Clinical Laboratory Reference Intervals in Ethiopia: Current Status and Future Considerations: Review

<i>Background:</i> Clinical laboratory reference intervals are derived from a sample of selected healthy population and they are used for disease diagnosis, management, and monitoring. International guidelines recommended that laboratories and manufacturers are supposed to establish their own RIs for a certain group of population. Therefore, the aim of this narrative review is to summarize the current status and to show future directions regarding reference intervals of clinical laboratory parameters among Ethiopian population. <i>Methods:</i> PubMed, Google Scholar, and Google databases were searched to access relevant reference interval studies in Ethiopia. Journal articles, guidelines, reports, and related documents published in English language were included without publication period restriction. <i>Results:</i> Fifteen studies were conducted to establish local reference intervals for hematology, immunology, and clinical chemistry parameters in Ethiopia from 1999 - 2018. The majority of those studies determined clinical laboratory reference intervals for adults only. Some other Ethiopian reference interval studies did not include the majority of routine hematology and clinical chemistry parameters. In addition, the studies we reviewed did not consider the cultural, ethnic, demographic, and geographical diversity of Ethiopian population. <i>Conclusions:</i> There is limited data regarding locally established reliable clinical laboratory reference intervals in Ethiopia though attempts are made. Therefore, further local reference interval studies should be undertaken considering the cultural, ethnic, demographical, and geographical diversity of the Ethiopian population.

Preanalytical external quality assessment of the Croatian Society of Medical Biochemistry and Laboratory Medicine and CROQALM: finding undetected weak spots

INTRODUCTION

The aim of this paper is to present results of first two years of preanalytical external quality assessment (EQA) in Croatia.

MATERIALS AND METHODS

This paper summarizes results from 6 rounds of preanalytical EQA during 2014-2016 in 161-175 Croatian laboratories (number ranged between cycles). EQA was designed as an online survey of the compliance with National recommendations for phlebotomy (NRP). Forty-seven questions in 5 categories are analyzed (materials and equipment, patient identification, patient preparation, sampling and storage). Additionally, preanalytical cases are presented. Overall performance scores (Question score (Qscore) for compliance with NRP and Case score (Cscore) for preanalytical cases) are calculated for each question/case as a proportion of laboratories with satisfactory procedure (x 100). Qscores and Cscores ≥ 70 were classified as acceptable (maximal score = 100).

RESULTS

In investigation of compliance with NRP, acceptable Qscores were obtained for 34/47 questions. The lowest scores were observed for the availability of sterile disposable tourniquets (Qscore = 15) and safe-sharp needles (Qscore = 34), obtaining patients address as an identifier (Qscore = 21), using glycolysis inhibitor tubes for glucose concentration measurement (Qscore = 21) and verification of manufacturers declarations on temperature and time of storage (Qscore = 31). There was no statistically significant difference in overall Qscore according to different categories of phlebotomy procedures (P = 0.284). The results of preanalytical cases showed acceptable Cscore values for all cases (89-96).

CONCLUSION

First two years of preanalytical EQA showed good compliance with the NRP and excellent expertise in resolving complex preanalytical issues. Major critical spots are lack of availability of safe-sharp needles, disposable tourniquets and glucose inhibitor tubes.

Policies and practices in haemostasis testing among laboratories in Croatia: a survey on behalf of a Working Group for Laboratory Coagulation of the Croatian Society of Medical Biochemistry and Laboratory Medicine

INTRODUCTION

The objective of this survey was to assess current policies and practice in haemostasis testing among both hospital and outpatient laboratories in Republic of Croatia.

MATERIALS AND METHODS

A questionnaire with seventy questions divided into nine sections was created in May 2015. Participants were asked about their practice related to test request form, sample collection, prothrombin time (PT) and activated partial thromboplastin time assays, other individual haemostasis assays, point-of-care testing (POCT), reporting of coagulation tests results and quality assurance of procedures, the personnel and other laboratory resources, as well as on issues related to education and implementation of additional coagulation assays in their laboratory. The survey was administered and data were collected between June and September 2015.

RESULTS

A total survey response rate was 104/170 (61.2%). Most respondents were faced with incomplete information on prescribed therapy and diagnosis on the test request or inappropriate samples withdrawn on distant locations, but also do not have protocols for handling samples with high haematocrit values. Reporting of PT-INR and D-dimer results was different between laboratories. Although almost all laboratories developed a critical value reporting system, reporting a value to general practitioners is still a problem. Result on coagulation POCT testing showed that not all devices were supervised by laboratories, which is not in compliance with Croatian Chamber of Medical Biochemistry acts.

CONCLUSION

Obtained results highlighted areas that need improvement and different practice patterns in particular field of haemostasis testing among laboratories. A harmonization of the overall process of haemostasis testing at national level should be considered and undertaken.

The role of EQA in harmonization in laboratory medicine - a global effort

There are many activities currently being undertaken in the field of laboratory medicine under the broad heading of "harmonization". These include traceability of results to international reference standards, processes to align results from assays where traceability has not been achieved (analytical harmonization) and international or national clinical guidelines based on studies from many parts of the world. Many of these issues are global in nature, with clinical evidence derived from studies performed in all parts of the world and multinational diagnostic companies providing assays worldwide. As with all aspects of medicine, progress can only be assured where these is evidence of effectiveness of the activities. External Quality Assurance (EQA) programs are designed to meet this need. Currently EQA processes have significant limitations in meeting the global needs of the laboratory medicine community. This paper aims to identify the steps that can be taken to allow current and future EQA programs to provide information on global variation in results. It is only by being aware of result differences that steps can be taken to improve performance.

An Analysis of Medical Laboratory Technology Journals' Instructions for Authors

Instructions for authors (IFA) need to be informative and regularly updated. We hypothesized that journals with a higher impact factor (IF) have more comprehensive IFA. The aim of the study was to examine whether IFA of journals indexed in the Journal Citation Reports 2013, "Medical Laboratory Technology" category, are written in accordance with the latest recommendations and whether the quality of instructions correlates with the journals' IF. 6 out of 31 journals indexed in "Medical Laboratory Technology" category were excluded (unsuitable or unavailable instructions). The remaining 25 journals were scored based on a set of 41 yes/no questions (score 1/0) and divided into four groups (editorial policy, research ethics, research integrity, manuscript preparation) by three authors independently (max score = 41). We tested the correlation between IF and total score and the difference between scores in separate question groups. The median total score was 26 (21-30) [portion of positive answers 0.63 (0.51-0.73)]. There was no statistically significant correlation between a journal's IF and the total score (rho = 0.291, P = 0.159). IFA included recommendations concerning research ethics and manuscript preparation more extensively than recommendations concerning editorial policy and research integrity (Ht = 15.91, P = 0.003). Some policies were poorly described (portion of positive answers), for example: procedure for author's appeal (0.04), editorial submissions (0.08), appointed body for research integrity issues (0.08). The IF of the "Medical Laboratory Technology" journals does not reflect a journals' compliance to uniform standards. There is a need for improving editorial policies and the policies on research integrity.

Task Analysis Revisited

A random sample of 500 phlebotomy technicians certified by a national organization was queried regarding perceptions of importance of 53 specific practice-related tasks representative of various departmental areas. The sample was surveyed via a mail questionnaire. Role centrality was assessed by considering mean importance ratings and by applying the Rasch measurement model to assigned importance ratings. Approximately 36% of the questionnaires received by respondents were returned. The results revealed which tasks were fundamental to the phlebotomy technician scope of practice. To assess longitudinal change in core duties, task saliency was considered with respect to similar data collected a decade earlier. Task importance may be considered by agencies that educate, credential, or employ phlebotomy technicians in providing current job function descriptions. The longitudinal methodology employed may be applicable to other job roles for which the assessment of change is of interest.

[Role of Medical Technologists as Certified Clinical Chemistry and Inununochemistry Test Quality Assurance Managers in International Standardization]

In Japan, biochemical testing has been standardized by establishing secondary reference measurement procedures for each method under the leadership of the Japan Society of Clinical Chemistry (JSCC). This has led to the assignment of values to secondary calibration materials, enabling laboratories to manage the accuracy of measurement values using them. To promote the sharing of test data by standardizing base facilities on a nationwide basis, the Japanese As- sociation of Medical Technologists (JAMT) launched the Laboratory Test Data Standardization Project. The range of reference for biochemical testing was calculated, and the absence of regional differences in such a range was confirmed by standardized base facilities throughout Japan. Through collaboration between the JSCC and JAMT, the Clinical Chemistry and Immunochemistry Test Quality Assurance Manager Certification System was established in 2014, with a view to promoting quality assurance in laboratories. It is expected that medical technologists who are certified as such managers will contribute to the nationwide provision of high-quality medical services. [Review].

[Standardization and Quality Assurance in Laboratory Medicine]

The standardization of clinical laboratory and compatible clinical data is needed for accurate diagnosis in routine medical practice or medical care. An external quality survey program (EQSP) in clinical laboratory testing and recommendation methods for laboratory test and/or standard materials are proposed. Many megaEQSPs in Japan have problems, such as examination samples (matrix and spike materials in abnormal specimens) and valuation basis. Proposals for EQSP are being developed: EQSP with fresh blood, EQSP using internal quality control, and control serum using donated blood (MaCRM).

Dystrophin quantification: Biological and translational research implications

OBJECTIVE

We formed a multi-institution collaboration in order to compare dystrophin quantification methods, reach a consensus on the most reliable method, and report its biological significance in the context of clinical trials.

METHODS

Five laboratories with expertise in dystrophin quantification performed a data-driven comparative analysis of a single reference set of normal and dystrophinopathy muscle biopsies using quantitative immunohistochemistry and Western blotting. We developed standardized protocols and assessed inter- and intralaboratory variability over a wide range of dystrophin expression levels.

RESULTS

Results from the different laboratories were highly concordant with minimal inter- and intralaboratory variability, particularly with quantitative immunohistochemistry. There was a good level of agreement between data generated by immunohistochemistry and Western blotting, although immunohistochemistry was more sensitive. Furthermore, mean dystrophin levels determined by alternative quantitative immunohistochemistry methods were highly comparable.

CONCLUSIONS

Considering the biological function of dystrophin at the sarcolemma, our data indicate that the combined use of quantitative immunohistochemistry and Western blotting are reliable biochemical outcome measures for Duchenne muscular dystrophy clinical trials, and that standardized protocols can be comparable between competent laboratories. The methodology validated in our study will facilitate the development of experimental therapies focused on dystrophin production and their regulatory approval.

[The requirements of standard and conditions of interchangeability of medical articles]

The article deals with possibility to apply specific approaches under evaluation of interchangeability of medical articles for laboratory analysis. The development of standardized analytical technologies of laboratory medicine and formulation of requirements of standards addressed to manufacturers of medical articles the clinically validated requirements are to be followed. These requirements include sensitivity and specificity of techniques, accuracy and precision of research results, stability of reagents' quality in particular conditions of their transportation and storage. The validity of requirements formulated in standards and addressed to manufacturers of medical articles can be proved using reference system, which includes master forms and standard samples, reference techniques and reference laboratories. This approach is supported by data of evaluation of testing systems for measurement of level of thyrotrophic hormone, thyroid hormones and glycated hemoglobin HB A1c. The versions of testing systems can be considered as interchangeable only in case of results corresponding to the results of reference technique and comparable with them. In case of absence of functioning reference system the possibilities of the Joined committee of traceability in laboratory medicine make it possible for manufacturers of reagent sets to apply the certified reference materials under development of manufacturing of sets for large listing of analytes.

Patient data algorithms

As the clinical laboratory attempts to manage and mitigate risk, individual patient results can be a useful complement to routine quality-control materials. Patient results can be used to detect error or identify potential testing complications at all phases of the total testing process. Patient-specific data algorithms include delta checks, tests to verify specimen or tube type, absurdity checks, and result-based reporting. Delta checks are highlighted because they can uniquely point to issues all along the testing cycle, from preanalytical to postanalytical concerns. When used properly, patient results can work to minimize risk and increase the quality of individual patient results.

[Medical support on human resources and clinical laboratory in Myanmar]

I have been involved in medical cooperation programs between Myanmar and Japan for over 10 years. The purpose of the first visit to Myanmar was the investigation of hepatitis C spreading among thalassemia patients. I learned that the medical system was underdeveloped in this country, and have initiated several cooperation programs together with Professor Shigeru Okada, such as the "Protection against hepatitis C in Myanmar", "Scientist exchange between the Ministry of Health, Myanmar and Okayama University", and "Various activities sponsored by a Non-Profit Organization". As for clinical laboratories, the laboratory system itself is pre-constructed and the benefit of a clinical laboratory in modern medicine is not given to patients in Myanmar. The donation of drugs and reagents for laboratory tests is helpful, but it will be more helpful to assist the future leaders to learn modern medicine and develop their own various systems to support modern medicine. Our activity in the cooperation program is described.

A professional development model for medical laboratory scientists working in the Core Laboratory

The Division of Pathology and Laboratory Medicine at The University of Texas MD Anderson Cancer Center has implemented a professional development model designed to further the education, expertise, and experiences of medical laboratory scientists in the core laboratory. The professional development model (PDM) has four competency levels: Discovery, Application, Maturation and Expert. All levels require the medical laboratory scientist to learn new skill sets, complete task and projects, and meet continuing education and certification requirements. Each level encourages personal development, recognizes increased competencies, and sets high standards for all services provided. Upon completion of a level within a given timeframe, the medical laboratory scientist receives a salary adjustment based on the competency level completed.

Determination of a reference interval in a population

The reference interval is the most widely used medical decision-making tool that separates healthy from diseased individuals. We briefly discuss the methods used to determine reference interval and its limitations.

It takes a community to resurrect a CLS program

Florida Gulf Coast University (FGCU) revised and reactivated its former 2+2 NAACLS accredited program in 2006, by instituting an innovative 3+1 approach. With the efforts of the community laboratories, FGCU instituted an innovative structure which made its CLS program more viable by greatly reducing expenses of operation without sacrificing the quality of education.

Research in the Medical Laboratory Science curriculum

Medical Laboratory Science (MLS) is increasing its numbers of advanced degree offerings and is accelerating involvement in evidence-based practice. Expectations of MLS faculty have increased to include research and scholarship. Many MLS programs have undergraduate requirements for research. To assist MLS faculty as they increase research productivity, information is provided to guide professionals and students striving to expand their research achievements.

The utility of essential functions in clinical laboratory science programs

OBJECTIVE

Essential functions (EF) define the nonacademic criteria used to determine an individual's qualifications for admission and capabilities of performing in the classroom and laboratory with or without reasonable accommodations. Directors of NAACLS approved and accredited programs were surveyed to investigate their knowledge and perceptions of EF and associations with disabilities and student behaviors.

DESIGN

This was a non-experimental survey consisting of questions related to the use of essential functions (EF) and student behaviors in NAACLS laboratory programs. SurveyMonkey was used to electronically provide the survey of 33 questions to 564 NAACLS programs.

RESULTS

Descriptive statistics were reported as aggregate data with a response rate of 267 (47.3%). EF are utilized in 95.5% of the programs; however, only 38.6% of the participants responded that EF are required by both the ADA and NAACLS. A student had never been dismissed based on EF in 80.0% of the programs. Many programs have been successful in mentoring students with disabilities to successful completion. Hearing impairment was the most reported disability (30.0%). Participants felt most comfortable referring students for academic coaching (96.2%) when compared to medical concerns (86.5%), and psychological concerns (82.7%).

CONCLUSIONS

While most programs utilized EF, many program directors were not aware that EF are required by both NAACLS and the ADA. Programs have successfully instructed and graduated students with a variety of disabilities and generally feel comfortable in referring students for assistance. Concerns with inappropriate behaviors present unique, generational challenges to faculty.

CLS entry level competencies in flow cytometry

OBJECTIVE

To define entry level competencies in flow cytometry for CLS generalists.

DESIGN

Flow cytometry practitioners completed an electronic survey. Of 134 respondents, 131 met the desired demographics and were analyzed.

SETTING

Links to the survey were mailed to 3 listservs (Medlab-L, CLSEduc, Purdue Cytometry) and 2 email groups (ASCLS and AMLI). Participants completed the survey on-line.

PARTICIPANTS

The target population was flow cytometry practitioners who had experienced CLS education, earned certification and practiced at least one year in flow. Survey instructions asked participants not to complete the survey if they did not meet the demographic criteria.

MAIN OUTCOME MEASURES

A competency was deemed important at entry level if > or = 50% of respondents agreed.

RESULTS

There was strong consensus (62-87%) that entry level CLS generalists should be able to 1) perform HIV CD4/CD8 monitoring, 2) gate cell populations using forward/side scatter and CD45/bright/dim markers and 3) evaluate specimen acceptability. Concepts to understand included leukemia immunophenotyping, quality control and instrument principles (61-83%). Most respondents (74%) felt that memorization of the leukemic CD panels was unnecessary. However, survey results indicated that the markers and cell type associations to memorize are CD3, CD4, CD8, CD19/20, CD34, CD45 and light chains. Hands-on experience with instruments was not identified as critical.

CONCLUSION

CLS educational programs can deliver almost all flow cytometry content in the didactic portion of the curriculum and can restrict CD marker memorization to a limited list. At minimum, HIV monitoring via CD4/CD8 counts and concepts of leukemia immunophenotyping should be included.

Technology as a force for improved diagnosis and treatment of breast disease

Increasing numbers of women are seeking evaluation of screen-detected breast abnormalities, and more women with breast cancer are living with the consequences of treatment. Improved technologies have helped to individualize diagnostic evaluation and treatment, improve efficacy and minimize morbidity. This article highlights some of these technologies. Superior imaging techniques have improved breast cancer screening and show promise for intraoperative surgical guidance and postoperative specimen evaluation. Digital mammography improves the sensitivity of mammography for women younger than 50 years with dense breasts, and tomosynthesis may improve specificity. Magnetic resonance imaging provides sensitive delineation of the extent of the disease and superior screening for women with a greater than 25% lifetime risk of breast cancer Minimally invasive techniques have been developed for the assessment of intraductal lesions, biopsy of imaging abnormalities, staging of the axilla and breast radiotherapy. Ductoscopy facilitates intraductal biopsy and localization of lesions for excision, sentinel lymph node biopsy is becoming standard for axillary staging, and intraoperative radiotherapy has the potential to reduce treatment time and morbidity. Three-dimensional imaging allows correlation of final histology with preoperative imaging for superior margin assessment. Related techniques show promise for translation to the intraoperative setting for surgical guidance. New classifications of breast cancers based on gene expression, rather than morphology, describe subtypes with different prognoses and treatment implications, and new targeted therapies are emerging. Genetic fingerprints that predict treatment response and outcomes are being developed to assign targeted treatments to individual patients likely to benefit. Surgeons play a vital role in the successful integration of new technologies into practice.

[Approach for prevention of medical test malpractice using ISO 15189]

With the increasing need for medical laboratory data, the importance of the medical laboratory in medical care has grown exponentially. Therefore, it is necessary that the medical laboratory provide the doctor and the patient receiving medical care with accurate, precise, and reliable medical laboratory data. Quality assurance and safety management in the medical laboratory are necessary to prevent medical test malpractice, which would lead to a medical accident, and to manage the overall processes required to provide high quality medical laboratory data. ISO 15189 is an international standard known as an organizational management tool for medical laboratories. Our medical laboratory acquired this ISO in March 2005 and we utilized PDCA cycle as required by the international standard in order to establish appropriate safety management and crisis control. We introduced practices for quality improvement and prevention of medical test malpractice proposed by the ISO committee of our medical laboratory and describe these practices in this report.

[Comprehensive management of clinical laboratory for appropriate antimicrobial use]

Accurate diagnosis of infectious diseases is essential for appropriate antimicrobial use. The following five factors should be promoted to accurately diagnose infectious diseases; everyday availability of microbiology laboratory, submitting only appropriate specimens for laboratory examination, providing accurate results to physicians with a rapid turnaround time, and reporting useful information to assist in treatment and delivering educational lectures on clinical microbiology to hospital staff. As a director of a clinical laboratory in a university hospital, I have tackled these issues. Not only laboratory performance and activity, but the information system for healthcare workers were significantly improved. As a result, appropriate antimicrobial use has been achieved in part.

The technology acceptance model: its past and its future in health care

Increasing interest in end users' reactions to health information technology (IT) has elevated the importance of theories that predict and explain health IT acceptance and use. This paper reviews the application of one such theory, the Technology Acceptance Model (TAM), to health care. We reviewed 16 data sets analyzed in over 20 studies of clinicians using health IT for patient care. Studies differed greatly in samples and settings, health ITs studied, research models, relationships tested, and construct operationalization. Certain TAM relationships were consistently found to be significant, whereas others were inconsistent. Several key relationships were infrequently assessed. Findings show that TAM predicts a substantial portion of the use or acceptance of health IT, but that the theory may benefit from several additions and modifications. Aside from improved study quality, standardization, and theoretically motivated additions to the model, an important future direction for TAM is to adapt the model specifically to the health care context, using beliefs elicitation methods.

Management of a point-of-care testing program

The approach to managing a point-of-care testing (POCT) program has evolved over recent years. Although many of the essential features of early POCT management programs remain intact, contemporary challenges including expansion of the test menu, changing regulatory requirements, and the development of more sophisticated data management connectivity require ongoing adaptation of POCT management programs. Despite improvements in test quality and regulatory compliance, significant challenges for the management of POCT will continue for the foreseeable future.

Preparing online students for comprehensive examinations

OBJECTIVE

Identify and remedy difficulties in the preparation of online students for certification examination success.

DESIGN

The final examination scores for the CLS Seminar course for the 2008 class of 27 on-campus and 10 online students were compared for statistical differences in seven examination areas. Problem areas were identified and changes in the CLS Seminar course were made in 2009 to improve the scores of the online students. The examination scores for the 2009 class of 33 on-campus and 10 online students were studied to determine improvement. Student's two-tailed t-test was used to determine statistical significance of differences between scores of on-campus and online students.

INTERVENTIONS

Interactive video over the web; used to answer online student questions, review games, more class time, and more recorded review sessions; were added to the Seminar. The study guides provided during preceptorships were tied to the objectives of the seminar course and the questions on examinations. Specific objectives for each question missed on the final examinations were provided to the student.

RESULTS

In 2008, examination scores for online students were lower in two of seven areas by a statistically significant amount than on-campus students. The difference approached significance in a third area. After interventions in 2009, the examinations scores had equalized with the exception of one area, Immunology.

CONCLUSION

Increasing the amount and method of review in areas deemed important to online education was successful in improving examination scores.

[On the issue of supplying the high-technology medical care to the oncological patients residing in the distant territories]

The article deals with the issue of improving the high-technology medical care provision to population with oncological pathology residing the northern territory. The results of sociological survey are presented. The medical personnel made the expertise of the criteria to develop the specification listing of medical services related to the category of high-technology medical care exemplified by the oncological care. This approach can be applied as a foundation for further identification of the population need in high-technology medical care at municipal and regional levels.

['State of the nation's healthcare 2008' annual report: technology is useful, but training comes first]

The Netherlands Health Care Inspectorate's annual report on the state of the nation's healthcare in 2008 is dedicated to the use of medical technology. The subtitle of the report is 'Risks of medical technology underestimated'. Lack of education and training expose patients to an unacceptable risk of injury within both the care and the cure setting. The Inspectorate urgently recommends applying a certification system to physicians to guarantee safe and appropriate use of devices and equipment. The administration of an institution has the primary responsibility for the visible implementation of risk and safety management. Also, the medical professional must become familiar with the principles of engineering and be trained in applying a systematic approach to safety and reliability within medical technology. This annual report provides recommendations on how to incorporate biomedical engineering into medical education.

Performance standards of the nerve conduction study technologist

The primary performance standard of the nerve conduction study technologist is to perform nerve conduction studies (NCS) on patients with trauma or diseases of the peripheral nervous system. However, to be in compliance with various healthcare/medical accreditation agencies, such as Occupational Safety and Health Administration (OSHA), Centers for Disease Control and Prevention (CDC), or The Joint Commission [formerly known as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO)], there are many other important performance objectives that must be met as well. It is the responsibility of the NCS technologist to meet these standards on a daily basis. Once these standards become an expected responsibility of the NCS technologist's position, the patient undergoing a nerve conduction study should be assured of a high quality test performed in an optimal safety environment.