Simultaneous measurement of beta-amyloid(1-42), total tau, and phosphorylated tau (Thr181) in cerebrospinal fluid by the xMAP technology

BACKGROUND

To simultaneously study several biomarkers for Alzheimer disease (AD), we used the xMAP technology to develop and evaluate a multiparametric bead-based assay for quantification of beta-amyloid((1-42)) [Abeta((1-42))], total tau (T-TAU), and hyperphosphorylated tau [P-TAU((181P))] in cerebrospinal fluid (CSF).

METHODS

We compared the new multianalyte assay format with established ELISA techniques for the same proteins. We then performed a clinical study using CSF samples from patients with AD or mild cognitive impairment with progression to AD, healthy controls, and patients with other neurologic disorders.

RESULTS

The INNO-BIA AlzBio3 selectively and specifically measured Abeta((1-42)), T-TAU, and P-TAU((181P)) in the CSF. The new assay format had intra- and interassay CVs <10% for all analytes, even at low concentrations. The measurement range of the new assay was 3 to 4 logs compared with 1 to 2 logs for ELISAs. By plotting the mean of the values obtained in ELISA and the xMAP technology against the difference, we found that a correction factor could be used to convert xMAP results to ELISA values. The clinical study demonstrated that the new multiparametric assay could accurately distinguish patients with AD from patients with other neurologic disorders or control patients, with the diagnostic accuracy reaching recommended consensus criteria for specificity and sensitivity.

CONCLUSION

The new multiparametric method may be able to replace the corresponding ELISA methods.

Determination of phenylalanine and tyrosine in dried blood specimens by ion-exchange chromatography using the Hitachi L-8800 analyzer

OBJECTIVES

The treatment for phenylketonuria (PKU) includes monitoring blood phenylalanine (Phe) levels on a regular basis. To reduce inconvenience to the patient and family, blood specimens on filter paper can be obtained at home and mailed to the clinic or analytical laboratory. For this reason, we validated an 8-min isothermal and isocratic HPLC method using the Hitachi L-8800 analyzer for quantitation of Phe and tyrosine (Tyr) from dried blood specimens (DBS).

DESIGN AND METHODS

The method was worked out using DBS fortified with Phe and Tyr. For method comparison, blood samples from 31 PKU patients and 5 non-PKU volunteers were analyzed as DBS by HPLC using the Hitachi L-8800 analyzer, and compared both to plasma analyzed by HPLC and DBS analyzed using tandem mass spectrometry (MS/MS).

RESULTS

For HPLC analysis of DBS, the within-run precision for Phe and Tyr was < or = 5.1% and < or = 4.5%, respectively, and total precision measured over a 3-month period was < or = 7.2% and < or = 8.7%, respectively. Correlation analysis was performed using results from fresh plasma analyzed by HPLC (r = 0.988 for Phe, r = 0.964 for Tyr) and from DBS analyzed by MS/MS (r = 0.960 for Phe, r = 0.942 for Tyr). Difference plots revealed good agreement between the HPLC and MS/MS methods.

CONCLUSIONS

Determination of Phe and Tyr in DBS using this HPLC technique compares well with other methods. This technique with its short analytical time is convenient for monitoring patients with PKU and might be particularly useful in centers following many patients.

Fasting and post-glucose load--reference limits for peripheral venous plasma glucose concentration in pregnant women

Recently both the American Diabetes Organization (ADA) and World Health Organization (WHO) have revised the diagnostic recommendations for gestational diabetes mellitus (GDM), however, they did not not reach agreement on the criteria for diagnosis, the referral criteria for the confirmatory oral glucose tolerance test (OGTT), its standardization, and diagnostic cut-off point. The aims of this study were to investigate if the fasting venous plasma glucose mmol/l (f-vPG) and the 2-hour venous plasma glucose mmol/l (2h-vPG) after a WHO standardized 75 g oral glucose tolerance test (OGTT) in a non-risk group of pregnant women during first and third trimester of pregnancy deviated from that of risk groups, to establish a reference interval for f-vPG and 2h-vPG, and to investigate the predictive role of f-vPG for the 2h-vPG glucose concentration. This is a population-based case-control study where a consecutive number of pregnant women were invited to screening irrespective of their risk factors for GDM. All women filled in a questionnaire of the Danish national screening program on risk factors and had f-vPG and the 2h-vPG measured. By ruling out women with GDM and risk factors, we isolated a non-risk reference class. The In f-vPG parametric 97.5 centile was less than 5% higher during week 32 of pregnancy than during week 20, and therefore these groups were combined. The f-vPG 95% reference interval was from 4.01 mmol/l (95% CI: 3.96 to 4.07 mmol/l) to 5.26 mmol/l (95% CI: 5.19 to 5.34 mmol/l). "The true upper normal limit", the 99.9 centile, was 5.69 mmol/l (95% CI: 5.59 to 5.80 mmol/l). The f-vPG was 0.6 mmol/l lower over the whole range in pregnant women compared to age-matched non-pregnant women. The distribution of 2h-vPG concentrations at week 20 was non-Gaussian and therefore considered non-homogeneous, while it was Gaussian distributed and homogeneous at week 32. The 2h-vPG 95% reference interval of the combined weeks was from 2.80 mmol/l (95% CI: 2.56 to 3.04 mmol/l) to 7.58 mmol/l (95% CI: 7.34 to 7.82 mmol/l), and the upper limit of normal (99.9 centile) was 8.96 mmol/l (95% CI: 8.63 to 9.29 mmol/l). Distributions of f-vPG and 2h-vPG were distinct in our defined risk classes. In individual cases, no systematic correlation was found between the f-vPG concentration at week 20 and week 32. The f-vPG concentrations at any of the weeks did not predict the 2h-vPG level and no single clinical risk factor was decisive for the presence of GDM.

Combination of analytical quality specifications based on biological within- and between-subject variation

At a conference on 'Strategies to Set Global Analytical Quality Specifications in Laboratory Medicine' in Stockholm 1999, a hierarchy of models to set analytical quality specifications was decided. The consensus agreement from the conference defined the highest level as 'evaluation of the effect of analytical performance on clinical outcomes in specific clinical settings' and the second level as 'data based on components of biological variation'. Here, the many proposals for analytical quality specifications based on biological variation are examined and the outcomes of the different models for maximum allowable combined analytical imprecision and bias are illustrated graphically. The following models were investigated. (1) The Cotlove et al. (1970) model defining analytical imprecision (%CVA) in relation to the within-subject biological variation (%CV(W-S)) as: %CVA < or = 0.5 x %CV(W-S) (where %CV is percentage coefficient of variation). (2) The Gowans et al. (1988) concept, which defines a functional relationship between analytical imprecision and bias for the maximum allowable combination of errors for the purpose of sharing common reference intervals. (3) The European Group for the Evaluation of Reagents and Analytical Systems in Laboratory Medicine (EGE Lab) Working Group concept, which combines the Cotlove model with the Gowans concept using the maximal acceptable bias. (4) The External Quality Assessment (EQA) Organizers Working Group concept, which is close to the EGE Lab Working Group concept, but follows the Gowans et al. concept of imprecision up to the limit defined by the model of Cotlove et al. (5) The 'three-level' concept classifying analytical quality into three levels: optimum, desirable and minimum. The figures created clearly demonstrated that the results obtained were determined by the basic assumptions made. When %CV(W-S) is small compared with the population-based coefficient of variation [%CV(P) = (%CV2(W-S) +%CV2(B-S))(1/2)], the EGE Lab and EQA Organizers Working Group concepts become similar. Examples of analytical quality specifications based on biological variations are listed and an application on external quality control is illustrated for plasma creatinine.

Setting Performance Goals and Evaluating Total Analytical Error for Diagnostic Assays

Background: Total analytical error has been a useful metric both to assess laboratory assay quality and to set goals. It is often estimated by combining imprecision (SD) and average bias in the equation: total analytical error = bias + 1.65 × imprecision. This indirect estimation model (referred to as the simple combination model) leads to different estimates of total analytical error than that of a direct estimation method (referred to as the distribution-of-differences method) or of simulation.

Methods: A review of the literature was undertaken to reconcile the different estimation approaches.

Results: The simple combination model can underestimate total analytical error by neglecting random interference bias and by not properly treating other error sources such as linear drift and outliers. A simulation method to estimate total analytical error is outlined, based on the estimation and combination of total analytical error source distributions. Goals for each total analytical error source can be established by allocation of the total analytical error goal. Typically, the allocation is cost-based and uses the probability of combinations of error sources. The distribution-of-differences method, simple combination model, and simulation method to evaluate total analytical error are compared. Outlier results can profoundly influence quality, but their rates are seldom reported.

Conclusions: Total analytical error should be estimated either directly by the distribution-of-differences method or by simulation. A systems engineering approach that uses allocation of the total analytical error goal into error source goals provides a cost-effective approach to meeting total analytical error. Because outliers can cause serious laboratory error, the inclusion of outlier rate estimates from large studies (e.g., those conducted by manufacturers) would be helpful in assessing assay quality.

Strategy for determining racial and environmental similarities and differences for plasma proteins

The aim of this protocol is to establish a common basis for the production of reference values and well-defined and documented reference intervals for plasma proteins, based on common standardization, using the IFCC/BCR/CAP Certified Reference Material CRM 470. The strategy is to search for racial and environmental/geographical similarities and sources of differences in order to describe the main causes for variability among smaller or larger groups in selected societies and to estimate the sizes of differences for the different proteins according to the investigated sources. For this purpose, groups of reference individuals are selected according to race and geographical/environmental location, e.g. African Americans and Caucasians from the US. The reference individuals are groups of approximately 160 healthy male blood donors, 20 to 60 years of age. Rule-out criteria are positivity for HIV, hepatitis B and C antibodies and blood hemoglobin below the lower reference limit. Exclusion in relation to different C-reactive protein (CRP) levels will be investigated. Coagulation, storage conditions, transport, and the procedure for thawing are specified. The laboratories undertaking the measurements must have adequate analytical performance, and calibration and quality of performance are defined and documented, together with recommended control materials and procedures. Statistical models for describing distributions and for comparing groups are described. It is recommended that the data be presented as reference limits with 90% confidence intervals of those limits.

Performance evaluation of nine hormone assays on the Immulite 2000 immunoassay system

We evaluated the analytical performance of the Immulite 2000 immunoassay analyzer (Diagnostic Products Corporation, Los Angeles, USA) based on a new detection technology, electrochemical luminescence. The evaluated analytes were thyrotropin, triiodothyronine, free thyroxine, follitropin, lutropin, prolactin, cortisol, estradiol and progesterone. We tested the assay precision, linearity, recovery, and correlation with comparison methods for these analytes. For most assays, within-run and between-day imprecisions were less than 8% and 10%, respectively. The linearity and recovery were acceptable for all assays. The correlation between the Immulite 2000 assays and comparison methods showed satisfactory results.

A study to examine the accuracy of potassium measurements in clinical laboratories across Canada

OBJECTIVE

To assess the accuracy of potassium measurements in clinical laboratories across Canada.

DESIGN AND METHOD

The flame atomic emission spectrophotometry reference method for the determination of potassium was established at the Canadian Reference Laboratory by using National Institute of Science and Technology standard reference materials. The method was subsequently used to assign target values for potassium to Canadian Reference Laboratory's External Quality Assessment human-serum-based testing material. A total of 503 laboratories participated and 9,279 individual External Quality Assessment test results were included in the study. Bias was determined by using difference plots.

RESULTS

Clinically significant bias (>1.6%) was observed in 45.9% of the laboratories. Bias ranged from 0.34 mmol/L to -0.54 mmol/L. At low concentrations (<3.5 mmol/L) a positive bias was most frequently observed (14.7% of analytical systems). At high potassium concentrations (>5.1 mmol/L) a negative bias was most frequently observed (31.4% of analytical systems).

CONCLUSION

Inaccuracy in potassium results can contribute to test redundancy and mismanagement of patients, while prohibiting the merger of laboratory data from disparate testing sites for the purpose of trending and consolidation within a "universal health record." Inaccurate test results and the lack of standardization among laboratories adversely impact our ability to establish common reference intervals and critical limits. This inability has an adverse effect on medical decisions and patient care.

Simple Microplate Method for Determination of Urinary Iodine

Background: Urinary iodine is a good biochemical marker for control of iodine deficiency disorders. Our aim was to develop and validate a simple, rapid, and quantitative method based on the Sandell–Kolthoff reaction, incorporating both the reaction and the digestion process into a microplate format.

Methods: Using a specially designed sealing cassette to prevent loss of vapor and cross-contamination among wells, ammonium persulfate digestion was performed in a microplate in an oven at 110 °C for 60 min. After the digestion mixture was transferred to a transparent microplate and the Sandell–Kolthoff reaction was performed at 25 °C for 30 min, urinary iodine was measured by a microplate reader at 405 nm.

Results: The mean recovery of iodine added to urine was 98% (range, 89–109%). The theoretical detection limit, defined as 2 SD from the zero calibrator, was 0.11 μmol/L (14 μg/L iodine). The mean intra- and interassay CVs for samples with iodine concentrations of 0.30–3.15 μmol/L were ≤10%. The new method agreed well with the conventional chloric acid digestion method (n = 70; r = 0.991; y = 0.944x + 0.04; Sy|x = 0.10) and with the inductively coupled plasma mass spectrometry method (n = 61; r = 0.979; y = 0.962x + 0.03; Sy|x = 0.20). The agreement was confirmed by difference plots. The distributions of iodine concentrations for samples from endemic areas of iodine deficiency diseases showed similar patterns among the above three methods.

Conclusions: Our new method, incorporating the whole process into a microplate format, is readily applicable and allows rapid monitoring of urinary iodine.

Adaptive control methods for the dose individualisation of anticancer agents

Numerous studies have found a clear relationship between systemic exposure and the toxicity or (more rarely) the efficacy of anticancer agents. Moreover, the clearance of most of these drugs differs widely between patients. These findings, combined with the narrow therapeutic index of anticancer drugs, suggest that patient outcome would be improved if doses were individualised to achieve a target systemic exposure. Bayesian maximum a posteriori probability (MAP) forecasting is an efficient and robust method for the optimisation of drug therapy, but its use for anticancer drugs is not yet extensive. The aim of this paper is to review the application of population pharmacokinetics and MAP to anticancer drugs and to evaluate whether and when MAP Bayesian estimation improves the clinical benefit of anticancer chemotherapy. For each drug, the relationships between pharmacokinetic variables [e.g. plasma concentration or the area under the concentration-time curve] and pharmacodynamic effects are described. Secondly, the methodologies employed are considered and, finally, the results are analysed in terms of predictive performance as well as, where possible, the impact on clinical end-points. Some studies were retrospective and intended only to evaluate individual pharmacokinetic parameter values using very few blood samples. Among the prospective trials, a few studied the pharmacokinetic/pharmacodynamic relationships which provided the basis for routine pharmacokinetic monitoring. Others were performed in clinical context where MAP Bayesian estimation was used to determine maximum tolerated systemic exposure (e.g. for carboplatin, topotecan, teniposide) or for pharmacokinetic monitoring (e.g. for methotrexate or platinum compounds). Indeed, its flexibility in blood sampling times makes this technique much more applicable than other limited sampling strategies. These examples demonstrate that individual dose adjustment helps manage toxicity. The performance of pharmacokinetic monitoring is linked to the methodology used at each step of its design and application. Moreover, a limitation to the use of pharmacokinetic monitoring for certain anticancer drugs has been the difficulty in obtaining pharmacokinetic or pharmacodynamic data. Recent progress in analytical methods, as well as the development of noninvasive methods (such as positron emission tomography) for evaluating the effects of chemotherapy, will help to define pharmacokinetic-pharmacodynamic relationships. Bayesian estimation is the strategy of choice for performing pharmacokinetic studies, as well as ensuring that a given patient benefits from the desired systemic exposure. Together, these methods could contribute to improving cancer chemotherapy in terms of patient outcome and survival.

Direct measurement of urinary testosterone and epitestosterone conjugates using high-performance liquid chromatography/tandem mass spectrometry

Measurement of the ratio of testosterone (T) and epitestosterone (E) in urine has been used as an indication of 'natural' steroid supplementation for a decade. The direct measurement of the glucuronide and sulfate conjugates of testosterone and epitestosterone by high-performance liquid chromatography/tandem mass spectrometry (HPLC/MS/MS) should resolve a number of issues regarding unusual metabolism due to either genetic disposition or attempts to avoid detection of abuse. Determination of nanomoles per liter (0.1 ppb) concentrations of analytes in a complex biological matrix by HPLC/MS/MS is complicated by sample matrix-specific ion suppression during ESI. Deuterated internal standards of all compounds were used to overcome the effects of suppression. Comparison of the HPLC/MS/MS method with a two-part gas chromatographic/mass spectrometric method showed statistical equivalence in urine samples. Analysis of urine samples with elevated T-glucuronide to E-glucuronide ratios did not show that a significant number could be explained by an elevated excretion of epitestosterone sulfate. The HPLC/MS/MS method was also used further to characterize genetic and metabolic factors that give rise to unusual T/E ratios.

Dried Plasma Spot Measurements of Ferritin and Transferrin Receptor for Assessing Iron Status

Background: Efforts to reduce the high global prevalence of nutritional anemia require the use of both reliable laboratory assays to distinguish iron deficiency from other causes of anemia and cost-effective methods for collection of blood specimens under field conditions. The suitability of using small plasma samples spotted and dried on filter paper for measurements of plasma ferritin and transferrin receptor was evaluated in the present study.

Methods: Blood specimens obtained from 73 male and 83 female subjects (19–40 years) representing a wide range of iron status were used to perform parallel measurements of plasma ferritin and transferrin receptor on whole plasma and spotted plasma samples.

Results: Ratio plots, evaluating the acceptability and precision of the spot method in ferritin and transferrin receptor assays, showed the expected proportion of data points within the 95% prediction interval. In the composite group of 156 subjects, both the whole plasma and plasma spot methods gave a geometric mean transferrin receptor/ferritin ratio of 18. The regression equation for the ratio was logy = 1.045 logx − 0.05126; r = 0.986; P &lt;0.0001. The ratio of transferrin receptor/ferritin determined from plasma spots correctly identified all 12 subjects with iron deficiency anemia compared with 11 of the 12 for whole plasma measurements.

Conclusions: Measurements of ferritin and transferrin receptor on plasma spotted and dried on filter paper are comparable to whole plasma values for the identification of iron deficiency anemia. The use of dried plasma spots will facilitate the collection, storage, and transport of samples in epidemiological studies of anemia prevalence.

Necessary Sample Size for Method Comparison Studies Based on Regression Analysis

Background: In method comparison studies, it is of importance to assure that the presence of a difference of medical importance is detected. For a given difference, the necessary number of samples depends on the range of values and the analytical standard deviations of the methods involved. For typical examples, the present study evaluates the statistical power of least-squares and Deming regression analyses applied to the method comparison data.

Methods: Theoretical calculations and simulations were used to consider the statistical power for detection of slope deviations from unity and intercept deviations from zero. For situations with proportional analytical standard deviations, weighted forms of regression analysis were evaluated.

Results: In general, sample sizes of 40–100 samples conventionally used in method comparison studies often must be reconsidered. A main factor is the range of values, which should be as wide as possible for the given analyte. For a range ratio (maximum value divided by minimum value) of 2, 544 samples are required to detect one standardized slope deviation; the number of required samples decreases to 64 at a range ratio of 10 (proportional analytical error). For electrolytes having very narrow ranges of values, very large sample sizes usually are necessary. In case of proportional analytical error, application of a weighted approach is important to assure an efficient analysis; e.g., for a range ratio of 10, the weighted approach reduces the requirement of samples by &gt;50%.

Conclusions: Estimation of the necessary sample size for a method comparison study assures a valid result; either no difference is found or the existence of a relevant difference is confirmed.

Automated Homogeneous Immunoassay for Gentamicin on the Dimension Clinical Chemistry System

Background: Monitoring of the concentration of gentamicin in serum and plasma during therapy is widely recommended and practiced in hospitals. Our aim was to develop a homogeneous immunoassay based on particle-enhanced turbidimetric inhibition immunoassay technology to quantify gentamicin on the Dimension® clinical chemistry system.

Methods: Assay performance was assessed on each of the Dimension models in a 15-instrument interlaboratory comparison study. A split-sample comparison (n = 1171) was also performed between the gentamicin methods on the Dimension system and the Abbott®TDx® analyzer, using multiple reagent and calibrator lots on multiple instruments.

Results: The Dimension method was linear to 25.1 μmol/L (12.0 μg/mL) with a detection limit of 0.63 μmol/L (0.3 μg/mL). Calibration was stable for 30 days. The within-run imprecision (CV) was &lt;1.3%, and total imprecision ranged from 1.8% to 3.2% between 4.2 μmol/L (2.0 μg/mL) and 16.7 μmol/L (8.0 μg/mL) gentamicin. Linear regression analysis of the results on the Dimension method (DM) vs the Abbott TDx yielded the following equation: DM = 0.98TDx − 0.42; r = 0.987. Minimal interference was observed from structurally related compounds such as sagamicin, netilmicin, and sisomicin.

Conclusion: The monoclonal antibody used in this method has similar reactivities toward the individual gentamicin subspecies C1, C1a, and C2, thus providing analytical recovery not significantly dependent on relative subspecies concentrations.

Detection of intracellular antigens by flow cytometry: comparison of two chemical methods and microwave heating

Detection of intracellular antigens by flow cytometry requires effective fixation and permeabilization of the cell membrane. This study compares three fixation/permeabilization techniques: two commercial chemical reagents, the ORTHOPermeaFixTM (OPF) and the FIX&PERM Cell Permeabilization Kit® (F&P), and a novel method based on microwave heating (MWH). They have been applied to the detection of two nuclear (p53 and rb/p105) and two cytoplasmic (bcl-2 and mdr-1/gp-170) antigens, using positive- and negative-control cell lines and peripheral blood mononuclear cells. Western blotting was performed as a control of protein expression. For the four antigens assessed, cellular morphology, discrimination between intact cells and debris, percentage of positive cells, and mean fluorescence intensity were examined. For this last parameter, the assessment of the MWH technique was performed using SD and a graphical approach inspired by the concepts described by Bland and Altman (Lancet 1986;346:1085–7) as well as Petersen et al. (Clin Chem 1997;43:2039–46). The statistical analysis shows that MWH is comparable to the commercial methods and that its reproducibility is also equivalent to OPF and F&P. As assessed for some of the most clinically relevant intracytoplasmic and intranuclear antigens, the MWH method appears to be a valuable and inexpensive alternative. It is worth noting that, unlike commercial reagents, MWH altered surface antigens. Interestingly, this feature, which would prevent cell selection on the basis of combined membrane and intracellular epitopes, is associated with a decrease of nonspecific background fluorescence.

Validity of linear regression in method comparison studies: is it limited by the statistical model or the quality of the analytical input data?

We compared the application of ordinary linear regression, Deming regression, standardized principal component analysis, and Passing–Bablok regression to real-life method comparison studies to investigate whether the statistical model of regression or the analytical input data have more influence on the validity of the regression estimates. We took measurements of serum potassium as an example for comparisons that cover a narrow data range and measurements of serum estradiol-17β as an example for comparisons that cover a wide data range. We demonstrate that, in practice, it is not the statistical model but the quality of the analytical input data that is crucial for interpretation of method comparison studies. We show the usefulness of ordinary linear regression, in particular, because it gives a better estimate of the standard deviation of the residuals than the other procedures. The latter is important for distinguishing whether the observed spread across the regression line is caused by the analytical imprecision alone or whether sample-related effects also contribute. We further demonstrate the usefulness of linear correlation analysis as a first screening test for the validity of linear regression data. When ordinary linear regression (in combination with correlation analysis) gives poor estimates, we recommend investigating the analytical reason for the poor performance instead of assuming that other linear regression procedures add substantial value to the interpretation of the study. This investigation should address whether (a) the x and y data are linearly related; (b) the total analytical imprecision (sa,tot) is responsible for the poor correlation; (c) sample-related effects are present (standard deviation of the residuals ≫ sa,tot); (d) the samples are adequately distributed over the investigated range; and (e) the number of samples used for the comparison is adequate.

Evaluation of a predictive kinetic procedure for the enzymatic measurement of creatinine in serum

We have evaluated the analytical performance of a predictive kinetic procedure for the enzymatic measurement of serum creatinine in comparison with equilibrium and kinetic fixed-time procedures. The procedure uses commercially available reagents and is based on calculating the total change in absorbance expected if the reaction were to proceed to equilibrium by fitting the initial part of the absorbance-time curve to a three-parameter function by non-linear regression. Total imprecision for different concentrations of creatinine ranges from 1.47 to 1.86% and is significantly better than that obtained for the fixed-time procedure. The results with the predictive procedure are less dependent on creatinine amidohydrolase activity in the reagent, pH of the reagent and temperature of analysis than are the results with the fixed-time procedure. All the procedures are interfered with by bilirubin and ascorbic acid to about the same extent. Recovery and linearity are quite acceptable, and the estimated accuracy is below 2.1%. However, in comparison with the equilibrium procedure, the predictive procedure tends to underestimate creatinine concentrations at values below 100 micromol/l, and the results obtained by the two procedures are not transferable. In conclusion, the predictive approach substantially improves the imprecision but not the specificity of the enzymatic assay of serum creatinine.

Evaluation of growth hormone assays using ratio plots

To permit comparison between growth hormone (GH) results obtained using the Pharmacia polyclonal assay and the Delfia monoclonal assay, we used both methods to measure GH concentrations in peak GH responses to the pyridostigmine-growth-hormone-releasing-hormone (PD-GHRH) test and in unstimulated samples from 40 healthy adults and 31 patients with suspected GH deficiency. Ratio plots were used for the comparison, and acceptability criteria were based on inherent analytical imprecision and on analytical quality specifications. The mean ratio (r; Pharmacia/Delfia) for the peak GH responses in 40 healthy adults was calculated to be 1.59, and the 95% prediction interval for ratios fulfilling the imprecision criterion was applied. For GH values &gt;1 mIU/L, the peak and unstimulated GH ratios in healthy adults and patients were within the 95% prediction interval, and fulfilled the biological criterion as well. Therefore, the conversion factor of 1.59 is applicable for the evaluation of GH-stimulation tests.

Intrinsic and routine quality of serum total potassium measurement as investigated by split-sample measurement with an ion chromatography candidate reference method

We evaluated the intrinsic quality of eight routine test systems for the measurement of serum total potassium (K+), as well as the routine quality of four of these systems, using a group of 60 single-donation serum samples that had been certified with an ion chromatography reference method. The intrinsic quality of the tests was evaluated by analysis of the sera in the manufacturers’ application laboratories under strict internal quality control. The routine quality was evaluated by analysis of the same sera in five (per system) routine laboratories under daily working conditions. The results of the study were interpreted in light of the most stringent specifications derived from the biological variation of K+, which require limits of 6.3% for total error and 1.6% for systematic error. The study revealed that the intrinsic quality of all systems was excellent. None of the test systems yielded a substantial number of results outside the 6.3% total error limit, and only one test system exceeded the 1.6% systematic error limit. The majority of the routine laboratories reproduced the manufacturers’ intrinsic quality. In particular, most laboratories satisfied the 6.3% total error limit. However, several laboratories exceeded the 1.6% systematic error limit. Generally, there was a considerable difference in quality between the participating laboratories. This showed that the major problems for serum K+ analysis (for samples with no unusual matrices and with concentrations within the reference interval) are at the routine laboratory.