Reference values: from philosophy to a tool for laboratory medicine

Distribution-free hyperrectangular tolerance regions for setting multivariate reference regions in laboratory medicine

Reference regions are important in laboratory medicine to interpret the test results of patients, and usually given by tolerance regions. Tolerance regions ofp   ( ≥ 2 ) $$ p\;\left(\ge 2\right) $$ dimensions are highly desirable when the test results containsp $$ p $$ outcome measures. Nonparametric hyperrectangular tolerance regions are attractive in real problems due to their robustness with respect to the underlying distribution of the measurements and ease of intepretation, and methods to construct them have been recently provided by Young and Mathew [Stat Methods Med Res. 2020;29:3569-3585]. However, their validity is supported by a simulation study only. In this paper, nonparametric hyperrectangular tolerance regions are constructed by using Tukey's [Ann Math Stat. 1947;18:529-539; Ann Math Stat. 1948;19:30-39] elegant results of equivalence blocks. The validity of these new tolerance regions is proven mathematically in [Ann Math Stat. 1947;18:529-539; Ann Math Stat. 1948;19:30-39] under the only assumption that the underlying distribution of the measurements is continuous. The methodology is applied to analyze the kidney function problem considered in Young and Mathew [Stat Methods Med Res. 2020;29:3569-3585].

Determining reference ranges and sample sizes in parallel-group studies

BACKGROUND AND OBJECTIVES

Reference ranges are widely used to locate the major range of the target probability distribution. When future measurements fall outside the reference range, they are classified as atypical and require further investigation. The fundamental principles and statistical properties of reference ranges are closely related to those of tolerance interval procedures. Existing investigations of reference ranges and tolerance intervals mainly devoted to the primitive cases of one- and paired-sample designs. Although reference ranges hold considerable promise for parallel group designs, the corresponding methodological and computational issues for determining reference limits and sample sizes have not been adequately addressed.

METHODS

This paper describes a complete collection of one- and two-sided reference ranges for assessing measurement differences in parallel-group studies that assume variance homogeneity.

RESULTS

The problem of sample size determination for precise reference ranges is also examined under the expected half-width and assurance probability considerations. Unlike the current methods, the suggested sample size criteria explicitly accommodate desired interval width in precise interval estimation.

CONCLUSIONS

Theoretical examinations and empirical assessments are presented to validate the usefulness of the proposed reference range and sample size procedures. To enhance the usages of the recommended techniques in practical applications, computer programs are developed for efficient calculation and exact analysis. A real data example regarding tablet absorption rate and extent is presented to illustrate the suggested assessments between two drug formulations.

Reference range: Which statistical intervals to use?

Reference ranges, which are data-based intervals aiming to contain a pre-specified large proportion of the population values, are powerful tools to analyse observations in clinical laboratories. Their main point is to classify any future observations from the population which fall outside them as atypical and thus may warrant further investigation. As a reference range is constructed from a random sample from the population, the event ‘a reference range contains (100 P)% of the population’ is also random. Hence, all we can hope for is that such event has a large occurrence probability. In this paper we argue that some intervals, including the P prediction interval, are not suitable as reference ranges since there is a substantial probability that these intervals contain less than (100 P)% of the population, especially when the sample size is large. In contrast, a (P,γ) tolerance interval is designed to contain (100 P)% of the population with a pre-specified large confidence γ so it is eminently adequate as a reference range. An example based on real data illustrates the paper’s key points.

Relational Stability in the Expression of Normality, Variation, and Control of Thyroid Function

Thyroid hormone concentrations only become sufficient to maintain a euthyroid state through appropriate stimulation by pituitary thyroid-stimulating hormone (TSH). In such a dynamic system under constant high pressure, guarding against overstimulation becomes vital. Therefore, several defensive mechanisms protect against accidental overstimulation, such as plasma protein binding, conversion of T4 into the more active T3, active transmembrane transport, counter-regulatory activities of reverse T3 and thyronamines, and negative hypothalamic-pituitary-thyroid feedback control of TSH. TSH has gained a dominant but misguided role in interpreting thyroid function testing in assuming that its exceptional sensitivity thereby translates into superior diagnostic performance. However, TSH-dependent thyroid disease classification is heavily influenced by statistical analytic techniques such as uni- or multivariate-defined normality. This demands a separation of its conjoint roles as a sensitive screening test and accurate diagnostic tool. Homeostatic equilibria (set points) in healthy subjects are less variable and do not follow a pattern of random variation, rather indicating signs of early and progressive homeostatic control across the euthyroid range. In the event of imminent thyroid failure with a reduced FT4 output per unit TSH, conversion efficiency increases in order to maintain FT3 stability. In such situations, T3 stability takes priority over set point maintenance. This suggests a concept of relational stability. These findings have important implications for both TSH reference limits and treatment targets for patients on levothyroxine. The use of archival markers is proposed to facilitate the homeostatic interpretation of all parameters.

Physiological and biochemical measurements before, during and after pregnancy of healthy rats

PURPOSE

To analyze the physiological and biochemical measurements before, during and after pregnancy of healthy rats.

METHODS

Wistar adult females rats (n=8) were weighed and blood samples were obtained before, during and after pregnancy for biochemical determinations, chow intake, water consumption and milk production were evaluated. At day 10 postpartum, the rats were killed for weighing of organs and adipose tissues.

RESULTS

The results showed increase in body weight, serum insulin and ingestion of water and chow. At day 17 pregnancy, presented normal values in the OGTT. At days 7, 14 and 20 of pregnancy, there was increase in triglyceride levels. At term pregnancy, there was weight gain due to fetal growth. In the postpartum period presented reduced blood glucose levels. The glycemic means were reduced during and after pregnancy compared to after pregnancy. The triglyceride concentrations were increased before and during pregnancy in relation to after pregnancy. The total cholesterol levels presented no changes.

CONCLUSION

The use of experimental animals is suitable for evaluation of metabolic changes because the profile of answers found in this study was similar to human profile, showing the relevance of translational research to better understand the pathophysiological mechanisms and possible treatment for diseases.

Reference ranges of coagulation tests

Reference ranges are a set of values that correctly include most of the subjects with characteristics similar to the reference group and exclude the others. When accurate, reference ranges aid physicians to interpret results of clinical measurements and thus establish diagnosis. However, obtaining accurate reference ranges is a very demanding procedure. This chapter provides basic definitions and theories as well as a step-by-step procedure for the analysis of reference values and determination of reference ranges of coagulation, focusing on quantitative clinical laboratory assays. Preanalytical and analytical factors as well as dependence on the age influencing reference values for coagulation assays and their transference are discussed.

Reference values for serum zinc concentration and prevalence of zinc deficiency in adult Iranian subjects

Zinc, as an essential trace element for health, plays various biological roles in human body functions. Serum zinc reference values are essential for assessing zinc-associated abnormalities and the prevalence of zinc deficiency. This study aims at determining age- and sex-specific reference values for serum zinc concentrations in adult Iranian subjects. Serum zinc concentration was measured by flame atomic absorption spectrometry in 4,698 adult subjects, aged 20-94 years, randomly selected from the population of the Tehran, Lipid, and Glucose Study. After application of exclusion criteria, reference values for serum zinc were determined in 2,632 apparently healthy subjects according to guidelines of the International Federation of Clinical Chemistry (nonparametric method). Dietary zinc was assessed in 2,906 individuals, of which 1,685 were healthy subjects, using a validated semiquantitative food frequency questionnaire. Reference values for serum zinc concentrations ranged between 9.6 and 31.6, 8.9 and 29.9, and 9.3 and 30.8 μmol/L in men, women, and the total population, respectively. Prevalence of serum zinc deficiency was 3.0 and 2.4 % in men and women, respectively (p = 0.267); in men, but not in women, the prevalence increased significantly with age (p for trend <0.001). Of the total participants, 10.3 % (6.5 men and 3.8 % women, p < 0.01) had lower zinc intake compared to dietary reference intakes. The zinc density of the population was 6.3 mg/1,000 kcal. In conclusion, this study presents reference values for serum zinc concentration in adult Iranian subjects for both sexes and different age groups. Prevalence of serum zinc deficiency and dietary zinc inadequacy seems to be lower in Iranians, compared to some other populations.

Using biomarkers in sewage to monitor community-wide human health: isoprostanes as conceptual prototype

Timely assessment of the aggregate health of small-area human populations is essential for guiding the optimal investment of resources needed for preventing, avoiding, controlling, or mitigating exposure risks. Seeking those interventions yielding the greatest benefit with respect to allocation of resources is essential for making progress toward community sustainability, promoting social justice, and maintaining or improving health and well-being. More efficient approaches are needed for revealing cause-effect linkages between environmental stressors and human health and for measuring overall aggregate health of small-area populations. A new concept is presented--community health assessment via Sewage Chemical Information Mining (SCIM)--for quickly gauging overall, aggregate health status or trends for entire small-area populations. The approach--BioSCIM--would monitor raw sewage for specific biomarkers broadly associated with human disease, stress, or health. A wealth of untapped chemical information resides in raw sewage, a portion comprising human biomarkers of exposure and effects. BioSCIM holds potential for capitalizing on the presence of biomarkers in sewage for accomplishing any number of objectives. One of the many potential applications of BioSCIM could use various biomarkers of stress resulting from the collective excretion from all individuals in a local population. A prototype example is presented using a class of biomarkers that measures collective, systemic oxidative stress--the isoprostanes (prostaglandin-like free-radical catalyzed oxidation products from certain polyunsaturated fatty acids). Sampling and analysis of raw sewage hold great potential for quickly determining aggregate biomarker levels for entire communities. Presented are the basic principles of BioSCIM, together with its anticipated limitations, challenges, and potential applications in assessing community-wide health. Community health assessment via BioSCIM could allow rapid assessments and intercomparisons of health status among distinct populations, revealing hidden or emerging trends or disparities and aiding in evaluating correlations (or hypotheses) between stressor exposures and disease.

Gender differences in serum CK-MB mass levels in healthy Brazilian subjects

The creatine kinase-isoenzyme MB (CK-MB) mass assay is one of the laboratory tests used for the diagnosis of myocardial infarction. It is recommended, however, that reference limits should take gender and race into account. In the present study, we analyzed the plasma CK-MB mass and troponin levels of 244 healthy volunteers without a personal history of coronary artery disease and with no chronic diseases, muscular trauma or hypothyroidism, and not taking statins. The tests were performed with commercial kits, CK-MB mass turbo kit and Troponin I turbo kit, using the Immulite 1000 analyzer from Siemens Healthcare Diagnostic. The values were separated according to gender and showed significant differences by the Mann-Whitney test. Mean (± SD) CK-MB mass values were 2.55 ± 1.09 for women (N = 121; age = 41.20 ± 10.13 years) and 3.49 ± 1.41 ng/mL for men (N = 123; age = 38.16 ± 11.12 years). Gender-specific reference values at the 99th percentile level, according to the Medicalc statistical software, were 5.40 ng/mL for women and 7.13 ng/mL for men. The influence of race was not considered because of the high miscegenation of the Brazilian population. The CK-MB values obtained were higher than the 5.10 mg/mL proposed by the manufacturer of the laboratory kit. Therefore, decision limits should be related to population and gender in order to improve the specificity of this diagnostic tool, avoiding misclassification of patients.

Pediatric reference values for serum magnesium levels in Iranian subjects

Magnesium (Mg), an essential element, plays important roles in many physiological functions. Mg deficiency is associated with insulin resistance, cardiovascular disease, and disorders of the nervous system. The aim of this study was to determine reference values for serum Mg concentration in pediatrics. Serum Mg level was measured by flame atomic absorption spectrophotometry in 306 subjects (141 boys and 165 girls), aged 3-19 years, selected from among participants of the Tehran Lipid and Glucose Study. The International Federation of Clinical Chemistry guidelines (IFCC) and the robust method were used for determining reference values for sample sizes greater or less than 120 subjects respectively. The 95% reference values for serum Mg concentrations were 0.76-1.0, 0.75-1.0, and 0.76-0.99 mmol/L in boys, girls, and the all subjects respectively. According to the reference values obtained in this study, the prevalences of hypo- and hypermagnesemia, were 5.9% and 5.6% respectively. In conclusion, the current study presents pediatric reference values for serum Mg levels derived from a randomly selected healthy population, values which could be instrumental in detecting serum Mg abnormalities.

Reference values for serum magnesium levels in young adult Iranian subjects

This study aims at determining the reference values for serum magnesium (Mg) concentrations in Iranian adults. Serum Mg level was measured using flame atomic absorption spectrometry in 491 subjects (233 men and 258 women), aged 20-50 years, randomly selected from a population-based study. The International Federation of Clinical Chemistry guidelines and the robust method were used for determining the reference values. The 95% reference values for serum Mg concentration were 1.83-2.49, 1.79-2.48, and 1.83-2.55 mg/dL in men, women, and total population, respectively. The prevalences of hypo- and hypermagnesemia, according to the reference values obtained in the current study, were 2.5% and 4.0%, respectively. In conclusion, this study reports serum Mg reference values based on current standards in a large healthy population of young Iranian adults.

Annual, seasonal and individual variation in hematology and clinical blood chemistry profiles in bottlenose dolphins (Tursiops truncatus) from Sarasota Bay, Florida

Hematology and clinical blood chemistry (HCBC) profiles in free-living bottlenose dolphins from Sarasota Bay, Florida have been monitored over a 14-year period. This long-term dataset includes samples from recaptured dolphins, enabling individual variation to be accounted for when investigating seasonal and annual variability. Four different laboratories carried out the assays and inter-laboratory comparisons found significant differences in 31 of 39 parameters measured. However, variability in comparable HCBCs by sex, age, condition, season and year could be investigated. Significant relationships with the independent variables were found for the majority of the HCBCs. Notable consistent seasonal differences included significantly elevated glucose and significantly lower creatinine concentrations in winter compared to summer. These differences may be due to energetic or thermoregulatory fluctuations in the animals by season and do not necessarily have any clinical significance. Erythrocyte counts were significantly lower in the winter, possibly also due to nutritional differences. Albumin and calcium levels in this population have increased significantly over the years of monitoring and consistently across seasons, being higher in the winter than the summer. Again, nutritional and thermal constraints seem to be the most likely environmental factors influencing these patterns.

Indirect estimation of pediatric Health Related Limits for serum thyrotropin using the ADVIA® Centaur™ analyzer

OBJECTIVES

To determine pediatric reference values for thyrotropin using Advia Centaur analyzer.

DESIGN AND METHODS

The study was conducted in a large regional hospital on TSH results obtained from 5741 females and 4332 males aged 0-17 years. After the exclusion of the results outside 4 standard deviations, we calculated the Health Related Limits (HRLs) following the indirect Kairisto's procedure and using the software GraphROC.

RESULTS

The lower HRL of TSH concentration was 0.70 mU/L in the years 0-11 and 0.50 mU/L in the following years. The upper TSH HRL was 6.9 mU/L in males vs. 5.7 mU/L in females in the first year and 6.7 mU/L vs. 5.3 in the period 1-2 years. The upper HRLs in females and males were similar in the following years and the upper HRL in the 13-17 years class was 3.8 mU/L.

CONCLUSIONS

The indirect methods appear reliable for calculating the pediatric HRLs for TSH.

A plea for intra-laboratory reference limits. Part 1. General considerations and concepts for determination

Accurate results for quantitative procedures can be useless if the reference limits for the interpretation of laboratory results are unreliable. Recent concepts for quality management systems require that laboratories pay more attention to identification and verification of reference limits. Scientific recommendations often claim that each laboratory should determine intra-laboratory reference limits, which should be reviewed periodically. This recommendation is currently neglected by most laboratories; instead they use reference limits from external sources, despite various problems of transference. Prospective and retrospective methods either using or neglecting disease prevalences (polymodal or unimodal concepts, respectively) and applying different statistical approaches for determining reference limits have been described. The various procedures are reviewed with regard to their diagnostic sensitivity, specificity and (non-)efficiency. The present gold standard is the reference limit concept according to IFCC recommendations (a unimodal prospective approach). This concept, together with trueness-based standardization, is the most useful basis for harmonization of the decision-making process with laboratory results, despite complex problems of traceability and transference. This harmonization is at present only achieved for a limited number of analytes for which SI units and traceability can be technically realized. For the majority of measurands in laboratory medicine, much research is still required and results cannot be expected in the near future. For these measurands, a need remains for internal, efficient and simple identification of population-based reference limits. Therefore, newer retrospective concepts were developed that use large data sets from laboratory information systems to derive intra-laboratory reference limits. These approaches appear promising and should be further developed.

Laboratory network of excellence: enhancing patient safety and service effectiveness

Clinical laboratories have undergone major changes due to technological progress and economic pressure. While costs of laboratory testing continue to be the dominant issue within the healthcare service worldwide, quality, effectiveness and impact on outcomes are also emerging as critical value-added features. Five Italian laboratories are therefore promoting a network of excellence by investigating markers of effectiveness of laboratory services and sharing their experience of using them in clinical practice. In the present study we report preliminary data on indicators of quality in all phases of the so-called total testing process, the key to evaluating all phases of the total testing process, including the appropriateness of test requests and data interpretation. Initial findings in evaluating pre-analytical causes of specimen rejection in three different laboratories and the effects of introducing three laboratory clinical guidelines are reported. These data should stimulate debate in the scientific community and encourage more clinical laboratories to use the same indicators to improve clinical effectiveness and clinical outcomes within the healthcare service.

Shifting the paradigm of coral-reef 'health' assessment

Coral reefs are in crisis. Globally, our reefs are degrading at an accelerating rate and present methodologies for coral-reef 'health' assessment, although providing important information in describing these global declines, have been unable to halt these declines. These assessments are usually employed with no clear purpose and using uncorrelated methods resulting in a failure to prevent or mitigate coral reef deterioration. If we are to ever successfully intervene, we must move beyond the current paradigm, where assessments and intervention decisions are based primarily on descriptive science and embrace a paradigm that promotes both descriptive and mechanistic science to recognize a problem, and recognize it before it becomes a crisis. The primary methodology in this alternative paradigm is analogous to the clinical and diagnostic methodologies of evidence-based medicine. Adopting this new paradigm can provide the evidence to target management actions on those stressors currently impacting reef ecosystems as well as providing a means for proactive management actions to avert irreversible habitat decline.

Glycemic control in diabetes in three Danish counties

Background: Hemoglobin A1c (HbA

Methods: We studied 2454 patients from a population of 807,000 inhabitants for whom routine monitoring of diabetes using HbA

Results: The age-standardized incidence of monitored patients was <0.5% in all regions. Patients with diabetic first HbA

Conclusion: Patients with diabetic first HbA