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Favaloro EJ, Arunachalam S, Chapman K, Pasalic L. Continued harmonization of the international normalized ratio across a large laboratory network: Evidence of sustained low interlaboratory variation and bias after a change in instrumentation. Am J Clin Pathol 2024:aqae090. [PMID: 39024475 DOI: 10.1093/ajcp/aqae090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Accepted: 06/22/2024] [Indexed: 07/20/2024] Open
Abstract
OBJECTIVES Our objective was to maintain low interlaboratory variation and bias in international normalized ratio (INR) results following a network change in instrumentation and reagents, using a process of ongoing standardization and harmonization. METHODS Network-wide standardization to new common instrument and reagent platforms followed by network-wide application of a simple novel process of verification of international sensitive index and mean normal prothrombin time values for each new lot of prothrombin time (PT) reagent that does not require use of World Health Organization reference thromboplastin or INR calibration/certified plasma. RESULTS The network transitioned from mechanical hemostasis detection instruments with associated PT reagent (Diagnostica Stago; NeoPTimal) to optical detection (ACL TOPs) with associated PT reagent (Werfen; RecombiPlasTin 2G). Comparing 3 years of data for each situation, the network (n = 27 laboratories) maintained low INR variability and bias relative to general mechanical and optical groups and other laboratories. CONCLUSIONS Harmonized support for patient management of vitamin K antagonists such as warfarin was continuously maintained in our geography, with potentially positive implications for other coagulation laboratories and geographies. For the United States in particular, paucity of US Food and Drug Administration-cleared INR certified plasmas potentially compromises INR test accuracy; our novel approach may provide workable alternatives for other laboratories/networks.
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Affiliation(s)
- Emmanuel J Favaloro
- Department of Haematology, Institute of Clinical Pathology and Medical Research (ICPMR), Sydney Centres for Thrombosis and Haemostasis, NSW Health Pathology, Westmead Hospital, Westmead, New South Wales, Australia
- School of Dentistry and Medical Sciences, Faculty of Science and Health, Charles Sturt University, Wagga Wagga, New South Wales, Australia
- School of Medical Sciences, Faculty of Medicine and Health, University of Sydney, Westmead Hospital, Westmead, New South Wales, Australia
| | | | - Kent Chapman
- Department of Haematology, NSW Health Pathology, John Hunter Hospital, Newcastle, New South Wales, Australia
| | - Leonardo Pasalic
- Department of Haematology, Institute of Clinical Pathology and Medical Research (ICPMR), Sydney Centres for Thrombosis and Haemostasis, NSW Health Pathology, Westmead Hospital, Westmead, New South Wales, Australia
- Westmead Clinical School, University of Sydney, Westmead, New South Wales, Australia
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Hu XG, Yang XX, Lu J, Li G, Dai JJ, Wang JM, Deng Y, Feng R. Correlation between serum markers and transjugular intrahepatic portosystemic shunt prognosis in patients with cirrhotic ascites. World J Gastrointest Surg 2024; 16:481-490. [PMID: 38463353 PMCID: PMC10921209 DOI: 10.4240/wjgs.v16.i2.481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 12/30/2023] [Accepted: 01/29/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND Individuals with refractory ascites in the context of liver cirrhosis typically face an adverse prognosis. The transjugular intrahepatic portosystemic shunt (TIPS) is an efficacious intervention, but there is a lack of reliable tools for postoperative prognosis assessment. Previously utilized clinical biochemical markers, such as the serum albumin concentration (Alb), sodium (Na+) concentration, and serum creatinine (Scr), have limited predictive value. Therefore, the quest for novel, specific biomarkers to evaluate the post-TIPS prognosis in patients with liver cirrhosis and refractory ascites holds significant practical importance. AIM To investigate the associations between the Child-Pugh score, model for end-stage liver disease (MELD) score, and serum cystatin C (Cys C) level and post-TIPS prognosis in patients with liver cirrhosis and refractory ascites. METHODS A retrospective analysis was conducted on 75 patients with liver cirrhosis and refractory ascites who underwent TIPS at our institution from August 2019 to August 2021. These patients were followed up regularly for two years, and the death toll was meticulously documented. The patients were allocated into a survival group (n = 45 patients) or a deceased group (n = 30 patients) based on their prognosis status. The clinical data of the two groups were collected, and Child-Pugh scores and MELD scores were calculated for analysis. Spearman correlation analysis was carried out to evaluate the correlation of prognosis with Child-Pugh grade, MELD score, and Cys C level. Additionally, a multiple-factor analysis utilizing the Cox proportional hazard model was used to identify independent risk factors affecting the post-TIPS prognosis of patients with liver cirrhosis and refractory ascites. The receiver operating characteristic curve (ROC) ascertained the predictive value of the Cys C concentration, Child-Pugh grade, and MELD score for the prognosis of liver cirrhosis with refractory ascites in post-TIPS patients. RESULTS During a 2-year follow-up period, among 75 patients with liver cirrhosis and refractory ascites who underwent TIPS treatment, 30 patients (40.00%) passed away. The deceased cohort exhibited heightened aspartate aminotransferase, alanine aminotransferase, total bilirubin, Scr, prothrombin time, Cys C, international normalized ratio, Child-Pugh, and MELD scores compared to those of the survival cohort, while Alb and Na+ levels were attenuated in the deceased group (P < 0.05). Spearman analysis revealed moderate to high positive correlations between prognosis and Child-Pugh score, MELD score, and Cys C level (r = 0.709, 0.749, 0.671, P < 0.05). Multivariate analysis using the Cox proportional hazard model demonstrated that the independent risk factors for post-TIPS prognosis in patients with liver cirrhosis and refractory ascites were Cys C (HR = 3.802; 95%CI: 1.313-11.015), Child-Pugh (HR = 3.030; 95%CI: 1.858-4.943), and MELD (HR = 1.222; 95%CI: 1.073-1.393) scores. ROC analysis confirmed that, compared to those of the classic prognostic models for Child-Pugh and MELD scores, the predictive accuracy of Cys C for post-TIPS prognosis in patients with liver cirrhosis and refractory ascites was slightly lower. This analysis yielded sensitivity and specificity values of 83.33% and 82.22%, respectively. The area under the curve value at this juncture was 0.883, with an optimal cutoff value set at 1.95 mg/L. CONCLUSION Monitoring the serum Cys C concentration is valuable for assessing the post-TIPS prognosis in patients with liver cirrhosis and refractory ascites. Predictive models based on serum Cys C levels, as opposed to Scr levels, are more beneficial for evaluating the condition and prognosis of patients with ascites due to cirrhosis.
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Affiliation(s)
- Xiao-Gang Hu
- Department of Interventional Radiology, The Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua 321000, Zhejiang Province, China
| | - Xiao-Xian Yang
- Medical College, Jinhua Polytechnic, Jinhua 321017, Zhejiang Province, China
| | - Jun Lu
- Department of Interventional Radiology, The Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua 321000, Zhejiang Province, China
| | - Gang Li
- Department of Interventional Radiology, The Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua 321000, Zhejiang Province, China
| | - Jian-Ji Dai
- Department of Interventional Radiology, The Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua 321000, Zhejiang Province, China
| | - Jia-Min Wang
- Department of Interventional Radiology, The Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua 321000, Zhejiang Province, China
| | - Yi Deng
- Department of Interventional Radiology, The Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua 321000, Zhejiang Province, China
| | - Rui Feng
- Department of Interventional Medicine, Zhejiang Provincial People’s Hospital, People’s Hospital of Hangzhou Medical College, Hangzhou 310000, Zhejiang Province, China
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3
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Gosselin RC, Castellone D, Dorgalaleh A, Hickey K, Lippi G, Moffat K, O'Toole R, Rigano J. International Council for Standardization in Haematology Guidance for New Lot Verification of Coagulation Reagents, Calibrators, and Controls. Semin Thromb Hemost 2023. [PMID: 37967836 DOI: 10.1055/s-0043-1776405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2023]
Abstract
The clinical laboratory uses commercial products with limited shelf life or certain expiry dates requiring frequent lot changes. Prior to implementation for clinical use, laboratories should determine the performance of the new reagent lot to ensure that there is no significant shift in reagent performance or reporting of patient data. This guideline has been written on behalf of the International Council for Standardization in Haematology (ICSH) to provide the framework and provisional guidance for clinical laboratories for evaluating and verifying the performance of new lot reagents used for coagulation testing. These ICSH Working Party consensus recommendations are based on good laboratory practice, regulatory recommendations, evidence emerged from scientific publications, and expert opinion and are meant to supplement regional standards, regulations, or requirements.
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Affiliation(s)
- Robert C Gosselin
- CLS Hemostasis and Thrombosis Center, University of California, Davis Health System, Sacramento, California
| | | | | | - Kieron Hickey
- Sheffield Laboratory Medicine, Royal Hallamshire Hospital, Sheffield, United Kingdom
| | - Giuseppe Lippi
- Section of Clinical Biochemistry and School of Medicine, University of Verona, Verona, Italy
| | - Karen Moffat
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton Ontario, Canada
| | - Rebecca O'Toole
- Hematology Department, Wellington Hospital and Health Care, Wellington, New Zealand
| | - Joe Rigano
- CCS Northern Pathology Victoria, Melbourne, Australia
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Lv Y, Liu N, Li Y, Wu J, Zheng J, Li X, Zeng M. Coagulation Dysfunction in Patients with Liver Cirrhosis and Splenomegaly and Its Countermeasures: A Retrospective Study of 1522 Patients. DISEASE MARKERS 2023; 2023:5560560. [PMID: 37325552 PMCID: PMC10266912 DOI: 10.1155/2023/5560560] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 05/18/2023] [Accepted: 05/25/2023] [Indexed: 06/17/2023]
Abstract
Objective Patients with cirrhosis and splenomegaly often have coagulation dysfunction which affects treatment and prognosis. This study explores the status, grading, and treatment strategies of coagulation dysfunction in patients with liver cirrhosis and splenomegaly. Methods A retrospective cohort study was conducted on the clinical data on consecutive patients with cirrhosis and splenomegaly treated at Hainan General Hospital, China, from January 2000 to December 2020. Starting research in January 2022. Results Among 1522 patients included into this study, 297 (19.5%) patients had normal results in all five coagulation tests (prothrombin time, prothrombin activity, activated partial thromboplastin time, thrombin time, and fibrinogen), and 1225 (80.5%) had coagulation dysfunction in at least one of these tests. There were significant differences (P < 0.05) in treatment efficacy on these patients for three of these five coagulation tests, with the exception of prothrombin activity and thrombin time. When coagulation dysfunction was classified into grades I, II, and III based on scores from the three significant coagulation tests, prothrombin time, activated partial thromboplastin time, and fibrinogen, significant differences in surgical outcomes were found among the three grades of coagulation dysfunction and between grades I and III (P < 0.05). The operative mortality rate in patients with grade III in treating liver cancer, portal hypersplenism, and/or splenomegaly was 6.5%. There was no significant difference between patients with grades I and II (P > 0.05). Conclusions Approximately, 80% of patients with liver cirrhosis and splenomegaly had coagulation dysfunction. Surgery is feasible for grade I and II patients. For grade III patients, nonsurgical treatment should be given first, and surgery should only be considered when the coagulation function returns to normal or near-normal levels after treatment. This trial is registered with MR-46-22-009299.
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Affiliation(s)
- Yunfu Lv
- Department of General Surgery, Hainan General Hospital (Hainan Medical College Affiliated People's Hospital), Haikou, 570311 Hainan Province, China
| | - Ning Liu
- Department of General Surgery, Hainan General Hospital (Hainan Medical College Affiliated People's Hospital), Haikou, 570311 Hainan Province, China
| | - Yejuan Li
- Reproductive Medicine Center of Hainan Women and Children's Medical Center, Haikou, 570206 Hainan Province, China
| | - Jincai Wu
- Department of General Surgery, Hainan General Hospital (Hainan Medical College Affiliated People's Hospital), Haikou, 570311 Hainan Province, China
| | - Jinfang Zheng
- Department of General Surgery, Hainan General Hospital (Hainan Medical College Affiliated People's Hospital), Haikou, 570311 Hainan Province, China
| | - Xinqiu Li
- Department of Surgery, Renhuai People's Hospital, Zunyi, 564500 Guizhou Province, China
| | - Min Zeng
- Department of General Surgery, Hainan General Hospital (Hainan Medical College Affiliated People's Hospital), Haikou, 570311 Hainan Province, China
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Favaloro EJ, Gosselin RC, Pasalic L, Lippi G. Hemostasis and Thrombosis: An Overview Focusing on Associated Laboratory Testing to Diagnose and Help Manage Related Disorders. Methods Mol Biol 2023; 2663:3-38. [PMID: 37204701 DOI: 10.1007/978-1-0716-3175-1_1] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
Hemostasis is a complex but balanced process that permit normal blood flow, without adverse events. Disruption of the balance may lead to bleeding or thrombotic events, and clinical interventions may be required. Hemostasis laboratories typically offer an array of tests, including routine coagulation and specialized hemostasis assays used to guide clinicians for diagnosing and managing patients. Routine assays may be used to screen patients for hemostasis-related disturbances but may also be used for drug monitoring, measuring efficacy of replacement or adjunctive therapy, and other indications, which may then be used to guide further patient management. Similarly, "specialized" assays are used for diagnostic purposes or may be used to monitor or measure efficacy of a given therapy. This chapter provides an overview of hemostasis and thrombosis, with a focus on laboratory testing that may be used to diagnose and help manage patients suspected of hemostasis- and thrombosis-related disorders.
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Affiliation(s)
- Emmanuel J Favaloro
- School of Medical Sciences, Faculty of Medicine and Health University of Sydney, Westmead Hospital, Westmead, NSW, Australia.
- School of Dentistry and Medical Sciences, Faculty of Science and Health, Charles Sturt University, Wagga, Wagga, NSW, Australia.
| | - Robert C Gosselin
- Hemostasis & Thrombosis Center, Davis Health System, University of California, Sacramento, CA, USA
| | - Leonardo Pasalic
- Department of Haematology, Sydney Centres for Thrombosis and Haemostasis, Institute of Clinical Pathology and Medical Research (ICPMR), NSW Health Pathology, Westmead Hospital, Westmead, NSW, Australia
- Westmead Clinical School, University of Sydney, Westmead, NSW, Australia
| | - Giuseppe Lippi
- Section of Clinical Biochemistry, University of Verona, Verona, Italy
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Favaloro EJ, Mohammed S, Priebbenow VU, Vong R, Pasalic L. Auto-validation of Routine Coagulation/Hemostasis Assays with Reflex Testing of Abnormal Test Results. Methods Mol Biol 2023; 2663:93-109. [PMID: 37204706 DOI: 10.1007/978-1-0716-3175-1_6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
Hemostasis laboratories play a crucial role in the diagnosis and treatment of individuals with bleeding or thrombotic disorders. Routine coagulation assays, including the prothrombin time (PT)/international normalized ratio (INR), and activated partial thromboplastin time (APTT), are used for various purposes. These include as a screen of hemostasis function/dysfunction (e.g., possible factor deficiency) and for monitoring of anticoagulant therapy, such as vitamin K antagonists (PT/INR) and unfractionated heparin (APTT). Clinical laboratories are also under increasing pressure to improve services, especially response (test turnaround) times. There is also a need for laboratories to try to reduce error rates and for laboratory networks to standardize/harmonize processes and policies. Accordingly, we describe our experience with the development and implementation of automated processes for reflex testing and validation of routine coagulation test results. This has been implemented in a large pathology network compromising 27 laboratories and is under consideration for expansion to our larger network (of 60 laboratories). These rules have been custom-built within our laboratory information system (LIS), perform reflex testing of abnormal results, and fully automate the process of routine test validation for appropriate results. These rules also permit adherence to standardized pre-analytical (sample integrity) checks, automate reflex decisions, automate verification, and provide an overall alignment of network practices in a large network of 27 laboratories. In addition, the rules enable clinically significant results to be quickly referred to hematopathologists for review. We also documented an improvement in test turnaround times, with savings in operator time and thus operating costs. Finally, the process was generally well received and determined to be beneficial for most laboratories in our network, in part identified by improved test turnaround times.
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Affiliation(s)
- Emmanuel J Favaloro
- School of Medical Sciences, Faculty of Medicine and Health University of Sydney, Westmead Hospital, Westmead, NSW, Australia.
- School of Dentistry and Medical Sciences, Faculty of Science and Health, Charles Sturt University, Wagga, Wagga, NSW, Australia.
| | - Soma Mohammed
- Department of Haematology, Institute of Clinical Pathology and Medical Research (ICPMR), NSW Health Pathology, Westmead Hospital, Westmead, NSW, Australia
| | - Violeta Ule Priebbenow
- Department of Haematology, Institute of Clinical Pathology and Medical Research (ICPMR), NSW Health Pathology, Westmead Hospital, Westmead, NSW, Australia
| | - Ronny Vong
- Department of Haematology, Institute of Clinical Pathology and Medical Research (ICPMR), NSW Health Pathology, Westmead Hospital, Westmead, NSW, Australia
| | - Leonardo Pasalic
- Department of Haematology, Institute of Clinical Pathology and Medical Research (ICPMR), NSW Health Pathology, Westmead Hospital, Westmead, NSW, Australia
- Sydney Centres for Thrombosis and Haemostasis, Westmead Hospital, Westmead, NSW, Australia
- Westmead Clinical School, University of Sydney, Westmead, NSW, Australia
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Dorgalaleh A, Favaloro EJ, Bahraini M, Rad F. Standardization of Prothrombin Time/International Normalized Ratio (PT/INR). Int J Lab Hematol 2020; 43:21-28. [PMID: 32979036 DOI: 10.1111/ijlh.13349] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 09/02/2020] [Accepted: 09/07/2020] [Indexed: 01/02/2023]
Abstract
The prothrombin time (PT) represents the most commonly used coagulation test in clinical laboratories. The PT is mathematically converted to the international normalized ratio (INR) for use in monitoring anticoagulant therapy with vitamin K antagonists such as warfarin in order to provide test results that are adjusted for thromboplastin and instrument used. The INR is created using two major PT 'correction factors', namely the mean normal PT (MNPT) and the international sensitivity index (ISI). Manufacturers of reagents and coagulometers have made some efforts to harmonizing INRs, for example, by tailoring reagents to specific coagulometers and provide associated ISI values. Thus, two types of ISIs may be generated, with one being a 'general' or 'generic' ISI and others being reagent/coagulometer-specific ISI values. Although these play a crucial role in improving INR results between laboratories, these laboratories reported INR values are known to still differ, even when laboratories use the same thromboplastin reagent and coagulometer. Moreover, ISI values for a specific thromboplastin can vary among different models of coagulometers from a manufacturer using the same method for clot identification. All these factors can be sources of error for INR reporting, which in turn can significantly affect patient management. In this narrative review, we provide some guidance to appropriate ISI verification/validation, which may help decrease the variability in cross laboratory reporting of INRs.
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Affiliation(s)
- Akbar Dorgalaleh
- Department of Hematology and Blood Transfusion, School of Allied Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Emmanuel J Favaloro
- Department of Haematology, Sydney Centres for Thrombosis and Haemostasis, Institute of Clinical Pathology and Medical Research, NSW Health Pathology, Westmead Hospital, Westmead, NSW, Australia
| | - Mehran Bahraini
- Department of Hematology and Blood Transfusion, School of Allied Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Fariba Rad
- Cellular and Molecular Research Center, Yasuj University of Medical Sciences, Yasuj, Iran.,Blood Transfusion Research Center, High Institute for Research and Education in Transfusion Medicine, Tehran, Iran
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Lippi G, Adcock D, Favaloro EJ. Understanding the "philosophy" of laboratory hemostasis. ACTA ACUST UNITED AC 2020; 6:223-226. [PMID: 30827079 DOI: 10.1515/dx-2018-0099] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2018] [Accepted: 11/30/2018] [Indexed: 02/06/2023]
Abstract
Unlike many other areas of laboratory medicine, laboratory hemostasis has some peculiarities, which makes it one of the most complex diagnostic domains in clinical medicine. The inherent complexity of the hemostasis process, the components of which have not yet been thoroughly unravelled, is mirrored by a large number of hemostasis disturbances, which can involve single or multiple components. Although laboratory diagnostics represents an unavoidable part of the diagnostic reasoning in patients with bleeding or thrombotic disorders, the basic concept beneath the assumption that in many human pathologies, one single test may be sufficient for the diagnosis, does not hold true in hemostasis. There are in fact many aspects that would lead us to conclude that laboratory hemostasis can be considered a very challenging arena for many clinicians and perhaps also for some laboratory professionals. The most challenging aspects typically include the following concepts; that hemostasis is an intricate and multifaceted process, that more than one test is typically needed to achieve a final diagnosis, that results of screening tests depend on many biological factors and do not allow making a final diagnosis, that harmonization of techniques is still an unmet target, and that the calculations used vary widely among laboratories. This article is hence aimed at discussing many of these aspects, with the hope of presenting a useful contribution to better understand the "philosophy" of laboratory hemostasis.
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Affiliation(s)
- Giuseppe Lippi
- Section of Clinical Biochemistry, University of Verona, P.le LA Scuro 10, Verona 37134, Italy
| | - Dorothy Adcock
- Laboratory Corporation of AmericaHoldings, Colorado Coagulation, Englewood, CO, USA
| | - Emmanuel J Favaloro
- Department of Haematology, Institute of Clinical Pathology and Medical Research (ICPMR), NSW Health Pathology, Westmead Hospital, Westmead, NSW, Australia
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Mohammed S, Ule Priebbenow V, Pasalic L, Favaloro EJ. Development and implementation of an expert rule set for automated reflex testing and validation of routine coagulation tests in a large pathology network. Int J Lab Hematol 2019; 41:642-649. [DOI: 10.1111/ijlh.13078] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Revised: 06/03/2019] [Accepted: 06/11/2019] [Indexed: 11/25/2022]
Affiliation(s)
- Soma Mohammed
- Institute of Clinical Pathology and Medical Research (ICPMR), NSW Health Pathology Westmead Hospital Westmead New South Wales Australia
| | - Violeta Ule Priebbenow
- Institute of Clinical Pathology and Medical Research (ICPMR), NSW Health Pathology Westmead Hospital Westmead New South Wales Australia
| | - Leonardo Pasalic
- Institute of Clinical Pathology and Medical Research (ICPMR), NSW Health Pathology Westmead Hospital Westmead New South Wales Australia
- Sydney Centres for Thrombosis and Haemostasis Westmead New South Wales Australia
- Westmead Clinical School University of Sydney Sydney Australia
| | - Emmanuel J. Favaloro
- Institute of Clinical Pathology and Medical Research (ICPMR), NSW Health Pathology Westmead Hospital Westmead New South Wales Australia
- Sydney Centres for Thrombosis and Haemostasis Westmead New South Wales Australia
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Wang Z, Peng C, Kang H, Fan X, Mu R, Zhou L, He M, Qu B. Design and evaluation of a LIS-based autoverification system for coagulation assays in a core clinical laboratory. BMC Med Inform Decis Mak 2019; 19:123. [PMID: 31269951 PMCID: PMC6609390 DOI: 10.1186/s12911-019-0848-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Accepted: 06/24/2019] [Indexed: 12/13/2022] Open
Abstract
Background The autoverification system for coagulation consists of a series of rules that allow normal data to be released without manual verification. With new advances in medical informatics, the laboratory information system (LIS) has growing potential for the autoverification, allowing rapid and accurate verification of clinical laboratory tests. The purpose of the study is to develop and evaluate a LIS-based autoverification system for validation and efficiency. Methods Autoverification decision rules, including quality control, analytical error flag, critical value, limited range check, delta check and logical check, as well as patient’s historical information, were integrated into the LIS. Autoverification limited range was constructed based on 5 and 95% percentiles. The four most commonly used coagulation assays, prothrombin time (PT), activated partial thromboplastin time (APTT), thrombin time (TT), and fibrinogen (FBG), were followed by the autoverification protocols. The validation was assessed by the autoverification passing rate, the true-positive cases, the true-negative cases, the false-positive cases, the false-negative cases, the sensitivity and the specificity; the efficiency was evaluated in the turnaround time (TAT). Results A total of 157,079 historical test results of coagulation profiles from January 2016 to December 2016 were collected to determine the distribution intervals. The autoverification passing rate was 77.11% (29,165/37,821) based on historical patient data. In the initial test of the autoverification version in June 2017, the overall autoverification passing rate for the whole sample was 78.75% (11,257/14,295), with 892 true-positive cases, 11,257 true-negative cases, 2146 false-positive cases, no false-negative cases, sensitivity of 100% and specificity of 83.99%. After formal implementation of the autoverification system for 6 months, 83,699 samples were assessed. The average overall autoverification passing rate for the whole sample was 78.86% and the 95% confidence interval (CI) of the passing rate was [78.25, 79.59%]. TAT was reduced from 126 min to 101 min, which was statistically significant (P < 0.001, Mann-Whitney U test). Conclusions The autoverification system for coagulation assays based on LIS can halt the samples with abnormal values for manual verification, guarantee medical safety, minimize the requirements for manual work, shorten TAT and raise working efficiency.
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Affiliation(s)
- Zhongqing Wang
- Department of Health Statistics, School of Public Health, China Medical University, 77 Puhe Road, Shenyang North New Area, Shenyang, 110122, China.,Department of Information Center, The First Affiliated Hospital of China Medical University, Shenyang, China
| | - Cheng Peng
- Key Lens Laboratory of Liaoning Province, Department of Ophthalmology, The Fourth Affiliated Hospital of China Medical University, Shenyang, China
| | - Hui Kang
- Department of Clinical Laboratory, The First Affiliated Hospital of China Medical University, Shenyang, China
| | - Xia Fan
- Department of Clinical Laboratory, The First Affiliated Hospital of China Medical University, Shenyang, China
| | - Runqing Mu
- Department of Clinical Laboratory, The First Affiliated Hospital of China Medical University, Shenyang, China
| | - Liping Zhou
- Department of Clinical Laboratory, The First Affiliated Hospital of China Medical University, Shenyang, China
| | - Miao He
- Department of Information Center, The First Affiliated Hospital of China Medical University, Shenyang, China
| | - Bo Qu
- Department of Health Statistics, School of Public Health, China Medical University, 77 Puhe Road, Shenyang North New Area, Shenyang, 110122, China.
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11
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Lippi G, Favaloro EJ. Laboratory hemostasis: from biology to the bench. Clin Chem Lab Med 2019; 56:1035-1045. [PMID: 29455188 DOI: 10.1515/cclm-2017-1205] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2017] [Accepted: 01/19/2018] [Indexed: 12/29/2022]
Abstract
Physiological hemostasis is an intricate biological system, where procoagulant and anticoagulant forces interplay and preserves blood fluidity when blood vessels are intact, or trigger clot formation to prevent excessive bleeding when blood vessels are injured. The modern model of hemostasis is divided into two principal phases. The first, defined as primary hemostasis, involves the platelet-vessel interplay, whilst the second, defined as secondary hemostasis, mainly involves coagulation factors, damaged cells and platelet surfaces, where the so-called coagulation cascade rapidly develops. The activation and amplification of the coagulation cascade is finely modulated by the activity of several physiological inhibitors. Once bleeding has been efficiently stopped by blood clot formation, dissolution of the thrombus is essential to restore vessel permeability. This process, known as fibrinolysis, also develops through coordinate action of a vast array of proteins and enzymes. An accurate diagnosis of hemostasis disturbance entails a multifaceted approach, encompassing family and personal history of hemostatic disorders, accurate collection of clinical signs and symptoms, integrated with laboratory hemostasis testing. Regarding laboratory testing, a reasonable approach entails classifying hemostasis testing according to cost, complexity and available clinical information. Laboratory workout may hence initiate with some rapid and inexpensive "screening" tests, characterized by high negative predictive value, then followed by second- or third-line analyses, specifically aimed to clarify the nature and severity of bleeding or thrombotic phenotype. This article aims to provide a general overview of the hemostatic process, and to provide some general suggestions to optimally facilitate laboratory hemostasis testing.
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Affiliation(s)
- Giuseppe Lippi
- Section of Clinical Biochemistry, University Hospital of Verona, Piazzale LA Scuro, 37100 - Verona, Italy
| | - Emmanuel J Favaloro
- Department of Clinical and Laboratory Haematology, Sydney Centres for Thrombosis and Haemostasis, Institute of Clinical Pathology and Medical Research and Westmead Hospital, Westmead, NSW, Australia
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Brake MA, Ivanciu L, Maroney SA, Martinez ND, Mast AE, Westrick RJ. Assessing Blood Clotting and Coagulation Factors in Mice. ACTA ACUST UNITED AC 2019; 9:e61. [PMID: 30875463 DOI: 10.1002/cpmo.61] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
The mammalian blood coagulation system was designed to restrict blood loss due to injury as well as keep the blood fluid within the blood vessels of the organism. Blood coagulation activity in inbred mouse strains varies widely among strains, suggesting that many genomic variants affect hemostasis. Some of these molecules have been discovered and characterized; however, many are still unknown. Genetically modified mouse technologies are providing a plethora of new mouse models for investigating the regulation of blood coagulation. Here we provide a protocol for the tail bleeding time as a primary assessment of in vivo blood coagulation, as well as in vitro methods such as the prothrombin time, activated partial thromboplastin time, and thrombin generation assay. We also provide protocols for the assessment of the activities of specific known factors involved in blood coagulation. © 2019 by John Wiley & Sons, Inc.
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Affiliation(s)
- Marisa A Brake
- Department of Biological Sciences, Oakland University, Rochester, Michigan
| | - Lacramioara Ivanciu
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Divison of Hematology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Susan A Maroney
- Blood Research Institute, Blood Center of Wisconsin, Milwaukee, Wisconsin
| | - Nicolas D Martinez
- Blood Research Institute, Blood Center of Wisconsin, Milwaukee, Wisconsin
| | - Alan E Mast
- Blood Research Institute, Blood Center of Wisconsin, Milwaukee, Wisconsin.,Department of Cell Biology, Neurobiology and Anatomy, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Randal J Westrick
- Department of Biological Sciences, Oakland University, Rochester, Michigan.,Center for Data Science and Big Data Analysis, Center for Biomedical Research, Oakland University, Rochester, Michigan
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Favaloro EJ, McVicker W, Mohammed S, Hamdam S. Mathematical rounding as a post-analytical issue in pathology reporting: generation of bias in INR resulting. Pathology 2018; 50:459-461. [PMID: 29731140 DOI: 10.1016/j.pathol.2017.11.090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Revised: 11/06/2017] [Accepted: 11/13/2017] [Indexed: 10/17/2022]
Affiliation(s)
- Emmanuel J Favaloro
- Department of Haematology, Institute of Clinical Pathology and Medical Research, NSW Health Pathology, Westmead Hospital, Westmead, NSW, Australia; Sydney Centres for Thrombosis and Haemostasis, Westmead, NSW, Australia.
| | - Wendy McVicker
- Department of Haematology, Institute of Clinical Pathology and Medical Research, NSW Health Pathology, Westmead Hospital, Westmead, NSW, Australia
| | - Soma Mohammed
- Department of Haematology, Institute of Clinical Pathology and Medical Research, NSW Health Pathology, Westmead Hospital, Westmead, NSW, Australia
| | - Sayed Hamdam
- NSW Health Pathology, Blacktown Hospital, Blacktown, NSW, Australia
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