Clinical Laboratory Research Articles

Accuracy of the HemoCue® to measure cell-free plasma hemoglobin and detect clinically significant hemolysis.

Monitoring cell-free plasma hemoglobin (PHb) during extracorporeal therapies allows early intervention of significant hemolysis, but timely measurements are often challenging. We thus present an analysis of a rapid benchtop device's ability to detect clinically significant hemolysis (PHb ≥50mg/dL). PHb was measured in 419 plasma samples from 88 pediatric patients undergoing cardiopulmonary bypass via both the benchtop device (HemoCue® Plasma/Low Hb system) and the clinical laboratory at the Children's Hospital of Pittsburgh (reference standards). Values of PHb ≥50mg/dL as measured by the reference standard was defined as the binary outcome of clinically significant hemolysis. Analyses included Pearson correlations, logistic regression, receiver operating characteristic curves, and Bland-Altman. Because the manufacturer specifications identify the measurement range of the HemoCue® system as 30-3000mg/dL, a secondary analysis was completed using PHb ≥30mg/dL. Using reference measurements, 66/88 subjects had at least one PHb level that fell within the range of detection (≥30mg/dL) of the benchtop device and 46/88 had significant hemolysis as defined by PHb ≥50mg/dL. PHb levels ≥30mg/dL largely correlated with measurements made with the benchtop device (r = 0.82, p < .001). The device was able to predict PHb values ≥30mg/dL (AUROC 0.9582) and ≥50mg/dL (AUROC 0.9637). The Bland-Altman demonstrated a mean difference of 7.0mg/dL with <5% outside the 95% limits of agreement. The HemoCue® system is an effective surrogate for more robust laboratory testing to identify clinically significant hemolysis during cardiopulmonary bypass.

Copy Number Analysis of Whole Exome Sequencing Data

Abstract Background Genetic alterations implicated in constitutional disorders range in size from single nucleotide substitutions to losses and gains of millions of bases. Whole exome sequencing (WES) captures many clinically relevant variants, but an analytic pipeline optimized for detection of small substitutions, insertions, and deletions may miss pathogenic copy number variants (CNVs). Historically, our laboratory performed separate cytogenetic tests to evaluate for larger genomic imbalances. Addition of copy number analysis to our WES pipeline could improve the assay’s diagnostic yield. This study describes part of our strategy to validate copy number analysis of our constitutional whole exome sequencing data. Methods We identified 18 CNV specimens that underwent both chromosomal microarray analysis (CMA) and WES between 2017 and 2023. Variants included 13 deletions (size range 14Kb-2Mb) and 5 duplications (size range 325Kb-10Mb). The standard method of constitutional copy number analysis in our clinical laboratory is CMA using the Affymetrix Cytoscan HD Array and analysis software. CNVs identified on CMA were reviewed with reference to the Database of Genomic Variants and multiple academic hospital databases. WES was performed on an Illumina sequencing system following capture-based library enrichment with the Integrated DNA Technologies xGen Exome Research, CNV Backbone, Human mtDNA Research, and Human ID Research Panel probes. CNVs identified on WES were called using the Broad Institute’s Genomic Analysis Toolkit (GATK) with a quality score cutoff of 120. Whole exome sequencing data was visualized on the Integrative Genomics Viewer. Results 14 out of 18 CNVs reported on CMA were also detected on WES with a quality score at or above 120 (78%). This includes 10 out of 13 deletions (77%) and 3 out of 5 duplications (60%). For both deletions and duplications, the size ranges of detected variants at or above the cutoff score and undetected variants overlapped. One duplication reported on CMA was detected on WES with a quality score below 120. Visualization of whole exome sequencing data showed variation in probe density that may have affected CNV calling. Conclusions The majority of CNVs reported after CMA (14/18, 78%) were also detected on WES data using a GATK quality score cutoff of 120. The data does not suggest an association between CNV size and detection by WES, although interpretation is limited by the small number of cases. Data visualization may be required to identify some CNVs. Future steps to characterize the limitations of copy number analysis of WES data include assessments of variance in probe density and read depth across the exome. Copy number analysis of WES data from cases with normal CMA results will also be performed for assay validation.

Evaluation of the Hematology Analyzer Test Performance Using Six Sigma Metrics: A Cross Sectional Study

Abstract Introduction/Objective The six sigma metric is used to assess the performance of a measurement procedure in comparison to the medical requirement. In clinical laboratories, it can be used to assess the quality of instruments or processes. This study aims to evaluate the performance of hematology analyzers using the six sigma scale. Methods/Case Report This is a descriptive cross-sectional study wherein quality control data from hematology analyzers were obtained. The mean, standard deviation, coefficient of variation, bias and sigma value of the RBC, WBC, hemoglobin, hematocrit, and platelet parameters were determined and the performance of Beckman Coulter DxH 900 was assessed by plotting a normalized OPSpecs chart. Results (if a Case Study enter NA) The WBC and platelet parameters had sigma values of more than 6. Less stringent quality control measures could be applied these parameters which include fewer Westgard rules and fewer control runs. The RBC and hemoglobin parameters had sigma values of at least 3. The hematocrit parameter had a sigma value of less than 3. Improving this parameter could be done by performing optical channel evaluation, using multiple Westgard control rules, increasing the number of control materials and the number of runs. Conclusion This study has demonstrated the analytical performance of hematology analyzers on the six sigma scale, which in turn allows for the selection of the appropriate statistical quality control rule. Ultimately, statistical quality control is only one part of a laboratory’s quality management system. The sigma quality of the testing process, as well as choosing the appropriate control rules and number of controls, may provide the basis for the total quality control strategy of the laboratory. Other pre-analytic and post-analytic factors must also be considered in formulating a laboratory total quality control plan. This would allow the laboratory to provide the best possible quality of services to its clients by increasing efficiency, reducing wastage, and incorporating continuous changes to improve the system.

Cherry-Red Plasma Unraveling the Impact of PV-10 on Chemistry Assays

Abstract Background The accuracy of clinical laboratory measurements can be compromised by laboratory test interferences. PV-10 (Rose Bengal), a chemotherapy medication used in the treatment of metastatic melanoma, was observed to cause a cherry-red discoloration in plasma. This plasma color change, resembling hemolysis, raises serious concerns about potential interference in clinical laboratory tests. Our study focused on understanding the potential interference of PV-10, particularly the impact on the hemolysis index (H index) and various chemistry assays to ensure result accuracy in cancer treatment. Methods To investigate the potential interference of PV-10, pooled normal and high baseline bilirubin plasma samples were spiked with a gradient of PV-10 concentrations (0 to 22 µg/100µL). Samples were analyzed on Roche Cobas 8000 analyzer with H index and all the chemistry assays measured. Results The presence of PV-10 in plasma significantly increased the H index, in a dose-dependent manner. Specifically, the H index increased from 14 (control plasma) to 2643 at the highest PV-10 concentration (22 µg/100µL) in pooled plasma. Among all chemistry assays, most of them were not affected by PV-10. However, certain assays like IRON have dose dependent increase with PV-10 concentration. CHO2A (Total Cholesterol), TP (Total Protein), and TRIG (Triglycerides) have shown a consistent increase trend. In contrast, the DBILI values decreased with increasing PV-10 concentrations, from 6.7 mg/dL to 0.2 mg/dL. TBIL levels also demonstrated a gradual decline from 9.6 mg/dL to 8.4 mg/dL as PV-10 concentration increased in pooled high baseline bilirubin plasma. Conclusion This study provides insights into the potential interference of PV-10 in clinical chemistry assays. The elevated H index by PV-10 is not attributed to hemolysis. It is imperative for both laboratory professionals and care providers to recognize the implications of PV-10-induced plasma discoloration and its potential interference in laboratory tests.

Long-term outcomes of high-risk human papillomavirus in anal infection support HPV men vaccination

Abstract Introduction/Objective The clinical laboratory in a local hospital has an important role in population surveillance. The clinical laboratory performs analyses on patients admitted to the hospital as inpatients or critical patients and it is also a reference point for people’s health check-ups and health surveillance. Infectious diseases normally have severe symptoms. To ensure benefits from therapeutic treatment, a timely diagnosis is necessary. The human papillomavirus (HPV) virus is among the most diagnosed sexually transmitted infections worldwide, and the male gender is not exempt from it. In fact, 1 out of 3 male individuals is infected with HPV and 1 out of 5 male individuals is infected with a high-risk strain (1). In Italy, vaccination is underway for women only. Vaccine prevention extended to male individuals could lead to a halving of HPV cases. Methods/Case Report From 2018 to 2022, we performed 7362 HPV tests using DNA extraction technique (QiaSimphony) and real-time Multiplex PCR (SeeGene 28 strains). Results (if a Case Study enter NA) 3762 out of 7362 HPV tests performed were positive for one (2059 patients) or more (1969 patients) HPV strains. Women, who are more aware of prevention, are more represented in our sample of subjects. The tests performed on women are 6499 and half (3331) are positive for at least one strain of HPV. Regarding men, 863 tests were performed. About half (431 patients) were positive for at least one HPV strain. Noteworthy, out of 175 anal HPV tests, 48% were positive and 1 patient had squamous cell carcinoma. Furthermore, in our male patients tested 2 - 12% had low or medium-risk injuries. In total, out of 7529 tests carried out from 2018 to 2022, over than 50% were found to be high-risk viral strains (5231). Of these, however, approximately half (2781) are now preventable with the monovalent HPV vaccine (strains covered: 6, 11, 16, 18, 31, 33, 45, 52, 58). Conclusion The Ospedale Isola Tiberina – Gemelli Isola is an Institution in the center of Rome, Italy. It is also a reference center for birthrates and women’s prevention. Therefore, our Institution is very efficient in raising awareness of the prevention of HPV-related cancer. Current data indicate that male cases are not negligible, being positive in almost 50% of anal tests, and associated with an increased risk of the related cancers. These data can have an important impact on the Italian population, both in terms of the spread of HPV and healthcare burden and in terms of high healthcare costs.

Challenges of Conducting Point-Of-Care Testing Operations In The Municipal Public Health System Based Ambulatory Care Clinics In New York City

Abstract Introduction/Objective Our New York City Municipal Public Health System- based multisite ambulatory clinics that offer various waived POCT (point of care tests) and provider-performed microscopy (PPM) to our communities, ensure standardization and quality of POC testing across our health system. Our laboratory service conducts system-wide centralized implementation, monitoring and oversight of the POCT operations regarding regulatory compliance, test performance, quality control and training. With our day-to-day POCT operations, like all other clinical laboratories, our ambulatory care clinics encounter various hurdles and challenges. Here we elaborated on the issues we encounter and how we manage to overcome them. Methods/Case Report We identified and stratified the challenges that affect our managerial as well as field-level laboratory operations and devised ways to deal with those POCT operational issues. Results (if a Case Study enter NA) Among the staffing issues, rapid staff turnover causes significant delays or cessation of POCT operations in our ambulatory care clinics, due to orientation, re-education and ensuring competency to the staff, that conducts POCT in our clinics. Besides, supply shortages, staff shortages and absences due to illness and overwork are the issues, noted at the laboratory field operational level. Delays in the processing of paperwork and new staff recruitments and in the laboratory supply chains are notable management issues. Conclusion Even though the vastness and complexity of our multisite ambulatory care network sometimes affect our ambulatory care clinic POCT operation in various challenging way, our timely, planned and coordinated intervention, close monitoring and communication and rapid initiatives handle those issues very effectively to ensure the quality of POC testing for the patient safety and care across our health system, which is one of the largest municipal-based public health care, in the country.

Standardizing Hypoglycemic Critical Values Across United States Hospitals

Abstract Introduction/Objective While previous diabetes studies have defined severe hypoglycemia as glucose &amp;lt; 50 mg/dL, the American Diabetes Association (ADA) classified glucose &amp;lt; 54 mg/dL as requiring immediate action in 2019. In response, some laboratories implemented 54 mg/dL as their hypoglycemia critical value. However, there is no standardization across the medical community. Methods/Case Report To investigate the variability of hypoglycemia critical values across hospitals in the United States, hypoglycemia critical value thresholds were collected from the top 50 hospitals from the Newsweek’s World’s Best Hospitals 2020 United States list via hospital websites or representatives from the clinical laboratory. To evaluate the potential burden to providers and laboratory staff of raising the hypoglycemia critical value at our institution, we retrospectively reviewed deidentified glucose laboratory data for inpatient and outpatient core laboratories and determined the volume of critical value alerts sent to ordering providers per month under different hypoglycemia critical value thresholds. Results (if a Case Study enter NA) Across the 45 hospitals included, median hypoglycemia critical value was 50 mg/dL (Range: 40-60 mg/dL). The hypoglycemia critical value was set at 40 mg/dL at 12 hospitals and 50 mg/dL at 21 hospitals. 22% of institutions set the hypoglycemia critical value at or above the ADA recommendation of 54 mg/dL. Increasing the hypoglycemia critical alert to 50 mg/dL at our institution would increase the average monthly alerts by 122 for inpatient and 41 for outpatient core laboratories, corresponding to 163 additional total core laboratory alerts per month. Increasing the critical alert to 55 mg/dL, would increase average monthly alerts by 243 for inpatient and 99 for outpatient core laboratories, corresponding to 342 total additional alerts per month. Conclusion Our analysis suggests standardizing 50 mg/dL as the hypoglycemia critical value across institutions to improve patient safety by reducing the risk of severe acute symptoms and long-term complications without adding excessive burden to laboratory staff and providers.

Activity Assessment of Factor Replacement Therapies to Guide Infusion Rate Protocols in Patients with Bleeding Disorders

Abstract Introduction The development of institutional protocols guiding administration of clotting factor replacements in patients with bleeding disorders requires an understanding of product stability over infusion duration. Inclusion of new factor products on formulary at our institution raised consideration for optimal administration routes, including whether a bolus intravenous push versus infusion over 4-12h provided acceptable factor activities. Here we assessed the activity of two clotting factor replacement therapies over a 24h period to guide clinical care protocols. Method This study was performed in the Special Coagulation Lab as a collaboration between pharmacy, hematology, and laboratory medicine. Two vials each of Novoeight, a recombinant antihemophilic factor used in patients with factor VIII deficiency, and Vonvendi, a recombinant von Willebrand Factor (VWF) replacement approved for prophylaxis in adults with Type 3 von Willebrand Disease, were reconstituted to clinically relevant potencies (13 IU/ml, Novoeight; 27 IU/ml, Vonvendi). Products were spiked separately into factor VIII-deficient plasma (Novoeight) or assay diluent (Vonvendi), given inability to obtain VWF-deficient plasma, and tested for activity at various timepoints. Novoeight samples were assessed by traditional one-stage FVIII assays, while Vonvendi samples were assessed for VWF antigen, ristocetin cofactor activity (RCA), and glycoprotein Ib binding activity (GP1bM). Results Novoeight samples maintained similar FVIII activities at all timepoints tested, with differences falling within the coefficient of variation of the assay. Specifically, the two samples had FVIII levels of 108% and 95% at baseline and levels of 98% and 91%, respectively, at 12h, which was the timepoint of greatest interest given plans to allow 12h infusion rates. For Vonvendi samples, measurement of VWF antigen remained fairly stable throughout the 24h period. However, VWF activity decreased in both RCA and GP1bM assays over time, including by 4h. RCA values were 193% and 190% at baseline, 113% and 95% at 4h, and 63% and 63% at 12h. GP1bM was 140% and 133% at baseline, 92% and 91% at 4h, and 56% and 70% at 12h. Together, these results supported implementation of protocols allowing for extended (up to 12h) infusion of Novoeight and short (3-5min) bolus infusion of Vonvendi. Conclusion Our study demonstrated maintained Novoeight activity over the study period, confirming infusion rates of 12h should be efficacious. Conversely, Vonvendi yielded significantly decreased activity levels in as little as 4h, indicating the need for faster infusion rates. Based on our results, current practices at our institution were adapted to include extended infusion for Novoeight only. Drug activity studies may not directly reflect patient outcomes, and additional studies of factor activities following product infusion into patients and clinical hemostasis correlates are necessary. Nevertheless, the clinical lab should continue to play a primary role in testing, monitoring, and developing patient care protocols for therapeutic drugs through multidisciplinary collaboration.

Perspectives on Long-Term Follow-Up Among Living Kidney Donors

Background: The long-term follow-up of living kidney donors is highly variable in Canada. Methods: We surveyed perspectives on post-donation follow-up among 685 living donors in the two largest transplant programs in Canada (43% survey response rate). The anonymous survey was informed by semi-structured interviews with 12 living kidney donors. The survey was developed based on themes identified in the semi-structured interviews, guidance from the research and clinical teams, and feedback from pilot testing with six previous donors. Results: Most (73%) respondents received follow-up after the first donation year from a primary care provider, and 70% reported annual follow-up visits including blood and urine tests. Most (71%) received a follow-up reminder from their transplant center, and follow-up was higher (86% versus 68%) among those receiving reminders. Donors wanted specialist involvement if new health or kidney-related events occurred. Most (70%) were satisfied with their follow-up, and 66% endorsed annual life-long follow-up. Donors wanted more information about lifestyle and living donor outcomes and wanted to contribute to research to increase understanding of long-term donor health outcomes. Conclusions: Donors wanted annual lifelong follow-up including clinical assessment and laboratory tests and more information about their post-donation health. A transplant center led, primary care provider administered model of long-term follow-up may best meet the care and information needs of most donors.

Case Series: Emerging Pathogens Aerococcus urinae and Aerococcus sanguinicola at a Canadian tertiary care hospital

Abstract Introduction/Objective Background: Aerococcus urinae and sanguinicola are emerging opportunistic pathogen linked with urinary tract infections. Unmanaged Aerococcus infections have the propensity to precipitated into urosepsis. The ongoing gestalt of managing these infections needs standardization. We reviewed A. urinae and sanguinicola isolates from our clinical microbiology laboratory to better characterize its spectrum of clinical presentation, sources of infection, microbiological characteristics, and antimicrobial management. Methods/Case Report Methods: The electronic microbiology database was utilized to review the retrospective clinical data of patients that grew positive cultures for Aerococcus urinae and sanguinicola on matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF) in Saskatchewan from January to July 2023. Demographic variables, site of presentation, microbiological parameters surrounding culture and sensitivities, and antimicrobial management were recorded. The results were analyzed on SPSS 28 software. Results (if a Case Study enter NA) Results: This cohort (n=115) had a median age 82 years [Range: 7 to 103] with a female predilection (F:M = 78:37). A. urinae and sanguinicola were primarily involved in UTI (n=96), obstructive uropathy (n=9), and urosepsis (n=6). The hypothyroidism (26.9%, n = 31) rate in this population was 3-fold higher than the age-matched background rate for our province. Aerococcus infections were predominantly monomicrobial (73.9%, n= 85 out of 115) and showed sensitivity for ceftriaxone, penicillin G, and vancomycin. Antimicrobials were seldom used in the UTI cohort (31.2%, n=30 out of 96). Amoxicillin-clavulanate (29.8%, n=25 out 84) was the most popular choice at patient discharge in monomicrobial Aerococcus infections only. Conclusion Conclusion: Aerococcus urinae and sanguinicola are emerging uropathogen. Despite this, the clinical significance of these Aerococcus species remains undervalued. Our case series shows that untreated or recurrent A. urinae and A. sanguinicola infections can precipitate into urosepsis. Clinicians should utilize the antimicrobial susceptibility profiles for these Aerococcus species to provide appropriate antimicrobial coverage and manage these pathogens effectively. Further studies should explore the link between hypothyroidism and these aerococcal infections.

Lost in the Ds: Unexplained Loss of Rh(D) Antigen Expression By Serological Testing In Two Patients

Abstract Introduction/Objective While the loss of ABOH antigens has been well documented, reduced-to-absent expression of the RHD antigen is comparatively rare. Here, we describe two cases with D antigen loss presenting associated clinical settings, smear results, and red blood cell (RBC) genotyping findings to elucidate this unusual phenomenon. Methods/Case Report Cases (n=2) were retrospectively reviewed based on discovery during routine serological testing in our Blood Bank. RhD blood typing was performed via gel methods [Grifols, Los Angeles, CA]. Clinical information and laboratory data were extracted via the electronic medical record. Case 1 is a 79-year-old female with metastatic breast cancer. She initially typed as D positive (4+) in at least two separate analyses, but her D front type progressively became weaker until turning entirely negative after several weeks. Spherocytes and stomatocytes were present on her peripheral blood smear. This patient received 10 D+ red blood cell (RBC) units without anti-D formation. RBC genotyping revealed traditional “dce” by standard polymerase chain reaction (PCR). Case 2 is a 61-year-old male with a history of pre-B acute lymphocytic leukemia post-stem cell transplant, myelodysplastic syndrome, and progressive loss of D antigen expression (4+ to 0). Standard RBC genotyping revealed “Dce” by PCR. The peripheral blood smear was significant for RBC anisopoikilocytosis with increased stomatocytes, spherocytes, and ovalocytes. Results (if a Case Study enter NA) NA Conclusion The disappearance of the D antigen is rare, and our experience suggests an association between malignancies (both hematopoietic and non-hematopoietic) and D antigenic loss. Beyond these disease associations, however, loss of RhD is not otherwise readily explained in either case. Further analysis to test for other RHAG and RHCE mutational variants is an ongoing area of investigation in these cases, as more sensitive testing may reconcile the traditional PCR results with our initial detection of the D antigen.

Clinical Utility of Recently FDA Approved IntelliSep test (Sepsis biomarker) for early Diagnosis of Sepsis: Comparison with other Biomarkers and von Willebrand Factor/ADAMTS13 Ration

Abstract Background Sepsis, a relatively common presentation in emergency departments, is a life-threatening disease. Recently, IntelliSep test by Cytovale (San Francisco, CA) received FDA approval as sepsis biomarker. We investigated clinical utility of this test using 44 patients (19 disease group and 25 non-disease group). Materials and Methods IntelliSep assesses cellular host response via deformability cytometry of leukocyte biophysical properties and intended for use in conjunction with clinical assessments and laboratory findings for early detection of sepsis. Test results are available within 10 minutes. Results consists of IntelliSep Band 1 (low risk, score: 0.1-4.9) to Band 3 (high risk, score: 6.3-10; total scale: 0.1-10). We measured IntelliSep score in 44 patients using EDTA blood. Left over plasma was used for measuring both plasma von Willebrand factor (vWF) antigen and ADAMTS13 antigen by ELISA assays. Monocyte distribution width (MDW) were obtained during routine CBC analysis using Beckman hematology analyzer. Lactate and high sensitivity troponin I were measured using Beckman analyzer. Results The median IntelliSep score was two-fold higher in the disease group (mean score 7.1, SD: 1.5, median: 7.4) compared to non-disease group (mean score 4.0, SD: 1.4, Median: 3.7) indicating that this new test can identify patients with high risk of developing sepsis and also rule out low risk patients (p&amp;lt;0.01 by both Mann-Whitney U test two tailed and t-test two tailed). The median MDW was also 34.8 % higher in the disease group (mean:25.6, SD: 5.0, Median: 24.4) compared to non-disease group (mean: 18.9, SD: 2.4, Median: 18.1) and difference was also statistically significant (p &amp;lt; 0.01 by both Mann-Whitney U test and t-test, two tailed). However, correlation between IntelliSep scores and MDW was only modest (overall, r= 0.66). Both lactate and procalcitonin concentrations were significantly higher in the disease group compared to the non-disease group. Interestingly, high-sensitivity troponin I concentrations were also significantly higher in the disease group. In addition, we observed significantly higher plasma vWF antigen in the disease group compared to the non-disease group (mean: 67.4 ug/mL in disease group vs 34.1 ug/mL in the non-disease group. However, in some patients in the disease group plasma vWF values were 6.8-fold higher than normal. In addition, vWF/ADAMTS13 ratio was also significantly elevated in the disease group compared to non-disease group. Discussion New IntelliSep test is useful in early prediction of sepsis in patients admitted to emergency department and may be superior to MDW and lactate for early diagnosis. Significant increase in plasma vWF in these patients indicate that vWF may also be a surrogate marker for endotheliopathy in sepsis. Lack of correlation between plasma VWF and Intellisep results indicates that these two markers probably measure different pathways for sepsis (endothelial activation vs neutrophil activation).

Relocating a highly complex 5 million test per year hospital based laboratory - what you should know and what you should avoid

Abstract Introduction/Objective A highly complex hospital based laboratory performing 5 million test per year in New York City was commanded to relocate due to a clinical department need to expand. This presented a challenge regarding the obtention of a suitable new space within the existing facility, the architectural design to optimize the performance of both Anatomic and Clinical Pathology, the choice between acquirring brand new instrumentation versus relocation of the existing instruments. At the same time, we had to interact with hospital wide Facilities Management and Information Services/ Electronic Medical records. In addtion, for quality improvement and to alleviate the shortage of licensed technologist in our state, it was decided that a robotic line was to be implemented in the new facility. Methods/Case Report Several space options were assessed. Once the most suitable space was found a decision was made to move in two phases, Anatomic Pathology first, and subsequently Clinical Pathology. New work stations were purchased for Anatomic Pathology. New instruments were obtained for Chemistry, Immunology and Hematology. All instruments were validated.. Our laboratory information system had to be upgraded in order to support the robotic line, which is to be implemented after the Clinical Laboratory move. This will facilitate the expansion of in house provision of laboratory services to outpatient facilities / clinics expandin our outreach. The new space includes room to expand as well as abundant swing space. Our next phase includes the relocation of our Blood Bank and expansion of our Microbiology Services Results (if a Case Study enter NA) Due to delays in the obtention of the State Occupational permit the move was postponed several times. It was decided to move in two phases, once the permit was received. The Laboratory successfully moved in a two week period, and was fully operational overnight. Conclusion The Laboratory successfully moved in a two week period, and one week later we underwent a routine State inspection, in which the rigourous inspectos encountered very few deficiencies. The Laboratory is fully operational to the satisfaction of our clinical departmenst and preparing to the next phase including Blood bank and expanding our outreach program

Mycobacterium terrae Complex Associated Lymphadenitis: Negative AFB PCR

Abstract Introduction/Objective Nontuberculous mycobacteria included with the Mycobacterium terrae complex (MTC) include a ubiquitous, slow-growing collection of mycobacteria known for causing severe resistant skin, joint, and bone infections. There are limited reports of M. Arupensis, included under MTC, causing human infections despite environmental ubiquity. Low sequencing sensitivity for species such as M. Arupensis may result in negative preliminary PCR speciation thus influencing the negative predictive value of this method of organism detection. No prior case reports have described MTC infection presenting as subacute lymphadenitis. Methods/Case Report A 48 year old El Salvadorian male with known diagnosis of HIV presented with oral thrush and significant left-sided lymphadenopathy. He was initially diagnosed with HIV in El Salvador and on ART until immigrating to the US six months prior. HIV antigen and antibody was positive with positive reflex viral PCR. QuantiFERON-TB Gold resulted positive, but CXR was without evidence of pulmonary TB. TB1, TB2, and mitogen minus NIL were negative. He was referred for fine needle aspiration and core needle biopsy of the left cervical lymph node. AFB and AFB FITE stains were performed, but no definitive mycobacteria were identified. GMS was performed and negative for fungal elements. A final histological diagnosis of necrotizing granuloma was given and the tissue was sent for bacterial, AFB, and fungal DNA PCR; no organisms were detected. A sputum sample was obtained and cultured four months after initial presentation and was positive for acid fast bacilli: Mycobacterium terrae complex, most closely resembling Mycobacterium arupensis. The Fite and AFB stains were again reviewed, revealing one single acid fast bacilli organism identified on Fite stain in the necrotizing granuloma. Results (if a Case Study enter NA) N/A Conclusion The negative AFB DNA PCR result may have been a false negative result due to poor sensitivity or selectivity for M. arupensis. There are no former reported cases of M. Arupensis associated necrotizing granulomas in lymph node. This unusual MTC infection presenting as chronic unilateral lymphadenitis underscores the importance of broadening clinical laboratory AFB DNA PCR sensitivity especially in cases of suspected AFB or modified AFB associated necrotizing granulomas.

NPM1 Minimal Residual Disease Detection at Any Time by Clinical Next Generation Sequencing Predicts Poor Survival in Acute Myeloid Leukemia

Abstract Introduction/Objective Acute Myeloid Leukemia (AML) is a deadly disease that accounts for 80% of adult leukemia cases and carries a 5-year survival rate of only 31.7%. Historically, prognosis hinged heavily on cytogenetic stratification, but more recently minimal residual disease (MRD) has emerged as a crucial prognostic marker. Flow cytometry, PCR, and NGS can all be employed for MRD detection, but each carries its own limitations. Though technically challenging, NGS has the advantage being able to simultaneously assay multiple mutations, thus providing for broader applicability. NPM1 is the most prevalently mutated gene in AML (25-35%). In this study, one of the largest of its kind, we investigate the feasibility and impact of NPM1 MRD detection by clinical NGS. Methods/Case Report IRB approval was obtained. We reviewed the medical record and clinical laboratory data sets from AML patients treated at Moffitt Cancer Center who had NPM1 status assessed by clinical NGS, Testing was performed at LabPMM (San Diego, CA). DNA was extracted, and NPM1 exon 12 was amplified. PCR products were sequenced on an Illumina MiSeq. The clinically reportable assay sensitivity was 5 x 10-5 though lower levels were detected on review of raw data. Kaplan-Meier analysis was conducted for overall survival assessment. Since patients often had multiple tests, we divide patients into those with NPM1+ at any time and NPM1 always negative. Results (if a Case Study enter NA) There was a total of 140 patients. Overall, 346 tests were conducted, with an average of 2.5 tests/patient. There were 85 patients (60%) who underwent serial testing. MRD+ patients (n=80) had a mean age of 66 years, while MRD- patients (n=60) had a mean age of 58 years. MRD+ patients exhibited a mean overall survival of 29.3 months versus 43.6 months for MRD- patients (p=0.005.) Conclusion Through our study encompassing a large patient cohort of 140 patients and nearly 350 testing data points, we confirm the feasibility and clinical utility of NPM1 MRD evaluation by NGS. The significantly poorer survival in patients who were MRD+ at any time during their disease provides a scientific rationale for serial NGS testing to enable risk stratification of NPM1+ AML patients.

Case-Based Training on Best Practices in Effective Test Utilization for Clinical Laboratories: A Comparison of Two Educational Formats

Abstract Introduction/Objective While a survey of ASCP membership showed improvements being made in effective test utilization (ETU), there is an ongoing need for formal education on best practices. Case-based education drawn from real-world scenarios provides an opportunity to address this need, aimed at increasing the understanding of evidence- based guidelines to inform clinical test ordering and reduce overconsumption of supplies without compromising patient care. The poster presents two examples of case-based education presented in an innovative microlearning format and an eLearning format designed for clinical laboratory professionals. Methods/Case Report The activities presented 9 - 10 practical, real-world scenarios as educational cases along with assessment questions addressing a range of topics that included ETU for pancreatitis and cardiac injury, blood collection tube consumption and conservation, strategies for reducing repeat daily lab test ordering, and others. Each case was designed for learners to be able to review the content and answer the assessment questions in 5 minutes. In the microlearning activity, learners received the cases and questions via email on a scheduled frequency and completed them via mobile device. The questions were repeated up to 2 times to reinforce learning. Participants in the eLearning activity accessed the same cases and assessment questions via a different learning platform (with no staggered delivery). Results (if a Case Study enter NA) More than 2,500 learners have participated in one or both ETU activities, and feedback has been highly positive. The assessment results show proficiency gains for a range of laboratory personnel, including laboratory managers/supervisors, histotechnologists, medical laboratory scientists, laboratory technicians, pathologists, and other laboratory roles. Conclusion The results also show how case-based scenarios can help promote best practices in ETU, which may be particularly beneficial for laboratory decision-makers. In addition to showing increased understanding of ETU strategies, the results also pose lessons learned for designing similar types of case-based education.

Sevelamer Treatment for Hyperphosphatemia in a Saudi Arabian Chronic Renal Disease Patient

Abstract Introduction/Objective Introduction: Patients with advanced chronic kidney disease (CKD) often require phosphate binders to manage elevated serum phosphorus levels due to phosphorus-restricted diets being insufficient. This study aimed to assess the safety and efficacy of sevelamer in lowering serum phosphorus and improving the serum lipid profile in a hemodialysis patient. Methods/Case Report A prospective study was conducted on a 59-year-old hemodialysis man with CKD. Sevelamer was administered orally as 800 mg tablets, with the dosage adjusted based on washout serum phosphorus levels (WSPL). Blood samples were collected every two weeks before dialysis, and all samples were analyzed using standard clinical laboratory methods. Sevelamer treatment resulted in a significant reduction in serum phosphorus levels from 6.9 mmol/l to 4.3 mmol/l. No major adverse events were observed during the trial period, and there was no evidence of negative consequences associated with sevelamer therapy. Additionally, sevelamer treatment led to a decrease in hemoglobin levels to 10.5 g/dl and a substantial reduction in total cholesterol concentration from 5.22 mmol/l to 4.26 mmol/l. Results (if a Case Study enter NA) NA Conclusion Conclusion: Sevelamer, a non-absorbable aluminum and calcium-free phosphate binder, effectively lowered serum phosphorus levels in dialysis patients while improving lipid profiles. It was well tolerated with no instances of hypercalcemia and resulted in significant reductions in intact parathyroid hormone (PTH) and total and LDL cholesterol. Sevelamer may serve as a valuable therapeutic option for managing hyperphosphatemia in patients with CKD.

Molecular Typing of Pseudomonas aeruginosa Isolates Collected in Abidjan Hospitals (Côte d'Ivoire) Using the Multiple-Locus Variable Number of Tandem Repeats Method.

Background/objectives:Pseudomonas aeruginosa can cause community-acquired infections affecting various body sites. The present retrospective study investigated the genetic diversity of 173 isolates (166 clinical, 7 environmental) of P. aeruginosa collected from clinical pathology laboratories in Abidjan, Côte d'Ivoire (2001-2011). Methods: Multiple-Locus Variable Number of Tandem Repeats (VNTR) Analysis (MLVA) using 13 loci was applied to all isolates and compared to published MLVA data. The antibiotics status of the isolates was compiled when available and compared to published profiles. Results: Among 95 isolates analyzed for their antibiotics status, 14 displayed concerning resistance profiles: five multidrug-resistant (MDR) and nine extensively drug-resistant (XDR). MLVA typing revealed a high genetic diversity (>130 genotypes), with many genotypes represented by a single strain. Notably, thirteen clusters (≥4 related isolates) were observed. Some clusters displayed close genetic relatedness to isolates from France, Korea, and well-studied strains (ST560, LES and PA14). Comparative analysis suggested the presence of international high-risk MDR clones (CC233, CC111) in Côte d'Ivoire. Importantly, MLVA clustering revealed a close relationship of CC235-MDR strains with a locally identified cluster (group 9). Conclusions: These findings support MLVA as a reliable and cost-effective tool for low-resource settings, allowing the selection of relevant strains for future whole genome sequence analyses. This approach can improve outbreak investigations and public health interventions aimed at curbing MDR P. aeruginosa transmission within hospitals and at the national level.

The clinical characteristics of systemic lupus erythematosus-related thoracic duct obstruction: a retrospective case-control study from China.

To investigate the clinical characteristics and treatment strategies of patients with systemic lupus erythematosus-related thoracic duct obstruction (SLE-TDO). Clinical data, laboratory tests, imaging data, and treatment strategies were retrospectively collected from 428 SLE patients with TDO treated from January 2010 to December 2020 at Beijing Shijitan Hospital. TDO was confirmed by TD imaging examination. We retrospectively examined 20 SLE patients with TDO as the case group, and 80 randomly matched SLE patients without any lymph-vessel dysfunction as the control group. The prevalence of TDO in patients with SLE was 4.67%, and the in-hospital fatality rate was 5%. Of these patients, 50% presented with TDO as the initial manifestation of SLE, with the others first diagnosed with SLE followed by TDO. The average SLE disease activity index (SLEDAI) was 7 ± 3.8. All patients were treated with glucocorticoids (GC) and immunosuppressants combined with a medium-chain triglycerides (MCT) diet. Eleven patients received TD-related surgery in parallel with anti-rheumatic treatment. Polyserositis, anti-Sm antibody positivity, and SLEDAI score were found to be independent risk factors for TDO in patients with SLE. While SLE patients may develop TDO during the course of their disease, TDO can also be the initial presentation of SLE. TDO should therefore attract the attention of rheumatologists and the surgeon. GC and immunosuppressants combined with lymphatic surgery may be an effective therapeutic strategy for SLE-TDO to relieve symptoms and improve prognosis. Key Points • Thoracic duct obstruction (TDO) is a rare complication of SLE. • SLE may develop TDO during the disease course, while TDO can also be the initial presentation of SLE, which should attract the attention of physicians. • Glucocorticoids and immunosuppressants combined with lymphatic surgery may be an effective therapeutic strategy for SLE-TDO to relieve symptoms and to improve prognosis.

Subcutaneous adipose tissue measured by computed tomography could be an independent predictor for early outcomes of patients with severe COVID-19.

Patients with severe Coronavirus Disease 2019 (COVID-19) can experience protein loss due to the inflammatory response and energy consumption, impairing immune function. The presence of excessive visceral and heart fat leads to chronic long-term inflammation that can adversely affect immune function and, thus, outcomes for these patients. We aimed to explore the roles of prognostic nutrition index (PNI) and quantitative fat assessment based on computed tomography (CT) scans in predicting the outcomes of patients with severe COVID-19. A total of 130 patients with severe COVID-19 who were treated between December 1, 2022, and February 28, 2023, were retrospectively enrolled. The patients were divided into survival and death groups. Data on chest CT examinations following admission were collected to measure cardiac adipose tissue (CAT), visceral adipose tissue (VAT), and subcutaneous adipose tissue (SAT) and to analyze the CT score of pulmonary lesions. Clinical information and laboratory examination data were collected. Univariate and multivariate logistic regression analyses were used to explore the risk factors associated with death, and several multivariate logistic regression models were established. Of the 130 patients included in the study (median age, 80.5 years; males, 32%), 68 patients died and 62 patients survived. PNI showed a strong association with the outcome of severe COVID-19 (p < 0.001). Among each part of the fat volume obtained based on a CT scan, SAT showed a significant association with the mortality of severe COVID-19 patients (p = 0.007). However, VAT and CAT were not significantly correlated with the death of patients. In the multivariate models, SAT had a higher predictive value than PNI; the area under the curve (AUC) of SAT was 0.844, which was higher than that of PNI (AUC = 0.833), but in the model of the combination of the two indexes, the prediction did not improve (AUC = 0.830), and SAT lost its significance (p = 0.069). Subcutaneous adipose tissue measured by computed tomography and PNI were found to be independent predictors of death in patients with severe COVID-19.