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Cotten SW, Block DR. A Review of Current Practices and Future Trends in Body Fluid Testing. J Appl Lab Med 2023; 8:962-983. [PMID: 37207691 DOI: 10.1093/jalm/jfad014] [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: 12/01/2022] [Accepted: 01/27/2023] [Indexed: 05/21/2023]
Abstract
BACKGROUND Body fluid testing in the clinical chemistry laboratory is a cornerstone in the diagnostic workup of pathological effusions. Laboratorians may not be aware of the preanalytical workflows used in the collection of body fluids though the value is evident whenever processes change or issues arise. The analytical validation requirements can vary depending on the regulations dictated by the laboratories' jurisdiction and accreditor requirements. Much of analytical validation hinges on how useful testing is to clinical care. Usefulness of testing varies with how well established and incorporated the tests and interpretation are in practice guidelines. CONTENT Body fluid collections are depicted and described so clinical laboratorians have a basic appreciation of what specimens are submitted to the laboratory for testing. A review of validation requirements by major laboratory accreditation entities is presented. A review of the usefulness and proposed decision limits for common body fluid chemistry analytes is presented. Body fluid tests that show promise and those that are losing (or lost long ago) value are also reviewed. SUMMARY The total testing process from collection to result interpretation can be complicated and easily overlooked by the clinical laboratory. This review aims to improve the understanding and awareness of collections, validation, result interpretation, and provide an update on recent trends.
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Affiliation(s)
- Steven W Cotten
- Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Darci R Block
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States
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Han S, Conwell DL, Li L, Cervantes A, Hart PA, Cruz-Monserrate Z, Hao W, Lesinski GB, Mace T, Palermo TM, Saloman JL, Yadav D, Vege SS, Topazian M. The phase 1/2 trial of indomethacin in chronic pancreatitis (The PAIR trial): Protocol for a parallel multi-center randomized controlled trial. Pancreatology 2023; 23:42-47. [PMID: 36535851 PMCID: PMC9839482 DOI: 10.1016/j.pan.2022.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 09/03/2022] [Accepted: 12/12/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND/OBJECTIVES Current treatments for chronic pancreatitis focus on symptom management and therapeutics targeting disease reversal are lacking. Given the role of the cyclooxygenase-2 (COX-2) enzyme in producing prostaglandin E2 (PGE2), a key component in the inflammatory pathway of chronic pancreatitis, this study evaluates the physiologic effect of oral indomethacin, a COX-2 inhibitor, on PGE2 levels in pancreatic fluid. METHODS This pilot two-center randomized controlled trial seeks to examine 32 subjects with chronic pancreatitis who have no contraindications to indomethacin. Subjects will be randomized to either oral indomethacin 50 mg twice a day or placebo twice a day for a total of 28 days. Baseline (pre-treatment) assessment of pain and quality of life will be performed using the Brief Pain Inventory and the PROMIS-10 questionnaires, respectively. Biological specimens including blood, urine, and saliva will be collected at pre-treatment and post-treatment(day 28). Endoscopic pancreatic function testing with concomitant pancreatic fluid collection will also be performed pre- and post-treatment to assess the change in pancreatic fluid PGE2 levels. The relationship between pancreatic fluid PGE2 levels with blood and saliva PGE2 levels will be examined. CONCLUSIONS This study will elucidate the effect of oral indomethacin on PGE2 levels in the pancreas to assess its role in the inflammatory pathway of chronic pancreatitis. Should indomethacin significantly reduce PGE2 levels, this may represent a potential disease-altering treatment for chronic pancreatitis.
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Affiliation(s)
- Samuel Han
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH, USA.
| | - Darwin L Conwell
- Department of Internal Medicine, University of Kentucky College of Medicine, Lexington, KY, USA
| | - Liang Li
- Department of Biostatistics, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Alejandra Cervantes
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Phil A Hart
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Zobeida Cruz-Monserrate
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH, USA; The James Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Wenrui Hao
- Department of Mathematics, Pennsylvania State University, University Park, PA, USA
| | - Gregory B Lesinski
- Department of Hematology and Medical Oncology, Emory University School of Medicine, Atlanta, GA, USA
| | - Thomas Mace
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Tonya M Palermo
- Department of Anesthesiology & Pain Medicine, University of Washington, Seattle, WA, USA
| | - Jami L Saloman
- Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh, Pittsburgh, PA, USA
| | - Dhiraj Yadav
- Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh, Pittsburgh, PA, USA
| | - Santhi Swaroop Vege
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Mark Topazian
- Department of Anesthesiology & Pain Medicine, University of Washington, Seattle, WA, USA
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Pyle-Eilola A, Pagan J, Kayatin A, Povse PN, Rietschlin JA, Cotten SW. Method Performance of Bicarbonate and Electrolytes by Use of Duodenal Fluid for Assessment of Exocrine Pancreatic Function. J Appl Lab Med 2018; 3:56-64. [PMID: 33626830 DOI: 10.1373/jalm.2017.024695] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Accepted: 04/05/2018] [Indexed: 11/06/2022]
Abstract
BACKGROUND Evaluation of exocrine pancreatic insufficiency is challenging for both clinicians and laboratories. Indirect pancreatic function tests such as serum trypsinogen, fecal elastase, and fecal fat measurements are moderately sensitive for diagnosis of advanced chronic pancreatitis but show reduced sensitivity and specificity for diagnosis of early disease. An alternative is the endoscopic pancreatic function test, which uses duodenal secretions after administration of IV secretin. Samples are collected at various times via the endoscopic tube and then analyzed for bicarbonate, sodium, potassium, and chloride. METHODS Precision, linearity, method comparison, and stability studies were performed on the Beckman Coulter AU5822 chemistry analyzer with duodenal fluid. Comparison with the Vitros 4600 dry slide chemistry instrument was used to interrogate differences between methods. RESULTS All assays produced a CV <2% without any measurable effects from the endoscopy fluid matrix and showed acceptable imprecision near the limit of detection (CV < 5%). All analytes showed linear dilution across the analytical measuring range. All the calculated error biases from dilutions were within 50% of the CLIA-allowable error for serum for each of the respective analytes. The calculated slopes ranged from 0.841 to 1.274 when compared to the Vitros 4600. Stability studies demonstrated that sodium, potassium, chloride, and bicarbonate remained stable after storage at -20 °C and after multiple freeze-thaw cycles. The percent change for all analytes was <5% mmol/L. CONCLUSIONS The AU5800 series demonstrated adequate performance for the analysis of bicarbonate in duodenal fluid and therefore can be used for assessment of exocrine pancreatic function. However, notable discrepancies were observed for sodium, potassium, and chloride between the AU5800 series and the Vitros 4600.
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Affiliation(s)
- Amy Pyle-Eilola
- Department of Pathology and Laboratory Medicine, Nationwide Children's Hospital, Columbus, OH
| | - Jill Pagan
- Department of Pathology, Ohio State University Wexner Medical Center, Columbus, OH
| | - Adam Kayatin
- Department of Pathology, Ohio State University Wexner Medical Center, Columbus, OH
| | - Patrick N Povse
- Department of Pathology, Ohio State University Wexner Medical Center, Columbus, OH
| | - Jacqua A Rietschlin
- Department of Pathology, Ohio State University Wexner Medical Center, Columbus, OH
| | - Steven W Cotten
- Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
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Hart PA, Topazian M, Raimondo M, Cruz-Monserrate Z, Fisher WE, Lesinski GB, Steen H, Conwell DL. Endoscopic Pancreas Fluid Collection: Methods and Relevance for Clinical Care and Translational Science. Am J Gastroenterol 2016; 111:1258-66. [PMID: 27481304 PMCID: PMC5568003 DOI: 10.1038/ajg.2016.297] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Accepted: 06/01/2016] [Indexed: 02/08/2023]
Abstract
Pancreatic secretions have an important role in the regulation of a normal nutritional state but can be altered owing to a variety of pathophysiological mechanisms in the context of exocrine pancreatic disease. The development of an endoscopic technique for collection of pancreatic fluid, termed endoscopic pancreatic function testing, has led to improved understanding of these alterations and is particularly helpful to characterize chronic pancreatitis. In addition, investigators have found endoscopically collected pancreatic fluid to be a valuable biofluid for the purposes of translational science. Techniques such as proteomic, cytokine, genetic mutation, DNA methylation, and microRNA analyses, among others, can be utilized to gain a better understanding of the molecular characteristics of chronic pancreatitis and other pancreatic diseases. Endoscopic collection of pancreatic fluid is safe and relatively straightforward, permitting opportunities for longitudinal analysis of these translational markers throughout the course of disease. This manuscript summarizes our current knowledge of pancreatic fluid, with an emphasis on proper techniques for sample collection and handling, its clinical utility, and preliminary observations in translational science.
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Affiliation(s)
- Phil A. Hart
- Section of Pancreatic Disorders, Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Mark Topazian
- Division of Gastroenterology and Hepatology, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Massimo Raimondo
- Division of Gastroenterology and Hepatology, Mayo Clinic Jacksonville, Jacksonville, Florida, USA
| | - Zobeida Cruz-Monserrate
- Section of Pancreatic Disorders, Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - William E. Fisher
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Gregory B. Lesinski
- Section of Pancreatic Disorders, Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Hanno Steen
- Department of Pathology, Boston Children’s Hospital and Harvard Medical School, Boston, Msaachusetts, USA
| | - Darwin L. Conwell
- Section of Pancreatic Disorders, Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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Automated spectrophotometric bicarbonate analysis in duodenal juice compared to the back titration method. Pancreatology 2016; 16:231-7. [PMID: 26876799 DOI: 10.1016/j.pan.2016.01.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Revised: 12/01/2015] [Accepted: 01/22/2016] [Indexed: 02/07/2023]
Abstract
OBJECTIVES We have recently evaluated a short endoscopic secretin test for exocrine pancreatic function. Bicarbonate concentration in duodenal juice is an important parameter in this test. Measurement of bicarbonate by back titration as the gold standard method is time consuming, expensive and technically difficult, thus a simplified method is warranted. We aimed to evaluate an automated spectrophotometric method in samples spanning the effective range of bicarbonate concentrations in duodenal juice. We also evaluated if freezing of samples before analyses would affect its results. METHODS Patients routinely examined with short endoscopic secretin test suspected to have decreased pancreatic function of various reasons were included. Bicarbonate in duodenal juice was quantified by back titration and automatic spectrophotometry. Both fresh and thawed samples were analysed spectrophotometrically. RESULTS 177 samples from 71 patients were analysed. Correlation coefficient of all measurements was r = 0.98 (p < 0.001). Correlation coefficient of fresh versus frozen samples conducted with automatic spectrophotometry (n = 25): r = 0.96 (p < 0.001) CONCLUSIONS: The measurement of bicarbonate in fresh and thawed samples by automatic spectrophotometrical analysis correlates excellent with the back titration gold standard. This is a major simplification of direct pancreas function testing, and allows a wider distribution of bicarbonate testing in duodenal juice. Extreme values for Bicarbonate concentration achieved by the autoanalyser method have to be interpreted with caution.
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Pancreatic juice prostaglandin e2 concentrations are elevated in chronic pancreatitis and improve detection of early disease. Clin Transl Gastroenterol 2015; 6:e72. [PMID: 25630864 PMCID: PMC4418410 DOI: 10.1038/ctg.2014.23] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2014] [Accepted: 12/22/2014] [Indexed: 02/06/2023] Open
Abstract
Objectives: Chronic pancreatitis (CP) may be difficult to diagnose in early stages. We aimed to measure pancreatic juice (PJ) prostaglandin E2 (PGE2) concentrations to determine whether they are elevated in CP and improve diagnosis of early disease. Methods: We measured PJ PGE2 in 10 patients with established CP, 25 patients who met criteria for “minimal change” chronic pancreatitis (MCCP), and 10 normal control participants. Results: Median PJ PGE2 was elevated in CP (307 pg/ml, IQR (249–362)) and MCCP (568 pg/ml, (418–854)) compared with normal controls (104 pg/ml, (68–206)) (P≤ 0.001). Area under receiving operator curve (AUROC) for diagnosis of CP and MCCP was 0.9 and 0.62, respectively, for PJ bicarbonate concentration alone; AUROC was 1.0 and 0.94 for the combination of PJ bicarbonate and PGE2 concentrations. Conclusions: PJ PGE2 appears to be a biomarker for CP and is elevated in both established and “minimal change” chronic pancreatitis.
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Sze KCP, Pirola RC, Apte MV, Wilson JS. Current options for the diagnosis of chronic pancreatitis. Expert Rev Mol Diagn 2014; 14:199-215. [PMID: 24512138 DOI: 10.1586/14737159.2014.883277] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The diagnostic options for chronic pancreatitis have evolved over recent years. The previous gold standard references for structural imaging and exocrine pancreatic function testing have both been supplanted and redesigned. Endoscopic retrograde pancreatography has now been overtaken by endoscopic ultrasound and magnetic resonance cholangiopancreatography, whilst the old technique for Dreiling tube pancreatic function testing has now been replaced by the endoscopic pancreatic function test. New advances in endoscopic ultrasound elastography have also extended the options for evaluating pancreatic masses to differentiate mass-forming chronic pancreatitis from malignancy. Genetic contribution to chronic pancreatitis is also now more widely recognized than ever before.
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Affiliation(s)
- Kenny Ching Pan Sze
- South Western Sydney Clinical School, University of New South Wales, Liverpool Hospital, Liverpool, NSW 2170, Australia
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