Measurement uncertainty in clinical chemistry: ISO 20914 versus nordtest or intermediate precision versus bias.

AIM: Measuring uncertainty (MU) is crucial to ensure the accuracy and precision of laboratory results. This study compares the ISO 20914 and Nordtest guidelines to analyze the MU values for 20 clinical chemistry analytes over six months. METHODS: The researchers calculated MU components, including within-laboratory reproducibility (Rw), laboratory analytical performance bias (u(bias)), and combined standard uncertainty (uc), based on internal quality control and external quality assessment data. The final expanded uncertainty (U) values were determined by multiplying the combined uncertainty with a coverage factor (k = 2 for 95% Confidence Interval), following each guideline's respective procedures. Clinical chemistry analytes were analyzed on Roche Cobas 6000 c501 auto analyzer (Roche Diagnostics, Mannheim, Germany) and manufacturer's kits were used analysis. RESULTS: The results show that 11 out of 20 clinical chemistry analytes met the targeted maximum allowable measurement uncertainty (MAU) values when calculated according to ISO 20914 guideline. Also, 11 out of 20 clinical chemistry analytes' MU values met the MAU values with the Nordtest guideline's recommended calculations. However, some tests met the MAU in the ISO 20914 approach but not in the Nordtest guideline, and vice versa. CONCLUSIONS: The study found that intermediate precision (uRw) in the ISO 20914 approach and performance bias (u(bias)) in the Nordtest approach significantly impacted MU values. The research highlights the importance of standardization in MU calculation approaches across clinical laboratories. These findings have implications for patient care and clinical decision-making, emphasizing the importance of selecting appropriate laboratory guidelines for routine use.

A comparative analysis of Sigma metrics using conventional and alternative formulas.

BACKGROUND AND AIM: The Six Sigma approach, employing Sigma Metrics (SM), is commonly used to evaluate analytical performance in clinical laboratories. However, there is ongoing debate regarding the suitability of the conventional SM formula, which incorporates total allowable error (TEa) and bias. To address this, an alternative formula based on within-subject biological variation (CVI) as the tolerance range (TR) has been proposed. The study aimed to calculate and compare SM values using both formulas. MATERIAL AND METHODS: Twenty clinical chemistry parameters were evaluated, and SM values were calculated using conventional formula with two TEa goals and the alternative formula. Intermediate precision (CVA%) values were obtained from internal quality control data, while bias values were derived from external quality assessment reports. RESULTS: The results showed that using the conventional formula, 11 SM values based on CLIA TEa goals and 21 SM values based on BV TEa goals were deemed unacceptable (SM < 3). Additionally, 22 SM values calculated using the alternative formula were below 3. CONCLUSION: The choice of TR had a substantial impact on the assessed analytical performance. Laboratories should carefully consider the appropriateness of each approach based on their specific quality objectives, analyte characteristics, and laboratory operations.

Negligible Specimen Hemolysis Is Observed With Sarstedt S-Monovette Coagulation Tubes in Aspiration Mode.

OBJECTIVES: We aimed to compare the levels of hemolysis in the blood collected using the vacuum and aspiration modes via Sarstedt S-Monovette coagulation tubes. METHODS: Forty volunteers were included in the study. Blood samples were collected using two different modes in the S-Monovette citrate tube (Sarstedt AG). Prothrombin time, active partial thromboplastin time, fibrinogen, and D-dimer analyses were performed using the STA-Compact-Max 3 analyzer (Stago). The hemolysis levels of the samples were measured by both Stago's semiquantitative hemolysis index (H-index) module and the quantitative H-index measurement of the Roche cobas 6000 (Roche Diagnostics) analyzer. RESULTS: Roche's quantitative H-index values were statistically significantly lower in the aspiration mode. No clinically significant difference was observed between coagulation test results. CONCLUSIONS: Using the S-Monovette citrate tubes can reduce spurious hemolysis and improve patient safety.

Could S-Monovette Serum Gel Tubes be Used for Clinical Chemistry Analysis Instead of Serum Separator Tube II Advance?

BACKGROUND: We aimed to compare the Sarstedt S-Monovette serum gel tube and the BD (Becton, Dickinson and Company) Serum Separator Tube II (SST II) Advance based on technical specifications and tests results. METHODS: One hundred and twenty volunteers were included in the technical evaluation and 42 of 120 volunteers in the clinical evaluation. Blood was collected into S-Monovette, and SST II. Twelve quality indicators (QI) were determined for technical evaluation. For clinical evaluation, 29 clinical chemistry analytes were analysed simultaneously on a Roche Cobas 6000 c501 (Roche Diagnostics, Mannheim, Germany). Calculations were made using the formula suggested by the EFLM according to the QIs. If the difference between S-Monovette and SST II was < 1%, S-Monovette was considered sufficient for relevant QI. For clinical evaluation, Passing Bablok regression analysis and Bland-Altman plots were used. Desirable bias values for comparison with mean percentage difference (MPD) were obtained from biological variation databases. RESULTS: S-Monovette tubes were found to be suitable for all QIs (difference < 1%). No significant differences were observed in analytes except lactate dehydrogenase (LDH). LDH results (U/L) obtained from the SST II were statistically significantly higher (SST II: 201 ± 42, S-Monovette: 195 ± 35, regression equation was y = 31.4 + 0.8x). The MPD of LDH (2.4%) remained within the desirable bias (3.4%); however, the 95% CI of the MPD of LDH (0.5% - 4.4%) exceeded the desirable bias. CONCLUSIONS: S-Monovette has been deemed appropriate for use in clinical chemistry analysis, as the MPD of LDH and other analytes remained within the bias limits. The LDH was considered sensitive to microhemolysis as a possible reason for the difference in LDH results.

Interferograms plotted with reference change value (RCV) may facilitate the management of hemolyzed samples.

Background: The European Federation of Clinical Chemistry and Laboratory Medicine (EFLM) Working Group for Preanalytical Phase (WG-PRE) have recommended an algorithm based on the reference change value (RCV) to evaluate hemolysis. We utilized this algorithm to analyze hemolysis-sensitive parameters. Methods: Two tubes of blood were collected from each of the 10 participants, one of which was subjected to mechanical trauma while the other was centrifuged directly. Subsequently, the samples were diluted with the participant's hemolyzed sample to obtain the desired hemoglobin concentrations (0, 1, 2, 4, 6, 8, and 10 g/L). ALT, AST, K, LDH, T. Bil tests were performed using Beckman Coulter AU680 analyzer. The analytical and clinical cut-offs were based on the biological variation for the allowable imprecision and RCV. The algorithms could report the values directly below the analytical cut-off or those between the analytical and clinical cut-offs with comments. If the change was above the clinical cut-off, the test was rejected. The linear regression was used for interferograms, and the hemoglobin concentrations corresponding to cut-offs were calculated via the interferograms. Results: The RCV was calculated as 29.6% for ALT. Therefore, ALT should be rejected in samples containing >5.9 g/L hemoglobin. The RCVs for AST, K, LDH, and T. Bil were calculated as 27.9%, 12.1%, 19.2%, and 61.2%, while the samples' hemoglobin concentrations for test rejection were 0.8, 1.6, 0.5, and 2.2 g/L, respectively. Conclusions: Algorithms prepared with RCV could provide evidence-based results and objectively manage hemolyzed samples.

Evaluation of the Relationship Between Transcutaneous Bilirubin Measurement and Total Serum Bilirubin in Neonatal Patients Followed for Jaundice.

OBJECTIVES: Jaundice is a physiological condition caused by hyperbilirubinemia, which is common in neonatal period. However, severe hyperbilirubinemia can cause kernicterus, which is a serious condition that leads to neurological problems. In this study, we aimed to investigate whether it is safe to use transcutaneous bilirubin (TcB) instead of blood for the evaluation of jaundice by comparing TcB measurement with standard total serum bilirubin (TSB) measurement values. METHODS: A total of 105 term and early term infants with gestational ages between 37 and 42 weeks were included in the study. MBJ20 TcB measuring device was used for TcB measurement. TcB was measured from the forehead and sternum. To evaluate the relationship between TcB measurements and TSB measurements, we performed Pearson correlation, Spearman correlation, linear regression analysis, and Bland-Altman analysis in which we evaluated the scatter plot of the differences between the average values of the measurements. RESULTS: There was a positive and statistically significant correlation between TcB forehead and TSB measurements and TcB sternum and TSB measurements (p<0.001). Linear regression analysis showed a positive directional correlation between TcB forehead and TSB measurements (R²=0.85) and TcB sternum and TSB measurements (R²=0.87). Bland-Altman analysis showed a good consistency between TSB and TcB forehead measurement methods (mean difference: 0.39±1.46, 95% CI: [-2.47]-[3.26]), and between TSB and TcB sternum measurement methods (mean difference: 0.49±1.32 95% CI: [-2.1]-[3.07]). CONCLUSION: As a result of our study, we found that TcB measurement can be reliable instead of taking blood for jaundice evaluation.

Could Some Laboratory Parameters Predict Mortality in COVID-19?

BACKGROUND: The number of confirmed cases of COVID-19 continues to increase worldwide and threatens public health. Our aim in this study is to examine the relationship between some laboratory parameters and hematological ratios with the severity of the disease and hospital mortality. METHODS: This study was designed as a retrospective cohort. The clinical data of 743 COVID-19 diagnosed patients who were eligible for hospitalization between March 16, and May 15, 2020 analyzed, retrospectively. The patients were separated into two groups as discharged from hospital (n = 681) and dead in hospital (n = 62). ROC curves and cutoff values of NLR (Neutrophil/Lymphocyte Ratio), PLR (Platelet/Lymphocyte Ratio), MLR (Monocyte/ Lymphocyte Ratio), CRP, and ferritin upon admission to hospital were calculated for the two groups. Binary Logistic Regression used to determine independent risk factors for mortality. RESULTS: The difference between both groups for age, duration in hospital, WBC, neutrophil, lymphocyte, NLR, PLR, MLR, CRP, and ferritin values were statistically significant. NLR had the highest area under the curve with a cutoff of 5.5 in the ROC curve [(AUC: 0.892, 95% CI: 0.844 - 0.939); Sensitivity = 85%, Specificity = 84%]. NLR, MLR, PLR, CRP and Ferritin groups have significant effects on the survival times of the Covid-19 patients. According to logistic regression analysis, increments of NLR (OR = 18.1, 95% CI: 6.4 - 51.4), CRP (OR = 5.5, 95% CI: 2.5 - 12.2), and age (OR = 2.7 95% CI: 1.3 - 5.5) values proportionally increase the death probability. CONCLUSIONS: NLR, CRP, and age are independent risk factors for mortality from COVID-19. We believe that evaluating these parameters together during diagnosis will be important in predicting the prognosis of the disease and in treatment approaches.

Effect of haemolysis on an enzymatic measurement of ethanol.

INTRODUCTION: We investigated the interference of haemolysis on ethanol testing carried out with the Synchron assay kit using an AU680 autoanalyser (Beckman Coulter, Brea, USA). MATERIALS AND METHODS: Two tubes of plasma samples were collected from 20 volunteers. Mechanical haemolysis was performed in one tube, and no other intervention was performed in the other tube. After centrifugation, haemolysed and non-haemolysed samples were diluted to obtain samples with the desired free haemoglobin (Hb) values (0, 1, 2, 5, 10 g/L). A portion of these samples was then separated, and ethanol was added to the separated sample to obtain a concentration of 86.8 mmol/L ethanol. After that, these samples were diluted with ethanol-free samples with the same Hb concentration to obtain samples containing 43.4, 21.7, and 10.9 mmol/L. Each group was divided into 20 equal parts, and an ethanol test was carried out. The coefficient of variation (CV), bias, and total error (TE) values were calculated. RESULTS: The TE values of haemolysis-free samples were approximately 2-5%, and the TE values of haemolysed samples were approximately 10-18%. The bias values of haemolysed samples ranged from nearly - 6.2 to - 15.7%. CONCLUSIONS: Haemolysis led to negative interference in all samples. However, based on the 25% allowable total error value specified for ethanol in the Clinical Laboratory Improvement Amendments (CLIA 88) criteria, the TE values did not exceed 25%. Consequently, ethanol concentration can be measured in samples containing free Hb up to 10 g/L.

The effect of quercetin on cerulein-induced acute pancreatitis / Efeito da quercetina sobre a pancreatite induzida por ceruleína

OBJECTIVE: The aim of this study was to evaluate the protective and therapeutic effects of quercetin on pancreatic injury in cerulein-induced acute pancreatitis. METHOD: Thirty-two rats were randomly divided into four groups, eight per group: (CT): untreated controls, (CER) treated with cerulein, 50 µg/kg body weight; (Q+CER) pre-treatment with quercetin, 100 mg/kg body weight, followed by cerulein, 50 µg/kg; (CER+Q) post-treatment, cerulein followed by quercetin, same doses. Cerulein was divided into four doses, given at 1-hour intervals by intraperitoneal injection. Quercetin was given either 1-hour before (in pre-treatment group) or 1-hour after (in post-treatment group) cerulein. Pancreatic malondialdehyde (MDA), carbonyl, myeloperoxidase (MPO), tumor necrosis factor-alpha (TNF-a), interleukin-6 (IL-6), reduced and oxidized glutathione (GSH and GSSG, respectively) were measured. Histology of the pancreas was studied. RESULTS: (1) MDA, carbonyl, MPO, TNF-a and IL-6 levels were significantly higher in CER vs CT rats. (2) MDA, carbonyl, MPO and TNF-α decreased significantly in pre-treated rats vs. CER. (3) MDA, MPO, TNF-α, IL-6 were significantly lower in post-treated rats vs. CER. (4) The reduced vs. oxidized glutathione ratio (GSH/GSSG) of was significantly lower CER vs. CT rats. (5) Pre- and post-treatment with quercetin significantly increased this ratio. (6) Pancreatic histology showed that quercetin had no significant effect on the histological image of the pâncreas CONCLUSION: These results suggest that quercetin can attenuate the severity of cerulein-induced acute pancreatitis by acting as an antioxidant and anti-inflammatory agent and combating oxidative stress. Further studies are needed to clearly explain its utility on acute pancreatitis.

OBJETIVO: O objetivo deste estudo foi avaliar os efeitos protetores e terapêuticos da quercetina na lesão pancreática da pancreatite aguda induzida por ceruleína. MÉTODO: Trinta e dois ratos foram divididos aleatoriamente em quatro grupos, oito por grupo: (CT): controles não tratados (CER) tratados com ceruleína, 50 µg/kg de peso corporal; (Q+CER) pré-tratamento com quercetina, 100 mg / kg de peso corporal, seguido de ceruleína, 50 µg/kg; (CER+Q) pós-tratamento, ceruleína seguida de quercetina, mesmas doses. A ceruleína foi dividida em quatro doses, administradas a intervalos de 1 hora por injeção intraperitoneal. A quercetina foi administrada 1 hora antes (no grupo de pré-tratamento) ou 1 hora após (no pós-tratamento) a administração de ceruleína. Foram medidos o malondialdeído pancreático (MDA), carbonilo, mieloperoxidase (MPO), fator de necrose tumoral alfa (TNF-a), interleucina-6 (IL-6), glutationa reduzida e oxidada (GSH e GSSG, respetivamente). Foi estudada a histologia do pâncreas. RESULTADOS: Os níveis de MDA, carbonila, MPO, TNF-a e IL-6 foram significativamente maiores nos ratos CER vs. CT. MDA, carbonila, MPO e TNF-α diminuíram significativamente em ratos pré-tratados versus CER. MDA, MPO, TNF-α, IL-6 também foram significativamente menores em ratos pós-tratados versus CER. A proporção reduzida de glutationa oxidada (GSH/GSSG) foi significativamente menor ratos CER vs. CT; pré e pós-tratamento com quercetina aumentaram significativamente esta proporção. A histologia pancreática mostrou que a quercetina não teve efeito morfológico significativo. CONCLUSÃO: Estes resultados sugerem que a quercetina pode atenuar a gravidade da pancreatite aguda induzida por ceruleína, atuando como agente antioxidante e anti-inflamatório e combater o estresse oxidativo. Mais estudos são necessários para explicar claramente suas utilidades na pancreatite aguda.