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Khalid MB, Zektser E, Chu E, Li M, Utoh J, Ryan P, Loving HS, Harb R, Kattappuram R, Chatman L, Hartono S, Claudio-Etienne E, Sun G, Feener EP, Li Z, Lai SK, Le Q, Schwartz LB, Lyons JJ, Komarow H, Zhou ZH, Raza H, Pao M, Laky K, Holland SM, Brittain E, Frischmeyer-Guerrerio PA. A randomized double-blinded trial to assess recurrence of systemic allergic reactions following COVID-19 mRNA vaccination. J Allergy Clin Immunol 2024:S0091-6749(24)00236-7. [PMID: 38460680 DOI: 10.1016/j.jaci.2024.03.001] [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: 11/28/2023] [Revised: 02/09/2024] [Accepted: 03/05/2024] [Indexed: 03/11/2024]
Abstract
BACKGROUND Systemic allergic reactions (sARs) following coronavirus disease 2019 (COVID-19) mRNA vaccines were initially reported at a higher rate than after traditional vaccines. OBJECTIVE We aimed to evaluate the safety of revaccination in these individuals and to interrogate mechanisms underlying these reactions. METHODS In this randomized, double-blinded, phase 2 trial, participants aged 16 to 69 years who previously reported a convincing sAR to their first dose of COVID-19 mRNA vaccine were randomly assigned to receive a second dose of BNT162b2 (Comirnaty) vaccine and placebo on consecutive days in a blinded, 1:1 crossover fashion at the National Institutes of Health. An open-label BNT162b2 booster was offered 5 months later if the second dose did not result in severe sAR. None of the participants received the mRNA-1273 (Spikevax) vaccine during the study. The primary end point was recurrence of sAR following second dose and booster vaccination; exploratory end points included biomarker measurements. RESULTS Of 111 screened participants, 18 were randomly assigned to receive study interventions. Eight received BNT162b2 second dose followed by placebo; 8 received placebo followed by BNT162b2 second dose; 2 withdrew before receiving any study intervention. All 16 participants received the booster dose. Following second dose and booster vaccination, sARs recurred in 2 participants (12.5%; 95% CI, 1.6 to 38.3). No sAR occurred after placebo. An anaphylaxis mimic, immunization stress-related response (ISRR), occurred more commonly than sARs following both vaccine and placebo and was associated with higher predose anxiety scores, paresthesias, and distinct vital sign and biomarker changes. CONCLUSIONS Our findings support revaccination of individuals who report sARs to COVID-19 mRNA vaccines. Distinct clinical and laboratory features may distinguish sARs from ISRRs.
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Affiliation(s)
- Muhammad B Khalid
- Food Allergy Research Section, Laboratory of Allergic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | - Ellen Zektser
- Food Allergy Research Section, Laboratory of Allergic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | - Eric Chu
- Clinical Monitoring Research Program Directorate, Frederick National Laboratory for Cancer Research, Frederick, Md
| | - Min Li
- Food Allergy Research Section, Laboratory of Allergic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | - Joanna Utoh
- Food Allergy Research Section, Laboratory of Allergic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | - Patrick Ryan
- Office of the Clinical Director, National Institute of Mental Health, National Institutes of Health, Bethesda, Md
| | - Hanna S Loving
- Department of Laboratory Medicine, Clinical Center, National Institutes of Health, Bethesda, Md
| | - Roa Harb
- Department of Laboratory Medicine, Clinical Center, National Institutes of Health, Bethesda, Md
| | - Robbie Kattappuram
- Investigational Drug Management and Research Section, Clinical Center, National Institutes of Health, Bethesda, Md
| | - Lindsay Chatman
- Food Allergy Research Section, Laboratory of Allergic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | - Stella Hartono
- Food Allergy Research Section, Laboratory of Allergic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | - Estefania Claudio-Etienne
- Food Allergy Research Section, Laboratory of Allergic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | - Guangping Sun
- Food Allergy Research Section, Laboratory of Allergic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | | | - Zhongbo Li
- Division of Pharmacoengineering and Molecular Pharmaceutics, Eshelman School of Pharmacy, University of North Carolina Chapel Hill, Chapel Hill, NC
| | - Samuel K Lai
- Division of Pharmacoengineering and Molecular Pharmaceutics, Eshelman School of Pharmacy, University of North Carolina Chapel Hill, Chapel Hill, NC
| | - Quang Le
- Department of Internal Medicine, Division of Rheumatology, Allergy, and Immunology, Virginia Commonwealth University, Richmond, Va
| | - Lawrence B Schwartz
- Department of Internal Medicine, Division of Rheumatology, Allergy, and Immunology, Virginia Commonwealth University, Richmond, Va
| | - Jonathan J Lyons
- Translational Allergic Immunopathology Unit, Laboratory of Allergic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | - Hirsh Komarow
- Mast Cell Biology Section, Laboratory of Allergic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | - Zhao-Hua Zhou
- Office of Biotechnology Products, Office of Pharmaceutical Quality, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Md
| | - Haniya Raza
- Office of the Clinical Director, National Institute of Mental Health, National Institutes of Health, Bethesda, Md
| | - Maryland Pao
- Office of the Clinical Director, National Institute of Mental Health, National Institutes of Health, Bethesda, Md
| | - Karen Laky
- Food Allergy Research Section, Laboratory of Allergic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | - Steven M Holland
- Laboratory of Clinical Immunology and Microbiology, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | - Erica Brittain
- Biostatistics Research Branch, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | - Pamela A Frischmeyer-Guerrerio
- Food Allergy Research Section, Laboratory of Allergic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md.
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Harb R, Tuggey R, Ladenson JH, Amukele T. Remote support of an external quality assessment program in 10 laboratories in Bhutan, Uganda, and Malawi: Pathologists Overseas experience between 2009 and 2017. Am J Clin Pathol 2024:aqae009. [PMID: 38387037 DOI: 10.1093/ajcp/aqae009] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 01/16/2024] [Indexed: 02/24/2024] Open
Abstract
OBJECTIVES This article describes Pathologists Overseas (PO) experience supporting external quality assessment (EQA) programs in 10 clinical laboratories across 3 countries between 2009 and 2017. METHODS Laboratories were enrolled in the condensed chemical pathology EQA program provided by the Royal College of Pathologists of Australasia Quality Assurance Program. Participants were given an initial 2- to 4-day in-person training, followed by 1 year of active feedback on performance via emails or phone calls by a PO volunteer. RESULTS There were 2 performance metrics: percentage of reported results as a measure of compliance and percentage of acceptable reported results as a measure of accuracy. Laboratories demonstrated high compliance with result reporting, with medians of 69.9%, 71.7%, and 81.3% before, during, and after feedback, respectively. Concomitant medians for the percentage of acceptable reported results were 41.2%, 57.3%, and 53.5%, respectively. Six laboratories had low performance in terms of accuracy at baseline (<60%). Active feedback improved the percentage of acceptable reported results for these lower-performing laboratories. CONCLUSIONS External quality assessment programs can be successfully adopted long term by laboratories in low-resource settings. Active feedback requires significant time and effort but could be especially beneficial for laboratories with poor baseline performance.
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Affiliation(s)
- Roa Harb
- Department of Laboratory Medicine, National Institutes of Health, Bethesda, MD, US
| | | | - Jack H Ladenson
- Pathologists Overseas, Fullerton, CA, US
- Department of Pathology and Immunology, Division of Laboratory and Genomic Medicine Washington University School of Medicine, St Louis, MO, US
| | - Timothy Amukele
- Pathologists Overseas, Fullerton, CA, US
- ICON Clinical Laboratories, Farmingdale, NY, US
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Glynn EH, Nelson AM, Tesfazghi M, Harb R, Amukele T. Pathologists Overseas: A volunteer-based model for building sustainable, high-quality pathology and laboratory medicine services in low- and middle-income countries. Front Med (Lausanne) 2022; 9:977840. [PMID: 36111111 PMCID: PMC9468261 DOI: 10.3389/fmed.2022.977840] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 08/08/2022] [Indexed: 11/13/2022] Open
Abstract
For thirty years Pathologists Overseas (PO) has worked in low- and middle-income countries (LMICs) to provide affordable, sustainable, and high-quality pathology and laboratory medicine (PALM) services through strategic partnerships and the efforts of our large volunteer network. We address low quality diagnostic services by targeting the 3 pillars of PALM quality: human resources, systems, and quality and accreditation. To improve human resource capacity, PO and our partnering organizations provide virtual continuing education to pathologists and laboratory professionals in these countries. To improve systems, we provide laboratory information system installation and implementation support. Lastly, to improve quality and help laboratories progress toward accreditation, we support an external quality assurance program for laboratories in LMICs. As a relatively small organization, PO demonstrates that a network of dedicated volunteers, in partnership with corporations and professional organizations, can initiate sustainable change in the quality of PALM services in LMICs by focusing efforts on the core components of laboratory quality.
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Affiliation(s)
- Emily H. Glynn
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, WA, United States
- *Correspondence: Emily H. Glynn,
| | | | - Merih Tesfazghi
- Department of Pathology, Rush University, Chicago, IL, United States
| | - Roa Harb
- Department of Laboratory Medicine, Clinical Center, National Institutes of Health, Bethesda, MD, United States
| | - Timothy Amukele
- ICON Laboratory Services, ICON plc, Farmingdale, NY, United States
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Loving HS, Sacks DB, Harb R. Antibody Response to SARS-CoV-2 Booster Vaccines. Clin Biochem 2022; 107:80-82. [PMID: 35716728 PMCID: PMC9197954 DOI: 10.1016/j.clinbiochem.2022.06.004] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 06/10/2022] [Accepted: 06/13/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Hanna S Loving
- Department of Laboratory Medicine, National Institutes of Health, Bethesda, MD, United States
| | - David B Sacks
- Department of Laboratory Medicine, National Institutes of Health, Bethesda, MD, United States
| | - Roa Harb
- Department of Laboratory Medicine, National Institutes of Health, Bethesda, MD, United States.
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5
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Loving HS, Stallcup P, Burbelo P, Cohen J, Remaley A, Sacks DB, Harb R. Early Antibody Temporal Responses to Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) in Vaccinated Subjects Determined by the cobas 6000 Spike Assay. Arch Pathol Lab Med 2022; 146:9-10. [PMID: 34491312 PMCID: PMC10986638 DOI: 10.5858/arpa.2021-0407-le] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/01/2021] [Indexed: 11/06/2022]
Affiliation(s)
- Hanna S Loving
- Department of Laboratory Medicine, Clinical Center, National Institutes of Health, Bethesda, Maryland
| | - Paulina Stallcup
- Department of Laboratory Medicine, Clinical Center, National Institutes of Health, Bethesda, Maryland
| | - Peter Burbelo
- National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, Maryland
| | - Jeffrey Cohen
- Laboratory of Infectious Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland
| | - Alan Remaley
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - David B Sacks
- Department of Laboratory Medicine, Clinical Center, National Institutes of Health, Bethesda, Maryland
| | - Roa Harb
- Department of Laboratory Medicine, Clinical Center, National Institutes of Health, Bethesda, Maryland
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Bunch DR, Firmender K, Harb R, El-Khoury JM. First- and Second-Trimester Reference Intervals for Thyroid Function Testing in a US Population. Am J Clin Pathol 2021; 155:776-780. [PMID: 33210132 DOI: 10.1093/ajcp/aqaa165] [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] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
OBJECTIVES Thyroid dysfunction in pregnancy is associated with increased risk of adverse outcomes to mother and child. Trimester-specific reference intervals for thyroid function tests are not routinely provided by clinical laboratories. In this study, we present first- and second-trimester-specific reference intervals in a US population for thyroid-stimulating hormone (TSH), free thyroxine (FT4), total thyroxine (T4), and total triiodothyronine (T3) measured on Roche analyzers. METHODS We used patient samples from first- and second-trimester prenatal screening. Samples were limited to singleton pregnancies and negative screening results for thyroid peroxidase and thyroglobulin antibodies. Analytes (TSH, FT4, T4, and T3) were measured on a Roche Modular e170 then verified on a Roche cobas e801. RESULTS The reference intervals established on the e170 and verified on the e801 for the first trimester were 0.16 to 2.82 mIU/L for TSH, 12.0 to 18.5 pmol/L for FT4, 62.8 to 177.9 nmol/L for T4, and 1.5 to 3.4 nmol/L for T3. The reference intervals for the second trimester were 0.40 to 3.62 mIU/L for TSH, 10.2 to 16.6 pmol/L for FT4, 66.6 to 176.0 nmol/L for T4, and 1.56 to 3.6 nmol/L for T3. CONCLUSIONS This is the first report of trimester-specific reference intervals for thyroid function tests on Roche analyzers in the United States, and it is consistent with worldwide reports.
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Affiliation(s)
- Dustin R Bunch
- Department of Laboratory Medicine, Yale-New Haven Hospital, New Haven, CT.,Yale School of Medicine, Yale University, New Haven, CT
| | - Kyle Firmender
- Department of Laboratory Medicine, Yale-New Haven Hospital, New Haven, CT
| | - Roa Harb
- Department of Laboratory Medicine, Yale-New Haven Hospital, New Haven, CT.,Yale School of Medicine, Yale University, New Haven, CT
| | - Joe M El-Khoury
- Department of Laboratory Medicine, Yale-New Haven Hospital, New Haven, CT.,Yale School of Medicine, Yale University, New Haven, CT
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7
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Harb R, Kachimanga C, Bangura M, Kanawa S, Stratton CW, Milner DA, Eichbaum Q. Providing Laboratory Medicine Training in a Low-Resource Setting. Am J Clin Pathol 2021; 155:473-478. [PMID: 33009558 DOI: 10.1093/ajcp/aqaa131] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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: 11/13/2022] Open
Abstract
OBJECTIVES We developed and participated in a 1-week laboratory medicine training presented from June 3, 2019, to June 7, 2019. METHODS The training was a combination of daily morning lectures and case presentations as well as afternoon practical sessions in the clinical laboratory. The content was selected over months by local organizers and the visiting faculty and further modified on site to reflect local needs. RESULTS Participants identified practice changes that could be realized in the short term but most faced significant barriers to implementation in the absence of structured and long-term follow-up. CONCLUSIONS In this report, we review insights learned from our experience and reflect on strategies for realistic, meaningful, and relevant contributions in the setting of laboratory medicine-oriented short-term programs.
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Affiliation(s)
- Roa Harb
- Department of Laboratory Medicine, Clinical Center, National Institutes of Health, Bethesda, MD
| | | | | | - Sahr Kanawa
- Ministry of Health and Sanitation, Freetown, Sierra Leone
| | - Charles W Stratton
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, TN
| | - Dan A Milner
- American Society for Clinical Pathology, Chicago, IL
| | - Quentin Eichbaum
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, TN
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8
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Ayala-Lopez N, Peaper DR, Harb R. Procalcitonin Correlates With but Is Not Superior to Other Diagnostic Markers of Bacterial Pneumonia. Am J Clin Pathol 2021; 155:537-546. [PMID: 33210111 DOI: 10.1093/ajcp/aqaa148] [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: 11/14/2022] Open
Abstract
OBJECTIVES Despite extensive research on procalcitonin (PCT)-guided therapy in lower respiratory tract infections, the association between PCT and bacterial pneumonia remains unclear. METHODS We evaluated retrospectively the performance of PCT in patients presenting with lower respiratory tract infection symptoms and grouped by seven diagnoses. All patients had microbial testing, chest imaging, and CBC counts within 1 day of PCT testing. RESULTS Median PCT level in patients diagnosed with bacterial pneumonia was significantly higher than in patients diagnosed with other sources of infections or those not diagnosed with infections. Median PCT levels were not different among patients grouped by type or quantity of pathogen detected. They were significantly higher in patients with higher pathogenicity scores for isolated bacteria, those with abnormal WBC count, and those with chest imaging consistent with bacterial pneumonia. A diagnostic workup that included imaging, WBC count, and Gram stain had an area under the receiver operating characteristic curve of 0.748, and the addition of PCT increased it to 0.778. CONCLUSIONS PCT was higher in patients diagnosed with bacterial pneumonia. Less clear is its diagnostic ability to detect bacterial pneumonia over and above imaging and laboratory data routinely available to clinicians.
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Affiliation(s)
| | - David R Peaper
- Department of Laboratory Medicine, Yale University, New Haven, CT
| | - Roa Harb
- Department of Laboratory Medicine, Yale University, New Haven, CT
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Sampson M, Ling C, Sun Q, Harb R, Ashmaig M, Warnick R, Sethi A, Fleming JK, Otvos JD, Meeusen JW, Delaney SR, Jaffe AS, Shamburek R, Amar M, Remaley AT. A New Equation for Calculation of Low-Density Lipoprotein Cholesterol in Patients With Normolipidemia and/or Hypertriglyceridemia. JAMA Cardiol 2021; 5:540-548. [PMID: 32101259 DOI: 10.1001/jamacardio.2020.0013] [Citation(s) in RCA: 221] [Impact Index Per Article: 73.7] [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: 01/16/2023]
Abstract
Importance Low-density lipoprotein cholesterol (LDL-C), a key cardiovascular disease marker, is often estimated by the Friedewald or Martin equation, but calculating LDL-C is less accurate in patients with a low LDL-C level or hypertriglyceridemia (triglyceride [TG] levels ≥400 mg/dL). Objective To design a more accurate LDL-C equation for patients with a low LDL-C level and/or hypertriglyceridemia. Design, Setting, and Participants Data on LDL-C levels and other lipid measures from 8656 patients seen at the National Institutes of Health Clinical Center between January 1, 1976, and June 2, 1999, were analyzed by the β-quantification reference method (18 715 LDL-C test results) and were randomly divided into equally sized training and validation data sets. Using TG and non-high-density lipoprotein cholesterol as independent variables, multiple least squares regression was used to develop an equation for very low-density lipoprotein cholesterol, which was then used in a second equation for LDL-C. Equations were tested against the internal validation data set and multiple external data sets of either β-quantification LDL-C results (n = 28 891) or direct LDL-C test results (n = 252 888). Statistical analysis was performed from August 7, 2018, to July 18, 2019. Main Outcomes and Measures Concordance between calculated and measured LDL-C levels by β-quantification, as assessed by various measures of test accuracy (correlation coefficient [R2], root mean square error [RMSE], mean absolute difference [MAD]), and percentage of patients misclassified at LDL-C treatment thresholds of 70, 100, and 190 mg/dL. Results Compared with β-quantification, the new equation was more accurate than other LDL-C equations (slope, 0.964; RMSE = 15.2 mg/dL; R2 = 0.9648; vs Friedewald equation: slope, 1.056; RMSE = 32 mg/dL; R2 = 0.8808; vs Martin equation: slope, 0.945; RMSE = 25.7 mg/dL; R2 = 0.9022), particularly for patients with hypertriglyceridemia (MAD = 24.9 mg/dL; vs Friedewald equation: MAD = 56.4 mg/dL; vs Martin equation: MAD = 44.8 mg/dL). The new equation calculates the LDL-C level in patients with TG levels up to 800 mg/dL as accurately as the Friedewald equation does for TG levels less than 400 mg/dL and was associated with 35% fewer misclassifications when patients with hypertriglyceridemia (TG levels, 400-800 mg/dL) were categorized into different LDL-C treatment groups. Conclusions and Relevance The new equation can be readily implemented by clinical laboratories with no additional costs compared with the standard lipid panel. It will allow for more accurate calculation of LDL-C level in patients with low LDL-C levels and/or hypertriglyceridemia (TG levels, ≤800 mg/dL) and thus should improve the use of LDL-C level in cardiovascular disease risk management.
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Affiliation(s)
- Maureen Sampson
- Clinical Center, Department of Laboratory Medicine, National Institutes of Health, Bethesda, Maryland
| | - Clarence Ling
- Clinical Center, Department of Laboratory Medicine, National Institutes of Health, Bethesda, Maryland
| | - Qian Sun
- Clinical Center, Department of Laboratory Medicine, National Institutes of Health, Bethesda, Maryland
| | - Roa Harb
- Clinical Center, Department of Laboratory Medicine, National Institutes of Health, Bethesda, Maryland
| | | | | | | | - James K Fleming
- Department of Science and Technology, Laboratory Corporation of America Holdings, Burlington, North Carolina
| | - James D Otvos
- NMR Diagnostics, Laboratory Corporation of America Holdings, Burlington, North Carolina
| | - Jeff W Meeusen
- Cardiovascular Laboratory Medicine, Mayo Clinic, Rochester, Minnesota
| | - Sarah R Delaney
- Cardiovascular Laboratory Medicine, Mayo Clinic, Rochester, Minnesota
| | - Allan S Jaffe
- Division of Clinical Core Laboratory Services, Mayo Clinic, Rochester, Minnesota
| | - Robert Shamburek
- Lipoprotein Metabolism Laboratory, Translational Vascular Medicine Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Marcelo Amar
- Lipoprotein Metabolism Laboratory, Translational Vascular Medicine Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Alan T Remaley
- Lipoprotein Metabolism Laboratory, Translational Vascular Medicine Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
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Affiliation(s)
- Roa Harb
- Department of Laboratory Medicine, National Institutes of Health, Bethesda, MD
| | - Alan T Remaley
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - David B Sacks
- Department of Laboratory Medicine, National Institutes of Health, Bethesda, MD
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Ayala-Lopez N, Harb R. Interpreting Anion Gap Values in Adult and Pediatric Patients: Examining the Reference Interval. J Appl Lab Med 2020; 5:126-135. [PMID: 32445342 DOI: 10.1373/jalm.2019.029496] [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: 02/24/2019] [Accepted: 05/06/2019] [Indexed: 11/06/2022]
Abstract
BACKGROUND The anion gap is primarily used in the diagnosis of acid-base disorders. We conducted a study to determine the anion gap reference interval in our patient population, investigated the workup of abnormal vs normal anion gaps, and examined the anion gap variation upon repeated testing. METHODS A retrospective review was performed on 17137 adult and pediatric patients who presented to Yale-New Haven Hospital outpatient clinics, emergency department, or intensive care units between 2012 and 2017. RESULTS We derived a new reference interval of 7 to 18 mmol/L with a median of 13 mmol/L in healthy adults with no significant differences owing to partitioning by sex or age. Based on the new reference interval, 5%, 23%, and 18% of healthy, emergency department, and intensive care unit adult patients, respectively, were misclassified as having high values with the previous interval of 6 to 16 mmol/L. However, there were no significant differences in the number of tests ordered in patients with anion gaps above and below the upper limit of the previous reference interval. The majority of increased anion gaps that were repeated normalized by 12 h. In a subgroup of healthy adult patients with annual testing, the median percent change in each patient's anion gap from 2015 to 2016 was approximately 13%. CONCLUSIONS The anion gap should be used with an appropriate reference interval to avoid misclassification. There may be a moderate degree of individuality that argues for comparing the anion gap with its baseline value in the same patient pending further studies that formally derive its biological variation.
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Affiliation(s)
- Nadia Ayala-Lopez
- Department of Laboratory Medicine, Yale School of Medicine, New Haven, CT
| | - Roa Harb
- Department of Laboratory Medicine, Yale School of Medicine, New Haven, CT
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12
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Harb R, Hajdasz D, Landry ML, Sussman LS. Improving laboratory test utilisation at the multihospital Yale New Haven Health System. BMJ Open Qual 2019; 8:e000689. [PMID: 31637323 PMCID: PMC6768328 DOI: 10.1136/bmjoq-2019-000689] [Citation(s) in RCA: 7] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Revised: 07/26/2019] [Accepted: 08/20/2019] [Indexed: 02/05/2023] Open
Abstract
Background Waste persists in healthcare and negatively impacts patients. Clinicians have direct control over test ordering and ongoing international efforts to improve test utilisation have identified multifaceted approaches as critical to the success of interventions. Prior to 2015, Yale New Haven Health lacked a coherent strategy for laboratory test utilisation management. Methods In 2015, a system-wide laboratory formulary committee was formed at Yale New Haven Health to manage multiple interventions designed to improve test utilisation. We report here on specific interventions conducted between 2015 and 2017 including reduction of (1) obsolete or misused testing, (2) duplicate orders, and (3) daily routine lab testing. These interventions were driven by a combination of modifications to computerised physician order entry, test utilisation dashboards and physician education. Measurements included test order volume, blood savings and cost savings. Results Testing for a number of obsolete/misused analytes was eliminated or significantly decreased depending on alert rule at order entry. Hard stops significantly decreased duplicate testing and educational sessions significantly decreased daily orders of routine labs and increased blood savings but the impact waned over time for select groups. In total, we realised approximately $100 000 of cost savings during the study period. Conclusion Through a multifaceted approach to utilisation management, we show significant reductions in low-value clinical testing that have led to modest but significant savings in both costs and patients’ blood.
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Affiliation(s)
- Roa Harb
- Department of Laboratory Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - David Hajdasz
- Clinical Redesign, Office of Strategy Management, Yale New Haven Health System, New Haven, Connecticut, USA
| | - Marie L Landry
- Departments of Laboratory Medicine and Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - L Scott Sussman
- Clinical Redesign, Department of Medicine, Yale New Haven Health System, New Haven, Connecticut, USA
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Ayala-Lopez N, Ghaedi M, Peaper D, Harb R. Performance of the Procalcitonin Test in Diagnosing Pneumonia in Real-World Practice. Am J Clin Pathol 2019. [DOI: 10.1093/ajcp/aqz112.069] [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] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Procalcitonin (PCT) rises early upon bacterial infection and has a long-half life, making it useful in the diagnosis of infections and antibiotic stewardship. We sought to determine the utility of PCT in diagnosing pneumonia (PNU) in the patient population presenting to our hospital during real-world clinical practice.
Methods
PCT results from patients in 2015 were reviewed retrospectively. Patients were eligible for inclusion if all of following criteria were met: PCT in 2015 and a lower respiratory tract culture, respiratory virus testing, chest x-ray, and white blood cell (WBC) count within 1 day of the PCT. Patients who opted out of research and those with mycobacterial infections and culture-positive infections of body sites other than urine and lower respiratory tract were excluded from further analysis.
Results
A total of 400 patients remained with 413 eligible PCT results across the ED (109), ICU (134), and inpatient (167) and outpatient (3) areas with a mean (SD) age of 66.2 (18.1). PCT was higher in patients with multiple pathogens reported on their respiratory cultures, direct fluorescence antibody (DFA), or PCR-based tests (mean ± SD = 2.43 ± 0.74 ng/mL; N = 32), than those with no pathogens reported (3.25 ± 1.13 ng/mL; N = 224; P < .05). Patients were grouped for the presence or absence of clinically defined PNU, according to a modification of the Centers for Disease Control (CDC) PNU1 criteria incorporating (1) chest x-ray results, (2) altered WBC number/altered mental status/fever, and (3) respiratory/breathing signs. PCT was higher in patients with clinically defined PNU, and the high PCTs were consistent with positive chest x-rays (criterion 1), and positive criterion 2 but not criterion 3. Incorporation of an elevated PCT >0.1 ng/mL into the PNU score slightly improved the area under the ROC curve (AUC) for the algorithm’s detection of PNU against the final clinical diagnosis (0.73 without PCT vs 0.76 with PCT). Furthermore, higher PCT was associated with higher 30-day and 1-year mortality.
Conclusion
PCT results were largely consistent with other markers of PNU such as imaging and CDC criterion 2, which suggests that PCT can be useful in evaluating for the presence of PNU. However, the PCT may not add additional information to assist in decision making above the already commonly ordered tests.
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Swift CP, Gwaikolo C, Ssentamu J, Wachekwa I, Adeiza MA, Adu E, Harb R. Body Fluid Testing at John F. Kennedy Medical Center in Liberia. Am J Clin Pathol 2019; 152:86-90. [PMID: 31165167 DOI: 10.1093/ajcp/aqz027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [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: 01/29/2023] Open
Abstract
OBJECTIVES To apply a simple method to validate testing for albumin, glucose, lactate dehydrogenase (LDH) and total protein (TP) in peritoneal, pleural, and cerebrospinal fluids (CSF) at a hospital in Liberia. METHODS Serum and body fluid specimens were mixed to create 100% serum and 25%, 50%, 75%, and 100% fluid tubes, which were tested on a Biotecnica BT3500. Differences less than 10% between calculated and measured concentrations were considered acceptable. RESULTS The means (confidence intervals) of the percent differences were: albumin/peritoneal 12.8 (6.0-19.7), albumin/pleural 2.8 (1.3-4.2), albumin/CSF 4.8 (2.2-7.5), glucose/peritoneal 4.0 (1.9-6.0), glucose/pleural 4.4 (3.1-5.7), glucose/CSF 2.9 (1.8-4.0), LDH/peritoneal 9.5 (6.3-12.7), LDH/pleural 9.5 (5.4-13.6), LDH/CSF 9.2 (5.2-13.3), TP/peritoneal 7.6 (3.8-11.4), TP/pleural 3.8 (1.5-6.2), and TP/CSF 4.5 (1.0-8.1). CONCLUSIONS All mean differences except for one were less than 10%, allowing for the adoption of clinical testing. The mixing study is a low-cost method for quality-assured testing that can be performed by resource-limited laboratories.
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Affiliation(s)
- Callum P Swift
- Tallaght University Hospital, Dublin, Ireland
- John F. Kennedy Medical Center, Monrovia, Liberia
| | | | - John Ssentamu
- Liberia College of Physicians and Surgeons, Monrovia, Liberia
| | - Ian Wachekwa
- John F. Kennedy Medical Center, Monrovia, Liberia
| | - Mukhtar A Adeiza
- Ahmadu Bello University Teaching Hospital, Zaria, Nigeria
- John F. Kennedy Medical Center, Monrovia, Liberia
| | - Eric Adu
- John F. Kennedy Medical Center, Monrovia, Liberia
| | - Roa Harb
- John F. Kennedy Medical Center, Monrovia, Liberia
- Department of Laboratory Medicine, Yale School of Medicine, New Haven, CT
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Ayala-Lopez N, Ghaedi M, Peaper D, Harb R. Procalcitonin's performance in diagnosing pneumonia in real-world practice. Clin Chim Acta 2019. [DOI: 10.1016/j.cca.2019.03.1170] [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: 10/26/2022]
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16
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Albright B, Dhaher R, Wang H, Harb R, Lee TSW, Zaveri H, Eid T. Progressive neuronal activation accompanies epileptogenesis caused by hippocampal glutamine synthetase inhibition. Exp Neurol 2016; 288:122-133. [PMID: 27769717 DOI: 10.1016/j.expneurol.2016.10.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Revised: 09/29/2016] [Accepted: 10/13/2016] [Indexed: 01/01/2023]
Abstract
Loss of glutamine synthetase (GS) in hippocampal astrocytes has been implicated in the causation of human mesial temporal lobe epilepsy (MTLE). However, the mechanism by which the deficiency in GS leads to epilepsy is incompletely understood. Here we ask how hippocampal GS inhibition affects seizure phenotype and neuronal activation during epilepsy development (epileptogenesis). Epileptogenesis was induced by infusing the irreversible GS blocker methionine sulfoximine (MSO) unilaterally into the hippocampal formation of rats. We then used continuous video-intracranial electroencephalogram (EEG) monitoring and c-Fos immunohistochemistry to determine the type of seizures and spatial distribution of neuronal activation early (1-5days postinfusion) and late (16-43days postinfusion) in epileptogenesis. Early in epileptogenesis, seizures were preferentially mild (stage 1-2), activating neurons in the entorhinal-hippocampal area, the basolateral amygdala, the piriform cortex, the midline thalamus, and the anterior olfactory area. Late in epileptogenesis, the seizures were generally more severe (stages 4-5) with neuronal activation extending to the neocortex, the bed nucleus of the stria terminalis, the mediodorsal thalamu\s, and the central nucleus of the amygdala. Our findings demonstrate that inhibition of GS focally in the hippocampal formation triggers a process of epileptogenesis characterized by gradual worsening of seizure severity and involvement of progressively larger neuronal populations over a period of several weeks. Knowledge about the underlying mechanism of epileptogenesis is important because such knowledge may result in more specific and efficacious treatments of MTLE by moving away from large and poorly specific surgical resections to highly targeted surgical or pharmacological interventions of the epileptogenic process.
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Affiliation(s)
- Benjamin Albright
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, CT 06520, USA
| | - Roni Dhaher
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, CT 06520, USA
| | - Helen Wang
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, CT 06520, USA
| | - Roa Harb
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, CT 06520, USA
| | - Tih-Shih W Lee
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT 06520, USA
| | - Hitten Zaveri
- Department of Neurology, Yale University School of Medicine, New Haven, CT 06520, USA
| | - Tore Eid
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, CT 06520, USA.
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Abstract
Fear is a well-characterized biological response to threatening or stressful situations in humans and other social animals. Importantly, fearful stimuli in the natural environment are likely to be encountered concurrently by a group of animals. The modulation of fear acquisition and fear memory by a group as opposed to an individual experience, however, remains largely unknown. Here, we demonstrate a robust reduction in fear memory to an aversive event undertaken in a group despite similar fear learning between individually- and group-conditioned rats. This reduction persists outside the group confines, appears to be a direct outcome of group cognizance and is counteracted by loss of olfactory signaling among the group members. These results show that a group experience of fear can be protective and suggest that distinct neural pathways from those classically studied in individuals modulate collective fear memories.
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Affiliation(s)
- Roa Harb
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, Connecticut, United States of America
| | - Jane R. Taulor
- Department of Psychiatry, Division of Molecular Psychiatry, Yale University School of Medicine, New Haven, Connecticut, United States of America
- * E-mail:
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Abstract
Cerebral function and viability are critically dependent on efficient delivery of oxygen and glucose through the microvasculature. Here, we studied individual microvessels in the intact brain using high-resolution confocal imaging and long-term time-lapse two-photon microscopy across the lifetime of a mouse. In the first postnatal month, we found large-scale sprouting but to our surprise the majority of sprouts underwent pruning and only a small fraction became perfused capillaries. After the first month, microvessel formation and elimination decreased and the net number of vessels stabilized. Although vascular stability was the hallmark of the adult brain, some vessel formation and elimination continued throughout life. In young adult mice, vessel formation was markedly increased after exposure to hypoxia; however, upon return to normoxia, no vessel elimination was observed, suggesting that new vessels constitute a long-term adaptive response to metabolic challenges. This plasticity was markedly reduced in older adults and aging where hypoxia-induced angiogenesis was absent. Our study describes, for the first time in vivo patterns of cerebral microvascular remodeling throughout life. Disruption of the observed balance between baseline turnover and vascular stability may underlie a variety of developmental and age-related degenerative neurological disorders.
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Affiliation(s)
- Roa Harb
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, CT, USA
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Allam R, Galal W, El-Damnhoury H, Mortada A, Guo R, Fang F, Xie JM, Zhang Q, Chan YS, Fung WH, Razali O, Azlan H, Lam KH, Chan CK, Yu CM, Wong FMF, Sit JWH, Wong EML, Lee V, Hemingway H, Harb R, Crake T, Lambiase P, Zhao QY, Yu SB, Huang H, Qin M, Cui HY, Huang T, Huang CX, Leung YW, Yue CS, Leung KF, Fung CYR, Mak YMW, Chow KS, Tang SK, Sperzel J, Tscheliessnigg K, Bucx JJJ, Silvestre J, Oza AL, Yu Mironov N, Golitsyn SP, Sokolov SF, Yuricheva YA, Maikov EB, Shlevkov NB, Mareev YV, Rosenstraukh LV, Chazov EI, Li BN, Qin J, Xiang K, Pang WM, Wang LS, Wu HS, Qin J, Wong TT, Yu CM, Heng PA, Clatot J, Ziyadeh-Isleem A, Coulombe A, Maugenre S, Dilanian G, Hatem S, Denjoy I, Neyroud N, Guicheney P, Plameras GB, Valentin MV, Ramirez M, Suga C, Hirahara T, Sugawara Y, Nakajima J, Wakaba H, Ako J, Momomura S, Ye Volkov D, Karpenko YI, Lopin DA, Chair SY, Lee JCK, Choi KC, Sit JWH, Wong EM, Chan CWH, So WKW, Cheng AHY, Hamid AK, Lainchbury JG, Troughton RW, Yandle TG, Frampton CM, Richards AM. P001 * Reversal of endothelial dysfunction after AF cardioversion. Eur Heart J Suppl 2012. [DOI: 10.1093/eurheartj/sur022] [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: 11/14/2022]
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El-Sahhar, K, Badr L, Harb R, Abd Al-Mageed H. MORPHOLOGICAL, HISTOLOGICAL AND CHEMICAL INVESTIGATIONS OF Tagetes patula L. Journal of Plant Production 2000; 25:5051-5076. [DOI: 10.21608/jpp.2000.259552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
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Abstract
Nitric oxide synthase (NOS) activity was measured in extensor digitorum longus (EDL) and soleus muscles during postnatal development in the rat. At 1 and 2 weeks of age, similar low levels were found in both muscles. After 2 weeks, activity increased significantly only in EDL. Adult NOS activity was significantly higher in EDL than soleus. Thus, the preferential expression of NOS in fast muscle only occurs once the adult pattern of motor activity is established.
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Affiliation(s)
- J Lincoln
- Autonomic Neuroscience Institute, Royal Free Hospital School of Medicine, London, United Kingdom
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