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Context.—Plasma transfusion guidelines support patient care and safety, management of product wastage, and compliance; yet, there is little information across multiple institutions about use of and adherence to plasma transfusion guidelines.Objective.—To survey multiple institutions regarding their plasma transfusion guidelines and compliance, plasma wastage rates, and incidence of transfusion reactions associated with plasma transfusion.Design.—The College of American Pathologists Q-Probes model was used to collect data from 89 participating institutions. Each site was asked to provide data relevant to its most recent 40 adult patient plasma transfusion episodes, and complete a questionnaire regarding plasma transfusion guidelines, utilization and wastage of plasma, and transfusion reactions related to plasma transfusion.Results.—The participating institutions reported a total of 3383 evaluable plasma transfusion episodes with transfusion of 9060 units of plasma. Compliance with institution-specific guidelines was seen in 3018 events (89%). Pretransfusion and posttransfusion coagulation testing was done in 3281 (97%) and 3043 (90%) of these episodes, respectively. Inappropriate criteria were noted for more than 100 transfusion episodes. Thirty-two plasma transfusion episodes (1%) were associated with a transfusion reaction. Serious and fatal reactions were reported. Median plasma wastage rate for the year preceding the study was 4.5%.Conclusions.—Most participating institutions are compliant with plasma transfusion guidelines based on published references, supported by appropriate testing. With transfusions for indications that lack evidence of efficacy and incidence of transfusion reactions, there is an ongoing role for transfusion service leaders to continue to update and monitor plasma transfusion practices.

Objectives : Timely reporting of immunosuppressant (ISP) drug level results is needed for transplant patient management. This study characterized the local ISP testing process, identified bottlenecks and implemented process improvements to meet turnaround time requirements. Methods : Laboratory information time stamps, direct observation and discussion with staff were used to construct a value stream map of the ISP testing process to identify process bottlenecks. Improvements were implemented to attain the required turnaround time. Results : Baseline performance of the existing ISP process (seven weeks, n = 272 samples) indicated that only 28% of samples were reported by 2:00 pm. Major bottlenecks were identified to be the analytical run schedule, instrument delays, difficulty identifying ISP samples at intake, and difficulty collecting specimens. Process changes resulted in a median of 76% samples reported by 2:00 pm. Conclusions : Adjusting ISP collection and analysis processes improved the laboratory’s ability to meet physician requested result reporting time of 2:00 pm.

Background Procalcitonin (PCT) concentration increases as a result of systemic inflammation owing to bacterial infection. Many PCT algorithms and medical decision concentrations (MDCs) have been clinically validated using the B·R·A·H·M·S PCT™ sensitive Kryptor™ assay. Alternative PCT assays have recently been approved by the Food and Drug Administration for clinical use in the US and require method verification before clinical implementation. Methods Precision, sensitivity, linearity, reportable range, and reference intervals were verified for the Architect B·R·A·H·M·S PCT assay. Accuracy of the Architect B·R·A·H·M·S PCT assay was evaluated by comparison with the B·R·A·H·M·S PCT sensitive Kryptor assay. Results The Architect B·R·A·H·M·S PCT assay was found to be precise (CV, ≤4.6%), sensitive (limit of blank, 0.001 ng/mL; limit of quantitation, ≤0.01 ng/mL), and linear according to the manufacturer's claims. The analytical measurement range (0.20–100.00 ng/mL) and the reference interval (≤0.07 ng/mL) were also verified. Patient result comparisons indicated high agreement at 0.10 ng/mL and 0.25 ng/mL and reduced positive agreement at 0.50 ng/mL and 2.00 ng/mL MDCs owing to negative bias compared with the B·R·A·H·M·S PCT sensitive Kryptor assay. Conclusions The Architect B·R·A·H·M·S PCT assay meets most performance specifications claimed by the manufacturer; however, negative bias at 0.50 ng/mL and 2.00 ng/mL PCT concentrations is evident.

Background The Jaffe and enzymatic methods are the 2 most common methods for creatinine measurement. The Jaffe method is less expensive but subject to interferences. Some laboratory scientists have called for the Jaffe method to be retired. Objective To determine the most cost-effective and safe protocol for creatinine measurement. Method We performed a retrospective database review of all outpatient creatinine measurements for 1 year, testing the risk-based reflex testing protocol we had implemented for creatinine measurement. Samples were first measured using the Jaffe method and were reflexed to the enzymatic method if the estimated glomerular filtration rate (eGFR) was between 55 and 65 mL per min per 1.73 m2. Results There were 104,530 creatinine measurements, of which 11,420 (10.9%) were reflexed to the enzymatic method. The Jaffe method had a positive bias of 0.08 mg per dL (-6.14 mL/min/1.73 m2 eGFR). A total of 3.4% of the paired reflexed specimens were discordant. Also, 133 (1.2%) of the Jaffe results were classified as false negatives and 3411 (29.9%) were classified as false positives. None of the false-negative results and 5 of the false-positive results were considered clinically significant. Using the reflex protocol saved approximately $40,000 per year. Conclusions The reflex protocol for creatinine measurement can reduce costs with acceptable risk.

Background Chemistry testing is requested for body fluid (BF) specimens despite the lack of assays approved by the US Food and Drug Administration (FDA). The criteria for categorizing fluids as transudate or exudate are not validated across analyzers. Objective To compare BF chemical analysis and classification by different analyzers. Methods We analyzed 10 pleural and 18 peritoneal fluids with corresponding plasma specimens using the Vitros 5,1 FS; Abbott ARCHITECT ci8200; and Roche Modular P platforms. Total protein (TP) and lactate dehydrogenase (LDH) were measured for pleural fluids. Light's criteria were applied. Albumin was measured for peritoneal specimens, and the plasma-ascites-albumin gradient was calculated. Results TP results showed agreement. The Vitros LDH assay produced higher fluid:plasma ratios. Classification by Light's criteria resulted in 1 discrepancy (ARCHITECT). Albumin results showed agreement. There were 2 discrepant gradient interpretations (Vitros). Conclusions These data suggest that analyses of pleural and peritoneal fluids using these platforms are diagnostically interchangeable.

Most information on compliance with audit criteria for red blood cell (RBC) transfusions comes from single institutions; few studies have compared practices among many hospitals.To survey a cross-section of hospitals in 2008 for criteria and compliance with RBC transfusion guidelines, using the College of American Pathologists Q-Probes format.One hundred twenty-eight hospitals, representing about 4.5% (724,332 of 16,212,000) of all annual RBC usage in the United States, provided information on their RBC audit practices and their recent rates of compliance. They also each examined 50 RBC transfusion episodes for compliance with their guidelines.The participants' median, pretransfusion hemoglobin thresholds for audit review were 8.0 to 8.9 g/dL for most clinical settings and 9.0 to 9.9 g/dL for patients with underlying cardiopulmonary disease. For the transfusion episodes examined, 60% (2063 of 6518) were for a single unit. The median of the institutional averages for pretransfusion hemoglobin was 8.1 g/dL, and the median rate of compliance was 69% (range, 0%-100%). Involvement by a pathologist or transfusion medicine expert in the audit system was associated with more-strict audit criteria and better compliance.Median hemoglobin thresholds for RBC transfusion audits were somewhat higher than currently evolving recommendations, but opportunities for improvement were provided by expert involvement and by the growing frequency of 1-unit transfusions.

Background Laboratories often adopt new methods. It would be useful to have a statistical procedure to estimate the incremental impact of a change in assay. Methods Mathematical modeling, statistical analysis, and case example. Results We derived equations to estimate the proportion of discordant results that can be attributed to the new laboratory method. The calculations were demonstrated by comparing eGFR values based on creatinine values determined using the enzymatic method (existing method) and Jaffe method (new method). The discordance rate at the 60 ml/min eGFR decision limit was 3.15%. In this example, we estimated that 60% of the discordant results could be attributed to the Jaffe method. Conclusion The sources of discordance in a laboratory method comparison study can be divided into three categories: The baseline discordance due to imprecision in the established method, the incremental discordance due to imprecision in the new method, and lack of analytical specificity. Discordance due to imprecision can be attributed to each individual method. Discordance due to bias can be attributed to individual methods if information is available to estimate the rate of biased observations in either method. Such information can be used to estimate the incremental cost effectiveness associated with the adoption of a new method.

Context.—Clinical laboratory specimens may be rejected as unsuitable for analysis for a variety of reasons and specimen rejection may have significant clinical consequences.Objective.—To quantify the clinical consequences of specimen rejection and determine the impact of laboratories' policies and practices on these consequences.Design.—Participants prospectively reviewed consecutive blood and urine specimens submitted to the chemistry and/or hematology laboratories to identify rejected specimens. For each rejected specimen, the patient's age, specimen type, testing priority, rejection reason, time from specimen receipt to receipt of recollected/relabeled specimen, recollection method, and test result time were recorded. Specimen/test abandonment was determined by failure to recollect or relabel a rejected specimen. Each laboratory's policy regarding relabeling of incorrectly labeled specimens was recorded, along with how many relabeled specimens were subsequently discovered to be mislabeled.Results.—Specimen rejection led to a (1) high rate of specimen recollection, (2) delay in result availability (median of 65 minutes), and (3) high rate of specimen/test abandonment. Longer test result delay was associated with higher hospital bed size; and higher test abandonment rate, with failure of the laboratory to request specimen recollection. Relabeling of incorrectly labeled specimens was found to be of little benefit and was associated with a substantial percentage of subsequently mislabeled specimens.Conclusion.—Specimen rejection has significant clinical consequences, including patient discomfort, significant delay in result availability, and high rate of specimen/test abandonment. Allowing routine relabeling of incorrectly labeled specimens is a dangerous practice, with little measureable benefit and with an increased risk to patient safety.

Context.— A common laboratory practice is to repeat critical values before reporting the test results to the clinical care provider. This may be an unnecessary step that delays the reporting of critical test results without adding value to the accuracy of the test result.Objectives.— To determine the proportions of repeated chemistry and hematology critical values that differ significantly from the original value as defined by the participating laboratory, to determine the threshold differences defined by the laboratory as clinically significant, and to determine the additional time required to analyze the repeat test.Design.— Participants prospectively reviewed critical test results for 4 laboratory tests: glucose, potassium, white blood cell count, and platelet count. Participants reported the following information: initial and repeated test result; time initial and repeat results were first known to laboratory staff; critical result notification time; if the repeat result was still a critical result; if the repeat result was significantly different from the initial result, as judged by the laboratory professional or policy; significant difference threshold, as defined by the laboratory; the make and model of the instrument used for primary and repeat testing.Results.— Routine, repeat analysis of critical values is a common practice. Most laboratories did not formally define a significant difference between repeat results. Repeated results were rarely considered significantly different. Median repeated times were at least 17 to 21 minutes for 10% of laboratories. Twenty percent of laboratories reported at least 1 incident in the last calendar year of delayed result reporting that clinicians indicated had adversely affected patient care.Conclusion.— Routine repeat analysis of automated chemistry and hematology critical values is unlikely to be clinically useful and may adversely affect patient care.

Exposure to drugs and toxins is a major cause for the rising number of emergency department visits each year. Immunoassays are commonly used in the emergency department to provide rapid turnaround time for acute care. The purpose of this study was to compare two automated immunoassay chemistry analyzers to determine which platform produced the fewest number of false positive/negative results. Residual patient urine samples were were collected for each of the following drugs/drug classes: cocaine (n = 40), opiates (n = 45), and amphetamines (n = 54) and confirmed either positive or negative by mass spectrometry. Split sample analyses of these specimens were performed on both the Roche COBAS INTEGRA 400 plus and Ortho Vitros 5,1 FS instruments. The results from the two chemistry analyzers were compared to confirmed results. Both immunoassays were prone to false positive results for cocaine and false negative results for opiates and amphetamines. The Vitros Fusion analyzer generated fewer false positive and false negative results for opiate and amphetamine testing than the Roche Integra, but the platforms performed comparably for cocaine.

Context.—Providing blood products for transfusions is a complex process subject to errors both within and outside the transfusion service. Transfusion-related errors can have grave consequences for the patient undergoing transfusion. As with many processes performed within health care systems, there is an expectation of error-free practice. Although this is an unobtainable goal, a focused quality-management plan, employing a medical event reporting system in a just working environment, can effect measurable system-quality improvement.Objective.—To illustrate the intrinsic value of quality-improvement activities through discussion of examples of quality misadventures from our transfusion service during the past 20 years.Data Sources.—Examples of quality-improvement activities were extracted from our quality-system archives. The published literature on transfusion quality was reviewed.Conclusions.—Active reporting, structured investigation, and systematic resolution of transfusion-related errors are effective methods for improving and maintaining transfusion quality.

Context.—Although a rare occurrence, ABO incompatible transfusions can cause patient morbidity and mortality. Up to 20% of all mistransfusions are traced to patient misidentification and/or sample mislabeling errors that occur before a sample arrives in the laboratory. Laboratories play a significant role in preventing mistransfusion by identifying wrong blood in tube and rejecting mislabeled samples. Objectives.—To determine the rates of mislabeled samples and wrong blood in tube for samples submitted for ABO typing and to survey patient identification and sample labeling practices and sample acceptance policies for ABO typing samples across a variety of US institutions. Design.—One hundred twenty-two institutions prospectively reviewed inpatient and outpatient samples submitted for ABO typing for 30 days. Labeling error rates were calculated for each participant and tested for associations with institutional demographic and practice variable information. Wrong-blood-in-tube rates were calculated for the 30-day period and for a retrospective 12-month period. A concurrent survey collected institution-specific sample labeling requirements and institutional policies regarding the fate of mislabeled samples. Results.—For all institutions combined, the aggregate mislabeled sample rate was 1.12%. The annual and 30-day wrong-blood-in-tube aggregate rates were both 0.04%. Patient first name, last name, and unique identification number were required on the sample by more than 90% of participating institutions; however, other requirements varied more widely. Conclusions.—The rates of mislabeled samples and wrong blood in tube for US participants in this study were comparable to those reported for most European countries. The survey of patient identification and sample labeling practices and sample acceptance policies for ABO typing samples revealed both practice uniformity and variability as well as significant opportunity for improvement.

Discard tubes have traditionally been obtained when drawing samples for coagulation testing to avoid potential tissue factor activation of coagulation in the first tube that may lead to inaccurate results. Although discard tubes are no longer required for prothrombin time and partial thromboplastin time, the practice is still recommended for other coagulation studies due to lack of sufficient evidence that discard tubes are not needed. The objective of the present study was to determine whether the first citrate tube drawn can be used for special coagulation testing. We performed testing for fibrinogen, D-dimer, factors VIII, IX, XI, proteins C and S, and antithrombin on 30 healthy individuals and factors II, VII, IX, X, and proteins C and S on a second group of 30 healthy individuals and 30 individuals receiving warfarin. Testing was performed on two consecutive samples to evaluate the level of agreement between the two tubes. Paired t-testing showed no statistically significant differences between tube 1 and tube 2 for any of the tests performed. Most data pairs (tube 1, tube 2) agreed within 10% difference or less, and no positive or negative biases were observed. To our knowledge, this study is the first to evaluate the need for discard tubes in a variety of coagulation tests using both normal and abnormal samples. Our data suggest that discard tubes are not necessary when drawing samples for specialized coagulation testing.

BACKGROUND: Idiopathic thrombotic thrombocytopenic purpura (TTP) is a rare form of thrombotic microangiopathy (TMA) characterized by extreme deficiency of ADAMTS13, an enzyme responsible for cleavage of von Willebrand factor. Plasma exchange therapy is the cornerstone of current treatment and is ineffective for most other forms of TMA. The availability of ADAMTS13 testing has improved diagnostic accuracy and appropriate selection of patients who are most likely to respond to plasma exchange. STUDY DESIGN AND METHODS: We performed a retrospective chart review of 110 cases of clinically suspected TTP with ADAMTS13 test results from 2005 to the present. The primary goal was to identify presenting clinical and/or laboratory features of patients with ADAMTS13 deficiency that would prove useful in increasing the likelihood of, or excluding the possibility of, TTP. In addition, patient outcomes including alternative diagnoses and response to plasma exchange were reviewed. RESULTS: Significant correlations for severe ADAMTS13 deficiency were seen for four of the observed variables: indirect bilirubin, reticulocyte percentage, creatinine, and platelet count; a fifth variable, D-dimer, just missed significance but performed well in subsequent analysis. Receiver operator characteristics curves for individual variables had area under the curve (AUC) values ranging from 0.75 to 0.85; a combined model had an AUC of 0.98. In addition, we constructed tree models both for clinical use as a diagnostic algorithm and for recursive partitioning to help establish cutoff points for categorical variables in developing an easy-to-use clinical prediction score. CONCLUSION: These results may enable the rapid exclusion and accurate diagnosis of TTP using readily available laboratory data.

The activated partial thromboplastin time (PTT) is the principal method by which laboratories monitor unfractionated heparin therapy. A review of the experimental basis for heparin monitoring by the PTT reveals significant shortcomings of the assay. The availability of anti-Xa heparin assays on automated coagulation analyzers presents a seemingly logical alternative because the PTT therapeutic range is derived from anti-Xa measurements of plasma from heparinized patients. The anti-Xa assay is not susceptible to many of the preanalytical interferences affecting the PTT, and adoption of anti-Xa monitoring would eliminate the need for validating a PTT therapeutic range. However, anti-Xa heparin monitoring has not been rigorously validated by clinical outcomes studies, and decreasing clinical use of unfractionated heparin makes it unlikely that such data is forthcoming. Nonetheless, many laboratories may find themselves in the position of being unable to continue to validate their PTT therapeutic ranges according to current recommendations and accreditation requirements.

BackgroundThe Jaffe and enzymatic methods are the two most common methods for measuring serum creatinine. The Jaffe method is less expensive than the enzymatic method but is also more susceptible to interferences. Interferences can lead to misdiagnosis but interferences may vary by patient population. The overall risk associated with the Jaffe method depends on the probability of misclassification and the consequences of misclassification. This study assessed the risk associated with the Jaffe method in an outpatient population. We analyzed the discordance rate in the estimated glomerular filtration rate based on serum creatinine measurements obtained by the Jaffe and enzymatic method.MethodsMethod comparison and risk analysis. Five hundred twenty-nine eGFRs obtained by the Jaffe and enzymatic method were compared at four clinical decision limits. We determined the probability of discordance and the consequence of misclassification at each decision limit to evaluate the overall risk.ResultsWe obtained 529 paired observations. Of these, 29 (5.5%) were discordant with respect to one of the decision limits (i.e. 15, 30, 45 or 60 ml/min/1.73m2). The magnitude of the differences (Jaffe result minus enzymatic result) were significant relative to analytical variation in 21 of the 29 (72%) of the discordant results. The magnitude of the differences were not significant relative to biological variation. The risk associated with misclassification was greatest at the 60 ml/min/1.73m2 decision limit because the probability of misclassification and the potential for adverse outcomes were greatest at that decision limit.ConclusionThe Jaffe method is subject to bias due to interfering substances (loss of analytical specificity). The risk of misclassification is greatest at the 60 ml/min/1.73m2 decision limit; however, the risk of misclassification due to bias is much less than the risk of misclassification due to biological variation. The Jaffe method may pose low risk in selected populations if eGFR results near the 60 ml/min/1.73m2 decision limit are interpreted with caution.

ContextHemolysis is an important clinical laboratory quality attribute that influences result reliability.ObjectiveTo determine hemolysis identification and rejection practices occurring in clinical laboratories.DesignWe used the College of American Pathologists Survey program to distribute a Q-Probes–type questionnaire about hemolysis practices to Chemistry Survey participants.ResultsOf 3495 participants sent the questionnaire, 846 (24%) responded. In 71% of 772 laboratories, the hemolysis rate was less than 3.0%, whereas in 5%, it was 6.0% or greater. A visual scale, an instrument scale, and combination of visual and instrument scales were used to identify hemolysis in 48%, 11%, and 41% of laboratories, respectively. A picture of the hemolysis level was used as an aid to technologists' visual interpretation of hemolysis levels in 40% of laboratories. In 7.0% of laboratories, all hemolyzed specimens were rejected; in 4% of laboratories, no hemolyzed specimens were rejected; and in 88% of laboratories, some specimens were rejected depending on hemolysis levels. Participants used 69 different terms to describe hemolysis scales, with 21 terms used in more than 10 laboratories. Slight and moderate were the terms used most commonly. Of 16 different cutoffs used to reject hemolyzed specimens, moderate was the most common, occurring in 30% of laboratories. For whole blood electrolyte measurements performed in 86 laboratories, 57% did not evaluate the presence of hemolysis, but for those that did, the most common practice in 21 laboratories (24%) was centrifuging and visually determining the presence of hemolysis in all specimens.ConclusionsHemolysis practices vary widely. Standard assessment and consistent reporting are the first steps in reducing interlaboratory variability among results.

Context Hemolyzed specimens delay clinical laboratory results, proliferate unnecessary testing, complicate physician decisions, injure patients indirectly, and increase health care costs. Objective To determine quality improvement practices when hemolysis occurs. Design We used the College of American Pathologists (CAP) Survey Program to distribute a Q-Probes–type questionnaire about hemolysis practices to CAP Chemistry Survey participants. Results Of 3495 participants sent the questionnaire, 846 (24%) responded. Although 85%, 69%, and 55% of participants had written hemolysis policies for potassium, lactate dehydrogenase, and glucose, respectively, only a few (46%, 40%, and 40%) had standardized hemolysis reports between their primary and secondary chemistry analyzers for these 3 analytes. Most participants (70%) had not attempted to validate the manufacturers' hemolysis data for these 3 analytes; however, essentially all who tried, succeeded. Forty-nine percent of participants had taken corrective action to reduce hemolysis during the past year and used, on average, 2.4 different actions, with collection and distribution of hemolysis data to administrative leadership (57%), troubleshooting outliers (55%), retraining phlebotomist (53%), and establishment of quality improvement teams among the laboratory and at problem locations (37%) being the most common actions. When asked to assess their progress in reducing hemolysis, 70% noted slow to no progress, and 2% gave up on improvement. Upon measuring potassium, lactate dehydrogenase, and glucose, approximately 60% of participants used the same specimen flag for hemolysis as for lipemia and icterus. Conclusions Hemolysis decreases the quality and increases the cost of health care. Practices for measuring, reporting, and decreasing hemolysis rates need improvement.

Transfusion Services are presented with many challenging coagulation problems. Most cases gain attention when out of the ordinary requests for blood products are received. The Transfusion Medicine Physician is often brought into a clinical scenario that has already become an emergency and quick response is imperative [1–8]. Decisions often have to be made empirically, or with the help of a very limited coagulation test menu. This chapter will focus on maximizing information from a short coagulation test menu, reviewing the tools available to correct coagulopathies, and applying these tests to emergency situations.

The cornerstone assays of coagulation testing are the prothrombin time (PT) and partial thromboplastin time (PTT). When combined with results of the platelet count obtained from the complete blood count (CBC), differential diagnoses can be generated to assist in the evaluation of patients with bleeding disorders. This chapter will summarize methodologies for the PT and PTT assays, as well as other clinically useful tests that many hospital laboratories provide. An approach to diagnosing bleeding disorders using results of the PT and PTT assays (and the platelet count) will also be presented. Lastly, limitations of these assays will be discussed in the context of evaluating patients for bleeding. All assays discussed in this chapter have FDA approval.

Acquired platelet disorders can be broadly categorized into disorders of platelet number and disorders of platelet function, though there can be overlap (e.g., myeloproliferative disorders). The hematology laboratory traditionally assesses platelet number using automated hematology analyzers, with targeted confirmation by manual counting. Platelet antibody assays may be performed by the immunology and/or coagulation laboratories, or by the transfusion service. Platelet function testing has traditionally been performed by special coagulation laboratories using platelet-rich plasma or whole blood platelet aggregation. However, new platelet function analyzers are being marketed as potential substitutes for traditional platelet aggregometry (see Chap. 3).

Background: The bleeding time (BT) test predicts a higher bleeding complication rate in populations at risk for inherited or acquired platelet dysfunction, but it is of limited assistance in evaluating individual patients. There are no reports of clinical outcomes after discontinuation of the BT test. Methods: Interviews with a subset of the physicians who had ordered the BT test before discontinuation of the test were conducted. The total number of platelet-aggregation tests, the mean number of monthly, unmodified platelet units transfused, the incidence of kidney biopsy complications, and the number of doses of 1-deamino-8-d-arginine vasopressin (DDAVP) administered 5 months before and after discontinuation of the BT test were compared. We recorded the rates of bleeding complications in the Major Surgery Risk Pool during the 12 months before and the 5 months after the discontinuation of the BT test. Results: Clinicians reported they did not significantly change their preprocedural work-ups, postpone an invasive procedure, experience an increase in bleeding complications, or increase their use of blood products after discontinuation of the BT test. Platelet-aggregation tests (n = 9, before and after), platelet transfusions (P = 0.958), and DDAVP administration (before = 24; after = 10) did not increase after discontinuation of the BT test. The rate of postprocedural bleeding complications did not increase significantly in either Major Surgery Risk Pool cases ( Conclusions: Our study failed to identify a clinically significant, negative impact of discontinuing the BT test.

During the last 2 years, regulatory agencies have taken a more visible role in the enforcement of statutory regulations that exist to protect the rights of human research subjects. In 1998 the Office of the Inspector General (OIG) of the Department of Health and Human Services (DHHS) issued a series of reports addressing inadequacies in the institutional review board (IRB) system and recommending several changes to increase the expertise, independence, resources, training, and accountability of IRBs.1-4 In April 2000, the OIG issued a follow-up report on the status of IRBs highlighting the lack of progress by government agencies in instituting the recommended reforms.5 In 1999, the Office for Protection from Research Risks (now the Office for Human Research Protections [OHRP]), which administers the Federal Policy for the Protection of Human Subjects or Common Rule (45 CFR Part 46), temporarily suspended all federally funded research involving human subjects at several major research institutions as a result of findings made during on-site inspections. Although evidence of harm to research subjects was not uncovered, infractions involving administration of human research studies were identified, including failure to conduct continuing review in a timely or appropriate fashion; conflict of interest of IRB members; inappropriate use of expedited review; failure to inform IRB members of expedited approvals; inadequate attendance at and documentation of IRB meetings; standard surgical informed consent documents lacking the required elements; inappropriate granting of exempt status for studies involving prospectively collected specimens, data, documents, or records; and inappropriate granting of waivers of consent without documentation of compliance with the required criteria for approval.6 In December 1999, the US Food and Drug Administration (FDA) issued a guidance document that addressed the regulatory requirements for in vitro diagnostic device (IVD) studies, including requirements for informed consent for use of leftover blood samples or previously collected samples.7 The FDA recently informed researchers at an institution that they should have been getting informed consent for use of residual clinical specimens in clinical trials of medical devices, as stipulated in 21 CFR Part 50,8 even though the local IRB had waived the requirement for consent. During a follow-up audio conference sponsored by the American Association for Clinical Chemistry, FDA representatives made it clear that research involving IVD submissions was subject to review of medical records by the FDA, even for so-called me-too 510K submissions,9 and that informed consent must indicate that the FDA may review the records. Most recently, the DHHS announced plans for increased scrutiny of clinical trials in response to the death of a research subject in a gene therapy trial and administrative deficiencies identified during a subsequent investigation.10 In addition to endorsing many of the elements of the OIG recommendations, the DHHS plan includes its pursuit of legislation that would permit the FDA to fine clinical researchers and research institutions for violations of the regulations, including informed consent practices, and an expectation that institutions will perform audits to verify compliance with informed consent requirements. This intense scrutiny of human research practices has had the intended effect of motivating research institutions to review and modify their policies and procedures, often after seeking advice from officials at formerly sanctioned programs.11 Why should pathologists be concerned about these developments? A review of several university IRB Web sites from around the United States (including the University of Utah) reveals significant changes in policies governing access

TBX3 is a member of the T-box family of transcription factors with critical roles in development, oncogenesis, cell fate, and tissue homeostasis. TBX3 mutations in humans cause complex congenital malformations and Ulnar-mammary syndrome. Previous investigations into TBX3 function focused on its activity as a transcriptional repressor. We used an unbiased proteomic approach to identify TBX3 interacting proteins in vivo and discovered that TBX3 interacts with multiple mRNA splicing factors and RNA metabolic proteins. We discovered that TBX3 regulates alternative splicing in vivo and can promote or inhibit splicing depending on context and transcript. TBX3 associates with alternatively spliced mRNAs and binds RNA directly. TBX3 binds RNAs containing TBX binding motifs, and these motifs are required for regulation of splicing. Our study reveals that TBX3 mutations seen in humans with UMS disrupt its splicing regulatory function. The pleiotropic effects of TBX3 mutations in humans and mice likely result from disrupting at least two molecular functions of this protein: transcriptional regulation and pre-mRNA splicing., Author Summary TBX3 is a protein with essential roles in development and tissue homeostasis, and is implicated in cancer pathogenesis. TBX3 mutations in humans cause a complex of birth defects called Ulnar-mammary syndrome (UMS). Despite the importance of TBX3 and decades of investigation, few TBX3 partner proteins have been identified and little is known about how it functions in cells. Unlike previous investigations focused on TBX3 as DNA binding factor that represses transcription, we took an unbiased approach to identify TBX3 partner proteins in mouse embryos and human cells. We discovered that TBX3 interacts with RNA binding proteins and binds mRNAs to regulate how they are spliced. The different mutations seen in human UMS patients produce mutant proteins that interact with different partners and have different splicing activities. TBX3 promotes or inhibits splicing depending on cellular context, its partner proteins, and the target mRNA. Eukaryotic cells have many more proteins than genes: alternative splicing is critical to generate the different mRNAs needed for production of the specific and vast repertoire of proteins a cell produces. Our finding that TBX3 regulates this process provides fundamental new insights into how altered quantity and molecular function of TBX3 contribute to human developmental disorders and cancer.

Context.—Utilization of stat testing priority is a balance between safe, efficient patient management and resource expenditure.Objective.—To determine the rate of stat testing, compare rates among institutions, and determine the distribution of turnaround time expectations for different turnaround time priorities.Design.—During a 7-day period, participants prospectively determined the total number of chemistry, hematology, and coagulation billable tests from inpatients and emergency department patients. Among these, the total numbers of billable tests performed stat were identified. Laboratories also reported the levels of test priority they offered and turnaround expectations for each level of test priority.Results.—Fifty institutions submitted data for the study, with 2 additional participants submitting partial results. Participants identified 639 589 chemistry, hematology, and coagulation billable tests, with 229 896 (35.9%) performed stat. The stat rate varied from 21.3% at the 10th percentile to 55.4% at the 90th percentile, with a median of 37.0% of participants' tests performed stat. Laboratories include a mean of 206 tests in chemistry, hematology, and coagulation test menus, with 67% of these tests offered stat. The fraction of the test menu offered stat varied from 29.0% at the 10th percentile to 97.8% at the 90th percentile, with a median of 73.3% of tests on the menu offered stat. The most common number of testing priorities offered by participating laboratories was 3 (44.2%).Conclusions.—Among the 52 participating laboratories, the median stat testing rate was 37.0% and a median 73.3% of the test menu was offered stat.

Blood components are modified to meet the clinical requirements of specific patient populations. The clinical indications for some well-established components have narrowed with the development of new technology. Leukoreduced blood components are being considered for a variety of clinical applications. Published data support the use of leukoreduced components to prevent febrile nonhemolytic transfusion reactions. The routine use of such components for other indications should be considered experimental, and the cost effectiveness of experimentally validated indications should be evaluated.

The development of a reliable polymerase chain reaction (PCR) technique for the routine detection of clonal immunoglobulin heavy chain (IgH) gene rearrangements would represent an attractive alternative to Southern hybridization analysis because of the relative simplicity of PCR protocols, and because the requirements for both quality and quantity of DNA would be considerably less stringent. To assess the utility of PCR for the routine detection of clonal IgH gene rearrangements, samples from 123 adult patients were evaluated and analysis by PCR amplification using IgH Framework 1 or Framework 3 variable region consensus primers was compared with analysis by restriction endonuclease digestion and Southern hybridization with genomic, IgH probes. The authors found that 90% of IgH genes found to be rearranged by Southern hybridization are detected by the PCR technique. An additional 9 patient samples had clonal IgH gene rearrangements that were detectable by PCR alone. Eight of these nine patients had a history of a clonal hematopoietic process at either the morphologic or molecular level, and six had a history of a B-cell malignancy. It is likely that these specimens contained clonal lymphoid populations undetected by the Southern hybridization technique. Thus, the diagnostic sensitivity and specificity of the PCR method for the detection of B-cell tumors were 91% and 95%, respectively. The combination of improved analytical sensitivity and specimen flexibility of the IgH PCR assay could make it the method of choice for the routine detection of clonal IgH gene rearrangements, if minor improvements in the diagnostic sensitivity of the assay can be achieved.

Qualitative and quantitative serum human chorionic gonadotropin (hCG) tests are used to diagnose pregnancy. We assessed physicians’ perceptions and compared turnaround times (TATs) and performance characteristics of both tests. We surveyed 1,058 physicians about their perceptions of hCG tests. Seven months of TAT data were analyzed. hCG was measured in all qualitative samples. Pregnancy status was determined by chart review. Of the physicians surveyed, 183 responded. Fortynine percent preferred qualitative over quantitative serum tests for determining pregnancy status. Physicians were willing to wait 45 minutes for results from either test. Qualitative tests are performed faster than quantitative tests, but TATs were not significantly different when sample transport time was considered. The negative predictive value of both tests was 99.9%. Qualitative serum hCG testing could be replaced by quantitative hCG tests, but there is no clear advantage to doing so. Rapid testing for the qualitative detection of human chorionic gonadotropin (hCG) in urine or serum using point-ofcare (POC) test devices is frequently performed in health care settings to identify a possible pregnancy. Qualitative urine hCG tests are attractive because the urine sample requires no special processing and the tests are granted waived status by the Clinical Laboratory Improvement Amendments (CLIA). As such, testing can truly be performed at the POC by any health care provider. In contrast, qualitative serum hCG tests are categorized by CLIA as moderately complex because they require the collection of a whole blood specimen that must be centrifuged before testing to obtain the serum sample. The need to perform qualitative hCG testing in serum

The availability of point-of-care (POC) medical devices for drug testing has surged. Reduction in turnaround time, and hence, rapid results are attractive, particularly to acute care facilities, rehabilitation facilities and specialized clinics such as pain management clinics. Here we describe our validation results for the Integrated E-Z Split Key Cup II, a low-cost, rapid urine test that utilizes competitive immunoassay technology to detect 12 drugs or drug classes of commonly abused drugs. Positivity is based on the absence of a colored band at a labeled portion of the detection strip; a negative result produces a distinct, colored band. Using reagent-grade standards, the apparent cut-off for each of the drugs was challenged. The stability of the results was monitored over time. Five urine samples known to be negative for all drug categories and 24 patient samples confirmed positive for a total of 95 drugs and/or drug metabolites claimed to be detected by the device were tested. Adulterants and potential cross-reacting compounds were also evaluated. One false-positive result for benzodizepines was observed. One false-negative result for barbiturates was observed, but was resolved. Overall, the cups demonstrated excellent sensitivity, specificity, and diagnostic efficiency for all drugs represented.

Aims: The role of anticoagulation during percutaneous coronary intervention has been well established. However, the role of anticoagulation during diagr ostie coronary anglography remains inclear. Prothrombin fragment 1+2 (PF 1+2 ) and D-dimer (DD) have been reported to be useful in evaluating thrombotic phenomena. This study was designed to determine whether activation of coagulation occurs during diagnostic coronary anglography as measured by DD and PF 1+2 . Methods and results: Patients not on anticoagulation (except for aspirin) and with no documented coagulopathy undergoing elective diagnostic coronary anglography were enrolled in this prospective study. Blood samples for DD and PF 1+2 were obtained serially after the femoral arterial sheatn was placed. Peripheral venous blood was drawn along with an initial arterial blood sample from the sheath; thereafter, arlerial blood samples from the sheath were obtained every 10 minutes for a maximum of 60 minutes or unti the procedure was completed or when anticoagulation was initiated. A final veneous sample was drawn at the end of the procedure. The data were analysed in time interval correlation to the i)D and PF 1+2 level. Forty two patients were enrolled in this study, 15 were female (35%). There were 25 (59%) patients with diabetes. The mean fluoroscopic time was 8.8±7.81 minutes and the average time for the procedure was 29±22 70 minutes. There were 192 blood samples analysed. 67% of patient completed the procedure with in 20 minutes and 91% within 30 minutes. Mean venous PF 1+2 level was 0.20 nm ol/L at baseline and 0.39 nmol/L (p=0.06) at the final interval, while the mean arterial PF 1+2 level was s gnificantly elevated. There was ar increases of 0.2 nmol/L of artenal PF 1+2 every 10 minutes (p

A broad spectrum of coagulation analyzers is available for purchase on the market today. Laboratories can choose from manual, semi-automated or fully automated, moderate or high-throughput analyzers with narrow or broad assay menus depending upon clinical and test volume requirements. These laboratory-based instruments require plasma prepared from spun, anticoagulated whole blood for analysis. In addition, a number of point of care (POC) devices designed to analyze fresh whole blood are available for use on hospital patient care units, in clinics and doctors’ offices, and even in patients’ homes. For a current summary of marketed devices, the reader is referred to the annual College of American Pathologists summary list of laboratory-based coagulation analyzers and their attributes published on the College’s web site (www.cap.org). A separate list of point of care analyzers can also be found on the site.

The availability of automated anti-Xa heparin assays provides the opportunity to manage patient unfractionated heparin levels directly, rather than by the activated partial thromboplastin time. Because critically ill patients can acquire an antithrombin deficiency, we compared the performance of 3 anti-Xa heparin assays, 1 with and 2 without antithrombin supplementation, by analyzing in vitro aliquots of plasma with defined antithrombin levels and specimens from intensive care patients receiving intravenous heparin therapy. Heparin concentration recovery, in vitro, was dependent on the plasma antithrombin concentration for all 3 assays. The antithrombin-supplemented assay demonstrated improved heparin recovery in direct correlation to the heparin concentration in the plasma. The greatest effect of antithrombin supplementation occurred when the antithrombin level dropped below 40%, a level present in only 5% of the patient specimens. Analysis of patient specimens demonstrated significant correlation among the 3 assays. Classification of the clinical adequacy of patient heparin levels showed agreement of 80% or more between the antithrombin-supplemented and nonsupplemented assays. The antithrombin-supplemented assay did not significantly improve clinical usefulness.

BACKGROUND: An understanding of factors affecting CD34+ cell collection efficacy is essential to minimize donor toxicity and cost. STUDY DESIGN AND METHODS: Peripheral blood CD34+ cell (CD34) measurements were determined at various intervals before, during, and after automated cell collection (Cobe Spectra 6.0). The serial mean of multiple, intraprocedural CD34 levels was calculated for each procedure as an estimate of the mean, inlet-line CD34 level. RESULTS: The CD34+ concentration fell a mean of 30 percent in the first 30 to 70 minutes of collection. The degree of decline was inversely correlated with donor blood volume (BV), but was not due to hemodilution. The mean of the CD34 level before and after collection slightly overestimated the serial mean CD34 level. Cell yields, normalized for the CD34 level before collection, were higher from donors with larger BVs. CONCLUSIONS: The CD34 concentration rapidly decreased to a relative equilibrium level during the collection procedure. The degree of decrease in the CD34 level inversely correlated with the BV of the donor and was consistent with cell pooling in the collection set. The higher equilibrium CD34 levels in donors with larger BVs resulted in increased collection of CD34+ cells, and therefore, large-volume apheresis should be most efficient in these donors.

A number of classes of endogenous antibodies, including heterophile, rheumatoid factor, and autoantibodies, can interfere with immunoassay measurements of many different analytes. Heterophile and rheumatoid factor antibody interferences have been described previously for the AxSYM cardiac troponin I assay. Several commercial products have been developed to neutralize heterophile antibody interferences. We describe a patient with multiple apparently falsely elevated cardiac troponin I results that were unique to the AxSYM analyzer. These cardiac troponin I results diluted linearly. When treated with 2 different heterophile-blocking reagents, the magnitudes of the falsely elevated results increased 17- and 26-fold, and these results also demonstrated dilution linearity. This interfering substance could be removed by passage through an immobilized protein A column and by polyethylene glycol precipitation. It does not appear to be a classic heterophile antibody, nor is it a paraprotein. Laboratorians must remain constantly vigilant for immunoassay interferences that lead to clinically significant inaccurate results and must recognize that accepted methods for detecting and neutralizing the interference may be ineffective.

A patient with multiple myeloma had an automated blood count performed on a Coulter STK-S counter that repeatedly failed internal limits for both mean corpuscular hemoglobin and mean corpuscular hemoglobin concentration. The calculated hematocrit agreed with a spun hematocrit, suggesting that the hemoglobin concentration was being overestimated by the automated counter. Measurement of the plasma hemoglobin concentration of the sample, which showed no visible hemolysis, gave a hemoglobin concentration of 32 g/L on the STK-S analyzer. Correction of the whole blood hemoglobin using the plasma hemoglobin gave a value consistent with the hematocrit. The corrected mean corpuscular hemoglobin and mean corpuscular hemoglobin concentration values were within standard limits. This patient's paraprotein was characterized as IgA-κ and was present at a concentration of 61 g/L. The hemoglobin concentration measured on whole blood by Sysmex NE 8000 and Technicon H*1E autoanalyzers agreed reasonably well with the corrected result from the STK-S.