Bedside Glucose Monitoring-Is it Safe? A New, Regulatory-Compliant Risk Assessment Evaluation Protocol in Critically Ill Patient Care Settings.

OBJECTIVES: New data have emerged from ambulatory and acute care settings about adverse patient events, including death, attributable to erroneous blood glucose meter measurements and leading to questions over their use in critically ill patients. The U.S. Food and Drug Administration published new, more stringent guidelines for glucose meter manufacturers to evaluate the performance of blood glucose meters in critically ill patient settings. The primary objective of this international, multicenter, multidisciplinary clinical study was to develop and apply a rigorous clinical accuracy assessment algorithm, using four distinct statistical tools, to evaluate the clinical accuracy of a blood glucose monitoring system in critically ill patients. DESIGN: Observational study. SETTING: Five international medical and surgical ICUs. PATIENTS: All patients admitted to critical care settings in the centers. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Glucose measurements were performed on 1,698 critically ill patients with 257 different clinical conditions and complex treatment regimens. The clinical accuracy assessment algorithm comprised four statistical tools to assess the performance of the study blood glucose monitoring system compared with laboratory reference methods traceable to a definitive standard. Based on POCT12-A3, the Clinical Laboratory Standards Institute standard for hospitals about hospital glucose meter procedures and performance, and Parkes error grid clinical accuracy performance criteria, no clinically significant differences were observed due to patient condition or therapy, with 96.1% and 99.3% glucose results meeting the respective criteria. Stratified sensitivity and specificity analysis (10 mg/dL glucose intervals, 50-150 mg/dL) demonstrated high sensitivity (mean = 95.2%, SD = ± 0.02) and specificity (mean = 95. 8%, SD = ± 0.03). Monte Carlo simulation modeling of the study blood glucose monitoring system showed low probability of category 2 and category 3 insulin dosing error, category 2 = 2.3% (41/1,815) and category 3 = 1.8% (32/1,815), respectively. Patient trend analysis demonstrated 99.1% (223/225) concordance in characterizing hypoglycemic patients. CONCLUSIONS: The multicomponent, clinical accuracy assessment algorithm demonstrated that the blood glucose monitoring system was acceptable for use in critically ill patient settings when compared to the central laboratory reference method. This clinical accuracy assessment algorithm is an effective tool for comprehensively assessing the validity of whole blood glucose measurement in critically ill patient care settings.

Biomarkers in prostate cancer: what's new?

PURPOSE OF REVIEW: This review is intended to provide an overview of the current state of biomarkers for prostate cancer (PCa), with a focus on biomarkers approved by the US Food and Drug Administration (FDA) as well as biomarkers available from Clinical Laboratory Improvement Amendment (CLIA)-certified clinical laboratories within the last 1-2 years. RECENT FINDINGS: During the past 2 years, two biomarkers have been approved by the US FDA. These include proPSA as part of the Prostate Health Index (phi) by Beckman Coulter, Inc and PCA3 as Progensa by Gen Probe, Inc. With the advances in genomic and proteomic technologies, several new CLIA-based laboratory-developed tests have become available. Examples are Oncotype DX from Genomics Health, Inc, and Prolaris from Myriad Genetics, Inc. In most cases, these new tests are based on a combination of multiple genomic or proteomic biomarkers. SUMMARY: Several new tests, as discussed in this review, have become available during the last 2 years. Although the intended use of most of these tests is to distinguish PCa from benign prostatic conditions with better sensitivity and specificity than prostate-specific antigen, studies have shown that some of them may also be useful in the differentiation of aggressive from nonaggressive forms of PCa.

Quantitative Analysis of Lysergic Acid Diethylamide and Metabolite in Urine by Automated Extraction and Liquid Chromatography-Tandem Mass Spectrometry.

Recently, lysergic acid diethylamide (LSD) has become a resurgent drug of abuse. The detection of LSD is problematic because of the low dosage taken by users, light and heat sensitivity of the analyte and the lack of efficient analytical methods. Presented here is the validation of an automated sample preparation method for the analysis of LSD and its primary urinary metabolite, 2-oxo-3-hydroxy-LSD (OHLSD), in urine samples by liquid chromatography-tandem mass spectrometry. Analytes were extracted from urine using an automated Dispersive Pipette XTRaction method on Hamilton STAR and STARlet liquid handling systems. The limit of detection for both analytes was administratively defined at the lowest calibrator used in the experiments, and the limit of quantitation was 0.05 ng/mL for both analytes. All validation criteria were acceptable per Department of Defense Instruction 1010.16 requirements. This method offers an efficient, sensitive analytical solution to routinely evaluate large numbers of urine specimens for LSD in workplace drug deterrence programs.

The Development and Implementation of Specimens for Accident Forensic Toxicology Investigation Kit for Special Operations Forces.

INTRODUCTION: After a vehicle rollover led to the death of a military member in Central Africa in 2018, it became apparent there was a significant gap in the capability to collect toxicology samples of Service Members involved in accidents and mishaps at remote Special Operations Forces locations in Africa. Multiple misconceptions surrounding sample collection, procedures for laboratory evaluation, and methods for shipment signaled the importance of establishing a procedure and a plan to provide the necessary medical inventory to properly collect and ship samples. MATERIALS AND METHODS: The Special Operations Command Africa (SOCAFRICA) Surgeon's Office gathered the appropriate supplies for collection of forensic toxicology samples, and simultaneously developed a step-by-step checklist to safely and correctly perform urine and blood collection. The procedures were further improved after the completion of cognitive interviews with a Navy corpsman and Army Civil Affairs medic. Multiple shipping iterations occurred to ensure safe movement and arrival of samples at Armed Forces Medical Examiner System Dover AFB. Two Separate Specimens for Accident Forensic Toxicology Investigation Kits were generated to accommodate personnel typically associated with accidents involving vehicles and aircraft. RESULTS: SOCAFRICA's toxicology kit supports legal and medical chain of custody requirements for investigations, and provides deployed forces in Africa with a mechanism to collect and ship samples from Africa to Dover AFB. The kits are provided to ensure these samples are successfully analyzed, thereby removing any ambiguity surrounding an accident or mishap. CONCLUSION: SOCAFRICA established a prepared kit with all of the materials for sample collection, accompanied by step-by-step descriptions of the procedure, and clear guidance on the proper completion of the requisite paperwork that meets medico-legal requirements.

Could Postnatal Age-Related Uridine Diphosphate Glucuronic Acid Be a Rate-Limiting Factor in the Metabolism of Morphine During the First Week of Life?

Neonates experience dramatic changes in the disposition of drugs after birth as a result of enzyme maturation and environmental adjustment, challenging therapeutic decision making. In this research, we establish postnatal age, postmenstrual age, and body weight as physiologically reasonable predictors of morphine's clearance in neonates. By integrating knowledge of bilirubin, morphine, and other drugs metabolized by glucuronidation pathways from previously published studies, we hypothesize that uridine diphosphate glucuronic acid, a postnatal age-dependent sugar, plays an important role in the metabolism of morphine during the first week of life. This finding can be extended to other drugs metabolized by uridine diphosphate glucuronosyltransferase pathways in neonates and thus has important clinical implications for the use of drugs in this population.

The development of a high-performance liquid chromatography-tandem mass spectrometric method for simultaneous quantification of morphine, morphine-3-ß-glucuronide, morphine-6-ß-glucuronide, hydromorphone, and normorphine in serum.

OBJECTIVES: Development and validation of a selective, robust high-performance liquid chromatography-tandem mass spectrometric (HPLC/MS-MS) method for the quantification of morphine, morphine-3-ß-glucuronide, morphine-6-ß-glucuronide, hydromorphone, and normorphine in human serum. DESIGN AND METHODS: Drug-free human serum samples spiked with morphine, morphine-3-ß-glucuronide, morphine-6-ß-glucuronide, hydromorphone, and normorphine were prepared by protein precipitation using methanol containing the internal standards. Samples were injected onto a Thermo Scientific AccuCore PFP column for chromatographic separation. Detection was achieved using a Thermo Scientific TSQ Vantage mass spectrometer. Assay validation followed the new Clinical and Laboratory Standards Institute (CLSI) C62-A guidelines. RESULTS: The analytical measuring range for all analytes was determined to be 5 to 1000 ng/mL. Intra- and inter-assay precision for three quality control levels were ≤ 7.0% and ≤ 13.5%, respectively. Carryover, stability, linearity, matrix effects, extraction and processing efficiency and method comparison characteristics were acceptable relative to the CLSI C62 guidelines. CONCLUSION: The validation of this HPLC-MS/MS method demonstrated a robust and rapid assay for the quantification of morphine, morphine-3-ß-glucuronide, morphine-6-ß-glucuronide, hydromorphone, and normorphine.

Nuclear magnetic resonance analysis of the solution and solvolysis of sulfur mustard in deuterium oxide.

Our laboratory performs in vitro experiments in which cell cultures are exposed to sulfur mustard (HD) to investigate the toxicity of this agent of chemical warfare. To perform these experiments, it is important to know the rate of hydrolysis of HD in order to calculate the concentrations of HD and its hydrolysis products during the experiment. Researchers have previously investigated the kinetics and mechanism of the hydrolysis of HD using a variety of methods. In the present study, we used nuclear magnetic resonance (NMR) spectroscopy and gas chromatography/mass spectrometry (GC/MS) to investigate HD's dissolution and solvolysis in deuterium oxide (D 2 O) at 2 mM. We followed activity in proton spectrums and determined the half-life (t 1/2) of HD to be 7.0 +/- 0.5 min in four experiments performed at 22 degrees C. In addition, we determined the t 1/2 of HD in D 2 O containing 0.17 M sodium chloride to be 24 +/- 1 min in three experiments performed at 22 degrees C. As further proof of the existence of HD dissolved into D 2 O, deutero-hexane was used to extract the D 2 O HD solution. The resulting deutero-hexane solution was studied by 1 H NMR and GC/MS. The results obtained match those received from a standard deutero-hexane HD solution. These results demonstrate that HD can be identified in D 2 O with proton NMR and that proton NMR data can be used to monitor the subsequent solvolysis of HD.