The effect of the Covid-19 shutdown on glycemic testing and control.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic caused a halt to in-person ambulatory care. We evaluated how the reduction in access to care affected HbA1c testing and patient HbA1c levels. METHODS: HbA1c data from 11 institutions were extracted to compare testing volume and the percentage of abnormal results between a pre-pandemic period (January-June 2019, period 1) and a portion of the COVID-19 pandemic period (Jan-June 2020, period 2). HbA1c results greater than 6.4% were categorized as abnormal. RESULTS: HbA1C testing volumes decreased in March, April and May by 23, 61 and 40% relative to the corresponding months in 2019. The percentage of abnormal results increased in April, May and June (25, 23, 9%). On average, we found that the frequency of abnormal results increased by 0.31% for every 1% decrease in testing volume (p < 0.0005). CONCLUSION: HbA1c testing volume for outpatients decreased by up to 70% during the early months of the pandemic. The decrease in testing was associated with an increase in abnormal HbA1c results.

Side-Effects of COVID-19 on Patient Care: An INR Story.

BACKGROUND: Numerous studies have documented reduced access to patient care due to the COVID-19 pandemic, including access to diagnostic or screening tests, prescription medications, and treatment for an ongoing condition. In the context of clinical management for venous thromboembolism, this could result in suboptimal therapy with warfarin. We aimed to determine the impact of the pandemic on utilization of International Normalized Ratio (INR) testing and the percentage of high and low results. METHODS: INR data from 11 institutions were extracted to compare testing volume and the percentage of INR results ≥3.5 and ≤1.5 between a pre-pandemic period (January-June 2019, period 1) and a portion of the COVID-19 pandemic period (January-June 2020, period 2). The analysis was performed for inpatient and outpatient cohorts. RESULTS: Testing volumes showed relatively little change in January and February, followed by a significant decrease in March, April, and May, and then returned to baseline in June. Outpatient testing showed a larger percentage decrease in testing volume compared to inpatient testing. At 10 of the 11 study sites, we observed an increase in the percentage of abnormal high INR results as test volumes decreased, primarily among outpatients. CONCLUSION: The COVID-19 pandemic impacted INR testing among outpatients which may be attributable to several factors. Increased supratherapeutic INR results during the pandemic period when there was reduced laboratory utilization and access to care is concerning because of the risk of adverse bleeding events in this group of patients. This could be mitigated in the future by offering drive-through testing and/or widespread implementation of home INR monitoring.

Measuring What Matters: How the Laboratory Contributes Value in the Opioid Crisis.

With over 20 years of the opioid crisis, our collective response has evolved to address the ongoing needs related to the management of opioid use and opioid use disorder. There has been an increasing recognition of the need for standardized metrics to evaluate organizational management and stewardship. The clinical laboratory, with a wealth of objective and quantitative health information, is uniquely poised to support opioid stewardship and drive valuable metrics for opioid prescribing practices and opioid use disorder (OUD) management. To identify laboratory-related insights that support these patient populations, a collection of 5 independent institutions, under the umbrella of the Clinical Laboratory 2.0 movement, developed and prioritized metrics. Using a structured expert panel review, laboratory experts from 5 institutions assessed possible metrics as to their relative importance, usability, feasibility, and scientific acceptability based on the National Quality Forum criteria. A total of 37 metrics spanning the topics of pain and substance use disorder (SUD) management were developed with consideration of how laboratory insights can impact clinical care. Monitoring these metrics, in the form of summative reports, dashboards, or embedded in laboratory reports themselves may support the clinical care teams and health systems in addressing the opioid crisis. The clinical insights and standardized metrics derived from the clinical laboratory during the opioid crisis exemplifies the value proposition of clinical laboratories shifting into a more active role in the healthcare system. This increased participation by the clinical laboratories may improve patient safety and reduce healthcare costs related to OUD and pain management.

Cannabis Legalization Does Not Influence Patient Compliance with Opioid Therapy.

BACKGROUND: Prescription opioid use and opioid related deaths continue to increase nationwide. Several states have adopted legislation allowing for recreational use of cannabis. Little is known about how recreational cannabis laws impact compliance in chronic pain patients who have been prescribed opioid therapy. The goals of this study were to (1) retrospectively assess the effect of cannabis use on compliance with opioid therapy in a high-risk patient population and (2) determine the impact of legalization of recreational cannabis on patients prescribed therapeutic opioids. METHODS: We conducted a retrospective cohort study on results from a "high-risk" urine drug testing panel. Results from 1 year before and 1 year after initiation of recreational cannabis legislation were analyzed. This testing panel included qualitative assays for cannabinoids and 9 other common drugs of abuse in addition to a quantitative LC-MS/MS assay for 23 different opioids and metabolites. Opioid compliance was assigned by reviewing pathologists' interpretations. RESULTS: In the pre-legalization period, 1776 panels were performed, and in the post-legalization, 1648 panels were performed. An increase (6%) in the rate of positive cannabinoids screening results was observed after legalization of recreational cannabis; however, the overall compliance rate was consistent. CONCLUSIONS: The results of this study suggest that legalization of recreational cannabis does not affect compliance rate in patients treated with opioid therapy for chronic pain.

Interassay Comparison of the Tumor Markers CA125, CA15.3, and CA27.29.

BACKGROUND: Cancer antigens 125, 27.29, and 15-3 (CA125, CA27.29, and CA15-3) are markers of ovarian and breast cancer. Comparing tumor marker results across methods is challenging because of the lack of harmonization. Documenting comparability of results is important. METHODS: Siemens Advia Centaur CA125 and CA27.29 assays were compared to their corresponding Beckman Coulter DxI CA125 and CA15-3 assays. The interassay bias was determined and the manufacturer-recommended reference intervals were evaluated. RESULTS: The DxI CA125 assay demonstrated an overall positive 29% bias relative to the Centaur CA125 assay. The DxI CA15-3 assay demonstrated an overall negative 65% bias relative to the Centaur CA27.29 assay. For patients with multiple comparisons during the study period, the trend of results over time was similar across both sets of assays. Implementing the manufacturer-recommended reference interval for the DxI CA125 assay increased the abnormal flagging rate by 4.5%. In contrast, implementing the manufacturer-recommended reference interval for the DxI CA15-3 assay decreased the abnormal flagging rate by 13.0%. CONCLUSIONS: The overall trends for the majority of patients were similar. Therefore, despite the overall biases, transitioning tumor marker assays should not affect clinical interpretation of results.

Quantifying MMA by SLE LC-MS/MS: Unexpected challenges in assay development.

OBJECTIVES: Analysis of serum/plasma methylmalonic acid (MMA) is important for the diagnosis and management of methylmalonic acidemia in pediatric populations. This work focuses on developing and validating a liquid chromatography tandem mass spectrometry (LC-MS/MS) method to monitor methylmalonic acidemia using a simple method preparation. DESIGN AND METHODS: MMA and stable isotope labeled d3-MMA was extracted using supported liquid extraction (SLE). Assay imprecision, bias, linearity, recovery and carryover were determined. The relationship between MMA and propionyl acylcarnitine (C3-acylcarnitine) was also evaluated using historical paired results from 51 unique individuals. RESULTS: Baseline separation between MMA and succinic acid was completed in 7min. The assay was linear from 0.1 to 500µM. The intra-day and inter-day imprecision CV ranged from 4.1 to 13.2% (0.3 to 526µM) and 5.0 to 15.7% (0.3 to 233µM), respectively. Recovery ranged from 93 to 125%. The correlation with a national reference laboratory LC-MS/MS assay showed a Deming regression of 1.026 and intercept of -1.335. Carryover was determined to be <0.04%. Patient-specific correlation was observed between MMA and C3-acylcarnitine. CONCLUSION: This report describes the first LC-MS/MS method using SLE for MMA extraction. In addition, we illustrate the challenges encountered during this method development that should be assessed and resolved by any laboratory implementing a SLE LC-MS/MS assay designed to quantify analytes across several orders of magnitude.

Filling in the gaps with non-standard body fluids.

OBJECTIVES: Body fluid specimens other than serum, plasma or urine are generally not validated by manufacturers, but analysis of these non-standard fluids can be important for clinical diagnosis and management. Laboratories, therefore, rely on the published literature to better understand the validation and implementation of such tests. This study utilized a data-driven approach to determine the clinical reportable range for 11 analytes, evaluated a total bilirubin assay, and assessed interferences from hemolysis, icterus, and lipemia in non-standard fluids. DESIGN AND METHODS: Historical measurements in non-standard body fluids run on a Beckman Coulter DxC800 were used to optimize population-specific clinical reportable ranges for albumin, amylase, creatinine, glucose, lactate dehydrogenase, lipase, total bilirubin, total cholesterol, total protein, triglyceride and urea nitrogen run on the Beckman Coulter AU680. For these 11 analytes, interference studies were performed by spiking hemolysate, bilirubin, or Intralipid® into abnormal serous fluids. Precision, accuracy, linearity, and stability of total bilirubin in non-standard fluids was evaluated on the Beckman Coulter AU680 analyzer. RESULTS: The historical non-standard fluid results indicated that in order to report a numeric result, 4 assays required no dilution, 5 assays required onboard dilutions and 2 assays required both onboard and manual dilutions. The AU680 total bilirubin assay is suitable for clinical testing of non-standard fluids. Interference studies revealed that of the 11 total AU680 analyte measurements on non-standard fluids, lipemia affected 1, icterus affected 3, and hemolysis affected 5. CONCLUSIONS: Chemistry analytes measured on the AU680 demonstrate acceptable analytical performance for non-standard fluids. Common endogenous interference from lipemia, icterus, and hemolysis (LIH) are observed and flagging rules based on LIH indices were developed to help improve the clinical interpretation of results.

A roadmap to defining the clinical reportable ranges of chemistry analytes: Increasing automation efficiency and decreasing manual dilutions.

BACKGROUND: Proper utilization of resources is an important operational objective for clinical laboratories. To reduce unnecessary manual interventions on automated instruments, we conducted a workflow analysis that optimized dilution parameters and reporting of abnormally high chemistry results for the Beckman AU series of chemistry analyzers while maintaining clinically acceptable reportable ranges. METHODS: Workflow analysis for the Beckman AU680/5812 and DxC800 chemistry analyzers was performed using historical data. Clinical reportable ranges for 53 chemistry analytes were evaluated. Optimized dilution parameters and upper limit of reportable ranges for the AU680/5812 instruments were derived and validated to meet these reportable ranges. The number of specimens that required manual dilutions before and after optimization was determined for both the AU680/5812 and DxC800, with the DxC800 serving as the reference instrument. RESULTS: Retrospective data analysis revealed that 7700 specimens required manual dilutions on the DxC over a 2-y period. Using our optimized AU-specific dilution and reporting parameters, the data-driven simulation analysis showed a 61% reduction in manual dilutions. For the specimens that required manual dilutions on the AU680/5812, we developed standardized dilution procedures to further streamline workflow. CONCLUSIONS: We provide a data-driven, practical outline for clinical laboratories to efficiently optimize their use of automated chemistry analyzers. The outcomes can be used to assist laboratories wishing to improve their existing procedures or to facilitate transitioning into a new line of instrumentation, regardless of the instrument model or manufacturer.

SM proteins Sly1 and Vps33 co-assemble with Sec17 and SNARE complexes to oppose SNARE disassembly by Sec18.

Secretory and endolysosomal fusion events are driven by SNAREs and cofactors, including Sec17/α-SNAP, Sec18/NSF, and Sec1/Munc18 (SM) proteins. SMs are essential for fusion in vivo, but the basis of this requirement is enigmatic. We now report that, in addition to their established roles as fusion accelerators, SM proteins Sly1 and Vps33 directly shield SNARE complexes from Sec17- and Sec18-mediated disassembly. In vivo, wild-type Sly1 and Vps33 function are required to withstand overproduction of Sec17. In vitro, Sly1 and Vps33 impede SNARE complex disassembly by Sec18 and ATP. Unexpectedly, Sec17 directly promotes selective loading of Sly1 and Vps33 onto cognate SNARE complexes. A large thermodynamic barrier limits SM binding, implying that significant conformational rearrangements are involved. In a working model, Sec17 and SMs accelerate fusion mediated by cognate SNARE complexes and protect them from NSF-mediated disassembly, while mis-assembled or non-cognate SNARE complexes are eliminated through kinetic proofreading by Sec18.DOI: http://dx.doi.org/10.7554/eLife.02272.001.

Intrinsic tethering activity of endosomal Rab proteins.

Rab small G proteins control membrane trafficking events required for many processes including secretion, lipid metabolism, antigen presentation and growth factor signaling. Rabs recruit effectors that mediate diverse functions including vesicle tethering and fusion. However, many mechanistic questions about Rab-regulated vesicle tethering are unresolved. Using chemically defined reaction systems, we discovered that Vps21, a Saccharomyces cerevisiae ortholog of mammalian endosomal Rab5, functions in trans with itself and with at least two other endosomal Rabs to directly mediate GTP-dependent tethering. Vps21-mediated tethering was stringently and reversibly regulated by an upstream activator, Vps9, and an inhibitor, Gyp1, which were sufficient to drive dynamic cycles of tethering and detethering. These experiments reveal a previously undescribed mode of tethering by endocytic Rabs. In our working model, the intrinsic tethering capacity Vps21 operates in concert with conventional effectors and SNAREs to drive efficient docking and fusion.