[Automated management systems for clinical microbiology. II. An information system for the bacteriology laboratory].
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Bacteriology↗
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A simple, rapid and semi-automated method for the quantitative determination of expired 14CO2 in metabolism studies with laboratory animals.
The automatic features of a commercial instrument which prepares 14CO2 for liquid scintillation counting have been adapted to assay the 14CO2 collected in aqueous NaOH from the expired air of experimental laboratory animals in metabolism experiments. The method involves the liberation of 14CO2 trapped as Na214CO3 with dilute H2SO4 and the entrainment of the 14CO2 with nitrogen into the sample handling system. Recoveries were 87.3+/-1.2% and precision+/-2.0%. The method was simple and rapid; 6-8 samples were processed in one hour.
Animals↗
Automated hematology: where we stand.
Rapid, accurate, and relevant laboratory testing is essential in an era of cost-effective medicine. The routine manual complete blood count (CBC) is a labor-intensive test that lacks reproducibility. The new automated instruments such as the Coulter S+ series offer "state of the art" precision and accuracy in counting more than 10,000 cells per blood sample. The nonoptical electronic impedance method yields RBC, WBC, and platelet data, as well as histograms that characterize hematologic data. Analysis of more than 3,500 cases yielded a false-negative rate of less than 4% and a false-positive rate of 30%, indicating the instrument's accuracy in recognizing and flagging abnormalities. All normal screened CBCs were free of significant abnormalities. The Coulter S+ series provides innovative parameters and histograms that aid in establishing differential diagnoses. We review the advantages and the limitations of automation. Morphologic examination of abnormal blood smears remains the cornerstone of diagnosis in both the new and the old hematology.
Anemia↗
Comparative multicentre study of a panel of thyroid tests using different automated immunoassay platforms and specimens at high risk of antibody interference.
The introduction of automation for immunoassays in recent years has brought about important and evident improvements in assay precision. Increasing standardization and comparability between platforms should enable the development of clinical guidelines and diagnostic algorithms for appropriate clinical decision making. A continuing source of variation between different automated immunoassay platforms is the sporadic effect of interfering antibodies or substances, thus causing aberrant results not supporting the patient's clinical status. The aim of this study was to describe current thyroid panel variation between automated immunoassay platforms including population specimens at risk of antibody interference. A multisite design with laboratories in three different countries using four different automated immunoassay platforms (Roche-Boehringer Mannheim Elecsys (Italy), Roche-Boehringer Mannheim ES300 (Wales), Bayer Immuno 1 and the Bayer ACS:180 evaluated the thyroid panel of thyrotropin (TSH), triiodothyromine (T3), free thyroxine (FT4) and free triiodothyronine (FT3). A common set of 158 randomly selected patient samples of non-thyroid and thyroid disorders, with and without treatment, was tested. Included were 62 patient samples at risk for endogenous antibody interference with high antimicrosomal antibody, anti-TSH receptor antibody and increased rheumatoid factor sub-populations. Across all controls and between platforms, precision measurements were comparable and varied between 0.7% and 12.8% for TSH, 2.8% and 13% for FT4, 1.8% and 10.5% for FT3 and 3.1% and 16% for T3 assay. Acceptable correlation and reproducibility were found between the three Bayer Immuno 1 platforms at each country's site with all four thyroid panel assays demonstrating r-values of 0.989 to 1.000 and slopes of 0.915 to 1.078. Comparisons between the different platforms showed acceptable correlation for all thyroid panel assays. Specimens containing rheumatoid factor were associated with a significantly increased variation between systems for the FT4 and FT3 assays (p < 0.01). This effect did not appear to be selective for a given platform. For specimens with raised autoimmune antibodies and therefore at risk of assay antibody interference, no variation could be observed between the platforms.
Antibodies↗
MEMS-based sample preparation for molecular diagnostics.
Completion of the Human Genome Project is driving the rapid development of molecular diagnostics in the laboratory. To accelerate the penetration of genetic tests and other nucleic acid-based tests into clinical markets, simple, compact, automatic sample-preparation systems for molecular diagnostics must be developed. Microelectromechanical systems (MEMS) is a promising approach for the development of automated sample preparation for the clinical laboratory or point-of-care setting. This review discusses MEMS-based components that could be applied to the different stages of the sample-preparation process such as cell separation, nucleic acid purification, and nucleic acid amplification. Examples of functional component integration are given. Issues discussed include partitioning of functions between the instrument and disposable unit, methods of propulsion of fluids and particles, vapor and liquid barriers, and sample size. Although further evaluation and development are needed to provide practical solutions to some of these issues, we conclude that MEMS-based components might contribute to some components in a sample-preparation system consisting of modular instruments and disposable units, but will not provide a generic or a totally integrated solution.
DNA, Bacterial↗
Managing utilization of new diagnostic tests.
In appropriate utilization of laboratory testing has been estimated to range from 10% to 50% of the volume encountered in hospital laboratories. Many strategies to control utilization of laboratory testing have been reported, including redesigning test requisitions, changing standing orders, the use of provider order entry, physician profiling, and educational initiatives. The major motivation to reduce utilization of unnecessary testing is financial, although other benefits also may be observed, such as reducing false-positive results stemming from testing patients in low prevalence populations, eliminating unnecessary follow-up procedures, avoiding iatrogenic anemia, and potentially lowering hospital length of stay resulting from the need to track down the significance of falsely abnormal tests. The majority of utilization control efforts have focused on reducing routine laboratory tests such as chemistry profiles and automated blood counts. In many hospitals novel diagnostic tests, especially in molecular genetics and oncology, are the major driver behind increasing laboratory costs. Traditional methods to control utilization of routine testing are usually ineffective in controlling testing of novel diagnostic methods. In most cases, test requests originate from a small group of physician specialists who typically are more knowledgeable in their area of expertise than is the clinical pathologist. For this reason, a different approach is generally required. It is particularly important to establish an institutional structure authorized to review and approve new laboratory tests. The clinical pathologist usually takes the lead in this effort because laboratory-based physicians are familiar with new tests being requested by physicians across a spectrum of medical specialties. To be successful, the laboratory physician must identify potential utilization issues, acquire and analyze data, function on interdepartmental teams, and develop strategies to satisfy the needs of clinicians while at the same time preventing introduction of inappropriate technologies into the laboratory. This article will give a perspective on approaches to laboratory test utilization and offer specific examples of initiatives we have undertaken in our institution. The examples will illustrate how the pathologist can use knowledge of medicine and the clinical laboratory in conjunction with organizational and team building skills. In the final analysis, the process is more of an art than a science.
CA-125 Antigen↗
Automation of manual components and image quantification of direct dual label fluorescence in situ hybridization (FISH) for HER2 gene amplification: A feasibility study.
Determination of HER2 status by fluorescence in situ hybridization (FISH) in breast carcinoma correlates well with response to targeted therapy and prognosis. However, manual time consuming methods and quantification aspects of the procedure may be challenging for some laboratories. We examined the feasibility of automating these components of the FISH assay using a tissue microarray (TMA-118 clinically annotated cases) and a series of 41 whole sections. An in situ hybridization automated staining workstation was used to automate a programmed overnight start, on line baking, deparaffinization, cell conditioning, protease digestion, and prehybridization buffer washing. Dual label probe/target codenaturation/hybridization and stringency washing were done off line. The HER2 and CEP17 spot counts were quantified, and the HER2/CEP17 ratio calculated, via an imaging workstation. Results were benchmarked against manual counts for whole sections, and bright field in situ hybridization [silver in situ hybridization (SISH)] for the TMA. Automated FISH results using whole sections correlated well with manual results: HER2/CEP17 ratio correlation coefficient r = 0.9154, r = 0.8380, P < 0.0001. Correlation between automated and manual TMA FISH results was also excellent, and disease-free survival was significantly shorter (P < 0.001) for the HER2 amplified cases. Automation of the laborious manual prehybridization and image quantification components of FISH using directly labeled probes is feasible. Operational gains and enhanced consistency are inherent in this automated approach to HER2 clinical FISH testing.
Automation↗
Molecular diversity of live-attenuated prototypic vaccine strains and clinical isolates of Staphylococcus aureus.
Bovine mastitis Staphylococcus aureus isolates and prototypic live-attenuated vaccine strains were analyzed by SmaI pulsed-field gel electrophoresis (PFGE) typing and automated ribotyping. The discriminatory index of these methods was 0.91 and 0.69, respectively. SmaI PFGE typing assigned all laboratory strains into cluster Q, which shared 49% similarity with clusters A and B, and 35% similarity with cluster C. Automated ribotyping placed laboratory strains within ribogroups different from those of bovine isolates. These methods have 70% concordance and permitted identification of the prototypic vaccine background from those of clinical isolates. This information is required before conducting field trials with the vaccine.
Animals↗
Audit of automated requesting of serum magnesium measurement in patients with hypocalcaemia.
Laboratory computer records for 71 consecutive hypocalcaemic patients (albumin-adjusted calcium < 2.00 mmol/L) without chronic renal failure revealed that 50 (70%) did not have serum magnesium measured. A second review of computer records was carried out 6 months after the initiation of an automated requesting program. This identified 14 patients with hypomagnesaemia (serum magnesium < 0.70 mmol/L) who may otherwise have been undiagnosed. The direct cost to the laboratory was an additional 19 magnesium analyses per month. It is concluded that hypomagnesaemia is commonly associated with hypocalcaemia but is under-diagnosed. Automated requesting of serum magnesium measurement is a cost-effective way of identifying these patients. However, the fact that only half of these patients had follow-up magnesium requests suggests that there may be a need for further education of clinicians in the significance of hypomagnesaemia.
Clinical Laboratory Information Systems↗
Helicobacter cinaedi-associated bacteremia and cellulitis in immunocompromised patients.
OBJECTIVE: To define the clinical spectrum of illness associated with Helicobacter cinaedi infection in the United States and to determine associated epidemiologic risk factors and optimal laboratory methods for recovery of H. cinaedi. DESIGN: A retrospective epidemiologic study of 23 patients with H. cinaedi-associated illness. PATIENTS: 23 patients with H. cinaedi infection identified between January 1982 and August 1990. Most isolates (22 of 23) were from blood; one was from stool. RESULTS: Ages ranged from 24 to 84 years (mean, 44 years). Eighty-three percent of patients were men; 17% were women. Clinical and laboratory data were obtained from 21 patients. Eighteen patients were febrile (15 required hospitalization); cellulitis was reported in 9 patients. Sixty percent were immunocompromised; 45% were reported to be seropositive for human immunodeficiency virus (HIV). For bacteremic patients, positive blood cultures were detected by a slightly elevated growth index in an automated blood culture system; many hospital laboratories had difficulty isolating the organism. CONCLUSIONS: Helicobacter cinaedi appears to cause recurrent cellulitis with fever and bacteremia in immunocompromised hosts. Blood cultures from immunocompromised patients with these symptoms may need special handling to isolate H. cinaedi.
Adult↗
Performance of a fully automated in vitro allergy testing system.
BACKGROUND: Since the development of the radioallergosorbent test (RAST) for quantification of allergen-specific IgE, numerous non-radoisotopic methods have been devised which combine the proven cellulose disc technology with enzyme-linked immunoassay methods. The HY.TEC EIA (Hycor Biomedical, Inc. Irvine, CA) was compared with Pharmacia CAP with respect to overall system features and assay performance characteristics. METHODS: The HY.TEC EIA and Pharmacia CAP were compared with respect to calibrator range, sensitivity, type of detection, type of solid phase, throughput, and mode of operation. To determine the assay sensitivity and specificity for a variety of allergens, a total of 2,447 tests were performed on both CAP and HY.TEC EIA. The samples were scored positive in both cases using a cutoff of 0.35 IU/mL. RESULTS: The general features of the HY.TEC EIA system are comparable to Pharmacia UniCAP, with the added advantage of higher throughput. Intra-assay precision was 7% and inter-assay precision was 9-15%. Using CAP as a comparative method, HY.TEC EIA has a sensitivity of 94.0% and a specificity of 94.4%. CONCLUSIONS: The HY.TEC EIA demonstrates excellent agreement with the Pharmacia CAP system in the determination of allergen-specific IgE. With the automation necessary in today's clinical laboratory, we conclude that the HY.TEC EIA is a state-of-the-art tool for the diagnosis of allergic disease.
Allergens↗
Problems that merit investigation in clinical microbiology laboratories.
Research is needed in the following areas in clinical microbiology: specimen collection, microbial identification, automation and instrumentation, rapid microbial diagnoses, microbial metabolism, computerization, relevance and laboratory utilization, physician influence, training in clinical microbiology, media and reagents, quality control, and antimicrobial susceptibility and assay determinations. For optimal progress in many of these categories, federal funding should be made available.
Humans↗
Automated mapping of observation codes using extensional definitions.
OBJECTIVE: To create "extensional definitions" of laboratory codes from derived characteristics of coded values in a clinical database and then use these definitions in the automated mapping of codes between disparate facilities. DESIGN: Repository data for two laboratory facilities in the Intermountain Health Care system were analyzed to create extensional definitions for the local codes of each facility. These definitions were then matched using automated matching software to create mappings between the shared local codes. The results were compared with the mappings of the vocabulary developers. MEASUREMENTS: The number of correct matches and the size of the match group were recorded. A match was considered correct if the corresponding codes from each facility were included in the group. The group size was defined as the total number of codes in the match group (e.g., a one-to-one mapping is a group size of two). RESULTS: Of the matches generated by the automated matching software, 81 percent were correct. The average group size was 2.4. There were a total of 328 possible matches in the data set, and 75 percent of these were correctly identified. CONCLUSIONS: Extensional definitions for local codes created from repository data can be utilized to automatically map codes from disparate systems. This approach, if generalized to other systems, can reduce the effort required to map one system to another while increasing mapping consistency.
Algorithms↗
[Further evolution and leukocyte differential using an automated blood cell counter].
In the leukocyte differential, morphological differential has been usually performed with chromatoaffinity of blood cells, but physical differential is recently performed with biophysicochemical characteristics of blood cells using an automated blood cell counter. The trend of the leukocyte differential has changed to physical differential (automated count method) from morphological differential (eye count method). In the automated count method, leukocytes are differentiated into neutrophils, lymphocytes, monocytes, eosinophils and basophils according to the predetermined region of each leukocyte population on the cytogram using an automated blood cell counter. An automated count method is very useful for the screening test in the laboratory because of its high precision and accuracy for the normal samples. However, it is not easy to identify abnormal cells such as leukemia cells by an automated count method. Therefore, an automated count method dealing with various suspect flags generated using an automated blood cell counter must be used for such abnormal samples. In case of absolutely few leukemia cells in the peripheral blood during complete remission, the automated count method can not detect a leukemia cell and no suspect WBC flags are recognized by the automated blood cell counter. Development of an automated blood cell counter with a higher efficiency than now and a standard automated count method is awaited in the clinical laboratory.
Automation↗
Evaluation of the automated coagulation analyzer Sysmex CA-7000.
INTRODUCTION: Centralization of laboratory diagnostics and an increasing number of urgent requests and nonstandard samples raise the need for short turn-around times and high-throughput analyzers for coagulation tests. The aim of the present study was to evaluate the analytical and technical performance of the Sysmex CA-7000 coagulation analyzer under routine laboratory conditions. MATERIALS AND METHODS: We evaluated the Sysmex CA-7000 in comparison to the Sysmex CA-6000 analyzer for PT, INR, aPTT, Clauss, and derived fibrinogen. We also compared antithrombin (AT) measured on the Sysmex CA-7000 and Dimension RxL. Imprecision studies were performed, and throughput, online, and STAT functions and the handling of routine samples were evaluated. RESULTS: The Sysmex CA-7000 showed very low intra-assay and interassay variability for all parameters. The method comparison study showed good comparability to the Sysmex CA-6000 and Dimension RxL. The throughput of the Sysmex CA-7000 was 2.5--3 times faster than that of Sysmex CA-6000. No interference was seen for total bilirubin up to 710 micromol/L. Triglyceride levels >11.4 mmol/L resulted in invalid PT measurements and levels >3.42 mmol/L gave invalid results for Clauss fibrinogen on the CA-7000 analyzer. CONCLUSIONS: This is the first published evaluation of the analytical and technical performance of the coagulation analyzer Sysmex CA-7000. We conclude that the CA-7000 is well suited for coagulation laboratories with high sample throughput and a high number of nonstandard samples.
Antithrombin III↗
Variation in synovial fluid analysis by hospital laboratories.
A survey of 42 hospitals revealed that the frequency of synovial fluid analysis was low (mean 3.9 per month). The mean was skewed upward by a higher frequency in 3 teaching hospitals, such that the overall median was 1.5 per month, with 15 hospitals studying 1 or less per month. There did not appear to be any consensus regarding what constitutes a routine synovial fluid analysis. Technical errors occurred, including dilution with acetic acid for cell counts and inappropriate use of automated cell counters. Twenty-six laboratories studied 4 "unknown" fluids for crystals. In 50 opportunities to detect each crystal type, calcium pyrophosphate was detected only 6 times, and sodium urate was detected 39 times. The white blood cell count reported for a single fluid ranged from 2,467-12,000/mm3 (mean +/- SD 6,683 +/- 1,992). The proportion of neutrophils identified varied from 0-30% (mean +/- SD 13.8 +/- 8.6). The majority of respondents believed that training and reference materials related to synovial fluid analysis should be improved.
Diagnostic Tests, Routine↗
Computer assisted interpretation of laboratory test data with 'MDI-LabLink'.
Physicians have to confront an enormous output of laboratory data. Normally, only a few experts manually perform the interpretation of highly specialised laboratory tests. PC Windows based 'MDI-LabLink' automates interpretation and expands traditional rule-based expert systems with flexibility and graphic illustrations of complex laboratory data. The laboratory can adjust the interpretation database to its specific needs, maintaining full control over program output. The structured input that 'MDI-LabLink' requires, supports dynamic test scheduling. It can be used to train personnel in the interpretation of laboratory test results. The program provides the clinician with a report that visualises the defect of the evaluated organ system with bitmap pictures and 3-dimensional graphics. Patient follow-ups present in tabular and graphical form. Changes in the severity of the pathobiochemical defect, induced, for example, by therapy, are monitored automatically. Applications available include interpretations of isoenzyme patterns, diagnosis of urinary proteinuria and cerebrospinal fluid analysis.
Chemistry, Clinical↗
Determination of reticulocytes: three methods compared.
Determination of reticulocytes in peripheral blood is a valuable tool for getting information about erythropoiesis of an individual. For many years, reticulocyte numbers were quantified manually by means of a microscope after staining with supravital dyes. However, this method is tedious and shows low reproducibility. Therefore, several methods for the automated determination of reticulocytes have been established in laboratory routine within the last years. The aim of this study was to compare three of these automated methods for reticulocyte analysis. Reticulocytes were determined in 130 subsequent routine samples by means of an ABX Pentra 120 Retic haematological analyser, a Coulter EPICS XL MCL flow cytometer and a Coulter STKS haematology system, using the fluorescent dye thiazole orange or the supravital dye new methylene blue for reticulocyte staining, respectively. The reticulocyte concentrations were slightly lower for the Coulter STKS haematology system (mean +/- SD 1.89+/-1.32%) when compared with the Coulter EPICS XL MCL flow cytometer or the ABX Pentra 120 Retic haematological analyser (2.11+/-1.25% and 2.12+/-1.15%, respectively). The correlations between all methods were significant (r(s) > or = 0.843, p < 0.001). Small intercepts were, however, observed in the correlation plots between the values obtained by means of the Coulter STKS haematology system and those obtained by the other two methods. Within-batch coefficients of variation were 6.0%, 6.9% and 7.8% for the ABX Pentra 120 Retic haematological analyser, the Coulter STKS haematology system and the Coulter EPICS XL MCL flow cytometer, respectively. The corresponding between-batch coefficient of variation values were 6.8%, 4.9% and 5.3% as well as 14.1%, 7.6% and 6.1% for the low, medium and high control levels determined by means of the ABX Pentra 120 Retic haematological analyser and the Coulter STKS haematology system, respectively. These data suggest that all three methods allow the efficient and reliable determination of reticulocyte counts under clinical routine conditions. However, although the obtained data are very similar, differences exist which should be taken into account for the normal values of the different methods.
Automation↗