Recordings of webinars, certificates of attendance.

Speaker: Anna Merino (ES)
Moderator: Ciriaco Carru (IT)

Recorded at  7th November 2017 18:00 CET

With the advance of the technology of hematology analyzers, the indications for peripheral blood film (PBF) review by an expert have declined, but still remain essential. PBF review contributes to the following: 1) Complements/validates the findings of automated hematology analyzers, 2) Provides information on hematologic abnormalities that cannot be assessed by the current hematology analyzers, 3) Abnormal red cell morphology detection, 4) Identification of blasts, lymphoma or other abnormal cells, 4) Platelet clumping or abnormal platelet morphology inspection and 5) Dyshematopoiesis detection. Some examples are provided in the presentation. It also discusses on some issues related to who performs the PBF review.

 The PBF review by laboratory technologists validates hematology analyzer flags and identifies specific cells or qualitative abnormalities that cannot be identified by hematology analyzers. In addition, technologists triage blood films that require expert morphology review. The contribution of the pathologists is relevant since they are able to make a specific diagnosis, provide differential diagnosis, and/or recommend further testing based on all hematologic quantitative and qualitative values. In addition, they can summarize the findings in a narrative interpretation that becomes part of patient’s medical chart.

 The International Council of Standardization in Hematology (ICSH) is developing standards, guidelines and recommendations in peripheral blood film review internationally, which can provide the following benefits for pathologists: 1) Define the role and standardize the expectations of laboratory physicians, 2) Narrow the indications for PBF review by pathologists to those that contribute to patient care, 3) Provide a framework for reporting and 4) Opportunity for national and international collaboration & advancement of the field. Some of the ICSH recommendations are discussed in the presentation.



Webinar recording + quiz.

Speaker: Ralf Lichtinghagen (GER)

Moderator: Merve Sibel Gungoren (TR)

Recorded at 18th October 2017

The stage of fibrosis is the most important single predictor of significant morbidity and mortality in chronic liver disease. The mechanisms leading to fibrosis and eventually cirrhosis are thought to be similar, irrespective of the underlying etiology. At cellular level, hepatic stellate cells (HSC) undergo a phenotypic switch usually addressed as transactivation. Activated HSC are regarded as the main source of extracellular matrix (ECM) in the fibrotic liver. Additional cell types namely fibroblasts and myofibroblasts may also contribute to ECM deposition. Despite the similarities in pathophysiology at cellular level, morphogenesis and histologic appearance of the fibrotic liver may differ according to the etiology.

Liver biopsy remains the gold standard to evaluate liver fibrosis. Not least, one has to keep in mind that liver biopsy provides additional information like histological grading and etiology that may be overlooked when surrogate markers are used. Ideally, those tests should answer two questions. 1) What is the stage of fibrotic organ damage (i.e. the amount of deposited ECM and the disturbed balance of hepatic microarchitecture)? 2) What is the net balance between ECM deposition and degradation (i.e. the dynamics of ECM turnover)? The former serves to evaluate the prognosis and indicate therapy, while the latter might be used to control the efficacy of treatment with regard to disease progression.

Many different parameters including standard clinical chemistry and parameters of matrix metabolism have been evaluated. In the last decade, markers were assembled to multiparametric scores. Here, we can distinguish scores assembled of standard clinical chemistry markers (e.g. aspartate aminotransferase-to-platelet ratio index, FibroTest, Forns’ index) from scores using circulating markers of hepatic matrix metabolism like hyaluronic acid (HA), tissue inhibitor of metalloproteinases-1 (TIMP-1), matrix metalloproteinase-2, propeptide of type III procollagen (PIIINP).

In the webinar we will learn further details about the relevant complex scores, the clinical evaluation and current practical guidelines.

A 66-year-old woman was admitted to our hospital with shock and multiorgan failure. She was resident in the United States, in a rural area of New Jersey. She had been on vacation in Europe for 3 weeks and had suffered fever and chills for 1 week, and nausea, vomiting and abdominal pain for 2 days.On admission she showed respiratory, hepatic and renal failure, anemia, lymphopenia, thrombocytopenia, high lactate dehydrogenase (3500 IU/L; normal: 250–450) and negative direct and indirect Coombs test.The peripheral blood (PB) film revealed the diagnosis of the patient. Some interesting images of the morphological findings in blood cells will be discussed during the presentation. It will be useful for the participants to learn about the differential diagnosis in this special case, since the abnormalities that we found in blood cells can be easily confused with those of other more frequent disease. Diagnosis can be challenging and therefore knowledge of the distinguishing clinical features and epidemiology of these diseases is important. In addition to morphology, an adequate clinical history is important for speedy and accurate diagnosis.

Biomarkers that are surrogates for cardiac pathophysiology may help us understand the "state of the heart" in heart failure and may be indications for certain treatments. A good biomarker will also be able to be monitored and a change in the level will reflect a change in the condition. I will speak of three biomarkers that do exactly this (natriuretic peptides, high sensitivity troponins and sST2). Natriuretic peptides (NPs) (BNP and NTproBNP) are guideline standards to confirm the diagnosis of heart failure. They are good for monitoring volume as we diurese the patient. Their weaknesses include wide variability in levels in a given patient as well as elevations not secondary to an increase in left sided filling pressures. Additionally, their value is questionable in patients receiving Entresto (a drug that inhibits breakdown of NPs). High sensitivity troponin in the setting of acute heart failure (and maybe chronic) represents subendocardial necrosis and has a bad prognosis. It is possible that drugs like nitrates will be used in heart failure treatment more commonly when levels of high sensitivity troponin are high. Finally, sST2 is a marker of fibrosis and is elevated in virtually all patients with heart failure. In the acute setting, it defines a "sicker" patient who needs advanced treatment to avoid re-hospitalization. In the chronic setting, titrating medication to a sST2 level below 35 ng/ml appears to mitigate risk, even in the setting of a continued high NP level. Data with Entresto suggest sST2 levels are going to be useful in both selection of patients for Entresto as well as monitoring treatment and maybe regulating the dose.

Fasting blood samples have been the standard for measurement of triglycerides and cholesterol, despite the fact that we spend the vast majority of our time in non-fasting conditions. However, when recent studies suggest that postprandial effects do not substantially alter lipid concentrations and do not weaken, and even may strengthen, their association with cardiovascular risk, then a non-fasting blood draw has many practical advantages. Non-fasting cholesterol measurements include the ‘remnant cholesterol’ fraction, a strong risk factor for developing atherosclerosis independent of LDL cholesterol. Remnant cholesterol reflects the cholesterol in chylomicron- and VLDL-remnant particles and it is included in the ‘non-HDL cholesterol’ calculation.
Until recently, most guidelines focused on targeting primarily LDL cholesterol for the prevention of cardiovascular disease, but they now recognize that non-HDL cholesterol (or apolipoprotein B, the molecule carried by all non-HDL particles) is a more accurate and comprehensive predictor of atherogenic lipoprotein-related risk.
In 2016, the European Atherosclerosis Society (EAS) and EFLM Joint Consensus Panel recommended using non-fasting lipid testing for routine clinical practice and provided specific cutpoints for desirable fasting and non-fasting lipid concentrations to be reported by the laboratories uniformly.

The estimate of measurement uncertainty is important in Laboratory Medicine because it is required for reference measurement laboratories to obtain/maintain the accreditation according to ISO 17025:2003 and ISO 15195:2005 and for clinical laboratories to obtain the accreditation according to ISO 15189:2012. There are two approaches to estimate measurement uncertainty, the so-called ‘bottom-up’ and ‘top-down’ approaches.

At the beginning of 2015 the monograph “Rational Ordering of Laboratory Parameters” in Slovak language has been issued. The monograph with 185 pages from 4 editors and 18 authors represents an attempt to create a common denominator contributing to the consensus between clinicians, laboratory specialists and healthcare providers. This webinar discusses common problems in rational ordering of laboratory test.

E-learning offers a broad variety of tools that can bridge information gap between these worlds. In this interactive webinar, we will cover following objectives:

  • overview of basic tools used in e-learning
  • familiarize attendants with 5 commonly used ways of delivering content by e-learning (webinar, voice-over presentation, quiz, user generated content + social media, e-book)
  • give examples and practical hints for creating attractive educational materials

The preanalytical phase is the main contributor to diagnostic errors. Modifying staff behaviour to conform to venous specimen collection practice guidelines and other recommended practices has proved to be a difficult task.