Mass spectrometry based analytical quality assessment of serum and plasma specimens with patterns of endo- and exogenous peptides.

Background Inappropriate preanalytical sample handling is a major threat for any biomarker discovery approach. Blood specimens have a genuine proteolytic activity that leads to a time dependent decay of peptidic quality control markers (QCMs). The aim of this study was to identify QCMs for direct assessment of sample quality (DASQ) of serum and plasma specimens. Methods Serum and plasma specimens of healthy volunteers and tumor patients were spiked with two synthetic reporter peptides (exogenous QCMs) and aged under controlled conditions for up to 24 h. The proteolytic fragments of endogenous and exogenous QCMs were monitored for each time point by mass spectrometry (MS). The decay pattern of peptides was used for supervised classification of samples according to their respective preanalytical quality. Results The classification accuracy for fresh specimens (1 h) was 96% and 99% for serum and plasma specimens, respectively, when endo- and exogenous QCMs were used for the calculations. However, classification of older specimens was more difficult and overall classification accuracy decreased to 79%. Conclusions MALDI-TOF MS is a simple and robust method that can be used for DASQ of serum and plasma specimens in a high throughput manner. We propose DASQ as a fast and simple step that can be included in multicentric large-scale projects to ensure the homogeneity of sample quality.

Improved prospective risk analysis for clinical laboratories compensated for the throughput in processes.

BACKGROUND: Practical application of prospective risk analysis (PRA) in clinical laboratories should reflect processes as they are carried out, while making the PRA results obtained from different processes comparable. This means that not only STAT and standard testing and testing for critical and less critical parameters should be distinguished (as published), but also that the throughput in processes and process steps should be taken into account. METHODS: Building on our previously published PRA, a method was developed to compensate for the throughput in processes and process steps. A factor T, related to the actually observed throughput, was introduced in the risk score calculation. Introduction of this compensation factor leads to different overall risk scores. The criteria by which the risk scores are evaluated were modified accordingly. RESULTS: Introduction of a factor in the PRA to compensate for throughput leads to a change in the risk score for various conceivable failures in process steps. As compared to the PRA in which no compensation for throughput is made, in a process with low throughput the risk score for various conceivable failures in process steps comes out higher after introduction of the compensation factor, while in a process with high throughput various risk scores come out lower. CONCLUSIONS: Introduction of a factor to account for the throughput in a process (and process steps) leads to an improved, more realistic PRA, the results of which makes the risk scores of different processes (and process steps) better comparable to each other.

Wrong Blood in Tube.

The following fictional case is intended as a learning tool within the Pathology Competencies for Medical Education (PCME), a set of national standards for teaching pathology. These are divided into three basic competencies: Disease Mechanisms and Processes, Organ System Pathology, and Diagnostic Medicine and Therapeutic Pathology. For additional information, and a full list of learning objectives for all three competencies, see http://journals.sagepub.com/doi/10.1177/2374289517715040.

Effect of prewarming EDTA blood samples to 37°C on platelet count measured by Sysmex XT-2000iV in dogs, cats, and horses.

BACKGROUND: Pseudothrombocytopenia secondary to platelet clumping is a common cause of preanalytic error for platelet counts in dogs, cats, and horses. In human beings, it is suggested that prewarming blood samples to 37°C prior to hematology analysis will reduce platelet clumping. OBJECTIVES: The purpose of the study was to evaluate the effect of prewarming EDTA blood samples to 37°C on measured platelet counts and other hematologic variables. METHODS: The EDTA blood samples from dogs, cats and horses submitted to the clinical pathology laboratory at the University of Cambridge were included. Complete blood cell counts performed using a Sysmex XT-2000iV hematology analyzer were done on samples at room temperature (approximately 22°C) and following warming of the samples to 37°C in a water bath. The Wilcoxon signed rank test was used to compare hematologic variables, including platelet count, before and after sample warming to 37°C. Data are presented as median (25(th) , 75(th) percentile) increase. RESULTS: Blood samples from 39 dogs, 19 cats, and 10 horses were included. Sample warming to 37°C resulted in a statistically significant increase in platelet counts in dogs (11 [-2, 30] ×10(9) /L), cats (36 [14, 84] ×10(9) /L), and horses (42 [31, 79] ×10(9) /L). Sample warming did not significantly affect other hematologic variables. CONCLUSIONS: Prewarming EDTA blood samples to 37°C prior to hematologic analysis increased platelet counts overall in canine, feline, and equine blood, but did not abrogate platelet clumping and pseudothrombocytopenia fully in some cases. Furthermore, true pseudothrombocytopenia was not confirmed in these animals.

Pre-Test and Post-Test Applications to Shape the Education of Phlebotomists in A Quality Management Program: An Experience in a Training Hospital.

BACKGROUND: After the introduction of modern laboratory instruments and information systems, preanalytic phase is the new field of battle. Errors in preanalytical phase account for approximately half of total errors in clinical laboratory. The objective of this study was to share an experience of an education program that was believed to be successful in decreasing the number of rejected samples received from the Emergency Department (ED). METHODS: An education program about laboratory procedures, quality requirements in the laboratory, patient and health-care worker safety was planned by the quality team to be performed on 36 people who were responsible for sample collection in the ED. A questionary which included 11 questions about the preanalytic phase was applied to all the attendees before and after training. The number of rejected samples per million was discovered with right proportion account over the number of accepted and rejected samples to laboratory after and before the training period. RESULTS: Most of the attendees were nurses (n: 22/55%), with over 12 years of experience in general and 2-4 years experience in the ED. Knowledge level of the attendees was calculated before training as 58.9% and after training as 91.8%. While the total rate of sample rejection before training was 2.35% (sigma value 3.37-3.50), the rate after training was 1.56% (sigma value 3.62-3.75). CONCLUSIONS: Increasing the knowledge of staff has a direct positive impact on the preanalytic phase. The application of a pre-test was observed to be a feasible tool to shape group specific education programs.

Validation of hemolysis index thresholds optimizes detection of clinically significant hemolysis.

OBJECTIVES: Automated hemolysis index (HI) measurement has standardized the identification and gradation of sample hemolysis. METHODS: This study evaluates whether clinically significant changes in the concentration of intracellular analytes occur at manufacturer-recommended automated HI thresholds (HI ≥3, >25 mg/dL hemoglobin). RESULTS: Adult outpatient results for serum potassium (K+), magnesium (Mg), lactate dehydrogenase (LDH), and aspartate aminotransferase (AST) were analyzed. Mean ± SD analyte concentration and distribution within the reference interval (RI) were calculated for each HI group (1-7). Potassium results with an HI of 4 or more demonstrated clinically significant differences (≥0.5 mmol/L) in mean K+ concentration and RI classification compared with non-hemolyzed samples (HI = 1). LDH and AST showed clinically significant differences (+20%) for an HI of 3 or more. For Mg, only the group with an HI of 7 demonstrated a clinically significant difference (>25%); however, the number was low. CONCLUSIONS: Mean measured potassium concentrations are not clinically significantly affected by hemolysis at the manufacturer-recommended HI threshold, while AST and LDH are. Aligning reporting of sample hemolysis with clinically significant changes provides clinically meaningful alerts regarding this common pre-analytic error.

Reducing error in feline platelet enumeration by addition of Iloprost to blood specimens: comparison to prostaglandin E1 and EDTA.

BACKGROUND: Prostaglandin E1 (PGE1) and Iloprost inhibit platelet aggregation and should prevent or minimize preanalytic error with feline platelet enumeration. OBJECTIVES: The objective was to compare the relative effectiveness in reducing errors in platelet enumeration by adding Iloprost to feline EDTA blood specimens in comparison to adding PGE1 or EDTA alone. In addition, a grading system for platelet aggregation in blood smears was evaluated for effectiveness in predicting prominent errors and compared to ADVIA's PLT-CLM flag. Finally, the use of plateletcrit in feline blood with platelet aggregation was evaluated. METHODS: Blood specimens from 35 cats were included. Blood was collected into EDTA tubes with or without Iloprost or PGE1, and was rapidly mixed. Platelet count (PLT), plateletcrit (PCT), mean platelet volume (MPV), and platelet flags were determined with an ADVIA 2120. Manual PLT was performed with a Leucoplate stain. PLT was determined by an IDEXX VetAutoread hematology analyzer (QBC). RESULTS: Neither addition of Iloprost nor PGE1 to EDTA blood specimens completely prevented platelet aggregation. Iloprost-treated specimens had the least severe aggregation. PGE1 was better than EDTA alone. Significant errors in PLT results were consistently identified by the grading system. ADVIA's PLT-CL flag usually predicted significant errors in PLT. QBC PLT results showed high imprecision. Manual PLT error was smaller than ADVIA PLT in EDTA specimens with aggregation. CONCLUSIONS: Adding Iloprost to feline blood specimens improved platelet enumeration accuracy. A grading system for severity of platelet aggregation and usually the ADVIA's PLT-CL alarm predicted specimens with significant errors in platelet enumeration.