Applying data science methodologies with artificial intelligence variant reinterpretation to map and estimate genetic disorder prevalence utilizing clinical data

Data science methodologies can be utilized to ascertain and analyze clinical genetic data that is often unstructured and rarely used outside of patient encounters. Genetic variants from all genetic testing resulting to a large pediatric healthcare system for a 5-year period were obtained and reinterpreted utilizing the previously validated Franklin© Artificial Intelligence (AI). Using PowerBI©, the data were further matched to patients in the electronic healthcare record to associate with demographic data to generate a variant data table and mapped by ZIP codes. Three thousand and sixty-five variants were identified and 98% were matched to patients with geographic data. Franklin© changed the interpretation for 24% of variants. One hundred and fifty-six clinically actionable variant reinterpretations were made. A total of 739 Mendelian genetic disorders were identified with disorder prevalence estimation. Mapping of variants demonstrated hot-spots for pathogenic genetic variation such as PEX6-associated Zellweger Spectrum Disorder. Seven patients were identified with Bardet-Biedl syndrome and seven patients with Rett syndrome amenable to newly FDA-approved therapeutics. Utilizing readily available software we developed a database and Exploratory Data Analysis (EDA) methodology enabling us to systematically reinterpret variants, estimate variant prevalence, identify conditions amenable to new treatments, and localize geographies enriched for pathogenic variants.

Performance of direct oral anticoagulant (DOAC) testing by hemostasis laboratories: The Australasian/Asia-Pacific experience

INTRODUCTION

Direct oral anticoagulants (DOACs) reflect anticoagulation agents given to treat or prevent thrombosis, having largely replaced vitamin K antagonists (VKAs) such as warfarin. DOACs are given in fixed daily doses and generally do not need monitoring. However, there may be a variety of reasons that justify measurement of plasma DOAC levels in individual patients.

METHODS

We report updated findings for DOAC testing in our geographic region, using recent data from the RCPAQAP, an international external quality assessment (EQA) program, currently with some 40-60 participants in each of the different DOAC (rivaroxaban, apixaban, dabigatran) modules, to assess laboratory performance in this area. Data has been assessed for the past 5 years (2019-2023 inclusive), with 20 samples each per DOAC.

RESULTS

Data shows a limited repertoire of assays in use, and mostly consistency in reported numerical values when assessing proficiency samples. Available assays mostly comprised reagents from four manufacturing suppliers. There was good consistency across what participants identified as 'DOAC detected', but some variability when participants attempted to grade DOAC levels as low vs moderate vs high. Inter-laboratory/method coefficient of variation (CVs) were generally <15% for each DOAC, when present at >100 ng/mL.

CONCLUSION

We hope our findings, reflecting on mostly consistent reporting of DOAC levels and interpretation provides reassurance for clinicians requesting these measurements, and helps support their implementation in regions where there is a paucity of test availability.

Laboratory tools for the direct detection of bacterial respiratory infections and antimicrobial resistance: a scoping review

Rapid laboratory tests are urgently required to inform antimicrobial use in food animals. Our objective was to synthesize knowledge on the direct application of long-read metagenomic sequencing to respiratory samples to detect bacterial pathogens and antimicrobial resistance genes (ARGs) compared to PCR, loop-mediated isothermal amplification, and recombinase polymerase amplification. Our scoping review protocol followed the Joanna Briggs Institute and PRISMA Scoping Review reporting guidelines. Included studies reported on the direct application of these methods to respiratory samples from animals or humans to detect bacterial pathogens ±ARGs and included turnaround time (TAT) and analytical sensitivity. We excluded studies not reporting these or that were focused exclusively on bioinformatics. We identified 5,636 unique articles from 5 databases. Two-reviewer screening excluded 3,964, 788, and 784 articles at 3 levels, leaving 100 articles (19 animal and 81 human), of which only 7 studied long-read sequencing (only 1 in animals). Thirty-two studies investigated ARGs (only one in animals). Reported TATs ranged from minutes to 2 d; steps did not always include sample collection to results, and analytical sensitivity varied by study. Our review reveals a knowledge gap in research for the direct detection of bacterial respiratory pathogens and ARGs in animals using long-read metagenomic sequencing. There is an opportunity to harness the rapid development in this space to detect multiple pathogens and ARGs on a single sequencing run. Long-read metagenomic sequencing tools show potential to address the urgent need for research into rapid tests to support antimicrobial stewardship in food animal production.

Challenges and Future Recommendations for Lightning Strike Damage Assessments of Composites: Laboratory Testing and Predictive Modeling

Lightning strike events pose significant challenges to the structural integrity and performance of composite materials, particularly in aerospace, wind turbine blade, and infrastructure applications. Through a meticulous examination of the state-of-the-art methodologies of laboratory testing and damage predictive modeling, this review elucidates the role of simulated lightning strike tests in providing inputs required for damage modeling and experimental data for model validations. In addition, this review provides a holistic understanding of what is there, what are current issues, and what is still missing in both lightning strike testing and modeling to enable a robust and high-fidelity predictive capability, and challenges and future recommendations are also presented. The insights gleaned from this review are poised to catalyze advancements in the safety, reliability, and durability of composite materials under lightning strike conditions, as well as to facilitate the development of innovative lightning damage mitigation strategies.

Impact of the COVID-19 outbreak on blood supply in two large university hospitals

OBJECTIVE

This study aimed to examine the relationship between the decrease in elective procedures and the need for blood donation during the novel coronavirus disease (COVID-19) pandemic at university hospitals.

BACKGROUND

The COVID-19 pandemic has immensely impacted transfusion medicine. By cancelling elective surgery, the German government hoped to increase the available resources for patients infected with COVID-19, especially in intensive care units, and prevent the shortage of blood products.

METHODS/MATERIALS

Over 26 weeks, from the 3rd of February 2020 to the 2nd of August 2020, during the first phase of the pandemic, we assessed the number of crossmatches, blood group typing, use of donated blood, and case mix indices by retrospectively analysing data from two major university hospitals' information systems in Essen and Hamburg, Germany. Data were pooled, analysed, and compared with that of the same period in the previous year.

RESULTS

Following the cessation of elective procedures, the number of requests for crossmatches and blood group typing significantly decreased in 2020 compared to that in 2019. However, the number of blood transfusions required was reduced to a lesser extent. The number of outpatient and inpatient cases significantly decreased, whereas the cases requiring transfusion decreased only.

CONCLUSION

During the initial phase of the pandemic, transfusion medicine, especially in large institutions, faced an almost unchanged high demand for donated blood. This should be considered regarding personnel and blood donation allocations. Therefore, we developed a monitoring system to display the availability of blood products in real-time. The quick and easy display of in-stock and expiring blood products can optimise the use of this valuable resource.

Von Willebrand Factor (VWF) multiplex activity assay differentiation of type 1 von Willebrand Disease (VWD) and variant VWD

INTRODUCTION

VWD diagnosis is challenging requiring multiple VWF activity tests using many individual assays. We have developed an ELISA-based VWF Multiplex Activity Assay (VWF-MAA) to address this concern; however, the ability of the VWF-MAA to discriminate between type 1 VWD, variant VWD, and normal subjects has not been evaluated.

AIM

To evaluate the VWF-MAA and its ability to differentiate between type 1 VWD, variant VWD and normal subjects in individuals undergoing an initial laboratory evaluation for bleeding.

METHODS

A total of 177 plasma samples from the Zimmerman Program: Comparative Effectiveness in the Diagnosis of VWD were evaluated from 11 centres across the US and Canada. The VWF-MAA was compared to Versiti Blood Research Institute (VBRI) and Local Center (LC) assigned VWD diagnosis.

RESULTS

Overall, 129/177 (72.9%) were correctly assigned as normal (non-VWD), type 1, or variant VWD compared to the VBRI assigned diagnosis. VWF-MAA assigned non-VWD accurately in 29/57 (50.9%) samples, and type 1 VWD accurately in 93/110 (84.6%) samples. Considering LC diagnosis where there was agreement with VWF-MAA and not VBRI diagnosis, type 1 VWD was accurate in 105/110 (95.5%) samples. Bland-Altman analysis demonstrated good correlation between laboratory methods. VWD, types 2A, 2B, 1C VWD were also assigned by the VWF-MAA.

CONCLUSIONS

We demonstrate that the VWF-MAA has utility in differentiating type 1 VWD, variant VWD and normal subjects in individuals undergoing an initial laboratory evaluation for bleeding.

Laboratory Scaled-Down Cementitious Concrete Model Used for Estimating the Bearing Capacity of a Bridge Girder Based on the Similitude Theory

Bridges are structures subjected to multiple types of loads and combinations during their service life. The uncertainties linked with the materials' behavior and manufacturing processes often necessitate the testing of produced elements on a real scale. This is particularly true for bridge concrete precast girders, which are frequently tested to predict the ultimate carrying load. Testing procedures are time-consuming, expensive in terms of both time and money, and involve a large amount of logistics and auxiliary equipment and devices. Thus, testing scaled-down models in laboratory conditions and extrapolating the obtained results with respect to the real-scale element using similitude theory has become a very common alternative method in the last decade. In this paper, experimental data regarding the efficiency of dimensional analysis computation are discussed. The proposed method involves comparing the values at which failure in bending and shear occurs for a 1:10 cementitious concrete bridge beam model with respect to the values computed for the prototype beam. Regarding the obtained results, a very small difference between the test results and the calculated values can be noticed.

Current detection methods of African swine fever virus

African swine fever (ASF), caused by the African swine fever virus (ASFV), is a highly contagious and notifiable animal disease in domestic pigs and wild boars, as designated by the World Organization for Animal Health (WOAH). The effective diagnosis of ASF holds great importance in promptly controlling its spread due to its increasing prevalence and the continuous emergence of variant strains. This paper offers a comprehensive review of the most common and up-to-date methods established for various genes/proteins associated with ASFV. The discussed methods primarily focus on the detection of viral genomes or particles, as well as the detection of ASFV associated antibodies. It is anticipated that this paper will serve as a reference for choosing appropriate diagnostic methods in diverse application scenarios, while also provide direction for the development of innovative technologies in the future.

Are Tumor Marker Tests Applied Appropriately in Clinical Practice? A Healthcare Claims Data Analysis

Tumor markers (TM) are crucial in the monitoring of cancer treatment. However, inappropriate requests for screening reasons have a high risk of false positive and negative findings, which can lead to patient anxiety and unnecessary follow-up examinations. We aimed to assess the appropriateness of TM testing in outpatient practice in Switzerland. We conducted a retrospective cohort study based on healthcare claims data. Patients who had received at least one out of seven TM tests (CEA, CA19-9, CA125, CA15-3, CA72-4, Calcitonin, or NSE) between 2018 and 2021 were analyzed. Appropriate determinations were defined as a request with a corresponding cancer-related diagnosis or intervention. Appropriateness of TM determination by patient characteristics and prescriber specialty was estimated by using multivariate analyses. A total of 51,395 TM determinations in 36,537 patients were included. An amount of 41.6% of all TM were determined appropriately. General practitioners most often determined TM (44.3%) and had the lowest number of appropriate requests (27.8%). A strong predictor for appropriate determinations were requests by medical oncologists. A remarkable proportion of TM testing was performed inappropriately, particularly in the primary care setting. Our results suggest that a considerable proportion of the population is at risk for various harms associated with misinterpretations of TM test results.

Small-volume tubes to reduce anemia and transfusion (STRATUS): a pilot study

PURPOSE

Blood sampling for diagnostic testing causes blood loss. Small-volume tubes have the same cost, dimensions, and blood-draw techniques as standard-volume tubes, and are compatible with laboratory equipment; however, they are not commonly used. We sought to assess the feasibility of a stepped-wedge cluster trial to determine whether small-volume tubes reduce transfusion compared with standard-volume tubes in intensive care unit (ICU) patients.

METHODS

We conducted a prospective mixed-methods pilot study (before-after design) in one ICU with a six-week control period (standard-volume tubes) and a six-week intervention period (small-volume tubes). All patients admitted to the ICU were included. Feasibility was assessed as successful switch to small-volume tubes; adherence to tube size; sufficient volume for testing; user acceptance; barriers and facilitators to implementation; and 95% transfusion collection. We explored end-user acceptability using focus groups.

RESULTS

One hundred and sixty-five patients were included in the standard-volume and 204 in the small-volume periods. Transition to small-volume tubes was successful. Random audits showed 100% compliance. The proportion of samples with inadequate volume for testing was the same for both groups (both, 0.2%). Based on ten focus groups, small-volume tubes were acceptable with no barriers identified. Transfusion data collection was 100%. Median [interquartile range] estimated blood loss due to laboratory testing per patient per day in ICU was 11 [8-17] mL with standard-volume and 6 [4-8] mL with small-volume tubes.

CONCLUSION

Small-volume tubes can be implemented with acceptability to end-users and without barriers. They did not result in an increased frequency of inadequate samples. These results inform a trial to determine whether small-volume tubes reduce transfusion.

STUDY REGISTRATION

ClinicalTrials.gov (NCT03284944); registered 15 September 2017.

Usefullness of Heparin Calibrated Anti-Xa Activity to Assess Anticoagulant Activity of Apixaban and Rivaroxaban in Emergency Patients Scheduled for Acute Interventions

(1) Background: Direct oral anticoagulants (DOACs) require monitoring in some critical clinical situations. The specific tests for DOAC monitoring are not yet available in all labs. The aim of this study was to evaluate if a unique, more widespread heparin-calibrated anti-Xa assay could be suitable to estimate the concentrations of apixaban and rivaroxaban in order to establish an algorithm helping our clinicians in their therapeutic decision for patients treated with DOACs in emergencies. (2) Methods: A first retrospective part allowed us to determine of a conversion factor between the measured DOAC concentration and the deducted anti-Xa heparin activity based on optic density. During the second prospective part, both DOAC concentration (ng/mL) and anti-Xa activity heparin (UI/mL) were measured on the same sample, and the previously determined conversion factor was applied to each UI/mL value. We then compared the calculated and measured DOAC concentration values. (3) Results: The analysis of the derivation cohort confirmed a good correlation, especially between the anti-Xa heparin activity and the apixaban concentrations (r = 0.97). Additionally, we determined heparin-calibrated anti-Xa assay cut-offs for invasive procedures at 0.3 UI/mL and for intravenous thrombolysis at 0.51 UI/mL using ROC curves with a sensitivity at 98% and specificity at 95% for 0.3 UI/mL and a sensitivity at 97.7% and specificity at 88.2% for the cut-off of 0.51 UI/mL. In the validation cohort, we confirmed the agreement between measured and calculated DOAC concentrations for the low values, especially around cut-offs with an excellent negative predictive value for 0.51 UI/mL (94% for apixaban and 100% for rivaroxaban) and a good negative predictive value for 0.3 UI/mL (83.3% for apixaban and 85.7% for rivaroxaban). (4) Conclusions: Our results confirm that it is possible to correctly predict or exclude the presence of apixaban/rivaroxaban in emergency situations when specific tests are not readily available.

Under the Hood: The Scientific Leadership, Clinical Operations, Statistical and Data Management, and Laboratory Centers of the Antibacterial Resistance Leadership Group

Developing and implementing the scientific agenda of the Antibacterial Resistance Leadership Group (ARLG) by soliciting input and proposals, transforming concepts into clinical trials, conducting those trials, and translating trial data analyses into actionable information for infectious disease clinical practice is the collective role of the Scientific Leadership Center, Clinical Operations Center, Statistical and Data Management Center, and Laboratory Center of the ARLG. These activities include shepherding concept proposal applications through peer review; identifying, qualifying, training, and overseeing clinical trials sites; recommending, developing, performing, and evaluating laboratory assays in support of clinical trials; and designing and performing data collection and statistical analyses. This article describes key components involved in realizing the ARLG scientific agenda through the activities of the ARLG centers.

The urgent need to implement point-of-care RNA testing for hepatitis C virus to support elimination

Hepatitis C virus (HCV) elimination is an important global public health goal. However, the United States (US) is not on track to meet the World Health Organization's 2030 targets for HCV elimination. Recently, the White House proposed an HCV elimination plan that includes point-of-care (POC) HCV RNA testing, which is currently in use in many countries, but is not approved in the US. POC HCV RNA testing is crucial for implementing community-based testing, and for enabling test-and-treat programs, assessing cure, and monitoring for reinfection.. In this commentary, we review the status of POC HCV RNA testing in the US, discuss factors that are needed for successful implementation, and issue specific public health and policy recommendations that would allow for the use of POC HCV RNA testing to support HCV elimination.

Laboratory diagnosis of von Willebrand disease in the age of the new guidelines: considerations based on geography and resources

von Willebrand disease (VWD) is considered the most common bleeding disorder and arises from deficiency and/or defect in the adhesive plasma protein von Willebrand factor (VWF). Diagnosis of VWD requires clinical assessment and is facilitated by laboratory testing. Several guidelines for VWD diagnosis exist, with the latest American Society of Hematology, International Society on Thrombosis and Haemostasis, National Hemophilia Foundation, and World Federation of Hemophilia 2021 guidelines presenting 11 recommendations, some of which have drawn controversy. In the current narrative review, we provide additional context around difficulties in laboratory diagnosis/exclusion/typing of VWD, with a focus on developing countries/resource-poor settings. In particular, there are many variations in assay methodology, and some methods express high assay variability and poor low-level VWF sensitivity that compromises their utility. Although we favor an initial 4-test assay panel, comprising factor (F) VIII coagulant activity, VWF antigen, VWF glycoprotein Ib binding (VWF:GPIbR or VWF:GPIbM favored over VWF Ristocetin cofactor) and VWF collagen binding, we also provide strategies for laboratories only able to incorporate an initial 3-test assay panel, as favored by the latest guidelines, to improve diagnostic accuracy.

Understanding the Utilization, Challenges, and Attitudes Towards Laboratory Testing and Radiological Imaging Among Chiropractors in Hong Kong: A Cross-Sectional Survey

Objective This cross-sectional survey aimed to investigate the utilization, challenges, and attitudes of chiropractors in Hong Kong towards laboratory testing and radiological imaging. Method An online survey was conducted between May 1, 2023, and June 1, 2023. The target population for the survey was registered chiropractors in Hong Kong, which has a total of 325 practitioners. A total of 151 chiropractors participated in the survey, resulting in a response rate of 46.5%. The respondents provided information on their demographics, years of experience, practice settings, awareness of their right to request diagnostic tests, utilization of laboratory testing and imaging, and attitudes towards evidence-based practice. The survey data were analyzed using descriptive statistics. Result The survey findings revealed that a significant proportion of chiropractors in Hong Kong utilized laboratory testing and radiological imaging in their practice. Most respondents reported using laboratory testing to diagnose medical conditions and monitor existing conditions. Imaging is commonly used for diagnosing medical conditions and monitoring disease progression. However, a notable proportion of chiropractors reported facing rejection of their tests and imaging requests, which limited their ability to provide optimal care to their patients. The identified challenges included high rejection rates for specific imaging requests, leading to patient frustration, increased costs, and delayed diagnosis. Nevertheless, chiropractors in Hong Kong showed a strong belief in evidence-based practice and demonstrated a willingness to search for literature and incorporate it into their daily practice. By addressing this issue, our aim was to gain valuable insights into the status of laboratory testing and radiological imaging among chiropractors in Hong Kong. The findings of this study underscore the necessity for collaborative efforts among chiropractors, healthcare professionals, healthcare facilities, policymakers, and insurance companies to effectively address the challenges identified and improve patient care outcomes. Specifically, enhancing access to diagnostic tests and working towards reducing rejection rates will play a pivotal role in supporting chiropractors' role as primary healthcare providers in Hong Kong.

Fungal Pathogens as Causes of Acute Respiratory Illness in Hospitalized Veterans: Frequency of Fungal Positive Test Results Using Rapid Immunodiagnostic Assays

Fungal respiratory illnesses caused by endemic mycoses can be nonspecific and are often mistaken for viral or bacterial infections. We performed fungal testing on serum specimens from patients hospitalized with acute respiratory illness (ARI) to assess the possible role of endemic fungi as etiologic agents. Patients hospitalized with ARI at a Veterans Affairs hospital in Houston, Texas, during November 2016-August 2017 were enrolled. Epidemiologic and clinical data, nasopharyngeal and oropharyngeal samples for viral testing (PCR), and serum specimens were collected at admission. We retrospectively tested remnant sera from a subset of patients with negative initial viral testing using immunoassays for the detection of Coccidioides and Histoplasma antibodies (Ab) and Cryptococcus, Aspergillus, and Histoplasma antigens (Ag). Of 224 patient serum specimens tested, 49 (22%) had positive results for fungal pathogens, including 30 (13%) by Coccidioides immunodiagnostic assays, 19 (8%) by Histoplasma immunodiagnostic assays, 2 (1%) by Aspergillus Ag, and none by Cryptococcus Ag testing. A high proportion of veterans hospitalized with ARI had positive serological results for fungal pathogens, primarily endemic mycoses, which cause fungal pneumonia. The high proportion of Coccidioides positivity is unexpected as this fungus is not thought to be common in southeastern Texas or metropolitan Houston, though is known to be endemic in southwestern Texas. Although serological testing suffers from low specificity, these results suggest that these fungi may be more common causes of ARI in southeast Texas than commonly appreciated and more increased clinical evaluation may be warranted.

Age, comorbidities, c-reactive protein and procalcitonin as predictors of severity in confirmed COVID-19 patients in the Philippines

Background

The Coronavirus Disease 2019 (COVID-19) pandemic has been affecting people globally, and the Philippines is one of the countries greatly struck by the virus. The continued rise of new positive cases has drawn attention to the urgent need for healthcare management to cope with this challenge. Severity prediction could help improve medical decision-making and optimise the patient's treatment plan with a good clinical outcome. This study aimed to identify the determinants of COVID-19 disease severity.

Methods

Demographic characteristics and laboratory findings were collected from electronic medical records and paper forms of all confirmed COVID-19 cases reported by the University of Perpetual Help DALTA Medical Center between the September 1, 2020 and the October 31, 2021. We performed statistical analyses and interpretation of data to compare severe and non-severe groups.

Results

5,396 confirmed cases were examined. Most of the severe cases were elderly, male, had blood type A, and with comorbidities. Cycle threshold (Ct) values were lower in the severe group. Most patients had higher-than-normal levels of all blood parameters except platelet, white blood cell (WBC), neutrophil, and lymphocyte counts. Age, sex, ABO blood groups, comorbidities, open reading frame 1 ab (ORF1ab) and nucleocapsid (N) gene Ct values, ferritin, C-reactive protein (CRP), procalcitonin (PCT), D-dimer, white blood cell (WBC) count, neutrophil count, and lymphocyte count were significantly associated with disease severity. In multivariate analysis, age groups >60 and 30–59 years, presence of comorbidities, CRP level >5 ng/mL, and PCT >0.05 ng/mL were identified as disease severity predictors.

Conclusions

Based on our results, age, comorbidities, CRP, and PCT level may be utilised as primary assessment factors for possible hospital admission and close monitoring upon testing. Early detection of these risk factors may provide strategic interventions that help reduce mortality, hospital admissions, and more expensive and extensive treatments.

Challenges in Drug Surveillance: Strengthening the Analysis of New Psychoactive Substances by Harmonizing Drug Checking Services in Proficiency Testing

BACKGROUND

Drug checking is a proven harm reduction strategy and provides real-time information on the market of new psychoactive substances (NPS). It combines chemical analysis of samples with direct engagement with people who use drugs (PWUD), giving the ability to increase preparedness and responsiveness towards NPS. Next to that, it supports rapid identification of potential unwitting consumption. However, NPS cause a toxicological battle for the researchers, as factors such as the unpredictability and quick shift of the market complicate the detection.

METHODS

To evaluate challenges posed towards drug checking services, proficiency testing was set up to evaluate existing analytical techniques and investigate the capability to correctly identify circulating NPS. Twenty blind substances, covering the most common categories of substances, were analyzed according to the existing protocols of the existing drug checking services, including several analytical methods such as gas chromatography-mass spectrometry (GC-MS) and liquid chromatography with diode array detector (LC-DAD).

RESULTS

The proficiency test scores range from 80 to 97.5% accuracy. The most common issues and errors are mainly unidentified compounds, presumably due to no up-to-date libraries, and/ or confusion between structural isomers, such as 3- and 4-chloroethcathinone, or structural analogs, such as MIPLA (N-methyl-N-isopropyl lysergamide) and LSD (D-lysergic acid diethylamide).

CONCLUSIONS

The participating drug checking services have access to adequate analytical tools to provide feedback to drug users and provide up-to-date information on NPS.

Utility of postmortem bacterial culture of abdominal organs at autopsy of young calves

Postmortem bacterial culture is controversial in human medicine, and veterinary-specific research in this area is lacking. To address this knowledge gap, we cultured liver, kidney, and spleen individually from on-farm calf mortalities to determine the number of bacterial species present, concordance between organ cultures, and agreement with gross and histologic findings. We hypothesized that the spleen, a filtering organ, would be the most useful organ with the least amount of postmortem contamination given that it does not have a direct conduit to a bacterial population. Fresh liver, kidney, and spleen were collected for culture from 30 calves 5-28-d-old with various causes of mortality. Bacterial growth of ≥2 species was observed in ~48% of cultures, with Escherichia coli and Streptococcus spp. being most frequent. One bacterial species was present in 20% of cultures, with E. coli predominating. No growth was observed in ~32% of cultures. In 43% of cases, there was agreement in the culture results for all 3 organs; however, the majority were mixed bacterial growth. The best agreement was observed when there were no gross and/or histologic septic lesions in target organs and no bacterial growth on culture. The spleen was not helpful in determining bacterial significance in comparison to kidney or liver.

Choosing which in-hospital laboratory tests to target for intervention: a scoping review

INTRODUCTION

Some laboratory testing practices may be of low value, leading to wasted resources and potential patient harm. Our scoping review investigated factors and processes that developers report using to inform decisions about what tests to target for practice improvement.

METHODS

We searched Medline on May 30th, 2019 and June 28th, 2021 and included guidelines, recommendation statements, or empirical studies related to test ordering practices. Studies were included if they were conducted in a tertiary care setting, reported making a choice about a specific test requiring intervention, and reported at least one factor informing that choice. We extracted descriptive details, tests chosen, processes used to make the choice, and factors guiding test choice.

RESULTS

From 114 eligible studies, we identified 30 factors related to test choice including clinical value, cost, prevalence of test, quality of test, and actionability of test results. We identified nine different processes used to inform decisions regarding where to spend intervention resources.

CONCLUSIONS

Intervention developers face difficult choices when deciding where to put scarce resources intended to improve test utilization. Factors and processes identified here can be used to inform a framework to help intervention developers make choices relevant to improving testing practices.

Monkeypox virus diagnosis and laboratory testing

The multi-country outbreak of monkeypox virus (MPXV) infection, while the coronavirus disease 2019 pandemic is still an ongoing issue, has caused a new challenge. The re-emergence of MPXV and the rising incidence in non-endemic countries is turning into an upcoming threat to global health. Hence, rapid identification of the virus with appropriate methodology with the lowest false results plays a critical role in estimating the global extent of the crisis and providing preventive measures. This review summarised the main applicable strategies for primary detection and confirmation of MPXV and highlighted available data in biosafety, requirements, standard operating procedures, specimen collection, transportation and storage of clinical samples, and waste disposal of the viral agent. Also, various assays including molecular techniques, immunoassays, histopathological methods, electron microscopy, genomic sequencing, and cell culture have been illustrated. Moreover, we reflected on current knowledge of the advantages and disadvantages of each approach.

Beyond the Urine Anion Gap: In Support of the Direct Measurement of Urinary Ammonium

Ammonium is a major urinary buffer that is necessary for the normal excretion of the daily acid load. Its urinary rate of excretion (UNH₄) may be increased several fold in the presence of extrarenal metabolic acidosis. Therefore, measurement of UNH₄ can provide important clues about causes of metabolic acidosis. Because UNH₄ is not commonly measured in clinical laboratories, the urinary anion gap (UAG) was proposed as its surrogate about 4 decades ago, and it is still frequently used for that purpose. Several published studies strongly suggest that UAG is not a good index of UNH₄ and support the concept that direct measurement of UNH₄ is an important parameter to define in clinical nephrology. Low UNH₄ levels have recently been found to be associated with a higher risk of metabolic acidosis, loss of kidney function, and death in persons with chronic kidney disease, while surrogates like the UAG do not recapitulate this risk. In order to advance the field it is necessary for the medical community to become more familiar with UNH₄ levels in a variety of clinical settings. Herein, we review the literature, searching for available data on UNH₄ under normal and various pathological conditions, in an attempt to establish reference values to interpret UNH₄ results if and when UNH₄ measurements become available as a routine clinical test. In addition, we present original data in 2 large populations that provide further evidence that the UAG is not a good predictor of UNH₄. Measurement of urine NH₄ holds promise to aid clinicians in the care of patients, and we encourage further research to determine its best diagnostic usage.

2021 Patient Preferences for Point of Care Testing Survey: More Acceptance and Less Concern

BACKGROUND

The evolving opinions of our community members provide insights into how end-users perceive the value and identify key point-of-care test (POCT) characteristics.

METHODS

We deployed our validated 45-item English-language survey to uncompensated volunteers and compared the results from 1264 respondents in 2021 with those obtained in 2020.

RESULTS

Average responses for items regarding the benefits of POCTs demonstrated that the 2021 respondents indicated agreement with all 14 potential benefits. Average responses for items regarding concerns were distinctly different from those for benefits. The only concern item that scored in the agree range was "not having insurance coverage for POCTs." Average responses to the other 13 concern items were in the disagree range. For 8 of these items, the magnitude of disagreement was greater in the 2021 survey than was observed for the 2020 survey. Differences in POCT exposure over time and by US regions suggest that higher levels of exposure to POCTs in the East are associated with stronger public support.

CONCLUSIONS

Community members strongly support the development of accurate, convenient, easy-to-use, affordable, equitably available, in-home POCTs that produce immediate results. This empowers patients and home caregivers to diagnose, manage, enhance their adherence to medical treatments, and more efficiently engage their physicians.

Effect of Nucleic Acid Screening Measures on COVID-19 Transmission in Cities of Different Scales and Assessment of Related Testing Resource Demands-Evidence from China

BACKGROUND

COVID-19 is in its epidemic period, and China is still facing the dual risks of import and domestic rebound. To better control the COVID-19 pandemic under the existing conditions, the focus of this study is to simulate the nucleic acid testing for different population size cities in China to influence the spread of COVID-19, assess the situation under different scenarios, the demand for the laboratory testing personnel, material resources, for the implementation of the nucleic acid screening measures, emergency supplies, and the configuration of human resources to provide decision-making basis.

METHODS

According to the transmission characteristics of COVID-19 and the current prevention and control strategies in China, four epidemic scenarios were assumed. Based on the constructed SVEAI_iQHR model, the number of people infected with COVID-19 in cities with populations of 10 million, 5 million, and 500,000 was analyzed and predicted under the four scenarios, and the demand for laboratory testing resources was evaluated, respectively.

RESULTS

For large, medium, and small cities, whether full or regional nucleic acid screening can significantly reduce the epidemic prevention and control strategy of different scenarios laboratory testing resource demand difference is bigger, implement effective non-pharmaceutical interventions and regional nucleic acid screening measures to significantly reduce laboratory testing related resources demand, but will cause varying degrees of inspection staff shortages.

CONCLUSION

There is still an urgent need for laboratory testing manpower in China to implement effective nucleic acid screening measures in the event of an outbreak. Cities or regions with different population sizes and levels of medical resources should flexibly implement prevention and control measures according to specific conditions after the outbreak, assess laboratory testing and human resource need as soon as possible, and prepare and allocate materials and personnel.

Anti-adalimumab Antibodies in Patients with Non-infectious Ocular Inflammatory Disease: A Case Series

PURPOSE

To report the clinical course of patients with ocular inflammatory disease treated with adalimumab in whom anti-adalimumab antibodies (AAA) were detected.

METHODS

Single center case series.

RESULTS

Eight patients with initial response to adalimumab developed a disease flare associated with positive AAA testing after 5 to 76 months of therapy. Six patients were receiving no concurrent antimetabolite therapy at the time of AAA diagnosis and four had a temporary lapse in adalimumab therapy prior to AAA discovery. AAA resulted in undetectable drug levels in five of the seven patients for whom data were available, and adalimumab was discontinued in six of the eight patients. Of two patients continued on adalimumab, one maintained detectable serum adalimumab despite AAA and one had a low AAA titer.

CONCLUSIONS

For patients receiving adalimumab for ocular inflammatory disease, a disease flare in the setting of previously well-controlled disease should prompt consideration of AAA testing.

Performance of the 2021 Race-Free CKD-EPI Creatinine- and Cystatin C-Based Estimated GFR Equations Among Kidney Transplant Recipients

RATIONALE & OBJECTIVE

Race-free estimated glomerular filtration rate (eGFR) equations incorporating creatinine with and without cystatin C were recently developed and recommended for routine use. However, the performance of these equations among kidney transplant recipients (KTRs) remains unknown.

STUDY DESIGN

Cross-sectional study to validate the 2021 race-free Chronic Kidney Disease (CKD) Epidemiology Collaboration (CKD-EPI) eGFR equation based on creatinine alone (eGFR_cr) or based on creatinine and cystatin C (eGFR_cr-cys) among KTRs.

SETTING & PARTICIPANTS

KTRs in stable condition (N = 415) from Canada and New Zealand with same-day measurements of creatinine, cystatin C, and glomerular filtration rate (GFR) using radiolabeled diethylenetriaminepentaacetic acid.

TESTS COMPARED

The 2009 CKD-EPI eGFR_cr, 2021 CKD-EPI eGFR_cr, 2012 CKD-EPI eGFR_cr-cys, 2021 CKD-EPI eGFR_cr-cys, 2012 CKD-EPI eGFR_cys, and Modification of Diet in Renal Disease (MDRD) Study eGFR equations were compared with measured GFR.

OUTCOMES

Bias, precision, accuracy, and correct classification by CKD stage. Bias was defined as the difference between estimated and measured GFR. Precision was represented by the interquartile range. Accuracy was defined as the percentages of participants with eGFRs within 10%/20%/30% (P₁₀/P₂₀/P₃₀) of measured GFR, root mean square error, and mean absolute error.

RESULTS

87% of patients studied were White, 3% Black, and 10% other races. Mean measured GFR was 53 ± 19 (SD) mL/min/1.73 m². The 2009 and 2021 CKD-EPI eGFR_cr equations demonstrated similar median bias (-2.3 vs -0.2 mL/min/1.73 m², respectively), precision (14.5 vs 14.9 mL/min/1.73 m²), and accuracy (P₁₀/P₂₀/P₃₀, 32%/65%/84% vs 33%/63%/84%). The 2012 and 2021 CKD-EPI eGFR_cr-cys equations also demonstrated similar median bias (-3.6 vs 0.3 mL/min/1.73 m², respectively), precision (13.3 vs 14.3 mL/min/1.73 m²), and accuracy (P₁₀/P₂₀/P₃₀, 32%/63%/80% vs 32%/67%/83%). No clear difference in performance was detected between the 2021 CKD-EPI eGFR_cr and eGFR_cr-cys equations among KTRs. The proportion of correct classification by CKD stage was similar across all eGFR equations.

LIMITATIONS

Moderate sample size, few patients had a GFR <30 mL/min/1.73 m², and the large majority of patients were White.

CONCLUSIONS

Among KTRs, the 2021 race-free CKD-EPI eGFR equations perform similarly to the previous CKD-EPI equations that included race correction terms. No significant difference in performance was observed between the 2021 CKD-EPI eGFR_cr and eGFR_cr-cys equations in the kidney transplant population.

Systematic Literature Review of Respiratory Syncytial Virus Laboratory Testing Practices and Incidence in United States Infants and Children <5 Years of Age

Background

Respiratory syncytial virus (RSV) can cause serious illness in those aged <5 years in the United States, but uncertainty remains around which populations receive RSV testing. We conducted a systematic literature review of RSV testing patterns in studies published from 2000 to 2021.

Methods

Studies of RSV, medically attended RSV lower respiratory tract infections (LRTIs), and bronchiolitis were identified using standard methodology. Outcomes were clinical decisions to test for RSV, testing frequency, and testing incidence proportions in inpatient (IP), emergency department (ED), outpatient (OP), and urgent care settings.

Results

Eighty good-/fair-quality studies, which reported data from the period 1988–2020, were identified. Twenty-seven described the clinical decision to test, which varied across and within settings. Two studies reported RSV testing frequency for multiple settings, with higher testing proportions in IP (n = 2, range: 83%–85%, 1996–2009) compared with ED (n = 1, 25%, 2006–2009) and OP (n = 2, 15%–25%, 1996–2009). Higher RSV testing incidence proportions were observed among LRTI infant populations in the ED (n = 1, 74%, 2007–2008) and OP (n = 2, 54%–69%, 1995–2008). Incidence proportions in LRTI populations were not consistently higher in the IP setting (n = 13). Across studies and time, there was heterogeneity in RSV testing patterns, which may reflect varying detection methods, populations, locations, time periods, and healthcare settings.

Conclusions

Not all infants and children with LRTI are tested for RSV, highlighting underestimation of RSV burden across all settings.

Respiratory Syncytial Virus During the COVID-19 Pandemic Compared to Historic Levels: A Retrospective Cohort Study of a Health System

Background

Surveillance in 2020–2021 showed that seasonal respiratory illnesses were below levels seen during prior seasons, with the exception of interseasonal respiratory syncytial virus (RSV).

Methods

Electronic health record data of infants aged <1 year visiting the Duke University Health System from 4 October 2015 to 28 March 2020 (pre–COVID-19) and 29 March 2020 to 30 October 2021 (COVID-19) were assessed. International Classification of Diseases-Tenth Revision (ICD-10) codes for RSV (B97.4, J12.1, J20.5, J21.0) and bronchiolitis (RSV codes plus J21.8, J21.9) were used to detail encounters in the inpatient (IP), emergency department (ED), outpatient (OP), urgent care (UC), and telemedicine (TM) settings.

Results

Pre–COVID-19, 88% of RSV and 92% of bronchiolitis encounters were seen in ambulatory settings. During COVID-19, 94% and 93%, respectively, occurred in ambulatory settings. Pre–COVID-19, the highest RSV proportion was observed in December–January (up to 38% in ED), while the peaks during COVID-19 were seen in July–September (up to 41% in ED) across all settings. RSV laboratory testing among RSV encounters was low during pre–COVID-19 (IP, 51%; ED, 51%; OP, 41%; UC, 84%) and COVID-19 outside of UC (IP, 33%; ED, 47%; OP, 47%; UC, 87%). Full-term, otherwise healthy infants comprised most RSV encounters (pre–COVID-19, up to 57% in OP; COVID-19, up to 82% in TM).

Conclusions

With the interruption of historical RSV epidemiologic trends and the emergence of interseasonal disease during COVID-19, continued monitoring of RSV is warranted across all settings as the changing RSV epidemiology could affect the distribution of health care resources and public health policy.

Patient Care Alterations After Point-of-Care Laboratory Testing During Critical Care Transport

OBJECTIVE

Point-of-care laboratory testing (POCT) is associated with a reduced time to testing results and critical decision making within emergency departments. POCT is an essential clinical assessment tool because laboratory data are used to support timely critical decisions regarding acute medical conditions onditions ; however, there is currently limited research to support the use of POCT in the critical care transport environment. Few studies have evaluated the changes in patient care that occur after POCT during critical care transport. This study aims to contribute to the limited data available correlating prehospital POCT and changes in patient care.

METHODS

After institutional review board approval, a retrospective review of patients transported by a critical care transport team between October 1, 2013 and September 31, 2015 was completed. During the study period, 11,454 patients were transported, and 632 (5.51%) received POCT testing.

RESULTS

Patient care changes were noted in 244 (38.6%) patient tests. The most frequent patient care alterations were ventilator settings (10.9%), electrolyte changes (10.4%), and unit bed upgrades (7.1%). POCT most frequently altered care for patients with post-cardiac arrest syndrome (64.7%), sepsis/septic shock (61.8%), diabetic ketoacidosis (54.5%), or pneumonia (49.3%).

CONCLUSION

Patient care alterations occurred in 38.6% of patients undergoing POCT. Patient care was most frequently changed when patients were diagnosed with post-arrest, sepsis/septic shock, diabetic ketoacidosis, and pneumonia.

The Current Status of Molecular Biomarkers for Inflammatory Bowel Disease

Diagnosis and prognosis of inflammatory bowel disease (IBD)-a chronic inflammation that affects the gastrointestinal tract of patients-are challenging, as most clinical symptoms are not specific to IBD, and are often seen in other inflammatory diseases, such as intestinal infections, drug-induced colitis, and monogenic diseases. To date, there is no gold-standard test for monitoring IBD. Endoscopy and imaging are essential diagnostic tools that provide information about the disease's state, location, and severity. However, the invasive nature and high cost of endoscopy make it unsuitable for frequent monitoring of disease activity in IBD patients, and even when it is possible to replace endoscopy with imaging, high cost remains a concern. Laboratory testing of blood or feces has the advantage of being non-invasive, rapid, cost-effective, and standardizable. Although the specificity and accuracy of laboratory testing alone need to be improved, it is increasingly used to monitor disease activity or to diagnose suspected IBD cases in combination with endoscopy and/or imaging. The literature survey indicates a dearth of summarization of biomarkers for IBD testing. This review introduces currently available non-invasive biomarkers of clinical importance in laboratory testing for IBD, and discusses the trends and challenges in the IBD biomarker studies.

Preventive Health Screening during the COVID-19 Pandemic: A Cross-Sectional Survey among 102,928 Internet Users in Poland

Preventive screening is a highly cost-effective public health intervention. The COVID-19 pandemic may impact preventive healthcare services. This study aimed to assess the frequency of preventive health screening, as well as to identify the factors associated with compliance with health screening guidelines among adults in Poland during the COVID-19 pandemic. This cross-sectional survey was carried out between October and December 2021, among Internet users in Poland. Respondents were asked about the last date that they performed seven different screening tests. Completed questionnaires were obtained from 102,928 adults aged 18−99 years, and 57.2% were female. The most common screening tests performed in the past 12 months were blood pressure measurement (83%), blood count (66.2%), and blood sugar (63.3%). Moreover, more than half of respondents had a urinalysis (53.1%) and lipid panel (55.1%) in the past 12 months. Out of 58,904 females, 69.2% had a cervical cytology in the past 3 years. Older age, having higher education, living in urban areas, being occupationally active, having at least one chronic disease, and visiting a doctor in the past 12 months were significantly associated (p < 0.001) with a higher level of compliance with screening guidelines. This study revealed a significant gap in the performance of preventive health screening.

Use of Cotton Balls in Diapers for Collection of Urine Samples Impacts the Analysis of Routine Chemistry Tests: An Evaluation of Cotton Balls, Diapers, and Chemistry Analyzers

OBJECTIVE

To evaluate the suitability of urine samples collected with cotton balls placed into diapers for routine laboratory chemistry analyses.

STUDY DESIGN

Twenty pools of residual unpreserved urine samples were separated into control and treated aliquots. The treated samples were absorbed into 2 different brands of cotton balls, wrapped in 3 different brands of diapers, and incubated at 37°C for 1 hour. The urine-soaked cotton balls were placed into a syringe and expressed via plunger depression. Urine sodium, potassium, creatinine, urea, calcium, magnesium, inorganic phosphorus, albumin, and total protein were measured on all samples on 5 automated clinical chemistry platforms: Ortho Vitros 4600, Siemens Dimension Vista 500, Beckman Coulter AU5822, Roche Cobas 6000, and Abbott Architect c8000 at 5 separate hospital laboratories. Criteria used to exclude the presence of significant effects of urine from presoaked cotton balls in a diaper on the measurement of chemistry laboratory tests were R² >0.95, slope of 0.9-1.1, and mean bias within ±10%.

RESULTS

Albumin and total protein measurements demonstrated significant negative bias in urine from both brands of presoaked cotton balls with all brands of diapers on all 5 chemistry platforms compared with the control urine. We did not observe a significant effect of presoaking urine in cotton balls in a diaper on the measurement of sodium, inorganic phosphorus, and urea. The remaining tests demonstrated significant effects when measured in urine from presoaked cotton balls and/or diapers that were specific to the chemistry analyzer platform or diaper.

CONCLUSIONS

Diaper and cotton ball-based urine collection significantly impacts the measurement of several common chemistry assays.

Fluid Handling Dynamics and Durability of Silver-Containing Gelling Fiber Dressings Tested in a Robotic Wound System

OBJECTIVE

To develop a robotic phantom system containing multiple simulated wound replicates to determine the synergy in fluid absorbency and retention (sorptivity) performances and the post-simulated-use mechanical durability of silver-containing gelling fiber primary dressings when used with a secondary dressing, as per clinical practice.

METHODS

Using a robotic system containing six identical wound simulators, the authors tested the sorptivity performances of the Exufiber Ag + (Mölnlycke Health Care, Gothenburg, Sweden) primary dressing (ExAg-polyvinyl alcohol [PVA]) against a market-leading comparator product, when used with a secondary foam dressing. The durability of the primary dressings after simulated use was further investigated through tensile mechanical testing.

RESULTS

The ExAg-PVA primary dressing delivered greater fluid amounts for absorbency and retention by the secondary foam dressing, approximately 2- and 1.5-fold more than the comparator dressing pair after 10 and 15 hours, respectively. The ExAg-PVA dressing was also substantially less sensitive to the direction of pulling forces and, accordingly, exhibited post-use mechanical strength that was approximately four and six times greater than that of the other primary dressing (when the latter dressing was tested out-of-alignment with its visible seams) after 10 and 15 hours, respectively.

CONCLUSIONS

The dynamics of the sorptivity and fluid sharing between primary and secondary dressings and the effect of directional preference of strength of the primary dressings for adequate durability, resulting in safe post-use removals, have been described. The comparative quantification of these capabilities should help clinical and nonclinical decision-makers select dressings that best meet their patient needs.

Laboratory Testing of Kinetic Sand as a Reference Material for Physical Modelling of Cone Penetration Test with the Possibility of Artificial Neural Network Application

Cone Penetration Testing (CPT) is a quick survey in situ method through which soil parameters are not determined directly, but have to be estimated using derived relations between required soil parameter and soil resistance at the testing probe. Boundary conditions affect the reliability of the estimated soil parameters, therefore controlled laboratory conditions were applied to the intended CPT procedure analysis. Density, pycnometry, oedometer and direct shear tests of kinetic sand were performed to prove its usability as a reference testing material for further CPT laboratory analysis. The results of testing the kinetic sand are presented in this paper. Executed tests proved the kinetic sand as a reliable material in terms of the homogeneity and consistency of its physical and mechanical parameters. The material is utilizable as a substitution of cohesive sandy soils in physical modeling without the negative impact of the consistency-dependent behavior of fine-grained soils. However, some differences in parameters with respect to the natural soils should be taken into account. Neural network theory and numerical approach will be applied to the intended CPT laboratory analysis under controlled boundary conditions using kinetic sand to evaluate its potential for the determination of soil parameters.

A retrospective analysis of diagnostic testing in a large North American cohort of patients with epidermolysis bullosa

BACKGROUND

Accurate diagnosis of epidermolysis bullosa (EB) has significant implications for prognosis, management, and genetic counseling.

OBJECTIVE

To describe diagnostic testing patterns and assess diagnostic concordance of transmission electron microscopy (TEM), immunofluorescence mapping (IFM), and genetic analysis for EB.

METHODS

A retrospective cohort included patients enrolled in the Epidermolysis Bullosa Clinical Characterization and Outcomes Database from January 1, 2004, to July 8, 2019. Tests concluding the same EB type (EB simplex, junctional EB, dominant dystrophic EB, and recessive dystrophic EB) were considered concordant; those concluding different EB types were considered discordant; and those with nonspecific/nondefinitive results were equivocal.

RESULTS

A total of 970 diagnostic tests were conducted from 1984 to 2018 in 771 patients. Genetic analyses were performed chronologically later than IFM or TEM (P < .001). The likelihood of undergoing genetic analysis was greater for junctional EB and recessive dystrophic EB, and the same for dominant dystrophic EB as compared with EB simplex. TEM results in 163 patients were equivocal (55%), concordant (42%), and discordant (3%). IFM results in 185 patients were equivocal (54%), concordant (42%), and discordant (4%).

LIMITATIONS

Retrospective design.

CONCLUSIONS

Diagnostic testing has shifted in favor of genetic analysis. TEM and IFM frequently offer equivocal findings when compared to the specificity afforded by genetic analysis.

Alternatives and preferences for materials in use for pressure ulcer prevention: An experiment-reinforced literature review

Alleviation of localised, sustained tissue loads and microclimate management are the most critical performance criteria for materials in use for pressure ulcer prevention, such as in prophylactic dressings, padding or cushioning. These material performance criteria can be evaluated by calculating the extents of matching between the material stiffness (elastic modulus) and the thermal conductivity of the protective dressing, padding or cushioning with the corresponding properties of native skin, separately or in combination. Based on these bioengineering performance criteria, hydrocolloids, which are commonly used for prophylaxis of medical device-related pressure ulcers, exhibit poor stiffness matching with skin. In addition, there is remarkable variability in the modulus and thermal conductivity matching levels of different material types used for pressure ulcer prevention, however, it appears that among the materials tested, hydrogels provide the optimal matching with skin, followed by gels and silicone foams. The stiffness matching for hydrocolloids appears to be inferior even to that of gauze. This article provides quantitative performance criteria and metrics for these evaluations, and grades commonly used material types to biomechanically guide clinicians and industry with regards to the selection of dressings for pressure ulcer prevention, both due to bodyweight forces and as a result of applied medical devices.

The fluid handling performance of the curea P1 multipurpose dressing against superabsorbent and foam dressing technologies

Using a novel, automated robotic phantom system containing multiple wound simulants, we determined the fluid handling performance of the curea P1 multipurpose dressing vs market‐leading comparator superabsorbent and foam‐based dressings (FBDs). Specifically, we measured the retained, residual, evaporated, and (potentially occurring) spillover fluid shares for high‐ vs low‐viscosity exudate‐simulant test fluids, at 12, 24, and 30 hours postapplication of the dressings. These experiments were conducted for off‐loaded (‘prone’), non‐off‐loaded (‘supine’), and vertical (‘side‐lying’) simulated body positions. We found that the multipurpose dressing exhibited the best and most robust fluid handling performance across all the test configurations, for both the low‐ and high‐viscosity fluids. The FBD consistently showed the poorest performance compared to the other dressings, rendering it unlikely to be able to manage viscous exudates in ambulant patients (such as when applied to venous leg ulcers) as effectively as the other dressings. The superabsorbent dressing performed better than the foam dressing, but its fluid handling metrics were inferior to those of the multipurpose dressing. The current comparative quantification of the shares of retained, residual, evaporated, and spillover fluid, acquired through standardised laboratory tests, should help decision‐makers to select dressings that best meet their patient needs.

Disparity in Availability of Laboratory Testing for Syphilis Among Different Hospitals in Shandong Province, Eastern China

The aim of this study was to understand the availability of laboratory testing for syphilis among hospitals in Shandong province. Basic information on hospitals that provide clinical health service for sexually transmitted infections (STIs) and the type of laboratory tests for syphilis provided was collected and analyzed using the chi-square test. A total of 410 and 456 hospitals that provided clinical services for STI were surveyed in 2012 and 2018. Significant differences in the availability of nontreponemal tests were observed among different levels (χ² = 6.624, P = .010) and types (χ² = 17.752, P = .001) of hospitals in 2012, but not in 2018. A significant difference in the availability of treponemal tests was observed among different levels of hospitals in 2012 (χ² = 9.937, P = .002) but not in 2018. Significant differences in the availability of nontreponemal tests, titer of nontreponemal tests, and treponemal tests were observed among hospitals with different affiliations in 2018 (P = 0.000; χ² = 15.274, P = .000; P = .021) but not in 2012. The availability of nontreponemal and treponemal tests for syphilis among hospitals in 2018 was higher than that in 2012 (90.13% vs. 57.56%, χ² = 121.219, P = .000). The availability of laboratory testing has been much improved. Further efforts are needed to reduce the disparity in the availability among different hospitals.

Raising the Bar: Improving Antimicrobial Resistance Detection by Clinical Laboratories by Ensuring Use of Current Breakpoints

Background

Antimicrobial resistance (AMR) is a pressing global challenge detected by antimicrobial susceptibility testing (AST) performed by clinical laboratories. AST results are interpreted using clinical breakpoints, which are updated to enable accurate detection of new and emerging AMR. Laboratories that do not apply up-to-date breakpoints impede global efforts to address the AMR crisis, but the extent of this practice is poorly understood.

Methods

A total of 1490 clinical laboratories participating in a College of American Pathologists proficiency testing survey for bacterial cultures were queried to determine use of obsolete breakpoints.

Results

Between 37.9% and 70.5% of US laboratories reported using obsolete breakpoints for the antimicrobials that were queried. In contrast, only 17.7%-43.7% of international laboratories reported using obsolete breakpoints (P < .001 for all comparisons). Use of current breakpoints varied by AST system, with more laboratories reporting use of current breakpoints in the US if the system had achieved US Food and Drug Administration clearance with current breakpoints. Among laboratories that indicated use of obsolete breakpoints, 55.9% had no plans to update to current standards. The most common reason cited was manufacturer-related issues (51.3%) and lack of internal resources to perform analytical validation studies to make the update (23.4%). Thirteen percent of laboratories indicated they were unaware of breakpoint changes or the need to update breakpoints.

Conclusions

These data demonstrate a significant gap in the ability to detect AMR in the US, and to a lesser extent internationally. Improved application of current breakpoints by clinical laboratories will require combined action from regulatory agencies, laboratory accreditation groups, and device manufacturers.

Laboratory testing for platelet factor 4 antibodies: differential utility for diagnosis/exclusion of heparin induced thrombocytopenia versus suspected vaccine induced thrombotic thrombocytopenia

Platelet factor 4 (PF4), a protein stored in the alpha-granules of platelets and released upon activation, forms cationic tetramers that bind with various polymeric anions, including heparin. Some individuals develop antibodies against PF4 in complex with heparin (PF4/H), which potentially lead to the onset of heparin induced thrombocytopenia (HIT). In some patients, this may cause activation and aggregation of platelets, promoting pathological thrombosis, in a process called heparin induced thrombocytopenia with thrombosis ('HITT'). Laboratories can assess for the presence of these antibodies using many PF4 antibody tests, including by enzyme linked immunosorbent assay (ELISA), latex immunoassay (LIA), chemiluminescence immunoassay (CLIA) and even rapid nanoparticle based lateral flow immunoassays. All these assays can identify such antibodies with high sensitivity, but methods may have variable specificity. For example, several studies have shown CLIA assays to have higher specificity to HITT than ELISA assays. Very recently, a new 'HITT-like' syndrome has been described in some individuals receiving adenovirus based COVID-19 (coronavirus disease 2019) vaccines. This condition has been given several names, including vaccine induced thrombotic thrombocytopenia (VITT) and thrombosis with thrombocytopenia syndrome (TTS), and also involves a mechanism mediated by antibodies formed against PF4. These antibodies can also be detected by PF4 antibody tests, but detection sensitivity appears to favour ELISA assays, with most other tests (including CLIA and LIA) not generally capable of detecting such antibodies. Additional functional assays assessing for PF4 mediated platelet activation may also be performed. The current review is focussed on laboratory testing for PF4 antibodies, in particular to distinguishing patterns in HITT versus VITT.

Review and evolution of guidelines for diagnosis of COVID-19 vaccine induced thrombotic thrombocytopenia (VITT)

Coronavirus disease 2019 (COVID-19) is a life-threatening infectious disease caused by Severe acute respiratory syndrome Coronavirus-2 (SARS-CoV-2). In response to the still ongoing pandemic outbreak, a number of COVID-19 vaccines have been quickly developed and deployed. Although minor adverse events, either local (e.g., soreness, itch, redness) or systematic (fever, malaise, headache, etc.), are not uncommon following any COVID-19 vaccination, one rare vaccine-associated event can cause fatal consequences due to development of antibodies against platelet factor 4 (PF4), which trigger platelet activation, aggregation, and possible resultant thrombosis, often at unusual vascular sites. Termed thrombosis with thrombocytopenia syndrome (TTS) by reporting government agencies, the term vaccine-induced (immune) thrombotic thrombocytopenia (VITT) is more widely adopted by workers in the field. In response to increasing reports of VITT, several expert groups have formulated guidelines for diagnosis and/or management of VITT. Herein, we review some key guidelines related to diagnosis of VITT, and also provide some commentary on their development and evolution.

Synthetic opioids: a review and clinical update

The term 'opioids' refers to both the natural compounds ('opiates') which are extracted from the opium poppy plant (Papaver somniferum) and their semi-synthetic and synthetic derivatives. They all possess relatively similar biochemical profiles and interact with the opioid receptors within the human body to produce a wide range of physiological effects. They have historically been used for medicinal purposes, their analgesic and sedative effects, and in the management of chronic and severe pain. They have also been used for non-medicinal and recreational purposes to produce feelings of relaxation, euphoria and well-being. Over the last decade, the emergence of an illegal market in new synthetic opioids has become a major global public health issue, associated with a substantial increase in unintentional overdoses and drug-related deaths. Synthetic opioids include fentanyl, its analogues and emerging non-fentanyl opioids. Their popularity relates to changes in criminal markets, pricing, potency, availability compared to classic opioids, ease of transport and use, rapid effect and lack of detection by conventional testing technologies. This article expands on our previous review on new psychoactive substances. We now provide a more in-depth review on synthetic opioids and explore the current challenges faced by people who use drugs, healthcare professionals, and global public health systems.

Patient Preferences for Point-of-Care Testing: Survey Validation and Results

Background

Studies of current opinion of our community members for the characteristics, mode, and location of use, use cases, and overall enthusiasm for point-of-care testing (POCT) diagnosis and management tools are needed.

Study Design and Methods

Qualitative research methods were used to develop, refine, and evaluate hardcopy and electronic versions of a 45-item English language survey. The accuracy of the instrument was measured by recorded structured interview, and its precision was measured by comparison to its administration to a group of uncompensated volunteers.

Main Findings and Results

Comparison of survey and structured interview data demonstrated high levels of accuracy. Highly concordant with significant levels of correlation and of direct association indicated favorable precision. Ninety-three percent of respondents believed that POCT could improve their care, and 56% identified having a POCT in their home as a top priority. Accuracy, insurance coverage, immediacy of results, and ease of use were identified as the most important characteristics of a POCT.

Conclusions

Community members strongly support the development of accurate, in-home devices that produce immediate results that can be used to diagnose, manage, and encourage their adherence to treatments for their medical conditions.

Ponatinib Exerts an Inhibitory Effect on Collagen-induced Platelet Aggregation and Generation of Coated-Platelets

BACKGROUND/AIM

BCR-ABL tyrosine kinase inhibitors (TKIs) are exceptionally effective drugs in the treatment of chronic myeloid leukemia, nevertheless, TKIs have also an effect on platelets. We aimed to investigate the effect of a third-generation TKI, ponatinib on platelet functions.

MATERIALS AND METHODS

Collagen-induced platelet aggregation and coated-platelet formation were examined using in vitro and in ex vivo samples of patients on ponatinib therapy.

RESULTS

In platelet rich plasma of healthy volunteers, ponatinib at a supra-therapeutic concentration (1,000 nM) significantly impaired collagen induced platelet aggregation (p≤0.01) and reduced the formation of coated-platelets at 150 nM ponatinib concentration (p≤0.05). In addition, upon glycoprotein VI (GPVI) receptor activation, a significantly lower percentage of PAC1 binding platelets (p≤0.05) was observed at 1,000 nM final concentration of ponatinib. Platelets, isolated from patients on ponatinib therapy showed impaired collagen elicited aggregation response, already in pre-dose samples compared to healthy donors.

CONCLUSION

The therapeutic concentration of ponatinib impairs platelet activation processes elicited by GPVI receptor agonists.

Physiological and metabolic adaptations in pregnancy: importance of trimester-specific reference intervals to investigate maternal health and complications

Diagnosis, prognostication, and monitoring of maternal health throughout pregnancy relies on laboratory testing, including but not limited to key markers of thyroid, hepatic, cardiac, hematology, and renal function. Dynamic physiological processes during gestation significantly influence the maternal biochemistry that supports both the mother and fetus. Resultant changes in blood biochemistry alter the expected values of common laboratory tests. However, the importance of pregnancy-specific reference intervals for laboratory test result interpretation and appropriate monitoring of maternal health and complications is underappreciated. Most clinical laboratories continue to use non-pregnant adult reference intervals for laboratory test interpretation in pregnancy. The current review summarizes and critically evaluates the available literature regarding physiological and metabolic adaptations in pregnancy and their influence on common biomarkers of health and disease. The main laboratory parameters discussed include thyroid, hepatic, metabolic, renal, hematology, inflammatory, and cardiac markers. Considering the available data, further studies are urgently needed to establish trimester-specific reference intervals in healthy pregnant women on updated analytical platforms. Without such data, the standard of clinical laboratory service in pregnancy remains compromised and affects the quality of maternal-fetal healthcare.

Evaluating errors in the laboratory identification of von Willebrand disease using contemporary von Willebrand factor assays

von Willebrand disease (VWD) arises from deficiency and/or defects of von Willebrand factor (VWF). Assessment requires test panels, including VWF activity and antigen. Appropriate diagnosis including differential identification of qualitative versus quantitative defects remains problematic but has important management implications. Data using a large set (n=27) of varied plasma samples comprising both quantitative VWF deficiency ('Type 1 and 3') vs qualitative defects ('Type 2') tested in a cross-laboratory setting have been evaluated to assess contemporary VWF assays for utility to differentially identify sample types. Different VWF assays and activity/antigen ratios showed different utility in VWD and type identification. Identification errors were linked to assay limitations, including variability, and laboratory issues (e.g., test result misinterpretation). Quantitative deficient (type 1) samples were misinterpreted as qualitative defects (type 2) on 35/467 occasions (7.5% error rate); 11.4% of these errors were due to laboratories misinterpreting their own data, which was instead consistent with quantitative deficiencies. Conversely, qualitative defects were misinterpreted as quantitative deficiencies at a higher error rate (14.3%), but this was more often due to laboratories misinterpreting their data (40% of errors). For test-associated errors, VWF:RCo and VWF:GPIbM were associated with the highest variability and error rate, which was many-fold higher than that using VWF:CB. Chemiluminescence ('CLIA') procedures were associated with lowest inter-laboratory variability and errors overall. These findings in part explain the high rate of errors associated with VWD diagnosis. VWF:GPIbM showed a surprisingly high rate of test associated errors, whilst CLIA procedures performed best overall.

Laboratory Testing Implications of Risk-Stratification and Management of COVID-19 Patients

Objective: To distinguish COVID-19 patients and non-COVID-19 viral pneumonia patients and classify COVID-19 patients into low-risk and high-risk at admission by laboratory indicators. Materials and methods: In this retrospective cohort, a total of 3,563 COVID-19 patients and 118 non-COVID-19 pneumonia patients were included. There are two cohorts of COVID-19 patients, including 548 patients in the training dataset, and 3,015 patients in the testing dataset. Laboratory indicators were measured during hospitalization for all patients. Based on laboratory indicators, we used the support vector machine and joint random sampling to risk stratification for COVID-19 patients at admission. Based on laboratory indicators detected within the 1st week after admission, we used logistic regression and joint random sampling to develop the survival mode. The laboratory indicators of COVID-10 and non-COVID-19 were also compared. Results: We first identified the significant laboratory indicators related to the severity of COVID-19 in the training dataset. Neutrophils percentage, lymphocytes percentage, creatinine, and blood urea nitrogen with AUC >0.7 were included in the model. These indicators were further used to build a support vector machine model to classify patients into low-risk and high-risk at admission in the testing dataset. Results showed that this model could stratify the patients in the testing dataset effectively (AUC = 0.89). Our model still has good performance at different times (Mean AUC: 0.71, 0.72, 0.72, respectively for 3, 5, and 7 days after admission). Moreover, laboratory indicators detected within the 1st week after admission were able to estimate the probability of death (AUC = 0.95). We identified six indicators with permutation p < 0.05, including eosinophil percentage (p = 0.007), white blood cell count (p = 0.045), albumin (p = 0.041), aspartate transaminase (p = 0.043), lactate dehydrogenase (p = 0.002), and hemoglobin (p = 0.031). We could diagnose COVID-19 and differentiate it from other kinds of viral pneumonia based on these laboratory indicators. Conclusions: Our risk-stratification model based on laboratory indicators could help to diagnose, monitor, and predict severity at an early stage of COVID-19. In addition, laboratory findings could be used to distinguish COVID-19 and non-COVID-19.

ADAMTS13 testing update: Focus on laboratory aspects of difficult thrombotic thrombocytopenic purpura diagnoses and effects of new therapies

TTP is a life-threatening disorder diagnosed using a combination of clinical information and laboratory results. ADAMTS13 activity and antibody testing represent a major advance in the field, but results can sometimes be difficult to interpret due to technical aspects of the tests and characteristics of the causative antibodies in acquired TTP. Genetic testing for ADAMTS13 mutations is also now available to assist with the diagnosis of inherited TTP. This review will focus on ADAMTS13 testing and will highlight patient and laboratory aspects that can lead to diagnostic difficulty. The effects of TTP therapies on test results will also be discussed.