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Amai M, Nojima M, Yuki Y, Kiyono H, Nagamura F. A review of criteria strictness in "Toxicity Grading Scale for Healthy Adult and Adolescent Volunteers Enrolled in Preventive Vaccine Clinical Trials". Vaccine 2023; 41:5622-5629. [PMID: 37532612 DOI: 10.1016/j.vaccine.2023.07.072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 07/25/2023] [Accepted: 07/29/2023] [Indexed: 08/04/2023]
Abstract
To assess safety in vaccine development, stricter grading scales, such as the "Toxicity Grading Scale for Healthy Adult and Adolescent Volunteers Enrolled in Preventive Vaccine Clinical Trials" issued by the U.S. Food and Drug Administration (FDA grading scale), are required. However, concern exists that their strictness may lead to an overestimation of some adverse events (AEs). We analyzed the details of AEs in a phase I clinical trial of a preventive vaccine for infectious diseases. In this trial, we observed the high occurrence of Grade 1 or greater AEs in hemoglobin changes from baseline value, and hypernatremia, and hypokalemia by FDA grading scale. The range considered as non-AE according to the FDA grading scale shifted or became narrower when compared to reference intervals, especially for a Japanese cohort. For sodium grading, the criterion for hypernatremia was around 2 to mEq/L lower than the upper limit of most standards in several countries. Also, the criterion for hypokalemia was around 0.2 mEq/L higher than the lower limit of most standards. Regarding a decrease in hemoglobin from baseline, the criterion of "any decrease" used for a Grade 1 AE was too strict and we suggest this be omitted. Upper and lower limits of AE criteria for sodium and potassium should be equal to, or 10-20% above, the reference interval consistent with other toxicities determined by laboratory tests. Consideration should be given to the issues surrounding the criteria that determine AEs before conducting clinical trials.
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Affiliation(s)
- Motoki Amai
- Center for Translational Research, IMSUT Hospital, The Institute of Medical Science, The University of Tokyo, Tokyo, Japan
| | - Masanori Nojima
- Center for Translational Research, IMSUT Hospital, The Institute of Medical Science, The University of Tokyo, Tokyo, Japan; Division of Advanced Medicine Promotion, The Institute of Medical Science, The University of Tokyo, Tokyo, Japan.
| | - Yoshikazu Yuki
- Department of Human Mucosal Vaccinology, Chiba University Hospital, Chiba, Japan; HanaVax Inc., Chiba, Japan
| | - Hiroshi Kiyono
- HanaVax Inc., Chiba, Japan; Chiba University Synergy Institute for Futuristic Mucosal Vaccine Research and Development (cSIMVa), Future Medicine Education and Research Organization, Chiba University, Chiba, Japan; CU-UCSD Center for Mucosal Immunology, Allergy, and Vaccine (cMAV), Departments of Medicine and Pathology, University of California, San Diego, CA, USA
| | - Fumitaka Nagamura
- Center for Translational Research, IMSUT Hospital, The Institute of Medical Science, The University of Tokyo, Tokyo, Japan; Division of Advanced Medicine Promotion, The Institute of Medical Science, The University of Tokyo, Tokyo, Japan
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Martinez-Sanchez L, Gabriel-Medina P, Villena-Ortiz Y, García-Fernández AE, Blanco-Grau A, Cobbaert CM, Bravo-Nieto D, Garriga-Edo S, Sanz-Gea C, Gonzalez-Silva G, López-Hellín J, Ferrer-Costa R, Casis E, Rodríguez-Frías F, den Elzen WPJ. Harmonization of indirect reference intervals calculation by the Bhattacharya method. Clin Chem Lab Med 2023; 61:266-274. [PMID: 36395007 DOI: 10.1515/cclm-2022-0439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 11/03/2022] [Indexed: 11/18/2022]
Abstract
OBJECTIVES The aim of this study was to harmonize the criteria for the Bhattacharya indirect method Microsoft Excel Spreadsheet for reference intervals calculation to reduce between-user variability and use these criteria to calculate and evaluate reference intervals for eight analytes in two different years. METHODS Anonymized laboratory test results from outpatients were extracted from January 1st 2018 to December 31st 2019. To assure data quality, we examined the monthly results from an external quality control program. Reference intervals were determined by the Bhattacharya method with the St Vincent's hospital Spreadsheet firstly using original criteria and then using additional harmonized criteria defined in this study. Consensus reference intervals using the additional harmonized criteria were calculated as the mean of four users' lower and upper reference interval results. To further test the operation criteria and robustness of the obtained reference intervals, an external user validated the Spreadsheet procedure. RESULTS The extracted test results for all selected laboratory tests fulfilled the quality criteria and were included in the present study. Differences between users in calculated reference intervals were frequent when using the Spreadsheet. Therefore, additional criteria for the Spreadsheet were proposed and applied by independent users, such as: to set central bin as the mean of all the data, bin size as small as possible, at least three consecutive bins and a high proportion of bins within the curve. CONCLUSIONS The proposed criteria contributed to the harmonization of reference interval calculation between users of the Bhattacharya indirect method Spreadsheet.
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Affiliation(s)
- Luisa Martinez-Sanchez
- Biochemistry Department, Clinical Laboratories, Vall d'Hebron University Hospital, Barcelona, Spain
- Departament de Bioquímica i Biologia Molecular, Universitat Autònoma de Barcelona, Bellaterra, Spain
- Department of Clinical Chemistry and Laboratory Medicine, Leiden University Medical Centre, Leiden, The Netherlands
- Clinical Biochemistry Research Team, Vall d'Hebron Institute of Research (VHIR), Barcelona, Spain
| | - Pablo Gabriel-Medina
- Biochemistry Department, Clinical Laboratories, Vall d'Hebron University Hospital, Barcelona, Spain
- Departament de Bioquímica i Biologia Molecular, Universitat Autònoma de Barcelona, Bellaterra, Spain
- Clinical Biochemistry Research Team, Vall d'Hebron Institute of Research (VHIR), Barcelona, Spain
| | - Yolanda Villena-Ortiz
- Biochemistry Department, Clinical Laboratories, Vall d'Hebron University Hospital, Barcelona, Spain
- Departament de Bioquímica i Biologia Molecular, Universitat Autònoma de Barcelona, Bellaterra, Spain
- Clinical Biochemistry Research Team, Vall d'Hebron Institute of Research (VHIR), Barcelona, Spain
| | - Alba E García-Fernández
- Biochemistry Department, Clinical Laboratories, Vall d'Hebron University Hospital, Barcelona, Spain
- Clinical Biochemistry Research Team, Vall d'Hebron Institute of Research (VHIR), Barcelona, Spain
| | - Albert Blanco-Grau
- Biochemistry Department, Clinical Laboratories, Vall d'Hebron University Hospital, Barcelona, Spain
- Departament de Bioquímica i Biologia Molecular, Universitat Autònoma de Barcelona, Bellaterra, Spain
- Clinical Biochemistry Research Team, Vall d'Hebron Institute of Research (VHIR), Barcelona, Spain
| | - Christa M Cobbaert
- Department of Clinical Chemistry and Laboratory Medicine, Leiden University Medical Centre, Leiden, The Netherlands
| | - Daniel Bravo-Nieto
- Biochemistry Department, Clinical Laboratories, Vall d'Hebron University Hospital, Barcelona, Spain
- Clinical Biochemistry Research Team, Vall d'Hebron Institute of Research (VHIR), Barcelona, Spain
| | - Sarai Garriga-Edo
- Biochemistry Department, Clinical Laboratories, Vall d'Hebron University Hospital, Barcelona, Spain
- Clinical Biochemistry Research Team, Vall d'Hebron Institute of Research (VHIR), Barcelona, Spain
| | - Clara Sanz-Gea
- Biochemistry Department, Clinical Laboratories, Vall d'Hebron University Hospital, Barcelona, Spain
- Clinical Biochemistry Research Team, Vall d'Hebron Institute of Research (VHIR), Barcelona, Spain
| | - Gonzalo Gonzalez-Silva
- Biochemistry Department, Clinical Laboratories, Vall d'Hebron University Hospital, Barcelona, Spain
- Clinical Biochemistry Research Team, Vall d'Hebron Institute of Research (VHIR), Barcelona, Spain
| | - Joan López-Hellín
- Biochemistry Department, Clinical Laboratories, Vall d'Hebron University Hospital, Barcelona, Spain
- Clinical Biochemistry Research Team, Vall d'Hebron Institute of Research (VHIR), Barcelona, Spain
| | - Roser Ferrer-Costa
- Biochemistry Department, Clinical Laboratories, Vall d'Hebron University Hospital, Barcelona, Spain
- Clinical Biochemistry Research Team, Vall d'Hebron Institute of Research (VHIR), Barcelona, Spain
| | - Ernesto Casis
- Clinical Laboratories, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Francisco Rodríguez-Frías
- Biochemistry Department, Clinical Laboratories, Vall d'Hebron University Hospital, Barcelona, Spain
- Departament de Bioquímica i Biologia Molecular, Universitat Autònoma de Barcelona, Bellaterra, Spain
- Clinical Biochemistry Research Team, Vall d'Hebron Institute of Research (VHIR), Barcelona, Spain
| | - Wendy P J den Elzen
- Clinical Biochemistry Research Team, Vall d'Hebron Institute of Research (VHIR), Barcelona, Spain
- Department of Clinical Chemistry, Amsterdam UMC, University of Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
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Koujiya E, Kabayama M, Yamamoto M, Higami Y, Kodama K, Mukai S, Yano T, Nako Y, Nakamura T, Hirotani A, Fukuda T, Tamatani M, Okuda Y, Ikushima M, Baba Y, Nagano M, Rakugi H, Kamide K. [Seasonal changes in blood pressure and related factors among older patients receiving home medical care]. Nihon Ronen Igakkai Zasshi 2021; 58:602-609. [PMID: 34880179 DOI: 10.3143/geriatrics.58.602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
AIM We investigated seasonal variations in blood pressure (BP) and factors related to these variations among older patients receiving home medical care. METHOD A total 57 patients ≥ 65 years old receiving home medical care who participated in the Osaka Home Care REgistry study (OHCARE), a prospective cohort study, were included. We investigated the seasonal patient characteristics and variations in the BP. In addition, to determine the influence of seasonal variations in the systolic blood pressure (SBP) on the occurrence of clinical events (hospitalization, falls and death), we classified patients into larger- and smaller- change groups based on the median seasonal variations in SBP. RESULT About 60% of subjects were very frail or bedridden. The mean BP was higher in winter than in summer (124.7±11/69.5±7 vs.120.5±12/66.9±8 mmHg) (P< 0.01). On comparing the characteristics of the two groups with larger and smaller changes in the SBP, the group with large BP changes had a significantly lower BP in summer than the group with small BP changes. In addition, the incidence of "hospitalization" was significantly higher in the group with large BP changes than in the group with small BP changes (P = 0.03). CONCLUSION The present study revealed that there were seasonal changes in the BP in older patients receiving home medical care. It was also suggested that seasonal changes in the BP might be associated with the risk of hospitalization events. Given these BP variations, doctors and visiting nurses should be alert for systemic abnormalities, especially in frail patients receinving home medical care.
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Affiliation(s)
- Eriko Koujiya
- Division of Health Sciences, Osaka University Graduate School of Medicine
| | - Mai Kabayama
- Division of Health Sciences, Osaka University Graduate School of Medicine
| | | | | | - Kana Kodama
- Division of Medicine, Osaka University Graduate School of Medicine
| | - Sakino Mukai
- Division of Health Sciences, Osaka University Graduate School of Medicine
| | - Tomoko Yano
- Division of Health Sciences, Osaka University Graduate School of Medicine
| | - Yumiko Nako
- Division of Health Sciences, Osaka University Graduate School of Medicine
| | | | | | | | | | | | | | | | | | - Hiromi Rakugi
- Department of Geriatric and General Medicine, Osaka University Graduate School of Medicine
| | - Kei Kamide
- Division of Health Sciences, Osaka University Graduate School of Medicine.,Department of Geriatric and General Medicine, Osaka University Graduate School of Medicine
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Rafique Z, Peacock F, Armstead T, Bischof JJ, Hudson J, Weir MR, Neuenschwander J. Hyperkalemia management in the emergency department: An expert panel consensus. J Am Coll Emerg Physicians Open 2021; 2:e12572. [PMID: 34632453 PMCID: PMC8485984 DOI: 10.1002/emp2.12572] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 08/18/2021] [Accepted: 09/16/2021] [Indexed: 01/11/2023] Open
Abstract
Hyperkalemia is a common electrolyte abnormality identified in the emergency department (ED) and potentially fatal. However, there is no consensus over the potassium threshold that warrants intervention or its treatment algorithm. Commonly used medications are at best temporizing measures, and the roles of binders are unclear in the emergent setting. As the prevalence of comorbid conditions altering potassium homeostasis rises, hyperkalemia becomes more common, and hence there is a need to standardize management. A panel was assembled to synthesize the available evidence and identify gaps in knowledge in hyperkalemia treatment in the ED. The panel was composed of 7 medical practitioners, including 5 physicians, a nurse, and a clinical pharmacist with collective expertise in the areas of emergency medicine, nephrology, and hospital medicine. This panel was sponsored by the American College of Emergency Physicians with a goal to create a consensus document for managing acute hyperkalemia. The panel evaluated the evidence on calcium for myocyte stabilization and potassium shifting and excretion. This article summarizes information on available therapies for hyperkalemia and proposes a hyperkalemia treatment algorithm for the ED practitioner based on the currently available literature and highlights diagnostic pitfalls and evidence gaps.
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Affiliation(s)
- Zubaid Rafique
- Baylor College of MedicineDepartment of Emergency MedicineBen Taub General HospitalHoustonTexasUSA
| | - Frank Peacock
- Baylor College of MedicineDepartment of Emergency MedicineBen Taub General HospitalHoustonTexasUSA
| | | | - Jason J. Bischof
- The Ohio State UniversityDepartment of Emergency MedicineColumbusOhioUSA
| | - Joanna Hudson
- The University of Tennessee Health Science CenterDepartments of Clinical Pharmacy and Translational Science & Medicine (Nephrology)MemphisTennesseeUSA
| | - Matthew R. Weir
- Division of NephrologyDepartment of MedicineUniversity of Maryland School of MedicineBaltimoreMarylandUSA
| | - James Neuenschwander
- The Ohio State UniversityDepartment of Emergency MedicineColumbusOhioUSA
- Genesis Healthcare SystemDepartment of Emergency MedicineZanesvilleOhioUSA
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Boo AYY, Koh YLE, Hu PL, Tan NC. Prevalence and factors associated with false hyperkalaemia in Asians in primary care: a cross-sectional study (the Unlysed Hyperkalaemia- the Unseen Burden (UHUB) study). BMJ Open 2020; 10:e033755. [PMID: 32963061 PMCID: PMC7509977 DOI: 10.1136/bmjopen-2019-033755] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
UNLABELLED Serum potassium is part of routine laboratory tests done for patients with hypertension or diabetes mellitus in primary care. Those found to have raised potassium (K>5.5 mmol/L) are recalled for repeat potassium in emergency departments or primary care clinics. Repeat potassium are often normal (≤5.5 mmo/L), that is, false hyperkalaemia. Haemolysis is known to cause false hyperkalaemia. We postulated that unlysed false hyperkalamia was prevalent and was associated with factors such as delayed processing time. OBJECTIVE We aimed to determine the prevalence of unlysed false hyperkalaemia and the factors associated with false-and-true-hyperkalaemia. SETTING Outpatients in a cluster of public primary care clinics (polyclinics) in Singapore. PARTICIPANTS All patients of any ethnicity aged ≥21 with serum potassium test done. METHODS Electronic health records of index patients with potassium >5.5 mmol/L and its corresponding laboratory processing time in seven local polyclinics were reviewed between August 2015 and August 2017. Haemolysed specimens and patients on sodium polystyrene sulfonate (SPS) suspension were excluded. If repeat potassium level was ≤5.5 mmol/L within 8 days, the case was defined as false hyperkalaemia. The proportion of such patients was computed to determine its prevalence. Linear and logistic regressions were used to identify the associated factors. RESULTS The study population comprised of 3014 index cases, of which 1575 had repeat potassium tests without preceding SPS. 86.4% (1362/1575) of them had potassium ≤5.5 mmol/L. The average processing time among specimens with potassium ≥6.0 mmol/L was 50 min longer, compared with those with potassium <5.1 mmol/L. Risk factors significantly associated with false hyperkalaemia included estimated glomerular filtration rate (eGFR) (60-89 mL/min/1.73 m2, OR=3.25, p<0.001;>90 mL/min/1.73 m2, OR=3.77, p<0.001) and delayed laboratory processing time (beta coefficient 0.001, p<0.001). CONCLUSION The prevalence of false hyperkalaemia was 86.4%. Recommendation to repeat potassium tests may target those with eGFR<60ml/min/1.73m2.
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Affiliation(s)
| | | | - Pei Lin Hu
- Family Medicine, SingHealth Polyclinics, Singapore
| | - Ngiap Chuan Tan
- Research, SingHealth Polyclinics, Singapore
- SingHealth-Duke NUS Medical School Academic Clinical Programme, Singapore
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Özçürümez MK, Haeckel R. Biological variables influencing the estimation of reference limits. Scandinavian Journal of Clinical and Laboratory Investigation 2018; 78:337-345. [PMID: 29764232 DOI: 10.1080/00365513.2018.1471617] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Reference limits (RLs) are required to evaluate laboratory results for medical decisions. The establishment of RL depends on the pre-analytical and the analytical conditions. Furthermore, biological characteristics of the sub-population chosen to provide the reference samples may influence the RL. The most important biological preconditions are gender, age, chronobiological influences, posture, regional and ethnic effects. The influence of these components varies and is often neglected. Therefore, a list of biological variables is collected from the literature and their influence on the estimation of RL is discussed. Biological preconditions must be specified if RL are reported as well for directly as for indirectly estimated RL. The influence of biological variables is especially important if RL established by direct methods are compared with those derived from indirect techniques. Even if these factors are not incorporated into the estimation of RL, their understanding can assist the interpretation of laboratory results of an individual.
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Affiliation(s)
- Mustafa K Özçürümez
- a IMD-Oderland GmbH , Frankfurt (Oder) , Germany.,b Institut für Klinische Chemie Medizinische Fakultät Mannheim der Universität Heidelberg , Mannheim , Germany
| | - Rainer Haeckel
- c Bremer Zentrum für Laboratoriumsmedizin Klinikum Bremen Mitte , Bremen , Germany
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