Abstract Background Thromboelastography (TEG) applications have been gaining momentum in various clinical settings and service lines. However, the utilization of the technology varies among clinical establishments and requires additional assessment for TEG optimization among its user groups. Methods TEG (Haemonetics TEG6s) was applied in a community hospital based setting in SICU, OR and ED service lines to identify instrument prompted blood product support over a two month time period. Results Forty one measurement were obtained from twenty patients. SICU represented the majority of TEG use (78%) followed by OR (15%). Global TEG run assessments were completed on 27%, platelet mapping on 46%, and heparin assessment on 56% of samples. Global TEG recommendations included factor deficiency with suggested FFC or PCC use (12%) or no recommendations (10%). Platelet assessments recommended no product (19.5%), or ADP inhibition with platelet consideration if bleeding (14.6%). Heparin assessment indicated no treatment (44%) and above normal CK/R time with FFP or PCC if bleeding (10%). Conclusion TEG applications in various services suggested no need for blood product or factor application in the majority of platelet mapping and heparin assessments. Other assessments yielded about a half dozen suggestions from the instrument’s 150 suggestion options. TEG application appears to be easily implementable and suggests no treatment or a few repetitive treatment options for the majority of patients assessed thereby reducing onboarding educational and improving management requirements for select user groups.

Abstract Background The rate of cultures ordered for patients in which infection is suspected is approximately 40% on Emergency Department patients at Maimonides Medical Center and represents a significant financial burden for our institution. Most blood cultures in clinical practice do not grow organisms suggesting that suboptimal blood culture collection practices (e.g., suboptimal blood volume) or suboptimal selection of patients to culture (patients with low likelihood of bacteremia may be occurring. •BV is a new host-protein test based on TRAIL, TNF-related apoptosis inducing ligand protein, IP-10, interferon gamma -induced protein 10 and CRP, C- reactive protein that produces a score between 1–100 indicating the likelihood of a bacterial vs viral infection. It has been validated in multiple studies to have sensitivity and specificity of more than 90%.• In this study we compare blood culture and BV results. Methods BV test were taken at ED physician discretion from March 2022 to December 2022 • BV score 0–35 is viral, 35–65 is equivocal and 65–100 is bacterial. • BV test was measured using MeMed BV (MeMed, Israel) and MeMed Key (MeMed, Israel) from serum samples. • This sub analysis focuses on patients presenting at the ED for whom blood culture was ordered and there was a record of the result. Results • BV test was taken for 545 patients during their ED visit, of these, 389 had blood cultures drawn and results recorded. • There were 233 cases with BV score bacterial, 42 with BV score equivocal and 114 with BV score viral • Out of the BV score viral, there were 7 with positive findings, of which 5 were considered contaminants Conclusion There is a high agreement between viral BV results and negative cultures. Ongoing collection of this data in real time will help establish this finding further in order to provide guidance for our clinicians to reduce the financial burden of unwarranted cultures as well as the unnecessary administration of antibiotics.

The viral agent SARS-CoV-2 clearly affects several organ systems, including the cardiovascular system. Angiopoietins are involved in vascular integrity and angiogenesis. Angiopoietin-1 (Ang1) promotes vessel stabilization, while angiopoietin-2 (Ang2), which is usually expressed at low levels, is significantly elevated in inflammatory and angiogenic conditions. Interleukin-6 (IL-6) is known to induce defective angiogenesis via the activation of the Ang2 pathway. Vasculitis and vasculopathy are some of the defining features of moderate to severe COVID-19-associated systemic disease. We investigated the serum levels of angiopoietins, as well as interleukin-6 levels and anti-SARS-CoV2 IgG titers, in hospitalized COVID-19 patients across disease severity and healthy controls. Ang2 levels were elevated in COVID-19 patients across all severity compared to healthy controls, while Ang1 levels were decreased. The patients with adverse outcomes (death and/or prolonged hospitalization) had relatively lower and stable Ang1 levels but continuously elevated Ang2 levels, while those who had no adverse outcomes had increasing levels of both Ang1 and Ang2, followed by a decrease in both. These results suggest that the dynamic levels of Ang1 and Ang2 during the clinical course may predict adverse outcomes in COVID-19 patients. Ang1 seems to play an important role in controlling Ang2-related inflammatory mechanisms in COVID-19 patients. IL-6 and anti-SARS-CoV2 spike protein IgG levels were significantly elevated in patients with severe disease. Our findings represent an informative pilot assessment into the role of the angiopoietin signaling pathway in the inflammatory response in COVID-19.

A large range of prognostic models for determining the risk of COVID-19 patient mortality exist, but these typically restrict the set of biomarkers considered to measurements available at patient admission. Additionally, many of these models are trained and tested on patient cohorts from a single hospital, raising questions about the generalisability of results. We used a Bayesian Markov model to analyse time series data of biomarker measurements taken throughout the duration of a COVID-19 patient’s hospitalisation for n = 1540 patients from two hospitals in New York: State University of New York (SUNY) Downstate Health Sciences University and Maimonides Medical Center. Our main focus was to quantify the mortality risk associated with both static (e.g. demographic and patient history variables) and dynamic factors (e.g. changes in biomarkers) throughout hospitalisation, by so doing, to explain the observed patterns of mortality. By using our model to make predictions across the hospitals, we assessed how predictive factors generalised between the two cohorts. The individual dynamics of the measurements and their associated mortality risk were remarkably consistent across the hospitals. The model accuracy in predicting patient outcome (death or discharge) was 72.3% (predicting SUNY; posterior median accuracy) and 71.3% (predicting Maimonides) respectively. Model sensitivity was higher for detecting patients who would go on to be discharged (78.7%) versus those who died (61.8%). Our results indicate the utility of including dynamic clinical measurements when assessing patient mortality risk but also highlight the difficulty of identifying high risk patients.

As Coronavirus Disease 2019 (COVID-19) hospitalization rates remain high, there is an urgent need to identify prognostic factors to improve patient outcomes. Existing prognostic models mostly consider the impact of biomarkers at presentation on the risk of a single patient outcome at a single follow up time. We collected data for 553 Polymerase Chain Reaction (PCR)-positive COVID-19 patients admitted to hospital whose eventual outcomes were known. The data collected for the patients included demographics, comorbidities and laboratory values taken at admission and throughout the course of hospitalization. We trained multivariate Markov prognostic models to identify high-risk patients at admission along with a dynamic measure of risk incorporating time-dependent changes in patients’ laboratory values. From the set of factors available upon admission, the Markov model determined that age >80 years, history of coronary artery disease and chronic obstructive pulmonary disease increased mortality risk. The lab values upon admission most associated with mortality included neutrophil percentage, red blood cells (RBC), red cell distribution width (RDW), protein levels, platelets count, albumin levels and mean corpuscular hemoglobin concentration (MCHC). Incorporating dynamic changes in lab values throughout hospitalization lead to dramatic gains in the predictive accuracy of the model and indicated a catalogue of variables for determining high-risk patients including eosinophil percentage, white blood cells (WBC), platelets, pCO2, RDW, large unstained cells (LUC) count, alkaline phosphatase and albumin. Our prognostic model highlights the nuance of determining risk for COVID-19 patients and indicates that, rather than a single variable, a range of factors (at different points in hospitalization) are needed for effective risk stratification.

Abstract Objectives A 42-year-old African American man with a history of HIV infection on highly active antiretroviral therapy (HARRT) presented with excessive thirst, polydipsia, polyuria, weight loss, and abnormal kidney function tests. Physical examination was normal. Methods The patient workup results were as follows: calcium 13.8 mg/dL (8.4-10.3 mg/dL), ACE 88 U/L (8-52 U/L), PTH 7.34 pg/mL (14-72 pg/mL), 1,25 (OH)2 vitamin D 125 pg/mL (19.9-79.3 pg/mL), BUN 38 mg/dL (6-20 mg/dL), Cr 2.42 mg/dL (0.4-1.2 mg/dL), glucose 87 mg/dL (70-99 mg/dL), CD4 count 303/μL (544-1,894/μL). Chest CT scan showed diffuse pulmonary nodules with mediastinal and bilateral hilar lymphadenopathy. A transbronchial biopsy was performed. Results Biopsy revealed noncaseating granuloma and Schaumann bodies. AFB and GMS stains were negative for micro-organisms. These findings were compatible with sarcoidosis. The patient received prednisone and showed significant improvement in his renal function (creatinine: 1.23 mg/dL) and calcium level (9.12 mg/dL). Conclusion CD4+ T lymphocytes have a crucial role in the formation of sarcoid granulomas. However, HIV infection is characterized by a profound loss of the CD4+ T-lymphocytes. Therefore, sarcoidosis in HIV-positive patients is rare. The development of sarcoidosis usually occurs when a significant increase in CD4+ T-cell count induced by HAART has taken place. Pulmonary involvement and symptoms are responsible for the majority of the morbidity and mortality in sarcoidosis. Renal involvement is significantly less common than respiratory symptoms. This patient was one out of two HI- positive cases of sarcoidosis among 200 patients who were diagnosed with sarcoidosis in our three major affiliated hospitals from 2000 to 2019. This case is unique and rare both in terms of unusual presentation of renal failure and hypercalcemia and also the co-occurrence of sarcoidosis in an HIV-positive patient while the CD4 count is lower than the normal limit.

Abstract Introduction Respiratory infections are very common in hospital patients. Viral pathogens including influenza (Flu) and respiratory syncytial virus (RSV) are frequent causes. Respiratory viral panels (RVPs) have been routinely ordered in our institution with a turnaround time (TAT) of 48 hours at a cost of approximately $170/test. Meanwhile, Flu and RSV PCR are offered in house with a TAT of only 40 minutes and much lower cost ($40/test) than RVP. Here, we examined the optimization of use of these tests in our medical center. Methods Results of the specimens sent for RVP testing as well as their results from Flu/RSV PCR and the negative result rate were reviewed. The TAT and costs were compared between RVP and Flu/RSV PCR. Results We reviewed 69 specimens from MICU sent for RVP during 10/1/2018 to 1/31/2019. Total negative specimen rate was 74%. The specimens identified positive for Flu or RSV by RVP were also positive for in-house Flu/RSV PCR. Therefore, we have recommended clinicians to order in-house highly sensitive and specific Flu/RSV PCR first for faster TAT and cost saving. Since the recommendation, the number of RVP orders has dropped from 660 (January 2018) to 131 (January 2019), with savings of more than $80,000 in 1 month. Conclusion In-house Flu/RSV PCR test is highly sensitive and specific for identifying the common viral pathogens in patients with respiratory infection. It is fast and relatively low cost compared to RVP and should be considered as an effective first-line test.

Objectives Long-term hospitalized patients have a higher risk of adverse outcomes and mortality rate. These patients often rapidly deteriorate, leading to death. We aim to evaluate end-of-life laboratory values time trends among deceased long-term inpatients. Methods Time-stamped laboratory data for adult inpatients who had died in the hospital were extracted. The data were normalized and time-series analysis was performed. The patients were also clustered based on the laboratory result trends. Results Laboratory results from 257 patients were evaluated. Significant time trends were observed: serum urea nitrogen, aspartate aminotransferase, alanine aminotransferase, alkaline phosphatase, and potassium increased while platelets and albumin decreased. Most patients showed significant shifts in at least four major laboratory indices within the last week of life. Conclusions In the last week of life in chronically hospitalized patients, an alteration of the physiologic state of the patient occurs that manifests as subtle changes in metabolite levels compared with the patient's baseline.

Abstract Objectives Bloodstream infection is a major cause of morbidity and mortality in the United States. Rapid identification of bloodstream pathogens is a critical laboratory practice that allows rapid transition to direct targeted therapy, providing timely and effective patient care. Here, we examined the utilization impact of Biofire blood culture identification panel in identifying bloodstream pathogens and subsequent implementation of treatment on patient care at our medical center. Methods Results of patients’ blood culture results and the subsequent medical interventions were reviewed. A policy of reviewing and reporting positive blood culture results every 2 hours was implemented and the results before and after the policy implementation were compared. Results We reviewed blood culture results from 288 patients during 1/20/2018 to 4/30/2018. In total, 96.5% of patients had antibiotic interventions. Based on the blood culture results, the interventions were adjusted: 32% changed in dosing, 32% escalated, 25% deescalated, and 11% added sensitivity. After the every 2-hour blood culture result reporting policy was implemented, the median time for physicians to order escalation dropped from 3 hours to 1 hour and median time to deescalate also dropped from 2 hours to 1 hour. Conclusion We were able to improve the timeliness of identifying bloodstream pathogens and support effective patient care by using the Biofire blood culture identification panel with timely result reports. Rapid identification of bloodstream pathogens had impacted patient outcomes in multiple ways, including reductions in mortality, morbidity, hospital length of stay, antibiotic use, and patient care cost.

Serum protein electrophoresis (SPEP) is frequently ordered by clinicians. Its main utility is to identify monoclonal gammopathies; however, other patterns may contribute to the diagnostic work-up of patients. Currently, there are no set guidelines on utilization of SPEP, and we have noticed an unbalanced rate of useful SPEP results among tests ordered by different departments. Here, we studied SPEP utilization patterns in our setting. All SPEP tests ordered in 2016 were extracted from the hospital database along with ordering physician and result. The results were compared among the different departments using a likelihood-ratio test. The results were simplified into three categories: noncontributory (normal or nonspecific), nonclonal diagnostic (inflammatory pattern), and clonal diagnostic result. Private practice tests performed on outpatient settings were bundled into one group. The results were also binarized into clonal and non-clonal, and a cost-benefit analysis was performed for each department. A total of 796 SPEP tests were performed by our lab in 2016. The results showed that SPEP utilization patterns are significantly different between departments (P = .005), with tests ordered by ER, family medicine, rheumatology, and neurology having the least probability of a contributory SPEP result. Hematology/oncology-, internal medicine-, and private practice-ordered tests had the highest likelihood of contributory results. The private practice had the lowest average cost for a single positive result ($63), followed by hematology/oncology ($66.96). Neurology and rheumatology had the highest average cost for a single positive result ($274.4 and $235.2, respectively). Our results show that SPEP is overused in some clinical settings, and a revision of guidelines for ordering SPEP may be required. We believe our approach will have great implications for understanding utilization patterns and optimizing use of hospital laboratories.

Trichomoniasis is the most prevalent non-viral sexually transmitted infection worldwide. It is caused by the protozoan Trichomonas vaginalis, and the estimated global incidence is over 170 million cases per year, with over 8 million new cases per year in the United States alone. Up to 70% affected are asymptomatic; when symptoms do occur, dysuria, dyspareunia, urethritis, and vaginitis can be observed. Additionally, women are affected at higher rates than men. Despite the relative large overall annual incidence, very few reports have described the characteristics of male patients with T. vaginalis organisms on cytology. We sought to determine the incidence and clinical significance of this finding in the urine cytology of male patients at our medium-sized academic medical center located in a major urban area. We retrospectively reviewed our archived urine cytology slides that reported T. vaginalis organisms spanning a 15-year period. Clinical histories from men with Trichomonas-positive urine were also reviewed and correlated. Slides were reviewed, and the morphologic characteristics of the organisms were recorded. T. vaginalis were detected in nine of 5,094 urine cytology specimens (0.1%). The patients included six women and three men. The age range for men with Trichomonas-positive urine was from 29 to 52 years (mean age, 44 years; median age, 51 years). On cytologic review, T. vaginalis organisms were pear-shaped, oval, or round; they had cyanophilic staining with often evident eosinophilic cytoplasmic granules; there were pale nuclei; and eccentrically located flagella occasionally observed. Acute inflammation was observed in two of three cases. Clinical history was available in three of three men. Lower urinary tract symptoms were reported in three of three men, most commonly hematuria. Urine cytology may represent the initial diagnostic test for Trichomonas in men, and accurate cytologic diagnosis may prevent undesired adverse outcomes for them and their partners.

Metastatic involvement of the appendix is rare but has been reported before. Acute appendicitis induced by a metastatic tumor is also uncommon. We herein present an unusual case of a patient with acute appendicitis secondary to metastatic mammary carcinoma. The patient was a 90-year-old woman who had undergone a left modified radical mastectomy with sentinel lymph node biopsy 14 years earlier. She had subsequently received radiation therapy and chemotherapy but not endocrine therapy. There had been no sign of recurrence for 14 years after the surgical procedure. The patient was recently admitted due to severe abdominal pain. Abdominal computed tomography showed an enlarged appendix with no sign of perforation or abscess, and diffuse mixed lytic and sclerotic osseous metastasis. She was clinically diagnosed with acute appendicitis and underwent appendectomy. Histopathological examination of the appendix revealed metastatic breast carcinoma, ductal type, present in the appendiceal wall. Upon review, the original tumor revealed similar morphological pattern. ER and GATA3 immunohistochemical stains demonstrated strong diffuse positivity, while mammaglobin was focally positive. The neoplasm was negative for chromogranin and synaptophysin. Ki-67 proliferative index was 10%. The appendiceal wall showed acute appendicitis with severe periappendicitis. The patient started endocrine therapy after the surgery. Our review of the literature revealed 13 documented cases of metastatic breast carcinoma identified in the appendix. Appendicitis induced by metastatic breast carcinoma was present in six of these cases. The possibility of metastasis to the appendix must be considered in the diagnosis of right lower quadrant pain in patients with a history of mammary carcinoma.

OBJECTIVES:Our medical center laboratory receives frozen clinical chemistry samples from outlying hospitals for which assays for critical enzyme activities are requested. Our objective is to determine the effects of freezing (-20°C) on these enzyme activities in samples over a one month period.METHODS:Enzyme activities for ALP, AST, ALT, CK and LD for 30 patient's sera were stored at-20°C and were assayed on a Beckman-Coulter AU5800 analyzer at 0, 15 and 30 days after collection. Statistical tests were performed to determine if the values were statistically the same or different.RESULTS:F-tests for all five enzyme levels showed no statistically significant differences (p>>0.05); linear regression analysis showed high correlation of results (r>0.99 for all correlations) with some bias for ALT.CONCLUSIONS:We conclude that the activities of these enzymes are stable, except possibly ALT, when stored frozen at -20°C over the 15- and 30-day storage periods.

Anaplastic large cell lymphoma (ALCL) constitutes approximately 15% of childhood lymphoma cases, showing male predominance. We report a rare case of ALCL presenting as a breast mass in a pediatric patient. The patient is a 14-year-old female who consulted for a lump in the left breast of 2 months’ duration that later progressed to an ulcerative lesion with axillary lymphadenopathy. The lesion was being treated as an abscess for 5 months but was unresponsive to antimicrobial treatment. Excisional biopsy showed breast tissue with overlying ulcerated skin and abscess with sinus formation. Histologically, it showed a mixture of inflammatory cells, including lymphocytes, neutrophils, plasma cells, and scattered large cells, which had abundant gray cytoplasm, large irregular nuclei, and prominent nucleoli. Numerous abnormal mitoses were seen. Immunohistochemical stains were done to delineate the phenotype of large cells. The anaplastic cells were positive for CD30 and MUM1 and negative for CD20, CD79a, CD3, ALK, CD68, S-100, EMA, CK7, mammaglobin, CK5/6, GCDFP, CD15, CD68, CD138, CAM5.2, AE1/AE3, and EBER (EBV in situ hybridization). They had a high proliferation index, 50%, by Ki-67 and expressed a null phenotype (CD4–, CD8–). Clonal rearrangement involving the TCR gamma gene was present. CT scan demonstrated lytic rib and vertebral lesions that were PET positive. Presence of sheets of large anaplastic cells that are CD30+ and ALK– is consistent with the diagnosis of ALCL. Diagnosis of primary breast lymphoma necessitates exclusion of primary cutaneous lymphoma and systemic lymphoma with secondary breast and cutaneous involvement. This is an unusual case of ALCL arising in a young female as a breast mass masquerading as an abscess.

Serum protein electrophoresis (SPEP) with serum protein immunofixation electrophoresis (SPIFE) are clinical laboratory techniques used to identify, evaluate and monitor a wide range of disease states where abnormal serum protein levels are observed.1 Such disorders include solid tumors, lymphoproliferative disorders (eg, multiple myeloma (MM), monoclonal gammopathy of undetermined significance (MGUS), Waldenstrom macroglobulinemia, primary amyloidosis, chronic lymphocytic leukemia, lymphoma), acute and chronic infections, trauma, connective tissue diseases, and liver disorders.2 Clinical indications for ordering SPEPs are varied: suspected lymphoproliferative disorders; unexplained back pain, anemia, weakness or fatigue; osteolytic lesions; unexplained renal insufficiency; hypercalcemia; unexplained peripheral neuropathy; elevated erythrocyte sedimentation rate; and recurrent infections.2 Changes observed in SPEPs follow predictable patterns guiding clinicians toward correct interpretation and diagnosis. Polyclonal gammaglobulin protein elevation typically results from reactive, inflammatory or infectious processes. Monoclonal gammaglobulin protein elevation (monoclonal gammopathy; MG) is typified by a sharp band or monoclonal spike (M-component) confined to the gammaglobulin region of the electrophoretogram; however, MG proteins can also be observed within α-1, α-2 and β-globulin regions.1 2 These monoclonal bands result from a single abnormal plasma cell or B lymphocyte clone, which could be from a malignant (MM, Waldenstrom macroglobulinemia) or premalignant process (MGUS).1 2 Initial SPEP evaluation is typically performed in conjunction with SPIFE to identify and confirm monoclonality, and determine the …

Osteogenesis imperfecta (OI) is an inherited connective disorder characterized by defect in the type 1 collagen and associated with a spectrum of findings ranging from premature osteoporosis and multiple bone fractures to fatal neonatal pulmonary failure.About 85-90% of OI is caused by mutations in the genes COL1A1 and COL1A2, which code for the a1 and a2 collagen I chains, respectively.

Restricted accessAbstractFirst published online February 1, 2016Monoclonal Gammopathy Characterization using Serum Protein Electrophoresis in a Major Urban Population DB Laskar, K Shafique, C Lu, a ZurettiDB Laskar, K Shafique, […], Lu Lu, and A Zuretti+1-1View all authors and affiliationsVolume 64, Issue 3https://doi.org/10.1136/jim-2016-000080.20