Capillary Microfluidics for Monitoring Medication Adherence

Medication adherence is a medical and societal issue worldwide, with approximately half of patients failing to adhere to prescribed treatments. The goal of this Minireview is to examine how recent work on microfluidics for point-of-care diagnostics may be used to enhance adherence to medication. It specifically focuses on capillary microfluidics since these devices are self-powered, easy to use, and well established for diagnostics and drug monitoring. Considering that an improvement in medication adherence can have a much larger effect than the development of new medical treatments, it is long overdue for the research communities working in chemistry, biology, pharmacology, and material sciences to consider developing technologies to enhance medication adherence. For these reasons, this Minireview is not meant to be exhaustive but rather to provide a quick starting point for researchers interested in joining this complex but intriguing and exciting field of research.

Evaluation of the Triage TOX Drug Screen Assay for Detection of 11 Drugs of Abuse and Therapeutic Drugs

The demand for rapid and broad clinical toxicology screens is on the rise. Recently, a new rapid toxicology screening test, the Triage TOX Drug Screen (Alere Inc., USA), which can simultaneously detect 11 drugs of abuse and therapeutic drugs with an instrument-read cartridge, was developed. In the present study, we evaluated the efficacy of this new on-site immunoassay using 105 urine specimens; the results were compared with those obtained by using ultra-performance liquid chromatography with tandem mass spectrometry (UPLC-TMS). Precision was evaluated according to the CLSI EP12-A2 for analyte concentrations near the cutoff, including C₅₀ and±30% of C₅₀, for each drug using standard materials. The C₅₀ specimens yielded 35–65% positive results and the ±30% concentration range of all evaluated drugs encompassed the C₅–C₉₅ interval. The overall percent agreement of the Triage TOX Drug Screen was 92.4–100% compared with UPLC-TMS; however, the Triage TOX Drug Screen results showed some discordant cases including acetaminophen, amphetamine, benzodiazepine, opiates, and tricyclic antidepressants. The overall performance of the Triage TOX Drug Screen assay was comparable to that of UPLC-TMS for screening of drug intoxication in hospitals. This assay could constitute a useful screening method for drugs of abuse and therapeutic drugs in urine.

Comprehensive Drug Screening by Thermal Desorption and Pyrolysis Combined with Direct Analysis in Real Time-Mass Spectrometry (TDP/DART-MS)

Rapid and accurate analysis of drugs using direct analysis in real time-mass spectrometry (DART-MS) combined with thermal desorption pyrolysis (TDP/DART-MS) is described in this chapter. Rapid drug screening is very important in cases of suspected drug abuse. However, acquiring accurate analytical data requires highly optimized sample handling and technical expertise. Although rapid drug analysis using mass spectrometry provides reliable data, it is not commonly used because of its complexity. Thus, a comprehensive analysis system for drugs that requires minimal optimization of sample preparation and analytical conditions is strongly desired. DART-MS involves ambient ionization mass spectrometric analysis with little to no sample preparation. We have coupled this approach with thermal TDP/DART-MS and demonstrate how it can be used to detect drugs in complex matrices such as urine or blood.

Evaluation of an Automated Reader and Color Interpretation-Based Immunoassays for Multiplexed Drug-of-Abuse Testing in Urine

On-site drugs of abuse testing devices have undergone continuous improvement. We evaluated three devices with different designs: an automated reader, the Multi-Drug Screen Test Device with DxLINK (DxLINK; Innovacon, Alere, San Diego, USA) and two colorimetric immunoassays, the One Step Multi-Line Screen Panel with Integrated E-Z Split Key Cup II (E-Z Cup; Innovacon, Alere) and the One Step Multi-Drug Screen Panel card (Multi4 card; Alere, Abon Biopharm, Hangzhou, China). Eleven drugs [amphetamine, secobarbital, oxazepam, buprenorphine, benzoylecgonine, methylenedioxymethamphetamine (MDMA), 11-nor-9-carboxy-Δ9-tetrahydrocannabinol (THC), methamphetamine, methadone, morphine and nortriptyline] were tested using the DxLINK and E-Z Cup. Four drugs (benzoylecgonine, THC, methamphetamine and morphine) were tested using the Multi4 card using control materials (Detectabuse Stat-Skreen; Biochemical Diagnostics, Edgewood, NY, USA). The concentrations (-50%, -25%, +25%, +50% and 3× cut-off values) of the control materials were confirmed by mass spectrometry. Concordance rates were calculated around cut-offs. All devices showed high overall agreement rates of >90% with a few exceptions: the DxLINK exhibited lower sensitivity for benzoylecgonine, methadone and nortriptyline (60% and 30%, 92% and 40%, and 96% and 60% sensitivity at +50% and +25% cut-off levels, respectively). The E-Z Cup exhibited lower sensitivity for oxazepam and nortriptyline (97% and 50%, and 97% and 40% sensitivity at +50% and +25% cut-off levels, respectively). We additionally evaluated test-band color by visual inspection using a standard color-scale card. When detailed color criteria for determination of positivity were applied for the E-Z Cup, using slightly less stringent criteria, oxazepam, buprenorphine, MDMA and nortriptyline showed increases in sensitivity from 70-80% to 90-100%, all with a specificity above 98%. Overall, all devices exhibited satisfactory performance at ±50% cut-off levels for commonly used drugs, with the exception of lower sensitivity for cocaine testing for DxLINK. Careful evaluation of devices and elaborate calibration of visual interpretation for determining positivity may help improve the performance of these devices.

Antigen detection based on background fluorescence quenching immunochromatographic assay

Gold immunochromatographic assay (GICA) has been around for quite a while, but it is qualitative in the vast majority of applications. A fast, simple and quantitative GICA is in call for better medicine. In the current study, we have established a novel, quantitative GICA based on fluorescence quenching and nitrocellulose membrane background signals, called background fluorescence quenching immunochromatographic assay (bFQICA). Using model analyte alpha-fetoprotein (AFP), the present study assessed the performance of bFQICA in numerous assay aspects. With serial dilutions of the international AFP standard, standard curves for the calculation of AFP concentration were successfully established. At 10 and 100ngmL(-1) of the international AFP standard, the assay variability was defined with a coefficient of variance at 10.4% and 15.2%, respectively. For samples with extended range of AFP levels, bFQICA was able to detect AFP at as low as 1ngmL(-1). Fluorescence in bFQICA strips stayed constant over months. A good correlation between the results from bFQICA and from a well-established Roche electrochemiluminescence immunoassay was observed in 27 serum samples (r=0.98, p<0.001). In conclusion, our study has demonstrated distinctive features of bFQICA over conventional GICA, including utilization of a unique fluorescence ratio between nitrocellulose membrane background and specific signals (F1/F2) to ensure accurate measurements, combined qualitative and quantitative capabilities, and exceptionally high sensitivity for detection of very low levels of antigens. All of these features could make bFQICA attractive as a model for antigen-antibody complex based GICA, and could promote bFQICA to a broad range of applications for investigation of a variety of diseases.

Discerning Trends in Multiplex Immunoassay Technology with Potential for Resource-Limited Settings

BACKGROUND

In the search for more powerful tools for diagnoses of endemic diseases in resource-limited settings, we have been analyzing technologies with potential applicability. Increasingly, the process focuses on readily accessible bodily fluids combined with increasingly powerful multiplex capabilities to unambiguously diagnose a condition without resorting to reliance on a sophisticated reference laboratory. Although these technological advances may well have important implications for the sensitive and specific detection of disease, to date their clinical utility has not been demonstrated, especially in resource-limited settings. Furthermore, many emerging technological developments are in fields of physics or engineering, which are not readily available to or intelligible to clinicians or clinical laboratory scientists.

CONTENT

This review provides a look at technology trends that could have applicability to high-sensitivity multiplexed immunoassays in resource-limited settings. Various technologies are explained and assessed according to potential for reaching relevant limits of cost, sensitivity, and multiplex capability. Frequently, such work is reported in technical journals not normally read by clinical scientists, and the authors make enthusiastic claims for the potential of their technology while ignoring potential pitfalls. Thus it is important to draw attention to technical hurdles that authors may not be publicizing.

SUMMARY

Immunochromatographic assays, optical methods including those involving waveguides, electrochemical methods, magnetorestrictive methods, and field-effect transistor methods based on nanotubes, nanowires, and nanoribbons reveal possibilities as next-generation technologies.

Fast DNA and protein microarray tests for the diagnosis of hepatitis C virus infection on a single platform

Hepatitis C virus (HCV) is a major cause of chronic liver disease and liver cancer, and remains a large health care burden to the world. In this study we developed a DNA microarray test to detect HCV RNA and a protein microarray to detect human anti-HCV antibodies on a single platform. A main focus of this study was to evaluate possibilities to reduce the assay time, as a short time-to-result (TTR) is a prerequisite for a point-of-care test. Significantly reducing hybridisation and washing times did not impair the assay performance. This was confirmed first using artificial targets and subsequently using clinical samples from an HCV seroconversion panel derived from a HCV-infected patient. We were able to reduce the time required for the detection of human anti-HCV antibodies to only 14 min, achieving nanomolar sensitivity. The protein microarray exhibited an analytical sensitivity comparable to that of commercial systems. Similar results were obtained with the DNA microarray using a universal probe which covered all different HCV genotypes. It was possible to reduce the assay time after PCR from 150 min to 16 min without any loss of sensitivity. Taken together, these results constitute a significant step forward in the design of rapid, microarray-based diagnostics for human infectious disease, and show that the protein microarray is currently the most favourable candidate to fill this role.

Analytical Ancestry: Evolution of the Array in Analysis

BACKGROUND

Macro-, micro-, and nanosized arrays of test sites at various densities have emerged as important types of analytical devices in response to the need for high volume parallel analysis in both the research and the clinical laboratory.

CONTENT

This review explores the diversity of arrays of reaction vessels and arrays of reagents and of samples, with an emphasis on the earliest descriptions of the different variations. The scope of such arrays includes linear and 2-dimensional arrays of reaction vessels (e.g., microwell strips, microplates); linear and 2-dimensional arrays of reagents arrayed on pillars and posts; beads in wells; and reagents randomly arrayed (or dis-ordered) for use in next-generation sequencing. Micro- and nanofabrication technologies have been applied to the miniaturization of arrays to increase array density (e.g., DNA probe arrays) and produce arrays of analytical structures (e.g., cantilevers, nanoelectrospray nozzles).

SUMMARY

Arrays are now firmly established in many types of analytical devices, and this analytical format has gained widespread acceptance owing to the advantages of high-throughput automation and multiplex analysis. Ongoing “big biology” genomic and proteomic studies will ensure the continued dominance of array-based methods into the foreseeable future.

Antibody-based microarrays

Antibody-based microarrays are a new powerful proteomic technology that can be used to generate rapid and detailed expression profiles of defined sets of protein analytes in complex samples as well as high-resolution portraits of entire proteomes. Miniaturized micro- and nanoarrays can be printed with numerous antibodies carrying the desired specificities. Multiplexed and ultra-sensitive assays, specifically targeting several analytes in a single experiment, can be performed, while consuming only minute amounts of the sample. The array images generated can then be converted into protein expression profiles, or maps, revealing the detailed composition of the sample. This promising proteomic research tool will thus provide unique opportunities for e.g. disease proteomics, biomarker discovery, disease diagnostics, and patient stratification. This review describes the antibody-based microarray technology and applications thereof.

Lateral flow (immuno)assay: its strengths, weaknesses, opportunities and threats. A literature survey

Lateral flow (immuno)assays are currently used for qualitative, semiquantitative and to some extent quantitative monitoring in resource-poor or non-laboratory environments. Applications include tests on pathogens, drugs, hormones and metabolites in biomedical, phytosanitary, veterinary, feed/food and environmental settings. We describe principles of current formats, applications, limitations and perspectives for quantitative monitoring. We illustrate the potentials and limitations of analysis with lateral flow (immuno)assays using a literature survey and a SWOT analysis (acronym for "strengths, weaknesses, opportunities, threats"). Articles referred to in this survey were searched for on MEDLINE, Scopus and in references of reviewed papers. Search terms included "immunochromatography", "sol particle immunoassay", "lateral flow immunoassay" and "dipstick assay".

Electrochemical biochips for protein analysis

Proteins bear important functions for most life processes. It is estimated that the human proteome comprises more than 250,000 proteins. Over the last years, highly sophisticated and powerful instruments have been developed that allow their detection and characterization with great precision and sensitivity. However, these instruments need well-equipped laboratories and a well-trained staff. For the determination of proteins in a hospital, in a doctor's office, or at home, low-budget protein analysis methods are needed that are easy to perform. In addition, for a proteomic approach, highly parallel measurements with small sample sizes are required. Biochips are considered as promising tools for such applications. The following chapter describes electrochemical biochips for protein analysis that use antibodies or aptamers as recognition elements.

Immunoassay on a power-free microchip with laminar flow-assisted dendritic amplification

We demonstrate a rapid (<30 min) and ultrasensitive (sub-picomolar) immunoassay on a microchip which needs no external power sources for fluid transport. We previously reported a rapid immunoassay of human C-reactive protein (CRP) on the power-free microchip with moderate sensitivity, i.e., a limit of detection (LOD) in sub-nanomolar range, due to the lack of signal amplification. In the current work, we have improved the LOD by 3 orders of magnitude by employing dendritic amplification (DA) methods. Specifically, a sandwich immunocomplex with a biotinylated secondary antibody was constructed on the inner surface of the microchannel as described in the previous report. Onto the immunocomplex, solutions of FITC-labeled streptavidin (F-SA) and biotinylated anti-streptavidin (B-anti-SA) were supplied to grow a dendritic structure. First, we alternately supplied the two solutions for layer-by-layer growth up to three layers. As a result, we obtained an LOD of 0.21 pM with a CRP sample volume of 1.0 microL and assay time of approximately 30 min under an ordinary fluorescence microscope. Second, to reduce the number of incubation steps, we have devised a new DA method: laminar flow-assisted dendritic amplification (LFDA). In this method, F-SA and B-anti-SA were simultaneously and continuously supplied from two laminar streams formed by a Y-shaped microchannel. The immunoassay with the LFDA for 10 min (total assay time of approximately 23 min) with a CRP sample volume of 0.5 microL yielded an LOD of 0.15 pM, which is equivalent to 75 zmol. The combination of the power-free microchip and the LFDA will provide a new opportunity for ultrasensitive point-of-care testing.

Triage test and HPLC assay for analysis of vegetamin, an antipsychotic agent, using gastric contents and blood specimens

Vegetamin is an antipsychotic agent composed of phenobarbital, promethazine and chlorpromazine. While phenobarbital can be detected by the Triage kit for screening drugs of abuse, the other two components cannot. We describe here the detection of promethazine and chlorpromazine using either a high performance liquid chromatography (HPLC) unit equipped with an ultraviolet, a photodiode array (PDA), or an electrochemical detector (ECD), or gas chromatograph-mass spectrometry (GC-MS). The absorption and mass spectra of promethazine and chlorpromazine were nonspecific, and thus the ECD-HPLC system was best equipped to quantitate these components. Comparison of the chromatograms of blood and gastric contents aids the identification of drug metabolites.

Multiplexed protein measurement: technologies and applications of protein and antibody arrays

The ability to measure the abundance of many proteins precisely and simultaneously in experimental samples is an important, recent advance for static and dynamic, as well as descriptive and predictive, biological research. The value of multiplexed protein measurement is being established in applications such as comprehensive proteomic surveys, studies of protein networks and pathways, validation of genomic discoveries and clinical biomarker development. As standards do not yet exist that bridge all of these applications, the current recommended best practice for validation of results is to approach study design in an iterative process and to integrate data from several measurement technologies. This review describes current and emerging multiplexed protein measurement technologies and their applications, and discusses the remaining challenges in this field.

Power-free sequential injection for microchip immunoassay toward point-of-care testing

This paper presents a simple fluid handling technique for microchip immunoassay. Necessary solutions were sequentially injected into a microchannel by air-evacuated poly(dimethylsiloxane), and were passively regulated by capillary force at the inlet opening. For heterogeneous immunoassay, microchips are potentially useful for reduction of sample consumption and assay time. However, most of the previously reported microchips have limitations in their use because of the needs for external power sources for fluid handling. In this paper, an on-chip heterogeneous immunofluorescence assay without such an external power source is demonstrated. The microchip consisting of poly(dimethylsiloxane) (PDMS) and glass has a simple structure, and therefore is suitable for single-use applications. Necessary solutions were sequentially injected into a microchannel in an autonomous fashion with the power-free pumping technique, which exploits the high solubility and the rapid diffusion of air in PDMS. For deionized water, this method yielded flow rates of 3-5 nL s-1 with reproducibility of 4-10%. The inlet opening of the microchannel functioned as a passive valve to hold the solution when the flow was finished. Rabbit immunoglobulin G (rIgG) and human C-reactive protein (CRP) were detected using the microchannel walls as reaction sites. With the sample consumption of 1 microL and the assay time of approximately 20 min including the antibody immobilization step, the sandwich immunoassay methods for rIgG and CRP exhibited the limits of detection of 0.21 nM (0.21 fmol) and 0.42 nM (0.42 fmol), respectively.

Evaluation of a rapid bedside toxicology screen in patients suspected of drug toxicity

Although rapid bedside toxicological screening is reliable, it has not been validated in the emergency department (ED) setting. We assessed the accuracy of a 10-min bedside immunoassay, Triage Panel (TP), for 7 drugs of abuse and tricyclic antidepressants (TCA) in ED patients suspected of drug toxicity. This was a prospective observational study conducted at an urban teaching ED (100,000 visits/year) of patients suspected of drug toxicity during a 7-month period. The assay was compared for agreement with combined SYVA EMIT and TLC. GC/MS or HPLC was used for analyzing sensitivity and specificity in discordant findings. A total of 172 cases (ages 0.6-73 years) were screened with TP, and 100 (58%) were found to be positive for at least one drug. Sensitivity (proportion and 95% CI) was as follows: cocaine 30/31 (90.6-100%), phencyclidine no cases, THC 21/24 (80.1-94.3), opiates 14/14 (100), amphetamines 1/1 (NA), barbiturates 10/10 (100), benzodiazepines 20/21 (90.5-99.9), and TCA 13/13 (100). Specificity was above 98% for every drug except TCAs (which was 95%), partly due to interference from iminostilbene (a carbamazepine metabolite) in three cases. Agreement between TP and hospital laboratory was over 90% for every drug class. Both benzodiazepines and THC showed significant disagreement between the two testing modalities. In conclusion, in a series of ED patients suspected of drug toxicity, the TP was an accurate tool to rule out the presence of seven drugs of abuse and TCAs. Further testing will be required to verify the efficacy of the test in populations with a higher prevalence of phencyclidine and amphetamine abuse.

Assessment of an automated solid phase competitive fluoroimmunoassay for benzoylecgonine in untreated urine

A new solid phase fluoroimmunoassay using a fully automated flow fluorometer adapted for urinalysis of drug metabolites is described. Fluorescein-conjugated benzoylecgonine (FL-BE) and monoclonal antibodies (mAb) against benzoylecgonine (BE) were the reagents used for demonstration. The solid phase consisted of anti-BE mAbs immobilized on the surface of polymethyl methacrylate (PMMA) beads. Free BE in solution competed with FL-BE and reduced bead-bound fluorescence in a concentration-dependent manner. The binding of FL-BE to the anti-BE mAb reached steady-state within minutes. FL-BE was not bound by uncoated beads nor beads coated with non-specific proteins or IgG. The signal-to-noise ratio was 33, and the sensitivity of the assay was 2 ng ml(-1) for BE. The effective concentration of BE was 1 to 100 ng ml(-1), with an IC50 value of 12 ng ml(-1). The mAb showed equal affinities for BE, cocaine, and cocaethylene, but a five order-of-magnitude lower affinity for ecgonine and ecgonine methylester. In a double-blind comparison using clinical urine samples, the data from this single-step competitive assay had excellent agreement with results obtained using a fiber-optic biosensor (FOB), and the EMIT assay performed commercially. The assay provided kinetic data rapidly and can be used to detect small analytes for which antibodies and fluorescein conjugates are available. The affinity of the mAb for FL-BE, calculated from kinetic analysis of the time course of the on and off reaction, was 2.25 x 10(-9) M.

Analysis of urinary drugs of abuse by a multianalyte capillary electrophoretic immunoassay

This paper characterizes a novel multianalyte competitive binding, electrokinetic capillary-based immunoassay for urinary methadone, opiates, benzoylecgonine (cocaine metabolite) and amphetamines. After incubation of 25 microliters urine with the reactants for several minutes in the presence of an internal standard, a small aliquot of the mixture is applied onto a fused-silica capillary and the unbound fluorescein labelled drug tracers are monitored by capillary electrophoresis with on-column laser induced fluorescence detection. The multianalyte assay is shown to be rapid, simple, quantitative, capable of recognizing urinary drug concentrations > or = 30 ng/ml and suitable for screening of patient urines. Data are demonstrated to compare well with those obtained by routine screening methods based on enzyme multiplied immunoassay techniques and fluorescence polarization immunoassays. The electrokinetic capillary assay has been validated via analysis of external quality control urines and confirmation analysis of patient urines using GC-MS.

Flumazenil in drug overdose: randomized, placebo-controlled study to assess cost effectiveness

OBJECTIVE

To investigate cost effectiveness of administration of flumazenil to patients presenting with suspected acute drug overdose.

DESIGN

Double-blind, prospective, placebo-controlled randomized study.

SETTING

University teaching hospital.

PATIENTS

Forty-three adults presenting with suspected drug overdose and having a Glasgow Coma Scale (GCS) score of <13. Patients with known benzodiazepine/tricyclic ingestion were excluded.

INTERVENTIONS

Intravenous administration of flumazenil (up to 2 mg) or placebo.

MEASUREMENTS AND MAIN RESULTS

Individual patient costs were assessed and data aggregated for each treatment group. Major diagnostic and therapeutic interventions were recorded and between group comparisons performed. Clinical response to study drug administration was assessed by obtaining pre- and post-drug GCS scores and observation of the patient for at least 180 mins for signs of resedation. Aggregate cost or number of major diagnostic and therapeutic interventions were not different between groups. Patients randomized to the flumazenil group showed a marked increase in GCS score (7.4 to 11.8) compared with those in the placebo group (8.2 to 8.6).

CONCLUSION

Use of flumazenil in intentional drug overdose of unknown etiology is not cost effective.

Capillary electrophoresis in clinical toxicology

During the past decade, capillary electrophoresis (CE) emerged as a promising, effective and economic approach for separation of a large variety of substances, including those encountered in clinical toxicology. Reliable and automated CE instruments became commercially available and promoted the exploration of an increasing number of CE methods for illicit and licit drugs in body fluids. The widespread applicability of CE, its enormous separation power and high-sensitivity detection schemes make this technology an attractive and promising tool. This review provides an overview of the key achievements encountered with CE in clinical toxicology, including (i) the rapid assessment of drug intoxications via direct sample injection, (ii) the screening for and determination of illicit and licit drugs in body fluids with drug extraction, drug concentration (stacking) and chiral discrimination, (iii) the application of immunological single and multianalyte assays in the capillary format to the screening for drugs in body fluids, and (iv) drug confirmation by on-column multiwavelength absorbance and fluorescence detection and/or CE coupled to mass spectrometry. With its distinct features (automation, small sample size, minimal sample preparation, requirement of almost no organic solvents, ease of buffer change and method development, speed of analysis, low cost of capillaries and chemicals) CE has a bright future and the twenty-first century will witness the widespread use of a large number of simple and reliable CE based assays for drugs, methods that will be employed in clinical toxicology, therapeutic drug monitoring and forensic science.

Screening for drugs of abuse (II): Cannabinoids, lysergic acid diethylamide, buprenorphine, methadone, barbiturates, benzodiazepines and other drugs

Requirements for the provision of an efficient and reliable service for drugs of abuse screening in urine have been summarized in Part I of this review. The requirements included rapid turn-around times, good communications between requesting clinicians and the laboratory, and participation in quality assessment schemes. In addition, the need for checking/confirmation of positive results obtained for preliminary screening methods was stressed. This aspect of the service has assumed even greater importance with widespread use of dip-stick technology and the increasing number of reasons for which drug screening is performed. Many of these additional uses of drug screening have possible serious legal implications, for example, screening school pupils, professional footballers, parents involved in child custody cases, persons applying for renewal of a driving licence after disqualification for a drug-related offence, doctors seeking re-registration after removal for drug abuse, and checking for compliance with terms of probation orders; as well as pre-employment screening and work-place testing. In many cases these requests will be received from a general practitioner or drug clinic with no indication of the reason for which testing has been requested. This also raises the serious problems of a chain of custody, provision of two samples, stability of samples, and secure and lengthy storage of samples in the laboratory-samples may be requested by legal authorities several months after the initial testing. The need for confirmation of positive results is now widely accepted but it may be equally important to confirm unexpected negative results. Failure to detect the presence of maintenance drugs may lead to the patient being discharged from a drug treatment clinic and, if attendance at the clinic is one of the terms of continued employment, to dismissal. It seems likely that increasing abuse of drugs and the efforts of regulatory authorities to control this, will lead to the manufacture of more designer drugs. Production of substituted phenethylamines was facilitated by the drug makers' cook book, 'PIHKAL' (Phenethylamines I Have Known And Loved) by Dr Alexander Shulgin and Ann Shulgin, and production of substituted tryptamines is promised in their next book, TIHKAL. Looking to the future, laboratories will need to ensure that they can detect and quantitate an ever-increasing number of drugs and related substances. The question of confidence in results of drugs of abuse testing raised in 1993 by Watson has assumed even greater importance as a result of attention focused on the OJ Simpson trial in Los Angeles. Toxicological investigations are likely to be challenged more frequently in the future. Even if analyses have been performed by GC-MS, there is a need to establish the level of match between the spectrum of the unknown substance and a library spectrum which is considered acceptable for legal purposes. It will also be essential to ensure that computer libraries contain spectra for all substances likely to be encountered in drugs of abuse screening.

Bedside diagnostic testing of body fluids

Numerous bedside diagnostic modalities are appropriate for the practice of emergency medicine. The proliferation of sophisticated technology is likely to increase both the availability and accuracy of commercial testing products. If health care reform in the United States results in a relaxation of the CLIA regulations, there will be a rapid expansion of research and development aimed at the biotechnology market. How much this would pertain to hospital-based emergency practice remains to be seen. Cost containment pressures may act in both directions on the utilization of available bedside technology. Although these tests are often less expensive than centralized laboratory determinations, the ready availability of near-patient testing may result in an increase in use that negates the lower cost. As with other diagnostic modalities, a thoughtful, considered approach based on scientific evidence will be necessary to formulate the appropriate use of bedside testing in individual emergency practice settings.

Evaluation of a colloidal metal immunoassay device for the detection of tricyclic antidepressants in urine

BACKGROUND

The sensitivity and selectivity of a colloidal metal immunoassay device (Triage Plus TCA) which is designed for the rapid detection of tricyclic antidepressant drugs in urine at a total tricyclic antidepressant concentration of 1000 ng/mL or greater were evaluated.

METHODS

The sensitivity of the Triage Plus assay was determined by adding known amounts of amitriptyline, nortriptyline, imipramine, desipramine, doxepin and desmethyl-doxepin to drug free urine. The selectivity of the assay was determined by adding known concentrations of 32 drugs or drug metabolites commonly encountered in emergency department admissions to drug free urine. Triage Plus results from clinical urine specimens containing either amitriptyline, nortriptyline, imipramine, desipramine, doxepin and desmethyl-doxepin were compared to those obtained with thin layer chromatography and high performance liquid chromatography.

RESULTS

Triage Plus yielded a positive response to gravimetrically prepared urines of tricyclic antidepressant at the stated cut-off value (1,000 ng/mL), and at 80% (800 ng/mL) and 50% (500 ng/mL) of the cut-off with amitriptyline, nortriptyline, imipramine, desipramine and doxepin. Other tricyclic antidepressant drugs, clomipramine and protriptyline were positive at 1000 ng/mL. Significant cross-reactivity was observed only with cyclobenzaprine at 1000 ng/mL. No significant cross reactivity was found at 1.0 g/L for 32 drugs commonly encountered in emergency department admissions. A 95% (70/74) agreement of positive tricyclic antidepressant results was observed between Triage Plus and thin layer chromatography. Discordant urines were found by high performance liquid chromatography to contain tricyclic antidepressant concentrations below the cut-off value of the colloidal metal assay.

CONCLUSION

Triage Plus was found to be an accurate device for the detection of tricyclic antidepressants in urine at the stated cut-off value of 1000 ng/mL tricyclic antidepressant. With the exception of cyclobenzaprine, significant cross-reactivity was not observed with other drugs commonly encountered in emergency department admissions.

Evaluation of Bionike one-step tests for the detection of drugs of abuse in urine

Bionike one-step tests were used to screen urine samples for amphetamines, methamphetamines, benzodiazepines, cannabinoids, methadone and opiates, and results were compared with those obtained using enzyme multiplied immunoassay technique d.a.u. assays. Taking into consideration different threshold levels and possible differences in cross-reactivities, there was good agreement between the methods. Results of Bionike tests correlated well with amphetamines, methadone and opiates detected in urine using gas chromatography-mass spectrometry. Bionike methods are rapid, simple to use, and relatively inexpensive for on-site testing of individual drugs or groups of drugs in urine.

Fatal methamphetamine poisoning in police custody

A fatal case of methamphetamine poisoning whilst in police custody is described. Drug identification and quantification in postmortem blood, urine, brain and gastric contents was achieved using gas chromatography-mass spectrometry. The blood concentration of methamphetamine was 4.92 micromol/100 g, which is in the lethal range. It is necessary for police officers to have a good knowledge of the toxic effects of abused drugs.

Forensic immunochemistry

Immunoassay has been established with polyclonal or monoclonal antibody even for a low molecular weight compound which has no antigenicity. In spite of the cross-reactivities of an antibody and also the difficulty in identification of the compound, an immunoassay is a useful method of choice for the detection of the compound in biological fluids because of the pretreatment simplicity and ability to treat many samples in a short time. Therefore, immunoassay has been established as a sensitive analytical and screening method for use in forensic sciences. In our laboratory, a radioimmunoassay (RIA) and an enzyme immunoassay (EIA) for phenobarbital, and enzyme-linked immunosorbent assays (ELISA) and latex agglutination inhibition reaction tests (LAIRT) for methamphetamine, benzoylecgonine and morphine have been established. These assays are described in addition to the two commercially available immunoassay kits, enzyme multiplied immunoassay technique (EMIT; Syva Co., USA) and Triage Biosite Piagnostics, Inc, USA.

Use of the USDT flow immunosensor for quantitation of benzoylecgonine in urine

The flow immunosensor works on a principle somewhat distinct from other immunoassay systems in that it performs a displacement immunoassay. Antibody-coated matrices are saturated with fluorescently labeled benzoylecgonine (BE), which is released and measured in the presence of BE-containing urine and measured downstream from the matrix. The same antibody matrix can be used for many samples. A flow immunosensor instrument, built by US Drug Testing, Inc., has recently received "Premarket Notification' (510(K)) from the Food and Drug Administration (FDA) to screen urine for the presence of the cocaine metabolite BE. The performance of the flow immunosensor for screening BE in urine was validated by comparison with results of a blind study using the Syva EMIT, the Abbott TDx and gas chromatography-mass spectroscopy (GC-MS). Potentially interfering drugs were also spiked into urine and evaluated using the flow immunosensor. While the FDA approval is for determining whether the BE concentration is above or below the 300 micrograms/l cutoff recommended by the National Institute of Drug Abuse, we have also shown that the flow immunosensor can be adapted to produce quantitative determinations of the amount of BE in the urine samples. The reliability of the quantitation was confirmed by testing 100 urine samples containing unknown amounts of BE using the flow immunosensor. GC-MS and the Abbott TDx system. Comparison of quantitative data obtained using the immunosensor and GC-MS showed a 97% correlation, compared with a much lower value for data from the TDx and GC-MS.

Use of a visual panel detection method for drugs of abuse: clinical and laboratory experience with children and adolescents

We evaluated the Triage panel for drugs of abuse, a visual method that simultaneously detects seven distinct drug classes in a single aliquot of urine, by use of 1214 urine specimens obtained from children and adolescent patients whose clinical findings warranted a toxicology evaluation. A total of 295 positive results were confirmed by gas chromatography-mass spectrometry. Additional toxicology investigations were not performed on specimens with negative results unless the clinical findings did not correspond with the urine Triage results. The positive predictive value of the test was found to be > 85% for detection of barbiturates, cannabinoid metabolite, cocaine metabolite, and opiates; for the benzodiazepines the positive predictive value was 77%. Positive predictive values were 53% for amphetamines and 40% for phencyclidine, although only five specimens were available for evaluation of the latter drug. Correlation between clinical findings of patients and results from the Triage test were good except for ingestion of sympathomimetic amines (because of selectivity of the antibodies used in the test for amphetamines) and in patients receiving either antianxiety or antidepressant drugs (some members of these classes of drugs or their metabolites appeared to cross-react with the benzodiazepine test). The primary advantages of the Triage test were the rapid turnaround time, the ease with which a specimen could be processed, and the ability to use rapidly provided information as part of a differential diagnosis.