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Coskun A. Prediction interval: A powerful statistical tool for monitoring patients and analytical systems. Biochem Med (Zagreb) 2024; 34:020101. [PMID: 38665871 PMCID: PMC11042565 DOI: 10.11613/bm.2024.020101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 01/23/2024] [Indexed: 04/28/2024] Open
Abstract
Monitoring is indispensable for assessing disease prognosis and evaluating the effectiveness of treatment strategies, both of which rely on serial measurements of patients' data. It also plays a critical role in maintaining the stability of analytical systems, which is achieved through serial measurements of quality control samples. Accurate monitoring can be achieved through data collection, following a strict preanalytical and analytical protocol, and the application of a suitable statistical method. In a stable process, future observations can be predicted based on historical data collected during periods when the process was deemed reliable. This can be evaluated using the statistical prediction interval. Statistically, prediction interval gives an "interval" based on historical data where future measurement results can be located with a specified probability such as 95%. Prediction interval consists of two primary components: (i) the set point and (ii) the total variation around the set point which determines the upper and lower limits of the interval. Both can be calculated using the repeated measurement results obtained from the process during its steady-state. In this paper, (i) the theoretical bases of prediction intervals were outlined, and (ii) its practical application was explained through examples, aiming to facilitate the implementation of prediction intervals in laboratory medicine routine practice, as a robust tool for monitoring patients' data and analytical systems.
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Affiliation(s)
- Abdurrahman Coskun
- Department of Medical Biochemistry, Acıbadem Mehmet Ali Aydinlar University, School of Medicine, Istanbul, Turkey
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2
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Coskun A, Lippi G. The impact of physiological variations on personalized reference intervals and decision limits: an in-depth analysis. Clin Chem Lab Med 2024; 0:cclm-2024-0009. [PMID: 38452477 DOI: 10.1515/cclm-2024-0009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Accepted: 02/27/2024] [Indexed: 03/09/2024]
Abstract
The interpretation of laboratory data is a comparative procedure. Physicians typically need reference values to compare patients' laboratory data for clinical decisions. Therefore, establishing reliable reference data is essential for accurate diagnosis and patient monitoring. Human metabolism is a dynamic process. Various types of systematic and random fluctuations in the concentration/activity of biomolecules are observed in response to internal and external factors. In the human body, several biomolecules are under the influence of physiological rhythms and are therefore subject to ultradian, circadian and infradian fluctuations. In addition, most biomolecules are also characterized by random biological variations, which are referred to as biological fluctuations between subjects and within subjects/individuals. In routine practice, reference intervals based on population data are used, which by nature are not designed to capture physiological rhythms and random biological variations. To ensure safe and appropriate interpretation of patient laboratory data, reference intervals should be personalized and estimated using individual data in accordance with systematic and random variations. In this opinion paper, we outline (i) the main variations that contribute to the generation of personalized reference intervals (prRIs), (ii) the theoretical background of prRIs and (iii) propose new methods on how to harmonize prRIs with the systematic and random variations observed in metabolic activity, based on individuals' demography.
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Affiliation(s)
- Abdurrahman Coskun
- Department of Medical Biochemistry, School of Medicine, Acibadem Mehmet Ali Aydinlar University, Istanbul, Türkiye
| | - Giuseppe Lippi
- Section of Clinical Biochemistry, 19051 University of Verona , Verona, Italy
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Coskun A, Lippi G. Personalized laboratory medicine in the digital health era: recent developments and future challenges. Clin Chem Lab Med 2024; 62:402-409. [PMID: 37768883 DOI: 10.1515/cclm-2023-0808] [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: 07/28/2023] [Accepted: 09/18/2023] [Indexed: 09/30/2023]
Abstract
Interpretation of laboratory data is a comparative procedure and requires reliable reference data, which are mostly derived from population data but used for individuals in conventional laboratory medicine. Using population data as a "reference" for individuals has generated several problems related to diagnosing, monitoring, and treating single individuals. This issue can be resolved by using data from individuals' repeated samples, as their personal reference, thus needing that laboratory data be personalized. The modern laboratory information system (LIS) can store the results of repeated measurements from millions of individuals. These data can then be analyzed to generate a variety of personalized reference data sets for numerous comparisons. In this manuscript, we redefine the term "personalized laboratory medicine" as the practices based on individual-specific samples and data. These reflect their unique biological characteristics, encompassing omics data, clinical chemistry, endocrinology, hematology, coagulation, and within-person biological variation of all laboratory data. It also includes information about individuals' health behavior, chronotypes, and all statistical algorithms used to make precise decisions. This approach facilitates more accurate diagnosis, monitoring, and treatment of diseases for each individual. Furthermore, we explore recent advancements and future challenges of personalized laboratory medicine in the context of the digital health era.
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Affiliation(s)
- Abdurrahman Coskun
- Acibadem Mehmet Ali Aydinlar University, School of Medicine, Istanbul, Türkiye
| | - Giuseppe Lippi
- Section of Clinical Biochemistry and School of Medicine, University of Verona, Verona, Italy
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Coşkun A, Carobene A, Demirelce O, Mussap M, Braga F, Sezer E, Aarsand AK, Sandberg S, Calle PF, Díaz-Garzón J, Erkaya M, Coskun C, Erol EN, Dağ H, Bartlett B, Serteser M, Jonker N, Unsal I. Sex-related differences in within-subject biological variation estimates for 22 essential and non-essential amino acids. Clin Chim Acta 2024; 552:117632. [PMID: 37940015 DOI: 10.1016/j.cca.2023.117632] [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: 11/02/2023] [Accepted: 11/04/2023] [Indexed: 11/10/2023]
Abstract
BACKGROUND Measurement of serum amino acid (AA) concentrations is important in particular for the diagnosis and monitoring of inborn errors of AA metabolism. To ensure optimal clinical interpretation of AAs, reliable biological variation (BV) data are essential. In the present study, we derived BV data for 22 non-essential, conditionally essential, and essential AAs and assessed differences in BV of AAs related to sex. METHODS Morning blood samples were drawn from 66 subjects (31 males and 35 females) once a week for 10 consecutive weeks. All samples were analyzed in duplicate using liquid chromatography-tandem mass-spectrometry. The data were assessed for outliers, trends, normality and variance homogeneity analysis prior to estimating within-subject (CVI) and between-subject (CVG) BV. RESULTS CVI estimates ranged from 9.0 % for histidine (male) to 33.0 % for taurine (male). CVI estimates in males and females were significantly different for all AAs except for aspartic acid, citrulline and phenylalanine, in most cases higher in females than in males. Apart from for arginine, CVG estimates in males and females were similar. CONCLUSIONS In this highly powered BV study, we provide updated BV estimates for 22 AAs and demonstrate that for most AAs, CVI estimates differ between males and females, with implications for interpretation and use of AAs in clinical practice.
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Affiliation(s)
- Abdurrahman Coşkun
- Acibadem Mehmet Ali Aydınlar University, School of Medicine, Department of Medical Biochemistry, Atasehir, Istanbul, Turkey; Acibadem Labmed Clinical Laboratories, Atasehir, Istanbul, Turkey; EFLM Working Group on Biological Variation, Milan, Italy; EFLM Task Group for the Biological Variation Database, Milan, Italy.
| | - Anna Carobene
- EFLM Working Group on Biological Variation, Milan, Italy; EFLM Task Group for the Biological Variation Database, Milan, Italy; Laboratory Medicine, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Ozlem Demirelce
- Acibadem Labmed Clinical Laboratories, Atasehir, Istanbul, Turkey
| | - Michele Mussap
- Laboratory Unit, Department of Surgical Sciences, University of Cagliari, Italy
| | - Federica Braga
- EFLM Working Group on Biological Variation, Milan, Italy; EFLM Task Group for the Biological Variation Database, Milan, Italy; Clinical Diagnostics Department, Laboratory Medicine Unit, ASST Bergamo Ovest, Treviglio, Bergamo, Italy
| | - Ebru Sezer
- EFLM Task Group for the Biological Variation Database, Milan, Italy; Ege University, School of Medicine, Department of Medicinal Biochemistry, Izmir, Turkey
| | - Aasne Karine Aarsand
- EFLM Working Group on Biological Variation, Milan, Italy; EFLM Task Group for the Biological Variation Database, Milan, Italy; Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, Bergen, Norway and Norwegian Organization for Quality Improvement of Laboratory Examinations (NOKLUS), Haraldsplass Deaconess Hospital, Bergen, Norway
| | - Sverre Sandberg
- EFLM Working Group on Biological Variation, Milan, Italy; EFLM Task Group for the Biological Variation Database, Milan, Italy; Norwegian Organization for Quality Improvement of Laboratory Examinations (NOKLUS), Haraldsplass Deaconess Hospital, Bergen, Norway and Department of Global Health and Primary Care, Faculty of Medicine, University of Bergen, Bergen, Norway
| | - Pilar Fernández Calle
- EFLM Working Group on Biological Variation, Milan, Italy; EFLM Task Group for the Biological Variation Database, Milan, Italy; Department of Laboratory Medicine, La Paz University Hospital, Madrid, Spain; and Analytical Quality Commission, Spanish Society of Laboratory Medicine (SEQCML), Barcelona, Spain
| | - Jorge Díaz-Garzón
- EFLM Working Group on Biological Variation, Milan, Italy; EFLM Task Group for the Biological Variation Database, Milan, Italy; Department of Laboratory Medicine, La Paz University Hospital, Madrid, Spain; and Analytical Quality Commission, Spanish Society of Laboratory Medicine (SEQCML), Barcelona, Spain
| | - Metincan Erkaya
- Acibadem Mehmet Ali Aydınlar University, School of Medicine, Atasehir, Istanbul, Turkey
| | - Cihan Coskun
- Department of Medical Biochemistry, Basaksehir Cam and Sakura City Hospital, Basaksehir, Istanbul, Turkey
| | - Esila Nur Erol
- Department of Laboratory Medicine, La Paz University Hospital, Madrid, Spain; and Analytical Quality Commission, Spanish Society of Laboratory Medicine (SEQCML), Barcelona, Spain
| | - Hunkar Dağ
- Acibadem Mehmet Ali Aydınlar University, School of Medicine, Atasehir, Istanbul, Turkey
| | - Bill Bartlett
- EFLM Working Group on Biological Variation, Milan, Italy; EFLM Task Group for the Biological Variation Database, Milan, Italy; School of Science and Engineering, University of Dundee, Dundee, UK
| | - Mustafa Serteser
- Acibadem Mehmet Ali Aydınlar University, School of Medicine, Department of Medical Biochemistry, Atasehir, Istanbul, Turkey; Acibadem Labmed Clinical Laboratories, Atasehir, Istanbul, Turkey
| | - Niels Jonker
- EFLM Working Group on Biological Variation, Milan, Italy; EFLM Task Group for the Biological Variation Database, Milan, Italy; Certe, Wilhelmina Ziekenhuis Assen, Assen, The Netherlands
| | - Ibrahim Unsal
- Acibadem Labmed Clinical Laboratories, Atasehir, Istanbul, Turkey
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Chen J, Fan L, Yang Z, Yang D. Comparison of results and age-related changes in establishing reference intervals for CEA, AFP, CA125, and CA199 using four indirect methods. Pract Lab Med 2024; 38:e00353. [PMID: 38221990 PMCID: PMC10787276 DOI: 10.1016/j.plabm.2023.e00353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Revised: 12/18/2023] [Accepted: 12/20/2023] [Indexed: 01/16/2024] Open
Abstract
•The reference intervals calculated using RefineR, Kosmic, TMC, and non-parametric methods are similar.•TMC algorithm is more robust, demonstrates a high pass rate among the four methods and has the ability to automatically isolate outliers.•The reference intervals of CA125 and CA199 showed significant differences between age and sex.
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Affiliation(s)
- Juping Chen
- Department of Laboratory Medicine, Liangzhu Branch of the First Affiliated Hospital of Zhejiang University, Zhejiang, China
- School of Public Health, Zhejiang University School of Medicine, Zhejiang, China
| | - Lina Fan
- Department of Laboratory Medicine, The First Affiliated Hospital, Zhejiang University School of Medicine, Zhejiang, China
| | - Zheng Yang
- Department of Laboratory Medicine, The First Affiliated Hospital, Zhejiang University School of Medicine, Zhejiang, China
| | - Dagan Yang
- Department of Laboratory Medicine, The First Affiliated Hospital, Zhejiang University School of Medicine, Zhejiang, China
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Blatter TU, Witte H, Fasquelle-Lopez J, Theodoros Naka C, Raisaro JL, Leichtle AB. The BioRef Infrastructure, a Framework for Real-Time, Federated, Privacy-Preserving, and Personalized Reference Intervals: Design, Development, and Application. J Med Internet Res 2023; 25:e47254. [PMID: 37851984 PMCID: PMC10620636 DOI: 10.2196/47254] [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: 03/13/2023] [Revised: 07/13/2023] [Accepted: 07/14/2023] [Indexed: 10/20/2023] Open
Abstract
BACKGROUND Reference intervals (RIs) for patient test results are in standard use across many medical disciplines, allowing physicians to identify measurements indicating potentially pathological states with relative ease. The process of inferring cohort-specific RIs is, however, often ignored because of the high costs and cumbersome efforts associated with it. Sophisticated analysis tools are required to automatically infer relevant and locally specific RIs directly from routine laboratory data. These tools would effectively connect clinical laboratory databases to physicians and provide personalized target ranges for the respective cohort population. OBJECTIVE This study aims to describe the BioRef infrastructure, a multicentric governance and IT framework for the estimation and assessment of patient group-specific RIs from routine clinical laboratory data using an innovative decentralized data-sharing approach and a sophisticated, clinically oriented graphical user interface for data analysis. METHODS A common governance agreement and interoperability standards have been established, allowing the harmonization of multidimensional laboratory measurements from multiple clinical databases into a unified "big data" resource. International coding systems, such as the International Classification of Diseases, Tenth Revision (ICD-10); unique identifiers for medical devices from the Global Unique Device Identification Database; type identifiers from the Global Medical Device Nomenclature; and a universal transfer logic, such as the Resource Description Framework (RDF), are used to align the routine laboratory data of each data provider for use within the BioRef framework. With a decentralized data-sharing approach, the BioRef data can be evaluated by end users from each cohort site following a strict "no copy, no move" principle, that is, only data aggregates for the intercohort analysis of target ranges are exchanged. RESULTS The TI4Health distributed and secure analytics system was used to implement the proposed federated and privacy-preserving approach and comply with the limitations applied to sensitive patient data. Under the BioRef interoperability consensus, clinical partners enable the computation of RIs via the TI4Health graphical user interface for query without exposing the underlying raw data. The interface was developed for use by physicians and clinical laboratory specialists and allows intuitive and interactive data stratification by patient factors (age, sex, and personal medical history) as well as laboratory analysis determinants (device, analyzer, and test kit identifier). This consolidated effort enables the creation of extremely detailed and patient group-specific queries, allowing the generation of individualized, covariate-adjusted RIs on the fly. CONCLUSIONS With the BioRef-TI4Health infrastructure, a framework for clinical physicians and researchers to define precise RIs immediately in a convenient, privacy-preserving, and reproducible manner has been implemented, promoting a vital part of practicing precision medicine while streamlining compliance and avoiding transfers of raw patient data. This new approach can provide a crucial update on RIs and improve patient care for personalized medicine.
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Affiliation(s)
- Tobias Ueli Blatter
- University Institute of Clinical Chemistry, University Hospital Bern, Bern, Switzerland
- Graduate School for Health Sciences, University of Bern, Bern, Switzerland
| | - Harald Witte
- University Institute of Clinical Chemistry, University Hospital Bern, Bern, Switzerland
| | | | - Christos Theodoros Naka
- University Institute of Clinical Chemistry, University Hospital Bern, Bern, Switzerland
- Laboratory of Biometry, University of Thessaly, Volos, Greece
| | - Jean Louis Raisaro
- Biomedical Data Science Center, University Hospital Lausanne, Lausanne, Switzerland
| | - Alexander Benedikt Leichtle
- University Institute of Clinical Chemistry, University Hospital Bern, Bern, Switzerland
- Center for Artificial Intelligence in Medicine, University of Bern, Bern, Switzerland
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Coşkun A, Sandberg S, Unsal I, Cavusoglu C, Serteser M, Kilercik M, Aarsand AK. Personalized and Population-Based Reference Intervals for 48 Common Clinical Chemistry and Hematology Measurands: A Comparative Study. Clin Chem 2023; 69:1009-1030. [PMID: 37525518 DOI: 10.1093/clinchem/hvad113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 07/10/2023] [Indexed: 08/02/2023]
Abstract
BACKGROUND Personalized reference intervals (prRIs) have the potential to improve individual patient follow-up as compared to population-based reference intervals (popRI). In this study, we estimated popRI and prRIs for 48 clinical chemistry and hematology measurands using samples from the same reference individuals and explored the effect of using group-based and individually based biological variation (BV) estimates to derive prRIs. METHODS 143 individuals (median age 28 years) were included in the study and had fasting blood samples collected once. From this population, 41 randomly selected subjects had samples collected weekly for 5 weeks. PopRIs were estimated according to Clinical Laboratory Standards Institute EP28 and within-subject BV (CVI) were estimated by CV-ANOVA. Data were assessed for trends and outliers prior to calculation of individual prRIs, based on estimates of (a) within-person BV (CVP), (b) CVI derived in this study, and (c) publically available CVI estimates. RESULTS For most measurands, the individual prRI ranges were smaller than the popRI range, but overall about half the study participants had a prRI wider than the popRI for 5 or more out of 48 measurands. The dispersion of prRIs based on CVP was wider than that of prRIs based on CVI. CONCLUSION The prRIs derived in our study varied significantly between different individuals, especially if based on CVP. Our results highlight the limitations of popRIs in interpreting test results of individual patients. If sufficient data from a steady-state situation are available, using prRI based on CVP estimates will provide a RI most specific for an individual patient.
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Affiliation(s)
- Abdurrahman Coşkun
- Acibadem Labmed Clinical Laboratories, Acibadem Mehmet Ali Aydinlar University, Istanbul, Turkey
- Department of Medical Biochemistry, School of Medicine, Acibadem Mehmet Ali Aydinlar University, Istanbul, Turkey
| | - Sverre Sandberg
- Norwegian Organization for Quality Improvement of Laboratory Examinations (Noklus), Haraldsplass Deaconess Hospital, Bergen, Norway
- Norwegian Porphyria Centre, Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, Bergen, Norway
- Department of Global Health and Primary Care, Faculty of Medicine and Dentistry, University of Bergen, Bergen, Norway
| | - Ibrahim Unsal
- Acibadem Labmed Clinical Laboratories, Acibadem Mehmet Ali Aydinlar University, Istanbul, Turkey
| | - Coskun Cavusoglu
- Acibadem Labmed Clinical Laboratories, Acibadem Mehmet Ali Aydinlar University, Istanbul, Turkey
| | - Mustafa Serteser
- Acibadem Labmed Clinical Laboratories, Acibadem Mehmet Ali Aydinlar University, Istanbul, Turkey
- Department of Medical Biochemistry, School of Medicine, Acibadem Mehmet Ali Aydinlar University, Istanbul, Turkey
| | - Meltem Kilercik
- Acibadem Labmed Clinical Laboratories, Acibadem Mehmet Ali Aydinlar University, Istanbul, Turkey
- Department of Medical Biochemistry, School of Medicine, Acibadem Mehmet Ali Aydinlar University, Istanbul, Turkey
| | - Aasne K Aarsand
- Norwegian Porphyria Centre, Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, Bergen, Norway
- Department of Global Health and Primary Care, Faculty of Medicine and Dentistry, University of Bergen, Bergen, Norway
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Coskun A, Zarepour A, Zarrabi A. Physiological Rhythms and Biological Variation of Biomolecules: The Road to Personalized Laboratory Medicine. Int J Mol Sci 2023; 24:ijms24076275. [PMID: 37047252 PMCID: PMC10094461 DOI: 10.3390/ijms24076275] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 03/24/2023] [Accepted: 03/24/2023] [Indexed: 03/29/2023] Open
Abstract
The concentration of biomolecules in living systems shows numerous systematic and random variations. Systematic variations can be classified based on the frequency of variations as ultradian (<24 h), circadian (approximately 24 h), and infradian (>24 h), which are partly predictable. Random biological variations are known as between-subject biological variations that are the variations among the set points of an analyte from different individuals and within-subject biological variation, which is the variation of the analyte around individuals’ set points. The random biological variation cannot be predicted but can be estimated using appropriate measurement and statistical procedures. Physiological rhythms and random biological variation of the analytes could be considered the essential elements of predictive, preventive, and particularly personalized laboratory medicine. This systematic review aims to summarize research that have been done about the types of physiological rhythms, biological variations, and their effects on laboratory tests. We have searched the PubMed and Web of Science databases for biological variation and physiological rhythm articles in English without time restrictions with the terms “Biological variation, Within-subject biological variation, Between-subject biological variation, Physiological rhythms, Ultradian rhythms, Circadian rhythm, Infradian rhythms”. It was concluded that, for effective management of predicting, preventing, and personalizing medicine, which is based on the safe and valid interpretation of patients’ laboratory test results, both physiological rhythms and biological variation of the measurands should be considered simultaneously.
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Sandberg S, Carobene A, Bartlett B, Coskun A, Fernandez-Calle P, Jonker N, Díaz-Garzón J, Aarsand AK. Biological variation: recent development and future challenges. Clin Chem Lab Med 2022; 61:741-750. [PMID: 36537071 DOI: 10.1515/cclm-2022-1255] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Accepted: 12/12/2022] [Indexed: 02/18/2023]
Abstract
Abstract
Biological variation (BV) data have many applications in laboratory medicine. However, these depend on the availability of relevant and robust BV data fit for purpose. BV data can be obtained through different study designs, both by experimental studies and studies utilizing previously analysed routine results derived from laboratory databases. The different BV applications include using BV data for setting analytical performance specifications, to calculate reference change values, to define the index of individuality and to establish personalized reference intervals. In this review, major achievements in the area of BV from last decade will be presented and discussed. These range from new models and approaches to derive BV data, the delivery of high-quality BV data by the highly powered European Biological Variation Study (EuBIVAS), the Biological Variation Data Critical Appraisal Checklist (BIVAC) and other standards for deriving and reporting BV data, the EFLM Biological Variation Database and new applications of BV data including personalized reference intervals and measurement uncertainty.
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Affiliation(s)
- Sverre Sandberg
- Norwegian Organization for Quality Improvement of Laboratory Examinations (Noklus), Haraldsplass Deaconess Hospital , Bergen , Norway
- Department of Medical Biochemistry and Pharmacology , Norwegian Porphyria Centre, Haukeland University Hospital , Bergen , Norway
- Department of Global Public Health and Primary Care , University of Bergen , Bergen , Norway
| | - Anna Carobene
- Laboratory Medicine, IRCCS San Raffaele Scientific Institute , Milan , Italy
| | - Bill Bartlett
- School of Science and Engineering, University of Dundee , Dundee , Scotland
| | - Abdurrahman Coskun
- Acibadem Mehmet Ali Aydınlar University, School of Medicine , Istanbul , Türkiye
| | - Pilar Fernandez-Calle
- Hospital Universitario La Paz, Quality Analytical Commission of Spanish Society of Clinical Chemistry (SEQC) , Madrid , Spain
| | - Niels Jonker
- Certe, Wilhelmina Ziekenhuis Assen , Assen , The Netherlands
| | - Jorge Díaz-Garzón
- Hospital Universitario La Paz, Quality Analytical Commission of Spanish Society of Clinical Chemistry (SEQC) , Madrid , Spain
| | - Aasne K. Aarsand
- Norwegian Organization for Quality Improvement of Laboratory Examinations (Noklus), Haraldsplass Deaconess Hospital , Bergen , Norway
- Department of Medical Biochemistry and Pharmacology , Norwegian Porphyria Centre, Haukeland University Hospital , Bergen , Norway
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