G Gessoni

Azienda ULSS numero 14 Chioggia, Chioggia, Veneto, Italy

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Publications (51)76.96 Total impact

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    ABSTRACT: Paroxysmal nocturnal hemoglobinuria (PNH) is a clonal nonneoplastic hematopoietic stem cell disease characterized by an acquired mutation of the PIG-A gene with reduction or absence of CD55 and CD59. The absence of these proteins renders PNH erythrocytes susceptible to complement-mediated hemolysis. We report the case of a PNH patient before and during pregnancy until delivery. We observed and treated some postpartum thrombotic complications. Eculizumab should be used with caution in pregnancy. There are several reports supporting its use in these patients. This case should be considered paradigmatic of a series of clinical situations that may occur in the course of a pregnancy in patients with PNH: increased need for transfusion, need to increase the dose of Eculizumab, and insurgence of fetal sufferance. Moreover, after delivery, the patient, despite adequate prophylaxis with low-molecular-weight heparins, presented severe complications: development of pleural and peritoneal effusion, pulmonary embolism, bilateral upper limbs thrombophlebitis, and a possible abdominal angina with a transient paralytic ileus. All these complications were overcome and now the baby is healthy and the mother has returned to the usual therapeutic regimen.
    Blood coagulation & fibrinolysis: an international journal in haemostasis and thrombosis 02/2015; 26(4). DOI:10.1097/MBC.0000000000000250 · 1.38 Impact Factor
  • Gianluca Gessoni · Sara Valverde · Francesca Gessoni · Roberto Valle
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    ABSTRACT: Urine culture is the most frequently requested test for a Microbiology Lab. A reliable screening tool would be of paramount importance both to clinicians and laboratorians, provided that it could get fast and accurate negative results in order to rule-out urinary tract infection (UTI). We evaluated 1907 consecutive urine samples from outpatients. Culture was performed on chromogenic agar with 1μL loop, using 10(5)CFU/mL as a limit of positive growth. Using Sysmex Uf-1000i analyzer we evaluated bacteria forward scatter (B_FSC) and fluorescent light scatter (B_FLH) in a preliminary discrimination step for UTI caused by Gram+ or Gram- bacteria. We got 512 positive samples. A mono-microbial infection was observed in 490 samples; two bacterial strains were isolated in 22 samples, so 534 bacterial strains were found: 392 Gram-, 133 Gram+ and 9 yeasts. Comparing Gram+ and Gram- bacteria we observed a statistically significant difference for B_FSC but not for B_FLH. In this application experimental cut-off value for B_FSC was 25ch. Using this cut-off to perform a presumptive identification of UTI sustained by Gram-+ bacteria, we observed a SE 0.68, SP 0.84. Our data although preliminary suggest that B_FSC could be useful in presumptive exclusion of UTI caused by Gram-positive bacteria. Copyright © 2014. Published by Elsevier B.V.
    Clinica Chimica Acta 11/2014; 440. DOI:10.1016/j.cca.2014.11.022 · 2.82 Impact Factor
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    ABSTRACT: We performed a multicenter study to calculate the upper reference limits (URL) for urine particle quantification in mid-stream samples by using automated urine analyzers. Two laboratories tested 283 subjects using a Sysmex UF-100, two other laboratories tested 313 subjects using Sysmex UF-1000i, whereas two other laboratories tested 267 subjects using Iris IQ®200. The URLs of UF-100 in females and males were 7.8/μL and 6.7/μL for epithelial cells (EC), 11.1/μL and 9.9/μL for red blood cells (RBC), 10.2/μL and 9.7/μL for white blood cells (WBC), and 0.85/μL and 0.87/μL for cylinders (CAST). The URLs of UF-1000i in females and males were 7.6/μL and 7.1/μL for EC, 12.2/μL and 11.1/μL for RBC, 11.9/μL and 11.7/μL for WBC, and 0.88/μL and 0.86/μL for CAST. The URLs of Iris IQ®200 in females and males were 7.8/μL and 6.6/μL for EC, 12.4/μL and 10.1/μL for RBC, 10.9/μL and 9.9/μL for WBC, and 1.1/μL and 1.0/μL for CAST. The URLs obtained in this study were comparable to the lowest values previously reported in the literature. Moreover, no gender-related difference was observed, and analyzer-specific upper reference limits were very similar.
    Clinica chimica acta; international journal of clinical chemistry 09/2013; 427. DOI:10.1016/j.cca.2013.09.012 · 2.76 Impact Factor
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    ABSTRACT: The purpose of this Italian multicenter study was to define pediatric upper references values for urine particles quantification by using automated flow cytometry. Design and Methods Four hospital-based clinical laboratories participated to this multicenter investigation, which included a total study population of 161 Italian children aged from 1 to 12years. Two laboratories used Sysmex UF-100 and analyzed 86 children, whereas the other two used Sysmex UF-1000i and analyzed 75 subjects. Particles quantification included the analysis of white blood cells (WBC), red blood cells (RBC), squamous epithelial cells (EC), transitional epithelial cells (TC), casts (CAST) and bacteria (BACT). The upper references values in subjects tested with the Sysmex UF-100 were 9.7 WBC/μL, 10.1 RBC/μL, 7.5 EC/μL, 2.5 TC/μL, 0.7 CAST/μL and 3090 BACT/μL, whereas the upper reference values in subjects tested with Sysmex UF-1000i were 10.5 WBC/μL, 8.3 RBC/μL, 7.2 EC/μL, 2.9 TC/μL, 0.7 CAST/μL, 48 BACT/μL. No statistically significant differences between genders were found in the value distribution of any of the parameter tested. Similarly, no statistically significant differences were observed between the two urine analyzers, except for BACT. Automated analysis of urine particles appears a suitable means to optimize the workflow of routine urinalysis of children specimens. The upper reference limits for pediatric subjects obtained in this study were comparable to those previously reported in the literature, with no significant differences between genders and analyzers.
    Clinical biochemistry 09/2013; 46(18). DOI:10.1016/j.clinbiochem.2013.09.005 · 2.28 Impact Factor
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    ABSTRACT: Background. FVG1691A (factor V Leiden, FVL) and FII G20210A (prothrombin G, GPRO) polymorphisms are the most common genetic causes of thrombophilia. For diagnosis of these polymorphisms, two years ago we adopted the GeneXpert instrument, after a preliminary study conducted on frozen plasma that had already been typed. We report our experience concerning the routine application of this analysis system. Methods. Between January 2011 and December 2012, 1106 patients were evaluated for detection of FVL and GPRO using the Cepheid GeneXpert system (Instrumentation Laboratory, Milan, Italy). The first 142 were also tested with the LightCycler system (Roche, Monza, MI, Italy). Results. Results obtained with the GeneXpert system showed full agreement with those obtained with the LightCycler system. Full agreement was also observed with previously characterized frozen samples. Among the 1,106 subjects examined, 235 were FVL heterozygous, 20 homozygous FVL, 37 GPRO heterozygous, 3 homozygous GPRO, 15 double heterozygous FVL/GPRO, and 796 genetically normal. In the 2-year period we observed only 37 invalid results with the need to repeat the test. Conclusions. The GeneXpert system is a fully automated analytical system. In less than 35 minutes, it is possible to perform a combined determination of FVL and GPRO from a subject’s anticoagulated whole blood. The design of the kit, based on the use of individual disposable cartridges, in which are contained all the necessary reagents for the extraction of nucleic acids, their amplification and the detection of the amplicons, eliminates waste and allows determinations to be performed on demand. On the other hand, the extremely simple manual makes the test accessible to those laboratories not specializing in molecular biology techniques. In our experience, the GeneXpert system has proven reliable with total concordance with the results obtained with the system already in use in our laboratory. We also observed only a small percentage of invalid results with a satisfactory ratio (1.03) of the number of tests performed to the number producing a result.
    Rivista Italiana della Medicina di Laboratorio 09/2013; 9(3). DOI:10.1007/s13631-013-0005-3
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    ABSTRACT: In type 3 polyendocrine syndrome (PAS3), autoimmune thyroiditis occurs with other organ-specific autoimmune disease, but not with autoimmune adrenalitis. In this report we described a family from Pakistan in which mother and three daughters were affected by a PAS3. We studied a family from Pakistan: Father MMu age 44, mother KN aged 44, three daughters MM age 20, MH age 16 and MA age 14 and a son MU age 18. These subjects were tested for thyroids function, metabolic function, adrenal function, autoimmune disease. In this family the four females were shown hypothyroidism with presence of anti thyroid autoantibodies (AA) and high TSH serum concentration in association with the presence of anti transglutaminase AA. Moreover KN, MM and MH were positive for anti nuclear AA (granular pattern) and for antibodies against Saccaromyces cerdevisiae. MM was positive for AA against nuclear extractable antigens (SSA and SSB) too. No diabetes or pernicious anemia were observed. Adrenal and Pituitary function were normal. PAS 3C is an uncommon disease. In this family from Pakistan we observed a PAS3C in the four female members: mother and three daughters while father and son were unaffected.
    Minerva endocrinologica 09/2013; 38(3):329-336. · 1.32 Impact Factor
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    ABSTRACT: BACKGROUND: Blood donors positive only for anti-HBc may have a resolved hepatitis B virus (HBV) infection, low grade chronic infection or infection with variant strains of HBV. We aimed to assess the significance of this serological pattern after hepatitis B vaccination in such cases. MATERIALS AND METHODS: Twenty-four anti-HBc only blood donors were vaccinated with the Engerix HBV vaccine and a serological and virological evaluation was performed before HBV vaccination and 7-10 days after each dose. Subjects were classified as non-responders if their anti-HBs levels stayed below 10 IU/L after full vaccination, while the response was considered secondary (anamnestic) if anti-HBs levels rose over 10 IU/L after the first vaccine dose, and primary if anti-HBs levels rose over 10 IU/L only after the second or third vaccine dose. RESULTS: Of the 21 fully evaluable donors, six had no response, eight showed a primary response and seven had an anamnestic response. One non-responder had transient positivity for HBV-DNA at low levels (12 IU/mL) with persistent negativity for HBsAg. DISCUSSION: Anti-HBc-only positive blood donors are a heterogeneous population including HBV naïve subjects with a likely false-positive anti-HBc reactivity, subjects with a resolved HBV infection, and subjects with persistent low-level HBV replication.The analysis of the anti-HBs response after a dose of HBV vaccine may help to distinguish among the different causes of the isolated anti-HBc positivity, thereby enabling proper counselling and potential readmission to blood donation.
    Blood transfusion = Trasfusione del sangue 02/2013; 12:1-6. DOI:10.2450/2013.0227-12 · 1.90 Impact Factor
  • G Gessoni · S Valverde · F Manoni
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    ABSTRACT: In this study, we evaluated the GeneXpert HemosIL Factor II and Factor V assay, an innovative assay for the detection of Factor V Leiden (FVL) and prothrombin G20210A mutation (GPRO). We evaluated 132 patients that were previously classified (with a concordant result) using two commercial real-time PCR assays supplied, by Applied Biosystems and Roche Molecular Biochemicals. The cohort comprised 75 normal subjects, 10 FVL homozygous, 35 FVL heterozygous, 7 GPRO heterozygous, 2 GPRO homozygous and 3 double heterozygous FVL and GPRO subjects. All of the samples were evaluated using the GeneXpert HemosIL Factor II and Factor V assay. All of the samples were correctly identified using the GeneXpert HemosIL Factor II and Factor V assay; therefore, in this patient series, the specificity and sensitivity of the test under evaluation was 1.00. We have shown that the GeneXpert HemosIL Factor II and Factor V assay, a rapid fully automated assay, can accurately characterise the presence of FV G1691A and FII G20210A polymorphisms with specificity and sensitivity that are comparable to other current real-time PCR-based methods. The theoretical advantages of such an assay include improved standardisation across varying healthcare environments, more thorough sample manipulation and reduced human error.
    Clinica chimica acta; international journal of clinical chemistry 04/2012; 413(7-8):814-6. DOI:10.1016/j.cca.2012.01.016 · 2.76 Impact Factor
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    ABSTRACT: In analogy with other areas of laboratory diagnostics, the pre-analytical phase is the leading source of variability also in urinalysis. We carried out a multicentric study for comparing results obtained from first-voided and mid-stream urine samples. Each of the six hospital-based clinical laboratories participating to this study recruited 50 healthy subjects among laboratory staff and/or their relatives. Two consecutive samples of the first morning micturition were collected by vacuum system, the first from the first-void and the second from the mid-stream. Routine urinalysis was performed using dip-stick automated analyzers for chemical examination and automated analyzers for formed particle examination (Sysmex UF-100, Sysmex UF-1000i and Iris iQ-200). Counts of epithelial cells (EC), erythrocytes (ERY) and leukocytes (LEU) but not for cylinders (CAS) were significantly higher in the first-voided samples. A significantly higher count of EC, ERY and LEU was also observed between females and males in first-voided samples, whereas no significant difference could be found in mid-stream samples. Health related analyzer specific upper reference limits (URL) were CAS≤1, EC≤5, ERY≤19, Leu≤13 for UF-100; CAS≤1, EC≤4, ERY≤15, Leu≤11 for UF-1000i; CAS≤1, EC≤4, ERY≤18, Leu≤10 for iQ200. The overall prevalence of subjects with cellular elements count exceeding URL was also higher in first-voided than in mid-stream samples. Mid-stream urine was confirmed as the most appropriate sample, since the presence of contaminating elements, such as bacteria, analytes and formed particles are minimized.
    Clinical Chemistry and Laboratory Medicine 04/2012; 50(4):679-84. DOI:10.1515/cclm.2011.823 · 2.96 Impact Factor
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    Blood transfusion = Trasfusione del sangue 03/2012; 10(3):384-6. DOI:10.2450/2012.0094-11 · 1.90 Impact Factor
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    Gianluca Gessoni · Sara Valverde Sara · Rosa Canistro · Fabio Manoni
    Blood transfusion = Trasfusione del sangue 12/2011; 10(2):228-9. DOI:10.2450/2011.0077-11 · 1.90 Impact Factor
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    ABSTRACT: Le presenti linee guida per la definizione della fase preanalitica dell’esame delle urine sono state predisposte sotto gli auspici della Società Italiana di Medicina di Laboratorio (SIMeL) e della Società Italiana di Biochimica Clinica e Biologia Molecolare Clinica (SIBioC). L’analisi delle urine, comprendente la valutazione microbiologica e l’esame chimico-fisico e morfologico, dovrebbe sempre essere eseguita sulla base di un appropriato quesito diagnostico e dovrebbe essere possibile selezionare il livello analitico idoneo da erogare in base al suddetto quesito, in base alla tipologia del paziente e della tecnologia disponibile. La documentazione di riferimento per l’esecuzione dell’esame delle urine dovrebbe comprendere un’accurata descrizione delle fasi preanalitica, analitica e post-analitica. Una corretta documentazione per la fase preanalitica dovrebbe prevedere istruzioni adeguate in merito alla preparazione del paziente, alla raccolta, alla conservazione e al trasporto del campione. Sarebbe inoltre auspicabile che ciascun Laboratorio dichiarasse esplicitamente le proprie competenze specifiche e quindi il livello delle prestazioni erogabili. L’esame chimico e morfologico delle urine ha subito una considerevole trasformazione negli ultimi anni ed è giunto il momento di aggiornare e modificare le fasi del processo analitico. Le nuove tecnologie, che hanno reso i risultati della morfologia urinaria assai più rilevanti in termini di precisione e accuratezza, hanno anche evidenziato la necessità di perfezionare e di assicurare la qualità nella fase preanalitica. Sono state inoltre considerate sia le opportunità di consolidamento e standardizzazione della fase analitica, sia la ridefinizione degli obiettivi clinici e del referto, per renderlo completo, integrato e il più significativo possibile per il clinico. Queste linee guida sono state elaborate sulla base dei dati di letteratura e delle esperienze personali degli autori. Gli aspetti più rilevanti appaiono essere i seguenti: l’analisi delle urine dovrebbe essere eseguita sulla base di una specifica richiesta clinica il campione raccomandato è il mitto intermedio della prima minzione del mattino, ottenuto dopo pulizia dei genitali ogni Servizio di Medicina di Laboratorio dovrebbe preparare istruzioni scritte (con illustrazioni, se possibile) concernenti le procedure di raccolta del campione è raccomandato l’uso di un contenitore standard per la raccolta del campione è raccomandato l’utilizzo di un adeguato sistema di etichettatura dei campioni l’analisi delle urine dovrebbe essere eseguita prima possibile qualora si prevedano dei ritardi nell’esecuzione dell’esame superiori alle 4 ore dalla raccolta, è necessario refrigerare (+4–8 °C) i campioni è necessaria la predisposizione di procedure adeguate per il trasporto, il trattamento e la conservazione dei campioni è necessaria la trasmissione di informazioni accurate relative alla fase preanalitica tra i punti di raccolta e il Laboratorio che esegue l’analisi; le eventuali violazioni della procedura standard devono essere sempre registrate ogni Laboratorio dovrebbe dichiarare il livello analitico (ad es. la tipologia dei test) che è in grado di erogare. Auspichiamo che queste linee guida, relative alla fase preanalitica dell’esame delle urine, possano essere implementate nell’ambito delle procedure di ogni Laboratorio, migliorando la qualità del processo e del prodotto, contribuendo a far sì che la fase analitica rifletta la reale situazione dell’apparato urinario dell’utente/paziente.
    Rivista Italiana della Medicina di Laboratorio 09/2011; 7(1):25-35. DOI:10.1007/s13631-011-0005-0
  • Gianluca Gessoni · Sara Valverde · Francesco Antico · Fabio Manoni
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    ABSTRACT: Urinary tract infections (UTIs) are usually diagnosed by urine particle detection and urine bacterial culturing, but an empiric treatment is often prescribed before the microbiological results are known. The aim of this study was to assess whether quantification of bacteriuria and leukocyturia could predict the outcome of empiric antibiotic therapy. By using a Sysmex UF-100 analyser, we performed a case-control study in which bact channel counts (BCCs) and leukocyte (WBC) quantification were compared in urine samples obtained from responsive patients (RPs) and non-responsive patients (NRPs) at diagnosis (t0) and 24h (t24) after the start of empiric antibacterial treatment. BCCs decreased significantly from t0 (median: 30,000 E6/L) to t24 (median: 700 E6/L; p<0.001) in RPs but not in NRPs (median at t0 31,000 E6/L, and 23,000 E6/L at t24; p>0.05). Similarly, WBC counts were reduced in RPs at t24 relative to the initial values (p<0.001) but not in NRPs. A reduction of 70% in the BCC count or 60% in the WBC count of paired samples was useful for discriminating between RPs and NRPs. Our results suggest that quantitative time course analysis of urine BCCs and WBCs can be used to predict the success of first-line empiric treatment for UTIs.
    Clinica chimica acta; international journal of clinical chemistry 09/2010; 411(17-18):1371-4. DOI:10.1016/j.cca.2010.05.023 · 2.76 Impact Factor
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    ABSTRACT: The study of urine particles plays a key role in the diagnosis of kidney diseases. In this study, the authors evaluated the correlation between the UF-1000i and quantitative manual microscopy. A total of 214 untreated urine samples were studied using the Sysmex UF-1000i and compared with results obtained from quantitative manual microscopy using the Fuchs-Rosenthal counting chamber. Using Pearson statistics, we observed satisfactory correlation between the UF-1000i and quantitative microscopy: for red blood cells (RBCs) r was 0.98, for white blood cells (WBCs) r was 1.00, for epithelial cells (EC) r was 0.96, and for casts r was 0.69. Using linear regression statistics, we also observed satisfactory correlation between the UF-1000i and quantitative microscopy: for RBCs R(2) was 0.95, for WBCs R(2) was 0.99, for EC R(2) was 0.92, and for casts R(2) was 0.48. In our experience, automated urine particle analysis performed using the Sysmex UF-1000i analyzer is sufficiently precise and improves the workflow in a routine laboratory. Precision was satisfactory and concordance with the reference method is good for RBC, WBC and EC; for casts microscopic observation is required for flagged samples to discriminate hyaline from pathologic casts.
    Clinical Chemistry and Laboratory Medicine 08/2010; 48(8):1107-11. DOI:10.1515/CCLM.2010.233 · 2.96 Impact Factor
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    Gianluca Gessoni · Sara Valverde · Rosa Canistro · Fabio Manoni
    Blood transfusion = Trasfusione del sangue 07/2010; 8(3):193-5. DOI:10.2450/2010.0157-09 · 1.90 Impact Factor
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    ABSTRACT: Because urinary tract infections (UTIs) are a quite common disease, the gold standard for diagnosing UTIs is still bacterial culture, although a large percentage of samples are negative: unnecessary cultures can be reduced by means of an effective screening test. The analytic performance of a new urine cytometer, the UF-1000i, has been tested on 1463 urine samples submitted to our laboratory for culture. Bacteria and leukocyte counts have been compared by means of the UF-1000i with colony-forming unit (CFU) quantification on citrate lactose electrolytes deficient agar to assess the best cutoff values. By using quantitative cultures and considering as positive a sample with 10 x 10(5) CFU/mL, 546 positive samples (37%) were observed. If compared with 10 x 10(5) CFU/mL, the cutoff values obtained were 125 bacteria/microL and 40 leukocytes/ microL, respectively. Analytic parameters such as sensitivity, specificity, positive predictive value, negative predictive value, and correctly classified incidence were satisfactory. Based on the results obtained in this study, when using the UF-1000i analyzer for a screening test for UTI, a cutoff value of 40 white blood cells/microL should be adopted. The cutoff value for bacteria should be 125/microL for those clinical conditions in which 10 x 10(5) CFU/mL indicates a positivity.
    Diagnostic microbiology and infectious disease 10/2009; 65(2):103-7. DOI:10.1016/j.diagmicrobio.2009.06.003 · 2.57 Impact Factor
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    ABSTRACT: Conductivity is a measure of a material's ability to conduct an electric current and it works thanks to movable charges. Conductivity in urine is directly proportional to ionic contents. The aim of this study was to evaluate the significance of urine conductivity by using the Sismex UF-100 analyser in correlations with other surrogate parameters of osmolality and renal diuresis, relative density, electrolytes and creatinine concentration. For this study 140 urine samples were submitted for diagnostic urinalysis to the Clinical Pathology laboratory. Samples were collected from 70 healthy subjects, 42 diabetics with poor metabolic control and significant glicosuria, 28 patients with monoclonal gammopathy of uncertain significance, with significant proteinuria. All the samples were assessed for conductivity (UF-100 Sysmex), relative density (refract meter Zeiss), sodium, potassium, chlorine, creatinine, urea, glucose, protein (Olympus AU-2700). Urine conductivity appears to be related to ionic concentration but not to glucose and/or protein presence. This study results suggest that conductivity determination should be useful in diabetic patients to study the tubular function minimising interferences due to osmotic action of glucose.
    Minerva urologica e nefrologica = The Italian journal of urology and nephrology 04/2009; 61(1):17-20. · 0.70 Impact Factor
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    G Gessoni · S Valverde · F Manoni
    International journal of laboratory hematology 03/2009; 32(1 Pt 1):e188-9. DOI:10.1111/j.1751-553X.2009.01144.x · 1.87 Impact Factor
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    ABSTRACT: Rapidly available and accurate platelet counts play an important role in the evaluation of haemorrhagic status and in assessing the need for platelet transfusions. We, therefore, evaluated platelet counting performance of haematology analysers using optical, impedance and immunological methods in thrombocytopenic patients. We considered 99 patients with a platelet (plt) count under 50 x 10(9) plt/L. We compared the platelet counts obtained using ADVIA 2120 (optical method), Cell-Dyn Sapphire (optical, impedance and immunological methods with CD61) and a reference, double staining (CD41+CD61) immunological method. The platelet counts of all the considered methods showed good correlation with those of the reference method, despite an overestimation in platelet quantification. The degree of inaccuracy was greater for platelet counts under 20 x10(9) plt/L. Clinicians who use platelet thresholds below 20 x10(9) plt/L for making clinical decisions must be aware of the limitations in precision and accuracy of cell counters at this level of platelet count. Inaccurate counts of low platelet numbers could create problems if attempts are made to reduce the threshold below 20 x 10(9) plt/L.
    Blood transfusion = Trasfusione del sangue 02/2009; 7(1):43-8. DOI:10.2450/2008.0039-08 · 1.90 Impact Factor

Publication Stats

307 Citations
76.96 Total Impact Points

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Institutions

  • 2004–2013
    • Azienda ULSS numero 14 Chioggia
      Chioggia, Veneto, Italy
  • 2002–2010
    • Civil Hospital, Raikot
      Rāikot, Punjab, India
  • 2009
    • Civil Protection Department of Italy
      Roma, Latium, Italy
  • 2007
    • Institute for Transfusion Medicine
      Pittsburgh, Pennsylvania, United States
  • 2003
    • University of Verona
      • Section of Infectious Disease
      Verona, Veneto, Italy
  • 2001
    • University of Padova
      Padua, Veneto, Italy