Exploring Biopharmaceutical Analysis with Compact Capillary Liquid Chromatography Instrumentation.

A recent trend in the design of liquid chromatography (LC) instrumentation is the move towards miniaturized and portable systems. These smaller platforms provide wider flexibility in operation, with the opportunity for conducting analysis directly at the point of sample collection rather than transporting the sample to a centralized laboratory facility. For the manufacturing of pharmaceutical and biopharmaceutical products, these platforms can be implemented for process monitoring and product characterization directly in manufacturing environments. This article describes a portable, miniaturized LC instrument coupled to a mass spectrometer (MS) for characterization of a biopharmaceutical monoclonal antibody (mAb).

The effect of the immunoassay curve fitting routine on bias in troponin.

OBJECTIVES: Unlike many dose-response curves used in clinical chemistry, the immunoassay curve used to quantitate measurands is often sigmoidal rather than linear. Consequently, a more complex curve fitting model is required. Various models are available, but they can introduce bias, and there can be little awareness of why this error can be introduced. CONTENT: These curve-fitting models include those based on the law of mass-action, empirical models such as splines or linearization models such as the log/logit function. All these models involve assumptions, which can introduce bias as the dose-response curve is 'forced' to fit or minimize the distance between the standard concentration points to the theoretical curve. The most common curve fitting model is the four or five parameter model, which uses four or five parameters to fit a sigmoidal curve to a set of standard points. SUMMARY AND OUTLOOK: Measurement of cardiac troponin is an important element in establishing a diagnosis of acute myocardial infarction. We use troponin, a cardiac biomarker, to demonstrate the potential effect of the bias that the curve fit could introduce. Troponin is used for both rule-in and rule-out decisions at different concentrations and at either end of the dose-response curve. The curve fitting process can cause lot-to-lot reagent (and calibrator) variation in immunoassay. However, laboratory staff need to be aware of this potential source of error and why it occurs. Understanding how the error occurs leads to a greater awareness of the importance of validating new reagent/calibrator assessment using patient samples with concentrations at crucial decision points.

Vitamin D testing: Impact of changes to testing guidelines on detection of patients at risk of vitamin D deficiency.

BACKGROUND: Changes were made to the Australian guidelines for vitamin D testing in November 2014 which restricted the patients who could be tested and reimbursed under the Medical Benefits Schedule. A retrospective study was conducted to assess the impact of the changes. METHODS: Data from 588,021 cases tested for vitamin D over the period of 2014 to 2017 were obtained and the results in 149,808 cases tested before the change in guidelines were compared to 438,213 cases tested afterwards. RESULTS: The results showed an initial fall in requests took place after the introduction of changes, but request numbers had returned to pre-change levels by November 2016. Furthermore, following the intervention, there was a significant reduction in the number of cases of vitamin D deficiency (<50 nmol/L) detected after November 2014 (P < 0.001) with odds ratio (OR) calculations showing the strongest effect for the sub-cohort of 0-20 nmol/L (OR = 1.77). For patient vitamin D levels >71 nmol/L, the pattern of detection inverted with more cases of sufficiency being detected after the intervention than before (OR from 0.84 to 0.48, P <0.001). CONCLUSIONS: The failure to show a sustained reduction in vitamin D testing is a common finding with demand management strategies to limit test requesting. More significant is the failure of the intervention to improve the detection of vitamin D deficiency. These failures highlight the need for better tools to manage test requesting including the use of audit and outcomes measurement to guide future interventions.

Comorbidity burden and nonclinical factors associated with sinonasal cancer all-cause mortality.

OBJECTIVE: To describe comorbidity burden and nonclinical factors associated with all-cause mortality of sinonasal cancer in the United States. METHODS: The National Cancer Database (2004-2013) was queried for adult cases of sinonasal cancer (n = 10,518). Outcome of interest was all-cause mortality. Independent variables included comorbidity score and nonclinical factors such as age, gender, race, facility type, distance to facility, insurance, and income. Survival analysis was conducted via multivariable extended Cox regression with Heaviside adjustments. RESULTS: Patients were mostly (79%), male (61%), and mean age of diagnosis was 63.5 years. Approximately one in five patients (18.7%) had a major comorbid condition (Charlson-Deyo score ≥ 1) at diagnosis. After adjusting for clinical factors, increasing comorbidity score was associated with a corresponding increase in hazard of mortality (aHR comorbidity score of 1 = 1.25; 95% CI, 1.16, 1.35), (aHR score of 2+ = 1.61; 95%, CI 1.41, 1.83). Hazard of mortality was also associated with being male (aHR = 1.11; 95% CI, 1.04, 1.17); black (aHR = 1.13, 95% CI, 1.03, 1.24); uninsured (aHR = 1.45; 95% CI, 1.25, 1.68) or on Medicaid (aHR = 1.50; 95% CI, 1.33, 1.69); residence in zip codes with lower median income quartile (aHR < $30,000 = 1.17; 95% CI, 1.06, 1.29); and treatment at community cancer programs (aHR = 1.14, 95% CI 1.01, 1.28). CONCLUSION: Comorbid disease is associated with all-cause sinonasal cancer mortality, and after accounting for known clinical factors, significant differences in mortality persist based on disparity-driven, nonclinical factors. LEVEL OF EVIDENCE: NA Laryngoscope, 130:1443-1449, 2020.

Diagnosis of Primary Aldosteronism by Seated Saline Suppression Test-Variability Between Immunoassay and HPLC-MS/MS.

BACKGROUND: In primary aldosteronism (PA), excessive, autonomous secretion of aldosterone is not suppressed by salt loading or fludrocortisone. For seated saline suppression testing (SSST), the recommended diagnostic cutoff 4-hour plasma aldosterone concentration (PAC) measured by high-performance liquid chromatography-mass spectrometry (HPLC-MS/MS is 162 pmol/L. Most diagnostic laboratories, however, use immunoassays to measure PAC. The cutoff for SSST using immunoassay is not known. We hypothesized that the cutoff is different between the assays. METHODS: We analyzed 80 of the 87 SSST tests that were performed during our recent study defining the HPLC-MS/MS cutoff. PA was confirmed in 65 by positive fludrocortisone suppression testing (FST) and/or lateralization on adrenal venous sampling and excluded in 15 by negative FST. PAC was measured by a chemiluminescence immunoassay (PACIA) in the SSST samples using the DiaSorin Liaison XL analyzer, and receiver operating characteristics (ROC) analysis was performed to identify the PACIA cutoff. RESULTS: ROC revealed good performance (area under the curve = 0.893; P < .001) of 4-hour postsaline PACIA for diagnosis of PA and an optimal diagnostic cutoff of 171 pmol/L, with sensitivity and specificity of 95.4% and 80.0%, respectively. A higher cutoff of 217 pmol/L improved specificity (86.7%) with lower sensitivity (86.2%). PACIA measurements strongly correlated with PAC measured by HPLC-MS (r = 0.94, P < .001). CONCLUSIONS: A higher diagnostic cutoff for SSST should be employed when PAC is measured by immunoassay rather than HPLC-MS/MS. The results suggest that (i) PA can be excluded if 4-hour PACIA is less than 171 pmol/L, and (ii) PA is highly likely if the PACIA is greater than 217 pmol/L by chemiluminescence immunoassay. A gray zone exists between the cutoffs of 171 and 217 pmol/L, likely reflecting a lower specificity of immunoassay.

Sleep reductions associated with illicit opioid use and clinic-hour changes during opioid agonist treatment for opioid dependence: Measurement by electronic diary and actigraphy.

Sleep problems are commonly reported during opioid agonist treatment (OAT) for opioid use disorders. Inpatient studies have found both sleep disturbances and improved sleep during OAT. Illicit opioids can also disrupt sleep, but it is unclear how they affect sleep in outpatients receiving OAT. Therefore, we used electronic diary entries and actigraphy to measure sleep duration and timing in opioid-dependent participants (n = 37) treated with methadone (n = 15) or buprenorphine (n = 22). For 16 weeks, participants were assigned to attend our clinic under different operating hours in a crossover design: Early hours (07:00-09:00) vs. Late hours (12:00-13:00) for 4 weeks each in randomized order, followed for all participants by our Standard clinic hours (07:00-11:30) for 8 weeks. Throughout, participants made daily electronic diary self-reports of their sleep upon waking; they also wore a wrist actigraph for 6 nights in each of the three clinic-hour conditions. Drug use was assessed by thrice-weekly urinalysis. In linear mixed models controlling for other sleep-relevant factors, sleep duration and timing differed by drug use and by clinic hours. Compared to when non-using, participants slept less, went to bed later, and woke later when using illicit opioids and/or both illicit opioids and cocaine. Participants slept less and woke earlier when assigned to the Early hours. These findings highlight the role OAT clinic schedules can play in structuring the sleep/wake cycles of OAT patients and clarify some of the circumstances under which OAT patients experience sleep disruption in daily life.

Survival differences in nasopharyngeal carcinoma among racial and ethnic minority groups in the United States: A retrospective cohort study.

OBJECTIVE: The literature on nasopharyngeal carcinoma survival in the United States has focused mostly on Whites or Asians and not much is known about survivorship in other minority racial and ethnic groups. We aimed to determine the disease-specific survival rate and prognostic factors for nasopharyngeal carcinoma survival across the minority United States population. DESIGN: A retrospective cohort study. SETTING: The Surveillance, Epidemiology and End Results (SEER) 13 database from 1992 to 2014 was queried for adult cases of nasopharyngeal carcinoma (n = 2549). PARTICIPANTS: Eligible cases were Blacks, Hispanics, Asians/Pacific Islanders, American Indians/Alaska Natives; White patients were excluded. MAIN OUTCOMES MEASURE: A multivariable competing risk survival analysis yielded hazard ratios (HR) for competing mortality and was used to identify independent prognostic factors for survival. RESULTS: Non-Hispanic American Indians/Alaska Natives consistently had the worst cause-specific survival of any group and that non-Hispanic Asians/Pacific Islanders consistently had the best survival (P < 0.001). Even after adjusting for other poor prognostic factors in the study, including older age, keratinising histology, and lack of radiation treatment, non-Hispanic American Indians/Alaska Natives had more than double hazards of death from nasopharyngeal cancer compared with non-Hispanic Asians/Pacific Islanders (aHR = 2.63, 95% CI 1.67, 4.13). CONCLUSIONS: There are disparities in nasopharyngeal carcinoma survival among racial and ethnic minority groups in the United States, with American Indians/Alaskan Natives faring worst. It is critical that future research focuses on nasopharyngeal carcinoma among this population to improve survivorship and mitigate cancer-related health disparities.

The investigation of interferences in immunoassay.

Immunoassay procedures have a wide application in clinical medicine and as such are used throughout clinical biochemistry laboratories both for urgent and routine testing. Clinicians and laboratory personnel are often presented with immunoassay results which are inconsistent with clinical findings. Without a high index of suspicion interferences will often not be suspected. Artifactual results can be due to a range of interferences in immunoassays which can include cross reacting substances, heterophile antibodies, autoantibodies and the high dose hook effect. Further, pre-analytical aspects and certain disease states can influence the potential for interference in immunoassays. Practical solutions for investigation of artifactual results in the setting of the routine clinical laboratory are provided.

Morbidity, mortality and cost from HPV-related oropharyngeal cancer: Impact of 2-, 4- and 9-valent vaccines.

OBJECTIVE: The incidence of oropharyngeal squamous cell carcinoma (OPSCC) related to human papillomavirus (HPV) is increasing at a dramatic rate, with men affected more commonly than women. Individuals who develop this disease suffer significant morbidity and potential mortality from their cancer and its associated treatment. We aim to evaluate the possible impact that the currently available HPV vaccines will have on this group of cancers. DATA SOURCES: Available peer-reviewed literature, practice guidelines, and statistics published by the Center for Disease Control and Prevention. REVIEW METHODS: Contemporary peer-reviewed medical literature was selected based on its scientific validity and relevance to the impact HPV vaccination may have on the morbidity, mortality and cost resulting from HPV-related OPSCC in the United States. CONCLUSIONS: The incidence of HPV-related OPSCC is increasing at a near epidemic rate in the United States. The cost of treatment of HPV-related OPSCC is high, and the disease and its therapy result in significant morbidity and potential mortality to individuals. Using a cut-off of $50,000/Quality-Adjusted Life Year, expansion of current HPV vaccine indications to include prevention of OPSCC in both men and women should be recommended.

Longitudinal voice outcomes following laryngeal reinnervation via vagus-to-recurrent laryngeal nerve anastomosis after vagal nerve sacrifice: a case series.

OBJECTIVE: This study aimed to describe longitudinal voice outcomes of vagus-to-recurrent laryngeal nerve anastomosis following operative vagal nerve sacrifice. METHODS: Two patients who underwent anastomosis were assessed by a multidisciplinary voice team at 1, 4, 9, 12, and 18 months after vagal sacrifice. RESULTS: Long-term changes in voice function based on auditory perceptual measures of voice quality and visual perceptual changes in glottal closure were observed and maintained for 18 months after vagus-to-recurrent laryngeal nerve anastomosis in 2 patients with proximal vagal nerve sacrifice. Patients achieved acceptable voice outcomes and elected not to undergo further treatment, which was supported by Voice Handicap Index scores. CONCLUSION: Gradual restoration of voice following operative vagal sacrifice can be achieved over an 18-month period using vagus-to-recurrent laryngeal nerve anastomosis and warrants further investigation in appropriately selected patients.

Harmonised Australian Reference Intervals for Serum PINP and CTX in Adults.

Bone turnover markers (BTMs) are classified as either formation or resorption markers. Their concentrations in blood or urine of adults are considered to reflect the rate of bone remodelling and may be of use in the management of patients with bone disease. Major inter-method differences exist for BTMs, and harmonisation of methods is currently being pursued at an international level. Based on published data, this article describes age- and sex-specific Australian consensus reference intervals for adults for serum procollagen type I amino-terminal propeptide (s-PINP) and serum ß-isomerised carboxy-terminal cross-linking telopeptide of type I collagen (s-CTX).

Transplantation of storm-generated coral fragments to enhance Caribbean coral reefs: A successful method but not a solution / Trasplante de fragmentos de coral generados por tormentas para mejorar los arrecifes de coral del Caribe: un método exitoso pero no una solución

In response to dramatic losses of reef-building corals and ongoing lack of recovery, a small-scale coral transplant project was initiated in the Caribbean (U.S. Virgin Islands) in 1999 and was followed for 12 years. The primary objectives were to (1) identify a source of coral colonies for transplantation that would not result in damage to reefs, (2) test the feasibility of transplanting storm-generated coral fragments, and (3) develop a simple, inexpensive method for transplanting fragments that could be conducted by the local community. The ultimate goal was to enhance abundance of threatened reef-building species on local reefs. Storm-produced coral fragments of two threatened reef-building species [Acropora palmata and A. cervicornis (Acroporidae)] and another fast-growing species [Porites porites (Poritidae)] were collected from environments hostile to coral fragment survival and transplanted to degraded reefs. Inert nylon cable ties were used to attach transplanted coral fragments to dead coral substrate. Survival of 75 reference colonies and 60 transplants was assessed over 12 years. Only 9% of colonies were alive after 12 years: no A. cervicornis; 3% of A. palmata transplants and 18% of reference colonies; and 13% of P. porites transplants and 7% of reference colonies. Mortality rates for all species were high and were similar for transplant and reference colonies. Physical dislodgement resulted in the loss of 56% of colonies, whereas 35% died in place. Only A. palmata showed a difference between transplant and reference colony survival and that was in the first year only. Location was a factor in survival only for A. palmata reference colonies and after year 10. Even though the tested methods and concepts were proven effective in the field over the 12-year study, they do not present a solution. No coral conservation strategy will be effective until underlying intrinsic and/or extrinsic factors driving high mortality rates are understood and mitigated or eliminated. Rev. Biol. Trop. 60 (Suppl. 1): 59-70. Epub 2012 March 01.

En respuesta a la dramática pérdida de corales constructores de arrecifes y la continua falta de recuperación, un proyecto de pequeña escala de transplante de corales, al cual se le dio seguimiento por 12 años, se inició en el Caribe (Islas Vírgenes de EUA) en 1999. Los principales objetivos fueron (1) identificar fuentes de colonias de coral para el trasplante, que no produjeran daños a los arrecifes, (2) evaluar la viabilidad del trasplante de fragmentos de coral generados por tormentas, y (3) desarrollar un método simple y barato para transplantar fragmentos que pudiera ser realizado por la comunidad local. La meta última era aumentar la abundancia de especies constructoras de arrecife amenazadas en los arrecifes locales. Fragmentos de coral producidos por tormenta de dos especies constructoras de arrecife amenazadas [Acropora palmata y A. cervicornis (Acroporidae)] y otras especies de crecimiento rápido [Porites porites (Poritidae)] fueron recolectadas en ambientes no adecuados para la supervivencia de fragmentos de coral y se trasplantaron a los arrecifes degradados. Fajitas de nylon inerte fueron utilizadas para unir los fragmentos de corales transplantados al sustrato de coral muerto. La sobrevivencia de 75 colonias de referencia y de 60 transplantadas fueron monitoreadas por más de 12 años. Sólo el 9% de las colonias estaban vivas tras 12 años, sin presencia de A. cervicornis, el 3% de los transplantes de A. palmata y el 18% de las colonias de referencia de Acropora. El 13% de los transplantes de P. porites y el 7% de las colonias de referencia sobrevivieron. El desprendimiento físico resultó en la pérdida del 56% de las colonias, mientras que el 35% murió en el lugar. Solamente A. palmata mostró una diferencia en sobrevivencia entre los trasplantes y las colonias de referencia, eso fue solo en el primer año. La ubicación fue un factor en la sobrevivencia sólo para las colonias de referencia de A. palmata y después de 10 años. A pesar de que los métodos y los conceptos fueron probados efectivamente en el campo por más de 12 años de estudio, no mostraron ser la solución. Ninguna estrategia de conservación va a ser efectiva hasta que se delimiten y sean entendidos, mitigados o eliminados los factores intrínsecos y/o extrínsecos que conducen a las altas tasas de mortalidad.

A retrospective study of the safety and efficacy of ERCP in octogenarians.

BACKGROUND: Pancreatobiliary disease is increased in elderly patients. Because of significant comorbidities, these patients may be at greater risk of developing complications related to endoscopic retrograde cholangiopantreatography (ERCP). OBJECTIVE: The purpose of this study was to compare the indications, interventions, and complications of ERCP of octogenarians with nonoctogenarians. METHODS: A retrospective review of patient records from a single tertiary care hospital was performed. Adult patients undergoing ERCP were divided into two groups according to age. Group 1 patients were of age < 80 years (N = 391), and group 2 patients were > 80 years of age (N = 102). Indications, therapeutic interventions, use of conscious sedation, duration of procedure and complications were retrieved from the patient records. Main outcome measurements included: indications, therapeutic interventions, use of conscious sedation, duration of procedure and complications. RESULTS: There was an increase in sphincterotomy rates (74 vs 63%; P < 0.05) and stent insertions (48 vs 29%; P < 0.001) in the octogenarian group. In group 1 there were 19 cases (4.9%) of post ERCP pancreatitis who spent 251 hospital days (including 59 ICU days) compared with one case (0.98%) in group 2 who required ten hospital days (P < 0.05) and 0 ICU days. Procedure time for octogenarians was greater than nonoctogenarians (33.1 vs 29.8 min; P < 0.05). Octogenarians required less conscious sedation than nonoctogenarians (midazolam 4.1 vs 5.9 mg; P < 0.05 and fentanyl 45.5 vs 80.4 mcg; P < 0.05). CONCLUSIONS: In octogenarians, ERCP is efficacious and safe. It is associated with a lower rate of hospitalization for pancreatitis. ERCP in octogenarians takes longer, is associated with increased interventions (stent insertion and sphincterotomy) and requires less sedation.

Automatic high-dynamic range image generation for dynamic scenes.

Automatic high-dynamic range image generation from low-dynamic range images offers a solution to conventional methods, which require a static scene. The method consists of two modules: a camera-alignment module and a movement detector, which removes the ghosting effects in the HDRI created by moving objects.

Interferences in immunoassay.

Substances that alter the measurable concentration of the analyte or alter antibody binding can potentially result in immunoassay interference. Interfering, endogenous substances that are natural, polyreactive antibodies or autoantibodies (heterophiles), or human anti-animal antibodies together with other unsuspected binding proteins that are unique to the individual, can interfere with the reaction between analyte and reagent antibodies in immunoassay. Lipaemia, cross-reactivity, and exogenous interferences due to pre-analytical variation, matrix and equipment reaction also affect immunoassay. Interfering substances may lead to falsely elevated or falsely low analyte concentration in one or more assay systems depending on the site of the interference in the reaction and possibly result in discordant results for other analytes. The prevalence of interference is generally low in assays containing blocking agents that neutralise or inhibit the interference but is often higher in new, untested immunoassays. A wide range of analytes measured by immunoassay including hormones, tumour markers, drugs, cardiac troponin and microbial serology may be affected. Interference in immunoassay may lead to the misinterpretation of a patient's results by the laboratory and the wrong course of treatment being given by the physician. Laboratories should put processes in place to detect, test and report suspected interferences. It is equally important that physicians communicate any clinical suspicion of discordance between the clinical and the laboratory data to the laboratory. The detection of interference may require the use of an alternate assay or additional measurements, before and after treatment with additional blocking reagent, or following dilution of the sample in non-immune serum. It is imperative that laboratories inform physicians of the follow-up procedure and report on the presence of any interference. The establishment of on-going laboratory-physician contact is essential to the continuing awareness of wrong patient results due to interference.