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Accumulating evidence shows a progressive decline in the efficacy of coronavirus disease 2019 (COVID-19) mRNA vaccines such as Pfizer-BioNTech (mRNA BNT161b2) and Moderna (mRNA-1273) in preventing breakthrough infections due to diminishing humoral immunity over time. Thus, this review characterizes the kinetics of anti-SARS-CoV-2 (Severe Acute Respiratory Syndrome Coronavirus 2) antibodies after the second dose of a primary cycle of COVID-19 mRNA vaccination. A systematic search of literature was performed and a total of 18 studies (N=15,980) were identified and reviewed. The percent difference of means of reported antibody titers were then calculated to determine the decline in humoral response after the peak levels post-vaccination. Findings revealed that the peak humoral response was reached at 21-28 days after the second dose, after which serum levels progressively diminished at 4-6 months post-vaccination. Additionally, results showed that regardless of age, sex, serostatus and presence of comorbidities, longitudinal data reporting antibody measurement exhibited a decline of both anti-receptor binding domain (RBD) IgG and anti-spike IgG, ranging from 94-95% at 90-180 days and 55-85% at 140-160 days, respectively, after the peak antibody response. This suggests that the rate of antibody decline may be independent of patient-related factors and peak antibody titers but mainly a function of time and antibody class/molecular target. Hence, this study highlights the necessity of more efficient vaccination strategies to provide booster administration in attenuating the effects of waning immunity, especially in the appearance of new variants of concerns (VoCs).

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As an inherited disorder characterized by severe pulmonary disease, cystic fibrosis (CF) could be considered a comorbidity for coronavirus disease 2019 (COVID-19)1. Instead, CF seems to constitute an advantage in COVID-19 infection2-5. To clarify whether host factors expressed by the CF epithelia may influence COVID-19 progression, we investigated the expression of SARS-CoV-2 receptor and coreceptors in primary airway epithelial cells. We found that angiotensin converting enzyme 2 (ACE2) expression and localization are regulated by cystic fibrosis transmembrane conductance regulator (CFTR) channels. Consistently, our results indicate that dysfunctional CFTR channels alter susceptibility to SARS-CoV-2 infection, resulting in reduced viral infection in CF cells. Depending on the pattern of ACE2 expression, the SARS-CoV-2 spike (S) protein induced high levels of Interleukin (IL)-6 in healthy donor-derived primary airway epithelial cells but a very weak response in primary CF cells. Collectively, these data support the hypothesis that CF condition is unfavorable for SARS-CoV-2 infection.

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With the advent of the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) pandemic, several vaccines have been developed to mitigate its spread and prevent adverse consequences of the Coronavirus Disease 2019 (COVID-19). The mRNA technology is an unprecedented vaccine, usually given in two doses to prevent SARS-CoV-2 infections. Despite effectiveness and safety, inter-individual immune response heterogeneity has been observed in recipients of mRNA-based vaccines. As a novel disease, the specific immune response mechanism responsible for warding off COVID-19 remains unclear at this point. However, significant evidence suggests that humoral response plays a crucial role in affording immunoprotection and preventing debilitating sequelae from COVID-19. As such this paper focused on the possible effects of age, sex, serostatus, and comorbidities on humoral response (i.e., total antibodies, IgG and/or IgA) of different populations post-mRNA-based Pfizer-BioNTech vaccination. A systematic search of literature was performed through PubMed, Cochrane CENTRAL, and Google Scholar. Studies were included if they reported humoral response to COVID-19 mRNA vaccines. A total of 32 studies was identified and reviewed, and the percent difference of means of reported antibody levels were calculated for comparison. Findings revealed that older individuals, the male sex, seronegativity, and those with more comorbidities mounted less humoral immune response. Given these findings, several recommendations were proposed regarding the current vaccination practices. These include giving additional doses of vaccination for immunocompromised and elderly populations. Another recommendation is conducting clinical trials in giving a combined scheme of mRNA vaccines, protein vaccines, and vector-based vaccines.

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The SARS-CoV-2 (Severe Acute Respiratory Syndrome Coronavirus 2) Lambda variant rapidly diffused across Peru following its identification in December 2020, and had now spread worldwide. In this study, we investigated infodemiologic trends in symptomatology associated with the Coronavirus Disease 2019 (COVID-19) following the spread of SARS-CoV-2 Lambda variant in Peru, enabling infodemiologic surveillance of SARS-CoV-2 in regions with high circulation of this new variant. Weekly Google Trends scores were obtained for key symptom keywords between March 1st, 2020 and July 4th, 2021, whilst case count data were obtained from Peruvian Ministry of Health. Multiple time series linear regression was used to assess trends in each score series, using the week of December 27th as cutoff for emergence of the Lambda variant. The significance of such trends was tested for each time period, before and after the cutoff date. A total 2,075,484 confirmed SARS-CoV-2 infections in Peru in relation to Google Trends data were analyzed. After Lambda variant emergence, searches for "diarrhea" demonstrated a change from a negative to positive correlation with weekly case counts and anticipated dynamic changes in case counts by 1-5 weeks. Searches for "shortness of breath" and "headache" remained consistently positively correlated to weekly case counts before and after Lambda emergence. No changes in searches for other common cold symptoms were observed, while no specific trends were observed for "taste loss" or "smell loss". Diarrhea, headache, and shortness of breath appear to be the most important symptoms for infodemiologic tracking the current outbreak in Peru and other regions with high circulation of SARS-CoV-2 Lambda variant.

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BackgroundSince universal vaccination is a pillar against coronavirus disease 2019 (COVID-19), monitoring anti-SARS-CoV-2 neutralizing antibodies is essential for deciphering post-vaccination immune response. MethodsThree healthcare workers received 30 g BNT162b2 mRNA Covid-19 Vaccine, followed by a second identical dose, 21 days afterwards. Venous blood was drawn at baseline and at serial intervals, up to 63 days afterwards, for assessing total immunoglobulins (Ig) anti-RBD (receptor binding domain), IgG anti-S1/S2, IgG anti-RBD, IgM anti-RBD, IgM anti-N/S1 and IgA anti-S1. ResultsAll subjects were SARS-CoV-2 seronegative at baseline. Total Ig anti-RBD, IgG anti-S1/S2 and IgG anti-RBD levels increased between 91-368 folds until 21 days after the first vaccine dose, then reached a plateau. The levels raised further after the second dose (by [~]30-, [~]8- and [~]8-fold, respectively), peaking at day 35, but then slightly declining and stabilizing [~]50 days after the first dose. IgA anti-S1 levels increased between 7-11 days after the first dose, slightly declined before the second dose, after which levels augmented by [~]24-fold from baseline. The anti-RBD and anti-N/S1 IgM kinetics were similar to that of anti-S1 IgA, though displaying substantially weaker increases and modest peaks, only 4 to 7-fold higher than baseline. Highly significant inter-correlation was noted between total Ig anti-RBD, anti-S1/S2 and anti-RBD IgG (all r=0.99), whilst other anti-SARS-CoV-2 antibodies displayed lower, though still significant, correlations. Serum spike protein concentration was undetectable at all time points. ConclusionsBNT162b2 mRNA vaccination generates a robust humoral immune response, especially involving IgG and IgA, magnified by the second vaccine dose.

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Brazil is currently suffering a deadly surge of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections, which has been attributed to the spread of a new strain known as P.1 (B.1.1.28.1). In this investigation, we analyzed coronavirus disease 2019 (COVID-19) public health data from Parana, the largest state in southern half of Brazil, between September 1, 2020 and March 17, 2021, to evaluate recent trends in case fatality rates in different age groups. A total of 553,518 cases of SARS-CoV-2, 8,853 currently registered as fatal, were finally included in our analysis. All age groups showed either decline or stabilization of the case fatality rates (CFRs) between September 2020 and January 2021. In February 2021, an increase in CFR for almost all age groups could be instead observed. All groups above 20 years of age showed statistically significant increases in CFR when diagnosed in February 2021 as opposed to January 2021. Patients aged 20-29 years experienced a tripling of their CFR, from 0.04% to 0.13%, while those aged 30-39, 40-49, 50-59 experienced approximate CFR doubling. Individuals between 20 and 29 years of age whose diagnosis was made in February 2021 had an over 3-fold higher risk of death compared to those diagnosed in January 2021 (Risk Ratio (RR): 3.15 [95%CI: 1.52-6.53], p<0.01), while those aged 30-39, 40-49, 50-59 years experienced 93% (1.93 [95%CI:1.31-2.85], p<0.01), 110% (RR: 2.10 [95%CI:1.62-2.72], p<0.01), and 80% (RR: 1.80 [95%CI:1.50-2.16], p<0.01) increases in risk of death, respectively. Notably, the observed CFR increase coincided with the second consecutive month of declining number of diagnosed SARS-CoV-2 cases. Taken together, these preliminary findings suggest significant increases in CFR in young and middle-aged adults after identification of a novel SARS-CoV-2 strain circulating in Brazil, and this should raise public health alarms, including the need for more aggressive local and regional public health interventions and faster vaccination.

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BackgroundAlthough evidence is accumulating that climate conditions may positively or negatively influence the scale of coronavirus disease 2019 (COVID-19) outbreaks, uncertainty remains concerning the real impact of climate factors on viral transmission. Methods. The number of new daily cases of COVID-19 diagnosed in Verona (Italy) was retrieved from the official website of Veneto Region, while information on daily weather parameters in the same area was downloaded from IlMeteo website, a renowned Italian technological company specialized in weather forecasts. The search period ranged between March 1 to November 11, 2020. The number of new daily COVID-19 cases and meteorological data in Verona were correlated using both univariate and multivariate analysis. ResultsThe number of daily COVID-19 diagnoses in Verona was positively associated with the number of days in lockdown and humidity, and inversely correlated with mean, min and max temperature, mean wind speed and number of days with rainfall. Days of lockdown, mean air temperature, humidity, mean wind speed and number of days with rainfall remained significantly associated in multivariate analysis. The four weather parameters contributed to explaining 61% of variance in new daily COVID-19 diagnoses. Each 1% increase in air temperature, 1% decrease in humidity, 1 km/h increase in wind speed and day with rainfall were independently associated with 1.0%, 0.3%, 1.2% and 5.4% reduction in new COVID-19 daily diagnoses. A significant difference was observed in values of all-weather parameters recorded in Verona between days with <100 or [≥]100 new daily COVID-19diagnoses. ConclusionsClimate conditions may play an essential role in conditions of viral transmission, and influence the likelihood or course of local outbreaks. Preventive measures, testing policies and hospital preparedness should be reinforced during periods of higher meteorological risk and in local environments with adverse climate conditions.

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BackgroundAs evidence emerged that loss of taste and/or loss of smell is frequently triggered by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, we investigated whether Google searches volume for these two disease-specific symptoms could be associated with disease epidemiology in United States (US). Materials and MethodsWe performed an electronic search in Google Trends using the keywords "taste loss" and "smell loss" within the US. The Google searches volume was correlated with the number of new weekly cases of coronavirus disease 2019 (COVID-19) in the country. ResultsThe weekly Google searches for taste and smell loss exhibited a trend similar to that of new weekly SARS-CoV-2 infections in the US. A nearly perfect correlation was found between Google Trends scores of taste and smell loss (r=0.98; 95% CI, 0.97-0.99; p<0.001). Although a significant association was found between Google searches for the two symptoms and the concomitant number of new weekly SARS-CoV-2 infections reported during the same week, the correlation improved over time. The highest correlation was found comparing Google Trends scores for taste or smell loss and the number of new weekly SARS-CoV-2 infections two weeks later. The correlation coefficient of summing Google Trends scores for the two symptoms and the number of new weekly SARS-CoV-2 infections two weeks later was 0.82 (95% CI, 0.68-0.90; p<0.001), and was associated 0.89 diagnostic accuracy. ConclusionsThese findings suggest that Google searches numbers for olfactory and gustatory dysfunctions may help predicting the epidemiological trajectory of COVID-19 early before official reporting.

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BackgroundThe approach to diagnosing, treating and monitoring severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection relies strongly on laboratory resources, with serological testing representing the mainstay for studying the onset, nature and persistence of humoral immune response. This study was aimed at evaluating the analytical performance of the novel Beckman Coulter anti-SARS-CoV-2 IgG chemiluminescent immunoassay. MethodsThis analytical assessment encompassed the calculation of intra-assay, inter-assay and total imprecision, linearity, limit of blank (LOB), limit of detection (LOD), functional sensitivity, and comparison of anti-SARS-CoV-2 antibodies values obtained on paired serum samples using DiaSorin Liaison SARS-CoV-2 S1/S2 IgG and Roche Elecsys Anti-SARS-CoV-2 total antibodies. Diagnostic performance was also tested against results of molecular testing on nasopharyngeal swabs, collected over the previous 4 months. ResultsIntra-assay, inter-assay and total imprecision of Beckman Coulter anti-SARS-CoV-2 IgG were between 4.3-4.8%, 2.3-3.9% and 4.9-6.2%, respectively. The linearity of the assay was excellent between 0.11-18.8 antibody titers. The LOB, LOD and functional sensitivity were 0.02, 0.02 and 0.05, respectively. The diagnostic accuracy (area under the curve; AUC) of Beckman Coulter anti-SARS-CoV-2 IgG compared to molecular testing was 0.87 (95% CI, 0.84-0.91; p<0.001) using manufacturers cut-off, and increased to 0.90 (95% CI, 0.86-0.94; p<0.001) with antibody titers. The AUC was non-significantly different from that of Roche Elecsys Anti-SARS-CoV-2, but was always higher than that of DiaSorin Liaison SARS-CoV-2 S1/S2 IgG. The correlation of Beckman Coulter Access SARS-CoV-2 IgG was 0.80 (95% CI, 0.75-0.84; p<0.001) with Roche Elecsys Anti-SARS-CoV-2 and 0.72 (95% CI, 0.66-0.77; p<0.001) with DiaSorin Liaison SARS-CoV-2 S1/S2 IgG, respectively. ConclusionsThe results of this analytical evaluation of Beckman Coulter Access anti-SARS-CoV-2 IgG suggests that this fully-automated chemiluminescent immunoassay represents a valuable resource for large and accurate seroprevalence surveys.

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ObjectivesSevere coronavirus disease 2019 (COVID-19) is associated with a dysregulated immune state, called cytokine storm. While research has focused on the hyperinflammation, little research has been performed on the compensatory anti-inflammatory response which if severe may lead to a state of functional immunoparalysis. The aim of this study was to evaluate the anti-inflammatory response to COVID-19, by assessing interleukin-10 (IL-10) and IL-10/lymphocyte count ratio and their association with patient outcomes. MethodsAdult patients presenting to the emergency department (ED) with laboratory-confirmed COVID-19 were recruited. The primary endpoint was peak COVID-19 severity within 30 days of index ED visit. Additional endpoints included COVID-19 severity at ED disposition, development of severe acute kidney injury (AKI) or secondary bacterial infections. ResultsA total of 52 COVID-19 patients were enrolled. IL-10 and IL-10/lymphocyte count were significantly higher in patients with severe disease at both time points (all p<0.05), as well as in those who developed severe AKI and secondary bacterial infection (all p[≤]0.01). In multivariable analysis, a one-unit increase in IL-10 was associated with 42% increased odds of severe COVID-19 (p=0.031), whilst a one-unit increase IL-10/lymphocyte ratio was also associated with 32% increase in odds of severe COVID-19 (p=0.013). ConclusionsThe hyperinflammatory response to COVID-19 is accompanied by a simultaneous anti-inflammatory response, which is associated with poor outcomes and may increase the risk of secondary bacterial infections. IL-10 and IL-10/lymphocyte ratio at ED presentation were independent predictors of COVID-19 severity. Functional immunoparalysis in COVID-19 requires further investigation to enable more precise immunomodulatory therapy against SARS-CoV-2.

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BackgroundThe ongoing outbreak of coronavirus disease (COVID-19) caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) poses formidable challenges to all health care systems. Serological assays may improve disease management when appropriately used, for better understanding the antibody responses mounted upon SARS-CoV-2 infection and for assessing its real prevalence. Although testing the whole population is impratical, well-designed serosurveys in selected subpopulations in specific risk groups may provide valuable information. Aimwe evaluated the prevalence of SARS-CoV-2 infection in health care workers who underwent molecular testing with reverse transcription real-time polymerase chain reaction (rRT-PCR) in the main hospitals of the Veneto Region by measuring specific antibodies (Abs). Methodsboth IgM and IgG antibodies against SARS-Cov-2 S-antigen and N-protein were measured using a validated chemiluminescent analytical system (CLIA) called Maglumi 2000 Plus (New Industries Biomedical EngineeringCo., Ltd [Snibe], Shenzhen, China) ResultsA total of 8285 health care workers were tested. SARS-CoV-2 specific antibodies (IgM, IgG or both) were detectable in 378 cases (4.6%, 95% CI 4.1-5.0%). Seroconversion was observed in 4.4% women and 5% men, but the difference was not significant. Although detectable antibodies were found in all severe COVID-19 patients (100%), lower seropositivity was found in mild disease (83%) and the lowest prevalence (58%) was observed in asymptomatic subjects. ConclusionSeroprevalence surveys are of utmost importance for understanding the rate of population that has already developed antibodies against SARS-CoV-2. The present study has the statistical power to define precisely the circulation of SARS-CoV-2 in a cohort of health workers in our region, with its prevalence (4.6%) reflecting a relatively low circulation. Symptomatic individuals or those hospitalized for medical care were 100% antibody positive, whilst Abs were only detectable in 58% of asymptomatic carriers.

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IntroductionCoronavirus disease-2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), is causing dramatic morbidity and mortality worldwide. The Red Blood Cell Distribution Width (RDW) has been strongly associated with increased morbidity and mortality in multiple diseases. ObjectiveTo assess if elevated RDW is associated with unfavorable outcomes in hospitalized COVID-19. MethodsWe retrospectively studied clinical outcomes of hospitalized COVID-19 patients for their RDW values. In-hospital mortality was defined as primary outcome, while septic shock, need for mechanical ventilation, and length of stay (LOS) were secondary outcomes. ResultsA total of 294 COVID-19 patients were finally studied. Overall prevalence of increased RDW was 49.7% (146/294). RDW was associated with increased risk of in-hospital mortality (aOR, 4.5; 95%CI, 1.4-14.3) and septic shock (aOR, 4.6; 95%CI, 1.4-15.1) after adjusting for anemia, ferritin, and lactate. The association remained unchanged even after adjusting for other clinical confounders such as age, sex, body mass index, coronary artery disease, hypertension, diabetes mellitus, and chronic obstructive pulmonary disease. No association was found instead with mechanical ventilation and median LOS. ConclusionElevated RDW in hospitalized COVID-19 patients is associated with a significantly increased risk of mortality and septic shock.

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The novel coronavirus disease 2019 (COVID-19) has recently been upgraded to a pandemic by the World Health Organization due to the alarming levels of spread and severity. Since several lines of evidence also attest that Lombardy region has an extraordinarily high level of environmental pollution, we aimed to explore the potential epidemiological association between the number of cases of COVID-19 and environmental pollution in Italy. Data on environmental pollution in Italy were retrieved from the 2019 annual report of the organization Legambiente (League for the Ambient). The adjusted correlation between the number of days in which environmental pollutants exceeded established limits and the overall number of COVID-19 cases reveals the existence of a highly significant positive association (r=0.66; 95% CI, 0.48-0.79; p<0.001). The association remained statistically significant even when the number of days above pollutant limits was correlated with the number of COVID-19 cases per 1000 inhabitants (r=0.43; 95% CI, 0.18-0.62; p=0.001). Living in a province with over 100 days per year in which environmental pollutants were exceeded was found to be associated with a nearly 3-fold higher risk of being positive for COVID-19 (0.014 vs. 0.005 COVID-19 cases per 1000 inhabitants; OR, 2.96; 95% 2.12-4.13; p<0.001). Reinforced restrictive measures shall be considered in areas with higher air pollution, where the virus is more likely to find a fertile biological or environmental setting.

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@#A recent study based on the use of experimental artificial intelligence (AI) tool showed 70%–80% accuracy in predicting development of severe disease in coronavirus disease 2019 (COVID-19) based on predictive parameters alanine aminotransferase (ALT), myalgia and hemoglobin, whilst only 5 of 53 patients developed acute respiratory distress syndrome (ARDS), 2 of whom reporting myalgia.[1] It is commonly advocated that myalgia may reflect generalized inflammation and cytokine response.[1] Multiple studies showed that myalgia is a common symptom at onset of COVID-19, seen in up to 36% of such patients.[2] Therefore, in this short article we aim to further assess whether myalgia may be a reliable predictor of severe COVID-19 disease.

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OBJECTIVE: To rapidly and safely identify the risk of developing acute coronary syndrome in patients with chest pain who present to the emergency department, the clinical use of the History, Electrocardiogram, Age, Risk Factors, and Troponin (HEART) scoring has recently been proposed. This study aimed to assess the inter-rater reliability of the HEART score calculated by a large number of Italian emergency physicians.METHODS: The study was conducted in three academic emergency departments using clinical scenarios obtained from medical records of patients with chest pain. Twenty physicians, who took the HEART score course, independently assigned a score to different clinical scenarios, which were randomly administered to the participants, and data were collected and recorded in a spreadsheet by an independent investigator who was blinded to the study’s aim.RESULTS: After applying the exclusion criteria, 53 scenarios were finally included in the analysis. The general inter-rater reliability was good (kappa statistics [κ], 0.63; 95% confidence interval, 0.57 to 0.70), and a good inter-rater agreement for the high- and low-risk classes (HEART score, 7 to 10 and 0 to 3, respectively; κ, 0.60 to 0.73) was observed, whereas a moderate agreement was found for the intermediate-risk class (HEART score, 4 to 6; κ, 0.51). Among the different items of the HEART score, history and electrocardiogram had the worse agreement (κ, 0.37 and 0.42, respectively).CONCLUSION: The HEART score had good inter-rater reliability, particularly among the high- and low-risk classes. The modest agreement for history suggests that major improvements are needed for objectively assessing this component.

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This meta-analysis aimed to establish the role of standardized emergency department (ED) observation protocols in the management of syncopal patients as an alternative to ordinary admission. A systematic electronic literature search was performed to identify randomized controlled trials or observational studies evaluating syncopal patients managed in ED observation units. Data regarding mean length of stay, rate of etiological diagnosis, admission rate, and incidence of short-term serious outcomes were extracted. Six mostly single-center, small sized studies characterized by high heterogeneity, were included. A total of 458 patients were included with a balanced sex distribution (male 50.2%), a mean age of 60.1 years, and a considerable prevalence of heart disease (32.4%). Pooled analysis of the outcomes showed a mean stay of 28.2 hours, an etiological diagnosis rate of 67.3%, an admission rate of 18.5%, and a very low incidence of short-term serious outcomes (2.8%). Due to elevated diagnostic yield and low incidence of short-term adverse events, ED observation units-based management strategy seems ideal for patients with syncope. Nevertheless, further research is needed to identify criteria for selecting patients to be managed with this approach, define evaluation protocols, and confirm the safety of this strategy.

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BACKGROUND: Preanalytical variability, including biological variability and patient preparation, is an important source of variability in laboratory testing. In this study, we assessed whether a regular light meal might bias the results of routine clinical chemistry testing. METHODS: We studied 17 healthy volunteers who consumed light meals containing a standardized amount of carbohydrates, proteins, and lipids. We collected blood for routine clinical chemistry tests before the meal and 1, 2, and 4 hr thereafter. RESULTS: One hour after the meal, triglycerides (TG), albumin (ALB), uric acid (UA), phosphatase (ALP), Ca, Fe, and Na levels significantly increased, whereas blood urea nitrogen (BUN) and P levels decreased. TG, ALB, Ca, Na, P, and total protein (TP) levels varied significantly. Two hours after the meal, TG, ALB, Ca, Fe, and Na levels remained significantly high, whereas BUN, P, UA, and total bilirubin (BT) levels decreased. Clinically significant variations were recorded for TG, ALB, ALT, Ca, Fe, Na, P, BT, and direct bilirubin (BD) levels. Four hours after the meal, TG, ALB, Ca, Fe, Na, lactate dehydrogenase (LDH), P, Mg, and K levels significantly increased, whereas UA and BT levels decreased. Clinically significant variations were observed for TG, ALB, ALT, Ca, Na, Mg, K, C-reactive protein (CRP), AST, UA, and BT levels. CONCLUSIONS: A significant variation in the clinical chemistry parameters after a regular meal shows that fasting time needs to be carefully considered when performing tests to prevent spurious results and reduce laboratory errors, especially in an emergency setting.

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