Preanalytical quality improvement: from dream to reality

Delta check limits for thyroid function tests adjusted for clinical settings

BACKGROUND

This study aimed to determine practical delta check limits (DCLs) for thyroid function tests (TFTs) to detect sample misidentifications across various clinical settings.

METHODS

Between 2020 and 2022, 610,437 paired TFT results were collected from six university hospitals. The absolute DCL (absDCL) was determined using the 95th percentile for each clinical setting from a random 60 % of the total data. These absDCLs were then tested within and across different settings using the remaining 40 % of the data, alongside mix-up datasets for result and sample comparisons. The sensitivities of absDCL were calculated within and across groups in the mix-up datasets.

RESULTS

Health screening absDCLs were notably lower than in other settings (2.58 vs. 5.93-7.08 for thyroid-stimulating hormone; 4.12 vs. 8.24-10.04 for free thyroxine; 0.49 vs. 0.82-0.91 for total triiodothyronine). The proportion of results exceeding absDCL of health screening differed from those of other clinical settings. Furthermore, sensitivity between health screening and other clinical settings was significantly different in both the result mix-up and sample mix-up datasets.

CONCLUSIONS

This study determined practical DCLs for TFTs and highlighted differences in absDCLs between health screening and other settings. These findings emphasize the importance of tailored DCLs in improving the accurate reporting of TFTs.

Consistency analysis of two fingertip capillary blood sampling methods for complete blood count

This study was performed to analyze fingertip capillary blood sampling in pediatric patients using microcapillary blood collection tubes and microhematocrit tubes and to compare the blood cell analysis results obtained via these two blood collection methods. Finger capillary blood was collected from 110 outpatients using microcapillary blood collection tubes and microhematocrit tubes and complete blood count analysis was performed with a Sysmex XS-900i hematology analyzer and manual microscopy for blood cell morphology. Paired data was evaluated for agreement and bias using the microhematocrit samples as the reference group and the samples from the microcapillary blood collection tubes as the observation group. The two blood collection methods demonstrated good agreement for measuring red blood cell (RBC) parameters (i.e., RBC, Hb, Hct, MCV, MCH and MCHC), wherein the relative bias was > allowable total error (TEa) in 0.91%, 1.82%, 11.82%, 1.82%, 0.91% and 8.18% of the parameter measures, respectively. According to industry requirements, the proportion of samples meeting the acceptable bias level should be > 80%. Additionally, the estimated biases at each medical decision level were within clinically acceptable levels for RBC, Hb, Hct, and MCV. However, the proportion of WBC and PLT counts with relative bias > TEa was 25.45% and 35.45%, respectively. Furthermore, the relative bias of the WBC count at the medical decision level of 0.5 × 109/L and that of the PLT counts at the medical decision levels of 10 × 109/L and 50 × 109/L were clinically significant. Bland-Altman analysis further showed a mean bias of 0.66 × 109/L (95% LoA, - 0.79 to 2.11) for the WBC count and 39 × 109/L (95% LoA, - 46 to 124) for the PLT count from the blood samples collected in the microcapillary blood collection tubes compared with the counts of those collected in the microhematocrit tubes. Neutrophil, monocyte, lymphocyte, eosinophil, and PLT counts increased significantly in the microcapillary blood collection tubes compared with those in the microhematocrit tubes, along with an elevated number of instrument false alarms (P < 0.05). The two capillary blood collection devices exhibit performance differences. Therefore, clinicians should pay attention to the variation in results caused by different blood collection methods.

Machine learning-based delta check method for detecting misidentification errors in tumor marker tests

OBJECTIVES

Misidentification errors in tumor marker tests can lead to serious diagnostic and treatment errors. This study aims to develop a method for detecting these errors using a machine learning (ML)-based delta check approach, overcoming limitations of conventional methods.

METHODS

We analyzed five tumor marker test results: alpha-fetoprotein (AFP), cancer antigen 19-9 (CA19-9), cancer antigen 125 (CA125), carcinoembryonic antigen (CEA), and prostate-specific antigen (PSA). A total of 246,261 records were used in the analysis. Of these, 179,929 records were used for model training and 66,332 records for performance evaluation. We developed a misidentification error detection model based on the random forest (RF) and deep neural network (DNN) methods. We performed an in silico simulation with 1 % random sample shuffling. The performance of the developed models was evaluated and compared to conventional delta check methods such as delta percent change (DPC), absolute DPC (absDPC), and reference change values (RCV).

RESULTS

The DNN model outperformed the RF, DPC, absDPC, and RCV methods in detecting sample misidentification errors. It achieved balanced accuracies of 0.828, 0.842, 0.792, 0.818, and 0.833 for AFP, CA19-9, CA125, CEA, and PSA, respectively. Although the RF method performed better than DPC and absDPC, it showed similar or lower performance compared to RCV.

CONCLUSIONS

Our research results demonstrate that an ML-based delta check method can more effectively detect sample misidentification errors compared to conventional delta check methods. In particular, the DNN model demonstrated superior and stable detection performance compared to the RF, DPC, absDPC, and RCV methods.

Point-of-care testing: state-of-the art and perspectives

Point-of-care testing (POCT) is becoming an increasingly popular way to perform laboratory tests closer to the patient. This option has several recognized advantages, such as accessibility, portability, speed, convenience, ease of use, ever-growing test panels, lower cumulative healthcare costs when used within appropriate clinical pathways, better patient empowerment and engagement, and reduction of certain pre-analytical errors, especially those related to specimen transportation. On the other hand, POCT also poses some limitations and risks, namely the risk of lower accuracy and reliability compared to traditional laboratory tests, quality control and connectivity issues, high dependence on operators (with varying levels of expertise or training), challenges related to patient data management, higher costs per individual test, regulatory and compliance issues such as the need for appropriate validation prior to clinical use (especially for rapid diagnostic tests; RDTs), as well as additional preanalytical sources of error that may remain undetected in this type of testing, which is usually based on whole blood samples (i.e., presence of interfering substances, clotting, hemolysis, etc.). There is no doubt that POCT is a breakthrough innovation in laboratory medicine, but the discussion on its appropriate use requires further debate and initiatives. This collective opinion paper, composed of abstracts of the lectures presented at the two-day expert meeting "Point-Of-Care-Testing: State of the Art and Perspective" (Venice, April 4-5, 2024), aims to provide a thoughtful overview of the state-of-the-art in POCT, its current applications, advantages and potential limitations, as well as some interesting reflections on the future perspectives of this particular field of laboratory medicine.

Comparison of the speed and quality of innovative and traditional pneumatic tube system transport outside of an emergency laboratory

Background

Ensuring the rapidity and accuracy of emergency laboratory test results is especially important to save the lives of patients with acute and critical conditions. To better meet the needs of clinicians and patients, detection efficiency can be improved by reducing extra-laboratory sample turnaround times (TATs) through the use of innovative pneumatic tube system (PTS) transport for sample transport. However, concerns remain regarding the potential compromise of sample quality during PTS transit relative to that occurring with manual transportation. This study was performed to evaluate the efficacy of an innovative PTS (Tempus600 PTS) relative to a traditional PTS in terms of sample transit time, sample quality, and the concordance of analytical results with those obtained from manually transported samples.

Methods

In total, 30 healthy volunteers aged >18 years were recruited for this study, conducted for five consecutive days. Venous blood samples were collected from six volunteers per day at fixed timepoints. From each volunteer, nine blood samples were collected into tubes with tripotassium ethylene diamine tetraacetic acid anticoagulant, tubes with 3.2 % sodium citrate, and serum tubes with separation gel (n = 3 each) and subjected to all tests conducted in the emergency laboratory in our hospital. 270 blood samples from 30 healthy volunteers were transported and analyzed, yielding 6300 test results. The blood samples were divided randomly into three groups (each containing one tube of each type) and transported to the emergency laboratory manually and with Tempus600 PTS and conventional Swisslog PTS, respectively. The extra-laboratory TATs, sample quality, and test results of the transported blood samples were compared.

Results

The sample quality and test results did not differ according to the delivery method. The TAT was much shorter with the Tempus600 than with the other two transport modes (58.40 ± 1.52 s vs. 1711.20 ± 77.56 s for manual delivery and 146.60 ± 1.82 s for the Swisslog PTS; P = 0.002).

Conclusion

Blood sample transport with the Tempus600 PTS significantly reduced the extra-laboratory TAT without compromising sample quality or test result accuracy, thereby improving the efficiency of sample analysis and the services provided to clinicians and patients.

Ten Clinical Pearls in Microbiology: How Effective Collaboration Optimizes Patient Care

Medical microbiology laboratories play an essential role in patient care-appertaining to infectious diseases diagnostics and treatment, infection prevention, and antimicrobial stewardship. Collaboration between clinicians and the microbiology laboratory can promote and enhance the safety, quality, and efficiency of patient care. We review practical, evidence-informed core concepts to explicate how effective partnership between clinicians and the microbiology laboratory improves patient outcomes.

ALISTER - Application for lipid stability evaluation and research

BACKGROUND AND AIMS

In lipidomic and metabolomic studies, pre-analytical pitfalls enhance the risk of misusing resources such as time and money, as samples that are analyzed may not yield accurate or reliable data due to poor sample handling. Guidance and pre-analytic know-how are necessary for translation of omics technologies into routine clinical testing. The present work aims to enable decision making regarding sample stability in every phase of lipidomics- and metabolomics-centered studies.

MATERIALS AND METHODS

Data of multiple pre-analytic studies were aggregated into a database. Flexible approaches for evaluating these data were implemented in an RShiny-based web-application, tailored towards broad applicability in clinical and bioanalytic research.

RESULTS

Our "Application for lipid stability evaluation & research" - ALISTER facilitates decision making on blood sample stability during lipidomic and metabolomic studies, such as biomarker research, analysis of biobank samples and clinical testing. The interactive tool gives sampling recommendations when planning sample collection or aids in the assessment of sample quality of experiments retrospectively.

CONCLUSION

ALISTER is available for use under https://itmp.shinyapps.io/alister/. The application enables and simplifies data-driven decision making concerning pre-analytic blood sample handling and fits the needs of clinical investigations from multiple perspectives.

Analysis of thicknesses of blood collection needle by scanning electron microscopy reveals wide heterogeneity

OBJECTIVES

The preanalytical phase in clinical laboratory diagnostics is currently receiving more and more attention. This term describes one part of actions and aspects of the "brain-to-brain cycle" of the medical laboratory diagnostic procedure that take place before the analytical phase. However, the preanalytical activities, the handling of unsuitable samples and the reporting procedures are neither fully standardized nor harmonized worldwide. The influence of the properties of the blood collection needle must be acknowledged. In this work, we focused on the investigation of the internal structure and size of standardized 21G blood collection needles.

METHODS

All parameters were measured with a scanning electron microscope using a Jeol model JSM-6000PLUS. Our.

RESULTS

The obtained data shows that the internal surfaces of the needles vary greatly from manufacturer to manufacturer (by around 35 %), and this may play an important role in influencing blood flow and even the risk of blood cell injury (especially hemolysis) during blood drawing.

CONCLUSIONS

The differential actual needle diameters can vary greatly between needle manufactures and this variety may have a significant impact on laboratory values and may also lead to specimen rejection.

Approaching sustainability in Laboratory Medicine

INTRODUCTION

Clinical laboratories and the total testing process are major consumers of energy, water, and hazardous chemicals, and produce significant amounts of biomedical waste. Since the processes in the clinical laboratory and the total testing process go hand in hand it mandates a holistic, and comprehensive approach towards sustainability.

CONTENT

This review article identifies the various sources and activities in Laboratory Medicine that challenge sustainability and also discusses the various approaches that can be implemented to achieve sustainability in laboratory operations to reduce the negative impact on the environment.

SUMMARY

The article highlights how the integration of technological advancements, efficient resource management, staff training and sensitization, protocol development towards sustainability, and other environmental considerations contributes significantly to a sustainable healthcare ecosystem.

OUTLOOK

Variables and resources that negatively impact the environment must be identified and addressed comprehensively to attain a long-lasting level of carbon neutrality.

Impact of Sample Type on D-Dimer Screening

Background

The quality of laboratory test results depends on various factors, including sample type selection. Blood samples, such as whole blood, plasma and serum are commonly used for most clinical laboratory examinations. D-dimer parameters are frequently analysed in haematology laboratories and serve as biomarkers for coagulation activation and fibrinolysis. This study aimed to assess the impact of using different sample types on the quality of D-dimer test results.

Method

An observational analytical method was used. D-dimer examination was performed using the fluorescent lateral flow immunoassay method. The study sample consisted of 26 participants aged between 18 years old and 22 years old who had no blood disorders. Whole blood and ethylenediaminetetraacetic acid (EDTA) plasma samples were used for the examination of D-dimer levels.

Results

D-dimer levels in 26 participants using whole blood samples had a mean value of 0.23 mg/L (230 ng/mL), while plasma samples yielded a mean value of 0.14 mg/L (140 ng/mL). D-dimer levels obtained from whole blood samples were higher than plasma samples but remained within the normal range of 0 mg/L-0.5 mg/L (0 ng/mL-500 ng/mL).

Conclusion

The results showed that whole blood samples were more practical than plasma samples. Nevertheless, plasma samples gave results within the normal range of D-dimer values.

Endoscopic Ultrasound-Guided Fine-Needle Biopsy Versus Aspiration for Tissue Sampling Adequacy for Molecular Testing in Pancreatic Ductal Adenocarcinoma

BACKGROUND AND AIMS

There is limited literature on sample adequacy for molecular testing in pancreatic ductal adenocarcinoma obtained via endoscopic ultrasound (EUS) fine-needle aspiration (FNA) versus EUS fine-needle biopsy (FNB). We aimed to compare these two modalities regarding sample adequacy for molecular and genomic sequencing.

METHODS

We reviewed all patients with pancreatic ductal adenocarcinoma who underwent EUS at Saint Luke's Hospital from 2018 to 2021. The patients were categorized based on the method of EUS tissue acquisition, specifically FNA or FNB. A comprehensive evaluation was conducted for all cases by cytotechnologists.

RESULTS

Out of 132 patients who underwent EUS-guided biopsies, 76 opted for FNA, 48 opted for FNB, and 8 opted for a combination of both. The average number of passes required for FNB and FNA was 2.58 ± 1.06 and 2.49 ± 1.07, respectively (p = 0.704), indicating no significant difference. Interestingly, 71.4% (35) of FNB-obtained samples were deemed adequate for molecular testing, surpassing the 32.1% (26) adequacy observed with FNA (p < 0.001). Additionally, 46.4% (26) of FNB-obtained samples were considered adequate for genomic testing, a notable improvement over the 23.8% (20) adequacy observed with FNA (p = 0.005).

CONCLUSION

Although the number of passes required for cytologic diagnosis did not differ significantly between EUS-FNB and EUS-FNA, the former demonstrated superiority in obtaining samples adequate for molecular testing. Tumor surface area and cellularity were crucial parameters in determining sample adequacy for molecular testing, irrespective of the chosen tissue acquisition modality.

Effects of Preanalytical Sample Collection and Handling on Comprehensive Metabolite Measurements in Human Urine Biospecimens

Epidemiology studies evaluate associations between the metabolome and disease risk. Urine is a common biospecimen used for such studies due to its wide availability and non-invasive collection. Evaluating the robustness of urinary metabolomic profiles under varying preanalytical conditions is thus of interest. Here we evaluate the impact of sample handling conditions on urine metabolome profiles relative to the gold standard condition (no preservative, no refrigeration storage, single freeze thaw). Conditions tested included the use of borate or chlorhexidine preservatives, various storage and freeze/thaw cycles. We demonstrate that sample handling conditions impact metabolite levels, with borate showing the largest impact with 125 of 1,048 altered metabolites (adjusted P < 0.05). When simulating a case-control study with expected inconsistencies in sample handling, we predicted the occurrence of false positive altered metabolites to be low (< 11). Predicted false positives increased substantially (³63) when cases were simulated to undergo alternate handling. Finally, we demonstrate that sample handling impacts on the urinary metabolome were markedly smaller than those in serum. While changes in urine metabolites incurred by sample handling are generally small, we recommend implementing consistent handling conditions and evaluating robustness of metabolite measurements for those showing significant associations with disease outcomes.

Fingerprinting and profiling in metabolomics of biosamples

This review focuses on metabolomics from an NMR point of view. It attempts to cover the broad scope of metabolomics and describes the NMR experiments that are most suitable for each sample type. It is addressed not only to NMR specialists, but to all researchers who wish to approach metabolomics with a clear idea of what they wish to achieve but not necessarily with a deep knowledge of NMR. For this reason, some technical parts may seem a bit naïve to the experts. The review starts by describing standard metabolomics procedures, which imply the use of a dedicated 600 MHz instrument and of four properly standardized 1D experiments. Standardization is a must if one wants to directly compare NMR results obtained in different labs. A brief mention is also made of standardized pre-analytical procedures, which are even more essential. Attention is paid to the distinction between fingerprinting and profiling, and the advantages and disadvantages of fingerprinting are clarified. This aspect is often not fully appreciated. Then profiling, and the associated problems of signal assignment and quantitation, are discussed. We also describe less conventional approaches, such as the use of different magnetic fields, the use of signal enhancement techniques to increase sensitivity, and the potential of field-shuttling NMR. A few examples of biomedical applications are also given, again with the focus on NMR techniques that are most suitable to achieve each particular goal, including a description of the most common heteronuclear experiments. Finally, the growing applications of metabolomics to foodstuffs are described.

Tutorial review for peptide assays: An ounce of pre-analytics is worth a pound of cure

The recent increase in peptidomimetic-based medications and the growing interest in peptide hormones has brought new attention to the quantification of peptides for diagnostic purposes. Indeed, the circulating concentrations of peptide hormones in the blood provide a snapshot of the state of the body and could eventually lead to detecting a particular health condition. Although extremely useful, the quantification of such molecules, preferably by liquid chromatography coupled to mass spectrometry, might be quite tricky. First, peptides are subjected to hydrolysis, oxidation, and other post-translational modifications, and, most importantly, they are substrates of specific and nonspecific proteases in biological matrixes. All these events might continue after sampling, changing the peptide hormone concentrations. Second, because they include positively and negatively charged groups and hydrophilic and hydrophobic residues, they interact with their environment; these interactions might lead to a local change in the measured concentrations. A phenomenon such as nonspecific adsorption to lab glassware or materials has often a tremendous effect on the concentration and needs to be controlled with particular care. Finally, the circulating levels of peptides might be low (pico- or femtomolar range), increasing the impact of the aforementioned effects and inducing the need for highly sensitive instruments and well-optimized methods. Thus, despite the extreme diversity of these peptides and their matrixes, there is a common challenge for all the assays: the need to keep concentrations unchanged from sampling to analysis. While significant efforts are often placed on optimizing the analysis, few studies consider in depth the impact of pre-analytical steps on the results. By working through practical examples, this solution-oriented tutorial review addresses typical pre-analytical challenges encountered during the development of a peptide assay from the standpoint of a clinical laboratory. We provide tips and tricks to avoid pitfalls as well as strategies to guide all new developments. Our ultimate goal is to increase pre-analytical awareness to ensure that newly developed peptide assays produce robust and accurate results.

Direct costs of blood drawings with pre-analytical errors in tertiary paediatric hospital care

BACKGROUND

Blood drawings is a common hospital procedure involving laboratory and clinical disciplines that is important for the diagnosis and management of illnesses in children. Blood drawings with pre-analytical error (PAE) can lead to increased costs for hospitals and healthcare organisations. The direct cost of blood drawings after a PAE is not fully understood in paediatric hospital care.

AIM

The aim of this study was to estimate the average direct cost of PAE per year and per 10,000 blood drawings in tertiary paediatric care.

METHODS

A cost analysis using a bottom-up approach was conducted on the basis of combined information from the hospital's laboratory register for the period 2013-2014 and clinical in-ward observations at a tertiary children's referral hospital in Sweden, the Astrid Lindgren Children's Hospital. For the analysis, we hypothesised the re-collection of all blood drawings with PAE and included the average costs of the sampling materials, the time of the healthcare personnel, the laboratory analyses, and in-ward premises based on the time spent on the blood sampling procedure.

RESULTS

The annual cost of PAE was estimated to be 74,267 euros per 54,040 blood drawings, which corresponds to 13,756 euros per 10,000 blood drawings or 1.5 euros per draw. The personnel cost represented 60.1% (45,261 euros per year) of the cost due to PAE, followed by costs for hospitalisation (25.2%), laboratory analyses (8.1%), and materials (5.7%).

CONCLUSION

PAEs lead to substantial increases in the costs in tertiary paediatric hospital care. If these PAEs can be avoided, costs related to the re-collection of blood drawings with PAE may be re-allocated to other health-promoting activities for children visiting hospital institutions.

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.

Retrospective analysis of intra-patient laboratory variation demonstrates that the BD Vacutainer® Barricor™ blood collection tube reduces troponin variation

OBJECTIVE

The BD Vacutainer® Barricor™ plasma blood collection tube uses a mechanical separator during centrifugation to separate plasma from the cellular elements of blood. Compared to use of plasma separator tubes (PST™) with gel, Barricor™ produces a cleaner sample with less residual cellular content. We sought to determine if Barricor™ reduces pre-analytical error compared to PST™.

DESIGN & METHODS

We used a model previously published that utilizes serial differences between intra-patient measurements transformed into a Taylor series of variation vs time with the y-intercept equal to the sum of short-term analytic variation, preanalytic variation and biologic variation. The intra-patient variation of chloride, sodium, potassium, and troponin-T (hs-TnT) obtained from the Emergency Department of a large tertiary care center sampled with PST™ (May 2015-April 2018, n = 59,762 specimens) or Barricor™ (May 2018-May 2021, n = 61,512 specimens) was evaluated. All specimens were analyzed on either Roche Modular or Cobas® instruments. For each analyte, pairs of intra-patient results were tabulated and separated by 1 h intervals. The average between-pair variations were then regressed against time. We also determined the number of intra-patient outliers using the reference change value for each analyte.

RESULTS

The Barricor™ hs-TnT y-intercept (-0.0132) was significantly lower than the PST™ intercept (0.9109; p = 0.022). This was also true for chloride (y-intercept = 1.0067 in Barricor™ and 1.3431 in PST™, p = 0.037). The percentage of hs-TnT outliers was significantly lower in Barricor™ (8.32 %) vs PST™ (12.2 %; p < 0.001).

CONCLUSION

The analytical and biological variations are assumed to be steady over the study periods; we ascribe the difference in the y-intercept to the preanalytical effect of the Barricor™ tube reducing platelets and other cellular debris.

Small molecule biomarker discovery: Proposed workflow for LC-MS-based clinical research projects

Mass spectrometry focusing on small endogenous molecules has become an integral part of biomarker discovery in the pursuit of an in-depth understanding of the pathophysiology of various diseases, ultimately enabling the application of personalized medicine. While LC-MS methods allow researchers to gather vast amounts of data from hundreds or thousands of samples, the successful execution of a study as part of clinical research also requires knowledge transfer with clinicians, involvement of data scientists, and interactions with various stakeholders. The initial planning phase of a clinical research project involves specifying the scope and design, and engaging relevant experts from different fields. Enrolling subjects and designing trials rely largely on the overall objective of the study and epidemiological considerations, while proper pre-analytical sample handling has immediate implications on the quality of analytical data. Subsequent LC-MS measurements may be conducted in a targeted, semi-targeted, or non-targeted manner, resulting in datasets of varying size and accuracy. Data processing further enhances the quality of data and is a prerequisite for in-silico analysis. Nowadays, the evaluation of such complex datasets relies on a mix of classical statistics and machine learning applications, in combination with other tools, such as pathway analysis and gene set enrichment. Finally, results must be validated before biomarkers can be used as prognostic or diagnostic decision-making tools. Throughout the study, quality control measures should be employed to enhance the reliability of data and increase confidence in the results. The aim of this graphical review is to provide an overview of the steps to be taken when conducting an LC-MS-based clinical research project to search for small molecule biomarkers.

Pre-analytical sample handling standardization for reliable measurement of metabolites and lipids in LC-MS-based clinical research

The emerging disciplines of lipidomics and metabolomics show great potential for the discovery of diagnostic biomarkers, but appropriate pre-analytical sample-handling procedures are critical because several analytes are prone to ex vivo distortions during sample collection. To test how the intermediate storage temperature and storage period of plasma samples from K3EDTA whole-blood collection tubes affect analyte concentrations, we assessed samples from non-fasting healthy volunteers (n = 9) for a broad spectrum of metabolites, including lipids and lipid mediators, using a well-established LC-MS-based platform. We used a fold change-based approach as a relative measure of analyte stability to evaluate 489 analytes, employing a combination of targeted LC-MS/MS and LC-HRMS screening. The concentrations of many analytes were found to be reliable, often justifying less strict sample handling; however, certain analytes were unstable, supporting the need for meticulous processing. We make four data-driven recommendations for sample-handling protocols with varying degrees of stringency, based on the maximum number of analytes and the feasibility of routine clinical implementation. These protocols also enable the simple evaluation of biomarker candidates based on their analyte-specific vulnerability to ex vivo distortions. In summary, pre-analytical sample handling has a major effect on the suitability of certain metabolites as biomarkers, including several lipids and lipid mediators. Our sample-handling recommendations will increase the reliability and quality of samples when such metabolites are necessary for routine clinical diagnosis.

The pre-analytical process management status and influencing factors of laboratory test before prescribing antimicrobial in developing country

INTRODUCTION

The results of laboratory testing are crucial basis for clinicians to prescribe antimicrobial. Laboratory testing is a highly complex process, and increasing evidence suggests that errors and obstacles in the pre-analytical process (PP) will affect reasonable antimicrobial use. However, PP was an easily neglected link in hospital infection management and the current situation of it and the influencing factors of management are not clear.

METHODS

A cross-sectional survey was conducted in the department of clinical, specimen collection, transportation, and inspection in 109 secondary and tertiary hospitals in Central China. The rate of antimicrobial susceptibility test request (AST) and related indexes of above departments were calculated to describe the situation. Management characteristics (frequency of training etc.) were described as proportions and fractional probit regression analysis was used to determine the influencing factors.

RESULTS

The average rate of non restricted-use antimicrobial was 63%, the restricted-use was 86%, the special-use was 95%. The zero obstacle rate of specimen collection was 27.3%, of specimen transportation was 19.4% and of inspection feedback was 61.7%. There was a difference between the secondary and tertiary hospitals on non restricted-use (X² = 22.968, P < 0.001); restricted-use (X² = 29.466, P < 0.001); special-use (X² = 27.317, P < 0.001). Taking non restricted-use as an example, training (OR = 0.312, 95%CI: 0.148,0.429), low-frequency appraisal (OR = 0.153, 95%CI: 0.082,0.224), guidance (OR = 0.32, 95%CI: 0.237,0.403) and information technology (OR = 0.104, 95%CI: 0.009,0.199) were positive factors.

CONCLUSIONS

There were substantial differences in the rate of AST request in clinical department between secondary and tertiary hospitals. The zero obstacle rate in collection, transportation and inspection department were still low. In most departments, training and performance appraisal were positive factors, guidance and information technology were positive supporting factors.

High false discovery rate of the Architect anti-HCV screening test in blood donors in Uganda and evaluation of an algorithm for confirmatory testing

BACKGROUND AND OBJECTIVES

Adequate supplies of donor blood remain a major challenge in sub-Saharan Africa. This is exacerbated by a lack of confirmatory testing for transfusion-transmitted infections by blood transfusion services (BTS), leading to significant blood disposal owing to putatively high seroprevalence rates amongst Ugandan blood donors. We aimed to ascertain the false discovery rate of the Architect anti-hepatitis C virus (HCV) screening assay and categorize screen-reactive samples into three groups: presumed false positive, active and past infection, and develop an algorithm for confirmatory testing.

MATERIALS AND METHODS

A total of 470 screen-reactive HCV blood donations were retested using the Architect anti-HCV assay, an alternative antibody test (SD Biosensor) and a core antigen (cAg) test. signal-to cut-off (S/CO) ratios and pre-analytical factors (centrifugation speed, haemolysis check, time between collection and testing) were recorded. Based on the S/CO ratio evaluation, we propose a testing algorithm to guide supplemental tests.

RESULTS

The false discovery rate of the Architect anti-HCV assay was 0.84 as 395/470 (84%) screen-reactive samples had no evidence of HCV infection (SD Biosensor and cAg negative) (presumed false positive), 38/470 (8.1%) were antigenaemic, and 32/470 (6.8%) had evidence of past infection. The median S/CO ratios of the presumed false-positive and active infection samples were 1.8 and 17.3, respectively. The positive predictive value of HCV positivity in samples with ratios above 12 was 91.8%. On retesting, 104/470 (22.1%) samples became negative.

CONCLUSION

The Architect anti-HCV assay has a very high false discovery rate in Ugandan BTSs, leading to excessive blood disposal. Pre-analytical factors likely contribute to this. An introduction of confirmatory testing using an algorithm based on S/CO ratio evaluation could limit unnecessary blood wastage and donor deferral.

Tracking the Stability of Clinically Relevant Blood Plasma Proteins with Delta-S-Cys-Albumin-A Dilute-and-Shoot LC/MS-Based Marker of Specimen Exposure to Thawed Conditions

Biomolecular integrity can be compromised when blood plasma/serum (P/S) specimens are improperly handled. Compromised analytes can subsequently produce erroneous results-without any indication of having done so. We recently introduced an LC/MS-based marker of P/S exposure to thawed conditions called ΔS-Cys-Albumin which, aided by an established rate law, quantitatively tracks exposure of P/S to temperatures greater than their freezing point of -30 °C. The purposes of this study were to (1) evaluate ΔS-Cys-Albumin baseline values in gastrointestinal cancer patients and cancer-free control donors, (2) empirically assess the kinetic profiles of ΔS-Cys-Albumin at 23 °C, 4 °C, and -20 °C, and (3) empirically link ΔS-Cys-Albumin to the stability of clinically relevant proteins. ΔS-Cys-Albumin was measured at ≥ 9 different time points per exposure temperature in serum and K₂EDTA plasma samples from 24 separate donors in aliquots kept separately at 23 °C, 4 °C, and -20 °C. Twenty-one clinically relevant plasma proteins were measured at four time points per temperature via a multiplexed immunoassay on the Luminex platform. Protein stability was assessed by mixed effects models. Coordinated shifts in stability between ΔS-Cys-Albumin and the unstable proteins were documented by repeated measures and Pearson correlations. Plasma ΔS-Cys-Albumin dropped from approximately 20% to under 5% within 96 h at 23 °C, 28 days at 4 °C, and 65 days at -20 °C. On average, 22% of the 21 proteins significantly changed in apparent concentration at each exposure temperature (p < 0.0008 with >10% shift). A linear inverse relationship was found between the percentage of proteins destabilized and ΔS-Cys-Albumin (r = -0.61; p < 0.0001)-regardless of the specific time/temperature of exposure. ΔS-Cys-Albumin tracks cumulative thawed-state exposure. These results now enable ΔS-Cys-Albumin to approximate the percentage of clinically relevant proteins that have been compromised by incidental plasma exposure to thawed-state conditions.

Impact of Pneumatic Transport System on Preanalytical Phase Affecting Clinical Biochemistry Results

Introduction PTS (pneumatic transport system) is extensively being used in modern hospitals for rapid transportation of blood samples and other specimens. However, it has a potential impact on blood components, which should be investigated and nullified accordingly. This study was part of a correction program aimed at reducing hemolysis. It was done by comparing paired samples transported manually and by PTS.

Materials and Methods This study was initiated to monitor the impact of PTS on hemolysis of clinical biochemistry blood samples. It was performed in two phases—before and after the corrective action taken. Phase I: done after PTS installation but before the corrective action was taken. Duplicate samples from 100 healthy individuals were collected, one set transported by PTS and the other by human carriers. Both sets were assessed for 25 biochemistry analytes, hemolysis index (HI), and acceleration profiles using a data logger. Corrective measures were then taken, followed by phase II of the study. In phase II, the sample size and study design remained the same as phase I. All the test results of PTS and hand-carried samples were statistically analyzed for any significant difference.

Result In phase I, all the hemolysis-manifesting parameters, LDH (lactate dehydrogenase), potassium, AST (aspartate transaminase), and phosphorus, were raised in PTS samples as compared with the manual samples. Their differences were significant as the p-values were 0.001, 0.000, 0.025, and 0.047, respectively. The differences for LDH and potassium were clinically significant as well. HI (9%) and peak acceleration (15.7 g) were high in PTS samples.

In phase II, no statistically significant difference between paired samples was found for all biochemistry parameters except for a few which were clinically nonsignificant. For PTS samples, HI was 2.5% and the peak acceleration was 11.2 g, whereas for manual samples, HI was 2%.

Conclusion Evidence of hemolysis was found in PTS samples as compared with handheld samples, which was resolved after several corrective actions were taken. Thereafter, PTS became reliable for sample delivery in a routine biochemistry laboratory. Hence, each hospital should scrutinize their PTS for its effects on sample integrity to get rid of PTS-induced preanalytical errors.

Autoverification-Based Algorithms to Detect Preanalytical Errors: Two Examples

The preanalytical phase of testing accounts for the majority of the errors. Software-based quality rules, such as autoverification, can assist in preanalytical error detection; therefore, preventing erroneous results from being reported. Two autoverification rules, turbidity/lipemia, and pseudohypoglycemia/pseudohyperkalemia alarms, are highlighted. Increased sample turbidity may arise from several causes outside of lipemia. Typically, this can be resolved by clarifying the sample with standard centrifugation. Truly lipemic specimens typically require higher centrifugation speeds and greater centrifugation time. At our facility, 96% of direct bilirubin (DBIL), 95% of aspartate transaminase (AST), and 98% of alanine transaminase (ALT) turbidity/lipemia alarms were found to be from sample turbidity versus lipemia. Secondly, a pseudohypoglycemia/pseudohyperkalemia rule was employed for specimens with delayed separation from cellular material. Of the total potassium results >6.0 mmol/L or glucose results <40 mg/dL (2.2 mmol/L), 30% and 50% respectively were noted to have delayed sample separation.

Long-Term Stability of Hydromorphone in Human Plasma Frozen at −20°C for Three Years Quantified by LC-MS/MS

The long-term stability of drugs under normal laboratory storage conditions (−20°C) for years is important for research purposes, clinical re-evaluation, and also for forensic toxicology. To evaluate the stability of the analgesic opioid hydromorphone, 44 human frozen plasma samples of a former clinical trial were reanalyzed after at least three years. Blood samples were disposed using solid-phase extraction with an additional substitution of stable isotope labelled hydromorphone as an internal standard. Hydromorphone concentrations were determined by ultra-performance liquid chromatography (UPLC) with gradient elution, followed by tandem mass spectrometry with electrospray ionization. Calibration curves demonstrated linearity of the assay in the concentration range of 0.3–20 ng/mL hydromorphone. The limit of detection of the hydromorphone plasma concentration was 0.001 ng/mL, and the lower limit of quantification was 0.3 ng/mL. Intra- and interassay errors did not exceed 16%. The percentage deviation of the measured hydromorphone plasma concentrations between the reanalysis and the first analysis was −1.07% ± 14.8% (mean ± SD). These results demonstrate that hydromorphone concentration in human plasma was stable when the samples were frozen at −20°C over three years. This finding is of value for re-evaluations or delayed analyses for research purposes and in pharmacokinetic studies, such as in forensic medicine.

The impact of laboratory staff training workshops on coagulation specimen rejection rates

Background

Pre-analytical variables can have a significant adverse impact on the quality and credibility of coagulation test results. Therefore, correct and consistent identification of pre-analytical variables that compromise coagulation specimen quality is of paramount importance. Lack of standardization and heterogeneity among laboratory staff when assessing coagulation specimens can lead to inconsistent identification of these variables. Failure to recognize such pre-analytical variables results in the analysis of poor quality specimens and the authorization of spurious test results.

Objectives

To determine the impact of a laboratory staff training workshop on coagulation specimen rejection rates and to ascertain the level of knowledge of laboratory personnel concerning coagulation specimen rejection criteria before and after the workshop.

Methods

A retrospective three-month audit was performed with rejection data of incorrect blood to additive ratio, clotted, aged and haemolysed specimens collected. Training workshops and evaluation sessions were subsequently presented. A revised standard operating procedure delineating coagulation specimen rejection criteria was implemented and a repeat three-month audit was conducted.

Results

In total, 13 162 coagulation specimens were received during the initial audit with 1 104 specimens (8.39%) rejected. Following the workshops, the rejection rate increased by 3.49% to 11.88% with 12 743 coagulation specimens received and 1 514 specimens rejected. Evaluation sessions performed before and after the workshops revealed that 95.2% of attendees attained improved knowledge.

Conclusion

This study demonstrated the pivotal importance of regular laboratory staff training. The increase in specimen rejection following the workshops signifies their success in educating laboratory personnel regarding the correct identification of pre-analytical variables. Since most pre-analytical variables occur outside the laboratory, educational workshops need to be extended to non-laboratory personnel responsible for specimen collection and transport.

Factors influencing degradation kinetics of mRNAs and half-lives of microRNAs, circRNAs, lncRNAs in blood in vitro using quantitative PCR

RNAs are rapidly degraded in samples and during collection, processing and testing. In this study, we used the same method to explore the half-lives of different RNAs and the influencing factors, and compared the degradation kinetics and characteristics of different RNAs in whole blood and experimental samples. Fresh anticoagulant blood samples were incubated at room temperature for different durations, RNAs were extracted, and genes, including internal references, were amplified by real-time quantitative PCR. A linear half-life model was established according to cycle threshold (Ct) values. The effects of experimental operations on RNA degradation before and after RNA extraction were explored. Quantitative analysis of mRNA degradation in samples and during experimental processes were explored using an orthogonal experimental design. The storage duration of blood samples at room temperature had the greatest influence on RNA degradation. The half-lives of messenger RNAs (mRNAs) was 16.4 h. The half-lives of circular RNAs (circRNAs), long non-coding RNAs (lncRNAs) and microRNAs (miRNAs) were 24.56 ± 5.2 h, 17.46 ± 3.0 h and 16.42 ± 4.2 h, respectively. RNA degradation occurred mainly in blood samples. The half-life of mRNAs was the shortest among the four kinds of RNAs. Quantitative experiments related to mRNAs should be completed within 2 h. The half-lives of circRNAs and lncRNAs were longer than those of the former two.

Impact of ultra-low temperature long-term storage on the preanalytical variability of twenty-one common biochemical analytes

OBJECTIVES

Retrospective studies frequently assume analytes long-term stability at ultra-low temperatures. However, these storage conditions, common among biobanks and research, may increase the preanalytical variability, adding a potential uncertainty to the measurements. This study is aimed to evaluate long-term storage stability of different analytes at <-70 °C and to assess its impact on the reference change value formula.

METHODS

Twenty-one analytes commonly measured in clinical laboratories were quantified in 60 serum samples. Samples were immediately aliquoted and frozen at <-70 °C, and reanalyzed after 11 ± 3.9 years of storage. A change in concentration after storage was considered relevant if the percent deviation from the baseline measurement was significant and higher than the analytical performance specifications.

RESULTS

Preanalytical variability (CV_P) due to storage, determined by the percentage deviation, showed a noticeable dispersion. Changes were relevant for alanine aminotransferase, creatinine, glucose, magnesium, potassium, sodium, total bilirubin and urate. No significant differences were found in aspartate aminotransferase, calcium, carcinoembryonic antigen, cholesterol, C-reactive protein, direct bilirubin, free thryroxine, gamma-glutamyltransferase, lactate dehydrogenase, prostate-specific antigen, triglycerides, thyrotropin, and urea. As nonnegligible, CV_P must remain included in reference change value formula, which was modified to consider whether one or two samples were frozen.

CONCLUSIONS

After long-term storage at ultra-low temperatures, there was a significant variation in some analytes that should be considered. We propose that reference change value formula should include the CV_P when analyzing samples stored in these conditions.

Effects of EDTA on chemiluminescent immunoassay measurement of ACTH, cortisol, and thyroid hormones in dogs

When measuring blood hormones, pre-analytical sample handling can impact the quality of the results. Previous studies have shown improved stability of canine cortisol in ethylenediaminetetraacetic acid (EDTA) plasma compared to serum and interchangeability of serum and plasma when cortisol is measured by radioimmunoassay. Additionally, cortisol samples were also interchangeable when measured by chemiluminescent immunoassay if the EDTA concentration was consistent with that of optimally filled tubes, whereas excess EDTA interfered with the measurement of cortisol and serum and EDTA plasma were not interchangeable when measuring total thyroxine (TT4). The main limitation of these studies was that they were performed by spiking pooled serum samples with EDTA or in previously collected blood samples submitted to a clinical pathology laboratory. The purpose of the present study was to evaluate the effect of EDTA on the measurement of adrenocorticotropic hormone (ACTH), cortisol, TT4, free thyroxine (FT4), and thyroid stimulating hormone (TSH) in healthy dogs using the Siemens IMMULITE 1000. Whole blood from forty dogs was aliquoted into three Monoject sample tubes: no additive, completely filled EDTA tube, and 50% filled EDTA tube. Handling and storage conditions were identical, and all samples were analyzed on the same day. Bland-Altman plots and Passing-Bablok regression were used to assess agreement and risks for error, respectively. Proportional errors were found between serum and plasma samples for ACTH, cortisol, TT4, FT4, and TSH; systematic errors were also found for FT4. There was poor agreement and clinically significant differences between the measured concentrations of all hormones in serum and plasma, proving that these sample types are not interchangeable. Incompletely filled EDTA tubes were associated with significantly lower ACTH concentrations compared to completely filled EDTA tubes. When measured by chemiluminescent immunoassays that utilize alkaline phosphatase at the reporter enzyme, serum should be used for cortisol, TT4, FT4, and TSH, while plasma from completely filled EDTA tubes should be used for ACTH.

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.

Pre-analytical rejection rates of clinical samples based on patients’ health status

Background and objective: The pre-analytical rejection rate is the proportion of samples rejected at the stage that includes the initial procedures of the testing process performed outside the laboratory walls by healthcare professionals. This study aimed to evaluate the pre-analytical rejection rate by considering the health status of the patients and the sample types and to examine the measures that can be taken against it.  Methods: The data of the samples that came to the laboratory for analysis for one year were included. These data were categorized according to sample types in complete blood count, biochemistry, hormones, urine, blood gases, coagulation, erythrocyte sedimentation rate (ESR), glycosylated hemoglobin (HbA1c). It was also categorized by emergency, outpatient, inpatient, and critically ill status. Considering the health status of the patients, the pre-analytical rejection rates determined in these sample types were compared.  Results: Complete blood count (0.40%) in emergency patients, HbA1c (0.78%) in outpatients, biochemistry (0.62%) in inpatients, hormones (0.29%), urine (6.19%) blood gases (1.03%), coagulation (1.26%), ESR (3.23%) in critical patients, sample types had the highest pre-analytical rejection rate.  Conclusions: The source of causes that affect pre-analytical rejection rates, such as hemolyzed sample, clotted sample, or insufficient sample, may be due to the patient's bed rest, critical or emergency. An underlying disease, treatment, or frequent phlebotomy may also be a factor. The source of the causes that affect the pre-analytical rejection rates, such as incorrect request, incorrect registration, and incorrect tube, can usually be attributed to non-laboratory healthcare personnel.

Impact of the pre-examination phase on multicenter metabolomic studies

The development of metabolomics in clinical applications has been limited by the lack of validation in large multicenter studies. Large population cohorts and their biobanks are a valuable resource for acquiring insights into molecular disease mechanisms. Nevertheless, most of their collections are not tailored for metabolomics and have been created without specific attention to the pre-analytical requirements for high-quality metabolome assessment. Thus, comparing samples obtained by different pre-analytical procedures remains a major challenge. Here, ¹H NMR-based analyses are used to demonstrate how human serum and plasma samples collected with different operating procedures within several large European cohort studies from the Biobanking and Biomolecular Resources Infrastructure - Large Prospective Cohorts (BBMRI-LPC) consortium can be easily revealed by supervised multivariate statistical analyses at the initial stages of the process, to avoid biases in the downstream analysis. The inter-biobank differences are discussed in terms of deviations from the validated CEN/TS 16945:2016 / ISO 23118:2021 norms. It clearly emerges that biobanks must adhere to the evidence-based guidelines in order to support wider-scale application of metabolomics in biomedicine, and that NMR spectroscopy is informative in comparing the quality of different sample sources in multi cohort/center studies.

Factors influencing the high rejection rates of HIV 1/2 serology samples at Charlotte Maxeke Johannesburg Academic Hospital and the cost implications

Background

HIV enzyme-linked immunosorbent assay (ELISA) is one of the most requested test sets within Virology and forms an essential part of patient management. Assessment of the rejection criteria is a key quality indicator, crucial for improving laboratory services and efficiency to ensure accurate and reliable results.

Objectives

The aim of this study was to identify the factors that influence the HIV 1/2 serology rejection rates (RR) at Charlotte Maxeke Johannesburg Academic Hospital and to evaluate the associated costs.

Methods

A retrospective study was conducted (June to December 2019) to identify the RR and rejection criteria of HIV serology samples throughout the total testing process. Descriptive analysis using percentages and frequencies was used to analyse the RR by phase, health establishment, ward and healthcare professional. A cost analysis incorporating minor and major costs was modelled in each phase of testing, and the total cost of rejections was calculated.

Results

A total of 6678 tests were received, and 738 were rejected (RR = 11.1%). The pre-analytical phase contributed significantly to the overall RR, with the requirement of a separate sample (57.44%) the most common reason for rejection. The total cost per rejected test was $2.47, which amounted to a total rejection cost of $197.55, of which $158.18 was caused by the pre-analytical rejection criteria.

Conclusion

High RR of HIV tests were noted, resulting in significant cost wastage. Identification and analysis of rejections must be implemented across all laboratories to improve the efficiency of testing, provide a cost-saving benefit and maintain high laboratory standards.

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

Analysis by real-time PCR of five transport and conservation mediums of nasopharyngeal swab samples to COVID-19 diagnosis in Santiago of Chile

Due to the COVID-19 pandemic, many transport kits have been manufactured to preserve and transport nasopharyngeal swab samples (NPSs) from patients. However, there is no information on the performance of the different virus transport media (VTM) used in COVID-19 diagnosis in the population of Santiago de Chile. We compared the RT-qPCR amplification profile of five different viral transport kit mediums, including DNA/RNA Shield™, NAT, VTM-N, Ezmedlab™, and phosphate-buffered saline (PBS), for NPSs from Central Metropolitan Health Service, Santiago, Chile. The DNA/RNA Shield™ medium showed a better performance in terms of Cq and RFU values for the internal reference RNase P and viral ORF1ab probes. By contrast, the PBS transport medium registered higher Cq values for the viral and reference gene, compared to the other VTM. DNA/RNA Shield™ shows higher relative fluorescence units (RFUs) and lower Cq values for the reference gene. Collectively, our results suggest that the PBS medium could compromise the sample diagnosis because of its lower RT-qPCR performance. The NAT, Ezmedlab and VTM-N, and DNA/RNA Shield™ media show acceptable RT-qPCR parameters and, consequently, seem suitable for use in COVID-19 diagnosis.

Diagnostic Challenges in Children With Congenital Bleeding Disorders: A Developing Country Perspective

OBJECTIVES

To assess the frequency and characteristics of children with inherited bleeding disorders that were initially misdiagnosed, leading to inappropriate disease management.

METHODS

This study was conducted at the Haematology/Pathology Department of Fauji Foundation Hospital, Rawalpindi, Pakistan, from August 2014 to August 2018. Children who were diagnosed with an inherited bleeding disorder but did not respond to initial therapy were reevaluated.

RESULTS

In total, 62 children were diagnosed with a bleeding disorder. Of these, 27 were diagnosed with an inherited bleeding disorder and 35 with an acquired bleeding disorder. Of the 27 children with inherited bleeding disorders, 18% (n = 5) were misdiagnosed and treated inappropriately. The median age of the misdiagnosed patients was 9 years (range, 5-13 years). Three patients with Bernard-Soulier syndrome had been misdiagnosed as having immune thrombocytopenic purpura, 1 patient with von Willebrand disease had been misdiagnosed as having hemophilia A, and 1 patient with haemophilia B had been misdiagnosed as having hemophilia A.

CONCLUSIONS

There are chances of misdiagnosis and improper or invasive management if comprehensive laboratory evaluation and a thorough clinical evaluation are not performed in children with congenital bleeding disorders.

Confounders in Identification and Analysis of Inflammatory Biomarkers in Cardiovascular Diseases

Proinflammatory biomarkers have been increasingly used in epidemiologic and intervention studies over the past decades to evaluate and identify an association of systemic inflammation with cardiovascular diseases. Although there is a strong correlation between the elevated level of inflammatory biomarkers and the pathology of various cardiovascular diseases, the mechanisms of the underlying cause are unclear. Identification of pro-inflammatory biomarkers such as cytokines, chemokines, acute phase proteins, and other soluble immune factors can help in the early diagnosis of disease. The presence of certain confounding factors such as variations in age, sex, socio-economic status, body mass index, medication and other substance use, and medical illness, as well as inconsistencies in methodological practices such as sample collection, assaying, and data cleaning and transformation, may contribute to variations in results. The purpose of the review is to identify and summarize the effect of demographic factors, epidemiological factors, medication use, and analytical and pre-analytical factors with a panel of inflammatory biomarkers CRP, IL-1b, IL-6, TNFa, and the soluble TNF receptors on the concentration of these inflammatory biomarkers in serum.

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.

Impact of COVID-19 on the pre and post analytical clinical laboratory testing processes- A performance evaluation study using six sigma

BACKGROUND

The aim of this study was to determine the impact of COVID-19 pandemic on the total testing process using six sigma metrics based on a comparison of pre and during pandemic periods.

MATERIAL & METHODS

The study duration was over 12 months, 6 months before and 6 months after the COVID-19 onset in Pakistan in March 2020 after the recognition of the first case, using quality indicators (QIs). QIs were chosen from a model of QIs recommended by the CAP. Analysis was performed using Six Sigma calculators and QIs were expressed in percentage (%) and Sigma value were computed. Three levels of performance quality i.e. 25th, 50th, and 75th percentile were derived, being best, common and worst performance respectively. Between-group differences were tested using the Mann-Whitney's U test.

RESULTS

The median defect percentages of these QIs ranged from 0% to 0.27% for the pre-pandemic period and 0% to 0.13% for the during pandemic period. Meanwhile, sigma values of the majority of the QIs were all above 4.0σ during the pre and the pandemic times. For the pre-analytical phase, sigma scores declined for 1 QI, improved for 3 QIs and remained same for 2. In the post analytical phase, no change in sigma metrics was noted for critical values notification. Considerable increase in defect percentage of inappropriate turnaround times was noted.

CONCLUSION

The emergency preparedness proved to be fruitful as depicted by exceptional performance on the sigma metrics for most Qis both prior to and during the pandemic. The pre-analytical and the post analytical phases, being the most error sensitive requires strict vigilance.

Quality Indicators for Evaluating Errors in the Preanalytical Phase

Objective  The aim of this study was to study the incidence of preanalytical errors in the clinical chemistry laboratory attached to a tertiary care hospital.

Design and Methods  The study was conducted in a clinical chemistry laboratory using the samples and forms received for analysis. Five hundred random samples were analyzed using a predefined set of quality indicators (QIs) over a period of 3 months. The incidence of each preanalytical error was described as a percentage of the total samples analyzed in the study.

Statistical Analysis  Individual QIs were assigned values as 0 and 1 and were used to assess each sample; 0 if the error was present, and 1 if absent. The incidence of each preanalytical error was described as a percentage of the total samples analyzed in the study.

Result  Out of the 500 samples observed, 138 samples were error free, while 21 samples had the maximum number of errors, that is, 6. The error committed most often was the omission of provisional diagnosis being mentioned on the requisition form. No preanalytical error was observed for QIs: selecting the appropriate blood collection vial or storage of sample.

Conclusion  This study confirms that error rate in the preanalytical phase is high and vastly ignored. Errors committed here may be overlooked, given the large number of samples received in the clinical laboratory of a tertiary center. To reduce these errors, the laboratory should provide training to all workers involved in the preanalytical phase. Daily or weekly QI scores should be recorded to assess and rectify shortcomings, thereby improving patient care.

Schemes and Performance Evaluation Criteria of Korean Association of External Quality Assessment (KEQAS) for Improving Laboratory Testing

External quality assessment (EQA) is important for evaluating clinical laboratories and enhancing their testing quality. EQA schemes are variable; thus, it is crucial that the EQA organizers share their experiences to continuously improve the EQA scheme. The Korean Association of External Quality Assessment Service (KEQAS) has been the leading, authorized EQA institute for the standardization and quality management of laboratory testing in Korean medical institutions since 1976. The EQA scheme underwent a major change in 2016, and the number of EQA programs increased significantly since then. The key changes implemented in EQA scheme include a fully computerized assessment to accelerate feedback and unification of the testing and reporting methods. We provide an overview of the EQA schemes and performance evaluation criteria of the KEQAS and suggest directions for achieving the global harmonization of EQA.

Challenges in Pathology Specimen Processing in the New Era of Precision Medicine

CONTEXT.—

Precision therapies for patients with driver mutations can offer deep and durable responses that correlate with diagnosis, metastasis prognosis, and improvement in survival. Such targeted therapies will continue to increase, pushing us to change our traditional approaches. We needed to search for new tools to effectively integrate technological advancements into our practices because of their capability to improve the efficiency and accuracy of our diagnostic and treatment approaches. Perhaps nothing is as relevant as identifying and implementing new workflows for processing pathologic specimens and for improving communication of critical laboratory information to and from clinicians for appropriate care of patients in an efficient and timely manner.

OBJECTIVES.—

To define the gold standard in delivering the best care for patients, to identify gaps in the process, and to identify potential solutions that would improve our process, including gaps related to knowledge, skills, attitudes, and practices.

DESIGN.—

We assembled a team across disciplines to systematically perform a gap analysis study to clarify the discrepancy between the current reality in pathology specimen processing and the desired optimal situation to deliver the results intended for patient care.

RESULTS.—

A practical collaborative workflow for specimen management seeking the cooperation of the stakeholders in each medical discipline to provide guidelines in specimen collection, delivery, processing, and reporting of results with the ultimate goal of improving patients' outcomes is provided.

CONCLUSIONS.—

New tools are required to effectively integrate data-driven approaches in specimen processing to meet the new demands.

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

Prevention of extra-analytical phase errors by non-analytical automation in clinical laboratory

During previous decades, significant improvements in laboratory errors have become a substantial part of reducing preventable diagnostic errors. In clinical laboratory practice, the errors in the testing process are primarily associated with extra-analytical phase error sources, influencing the test result quality profoundly. Thus, the management of these critical error sources makes their effects preventable thanks to automation and computer sciences. The implementation of non-analytical automated systems requires a risk management strategy based on laboratory’s workflow and bottlenecks. Then, the improvements can be measured and evaluated by the usage of quality indicators (QI). Consequently, the total quality of laboratory diagnostics and higher patient safety is closely dependent on this type of automation. This review will help laboratory professionals, managers, and directors improve the total testing processes (TTP). The automation technologies have added a serious impact on the proficiency of laboratory medicine. Several instrumentations have now partially or entirely automated many manual tasks to improve standardization, organization, efficiency, and TTP quality. The implementation of non-analytical automation has made them manageable. As a result, non-analytical automation within and outside the clinical laboratory will necessarily lessen the error sources’ effect on the total test process, enhancing the quality of the test results.

A Quality Improvement Initiative to Reduce Rejected Laboratory Samples and Enhance Specimen Acceptability

BACKGROUND

Clinical laboratories play a vital role in patient diagnosis and management. However, blood specimens may be rejected for a variety of reasons, which may have substantial clinical consequences for patient safety. The quality team observed significant numbers of rejected samples from the emergency department and inpatient units due to hemolysis. A total of 1.43% of the blood samples were rejected, which was considerably higher than the target of 0.4%.

METHODS

This project aimed to reduce the percentage of rejected blood samples from 1.43% (measured between January 2015 and April 2016) by 50% in the emergency department and the coronary ICU by December 2017. The team identified preanalytical errors as the primary reason for rejections. A multidisciplinary team was formed and tested several changes, including phlebotomy education, competency validation by direct observations, the use of appropriate consumables for sampling, and physician education for proper orders.. All specimens sent for blood chemistry, arterial blood gas analysis, hematology, and coagulation tests were included. Microbiology test specimens and point-of-care testing samples were excluded.

RESULTS

The percentage of rejected blood samples dropped from 1.43% (January 2015-April 2016) to 0.47% in 2018, which was a statistically significant reduction (p < 0.001).

CONCLUSION

Using a quality improvement approach for the detailed analyses of specimen rejection rates and related issues helped to formulate efficient plans to target this issue. Weekly rapid cycle improvements from January 2018 helped to achieve the team's goals quickly and had a major impact in combination with other interventions.

The stability of 'add-on' coagulation assays in refrigerated citrated plasma stored on a packed cellular fraction

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.

Approaches to handling missing or "problematic" pharmacology data: Pharmacokinetics

Missing or erroneous information is a common problem in the analysis of pharmacokinetic (PK) data. This may present as missing or inaccurate dose level or dose time, drug concentrations below the analytical limit of quantification, missing sample times, or missing or incorrect covariate information. Several methods to handle problematic data have been evaluated, although no single, broad set of recommendations for commonly occurring errors has been published. In this tutorial, we review the existing literature and present the results of our simulation studies that evaluated common methods to handle known data errors to bridge the remaining gaps and expand on the existing knowledge. This tutorial is intended for any scientist analyzing a PK data set with missing or apparently erroneous data. The approaches described herein may also be useful for the analysis of nonclinical PK data.