Clinical usefulness of automated cellular analysis of synovial fluids: a paradigmatic case report for diagnosing peri-prosthetic infections

We describe here the case of an 18 years old male patient who underwent osteosynthesis surgery with a plate and screws for multi-fragment fracture of his right femur, in December 2000. The patient developed a series of complications up to May 2017, when he was readmitted with severe functional impairment and inability to walk without crutches. Physical examination revealed erythema, swelling at surgical site and leakage of pus from sinus-tract. An arthrocentesis was hence performed, followed by white blood cell count and differential in synovial fluid with Sysmex XN 2000 body fluid mode. The final leukocyte count was 38 7109/L, with 95% polymorphonuclear leukocytes (PMN), thus compatible with peri-prosthetic infection. The patient underwent additional surgery to remove the knee replacement, accurate debridement and antibiotic impregnated static cement spacer implantation. Three months after surgery, the patient was readmitted for removing the spacer, replaced by a new static device. In May 2018, surgical debridement and removal of the spacer was scheduled with resection arthroplasty. In November 2018 the patient presented again a sinus tract, and underwent another arthrocentesis for physical and microbiological examination of synovial fluid. The leukocyte count in the synovial fluid was again performed with Sysmex XN 2000 body fluid mode, and revealed the presence of 44.5 7109/L cells, with 90% PMN. The synovial fluid was positive for Van-A Enterococcus faecalis, so that right hip disarticulation was urgently planned. In conclusions, this case provides clear evidence that automated leukocyte count and differential in synovial fluid shall now be considered an unavoidable part of the diagnostic approach to patients with suspected peri-prosthetic infections

Colorectal Cancer Stage at Diagnosis Before vs During the COVID-19 Pandemic in Italy

IMPORTANCE Delays in screening programs and the reluctance of patients to seek medical attention because of the outbreak of SARS-CoV-2 could be associated with the risk of more advanced colorectal cancers at diagnosis. OBJECTIVE To evaluate whether the SARS-CoV-2 pandemic was associated with more advanced oncologic stage and change in clinical presentation for patients with colorectal cancer. DESIGN, SETTING, AND PARTICIPANTS This retrospective, multicenter cohort study included all 17 938 adult patients who underwent surgery for colorectal cancer from March 1, 2020, to December 31, 2021 (pandemic period), and from January 1, 2018, to February 29, 2020 (prepandemic period), in 81 participating centers in Italy, including tertiary centers and community hospitals. Follow-up was 30 days from surgery. EXPOSURES Any type of surgical procedure for colorectal cancer, including explorative surgery, palliative procedures, and atypical or segmental resections. MAIN OUTCOMES AND MEASURES The primary outcome was advanced stage of colorectal cancer at diagnosis. Secondary outcomes were distant metastasis, T4 stage, aggressive biology (defined as cancer with at least 1 of the following characteristics: signet ring cells, mucinous tumor, budding, lymphovascular invasion, perineural invasion, and lymphangitis), stenotic lesion, emergency surgery, and palliative surgery. The independent association between the pandemic period and the outcomes was assessed using multivariate random-effects logistic regression, with hospital as the cluster variable. RESULTS A total of 17 938 patients (10 007 men [55.8%]; mean [SD] age, 70.6 [12.2] years) underwent surgery for colorectal cancer: 7796 (43.5%) during the pandemic period and 10 142 (56.5%) during the prepandemic period. Logistic regression indicated that the pandemic period was significantly associated with an increased rate of advanced-stage colorectal cancer (odds ratio [OR], 1.07; 95%CI, 1.01-1.13; P = .03), aggressive biology (OR, 1.32; 95%CI, 1.15-1.53; P < .001), and stenotic lesions (OR, 1.15; 95%CI, 1.01-1.31; P = .03). CONCLUSIONS AND RELEVANCE This cohort study suggests a significant association between the SARS-CoV-2 pandemic and the risk of a more advanced oncologic stage at diagnosis among patients undergoing surgery for colorectal cancer and might indicate a potential reduction of survival for these patients

Biochemical markers in the follow-up of the osteoporotic patients

Osteoporosis, a disease characterised by low bone mass and micro-architectural deterioration of bone tissue, is viewed as an emerging medical condition. Bone mineral density (BMD) is considered the gold standard of bone status assessment, however it does not offer the timely response desirable for monitoring. Biochemical markers of bone turnover (BTMs) are claimed to be suitable for that purpose. There is not generalized agreement on which marker could be used in routine. The present paper reviews pros and cons of currently used BTMs and relative analytical methods. Several analytical issues, such as biological variability, molecules stability, lack of reference materials jeopardize the field and, consequently, recommendations are difficult to be drawn. Reference range can’t be used to support clinical judgement and, in this view, Least Significant Change (LSC) is regarded as a way to improve the interpretation of analytical results. Bone alkaline phosphatase (bALP) is still a marker of interest and its use is widespread in clinical laboratories; Tartrate Resistant Acid Phosphatase band 5b (TRAP 5b) appears to be a promising marker. N-terminal propeptides of type I collagen (s-PINP) and beta-collagen 1 C-terminal cross linked telopeptides (s-CTX), given low biological variability and assay availability for automatised instruments, should be the marker of choice in future clinical trials, to overcome the paucity of uniform data and should be used in clinical routine, to monitor osteoporosis treatment. Finally, the lack of standardisation of currently available diagnostic methods, could be overcome by harmonisatio

Analytical Evaluation of a Vancomycin Immunoassay in Synovial Fluid

In clinical laboratories performing routine activities, the need to answer the burning clinical question in emerging field may be limited by lack of technology support or assays accessibility. Commercially available methods, although originally validated for specific biological matrices, may be employed for other matrices, following appropriate guidelines such as Clinical and Laboratory Standards Institute (CLSI) EP 19. We investigated the use of a vancomycin assay with synovial fluid samples, in view of a possible employment in vancomycin release study. The standard of care of periprosthetic joint infection is a two- stage revision surgery with antibiotic-loaded bone cement implantation. Vancomycin, for its activity against gram-positive bacteria even multidrug-resistant staphylococci, is the most widely used antibiotic. Despite the widespread use of such devices, little is known about the in vivo elution in the joint space. Clinical laboratories equipped with a validated, affordable method to quantify vancomycin in synovial fluid, may support clinical research, and give an important contribution to the study of the pharmacokinetics of antibiotic release from bone cement matrix

Validation of an immunoturbidimetric assay for assessment of C reactive protein in synovial fluid

Validation of an immunoturbidimetric assay for assessment of C reactive protein in synovial flui

Forcing host-pathogen interactions in C. gigas and M. galloprovincialis transplanted into the Goro lagoon (North Adriatic Sea, Italy)

Located south of the Po River Delta, the lagoon of Goro is one of the main clam farming areas in Italy and has been object of previous investigations. C. gigas is naturally present beyond the Scanno di Goro (off-shore) and has been reported inside the lagoon. In 2010, French oyster seed deployed locally resulted positive to OsHV-1 \u3bcVar, though no evidence of oyster mortality was recorded. For the monitoring purposes, juvenile native mussels and oysters obtained from French seed have been allowed to grow close, in sectors of baskets suspended in the lagoon water, hence more likely affected by potential pathogens and parasites. Bivalve mortality rates as well as biological and environmental parameters were monitored at each sampling. According to previous inter-laboratory calibration exercises, molecular and histological methods have been applied to the detection of OsHV-1 \u3bcVar and other typical pathogens. The presence of Vibrio splendidus and V. aestuarianus was analyzed in the bivalve flesh by culture-dependent and molecular assays. To better understand the effects of biotic and abiotic factors on the host defense mechanisms, selected paired sets of oyster and mussel tissues have been processed to purify the total RNA and perform comparative gene expression studies via advanced transcriptome sequencing (Illumina). The resulting output reads from both oysters and mussels have been re-assembled together with pre-existing sequence data in order to obtain a more comprehensive view of the species-specific transcriptomes

The gap between practice and methodology: the case of esterase in Periprosthetic Joint Infection

Introduction: the diagnosis of periprosthetic joint infection (PJI) is a clinical challenge. Among other clinical and laboratory parameters, recent recommendations for the diagnosis of PJI advocate the assessment of leukocyte esterase in synovial fluid (SF), commonly performed with urine test strips, a method that is not validated for such a matrix. To challenge this practice, we evaluated the performance of a commercial urine test strip to assess leukocyte esterase in SF compared with leukocyte counting. Methods: between October 2017 and September 2019, SF samples were collected from patients scheduled for revision surgery for 6 painful total knee arthroplasties. International Consensus Meeting (ICM) criteria were used to classify PJI. Leukocyte esterase (visual assessment with Menarini Aution test strips) and automated leukocyte count (Sysmex 2000, XN- 8 Body Fluids Module) were assessed in 74 SF specimens. Results: the AUC of leukocyte esterase compared with automated leukocyte counting ranged from 0.88 to 0.94. Leukocyte esterase cutoff values of 500, 250, and 75 leukocytes/μL yielded sensitivity values ranging from 0.78-1.00, 0.87-1.00, and >0.96, respectively, whereas specificity ranged from 0.76-0.94, 0.61-0.78, and <0.37. The diagnostic performance of leukocyte esterase was higher when hemolyzed samples were excluded. Discussion: our results highlight the many limitations of using conventional urine test strips to visually assess leukocyte esterase in SF specimens, underscoring the need to develop specific assays or perform validation studies before implementing a diagnostic procedure

Optimization of Cellular analysis of Synovial Fluids by optical microscopy and automated count using the Sysmex XN Body Fluid Mode

This study was planned to assess the impact of pre-treating synovial fluid (SF) samples with hyaluronidase (HY), defining the best procedure for optical microscopy (OM) analysis and evaluating the performance of Sysmex XN-9000 Body Fluid module (XN-BF)

Recommendations for the detection and management of critical results in clinical laboratories

Critical results, (also known as panic or alarm results) identify a laboratory test result associated with a serious risk for the patient\u2019s health, requiring immediate communication to the physician to establish appropriate therapeutic interventions. The adoption of an efficient procedure for the communication of critical values/results is crucial for clinical, ethical, organizational reasons, because it is a requirement for laboratory accreditiation and because of potential legal consequences related to the lack of notification of harmful laboratory results. In 2008, the Italian Society of Clinical Biochemistry and Laboratory Medicine (SIBioC) published its first consensus-based recommendation for the detection and management of critical values in clinical laboratories, with the aim to improve the implementation of standardized and universally accepted procedures, promoting an essential policy toward rational and efficient solutions to this issue. These new recommendations represent a complete review of the first document. Using the same consensus conference method between experts of scientific societies, the main aspects of clinical risk, patient safety and legal liability of health care workers were re-considered. The SIBioC and the Italian Society of Laboratory Medicine (SIPMeL), Intersociety Study Group on Standardization of extra-analytical variability of laboratory results, together with the Italian Society of Ergonomics and Human Factors (SIE) collaboration, issued the present join document