National Kidney Foundation Laboratory Engagement Working Group Recommendations for Implementing the CKD-EPI 2021 Race-Free Equations for Estimated Glomerular Filtration Rate: Practical Guidance for Clinical Laboratories.

Recognizing that race is a social and not a biological construct, healthcare professionals and the public have called for removal of race in clinical algorithms. In response, the National Kidney Foundation and the American Society of Nephrology created the Task Force on Reassessing the Inclusion of Race in Diagnosing Kidney Diseases to examine the issue and provide recommendations. The final report from the Task Force recommends calculating estimated glomerular filtration rate (eGFR) without a race coefficient using the recently published CKD-EPI 2021 creatinine (cr) and creatinine-cystatin C (cr-cys) equations. The Task Force recommends immediately replacing older eGFRcr equations (MDRD Study and CKD-EPI 2009) with the new CKD-EPI 2021 equation. In a 2019 survey by the College of American Pathologists, 23% of 6200 laboratories reporting eGFRcr used an incorrect equation that is not suitable for use with standardized creatinine measurements, 34% used the CKD-EPI 2009 equation and 43% used the MDRD Study 2006 equation re-expressed for standardized creatinine measurement. Rapid transition to using the CKD-EPI 2021 equation is an opportunity for laboratories to standardize to a single equation to eliminate differences in eGFRcr due to different equations used by different laboratories, and to report eGFR without use of race. We provide guidance to laboratories for implementing the CKD-EPI 2021 equations for both eGFRcr and eGFRcr-cys.

The Veteran-Initiated Electronic Care Coordination: A Multisite Initiative to Promote and Evaluate Consumer-Mediated Health Information Exchange.

INTRODUCTION: Information continuity is critical to person-centered care when patients receive care from multiple healthcare systems. Patients can access their electronic health record data through patient portals to facilitate information exchange. This pilot was developed to improve care continuity for rural Veterans by (1) promoting the use of the Department of Veterans Affairs (VA) patient portal to share health information with non-VA providers, and (2) evaluating the impact of health information sharing at a community appointment. MATERIALS AND METHODS: Veterans from nine VA healthcare systems were trained to access and share their VA Continuity of Care Document (CCD) with their non-VA providers. Patients and non-VA providers completed surveys on their experiences. RESULTS: Participants (n = 620) were primarily older, white, and Vietnam era Veterans. After training, 78% reported the CCD would help them be more involved in their healthcare and 86% planned to share it regularly with non-VA providers. Veterans (n = 256) then attended 277 community appointments. Provider responses from these appointments (n = 133) indicated they were confident in the accuracy of the information (97%) and wanted to continue to receive the CCD (96%). Ninety percent of providers reported the CCD improved their ability to have an accurate medication list and helped them make medication treatment decisions. Fifty percent reported they did not order a laboratory test or another procedure because of information available in the CCD. CONCLUSIONS: This pilot demonstrates feasibility and value of patient access to a CCD to facilitate information sharing between VA and non-VA providers. Outreach and targeted education are needed to promote consumer-mediated health information exchange.

Unusual galactofuranose modification of a capsule polysaccharide in the pathogenic yeast Cryptococcus neoformans.

Galactofuranose (Galf) is the five-membered ring form of galactose. Although it is absent from mammalian glycans, it occurs as a structural and antigenic component of important cell surface molecules in a variety of microbes, ranging from bacteria to parasites and fungi. One such organism is Cryptococcus neoformans, a pathogenic yeast that causes lethal meningoencephalitis in immunocompromised individuals, particularly AIDS patients. C. neoformans is unique among fungal pathogens in bearing a complex polysaccharide capsule, a critical virulence factor reported to include Galf. Notably, how Galf modification contributes to the structure and function of the cryptococcal capsule is not known. We have determined that Galf is ß1,2-linked to an unusual tetrasubstituted galactopyranose of the glucuronoxylomannogalactan (GXMGal) capsule polysaccharide. This discovery fills a longstanding gap in our understanding of a major polymer of the cryptococcal capsule. We also engineered a C. neoformans strain that lacks UDP-galactopyranose mutase; this enzyme forms UDP-Galf, the nucleotide sugar donor required for Galf addition. Mutase activity was required for the incorporation of Galf into glucuronoxylomannogalactan but was dispensable for vegetative growth, cell integrity, and virulence in a mouse model.

Increasing colorectal cancer screening in an overdue population: participation and cost impacts of adding telephone calls to a FIT mailing program.

Many people who live in rural areas face distance barriers to colonoscopy. Our previous study demonstrated the utility of mailing fecal immunochemical tests (FIT) to average risk patients overdue for colorectal cancer (CRC screening). The aims of this study were to determine if introductory and reminder telephone calls would increase the proportion of returned FITs as well as to compare costs. Average risk patients overdue for CRC screening received a high intensity intervention (HII), which included an introductory telephone call to see if they were interested in taking a FIT prior to mailing the test out and reminder phone calls if the FIT was not returned. This HII group was compared to our previous low intensity intervention (LII) where a FIT was mailed to a similar group of veterans with no telephone contact. While a higher proportion of eligible respondents returned FITs in the LII (92 vs. 45 %), there was a much higher proportion of FITs returned out of those mailed in the HII (85 vs. 14 %). The fewer wasted FITs in the HII led to it having lower cost per FIT returned ($27.43 vs. $44.86). Given that either intervention is a feasible approach for patients overdue for CRC screening, health care providers should consider offering FITs using a home-based mailing program along with other evidence-based CRC screening options to average risk patients. Factors such as location, patient population, FIT cost and reimbursement, and personnel costs need to be considered when deciding the most effective way to implement FIT screening.

Quantitative cultures of bronchoscopically obtained specimens should be performed for optimal management of ventilator-associated pneumonia.

Ventilator-associated pneumonia (VAP) is a leading cause of health care-associated infection. It has a high rate of attributed mortality, and this mortality is increased in patients who do not receive appropriate empirical antimicrobial therapy. As a result of the overuse of broad-spectrum antimicrobials such as the carbapenems, strains of Acinetobacter, Enterobacteriaceae, and Pseudomonas aeruginosa susceptible only to polymyxins and tigecycline have emerged as important causes of VAP. The need to accurately diagnose VAP so that appropriate discontinuation or de-escalation of antimicrobial therapy can be initiated to reduce this antimicrobial pressure is essential. Practice guidelines for the diagnosis of VAP advocate the use of bronchoalveolar lavage (BAL) fluid obtained either bronchoscopically or by the use of a catheter passed through the endotracheal tube. The CDC recommends that quantitative cultures be performed on these specimens, using ≥ 10(4) CFU/ml to designate a positive culture (http://www.cdc.gov/nhsn/TOC_PSCManual.html, accessed 30 October 2012). However, there is no consensus in the clinical microbiology community as to whether these specimens should be cultured quantitatively, using the aforementioned designated bacterial cell count to designate infection, or by a semiquantitative approach. We have asked Vickie Baselski, University of Tennessee Health Science Center, who was the lead author on one of the seminal papers on quantitative BAL fluid culture, to explain why she believes that quantitative BAL fluid cultures are the optimal strategy for VAP diagnosis. We have Stacey Klutts, University of Iowa, to advocate the semiquantitative approach.

Analysis of promoter function in Aspergillus fumigatus.

The filamentous fungus Aspergillus fumigatus is an important opportunistic pathogen that can cause high mortality levels in susceptible patient populations. The increasing dependence on antifungal drugs to control A. fumigatus has led to the inevitable acquisition of drug-resistant forms of this pathogen. In other fungal pathogens, drug resistance is often associated with an increase in transcription of genes such as ATP-binding cassette (ABC) transporters that directly lead to tolerance to commonly employed antifungal drugs. In A. fumigatus, tolerance to azole drugs (the major class of antifungal) is often associated with changes in the sequence of the azole target enzyme as well as changes in the transcription level of this gene. The target gene for azole drugs in A. fumigatus is referred to as cyp51A. In order to dissect transcription of cyp51A transcription and other genes of interest, we constructed a set of firefly luciferase reporter genes designed for use in A. fumigatus. These reporter genes can either replicate autonomously or be targeted to the pyrG locus, generating an easily assayable uracil auxotrophy. We fused eight different A. fumigatus promoters to luciferase. Faithful behaviors of these reporter gene fusions compared to their chromosomal equivalents were evaluated by 5' rapid amplification of cDNA ends (RACE) and quantitative reverse transcription-PCR (qRT-PCR) analysis. We used this reporter gene system to study stress-regulated transcription of a Hsp70-encoding gene, map an important promoter element in the cyp51A gene, and correct an annotation error in the actin gene. We anticipate that this luciferase reporter gene system will be broadly applicable in analyses of gene expression in A. fumigatus.

Development and validation of a standardized blood culture contamination definition and metric dashboard for a large health care system.

OBJECTIVES: Blood culture contamination is a major problem in health care, with significant impacts on both patient safety and cost. Initiatives to reduce blood culture contamination require a reliable, consistent metric to track the success of interventions. The objective of our project was to establish a standardized definition of blood culture contamination suitable for use in a Veterans Health Administration (VHA) national data query, then to validate this definition and query. A secondary objective was to construct a national VHA data dashboard to display the data from this query that could be used in VHA quality improvement projects aimed at reducing blood culture contamination. METHODS: A VHA microbiology expert work group was formed to generate a standardized definition and oversee the validation studies. The standardized definition was used to generate data for calendar year 2021 using a Structured Query Language data query. Twelve VHA hospital microbiology laboratories compared the data from the query against their own locally derived contamination data and recorded those data in a data collection worksheet that all sites used. Data were collated and presented to the work group. RESULTS: More than 50,000 blood culture accessions were in the validation data set, with more than 1,200 contamination events. The overall blood culture contamination rate for the 12 facilities participating was 2.56% with local definitions and data and 2.43% with the standardized definitions and data query. The main differences noted between the 2 data sets were deemed to be issues in local definitions. The query and definition were then converted into a national data dashboard that all VHA facilities can now access. CONCLUSIONS: A standardized definition for blood culture contamination and a national data query were validated for enterprise-wide VHA use. To our knowledge, this represents the first reported standardized, validated, and automated approach for calculating and tracking blood culture contamination. This tool will be key in quality initiatives aimed at reducing contamination events in VHA.

Eliminating Algorithmic Racial Bias in Clinical Decision Support Algorithms: Use Cases from the Veterans Health Administration.

The Veterans Health Administration uses equity- and evidence-based principles to examine, correct, and eliminate use of potentially biased clinical equations and predictive models. We discuss the processes, successes, challenges, and next steps in four examples. We detail elimination of the race modifier for estimated kidney function and discuss steps to achieve more equitable pulmonary function testing measurement. We detail the use of equity lenses in two predictive clinical modeling tools: Stratification Tool for Opioid Risk Mitigation (STORM) and Care Assessment Need (CAN) predictive models. We conclude with consideration of ways to advance racial health equity in clinical decision support algorithms.

Increased carbapenemase testing following implementation of national VA guidelines for carbapenem-resistant Enterobacterales (CRE).

Objective: To describe national trends in testing and detection of carbapenemases produced by carbapenem-resistant Enterobacterales (CRE) and associate testing with culture and facility characteristics. Design: Retrospective cohort study. Setting: Department of Veterans' Affairs medical centers (VAMCs). Participants: Patients seen at VAMCs between 2013 and 2018 with cultures positive for CRE, defined by national VA guidelines. Interventions: Microbiology and clinical data were extracted from national VA data sets. Carbapenemase testing was summarized using descriptive statistics. Characteristics associated with carbapenemase testing were assessed with bivariate analyses. Results: Of 5,778 standard cultures that grew CRE, 1,905 (33.0%) had evidence of molecular or phenotypic carbapenemase testing and 1,603 (84.1%) of these had carbapenemases detected. Among these cultures confirmed as carbapenemase-producing CRE, 1,053 (65.7%) had molecular testing for ≥1 gene. Almost all testing included KPC (n = 1,047, 99.4%), with KPC detected in 914 of 1,047 (87.3%) cultures. Testing and detection of other enzymes was less frequent. Carbapenemase testing increased over the study period from 23.5% of CRE cultures in 2013 to 58.9% in 2018. The South US Census region (38.6%) and the Northeast (37.2%) region had the highest proportion of CRE cultures with carbapenemase testing. High complexity (vs low) and urban (vs rural) facilities were significantly associated with carbapenemase testing (P < .0001). Conclusions: Between 2013 and 2018, carbapenemase testing and detection increased in the VA, largely reflecting increased testing and detection of KPC. Surveillance of other carbapenemases is important due to global spread and increasing antibiotic resistance. Efforts supporting the expansion of carbapenemase testing to low-complexity, rural healthcare facilities and standardization of reporting of carbapenemase testing are needed.

VA-Wide, Multicenter Verification Study of the Cepheid Xpert SARS-CoV-2 Assay.

Early in the Severe Acute Respiratory Syndrome Coronavirus 2 pandemic, there was a progressive increase in diagnostic demands that developed within a relatively short period of time. On February 4, 2020, the Secretary of Health and Human Services issued the Emergency Use Authorization for in vitro diagnostics assays for the Severe Acute Respiratory Syndrome Coronavirus 2 virus. Subsequently, multiple assays were approved under the Emergency Use Authorization, including the Cepheid Xpert SARS-CoV-2 assay. Presented here is a description of the nationally coordinated verification study of the Cepheid assay that was performed within the Veteran's Affairs Health System. This coordinated study helped to expedite the verification process for a majority of the Veteran's Affairs system labs, preserved precious system resources, and highlighted the power of a national medical system in response to an emergency.

Case Report: Severe COVID-19 in a Kidney Transplant Recipient Without Humoral Response to SARS-CoV-2 mRNA Vaccine Series.

Supplemental Digital Content is available in the text.

A novel xylosylphosphotransferase activity discovered in Cryptococcus neoformans.

Cryptococcus neoformans is a fungal pathogen that causes serious disease in immunocompromised individuals. The organism produces a distinctive polysaccharide capsule that is necessary for its virulence, a predominantly polysaccharide cell wall, and a variety of protein- and lipid-linked glycans. The glycan synthetic pathways of this pathogen are of great interest. Here we report the detection of a novel glycosylphosphotransferase activity in C. neoformans, identification of the corresponding gene, and characterization of the encoded protein. The observed activity is specific for UDP-xylose as a donor and for mannose acceptors and forms a xylose-alpha-1-phosphate-6-mannose linkage. This is the first report of a xylosylphosphotransferase activity in any system.

Beta1,2-xylosyltransferase Cxt1p is solely responsible for xylose incorporation into Cryptococcus neoformans glycosphingolipids.

The Manalpha1,3(Xylbeta1,2)Manalpha structural motif is common to both capsular polysaccharides of Cryptococcus neoformans and to cryptococcal glycosphingolipids. Comparative analysis of glycosphingolipid structural profiles in wild-type and mutant strains showed that the Xylbeta1,2-transferase (Cxt1p) that participates in capsular polysaccharide biosynthesis is also the sole transferase responsible for adding xylose to C. neoformans glycosphingolipids.

Laboratory practices for identification and reporting of carbapenem-resistant Enterobacteriaceae in Department of Veterans Affairs facilities.

Laboratory identification of carbapenem-resistant Enterobacteriaceae (CRE) is a key step in controlling its spread. Our survey showed that most Veterans Affairs laboratories follow VA guidelines for initial CRE identification, whereas 55.0% use PCR to confirm carbapenemase production. Most respondents were knowledgeable about CRE guidelines. Barriers included staffing, training, and financial resources.

Diagnostic performance of a new automated heterophile antibody test in adults and children.

Epstein-Barr virus serologic profiles were obtained from 618 patients using an automated platform, including the new BioPlex heterophile assay. When compared with 2 IgM viral capsid antigen (VCA) assays and a predicate heterophile assay, the BioPlex heterophile assay was more likely to be associated with serologic patterns of acute infection.

Using Focused Laboratory Management and Quality Improvement Projects to Enhance Resident Training and Foster Scholarship.

Training in patient safety, quality, and management is widely recognized as an important element of graduate medical education. These concepts have been intertwined in pathology graduate medical education for many years, although training programs face challenges in creating explicit learning opportunities in these fields. Tangibly involving pathology residents in management and quality improvement projects has the potential to teach and reinforce key concepts and further fulfill Accreditation Council for Graduate Medical Education goals for pursuing projects related to patient safety and quality improvement. In this report, we present our experience at a pathology residency program (University of Iowa) in engaging pathology residents in projects related to practical issues of laboratory management, process improvement, and informatics. In this program, at least 1 management/quality improvement project, typically performed during a clinical chemistry/management rotation, was required and ideally resulted in a journal publication. The residency program also initiated a monthly management/informatics series for pathology externs, residents, and fellows that covers a wide range of topics. Since 2010, all pathology residents at the University of Iowa have completed at least 1 management/quality improvement project. Many of the projects involved aspects of laboratory test utilization, with some projects focused on other areas such as human resources, informatics, or process improvement. Since 2012, 31 peer-reviewed journal articles involving effort from 26 residents have been published. Multiple projects resulted in changes in ongoing practice, particularly within the hospital electronic health record. Focused management/quality improvement projects involving pathology residents can result in both meaningful quality improvement and scholarly output.

Patient Education for Consumer-Mediated HIE. A Pilot Randomized Controlled Trial of the Department of Veterans Affairs Blue Button.

OBJECTIVES: Consumer-mediated health information exchange (HIE) is one of the three types of HIE designated by the Office of the National Coordinator. HIE is intended to improve the quality of care while reducing cost, yet empirical support for this claim is mixed. Future research should identify the contexts whereby HIE is most effective. METHODS: This study was conducted as a pilot two-arm randomized controlled trial. In the intervention arm, 27 veterans were taught how to generate a Continuity of Care Document (CCD) within the Blue Button feature of their VA patient portal and were then asked to share it with their community non-VA provider. In the attention control condition, 25 Veterans were taught how to look up health information on the Internet. The impact of this training on the next non-VA medical visit was examined. RESULTS: Nineteen (90%) veterans in the intervention arm shared their CCD with their non-VA provider as compared with 2 (17%) in the attention control arm (p<0.001). Both veterans and non-VA providers indicated high satisfaction with the CCD. Comparison of medical records between the VA and non-VA providers did not indicate improved medication reconciliation (p=0.72). If veterans shared their CCD prior to their non-VA providers ordering laboratory tests, the number of duplicate laboratories was significantly reduced (p=0.02). CONCLUSIONS: In this pilot randomized controlled trial, training 52 veterans to share their CCD was feasible and accepted by both patients and providers. Sharing this document appeared to reduce duplicate laboratory draws, but did not have an impact on documented medication list concordance.

Identification and deletion of Tft1, a predicted glycosyltransferase necessary for cell wall ß-1,3;1,4-glucan synthesis in Aspergillus fumigatus.

Aspergillus fumigatus is an environmental mold that causes severe, often fatal invasive infections in immunocompromised patients. The search for new antifungal drug targets is critical, and the synthesis of the cell wall represents a potential area to find such a target. Embedded within the main ß-1,3-glucan core of the A. fumigatus cell wall is a mixed linkage, ß-D-(1,3;1,4)-glucan. The role of this molecule or how it is synthesized is unknown, though it comprises 10% of the glucans within the wall. While this is not a well-studied molecule in fungi, it has been studied in plants. Using the sequences of two plant mixed linkage glucan synthases, a single ortholog was identified in A. fumigatus (Tft1). A strain lacking this enzyme (tft1Δ) was generated along with revertant strains containing the native gene under the control of either the native or a strongly expressing promoter. Immunofluorescence staining with an antibody against ß-(1,3;1,4)-glucan and biochemical quantification of this polysaccharide in the tft1Δ strain demonstrated complete loss of this molecule. Reintroduction of the gene into the knockout strain yielded reappearance in amounts that correlated with expected expression of the gene. The loss of Tft1 and mixed linkage glucan yielded no in vitro growth phenotype. However, there was a modest increase in virulence for the tft1Δ strain in a wax worm model. While the precise roles for ß-(1,3;1,4)-glucan within A. fumigatus cell wall are still uncertain, it is clear that Tft1 plays a pivotal role in the biosynthesis of this cell wall polysaccharide.