Challenges in the implementation of the NeoOBS study, a global pragmatic observational cohort study, to investigate the aetiology and management of neonatal sepsis in the hospital setting

Neonatal sepsis is a significant cause of mortality and morbidity in low- and middle-income countries. To deliver high-quality data studies and inform future trials, it is crucial to understand the challenges encountered when managing global multi-centre research studies and to identify solutions that can feasibly be implemented in these settings. This paper provides an overview of the complexities faced by diverse research teams in different countries and regions, together with actions implemented to achieve pragmatic study management of a large multi-centre observational study of neonatal sepsis. We discuss specific considerations for enrolling sites with different approval processes and varied research experience, structures, and training. Implementing a flexible recruitment strategy and providing ongoing training were necessary to overcome these challenges. We emphasize the attention that must be given to designing the database and monitoring plans. Extensive data collection tools, complex databases, tight timelines, and stringent monitoring arrangements can be problematic and might put the study at risk. Finally, we discuss the complexities added when collecting and shipping isolates and the importance of having a robust central management team and interdisciplinary collaborators able to adapt easily and make swift decisions to deliver the study on time and to target. With pragmatic approaches, appropriate training, and good communication, these challenges can be overcome to deliver high-quality data from a complex study in challenging settings through a collaborative research network

Challenges in the Implementation of the NeoOBS Study, a Global Pragmatic Observational Cohort Study, to Investigate the Aetiology and Management of Neonatal Sepsis in the Hospital Setting

Neonatal sepsis is a significant cause of mortality and morbidity in low- and middle-income countries. To deliver high-quality data studies and inform future trials, it is crucial to understand the challenges encountered when managing global multi-centre research studies and to identify solutions that can feasibly be implemented in these settings. This paper provides an overview of the complexities faced by diverse research teams in different countries and regions, together with actions implemented to achieve pragmatic study management of a large multi-centre observational study of neonatal sepsis. We discuss specific considerations for enrolling sites with different approval processes and varied research experience, structures, and training. Implementing a flexible recruitment strategy and providing ongoing training were necessary to overcome these challenges. We emphasize the attention that must be given to designing the database and monitoring plans. Extensive data collection tools, complex databases, tight timelines, and stringent monitoring arrangements can be problematic and might put the study at risk. Finally, we discuss the complexities added when collecting and shipping isolates and the importance of having a robust central management team and interdisciplinary collaborators able to adapt easily and make swift decisions to deliver the study on time and to target. With pragmatic approaches, appropriate training, and good communication, these challenges can be overcome to deliver high-quality data from a complex study in challenging settings through a collaborative research network

Antinuclear antibodies in diagnosis of connective tissue diseases: application of a diagnostic algorithm in autoantibody testing and the assessment of economic efficiency

Serological testing for the detection of autoantibodies is without doubt vital ineveryday clinical practice, regarding initial diagnosis of connective tissue disorders,their systematic monitoring as well as evaluation of treatment used.A clinical laboratory oriented towards autoimmune disorders evaluation, performs,among others, anti-nuclear (ANA) and anti-extractable nuclear antigen (anti-ENA), aswell as anti-double stranded DNA (anti-dsDNA) antibodies detection.One should consider the impact of unwarranted testing not only due to cost but alsoon timely result delivery, which can lead to prolonged undue hospitalizations andeven delays in necessitated prompt treatment so it is evident that these tests shouldbe ordered following careful consideration. To this end the presence of substantialindications of an underlying immunological disorder from the patient’s medicalhistory and current clinical presentation is essential, as well as the closecollaboration of the clinical and laboratory staff not only in interpreting results butalso in planning additional patient-tailored testing.AIMThe aim of this large retrospective study was to evaluate the presence of antinuclearantibodies as well as their specificity in autoimmune disorders diagnosis,differential diagnosis and disease prognosis. Finally, a diagnostic algorithm onsystemic autoantibodies detection and identification is proposed in order lowlaboratory cost with maximum diagnostic accuracy and value to be obtained.Patients and methodsThe study included a total of 23.822 consecutive blood samples collected over athree year period, from both hospitalized and outpatients of the “Evangelismos”General Hospital, referred to the Dept of Immunology-Histocompatibility for ANAand other specific autoantibodies testing. The majority of patients tested werefemales 70,2% (16.727) while the remaining 29,8% (7.095) males. Outpatientsamples accounted for 59,7% of the total samples assessed. During the study period different clinical Depts requested autoimmune antibody testing for hospitalizedpatients with the Internal Medicine and Neurology Depts exhibiting the largestpercentages of referrals (13,5% and 8,3% respectively).ANA were detected by indirect immunofluorescence using Hep-2 cells. Samplesreferred for anti-dsDNA antibodies were initially screened using indirectimmunofluorescence with Crithidia luciliae as a substrate and subsequently positivesamples were quantified with a radioimmunology assay (RIA). Enzyme-linkedimmunosorbent assay (ELISA) was used to screen for anti-ENA antibodies and toidentify anti-rib P, anti-HIST and anti-ENA (anti-Sm, anti-RNP, anti-SSA, anti-SSB andanti-Jo-1) antibodies. Finally, anti- Scl-70 antibodies were detected usingOuchterlony double immunodiffusion.Statistical analysisFor the results statistical analysis the program SPSS 17.0 was used. Absolute (Ν) andrelative values (%) were used for the definition of qualitative variables, whereas thePearson’s χ2 or the Fisher's exact test was applied for the correlation, where it wasnecessary. The significance level was set at 0.05.ResultsTesting for ANA was requested and performed on all samples (23.822), anti-dsDNAwere sought on a total of 18.111 samples, while anti-ENA on 13.018 samples. For themajority of samples (46,1%) the initial referral included all three of theaforementioned antibodies, while only 15,4% requested only the detection of ANA,which is however the basic screening test for immunological disorders.1. Determination of ANA fluorescence titre and pattern showed the followingresults: a. About half of the samples sent to our laboratory (11.944 - 50,1%) werenegative for ANA, while 49,9% were positive. In positive samples ANA titre ofmarginally positive values (1:160) accounted for the largest percentage (18,8%),while significantly positive titres of (>1/640) were next in frequency (13,8%). b. Speckled type fluorescence was the most commonly observed (68,40%),followed by the homogeneous type (22,4%). Pleomorphic patterns due toproliferating cell nuclear antibodies (PCNA) and Golgi apparatus were rarelyobtained, at low incidence (0,05% and 0,01% respectively).c. Highly positive samples (titres > 1:640) were more commonly found in femalesthan in males (17,2% and 5,9% respectively).2. In regards to ANA specificity, positive anti-dsDNA were noticed in 5,0% of thesamples tested. The highest percentages were found in those samples sent frompatients of the Rheumatology (19,3%) and Nephrology (15,0%) Dept and from theoutpatient pool (5,8%). Anti-dsDNA retrieval rates from other Hospital Depts weresignificantly lower (0,6%-2,5%).3. Positive anti-ENA screening tests were noticed in 11,1% of the samples tested.Outpatient samples statistically accounted for the largest percentage (11,6%).However in absolute numbers the majority of positive anti-ENA samples originatedfrom patients of the Rheumatology Dept followed by those from the InternalMedicine and Nephrology Depts.4. Statistically significant difference (p 1:640.β. Ο πιο συχνός τύπος φθορισμού ήταν ο στικτός (68,40%) και ακολουθεί ο διάχυτος (22,47%), ενώ η παρουσία φθορισμού PCNA (proliferating cell nuclearantibodies) και συσκευής Golgi εμφανίζονται σπανιότατα (0,05 και 0,01 αντίστοιχα).γ. Θετικά δείγματα σε υψηλούς τίτλους (>1:640) ανευρίσκονται σε μεγαλύτερα ποσοστά στις γυναίκες απ’ ότι στους άνδρες (17,2% έναντι 5,9%)2. Αναφορικά με την αναζήτηση της ειδικότητας των ΑΝΑ, θετικά αντι-dsDNAαντισώματα καταγράφηκαν στο 5,0% του συνόλου των δειγμάτων, με υψηλότερα ποσοστά στους ασθενείς της Ρευματολογικής (19,3%) και της Νεφρολογικής Kλινικής (15,0%) και του Eξωτερικού Iατρείου (5,8%). Σε όλες τις άλλες κλινικές θετικά αντι-dsDNA καταγράφηκαν σε πολύ χαμηλότερα επίπεδα (0,6%-2,5%).3. Θετικά αντι-ΕΝΑ (screening test) αντισώματα προσδιορίστηκαν στο 11,1% του συνόλου των δειγμάτων, με υψηλότερο ποσοστό σε δείγματα του Εξωτερικού Ιατρείου (11,6%). Σε απόλυτους όμως αριθμούς τα περισσότερα αντι-ΕΝΑ θετικά δείγματα καταγράφονται στην Ρευματολογική και ακολουθεί η Παθολογική και η Νεφρολογική Kλινική. 4. Στατιστικά σημαντική διαφορά (p<0,001) προκύπτει από την σύγκριση της ειδικότητας των ΑΝΑ με την θετικότητα τους, καθώς η παρουσία ειδικότητας κυμαίνεται σε ποσοστό από 0% έως 3,4% για τις περισσότερες παραμέτρους, όταντα ΑΝΑ είναι αρνητικά. Εξαίρεση αποτελεί η παρουσία των αντι-rib P και αντι-Jo1 σε ποσοστό 14,8% (p=0,720) και 1,2% (p=0,702) αντίστοιχα, διότι δίνουνκυτταροπλασματική εικόνα φθορισμού στα Hep-2, άρα αρνητικά ΑΝΑ. Αξίζει όμως να σημειωθεί ότι στατιστικά σημαντική διαφορά (p<0,001) καταγράφεται επίσης από την σύγκριση της ειδικότητας των ΑΝΑ με την αύξηση του τίτλου των ΑΝΑ. 5. Από την εκτίμηση του συνδυασμού της ειδικότητας των ΑΝΑ με τον τύπο φθορισμού προκύπτει ότι τα αντι-dsDNA αντισώματα συνοδεύονται συνήθως με διάχυτο τύπο (23,3%), ενώ τα αντι-ΕΝΑ με στικτό τύπο (20,1%) φθορισμού.6. Από την καταγραφή και αξιολόγηση των επαναληπτικών μετρήσεων των ΑΝΑ(7864 δείγματα) προκύπτουν τα ακόλουθα αποτελέσματα:α. Το 58,2% των επαναλήψεων αφορούν σε εξωτερικούς ασθενείς, ενώ σχετικά χαμηλό ποσοστό (3,5%) αφορά σε ασθενείς της Ρευματολογική ςΚλινικής. β. Ο αριθμός των επαναληπτικών μετρήσεων ανά ασθενή κυμαίνεται από 2 έως 15 στην τριετία που μελετήθηκε. Αξίζει να σημειωθεί ότι υψηλό ποσοστό (39,7%) επαναλήψεων παρατηρήθηκε και επί αρνητικών ΑΝΑ σε προηγούμενη μέτρηση.γ. Από την ανάλυση των μεταβολών του τίτλου των ΑΝΑ σε επαναλαμβανόμενες μετρήσεις, πολύ χαμηλά ποσοστά, 1,6%, 4,1% και 9%καταγράφονται σε μεταβολές 4, 3 και 2 αραιώσεων αντίστοιχα.δ. Το μεγαλύτερο ποσοστό των επαναλήψεων (73,2%) ζητήθηκε μέσα στον πρώτο χρόνο και μάλιστα από αυτό το ποσοστό το 33,3% στο πρώτο τρίμηνο, το 19,7% στο δεύτερο και μόνο το 7,1% τον τρίτο χρόνο από την αρχική μέτρηση. Συμπεράσματα. Η συνεχώς αυξανόμενη συχνότητα αυτοάνοσων νοσημάτων που παρατηρείται παγκοσμίως, σε συνδυασμό με την ραγδαία εξέλιξη της τεχνολογίας και την εφαρμογή νέων μεθοδολογιών ανίχνευσης αυτοαντισωμάτων, έχει οδηγήσει σε αύξηση της ζήτησης του προσδιορισμού αυτών. Στο σημερινό περιβάλλον, όπου υπάρχει μια διάχυτη τάση για μείωση του κόστους υγείας σε όλα τα επίπεδα επιβάλλεται η ορθολογική χρήση των δοκιμασιών αυτών για μια καλύτερη σχέση κόστους/οφέλους, χωρίς βέβαια να γίνεται εις βάρος της βέλτιστης ποιότητας περίθαλψης των ασθενών. Σεβόμενοι τις ανάγκες των κλινικών γιατρών στην καθημέρα κλινική πράξη, καθώς και τις ιδιαιτερότητες του Ανοσολογικού Εργαστηρίου αναφορικά με την χρησιμοποιούμενη μεθοδολογία, προτείνουμε την εφαρμογή κατευθυντήριων οδηγιών ως προς την αναζήτηση των αυτοαντισωμάτων αφενός μεν για την αποφυγή περιττών εργαστηριακών εξετάσεων αφετέρου δε, για την πληρέστερη διαγνωστική προσέγγιση των αυτοάνοσων νοσημάτων

Impact of Age and Sex on Antibody Response Following the Second Dose of COVID-19 BNT162b2 mRNA Vaccine in Greek Healthcare Workers

International audienceAnti-SARS-CoV-2 spike RBD (receptor-binding domain) IgG antibody levels were monitored in 1643 volunteer healthcare workers of Eginition, Evangelismos, and Konstantopoulio General Hospitals (Athens, Greece), who underwent vaccination with two doses of COVID-19 BNT162b2 mRNA vaccine (Pfizer) and had no history of SARS-CoV-2 infection. Venous blood was collected 20–30 days after the second vaccine dose and anti-RBD IgG levels were determined using CMIA SARS-CoV-2 IgG II Quant (Abbott) on ARCHITECT i System or ADVIA Centaur SARS-CoV-2 IgG (Siemens) on Centaur XP platform. From the total population of 1643 vaccinees (533 M/1110 F; median age = 49; interquartile range-IQR = 40–56), 1636 (99.6%) had anti-SARS-CoV-2 IgG titers above the positivity threshold of the assay used. One-Way ANOVA Kruskal-Wallis H test showed a statistically significant difference in the median of antibody titers between the different age groups (p < 0.0001). Consistently, Spearman’s correlation coefficient (r) for IgGs and age as continuous variables was −0.2380 (p = 1.98 × 10−17). Moreover, antibody titers were slightly higher by 1.2-mean fold (p = 3 × 10−6) in the total female population of the three hospitals (median = 1594; IQR = 875–2584) as compared to males (median = 1292; IQR = 671.9–2188). The present study supports that BNT162b2 vaccine is particularly effective in producing high anti-SARS-CoV-2 IgG levels in healthy individuals, and this humoral response is age- and gender-dependent