequisite for proper transport and preservation of samples to avoid laboratory errors. The new version of ISO 15189:2022 and the European directive 2017/746 increase the requirements on this topic for manufacturers and laboratories. Within the project to generate a stability database of European Federation of Clinical Chemistry and Laboratory Medicine (EFLM) Working Group Preanalytical Phase (WG-PRE), the need to standardise and improve the quality of published stability studies has been detected, being a manifest deficit the absence of international guidelines for the performance of stability studies on clinical specimens.

METHODS

These recommendations have been developed and summarised by consensus of the WG-PRE and are intended primarily to improve the quality of sample stability claims included in information for users provided by assay supplier companies, according to the requirements of the new European regulations and standards for accreditation.

RESULTS

This document provides general recommendations for the performance of stability studies, oriented to the estimation of instability equations in the usual working conditions, allowing flexible adaptation of the maximum permissible error specifications to obtain stability limits adapted to the intended use.

CONCLUSIONS

We present this recommendation based on the opinions of the EFLM WG-PRE group for the standardisation and improvement of stability studies, with the intention to improve the quality of the studies and the transferability of their results to laboratories.

Epigenetic Aspects of a New Probiotic Concept-A Pilot Study

Several studies report the important role of an altered gut microbiota in the development of obesity, highlighting the potential use of probiotics in the treatment of obesity. The aim of this study is to investigate the effect of a novel probiotic approach on the expression of specific miRNAs and mRNAs associated with obesity in combination with the hypocholesterolemic octacosanol. Twenty overweight/obese women participated in a randomized, placebo-controlled, double-blind study and were randomly divided into two groups: the intervention group (daily one capsule containing Lactobacillus plantarum 299v (DSM9843), Saccharomyces cerevisiae var. boulardii, and 40 mg octacosanol; N = 12) and the placebo group (N = 8). Changes in lipid parameters and expression of miRNAs and mRNAs were assessed before (T0) and after the 12-week intervention (T1). After the intervention, the expression of miR-155-5p (9.38 ± 0.85 vs. 8.38 ± 1.06, p = 0.05) and miR-24-3p (3.42 ± 0.38 vs. 2.71 ± 0.97, p = 0.031) showed significant decreases in the intervention group when compared to the control group. At T1, the expression of miR-155-5p (8.69 ± 1.31 vs. 9.3 ± 0.85, p = 0.04), miR-125b-5p (5.41 ± 1.18 vs. 5.99 ± 1.36, p = 0.049), and TNF-α (10.24 ± 1.66 vs. 11.36 ± 1.12, p = 0.009) were significantly decreased in the intervention group. No changes in lipids and anthropometric parameters were observed. The novel probiotic approach had a positive effect on regulating the expression of certain miRNAs and mRNAs important for regulating inflammation and adipogenesis, which are essential for obesity onset and control.

Erroneous potassium results: preanalytical causes, detection, and corrective actions

Potassium is one of the most requested laboratory tests. Its level is carefully monitored and maintained in a narrow physiological range. Even slightly altered potassium values may severely impact the patient's health, which is why an accurate and reliable result is of such importance. Even if high-quality analytics are available, there are still numerous ways in which potassium measurements may be biased, all of which occur in the preanalytical phase of the total laboratory testing process. As these results do not reflect the patient's in-vivo status, such results are referred to as pseudo-hyper/hypokalemia or indeed pseudo-normokalemia, depending on the true potassium result. Our goal in this review is to present an in-depth analysis of preanalytical errors that may result in inaccurate potassium results. After reviewing existing evidence on this topic, we classified preanalytical errors impacting potassium results into 4 categories: 1) patient factors like high platelet, leukocytes, or erythrocyte counts; 2) the sample type 3) the blood collection procedure, including inappropriate equipment, patient preparation, sample contamination and others and 4) the tube processing. The latter two include sample transport and storage conditions of whole blood, plasma, or serum as well as sample separation and subsequent preanalytical processes. In particular, we discuss the contribution of hemolysis, as one of the most frequent preanalytical errors, to pseudo-hyperkalemia. We provide a practical flow chart and a tabular overview of all the discussed preanalytical errors including possible underlying mechanisms, indicators for detection, suggestions for corrective actions, and references to the according evidence. We thereby hope that this manuscript will serve as a resource in the prevention and investigation of potentially biased potassium results.

Analysis of the Six Sigma Principle in Pre-analytical Quality for Hematological Specimens

Introduction Blood tests are essential for detecting and treating hospitalized individuals with diseases. Laboratory blood tests provide doctors with critical information required to treat their patient's illnesses. The most common sources of error in clinical laboratories are pre-analytical errors. Although quality control measures can remediate analytical errors, there is a requirement for stringent quality checks in the pre-analytical sector as these activities are performed outside of the laboratory. Pre-analytical errors when combined with the sigma value can reflect a better picture as the sigma value represents the laboratory's performance.  Aim In this study, six sigma and the Pareto principle were utilized to assess pre-analytical quality indicators for evaluating the performance of a clinical hematology laboratory.  Methodology  This is a retrospective observational study conducted from 2015 to 2023 (for a period of eight years). Information about the frequency of pre-analytical errors was retrieved from the hematology section of the central diagnostic research laboratory information system and the data was entered into an MS Excel sheet and data was evaluated utilizing SPSS version 23 (IBM Corp., Armonk, NY). Results In the current research, total of 15 pre-analytical errors were noted. Out of the total 15 pre-analytical errors studied, 55.4% of pre-analytical errors were noted among which 80% errors were due to lack of mention of sample type or received time and 20% of errors were attributed to no mention of diagnosis in requisition forms. The next most common errors noted were insufficient samples (8.26%) followed by absence of physician's signature (7%), incomplete request form (5.4%), age (4.2%), unique hospital identification (UHID) number (3.7%), clotted samples and transportation of the samples (3.6%), date and incorrect vials (2.6%). Gender (0.95%), hemolysed (0.85%), and lipemic samples (0.45%). Hemolysed and lipemic samples had a sigma value of 4.4 and 4.6, respectively, whereas gender and age had a sigma value of 4.3 and 3.8, inadequate sample for testing and an incorrect anticoagulant to blood ratio had a sigma value of 3.6, indicating that sample collection has to be improved as the inverse relationship is noted between sigma value and laboratory performance. Conclusion Pareto chart and sigma value can help recognize most common pre-analytical errors, which consequently will help to prevent further recurrence of pre-analytical errors. Adequate training with regard to best practices in phlebotomy for interns, clinicians and technicians must be provided to decrease quantitative errors, which will further enhance total quality management in the laboratory.

Coffee intake one hour prior to phlebotomy produces no clinically significant changes in routine biochemical test results

Introduction

Although current guidelines recommend not drinking coffee prior to phlebotomy, our hypothesis is that drinking coffee does not affect the clinical interpretation of biochemical and haematological test results.

Materials and methods

Twenty-seven volunteers were studied in basal state (T0) and 1h after (T1) drinking coffee. Routine haematological (Sysmex-XN1000 analyser) and biochemistry parameters (Vitros 4600 analyser) were studied. Results were compared using the Wilcoxon test (P < 0.05). A clinical change was considered when mean percent difference (MD%) was higher than the reference change value (RCV).

Results

Coffee intake produced statistically, but not clinically, significant: i) increases in haemoglobin (P = 0.009), mean cell haemoglobin concentration (P = 0.044), neutrophils (P = 0.001), albumin (P = 0.001), total protein (P = 0.000), cholesterol (P = 0.025), high density lipoprotein cholesterol (P = 0.007), uric acid (P = 0.011), calcium (P = 0.001), potassium (P = 0.010), aspartate aminotransferase (P = 0.001), amylase (P = 0.026), and lactate dehydrogenase (P = 0.001), and ii) decreases in mean cell volume (P = 0.002), red cell distribution width (P = 0.001), eosinophils (P = 0.002), and lymphocytes (P = 0.001), creatinine (P = 0.001), total bilirubin (P = 0.012), phosphorus (P = 0.001), magnesium (P = 0.007), and chloride (P = 0.001).

Conclusion

Drinking a cup of coffee 1 hour prior to phlebotomy produces no clinically significant changes in routine biochemical and haematological test results.

Lack of an association between first-trimester concentration of mid-regional pro-atrial natriuretic peptide and risk of early-onset preeclampsia <34 weeks' gestation

AIM

We examined the heart failure biomarker mid-regional pro-atrial natriuretic peptide during the first trimester of pregnancy in relation to early-onset preeclampsia <34 weeks.

MATERIALS AND METHODS

This case-control study included 34 women with singleton pregnancies with a preeclampsia diagnosis and delivery before 34 weeks of gestation who had attended the routine first-trimester ultrasound scan at 11-13+6 weeks of gestation between August 2010 and October 2015 at the Copenhagen University Hospital Rigshospitalet, Denmark, and 91 uncomplicated singleton pregnancies matched by time of the routine first-trimester blood sampling at 8-13+6 weeks. Descriptive statistical analyses were performed for maternal characteristics and obstetric and medical history for the case versus the control group. Concentrations of mid-regional pro-atrial natriuretic peptide, placental growth factor, soluble fms-like tyrosine kinase-1, and pregnancy-associated plasma protein A between early-onset preeclampsia cases and the control group were compared using Students t-test and the Mann-Whitney U test. Biochemical marker concentrations were converted into multiples of the expected median values after adjustment for gestational age.

RESULTS

Mid-regional pro-atrial natriuretic peptide levels were not significantly different between early-onset preeclampsia cases and the control group in the first trimester of pregnancy. As expected, both placental growth factor and pregnancy-associated plasma protein A levels were significantly lower in early-onset preeclampsia, whereas soluble fms-like tyrosine kinase-1 levels were not statistically significantly different.

CONCLUSION

The maternal first-trimester concentration of mid-regional pro-atrial natriuretic peptide, a peptide with multiple biological functions including a relation to cardiovascular disease, was not significantly different in women with early-onset preeclampsia.

Comparison of Turkish and English YouTube videos on phlebotomy in terms of content, reliability and quality

AIM

This study was conducted to evaluate the content, reliability and quality of YouTube videos about phlebotomy.

METHOD

A retrospective, register-based study was conducted exclusively with videos publicly available on YouTube in June 2022. Ninety videos have been evaluated in terms of content, reliability and quality. This evaluation was performed by two independent researchers. The skill checklist created with reference to the WHO blood collection guide was used for the content evaluation of the videos. The short form of the DISCERN questionnaire was used to evaluate the reliability of the video. The quality of the videos was evaluated with a 5-point Global Quality Scale.

RESULTS

The mean validity score of the English videos was 2.58 ± 0.88, the quality score was 2.98 ± 1.02 and the content score was 8.78 ± 1.47. In the Turkish videos, the mean validity score was 1.90 ± 1.27, the quality score was 2.35 ± 0.97 and the content score was 8.02 ± 1.07. The content, validity and quality scores of the English videos were found to be significantly higher than the Turkish videos.

CONCLUSION

Some videos do not include evidence-based practice and some videos contain technical differences as in the literature. In addition, in some videos, non-recommended techniques such as touching the cleaning area, opening and closing the fist were used. For these reasons, the results show that YouTube videos on phlebotomy are a limited resource for students.

Instructions on appropriate fasting prior to phlebotomy; effects on patient awareness, preparation, and biochemical parameters

OBJECTIVES

This study investigated the effect of appropriate pre-phlebotomy instructions on patients' awareness of the need to fast, their fasting status at phlebotomy, and the measurement of specific biochemical analytes and indices.

METHODS

While booking their phlebotomy appointments, two-hundred outpatients, with a wide range of pre-existing medical conditions, were recruited and randomly assigned to either control or intervention groups. The control group received no instructions while the intervention group was verbally instructed to fast for precisely 12 h prior to their appointment. Serum samples were collected from participants to quantify common biochemical analytes and serum indices, some of which were known to be influenced by fasting status, such as triglyceride and the lipaemic index. At the same appointment, participants completed a survey assessing their perception of, and adherence to, fasting requirements.

RESULTS

In the intervention group, 99% responded that they had fasted before phlebotomy vs. 16% of controls. Subjects stated they fasted for 12 h in 51% of the intervention group and 7% of the controls. Median concentrations for potassium and total bilirubin were statistically, but not clinically, significantly different. In the study, a single patient in the intervention group was found to have a lipaemic sample.

CONCLUSIONS

Without instruction, it appears few patients will fast appropriately prior to blood collection. This study suggests that most patients recall and adhere to verbal instructions regarding fasting. Though many in the control group stated they did not fast, triglyceride concentration and lipaemia were not significantly different from the intervention group, and biochemical analyses appear unaffected by fasting status.

Do different wiping techniques in phlebotomy have an effect on vessel visibility, procedural success, and phlebotomy-related complications?

Background:

This study was conducted to evaluate the effects of different wiping techniques used in phlebotomy on vein visibility, procedural success, and phlebotomy-related complications.

Materials and methods:

This single-center, comparative, randomized study was conducted with 90 patients in the internal medicine clinic of a tertiary hospital. During the phlebotomy procedure, the phlebotomy site was wiped with circular technique in the Group-I, vertical technique in the Group-II, and vertical + circular technique in the Group-III.

Results:

There was a significant difference between the three groups in terms of vein visibility after wiping of the phlebotomy site ( p < 0.05). The time spent for blood sampling was shorter in the Groups I and II ( p > 0.05). In the 3-day follow-up after the blood sample was taken, the ecchymosis and hematoma rates of the groups were similar ( p > 0.05).

Conclusions:

Vertical wiping and vertical + circular wiping techniques used in the cleaning of the phlebotomy site increased the visibility of the vein compared to only circular wiping. The time spent for blood sampling was shorter in the vertical wiping and vertical + circular wiping groups.

Neurofilament light chain as neuronal injury marker - what is needed to facilitate implementation in clinical laboratory practice?

Neurobiomarkers have attracted significant attention over the last ten years. One promising biomarker is the neurofilament light chain protein (NfL). Since the introduction of ultrasensitive assays, NfL has been developed into a widely used axonal damage marker of relevance to the diagnosis, prognostication, follow-up, and treatment monitoring of a range of neurological disorders, including multiple sclerosis, amyotrophic lateral sclerosis, and Alzheimer's disease. The marker is increasingly used clinically, as well as in clinical trials. Even if we have validated precise, sensitive, and specific assays for NfL quantification in both cerebrospinal fluid and blood, there are analytical, as well as pre- and post-analytical aspects of the total NfL testing process, including biomarker interpretation, to consider. Although the biomarker is already in use in specialised clinical laboratory settings, a more general use requires some further work. In this review, we provide brief basic information and opinions on NfL as a biomarker of axonal injury in neurological diseases and pinpoint additional work needed to facilitate biomarker implementation in clinical practice.

Preanalytical Errors in Clinical Biochemistry Laboratory and Relationship With Hospital Departments and Staff: A Record-Based Study

OBJECTIVE

Despite many efforts to improve the overall quality of clinical laboratory service, errors that compromise patient safety and increase healthcare costs continue to occur even infrequently. We aimed to determine the causes of preanalytical errors and related factors by evaluating the laboratory records of a tertiary hospital.

METHODS

In this retrospective study, 7,762,981 requests that were registered in the biochemistry laboratory records of Ondokuz Mayıs University Health Practice and Research Center during 2019 were examined. All rejected samples were analyzed according to the department where they were collected and the reasons for rejection.

RESULTS

Of the total sample rejections, 99,561 (74.8%) were preanalytical and 33,474 (25.2%) belonged to the analytical phase. The preanalytical rejection rate was 1.28%, with the highest rejection rate in the inpatients (2.26%) and the lowest in the outpatients (0.02%). Insufficient sample (43.7%), clotted sample (35.1%), and inappropriate sample (11.1%) were the first 3 rows of rejection reasons. It was determined that sample rejection rates were low during routine working hours and high during nonworking hours.

CONCLUSIONS

Preanalytical errors were most common in inpatient wards and were most likely due to incorrect phlebotomy techniques. Education of health personnel on good laboratory practices, systematic monitoring of errors, and the development of quality indicators will play an important role in reducing the vulnerability of the preanalytical phase.

Serum bicarbonate stability study at room temperature - influence of time to centrifugation and air exposure on bicarbonate measurement reported according to the CRESS checklist

OBJECTIVES

The aim was to evaluate the stability of serum bicarbonate at room temperature, depending on time to centrifugation and air exposure.

METHODS

Stability study was conducted in the laboratory of Clinical Hospital Centre Rijeka, Croatia in January-February 2022. Nine samples from 10 volunteers were collected in clot activator gel tubes (Greiner Bio-One). Bicarbonate was measured on Beckman Coulter AU480 (Beckman Coulter, Brea, USA). Three tubes were left at room temperature for 30 min, three tubes for 2 h, three tubes for 4 h until centrifugation. First tube from first group (baseline) was measured immediately after centrifugation. Other measurements were expressed as percentage deviation (PD%) from baseline. First tube was remeasured after 1 and 2 h (OT_0h_1h; OT_0h_2h). Second and third tubes were opened 1 and 2 h after centrifugation (C_0h_1h; C_0h_2h). Second group of tubes was processed the same way with 2-hour centrifugation delay (WB_2h; OT_2h_1h; OT_2h_2h; C_2h_1h; C_2h_2h), and third group with 4-hour delay (WB_4h; OT_4h_1h; OT_4h_2h; C_4h_1h; C_4h_2h). PD% was compared to Maximum Permissible Difference (MPD=5.69%). MedCalc statistical software was used (MedCalc, Ostend, Belgium).

RESULTS

Bicarbonate baseline mean value (range) was 27.3 (23.4-29.6) mmol/L. Obtained PD% (95%CI) were: C_0h_1h 0.46 (-1.21, 2.12); C_0h_2h 0.18 (-2.22, 2.57); OT_0h_1h -6.46 (-7.57, -5.36); OT_0h_2h -10.67 (-12.13, -9.21); WB_2h -0.15 (-2.04, 1.74); C_2h_1h 0.01 (-1.52, 1.54); C_2h_2h -0.40 (-2.65, 1.85); OT_2h_1h -5.43 (-7.30, -3.55); OT_2h_2h -11.32 (-13.57, -9.07); WB_4h -0.85 (-3.28, 1.58); C_4h_1h -2.52 (-4.93, 0.11); C_4h_2h -3.02 (-5.62, 0.43); OT_4h_1h -7.34 (-9.64, -5.05); OT_4h_2h -11.85 (-14.38, -9.33).

CONCLUSIONS

Serum bicarbonate is stable for 4 h in closed uncentrifuged tubes, another 2 h in closed tubes after centrifugation, and is unstable within 1 h in opened tube.

Type 2 Diabetes Related Mitochondrial Defects in Peripheral Mononucleated Blood Cells from Overweight Postmenopausal Women

Type 2 diabetes (T2D) is a multisystem disease that is the subject of many studies, but the earliest cause of the disease has yet to be elucidated. Mitochondrial impairment has been associated with diabetes in several tissues. To extend the association between T2D and mitochondrial impairment to blood cells, we investigated T2D-related changes in peripheral mononucleated blood cells’ (PBMCs) mitochondrial function in two groups of women (CTRL vs. T2D; mean age: 54.1 ± 3.8 vs. 60.9 ± 4.8; mean BMI 25.6 ± 5.2 vs. 30.0 ± 5), together with a panel of blood biomarkers, anthropometric measurements and physiological parameters (VO2max and strength tests). Dual-energy X-ray absorptiometry (DXA) scan analysis, cardio-pulmonary exercise test and blood biomarkers confirmed hallmarks of diabetes in the T2D group. Mitochondrial function assays performed with high resolution respirometry highlighted a significant reduction of mitochondrial respiration in the ADP-stimulated state (OXPHOS; −30%, p = 0.006) and maximal non-coupled respiration (ET; −30%, p = 0.004) in PBMCs samples from the T2D group. The total glutathione antioxidant pool (GSHt) was significantly reduced (−38%: p = 0.04) in plasma samples from the T2D group. The fraction of glycated hemoglobin (Hb1Ac) was positively associated with markers of inflammation (C-reactive protein-CRP r = 0.618; p = 0.006) and of dyslipidemia (triglycerides-TG r = 0.815; p < 0.0001). The same marker (Hb1Ac) was negatively associated with mitochondrial activity levels (OXPHOS r = −0.502; p = 0.034; ET r = −0.529; p = 0.024). The results obtained in overweight postmenopausal women from analysis of PBMCs mitochondrial respiration and their association with anthropometric and physiological parameters indicate that PBMC could represent a reliable model for studying T2D-related metabolic impairment and could be useful for testing the effectiveness of interventions targeting mitochondria.

An Overview of Complete Blood Count Sample Rejection Rates in a Clinical Hematology Laboratory Due to Various Preanalytical Errors

Introduction The Chughtai Laboratory collects blood samples for complete blood counts from various hospitals, emergency departments, ICUs, and through home sampling services all across the country. The preanalytical phase is an integral component of laboratory medicine. A laboratory report has a key role in patient treatment and the clinician's decision in the management of the disease. Preanalytical errors are most frequently caused by the absence of a sample and/or inappropriate understanding of a test request, mislabeling, contamination from the sampling site, hemolyzed, clotted, insufficient samples, storage issues, and inappropriate blood to anticoagulant proportion or inappropriate choice of anticoagulant. Objective To identify the cause of rejection rates of the complete blood count samples and reduce the rejection rates by improving the accuracy of the results and lowering pre-analytical errors. Methods This cross-sectional study was done in the Hematology Department of Chughtai Laboratory's head office in Lahore between 19-06-2021 and 19-10-2021. Simple random sampling was applied to collect the data. About 3 ml of each blood sample was received in an ethylenediaminetetraacetic acid (EDTA) vial, inspected visually, run on Sysmex XN-9000 (Sysmex Corporation, Kobe, Hyogo, Japan), and was reviewed on peripheral smears. Results Out of 231,008 blood samples, 11,897 (5.15%) samples were rejected. The most common pre-analytical mistake was storage issues due to transportation delay (19.45%) followed by wrong medical records (19.16%), diluted samples (16.35%), incorrect tubes (16.01%), hemolyzed samples (15.13%), unlabeled samples (10.01%), and clotted sample (3.88%). Conclusion In the hematology department, the total rejection rate observed during the study period was 5.15%. Recognition of preanalytical errors and avoiding them will help us lower the sample rejection rate and raise the overall quality of laboratory management.

Laboratory evaluation of a new integrative assay to phenotype plasma fibrinolytic system

BACKGROUND

There is currently no universal and standardized test available to phenotype plasma fibrinolytic system.

AIMS

Our main aims were to evaluate the performances of the 'global fibrinolysis capacity' assay (GFC) performed with the Lysis Timer® instrument, and to study the influence of some preanalytical conditions.

METHOD

Euglobulin clot lysis time (ECLT) and GFC were performed under several preanalytical conditions.

RESULTS

GFC showed satisfactory intra- and inter-run precision. Frozen controls and reagents showed stability over the studied period. There was no statistically significant difference between GFC assessed in plasma samples processed at 4 °C or at 20 °C. GFC assessed with frozen-thawed plasma samples was prolonged when compared to fresh samples (p = 0.014). The centrifugation scheme had no influence on PAI-1 activity levels, GFC and ECLT. Reference interval for GFC ranges from 29.3 (C I90% = 26.9-31.9) to 49.5 (90% CI = 45.9-52.2) minutes. In addition, a preliminary study in 40 healthy volunteers and 43 adult patients referred for investigation of a bleeding disorder was conducted to compare GFC and ECLT assays in their ability to classify samples with shortened or prolonged clot lysis times. Disagreements between ECLT and GFC were observed for 23 samples (out of 83), most of them minor.

CONCLUSION

GFC is suitable and convenient for a broad clinical use and can be performed with frozen-thawed plasma samples. Unlike ECLT, GFC is designed to take into account the balance between inhibitors and activators of the fibrinolytic system and could detect both hypo- and hyperfibrinolytic states. Whether it is as suitable as or even better than ECLT to detect a bleeding tendency due to a hyperactive fibrinolytic system deserves to be properly investigated.

A case of discrepant laboratory results in samples obtained from a central venous catheter and peripheral veins: when solving a pre-analytical mystery could improve patient care

It is now generally accepted that laboratory errors or inaccurate results are mainly due to deficiencies in the pre-analytical phase. In this report, we describe the case of a 64-year-old male affected by a relapsing follicular lymphoma, who has been treated with chemotherapy through a central venous catheter (CVC). Four different samples were collected alternatively through peripheral venipuncture and CVC sampling. Unexpectedly, the samples collected from the two different sources showed contrasting results, with the presence of unusual macrophage-like cells in the samples obtained from CVC. It was later found that the CVC was displaced into the pleural space. This case report shows how the sampling process can sometimes influence test results and how it can help clinicians identify clinical conditions that have not yet manifested.

Quality in laboratory medicine and the Journal: walking together

Quality in laboratory medicine is defined as "an unfinished journey", as the more essential the laboratory information provided, the more assured its quality should be. In the past decades, the Journal Clinical Chemistry and Laboratory Medicine has provided a valuable forum for garnering new insights into the analytical and extra-analytical phases of the testing cycle, and for debating crucial aspects of quality in clinical laboratories. The impressive number of papers published in the Journal is testimony to the efforts made by laboratory professionals, national and international scientific societies and federations in the quest to continuously improve upon the pre-, intra- and post-analytical steps of the testing cycle, thus enhancing the quality of laboratory information. The paper appearing in this special issue summarizes the most important and interesting contributions published in the Journal, thus updating our knowledge on quality in laboratory medicine and offering further stimuli to identify the most valuable measures of quality in clinical laboratories.

Senior nursing students' reflections on deviations from guideline adherence regarding venous blood specimen collection practice: A qualitative study

BACKGROUND

Venous blood specimen collection is a common procedure within healthcare and both diagnoses as well as treatment evaluation, are often based on results from these analyses. However, studies among both students and staff have demonstrated suboptimal adherence to venous blood specimen collection practice guidelines which in turn might jeopardize patient safety.

OBJECTIVES

This study aimed to describe final semester nursing students' experiences of deviations from venous blood specimen collection practice guidelines during clinical training.

METHODS

This study adopted a qualitative design. Twentysix final (6th) semester nursing students were recruited through purposive sampling at a Swedish university. Data were collected through semi-structured, face-to-face, focus group interviews in September 2015. The transcribed interviews were analyzed using qualitative content analysis.

RESULTS

The students' experiences generated two categories; 1) Striving to blend in (subcategories Feeling uncomfortable and Adapting to the prevailing practice culture) and 2) Diminished confidence (subcategories Being confused due to inconsistency and Being uncertain about guideline usefulness) forming the overall theme Being a copycat.

CONCLUSION

The research concludes that nursing students adapt to the prevailing practice culture encountered during clinical training, often at the expense of guidelines adherence. Since the students are being assessed during clinical training, the eagerness to belong to the team and be well-liked might be stronger than the ambition to follow guidelines. As a consequence, nursing students in clinical training might become copycats by aligning themselves with the prevailing practice culture which in turn might jeopardize adherence with VBSC guideline practice and thereby patient safety. With the ambition to support nursing students' learning in clinical training, facilitators of learning to comprise both students and supervisors need to be further addressed.

TWEETABLE ABSTRACT

Nursing students adapt to the prevailing venous blood sample collection practice culture and become copycats.

Stability of direct renin concentration and plasma renin activity in EDTA whole blood and plasma at ambient and refrigerated temperatures from 0 to 72 hours

OBJECTIVES

The aim of this study was to determine the appropriate transport and storage conditions for blood taken for direct renin concentration and plasma renin activity measurement, and whether cryoactivation of prorenin is seen at time points relevant to clinical practice.

METHODS

Blood was extracted from n=10 volunteers into K₂-EDTA tubes. Stability of renin was assessed in whole blood stored at room temperature (15-25 °C) and in the refrigerator (2-8 °C) at 0 h, 8 h, and 24 h. The stability of renin in plasma was determined under the same conditions at 0 h, 24 h and 72 h.

RESULTS

Stability of plasma renin activity and direct renin concentration in whole blood stored at room temperature was found to be acceptable for up to 24 h. At refrigerated temperature, whole blood stability was acceptable for measurement of direct renin concentration up to 8 h and plasma renin activity up to 24 h. In contrast, plasma renin activity was not stable in plasma stored at either room or refrigerated temperatures up to 24 h; however, direct renin concentration had acceptable stability in plasma stored at room temperature for up to 24 h, but stability was unacceptable at refrigerated temperatures.

CONCLUSIONS

Samples collected for plasma renin activity and direct renin concentration should be transported as whole blood to optimise stability. After sample processing, plasma can be kept at room temperature for up to 24 h for direct renin concentration, however, for determination of plasma renin activity separated plasma should be analysed or frozen as soon as possible.

Detecting Preanalytical Errors Using Quality Indicators in a Hematology Laboratory

BACKGROUND AND OBJECTIVES

Monitoring laboratory performance continuously is crucial for recognizing errors and fostering further improvements in laboratory medicine. This study aimed to review the quality indicators (QIs) and describe the laboratory errors in the preanalytical phase of hematology testing in a clinical laboratory.

METHODS

All samples received in the Hematology Laboratory of the Maternity and Pediatric Hospital in Hail for 3 years were retrospectively reviewed and evaluated for preanalytical issues using a set of QIs. The rate of each QI was compared to the quality specifications cited in the literature.

RESULTS

A total of 95002 blood samples were collected for analysis in the hematology laboratory from January 2017 through December 2019. Overall, 8852 (9.3%) were considered to show preanalytical errors. The most common were "clotted specimen" (3.6%) and "samples not received" (3.5%). Based on the quality specifications, the preanalytical QIs were classified generally as low and medium level of performance. In contrast, the sigma-based performance level indicates acceptable performance on all the key processes. Further analysis of the study showed a decreasing rate of preanalytical errors from 11.6% to 6.5%.

CONCLUSIONS

Preanalytical errors remain a challenge to hematology laboratories. The errors in this case were predominantly related to specimen collection procedures that compromised the specimen quality. Quality indicators are a valuable instrument in the preanalytical phase that allows an opportunity to improve and explore clinical laboratory process performance and progress. Continual monitoring and management of QI data are critical to ensure ongoing satisfactory performance and to enhance the quality in the preanalytical phase.

Stability of Anti-thyroid Stimulating Hormone Receptor Antibody in Whole Blood and Serum: Caution Required for Reflective and Batch Testing

INTRODUCTION

Anti-thyroid stimulating hormone receptor antibody (TRAb) stability is stated as 7h at 20-25°C in the Roche Elecsys assay kit insert. The purpose of this study was to determine TRAb stability in whole blood and serum to assess the suitability of samples for reflective and weekly batch testing (with a single freeze-thaw cycle).

METHODS

In the first study, blood from n = 5 volunteers was used to assess: (1) stability in whole blood at room temperature up to 24h, and (2) stability in serum at 4-8°C up to 72h. In the second study, n = 21 patient samples were analysed in serum stored at 4-8°C for two and five days post-preliminary analysis.

RESULTS

There was a statistically significant decrease in TRAb concentration caused by the single freeze-thaw cycle of -8.9% ± 5.2% (p = 0.03). TRAb concentration decreased in whole blood between 0 and 24h by -16.5% ±9.2%, and declined in serum over time by -11.6% ±6.6% (at 12h). In the patient samples, serum TRAb concentration decreased over time by -4.6% ± 2.5% at day two and -6.5% ± 4.0% at day five.

CONCLUSION

TRAb concentration decreases over time in both whole blood at room temperature and serum samples stored at 4-8°C. A single freeze-thaw cycle also has a statistically significant effect on TRAb concentration.

Serum and urine osmolality: 8 hours, 24 hours and 1-month sample stability

OBJECTIVES

The body of literature varies significantly regarding serum and urine osmolality stability. Therefore, our aim was to investigate the stability of serum and urine osmolality at different temperatures (room temperature (RT) 4-8 °C, -20 °C) and time conditions (8 h, 24 h, 1 month).

METHODS

The stability study was conducted following the CRESS guidelines, including 40 serum and urine samples. Samples were aliquoted into three aliquots and stored as follows: primary tube stored at RT for 8 h; two capped aliquots stored at 4-8 °C for 8 h and 24 h; one aliquot stored at -20 °C for 1 month. To minimize imprecision error, serum and urine osmolality were measured by the freezing point depression method in triplicate on OSMOMAT 3000 (Gonotech, Germany) analyzer. Percentage difference (PD%) against baseline measurement was calculated. Deviations were assessed against a reference change value of 5.0%.

RESULTS

The PD% for serum and urine osmolality was below 2.0% for all time/temperature conditions. For serum samples: primary tube after 8 h at RT PD% (95% CI) = 0.0% (-0.3, 0.2%); 8 h at 4-8 °C PD% (95% CI) = -0.4% (-0.7, 0.0%); 24 h at 4-8 °C PD% (95% CI) = -0.7% (-0.7, -0.6%); 1 month at -20 °C PD% (95% CI) = -2.1% (-2.4, -1.5%). For urine samples: after 8 h at RT PD% (95% CI) =0.6% (0.2, 0.9%); 8 h at 4-8 °C PD% (95% CI) = -0.2% (-0.5, 0.1%); 24 h at 4-8 °C PD% (95% CI) = -0.2% (-0.5, 0.0%); 1 month at -20 °C PD% (95% CI) = -2.0% (-3.0, -1.0%).

CONCLUSIONS

Changes in osmolality for tested conditions for serum and urine samples, were within acceptance criteria. Reflex and add-on osmolality testing can be performed within the same day in samples kept at RT for 8 h in primary tube and within 24 h, in aliquoted refrigerated samples, without compromising the reliability of test results. For longer storage, samples should be kept at -20 °C.

Activation of NLRP3 inflammasome in stable chronic obstructive pulmonary disease

Nucleotide-binding oligomerization domain-like receptor family pyrin domain-containing 3 (NLRP3) inflammasome activation plays an important role in chronic obstructive pulmonary disease (COPD) pathogenesis and might be involved in ongoing chronic inflammation. This study aimed to determine interleukin-1beta (IL-1β) plasma concentration as well as IL1B, NLRP3 and caspase-1 (CASP1) gene expression in the Croatian COPD patients. 109 patients with stable COPD and age- and sex-matched 95 controls were included in the study. Plasma IL-1β concentration was measured by Luminex technology, and gene expression analysis was performed using TaqMan assays. It was shown that COPD patients had increased concentration of IL-1β and enhanced gene expression of IL1B, NLRP3 and CASP1 compared to controls. There was no difference in IL-1β or IL1B, NLRP3 and CASP1 in patients with COPD regarding airflow obstruction severity and smoking history. Finally, the diagnostic potential of the determined parameters was evaluated, and it was found that IL-1β correctly classified 89% of cases in the combination with common inflammatory biomarkers, white blood cell count and fibrinogen, showing a potential in COPD prediction. In conclusion, up-regulation of IL1B, NLRP3, CASP1 and increased IL-1β concentration suggest the activation of NLRP3 inflammasome in the systemic compartment of patients with stable COPD.

A Potassium-Based Quality-of-Service Metric Reduces Phlebotomy Errors, Resulting in Improved Patient Safety and Decreased Cost

OBJECTIVES

Poor phlebotomy technique can introduce pseudohyperkalemia without hemolysis, requiring additional workup and placing a significant burden on patients, clinical teams, and laboratories. Such preanalytical biases can be detected through systematic evaluation of potassium concentrations on a per-phlebotomist basis. We report our long-term experience with a potassium-based quality-of-service phlebotomy metric and its effects on resource utilization.

METHODS

Potassium monitoring and retraining of 26 full-time phlebotomists were piloted as a quality-of-service intervention. Changes in potassium concentrations and impact on resource utilization were assessed. An algorithm for data monitoring and phlebotomist feedback was developed, followed by institution-wide implementation.

RESULTS

Systematic intervention and retraining normalized K+ concentrations and lowered the percentage of venipunctures with K+ above 5.2 mmol/L, leading to a marked increase in phlebotomist compliance. This change resulted in resources savings of 13% to 100% for individual phlebotomists, reducing the total extra laboratory time required for repeat phlebotomies to determine hyperkalemia, mostly in the high-volume phlebotomist group.

CONCLUSIONS

A quality-of-service algorithm that involved monitoring potassium concentrations on a per-phlebotomist basis with feedback and retraining contributed to a concrete, data-based quality improvement plan. The institution-wide implementation of this metric allowed for significant cost savings and a reduction in critical value alerts, directly affecting the quality of patient care.

Interferences in immunoassays: review and practical algorithm

Immunoassays are currently the methods of choice for the measurement of a large panel of complex and heterogenous molecules owing to full automation, short turnaround time, high specificity and sensitivity. Despite remarkable performances, immunoassays are prone to several types of interferences that may lead to harmful consequences for the patient (e.g., prescription of an inadequate treatment, delayed diagnosis, unnecessary invasive investigations). A systematic search is only performed for some interferences because of its impracticality in clinical laboratories as it would notably impact budget, turnaround time, and human resources. Therefore, a case-by-case approach is generally preferred when facing an aberrant result. Hereby, we review the current knowledge on immunoassay interferences and present an algorithm for interference workup in clinical laboratories, from suspecting their presence to using the appropriate tests to identify them. We propose an approach to rationalize the attitude of laboratory specialists when faced with a potential interference and emphasize the importance of their collaboration with clinicians and manufacturers to ensure future improvements.

Nurses' experiences of blood sample collection from children: a qualitative study from Swedish paediatric hospital care

Background

Nurses play an active role in supporting the children with the blood sampling experience. Unfortunately, the blood sampling collection procedure is often affected by pre-analytical errors, leading to consequences such as delayed diagnosis as well as repeated sampling. Moreover, children state that needle procedures are the worst experience of their hospital stay. The nurses’ experiences of errors occurring during blood sample collection is unknown. Therefore, the aim of this study therefore was to describe paediatric nurses’ experiences of blood sampling collections from children.

Method

We used a qualitative study design with a (reflexive) thematic analysis (TA) method described by Braun and Clarke. Three focus group interviews were conducted, with 19 nurses collected by purposeful sampling from Sweden working at two different paediatric hospitals, focusing on their experiences of the blood sample collection procedure.

Results

From the three focus group interviews we analysed patterns and meanings of the following main theme Paediatric blood sampling is a challenge for the nurses and the four subthemes Nurses’ feelings of frustration with unsuccessful samplings, Nurses believe in team work, Venous blood sampling was experienced as the best option, and Nurses’ thoughts and needs regarding skills development in paediatric blood sampling.

Conclusion

The narrative results of this study illustrate that nurses working in paediatric hospital care face a big challenge in blood sampling collection from children. The nurses felt frustrated due to unsuccessful blood samplings and frequently could not understand why pre-analytical errors occurred. Nevertheless, they felt strengthened by colleagues in their team and shared feelings of responsibility to help each other with this complex procedure. The implications of this study are that paediatric hospital care needs to focus on improving guidelines for and increasing competence in blood sampling children and helping nurses to understand why samplings may be unsuccessful and how this can be avoided.

Preanalytical quality improvement - an interdisciplinary journey, on behalf of the European Federation for Clinical Chemistry and Laboratory Medicine (EFLM) Working Group for Preanalytical Phase (WG-PRE)

Since the beginning of laboratory medicine, the main focus was to provide high quality analytics. Over time the importance of the extra-analytical phases and their contribution to the overall quality became evident. However, as the initial preanalytical processes take place outside of the laboratory and mostly without its supervision, all professions participating in these process steps, from test selection to sample collection and transport, need to engage accordingly. Focusing solely on intra-laboratory processes will not be sufficient to achieve the best possible preanalytical quality. The Working Group for the Preanalytical Phase (WG-PRE) of the European Federation of Clinical Chemistry and Laboratory Medicine (EFLM) has provided several recommendations, opinion papers and scientific evidence over the past years, aiming to standardize the preanalytical phase across Europe. One of its strategies to reach this goal are educational efforts. As such, the WG-PRE has organized five conferences in the past decade with the sole focus on preanalytical quality. This year's conference mainly aims to depict the views of different professions on preanalytical processes in order to acquire common ground as basis for further improvements. This article summarizes the content of this 6th preanalytical conference.

New Evidence on Regucalcin, Body Composition, and Walking Ability Adaptations to Multicomponent Exercise Training in Functionally Limited and Frail Older Adults

BACKGROUND

Regucalcin, or senescence marker protein-30 (SMP30), is a Ca²⁺-binding protein with multiple functions reported in the literature. Physical exercise has been shown to improve aging markers; nevertheless, SMP30 in humans has not been extensively researched. Older adults experience a decline in functional capacity and body composition. The purpose of this study was to examine the effects of a multicomponent training (MCT) program on SMP30 and its regulation of walking ability and body composition in functionally limited, frail, and pre-frail older adults.

METHODS

A total of 34 older adults (aged 80.3 ± 6.1 years) were divided into an intervention group (IG = 20) and control group (CG = 14). The IG performed a supervised MCT (strength, endurance, balance, coordination, and flexibility) program for 6 months, 3 days per week, whereas the CG continued their normal lives without any specific physical training. SMP30 was analyzed in plasma after 3 and 6 months of MCT, while some physical fitness variables (Timed Up and Go (TUG) and 6-min walk test (6MWT)) and body composition (fat mass and lean mass) were measured at baseline, as well as after 3 months and 6 months of MCT.

RESULTS

No significant changes were observed in SPM30 between the IG (877.5 a.u. to 940.5 a.u., respectively) and CG (790.4 a.u. to 763.8 a.u., respectively). Moreover, no SMP30 differences were found between groups after 3 and 6 months of MCT. The IG improved significantly in the 6MWT after 3 months (472.2 ± 84.2 m) compared to baseline (411.2 ± 75.2 m). The IG also significantly enhanced their TUG performance after 3 months (7.6 ± 1.6 s) and 6 months (7.3 ± 1.8 s) of training compared to baseline (9.3 ± 3.2 s) (all, p < 0.001). There were no significant differences in body composition between the IG and CG through the 6 months of MCT.

CONCLUSIONS

The present study suggests that MCT did not change SMP30 levels from 3 to 6 months, where there were changes in neither walking ability nor body composition; however, MCT was effective in improving 6MWT and TUG performance from baseline to 3 months.

Proficiency-based progression intern training to reduce critical blood sampling errors including ‘wrong blood in tube’

Background: Blood sampling errors including ‘wrong blood in tube’ (WBIT) may have adverse effects on clinical outcomes. WBIT errors occur when the blood sample in the tube is not that of the patient identified on the label. This study aims to determine the effect of proficiency-based progression (PBP) training in phlebotomy on the rate of blood sampling errors (including WBIT). Methods: A non-randomised controlled trial compared the blood sampling error rate of 43 historical controls who had not undergone PBP training in 2016 to 44 PBP trained interventional groups in 2017. In 2018, the PBP training programme was implemented and the blood sampling error rate of 46 interns was compared to the 43 historical controls in 2016. Data analysis was performed using logistic regression analysis adjusting for sample timing. Results: In 2016, 43 interns had a total blood sample error rate of 2.4%, compared to 44 interns in 2017, who had error rate of 1.2% (adjusted OR=0.50, 95% CI 0.36-0.70; <0.01). In 2018, 46 interns had an error rate of 1.9% (adjusted OR=0.89, 95% CI 0.65-1.21; p=0.46) when compared to the 2016 historical controls. There were three WBITs in 2016, three WBITs in 2017 and five WBITs in 2018.  Conclusions: The study demonstrates that PBP training in phlebotomy has the potential to reduce blood sampling errors. Trial registration number: NCT03577561

The use of the thrombodynamics test in the diagnostics of hemostasis disorders in patients with COVID-19 of varying severity

Background: At the present moment, an urgent and unresolved problem is the search for a method to diagnose disorders of the hemostasis system in patients with the new coronavirus infection. The integral tests, in particular, the thrombodynamics test, will presumably make it possible to monitor changes in blood clotting, and predict the course of the disease in patients with COVID-19. Aims: To comparatively assess the plasma hemostasis parameters and results of the thrombodynamics test in patients with COVID-19 viral infection of different severity. Methods: The study included 96 patients with a confirmed diagnosis of COVID-19, admitted to a hospital for infectious diseases on the base of the V.I. Kulakov National Medical Research Center for Obstetrics, Gynecology, and Perinatology in the period from April 23, 2020, to June 20, 2020, and discharged at the end of treatment. SARS-CoV-2 was identified by PCR. The patients were stratified by the severity into 3 groups: mild course (n=25), moderate course (n=54), severe course (n=17). The diagnostics and treatment of patients were carried out in accordance with the Temporary Methodological Recommendations of the Ministry of Health of the Russian Federation for the prevention, diagnosis and treatment of the new coronavirus infection, versions 5, 6, 7. In the course of the treatment, the patients were assessed for APTT, prothrombin %, prothrombin time (PT) and thrombin time, fibrinogen, D-dimer, platelet count, and the thrombodynamic test parameters (V/Vi/Vst, Tlag, Cs, D). Results: Significant differences were observed in the thrombin time, D-dimer, platelet count, and the thrombodynamic parameters of V/Vst, Cs, and D taken before admission and a week after admission. We found a relationship between the parameters of hemostasis (fibrinogen concentration, PT, prothrombin %, APTT, Tlag, D) and the duration of hospital stay. There was a positive relationship between the content of fibrinogen and D (r=0.6307, p 0.0001) and a strong positive relationship between PT and Tlag (r=0.7499, p 0.0001). Conclusions: The thrombodynamics test can be recommended as a potential tool for a personalized approach to monitoring the hemostasis system and treating patients with COVID-19.

Elevated Humoral Immune Response to SARS-CoV-2 at High Altitudes Revealed by an Anti-RBD "In-House" ELISA

The severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) has caused a global pandemic with dramatic health and socioeconomic consequences. The Coronavirus Disease 2019 (COVID-19) challenges health systems to quickly respond by developing new diagnostic strategies that contribute to identify infected individuals, monitor infections, perform contact-tracing, and limit the spread of the virus. In this brief report, we developed a highly sensitive, specific, and precise “In-House” ELISA to correctly discriminate previously SARS-CoV-2-infected and non-infected individuals and study population seroprevalence. Among 758 individuals evaluated for anti-SARS-CoV-2 serology in the province of Tucumán, Argentina, we found a weak correlation between antibodies elicited against the RBD, the receptor-binding domain of the Spike protein, and the nucleocapsid (N) antigens of this virus. Additionally, we detected mild levels of anti-RBD IgG antibodies in 33.6% of individuals diagnosed with COVID-19, while only 19% showed sufficient antibody titers to be considered as plasma donors. No differences in IgG anti-RBD titers were found between women and men, neither in between different age groups ranging from 18 to 60. Surprisingly, individuals from a high altitude village displayed elevated and longer lasting anti-RBD titers compared to those from a lower altitude city. To our knowledge, this is the first report correlating altitude with increased humoral immune response against SARS-CoV-2 infection.

Pre-Analytical Modification of Serum miRNAs: Diagnostic Reliability of Serum miRNAs in Hemolytic Diseases

Circulating microRNAs (miRNAs) are useful biomarkers of hemolysis. Since blood cells are the main origins of circulating miRNAs, we evaluated blood cell-related pre-analytical modification of the miRNA signatures during blood drawing and serum processing. The levels of miRNA before and after ex vivo blood drawing were analyzed with the reverse transcriptase-based polymerase chain reaction method. Furthermore, the changes of miRNA signatures caused by different time-lag between blood drawing and serum preparation by 24 h were evaluated. Finally, we compared the miRNA levels between leftover samples and samples of hemolytic diseases. Blood drawing procedure induced increments of red blood cell (RBC)-related miRNAs (miR-451a, miR-486) about 2-fold. One hour standing of blood samples before serum separation induced almost the same increases in RBC-related miRNAs. To test the clinical usefulness of miR-451a as a biomarker of hemolytic diseases, we analyzed miRNAs of samples from 10 normal subjects, 30 leftover samples in the clinical laboratory, and 20 samples from patients with hemolytic diseases. Serum miR-451a significantly increased in patients with hemolytic anemia more than the levels of pre-analytical modification. In conclusion, the pre-analytical modification of serum miRNAs did not disturb the usefulness of RBC-derived miRNAs as biomarkers of hemolytic diseases.

Capillary blood sampling increases the risk of preanalytical errors in pediatric hospital care: Observational clinical study

PURPOSE

The blood sampling procedure is complex and prone to failure, as reflected by preanalytical errors in pediatric hospital care. The primary aim was to evaluate if the risk of preanalytical errors was higher with capillary blood sampling than with venous blood sampling, and secondary, explore specific factors associated with preanalytical errors, both overall and stratified by capillary and venous blood sampling.

DESIGN AND METHODS

This observational pediatric hospital study collected outcomes from medical records and blood sampling surveys from year 2014 to 2016. The risk of preanalytical errors was analyzed with adjusted-odds ratio (adj-OR) by multivariable logistic regression with 95% confidence intervals (CIs).

RESULTS

Overall, 128 (13%) preanalytical errors were identified among 951 blood samples. The proportion and adj-OR of errors was significantly higher in capillary compared with venous blood samples, 72 (20%) of 354 versus 56 (9.4%) of 597, p = .001, adj-OR 2.88 (CI 1.79-4.64). Blood collection with multiple sample tubes was significantly associated with increased risk of preanalytical errors (n = 97 of 601, 16%), while log weight (kg) significantly decreased the risk of preanalytical errors adj-OR 0.66 (CI 0.50-0.86), indicating a protective effect of increasing weight. However, stratified analyses indicated a protective effect of increasing log weight for venous blood sampling adj-OR 0.52 (CI 0.38-0.72), but not capillary blood sampling, adj-OR 1.08 (CI 0.76-1.55).

CONCLUSION

This study indicates that capillary blood sampling collection increases the risk of preanalytical errors. Further, a child's increasing body weight reduced the risk of preanalytical errors, while multiple sample tube collections significantly increased the risk of preanalytical errors.

PRACTICE IMPLICATIONS

This new information may help nurses improve their knowledge concerning blood sampling collection in pediatrics. Altogether, this study also indicates that implementing more venous blood sampling and improve the cases of capillary sampling could reduce the number of preanalytical errors in pediatric hospitals.

Improving the Quality of Venous Blood Sampling Procedure (Phlebotomy): Avoiding Tourniquet Use

Background Phlebotomy guidelines discourage tourniquet use whenever possible. We assessed phlebotomists' capability of not using the tourniquet in venous blood sampling, hypothesizing it to be equal to 50% of the patients attended, and identifying the most frequent venipuncture site.

Materials and Methods We assigned two phlebotomists of the same age (41 years) and experience (20 years) to record 10 phlebotomy days, the first with prioritized and the latter with nonprioritized patients. Each acquired daily data for the number of attended patients, age, gender, frequency of nontourniquet usage, and punctured vein. To test our work hypothesis we used the two-tailed single sample t-test. Differences between age-group means and nontourniquet use means by each phlebotomist were tested by two-tailed t-test for independent means.

Results In 10 phlebotomy days, 683 patients were attended (males 43.2%). We found no statistically significant difference between age-group means. The combined capability of nontourniquet use was 50.5%, which did not differ from our null hypothesis, but the difference in individual group means was statistically significant, the means being 33% and 66.9% (prioritized vs. nonprioritized). The medial cubital vein was the most prone to be punctured (77.7%).

Conclusion Performing phlebotomies without tourniquet was possible in at least half of the attended patients, though it was more limited in specific group populations.