T Cell Senescence by Extensive Phenotyping: An Emerging Feature of COVID-19 Severity.

OBJECTIVE: To identify the potential prognostic value of lymphocyte subsets in COVID-19 patients, where lymphopenia is a common finding. METHODS: In 353 COVID-19 inpatients and 40 controls T cell subsets with markers of senescence and exhaustion were studied by flow cytometry. RESULTS: In severe illness, total lymphocytes B, NK, and all T subsets were dampened. Senescent CD4+, but mainly CD8+ T cells, increased in patients with respect to controls. The most significant index predicting fatal outcome was neutrophils/CD3+ T ratio. CONCLUSION: In conclusion, an altered T cell pattern underlies COVID-19 severity and is involved in predicting the outcome.

The VES-Matic 5 system: performance of a novel instrument for measuring erythrocyte sedimentation rate.

OBJECTIVES: The VES-Matic 5 is an automated analyzer that assesses erythrocyte sedimentation rate based on a modified Westergren sedimentation technique. Instrument performance was established by addressing the recommendations of the International Council for Standardization in Haematology. METHODS: Comparison against the reference Westergren method was performed for all samples, and further for the low, middle, and upper third of the analytical range. Intra-run precision, inter-run precision, and interference studies were further assessed. This study included the evaluation of reference ranges. RESULTS: The comparison of methods by Passing-Bablok analysis has shown a good agreement without systematic or proportional differences. The regression equation was y=-0.646 + 0.979x. The mean bias of -0.542 was obtained by Bland-Altman analysis and the upper limit of 8.03 with the lower limit of -9.11 can be considered clinically acceptable. Intra-run and inter-run precision were good for each parameter and interference studies did not show any significant bias with exception of anemia samples, which showed a proportional difference when comparing high erythrocyte sedimentation rate values. Using the local adult reference population, we verified the reference ranges in comparison to those available in the literature, and according to the Clinical Laboratory Standards Institute (CLSI) EP28-A3C document. We determined the upper limit partitioned by gender and the following age groups: from 18 to 50, from 50 to 70, and over 70. CONCLUSIONS: The VES-Matic 5 analyzer presented good comparability with the reference method. As there are commercial quality control and suitable external quality assessment (EQA) material and programs, the VES-Matic 5 can be employed appropriately for routine purposes.

Monocyte distribution width (MDW) parameter as a sepsis indicator in intensive care units.

OBJECTIVES: Patients in Intensive Care Units (ICU) are a high-risk population for sepsis, recognized as a major cause of admission and death. The aim of the current study was to evaluate the diagnostic accuracy and prognostication of monocyte distribution width (MDW) in sepsis for patients admitted to ICU. METHODS: Between January and June 2020, we conducted a prospective observational study during the hospitalization of 506 adult patients admitted to the ICU. MDW was evaluated in 2,367 consecutive samples received for routine complete blood counts (CBC) performed once a day and every day during the study. Sepsis was diagnosed according to Sepsis-3 criteria and patients enrolled were classified in the following groups: no sepsis, sepsis and septic shock. RESULTS: MDW values were significantly higher in patients with sepsis or septic shock in comparison to those within the no sepsis group [median 26.23 (IQR: 23.48-29.83); 28.97 (IQR: 21.27-37.21); 21.99 (IQR: 19.86-24.36) respectively]. ROC analysis demonstrated that AUC is 0.785 with a sensitivity of 66.88% and specificity of 77.79% at a cut-off point of 24.63. In patients that developed an ICU-acquired sepsis MDW showed an increase from 21.33 [median (IQR: 19.47-21.72)] to 29.19 [median (IQR: 27.46-31.47)]. MDW increase is not affected by the aetiology of sepsis, even in patients with COVID-19. In sepsis survivors a decrease of MDW values were found from the first time to the end of their stay [median from 29.14 (IQR: 26.22-32.52) to 25.67 (IQR: 22.93-30.28)]. CONCLUSIONS: In ICU, MDW enhances the sepsis detection and is related to disease severity.

Ibrutinib in relapsed hairy cell leukemia variant: A case report and review of the literature.

Hairy cell leukemia variant (HCLv) is a provisional disease in the 2016 WHO classification of lymphomas, characterized by unfavorable prognosis and early relapse following conventional purine analog-based regimens. In this study, we report 2 patients with relapsed HCLv treated with ibrutinib. The first patient achieved a partial response following ibrutinib treatment and received the drug for 16 months, without severe adverse events. However, at disease progression venetoclax was not clinically active. The second patient discontinued the drug early due to intolerance. Ibrutinib was active in our patients with HCLv and deserve further investigations.

Assessment and monitoring of agreement among professionals for morphological evaluation in compliance with International accreditation standard requirements.

OBJECTIVES: Standardized criteria guaranteeing harmonized interpretation among morphologists in the provision of morphology results represent an important tool to be adopted for risk management and patient safety. Aim of this work is to assess agreement among morphologists in the microscopic evaluation of the peripheral blood smear. METHODS: 17 morphologists participating in the external quality assessment (EQA) program individually evaluated the blood smear and recorded the results using a personal username and password. Agreement among operators was evaluated. RESULTS: The overall agreement rate in microscopic differential was 95% in 2016 and 97% in 2017 (acceptance limit 90%), with 6/120 and 4/120 incongruent results, respectively. The agreement for the diagnostic hypothesis was satisfactory with a full agreement being reached in 5 out of 16 cases. CONCLUSIONS: The creation of a tool to assess the agreement of readers providing morphological evaluations is a valuable step forward in ensuring patient safety and quality laboratory medicine.

Analytical validation of the iSED automated analyzer for erythrocyte sedimentation rate.

INTRODUCTION: iSED is an alternate automated analyzer for erythrocyte sedimentation rate (ESR) based on photometric rheology technology that estimates ESR by measuring rouleaux formation. The aim was to evaluate the analytical performance of the iSED analyzer and compare the results with the Westergren method and another alternate ESR analyzer, TEST1. METHODS: Validation was performed at two study sites according to the recommendations by the International Council for Standardization in Haematology and included determination of intrarun precision and inter-run precision, bias, carryover, and method comparison, which was further assessed for samples with normal and low hematocrit, as well as per low, middle, and upper third of the analytical range. RESULTS: Intrarun coefficients of variation (CVs) with commercial controls were 4.0% and 1.8%, while inter-run CVs 7.5% and 0.7%, for the normal and pathological range, respectively. Intrarun CVs obtained with patient samples were 19.9%, 9.9%, 10.3%, and 9.4%, the highest being for the lowest ESR value. Correlation coefficients for the comparison between iSED and Westergren were 0.862 (Site-1) and 0.916 (Site-2). While proportional difference with a positive bias was revealed at Site-1, comparison at Site-2 showed both constant and proportional difference and a negligible negative bias. Higher correlation was obtained for samples with low than normal hematocrit. Comparison between iSED and TEST1 yielded a correlation coefficient of 0.986, constant and proportional difference, and positive bias. Carryover was 3.2%. CONCLUSION: This study proved the analytical validity of the iSED analyzer, despite minor discrepancies to the Westergren method that can be attributed to methodological differences.

Comparison of Presepsin, Procalcitonin, Interleukin-8 and C-Reactive Protein in Predicting Bacteraemia in Febrile Neutropenic Adult Patients with Haematological Malignancies.

Bacterial infections represent life-threatening complications in patients with febrile neutropenia (FN). Diagnostic biomarkers of infections may help to differentiate bacteraemia from non-bacteraemia FN. We aimed to evaluate the utility of procalcitonin (PCT), presepsin (PS), C-reactive protein (CRP) and interleukin-8 (IL-8) as biomarkers of bacteraemia in adult FN patients with haematological malignancies. Concentrations of PCT, PS, CRP and IL-8 were prospectively measured in 36 FN episodes experienced by 28 oncohaematological patients. 11 out of 36 episodes were classified as bacteraemia. PCT was the best biomarker to predict bacteraemia with the area under the curve (AUC) ROC of 0,9; specificity 100% and positive predictive value 100%, while the most sensitive was IL-8 (90,9%) with AUC ROC of 0,88 and negative predictive value 95,2%. All patients with PCT concentrations above 1,6 µg/l had bacteraemia. Patients with IL-8 concentrations superior to 170 pg/ml had a 40 times higher risk for bacteraemia than the ones with lower levels. Patients with PS concentrations superior to 410 pg/ml had 24 times higher risk for bacteraemia than the patients with lower levels. PCT has higher accuracy than CRP, IL-8 and PS in predicting bacteraemia in adult hematologic patients with FN.

Ves-Matic CUBE 200: is modified Westergren method for erythrocyte sedimentation rate a valid alternative to the gold standard?

Ves-Matic CUBE 200 is an automated erythrocyte sedimentation rate (ESR) analyser based on the modified Westergren principle of measurement. In this study, we aimed to assess its analytical performance following the key points addressed by the International Council for Standardization in Haematology and the comparability with the gold standard Westergren method. Comparison of the two methods yielded a correlation coefficient of 0.852, no significant bias and a small constant difference between compared results. Intrarun coefficients of variation (CV) ranged from 2.2% to 22.2%, the higher being for lower ESR values, while inter-run CVs were 19.7% for the normal range and 3.0% for the abnormal range. This study proved the analytical validity of the Ves-Matic CUBE 200 and its high comparability with the Westergren method, showing obvious improvements in the technology applied for automated determination of ESR and a valuable step forward in standardisation of ESR methods.

Automated measurement of the erythrocyte sedimentation rate: method validation and comparison.

Background Development of automated analyzers for erythrocyte sedimentation rate (ESR) has imposed the need for extensive validation prior to their implementation in routine practice, to ensure comparability with the reference Westergren method. The aim of our study was to perform the analytical validation of two automated ESR analyzers, the Ves-Matic Cube 200 and the TEST1. Methods Validation was performed according to the recent International Council for Standardization in Hematology recommendations and included determination of intrarun and inter-run precision, assessment of sample carryover, hemolysis interference, sensitivity to fibrinogen, method comparison with the gold standard Westergren method and stability test. Results The highest intrarun imprecision was obtained for the low ESR range (33.5% for Ves-Matic Cube; 37.3% for TEST1) while inter-run coefficients of variation on three levels were much better for the TEST1 (0%, 2% and 1.2%) compared to the Ves-Matic Cube 200 on two levels (24.9% and 5.8%). Both Ves-Matic Cube 200 and TEST1 showed no statistically significant difference when compared with Westergren. Bland-Altman analysis yielded overall insignificant mean biases for all comparisons, but a wider dispersion of results and 95% limits of agreement for comparisons including the Ves-Matic Cube 200. Carryover was considered insignificant, while hemolysis had a negative effect on all assessed ESR methods. The highest sensitivity to fibrinogen was observed for the Ves-Matic Cube 200, followed by Westergren and the least sensitive was the TEST1. Conclusions The obtained results proved the analytical validity of the TEST1 and the Ves-Matic Cube 200, and high comparability with the gold standard Westergren method, showing obvious improvements in standardization of ESR methods.

Quality of plasma samples and BD Vacutainer Barricor tubes: Effects of centrifugation.

BACKGROUNDS: The BD Vacutainer® Barricor™ Plasma collection tube (BD Barricor) uses an innovative non-gel separation method. This study compared the plasma residual cell count (PRCC) obtained from BD Barricor and from BD PST II plasma tubes. METHODS: Four BD Barricors and one BD PST II were collected from 40 donors. BD PST II was centrifuged at 1300g/10 min, while the BD Barricors were centrifuged at 1800g/10 min, 4000g/3 min, 4000g/7 min and 4000g/15 min. PRCC was evaluated measuring white blood cells (WBC), red blood cells (RBC) and Platelets (PLT) counts by Siemens ADVIA 2120. Cell-free hemoglobin was quantified by haemolysis index (HI) by Roche Cobas c501. RESULTS: BD PST II Median WBC, RBC and PLT counts were 0.38 (109/L), 0.0291 (1012/L) and 113.5 (109/L), respectively. Considering the BD PST II as reference, PRCC differences were expressed as median bias percentage. WBC showed a significant reduction at all the conditions (p < 0.01), being the reductions: 63.9% (1800g/10 min), 69.9% (4000g/3 min), 75.0% (4000g/7 min) and 82.7% (4000g/15 min). RBC reductions 29.7% (1800g/10 min), 33.8% (4000g/3 min), 39.6% (4000g/7 min) and 66.4 (4000g/15 min) were all significant (p < 0.01). PLT reductions were 1.6% at 1800g/10 min (p = ns), 1.2% at 4000g/3 min (p = ns), 27.1% at 4000g/7 min (p = 0.046) and 46.6% at 4000g/15 min (p = 0.005). BD Barricor centrifuged for 7 and 15 min at 4000g showed an increased haemolysis. CONCLUSIONS: BD Barricors plasma quality improved with increasing the centrifugation times but already at 4000g/3 min, the suggested centrifugation condition, a significant improvement was achieved.

Avaliação do conhecimento sobre o vírus do papiloma humano (HPV) e sua vacinação entre agentes comunitários de saúde na cidade de Tubarão, Santa Catarina, em 2014 / Evaluación del conocimiento acerca del papiloma vírus humano (HPV) y su vacuna, en agentes comunitarios de salud en la ciudad de Tubarão, Santa Catarina, Brasil, in 2014 / Evaluation of knowledge about the Human Papilloma Virus (HPV) and its vaccination among Community Health Agents in the municipality of Tubarão, Santa Catarina, Brazil, in 2014

Resumo OBJETIVO: avaliar o conhecimento de agentes comunitários de saúde (ACS) acerca do vírus do papiloma humano (HPV) e sua vacinação. MÉTODOS: foi realizado inquérito com ACS atuantes no município de Tubarão-SC, Brasil, em 2014; os dados foram coletados por um instrumento de avaliação do conhecimento sobre HPV e sua vacinação, validado para o idioma inglês e adaptado - transculturalmente - para o português. RESULTADOS: participaram do estudo 124 ACS; todos já haviam ouvido falar do HPV mas apenas 25,0% sobre o teste para o HPV; 72,6% acertaram menos de 70,0% das respostas do instrumento de avaliação; os ACS que acertaram mais de 70,0% dos questionamentos apresentavam, em conjunto, menor média de idade (p=0,010). CONCLUSÃO: há pouco conhecimento dos ACS sobre o HPV, o que pode repercutir em sua atuação como agentes multiplicadores de (i) prevenção de doenças e agravos, e de (ii) educação em saúde.

Resumen OBJETIVO: ese trabajo tuvo como objetivo evaluar el conocimiento de los Agentes Comunitarios de Salud (ACS) acerca del Papiloma Virus Humano (HPV) y su vacuna. MÉTODOS: realizamos un estudio transversal con ACS activos en la ciudad de Tubarão-SC, Brasil, en 2014; los datos fueron colectados a través de un instrumento de evaluación sobre el conocimiento acerca del HPV y su vacuna, validado para el inglés y adaptado para el portugués. RESULTADOS: participaron del estudio 124 ACS; todos ya tenían escuchado del HPV, pero solamente 25,0% del teste para el virus; del total de preguntas, 72,6% de los ACS respondieron menos de 70,0% de forma correcta; los que acertaron más que 70,0% tenían, en promedio, una edad más baja (p=0,010). CONCLUSIÓN: el conocimiento de los ACS acerca del HPV está debajo de lo esperado, eso puede repercutir en su actuación como agentes multiplicadores de prevención y educación en salud.

Abstract OBJECTIVE: to evaluate the knowledge of Community Health Agents (CHA) about the Human Papilloma Virus (HPV) and its vaccination. METHODS: this is a cross-sectional study with CHA who worked in Tubarão-SC, Brazil, in 2014; data were collected through an evaluation tool about HPV and its vaccination, validated for English language and translated and adapted into Portuguese. RESULTS: 124 CHA participated in this study; all of them had already heard about HPV, but only 25.0% had heard about HPV testing; 72.6% answered correctly less than 70.0% of the questions; those who answered correctly more than 70.0% were, in general, younger than the other CHA (p=0.010). CONCLUSION: CHA demonstrated little knowledge on HPV, which may affect their work as multipliers in the prevention of diseases and in education in health.

Evaluation of knowledge about the Human Papilloma Virus (HPV) and its vaccination among Community Health Agents in the municipality of Tubarão, Santa Catarina, Brazil, in 2014. / Avaliação do conhecimento sobre o vírus do papiloma humano (HPV) e sua vacinação entre agentes comunitários de saúde na cidade de Tubarão, Santa Catarina, em 2014.

OBJECTIVE: to evaluate the knowledge of Community Health Agents (CHA) about the Human Papilloma Virus (HPV) and its vaccination. METHODS: this is a cross-sectional study with CHA who worked in Tubarão-SC, Brazil, in 2014; data were collected through an evaluation tool about HPV and its vaccination, validated for English language and translated and adapted into Portuguese. RESULTS: 124 CHA participated in this study; all of them had already heard about HPV, but only 25.0% had heard about HPV testing; 72.6% answered correctly less than 70.0% of the questions; those who answered correctly more than 70.0% were, in general, younger than the other CHA (p=0.010). CONCLUSION: CHA demonstrated little knowledge on HPV, which may affect their work as multipliers in the prevention of diseases and in education in health.

Performance specifications of critical results management.

Formerly defined "critical values", the importance of critical results (CRs) management in patient care has grown in recent years. According to the George Lundberg definition the result becomes "critical" when, exceeding actionable thresholds, it suggests imminent danger for the patient, unless appropriate therapy is initiated promptly. As required in most important accreditation standards, such as the ISO:15,189 or the Joint Commission standards, a quality reporting system should deliver the correct result to the appropriate clinician in a time-frame that ensures patient safety. From this point of view, medical laboratories should implement a process that assures the most effective communication in a timely manner, to the referring physician or care team member. Failure in communication, particularly in this type of situation, continues to be one of the most common factors contributing to the occurrence of adverse events. In the last few decades, Information Technology (IT) in Health Care has become increasingly important. The ability to interface radiology, anatomic pathology or laboratory information systems with electronic medical records is now a real opportunity, offering much safer communication than in the past. Future achievements on performance criteria and quality indicators for the notification of CRs, should ensure a comparable examination across different institutions, adding value to clinical laboratories in controlling post-analytical processes that concern patient safety. Therefore, the novel approach to CRs should combine quality initiatives, IT solutions and a culture to strengthen professional interaction.

Observational retrospective study of vascular modulator changes during treatment in essential thrombocythemia.

Essential thrombocythemia (ET) patients are at risk of developing thrombotic events. Qualitative platelet (PLT) abnormalities and activation of endothelial cells (ECs) and PLTs are thought to be involved. Microparticles (MPs) can originate from PLTs (PMPs), ECs (EMPs), or red cells (RMPs). Previous studies have indicated that MPs contribute to ET pathophysiology. Endothelial modulators (eg, nitric oxide [NO], adrenomedullin [ADM], and endothelin-1 [ET-1]) are also involved in the pathophysiology of this condition. We hypothesized that treatments for reducing PLT count might also indirectly affect MP generation and endothelial activity by altering endothelial modulator production. The rationale of this study was that hydroxyurea (HU), a cytostatic drug largely used in ET, induces the production of a potent vasoactive agent NO in ECs. An observational retrospective study was designed to investigate the relationship between MPs, NO, ADM, and ET-1 in ET patients on treatment with HU, anagrelide (ANA), aspirin (ASA), and a group of patients before treatment. A total of 63 patients with ET diagnosis: 18 on HU + ASA, 15 on ANA + ASA, 19 on ASA only, and 11 untreated patients, and 18 healthy controls were included in this study. Blood samples were analyzed for MP (absolute total values) and functional markers (percentage values) by flow cytometry. PLT-derived MPs were studied using CD61, CD62P, CD36, and CD63, whereas endothelial-derived MPs were studied using CD105, CD62E, and CD144. Endothelial modulator markers (NO, ADM, and ET-1) were measured by ELISA. Total MP count was higher in the group treated with ANA + ASA (P < 0.01). MP markers modified in ET patients returned to levels of healthy controls following treatment, in particular, in patients on ANA treatment. NO and ADM values were higher in the HU group (P < 0.001). HU and ANA treatment also affected MP production in a cell origin-specific manner. HU and ANA, although acting via different pathways, have similar final effects. For instance, HU causes vasodilatation by increasing NO and ADM levels, whereas ANA impairs vasoconstriction by reducing ET-1. In conclusion, therapy with HU cytostatic drugs and ANA can reduce PLT count in ET, and also affect endothelial modulatory agents, with HU sustaining vasodilation and prothrombotic MP concentration, whereas ANA decreases vasoconstriction.

Bendamustine plus rituximab is an effective first-line treatment in hairy cell leukemia variant: a report of three cases.

Hairy cell leukemia variant (HCLv) is a chronic lymphoproliferative disorder classified as a provisional entity in the 2016 WHO Classification of Lymphoid Tumors. HCLv is characterized by unfavorable prognosis, low complete remission rates and limited disease control following classical hairy cell leukemia-based regimens. In this study, we report 3 cases of elderly patients with treatment-naive, TP53 un-mutated HCLv, who were effectively treated with four cycles of bendamustine plus rituximab. The regimen was completed in all the patients with acceptable toxicity. All patients achieved a complete clinical response with no evidence of residual disease at bone marrow biopsy and flow-cytometry examination. After a median follow-up of 19 months, the 3 subjects are still in complete remission. In this work, bendamustine plus rituximab proved to be an effective and feasible first-line treatment strategy for elderly patients with TP53 un-mutated HCLv.

Performance criteria and quality indicators for the post-analytical phase.

BACKGROUND: Quality indicators (QIs) used as performance measurements are an effective tool in accurately estimating quality, identifying problems that may need to be addressed, and monitoring the processes over time. In Laboratory Medicine, QIs should cover all steps of the testing process, as error studies have confirmed that most errors occur in the pre- and post-analytical phase of testing. Aim of the present study is to provide preliminary results on QIs and related performance criteria in the post-analytical phase. METHODS: This work was conducted according to a previously described study design based on the voluntary participation of clinical laboratories in the project on QIs of the Working Group "Laboratory Errors and Patient Safety" (WG-LEPS) of the International Federation of Clinical Chemistry and Laboratory Medicine (IFCC). RESULTS: Overall, data collected highlighted an improvement or stability in performances over time for all reported indicators thus demonstrating that the use of QIs is effective in the quality improvement strategy. Moreover, QIs data are an important source for defining the state-of-the-art concerning the error rate in the total testing process. The definition of performance specifications based on the state-of-the-art, as suggested by consensus documents, is a valuable benchmark point in evaluating the performance of each laboratory. CONCLUSIONS: Laboratory tests play a relevant role in the monitoring and evaluation of the efficacy of patient outcome thus assisting clinicians in decision-making. Laboratory performance evaluation is therefore crucial to providing patients with safe, effective and efficient care.