Integrated network of the ECMU (physical, chemical and morphological urine examination) of the Azienda USL Toscana Sud Est

INTRODUCTION Following the Sars-Cov2 pandemic of the last 2 years, telemedicine has become fundamental for the territorial assistance of patients and the consultation of professionals among them to carry out assistance services in a very complex territory such as that of the Azienda USL Toscana Sud Est (TSE). Currently, the middleware, on the network, allows for the integration of all data from the physical, chemical and morphological urine examination (ECMU), allowing the transmission of data and images between computer-connected laboratories. This work illustrates the organizational architecture of an analytical integration network managed in telemedicine and teleconsulting applied to the ECMU and consisting of all the laboratories of the Azienda TSE. MATERIALS AND METHODS The integrated network of the ECMU includes the territorial laboratories of the Azienda TSE, such as the hub centers of Arezzo, Grosseto, Nottola and Campostaggia with the spoke centers of Cortona, Bibbiena, Sansepolcro, Valdarno, Massa Marittima, Orbetello, Pitigliano, Abbadia San Salvatore , Castel del Piano. The instrumentation used by the laboratories is Aution Max 4030 (Menarini) and Pochet Chem UA for the chemical-physical examination, Sedimax Contrust (Menarini) and the Director Web (Menarini) management software. RESULTS The integrated network of the ECMU consists of all the Azienda TSE laboratories, which are connected to each other electronically through the middleware Director Web, which allows the sharing of rules, chemical-physical analysis data and images of the urinary sediment. Through the Director Web management software it is possible, in fact, for hub laboratories not only to consult and validate the ECMU carried out by the spoke centers in the area, but to receive and give "second opinion" advice between the network laboratories. CONCLUSIONS The use of the same analytical systems and the middleware system common throughout the Azienda TSE allows to obtain harmonized and standardized results throughout the territory with shared criteria in the integrated network of the ECMU, in fact, the collaboration of specialists is indirectly promoted with time much faster diagnosis and a less rigid and leaner organization of work, uniform throughout the territory.

Case report of Candida parapsilosis sepsis detected in peripheral blood smear

Introduction During long periods of hospitalization, debilitated and immunosuppressed patients are prone to contracting nosocomial fungal infections, such as Candida parapsilosis, which can cause sepsis. Candida parapsilosis, indeed, is able to form firm and persistent biofilms in central venous catheters (CVC) in addition to other medical devices, thus threatening patients undergoing invasive medical procedures [1]. We report a case of Candida parapsilosis sepsis detected in the peripheral blood smear and by the change of the cytograms of the hematology analyzer before to blood culture positivization. Case presentation An 89-year-old woman, positive for the Sars-Cov2 virus, was admitted at the San Donato hospital (Arezzo) for 40 days for Covid symptoms. Laboratory tests show an increase in C reactive protein (10.6 mg/dL), gamma GT (76 U/L), total bilirubin (2.31 mg/dL) and direct (1.46 mg/ dL), creatinine (1.00 mg/dL ) and reduction of glomerular filtrate (50.4 mL/min /1.73 mq). In addition, at the CBC anemia is detected with hemoglobin of 102 (g/L) and thrombocytopenia (32 x 10

Implementation of a Poct (Point-Ofcare) System for the Detection of the Antigen of the Sars-Cov2 Virus in Emergency Department and for the Prehospitalization of the Hospitals of the Company Usl Toscana Sud Est

Introduction Following the release of the regional circulars recommending the execution of antigen tests for the diagnosis of Sars-Cov2 infection for all patients entering the emergency Department and in case of pre-hospitalization, it was decided to implement a system of POCT (Point-Of-Care) instruments in hospitals throughout the South-East USL area. Materials and methods The managers of the POCT network have provided each hospital with third generation tests capable of guaranteeing a sensitivity of over 95% and a specificity of 100%.The necessary skills for the staff were then determined and training sessions were planned to cover all the staff concerned thanks to the involvement of the specialized staff of the supplier company and the previously trained laboratory staff.Following the training of over 300 operators, its effectiveness was verified through online self-assessment questionnaires and each user was enabled to use the tool with their own identification. The insertion of the identification code for the individual operators, it was possible to monitor the correct performance of the pre-analytical procedures and to implement any corrective measures where necessary. Results All this has ensured, in addition to an optimal collaboration between the laboratory, the supplier company and the emergency room, a high level of data security related to a very low rate of invalid or discordant results. This resulted in a considerable time and cost saving when compared with the need to carry out repeated tests or confirmations with molecular tests. Conclusions This organization has allowed not only a supply of tests with superior performances, but to have a complete traceability of the results following the connection of the instruments to the systems of the hospitals and in the ability to apply the criteria necessary for an aware training of the operators, in accordance with what is reported in the ISO 9001/2015 standard.

The Lean methodology applied to risk assessment in the Blood Gas Analysis process

INTRODUCTION The BGA (Blood Gas Analysis) is a bedside testing that ensure results in a short time, usually performed in Emergency-Urgency for time-dependent clinical condition. Lean Thinking for 'KAIZEN' or rather, continuous improvement in services provision increasing the value perceived by the user reducing of waste. The aim of the present analysis has been to assess, applying Lean methods, the likelihood of risk in the BGA testing, related to the increase in their use during the COVID19 pandemic. MATERIALS AND METHODS To carry out the risk assessment, the context was studied through the use of distribution maps of the BGA analyzers in the Covid19 and non-Covid19 wards of the San Donato Hospital in Arezzo. Data was collected on the entire BGA process: activities, hours of greatest use, instrumental stops and maintenance, in the year 2020. The spaghetti chart, Lean mapping method, was used to calculate the distances between the instruments (used and backup) and patient beds. In addition, Lean methods were used: the Hishikawa Diagram with the cause-effect matrix, the HFMECA, the Swot, the monitoring indicators of the entire process and the A3 report. RESULTS The analysis carried out using the Lean methodology has shown that the entire ABG process is well governed within the wards. However, there remain the risks associated with the new staff employed and their training on the which much of the implementation plan was focused. The risk is mainly linked to the high turnover, to the reorganization of human resources that had to be used to deal the pandemic. CONCLUSIONS For optimal governance of BGA analyzers and reduce the risk in entire process, it is essential to maintain adequate and continuous training of personnel.

HCV (Genotype) distribution in the area of Arezzo: Epidemiological data in the eradication strategy

INTRODUCTION Infection with hepatitis C virus (HCV) is a major cause of chronic liver disease worldwide. HCV is enveloped, small circular, positive-sense and single stranded ribonucleic acid (RNA) virus from genus Hepacivirus, family Flaviviridae. The ability of the HCV to mutate has resulted in the existence seven main genotypes (1-7) with multiple subtypes. Genotyping is most significant for planning of HCV treatment and helps to cure HCV infection. The Tuscany region has declared its intention to proceed with the eradication of the Hepatitis C virus in the population. The aim of this retrospective study is to investigate the incidence of HCV in a population screened in the area of Arezzo from 2016-2020. Furthermore, genotype distribution in those subjects positive for screening was studied. MATERIALS AND METHODS The subjects included in the study 5012(31.3%) were positive for HCV-RNA quantification, so they were enrolled for viral genotyping. Blood sample collected in BD Vacutainer® PPT™ Plasma Preparation Tube were used to perform the viral load quantification of the HCV and for genotyping analyses. RESULTS In the patients examined from 2016 to 2020 years we have been note a reduction in positive cases of HCV: 1250(35.4%) in 2016 respect 521(25.4%) in 2020. Among the patients examined from 2016 to 2020 years have been seen a major incidence for genotype 1(55.8%), comparable fraction for type 2(19.2%) and 3(19.1%) and lower incidence for genotype 4(0.05%). The distribution of the HCV genotypes in the years showed that genotype 1a reach the peak of incidence in the 2018 year, while the trend of 1b genotype was almost constant in the period 2016-2020. The genotype 2a/2c reach a peak in the years 2018 and 2019, the genotype 3a were observed an increase in the 2017, then a reduction. The genotype 4 was constant in the years. Conclusion The data from the present study seem to suggest that there has been a slight change in the epidemiology of HCV genotypes in the Arezzo, although the genotype 1b remain the most prevalent in Italy, the genotype 3a in surprisingly increased in the area of Arezzo. This study show a reduction of positive cases during the years, as a result of the Tuscany's new eradication strategy, despite the reduced requests during covid emergency.

MDW (Monocyte Distribution Width): Between sepsis and Covid-19

Introduction As part of the ' Lotta alla sepsi -Call to Action' project of the ARS (Regional Health Agency) of Tuscany, a study was undertaken on sepsis which had the aim of evaluating the biomarker MDW (Monocyte distribution width) of all enrolled patients of the PS with suspected sepsis. MDW is a hematological parameter that measures the dispersion around the mean of the monocyte volume population and has been proposed as an early indicator of sepsis. Given the timeliness and ease of measurement with complete blood count (CBC), MDW can quickly help the clinician in risk stratification. Patients who tested positive for Covid-19 were also enrolled during the study. This contribution reports on how the MDW biomarker behaves in patients with similar presentation who may progress to sepsis or Covid-19. Materials and methods For the study, 397 patients (178 F + 219 M) aged between 18 and 98 years (mean 62.6 SD ± 21.7) were enrolled by the Emergency Department of the San Donato Hospital in Arezzo between 5 July 2019 and 30 April 2020 with suspected sepsis. Of these, 133 tested positive and 264 negative for the nasopharyngeal molecular swab for SARS-CoV-2. Diagnostic stratification for sepsis was performed according to the definition of Sepsis-3. Complete blood count (CBC), which includes MDW, was performed on the UniCel DxH 900 analyzer (Beckman Coulter) using whole blood collected in tubes with K2 EDTA anticoagulant. Data analysis was performed by IBM SPSS statistics version 20.0 (SPSS, Chicago, IL). Results For Covid-19 patients, MDW AUC is 0.85 (95% CI 0.80-0.90) and PCT (procalcitonin) AUC is 0.81 (95% CI 0.75-0.87). The PCT at the cutoff of 0.5 ng / mL had a sensitivity of 13% and specificity of 92%, while the MDW at the cutoff of 22 had a sensitivity of 86% and specificity of 74%. In patients with sepsis MDW AUC is 0.83 (95% CI 0.76-0.90) and PCT AUC is 0.84 (95% CI 0.78-0.91). The PCT at the cutoff of 0.5 ng / mL showed a sensitivity of 66% and specificity of 82%, while the MDW at the cutoff of 22 had a sensitivity and specificity of 90% and 55% respectively. Conclusion In both sepsis and Covid-19 infection, the two parameters convey different information and have complete effectiveness in terms of sensitivity and specificity.