The Effects of Education and Training Given to Phlebotomists for Reducing Preanalytical Errors

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.

The utility of serum amyloid A and other acute-phase reactants determination in ambulatory care COVID-19 patients

Background

The unpredictable course of Coronavirus Disease 19 (COVID-19) is making good severity assessment tools crucial. This study aimed to assess the usefulness of serum amyloid A (SAA) and other acute-phase reactants (APRs) in ambulatory care COVID-19 patients and identified relationships between these markers and disease outcomes.

Methods

From August to November 2020, patients seen in the outpatient department of the Clinic for Infectious and Tropical Diseases (Belgrade, Serbia) with confirmed COVID-19 were included. Patients were classified into mild, moderate, and severe disease groups based on World Health Organization criteria. SAA, C-reactive protein (CRP), interleukin-6 (IL-6), procalcitonin (PCT), ferritin, fibrinogen, D-dimer, albumin, and transferrin were measured. The median values of all APRs were compared between COVID-19 severity groups, hospitalized and non-hospitalized patients, and survivors and non-survivors. The Receiver operator characteristic (ROC) curve analysis was used for the classification characteristics assessment of individual APRs for the severity of illness, hospitalization, and survival.

Moving Toward a Safer Health Care Facility: Improving Patient Identification at a Public Hospital in Saudi Arabia

BACKGROUND AND OBJECTIVES

Patient misidentification errors continue to represent a significant risk to patients, health care staff, and hospitals. The study's purpose was to present a successful quality improvement project implemented in a public hospital in Saudi Arabia. The project focused on increasing staff's compliance with and awareness of the hospital's patient identification policy to thus reducing the number of patient misidentification-related incidents.

METHODS

Through a quality improvement project, we employed FOCUS PDSA to address the issue of patient misidentification at outpatient departments. A total of 640 staff members participated in the educational program including physicians, nurses, receptionists, radiologists, physiotherapists, and laboratory staff. Collected data included measures of compliance and awareness levels as well as patient misidentification incidents, before and after the project. Statistical analysis was conducted to measure significant differences in the study indicators before and after the project.

RESULTS

Results from the post-project assessment revealed that the project was successful in achieving its objectives. The overall compliance rate and awareness level increased from 59% to 78% and from 75% to 90%, respectively. Improvement in the levels of compliance and awareness was statistically significant. The average number of patient misidentification errors also reduced after the project's implementation with an average of 3 errors per month. The mean difference of patient misidentification errors before and after the project was significant ( P < .01).

CONCLUSION

This project demonstrated how quality improvement projects can be used to address a critical issue such as patient misidentification. The project furthers efforts made by national and international agencies to improve patient safety. It also highlights the importance of continuous education and training to ensure compliance with patient identification policies that ultimately contributes to a safer hospital environment.

Preanalytical Errors in a Hematology Laboratory: An Experience from a Tertiary Care Center

BACKGROUND

Laboratory errors arise at any stage of testing. Detecting these inaccuracies before results are revealed might delay diagnosis and treatment, causing patient distress. Here, we studied the preanalytical errors in a hematology laboratory.

METHODS

This one-year retrospective analysis was conducted at the laboratory of a tertiary care hospital and included information on blood samples that were taken for hematology tests from both outpatients and inpatients. Laboratory records included sample collection and rejection information. The type and frequency of preanalytical errors were expressed as a proportion of total errors and sample number. Microsoft Excel was utilized to enter data. The results were presented in the form of frequency tables.

RESULTS

This research included 67,892 hematology samples. For preanalytical errors, 886 samples (1.3%) were discarded. The most common preanalytical error was insufficient sample (54.17%), and the least common was an empty/damaged tube (0.4%). Erroneous samples in the emergency department were mostly insufficient and clotted, whereas pediatric sample errors were caused by insufficient and diluted samples.

CONCLUSION

Inadequate samples and clotted samples account for the vast majority of preanalytical factors. Insufficiency and dilutional errors were most frequent from pediatric patients. Adherence to best laboratory practices can drastically cut down on preanalytical errors.

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.

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.

Magnesium supplementation and iron status among female students: the intervention study

Background

Literature data indicate the benefit of magnesium (Mg) supplementation. The aim of this study was to examine the effect of short-term Mg supplementation on iron status in healthy female participants.

Methods

One hundred healthy female students of the University of Belgrade - Faculty of Pharmacy participated the study during eleven intervention days. Students ingested Mg preparations with the same dose of the active substance. The analysis included the measurement of serum iron, unsaturated iron binding capacity (UIBC), total iron binding capacity (TIBC), total Mg (tMg), ionized Mg (iMg), complete blood count, met-, carboxyand oxy-haemoglobin (metHgb, COHgb, O2Hgb). Transferrin concentrations and percentage of transferrin saturation (SAT) were calculated manually. The association among the analyzed biochemical parameters was examined using polynomial regression. A principal component analysis (PCA) was used for the evaluation of interdependence between the analyzed parameters.

Results

A statistically significant trend for change in O2Hgb (%) by tertiles of iMg concentrations was found (P = 0.029). Serum tMg reached significant positive correlation with the SAT at concentration levels greater than 0.9 mmol/L, after 11 days of intervention (R2=0.116). Ionized Mg in a concentration higher than 0.6 mmol/L is positively correlated with SAT and serum Fe (R2=0.214; 0.199, respectively). PCA revealed variability of 64.7% for two axes after 11 days.

Conclusions

Mg supplementation leads to an improvement in the certain iron status parameters even in individuals with optimal levels of these indices. However, caution should be exercised when supplementing Mg, and laboratory monitoring of the interaction is required.

Decreasing Complete Blood Count Clotting Rates: An Improvement Project in an Academic Neonatal Intensive Care Unit

BACKGROUND

In premature and critically ill infants, a complete blood count (CBC) is commonly collected via the heel-stick method, which is preferred because of the ongoing requirements to preserve intravenous sites. However, because of sample clotting, these specimens are often rejected, leading to unnecessary repeat heel sticks, painful stimuli, and increased costs.

PURPOSE

The purpose of this quality improvement project was to decrease the rate of clotted CBC samples obtained from neonates admitted in the neonatal intensive care unit.

METHODS

The RE-AIM translation model, which stands for Reach, Effectiveness, Adoption, Implementation, and Maintenance, was adopted to decrease the rate of clotted CBC samples through staff education, randomized audits of the staff's heel-stick technique, and the development and implementation of a standardized capillary blood sampling protocol. The primary outcome measure was the rate of clotted CBC samples, which was defined as the proportion of clotted CBC samples.

RESULTS

CBC clotted sample rates decreased by 27%, resulting in a cost saving of $1136, and overall CBC rejection rates decreased by 23%.

IMPLICATIONS FOR PRACTICE

All hospital units should provide staff with an evidence-based resource, recurrent education, and evaluation of skills to avoid unnecessary repeat heel sticks and prevent increased pain sensitivity, social hypervigilance, and avoidance behavior in early infancy.

IMPLICATIONS FOR RESEARCH

Future efforts should focus on the long-term benefits of routine education and its effects on clotted sample rates and whether samples drawn by laboratory phlebotomy staff versus registered nurses/patient care technicians result in disproportionate rejection rates.

Verification of quantitative analytical methods in medical laboratories

Background

Globally, all medical laboratories seeking accreditation should meet international quality standards to perform certain specific tests. Quality management program provides disciplines targeted to ensure that quality standards have been implemented by a laboratory in order to generate correct results. The hallmark of the accreditation process is method verification and quality assurance. Before introducing a new method in your laboratory, it is important to assess certain performance characteristics that reflect the concept of method verification.

Methods

In this review, we illustrated how to verify the performance characteristics of a new method according to the recent guidelines. It includes an assessment of precision, trueness, analytical sensitivity, detection limits, analytical specificity, interference, measuring range, linearity, and measurement uncertainty.

Conclusions

Although the presence of several updated guidelines used to determine the performance characteristics of new methods in clinical chemistry laboratories, the real practice raised several concerns with the application of these guidelines which in need for further consideration in the upcoming updates of these guidelines.

The results of a close follow-up of trainees to gain a good blood collection practice

Background

Phlebotomy is one of the most important steps in the preanalytical phase of a clinical laboratory process. In order to decrease phlebotomy errors, this specific procedure should be taught in detail by laboratory organizations. Our study aims to practice the training program on venous blood sampling and observe the close follow-up results.

Methods

In this observational study, 127 students who started their summer internship in Antalya Education and Research Hospital were given a one-day theoretical phlebotomy training in accordance with the Venous Blood Sampling Guidelines. After the theoretical training, phlebotomy applications of 10 students who were working in the field of out-patient blood sampling were observed both with and without their knowledge. A comprehensive checklist related to phlebotomy was created by the trainers in Antalya Education and Research Hospital and the observers answered each question as yes or no. For the statistical analysis, IBM SPSS Statistics 21.0 was used.

Results

After the theoretical education, the trainees were observed but no significant difference was found between the first and the second informed observations (p = 0.125). The students were observed three times more in the following week without their knowledge. There was a statistically significant difference between the first and the third unannounced observations (p=0.001).

Conclusions

In order to perform phlebotomy correctly, apart from theoretical education, a close follow-up is necessary too.

Quality improvement project: Reducing non-conformities of the samples for haemostasis testing in a secondary healthcare centre through the nurses' education in phlebotomy

Introduction

Poor compliance to the current guidelines and lack of knowledge among nurses about proper blood sampling is set as the study hypothesis. Here is presented a quality improvement project with following aims: a) to identify the most prevalent non-conformity of the samples for haemostasis testing, b) to identify the cause of sample non-conformity, c) to perform corrective action(s) and d) to assess the effectiveness of the corrective action(s).

Materials and methods

The rate of non-conformity of samples collected for haemostasis tests was established for hospital wards with inpatients. Phlebotomy practice was audited throughout anonymous questionnaire among hospital’s nurses who perform phlebotomy. Education about blood sampling was performed as a 1-hour lecture in different small groups each working day within one month. Education effectiveness was assessed through the evaluation of sample quality and is considered effective if more than half of the hospital wards significantly reduced their sample non-conformities rate.

Results

Clotted sample constituted 84% of sample non-conformities. The questionnaire revealed nurses’ poor knowledge in phlebotomy. There was no difference in nurses’ knowledge regarding the level of education or work experience. Reduction in sample non-conformities was observed in 7 out of 9 wards 4 months after education; this improvement was statistically significant for 5 wards.

Conclusion

Clotted sample as the most prevalent non-conformity of the samples for haemostasis testing is caused by the lack of knowledge of the nurses in several parts of the phlebotomy process. Specific education of the motivated personnel in small groups was successful and long-term effective.

Peripheral Venipuncture Education Strategies for Nursing Students: An Integrative Literature Review

This integrative literature review identified strategies to teach peripheral venipuncture to nursing students. The following databases were searched for primary studies: Biblioteca Virtual em Saúde (BVS), PubMed, Web of Science, Education Resources Information Center (ERIC), SCOPUS, and Cumulative Index to Nursing and Allied Health Literature (CINAHL). The final sample was composed of 24 studies. The literature ranged from descriptive studies to controlled clinical trials and methodologic studies to construct products/instruments for teaching peripheral venipuncture. The most frequently identified teaching strategies were theoretical contents taught via theoretical lecture, e-learning courses, video lessons, and demonstration by specialists combined with practical exercises using a mannequin, human arms, and/or haptic devices. Despite the different methods used currently, the best patient outcomes were achieved when the student received the theoretical content in an educational setting before the practical training on a mannequin and/or a virtual simulator.

Interaction of apelin, elabela and nitric oxide in schizophrenia patients

Background

Apelin (APLN), elabela (ELA), and nitric oxide (NO) have effects on physiological and behavioural properties in biological systems. This study was designed to determine APLN, ELA and NO levels in schizophrenia patients and assess whether these molecules are of diagnostic value.

Methods

A total of 33 schizophrenic patients and 32 ageand sex-adjusted healthy participants were included in the study. ELA, APLN and NO levels were measured using ELISA methods.

Results

Although the ELA and NO levels of the patients were lower than the control group, APLN levels were higher (p = 0.039, p = 0.019, p = 0.048, respectively). There was a significant negative correlation between APLN levels and triglyceride (TG) and body mass index (BMI) levels (r = -0.426, p = < 0.001 and r = -0.330, p = 0.007, respectively). Respectively, the areas under the receiver-operating characteristic (ROC) curves of the ELA/APLN, ELA/NO and APLN/NO ratios were 0.628, 0.590 and 0.709, 95% confident intervals (CI): 0.491-0.764, 0.450-0.730 and 0.579-0.840.

Conclusions

Decreased levels of ELA and NO and increased APLN levels in schizophrenia suggest that these molecules may be involved in its etiopathology. The APLN/NO ratio also seems to show promise in the diagnosis of the disease and may be used in future.

Newborns bilirubin concentration determined by different methods in relation to hematocrit and albumin level

Background

Monitoring of bilirubin is essential during early neonatal life. Bilirubin in high concentration is toxic to the brain and might cause irreversible neurological damage. Several different methods for bilirubin determination are available nowadays, but inconsistent results may be obtained. The study aimed to compare dry chemistry methods with vanadate oxidation method for bilirubin determination in relation to hematocrit and albumin level in neonates and infants.

Methods

The study included 98 consecutive serum samples from newborns and infants (47 boys and 51 girls, mean age 19 ± 15 days) treated in the University Children's Hospital in Krakow. Total bilirubin (TBil) and neonatal bilirubin (NBil) concentration were measured by dry chemistry analyser (Vitros 4600, Ortho Clinical Diagnostics Inc.). Total bilirubin (TBil_V) was also measured using vanadate oxidation method (Cormay, Poland). Albumin concentration and blood morphology have been routinely determined in all children.

Results

No significant differences between the mean value of NBil (69.00 ± 67.76 μmol/L), TBil (81.26 ± 70.13 μmol/L) and TBilV (75.90 ± 60.62 μmol/L) were noticed. High coefficient correlation between NBil and TBil as well as between NBil and TBil_V were noticed (Pearson's analysis, r = 0.99, r = 0.97, respectively; p < 0.0001 in both cases). There was a positive correlation between the difference (TBil_V - NBil) and hematocrit (p < 0.009, r = 0.2664).

Conclusions

In newborns and infants the same method for bilirubin determination should be used when the concentration of bilirubin is monitored. When using vanadate oxidation method for bilirubin determination, hematocrit value should be taken into account when results are interpreted.

Platelet glutamate dehydrogenase activity and efficacy of antipsychotic therapy in patients with schizophrenia

Background

Evaluation of possible relationship between platelet glutamate dehydrogenase (GDH) activity and mental state of schizophrenia patients after antipsychotic pharmacotherapy.

Methods

Patients (n = 50) with chronic paranoid schizophrenia (F20.0) initially in acute psychotic state were examined before and after a treatment course with antipsychotics. When assessing the patients' states using PANSS, the "responder" category was attributed to those patients who had not less than 30% reduction in the score for the corresponding PANSS "subscale". The control group (n = 48) was ageand gender-matched with the patient group. Platelet glutamate dehydrogenase (GDH) activity was measured in patients twice, before and after the treatment course, and once in controls.

Results

Significantly reduced GDH activity was found in patients compared with controls. The patient group was divided into two subgroups according to median GDH activity at baseline: above and below the median GDH, subgroup 1 and subgroup 2, respectively. GDH activity significantly increased from its level at baseline after antipsychotic treatment in subgroup 2. Distribution of non responders / responders to antipsychotic treatment (by PANSS scores) was significantly uneven among subgroups 1 and 2. In subgroup 1, GDH activity levels significantly correlated with PANSS scores after the treatment course.

Conclusions

Baseline platelet GDH activity might serve as a predictor of antipsychotic therapy efficacy in schizophrenia patients.

Is dynamic thiol/disulfide homeostasis associated with the prognosis of myelodysplastic syndrome?

Background

This study planned to investigate the relationship of dynamic thiol/disulfide homeostasis with the prognosis of myelodysplastic syndrome (MDS).

Methods

80 patients who had been diagnosed with MDS between 2012 and 2017 and who were older than 18 were included in the study together with 80 healthy control subjects. The MDS diagnosis was confirmed using bone marrow aspiration-biopsy immunostaining. Dynamic thiol/disulfide homeostasis and ischemia-modified albumin (IMA) levels were examined.

Results

The average IMA (0.71±0.08 vs. 0.67±0.09; p=0.002), median disulfide (18.0 vs. 11.6; p<0.001), median disulfide/native thiol (6 vs. 3; p<0.001), and median disulfide/total thiol (5.4 vs. 2.9; p<0.001) were found higher in the MDS patients compared to control group, and the median hemoglobin, median white blood cell count, median neutrophil count, median lymphocyte count, average native thiol (290.7±48.5 vs. 371.5±103.8; p<0.001), average total thiol (328.2±48.9 vs. 393±105.5; p<0.001), and average native thiol/total thiol (%) (88.3±4.3 vs. 94.2±2.1; p<0.001) were found to below. Risk factors such as collagen tissue disease (HR:9.17; p=0.005), MDS-EB-1 (HR:10.14; p=0.032), MDS-EB-2 (HR:18.2; p=0.043), and disulfide/native thiol (HR:1.17; p=0.023) were found as the independent predictors anticipating progression to acute myeloid leukemia. In the Cox regression model, risk factors such as age (HR:1.05; p=0.002), MDS-EB-1 (HR:12.58; p<0.001), MDS-EB-2 (HR:5.75; p=0.033), disulfide/native thiol (HR:1.14; p=0.040), and hemoglobin (HR:0.64; p=0.007) were found as predictors anticipating for mortality.

Conclusions

We can argue that dynamic thiol/disulfide homeostasis could have significant effects on both the etiopathogenesis and the survival of patients with MDS, and it could be included in new prognostic scoring systems.

Determination of non-cholesterol sterols in serum and HDL fraction by LC/MS-MS: Significance of matrix-related interferences

Background

Non-cholesterol sterols (NCS) are promising biomarkers for estimation of cholesterol homeostasis properties. In addition, determination of NCS in high-density lipoprotein (HDL) fraction (HDL-NCS) could provide information on cholesterol efflux. However, matrix effects interfere in liquid chromatography-mass spectrometry (LC-MS) analysis of NCS, thereby impairing the method sensitivity. The aims of this study were development, optimization and validation of LC-MS method for quantification of NCS in serum and HDL-NCS. Additionally, matrix effect interferences and methods application in individual serum samples were examined.

Methods

HDL precipitating reagent was used for HDL isolation. Matrix effect was examined by comparing different surrogates by simple regression analysis. Validation was conducted according to the FDA-ICH guideline. 20 healthy volunteers were recruited for testing of method application.

Results

The observed matrix effect was 30%, and matrix comparison showed that cholesterol was the dominant contributor to the matrix effect. Cholesterol concentration was adjusted by construction of the calibration curve for serum and HDL fraction (5 mmol/L and 2.5 mmol/L, respectively). The intraand interrun variabilities for NCSs were 4.7-10.3% for serum NCS and 3.6-13.6% for HDLNCS and 4.6-9.5% for serum NCSs and 2.5-9.8% for HDL-NCS, respectively. Recovery studies showed satisfactory results for NCSs: 89.8-113.1% for serum NCS and 85.3-95.8% for HDL-NCS.

Conclusions

The method was successfully developed and optimized. The matrix interference was solved by customising calibration curves for each method and sample type. The measurement of NCS in HDL fraction was proposed for the first time as potentially useful procedure in biomedical researches.

Detection of Lipoprotein X (LpX): A challenge in patients with severe hypercholesterolaemia

Background

Lipoprotein X (LpX) is an abnormal lipoprotein fraction, which can be detected in patients with severe hypercholesterolaemia and cholestatic liver disease. LpX is composed largely of phospholipid and free cholesterol, with small amounts of triglyceride, cholesteryl ester and protein. There are no widely available methods for direct measurement of LpX in routine laboratory practice. We present the heterogeneity of clinical and laboratory manifestations of the presence of LpX, a phenomenon which hinders LpX detection.

Methods

The study was conducted on a 26-year-old female after liver transplantation (LTx) with severely elevated total cholesterol (TC) of 38 mmol/L and increased cholestatic liver enzymes. TC, free cholesterol (FC), cholesteryl esters (CE), triglycerides, phospholipids, HDL-C, LDL-C, and apolipoproteins AI and B were measured. TC/apoB and FC:CE ratios were calculated. Lipoprotein electrophoresis was performed using a commercially available kit and laboratory-prepared agarose gel.

Results

Commercially available electrophoresis failed to demonstrate the presence of LpX. Laboratory-prepared gel clearly revealed the presence of lipoproteins with γ mobility, characteristic of LpX. The TC/apoB ratio was elevated and the CE level was reduced, confirming the presence of LpX. Regular lipoprotein apheresis was applied as the method of choice in LpX disease and a bridge to reLTx due to chronic liver insufficiency.

Conclusions

The detection of LpX is crucial as it may influence the method of treatment. As routinely available biochemical laboratory tests do not always indicate the presence of LpX, in severe hypercholesterolaemia with cholestasis, any discrepancy between electrophoresis and biochemical tests should raise suspicions of LpX disease.

Correlation of Fgf23 and Balp with Bone Mineral Density in Hemodialysis Patients

Background

Chronic kidney disease (CKD) is associated with numerous complications such as bone mineral disorder. The aim of our study was to analyze the correlation of bone turnover markers with Bone Mineral Density (BMD) measurements in Tunisian end stage renal diseases (ESRD) patients.

Methods

This study included 100 ESRD Tunisian patients. Their estimated glomerular filtration rate (eGFR) was < 15 mL × min^-1 × (1.73 m²)^-1, which requires hemodialysis. Bone-specific alkaline phosphatase (BALP) serum concentration was determined with a chemiluminescence immunoassay. Fibroblast Growth Factor 23 (FGF23) serum was assessed by Enzyme-Linked Immunosorbent Assay method. The serum levels of 25-Hydroxyvitamin D (25(OH)D), intact parathyroid hormone (iPTH) and Beta cross-laps (CTX) was measured by Electrochemiluminescence Technology. DEXA (dual-energy x-ray absorptiometry) technique was used to evaluate BMD.

Results

We observed a statistically significant negative correlation between BALP levels and total body BMD (r = -0.268; P = 0.015) particularly in femoral neck (FN) (r = -0.219; P = 0.037). BALP concentrations were negatively associated with total BMD especially in FN for patients with BMI < 30, FGF23 concentrations were also negatively correlated with BMD in lumbar spine site (LS) (r = -0.209; P = 0.046). For osteopenic patients we found an inverse correlation between 25(OH)D concentrations and BMD in LS position (r = -0.336; P = 0.038). In men group, we have also found a negative correlation between iPTH and total BMD (r = -0.326; P = 0.015). However we found a positive correlation between calcium expression and BMD in LS site (r = 0.270; P = 0.031).

Conclusions

FGF23 and BALP can predict bone loss in ESRD through their strong correlation with BMD in LS and FN sites respectively.

Nitric Oxide Products are not Associated with Metabolic Syndrome

Background

Nitric oxide (NO) is oxidative stress biomarker which is regarded as one of the key determinants of energy metabolism and vascular tone. Considering the controversial reports on the association between nitric oxide products (NOx) and metabolic syndrome (MetS), the aim of the current study was to examine that potential relationship. Additionally, we aimed to evaluate a broad spectrum of other oxidative stress biomarkers [i.e., malondialdehyde (MDA), advanced oxidation protein products (AOPP), xanthine oxidoreductase (XOD), xanthine oxidase (XO) xanthine dehydrogenase (XDH)] in relation with MetS.

Methods

A total of 109 volunteers (46.8% of them with MetS) were included in this cross-sectional study. Biohemical and anthropometric parameters, as well as blood pressure, were obtained. The MetS was diagnosed according to the International Diabetes Federation criteria.

Results

Multivariate logistic regression analysis showed that XOD (OR=1.011; 95% CI 1.002-1.019; p=0.016), XO (OR=1.014; 95% CI 1.003-1.026; p=0.016), MDA (OR=1.113; 95% CI 1.038-1.192; p=0.003) and AOPP (OR=1.022; 95% CI 1.005-1.039; p=0.012) were the independent predictors of MetS, whereas no association between NOx and MetS was found. As XOD rose for 1 U/L, XO for 1 U/L, MDA for 1 μmol/L and AOPP for 1 T/L, probability for MetS rose for 1.1%, 1.4%, 11.3% and 2.2%, respectively. Adjusted R² for the Model was 0.531, which means that 53.1% of variation in MetS could be explained with this Model.

Conclusion

Unlike XOD, MDA and AOPP, NOx is not associated with MetS.

Determining the Need for Repeat Testing of Blood Ethanol Concentration: Evaluation of the Synchron Blood Ethyl Alcohol Assay Kit

Background

In clinical laboratories, a common practice used to verify tests prior to reporting is repeat testing. Our objective was to evaluate the differences between the results of blood ethanol concentration (BEC) test repetitions and report on the role of repeat testing to prevent reporting of incorrect results.

Methods

We conducted a retrospective study of data retrieved from the Bursa Yuksek Ihtisas Training and Research Hospital’s document management system by calculating the percentage change between repeated BEC test runs. To assess for clinical relevance, the bias between two results from the same sample was compared using the 1988 Clinical Laboratory Improvement Amendments’ (CLIA) proficiency testing allowable total error (TEa) limits.

Results

From a total of 1,627 BEC tests performed between January 2017 and January 2018, 70% (1,133) were repeat tested. Of these, 830 resulted in BECs between 0–5 mmol/L, of which 237 (28.5%) were above the 25% acceptable TEa. Two hundred seventy-six BEC test results were greater than >14 mmol/L, and there was a good consensus between the initial and repeat test results (99%). In this group, the mean bias was 0.0% (95%, CI = -9.8–9.8%). However, three of the repeat test results were considered significantly different. There were two discordant results in the 5–14 mmol/L ethanol level, and the mean bias was 2.1% (95%, CI = -15.0–19.1%).

Conclusion

The majority of the repeated BEC test values were the same as the baseline value; therefore, there may be limited benefit in continuing such frequent repeated analyses.

Glucose meters: What’s the laboratory reference glucose?

Background

The accuracy of glucose meters is evaluated by comparing their results with those from a reference laboratory glucose analyser. The main scientific societies recommend the use of a prompt glycolysis inhibitor such as citrate for an accurate glucose determination. In the present preliminary study, we discuss the bias between capillary and plasma glucose measured concentrations, determined in two Italian clinical laboratories, using tubes containing an NaF and citrate mixture in liquid and granular form.

Methods

139 volunteers in whom 75 g OGTT was requested were recruited. Basal capillary glucose was determined using Abbott FreeStyle Precision Neo in Brescia (n=63), while clinical laboratory reference P-glucose was determined using tubes containing NaF/K3EDTA and liquid NaF/Na2EDTA/citrate. Basal capillary glucose was determined using a Roche Cobas Accu-Chek Inform II in Vicenza (n=76), while P-glucose was determined using tubes containing NaF/K2Ox and NaF/Na2EDTA/citrate in granulated form. Reference P-glucose was determined with a hexokinase method on Dimension Vista systems. Differences between capillary and reference P-glucose were evaluated according to ADA/ISO 15197:2013 specifications.

Results

96.82% and 97.37% of capillary determinations were within specifications when liquid and granular citrate mixture tubes were used, respectively. Conversely, only 73.02% and 80.26% of determinations were within criteria using NaF.

Conclusions

It’s important to know what is the laboratory reference glucose in evaluating glucose meters’ accuracy. The evaluation of glucometers’ accuracy with respect to a reference laboratory may be wrong if tubes containing only NaF are used due to in vitro glycolysis. Only tubes containing citrate mixture permit the correct evaluation of glucose meters’ accuracy.