Can serum beta-hydroxybutyrate be used to diagnose diabetic ketoacidosis?

OBJECTIVE

Current criteria for the diagnosis of diabetic ketoacidosis (DKA) are limited by their nonspecificity (serum bicarbonate [HCO(3)] and pH) and qualitative nature (the presence of ketonemia/ketonuria). The present study was undertaken to determine whether quantitative measurement of a ketone body anion could be used to diagnose DKA.

RESEARCH DESIGN AND METHODS

A retrospective review of records from hospitalized diabetic patients was undertaken to determine the concentration of serum beta-hydroxybutyrate (betaOHB) that corresponds to a HCO(3) level of 18 mEq/l, the threshold value for diagnosis in recently published consensus criteria. Simultaneous admission betaOHB and HCO(3) values were recorded from 466 encounters, 129 in children and 337 in adults.

RESULTS

A HCO(3) level of 18 mEq/l corresponded with betaOHB levels of 3.0 and 3.8 mmol/l in children and adults, respectively. With the use of these threshold betaOHB values to define DKA, there was substantial discordance (approximately > or = 20%) between betaOHB and conventional diagnostic criteria using HCO(3), pH, and glucose. In patients with DKA, there was no correlation between HCO(3) and glucose levels on admission and a significant but weak correlation between betaOHB and glucose levels (P < 0.001).

CONCLUSIONS

Where available, serum betaOHB levels > or = 3.0 and > or = 3.8 mmol/l in children and adults, respectively, in the presence of uncontrolled diabetes can be used to diagnose DKA and may be superior to the serum HCO(3) level for that purpose. The marked variability in the relationship between betaOHB and HCO(3) is probably due to the presence of other acid-base disturbances, especially hyperchloremic, nonanion gap acidosis.

Evaluation of the impact of hematocrit and other interference on the accuracy of hospital-based glucose meters

BACKGROUND

Most glucose meter comparisons to date have focused on performance specifications likely to impact subcutaneous dosing of insulin. We evaluated four hospital-based glucose meter technologies for accuracy, precision, and analytical interferences likely to be encountered in critically ill patients, with the goal of identifying and discriminating glucose meter performance specifications likely to impact intensive intravenous insulin dosing.

METHODS

Precision, both within-run and day-to-day, was evaluated on all four glucose meters. Accuracy (bias) of the meters and analytical interference were evaluated by comparing results obtained on whole blood specimens to plasma samples obtained from these whole blood specimens run on a hexokinase reference method.

RESULTS

Precision was acceptable and differed little between meters. There were significant differences in the degree to which the meters correlated with the reference hexokinase method. Ascorbic acid showed significant interference with three of the four meters. Hematocrit also affected the correlation between whole blood and plasma hexokinase glucose on three of the four glucose meters tested, with the magnitude of this interference also varying by glucose meter technology.

CONCLUSIONS

Correlation to plasma hexokinase values and hematocrit interference are the main variables that differentiate glucose meters. Meters that correlate with plasma glucose measured by a reference method over a wide range of glucose concentrations and minimize the effects of hematocrit will allow better glycemic control for critically ill patients.

Glucose Meter Performance Criteria for Tight Glycemic Control Estimated by Simulation Modeling

Background: Glucose meter analytical performance criteria required for safe and effective management of patients on tight glycemic control (TGC) are not currently defined. We used simulation modeling to relate glucose meter performance characteristics to insulin dosing errors during TGC.

Methods: We used 29 920 glucose values from patients on TGC at 1 institution to represent the expected distribution of glucose values during TGC, and we used 2 different simulation models to relate glucose meter analytical performance to insulin dosing error using these 29 920 initial glucose values and assuming 10%, 15%, or 20% total allowable error (TEa) criteria.

Results: One-category insulin dosing errors were common under all error conditions. Two-category insulin dosing errors occurred more frequently when either 20% or 15% TEa was assumed compared with 10% total error. Dosing errors of 3 or more categories, those most likely to result in hypoglycemia and thus patient harm, occurred infrequently under all error conditions with the exception of 20% TEa.

Conclusions: Glucose meter technologies that operate within a 15% total allowable error tolerance are unlikely to produce large (≥3-category) insulin dosing errors during TGC. Increasing performance to 10% TEa should reduce the frequency of 2-category insulin dosing errors, although additional studies are necessary to determine the clinical impact of such errors during TGC. Current criteria that allow 20% total allowable error in glucose meters may not be optimal for patient management during TGC.

Accuracy of roche accu-chek inform whole blood capillary, arterial, and venous glucose values in patients receiving intensive intravenous insulin therapy after cardiac surgery

Intravenous insulin protocols are increasingly common in the intensive care unit to maintain normoglycemia. Little is known about the accuracy of point-of-care glucometers for measuring glucose in this patient population or the impact of sample source (capillary, arterial, or venous whole blood) on the accuracy of glucometer results. We compared capillary, arterial, and venous whole blood glucose values with laboratory plasma glucose values in 20 patients after cardiac surgery. All 4 samples (capillary, arterial, and venous whole blood and laboratory plasma glucose) were analyzed hourly for the first 5 hours during intravenous insulin therapy in the intensive care unit. There were no significant differences between median capillary whole blood (149 mg/dL [8.3 mmol/L]) and laboratory plasma (151 mg/dL [8.4 mmol/L]) glucose levels. The median arterial (161 mg/dL [8.9 mmol/L]) and venous (162 mg/dL [9.0 mmol/L]) whole blood glucose levels were significantly higher than the median laboratory plasma glucose level. Capillary whole blood glucose levels correlate most closely with laboratory plasma glucose levels in patients receiving intensive intravenous insulin therapy after cardiac surgery.

Precision and Reliability of 5 Platelet Function Tests in Healthy Volunteers and Donors on Daily Antiplatelet Agent Therapy

BACKGROUND

Anticoagulation protocols used during mechanical circulatory support call for titration of antiplatelet agents. We compared the precision and reliability of 5 platelet function tests in healthy volunteers and donors on daily antiplatelet therapy to distinguish their efficacy for titrating antiplatelet therapy.

METHODS

We assessed arachidonic acid–induced platelet function by light transmission aggregometry (LTA), Multiplate impedance aggregometry, VerifyNow, and platelet mapping by thromboelastography (TEG PM). We assessed ADP-induced platelet function by the same methods and flow cytometry. Forty healthy volunteers and 10–13 volunteers on daily aspirin and/or clopidogrel therapy were evaluated. We compared tests for intraassay precision, interassay precision (samples from 2 separate blood draws), and reliability coefficient.

RESULTS

For arachidonic acid–induced platelet aggregation in healthy volunteers, intra- and interassay CVs were ≤10% for all methods. Intra- and interassay precision among donors on daily aspirin was ≤30% for all methods except LTA (38% interassay CV) and TEG PM (95% intraassay and 104% interassay CV). For ADP-induced platelet function, intra- and interassay precision was ≤10% and ≤30% for all methods. Only Multiplate demonstrated moderate or greater (R &gt; 0.40) reliability coefficients for arachidonic acid–induced platelet function among all subjects. All methods of ADP-induced platelet function, except TEG PM, demonstrated substantial or greater (R &gt; 0.60) reliability among all subjects.

CONCLUSIONS

TEG PM is least suited to monitor effects of antiplatelet agents. Multiplate impedance aggregometry was the only method to demonstrate an acceptable reliability coefficient among healthy volunteers and donors on both aspirin and clopidogrel therapy.

Comparison of lactate values between point-of-care and central laboratory analyzers

Measurement of lactate levels is important in the care of critically ill adult and pediatric patients. We compared 3 whole blood lactate methods (Radiometer ABL 725, Radiometer Medical A/S, Bronshoj, Denmark; i-STAT, i-STAT, East Windsor, NJ; and Nova Lactate Plus, Nova Biomedical, Waltham, MA) with 2 plasma-based methods (Roche Integra, Roche Diagnostics, Indianapolis, IN; and Vitros, Ortho Clinical Diagnostics, Rochester, NY). The Vitros LAC slide assay was used as the reference method. Results were compared by least squares regression and Bland-Altmann plots and by comparing concordance within clinically relevant lactate ranges. Correlation between lactate methods was good with slopes between 0.87 and 1.06 and intercepts of 0.9 to 1.8 mg/dL (0.1-0.2 mmol/L) of lactate for all 4 methods compared with the Vitros. At high (>54.1 mg/dL [6 mmol/L]) lactate values, the Radiometer and i-STAT methods reported lower lactate results compared with the Vitros and Integra. The Nova analyzer reported higher lactate results than either the Vitros or Integra. The negative bias in i-STAT and Radiometer results may confound the interpretation of patient condition if multiple methods are used within the same institution.

Evaluation of the Cue Health point-of-care COVID-19 (SARS-CoV-2 nucleic acid amplification) test at a community drive through collection center

Point-of-care (POC) tests are in high demand in order to facilitate rapid care decisions for patients suspected of SARS-CoV-2. We conducted a clinical validation study of the Cue Health POC nucleic acid amplification test (NAAT) using the Cue lower nasal swab, compared to a reference NAAT using standard nasopharyngeal swab, in 292 symptomatic and asymptomatic outpatients for SARS-CoV-2 detection in a community drive through collection setting. Positive percent agreement between Cue COVID-19 and reference SARS-CoV-2 test was 91.7% (22 of 24); or 95.7% (22 of 23) when one patient with no tie-breaker method was excluded. Negative percent agreement was 98.4% (239 of 243), and there were 25 (8.6%) invalid or canceled results. The Cue COVID-19 test demonstrated very good positive and negative percent agreement with central laboratory tests and will be useful in settings where accurate POC testing is needed to facilitate management of patients suspected of COVID-19.

Anesthetics alter the physical and functional properties of the Ca-ATPase in cardiac sarcoplasmic reticulum

We have studied the effects of the local anesthetic lidocaine, and the general anesthetic halothane, on the function and oligomeric state of the CA-ATPase in cardiac sarcoplasmic reticulum (SR). Oligomeric changes were detected by time-resolved phosphorescence anisotropy (TPA). Lidocaine inhibited and aggregated the Ca-ATPase in cardiac SR. Micromolar calcium or 0.5 M lithium chloride protected against lidocaine-induced inhibition, indicating that electrostatic interactions are essential to lidocaine inhibition of the Ca-ATPase. The phospholamban (PLB) antibody 2D12, which mimics PLB phosphorylation, had no effect on lidocaine inhibition of the Ca-ATPase in cardiac SR. Inhibition and aggregation of the Ca-ATPase in cardiac SR occurred at lower concentrations of lidocaine than necessary to inhibit and aggregate the Ca-ATPase in skeletal SR, suggesting that the cardiac isoform of the enzyme has a higher affinity for lidocaine. Halothane inhibited and aggregated the Ca-ATPase in cardiac SR. Both inhibition and aggregation of the Ca-ATPase by halothane were much greater in the presence of PLB antibody or when PLB was phosphorylated, indicating a protective effect of PLB on halothane-induced inhibition and aggregation. The effects of halothane on cardiac SR are opposite from the effects of halothane observed in skeletal SR, where halothane activates and dissociates the Ca-ATPase. These results underscore the crucial role of protein-protein interactions on Ca-ATPase regulation and anesthetic perturbation of cardiac SR.

Mechanisms of dopamine and dobutamine interference in biochemical tests that use peroxide and peroxidase to generate chromophore

Dopamine and dobutamine have recently been shown to produce a negative interference in several biochemical tests that use peroxide and peroxidase to generate a chromophore. To define the chemical mechanism of this interference, we examined the effects of dopamine and dobutamine in various peroxidase-based biochemical tests. Dopamine interfered stoichiometrically with peroxidase-based tests that use 4-aminophenazone to form chromophore but interfered little in those that use other compounds to generate chromophore. Dopamine reacts with 4-aminophenazone in the presence of peroxide and peroxidase to form a novel quinone-imine dye, with a smaller absorptivity than the chromophore formed in the absence of dopamine. The smaller absorptivity of this novel chromophore results in negative interference by reducing the total absorbance at the wavelength used to measure analyte. In contrast, dobutamine interfered stoichiometrically with all peroxidase-based tests studied, regardless of whether 4-aminophenazone was used to form the chromophore. Dobutamine was rapidly oxidized by peroxide in the presence of peroxidase, thus depleting the peroxide necessary to generate chromophore. Dopamine and dobutamine demonstrate two distinct general mechanisms of interference in peroxidase-based biochemical tests.

Catecholamine interference in enzymatic creatinine assays

BACKGROUND

Enzymatic creatinine assays are routinely used in clinical laboratories to provide more accurate estimated glomerular filtration rates and to avoid a perceived lack of analytical specificity associated with picrate (Jaffe) methods. Negative interferences with the enzymatic creatinine assay, which we noted in several patients on dopamine or dobutamine, prompted our further investigation into interference of catecholamines with enzymatic methods.

METHODS

Spiked solutions of dopamine, dobutamine, epinephrine, and norepinephrine were added to pooled sera at catecholamine concentrations consistent with clinically relevant dosing. Creatinine was measured enzymatically on the Roche P-Modular, Ortho Clinical Diagnostics Vitros 350, and Abbott i-STAT. Jaffe methods were performed on the Roche P-Modular and Siemens Dimension RxL. In 10 patients receiving dopamine and/or dobutamine via a venous or arterial line we evaluated and compared the extent of in vivo creatinine interference in paired serum samples obtained by venipuncture and from indwelling catheters.

RESULTS

All catecholamines caused significant negative interference with the Roche enzymatic creatinine assay, most pronounced for dopamine and dobutamine. The Vitros enzymatic assay demonstrated slight negative interferences, and i-STAT enzymatic and Jaffe methods were unaffected by the presence of catecholamines. Significant (P < 0.001) differences in creatinine concentrations by Roche enzymatic vs Jaffe methods were observed in venipuncture specimens compared with arterial or venous catheter specimens, suggesting dopamine and dobutamine reversibly adhere to the catheter lumen.

CONCLUSIONS

Negative interferences were pronounced for Roche enzymatic results in blood samples obtained from indwelling catheters, a phenomenon not observed in peripheral draws. Physicians and laboratorians should be alert to the possibility of a falsely low creatinine result and reevaluate questionable samples using a method unaffected by catecholamines.

Changes in Band 3 oligomeric state precede cell membrane phospholipid loss during blood bank storage of red blood cells

BACKGROUND

Lipid loss in the form of vesicles contributes to the red blood cell (RBC) storage lesion, and this loss of lipid is correlated with changes in membrane protein function. Sensitive spectroscopic techniques were used to measure changes in Band 3 oligomeric state during storage of RBCs, compared to metabolic changes and phospholipid loss. The aim of the study was to determine whether changes in the macromolecular organization of membrane proteins occur before, coincident with, or after lipid loss during RBC storage.

STUDY DESIGN AND METHODS

Five RBC units were collected from normal volunteers and stored under standard blood bank conditions, and both metabolic changes and lipid loss were measured by multiple assays. Band 3 oligomeric state was assessed by time-resolved phosphorescence anisotropy and fluorescence resonance energy transfer of eosin-5-maleimide-labeled RBC ghosts.

RESULTS

Extracellular pH decreased and extracellular potassium increased rapidly during cold storage of blood. Band 3 on the RBC membrane exhibited a shift from small to large oligomers early in the storage period and before detectable loss of phospholipid from the RBC membrane. The immobilized fraction of Band 3, that which is tethered to the cytoskeletal network via spectrin and ankyrin, did not change during cold storage.

CONCLUSION

Our results demonstrate that changes in the macromolecular organization of membrane proteins on the RBC occur early in storage, and these changes may induce phospholipid loss, irreversible morphologic changes, and loss of function during RBC storage.

Leadership and Management Training for Residents and Fellows: A Curriculum for Future Medical Directors

Context.—Management of laboratories and pathology practices is increasingly complex. Residents and fellows in laboratory medicine and pathology need more structured curricula in leadership and management (L&M) training to function as medical and laboratory directors.

Objective.—To define a curriculum that provides basic competency in L&M for residents and fellows in pathology.

Design.—A year-long formal L&M course included didactic lectures, interactive sessions, case scenarios, team-building exercises, formal team presentations (capstone project), and precourse and postcourse assessment of L&M knowledge. The curriculum meets requirements of American College of Graduate Medical Education and supports goals for leadership training of the College of American Pathologists. Participants evaluated (5-point scale) the content and speakers of all sessions. Trainees were evaluated after considering postcourse examination results, quality of the capstone presentation, and a global assessment.

Results.—The 5 non-capstone sessions received evaluation scores ranging from 4.4 (informatics) to 5 (L&M basics). Postcourse test scores showed significant improvement when compared with the pretest scores for the 2003– 2004 and 2004–2005 trainee cohorts.

Conclusions.—Short-term results indicate that the course described improves trainee knowledge of L&M issues.

Aspirin responsiveness in healthy volunteers measured with multiple assay platforms

BACKGROUND

We evaluated the sensitivity, precision, and concordance of 4 assays designed to detect aspirin responsiveness or resistance.

METHODS

Twenty-nine healthy laboratory volunteers took 80 mg aspirin for 7 days, and a subset of volunteers took 325 mg aspirin for an additional 7 days. We measured platelet function by light transmission aggregometry with arachidonic acid, PFA-100, and VerifyNow. PFA-100 and VerifyNow assays were performed in duplicate to assess method imprecision. Some volunteers had samples taken within 2-4 h of the final dose of aspirin and again within 20-24 h of the final dose. We measured urinary 11-dehydro-thromboxane B(2) at baseline and after 80 or 325 mg aspirin.

RESULTS

No volunteers were nonresponsive to aspirin therapy as measured by the PFA-100. One of 29 participants demonstrated lack of response to aspirin as measured by VerifyNow and urinary 11-dehydro-thromboxane B(2); 2 of 29 demonstrated lack of response as measured by light transmission aggregometry. Imprecision was <10% for the PFA-100 and VerifyNow. Concordance was high (>90%) between all assays. Neither aspirin dose (80 vs 325 mg) nor timing between final dose of aspirin and blood draw (2-4 vs 20-24 h) affected any of the assays.

CONCLUSIONS

Light transmission aggregometry, PFA-100, VerifyNow, and urinary 11-dehydro-thromboxane B(2) are all sensitive to the effects of aspirin in healthy individuals. Variables such as aspirin dose, timing between final dose of aspirin and blood collection, and imprecision do not affect the ability of the assays to detect aspirin effect on platelet function.

Comparison of three whole blood creatinine methods for estimation of glomerular filtration rate before radiographic contrast administration

We compared the clinical concordance of estimated glomerular filtration rate (eGFR) based on 3 whole blood creatinine assays with the eGFR calculated from a reference plasma creatinine assay. Whole blood creatinine on the Radiometer ABL800 FLEX (Radiometer A/S, Bronshoj, Denmark) demonstrated the best correlation and concordance to plasma creatinine/eGFR compared with the i-STAT (i-STAT, East Windsor, NJ) and StatSensor (Nova Biomedical, Waltham, MA). The i-STAT had better sensitivity (compared with Radiometer) but poorer specificity for prediction of plasma eGFR less than 60 mL/min/1.73 m(2). The StatSensor demonstrated lower concordance of whole blood to plasma eGFR but offered a slope and an intercept offset feature that partially compensates for this effect. The optimal device for use in rapid determination of eGFR from whole blood creatinine may depend on whether it is more important in a given practice to optimize sensitivity, specificity, or overall concordance for determining plasma eGFR less than 60 mL/min/1.73 m(2).

Halothane and cyclopiazonic acid modulate Ca-ATPase oligomeric state and function in sarcoplasmic reticulum

We have studied the effects of cyclopiazonic acid (CPA) and halothane on the enzymatic activity, oligomeric state, and conformational equilibrium of the Ca-ATPase in skeletal muscle sarcoplasmic reticulum (SR). CPA is a potent inhibitor of Ca-ATPase activity, and this inhibition is competitive with respect to ATP concentration. Time-resolved phosphorescence anisotropy was used to detect the fraction of Ca-ATPase monomers, dimers, and larger aggregates in the absence and presence of CPA. CPA increased the fraction of dimers and larger aggregates of the Ca-ATPase. Addition of halothane to SR, or detergent solubilization of the Ca-ATPase, increased the apparent KI of CPA inhibition, and increased the fraction of Ca-ATPase present as monomers. CPA stabilized the E2 conformational state of the Ca-ATPase relative to the E1 and E2-P states, as measured by fluorescein 5-isothiocyanate fluorescence and enzyme phosphorylation from inorganic phosphate. E2-P formation in the presence of CPA was partially restored by halothane and solubilization. We conclude that CPA inhibits the Ca-ATPase in part by overstabilizing dimers or small oligomers of the Ca-ATPase, which is correlated with stabilization of the E2 conformation of the enzyme.

Retrospective evaluation of the accuracy of Roche AccuChek Inform and Nova StatStrip glucose meters when used on critically ill patients

BACKGROUND

More stringent accuracy guidelines for hospital-use glucose meters have recently been published, but it remains unclear whether glucose meters can meet these accuracy guidelines when measurement is performed on critically ill patients with fresh whole blood samples.

MATERIALS AND METHODS

We performed a retrospective evaluation of a conventional (Roche Diagnostics [Indianapolis, IN] AccuChek® Inform) and a newer-generation (Nova Biomedical [Waltham, MA] StatStrip®) glucose system by comparing paired (drawn within 5 min of each other) whole blood glucose meter and laboratory serum glucose values obtained from intensive care unit (ICU) patients. We also performed a prospective evaluation of the accuracy of the Nova StatStrip.

RESULTS

The median (interquartile range) bias between Roche AccuChek Inform and serum laboratory glucose measurements was 11 (6-18) mg/dL, compared with a median bias between the Nova StatStrip and serum glucose measurements of 1 (-5 to 5) mg/dL. StatStrip met International Organization for Standardization 15197 and Clinical and Laboratory Standards Institute (CLSI) POCT12-A3 accuracy guidelines using both retrospective and prospective datasets.

CONCLUSIONS

The newer-generation (StatStrip) glucose meter met more stringent CLSI POCT12-A3 accuracy criteria because of reduced bias compared with the previous-generation device. Reduced glucose meter bias led to fewer insulin dosing discrepancies when the insulin dose determined from serum glucose was compared with that determined from the glucose meter value using the institutional glycemic control protocol.

Temporal sequence of major biochemical events during blood bank storage of packed red blood cells

BACKGROUND

We used sensitive spectroscopic techniques to measure changes in Band 3 oligomeric state during storage of packed red blood cells (RBC); these changes were compared to metabolic changes, RBC morphology, cholesterol and membrane protein loss, phospholipid reorganisation of the RBC membrane, and peroxidation of membrane lipid. The aim of the study was to temporally sequence major biochemical events occurring during cold storage, in order to determine which changes may underlie the structural defects in stored RBC.

MATERIALS AND METHODS

Fifteen RBC units were collected from normal volunteers and stored under standard blood bank conditions; both metabolic changes and lipid parameters were measured by multiple novel assays including a new mass spectrometric measurement of isoprostane (lipid peroxidation) and flow cytometric assessment of CD47 expression. Band 3 oligomeric state was assessed by time-resolved phosphorescence anisotropy, and RBC morphology by microscopy of glutaraldehyde-fixed RBC.

RESULTS

Extracellular pH decreased and extracellular potassium increased rapidly during cold storage. Band 3 on the RBC membrane aggregated into large oligomers early in the storage period and coincident with changes in RBC morphology. Membrane lipid changes, including loss of unesterified cholesterol, lipid peroxidation and expression of CD47, also changed early during the storage period. In contrast loss of acetylcholinesterase activity and haemolysis of RBC occurred late during storage.

DISCUSSION

Our results demonstrate that changes in the macromolecular organisation of membrane proteins on the RBC occur early in storage and suggest that lipid peroxidation and/or oxidative damage to the membrane are responsible for irreversible morphological changes and loss of function during red cell storage.

Evaluation of the BiliChek noninvasive bilirubin analyzer for prediction of serum bilirubin and risk of hyperbilirubinemia

We identified clinical and laboratory variables affecting the relationship between transcutaneous and serum bilirubin levels and determined whether transcutaneous bilirubin values could be used to predict the risk of hyperbilirubinemia. Median bias between transcutaneous and diazo serum bilirubin was 2.0 mg/dL (34.2 micromol/L), while median bias between transcutaneous and the Vitros (Ortho Clinical Diagnostics, Rochester, NY) serum bilirubin values was 1.3 mg/dL (22.2 micromol/L). The mother's ethnicity, the gestational age, and postnatal age did not impact the relationship between transcutaneous and serum bilirubin values. In contrast, the serum bilirubin method (diazo vs Vitros) and collection container (clear vs amber tube) significantly impacted the relationship between transcutaneous and serum bilirubin values. Transcutaneous bilirubin was a sensitive but not specific predictor of the risk of hyperbilirubinemia using a conventional risk nomogram. Because systematic differences between serum bilirubin methods and local laboratory practices impact the relationship between transcutaneous and serum bilirubin values, the effectiveness of transcutaneous prediction of the serum bilirubin risk zone will vary by institution.

Molecular mechanism of Ca-ATPase activation by halothane in sarcoplasmic reticulum

We have studied the molecular mechanism of Ca-ATPase activation in sarcoplasmic reticulum (SR) by the volatile anesthetic halothane. Using time-resolved phosphorescence anisotropy, we determined the rotational correlation times and mole fractions of different oligomeric states of the enzyme, as a function of halothane and temperature. Lipid fluidity was measured independently, using EPR of spin-labeled lipids. At 4 and 7 degrees C, the principal effects of halothane were to increase the activity of the Ca-ATPase and to promote the formation of monomers and dimers of the enzyme from larger aggregates. At higher temperatures (up to 25 degrees C), halothane activated the enzyme, but to a lesser extent than observed at lower temperatures. While the functional effects of halothane were temperature dependent, the effects of halothane on lipid fluidity and protein aggregation state were similar at all temperatures tested. We conclude that at low temperatures Ca-ATPase activity is dominated by aggregation state, so halothane activates the enzyme primarily by promoting the formation of monomers and dimers of the enzyme from larger aggregates. At higher temperatures, the activity of the enzyme is dominated by lipid fluidity, so halothane activates the enzyme by increasing the lipid fluidity. The physical mechanism of Ca-ATPase activation, dominated by aggregation state at low temperature and lipid fluidity at higher temperature, provides an explanation for the break in the Arrhenius plot of Ca-ATPase activity (in the absence of halothane) at approximately 20 degrees C.

Accuracy of capillary whole blood international normalized ratio on the CoaguChek S, CoaguChek XS, and i-STAT 1 point-of-care analyzers

We evaluated the accuracy of capillary whole blood international normalized ratio (INR) on the CoaguChek S (Roche Diagnostics, Indianapolis, IN), CoaguChek XS (Roche Diagnostics), and i-STAT 1 (i-STAT, East Windsor, NJ) point-of-care (POC) analyzers compared with venous plasma INRs determined by a reference laboratory method. Overall agreement between POC and laboratory plasma INR was very good, with median bias between capillary whole blood and laboratory plasma INRs varying from 0.0 to -0.2 INR units on all devices. More than 90% of results on the CoaguChek XS and i-STAT 1 and 88% of CoaguChek S results were within 0.4 INR units of the reference laboratory method. The CoaguChek XS and i-STAT 1 demonstrated greater accuracy than the CoaguChek S as measured by the number of results that differed by more than 0.5 INR units from the reference method. Median bias between CoaguChek S capillary whole blood and laboratory plasma INRs changed over time, demonstrating the need for ongoing quality assurance measures for POC INR programs.

Implementation of Clinical Decision Support Rules to Reduce Repeat Measurement of Serum Ionized Calcium, Serum Magnesium, and N-Terminal Pro-B-Type Natriuretic Peptide in Intensive Care Unit Inpatients

BACKGROUND

We assessed the impact of clinical decision support (CDS) rules within the electronic health record for ionized calcium (iCa), serum magnesium (Mg), and N-terminal pro-B-type natriuretic peptide (NT-proBNP) in intensive care unit (ICU) inpatients at a large academic center.

METHODS

A repeat order for measurement of iCa or Mg placed within 24 (iCa) or 48 (Mg) h of a previously nonactionable result, or additional orders for NT-proBNP beyond 1 within a single hospitalization, triggered a CDS pop-up alert showing the prior result and offering the opportunity to cancel the order or to place the order after entering an indication for repeat testing. The number of tests performed for each of these analytes and incidence of adverse clinical outcomes potentially associated with hypocalcemia or hypomagnesemia were compared between the 90-day period before CDS implementation and two 90-day periods immediately following.

RESULTS

iCa test volumes decreased by 48%, Mg by 39%, and NT-proBNP by 28% in the 90-day period immediately following implementation and remained decreased by 54%, 49%, and 22%, respectively, during the following 90-day period (all P values <0.0002). Adverse clinical outcomes potentially associated with hypocalcemia or hypomagnesemia did not increase (all P-values >0.17).

CONCLUSIONS

Implementation of CDS dramatically decreased repeat testing of iCa, Mg, and NT-proBNP without adversely impacting clinical outcomes in the ICU. Expansion of the rules from the ICU units to include the entire hospitalized patient population and expansion to additional analytes is expected to lead to further reductions in testing.

Analytical sensitivity and specificity of four point of care rapid antigen diagnostic tests for SARS-CoV-2 using real-time quantitative PCR, quantitative droplet digital PCR, and a mass spectrometric antigen assay as comparator methods

BACKGROUND

We evaluated the analytical sensitivity and specificity of four rapid antigen diagnostic tests (Ag RDTs) for SARS-CoV-2, using reverse transcription quantitative PCR (RT-qPCR) as the reference method; and further characterizing samples using droplet digital quantitative PCR (ddPCR) and a mass spectrometric antigen test.

METHODS

350 (150 negative and 200 RT-qPCR positive) residual phosphate buffered saline (PBS) samples were tested for antigen using the BD Veritor lateral flow (LF), ACON LF, ACON fluorescence immunoassay (FIA), and LumiraDx FIA. ddPCR was performed on RT-qPCR positive samples to quantitate the viral load in copies/mL applied to each Ag RDT. Mass spectrometric antigen testing was performed on PBS samples to obtain a set of RT-qPCR positive, antigen positive samples for further analysis.

RESULTS

All Ag RDTs had nearly 100% specificity compared to RT-qPCR. Overall analytical sensitivity varied from 66.5% to 88.3%. All methods detected antigen in samples with viral load >1,500,000 copies/mL RNA, and detected ≥75% of samples with viral load of 500,000 to 1,500,000 copies/mL. The BD Veritor LF detected only 25% of samples with viral load between 50,000-500,000 copies/mL, compared to 75% for the ACON LF device and >80% for LumiraDx and ACON FIA. The ACON FIA detected significantly more samples with viral load <50,000 copies/mL compared to the BD Veritor. Among samples with detectable antigen and viral load <50,000 copies/mL, sensitivity of the Ag RDT varied between 13.0% (BD Veritor) and 78.3% (ACON FIA).

CONCLUSIONS

Ag RDTs differ significantly in analytical sensitivity, particularly at viral load <500,000 copies/mL.