bluuebunny/crossref_metadata_2025 huggingface dataset:
Exploring TFE3-Rearranged Renal Cell Carcinoma: A Case Study showing minimal expression of PAX-8
Authors: Rivera Sustache J M , Bhalla R
Published: October 2024

Introduction/Objective

TFE3-rearranged renal cell carcinoma accounts for 1.6-4% of adult renal cell carcinomas (RCC). The histological characteristics of this entity can mimic many other renal cell neoplasms and definite diagnosis is based on immunohistochemical (IHC) and fluorescent in situ hybridization (FISH) analysis. Nonspecific IHC findings can lead to diagnostic challenges delaying confirmatory studies and underdiagnosis.

Methods/Case Report

A 28-year-old male with sickle cell disease and a right kidney multilocular cystic mass incidentally found during evaluation of splenomegaly underwent partial nephrectomy. The tumor showed papillary, alveolar and sheet-like growth patterns composed of eosinophilic to clear cells with pleomorphic nuclei, including multinucleate forms. Initial ancillary studies showed minimal neoplastic expression (less than 5%) of PAX-8. Repeat PAX-8 yielded similar results and laboratory controls were evaluated successfully. A full work-up showed positivity of AMACR (diffuse), CD10 (diffuse), Cathepsin K (patchy), CK7 (focal), CAIX (focal), and no significant expression of pancytokeratin, HMB-45, Melan-A and SMA. Fumarate hydratase was retained, and the tumor showed a non-specific staining pattern of S (2-succinyl)-cysteine. Controls were appropriate. A high suspicion for a TFE-rearranged RCC was maintained, and a final diagnosis was confirmed with FISH analysis demonstrating a TFE3 (Xp11.23) rearrangement.

Results (if a Case Study enter NA)

NA

Conclusion

Reports in the literature detail diffuse PAX-8 expression in TFE3-rearranged RCC. A high index of suspicion based on morphology in our case prompted FISH analysis leading to correct diagnosis. This case highlights the inconsistencies in the reported IHC profile of this entity. More studies are required to elaborate the presentations of this RCC subtype with numerous histologic mimics including the spectrum of immunostaining patterns to better assist patient care for this uncommon variant.
Case-Based Training on Best Practices in Effective Test Utilization for Clinical Laboratories: A Comparison of Two Educational Formats
Authors: Kelly M , Basu D , Engel M , Landgraf K
Published: October 2024

Introduction/Objective

While a survey of ASCP membership showed improvements being made in effective test utilization (ETU), there is an ongoing need for formal education on best practices. Case-based education drawn from real-world scenarios provides an opportunity to address this need, aimed at increasing the understanding of evidence- based guidelines to inform clinical test ordering and reduce overconsumption of supplies without compromising patient care. The poster presents two examples of case-based education presented in an innovative microlearning format and an eLearning format designed for clinical laboratory professionals.

Methods/Case Report

The activities presented 9 - 10 practical, real-world scenarios as educational cases along with assessment questions addressing a range of topics that included ETU for pancreatitis and cardiac injury, blood collection tube consumption and conservation, strategies for reducing repeat daily lab test ordering, and others. Each case was designed for learners to be able to review the content and answer the assessment questions in 5 minutes. In the microlearning activity, learners received the cases and questions via email on a scheduled frequency and completed them via mobile device. The questions were repeated up to 2 times to reinforce learning. Participants in the eLearning activity accessed the same cases and assessment questions via a different learning platform (with no staggered delivery).

Results (if a Case Study enter NA)

More than 2,500 learners have participated in one or both ETU activities, and feedback has been highly positive. The assessment results show proficiency gains for a range of laboratory personnel, including laboratory managers/supervisors, histotechnologists, medical laboratory scientists, laboratory technicians, pathologists, and other laboratory roles.

Conclusion

The results also show how case-based scenarios can help promote best practices in ETU, which may be particularly beneficial for laboratory decision-makers. In addition to showing increased understanding of ETU strategies, the results also pose lessons learned for designing similar types of case-based education.
Assessing the Effect of Changing the Average Hematocrit in Red Blood Cell (RBC) Units on the Post- Procedure Hematocrits of Patients Undergoing Erythrocytapheresis
Authors: Musante K L , Roome L , Yurtsever N , Rinder H , Tormey C , Lee E S
Published: October 2024

Introduction/Objective

Red cell exchange (RCE) is utilized as a therapeutic or prophylactic procedure for patients with sickle cell disease (SCD). When performing RCE, three hematocrits (Hct) are taken into account: pre-procedure and goal Hct for the patient and average Hct (avg-Hct) of the transfused RBC units. Although there is no definitive community consensus, many transfusion services employ RBC unit avg-Hct of 55% per available guidance. Our center anecdotally observed that utilizing RBC unit avg-Hct of 55% often resulted in post-procedure patient Hcts higher than intended goal Hct, potentially causing hyperviscosity. This study aims to examine the effect of changing the avg-Hct from 55% to 60% on the accuracy of post-procedure HCTs, with the 60% avg-Hct employed based on prior quality studies of RBC units at our facility.

Methods/Case Report

We performed a retrospective chart review for SCD patients receiving chronic, prophylactic RCE at a large academic hospital, collecting the following for each procedure: goal procedure Hct, number of RBC units exchanged, avg-Hct used, and pre-/post-procedure patient Hcts. Differences between goal Hcts and post- procedure Hcts for each procedure in the avg-Hct=55% and avg-Hct=60% groups were calculated. Next, mean calculated differences for both groups were compared using a two-sample t-test (P<0.05 was considered significant).

Results (if a Case Study enter NA)

From 1/2023–2/2024, 293 prophylactic RCEs were performed for SCD patients. Median number of RBC units per procedure was 7, with 51% of procedures (n=149) employing unit avg-Hct=55%, while 49% of procedures (n=144) used a unit avg-Hct=60%. Post-procedure patient Hct and goal Hct differences were statistically different according to unit avg-Hct values utilized (mean difference=1.31% for avg-Hct=55% vs mean difference=0.52% for avg-Hct=60%; P<0.0001).

Conclusion

Changing our protocol to use RBC unit avg-Hct=60% resulted in post-procedure patient Hcts significantly closer to intended goals. Utilization of a more accurate average-Hct value has a substantial impact on post-procedure Hct in RCEs and may limit adverse events.
Transfusion reaction patterns by blood component
Authors: Yune S , O’Brien K
Published: October 2024

Introduction/Objective

Blood transfusion is becoming safer by continuous improvement of donor screening, patient identification, blood management, and infectious disease screening. This study was conducted to examine the rate and characteristics of transfusion reactions in the setting of universal leukoreduction of cellular products as well as pathogen reduction and/or irradiation of apheresis platelets.

Methods/Case Report

Data from the blood bank database for a 5-year period from 1/1/2019 to 12/31/2023 was collected. Transfusion reaction data as reported to National Healthcare Safety Network (NHSN) was analyzed.

Results (if a Case Study enter NA)

A total of 134,552 transfusions and 491 transfusion reactions were reported over the study period, resulting in the overall transfusion reaction rate of 0.36%. Allergic reaction was the most common reaction (38%), followed by febrile non-hemolytic transfusion reaction (FNHTR, 30%), delayed serologic transfusion reaction (DSTR, 14%), transfusion-associated circulatory overload (TACO, 10%), and transfusion-associated dyspnea (TAD, 4%).

Platelets had the highest rate of transfusion reaction at 0.61% (n=167 of 27,180), red blood cells (RBC) at 0.35% (n=289 of 82,963), plasma at 0.13% (n=24 of 19,114), and cryoprecipitate at 0.06% (n=3 of 5295). The most common reaction associated with platelet transfusion was allergic reaction (64%, n=107), while FNHTR was the most common reaction associated with RBC transfusion (37%, n=106).

By severity, 9 (2%) reactions were life-threatening, 21 (4%) were severe, 374 (75%) were non-severe, and 87 (18%) were not determined. Of life-threatening reactions, allergic reactions were the most common (5 of 9), while TACO was the most common severe reaction (9 of 21). Platelets were the most commonly implicated component in life- threatening reactions (4 allergic and 2 TACO), and RBCs were more commonly implicated in severe reactions.

Conclusion

Platelet transfusions were associated with a higher rate of transfusion reactions and life-threatening allergic reactions compared to other blood components.
Neonatal Alloimmune Thrombocytopenia with HLA and HPA-3a Antibodies in a Down Syndrome Neonate
Authors: Yakut E , Talabong D , Gabutan E , Ahmadi M , Kang S
Published: October 2024

Introduction/Objective

Neonatal Alloimmune Thrombocytopenia (NAIT) is a rare cause of thrombocytopenia seen in 1 in 11,000 neonates with lethal risks such as intracranial hemorrhage. This is caused by maternal antibodies against fetal platelets and the most common culprits are antibodies to Human Platelet Antigen-1b (HPA-1b) but rarely to Human Leukocyte Antigen (HLA) antibodies. We describe a rare case of a newborn with Down syndrome with maternal antibodies against HLA and presumed antibodies against HPA-3a. Down syndrome causes hematologic abnormalities with mild thrombocytopenia.

Methods/Case Report

A preterm male with Down syndrome was born via Cesarean delivery due to non-reassuring fetal heart tracing at a gestational age of 35 weeks. He was admitted for low birth weight and his hospital course was complicated by severe thrombocytopenia of 37 x 10^9/L without bleeding symptoms. Initially attributed to his trisomy 21 but due to his suboptimal response to platelet transfusion, NAIT was suspected. The mother had antibodies against HLA on initial screen and was presumed to have HPA-3a antibodies since she was homozygous for HPA-3b antigen. The neonate was managed with multiple transfusions of platelets and Intravenous Immunoglobulin (IVIG).

The platelet count stabilized to 325 x 10^9/L on his 25th day of life.

Results (if a Case Study enter NA)

n/a

Conclusion

To our knowledge, this is the only published case of NAIT with both HPA-3a and HLA antibodies in a Down syndrome neonate. It is unclear whether the primary reason for thrombocytopenia is due to NAIT caused by HPA-3a antibodies or HLA antibodies or his existing Down syndrome. This case contributes to understanding the complexity between immune-related diseases such as NAIT and genetic conditions such as Down syndrome.

Although NAIT occurs rarely, timely diagnosis and treatment is of utmost importance to prevent lethal complications.
Where did my O units go? Assessing a Month of O RBC Utilization in a Level 1 Trauma Center
Authors: Haque A , Agaronov M , Talabong D , NGICHABE J , Yakut E , Rana-Gupta T , Gabutan E , Kang S
Published: October 2024

Introduction/Objective

The availability of red blood cells (RBCs) can be unpredictable and influenced by various factors affecting inventory levels. Anticipating future requirements can prove difficult, particularly in medical facilities catering to both trauma and chronically ill patients. By analyzing the fluctuation in blood indications, we can improve our planning and promote the responsible use of O RBCs.

Methods/Case Report

O units transfused in December 2023 in a level 1 trauma center were reviewed for transfusion indication, which was categorized into symptomatic anemia (SA), bleeding, sickle cell-related transfusion (SCRT), and surgery-related transfusion (SRT).

Results (if a Case Study enter NA)

During this month, our institution transfused 320 O units, of which 79% (254/320) were D positive. Most RBCs were given to patients with bleeding (43%,136/320) and SA (36%, 115/320). About half of the units used for acutely bleeding patients had massive transfusion protocol (MTP) activated (48%, 51/105), with 2/3 of those units used for trauma patients. Because most of our patients are African Americans, SCRT was also evaluated. Only 17/320(5%) of the units were given to our sickle cell disease patients. Lastly, we evaluated SRT because of our busy surgical service. We noted that 46 (14%) are SRT units, with 20% used prophylactically on the same admission and 50% used post-operatively.

Conclusion

It’s important to note that while patients with acute bleeding can cause a sudden depletion in the blood supply, patients with chronic anemia and bleeding can still make up a significant portion of those who require RBCs in a level 1 trauma hospital. In such a setting, where cases requiring MTP can be unpredictable, managing inventory levels can be challenging, and it requires careful monitoring to ensure that the appropriate blood units are used.
Validating a Pneumatic Tube System for Blood Product Delivery
Authors: CHAUDHARY R , Maheshwari T , Kyle P , Johnston S E
Published: October 2024

Introduction/Objective

Timely delivery of blood products can be of utmost importance to providing quality care. We aimed to validate the use of a high-speed pneumatic tube system (PTS) that was already installed at our hospital. By reducing delivery times, patient resuscitation and survivability can be increased.

Methods/Case Report

We followed the Association for the Advancement of Blood & Biotherapies (AABB) guidelines to validate a PTS in a large tertiary academic medical center. The requirements include: verifying product suitability, ensuring product integrity, temperature monitoring, transportation time measurements, and proper packaging and tracking of product receipt. We validated the transfer of packed red blood cells (PRBC), plasma, platelets, and cryoprecipitate from the central blood transfusion services lab (BTS) to nursing stations in a separate building up to 1500 feet (>1/4 mile) away using a Swisslog Translogic® PTS Inclusion with foam inside the PTS carriers helped reduce bumps during transit and insulated products from heat.

Results (if a Case Study enter NA)

The mean temperature of the PRBC was 6.6 degrees Celsius and none exceeded the AABB maximum of 10 degrees Celsius. The mean time for blood products transit to the nursing stations was 3 minutes (m) and 33 seconds (s). The median time was 3m 31s, and it ranged from 2m 18s to 5m 38s. The PTS reduced delivery times of blood products by up to 10-12 minutes compared to manual porters.

Conclusion

Transporting blood products via PTS is an efficient method that reduces the required manpower and leads to better utilization of resources. However, it is essential to validate the PTS system before implementing it operationally.
Molecular testing in a patient with multiple alloantibodies and warm autoimmune hemolytic anemia: A case study
Authors: Bauer L J , O’Brien T E , Mumtaz M
Published: October 2024

Introduction/Objective

We present a case of RBC alloimmunization and warm autoimmune hemolytic anemia (WAIHA) in a patient with a recent RBC transfusion. Serological testing followed by molecular testing revealed a rare D+ C- E- partial c+ partial e+ VS+ V+ hrS+ hrB+vw/- predicted phenotype.

Methods/Case Report

A 75-year-old black male with secondary myelofibrosis presented with a sudden onset of chest pain, dyspnea and weakness during an RBC transfusion. The patient was subsequently admitted for further workup. Labs showed low hemoglobin, low haptoglobin, elevated LDH and a positive direct antiglobulin (DAT) test. The patient was started on intravenous immunoglobulin and steroids for suspected WAIHA. On immunohematology serologic testing, blood typed as B-positive and polyspecific DAT positive with anti-IgG positive and anti-C3 negative. Serum plasma studies showed probable warm autoimmune hemolytic anemia and allo anti-S, -E, and -C by previous history. Eluate studies showed panagglutinin and antibody with D-like specificity. Immucor PreciseTypeTM Human Erythrocyte Antigen (HEA) Molecular BeadChip test predicted a partial e antigen and potential hrB-. Genotyping for RHD variants was performed and revealed RHD*01 (homozygous or hemizygous). Targeted genomic testing did not detect variants associated with common partial or weak RhD antigens. Based on this testing, the patient was not predicted to be at risk of allo-anti-D. An RHCE genotype for C, c, E and e variants including hrB and hrS showed RHCE*ce48C,733G/RHCE*ce733G with predicated phenotype of D+ C- E- partial c+ partial e+ VS+ V+ hrS+ hrB+vw/-. Based on the RHCE testing, the patient was predicted to be at risk for allo-anti-c, -e, -f (ce) and possibly anti-hrB.

Results (if a Case Study enter NA)

NA

Conclusion

In this case, serologic testing alone did not reveal a precise diagnosis. Molecular testing aided in the diagnosis of WAIHA and will help guide future transfusions. Pathologists must consider molecular testing when faced with a challenging serologic diagnosis.
Sub-Acute Toxicity Assay of the smoke of Seeds of Azadirachta indica and Peels of Citrus sinensis used as natural insecticides on the Liver, Kidney, Lungs and Heart of Albino Rats
Authors: Bello Aliyu Maje , Babagana Kamaluddeen , Yakasai Hafeez Muhammad , Mohammed Ibrahim Ahmed , Abubakar Salisu Adam , Muhammad Murtala , Wudil Alhassan Muhammad , Madungurum Muhammad Abubakar
Published: October 2024

Natural plant parts such as seeds of Azadirachta indica (neem seeds) and peels of Citrus sinensis (sweet orange) have been used as house-hold remedies against various ailments and bio-pesticides for agricultural purpose due to their repellent, growth regulatory and anti-feedant properties against insects. Despite their beneficial role, these natural insecticides could also have toxic effects on some vital organs of human. Therefore, this study aimed to investigate the sub-acute toxicity of smoke of the Seeds of Azadirachta indica and Peels of Citrus sinensis on the liver, kidney, lungs and heart of swiss albino rats. In this study, three groups of white swiss albino rats were exposed to the smoke of A indica seeds, peels of C sinensis and their combination at different duration of one hour and two hours respectively. The Control group were not exposed to any of the natural insecticides and were fed normal diet and water. After four weeks of the treatment, the animals were all sacrificed and their liver, kidneys, lung and heart were evaluated using standard biochemical and histopathological techniques. The levels of serum biochemical indices for liver (aspartate amino transferase (AST), alanine amino transferase (ALT), alkaline phosphatase (ALP), total bilirubin and protein), kidneys (urea, creatinine and electrolytes), and heart (creatine kinase and lactate dehydrogenase) were found to be significantly higher at (p<0.05) for all the groups treated with the two natural insecticides when compared to control group. Histopathological changes including fibrosis, hemorrhages, vascular congestion and necrosis were observed in the liver, kidneys and lungs tissues of the rats exposed to the smoke of the seeds of A indica. However, no histopathological changes were observed in all organs of rats exposed to the smoke of the peels of C sinensis compared to control group. Moreover, the severity of the effects of smoke of these natural insecticides on both biochemical and histopathological indices increases with increase in duration of exposure. The results of this study revealed that seeds of A indica have significant toxic effects on both the tissue and biochemical markers of all the major organs of the Swiss albino rats, while peels of C sinensis shows effect on only the biochemical indices at the specific duration of time studied.
Resolving Ambiguities in Deceased Donor HLA Typing: Next Generation Sequencing’s Role in DPB1 Allele Discrimination and Immunological Implications
Authors: Achram Robert , Morris Anna , Bray Robert , Sullivan H Cliff
Published: October 2024

HLA typing is crucial for assessing immunological compatibility between donors and recipients before transplantation. Deceased donor (DD) typing, typically via real-time PCR (rtPCR), provides rapid results vital for organ allocation. rtPCR primarily targets exons encoding the highly polymorphic peptide binding region (PBR) of HLA molecules. rtPCR cannot target all polymorphic sequences. Consequently, several possibilities of allele combinations are provided, leading to ambiguous typing results. As recent evidence suggests antibody responses can target regions in exons outside the PBR, notably in Exon 3 of the DPB1 locus, typing ambiguities can lead to the inability to assess histocompatibility between a donor and recipient. Herein, the aim was to investigate the utility of Next Generation Sequencing (NGS) in resolving DPB1 ambiguities in DD typing. A retrospective analysis of DD typing from February 2022 to January 2024 examined instances where NGS was used to resolve ambiguities reported via rtPCR. Each case was reviewed to understand the reason for resorting to NGS typing. The study focused on DPB1 ambiguities and assessed whether NGS effectively reduced ambiguity and differentiated alleles with polymorphisms outside the PBR. In total, 29 DD cases were found to have NGS testing results. In 14 cases, NGS was specifically performed to resolve DPB1 ambiguities. The ambiguities were significantly reduced from hundreds detected in rtPCR to 4 or fewer possible allele combinations with NGS. Eleven cases demonstrated polymorphism in exons outside the PBRs. Of these, only 2 cases showed no typing ambiguity with NGS. In the remaining 9 cases, though polymorphisms could be resolved in the PBR, ambiguities remained in exon 3, specifically at codon 96. In these cases, NGS could not distinguish lysine (K) from arginine (R). For example, DPB1*835:01 with the 96R motif could not be distinguished from DPB1*34:01with the 96K motif. The current investigation found that NGS cannot resolve all ambiguities at position 96, likely due, at least in part, to persistent cis-trans ambiguities. Our results suggest that although NGS drastically limited the number of ambiguities in 9 of 11 cases, it still could not adequately distinguish all immunologically relevant alleles. Inability to resolve the 96R/K epitope, which has been shown to be immunogenic, could impact solid organ transplantation, potentially leading to rejection in mismatched recipient-donor pairs at this position. Sequencing methods that generate longer reads, such as nanopore, may help resolve some of these cases if they are indeed due to cis-trans ambiguities.
Subclonal Populations Detected by Flow Cytometry in Chronic Lymphocytic Leukemia
Authors: Yip James , Simonson Paul
Published: October 2024

Introduction

Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL) is a mature, small B-cell lymphoma that typically co-expresses CD5 and CD23. Molecular-targeted therapies have produced remarkable therapeutic benefits in CLL, yet many patients are resistant to treatment. This study aims to identify subpopulations in CLL by conventional flow cytometry and clustering analysis.

Methods

One-hundred-and-forty-one CLL cases were taken from a public database and analyzed by uniform manifold approximation and projection (UMAP). Differences in size, granularity, and intensities of CD19, CD20, CD79a, CD5, CD23, CD10, and FMC7 were plotted with BD FACSDiva Software.

Eighteen cases with a new diagnosis of CLL at our institution between January 1, 2021 to December 31, 2022 were analyzed. Only peripheral blood samples were included. Markers including forward scatter, side scatter, and fluorescent intensities of CD19, CD20, CD5, CD23, CD10, surface kappa, and surface lambda were used to identify discrete CLL clusters in UMAP plots.

Results: Public Dataset

Clustering analysis of conventional flow cytometry data from 141 cases from a public database reveals discrete populations of cells exhibiting varying sizes, granularity and fluorescent intensities. Among the 141 cases, 33 (23.4%) had 1 cluster, 64 (45.4%) with 2 clusters, 42 (29.8%) with 3 clusters and 2 (1.4%) with 4 clusters. Among the cases with 2 clusters, a smaller population of cells deviated from the main neoplastic population. This smaller population had a higher forward and side scatter, and brighter intensities in CD45 and CD19, consistent with prolymphocytes. Among the cases with 3 clusters, a third population recurrently had a smaller size by forward scatter. A few cases additionally had varying intensities by CD23 and CD19. Among the 2 cases with 4 clusters, only slight deviations by UMAP were seen and may be artifactual.

Institutional Dataset

Clustering analysis of 18 cases at our institution revealed complex patterns of cell clusters exhibiting varying sizes, granularity and surface receptor expression intensity. Among the 18 cases, 1 (5.6%) had 1 cluster, 1 (5.6%) with 2 clusters, 10 (55.6%) with 3 clusters, 3 (16.7%) with 4 clusters, and 3 (16.7%) with 5 clusters. Similar to the public dataset, the third population, in addition to the predominant population and prolymphocytes, consistently varied by lower forward scatter. Additional clusters, such as a population with varying CD23 signal intensities, were identified in some cases.

Conclusions

In our study, multiple clonal subsets in CLL/SLL are detected by conventional flow cytometry analysis. These subclonal populations may result in therapy resistance for these patients, and identifying them by flow cytometry analysis may provide additional prognostic information in the clinical setting. Furthermore, the ability to detect these subclonal populations may allow for isolation of specific clones for future investigation in research settings.
Clinical Utility of Metagenomic Next-Generation Sequencing of Plasma Microbial Cell-Free DNA: a Single-Center Retrospective Study
Authors: Almeida Guilherme Gomide , Dumm Rebekah
Published: October 2024

Infectious diseases account for significant morbidity and mortality in healthcare, and metagenomic next-generation sequencing of plasma microbial cell-free DNA has emerged as a promising non-invasive diagnostic tool in this scenario. However, the available data on the real impact of this test in clinical practice is limited and conflicting. In this context, we performed a retrospective evaluation of the utilization of this test at our institution since February 17, 2019. A total of 76 tests were performed in this period in 68 different patients. The mean age of the patients was 9 years old, with 40 being male (58.82%) and 28 female (41.18%). The ordering specialties included infectious diseases (82.90%), hematology/oncology (9.21%), neurology (3.95%), pulmonology (2.63%), and dermatology (1.31%). The vast majority of the tests were ordered as inpatient (73 tests, 96.05%). 45 tests (59.21%) resulted as positive, of which 19 (42.22%) were polymicrobial. The tests were concordant with conventional microbiological studies 47 times (61.84%). Most tests (67 tests, 88.16%) had no significant clinical impact, 8 tests (10.53%) had a positive impact, and one test (1.31%) had an indeterminate impact. No tests were determined to have a negative clinical impact. Overall, our data is consistent with most studies which assessed the clinical utility of metagenomic next-generation sequencing of plasma microbial cell-free DNA in the literature, showing that testing did not have a significant impact on patient care for the majority of cases. There were some cases, however, in which testing showed a positive impact in escalating or de-escalating antibiotic therapy. In conclusion, despite being mostly a bystander, in selected cases and in the right clinical context, the test can be useful to guide antimicrobial treatment without causing significant harm. More studies are needed to further investigate the real utility of the test.
Development of a Novel and Rapid LC-MS/MS Method for Measuring Phosphatidylethanol in Whole Blood
Authors: Nielsen Jacob , Yang Qingwen , Lahorewala Sarrah , Yi Xin
Published: October 2024

Alcohol consumption can lead to serious health repercussions, including motor impairments and organ failure. Testing for short-term alcohol use is routinely conducted using blood ethanol tests in clinical laboratories. However, there is an emergent need to identify heavy alcohol users, especially crucial for patients undergoing organ transplant evaluations. With the advent of various biomarkers to detect heavy alcohol use, phosphatidyl ethanol (PEth), a group of abnormal phospholipids formed in cell membranes due to alcohol consumption, has gained prominence. PEth has been analyzed in whole blood with liquid chromatography-tandem mass spectrometry (LC-MS/MS) as two isomers: 18:1 (fatty acid:double bond) and 18:2 (fatty acid:double bond). We have developed an LC-MS/MS method that can detect these isomers in 4.5 minutes at concentrations of 10-500 ng/mL with excellent linearity and precision. In contrast to most LC-MS/MS methods where phospholipids are removed to minimize ion suppression, this method requires retaining phospholipids because the analyte, PEth, is a type of phospholipid. This was achieved through a ‘reverse extraction’ approach using phospholipid removal cartridges. Subsequently, the extracted samples were separated in an Agilent Protoshell 120 HPLC column on a Vanquish UHPLC instrument using 1 mM ammonium formate with 0.2% formic acid in water as Solution A and 50/50 isopropanol/acetonitrile as Solution B. The separation is performed starting at 80% Solution B (rest is Solution A) followed by a gradient elution where Solution B was increased to 95% over 2.3 minutes. Ions were analyzed using a ThermoFisher TSQ Endura MS/MS instrument in the negative mode. Additionally, commercially available whole blood was found to contain detectable levels of PEth in random lots, rendering them unsuitable for use as blank blood in the preparation of calibrators and quality controls. Instead, synthetic was used for this purpose. Ion suppression was observed, and various strategies were attempted to minimize it, including adjusting additives in the mobile phase, extending LC separation times, among others. More details on the impact of these adjustments and their effectiveness in improving the method’s performance will be presented.
Changes in platelet transfusion thresholds utilized in the NICU since PlaNeT-2
Authors: Hasan Rida , Upadhyay Kirtikumar , Breit Nathan , Tsang Hamilton , Hess John , Asif Maryam , Pagano Monica
Published: October 2024

Background

Use of prophylactic platelet transfusions in the neonatal setting is a common practice due to concerns about bleeding despite evidence of a developmental mismatch with transfusion of adult platelets. The Platelets for Neonatal Transfusion-Study 2 (PlaNeT-2) published in January 2019 showed that using higher platelet thresholds (50 x 109/L) was associated with more adverse outcomes and no improvement in bleeding events compared to lower platelet thresholds (25 x 109/L). Following this trial, implementation of a lower threshold was provider dependent as there were no changes made to the neonatal intensive care unit (NICU) institutional policies. Our goal was to determine if there were any overall changes in individual clinical practice with thresholds used for platelet transfusions in our NICU and number of transfusions per patient.

Methods

Our center has a 52 bed level IV NICU that specializes in care for critical and/or preterm infants. We performed a retrospective review from 2017 to 2023 of patients admitted in the NICU who received platelet transfusion and had an available platelet count in the 12 hours prior to the transfusion.

Results

There were 272 platelet transfusions given to 107 unique NICU patients who had platelet counts available. There were 66 transfusions given to 32 patients pre-PlaNeT-2 (2017-2018) and 206 transfusions given to 75 patients post-PlaNeT-2 (2019-2023). The average platelet count pre-PLaNeT-2(2017 to 2018) was 43 x 109/L (SD±24 x 109/L) and post-PLaNeT-2 (2019 to 2023) was 36 x 109/L (SD±21 x 109/L, p=0.03). Prior to PLaNeT-2, 26% of platelet transfusions were for platelet counts ≤ 25 x 109/L and 35% were for platelet counts between 51 to 100x9/L. Post PLaNeT-2 the percentages changed to 35% and 21% respectively. The percentage of transfusions occurring for platelet counts between 26 to ≤50 x 109/L was 38% and 44%, respectively.

The number of platelet transfusions per year did not decrease significantly after the PLaNeT-2 trial (average of 33/year versus 41/year, p=0.5). The number of transfusions per patient before and after PLaNeT-2 did not change (2.1 transfusions per patient versus 2.6 transfusions per patient, p=0.3).

Conclusion

Platelet thresholds utilized in our center decreased after the PLaNeT-2 trial with less transfusions occurring for platelet counts greater than 50 x 109/L. Although thresholds decreased, the number of transfusions per year and the number of transfusions per patient did not significantly change. Further studies are needed to understand changes in patient outcomes and platelet utilization in the NICU.
Performance of Gram Stain Characteristics for Predicting Culture Growth in Lower Respiratory Specimens Across Multiple Institutions
Authors: Spies Nicholas , Chamberland Robin , Rhoads Daniel , Wallace Meghan , Bussian David , Buchan Blake , Burnham Carey-Ann , Yarbrough Melanie
Published: October 2024

Data from Gram stains performed on clinical specimens can guide clinical decision-making and downstream laboratory workflows. However, the extent to which Gram stain results predict gold-standard culture results, and the generalizability of this performance across sites, warrants additional exploration. We sought to discover which Gram stain features would be associated with clinically significant culture growth (“growth”). To do so, 574 remnant specimens from the lower respiratory tract collected from four institutions were analyzed. A standardized Gram stain and culture protocol was performed across all study sites. Final reference organism identification was assigned using MALDI-ToF MS, and clinically significant growth was defined as any organism reported to the medical record. Gram stains with mixed microorganisms detected were considered concordant if ≥2 organisms of different Gram stain appearances were identified in culture. Growth was observed in 53% of specimens, including 25% of specimens in which Gram stain demonstrated no organisms. The 95% confidence intervals (CI) of the site-wise growth rates were 30-42%, 42-52%, 51-67%, and 60-77% (p < 0.001 by Chi-squared). By Gram stain morphology, 53-69% of specimens with Gram-positive cocci grew any clinically significant bacteria, while 31-49% grew a concordant Gram-positive cocci. 65-85% of specimens with Gram-negative bacilli grew any clinically significant bacteria, while 59-74% grew a concordant Gram-negative bacilli. 63-83% of specimens with mixed microorganisms grew 2 or more clinically relevant bacteria of differing Gram stain morphologies. Specimens from bronchoalveolar lavages (BALs) were less likely to have growth (30-42%) than endotracheal aspirates (66-77%). Polymorphonuclear leukocyte (PMNs) abundance was associated with culture growth, with Gram stains showing no, rare, few, moderate, or abundant PMNs demonstrating growth 28, 44, 52, 60, and 67% of the time (p < 0.001). Specimens with None and few squamous epithelial cells on Gram stain demonstrated growth 38-52% and 59-68% of the time (p < 0.001). No significant difference in growth was observed for red blood cells. Organism abundance on Gram stain was significantly associated with culture growth, with growth rate CIs being 20-32% for no organisms, 44-62% for rare, 58-77% for few, 70-93% for moderate, and 81-95% for abundant organisms seen. The extent to which these associations could guide the development of decision rules or machine learning models that demonstrate acceptable negative predictive value for pathogen growth to alleviate the operational burden of low-utility cultures is an exciting future direction to explore.
Concordance Between Platelet Expression Assay (PEA) and Serotonin Release Assay (SRA) in Heparin-Induced Thrombocytopenia: Implications for Diagnostic Accuracy and Laboratory Test Utilization
Authors: Grewal Sarah K , Hanson Laura , Choe Yeon-Whan , Barrette Eileen , Lee Kathi , Maier Cheryl
Published: October 2024

Introduction

The Serotonin Release Assay (SRA) serves as the gold standard functional assay for heparin-induced thrombocytopenia (HIT) diagnosis at our institution. The present turnaround time (TAT) for SRA results ranges from 4-5 days, occasionally extending beyond 8 days, given outsourcing to a reference laboratory. Recently, an alternative functional assay, the Platelet Expression Assay (PEA), has been introduced. The PEA detects platelet activation through p-selectin expression by flow cytometry, with a reported sensitivity of 100% and specificity of 95% for HIT. The PEA is also a send-out test, and thus has similar TAT and cost profiles as the SRA, but with potential to transition into an in-house assay in the future. Herein, we sought to determine the concordance of the PEA and SRA for the detection and diagnosis of HIT within our patient population.

Methods

A retrospective review was conducted on all cases in which a HIT ELISA (screening immunoassay) was performed by the Special Coagulation Laboratory during a one-year period. A 4Ts score was calculated if not already documented by chart review. In a subset analysis, specimens with a positive screening ELISA were concurrently tested by both SRA and PEA to compare performance.

Results

Of the 1341 cases, a 4Ts score was calculated and found to be less than 4 for 30-50% of cases. A total of 490 cases were sent out for SRA, of which 49 (10%) returned positive results. In a subset analysis of 20 samples from 14 patients, all with positive ELISAs, results revealed concordance between the SRA and PEA for all but one sample (19/20, 95%). Specifically, three successive samples from one patient had [negative, negative, positive] results for SRA, and [negative, positive, positive] results for PEA, respectively. This discordant result suggests a potential difference in sensitivity between the two assays. Further subset analysis focused on an additional 13 samples from 10 patients, all with SRA-positive results. Only 8 samples were concordant (8/13, 62%). One case showed a negative PEA and presumed false positive SRA, given the clinical history, while 4 samples showed likely true positive SRA results, given strength of ELISA results and 4Ts score, but were negative by PEA.

Conclusions

The lack of adherence to the 4Ts score algorithm to drive laboratory test utilization resulted in unnecessary ELISA and functional assay testing, potentially resulting in increased costs and false positive results. This result underscores the need for vigilance in assessing and refining diagnostic strategies. Additionally, our discordant findings in the subset analysis underscore the importance of evaluating the concordance and discordance between SRA and PEA results, providing insights into the diagnostic accuracy and potential limitations of each assay in identifying HIT.
A personalized and systematically designed adherence intervention improves photoprotection in adults with xeroderma pigmentosum (XP): results of the XPAND randomized controlled trial
Authors: Walburn Jessica , Norton Sam , Sarkany Robert , Canfield Martha , Sainsbury Kirby , McCrone Paul , Araújo-Soares Vera , Morgan Myfanwy , Boadu Janette , Foster Lesley , Heydenreich Jakob , Mander Adrian P , Sniehotta Falko F , Wulf Hans Christian , Weinman John
Published: October 2024

Background

Poor adherence to photoprotection in xeroderma pigmentosum (XP) increases morbidity and shortens lifespan due to skin cancers.

Objectives

To test a highly personalized intervention (XPAND) to reduce the dose of ultraviolet radiation (UVR) reaching the face in adults with XP, designed using known psychosocial determinants of poor photoprotection.

Methods

A two-arm parallel group randomized controlled trial, including patients with suboptimal photoprotection to receive XPAND or a delayed-intervention control arm that received XPAND the following year. XPAND comprises seven 1 : 1 sessions targeting photoprotection barriers (e.g. misconceptions about UVR) supported by personalized text messages, activity sheets and educational materials incorporating behaviour change techniques. The primary outcome, mean daily UVR dose to face across 21 days in June–July 2018, was calculated by combining UVR exposure at the wrist with a face photoprotection activity diary. Secondary outcomes were UVR dose to face across 21 days in August 2018, time spent outside, photoprotective measures used outside, mood, automaticity and confidence to photoprotect. Financial costs and quality-adjusted life years (QALYs) were calculated.

Results

Sixteen patients were randomized; 13 provided sufficient data for primary outcome analysis. The XPAND group (n = 8) had lower mean daily UVR dose to face [0.03 standard error of difference (SED) (SD 0.02)] compared with controls (n = 7) [0.43 SED (SD 0.17)] (adjusted difference = –0.25, P < 0.001, Hedge’s g = 2.21) at the June 2018 assessment. No significant between-group differences were observed in time spent outside, photoprotection outside, mood or confidence. The delayed-intervention control showed improvements in UVR dose to face (adjusted difference = –0.05; Hedge’s g = –0.1), time outside (adjusted difference = –69.9; Hedge’s g = –0.28) and photoprotection (adjusted difference = –0.23, Hedge’s g = 0.45) after receiving XPAND (June 2019 assessment). XPAND was associated with lower treatment costs [–£2642; 95% confidence interval (CI) –£8715 to £3873] and fewer QALYs (–0.0141; 95% CI –0.0369 to 0.0028).

Conclusions

XPAND was associated with a lower UVR dose to face in patients with XP and was cost-effective.
Intrinsic functional defects in B cells of patients with NFKB2 mutations
Authors: Min Qing , Li Yaxuan , Wu Xuzhe , Yu Meiping , Ying Wenjing , Zhou Qinhua , Hou Jia , Sun Bijun , Hui Xiaoying , Dong Lulu , Meng Xin , Zhang Hai , Hu Ziying , Feng Xiaoqian , Sun Jinqiao , Wang Wenjie , Wang Xiaochuan , Wang Ji-Yang
Published: October 2024

Mutations in the human nuclear factor-κB2 gene (NFKB2) are associated with common variable immunodeficiency (CVID) or combined immunodeficiency diseases (CID), characterized by B-cell lymphopenia, hypogammaglobulinemia, and T-cell dysfunction. This study investigated whether B cells with NFKB2 mutations exhibit intrinsic impairments in activation, class-switch recombination, and differentiation. We analyzed five patients from four unrelated families with CVID, each carrying a heterozygous NFKB2 mutation: P1 (C.2595_2614del, p.A867Gfs*12), P2 (C.2597G > A, p.S866N), P3 (C.2540dupT, p.R848Efs*38), and P4 and P5 (C.2570_2571insCAGCACA, p.A860Qfs*28). The patients with frameshift mutations (P1, P3, P4, and P5) exhibited truncated proteins detectable in their peripheral blood mononuclear cells, while P2 had a missense mutation. All identified mutations disrupted the processing of p100 into the active p52 form, resulting in NF-κB2 loss of function and IκBδ gain of function. Clinically, P1, P2, and P3 exhibited B-cell lymphopenia, and all five patients presented with hypogammaglobulinemia. Notably, P2 exhibited a markedly low B-cell count, associated with increased proportions of memory B and IgD−CD27− double-negative B cells. In vitro experiments with naïve B cells from P1 and P4 demonstrated decreased survival, impaired activation, and reduced differentiation into CD27+IgD− cells and plasmablasts, while class-switch recombination was unaffected. These findings reveal novel B-cell intrinsic functional defects in patients with NFKB2 mutations.
Emergency department use of a high-sensitivity point-of-care troponin assay reduces length of stay: an implementation study preliminary report
Authors: Pickering John W , Joyce Laura R , Florkowski Christopher M , Buchan Vanessa , Hamill Laura , Than Martin P
Published: October 2024

Aims

Point-of-care (POC) high-sensitivity troponin (hs-cTn) assays within a clinical pathway may safely reduce length of stay (LoS) for patients presenting to the emergency department (ED) with possible acute myocardial infarction (AMI). In this early report, we present the first evaluation of a POC hs-cTn in real-life care.

Methods and results

In adult patients presenting to ED investigated for possible AMI, we compared the LoS in patients assessed with a troponin in the 8 weeks before (usual-care phase) and the 8 weeks following introduction of the Siemens Atellica VTLi POC hs-cTnI for decision-making (intervention phase). The VTLi replaced the laboratory (Beckman Coulter) assay as the default hs-cTn test within the clinical pathway. This was the only change to the pathway process. The safety outcome was first event AMI or cardiac death within 30 days. There were 2376 presentations in the usual-care phase with 188 individuals with AMI and 2392 in the intervention phase with 198 AMI. In the intervention phase, there was a mean (95% CI) reduction in LoS of 32 min (22–41 min) compared with the usual-care phase. This represents 21.4 fewer patient-hours in the ED each day (1196 in the 8-week period). In both phases, the pathway correctly identified all cases of AMI at index attendance. There were four follow-up events (two usual-care, two intervention) within 30 days.

Conclusion

The deployment of a hs-cTn POC analyser into a large ED safely reduced length of stay. If translatable to other EDs, this could represent an important advancement to patient care.

Trial registration

Australia New Zealand Clinical Trials Registry, No. ACTRN12619001189112.
Decomposing sibling correlations: a new measure of group-specific intergenerational persistence in socioeconomic outcomes
Authors: Karlson Kristian Bernt , In Jung
Published: October 2024

We introduce a novel approach for decomposing sibling correlations in socioeconomic attainment into group-specific components. These groups are defined at the family level, based on factors such as parental income, marital status, race, or the gender composition of siblings. Unlike existing studies that compare sibling correlations across different groups, our method accounts for differences in average outcomes between groups in the overall outcome distribution. This approach results in a group-specific measure of persistence in the overall outcome distribution, contrasting with the ‘within-group’ measure commonly used in the literature. Additionally, we propose a straightforward ‘counterfactual’ framework to identify which groups have a greater impact on trends or country differences in sibling correlations. We present three examples that demonstrate the utility of our method.
Bioinformatic Resources for Exploring Human–virus Protein–protein Interactions Based on Binding Modes
Authors: Chen Huimin , Liu Jiaxin , Tang Gege , Hao Gefei , Yang Guangfu
Published: October 2024

Historically, there have been many outbreaks of viral diseases that have continued to claim millions of lives. Research on human–virus protein–protein interactions (PPIs) is vital to understanding the principles of human–virus relationships, providing an essential foundation for developing virus control strategies to combat diseases. The rapidly accumulating data on human–virus PPIs offer unprecedented opportunities for bioinformatics research around human–virus PPIs. However, available detailed analyses and summaries to help use these resources systematically and efficiently are lacking. Here, we comprehensively review the bioinformatic resources used in human–virus PPI research, and discuss and compare their functions, performance, and limitations. This review aims to provide researchers with a bioinformatic toolbox that will hopefully better facilitate the exploration of human–virus PPIs based on binding modes.