Estimation of Numbers of Testing Personnel and Test Volume in the Clinical Laboratory Improvement Amendments of 1988 Certificate of Accreditation and Certificate of Compliance Laboratories in the United States

CONTEXT.—

Two major categories of laboratories performing nonwaived testing under the Clinical Laboratory Improvement Amendments of 1988 (CLIA) are the Certificate of Accreditation (CoA) and Certificate of Compliance (CoC) laboratories. Accreditation organizations collect more detailed laboratory personnel information than the Centers for Medicare & Medicaid Services (CMS) Quality Improvement and Evaluation System (QIES).

OBJECTIVE.—

To estimate total numbers of testing personnel and testing volumes in CoA and CoC laboratories, by laboratory type and state.

DESIGN.—

We developed a statistical inference method by using the respective correlations between testing personnel counts and test volume by laboratory type.

RESULTS.—

QIES reported 33 033 active CoA and CoC laboratories in July 2021. We estimated testing personnel to be 328 000 (95% CI, 309 000-348 000), which is supported by the count of 318 780 reported by the US Bureau of Labor Statistics. There were twice as many testing personnel in hospital laboratories as in independent laboratories (158 778 versus 74 904, P < .001). Independent laboratories had the highest test volume per person, which was twice as high as physician office laboratories (62 228 versus 30 102, P < .001). Hospital and independent laboratories comprised 34% of all CoA and CoC laboratories but performed the largest portion of testing (81%). Physician office laboratories, accounting for 44% of all CoA and CoC laboratories, performed a comparatively low proportion of total tests (9%).

CONCLUSIONS.—

Numbers of testing personnel vary considerably by laboratory type and across states. These data can provide valuable insight when assessing laboratory workforce training needs and planning for public health emergencies.

Logistic analysis of delayed reporting of emergency blood potassium and comparison of improved outcomes

Potassium testing is an essential test in emergency medicine. Turnaround time (TAT) is the time between specimen receipt by the laboratory and the release of the test report. A brief in-laboratory TAT increases emergency department effectiveness. Optimizing processes to shorten TAT using other tools requires extensive time, resources, training, and support. Therefore, we aimed to find a convenient way to shorten TAT, identify risk factors affecting the timeliness of emergency potassium test reporting, and verify the intervention's effects. The dependent variable was emergency potassium reporting time > 30 or < 30 min. Logistic analysis was performed on monitorable factors, such as sex, age, potassium results, number of items, specimen processing time (including centrifugation and time before specimen loading), critical value ratio, instrument status, shift where the report was issued, specimen status, and work experience, as independent variables. In the multivariate analysis, work experience, instrument failure rate, and specimen processing time were risk factors for emergency blood potassium reporting exceeding 30 min. Improvement measures were implemented, significantly decreasing the timeout rate for acute potassium reporting. Our study confirms the usefulness of logistics in reducing the time required to report potassium levels in the emergency department, providing a new perspective on quality management.

Retrospective evaluation of clinical decision support for within-laboratory optimization of SARS-CoV-2 NAAT workflow

The unprecedented demand for severe acute respiratory syndrome coronavirus 2 (SARS‑CoV‑2) testing led to challenges in prioritizing and processing specimens efficiently. We describe and evaluate a novel workflow using provider- and patient-facing ask at order entry (AOE) questions to generate distinctive icons on specimen labels for within-laboratory clinical decision support (CDS) for specimen triaging. A multidisciplinary committee established target turnaround times (TATs) for SARS-CoV-2 nucleic acid amplification test (NAAT) based on common clinical scenarios. A set of AOE questions was used to collect relevant clinical information that prompted icon generation for triaging SARS-CoV-2 NAAT specimens. We assessed the collect-to-verify TATs among relevant clinical scenarios. Our study included a total of 1,385,813 SARS-CoV-2 NAAT conducted from March 2020 to June 2022. Most testing met the TAT targets established by institutional committees, but deviations from target TATs occurred during periods of high demand and supply shortages. Median TATs for emergency department (ED) and inpatient specimens and ambulatory pre-procedure populations were stable over the pandemic. However, healthcare worker and other ambulatory test TATs varied substantially, depending on testing volume and community transmission rates. Median TAT significantly differed throughout the pandemic for ED and inpatient clinical scenarios, and there were significant differences in TAT among label icon-signified ambulatory clinical scenarios. We describe a novel approach to CDS for triaging specimens within the laboratory. The use of CDS tools could help clinical laboratories prioritize and process specimens efficiently, especially during times of high demand. Further studies are needed to evaluate the impact of our CDS tool on overall laboratory efficiency and patient outcomes. IMPORTANCE We describe a novel approach to clinical decision support (CDS) for triaging specimens within the clinical laboratory for severe acute respiratory syndrome coronavirus 2 (SARS‑CoV‑2) nucleic acid amplification tests (NAAT). The use of our CDS tool could help clinical laboratories prioritize and process specimens efficiently, especially during times of high demand. There were significant differences in the turnaround time for specimens differentiated by icons on specimen labels. Further studies are needed to evaluate the impact of our CDS tool on overall laboratory efficiency and patient outcomes.

Aggregated data from the same laboratories participating in two glucose external quality assessment schemes show that commutability and transfers of values to control materials are decisive for the biases found

OBJECTIVES

We report the results of glucose measurements performed during one year by the same measurement procedures (MPs) in 58 Norwegian hospital laboratories using control materials provided by external quality assessment (EQA) schemes from two different providers. The providers used materials with presumed vs. verified commutability and transfers of values using reference material vs. using a highest-order reference MP.

METHODS

Data from six Labquality and three Noklus glucose EQA surveys were aggregated for each MP (Abbott Alinity, Abbott Architect, Roche Cobas, and Siemens Advia) in each scheme. For each EQA result, percent difference from target value (% bias) was calculated. Median percent bias for each MP per scheme was then calculated.

RESULTS

The median % biases observed for each MP in the Labquality scheme were significantly larger than those in the Noklus scheme, which uses verified commutable control materials and highest-order reference MP target values. The difference ranged from 1.2 (Roche Cobas, 2.9 vs. 1.7 %) to 4.4 percentage points (Siemens Advia, 3.2 % vs. -1.2 %). The order of bias size for the various MPs was different in the two schemes. In contrast to the Labquality scheme, the median % biases observed in the Noklus scheme for Abbott Alinity (-0.1 %), Abbott Architect (-0.5 %), and Siemens Advia (-1.2 %) were not significantly different from target value (p>0.756).

CONCLUSIONS

This study underlines the importance of using verified commutable EQA materials and target values traceable to reference MPs in EQA schemes designed for assessment of metrological traceability of laboratory results.

A response playbook for early detection and population surveillance of new SARS-CoV-2 variants in a regional public health laboratory

BACKGROUND

Timely genomic surveillance is required to inform public health responses to new SARS-CoV-2 variants. However, the processes involved in local genomic surveillance introduce inherent time constraints. The Regional Innovative Public Health Laboratory in Chicago developed and employed a genomic surveillance response playbook for the early detection and surveillance of emerging SARS-CoV-2 variants.

METHODS

The playbook outlines modifications to sampling strategies, laboratory workflows, and communication processes based on the emerging variant's predicted viral characteristics, observed public health impact in other jurisdictions and local community risk level. The playbook outlines procedures for implementing and reporting enhanced and accelerated genomic surveillance, including supplementing whole genome sequencing (WGS) with variant screening by quantitative PCR (qPCR).

RESULTS

The ability of the playbook to improve the response to an emerging variant was tested for SARS-CoV-2 Omicron BA.1. Increased submission of clinical remnant samples from local hospital laboratories enabled detection of a new variant at an average of 1.4% prevalence with 95% confidence rather than 3.5% at baseline. Genotyping qPCR concurred with WGS lineage assignments in 99.9% of 1541 samples with results by both methods, and was more sensitive, providing lineage results in 90.4% of 1833 samples rather than 85.1% for WGS, while significantly reducing the time to lineage result.

CONCLUSIONS

The genomic surveillance response playbook provides a structured, stepwise, and data-driven approach to responding to emerging SARS-CoV-2 variants. These pre-defined processes can serve as a template for other genomic surveillance programs to streamline workflows and expedite the detection and public health response to emerging variants. Based on the processes piloted during the Omicron BA.1 response, this method has been applied to subsequent Omicron subvariants and can be readily applied to future SARS-CoV-2 emerging variants and other public health surveillance activities.

Productivity Improvement in Pathology Laboratories Using Motion and Time Study Techniques

OBJECTIVE

This study aimed to determine the standard time required for the performed job and to examine the standard job critically for productivity improvement in the pathology laboratory.

MATERIAL AND METHODS

In this study that was conducted at a tertiary teaching hospital, observation, fishbone diagram, and flow charts were used to collect the information about the job process. All employees were observed from September 2017 to June 2018. The observations were recorded by video camera in order to overcome the Hawthorne effect. Nine basic procedure steps were followed for productivity improvement.

RESULTS

Within the scope of the study, the jobs of `trimming tissue blocks` and `sectioning of tissue blocks` was selected. The standard time required was 0.19 minutes for `trimming tissue blocks` and 0.34 minutes for `sectioning of tissue blocks`. The procedure steps, named `Removal of tissue block` and `Fixing the block to the device`, were removed from the flow chart to define the improved method. The implementation of the improved method brought in a gain of 11.28 work days per year.

CONCLUSION

It is obvious that the pathology laboratory needs to take certain measures to improve working conditions and increase efficiency. Our results demonstrate applying the study techniques could reduce the workload and processing time. This study also shows that the study techniques can be applied in the hospital laboratory. Incorporation of all pathology technicians in the change or innovation process will be important in maintaining the achievements.

Recording and Reporting of Antimicrobial Resistance (AMR) Priority Variables and Its Implication on Expanding Surveillance Sites in Nepal: A CAPTURA Experience

Data on antimicrobial resistance (AMR) from sites not participating in the National AMR surveillance network, conducted by National Public Health Laboratory (NPHL), remain largely unknown in Nepal. The "Capturing Data on Antimicrobial Resistance Patterns and Trends in Use in Regions of Asia" (CAPTURA) assessed AMR data from previously untapped data sources in Nepal. A retrospective cross-sectional data review was carried out for the AMR data recorded between January 2017 and December 2019 to analyze AMR data from 26 hospital-based laboratories and 2 diagnostic laboratories in Nepal. Of the 56 health facilities initially contacted to participate in this project activity, 50.0% (28/56) signed a data-sharing agreement with CAPTURA. Eleven of the 28 hospitals were AMR surveillance sites, whereas the other 17, although not part of the National AMR surveillance network, recorded AMR-related data. Data for 663 602 isolates obtained from 580 038 patients were analyzed. A complete record of the 11 CAPTURA priority variables was obtained from 45.5% (5/11) of government hospitals, 63.6% (7/11) of private hospitals, and 54.6% (6/11) of public-private hospitals networked with NPHL for AMR surveillance. Similarly, 80% (8/10) of clinics and 54.6% (6/11) of laboratories outside the NPHL network recorded complete data for the 10 Global Antimicrobial Resistance and Use Surveillance System (GLASS) priority variables and 11/14 CAPTURA priority variables. Retrospective review of the data identified areas requiring additional resources and interventions to improve the quality of data on AMR in Nepal. Furthermore, we observed no difference in the priority variables reported by sites within or outside the NPHL network, thus suggesting that policies could be made to expand the surveillance system to include these sites without substantially affecting the government's budget.

Hundred-fold increase in SARS-CoV-2 spike antibody levels over three years in a hospital clinical laboratory

IMPORTANCE

Despite the evolution of SARS-CoV-2 variants of concern and ongoing transmission, COVID-19 hospitalization and mortality rates continue to decline. Both the percent seropositive and antibody levels have risen over the past 3 years. Here, we observe more than 90% seropositivity as well as more than a hundred-fold increase in spike IgG levels in a tertiary hospital clinical immunology laboratory setting. Antibody effector functions (such as neutralization, opsonization, and complement activation) and cell-mediated immunity all contribute to protection from COVID-19 progression to hospitalization, and all correlate to the total SARS-CoV-2 antibody levels. We recommend therapeutic COVID-19 convalescent plasma be restricted to the top 20% of potential donors to maintain activity against ongoing SARS-CoV-2 variant evolution.

A Machine Learning Model for the Routine Detection of "Wrong Blood in Complete Blood Count Tube" Errors

BACKGROUND

Current laboratory procedures may fail to detect wrong blood in tube (WBIT) errors. Machine learning models have the potential to improve WBIT error detection, as demonstrated by proof-of-concept studies. The models developed so far, however, are not appropriate for routine use because they are unable to handle missing values and have low positive predictive value (PPV). In this study, a machine learning model suitable for routine use was developed.

METHODS

A model was trained and a preliminary evaluation performed on a retrospective data set of 135 128 current and previous patient complete blood count (CBC) results. The model was then applied prospectively to routine samples tested in a public hospital laboratory over a period of 22 weeks. Each week, the 5 samples identified by the model as most likely to be WBIT errors underwent further investigation by testing blood group and red cell phenotype. The study assessed the number of WBIT errors that were missed by current procedures but detected by the model, as well as the PPV of the model.

RESULTS

The model was applied prospectively to 38 187 CBC results that had passed routine laboratory checks. One hundred and ten samples were identified for further testing and 12 WBIT errors were detected. The PPV of the model was 10.9%.

CONCLUSION

A machine learning model suitable for routine use was able to identify WBIT errors missed by the laboratory's current procedures. Machine learning models are valuable for the identification of WBIT errors, and their validation and deployment in clinical laboratories would improve patient safety.

Serum CXCL8 and CXCR2 as diagnostic biomarkers for noninvasive screening of cervical cancer

BACKGROUND

Cervical cancer (CC) is the fourth most frequently diagnosed cancer and the fourth leading cause of cancer-related death in women. Identifying new biomarkers for the early detection of CC is an essential requirement in this field. CXCL8 was originally discovered because of its role in inflammation by binding to CXCR1 and CXCR2; however, it is now known to play an important role in cancer. In this study, we aimed to evaluate the expression levels of potential biomarkers (CXCL8, CXCR1, and CXCR2) and to explore their diagnostic potential in CC.

METHODS

The expression levels of serum CXCL8, CXCR1, and CXCR2 were investigated by kit method on Immulite-1000 in 30 healthy volunteers, 30 precancerous patients and 70 CC patients.

RESULTS

The results indicated that the expression of CXCL8 and CXCR2 was significantly higher in the serum of CC patients than in healthy volunteers, similar to the well-established tumor marker (squamous-cell cancerantigen [SCC]). Receiver operating characteristic analyses showed that the combination of CXCL8, CXCR2, and SCC had the highest diagnostic sensitivity and area under the curve value. Meanwhile, the positive predictive value and negative predictive value were not very low. Moreover, high concentrations of CXCL8 and CXCR2 are associated with an increased risk of CC.

CONCLUSIONS

In conclusion, our data demonstrated that combined serum CXCL8, CXCR2, and SCC measurements are helpful for CC diagnosis and can be used as potential biomarkers for the early detection of CC. Cytokines, such as CXCL8 and CXCR2, can be easily measured in most university hospital laboratories and in some private laboratories with a routine test.

An Innovative Workshop Embedding Pathology Service Users into the Undergraduate Biomedical Science Curriculum

The integration of pathology service users into the biomedical science curriculum has been driven by the refinement of the Health and Care Professions Council (HCPC) Standards of Proficiency. This study aimed to design and implement a novel and innovative service user event with a reflective assessment to enhance students' knowledge and understanding of the impact of pathology laboratory results on the patient pathway. The 4-h workshop consisted of a series of service users. Patients discussed how pathology services had contributed to their diagnosis and treatment, while service providers-a Microbiology Consultant, a director of primary care, and the patient referral optimisation officer-discussed their roles and their interactions with pathology services. Post-event, students completed a 750-word reflective assessment, highlighting challenges experienced by service users and providing suggestions for improving the delivery of pathology services. In total, 57.5% of respondents (57/99) completed a post-reflection survey, which included open- and closed-ended questions. Quantitative analysis of the survey data revealed that over 87.7% of respondents had increased knowledge and understanding of the revised HCPC standards. Following the assessment, students reported a significant increase in their confidence with respect to reflective writing (p < 0.001), with over 90% of respondents agreeing that the reflective assessment had increased their knowledge and understanding of the limitations that may negatively impact service users and patient care. Moreover, respondents highlighted how advancements in point-of-care testing (POCT) and improvements in communication can improve patient experiences. Thematic analysis revealed that respondents agreed that embedding patients into the curriculum reinforced the importance of there being a patient behind every sample. Respondents reported that reflecting upon service user experiences enabled them to identify improvements to the delivery of pathology services while recognising the essential role that Biomedical Scientists play in the patient pathway. This successful workshop has created a platform encompassing a range of pathology service users in the undergraduate curriculum. We recommend that other accredited biomedical science programmes adopt and embed this innovative workshop and reflective assessment into their programmes to help them meet these standards relating to service users while fostering important transferable skills in their students.

Deployment of Smart Specimen Transport System Using RFID and NB-IoT Technologies for Hospital Laboratory

In this study, we propose a specimen tube prototype and smart specimen transport box using radio frequency identification (RFID) and narrow band-Internet of Things (NB-IoT) technology to use in the Department of Laboratory Medicine, King Chulalongkorn Memorial Hospital. Our proposed method replaces the existing system, based on barcode technology, with shortage usage and low reliability. In addition, tube-tagged barcode has not eliminated the lost or incorrect delivery issues in many laboratories. In this solution, the passive RFID tag is attached to the surface of the specimen tube and stores information such as patient records, required tests, and receiver laboratory location. This information can be written and read multiple times using an RFID device. While delivering the specimen tubes via our proposed smart specimen transport box from one clinical laboratory to another, the NB-IoT attached to the box monitors the temperature and humidity values inside the box and tracks the box's GPS location to check whether the box arrives at the destination. The environmental condition inside the specimen transport box is sent to the cloud and can be monitored by doctors. The experimental results have proven the innovation of our solution and opened a new dimension for integrating RFID and IoT technologies into the specimen logistic system in the hospital.

Two-Period Study Results from a Large Italian Hospital Laboratory Attesting SARS-CoV-2 Variant PCR Assay Evolution

In keeping with the evolution of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the COVID-19 causative agent, PCR assays have been developed to rapidly detect SARS-CoV-2 variants, which have emerged since the first (Alpha) variant was identified. Based on specific assortment of SARS-CoV-2 spike-protein mutations (ΔH69/V70, E484K, N501Y, W152C, L452R, K417N, and K417T) among the major variants known to date, Seegene Allplex SARS-CoV-2 Variants I and Variants II assays have been available since a few months before the last (Omicron) variant became predominant. Using S gene next-generation sequencing (NGS) as the SARS-CoV-2 variant identification reference method, we assessed the results of SARS-CoV-2-positive nasopharyngeal swab samples from two testing periods, before (n = 288, using only Variants I) and after (n = 77, using both Variants I and Variants II) the appearance of Omicron. The Variants I assay allowed correct identification for Alpha (37/37), Beta/Gamma (28/30), or Delta (220/221) variant-positive samples. The combination of the Variants I and Variants II assays allowed correct identification for 61/77 Omicron variant-positive samples. While 16 samples had the K417N mutation undetected with the Variants II assay, 74/77 samples had both ΔH69/V70 and N501Y mutations detected with the Variants I assay. If considering only the results by the Variants I assay, 6 (2 Beta variant positive, 1 Delta variant positive, and 3 Omicron variant positive) of 365 samples tested in total provided incorrect identification. We showed that the Variants I assay alone might be more suitable than both the Variants I and Variants II assays to identify currently circulating SARS-CoV-2 variants. Inclusion of additional variant-specific mutations should be expected in the development of future assays. IMPORTANCE Omicron variants of SARS-CoV-2 pose more important public health concerns than the previously circulating Alpha or Delta variants, particularly regarding the efficacy of anti-SARS-CoV-2 vaccines and therapeutics. Precise identification of these variants highly requires performant PCR-based assays that allow us to reduce the reliance on NGS-based assays, which remain the reference method in this topic. While the current epidemiological SARS-CoV-2 pandemic context suggests that PCR assays such as the Seegene Variants II may be dispensable, we took advantage of NGS data obtained in this study to show that the array of SARS-CoV-2 spike protein mutations in the Seegene Variants II assay may be suboptimal. This reinforces the concept that initially developed PCR assays for SARS-CoV-2 variant detection could be no longer helpful if the SARS-CoV-2 pandemic evolves to newly emerging variants.

Abstract of the 19th Annual Scientific Meeting, College of Pathologists, Academy of Medicine of Malaysia: Pathology and Laboratory Medicine: Current, Advancement and Emerging Trends, co-organised by Department of Pathology, Hospital Melaka, Department of Clinical Diagnostic Laboratories, Hospital Universiti Teknologi MARA (HUiTM) and the College of Pathologists, Academy of Medicine of Malaysia and held virtually on 22nd-24th June 2022

No abstract available.

Analysis of preanalytical errors in a clinical chemistry laboratory: A 2-year study

Patient safety and medical diagnosis of patients are mainly influenced by laboratory results. The present study aimed to evaluate the errors in the preanalytical phase of testing in a Clinical Chemistry diagnostic laboratory. A review was conducted at the Clinical Chemistry Laboratory of a hospital in Saudi Arabia from January 2019 to December 2020. Using the laboratory information system, the data of all canceled tests and requests were retrieved and evaluated for preanalytical errors. A total of 55,345 laboratory test requests and samples from different departments were evaluated for preanalytical errors. An overall rate of 12.1% (6705) was determined as preanalytical errors. The occurrence of these errors was found to be highest in the emergency department (21%). The leading preanalytical errors were nonreceived samples (3.7%) and hemolysis (3.5%). The annual preanalytical errors revealed an increasing rate in outpatient and inpatient departments, while a decreasing rate was observed in the emergency department. An increased rate of errors was also noted for the 2-year study period from 11.3% to 12.9%. The preanalytical phase has a significant impact on the quality of laboratory results. The rate of error in the study was high and the leading causes were nonreceived samples and hemolysis. An increased occurrence of hemolyzed samples in the outpatient department was noted. Enhanced educational efforts emphasizing specimen quality issues and training in sample collection among hospital staff must be carried out.

Pathologist workload, work distribution and significant absences or departures at a regional hospital laboratory

Objective

Assess the work environment of salaried pathologists via (1) the national workload system (L4E), (2) work distribution among/in three hospital groups, and (3) the frequency of significant absences or departures (SADs).

Methods

Automated analysis of pathology reports from a regional laboratory (accessioned 2011–2019) using validated computer code.

Results

The study set contained 574,099 pathology reports, reported by 63 pathologists. The average yearly L4E workload units/full-time equivalent for three hospital groups were 8,101.6, 6,906.5 and 4,215.8. The average Gini coefficient for full-time pathologists in the three hospital groups were respectively 0.05, 0.16 and 0.23. The average yearly SADs rates were respectively 13%, 16% and 9%. The group with the highest SADs rate had the intermediate Gini coefficient and intermediate workload.

Conclusions

High individual workload and work maldistribution appear to be associated with SADs. Individual workload maximums and greater transparency may be essential for limiting staff turnover, maintaining high morale, and efficient laboratory function with a high quality of care.

Molecular determination, serotyping, antibiotic profile and virulence factors of group B Streptococcus isolated from invasive patients at Arabcare Hospital Laboratory, Palestine

BACKGROUND

Streptococcus agalactiae (group B Streptococcus) is beta-hemolytic, catalase negative, gram-positive cocci, recognized as main bacterial pathogen causing infections in newborns, infants, adults, and elderly people around the world. The aim of this study is to investigate group B Streptococcus samples recovered from invasive patients and determine serotype, virulent genes, and antibiotic-resistant profile of Streptococcus agalactiae in Palestine.

METHODS

A total of 95 group B Streptococcus strains were isolated from neonates, infants, pregnant and non-pregnant women and males at Arabcare Hospital Laboratory, Palestine, between the period of June 2018 and September 2020. Species identification was carried out through cultivation and conventional biochemical tests. A conventional Polymerase Chain Reaction (cPCR) was used to determine the 5 serotypes and virulent genes of the Streptococcus agalactiae strains. The antibiotic resistance test of group B Streptococcus was evaluated using Kirby-Bauer disk susceptibility. Sequencing and BLAST analysis were used to determine the relationship of the isolates in this study to worldwide isolates.

RESULTS

Serotype III (35%) was the major group B Streptococcus strains serotype causing invasive infections in neonates, infants, pregnant and nonpregnant women, and males, followed by serotypes V (19%), Ia, and II (15%), Ib (6%), respectively. All our isolates encoding for surface protein virulent factors, including a highly virulent gene (HvgA) were mostly found in strains isolated from pregnant women (12%). These group B Streptococcus strains exhibited a high rate of resistance to clindamycin (26%). The overall percentage of levofloxacin resistance was 11%, while vancomycin and ampicillin showed higher resistance, at 14.7 and 16% respectively. In addition, the phylogenetic relationship dendrogram illustrates that Streptococcus agalactiae isolated from an invasive patient (newborn) in Palestine was similar to strains found in China and Japan.

CONCLUSIONS

The outcomes of this study demonstrate that resistant group B Streptococcus strains are common in Palestine, therefore, evidence-based infection prevention and antibiotic stewardship efforts are necessary.

Indoor lighting design for healthier workplaces: natural and electric light assessment for suitable circadian stimulus

Light, especially daylight, plays a critical role in human health as the main timer for circadian rhythms. Indoor environments usually lack the correct exposure to daylight and are highly dependent on electric lighting, disrupting the circadian rhythm and compromising the health of occupants. The methodology proposed assesses the combination of natural and electric lighting on circadian rhythms for operational environments. The case study chosen examines a 24/7 laboratory area representing an open-plan shift-work area. Several electric lighting scenarios under different sky conditions have been assessed, considering a variable window size and resulting in a spectrum which establishes the indoor circadian regulation performance according to the amount of light perceived. A set of configurations is presented to determine optimal electric lighting configuration based on natural light conditions in order to ensure a suitable circadian stimulus and the electric lighting flux threshold for different scenarios, benefiting occupants' health while also ensuring energy conservation.

Preanalytical errors in a satellite stat laboratory: A Six Sigma analysis of seven years' data

BACKGROUND

There have been few reports regarding the frequency and types of preanalytical errors in stat laboratories, in particular those occurring in the satellite laboratory setting. The impact of this error type on laboratory performance in this environment is largely unknown. We assessed the performance of a stat laboratory serving a population of predominantly elderly patients with suspected or established diagnoses of cancer using Six Sigma methodology and compared the results to previous work on this subject.

METHODS

We performed an observational retrospective study using data from the period 2013-2020. The clinical setting was a satellite laboratory supporting an outpatient medical clinic. The type and frequency of each type of preanalytical error were compiled and were used to derive the quarterly error rate. Overall and quarterly performance were calculated using Six Sigma methodology.

RESULTS

During the study period 1314 preanalytical errors were identified from 247,271 laboratory tests (0.5% of total test volume). There was a steady decrease in the error rate over the course of the study period, ranging from 1.4% in 2013 to 0.14% in 2020, despite a 290% increase in quarterly test volume during this period. The most common error types encountered were order error, hemolysis, collection error, and lab accident.

CONCLUSION

1) The overall performance of a satellite laboratory with a stat testing menu is comparable to hospital-based laboratory stat testing. 2) The most frequent error types encountered in satellite laboratory stat testing differ from those found in hospital-based laboratories. 3) There was an overall improvement in laboratory performance based on Six Sigma methodology.

Behind Every Great Infection Prevention Program is a Great Microbiology Laboratory: Key Components and Strategies for an Effective Partnership

A great clinical microbiology laboratory supporting a great infection prevention program requires focusing on the following services: rapid and accurate identification of pathogens associated with health care-associated infections; asymptomatic surveillance for health care-acquired pathogens before infections arise; routine use of broad and flexible antimicrobial susceptibility testing to direct optimal therapy; implementation of epidemiologic tracking tools to identify outbreaks; development of clear result communication with interpretative comments for clinicians. These goals are best realized in a collaborative relationship with the infection prevention program so that both can benefit from the shared priorities of providing the best patient care.

Validation of GeneXpert testing for SARS-CoV-2 RNA in eight hospital laboratories in Oman

In response to the current COVID-19 pandemic, numerous commercial assays have been developed for the detection of SARS-CoV-2 for use in the clinical diagnostic laboratories. To date, there is limited comparison of testing methods performed in different hospital laboratory sites. The aims of the study were to evaluate the analytical performance of Cepheid Xpert Xpress SARS-CoV-2 when compared to RT-PCR. This is a cross-sectional study. A total of 155 nasopharyngeal swabs were taken in duplicate from patients presenting with suspected COVID-19 to 8 hospitals in Oman. One swab was tested by the hospital laboratory and the duplicate swab was sent to the national Central Public Health Laboratory (CPHL) for testing. We compared the analytical performance of the commercially available point of care Cepheid Xpert Xpress SARS-CoV-2 assay which was used in the 8 different hospitals with assays including Liferiver, Sansure, TIB MOL BIOL, Kingfisher and COBAS 6800 by Roche which were performed at the CPHL. Testing of the duplicate swabs revealed excellent agreement of results with the viral loads of Ct values ranging from 16-43 for the E gene, 18-44 for the N gene and 17-44 for the ORF gene using the Liferiver assay. The overall sample sensitivity and specificity of the Cepheid Xpert Xpress SARS-CoV-2 assay were both 100% and there was 100% agreement across specimens. We conclude that the rapid GeneXpert and RT-PCR kits assessed in this study may be used for routine diagnostic testing of COVID-19 patients by experienced clinical microbiology diagnostic laboratories. Our results highlight the importance of rapid molecular testing at different sites within a country in a public health emergency.

Laboratory-based surveillance of COVID-19 in the Greater Helsinki area, Finland, February-June 2020

OBJECTIVES

The aim was to characterise age- and sex-specific severe acute respiratory syndrome coronavirus disease-2 (SARS-CoV-2) RT-PCR sampling frequency and positivity rate in Greater Helsinki area in Finland during February-June 2020. We also describe the laboratory capacity building for these diagnostics.

METHODS

Laboratory registry data for altogether 80,791 specimens from 70,517 individuals was analysed. The data included the date of sampling, sex, age and the SARS-CoV-2 RT-PCR test result on specimens collected between 1 February and 15 June 2020.

RESULTS

Altogether, 4057/80,791 (5.0%) of the specimens were positive and 3915/70,517 (5.6%) of the individuals were found positive. In all, 37% of specimens were from male and 67% from female subjects. While the number of positive cases was similar in male and female subjects, the positivity rate was significantly higher in male subjects: 7.5% of male and 4.4% of female subjects tested positive. The highest incidence/100,000 was observed in those aged ≥80 years. The proportion of young adults in positive cases increased in late May 2020. Large dips in testing frequency were observed during every weekend and also during public holidays.

CONCLUSIONS

Our data suggest that men pursue SARS-CoV-2 testing less frequently than women. Consequently, a subset of coronavirus disease-2019 infections in men may have gone undetected. People sought testing less frequently on weekends and public holidays, and this may also lead to missing of positive cases. The proportion of young adults in positive cases increased towards the end of the study period, which may suggest their returning back to social behaviour with an increased risk of infection.

Evaluation of in-service training program of laboratory professionals in Amhara Public Health Institute Dessie Branch, northeast Ethiopia: A concurrent mixed-method study

Background

In-service training programs should be evaluated and modified regularly to enhance training quality. However, in Ethiopia, there is no published evidence regarding its effectiveness. Therefore, we evaluated the Amhara Public Health Institute Dessie Branch (APHI_DB) in-service training program using the Kirkpatrick model.

Methods

In October 2019, a concurrent nested mixed method facility-based cross-sectional study was conducted among 107 laboratory stakeholders from 22 randomly selected government health facilities in the eastern part of the Amhara region. The qualitative part involved interviews with each of these key stakeholders. We collected data using a semi-structured questionnaire through face-to-face interviews. EpiData 3.1 and Microsoft Excel 2016 software were used for data entry and analysis respectively. The major qualitative findings were narrated and summarized based on four thematic areas to supplement the quantitative findings.

Results

A total of 107 laboratory personnel were interviewed, which makes a response rate of 97.3%. At the reaction level, 82.1% of the participants agree/strongly agree with the course structures, training contents, and learning tools. Likewise, 85.4% of the participants agreed/ strongly agreed on the trainer’s knowledge and their communication skills. In addition, 93.1% of the participants stated an improvement in knowledge and skills after attending the training. As a result, 65.6% of them were able to transfer their knowledge and skills into practice. Regarding the training set-ups and environment, 45.1% of the respondents disagree/strongly disagree with the training hall, toilet, cafe, tea and snacks, financial process, and accommodation perdiem.

Conclusion

Generally, the laboratory in-service training program of APHI_DB was more or less effective. Our findings suggest regular monitoring of each training event and evaluation of training programs against a clearly defined criterion. Furthermore, the institute is mandated to create a conducive learning environment and well-established training setups for trainees.

Adaptation of Clinical Laboratories to COVID 19 Pandemic: Changes in Test Panels, Overcoming Problems and Preparation Suggestions for Future Pandemics Adaptation of Clinical Laboratories to COVID 19 Pandemic

BACKGROUND

For Coronavirus Disease 2019 (Covid-19) infection, clinical laboratories provide essential contributions in the diagnosis of infection, stage prognostication, and evaluation of disease severity. We aimed to show laboratory problems including changes of test numbers, changes of test panels, and differences of preanalytical errors during Covid-19 pandemic and, in the current study, we also intended to give solutions for the obstacles to guide other possible pandemics.

METHODS

Our study was based on data between January 10, 2020, and May 10, 2020. The first Covid-19 case of the Republic of Turkey was seen March 10, 2020, which was determined as the threshold date for comparisons. This was a single center, data mining, retrospective study.

RESULTS

The number of patients admitted to hospital were 34,260 and 15,573, the number of total tests were 66,263 and 42,066 before and after pandemic, respectively, for the two-month interval. Test percentage changes were increased for D-dimer 136%, fibrinogen 3,113%, troponin 6%, and LDH 17%. Test percentage changes were decreased for CBC 37%, sedimentation 45%, aPTT 30%, PT 37%, CRP 28%, ProCT 10%, ferritin 29%, CK-MB 27%, blood gases 47%, ALT 43%, AST 42%, urea 42%, creatinine 42%, triglycerides 45%, sodium 42%, potassium 41%, chloride 21%, urine culture 58%, and blood culture 44%. When preanalytical sources of errors were investigated no differences were found.

CONCLUSIONS

Laboratories must take quick action and be prepared for changes in patient services during pandemics. The most reliable ways for this are past experiences, statistical analysis, co-operation with administrations, high quality communication skills, and a risk-based management system.

Extended storage of SARS-CoV-2 nasopharyngeal swabs does not negatively impact results of molecular-based testing across three clinical platforms

With the global outbreak of COVID-19, the demand for testing rapidly increased and quickly exceeded the testing capacities of many laboratories. Clinical tests which receive CE (Conformité Européenne) and Food and Drug Administration (FDA) authorisations cannot always be tested thoroughly in a real-world environment. Here we demonstrate the long-term stability of nasopharyngeal swab specimens for SARS-CoV-2 molecular testing across three assays recently approved by the US FDA under Emergency Use Authorization. This study demonstrates that nasopharyngeal swab specimens can be stored under refrigeration or even ambient conditions for 21 days without clinically impacting the results of the real-time reverse transcriptase-PCR testing.

The implementation of a rapid sample preparation method for the detection of SARS-CoV-2 in a diagnostic laboratory in South Africa

The SARS-CoV-2 pandemic has resulted in shortages of both critical reagents for nucleic acid purification and highly trained staff as supply chains are strained by high demand, public health measures and frequent quarantining and isolation of staff. This created the need for alternate workflows with limited reliance on specialised reagents, equipment and staff. We present here the validation and implementation of such a workflow for preparing samples for downstream SARS-CoV-2 RT-PCR using liquid handling robots. The rapid sample preparation technique evaluated, which included sample centrifugation and heating prior to RT-PCR, showed a 97.37% (95% CI: 92.55-99.28%) positive percent agreement and 97.30% (95% CI: 90.67-99.52%) negative percent agreement compared to nucleic acid purification-based testing. This method was subsequently adopted as the primary sample preparation method in the Groote Schuur Hospital Virology Diagnostic Laboratory in Cape Town, South Africa.

Staining Performance of ALK and ROS1 Immunohistochemistry and Influence on Interpretation in Non-Small-Cell Lung Cancer

Selection of non-small-cell lung cancer patients for treatment relies on the detection of expression of anaplastic lymphoma kinase (ALK) and ROS proto-oncogene 1 (ROS1) protein by immunohistochemistry (IHC). We evaluated staining performance for different IHC protocols and laboratory characteristics, and their influence on ALK and ROS1 interpretation during external quality assessment schemes between 2015 and 2018. Participants received five formalin-fixed, paraffin-embedded cases for staining by their routine protocol, whereafter at least two pathologists scored them simultaneously under a multihead microscope and awarded a graded expert staining score (ESS) from 1 to 5 points based on staining quality. European Conformity in Vitro Diagnostic kits (such as D5F3) revealed a better ALK ESS compared with laboratory-developed tests. ESS was indifferent to the applied antibody dilution or a recent protocol change. Lower ESSs were observed for higher antibody incubation times and temperatures. ESS for various ROS1 protocols were largely similar. Overall, for both markers, ESS improved over time and for repeated external quality assessment participation but was independent of laboratory setting or experience. Except for ROS1, ESS positively correlated with laboratory accreditation. IHC stains with lower ESS correlated with increased error rates in ALK and ROS1 interpretation and analysis failures. Laboratory characteristics differently affected staining quality and interpretation, and laboratories should assess both aspects, and less common protocols need improvement in staining performance.

Be cautious during the interpretation of arterial blood gas analysis performed outside the intensive care unit

INTRODUCTION

Reliable results of an arterial blood gas (ABG) analysis are crucial for the implementation of appropriate diagnostics and therapy. We aimed to investigate the differences (Δ) between ABG parameters obtained from point-of-care testing (POCT) and central laboratory (CL) measurements, taking into account the turnaround time (TAT).

MATERIALS AND METHODS

A number of 208 paired samples were collected from 54 intensive care unit (ICU) patients. Analyses were performed using Siemens RAPIDPoint 500 Blood Gas System on the samples just after blood retrieval at the ICU and after delivery to the CL.

RESULTS

The median TAT was 56 minutes (IQR 39-74). Differences were found for all ABG parameters. Median Δs for acid-base balance ere: ΔpH=0.006 (IQR -0.0070-0.0195), ΔBEef=-0.9 (IQR -2.0-0.4) and HCO3-act=-1.05 (IQR -2.25-0.35). For ventilatory parameters they were: ΔpO2=-8.3 mmHg (IQR -20.9-0.8) and ΔpCO2=-2.2 mmHg (IQR -4.2--0.4). For electrolytes balance the differences were: ΔNa+=1.55 mM/L (IQR 0.10-2.85), ΔK+=-0.120 mM/L (IQR -0.295-0.135) and ΔCl-=1.0 mM/L (IQR -1.0-3.0). Although the Δs might have caused misdiagnosis in 51 samples, Bland-Altman analysis revealed that only for pO2 the difference was of clinical significance (mean: -10.1 mmHg, ±1.96SD -58.5; +38.3). There was an important correlation between TAT and ΔpH (R=0.45, p<0.01) with the safest time delay for proper assessment being less than 39 minutes.

CONCLUSIONS

Differences between POCT and CL results in ABG analysis may be clinically important and cause misdiagnosis, especially for pO2. POCT should be advised for ABG analysis due to the impact of TAT, which seems to be the most important for the analysis of pH.

Analysis of Prescribed Critical Values in Istanbul Training and Research Hospital Biochemistry Laboratory: Should Critical Values Be Repeated?

BACKGROUND

Clinically important critical values must be readily available to the clinician. Repeating critical values may cause a delay. In this study, we evaluated the requirement of repeating critical values.

METHODS

We extracted initial and repeated critical values and reporting times for a six-month period via the hospital laboratory information management system. Ten parameters from our critical value list (glucose, urea, mag-nesium (Mg++), calcium (Ca++), sodium (Na+), potassium (K+), chloride (Cl-), white blood cells (WBC), platelets, hemoglobin) were evaluated. We assessed whether the difference between the first measurement of the initial critical value and the repeated measurement value exceeded total allowable error (TEa).

RESULTS

Repeated critical values of Mg++, Ca++, WBC, platelets, and hemoglobin did not exceed TEa. However, repeated critical values of glucose, urea, Na+, K+, and Cl- did exceed TEa. In addition, parameters such as glucose and urea did not affect the clinical decision although their critical values exceeded the TEa. This study showed that critical values for Na+, K+, and Cl- may need to be repeated.

CONCLUSIONS

Each laboratory should assess the requirement of repeating critical values under its own operating conditions and, accordingly, establish and implement a suitable policy.

Reproductive outcomes and Y chromosome instability in radiation-exposed male workers in cardiac catheterization laboratory

Occupational radiation exposure may impact the reproductive outcome of male workers in the cardiac catheterization laboratory (cath Lab) who receive a dose of ~1-10 mSv/year. An increased copy number variation (CNV) in azoospermia factor region c (AZFc) of the Y chromosome is a marker of spermatogenic failure, previously associated with radiation exposure. This study sought to investigate the association between paternal exposure in the Cath Lab and adverse reproductive outcomes as well as to assess the induction of CNV in the AZFc region. In a case-control study, we enrolled 193 catheterization lab workers (Group I) and 164 age-matched unexposed controls (Group II). Reproductive outcomes were assessed through a structured questionnaire. Two sequence-tagged sites (SY1197 and SY579) in AZFc region were evaluated by qRT-PCR in 83 exposed and 47 unexposed subjects. Exposed workers had a higher prevalence of low birth weight in offspring (Group I = 13% vs. II = 5.3%, P = 0.02; OR_adjusted = 2.7; 95% CI: 1.1-6.3; P = 0.02). The mean of CNV (microdeletion and microduplication) for SY1197 was significantly higher in the exposed workers (Group I = 1.53 ± 0.85 vs. Group II = 1.02 ± 0.41; P = 0.0005). Despite the study design limitations, our findings show that chronic occupational radiation exposure of male workers is correlated with higher prevalence of low birth weight in offspring and instability in the Y chromosome AZFc region. Environ. Mol. Mutagen. 61:361-368, 2020. © 2019 Wiley Periodicals, Inc.

Diagnosis of Gestational Diabetes Mellitus with Point-of-Care Methods for Glucose versus Hospital Laboratory Method Using Isotope Dilution Gas Chromatography-Mass Spectrometry as Reference

BACKGROUND

In Sweden, both glucose analyzers in accredited laboratories and point-of-care glucose devices are used for gestational diabetes mellitus (GDM) diagnosis. The aim of this study was to compare the diagnostic performance of the HemoCue Glucose 201+ (HC201+) and RT (HC201RT) systems with that of the hospital central laboratory hexokinase method (CL) based on lyophilized citrate tubes, using the isotope dilution gas chromatography-mass spectrometry (ID GC-MS) as reference.

METHODS

A 75 g oral glucose tolerance test was performed on 135 women screened positive for GDM. Diagnosis was based on the World Health Organization 2013 diagnostic thresholds for fasting (n = 135), 1 h (n = 135), 1 h (n = 135), 1 h (.

RESULTS

Significantly more women were diagnosed with GDM by HC201+ (80%) and CL (80%) than with the reference (65%, P < 0.001) based on fasting and/or 2 h thresholds, whereas the percentage diagnosed by HC201RT (60%) did not differ significantly from the reference. In Bland-Altman analysis, a positive bias was observed for HC201+ (4.2%) and CL (6.1%) and a negative bias for HC201RT (-1.8%). In the surveillance error grid, 95.9% of the HC201+ values were in the no-risk zone as compared to 98.1% for HC201RT and 97.5% for CL.

CONCLUSIONS

A substantial positive bias was found for CL measurements resulting in overdiagnosis of GDM. Our findings suggest better performance of HC201RT than HC201+ in GDM diagnosis. The results may have possible implications for GDM diagnosis in Sweden and require further elucidation.

Macroepidemiological aspects of porcine reproductive and respiratory syndrome virus detection by major United States veterinary diagnostic laboratories over time, age group, and specimen

This project investigates the macroepidemiological aspects of porcine reproductive and respiratory syndrome virus (PRRSV) RNA detection by veterinary diagnostic laboratories (VDLs) for the period 2007 through 2018. Standardized submission data and PRRSV real-time reverse-transcriptase polymerase chain reaction (RT-qPCR) test results from porcine samples were retrieved from four VDLs representing 95% of all swine samples tested in NAHLN laboratories in the US. Anonymized data were retrieved and organized at the case level using SAS (SAS® Version 9.4, SAS® Institute, Inc., Cary, NC) with the use of PROC DATA, PROC MERGE, and PROC SQL scripts. The final aggregated and anonymized dataset comprised of 547,873 unique cases was uploaded to Power Business Intelligence-Power BI® (Microsoft Corporation, Redmond, Washington) to construct dynamic charts. The number of cases tested for PRRSV doubled from 2010 to 2018, with that increase mainly driven by samples typically used for monitoring purposes rather than diagnosis of disease. Apparent seasonal trends for the frequency of PRRSV detection were consistently observed with a higher percentage of positive cases occurring during fall or winter months and lower during summer months, perhaps due to increased testing associated with well-known seasonal occurrence of swine respiratory disease. PRRSV type 2, also known as North American genotype, accounted for 94.76% of all positive cases and was distributed across the US. PRRSV type 1, also known as European genotype, was geographically restricted and accounted for 2.15% of all positive cases. Co-detection of both strains accounted for 3.09% of the positive cases. Both oral fluid and processing fluid samples, had a rapid increase in the number of submissions soon after they were described in 2008 and 2017, respectively, suggesting rapid adoption of these specimens by the US swine industry for PRRSV monitoring in swine populations. As part of this project, a bio-informatics tool defined as Swine Disease Reporting System (SDRS) was developed. This tool has real-time capability to inform the US swine industry on the macroepidemiological aspects of PRRSV detection, and is easily adaptable for other analytes relevant to the swine industry.

Incomplete Filling of Laboratory Request Forms: A Look at the Practice at a Federal Medical Centre in South Eastern Nigeria

BACKGROUND

Laboratory request forms serve as a medium for communication between clinicians managing medical cases and the pathologist. Improperly filled forms impairs the ability of pathologists to generate sound and valuable reports. This research focused on finding out the extent to which doctors in Federal Medical Centre, Umuahia properly fill laboratory request forms.

METHODOLOGY

A total of 1,509 laboratory request forms directed to the electrolyte bench, already filled out by various doctors in the hospital between May and October, 2018 were retrospectively studied. The completeness of information supplied by requesting physician based on some parameters were analysed.

RESULTS

In descending order, the most frequently provided data were as follows; name of patient, 1,509[100.0%]; gender,973[64.5%]; provisional diagnosis,866[57.4%]; age,639[42.4%]; hospital number,428[28.4%]; clinical summary,47[3.1%]. 26[2%] forms were completed in their entirety per the 6 variables assessed.

CONCLUSION

Proper and adequate filling of laboratory request forms is very poor in this hospital. Therefore, continuous medical education on the need for adequate completion of request forms is absolutely necessary.

Algorithm to Estimate the Extended Turnaround Time Including Outpatient Waiting Time for Blood Specimen Collection when a Stand-alone Queue Ticket System not Connectable to Laboratory Information System Is Used

BACKGROUND

A queue ticket system (QTS) used in an outpatient phlebotomy clinic was unable to be directly integrated with the laboratory information system (LIS). To monitor patient's waiting time and extended turnaround time (TAT) as patient-centered quality indicators for outpatient laboratory services, we developed an algorithm to integrate data between the QTS and the LIS.

METHODS

Between June 1 to September 30, 2017, data files were exported from a QSYS-8000 (HION Tech, Seoul, Korea). Each calling event from the QTS data was matched to a barcode of test requests from the LIS if the following conditions were met: (1) time interval between "call time" from QTS and "barcode printing time" from LIS <90 s; (2) "Counter Number" from LIS="Counter Number" from QTS. Extended TAT was estimated as the interval between pulling the queue ticket and the reporting of the test result.

RESULTS

82.66%±3.14% of the barcodes from the LIS were matched to issued tickets. Median waiting time (mean±SD) was 6.5±5.3 min. Median extended TAT was 84.7±11.2 min for non-STAT and 53.0±6.4 min for STAT.

CONCLUSION

When a stand-alone QTS was used in the outpatient phlebotomy clinic, data from the QTS and the LIS were integrated using a novel algorithm we developed.

Clostridium difficile colonization among patients with clinically significant diarrhea and no identifiable cause of diarrhea

OBJECTIVE

To determine the prevalence of Clostridium difficile colonization among patients who meet the 2017 IDSA/SHEA C. difficile infection (CDI) Clinical Guideline Update criteria for the preferred patient population for C. difficile testing.

DESIGN

Retrospective cohort.

SETTING

Tertiary-care hospital in St. Louis, Missouri.PatientsPatients whose diarrheal stool samples were submitted to the hospital's clinical microbiology laboratory for C. difficile testing (toxin EIA) from August 2014 to September 2016.InterventionsElectronic and manual chart review were used to determine whether patients tested for C. difficile toxin had clinically significant diarrhea and/or any alternate cause for diarrhea. Toxigenic C. difficile culture was performed on all stool specimens from patients with clinically significant diarrhea and no known alternate cause for their diarrhea.

RESULTS

A total of 8,931 patients with stool specimens submitted were evaluated: 570 stool specimens were EIA positive (+) and 8,361 stool specimens were EIA negative (-). Among the EIA+stool specimens, 107 (19% of total) were deemed eligible for culture. Among the EIA- stool specimens, 515 (6%) were eligible for culture. One EIA+stool specimen (1%) was toxigenic culture negative. Among the EIA- stool specimens that underwent culture, toxigenic C. difficile was isolated from 63 (12%).

CONCLUSIONS

Most patients tested for C. difficile do not have clinically significant diarrhea and/or potential alternate causes for diarrhea. The prevalence of toxigenic C. difficile colonization among EIA- patients who met the IDSA/SHEA CDI guideline criteria for preferred patient population for C. difficile testing was 12%.

Removing Lipemia in Serum/Plasma Samples: A Multicenter Study

BACKGROUND

Lipemia, a significant source of analytical errors in clinical laboratory settings, should be removed prior to measuring biochemical parameters. We investigated whether lipemia in serum/plasma samples can be removed using a method that is easier and more practicable than ultracentrifugation, the current reference method.

METHODS

Seven hospital laboratories in Spain participated in this study. We first compared the effectiveness of ultracentrifugation (108,200×g) and high-speed centrifugation (10,000×g for 15 minutes) in removing lipemia. Second, we compared high-speed centrifugation with two liquid-liquid extraction methods-LipoClear (StatSpin, Norwood, USA), and 1,1,2-trichlorotrifluoroethane (Merck, Darmstadt, Germany). We assessed 14 biochemical parameters: serum/plasma concentrations of sodium ion, potassium ion, chloride ion, glucose, total protein, albumin, creatinine, urea, alkaline phosphatase, gamma-glutamyl transferase, alanine aminotransferase, aspartate-aminotransferase, calcium, and bilirubin. We analyzed whether the differences between lipemia removal methods exceeded the limit for clinically significant interference (LCSI).

RESULTS

When ultracentrifugation and high-speed centrifugation were compared, no parameter had a difference that exceeded the LCSI. When high-speed centrifugation was compared with the two liquid-liquid extraction methods, we found differences exceeding the LCSI in protein, calcium, and aspartate aminotransferase in the comparison with 1,1,2-trichlorotrifluoroethane, and in protein, albumin, and calcium in the comparison with LipoClear. Differences in other parameters did not exceed the LCSI.

CONCLUSIONS

High-speed centrifugation (10,000×g for 15 minutes) can be used instead of ultracentrifugation to remove lipemia in serum/plasma samples. LipoClear and 1,1,2-trichlorotrifluoroethane are unsuitable as they interfere with the measurement of certain parameters.

Comparison between Two Methods in the Determination of Circulating Chromogranin A in Neuroendocrine Tumors (NETs): Results of a Prospective Multicenter Observational Study

Several methods for analyzing CgA using either monoclonal or polyclonal antibodies have been developed, which differ in their diagnostic performance. The present paper describes the results of a prospective multicenter study aimed at comparing the clinical value of the two most widely used commercially available CgA assay kits in patients affected by neuroendocrine tumors (NETs). Two hundred sixty-one patients from 40 different centers and 99 healthy subjects were evaluated. CgA levels were measured with two different methods, a two-step immunoradiometric assay (IRMA) and an enzyme-linked immunosorbent assay (ELISA). CgA was measured centrally by two reference laboratories, one of which used IRMA and the other ELISA, and it was measured by the participating institutions with the method routinely used by each of them. The major findings of the present study were: (i) the two assays for the determination of CgA present good diagnostic performance; (ii) both assays are robust and guarantee comparable results when applied in different settings (central vs local laboratory); (iii) the negative/positive cutoff points (87 ng/mL for IRMA and 21.3 U/L for ELISA) were established according to standardized criteria; (iv) the results obtained with the two assays in basal clinical samples of patients affected by NETs show an apparently satisfactory correlation (rs=0.843, p<0.0001). However, a possibly clinically meaningful 36% discordance rate was found. These findings support the hypothesis that the two CgA kits might provide partially different information.

In vitro activity of eravacycline against 2213 Gram-negative and 2424 Gram-positive bacterial pathogens isolated in Canadian hospital laboratories: CANWARD surveillance study 2014-2015

Gram-negative (n=2213) and Gram-positive (n=2424) pathogens isolated from patients in 13 Canadian hospitals in 2014 and 2015 were tested for in vitro susceptibility to eravacycline and comparators using the Clinical and Laboratory Standards Institute broth microdilution method. The concentration of eravacycline inhibiting 90% of isolates (MIC₉₀) ranged from 0.5 to 2μg/mL for 9 species of Enterobacteriaceae tested (n=2067). Eravacycline activity was largely unaffected by extended-spectrum β-lactamase phenotypes in Escherichia coli (n=141) and Klebsiella pneumoniae (n=21). Eravacycline was active against Acinetobacter baumannii (n=28; MIC₉₀, 0.5μg/mL) and Stenotrophomonas maltophilia (n=118; MIC₉₀, 4μg/mL). Eravacycline MIC₉₀ for staphylococci (n=1653), enterococci (n=289), and streptococci (n=482) ranged from 0.12 to 0.25, 0.06 to 0.12, and 0.015 to 0.06μg/mL, respectively. Eravacycline's potency was equivalent to or 2- to 4-fold greater than tigecycline against Enterobacteriaceae and Gram-positive cocci tested. Eravacycline demonstrates promising activity against recent clinical Gram-negative and Gram-positive bacteria, including multidrug-resistant pathogens.

Diagnostic performance of point-of-care and central laboratory cardiac troponin assays in an emergency department

Early diagnosis of myocardial infarction (MI) with cardiac troponin (cTn) assays at the point-of-care (POC) is suggested to shorten turn-around-time in the emergency department (ED). The present study aimed at comparing the diagnostic performance of two POC cTn assays with that of a central laboratory high-sensitivity (hs) method, under routine ED conditions. In 2,163 non-selected ED patients suspected for MI, the diagnostic performance of the POC troponin I (TnI), troponin T (TnT), and hs-TnT assay for the prediction of MI was evaluated based on receiver operating characteristic (ROC) analyses and compared with the performance based on the manufacturers’ cut-offs. Due to an observed association between renal function as determined by estimated glomerular filtration rate (eGFR) and cTn concentrations, all analyses were stratified by renal function. In patients with normal renal function (eGFR > 60 mL/min/1.73m²), POC and hs assays showed a comparable diagnostic performance as quantified by the area under the ROC curve (AUC) of about 0.88. The ROC-derived optimal cut-off (OCO) levels for the different cTn assays clearly changed with decreasing kidney function. Impaired kidney function required OCO to be three to five times higher to achieve a comparable performance. Particularly cTnT concentrations were strongly associated with renal function. The three cTn assays demonstrated equivalent diagnostic performance in ED-patients admitted with suspected ACS in relation to the release diagnosis, supporting the use of POC testing in this setting. The present results implicate that application of eGFR-specific OCOs may decrease false-positives among patients with impaired renal function. Providing individual cut-offs depending on patients’ eGFR might be an appropriate add-on tool to improve specificity in the diagnosis of MI.

Susceptibility pattern of methicillin resistant Staphylococcus aureus to vancomycin and other alternate agents: report from a private sector hospital laboratory

With increasing prevalence of methicillin resistant Staphylococcus aureus in clinical settings and injudicious use of antibiotics, resistance among MRSA against commonly used antibiotics is increasing. To assess the susceptibility pattern of MRSA against vancomycin, linezolid, tigecycline, rifampicin, fosfomycin fusidic acid, clindamycin, trimethoprim-sulfamethoxazole and teicoplanin, minimum inhibitory concentrations (MICs) for given antimicrobials were performed on 234 MRSA clinical isolates using automated VITEK 2 system. Vancomycin, linezolid, rifampicin, clindamycin, co-trimoxazole and teicoplanin susceptibilities were interpreted according to CLSI breakpoints, while tigecycline, fosfomycin and fusidic acid were interpreted according to BSAC breakpoints. All isolates were found susceptible to vancomycin, tigecycline, teicoplanin and linezolid. Non-susceptibility of the isolates for rifampicin, fusidic acid and fosfomycin was noted for 58(25%). Co-trimoxazole and clindamycin were found less susceptible showing high resistance rates of 61.5% and 42.3%, respectively. Vancomycin resistance was not found, however an increased MIC of 1 mg/ml was observed in about 25% of clinical strains. Increase in vancomycin MICs in MRSA is of concern and alternative antimicrobial options must be evaluated and considered for treatment of MRSA infections. Continuous antimicrobial surveillance is needed to monitor resistance patterns and detect possible emergence of vancomycin non-susceptible isolates.

The effects of culture independent diagnostic testing on the diagnosis and reporting of enteric bacterial pathogens in Queensland, 2010 to 2014

Changes in diagnostic laboratory testing procedures can impact on the number of cases notified and the public health surveillance of enteric pathogens. Culture independent diagnostic testing using a multiplex polymerase chain reaction (PCR) test was introduced for the rapid detection of bacterial enteric pathogens in pathology laboratories in Queensland, Australia, from late 2013 onwards. We conducted a retrospective descriptive study using laboratory data to assess the impact of the introduction of PCR testing on four common enteric pathogens, Salmonella, Campylobacter, Shigella and Yersinia, in Queensland between 2010 and 2014. The number of stool specimens tested and the proportion positive for each of the four pathogens increased in 2014 after the introduction of culture independent diagnostic testing. Among the specimens tested by both PCR and culture, 12% of Salmonella positive stools, 36% of Campylobacter positive stools, 74% of Shigella / enteroinvasive Escherichia coli positive stools and 65% of Yersinia positive stools were PCR positive only. Including those where culture was not performed, 19% of Salmonella positive stools, 44% of Campylobacter positive stools, 83% of Shigella positive stools and 79% of Yersinia positive stools had no cultured isolate available for further characterisation. The detection and tracking of foodborne and non-foodborne gastrointestinal outbreaks will become more difficult as culture independent diagnostic testing becomes more widespread. Until new techniques for characterisation of pathogens directly from clinical specimens have been developed, we recommend laboratories continue to culture specimens concurrently or reflexively with culture independent diagnostic tests.

Should We Still Have Bare-Metal Stents Available in Our Catheterization Laboratory?

The introduction of bare-metal stents (BMS) has represented a major advancement over plain old balloon angioplasty in the management of coronary artery disease. However, the high rates of target lesion revascularization associated with use of BMS have led to the development of drug-eluting stents, which require prolonged dual antiplatelet therapy due to the increased risk of late and very late stent thrombosis. The improvements in newer-generation drug-eluting stents have translated into better safety and efficacy compared with earlier generation and BMS, thus allowing shorter dual antiplatelet therapy duration. Here, we aim to provide reasons as to why we still need BMS in our cardiac catheterization laboratory.

Addressing the key communication barriers between microbiology laboratories and clinical units: a qualitative study

Background

Many countries are on the brink of establishing antibiotic stewardship programmes in hospitals nationwide. In a previous study we found that communication between microbiology laboratories and clinical units is a barrier to implementing efficient antibiotic stewardship programmes in Norway. We have now addressed the key communication barriers between microbiology laboratories and clinical units from a laboratory point of view.

Methods

Qualitative semi-structured interviews were conducted with 18 employees (managers, doctors and technicians) from six diverse Norwegian microbiological laboratories, representing all four regional health authorities. Interviews were recorded and transcribed verbatim. Thematic analysis was applied, identifying emergent themes, subthemes and corresponding descriptions.

Results

The main barrier to communication is disruption involving specimen logistics, information on request forms, verbal reporting of test results and information transfer between poorly integrated IT systems. Furthermore, communication is challenged by lack of insight into each other's area of expertise and limited provision of laboratory services, leading to prolonged turnaround time, limited advisory services and restricted opening hours.

Conclusions

Communication between microbiology laboratories and clinical units can be improved by a review of testing processes, educational programmes to increase insights into the other's area of expertise, an evaluation of work tasks and expansion of rapid and point-of-care test services. Antibiotic stewardship programmes may serve as a valuable framework to establish these measures.