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Jacobs JW, Sharma D, Stephens LD, Figueroa Villalba CA, Rinder HM, Woo JS, Wheeler AP, Gerberi D, Goel R, Tormey CA, Booth GS, Bloch EM, Adkins BD. Thrombosis risk with haemoglobin C trait and haemoglobin C disease: A systematic review. Br J Haematol 2024; 204:1500-1506. [PMID: 38291731 DOI: 10.1111/bjh.19313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 01/02/2024] [Accepted: 01/11/2024] [Indexed: 02/01/2024]
Abstract
The thrombotic risk with haemoglobin C trait (HbAC) or haemoglobin C disease (HbCC) is unclear. However, individuals with HbCC have demonstrated chronic haemolysis, higher blood viscosity and altered rheology when compared to individuals with wild-type haemoglobin (HbAA). These physiological alterations may theoretically translate to increased risk of thrombosis; therefore, a systematic literature review was performed to investigate the possible association between HbAC and/or HbCC and thrombosis. Twenty-two studies met inclusion criteria representing 782 individuals with HbAC (n = 694) or HbCC (n = 88). Fifteen studies described the presence/absence of venous thromboembolism (VTE) in patients with HbAC (n = 685) or HbCC (n = 79), while seven studies described patients with HbAC (n = 9) or HbCC (n = 9) and arterial thrombosis. Most (n = 20) studies were case reports or case series; however, two studies suggested a potential increased VTE risk with HbAC compared to HbAA in (i) all patients (OR 2.2, 95% CI: 0.9-5.5) and in (ii) pregnant individuals (RR 3.7, 95% CI 0.9-16). This review is the largest assessment of patients with HbC trait or disease and thrombosis to date; despite its limitations, the findings suggest HbC may be a predisposing risk factor to thrombosis. Prospective cohort studies are warranted to definitively elucidate the risk of thrombosis in this population.
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Affiliation(s)
- Jeremy W Jacobs
- Special Coagulation Laboratory, Division of Hematopathology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Deva Sharma
- Division of Transfusion Medicine, Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Division of Hematology/Oncology, Department of Medicine, Vanderbilt-Meharry Center for Excellence in Sickle Cell Disease, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Laura D Stephens
- Department of Pathology, University of California San Diego, La Jolla, California, USA
| | | | - Henry M Rinder
- Department of Laboratory Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Department of Hematology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Jennifer S Woo
- Department of Pathology, City of Hope National Medical Center, Irvine, California, USA
| | - Allison P Wheeler
- Division of Coagulation Medicine, Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Division of Hematology/Oncology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Dana Gerberi
- Mayo Clinic Libraries, Mayo Clinic, Rochester, Minnesota, USA
| | - Ruchika Goel
- Department of Internal Medicine, Simmons Cancer Institute, Southern Illinois University School of Medicine, Springfield, Illinois, USA
- Vitalant, Corporate Medical Affairs, Scottsdale, Arizona, USA
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Christopher A Tormey
- Department of Laboratory Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Garrett S Booth
- Division of Transfusion Medicine, Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Evan M Bloch
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Brian D Adkins
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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Burke O, Jacobs JW, Tormey CA, Rinder HM, Figueroa Villalba CA, Lee ES, Silva Campos JJ, Abels E, Yurtsever N. Heidenhain variant of Creutzfeldt-Jakob disease masquerading as neuromyelitis optica spectrum disorder: recognizing when apheresis is not the answer. Lab Med 2023:lmad107. [PMID: 38142129 DOI: 10.1093/labmed/lmad107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2023] Open
Abstract
The Heidenhain variant of Creutzfeld-Jakob disease (CJD) is a rare form that initially presents with visual disturbances. In early stages, the presentation can mimic neuromyelitis optica spectrum disorders (NMOSD) and lead to unnecessary treatment modalities. Herein, we describe a case of a 66-year-old man who presented with bilateral vision loss and retro-orbital discomfort. In addition to immunosuppressive therapy, he received 4 rounds of therapeutic plasma exchange after his preliminary diagnosis of NMOSD. We were surprised to note that his condition did not show improvement but deteriorated, with severe neurocognitive symptoms. Eventually, CJD was suspected, and real-time quaking-induced conversion (RT-QuIC) was performed. By the time the diagnosis of Heidenhain variant of CJD was confirmed, the patient was discharged to hospice care and died shortly after.
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Affiliation(s)
- Olivia Burke
- Department of Laboratory Medicine, Yale School of Medicine, New Haven, CT, USA
- Department of Pathology, Yale School of Medicine, New Haven, CT, USA
| | - Jeremy W Jacobs
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, US
| | | | - Henry M Rinder
- Department of Laboratory Medicine, Yale School of Medicine, New Haven, CT, USA
- Internal Medicine (Hematology), Yale School of Medicine, New Haven, CT, US
| | | | - Edward S Lee
- Department of Laboratory Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Juan J Silva Campos
- Department of Laboratory Medicine, Yale School of Medicine, New Haven, CT, USA
- Department of Pathology, Yale School of Medicine, New Haven, CT, USA
| | - Elizabeth Abels
- Department of Pathology, Baylor College of Medicine, Houston, TX, US
| | - Nalan Yurtsever
- Department of Laboratory Medicine, Yale School of Medicine, New Haven, CT, USA
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Silva Campos JJ, Abels E, Rinder HM, Tormey CA, Jacobs JW. Botulism mimicking Guillain-Barre syndrome: The question of plasma exchange in an unusual case of acute paralysis. J Clin Apher 2023; 38:760-763. [PMID: 37519071 DOI: 10.1002/jca.22081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 07/17/2023] [Accepted: 07/22/2023] [Indexed: 08/01/2023]
Abstract
Guillain-Barré syndrome (GBS) is an immune-mediated polyradiculoneuropathy and the most common cause of acute flaccid paralysis worldwide. GBS classically presents with acute, progressive, ascending weakness, reduced to absent reflexes, and albuminocytological dissociation on cerebrospinal fluid (CSF) analysis. Botulism is a neurotoxin-mediated acute descending flaccid paralysis with cranial nerve palsies and dysautonomia. Botulism in adults is caused by ingestion/inhalation of botulinum toxin or wound infection with Clostridium botulinum. Both GBS and botulism can rapidly precipitate respiratory failure; thus, prompt diagnosis and treatment are crucial to mitigate poor outcomes. Herein, we describe a case of botulism initially diagnosed as GBS given classic laboratory features, and describe the importance of careful consideration of the most appropriate therapeutic modalities in cases of acute flaccid paralysis, particularly regarding empiric administration of botulinum antitoxin and use of intravenous immune globulin in lieu of plasma exchange for potential GBS to prevent removal of antitoxin.
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Affiliation(s)
- Juan J Silva Campos
- Department of Laboratory Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Department of Pathology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Elizabeth Abels
- Department of Laboratory Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Henry M Rinder
- Department of Laboratory Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Department of Internal Medicine (Hematology), Yale School of Medicine, New Haven, Connecticut, USA
| | - Christopher A Tormey
- Department of Laboratory Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Jeremy W Jacobs
- Department of Laboratory Medicine, Yale School of Medicine, New Haven, Connecticut, USA
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4
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Puzo CJ, Tormey CA, Rinder HM, Siddon AJ. Optimizing Donor Chimerism Threshold for Next Generation Sequencing Monitoring of Measurable Residual Disease Post-Allogeneic Stem Cell Transplant for Myeloid Neoplasms. Transplant Cell Ther 2023:S2666-6367(23)01237-X. [PMID: 37062510 DOI: 10.1016/j.jtct.2023.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 03/30/2023] [Accepted: 04/05/2023] [Indexed: 04/18/2023]
Abstract
BACKGROUND Next-Generation Sequencing (NGS) is used to monitor genetically-measurable residual disease (gMRD) following allogeneic stem cell transplant (aSCT). It is unknown whether an upper limit of chimerism exists such that gMRD NGS testing can be safely forgone. METHODS We reviewed 61 AML and 24 MDS patients between 2016-2020 with at least 1 NGS panel before and after aSCT. Donor chimerism was quantified. Logistic regression characterized which factors predicted gMRD. Receiver operator curves (ROC) determined the optimal chimerism threshold for which gMRD would not be detected. Data from an additional 22 patients with follow-up NGS testing in 2022, was also analyzed to validate our proposed threshold. RESULTS Donor chimerism (OR= 0.38, 95% CI[0.10,0.62], p=0.02), as expected, was a significant predictor of gMRD. Age, gender, conditioning regimen, presence of a related donor, and diagnosis were not associated with gMRD. A chimerism threshold of 92.5% optimized sensitivity (97.7) and specificity (95.4) such that values >92.5% strongly predicted absence of gMRD (AUC= .986). The validation cohort demonstrated similar strongly predictive capability (AUC= .974) with appropriate sensitivity (100%) and specificity (90.9%). CONCLUSION NGS monitoring of gMRD is redundant at chimerism values greater than a more conservative threshold of 92.5% after stem cell transplant.
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Affiliation(s)
| | | | - Henry M Rinder
- Yale School of Medicine, Department of Laboratory Medicine, New Haven CT, USA
| | - Alexa J Siddon
- Yale School of Medicine, Department of Laboratory Medicine, New Haven CT, USA; Yale School of Medicine, Department of Pathology, New Haven CT, USA.
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Khan W, Tormey CA, Rinder HM, Siddon AJ. Quantitative Risk for Single-Positive Lupus Anticoagulant Results With Different Anticoagulants. Am J Clin Pathol 2023; 159:417-419. [PMID: 36940149 DOI: 10.1093/ajcp/aqac183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 12/19/2022] [Indexed: 03/21/2023] Open
Abstract
OBJECTIVES Clinical experts recommend against testing for lupus anticoagulant (LAC) during anticoagulation. METHODS We quantitated the risk of a single-positive dilute Russell viper venom time (dRVVT) result or partial thromboplastin time-based phospholipid neutralization (PN) result on anticoagulation. RESULTS Any anticoagulation led to a fourfold greater likelihood of single-positive results, primarily by rivaroxaban (odds ratio [OR] = 8.6) and warfarin (OR = 6.6), resulting in a positive dRVVT test with a normal PN test. Heparin and apixaban were twofold more likely to show single-positive results, but enoxaparin did not show significant single positivity. CONCLUSIONS Our results quantitatively support experts' avoidance of LAC testing during anticoagulation.
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Affiliation(s)
- Waleed Khan
- Department of Laboratory Medicine, Pathology, Yale School of Medicine, New Haven CT, USA
| | - Christopher A Tormey
- Department of Laboratory Medicine, Pathology, Yale School of Medicine, New Haven CT, USA
| | - Henry M Rinder
- Department of Laboratory Medicine, Pathology, Yale School of Medicine, New Haven CT, USA.,Department of Internal Medicine (Hematology), Pathology, Yale School of Medicine, New Haven CT, USA
| | - Alexa J Siddon
- Department of Laboratory Medicine, Pathology, Yale School of Medicine, New Haven CT, USA
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Jacobs JW, Gisriel SD, Iyer K, Rinder HM. Concomitant factor VIII inhibitor and lupus anticoagulant in an asymptomatic patient. J Thromb Thrombolysis 2021; 53:945-949. [PMID: 34697688 PMCID: PMC8544916 DOI: 10.1007/s11239-021-02591-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/13/2021] [Indexed: 10/31/2022]
Abstract
Acquired hemophilia A, caused by autoantibodies that bind to and neutralize the activity of coagulation factor VIII (FVIII), almost universally presents as a severe bleeding diathesis. Lupus anticoagulants (LAs), autoantibodies directed against phospholipids or protein-phospholipid complexes, manifest clinically with an increased risk of thrombosis. While these autoantibodies are uncommon, the distinctive clinical presentation in conjunction with the typical laboratory findings often enable straightforward identification of the underlying autoantibody. However, the presence of a concomitant acquired FVIII inhibitor and LA is exceedingly rare with fewer than 20 documented cases. All prior patients presented with life-threatening hemorrhage, thrombosis, or both, prompting comprehensive hematologic evaluation and subsequent identification of the pathologic antibodies. We describe a novel case of a patient with no signs of hemorrhage or thrombosis who was incidentally found to have both a FVIII inhibitor and LA during evaluation of a prolonged partial thromboplastin time (PTT). This finding resulted in FVIII inhibitor-directed management, including immunosuppressive therapy. The unique presentation of an incidental FVIII inhibitor and LA in an asymptomatic patient without thrombotic or bleeding complications highlights the potential challenge in elucidating the etiology of a prolonged PTT, as LAs and FVIII inhibitors both prolong the PTT, and each entity can interfere with assays designed to detect the presence of the other autoantibody. This case underscores the importance of recognizing that patients with major underlying disturbances in their hematologic physiology, but in whom clinical symptoms have yet to manifest, may potentially be overlooked until such symptoms are evident.
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Affiliation(s)
- Jeremy W Jacobs
- Department of Laboratory Medicine, Yale School of Medicine, 330 Cedar Street, New Haven, CT, 06520, USA.
| | - Savanah D Gisriel
- Departments of Laboratory Medicine and Pathology, Yale School of Medicine, New Haven, CT, USA
| | - Krishna Iyer
- Departments of Laboratory Medicine and Pathology, Yale School of Medicine, New Haven, CT, USA
| | - Henry M Rinder
- Department of Internal Medicine (Hematology) & Laboratory Medicine, Yale School of Medicine, New Haven, CT, USA
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7
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LeJeune A, Brock JE, Morgan EA, Kasten JL, Martei YM, Fadelu T, Rinder HM, Goulart R, Shulman LN, Milner DA. Harmonization of the Essentials: Matching Diagnostics to Treatments for Global Oncology. JCO Glob Oncol 2021; 6:1352-1356. [PMID: 32886559 PMCID: PMC7529511 DOI: 10.1200/go.20.00338] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Affiliation(s)
- Analise LeJeune
- Center for Global Health, American Society for Clinical Pathology, Chicago, IL
| | - Jane E Brock
- Department of Pathology, Brigham and Women's Hospital, Boston, MA.,Harvard Medical School, Boston, MA
| | - Elizabeth A Morgan
- Department of Pathology, Brigham and Women's Hospital, Boston, MA.,Harvard Medical School, Boston, MA
| | - Jennifer L Kasten
- Department of Pathology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Yehoda M Martei
- Department of Medicine, Division of Hematology-Oncology, University of Pennsylvania, Philadelphia, PA
| | | | | | - Robert Goulart
- New England Pathology Associates, Trinity Health of New England, Springfield, MA
| | - Lawrence N Shulman
- Department of Medicine, Division of Hematology-Oncology, University of Pennsylvania, Philadelphia, PA
| | - Danny A Milner
- Center for Global Health, American Society for Clinical Pathology, Chicago, IL.,Harvard Medical School, Boston, MA
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8
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Meizlish ML, Goshua G, Liu Y, Fine R, Amin K, Chang E, DeFilippo N, Keating C, Liu Y, Mankbadi M, McManus D, Wang SY, Price C, Bona RD, Ochoa Chaar CI, Chun HJ, Pine AB, Rinder HM, Siner JM, Neuberg DS, Owusu KA, Lee AI. Intermediate-dose anticoagulation, aspirin, and in-hospital mortality in COVID-19: A propensity score-matched analysis. Am J Hematol 2021; 96:471-479. [PMID: 33476420 PMCID: PMC8013588 DOI: 10.1002/ajh.26102] [Citation(s) in RCA: 108] [Impact Index Per Article: 36.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 01/18/2021] [Indexed: 02/06/2023]
Abstract
Thrombotic complications occur at high rates in hospitalized patients with COVID-19, yet the impact of intensive antithrombotic therapy on mortality is uncertain. We examined in-hospital mortality with intermediate- compared to prophylactic-dose anticoagulation, and separately with in-hospital aspirin compared to no antiplatelet therapy, in a large, retrospective study of 2785 hospitalized adult COVID-19 patients. In this analysis, we established two separate, nested cohorts of patients (a) who received intermediate- or prophylactic-dose anticoagulation ("anticoagulation cohort", N = 1624), or (b) who were not on home antiplatelet therapy and received either in-hospital aspirin or no antiplatelet therapy ("aspirin cohort", N = 1956). To minimize bias and adjust for confounding factors, we incorporated propensity score matching and multivariable regression utilizing various markers of illness severity and other patient-specific covariates, yielding treatment groups with well-balanced covariates in each cohort. The primary outcome was cumulative incidence of in-hospital death. Among propensity score-matched patients in the anticoagulation cohort (N = 382), in a multivariable regression model, intermediate- compared to prophylactic-dose anticoagulation was associated with a significantly lower cumulative incidence of in-hospital death (hazard ratio 0.518 [0.308-0.872]). Among propensity-score matched patients in the aspirin cohort (N = 638), in a multivariable regression model, in-hospital aspirin compared to no antiplatelet therapy was associated with a significantly lower cumulative incidence of in-hospital death (hazard ratio 0.522 [0.336-0.812]). In this propensity score-matched, observational study of COVID-19, intermediate-dose anticoagulation and aspirin were each associated with a lower cumulative incidence of in-hospital death.
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Affiliation(s)
| | - George Goshua
- Section of Hematology, Department of MedicineYale School of MedicineNew HavenConnecticutUSA
| | - Yiwen Liu
- Dana‐Farber Cancer InstituteBostonMassachusettsUSA
| | - Rebecca Fine
- Department of MedicineYale School of MedicineNew HavenConnecticutUSA
| | - Kejal Amin
- Department of PharmacyYale‐New Haven HospitalNew HavenConnecticutUSA
| | - Eric Chang
- Section of Hematology, Department of MedicineYale School of MedicineNew HavenConnecticutUSA
| | - Nicholas DeFilippo
- Department of PharmacyYale‐New Haven HospitalNew HavenConnecticutUSA
- School of PharmacyUniversity of ConnecticutStorrsConnecticutUSA
| | - Craig Keating
- Joint Data Analytics TeamYale New Haven HospitalNew HavenConnecticutUSA
| | - Yuxin Liu
- Section of Hematology, Department of MedicineYale School of MedicineNew HavenConnecticutUSA
| | - Michael Mankbadi
- Department of MedicineYale School of MedicineNew HavenConnecticutUSA
| | - Dayna McManus
- Department of PharmacyYale‐New Haven HospitalNew HavenConnecticutUSA
| | - Stephen Y. Wang
- Department of MedicineYale School of MedicineNew HavenConnecticutUSA
| | - Christina Price
- Section of Allergy and Immunology, Department of MedicineYale School of MedicineNew HavenConnecticutUSA
| | - Robert D. Bona
- Section of Hematology, Department of MedicineYale School of MedicineNew HavenConnecticutUSA
| | - Cassius Iyad Ochoa Chaar
- Section of Vascular Surgery, Department of SurgeryYale School of MedicineNew HavenConnecticutUSA
| | - Hyung J. Chun
- Section of Cardiology, Department of MedicineYale School of MedicineNew HavenConnecticutUSA
| | - Alexander B. Pine
- Section of Hematology, Department of MedicineYale School of MedicineNew HavenConnecticutUSA
| | - Henry M. Rinder
- Section of Hematology, Department of MedicineYale School of MedicineNew HavenConnecticutUSA
- Department of Laboratory MedicineYale School of MedicineNew HavenConnecticutUSA
| | - Jonathan M. Siner
- Section of Pulmonary, Critical Care, and Sleep Medicine, Department of MedicineYale School of MedicineNew HavenConnecticutUSA
| | | | - Kent A. Owusu
- Department of PharmacyYale‐New Haven HospitalNew HavenConnecticutUSA
- Clinical RedesignYale New Haven HealthNew HavenConnecticutUSA
| | - Alfred Ian Lee
- Section of Hematology, Department of MedicineYale School of MedicineNew HavenConnecticutUSA
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Meizlish ML, Pine AB, Bishai JD, Goshua G, Nadelmann ER, Simonov M, Chang CH, Zhang H, Shallow M, Bahel P, Owusu K, Yamamoto Y, Arora T, Atri DS, Patel A, Gbyli R, Kwan J, Won CH, Dela Cruz C, Price C, Koff J, King BA, Rinder HM, Wilson FP, Hwa J, Halene S, Damsky W, van Dijk D, Lee AI, Chun HJ. A neutrophil activation signature predicts critical illness and mortality in COVID-19. Blood Adv 2021; 5:1164-1177. [PMID: 33635335 PMCID: PMC7908851 DOI: 10.1182/bloodadvances.2020003568] [Citation(s) in RCA: 196] [Impact Index Per Article: 65.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 01/13/2021] [Indexed: 12/29/2022] Open
Abstract
Pathologic immune hyperactivation is emerging as a key feature of critical illness in COVID-19, but the mechanisms involved remain poorly understood. We carried out proteomic profiling of plasma from cross-sectional and longitudinal cohorts of hospitalized patients with COVID-19 and analyzed clinical data from our health system database of more than 3300 patients. Using a machine learning algorithm, we identified a prominent signature of neutrophil activation, including resistin, lipocalin-2, hepatocyte growth factor, interleukin-8, and granulocyte colony-stimulating factor, which were the strongest predictors of critical illness. Evidence of neutrophil activation was present on the first day of hospitalization in patients who would only later require transfer to the intensive care unit, thus preceding the onset of critical illness and predicting increased mortality. In the health system database, early elevations in developing and mature neutrophil counts also predicted higher mortality rates. Altogether, these data suggest a central role for neutrophil activation in the pathogenesis of severe COVID-19 and identify molecular markers that distinguish patients at risk of future clinical decompensation.
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Affiliation(s)
| | | | - Jason D Bishai
- Yale Cardiovascular Research Center, Section of Cardiovascular Medicine, Department of Internal Medicine, and
- Department of Microbial Pathogenesis, Yale School of Medicine, New Haven, CT
| | - George Goshua
- Section of Hematology, Department of Internal Medicine
| | | | - Michael Simonov
- Clinical and Translational Research Accelerator, Department of Internal Medicine
- Department of Dermatology, and
| | - C-Hong Chang
- Yale Cardiovascular Research Center, Section of Cardiovascular Medicine, Department of Internal Medicine, and
| | - Hanming Zhang
- Yale Cardiovascular Research Center, Section of Cardiovascular Medicine, Department of Internal Medicine, and
| | - Marcus Shallow
- Yale Cardiovascular Research Center, Section of Cardiovascular Medicine, Department of Internal Medicine, and
| | - Parveen Bahel
- Department of Laboratory Medicine, Yale School of Medicine, New Haven, CT
| | - Kent Owusu
- Department of Pharmacy, Yale New Haven Health System, New Haven, CT
| | - Yu Yamamoto
- Clinical and Translational Research Accelerator, Department of Internal Medicine
| | - Tanima Arora
- Clinical and Translational Research Accelerator, Department of Internal Medicine
| | - Deepak S Atri
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA; and
| | - Amisha Patel
- Section of Hematology, Department of Internal Medicine
| | - Rana Gbyli
- Section of Hematology, Department of Internal Medicine
| | - Jennifer Kwan
- Yale Cardiovascular Research Center, Section of Cardiovascular Medicine, Department of Internal Medicine, and
| | - Christine H Won
- Section of Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, and
| | - Charles Dela Cruz
- Section of Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, and
| | - Christina Price
- Section of Immunology, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Jonathan Koff
- Section of Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, and
| | - Brett A King
- Section of Immunology, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Henry M Rinder
- Section of Hematology, Department of Internal Medicine
- Department of Laboratory Medicine, Yale School of Medicine, New Haven, CT
| | - F Perry Wilson
- Clinical and Translational Research Accelerator, Department of Internal Medicine
| | - John Hwa
- Yale Cardiovascular Research Center, Section of Cardiovascular Medicine, Department of Internal Medicine, and
| | | | | | - David van Dijk
- Yale Cardiovascular Research Center, Section of Cardiovascular Medicine, Department of Internal Medicine, and
| | - Alfred I Lee
- Section of Hematology, Department of Internal Medicine
| | - Hyung J Chun
- Yale Cardiovascular Research Center, Section of Cardiovascular Medicine, Department of Internal Medicine, and
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10
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Zanetto A, Rinder HM, Senzolo M, Simioni P, Garcia‐Tsao G. Reduced Clot Stability by Thromboelastography as a Potential Indicator of Procedure-Related Bleeding in Decompensated Cirrhosis. Hepatol Commun 2021; 5:272-282. [PMID: 33553974 PMCID: PMC7850311 DOI: 10.1002/hep4.1641] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 10/10/2020] [Accepted: 10/27/2020] [Indexed: 02/06/2023] Open
Abstract
In patients with decompensated cirrhosis, procedure-related bleeding is a potentially lethal complication. Routine coagulation tests such as international normalized ratio and platelet count do not predict bleeding risk. We investigated whether thromboelastography (TEG) can identify patients with cirrhosis who are at risk of procedure-related bleeding. As a part of a prospective study on hemostasis in decompensated cirrhosis, patients had TEG performed on admission and were followed prospectively during hospitalization for the development of procedure-related bleeding. Eighty patients with cirrhosis were included. Among the 72 who had procedures performed, 7 had procedure-related bleeding, which was major in three cases (two following paracentesis and one following thoracentesis). Conventional coagulation tests were comparable between bleeding and nonbleeding patients, whereas TEG parameters of k-time (4.5 minutes vs. 2.2 minutes; P = 0.02), α-angle (34° vs. 59°; P = 0.003), and maximum amplitude (37 mm vs. 50 mm; P = 0.004) were significantly different (all indicative of hypocoagulability). TEG maximum amplitude (MA), a marker of overall clot stability, accurately discriminated between patients who had major, life-threatening bleeding (all with MA < 30 mm) and those who had mild or no bleeding (all with MA > 30 mm), whereas a platelet count < 50 × 109/L could not discriminate between bleeding (minor or major) and nonbleeding patients. Conclusion: In a prospective cohort of hospitalized patients with decompensated cirrhosis, TEG parameters associated with hypocoagulability appeared to predict procedure-related bleeding, particularly a TEG MA < 30 mm. If results are validated in a larger cohort, this could be a threshold to identify patients with decompensated cirrhosis at higher risk for procedure-related bleeding, in whom to consider preprocedural prophylaxis.
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Affiliation(s)
- Alberto Zanetto
- Digestive Disease SectionInternal MedicineYale School of MedicineNew HavenCTUSA
- VA‐Connecticut Healthcare SystemWest HavenCTUSA
- Gastroenterology and Multivisceral Transplant UnitDepartment of Surgery, Oncology, and GastroenterologyPadova University HospitalPadovaItaly
| | - Henry M. Rinder
- Laboratory MedicineYale School of MedicineNew HavenCTUSA
- HematologyInternal MedicineYale School of MedicineNew HavenCTUSA
| | - Marco Senzolo
- Gastroenterology and Multivisceral Transplant UnitDepartment of Surgery, Oncology, and GastroenterologyPadova University HospitalPadovaItaly
| | - Paolo Simioni
- Thrombotic and Hemorrhagic Diseases UnitGeneral Internal MedicinePadova University HospitalPadovaItaly
| | - Guadalupe Garcia‐Tsao
- Digestive Disease SectionInternal MedicineYale School of MedicineNew HavenCTUSA
- VA‐Connecticut Healthcare SystemWest HavenCTUSA
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11
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Meizlish ML, Goshua G, Liu Y, Fine R, Amin K, Chang E, DeFilippo N, Keating C, Liu Y, Mankbadi M, McManus D, Wang S, Price C, Bona RD, Chaar CIO, Chun HJ, Pine AB, Rinder HM, Siner J, Neuberg DS, Owusu KA, Lee AI. Intermediate-dose anticoagulation, aspirin, and in-hospital mortality in COVID-19: a propensity score-matched analysis. medRxiv 2021:2021.01.12.21249577. [PMID: 33469595 PMCID: PMC7814841 DOI: 10.1101/2021.01.12.21249577] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Background Thrombotic complications occur at high rates in hospitalized patients with COVID-19, yet the impact of intensive antithrombotic therapy on mortality is uncertain. Research Question How does in-hospital mortality compare with intermediate- versus prophylactic-dose anticoagulation, and separately with in-hospital aspirin versus no antiplatelet therapy, in treatment of COVID-19? Study Design and Methods Using data from 2785 hospitalized adult COVID-19 patients, we established two separate, nested cohorts of patients (1) who received intermediate- or prophylactic-dose anticoagulation ("anticoagulation cohort", N = 1624), or (2) who were not on home antiplatelet therapy and received either in-hospital aspirin or no antiplatelet therapy ("aspirin cohort", N = 1956). Propensity score matching utilizing various markers of illness severity and other patient-specific covariates yielded treatment groups with well-balanced covariates in each cohort. The primary outcome was cumulative incidence of in-hospital death. Results Among propensity score-matched patients in the anticoagulation cohort (N = 382), in a multivariable regression model, intermediate- compared to prophylactic-dose anticoagulation was associated with a significantly lower cumulative incidence of in-hospital death (hazard ratio 0.518 [0.308-0.872]). Among propensity-score matched patients in the aspirin cohort (N = 638), in a multivariable regression model, in-hospital aspirin compared to no antiplatelet therapy was associated with a significantly lower cumulative incidence of in-hospital death (hazard ratio 0.522 [0.336-0.812]). Interpretation In this propensity score-matched, observational study of COVID-19, intermediate-dose anticoagulation and aspirin were each associated with a lower cumulative incidence of in-hospital death.
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Affiliation(s)
| | - George Goshua
- Section of Hematology, Department of Medicine, Yale School of Medicine, New Haven, CT
| | - Yiwen Liu
- Dana-Farber Cancer Institute, Boston, MA
| | - Rebecca Fine
- Department of Medicine, Yale School of Medicine, New Haven, CT
| | - Kejal Amin
- Department of Pharmacy, Yale-New Haven Hospital, New Haven, CT
| | - Eric Chang
- Section of Hematology, Department of Medicine, Yale School of Medicine, New Haven, CT
| | - Nicholas DeFilippo
- Department of Pharmacy, Yale-New Haven Hospital, New Haven, CT
- School of Pharmacy, University of Connecticut, Storrs, CT
| | - Craig Keating
- Joint Data Analytics Team, Yale New Haven Hospital, New Haven, CT
| | - Yuxin Liu
- Section of Hematology, Department of Medicine, Yale School of Medicine, New Haven, CT
| | | | - Dayna McManus
- Department of Pharmacy, Yale-New Haven Hospital, New Haven, CT
| | - Stephen Wang
- Department of Medicine, Yale School of Medicine, New Haven, CT
| | - Christina Price
- Section of Allergy and Immunology, Department of Medicine, Yale School of Medicine, New Haven, CT
| | - Robert D. Bona
- Section of Hematology, Department of Medicine, Yale School of Medicine, New Haven, CT
| | | | - Hyung J. Chun
- Section of Cardiology, Department of Medicine, Yale School of Medicine, New Haven, CT
| | - Alexander B. Pine
- Section of Hematology, Department of Medicine, Yale School of Medicine, New Haven, CT
| | - Henry M. Rinder
- Section of Hematology, Department of Medicine, Yale School of Medicine, New Haven, CT
- Department of Laboratory Medicine, Yale School of Medicine, New Haven, CT
| | - Jonathan Siner
- Section of Pulmonary and Sleep Medicine, Department of Medicine, Yale School of Medicine, New Haven, CT
| | | | - Kent A. Owusu
- Department of Pharmacy, Yale-New Haven Hospital, New Haven, CT
- Clinical Redesign, Yale New Haven Health, New Haven, CT
| | - Alfred Ian Lee
- Section of Hematology, Department of Medicine, Yale School of Medicine, New Haven, CT
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12
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Olsen GM, Rinder HM, Tormey CA. De novo acquired hemophilia as an immune dysregulation phenomenon following SARS-CoV-2 infection. Transfusion 2021; 61:989-991. [PMID: 33368293 DOI: 10.1111/trf.16254] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 12/02/2020] [Accepted: 12/07/2020] [Indexed: 12/12/2022]
Affiliation(s)
- Gregory M Olsen
- Department of Laboratory Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Henry M Rinder
- Department of Laboratory Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Christopher A Tormey
- Department of Laboratory Medicine, Yale School of Medicine, New Haven, Connecticut, USA
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13
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Mendoza H, Tormey CA, Rinder HM, Howe JG, Siddon AJ. The utility and limitations of B- and T-cell gene rearrangement studies in evaluating lymphoproliferative disorders. Pathology 2020; 53:157-165. [PMID: 33358756 DOI: 10.1016/j.pathol.2020.09.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 08/05/2020] [Accepted: 09/10/2020] [Indexed: 12/16/2022]
Abstract
A hallmark of lymphoid malignancies is the presence of a monoclonal lymphocyte population. Monoclonality of B- and T-cell populations can be established through immunoglobulin (IG) or T-cell receptor (TCR) gene rearrangement analysis, respectively. The biological rationale of IG and TCR gene rearrangement analysis is that due to the extensive combinatorial repertoire made possible by V(D)J recombination in lymphocytes, it is unlikely that any substantive lymphocyte population would share the same IG or TCR gene rearrangement pattern unless there is an underlying neoplastic or reactive origin. Modern IG and TCR gene rearrangement analysis is typically performed by polymerase chain reaction (PCR) using commercially available primer sets followed by gel capillary electrophoresis. This process is highly sensitive in the detection of nearly all lymphoid malignancies. Several pitfalls and limitations, both biological and technical, apply to IG/TCR gene rearrangement analysis, but these can be minimised with high quality controls, performance of assays in duplicate, and adherence to strict criteria for interpreting and reporting results. Next generation sequencing (NGS) will likely replace PCR based methods of IG/TCR gene rearrangement analysis but is not yet widespread due to the absence of standardised protocols and multicentre validation.
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Affiliation(s)
- Hadrian Mendoza
- Department of Laboratory Medicine, Yale School of Medicine, New Haven, CT, USA
| | | | - Henry M Rinder
- Department of Laboratory Medicine, Yale School of Medicine, New Haven, CT, USA; Hematology Section, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - John G Howe
- Department of Laboratory Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Alexa J Siddon
- Department of Laboratory Medicine, Yale School of Medicine, New Haven, CT, USA; Department of Pathology, Yale School of Medicine, New Haven, CT, USA.
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14
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Wang SY, Chang CH, Meizlish ML, Bahel P, Rinder HM, Lee AI, Chun HJ. Changes in inflammatory and immune drivers in response to immunomodulatory therapies in COVID-19. medRxiv 2020:2020.12.23.20248547. [PMID: 33398292 PMCID: PMC7781335 DOI: 10.1101/2020.12.23.20248547] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
As the global community strives to discover effective therapies for COVID-19, immunomodulatory strategies have emerged as a leading contender to combat the cytokine storm and improve clinical outcomes in patients with severe disease. Systemic corticosteroids and selective cytokine inhibitory agents have been utilized both as empiric therapies and in clinical trials. While multiple randomized, placebo controlled trials have now demonstrated that corticosteroids improve survival in patients with COVID-19,1, 2 IL-6 inhibition, which gained significant early interest based on observational studies, has not demonstrated reliable efficacy in randomized, placebo controlled trials.3, 4 To better understand the mechanistic basis of immunomodulatory therapies being implemented for treatment of COVID-19, we assessed longitudinal biochemical changes in response to such approaches in hospitalized patients with COVID-19. We demonstrate broad suppression of multiple immunomodulatory factors associated with adverse clinical outcomes in COVID-19 in patients who received corticosteroids, but no such response was seen in patients who either received tocilizumab or no immunomodulatory therapy. Our findings provide early insights into molecular signatures that correlate with immunomodulatory therapies in COVID-19 which may be useful in understanding clinical outcomes in future studies of larger patient cohorts.
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Affiliation(s)
| | - C-Hong Chang
- Yale Cardiovascular Research Center, Section of Cardiovascular Medicine, New Haven, CT
| | | | | | | | | | - Hyung J. Chun
- Yale Cardiovascular Research Center, Section of Cardiovascular Medicine, New Haven, CT
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15
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Gupta GK, Hendrickson JE, Bahel P, Siddon AJ, Rinder HM, Tormey CA. Factor V activity in apheresis platelets: Implications for management of FV deficiency. Transfusion 2020; 61:405-409. [PMID: 33166428 DOI: 10.1111/trf.16179] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 08/04/2020] [Accepted: 09/29/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Allogeneic platelet (PLT) infusion is a strategy to raise Factor V (FV) levels in patients with congenital FV deficiency. However, since FV is labile in vitro, we hypothesized that FV activity could be low in PLT units. STUDY DESIGN AND METHODS FV activity was tested using a prothrombin time-based platform in the supernatant and platelet lysate (PL) of apheresis PLT units (16 units stored in PLT additive solution with acetate and phosphate [PAS-C] and 10 units stored in plasma only), on post-collection days 3-6. Statistical analysis was performed using Student's t test (P < .05). RESULTS FV activity was severely diminished in PAS-C PLTs (N = 16) supernatant (3.70% ± 1.02%) and PL (3.26% ± 1.02%). FV activity in plasma-only PLTs (N = 10) was lower in both supernatant (44.55% ± 6.46%) and lysate (39.67% ± 6.33%) relative to normal plasma levels, but both were significantly higher (P < .0001) compared to PAS-C PLTs. In a separate set of experiments, FV activity in PAS-C PLTs examined serially over storage time (N = 3 for these experiments) showed that FV levels were reduced by day 3 and not significantly different by day 5 of storage (Day 3 supernatant 5.03% ± 1.41%; Day 5 supernatant: 3.10% ± 0.57%; P = .2; Day 3 lysate: 3.89% ± 1.03%; Day 5 lysate: 2.61% ± 0.41%; P = .4). CONCLUSION Plasma should be considered over PLTs as first-line therapy for non-complex FV deficiency-associated hemorrhage. If PLTs are considered for transfusion, plasma-only PLT units should be preferentially utilized, as PAS-C PLT have near-absent FV activity.
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Affiliation(s)
- Gaurav K Gupta
- Department of Laboratory Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Jeanne E Hendrickson
- Department of Laboratory Medicine, Yale School of Medicine, New Haven, Connecticut, USA.,Department of Pediatrics, Yale School of Medicine, New Haven, Connecticut, USA
| | - Parveen Bahel
- Department of Laboratory Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Alexa J Siddon
- Department of Laboratory Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Henry M Rinder
- Department of Laboratory Medicine, Yale School of Medicine, New Haven, Connecticut, USA.,Department of Internal Medicine (Hematology), Yale School of Medicine, New Haven, Connecticut, USA
| | - Christopher A Tormey
- Department of Laboratory Medicine, Yale School of Medicine, New Haven, Connecticut, USA
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16
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Zanetto A, Rinder HM, Campello E, Saggiorato G, Deng Y, Ciarleglio M, Wilson FP, Senzolo M, Gavasso S, Bulato C, Simioni P, Garcia-Tsao G. Acute Kidney Injury in Decompensated Cirrhosis Is Associated With Both Hypo-coagulable and Hyper-coagulable Features. Hepatology 2020; 72:1327-1340. [PMID: 32614088 PMCID: PMC8672302 DOI: 10.1002/hep.31443] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 05/29/2020] [Accepted: 06/05/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Recent evidence suggests that acute kidney injury (AKI) is the main predictor of postparacentesis bleeding in patients with cirrhosis. To assess the factors responsible for bleeding tendency in AKI, we performed a prospective study comparing all three aspects of hemostasis (platelets, coagulation, and fibrinolysis) in patients with decompensated cirrhosis with and without AKI. APPROACH AND RESULTS Primary hemostasis assessment included platelet aggregation and secretion (platelet function markers) and von Willebrand factor. Secondary hemostasis assessment included pro-coagulant (factor VIII and factor XIII) and anti-coagulant (protein C, protein S, and antithrombin) factors and thrombin generation. Tertiary hemostasis assessment included fibrinolytic factors and plasmin-antiplasmin complex. Eighty patients with decompensated cirrhosis were recruited (40 each with and without AKI). Severity of cirrhosis and platelet count were comparable between groups. Median serum creatinine was 1.8 mg/dL and 0.8 mg/dL in patients with and without AKI, respectively. At baseline, patients with cirrhosis and AKI had lower platelet aggregation and secretion, indicative of impaired platelet function (increased bleeding tendency), without differences in von Willebrand factor. Regarding coagulation factors, factor VIII was higher, whereas protein C, protein S, and antithrombin were all lower, which, together with increased thrombin generation, indicate hypercoagulability. In contrast, factor XIII was lower in AKI (increased bleeding tendency). Finally, while both hypofibrinolytic and hyperfibrinolytic changes were present in AKI, a higher plasmin-antiplasmin complex indicated a hyperfibrinolytic state. After AKI resolution (n = 23 of 40), platelet function and coagulation improved to levels observed in patients with cirrhosis patients without AKI; however, fibrinolysis remained hyperactivated. CONCLUSIONS In patients with decompensated cirrhosis, AKI is associated with both hypocoagulable and hypercoagulable features that can potentially increase the risk of both bleeding and thrombosis.
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Affiliation(s)
- Alberto Zanetto
- Digestive Disease Section, Internal Medicine, Yale School of Medicine, New Haven, CT,VA-Connecticut Healthcare System, West Haven, CT,Gastroenterology and Multivisceral Transplant Unit, Department of Surgery, Oncology, and Gastroenterology, Padova University Hospital, Padova, Italy
| | - Henry M. Rinder
- Laboratory Medicine, Yale School of Medicine, New Haven, CT,Hematology, Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Elena Campello
- Thrombotic and Hemorrhagic Diseases Unit, General Internal Medicine, Padova University Hospital, Padova, Italy
| | - Graziella Saggiorato
- Thrombotic and Hemorrhagic Diseases Unit, General Internal Medicine, Padova University Hospital, Padova, Italy
| | - Yanhong Deng
- Yale Center for Analytical Sciences, Yale School of Public Health, New Haven, CT
| | - Maria Ciarleglio
- Yale Center for Analytical Sciences, Yale School of Public Health, New Haven, CT
| | - Francis P. Wilson
- Program of Applied Translational Research, Yale School of Medicine, New Haven, CT
| | - Marco Senzolo
- Gastroenterology and Multivisceral Transplant Unit, Department of Surgery, Oncology, and Gastroenterology, Padova University Hospital, Padova, Italy
| | - Sabrina Gavasso
- Thrombotic and Hemorrhagic Diseases Unit, General Internal Medicine, Padova University Hospital, Padova, Italy
| | - Cristiana Bulato
- Thrombotic and Hemorrhagic Diseases Unit, General Internal Medicine, Padova University Hospital, Padova, Italy
| | - Paolo Simioni
- Thrombotic and Hemorrhagic Diseases Unit, General Internal Medicine, Padova University Hospital, Padova, Italy
| | - Guadalupe Garcia-Tsao
- Digestive Disease Section, Internal Medicine, Yale School of Medicine, New Haven, CT,VA-Connecticut Healthcare System, West Haven, CT
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17
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Balbuena-Merle RI, Tormey CA, DiAdamo A, Rinder HM, Siddon AJ. Monocytic Acute Myeloid Leukemias with KM2TA Translocations to Chromosome 17q that May Clinically Mimic Acute Promyelocytic Leukemia. Lab Med 2020; 52:290-296. [PMID: 32984885 DOI: 10.1093/labmed/lmaa078] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE Acute promyelocytic leukemia (APL) with variant RARA translocation, eg, t(11;17), is not sensitive to all-trans retinoic acid and requires distinct chemotherapy. However, there are some leukemic entities that may mimic aspects of the clinical and/or laboratory picture of APL and cause confusion because of karyotype nomenclature. Therefore, recognition of such entities may be of therapeutic and prognostic significance. METHODS We present 2 cases of acute myeloid leukemia (AML) with t(11;17) that were clinically concerning for APL based primarily on clinical presentation but were ultimately diagnosed as AML with monocytic differentiation. RESULTS Both leukemias harbored KMT2A translocations, one located near but not involving RARA and the other with SEPT9. CONCLUSION In leukemias that clinically and/or immunophenotypically mimic APL, identification of specific gene translocations can lead to the correct diagnosis and may carry therapeutic/prognostic implications.
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Affiliation(s)
- Raisa I Balbuena-Merle
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, Connecticut.,Pathology and Laboratory Medicine Service, VA Connecticut Healthcare System, West Haven, Connecticut
| | - Christopher A Tormey
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, Connecticut
| | | | - Henry M Rinder
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, Connecticut.,Internal Medicine (Hematology), Yale University School of Medicine, New Haven, Connecticut
| | - Alexa J Siddon
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, Connecticut
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18
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Meizlish ML, Pine AB, Bishai JD, Goshua G, Nadelmann ER, Simonov M, Chang CH, Zhang H, Shallow M, Bahel P, Owusu K, Yamamoto Y, Arora T, Atri DS, Patel A, Gbyli R, Kwan J, Won CH, Dela Cruz C, Price C, Koff J, King BA, Rinder HM, Wilson FP, Hwa J, Halene S, Damsky W, van Dijk D, Lee AI, Chun H. A neutrophil activation signature predicts critical illness and mortality in COVID-19. medRxiv 2020. [PMID: 32908988 DOI: 10.1101/2020.09.01.20183897] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Pathologic immune hyperactivation is emerging as a key feature of critical illness in COVID-19, but the mechanisms involved remain poorly understood. We carried out proteomic profiling of plasma from cross-sectional and longitudinal cohorts of hospitalized patients with COVID-19 and analyzed clinical data from our health system database of over 3,300 patients. Using a machine learning algorithm, we identified a prominent signature of neutrophil activation, including resistin, lipocalin-2, HGF, IL-8, and G-CSF, as the strongest predictors of critical illness. Neutrophil activation was present on the first day of hospitalization in patients who would only later require transfer to the intensive care unit, thus preceding the onset of critical illness and predicting increased mortality. In the health system database, early elevations in developing and mature neutrophil counts also predicted higher mortality rates. Altogether, we define an essential role for neutrophil activation in the pathogenesis of severe COVID-19 and identify molecular neutrophil markers that distinguish patients at risk of future clinical decompensation.
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19
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Schulz WL, Rinder HM, Durant TJS, Tormey CA, Torres R, Smith BR, Hager KM, Howe JG, Siddon AJ. Impact of intra-tumoral heterogeneity detected by next-generation sequencing on acute myeloid leukemia survival. Leuk Lymphoma 2020; 61:3269-3271. [PMID: 32715805 DOI: 10.1080/10428194.2020.1797016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Wade L Schulz
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, CT, USA.,Center for Outcomes Research & Evaluation, Yale New Haven Hospital, New Haven, CT, USA
| | - Henry M Rinder
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Thomas J S Durant
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, CT, USA.,Center for Outcomes Research & Evaluation, Yale New Haven Hospital, New Haven, CT, USA
| | - Christopher A Tormey
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Richard Torres
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Brian R Smith
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Karl M Hager
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - John Greg Howe
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Alexa J Siddon
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, CT, USA.,Department of Pathology, Yale University School of Medicine, New Haven, CT, USA
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20
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Goshua G, Pine AB, Meizlish ML, Chang CH, Zhang H, Bahel P, Baluha A, Bar N, Bona RD, Burns AJ, Dela Cruz CS, Dumont A, Halene S, Hwa J, Koff J, Menninger H, Neparidze N, Price C, Siner JM, Tormey C, Rinder HM, Chun HJ, Lee AI. Endotheliopathy in COVID-19-associated coagulopathy: evidence from a single-centre, cross-sectional study. Lancet Haematol 2020; 7:e575-e582. [PMID: 32619411 PMCID: PMC7326446 DOI: 10.1016/s2352-3026(20)30216-7] [Citation(s) in RCA: 723] [Impact Index Per Article: 180.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 06/12/2020] [Accepted: 06/12/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND An important feature of severe acute respiratory syndrome coronavirus 2 pathogenesis is COVID-19-associated coagulopathy, characterised by increased thrombotic and microvascular complications. Previous studies have suggested a role for endothelial cell injury in COVID-19-associated coagulopathy. To determine whether endotheliopathy is involved in COVID-19-associated coagulopathy pathogenesis, we assessed markers of endothelial cell and platelet activation in critically and non-critically ill patients admitted to the hospital with COVID-19. METHODS In this single-centre cross-sectional study, hospitalised adult (≥18 years) patients with laboratory-confirmed COVID-19 were identified in the medical intensive care unit (ICU) or a specialised non-ICU COVID-19 floor in our hospital. Asymptomatic, non-hospitalised controls were recruited as a comparator group for biomarkers that did not have a reference range. We assessed markers of endothelial cell and platelet activation, including von Willebrand Factor (VWF) antigen, soluble thrombomodulin, soluble P-selectin, and soluble CD40 ligand, as well as coagulation factors, endogenous anticoagulants, and fibrinolytic enzymes. We compared the level of each marker in ICU patients, non-ICU patients, and controls, where applicable. We assessed correlations between these laboratory results with clinical outcomes, including hospital discharge and mortality. Kaplan-Meier analysis was used to further explore the association between biochemical markers and survival. FINDINGS 68 patients with COVID-19 were included in the study from April 13 to April 24, 2020, including 48 ICU and 20 non-ICU patients, as well as 13 non-hospitalised, asymptomatic controls. Markers of endothelial cell and platelet activation were significantly elevated in ICU patients compared with non-ICU patients, including VWF antigen (mean 565% [SD 199] in ICU patients vs 278% [133] in non-ICU patients; p<0·0001) and soluble P-selectin (15·9 ng/mL [4·8] vs 11·2 ng/mL [3·1]; p=0·0014). VWF antigen concentrations were also elevated above the normal range in 16 (80%) of 20 non-ICU patients. We found mortality to be significantly correlated with VWF antigen (r = 0·38; p=0·0022) and soluble thrombomodulin (r = 0·38; p=0·0078) among all patients. In all patients, soluble thrombomodulin concentrations greater than 3·26 ng/mL were associated with lower rates of hospital discharge (22 [88%] of 25 patients with low concentrations vs 13 [52%] of 25 patients with high concentrations; p=0·0050) and lower likelihood of survival on Kaplan-Meier analysis (hazard ratio 5·9, 95% CI 1·9-18·4; p=0·0087). INTERPRETATION Our findings show that endotheliopathy is present in COVID-19 and is likely to be associated with critical illness and death. Early identification of endotheliopathy and strategies to mitigate its progression might improve outcomes in COVID-19. FUNDING This work was supported by a gift donation from Jack Levin to the Benign Hematology programme at Yale, and the National Institutes of Health.
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Affiliation(s)
| | | | | | - C-Hong Chang
- Yale Cardiovascular Research Center, Section of Cardiovascular Medicine, New Haven, CT, USA
| | - Hanming Zhang
- Yale Cardiovascular Research Center, Section of Cardiovascular Medicine, New Haven, CT, USA
| | - Parveen Bahel
- Department of Laboratory Medicine, New Haven, CT, USA
| | | | - Noffar Bar
- Section of Hematology, New Haven, CT, USA
| | | | | | | | | | | | - John Hwa
- Yale Cardiovascular Research Center, Section of Cardiovascular Medicine, New Haven, CT, USA
| | - Jonathan Koff
- Section of Pulmonary, Critical Care, and Sleep Medicine, New Haven, CT, USA
| | | | | | | | - Jonathan M Siner
- Section of Pulmonary, Critical Care, and Sleep Medicine, New Haven, CT, USA
| | | | | | - Hyung J Chun
- Yale Cardiovascular Research Center, Section of Cardiovascular Medicine, New Haven, CT, USA
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21
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Affiliation(s)
- Richard Torres
- Yale University School of Medicine, Department of Laboratory Medicine
| | - Henry M Rinder
- Yale University School of Medicine, Department of Laboratory Medicine
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22
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Affiliation(s)
- Richard Torres
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, CT
| | - Henry M Rinder
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, CT
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23
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Chen PP, Tormey CA, Eisenbarth SC, Torres R, Richardson SS, Rinder HM, Smith BR, Siddon AJ. False-Positive Light Chain Clonal Restriction by Flow Cytometry in Patients Treated With Alemtuzumab: Potential Pitfalls for the Misdiagnosis of B-Cell Neoplasms. Am J Clin Pathol 2019; 151:154-163. [PMID: 30307483 DOI: 10.1093/ajcp/aqy129] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Objectives To increase awareness of potential diagnostic test interference associated with alemtuzumab, which is a therapeutic immunoglobulin G1 κ monoclonal antibody used in hematologic malignancies, autoimmune diseases, and transplant-related disorders. Methods Bone marrow and blood from patients with T-cell prolymphocytic leukemia treated with alemtuzumab were evaluated by flow cytometry. Healthy donor blood was analyzed with or without in vitro treatment with alemtuzumab for comparison. Results Immunophenotypic analysis of bone marrow collected 4 weeks after alemtuzumab treatment demonstrated artifactual surface κ light chain restriction in CD19+ B cells and CD3+ T cells. Similar findings were observed in blood from another patient in a specimen collected 3 days after alemtuzumab treatment. These findings were recapitulated in healthy donor blood incubated with alemtuzumab. Conclusions Alemtuzumab can produce direct interference during flow cytometry analysis, resulting in false-positive evidence of light chain clonality. Clinicians and laboratorians should be cognizant of this risk to avoid misdiagnosis of B-cell neoplasms.
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Affiliation(s)
- Peter P Chen
- Department of Pathology, Yale School of Medicine, New Haven, CT
- Department of Laboratory Medicine, Yale School of Medicine, New Haven, CT
| | - Christopher A Tormey
- Department of Laboratory Medicine, Yale School of Medicine, New Haven, CT
- Pathology and Laboratory Medicine Service, VA Connecticut Healthcare System, West Haven
| | | | - Richard Torres
- Department of Laboratory Medicine, Yale School of Medicine, New Haven, CT
| | - Susan S Richardson
- Department of Laboratory Medicine, Yale School of Medicine, New Haven, CT
| | - Henry M Rinder
- Department of Laboratory Medicine, Yale School of Medicine, New Haven, CT
| | - Brian R Smith
- Department of Laboratory Medicine, Yale School of Medicine, New Haven, CT
| | - Alexa J Siddon
- Department of Pathology, Yale School of Medicine, New Haven, CT
- Department of Laboratory Medicine, Yale School of Medicine, New Haven, CT
- Pathology and Laboratory Medicine Service, VA Connecticut Healthcare System, West Haven
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Haspel RL, Ali AM, Huang GC, Smith MH, Atkinson JB, Chabot-Richards DS, Elliott RM, Kaul KL, Powell SZ, Rao A, Rinder HM, Vanderbilt CM, Wilcox R. Teaching Genomic Pathology: Translating Team-Based Learning to a Virtual Environment Using Computer-Based Simulation. Arch Pathol Lab Med 2018; 143:513-517. [PMID: 30500295 DOI: 10.5858/arpa.2018-0153-oa] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
CONTEXT.— Developing skills related to use of computer-based tools is critical for practicing genomic pathology. However, given the relative novelty of genomics education, residency programs may lack faculty members with adequate expertise and/or time to implement training. A virtual team-based learning (TBL) environment would make genomic pathology education available to more trainees. OBJECTIVE.— To translate an extensively implemented in-person TBL genomic pathology workshop into a virtual environment and to evaluate both knowledge and skill acquisition. DESIGN.— Using a novel interactive simulation approach, online modules were developed translating aspects of the TBL experience into the virtual environment with a goal of acquisition of necessary computer-related skills. The modules were evaluated at 10 postgraduate pathology training programs using a pre-post test design with participants deidentified. A postmodule anonymous survey obtained participant feedback on module quality and efficacy. RESULTS.— There were 147 trainees who received an email request to voluntarily participate in the study. Of these, 43 trainees completed the pretest and 15 (35%) subsequently completed the posttest. Mean overall scores were 45% on the pretest compared with 70% on the posttest ( P < .001; effect size = 1.4). Posttest improvement of results was similar for questions testing acquisition of knowledge versus skills. Regarding the 19 participants who took the survey, 18 (95%) would recommend the modules to others and believed they met the stated objectives. CONCLUSIONS.— A simulation-based approach allows motivated pathology trainees to acquire computer-related skills for practicing genomic pathology. Future work can explore efficacy in a nonvoluntary setting and adaptation to different specialties, learners, and computer tools.
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Affiliation(s)
- Richard L Haspel
- From the Departments of Pathology (Dr Haspel) and Medicine (Dr Huang), Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts; the American Society for Clinical Pathology, Chicago, Illinois (Dr Ali and Mr Smith); the Department of Pathology, Microbiology, and Immunology, Vanderbilt University School of Medicine, Nashville, Tennessee (Dr Atkinson); the Department of Pathology, TriCore Reference Laboratories and the University of New Mexico, Albuquerque (Dr Chabot-Richards); the Department of Pathology, UH Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, Ohio (Dr Elliott); the Department of Pathology, NorthShore University HealthSystem and the University of Chicago Pritzker School of Medicine, Evanston, Illinois (Dr Kaul); the Department of Pathology and Genomic Medicine, Houston Methodist Hospital and Weill Cornell Medical College, Houston, Texas (Dr Powell); Baylor Scott and White Central Region Pathology and Texas A&M Medical School, Temple (Dr Rao); the Department of Laboratory Medicine, Yale School of Medicine, New Haven, Connecticut (Dr Rinder); the Department of Pathology, Memorial Sloan-Kettering Cancer Center, New York, New York (Dr Vanderbilt); and the Department of Pathology and Laboratory Medicine, Larner College of Medicine and University of Vermont Medical Center, Burlington (Dr Wilcox). Dr Ali is now with AA Associates, Oak Park, Illinois. Mr Smith is now with Intracon Spain, Barcelona, Spain
| | - Asma M Ali
- From the Departments of Pathology (Dr Haspel) and Medicine (Dr Huang), Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts; the American Society for Clinical Pathology, Chicago, Illinois (Dr Ali and Mr Smith); the Department of Pathology, Microbiology, and Immunology, Vanderbilt University School of Medicine, Nashville, Tennessee (Dr Atkinson); the Department of Pathology, TriCore Reference Laboratories and the University of New Mexico, Albuquerque (Dr Chabot-Richards); the Department of Pathology, UH Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, Ohio (Dr Elliott); the Department of Pathology, NorthShore University HealthSystem and the University of Chicago Pritzker School of Medicine, Evanston, Illinois (Dr Kaul); the Department of Pathology and Genomic Medicine, Houston Methodist Hospital and Weill Cornell Medical College, Houston, Texas (Dr Powell); Baylor Scott and White Central Region Pathology and Texas A&M Medical School, Temple (Dr Rao); the Department of Laboratory Medicine, Yale School of Medicine, New Haven, Connecticut (Dr Rinder); the Department of Pathology, Memorial Sloan-Kettering Cancer Center, New York, New York (Dr Vanderbilt); and the Department of Pathology and Laboratory Medicine, Larner College of Medicine and University of Vermont Medical Center, Burlington (Dr Wilcox). Dr Ali is now with AA Associates, Oak Park, Illinois. Mr Smith is now with Intracon Spain, Barcelona, Spain
| | - Grace C Huang
- From the Departments of Pathology (Dr Haspel) and Medicine (Dr Huang), Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts; the American Society for Clinical Pathology, Chicago, Illinois (Dr Ali and Mr Smith); the Department of Pathology, Microbiology, and Immunology, Vanderbilt University School of Medicine, Nashville, Tennessee (Dr Atkinson); the Department of Pathology, TriCore Reference Laboratories and the University of New Mexico, Albuquerque (Dr Chabot-Richards); the Department of Pathology, UH Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, Ohio (Dr Elliott); the Department of Pathology, NorthShore University HealthSystem and the University of Chicago Pritzker School of Medicine, Evanston, Illinois (Dr Kaul); the Department of Pathology and Genomic Medicine, Houston Methodist Hospital and Weill Cornell Medical College, Houston, Texas (Dr Powell); Baylor Scott and White Central Region Pathology and Texas A&M Medical School, Temple (Dr Rao); the Department of Laboratory Medicine, Yale School of Medicine, New Haven, Connecticut (Dr Rinder); the Department of Pathology, Memorial Sloan-Kettering Cancer Center, New York, New York (Dr Vanderbilt); and the Department of Pathology and Laboratory Medicine, Larner College of Medicine and University of Vermont Medical Center, Burlington (Dr Wilcox). Dr Ali is now with AA Associates, Oak Park, Illinois. Mr Smith is now with Intracon Spain, Barcelona, Spain
| | - Matt H Smith
- From the Departments of Pathology (Dr Haspel) and Medicine (Dr Huang), Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts; the American Society for Clinical Pathology, Chicago, Illinois (Dr Ali and Mr Smith); the Department of Pathology, Microbiology, and Immunology, Vanderbilt University School of Medicine, Nashville, Tennessee (Dr Atkinson); the Department of Pathology, TriCore Reference Laboratories and the University of New Mexico, Albuquerque (Dr Chabot-Richards); the Department of Pathology, UH Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, Ohio (Dr Elliott); the Department of Pathology, NorthShore University HealthSystem and the University of Chicago Pritzker School of Medicine, Evanston, Illinois (Dr Kaul); the Department of Pathology and Genomic Medicine, Houston Methodist Hospital and Weill Cornell Medical College, Houston, Texas (Dr Powell); Baylor Scott and White Central Region Pathology and Texas A&M Medical School, Temple (Dr Rao); the Department of Laboratory Medicine, Yale School of Medicine, New Haven, Connecticut (Dr Rinder); the Department of Pathology, Memorial Sloan-Kettering Cancer Center, New York, New York (Dr Vanderbilt); and the Department of Pathology and Laboratory Medicine, Larner College of Medicine and University of Vermont Medical Center, Burlington (Dr Wilcox). Dr Ali is now with AA Associates, Oak Park, Illinois. Mr Smith is now with Intracon Spain, Barcelona, Spain
| | - James B Atkinson
- From the Departments of Pathology (Dr Haspel) and Medicine (Dr Huang), Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts; the American Society for Clinical Pathology, Chicago, Illinois (Dr Ali and Mr Smith); the Department of Pathology, Microbiology, and Immunology, Vanderbilt University School of Medicine, Nashville, Tennessee (Dr Atkinson); the Department of Pathology, TriCore Reference Laboratories and the University of New Mexico, Albuquerque (Dr Chabot-Richards); the Department of Pathology, UH Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, Ohio (Dr Elliott); the Department of Pathology, NorthShore University HealthSystem and the University of Chicago Pritzker School of Medicine, Evanston, Illinois (Dr Kaul); the Department of Pathology and Genomic Medicine, Houston Methodist Hospital and Weill Cornell Medical College, Houston, Texas (Dr Powell); Baylor Scott and White Central Region Pathology and Texas A&M Medical School, Temple (Dr Rao); the Department of Laboratory Medicine, Yale School of Medicine, New Haven, Connecticut (Dr Rinder); the Department of Pathology, Memorial Sloan-Kettering Cancer Center, New York, New York (Dr Vanderbilt); and the Department of Pathology and Laboratory Medicine, Larner College of Medicine and University of Vermont Medical Center, Burlington (Dr Wilcox). Dr Ali is now with AA Associates, Oak Park, Illinois. Mr Smith is now with Intracon Spain, Barcelona, Spain
| | - Devon S Chabot-Richards
- From the Departments of Pathology (Dr Haspel) and Medicine (Dr Huang), Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts; the American Society for Clinical Pathology, Chicago, Illinois (Dr Ali and Mr Smith); the Department of Pathology, Microbiology, and Immunology, Vanderbilt University School of Medicine, Nashville, Tennessee (Dr Atkinson); the Department of Pathology, TriCore Reference Laboratories and the University of New Mexico, Albuquerque (Dr Chabot-Richards); the Department of Pathology, UH Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, Ohio (Dr Elliott); the Department of Pathology, NorthShore University HealthSystem and the University of Chicago Pritzker School of Medicine, Evanston, Illinois (Dr Kaul); the Department of Pathology and Genomic Medicine, Houston Methodist Hospital and Weill Cornell Medical College, Houston, Texas (Dr Powell); Baylor Scott and White Central Region Pathology and Texas A&M Medical School, Temple (Dr Rao); the Department of Laboratory Medicine, Yale School of Medicine, New Haven, Connecticut (Dr Rinder); the Department of Pathology, Memorial Sloan-Kettering Cancer Center, New York, New York (Dr Vanderbilt); and the Department of Pathology and Laboratory Medicine, Larner College of Medicine and University of Vermont Medical Center, Burlington (Dr Wilcox). Dr Ali is now with AA Associates, Oak Park, Illinois. Mr Smith is now with Intracon Spain, Barcelona, Spain
| | - Robin M Elliott
- From the Departments of Pathology (Dr Haspel) and Medicine (Dr Huang), Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts; the American Society for Clinical Pathology, Chicago, Illinois (Dr Ali and Mr Smith); the Department of Pathology, Microbiology, and Immunology, Vanderbilt University School of Medicine, Nashville, Tennessee (Dr Atkinson); the Department of Pathology, TriCore Reference Laboratories and the University of New Mexico, Albuquerque (Dr Chabot-Richards); the Department of Pathology, UH Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, Ohio (Dr Elliott); the Department of Pathology, NorthShore University HealthSystem and the University of Chicago Pritzker School of Medicine, Evanston, Illinois (Dr Kaul); the Department of Pathology and Genomic Medicine, Houston Methodist Hospital and Weill Cornell Medical College, Houston, Texas (Dr Powell); Baylor Scott and White Central Region Pathology and Texas A&M Medical School, Temple (Dr Rao); the Department of Laboratory Medicine, Yale School of Medicine, New Haven, Connecticut (Dr Rinder); the Department of Pathology, Memorial Sloan-Kettering Cancer Center, New York, New York (Dr Vanderbilt); and the Department of Pathology and Laboratory Medicine, Larner College of Medicine and University of Vermont Medical Center, Burlington (Dr Wilcox). Dr Ali is now with AA Associates, Oak Park, Illinois. Mr Smith is now with Intracon Spain, Barcelona, Spain
| | - Karen L Kaul
- From the Departments of Pathology (Dr Haspel) and Medicine (Dr Huang), Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts; the American Society for Clinical Pathology, Chicago, Illinois (Dr Ali and Mr Smith); the Department of Pathology, Microbiology, and Immunology, Vanderbilt University School of Medicine, Nashville, Tennessee (Dr Atkinson); the Department of Pathology, TriCore Reference Laboratories and the University of New Mexico, Albuquerque (Dr Chabot-Richards); the Department of Pathology, UH Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, Ohio (Dr Elliott); the Department of Pathology, NorthShore University HealthSystem and the University of Chicago Pritzker School of Medicine, Evanston, Illinois (Dr Kaul); the Department of Pathology and Genomic Medicine, Houston Methodist Hospital and Weill Cornell Medical College, Houston, Texas (Dr Powell); Baylor Scott and White Central Region Pathology and Texas A&M Medical School, Temple (Dr Rao); the Department of Laboratory Medicine, Yale School of Medicine, New Haven, Connecticut (Dr Rinder); the Department of Pathology, Memorial Sloan-Kettering Cancer Center, New York, New York (Dr Vanderbilt); and the Department of Pathology and Laboratory Medicine, Larner College of Medicine and University of Vermont Medical Center, Burlington (Dr Wilcox). Dr Ali is now with AA Associates, Oak Park, Illinois. Mr Smith is now with Intracon Spain, Barcelona, Spain
| | - Suzanne Z Powell
- From the Departments of Pathology (Dr Haspel) and Medicine (Dr Huang), Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts; the American Society for Clinical Pathology, Chicago, Illinois (Dr Ali and Mr Smith); the Department of Pathology, Microbiology, and Immunology, Vanderbilt University School of Medicine, Nashville, Tennessee (Dr Atkinson); the Department of Pathology, TriCore Reference Laboratories and the University of New Mexico, Albuquerque (Dr Chabot-Richards); the Department of Pathology, UH Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, Ohio (Dr Elliott); the Department of Pathology, NorthShore University HealthSystem and the University of Chicago Pritzker School of Medicine, Evanston, Illinois (Dr Kaul); the Department of Pathology and Genomic Medicine, Houston Methodist Hospital and Weill Cornell Medical College, Houston, Texas (Dr Powell); Baylor Scott and White Central Region Pathology and Texas A&M Medical School, Temple (Dr Rao); the Department of Laboratory Medicine, Yale School of Medicine, New Haven, Connecticut (Dr Rinder); the Department of Pathology, Memorial Sloan-Kettering Cancer Center, New York, New York (Dr Vanderbilt); and the Department of Pathology and Laboratory Medicine, Larner College of Medicine and University of Vermont Medical Center, Burlington (Dr Wilcox). Dr Ali is now with AA Associates, Oak Park, Illinois. Mr Smith is now with Intracon Spain, Barcelona, Spain
| | - Arundhati Rao
- From the Departments of Pathology (Dr Haspel) and Medicine (Dr Huang), Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts; the American Society for Clinical Pathology, Chicago, Illinois (Dr Ali and Mr Smith); the Department of Pathology, Microbiology, and Immunology, Vanderbilt University School of Medicine, Nashville, Tennessee (Dr Atkinson); the Department of Pathology, TriCore Reference Laboratories and the University of New Mexico, Albuquerque (Dr Chabot-Richards); the Department of Pathology, UH Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, Ohio (Dr Elliott); the Department of Pathology, NorthShore University HealthSystem and the University of Chicago Pritzker School of Medicine, Evanston, Illinois (Dr Kaul); the Department of Pathology and Genomic Medicine, Houston Methodist Hospital and Weill Cornell Medical College, Houston, Texas (Dr Powell); Baylor Scott and White Central Region Pathology and Texas A&M Medical School, Temple (Dr Rao); the Department of Laboratory Medicine, Yale School of Medicine, New Haven, Connecticut (Dr Rinder); the Department of Pathology, Memorial Sloan-Kettering Cancer Center, New York, New York (Dr Vanderbilt); and the Department of Pathology and Laboratory Medicine, Larner College of Medicine and University of Vermont Medical Center, Burlington (Dr Wilcox). Dr Ali is now with AA Associates, Oak Park, Illinois. Mr Smith is now with Intracon Spain, Barcelona, Spain
| | - Henry M Rinder
- From the Departments of Pathology (Dr Haspel) and Medicine (Dr Huang), Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts; the American Society for Clinical Pathology, Chicago, Illinois (Dr Ali and Mr Smith); the Department of Pathology, Microbiology, and Immunology, Vanderbilt University School of Medicine, Nashville, Tennessee (Dr Atkinson); the Department of Pathology, TriCore Reference Laboratories and the University of New Mexico, Albuquerque (Dr Chabot-Richards); the Department of Pathology, UH Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, Ohio (Dr Elliott); the Department of Pathology, NorthShore University HealthSystem and the University of Chicago Pritzker School of Medicine, Evanston, Illinois (Dr Kaul); the Department of Pathology and Genomic Medicine, Houston Methodist Hospital and Weill Cornell Medical College, Houston, Texas (Dr Powell); Baylor Scott and White Central Region Pathology and Texas A&M Medical School, Temple (Dr Rao); the Department of Laboratory Medicine, Yale School of Medicine, New Haven, Connecticut (Dr Rinder); the Department of Pathology, Memorial Sloan-Kettering Cancer Center, New York, New York (Dr Vanderbilt); and the Department of Pathology and Laboratory Medicine, Larner College of Medicine and University of Vermont Medical Center, Burlington (Dr Wilcox). Dr Ali is now with AA Associates, Oak Park, Illinois. Mr Smith is now with Intracon Spain, Barcelona, Spain
| | - Chad M Vanderbilt
- From the Departments of Pathology (Dr Haspel) and Medicine (Dr Huang), Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts; the American Society for Clinical Pathology, Chicago, Illinois (Dr Ali and Mr Smith); the Department of Pathology, Microbiology, and Immunology, Vanderbilt University School of Medicine, Nashville, Tennessee (Dr Atkinson); the Department of Pathology, TriCore Reference Laboratories and the University of New Mexico, Albuquerque (Dr Chabot-Richards); the Department of Pathology, UH Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, Ohio (Dr Elliott); the Department of Pathology, NorthShore University HealthSystem and the University of Chicago Pritzker School of Medicine, Evanston, Illinois (Dr Kaul); the Department of Pathology and Genomic Medicine, Houston Methodist Hospital and Weill Cornell Medical College, Houston, Texas (Dr Powell); Baylor Scott and White Central Region Pathology and Texas A&M Medical School, Temple (Dr Rao); the Department of Laboratory Medicine, Yale School of Medicine, New Haven, Connecticut (Dr Rinder); the Department of Pathology, Memorial Sloan-Kettering Cancer Center, New York, New York (Dr Vanderbilt); and the Department of Pathology and Laboratory Medicine, Larner College of Medicine and University of Vermont Medical Center, Burlington (Dr Wilcox). Dr Ali is now with AA Associates, Oak Park, Illinois. Mr Smith is now with Intracon Spain, Barcelona, Spain
| | - Rebecca Wilcox
- From the Departments of Pathology (Dr Haspel) and Medicine (Dr Huang), Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts; the American Society for Clinical Pathology, Chicago, Illinois (Dr Ali and Mr Smith); the Department of Pathology, Microbiology, and Immunology, Vanderbilt University School of Medicine, Nashville, Tennessee (Dr Atkinson); the Department of Pathology, TriCore Reference Laboratories and the University of New Mexico, Albuquerque (Dr Chabot-Richards); the Department of Pathology, UH Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, Ohio (Dr Elliott); the Department of Pathology, NorthShore University HealthSystem and the University of Chicago Pritzker School of Medicine, Evanston, Illinois (Dr Kaul); the Department of Pathology and Genomic Medicine, Houston Methodist Hospital and Weill Cornell Medical College, Houston, Texas (Dr Powell); Baylor Scott and White Central Region Pathology and Texas A&M Medical School, Temple (Dr Rao); the Department of Laboratory Medicine, Yale School of Medicine, New Haven, Connecticut (Dr Rinder); the Department of Pathology, Memorial Sloan-Kettering Cancer Center, New York, New York (Dr Vanderbilt); and the Department of Pathology and Laboratory Medicine, Larner College of Medicine and University of Vermont Medical Center, Burlington (Dr Wilcox). Dr Ali is now with AA Associates, Oak Park, Illinois. Mr Smith is now with Intracon Spain, Barcelona, Spain
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Chandler JB, Siddon AJ, Bahel P, Torres R, Rinder HM, Tormey CA. Modified approach to fibrinogen replacement in the setting of dysfibrinogenaemia. J Clin Pathol 2018; 72:177-180. [DOI: 10.1136/jclinpath-2018-205438] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Revised: 10/12/2018] [Accepted: 10/16/2018] [Indexed: 11/03/2022]
Abstract
Most fibrinogen replacement strategies focus on quantitative deficiencies. A thrombin time (TT) mixing study helped to assess qualitative defects caused by dysfibrinogens. Plasma samples were collected from non-anticoagulated subjects (n=6) meeting laboratory criteria for suspected dysfibrinogenaemia (TT > 22 s; fibrinogen activity <180) and from a control group. TT mixing studies were performed on subject plasma with increasing volumes of pooled normal plasma at 1:2, 1:4 and 1:5 dilutions. No subjects with dysfibrinogenaemia demonstrated a complete TT correction at 1:2, but 50% corrected at 1:4 and 100% at 1:5 dilution. Based on these data, a correction factor (CF), defined as the reciprocal dilution yielding complete correction, was incorporated into our clinical practice formula for fibrinogen dosing in patients with dysfibrinogenaemias. Our study incorporates TT mixing studies for assessment of dysfibrinogens. The addition of a mix-derived CF to classical formulae may better approximate dosing in patients with dysfibrinogenaemia.
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Rinder HM, Tracey JL, Rinder CS, Leitenberg D, Smith BR. Neutrophil but not Monocyte Activation Inhibits P-Selectin-Mediated Platelet Adhesion. Thromb Haemost 2018. [DOI: 10.1055/s-0038-1648953] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
SummarySelectins are Ca2+-dependent glycoprotein receptors that mediate the adhesion of activated platelets or endothelial cells to unstimulated leukocytes. Using purified cell fractions, we examined activated neutrophil adhesion to P-selectin-expressing platelets and found that phorbol 12-myristate 13-acetate (PMA), platelet activating factor C16 (PAF), and n-formyl-met-leu-phe (fMLP) pretreatment of neutrophils inhibited activated platelet adhesion. Furthermore, PMA and PAF were capable of dissociating established resting neutrophil-activated platelet conjugates. Since L-selectin is downregulated after leukocyte activation and has been postulated as a ligand for P-selectin, we preincubated resting neutrophils with Dreg-2 and Dreg-56, blocking monoclonal antibodies (MoAb) to L-selectin; these MoAb failed to inhibit activated platelet adhesion. To more closely approximate in vivo conditions of leukocyte and platelet activation, we also employed a whole blood (WB) model of leukocyte-platelet adhesion. We found that simultaneous activation of both platelets and leukocytes by PMA caused an immediate rise in the % of P-selectin-positive platelets accompanied by a rapid increase in monocyte-platelet and neutrophil-platelet conjugates; however, the % of neutrophil-platelet conjugates subsequently declined over 30-60 min to baseline levels while monocyte-platelet adhesion remained elevated over 90 min. By contrast, selective platelet activation in WB by thrombin resulted in an increase in platelet P-selectin expression accompanied by a sustained (90 min) elevation in both monocyte- and neutrophil-platelet conjugates. This increase in leukocyte-platelet conjugates after thrombin was not inhibited by preincubation of WB with Dreg-2 or Dreg-56. We conclude that neutrophil activation decreases the expression of the ligand for platelet P-selectin within 30-60 min resulting in inhibition of neutrophil-platelet adhesion and dissociation of existing neutrophil-platelet conjugates. By contrast, monocyte activation over 90 min does not affect monocyte adhesion to activated platelets in whole blood.
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Affiliation(s)
- Henry M Rinder
- The Departments of Laboratory Medicine and Anesthesiology, Yale University School of Medicine, New Haven, CT, USA
| | - Jayne L Tracey
- The Departments of Laboratory Medicine and Anesthesiology, Yale University School of Medicine, New Haven, CT, USA
| | - Christine S Rinder
- The Departments of Laboratory Medicine and Anesthesiology, Yale University School of Medicine, New Haven, CT, USA
| | - David Leitenberg
- The Departments of Laboratory Medicine and Anesthesiology, Yale University School of Medicine, New Haven, CT, USA
| | - Brian R Smith
- The Departments of Laboratory Medicine and Anesthesiology, Yale University School of Medicine, New Haven, CT, USA
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Esposito CJ, Popescu WM, Rinder HM, Schwartz JJ, Smith BR, Rinder CS. Increased leukocyte-platelet adhesion in patients with graft occlusion after peripheral vascular surgery. Thromb Haemost 2017; 90:1128-34. [PMID: 14652647 DOI: 10.1160/th03-04-0226] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
SummaryGraft occlusion following peripheral vascular surgery is attributable to some combination of acute thrombosis, and progression of atherosclerosis: interactions between leukocytes and activated platelets may play a role in both of these processes. This investigation measured perioperative leukocyte-platelet conjugate formation, and leukocyte and platelet activation in 46 patients undergoing surgery for lower extremity peripheral vascular disease (PVD). All patients were followed for graft patency over the next 6 months; 27 patients had grafts that remained patent while 19 had graft occlusion. On postoperative day #1 (POD#1), the graft occlusion group demonstrated a significantly greater increase in circulating levels of both mono-cyteplatelet and neutrophil (PMN)-platelet conjugates compared to the patent graft patients (p=0.015 and 0.018, respectively). PMN activation, assessed by increases in surface CD11b expression, was also significantly increased on POD#1 in the graft occlusion group compared to the patent group (p=0.026). The percentage of circulating activated (CD62P+) platelets did not differ between groups, but patients with graft occlusion demonstrated a higher percentage of younger, reticulated platelets throughout the study period (p=0.008), indicating increased platelet turnover.We conclude that in the early postoperative period, leukocyte-platelet adhesion, PMN activation, and platelet turnover are significantly greater in PVD patients who go on to develop later graft occlusion. Cellular activation and heterotypic cell interactions in peripheral vascular surgery patients may be important in the etiologies of thrombosis and/or accelerated atherosclerosis leading to graft loss.
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Affiliation(s)
- Claire J Esposito
- Department of Anesthesiology, Yale School of Medicine, New Haven, Connecticut 06520, USA
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Monaghan SA, Felgar RE, Kelly MA, Ali AM, Anastasi J, Bellara AP, Rinder HM, Sargent RL, Wagner J, Swerdlow SH, Johnson RL. Does Taking the Fellowship In-Service Hematopathology Examination and Performance Relate to Success on the American Board of Pathology Hematology Examination? Am J Clin Pathol 2016; 146:107-12. [PMID: 27357289 DOI: 10.1093/ajcp/aqw085] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES The biannual Fellow In-Service Hematopathology Examination (FISHE) assesses knowledge in five content areas. We examined the relationship between taking the FISHE and performance on it with outcomes on the first attempted American Board of Pathology Hematology subspecialty certifying examination (ABP-HE). METHODS The pass rate between the ABP-HE candidates who took the spring FISHE and those who did not were compared. The likelihood of fellows passing the ABP-HE based on their percentiles on the FISHE was also assessed. RESULTS ABP-HE candidates who took the spring FISHE had a higher pass rate (96.4%) than those who did not (76.1%, P < .001). Spring FISHE performance, including total percentile and percentiles in four of five FISHE content areas, was only a weak predictor of passing the ABP-HE. CONCLUSIONS Candidates who take the spring FISHE do better on the ABP-HE than those who do not. Most fellows passed the first attempted ABP-HE regardless of FISHE performance. Whether this is due to fellows making use of the FISHE as a self-evaluation tool to help identify and then correct their knowledge deficiencies remains to be determined.
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Affiliation(s)
- Sara A Monaghan
- From the Department of Pathology, University of Texas Southwestern Medical Center, Dallas
| | - Raymond E Felgar
- Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Melissa A Kelly
- Department of Evaluation, Measurement, and Assessment, American Society for Clinical Pathology, Chicago, IL
| | - Asma M Ali
- Department of Evaluation, Measurement, and Assessment, American Society for Clinical Pathology, Chicago, IL
| | - John Anastasi
- Department of Pathology, University of Chicago Medical Center, Chicago, IL
| | - Aarti P Bellara
- American Board of Pathology, Tampa, FL Department of Educational Psychology, University of Connecticut, Storrs
| | - Henry M Rinder
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, CT
| | - Rachel L Sargent
- Department of Pathology and Laboratory Medicine, Hospital of the University of Pennsylvania, Philadelphia
| | - Jay Wagner
- Department of Evaluation, Measurement, and Assessment, American Society for Clinical Pathology, Chicago, IL
| | - Steven H Swerdlow
- Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, PA American Board of Pathology, Tampa, FL
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Rinder HM. Academic laboratory medicine at 50 years and getting stronger. Am J Clin Pathol 2015; 143:612-3. [PMID: 25873490 DOI: 10.1309/ajcpeajdrxenzlu5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Affiliation(s)
- Henry M. Rinder
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, CT
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Haspel RL, Rinder HM, Frank KM, Wagner J, Ali AM, Fisher PB, Parks ER. The current state of resident training in genomic pathology: a comprehensive analysis using the resident in-service examination. Am J Clin Pathol 2014; 142:445-51. [PMID: 25239410 DOI: 10.1309/ajcph2a4xtxjukdz] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVES To determine the current state of pathology resident training in genomic and molecular pathology. METHODS The Training Residents in Genomics (TRIG) Working Group developed survey and knowledge questions for the 2013 pathology Resident In-Service Examination (RISE). Sixteen demographic questions related to amount of training, current and predicted future use, and perceived ability in molecular pathology vs genomic medicine were included, along with five genomic pathology and 19 molecular pathology knowledge questions. RESULTS A total of 2,506 pathology residents took the 2013 RISE, with approximately 600 individuals per postgraduate year (PGY). For genomic medicine, 42% of PGY-4 respondents stated they had no training, compared with 7% for molecular pathology (P < .001). PGY-4 residents' perceived ability, comfort in discussing results, and predicted future use as a practicing pathologist were reported to be less in genomic medicine than in molecular pathology (P < .001). Based on PGY, knowledge question scores showed a greater increase in molecular pathology than in genomic pathology. CONCLUSIONS The RISE is a powerful tool for assessing the state of resident training in genomic pathology and current results suggest a significant deficit. The results also provide a baseline to assess future initiatives to improve genomics education for pathology residents such as those developed by the TRIG Working Group.
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Affiliation(s)
- Richard L. Haspel
- Department of Pathology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA
| | - Henry M. Rinder
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, CT
| | - Karen M. Frank
- Department of Laboratory Medicine, Clinical Center, National Institutes of Health, Bethesda, MD
| | - Jay Wagner
- American Society for Clinical Pathology, Chicago, IL
| | - Asma M. Ali
- American Society for Clinical Pathology, Chicago, IL
| | | | - Eric R. Parks
- American Society for Clinical Pathology, Chicago, IL
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Chandler JB, Torres R, Rinder HM, Tormey CA. Lupus anticoagulant testing and anticoagulation do not mix: quantitation of discrepant results and potential approaches to reduce false positives. Br J Haematol 2014; 167:704-7. [PMID: 25041401 DOI: 10.1111/bjh.13030] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Jocelyn B Chandler
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, CT, USA; Department of Pathology, Yale University School of Medicine, New Haven, CT, USA.
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Streimish I, Bizzarro M, Northrup V, Wang C, Renna S, Koval N, Li FY, Ehrenkranz RA, Rinder HM, Bhandari V. Neutrophil CD64 with hematologic criteria for diagnosis of neonatal sepsis. Am J Perinatol 2014; 31:21-30. [PMID: 23456906 DOI: 10.1055/s-0033-1334453] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To assess the sensitivity and specificity of neutrophil CD64 as a diagnostic marker for clinical sepsis (based on a hematologic score) and as an additional marker with hematologic parameters for culture-proven sepsis in neonates. STUDY DESIGN Prospective observational cohort over 18 months in a single-center neonatal intensive care unit. RESULTS Hematologic and CD64 data were available on 1,156 sepsis evaluations done in 684 infants, of which 411 (36%) instances of positive clinical sepsis were identified. The CD64 index for clinical sepsis had an overall area under the receiver operating characteristic curve of 0.71. An optimum CD64 cut point value of 2.19 for late-onset clinical sepsis was calculated with a sensitivity of 78%, a specificity of 59%, and a negative predictive value of 81%. The birth weight-specific CD64 cut point for early onset clinical sepsis was 3.13, 2.34, and 2.05 for very low, low, and normal birth weight, respectively. Neutrophil CD64, in combination with the absolute neutrophil count or the absolute band count, had the highest sensitivity (91%) and specificity (93%), respectively, to diagnose culture-proven sepsis. CONCLUSION We conclude that neutrophil CD64 index can be incorporated with specific hematologic criteria as an additional marker for diagnosis of neonatal sepsis.
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Affiliation(s)
- Iris Streimish
- Division of Perinatal Medicine, Departments of Pediatrics, Yale University School of Medicine, New Haven, Connecticut
| | - Matthew Bizzarro
- Division of Perinatal Medicine, Departments of Pediatrics, Yale University School of Medicine, New Haven, Connecticut
| | | | - Chao Wang
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Sara Renna
- Division of Perinatal Medicine, Departments of Pediatrics, Yale University School of Medicine, New Haven, Connecticut
| | - Nancy Koval
- Division of Perinatal Medicine, Departments of Pediatrics, Yale University School of Medicine, New Haven, Connecticut
| | - Fang-Yong Li
- Yale Center for Analytical Sciences, New Haven, Connecticut
| | - Richard A Ehrenkranz
- Division of Perinatal Medicine, Departments of Pediatrics, Yale University School of Medicine, New Haven, Connecticut
| | - Henry M Rinder
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Vineet Bhandari
- Division of Perinatal Medicine, Departments of Pediatrics, Yale University School of Medicine, New Haven, Connecticut
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Siddon AJ, Rinder HM. Pathology consultation on evaluating prognosis in incidental monoclonal lymphocytosis and chronic lymphocytic leukemia. Am J Clin Pathol 2013; 139:708-12. [PMID: 23690112 DOI: 10.1309/ajcplir4gzwx3xka] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Chronic lymphocytic leukemia (CLL) is a monoclonal B-cell lymphoproliferative disorder generally characterized by an indolent clinical course. However, some patients with CLL will have more aggressive disease progression, and identifying that subgroup may be important for early, or perhaps more aggressive, intervention. In addition, monoclonal B-cell lymphocytosis is often found on routine laboratory evaluation, and it is important to distinguish this entity from overt CLL. Moreover, since many patients with CLL are discovered incidentally and before significant disease progression, prognostic laboratory evaluation may become increasingly efficacious as therapeutic options replace the older strategy of expectant observation. Prognostication may be especially critical if it correctly identifies patients with early stage CLL who are at high risk of clonal evolution and/ or resistance to chemoimmunotherapy. Laboratory studies include surface CD38 and intracellular ZAP-70 expression by flow cytometry, serum β2-microglobulin, and immunoglobulin heavy-chain variable gene mutational status. Cytogenetics for targeted chromosome alterations may similarly aid in predicting outcome and guiding early intervention. This article concisely reviews the utility of commonly performed prognostic markers and addresses the laboratory evaluation in patients with incidentally discovered early stage CLL.
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Andrews RK, Aster RH, Atkinson BT, Barnard MR, Bavry AA, Bayer AS, Beaulieu LM, Berndt MC, Berny-Lang MA, Bhatt DL, Bizzaro N, Bledzka K, Bouchard BA, Brass LF, Bray PF, Briggs C, Bussel JB, Cattaneo M, Chakravorty S, Chong BH, Clemetson J, Clemetson KJ, Coller BS, Covic L, Davì G, del Zoppo GJ, Dowling MR, Dubois C, Eisert WG, Evangelista V, Flaumenhaft R, Freedman JE, Freedman J, Frelinger AL, Furie BC, Furie B, Gardiner C, Gawaz M, Geisler T, Greinacher A, Gurbel PA, Harrison P, Hartwig JH, Hayward CP, Hughes CE, Ikeda Y, Israels SJ, Italiano JE, Jackson S, Jain S, Jones CI, Josefsson EC, Kaplan C, Kile BT, Kimura Y, Klement GL, Kolandaivelu K, Kuliopulos A, Kuter DJ, Lambert MP, Langer HF, Lebois M, Levin J, Lordkipanidzé M, Ma YQ, Mannucci PM, McCrae KR, Merrill-Skoloff G, Michelson AD, Moffat KA, Mutch NJ, Newman DK, Newman PE, Ni H, Nieuwland R, Ouwehand WH, Parsons J, Patrono C, Perrotta PL, Pesho MM, Plow EF, Politt AY, Poncz M, Poon MC, Provost P, Psaila B, Rao AK, Rinder HM, Roberts IA, Rondina MT, Ruggeri ZM, Santilli F, Schwertz H, Shai E, Silveira JR, Smith BR, Smith MC, Smyth SS, Snyder EL, Sobel M, Soranzo N, Stalker TJ, Sturk A, Sudo T, Sullivan S, Tantry US, Tefferi A, Tracy PB, Tsai HM, van der Pol E, Varon D, Vazzana N, Vieira-de-Abreu A, Wannemacher K, Ware J, Warkentin TE, Watson SP, Weyrich AS, White JG, Wilcox DA, Yeaman MR, Zhang P, Zhu L, Zimmerman GA. List of Contributors. Platelets 2013. [DOI: 10.1016/b978-0-12-387837-3.00072-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Streimish I, Bizzarro M, Northrup V, Wang C, Renna S, Koval N, Li FY, Ehrenkranz R, Rinder HM, Bhandari V. Neutrophil CD64 as a diagnostic marker in neonatal sepsis. Pediatr Infect Dis J 2012; 31:777-81. [PMID: 22481422 PMCID: PMC3375383 DOI: 10.1097/inf.0b013e318256fb07] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
We assessed neutrophil CD64 as a diagnostic marker for neonatal sepsis. For early-onset sepsis, the CD64 index with a cut-point value of 2.38 had sensitivity, specificity and negative predictive values of 100%, 68% and 100%, respectively. For late-onset sepsis, the respective values were 3.62, 75%, 77% and 96%. Neutrophil CD64 index can be incorporated as a valuable marker for excluding neonatal sepsis.
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Affiliation(s)
- Iris Streimish
- Division of Perinatal Medicine, Department of Pediatrics, Yale University School of Medicine, New Haven, CT
| | - Matthew Bizzarro
- Division of Perinatal Medicine, Department of Pediatrics, Yale University School of Medicine, New Haven, CT
| | | | - Chao Wang
- Division of Perinatal Medicine, Department of Laboratory Medicine, Yale University School of Medicine, New Haven, CT
| | - Sara Renna
- Division of Perinatal Medicine, Department of Pediatrics, Yale University School of Medicine, New Haven, CT
| | - Nancy Koval
- Division of Perinatal Medicine, Department of Pediatrics, Yale University School of Medicine, New Haven, CT
| | - Fang-Yong Li
- Yale Center for Analytical Sciences, New Haven, CT, USA
| | - Richard Ehrenkranz
- Division of Perinatal Medicine, Department of Pediatrics, Yale University School of Medicine, New Haven, CT
| | - Henry M. Rinder
- Division of Perinatal Medicine, Department of Laboratory Medicine, Yale University School of Medicine, New Haven, CT
| | - Vineet Bhandari
- Division of Perinatal Medicine, Department of Pediatrics, Yale University School of Medicine, New Haven, CT,Address for correspondence: Vineet Bhandari, MD, DM, Yale University School of Medicine, Yale Child Health Research Center, Room Number: 219, P.O. Box 208081, 464 Congress Avenue, New Haven, CT 06520, Phone: 203-785-2613, Fax: 203-737-5872,
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Haspel RL, Atkinson JB, Barr FG, Kaul KL, Leonard DG, O'Daniel J, Rinder HM, Scott J, Sobel ME, Speights VO. TRIG on TRACK: educating pathology residents in genomic medicine. Per Med 2012; 9:287-293. [PMID: 29758790 DOI: 10.2217/pme.12.6] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Genomic technologies are dramatically changing the practice of medicine. Next-generation sequencing has allowed prognostic stratification of cancer patients, personalized drug therapy and the identification of genetic risk factors for a multitude of diseases. As the physicians who oversee tissue- and laboratory-based diagnostic testing, pathologists must understand and utilize this new technology for the benefit of patients; however, only a minority of pathology residency programs currently provide training in genomics. In response to this urgent need, the Training Residents in Genomics (TRIG) Working Group has made significant progress towards creating, implementing, evaluating and disseminating a national curriculum in genomic pathology. Although presented in the context of pathology training, the approach described in this review can serve as model for education in genomic medicine of students, trainees or professionals in other areas of healthcare.
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Affiliation(s)
- Richard L Haspel
- Department of Pathology, Beth Israel Deaconess Medical Center & Harvard Medical School, Boston, MA, USA.
| | - James B Atkinson
- Department of Pathology, Microbiology & Immunology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Frederic G Barr
- Laboratory of Pathology, National Cancer Institute, Bethesda, MD, USA
| | - Karen L Kaul
- Department of Pathology & Laboratory Medicine, North Shore University Health System, Evanston, IL, USA
| | - Debra Gb Leonard
- Department of Pathology & Laboratory Medicine, Weill Cornell Medical College, New York, NY, USA
| | | | - Henry M Rinder
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Joan Scott
- National Coalition for Health Professional Education in Genetics, Lutherville, MD, USA
| | - Mark E Sobel
- American Society for Investigative Pathology, Bethesda, MD, USA
| | - V O Speights
- Department of Pathology, Scott & White Memorial Hospital, Texas A & M Health Science Center, Temple, TX, USA
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Hager K, Jennings K, Hosono S, Howell S, Gruen JR, Rivkees SA, Tartaglia NR, Rinder HM. Molecular diagnostic testing for Klinefelter syndrome and other male sex chromosome aneuploidies. Int J Pediatr Endocrinol 2012; 2012:8. [PMID: 22524164 PMCID: PMC3411476 DOI: 10.1186/1687-9856-2012-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/03/2012] [Accepted: 04/23/2012] [Indexed: 12/24/2022]
Abstract
Background Male sex chromosome aneuploidies are underdiagnosed despite concomitant physical and behavioral manifestations. Objective To develop a non-invasive, rapid and high-throughput molecular diagnostic assay for detection of male sex chromosome aneuploidies, including 47,XXY (Klinefelter), 47,XYY, 48,XXYY and 48,XXXY syndromes. Methods The assay utilizes three XYM and four XA markers to interrogate Y:X and X:autosome ratios, respectively. The seven markers were PCR amplified using genomic DNA isolated from a cohort of 323 males with aneuploid (n = 117) and 46,XY (n = 206) karyotypes. The resulting PCR products were subjected to Pyrosequencing, a quantitative DNA sequencing method. Results Receiver operator characteristic (ROC) curves were used to establish thresholds for the discrimination of aneuploid from normal samples. The XYM markers permitted the identification of 47,XXY, 48,XXXY and 47,XYY syndromes with 100% sensitivity and specificity in both purified DNA and buccal swab samples. The 48,XXYY karyotype was delineated by XA marker data from 46,XY; an X allele threshold of 43% also permitted detection of 48,XXYY with 100% sensitivity and specificity. Analysis of X chromosome-specific biallelic SNPs demonstrated that 43 of 45 individuals (96%) with 48,XXYY karyotype had two distinct X chromosomes, while 2 (4%) had a duplicate X, providing evidence that 48,XXYY may result from nondisjunction during early mitotic divisions of a 46,XY embryo. Conclusions Quantitative Pyrosequencing, with high-throughput potential, can detect male sex chromosome aneuploidies with 100% sensitivity.
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Affiliation(s)
- Karl Hager
- JS Genetics, Inc, 2 Church St, South, B-05, New Haven, CT, 06519, USA.
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Rinder HM, Grimes MM, Wagner J, Bennett BD. Senior pathology resident in-service examination scores correlate with outcomes of the American Board of Pathology certifying examinations. Am J Clin Pathol 2011; 136:499-506. [PMID: 21917671 DOI: 10.1309/ajcpa7o4bbuglsww] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
Abstract
The Resident In-Service Examination (RISE) addresses 1 area of the Accreditation Council for Graduate Medical Education Outcome Project; RISE results demonstrate progressive attainment of pathology knowledge during training. We compared RISE scores with primary pathology board certification success for residents graduating in 2008 and 2009. Overall RISE and nearly all sectional scores in anatomic and clinical pathology were significantly higher for residents passing all certifying examinations at the first attempt vs residents who failed any examination. The risk of failing increased with each lower quartile of overall RISE score, such that 34% (2009) and 54% (2008) of residents in the lowest quartile failed at least 1 certifying examination. Two thirds of graduating residents with lowest quartile scores had a similar quartile ranking in the previous RISE, identifying them as at risk. Residents passing the American Board of Pathology certifying examinations have a higher level of medical knowledge in general and specific pathology disciplines as assessed by senior RISE scores.
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Affiliation(s)
- Henry M. Rinder
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, CT
| | | | - Jay Wagner
- Examination Development & Outcomes Assessment Products, American Society for Clinical Pathology, Chicago, IL
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Abstract
OBJECTIVE Turner syndrome (TS) occurs when an X-chromosome is completely or partially deleted or when X-chromosomal mosaicism is present. Girls with TS benefit from early diagnosis and treatment with GH; however, many girls with TS are not detected until after 10 yr of age, resulting in delayed evaluation and treatment. METHODS We developed a high-throughput test for TS, based on a quantitative method of genotyping to detect X-chromosome abnormalities. This test uses pyrosequencing to quantitate relative allele strength (RAS) from single-nucleotide polymorphisms using 18 informative single-nucleotide polymorphisms markers that span the X-chromosome and one marker for the detection of Y-chromosome material. RESULTS Cutoff ranges for heterozygous, homozygous, or out-of-range RAS values were established from a cohort of 496 males and females. Positive TS scoring criteria were defined as the presence of homozygosity for all 18 markers or the presence of at least one out-of-range RAS value. To determine the validity of this rapid test for TS detection, we undertook a large-scale study using DNA from 132 females without TS and 74 females with TS for whom karyotypes were available. TS was identified with 96.0% sensitivity and 97.0% specificity in this cohort. We also tested buccal swab DNA from a group of 19 females without TS and 69 females with TS. In this group, TS was identified with 97.1% sensitivity and 84.2% specificity. CONCLUSIONS These results demonstrate the validity of a high-throughput, pyrosequencing based test for the accurate detection of TS, providing a potential alternative to karyotype testing.
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Affiliation(s)
- Scott A Rivkees
- Yale Child Health Research Center, Yale University School of Medicine, 464 Congress Avenue, New Haven, Connecticut 06520, USA.
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Marques MB, Anastasi J, Ashwood E, Baron B, Fitzgerald R, Fung M, Krasowski M, Laposata M, Nester T, Rinder HM. The clinical pathologist as consultant. Am J Clin Pathol 2011; 135:11-2. [PMID: 21173119 DOI: 10.1309/ajcp0ezmp6hjorbk] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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Booth CJ, Brooks MB, Rockwell S, Murphy JW, Rinder HM, Zelterman D, Paidas MJ, Compton SR, Marks PW. WAG-F8(m1Ycb) rats harboring a factor VIII gene mutation provide a new animal model for hemophilia A. J Thromb Haemost 2010; 8:2472-7. [PMID: 20626616 DOI: 10.1111/j.1538-7836.2010.03978.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND We recently described an inherited coagulopathy arising in an inbred colony of WAG/RijYcb rats. The bleeding phenotype, demonstrated by both male and female rats, included periarticular hemorrhage, spontaneous bruising, prolonged bleeding from minor wounds and maternal peripartum deaths. Coagulation testing of affected rats revealed normal prothrombin time but prolongation of activated partial thromboplastin time to twice that of controls. OBJECTIVE To determine the specific coagulation factor and the underlying genetic defect responsible for the inherited coagulopathy in the WAG/RijYcb rats. RESULTS Evaluation of individual clotting factor activities revealed that the affected animals had a specific deficiency of factor (F) VIII (FVIII). The FVIII gene (F8) has an autosomal location on chromosome 18 in rats, in contrast to its location on the X chromosome in mice and humans. Sequencing of F8 cDNA led to the identification of a point mutation resulting in a substitution, Leu176Pro, in the A1 domain, that is predicted to disrupt the tertiary structure of the FVIII molecule. Administration of human plasma or human recombinant FVIII corrects the coagulation abnormality in the affected animals. CONCLUSIONS We have now identified the genetic basis of the hemostatic defect in the WAG/RijYcb rat colony. The larger size of rats relative to mice and the presence of this coagulation defect in both sexes provide a unique model, well-suited to the development of novel therapies for acquired and hereditary FVIII deficiencies.
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Affiliation(s)
- C J Booth
- The Section of Comparative Medicine, Yale University School of Medicine, New Haven, CT 06519-1404, USA.
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Smith BR, Aguero-Rosenfeld M, Anastasi J, Baron B, Berg A, Bock JL, Campbell S, Crookston KP, Fitzgerald R, Fung M, Haspel R, Howe JG, Jhang J, Kamoun M, Koethe S, Krasowski MD, Landry ML, Marques MB, Rinder HM, Roberts W, Schreiber WE, Spitalnik SL, Tormey CA, Wolf P, Wu YY. Educating medical students in laboratory medicine: a proposed curriculum. Am J Clin Pathol 2010; 133:533-42. [PMID: 20231605 DOI: 10.1309/ajcpqct94sferlni] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
As the 100th anniversary of the Flexner report nears, medical student education is being reviewed at many levels. One area of concern, expressed in recent reports from some national health care organizations, is the adequacy of training in the discipline of laboratory medicine (also termed clinical pathology). The Academy of Clinical Laboratory Physicians and Scientists appointed an ad hoc committee to review this topic and to develop a suggested curriculum, which was subsequently forwarded to the entire membership for review. The proposed medical student laboratory medicine curriculum defines goals and objectives for training, provides guidelines for instructional methods, and gives examples of how outcomes can be assessed. This curriculum is presented as a potentially helpful outline for use by medical school faculty and curriculum committees.
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Abstract
This article briefly details the physiologic and interdependent mechanisms of vascular hemostasis, with an eye toward how the laboratory can assist in diagnosing and maintaining the balance of procoagulant and anticoagulant functions. These functions include determining characteristics of the blood vessel wall, platelet components and receptor-ligand interactions critical for hemostasis, the regulation of thrombin generation and its effects, and the complex fibrinolytic pathways that complete the coagulation cascade.
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Affiliation(s)
- Nancy Kriz
- Department of Laboratory Medicine, Yale-New Haven Hospital, Yale University School of Medicine, New Haven, CT 05620, USA
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Affiliation(s)
- Henry M Rinder
- Department of Laboratory Medicine, Yale University School of Medicine, 333 Cedar Street, PO Box 208035, New Haven, CT 05620-8035, USA.
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Greilich PE, Brouse CF, Rinder HM, Jessen ME, Rinder CS, Eberhart RC, Whitten CW, Smith BR. Monocyte Activation in On-Pump Versus Off-Pump Coronary Artery Bypass Surgery. J Cardiothorac Vasc Anesth 2008; 22:361-8. [DOI: 10.1053/j.jvca.2007.08.009] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2007] [Indexed: 11/11/2022]
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Tang YD, Rinder HM, Katz SD. Effects of recombinant human erythropoietin on antiplatelet action of aspirin and clopidogrel in healthy subjects: results of a double-blind, placebo-controlled randomized trial. Am Heart J 2007; 154:494.e1-7. [PMID: 17719296 DOI: 10.1016/j.ahj.2007.06.036] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2007] [Accepted: 06/25/2007] [Indexed: 10/22/2022]
Abstract
BACKGROUND Recombinant human erythropoietin (rHuEpo) reduces myocardial injury in experimental ischemia and has been proposed as a cardioprotective agent for potential use in acute coronary syndromes. Its safety profile in clinical acute ischemic settings is uncertain because rHuEpo has been reported to increase platelet reactivity and the risk of thromboembolism in some disease populations. Whether prothrombotic effects of rHuEpo mitigate the effects of antiplatelet agents used in acute coronary syndrome patients is unknown. METHODS Recombinant human erythropoietin 100, 200, 400 U/kg, or placebo was given intravenously once daily for 3 consecutive days in a double-blind randomized trial in 96 healthy subjects. A single oral dose of aspirin 325 mg or clopidogrel 300 mg was given immediately after the last dose of study drug. Bleeding time and in vitro high shear stress platelet function assays (PFA)-100 were determined before; 5 hours; and 1, 5, and 7 days after aspirin or clopidogrel. RESULTS Recombinant human erythropoietin at doses of 100 and 200 U/kg did not alter bleeding time or PFA-100 closure times at any time point when compared with placebo. Recombinant human erythropoietin at a dose of 400 U/kg significantly blunted the post-aspirin increase in bleeding time when compared with placebo (P = .03) but did not alter post-clopidogrel bleeding times nor PFA closure times. The 400-U/kg dose did not change hematocrit but did significantly increase the platelet count at 5 days after study drug administration when compared with placebo (P = .014). CONCLUSION Short-term rHuEpo at doses up to 200 U/kg did not mitigate the effects of administration of aspirin or clopidogrel on either in vivo or in vitro measures of platelet function in healthy subjects. The 400-U/kg dose attenuated the effects of aspirin on bleeding time and increased the platelet count. Studies of the effects of rHuEpo on platelet function in patients with coronary artery disease are warranted to further characterize dose/safety profile.
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Affiliation(s)
- Yi-Da Tang
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT 06510, USA
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Abstract
Many methodologies have been employed in training laboratory medicine (clinical pathology) residents. Apprenticeship activities (observing and reproducing the job of an attending clinical pathologist in a direct practice setting) likely remain the most popular for trainees and arguably one of the most effective. The utility and current status of morning report, journal club, resident-led-grand rounds style presentations, faculty didactics, research by residents, placing residents specifically in the role of teachers themselves, hands-on activities in clinical laboratories, and emerging computer-based learning modalities are compared with each other and to similar exercises in other medical disciplines.
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Affiliation(s)
- Henry M Rinder
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, CT 06520-8035, USA
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Rinder CS, Smith MJ, Rinder HM, Cortright DN, Brodbeck RM, Krause JE, Smith BR. Leukocyte effects of C5a-receptor blockade during simulated extracorporeal circulation. Ann Thorac Surg 2007; 83:146-52. [PMID: 17184649 DOI: 10.1016/j.athoracsur.2006.08.019] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2006] [Revised: 08/03/2006] [Accepted: 08/04/2006] [Indexed: 12/22/2022]
Abstract
BACKGROUND Distinct pathways of leukocyte activation during simulated cardiopulmonary bypass are mediated by the complement C5a anaphylatoxin. We hypothesized that a human C5a receptor antagonist would specifically inhibit the inflammatory response of neutrophils to simulated extracorporeal circulation, while preserving the C5b-9 pathway for innate immunity. METHODS An in vitro extracorporeal circuit recirculated fresh heparinized whole blood through a membrane oxygenator with and without addition of a small molecule human C5a receptor antagonist. Samples were periodically drawn over 90 minutes for complement and leukocyte activation studies. RESULTS Addition of the C5a receptor antagonist to simulated extracorporeal circulation abrogated both neutrophil CD11b upregulation and interleukin 8 release (p < 0.01 for both), despite full generation of C3a and C5b-9; however, elastase release from neutrophils was unaffected. Although C5a receptor blockade only trended toward inhibiting monocyte CD11b upregulation (p = 0.09), circuit clearance of both monocytes (p = 0.04) and neutrophils (p = 0.01) was significantly decreased. In addition, the C5a receptor antagonist completely blocked both neutrophil-platelet and monocyte-platelet conjugate formation (p < 0.001 for both), without affecting platelet P-selectin expression. CONCLUSIONS C5a receptor blockade during simulated extracorporeal circulation completely blocked neutrophil beta2 integrin upregulation and induction of plasma interleukin 8, suggesting an acute downregulatory effect on neutrophil chemotaxis-related pathways, while preserving terminal complement generation and neutrophil elastase release. Inhibition of leukocyte-platelet conjugate formation suggests a novel function for leukocyte adhesive receptors, possibly related to preservation of elastase generation.
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Affiliation(s)
- Christine S Rinder
- Department of Anesthesiology, Yale University School of Medicine, New Haven, Connecticut 06520-8051, USA.
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Afshar-Kharghan V, Agah R, Andrews RK, Aster RH, Atkinson B, Awtry EH, Bahou WF, Barnard MR, Bavry AA, Bayer AS, Becker RC, Bergmeier W, Berndt MC, Bhatt DL, Bizzaro N, Blajchman MA, Bouchard BA, Brass LF, Bray PF, Briggs C, Brill A, Bussel JB, Butenas S, Cattaneo M, Chong BH, Clemetson KJ, Clemetson JM, Coller BS, Crawford LE, de Groot PG, del Zoppo GJ, Dubois C, Eisert WG, FitzGerald GA, Francis JL, Freedman JE, Freedman J, Frelinger III A, Fries S, Furie BC, Furie B, Furman MI, García-Alonso Á, Goldschmidt PJ, Grosser T, Gurguis GN, Harrison P, Hartwig JH, Ike da YU, Israels SJ, Italiano JE, Jennings LK, Kaplan C, Karpatkin S, Keeling DM, Kimura Y, Kurkjian CD, Kuter DJ, Lambert MP, Lee DH, Levin J, Li QX, Li Z, Lind SE, Linden MD, Lopes NH, López JA, Loscalzo J, Ma YQ, Machin SJ, Mann KG, Mannucci PM, Maron BA, Masters CL, McCrae KR, McEver RP, Menart B, Michelson AD, Moake J, Murray N, Nardi MA, Newman DK, Newman PJ, Nierodzik ML, Nieuwland R, Novinska M, Nurden AT, Nurden P, Perrotta PL, Pesho MM, Plow EF, Poncz M, Poon MC, Prévost N, Rao AK, Rathore V, Reed GL, Rex S, Rinder CS, Rinder HM, Roberts I, Ruggeri ZM, Savage B, Savion N, Senis Y, Shattil SJ, Sixma JJ, Smith BR, Snyder EL, Sobel M, Stalker TJ, Steinhubl SR, Stratmann B, Sturk A, Sudo T, Tef feri AL, Tomlinson MG, Topol EJ, Tracy PB, Tschoepe D, Varon D, Vijayan KV, Wagner DD, Watson SP, White, II GC, White JG, McCabe White M, Wilcox DA, Woulfe DS, Yeaman MR, Zhu L. Contributors. Platelets 2007. [DOI: 10.1016/b978-012369367-9/50760-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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