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Gounden V, Banerjee M, Amundsen EK, Serdar MA, Suárez Sánchez CI, Strain C, Kinniburgh D, Zhao Z. Linking Laboratory Testing to Clinical Outcomes: Bridging the Gap through Outcome-Based Studies in Laboratory Medicine. Clin Chem 2023; 69:1317-1321. [PMID: 37688514 DOI: 10.1093/clinchem/hvad132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 08/21/2023] [Indexed: 09/11/2023]
Affiliation(s)
- Verena Gounden
- Department of Chemical Pathology, Inkosi Albert Luthuli Central Hospital, National Health Laboratory Service and University of KwaZulu Natal, Durban, South Africa
| | - Mithu Banerjee
- Department of Biochemistry, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Erik Koldberg Amundsen
- Department of Medical Biochemistry, Oslo University Hospital, Oslo, Norway
- Department of Life Sciences and Health, Oslo Metropolitan University, Oslo, Norway
| | - Muhittin A Serdar
- Department of Medical Biochemistry, Acibadem University, Istanbul, Turkey
| | | | - Colleen Strain
- Scientific Leadership and Education, Core Diagnostics, Scientific and Medical Affairs, Abbott, Canada
| | - David Kinniburgh
- Department of Physiology and Pharmacology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Zhen Zhao
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, NY, United States
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Dlamini IS, Gounden V, Moodley N. Evaluation of tumour marker utilisation and impact of electronic gatekeeping in the province of KwaZulu-Natal, South Africa. Afr J Lab Med 2023; 12:2027. [PMID: 37434992 PMCID: PMC10331048 DOI: 10.4102/ajlm.v12i1.2027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 04/13/2023] [Indexed: 07/13/2023] Open
Abstract
Background Inappropriate testing remains a high healthcare cost driver. Tumour marker tests are more expensive than routine chemistry testing. Implementing test demand management systems like electronic gatekeeping (EGK) has reportedly decreased test requests. Objective This study aimed to describe the appropriateness of tumour marker tests, carcinoembryonic antigen, alpha foetal protein, prostate-specific antigen, carbohydrate antigen 19-9, cancer antigen 15-3, cancer antigen 125, and human chorionic gonadotropin, and determine the effectiveness of the EGK used in the public health sector in KwaZulu-Natal, South Africa. Methods Tumour marker test data for the KwaZulu-Natal province were extracted from the National Health Laboratory Service Central Data Warehouse for 01 January 2017 - 30 June 2017 (pre-EGK) and 01 January 2018 - 30 June 2018 (post-EGK implementation). Questionnaires were sent to the clinicians in the regional hospitals ordering the most tumour marker tests to assess ordering practices. In addition, we assessed monthly rejection reports to determine the effect of the EGK. Results The EGK minimally reduced tumour marker requests or associated costs (1.4% average EGK rejection rate). An overall 18% increase in the tumour marker tests occurred in 2018. The data suggest inappropriate tumour marker test utilisation, particularly for screening. Conclusion The introduction of EGK as a test demand management had little impact on tumour marker test requests and costs. Continuous education and reiteration of indications for tumour marker test use are required. What this study adds This study demonstrates the ineffectiveness of EGK in tumour marker orders, and provides some insight as to why these markers are being ordered, which is important in trying to decrease inappropriate ordering of these tests.
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Affiliation(s)
- Immaculate S. Dlamini
- Department of Chemical Pathology, Faculty of Laboratory Medicine, National Health Laboratory Service, Durban, South Africa
- Department of Chemical Pathology, Faculty of Laboratory Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Verena Gounden
- Department of Chemical Pathology, Faculty of Laboratory Medicine, National Health Laboratory Service, Durban, South Africa
- Department of Chemical Pathology, Faculty of Laboratory Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Nareshni Moodley
- Department of Chemical Pathology, Faculty of Laboratory Medicine, National Health Laboratory Service, Durban, South Africa
- Department of Chemical Pathology, Faculty of Laboratory Medicine, University of KwaZulu-Natal, Durban, South Africa
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Gounden V, Warasally Z, Magwai T, Naidoo R, Chuturgoon A. T163 A pilot study: The relationship between serum bisphenol a and sex steroid hormone levels in maternal and child pairs in a South African population. Clin Chim Acta 2022. [DOI: 10.1016/j.cca.2022.04.642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Moodley N, Gounden V. Assessment of Sigma Metrics for Routine Chemistry Testing in 4 Laboratories in Kwa-Zulu Natal, South Africa. J Appl Lab Med 2021; 7:689-697. [PMID: 34636901 DOI: 10.1093/jalm/jfab117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 08/16/2021] [Indexed: 11/12/2022]
Abstract
BACKGROUND Sigma metrics is a quantitative management tool. This study assessed the Six Sigma score for 26 chemistry analytes, compared scores with different total allowable errors (TEa) and use of scores for internal quality control (IQC) rules in 4 Laboratories in Kwa-Zulu Natal, South Africa. METHODS Utilizing 6 months of IQC SD, CV, and bias data on albumin, alkaline phosphatase, alanine aminotransferase, amylase, aspartate aminotransferase, bicarbonate, calcium, total cholesterol, creatine kinase, chloride, creatinine, gamma glutamyl transferase, glucose, HDL-cholesterol, potassium, lactate dehydrogenase, magnesium, sodium, inorganic phosphate, direct bilirubin, total bilirubin, triglycerides, total protein, urea nitrogen, uric acid, and C-reactive protein (CRP) Six Sigma scores were calculated using Microsoft Excel 2016 and ideal IQC rules were determined. Six Sigma scores using Ricos et al. 2014, Royal College of Pathologists Australasia, and Clinical Laboratory Improvement Amendments TEas were compared. RESULTS For levels 1, 2, and 3 respectively, analytes scoring >3 sigma was 9 (35%), 12 (46%), and 14 (54%) in Laboratory A; Laboratory B had 15 (58%), 19 (73%), and 17 (65%); Laboratory C had 12 (46%), 13 (50%), and 15 (58%); and Laboratory D had 13 (50%), 18 (69%), and 18 (69%). Albumin, calcium, sodium, magnesium, bicarbonate, and chloride scored <3; CRP scored >6 for all. In Laboratories A, B, C, and D, 7 (27%), 7 (27%), 6 (23%), and 8 (31%) analytes, respectively, required only 1 IQC rule. One of 21 analytes for Laboratories C and D, 3 for Laboratory A, and 0 for Laboratory B had the same sigma score with all 3 databases. CONCLUSION Despite South Africa being a developing nation, many analytes are able to achieve >3 sigma.
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Affiliation(s)
- Nareshni Moodley
- Department of Chemical Pathology, Inkosi Albert Luthuli Central Hospital, National Health Laboratory Services and University of Kwa-Zulu Natal, Durban, South Africa
| | - Verena Gounden
- Department of Chemical Pathology, Inkosi Albert Luthuli Central Hospital, National Health Laboratory Services and University of Kwa-Zulu Natal, Durban, South Africa
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Reddy A, Rapiti N, Gounden V. Comparison of 24-hour versus random urine samples for determination and quantification of Bence Jones protein in a South African population. Afr J Lab Med 2021; 10:1228. [PMID: 34522630 PMCID: PMC8424753 DOI: 10.4102/ajlm.v10i1.1228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 03/04/2021] [Indexed: 11/15/2022] Open
Abstract
Background The International Myeloma Working Group and College of American Pathologists recommend a 24-h urine collection to determine the Bence Jones protein (BJP) excretion level for monitoring treatment response in patients with multiple myeloma (MM). There are several issues related to sample collection and the method is prone to inaccuracy. Objective This study compared measured 24-h to random urine collections for the quantitation of BJP in a South African population. Methods Sixty-six patients with MM submitted random urine samples with their routine 24-h urine collection from April 2016 – March 2018. Measured 24-h urine BJP was compared to two estimated 24-h BJP excretions calculated as follows: Estimation 1 (E1): Estimated 24-h BJP (mg/24 h) = Urine BJP/Creatinine ratio (mg/mmol) × 10. Estimation 2 (E2): Estimated 24-h BJP (mg/24 h) = Urine BJP/Creatinine ratio (mg/mmol) × 15 mg/kg for women or × 20 mg/kg for men. Results Correlation of estimation equations E1 and E2 to the measured 24-h urine BJP was 0.893. Patients showed no difference in classification of treatment response using either the E1 or E2 estimation equations when compared to the measured 24-h urine BJP results. Conclusion This study demonstrates that the estimated 24-h BJP shows a high degree of correlation with the measured 24-h BJP and can likely be used to monitor treatment response in South African patients with MM.
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Affiliation(s)
- Ashandree Reddy
- Department of Chemical Pathology, Faculty of Health Sciences, University of KwaZulu-Natal, Durban, South Africa.,National Health Laboratory Service, Durban, South Africa
| | - Nadine Rapiti
- National Health Laboratory Service, Durban, South Africa.,Department of Haematology, Faculty of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Verena Gounden
- Department of Chemical Pathology, Faculty of Health Sciences, University of KwaZulu-Natal, Durban, South Africa.,National Health Laboratory Service, Durban, South Africa
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Gounden V, Warasally MZ, Magwai T, Naidoo R, Chuturgoon A. A pilot study: Relationship between Bisphenol A, Bisphenol A glucuronide and sex steroid hormone levels in cord blood in A South African population. Reprod Toxicol 2021; 100:83-89. [PMID: 33453334 DOI: 10.1016/j.reprotox.2021.01.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Revised: 01/03/2021] [Accepted: 01/09/2021] [Indexed: 11/17/2022]
Abstract
Exposure to Bisphenol A (BPA) during early development particularly in- utero has been linked to a wide range of pathology. The aim of this study was to examine the relationship of BPA and its naturally occurring metabolite BPA-glucuronide (BPA-g) with sex steroid hormone levels in South African mother-child pairs. Third-trimester serum maternal samples and matching cord blood samples were analyzed for BPA, BPA-g and nine sex steroid hormones using liquid chromatography tandem mass spectrometry (LC-MS/MS). Sixty maternal and child pairs were analyzed. Rank correlation demonstrated a significant positive relationship between cord blood estradiol and cord blood BPA (p = 0.002) and maternal BPA levels (p = 0.02) respectively. Cord blood testosterone from male infants showed a negative Spearman's correlation (r=-0.5, p = 0.02) with maternal BPA-g. There was no statistical difference in total testosterone levels in cord blood from male and female infants. The findings of the current study indicate a significant relationship between some key sex steroid hormones namely testosterone, dihydrotestosterone and estradiol and fetal exposure BPA.
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Affiliation(s)
- Verena Gounden
- Department of Chemical Pathology, University of KwaZulu-Natal and National Health Laboratory Services, Inkosi Albert Luthuli Central Hospital, Durban, South Africa.
| | - Mohamed Zain Warasally
- Department of Chemical Pathology, National Health Laboratory Services, Inkosi Albert Luthuli Central Hospital, Durban, South Africa
| | - Thabo Magwai
- Department of Chemical Pathology, National Health Laboratory Services, Inkosi Albert Luthuli Central Hospital, Durban, South Africa
| | - Rajen Naidoo
- Department of Occupational Health, University of KwaZulu-Natal, Durban, South Africa
| | - Anil Chuturgoon
- Department of Medical Biochemistry, University of KwaZulu-Natal, Durban, South Africa
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Magwai T, Warasally Z, Naidoo N, Gounden V. Reducing sample rejection in Durban, South Africa. Clin Chem Lab Med 2020; 59:687-692. [PMID: 33079694 DOI: 10.1515/cclm-2020-0827] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 10/07/2020] [Indexed: 11/15/2022]
Abstract
Objectives Rejections of clinical chemistry specimens delays the availability of results, which may impact patient management. The study aims to measure sample rejection rate, identify reasons for sample rejection, evaluate the effect of a campaign to reduce rejection rates and discover which clinical units produced the most insufficient specimen. Methods The study measured specimen rejection rates and the contributions of different rejection reasons in calendar 2016 and April 2018-March 2019. The study undertook a 7-intervention campaign to reduce specimen rejection during the 2018-2019 intervention period. It compared rejections rates, number of months with rejection rates ≤1.2%, and distribution of rejection reasons between the two year-long intervals. The study also determined the origin for specimens rejected for the most common rejection reason during one month in the second period. Results The overall rejection rate fell significantly from 1.4% in pre-intervention period to 1.2% in the intervention period. The number of months with rejection rates within the target range increased significantly from 2 in the post-intervention period to 6 in the intervention period. Insufficient, hemolysed, and 'too-old' specimen decreased significantly, however, insufficient specimen remained the most frequent rejection reason. In February 2019, one-third of all insufficient specimen came from neonatal units and 24% from the pediatric units. Conclusions Interventions decreased significantly both overall and monthly rejection rates above target levels. Insufficient, hemolysed, 'too-old' specimen, became significantly less frequent, however, insufficient specimen remained the most frequent rejection reason. Over a month, most insufficient specimen came from neonatal and pediatric sites.
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Affiliation(s)
- Thabo Magwai
- Chemical Pathology, National Health Laboratory Service, Durban, Kwa-Zulu Natal, South Africa
| | - Zain Warasally
- Chemical Pathology, National Health Laboratory Service, Durban, Kwa-Zulu Natal, South Africa
| | - Naleeni Naidoo
- Chemical Pathology, National Health Laboratory Service, Durban, Kwa-Zulu Natal, South Africa
| | - Verena Gounden
- Chemical Pathology, National Health Laboratory Service, Durban, Kwa-Zulu Natal, South Africa.,Chemical Pathology, University of KwaZulu-Natal, Durban, Kwa-Zulu-Natal, South Africa
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Affiliation(s)
- Siphelele Dlamini
- Department of Chemical Pathology, University of KwaZulu Natal, Durban, South Africa.,National Health Laboratory Services, Inkosi Albert Luthuli Central Hospital, Durban, South Africa
| | - Ashandree Reddy
- Department of Chemical Pathology, University of KwaZulu Natal, Durban, South Africa.,National Health Laboratory Services, Inkosi Albert Luthuli Central Hospital, Durban, South Africa
| | - Verena Gounden
- Department of Chemical Pathology, University of KwaZulu Natal, Durban, South Africa; .,National Health Laboratory Services, Inkosi Albert Luthuli Central Hospital, Durban, South Africa
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Gounden V, Zain Warasally M, Magwai T, Naidoo R, Chuturgoon A. A pilot study: Bisphenol-A and Bisphenol-A glucuronide levels in mother and child pairs in a South African population. Reprod Toxicol 2019; 89:93-99. [PMID: 31302198 DOI: 10.1016/j.reprotox.2019.07.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 07/03/2019] [Accepted: 07/10/2019] [Indexed: 12/31/2022]
Abstract
Exposure to Bisphenol A (BPA) during early development particularly in- utero has been linked to a wide range of pathology. The aim of this study was to determine serum levels of BPA and its naturally occurring metabolite BPA-glucuronide (BPA-g) in South African mother-child pairs. METHOD Third-trimester serum maternal samples and matching cord blood samples were analysed for BPA and BPA-g using LC-MS/MS. RESULTS Ninety maternal and child pairs were analysed. BPA was detectable in more than 25% of maternal and cord blood samples. Spearman correlation demonstrated significant positive correlation between maternal and child BPA and BPA-g levels with correlation coefficients of 0.892 and 0.744, respectively. A significant positive association between cord BPA levels and child birth-weight (p = 0.02) as well as with maternal BMI (p = 0.04) was noted. CONCLUSION This is the first study to describe the presence of detectable BPA levels using LC-MS/MS methodology in a South African population.
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Affiliation(s)
- Verena Gounden
- Department of Chemical Pathology, University of KwaZulu-Natal and National Health Laboratory Services, Inkosi Albert Luthuli Central Hospital, Durban, South Africa.
| | - Mohamed Zain Warasally
- Department of Chemical Pathology, National Health Laboratory Services, Inkosi Albert Luthuli Central Hospital, Durban, South Africa
| | - Thabo Magwai
- Department of Chemical Pathology, National Health Laboratory Services, Inkosi Albert Luthuli Central Hospital, Durban, South Africa
| | - Rajen Naidoo
- Department of Occupational Health, University of KwaZulu-Natal, Durban, South Africa
| | - Anil Chuturgoon
- Department of Medical Biochemistry, University of KwaZulu-Natal, Durban, South Africa
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Ndlovu KCZ, Chikobvu P, Mofokeng T, Gounden V, Assounga A. Serum albumin and mortality in patients with HIV and end-stage renal failure on peritoneal dialysis. PLoS One 2019; 14:e0218156. [PMID: 31181128 PMCID: PMC6557525 DOI: 10.1371/journal.pone.0218156] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2019] [Accepted: 05/27/2019] [Indexed: 11/19/2022] Open
Abstract
Background Peritoneal dialysis (PD) is an easily implementable dialysis modality in end-stage renal disease (ESRD). PD may improve access to renal replacement therapy in low- and middle-income countries; however, these countries have a higher prevalence of protein-energy wasting in patients and poorer socioeconomic conditions. We evaluated the effects of HIV infection on serum albumin levels in ESRD patients starting continuous ambulatory PD (CAPD) and mortality outcomes. Methods We conducted a single-center prospective cohort study of consecutive incident CAPD patients recruited from two hospitals in Durban, South Africa, from September 2012 to February 2015. Seventy HIV-negative and 70 HIV-positive ESRD patients were followed monthly for serum albumin levels and mortality events during the first 18 months of CAPD therapy. Results The HIV-positive cohort recorded 28 deaths (40%) among patients with a functional CAPD catheter at 18 months and 13 deaths (18.6%) in the HIV-negative cohort (p = 0.005). The mean serum albumin levels were lower in the HIV-positive cohort than in the HIV-negative cohort during the 18-month follow-up. The mean difference in serum albumin levels between the two cohorts was 4.24 g/L (95% confidence interval [CI] 2.02–6.46, p<0.001) at baseline and 3.99 g/L (95% CI 1.19–6.79, p = 0.006) at 18 months. HIV-positive status (adjusted regression coefficient -2.84, CI -5.00–-0.67, p = 0.011), diabetes (adjusted coefficient -2.85; CI, -5.58–-0.12; p = 0.041), and serum C-reactive protein and blood hemoglobin levels were independent predictors of serum albumin levels on multivariable linear regression. Baseline serum albumin <25 g/L (subdistribution-hazard ratio [SHR] 13.06, 95% CI 3.09–55.14, p<0.001) and CD4+ cell count <200 cells/μL (SHR 3.2, CI 1.38–7.45, p = 0.007) were independent predictors of mortality in our competing risk model. Conclusions HIV infection can adversely affect serum albumin levels in ESRD patients managed with CAPD, while low baseline serum albumin levels and impaired immunity reliably predict mortality.
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Affiliation(s)
- Kwazi Celani Zwakele Ndlovu
- Division of Nephrology, University of the Free State, Bloemfontein, South Africa
- Department of Internal Medicine, University of the Free State, Bloemfontein, South Africa
- * E-mail:
| | - Perpetual Chikobvu
- Department of Health of the Free State, Bloemfontein, South Africa
- Department of Community Health, University of the Free State, Bloemfontein, South Africa
| | - Thabiso Mofokeng
- Department of Internal Medicine, University of the Free State, Bloemfontein, South Africa
| | - Verena Gounden
- Department of Chemical Pathology, Inkosi Albert Luthuli Hospital, Durban, South Africa
| | - Alain Assounga
- Department of Nephrology, University of KwaZulu-Natal, Durban, South Africa
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Gounden V, Warasally Z, Magwai T, Naidoo R, Chuturgoon A. Determination of bisphenol A and bisphenol A glucuronide in maternal and child pairs in a South African cohort. Clin Chim Acta 2019. [DOI: 10.1016/j.cca.2019.03.1603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Mallappa A, Nella AA, Sinaii N, Rao H, Gounden V, Perritt AF, Kumar P, Ling A, Liu CY, Soldin SJ, Merke DP. Long-term use of continuous subcutaneous hydrocortisone infusion therapy in patients with congenital adrenal hyperplasia. Clin Endocrinol (Oxf) 2018; 89:399-407. [PMID: 30003563 PMCID: PMC6166869 DOI: 10.1111/cen.13813] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Revised: 06/18/2018] [Accepted: 07/08/2018] [Indexed: 12/01/2022]
Abstract
BACKGROUND In a phase 2 short-term (6 months) study of patients with congenital adrenal hyperplasia (CAH), continuous subcutaneous hydrocortisone infusion (CSHI) was found to be a safe, effective and well-tolerated method of replacing cortisol with improved disease and patient-related outcomes. OBJECTIVE To evaluate the safety and efficacy of long-term CSHI. DESIGN Single-centre, open-label, phase 2 extension study. PATIENTS Five adults with classic CAH. MEASUREMENTS Biomarkers of disease control, metabolic indices and health-related quality-of-life (HRQoL) estimates. RESULTS Six of eight patients chose to continue on long-term CSHI therapy. Compared to baseline, eighteen months of CSHI resulted in decreased (P = 0.043) 0700-hour ACTH, 17-hydroxyprogesterone, androstenedione and progesterone; increased whole-body lean mass (P = 0.024); and improved HRQoL, especially symptoms of adrenal insufficiency (P = 0.003). Findings at six and eighteen months did not differ, and improvements achieved in androgen control, lean body mass and HRQoL after 6 months of CSHI were maintained at eighteen months. The hydrocortisone dose appeared to decrease with time [6 vs 18 months: 38.3 ± 8.8 vs 33.6 ± 12.2 mg/day (P = 0.062)], especially in women receiving oral contraceptives. Reduction of testicular adrenal rest and adrenal size observed at 6 months remained stable. In one patient, an adrenal adenoma continually decreased over time. Subjective improvement in hirsutism was reported. CONCLUSIONS Long-term use of CSHI is a safe and well-tolerated treatment option in a select set of adults with classic CAH. Improvements observed short term in disease control and subjective health status continued long term.
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Affiliation(s)
- Ashwini Mallappa
- National Institutes of Health Clinical Center, Bethesda MD, USA 20892
| | - Aikaterini A. Nella
- National Institutes of Health Clinical Center, Bethesda MD, USA 20892
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA 20892
| | - Ninet Sinaii
- National Institutes of Health Clinical Center, Bethesda MD, USA 20892
| | - Hamsini Rao
- National Institutes of Health Clinical Center, Bethesda MD, USA 20892
| | - Verena Gounden
- National Institutes of Health Clinical Center, Bethesda MD, USA 20892
| | - Ashley F. Perritt
- National Institutes of Health Clinical Center, Bethesda MD, USA 20892
| | - Parag Kumar
- National Institutes of Health Clinical Center, Bethesda MD, USA 20892
| | - Alexander Ling
- National Institutes of Health Clinical Center, Bethesda MD, USA 20892
| | - Chia-Ying. Liu
- National Institutes of Health Clinical Center, Bethesda MD, USA 20892
| | - Steven J. Soldin
- National Institutes of Health Clinical Center, Bethesda MD, USA 20892
| | - Deborah P. Merke
- National Institutes of Health Clinical Center, Bethesda MD, USA 20892
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA 20892
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Gounden V, Rampursat YD, Jialal I. Secretory tumors of the pituitary gland: a clinical biochemistry perspective. ACTA ACUST UNITED AC 2018; 57:150-164. [DOI: 10.1515/cclm-2018-0552] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2018] [Accepted: 07/16/2018] [Indexed: 12/24/2022]
Abstract
Abstract
The pituitary gland is responsible for the production and/or secretion of various hormones that play a vital role in regulating endocrine function within the body. Secretory tumors of the anterior pituitary predominantly, pituitary adenomas, collectively account for 10%–25% of central nervous system tumors requiring surgical treatment. The most common secretory tumors are prolactinomas, which can be diagnosed by basal prolactin levels. Acromegaly can be diagnosed by basal insulin growth-like factor 1 levels and the failure of growth hormone (GH) to suppress during an oral glucose tolerance test. Cushing disease can be diagnosed by demonstrating hypercortisolemia evidenced by increased salivary cortisol levels in the evening, increased urine free cortisol excretion and failure of plasma cortisol to suppress following oral dexamethasone given overnight (1.0 mg). We also discuss the diagnosis of the rarer thyroid-stimulating hormone and gonadotrophin secretory tumors. Morbidity is associated with tumor occurrence, clinical sequelae as well as the related medical, surgical and radiological management. This review focuses on the pathogenesis of secretory tumors of the anterior pituitary with emphasis on molecular mechanisms associated with tumorigenesis and the major role of the clinical chemistry laboratory in diagnosis and management of these tumors.
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Affiliation(s)
- Verena Gounden
- Department of Chemical Pathology , University of KwaZulu Natal and National Health Laboratory Services, Inkosi Albert Luthuli Central Hospital , Durban , South Africa
| | - Yashna D. Rampursat
- Department of Chemical Pathology , University of KwaZulu Natal and National Health Laboratory Services, Inkosi Albert Luthuli Central Hospital , Durban , South Africa
| | - Ishwarlal Jialal
- California North-State University, College of Medicine , Elk Grove, CA 95757 , USA
- Director, Section of Clinical Chemistry, VA Medical Center , Sacramento, CA , USA
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Moodley N, Hariparshad S, Peer F, Gounden V. Evaluation of the CKD-EPI creatinine based glomerular filtration rate estimating equation in Black African and Indian adults in KwaZulu-Natal, South Africa. Clin Biochem 2018; 59:43-49. [PMID: 29940141 DOI: 10.1016/j.clinbiochem.2018.06.014] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Revised: 06/21/2018] [Accepted: 06/21/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND The estimation of glomerular filtration rate (GFR) plays a vital role in assessment of the renal function. This study evaluated the performance of the CKD-EPIcreat and MDRD equations in the South African Kwa-Zulu Natal population. OBJECTIVES The objectives if the study were to compare the of CKD-EPIcreat and MDRD equations in the selected population to the measured GFR using Sodium Technetium-99 m-diethylene-triamine-pentaacetate clearance derived GFR. METHOD Records of adult patients with measured GFR performed at the Nuclear Medicine Department at Inkosi Albert Luthuli Central Hospital, Durban, South Africa from 1 April 2014 to 31 March 2016 were reviewed. eGFR for all included patients was calculated using the MDRD equation without African American correction factor and the CKD-EPIcreat equation with and without the African American correction factor for the Black African patients. Statistical comparison of the eGFR with measured GFR was performed with Bland Altman bias plots, Wilcoxon match pairs signed ranks test and accuracy within 10% and 30%.ROC curve analysis assessed the sensitivity and specificity at eGFR <90 and < 60 ml/min/1.73m2. RESULTS After exclusion, 287 patients were included for analysis with sufficient numbers for only the Black African and Indian patients. None of the equations showed accuracy of eGFR within 30% of measured GFR for 90% of patients. In the Black African population, the CKD-EPIcreat equation without the correction factor performed best. 17% and 14.4% of the Black African participants would be reclassified with the CKD-EPIcreat equation without and with the African American correction factor respectively compared to mGFR at a cut-off of 60 mls/min/1.73m2. CONCLUSION None of the evaluated equations attained the 2002 KDOQI benchmark of P30 >90%. 11.1-17% of individuals would have been incorrectly classified using the CKD-EPIcreat equation.
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Affiliation(s)
- Nareshni Moodley
- Department of Chemical Pathology, Inkosi Albert Luthuli Central Hospital, National Health Laboratory Services and University of Kwa-Zulu Natal, South Africa
| | - Sudesh Hariparshad
- Department of Nephrology, Nelson R Mandela Medical School of Medicine, University of KwaZulu-Natal and Inkosi Albert Luthuli Central Hospital, South Africa.
| | - Fozy Peer
- Department of Nuclear Medicine, Nelson R Mandela Medical School University of Kwa Zulu Natal and Inkosi Albert Luthuli Central Hospital, South Africa.
| | - Verena Gounden
- Department of Chemical Pathology, Inkosi Albert Luthuli Central Hospital, National Health Laboratory Services and University of Kwa-Zulu Natal, South Africa.
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Rampursat Y, Bhimma R, Naicker E, Peer F, Gounden V. Evaluation of the revised Schwartz creatinine-based glomerular filtration rate estimating equation in Black African children in KwaZulu-Natal, South Africa. Ann Clin Biochem 2017; 55:505-508. [PMID: 28920466 DOI: 10.1177/0004563217734573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background The use of serum creatinine equations for estimating glomerular filtration rate is well known in adults and children. We evaluated the revised Schwartz creatinine-based estimated glomerular filtration rate prediction equation in Black African children in KwaZulu-Natal, South Africa. Methods Review of medical records of all Black African patients aged 2-18 years old who have had glomerular filtration rate determined by intravenous Technetium-99 m-diethylene-triamine-pentaacetate, for the period 1 January 2010 to 31 December 2014 at the Inkosi Albert Luthuli Central Hospital, Durban, South Africa was performed. Estimated glomerular filtration rate result obtained using the revised Schwartz equation was compared to Technetium-99 m-diethylene-triamine-pentaacetate plasma clearance measured glomerular filtration rate. Accuracy of the estimated glomerular filtration rate equations within 10% (P10) and 30% (P30) of the measured glomerular filtration rate, sensitivity and specificity for predicting glomerular filtration rate < 60 mL/min/1.73 m2 and < 30 mL/min/1.73 m2 was determined. Results Results from 148 African children between 2 and 18 years old were analysed. P10 and P30 values were 16 and 49%, respectively. Sensitivity of 92.9% (95% CI: 80.5-85), specificity of 95.3 (95% CI: 89.3-98.5) and AUC of 0.96 (95% CI 0.92-0.99) were obtained for measured estimated glomerular filtration rate < 60 mL/min/1.73 m2. Sensitivity of 88.2% (95% CI: 63.6-98.5), specificity of 90.8 (95% CI: 84.5-95.2) and area under the curve of 0.93 (95% CI 0.88-0.96) were obtained for measured estimated glomerular filtration rate < 30 mL/min/1.73 m2. Conclusions The revised Schwartz equation did not meet the National Kidney Foundation Kidney Disease Outcomes Quality Initiative guidelines of 90% of estimated glomerular filtration rate results within 30% of measured glomerular filtration rate.
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Affiliation(s)
- Yashna Rampursat
- 1 Department of Chemical Pathology, Nelson R Mandela Medical School, University of KwaZulu-Natal, Durban, South Africa.,2 National Health Laboratory Services, Inkosi Albert Luthuli Central Hospital, Durban, South Africa
| | - Rajendra Bhimma
- 3 Department of Paediatrics, Nelson R Mandela Medical School, University of KwaZulu-Natal, Durban, South Africa.,4 Inkosi Albert Luthuli Central Hospital, Durban, South Africa
| | - Elaene Naicker
- 3 Department of Paediatrics, Nelson R Mandela Medical School, University of KwaZulu-Natal, Durban, South Africa.,4 Inkosi Albert Luthuli Central Hospital, Durban, South Africa
| | - Fozy Peer
- 4 Inkosi Albert Luthuli Central Hospital, Durban, South Africa.,5 Department of Nuclear Medicine, Nelson R Mandela Medical School, University of KwaZulu-Natal, Durban, South Africa
| | - Verena Gounden
- 1 Department of Chemical Pathology, Nelson R Mandela Medical School, University of KwaZulu-Natal, Durban, South Africa.,2 National Health Laboratory Services, Inkosi Albert Luthuli Central Hospital, Durban, South Africa
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Jialal I, Gounden V. Reporting LDL-cholesterol levels in the era of intensive lipid management: a clarion call. ACTA ACUST UNITED AC 2017; 55:1447-1449. [DOI: 10.1515/cclm-2017-0639] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Nella AA, Mallappa A, Perritt AF, Gounden V, Kumar P, Sinaii N, Daley LA, Ling A, Liu CY, Soldin SJ, Merke DP. A Phase 2 Study of Continuous Subcutaneous Hydrocortisone Infusion in Adults With Congenital Adrenal Hyperplasia. J Clin Endocrinol Metab 2016; 101:4690-4698. [PMID: 27680873 PMCID: PMC5155681 DOI: 10.1210/jc.2016-1916] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT Classic congenital adrenal hyperplasia (CAH) management remains challenging, given that supraphysiologic glucocorticoid doses are often needed to optimally suppress the ACTH-driven adrenal androgen overproduction. OBJECTIVE This study sought to approximate physiologic cortisol secretion via continuous subcutaneous hydrocortisone infusion (CSHI) and evaluate the safety and efficacy of CSHI in patients with difficult-to-treat CAH. DESIGN Eight adult patients with classic CAH participated in a single-center open-label phase I-II study comparing CSHI to conventional oral glucocorticoid treatment. All patients had elevated adrenal steroids and one or more comorbidities at study entry. Assessment while receiving conventional therapy at baseline and 6 months following CSHI included: 24-hour hormonal sampling, metabolic and radiologic evaluation, health-related quality-of-life (HRQoL), and fatigue questionnaires. MAIN OUTCOME MEASURES The ability of CSHI to approximate physiologic cortisol secretion and the percent of patients with 0700-hour 17-hydroxyprogesterone (17-OHP) ≤1200 ng/dL was measured. RESULTS CSHI approximated physiologic cortisol secretion. Compared with baseline, 6 months of CSHI resulted in decreased 0700-hour and 24-hour area under the curve 17-OHP, androstenedione, ACTH, and progesterone, increased osteocalcin, c-telopeptide and lean mass, and improved HRQoL (and SF-36 Vitality Score), and fatigue. One of three amenorrheic women resumed menses. One man had reduction of testicular adrenal rest tissue. CONCLUSIONS CSHI is a safe and well-tolerated modality of cortisol replacement that effectively approximates physiologic cortisol secretion in patients with classic CAH poorly controlled on conventional therapy. Improved adrenal steroid control and positive effects on HRQoL suggest that CSHI should be considered a treatment option for classic CAH. The long-term effect on established comorbidities requires further study.
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Affiliation(s)
- Aikaterini A Nella
- Eunice Kennedy Shriver National Institute of Child Health and Human Development (A.A.N. D.P.M.), National Institutes of Health, Bethesda, Maryland 20892; and National Institutes of Health Clinical Center (A.A.N., A.M., A.F.P., V.G., P.K., N.S., L.-A.D., A.L., C.-Y.L., S.J.S., D.P.M.), Bethesda, Maryland 20892
| | - Ashwini Mallappa
- Eunice Kennedy Shriver National Institute of Child Health and Human Development (A.A.N. D.P.M.), National Institutes of Health, Bethesda, Maryland 20892; and National Institutes of Health Clinical Center (A.A.N., A.M., A.F.P., V.G., P.K., N.S., L.-A.D., A.L., C.-Y.L., S.J.S., D.P.M.), Bethesda, Maryland 20892
| | - Ashley F Perritt
- Eunice Kennedy Shriver National Institute of Child Health and Human Development (A.A.N. D.P.M.), National Institutes of Health, Bethesda, Maryland 20892; and National Institutes of Health Clinical Center (A.A.N., A.M., A.F.P., V.G., P.K., N.S., L.-A.D., A.L., C.-Y.L., S.J.S., D.P.M.), Bethesda, Maryland 20892
| | - Verena Gounden
- Eunice Kennedy Shriver National Institute of Child Health and Human Development (A.A.N. D.P.M.), National Institutes of Health, Bethesda, Maryland 20892; and National Institutes of Health Clinical Center (A.A.N., A.M., A.F.P., V.G., P.K., N.S., L.-A.D., A.L., C.-Y.L., S.J.S., D.P.M.), Bethesda, Maryland 20892
| | - Parag Kumar
- Eunice Kennedy Shriver National Institute of Child Health and Human Development (A.A.N. D.P.M.), National Institutes of Health, Bethesda, Maryland 20892; and National Institutes of Health Clinical Center (A.A.N., A.M., A.F.P., V.G., P.K., N.S., L.-A.D., A.L., C.-Y.L., S.J.S., D.P.M.), Bethesda, Maryland 20892
| | - Ninet Sinaii
- Eunice Kennedy Shriver National Institute of Child Health and Human Development (A.A.N. D.P.M.), National Institutes of Health, Bethesda, Maryland 20892; and National Institutes of Health Clinical Center (A.A.N., A.M., A.F.P., V.G., P.K., N.S., L.-A.D., A.L., C.-Y.L., S.J.S., D.P.M.), Bethesda, Maryland 20892
| | - Lori-Ann Daley
- Eunice Kennedy Shriver National Institute of Child Health and Human Development (A.A.N. D.P.M.), National Institutes of Health, Bethesda, Maryland 20892; and National Institutes of Health Clinical Center (A.A.N., A.M., A.F.P., V.G., P.K., N.S., L.-A.D., A.L., C.-Y.L., S.J.S., D.P.M.), Bethesda, Maryland 20892
| | - Alexander Ling
- Eunice Kennedy Shriver National Institute of Child Health and Human Development (A.A.N. D.P.M.), National Institutes of Health, Bethesda, Maryland 20892; and National Institutes of Health Clinical Center (A.A.N., A.M., A.F.P., V.G., P.K., N.S., L.-A.D., A.L., C.-Y.L., S.J.S., D.P.M.), Bethesda, Maryland 20892
| | - Chia-Ying Liu
- Eunice Kennedy Shriver National Institute of Child Health and Human Development (A.A.N. D.P.M.), National Institutes of Health, Bethesda, Maryland 20892; and National Institutes of Health Clinical Center (A.A.N., A.M., A.F.P., V.G., P.K., N.S., L.-A.D., A.L., C.-Y.L., S.J.S., D.P.M.), Bethesda, Maryland 20892
| | - Steven J Soldin
- Eunice Kennedy Shriver National Institute of Child Health and Human Development (A.A.N. D.P.M.), National Institutes of Health, Bethesda, Maryland 20892; and National Institutes of Health Clinical Center (A.A.N., A.M., A.F.P., V.G., P.K., N.S., L.-A.D., A.L., C.-Y.L., S.J.S., D.P.M.), Bethesda, Maryland 20892
| | - Deborah P Merke
- Eunice Kennedy Shriver National Institute of Child Health and Human Development (A.A.N. D.P.M.), National Institutes of Health, Bethesda, Maryland 20892; and National Institutes of Health Clinical Center (A.A.N., A.M., A.F.P., V.G., P.K., N.S., L.-A.D., A.L., C.-Y.L., S.J.S., D.P.M.), Bethesda, Maryland 20892
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Stolze BR, Gounden V, Gu J, Elliott EA, Masika LS, Abel BS, Merke DP, Skarulis MC, Soldin SJ. An improved micro-method for the measurement of steroid profiles by APPI-LC-MS/MS and its use in assessing diurnal effects on steroid concentrations and optimizing the diagnosis and treatment of adrenal insufficiency and CAH. J Steroid Biochem Mol Biol 2016; 162:110-6. [PMID: 26721696 PMCID: PMC4917495 DOI: 10.1016/j.jsbmb.2015.12.024] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Revised: 12/03/2015] [Accepted: 12/15/2015] [Indexed: 12/12/2022]
Abstract
Our goals were to (1) develop an improved micro-method usable for neonates for steroid profile measurements and a method to measure androsterone, a key steroid in the recently described androgen backdoor pathway together, with dehydroepiandrosterone and (2) to assess if dehydroepiandrosterone diurnal concentration fluctuations exist potentially necessitating strict adherence to time of blood sample draw and requirement of separate time-dependent reference intervals. Liquid chromatography-tandem mass spectrometry was performed with an atmospheric pressure photoionization source [1]. For each sample 50μL (100μL for the backdoor pathway) of serum was deproteinized by adding 75μL (150μL for the backdoor pathway) of acetonitrile containing the internal standards. After centrifugation, 75μL (150μL for the backdoor pathway) of supernatant was diluted with 250μL of water and injected onto a Poroshell 120 EC-C8 column (SB-C8 column for the backdoor pathway). Within-run coefficients of variation ranged from 2.4 to 10.4% and between-day coefficients of variation from 2.9 to 11.2%. Comparison studies yielded correlation coefficient between 0.97 and 1.00 with recoveries of 90% or greater. Our methods analyze a 9 steroid profile and an additional 2 steroid profile (backdoor pathway) with minimal sample volume (usable in neonates optimizing early diagnosis of endocrinopathies and genetic diseases). Low limits of quantitation make these methods ideal for steroid measurement in women and prepubertal children. As diurnal variations of dehydroepiandrosterone and other steroids [2] concentrations are clinically significant we recommend that separate reference intervals be developed for 8 am, 8 pm, and midnight sample draws. The use of this approach in improving the diagnosis of patients with adrenal insufficiency and congenital adrenal hyperplasia is discussed.
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Affiliation(s)
- Brian R Stolze
- Department of Laboratory Medicine, National Institutes of Health, 10 Center Drive, Building 10, Room 2C-306, Bethesda, MD 20814, USA
| | - Verena Gounden
- Department of Laboratory Medicine, National Institutes of Health, 10 Center Drive, Building 10, Room 2C-306, Bethesda, MD 20814, USA
| | - Jianghong Gu
- Department of Laboratory Medicine, National Institutes of Health, 10 Center Drive, Building 10, Room 2C-306, Bethesda, MD 20814, USA
| | - Elizabeth A Elliott
- Department of Laboratory Medicine, National Institutes of Health, 10 Center Drive, Building 10, Room 2C-306, Bethesda, MD 20814, USA
| | - Likhona S Masika
- Department of Laboratory Medicine, National Institutes of Health, 10 Center Drive, Building 10, Room 2C-306, Bethesda, MD 20814, USA
| | - Brent S Abel
- National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), National Institutes of Health, 10Center Drive, Building 10, Room 6-3940, Bethesda, MD, 20814, USA
| | - Deborah P Merke
- Clinical Center and Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health, 10 Center Drive, Building 10, Room 1-2740, Bethesda, MD, 20814, USA
| | - Monica C Skarulis
- National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), National Institutes of Health, 10Center Drive, Building 10, Room 6-3940, Bethesda, MD, 20814, USA
| | - Steven J Soldin
- Department of Laboratory Medicine, National Institutes of Health, 10 Center Drive, Building 10, Room 2C-306, Bethesda, MD 20814, USA; Department of Medicine, Division of Endocrinology and Metabolism, Georgetown University, 3700 O St NW, Washington, D.C. 20057, USA.
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Korde N, Roschewski M, Zingone A, Kwok M, Manasanch EE, Bhutani M, Tageja N, Kazandjian D, Mailankody S, Wu P, Morrison C, Costello R, Zhang Y, Burton D, Mulquin M, Zuchlinski D, Lamping L, Carpenter A, Wall Y, Carter G, Cunningham SC, Gounden V, Sissung TM, Peer C, Maric I, Calvo KR, Braylan R, Yuan C, Stetler-Stevenson M, Arthur DC, Kong KA, Weng L, Faham M, Lindenberg L, Kurdziel K, Choyke P, Steinberg SM, Figg W, Landgren O. Treatment With Carfilzomib-Lenalidomide-Dexamethasone With Lenalidomide Extension in Patients With Smoldering or Newly Diagnosed Multiple Myeloma. JAMA Oncol 2016; 1:746-54. [PMID: 26181891 DOI: 10.1001/jamaoncol.2015.2010] [Citation(s) in RCA: 246] [Impact Index Per Article: 30.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Carfilzomib-lenalidomide-dexamethasone therapy yields deep responses in patients with newly diagnosed multiple myeloma (NDMM). It is important to gain an understanding of this combination's tolerability and impact on minimal residual disease (MRD) negativity because this end point has been associated with improved survival. OBJECTIVE To assess the safety and efficacy of carfilzomib-lenalidomide-dexamethasone therapy in NDMM and high-risk smoldering multiple myeloma (SMM). DESIGN, SETTING, AND PARTICIPANTS Clinical and correlative pilot study at the National Institutes of Health Clinical Center. Patients with NDMM or high-risk SMM were enrolled between July 11, 2011, and October 9, 2013. Median follow-up was 17.3 (NDMM) and 15.9 months (SMM). INTERVENTIONS Eight 28-day cycles were composed of carfilzomib 20/36 mg/m2 on days 1, 2, 8, 9, 15, and 16; lenalidomide 25 mg on days 1 through 21; and dexamethasone 20/10 mg (cycles 1-4/5-8) on days 1, 2, 8, 9, 15, 16, 22, and 23. Patients who achieved at least stable disease subsequently received 24 cycles of lenalidomide extended dosing. MAIN OUTCOMES AND MEASURES Primary end points were neuropathy of grade 3 or greater (NDMM) and at least very good partial response rates (SMM). Minimal residual disease was also assessed. RESULTS Of 45 patients with NDMM, none had neuropathy of grade 3 or greater. Of 12 patients with high-risk SMM, the most common of any-grade adverse events were lymphopenia (12 [100%]) and gastrointestinal disorders (11 [92%]). All patients with SMM achieved at least a very good partial response during the study period. Among the 28 patients with NDMM and the 12 with SMM achieving at least a near-complete response, MRD negativity was found in 28 of 28 (100% [95% CI, 88%-100%]), 11 of 12 (92% [95% CI, 62%-100%]) (multiparametric flow cytometry), 14 of 21 (67% [95% CI, 43%-85%]), and 9 of 12 (75% [95% CI, 43%-94%]) (next-generation sequencing), respectively. In patients with NDMM, 12-month progression-free survival for MRD-negative vs MRD-positive status by flow cytometry and next-generation sequencing was 100% vs 79% (95% CI, 47%-94%; P < .001) and 100% vs 95% (95% CI, 75%-99%; P = .02), respectively. CONCLUSIONS AND RELEVANCE Carfilzomib-lenalidomide-dexamethasone therapy is tolerable and demonstrates high rates of MRD negativity in NDMM, translating into longer progression-free survival in patients achieving MRD negativity. Carfilzomib-lenalidomide-dexamethasone therapy also demonstrates efficacy in high-risk SMM.
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Affiliation(s)
- Neha Korde
- Multiple Myeloma Section, Lymphoid Malignancies Branch, National Cancer Institute, National Institutes of Health, New York, New York2Myeloma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Mark Roschewski
- Multiple Myeloma Section, Lymphoid Malignancies Branch, National Cancer Institute, National Institutes of Health, New York, New York
| | - Adriana Zingone
- Multiple Myeloma Section, Lymphoid Malignancies Branch, National Cancer Institute, National Institutes of Health, New York, New York
| | - Mary Kwok
- Multiple Myeloma Section, Lymphoid Malignancies Branch, National Cancer Institute, National Institutes of Health, New York, New York
| | - Elisabet E Manasanch
- Multiple Myeloma Section, Lymphoid Malignancies Branch, National Cancer Institute, National Institutes of Health, New York, New York3Department of Lymphoma and Myeloma, University of Texas MD Anderson Cancer Center, Houston
| | - Manisha Bhutani
- Multiple Myeloma Section, Lymphoid Malignancies Branch, National Cancer Institute, National Institutes of Health, New York, New York4Medical Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland5Department of Hemato
| | - Nishant Tageja
- Multiple Myeloma Section, Lymphoid Malignancies Branch, National Cancer Institute, National Institutes of Health, New York, New York4Medical Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Dickran Kazandjian
- Multiple Myeloma Section, Lymphoid Malignancies Branch, National Cancer Institute, National Institutes of Health, New York, New York
| | - Sham Mailankody
- Multiple Myeloma Section, Lymphoid Malignancies Branch, National Cancer Institute, National Institutes of Health, New York, New York4Medical Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Peter Wu
- Multiple Myeloma Section, Lymphoid Malignancies Branch, National Cancer Institute, National Institutes of Health, New York, New York
| | - Candis Morrison
- Multiple Myeloma Section, Lymphoid Malignancies Branch, National Cancer Institute, National Institutes of Health, New York, New York
| | - Rene Costello
- Multiple Myeloma Section, Lymphoid Malignancies Branch, National Cancer Institute, National Institutes of Health, New York, New York
| | - Yong Zhang
- Multiple Myeloma Section, Lymphoid Malignancies Branch, National Cancer Institute, National Institutes of Health, New York, New York
| | - Debra Burton
- Multiple Myeloma Section, Lymphoid Malignancies Branch, National Cancer Institute, National Institutes of Health, New York, New York
| | - Marcia Mulquin
- Multiple Myeloma Section, Lymphoid Malignancies Branch, National Cancer Institute, National Institutes of Health, New York, New York
| | - Diamond Zuchlinski
- Multiple Myeloma Section, Lymphoid Malignancies Branch, National Cancer Institute, National Institutes of Health, New York, New York
| | - Liz Lamping
- Multiple Myeloma Section, Lymphoid Malignancies Branch, National Cancer Institute, National Institutes of Health, New York, New York
| | - Ashley Carpenter
- Multiple Myeloma Section, Lymphoid Malignancies Branch, National Cancer Institute, National Institutes of Health, New York, New York
| | - Yvonne Wall
- Multiple Myeloma Section, Lymphoid Malignancies Branch, National Cancer Institute, National Institutes of Health, New York, New York
| | - George Carter
- Multiple Myeloma Section, Lymphoid Malignancies Branch, National Cancer Institute, National Institutes of Health, New York, New York
| | - Schuyler C Cunningham
- Multiple Myeloma Section, Lymphoid Malignancies Branch, National Cancer Institute, National Institutes of Health, New York, New York
| | - Verena Gounden
- Hematology Service, Department of Laboratory Medicine, Center for Cancer Research, National Institutes of Health, Bethesda, Maryland
| | - Tristan M Sissung
- Department of Pharmacokinetics, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Cody Peer
- Department of Pharmacokinetics, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Irina Maric
- Hematology Service, Department of Laboratory Medicine, Center for Cancer Research, National Institutes of Health, Bethesda, Maryland
| | - Katherine R Calvo
- Hematology Service, Department of Laboratory Medicine, Center for Cancer Research, National Institutes of Health, Bethesda, Maryland
| | - Raul Braylan
- Hematology Service, Department of Laboratory Medicine, Center for Cancer Research, National Institutes of Health, Bethesda, Maryland
| | - Constance Yuan
- Lab of Pathology, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Maryalice Stetler-Stevenson
- Lab of Pathology, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Diane C Arthur
- Lab of Pathology, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | | | - Li Weng
- Sequenta Inc, San Francisco, California
| | | | - Liza Lindenberg
- Molecular Imaging Program, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Karen Kurdziel
- Molecular Imaging Program, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Peter Choyke
- Molecular Imaging Program, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Seth M Steinberg
- Biostatistics and Data Management Section, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - William Figg
- Department of Pharmacokinetics, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Ola Landgren
- Multiple Myeloma Section, Lymphoid Malignancies Branch, National Cancer Institute, National Institutes of Health, New York, New York2Myeloma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
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Little DJ, Yuan CM, Thurlow JS, Gounden V, Doi SQ, Pruziner A, Abbott KC, Theeler BJ, Olson SW. Effects of Traumatic Amputation on β-Trace Protein and β2-Microglobulin Concentrations in Male Soldiers. Am J Nephrol 2016; 42:436-42. [PMID: 26800100 DOI: 10.1159/000443775] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Accepted: 01/04/2016] [Indexed: 11/19/2022]
Abstract
BACKGROUND Serum creatinine (SCr) levels are decreased following traumatic amputation, leading to the overestimation of glomerular filtration rate (GFR). β-Trace protein (BTP) and β2-microglobulin (B2M) strongly correlate with measured GFR and have not been studied following amputation. We hypothesized that BTP and B2M would be unaffected by traumatic amputation. METHODS We used the Department of Defense Serum Repository to compare pre- and post-traumatic amputation serum BTP and B2M levels in 33 male soldiers, via the N Latex BTP and B2M nephelometric assays (Siemens Diagnostics, Tarrytown, N.Y., USA). Osterkamp estimation using DEXA scan measurements was used to establish percent estimated body weight loss (%EBWL). Results were analyzed for small (3-5.9% EBWL), medium (6-13.5%), and large (>13.5%) amputation subgroups; and for a control group matched 1:1 to the 12 large amputation subjects. Paired Student's t test was used for comparisons. RESULTS Mean serum BTP levels were unchanged in controls, all amputees, and the small and medium amputation subgroups. BTP appeared to decrease following large %EBWL amputation (p = 0.05). Mean serum B2M levels were unchanged in controls, all amputees, and the small and medium amputation subgroups. B2M appeared to increase following large %EBWL amputation (p = 0.05). CONCLUSIONS BTP and B2M levels are less affected than SCr by amputation, and should be considered for future study of GFR estimation. BTP and B2M changes following large %EBWL amputation require validation and may offer insight into non-GFR BTP and B2M determinants as well as increased cardiovascular disease and mortality following amputation.
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Affiliation(s)
- Dustin J Little
- Nephrology Service, Department of Medicine, Walter Reed National Military Medical Center, Bethesda, Md., USA
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Debono M, Mallappa A, Gounden V, Nella AA, Harrison RF, Crutchfield CA, Backlund PS, Soldin SJ, Ross RJ, Merke DP. Hormonal circadian rhythms in patients with congenital adrenal hyperplasia: identifying optimal monitoring times and novel disease biomarkers. Eur J Endocrinol 2015; 173:727-37. [PMID: 26340969 PMCID: PMC4623929 DOI: 10.1530/eje-15-0064] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2015] [Accepted: 09/04/2015] [Indexed: 11/08/2022]
Abstract
OBJECTIVES The treatment goal in congenital adrenal hyperplasia (CAH) is to replace glucocorticoids while avoiding androgen excess and iatrogenic Cushing's syndrome. However, there is no consensus on how to monitor disease control. Our main objectives were to evaluate hormonal circadian rhythms and use these profiles to identify optimal monitoring times and novel disease biomarkers in CAH adults on intermediate- and long-acting glucocorticoids. DESIGN This was an observational, cross-sectional study at the National Institutes of Health Clinical Center in 16 patients with classic CAH. METHODS Twenty-four-hour serum sampling for ACTH, 17-hydroxyprogesterone (17OHP), androstenedione (A4), androsterone, DHEA, testosterone, progesterone and 24-h urinary pdiol and 5β-pdiol was carried out. Bayesian spectral analysis and cosinor analysis were performed to detect circadian rhythmicity. The number of hours to minimal (TminAC) and maximal (TmaxAC) adrenocortical hormone levels after dose administration was calculated. RESULTS A significant rhythm was confirmed for ACTH (r(2), 0.95; P<0.001), 17OHP (r(2), 0.70; P=0.003), androstenedione (r(2), 0.47; P=0.043), androsterone (r(2), 0.80; P<0.001), testosterone (r(2), 0.47; P=0.042) and progesterone (r(2), 0.64; P=0.006). The mean (s.d.) TminAC and TmaxAC for 17OHP and A4 were: morning prednisone (4.3 (2.3) and 9.7 (3.5) h), evening prednisone (4.5 (2.0) and 10.3 (2.4) h), and daily dexamethasone (9.2 (3.5) and 16.4 (7.2) h). AUC0-24 h progesterone, androsterone and 24-h urine pdiol were significantly related to 17OHP. CONCLUSION In CAH patients, adrenal androgens exhibit circadian rhythms influenced by glucocorticoid replacement. Measurement of adrenocortical hormones and interpretation of results should take into account the type of glucocorticoid and time of dose administration. Progesterone and backdoor metabolites may provide alternative disease biomarkers.
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Affiliation(s)
- Miguel Debono
- National Institutes of Health Clinical CenterBuilding 10, Room 1-2742, 10 Center Drive, Bethesda, Maryland 20892, USAThe Eunice Kennedy Shriver National Institute of Child Health and Human DevelopmentBethesda, Maryland, USADepartment of Automatic Control and Systems EngineeringUniversity of Sheffield, Sheffield, UKAcademic Unit of EndocrinologyUniversity of Sheffield, Sheffield, UK National Institutes of Health Clinical CenterBuilding 10, Room 1-2742, 10 Center Drive, Bethesda, Maryland 20892, USAThe Eunice Kennedy Shriver National Institute of Child Health and Human DevelopmentBethesda, Maryland, USADepartment of Automatic Control and Systems EngineeringUniversity of Sheffield, Sheffield, UKAcademic Unit of EndocrinologyUniversity of Sheffield, Sheffield, UK
| | - Ashwini Mallappa
- National Institutes of Health Clinical CenterBuilding 10, Room 1-2742, 10 Center Drive, Bethesda, Maryland 20892, USAThe Eunice Kennedy Shriver National Institute of Child Health and Human DevelopmentBethesda, Maryland, USADepartment of Automatic Control and Systems EngineeringUniversity of Sheffield, Sheffield, UKAcademic Unit of EndocrinologyUniversity of Sheffield, Sheffield, UK
| | - Verena Gounden
- National Institutes of Health Clinical CenterBuilding 10, Room 1-2742, 10 Center Drive, Bethesda, Maryland 20892, USAThe Eunice Kennedy Shriver National Institute of Child Health and Human DevelopmentBethesda, Maryland, USADepartment of Automatic Control and Systems EngineeringUniversity of Sheffield, Sheffield, UKAcademic Unit of EndocrinologyUniversity of Sheffield, Sheffield, UK
| | - Aikaterini A Nella
- National Institutes of Health Clinical CenterBuilding 10, Room 1-2742, 10 Center Drive, Bethesda, Maryland 20892, USAThe Eunice Kennedy Shriver National Institute of Child Health and Human DevelopmentBethesda, Maryland, USADepartment of Automatic Control and Systems EngineeringUniversity of Sheffield, Sheffield, UKAcademic Unit of EndocrinologyUniversity of Sheffield, Sheffield, UK
| | - Robert F Harrison
- National Institutes of Health Clinical CenterBuilding 10, Room 1-2742, 10 Center Drive, Bethesda, Maryland 20892, USAThe Eunice Kennedy Shriver National Institute of Child Health and Human DevelopmentBethesda, Maryland, USADepartment of Automatic Control and Systems EngineeringUniversity of Sheffield, Sheffield, UKAcademic Unit of EndocrinologyUniversity of Sheffield, Sheffield, UK
| | - Christopher A Crutchfield
- National Institutes of Health Clinical CenterBuilding 10, Room 1-2742, 10 Center Drive, Bethesda, Maryland 20892, USAThe Eunice Kennedy Shriver National Institute of Child Health and Human DevelopmentBethesda, Maryland, USADepartment of Automatic Control and Systems EngineeringUniversity of Sheffield, Sheffield, UKAcademic Unit of EndocrinologyUniversity of Sheffield, Sheffield, UK
| | - Peter S Backlund
- National Institutes of Health Clinical CenterBuilding 10, Room 1-2742, 10 Center Drive, Bethesda, Maryland 20892, USAThe Eunice Kennedy Shriver National Institute of Child Health and Human DevelopmentBethesda, Maryland, USADepartment of Automatic Control and Systems EngineeringUniversity of Sheffield, Sheffield, UKAcademic Unit of EndocrinologyUniversity of Sheffield, Sheffield, UK
| | - Steven J Soldin
- National Institutes of Health Clinical CenterBuilding 10, Room 1-2742, 10 Center Drive, Bethesda, Maryland 20892, USAThe Eunice Kennedy Shriver National Institute of Child Health and Human DevelopmentBethesda, Maryland, USADepartment of Automatic Control and Systems EngineeringUniversity of Sheffield, Sheffield, UKAcademic Unit of EndocrinologyUniversity of Sheffield, Sheffield, UK
| | - Richard J Ross
- National Institutes of Health Clinical CenterBuilding 10, Room 1-2742, 10 Center Drive, Bethesda, Maryland 20892, USAThe Eunice Kennedy Shriver National Institute of Child Health and Human DevelopmentBethesda, Maryland, USADepartment of Automatic Control and Systems EngineeringUniversity of Sheffield, Sheffield, UKAcademic Unit of EndocrinologyUniversity of Sheffield, Sheffield, UK
| | - Deborah P Merke
- National Institutes of Health Clinical CenterBuilding 10, Room 1-2742, 10 Center Drive, Bethesda, Maryland 20892, USAThe Eunice Kennedy Shriver National Institute of Child Health and Human DevelopmentBethesda, Maryland, USADepartment of Automatic Control and Systems EngineeringUniversity of Sheffield, Sheffield, UKAcademic Unit of EndocrinologyUniversity of Sheffield, Sheffield, UK National Institutes of Health Clinical CenterBuilding 10, Room 1-2742, 10 Center Drive, Bethesda, Maryland 20892, USAThe Eunice Kennedy Shriver National Institute of Child Health and Human DevelopmentBethesda, Maryland, USADepartment of Automatic Control and Systems EngineeringUniversity of Sheffield, Sheffield, UKAcademic Unit of EndocrinologyUniversity of Sheffield, Sheffield, UK
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Sampson ML, Gounden V, van Deventer HE, Remaley AT. CUSUM-Logistic Regression analysis for the rapid detection of errors in clinical laboratory test results. Clin Biochem 2015; 49:201-7. [PMID: 26523981 DOI: 10.1016/j.clinbiochem.2015.10.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2015] [Revised: 10/20/2015] [Accepted: 10/28/2015] [Indexed: 11/24/2022]
Abstract
OBJECTIVE The main drawback of the periodic analysis of quality control (QC) material is that test performance is not monitored in time periods between QC analyses, potentially leading to the reporting of faulty test results. The objective of this study was to develop a patient based QC procedure for the more timely detection of test errors. METHOD Results from a Chem-14 panel measured on the Beckman LX20 analyzer were used to develop the model. Each test result was predicted from the other 13 members of the panel by multiple regression, which resulted in correlation coefficients between the predicted and measured result of >0.7 for 8 of the 14 tests. A logistic regression model, which utilized the measured test result, the predicted test result, the day of the week and time of day, was then developed for predicting test errors. The output of the logistic regression was tallied by a daily CUSUM approach and used to predict test errors, with a fixed specificity of 90%. RESULTS The mean average run length (ARL) before error detection by CUSUM-Logistic Regression (CSLR) was 20 with a mean sensitivity of 97%, which was considerably shorter than the mean ARL of 53 (sensitivity 87.5%) for a simple prediction model that only used the measured result for error detection. CONCLUSION A CUSUM-Logistic Regression analysis of patient laboratory data can be an effective approach for the rapid and sensitive detection of clinical laboratory errors.
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Affiliation(s)
- Maureen L Sampson
- Department of Laboratory Medicine, National Institutes of Health Clinical Center, Building 10, Room 2C-407, 9000 Rockville Pike, Bethesda, MD 20892, USA.
| | - Verena Gounden
- Department of Laboratory Medicine, National Institutes of Health Clinical Center, Building 10, Room 2C-407, 9000 Rockville Pike, Bethesda, MD 20892, USA.
| | - Hendrik E van Deventer
- Department of Laboratory Medicine, National Institutes of Health Clinical Center, Building 10, Room 2C-407, 9000 Rockville Pike, Bethesda, MD 20892, USA.
| | - Alan T Remaley
- Department of Laboratory Medicine, National Institutes of Health Clinical Center, Building 10, Room 2C-407, 9000 Rockville Pike, Bethesda, MD 20892, USA.
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Abstract
BACKGROUND High doses of Eltrombopag have been previously reported to cause bilirubin interference. Following receipt of a sample from a patient receiving high-dose Eltrombopag therapy, the laboratory decided to investigate the effect of this drug on routine chemistry testing. METHODS Interference studies were performed by spiking Eltrombopag into aliquots of a serum pool to give concentrations ranging from 0 to 500 µg/mL. The following analytes, namely albumin, alkaline phosphatase, alanine transaminase, aspartate transaminase, Urea, total calcium, cholesterol, triglycerides, glucose, high-density lipoprotein cholesterol, iron, magnesium, inorganic phosphate, creatinine, bicarbonate, transferrin, ferritin, electrolytes, total and direct bilirubin and serum indices (hemolysis, icterus and lipaemia) were then measured on the Roche Cobas 6000 chemistry analyzer (Roche, Indianapolis, USA). RESULTS Eltrombopag interference (>10% change of the baseline value) was observed for total cholesterol, triglycerides, inorganic phosphate and high-density lipoprotein cholesterol. Clinical significant interference was observed for total cholesterol, inorganic phosphate and high-density lipoprotein cholesterol CONCLUSIONS Presence of high Eltrombopag concentrations in blood samples has been demonstrated to cause interference in the measurement of certain spectrophotometric-based assays on the Roche Cobas 6000 analyzer.
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Affiliation(s)
- Verena Gounden
- Department of Laboratory Medicine, National Institutes of Health Clinical Center, Bethesda, Maryland, USA
| | - Zhen Zhao
- Department of Laboratory Medicine, National Institutes of Health Clinical Center, Bethesda, Maryland, USA
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Reddy A, Gounden V. The fat of the matter. Clin Chem 2015; 61:1307-8. [PMID: 26416921 DOI: 10.1373/clinchem.2015.240093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Ashandree Reddy
- Department of Chemical Pathology, University of KwaZulu Natal, Durban, South Africa; National Health Laboratory Services, Inkosi Albert Luthuli Central Hospital, Durban, South Africa
| | - Verena Gounden
- Department of Chemical Pathology, University of KwaZulu Natal, Durban, South Africa; National Health Laboratory Services, Inkosi Albert Luthuli Central Hospital, Durban, South Africa.
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25
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Seape T, Gounden V, van Deventer HE, Candy GP, George JA. Cystatin C- and creatinine-based equations in the assessment of renal function in HIV-positive patients prior to commencing Highly Active Antiretroviral Therapy. Ann Clin Biochem 2015; 53:58-66. [PMID: 25766385 DOI: 10.1177/0004563215579695] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/09/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND We evaluated the accuracy and precision of creatinine- and cystatin C-based prediction equations for estimating glomerular filtration rate compared to measured glomerular filtration rate in an antiretroviral-naive human immunodeficiency virus population. METHODS The study population consisted of 100 treatment-naive HIV patients. Glomerular filtration rate was estimated using the Cockcroft-Gault, Modification of Diet in Renal Disease (MDRD) and Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equations, as well as cystatin C-based equations (CKD-EPIcystatin C, cystatin Cvan Deventer and CKD-EPIcombined)) compared to (51)Cr-EDTA plasma clearance-measured glomerular filtration rate. We calculated percentage bias, standard deviation of the differences, accuracy within 15 and 30% of measured glomerular filtration rate and sensitivity and specificity for predicting measured glomerular filtration rate <60 mL/min/1.73 m(2). RESULTS Bias for all estimating glomerular filtration rate equations ranged from -9.4% to 38.4%. The CKD-EPIcombined without ethnicity correction factor equation had the least bias, 2.9% (-2.9 to 8.8). Bias was higher for the Modification of Diet in Renal Disease and CKD-EPI equation with the African-American ethnicity factor (38.4 and 33.7%) than without (14.2 and 15.3%). Standard deviation of the differences ranged from 29.2% (CKD-EPIcombined without ethnicity factor) to 54.0% (Modification of Diet in Renal Disease with ethnicity factor). Accuracy within 30% of measured glomerular filtration rate ranged from 78% for CKD-EPIcombined without ethnicity factor to 56.7% for the Cockcroft-Gault equation. Sensitivity for creatinine-based equations was less than 50% and for the CKD-EPIcystatin C equation was 75%. CONCLUSION Sensitivity of creatinine-based equations for predicting glomerular filtration rate was poor in this group of patients. The CKD-EPIcombined equation performed better than creatinine-based equations.
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Affiliation(s)
- Tebogo Seape
- Department of Chemical Pathology, University of Witwatersrand and National Health Laboratory Services, Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, South Africa
| | - Verena Gounden
- Department of Chemical Pathology, University of Witwatersrand and National Health Laboratory Services, Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, South Africa Department of Chemical Pathology, University of Kwa Zulu Natal and National Health Laboratory Services, Inkosi Albert Luthuli Central Hospital, Durban, South Africa
| | - Hendrick E van Deventer
- Department of Chemical Pathology, University of Witwatersrand and National Health Laboratory Services, Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, South Africa Lancet Laboratories, Auckland Park, Johannesburg, South Africa
| | - Geoffrey P Candy
- Department of Surgery, University of Witwatersrand, Johannesburg, South Africa
| | - Jaya A George
- Department of Chemical Pathology, University of Witwatersrand and National Health Laboratory Services, Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, South Africa
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Stolze BR, Gounden V, Gu J, Abel BS, Merke DP, Skarulis MC, Soldin SJ. Use of Micro-HPLC-MS/MS Method to Assess Diurnal Effects on Steroid Hormones. Clin Chem 2015; 61:556-8. [DOI: 10.1373/clinchem.2014.232546] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Brian R Stolze
- Department of Laboratory Medicine Clinical Center NIH, Bethesda, MD
| | - Verena Gounden
- Department of Laboratory Medicine Clinical Center NIH, Bethesda, MD
| | - Jianghong Gu
- Department of Laboratory Medicine Clinical Center NIH, Bethesda, MD
| | - Brent S Abel
- National Institute of Diabetes and Digestive and Kidney Diseases NIH, Bethesda, MD
| | - Deborah P Merke
- Clinical Center and Eunice Kennedy Shriver National Institute of Child Health and Human Development NIH, Bethesda, MD
| | - Monica C Skarulis
- National Institute of Diabetes and Digestive and Kidney Diseases NIH, Bethesda, MD
| | - Steven J Soldin
- Department of Laboratory Medicine Clinical Center NIH, Bethesda, MD
- Department of Medicine Georgetown University Washington, DC
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Gounden V, Sacks DB, Zhao Z. Interference of cerebrospinal fluid total protein measurement by povidone-iodine contamination. Clin Chim Acta 2015; 440:3-5. [PMID: 25446880 DOI: 10.1016/j.cca.2014.10.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2014] [Revised: 10/05/2014] [Accepted: 10/06/2014] [Indexed: 11/28/2022]
Abstract
BACKGROUND A falsely high cerebrospinal fluid (CSF) total protein (TP) result measured by pyrogallol red (PGR) method was suspected to be caused by preparation of the collection site with povidone-iodine (PVP-iodine) solution. METHODS CSF TP was evaluated for interference in samples with different final concentrations of PVP-iodine (up to 0.25% PVP and 0.025% iodine) or iodine alone (up to 0.025% iodine) using three methods: PGR, modified biuret and benzethonium chloride (BZTC). Interference exceeding ±20% of the baseline value is considered clinically significant according to the criterion defined by the College of American Pathologists. RESULTS There were positive interference with the PGR method and negative inference for the BZTC method in CSF samples spiked with PVP-iodine. The PVP-iodine (up to 0.25% PVP and 0.025% iodine) did not cause a clinically significant interference with the modified biuret method. PVP alone without iodine caused a positive interference with the PGR method but did not interfere with the modified biuret or the BZTC method. When the samples were spiked with iodine alone, none of the three methods was affected (change<20%) by iodine concentration up to 0.025%. CONCLUSIONS Contamination of CSF specimens with PVP-iodine can lead to interference with CSF TP measurements using PGR or BZTC methods.
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Affiliation(s)
- Verena Gounden
- Department of Laboratory Medicine, NIH Clinical Center, Building 10, Room 2C-249, Bethesda, MD 20892 USA
| | - David B Sacks
- Department of Laboratory Medicine, NIH Clinical Center, Building 10, Room 2C-249, Bethesda, MD 20892 USA
| | - Zhen Zhao
- Department of Laboratory Medicine, NIH Clinical Center, Building 10, Room 2C-249, Bethesda, MD 20892 USA.
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Kuzmina Z, Gounden V, Curtis L, Avila D, RNP TT, Baruffaldi J, Cowen EW, Naik HB, Hasni SA, Mays JW, Mitchell S, Baird K, Steinberg SM, Pavletic SZ. Clinical significance of autoantibodies in a large cohort of patients with chronic graft-versus-host disease defined by NIH criteria. Am J Hematol 2015; 90:114-9. [PMID: 25363867 DOI: 10.1002/ajh.23885] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2014] [Revised: 10/22/2014] [Accepted: 10/27/2014] [Indexed: 12/26/2022]
Abstract
There is an unmet need for identifying new clinical biomarkers in chronic Graft-versus-Host-disease (cGVHD) suitable for diagnosis and disease monitoring. Circulating autoantibodies represent an ongoing immune response and suggest a pathogenic role for B cells in cGVHD. Autoantibodies could be useful markers of cGVHD disease activity, severity, or organ specificity; however, their clinical utility is not established. The focus of this study was to determine the incidence and associations of a broad array of clinical autoantibodies with cGVHD manifestations in a large patient cohort characterized by NIH criteria. A panel of 21 circulating antibodies commonly used in clinical medicine was tested in 280 cGVHD patients (70% severe) enrolled in a cross-sectional prospective natural history study. Median cGVHD duration was two years. Patients with circulating autoantibodies (62%) had significantly higher levels of IgM (P < 0.0001), IgG (P < 0.0001), and IgA (P = 0.001), elevated uric acid (P = 0.008) and total protein (P = 0.0004), and higher numbers of CD3+ (P = 0.002), CD4+ (P = 0.001), CD8+ (P = 0.023) T cells, and CD19+ B cells (P < 0.0001). Multiple antibodies were detected in 35% of patients. Prior rituximab therapy (n = 66) was associated with reduced presence of autoantibodies (48 vs. 66% P = 0.01). Only oral cGVHD was significantly associated with presence of autoantibodies in this study (P = 0.028). No significant associations were found between cGVHD activity and severity, and presence of autoantibodies. Circulating autoantibodies are common in patients with advanced cGVHD. Their presence is associated with better quantitative immunologic reconstitution but does not have utility as a clinical biomarker of cGVHD.
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Affiliation(s)
- Zoya Kuzmina
- Graft-versus-Host and Autoimmunity Unit, Experimental Transplantation and Immunology Branch, National Cancer Institute NCI, National Institutes of Health; Bethesda Maryland
- Internal Medicine Department; Evangelical Hospital; Vienna Austria
| | - Verena Gounden
- Department of Laboratory Medicine; Clinical Center, National Cancer Institute NCI, National Institutes of Health
| | - Lauren Curtis
- Graft-versus-Host and Autoimmunity Unit, Experimental Transplantation and Immunology Branch, National Cancer Institute NCI, National Institutes of Health; Bethesda Maryland
| | - Daniele Avila
- Graft-versus-Host and Autoimmunity Unit, Experimental Transplantation and Immunology Branch, National Cancer Institute NCI, National Institutes of Health; Bethesda Maryland
| | - Tiffani Taylor RNP
- Graft-versus-Host and Autoimmunity Unit, Experimental Transplantation and Immunology Branch, National Cancer Institute NCI, National Institutes of Health; Bethesda Maryland
| | - Judy Baruffaldi
- Graft-versus-Host and Autoimmunity Unit, Experimental Transplantation and Immunology Branch, National Cancer Institute NCI, National Institutes of Health; Bethesda Maryland
| | - Edward W. Cowen
- Dermatology Branch, National Cancer Institute NCI, National Institutes of Health
| | - Haley B. Naik
- Dermatology Branch, National Cancer Institute NCI, National Institutes of Health
| | - Sarfaraz A. Hasni
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Cancer Institute NCI, National Institutes of Health
| | | | - Sandra Mitchell
- Outcomes Research Branch, Division of Cancer Control and Population Sciences NIH
| | - Kristin Baird
- Pediatric Oncology Branch, National Cancer Institute NCI, National Institutes of Health
| | - Seth M. Steinberg
- Biostatistics and Data Management Section NIH, Center for Cancer Research
| | - Steven Z. Pavletic
- Graft-versus-Host and Autoimmunity Unit, Experimental Transplantation and Immunology Branch, National Cancer Institute NCI, National Institutes of Health; Bethesda Maryland
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Gounden V, Rampursat Y. An audit of immunofixation requesting practices at a South African referral laboratory. Afr J Lab Med 2014; 3:91. [PMID: 29043173 PMCID: PMC5637766 DOI: 10.4102/ajlm.v3i1.91] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2013] [Accepted: 07/09/2014] [Indexed: 12/02/2022] Open
Abstract
Background It is common practice in most chemical pathology laboratories for reflective immunofixation electrophoresis (IFE) to occur following the detection or suspicion of a paraprotein on serum protein electrophoresis (SPEP). The chemical pathology laboratory at Inkosi Albert Luthuli Central Hospital (IALCH) in Durban, South Africa, is currently the only non-private laboratory in the KwaZulu Natal province that performs SPEP analysis, with current practice requiring that the clinician request IFE following suggestion by the laboratory after a suspicious SPEP result. Objectives To review the current process for IFE at IALCH in the context of reflective testing and to examine the use of the alpha-2-globulin/alpha-1-globulin ratio as a predictor of a positive IFE result. Methods Data for 1260 consecutive SPEP tests performed at the IALCH National Health Laboratory Service were collected between February and July 2011. SPEP and IFE were performed with a Sebia Hydrasys automated electrophoresis system. The alpha-2-globulin/alpha-1-globulin ratio was calculated using density of corresponding fractions on SPEP. Results Analysis revealed that of the 1260 SPEPs performed during the analysis period, 304 IFEs were suggested by the reviewing pathologist. A total of 45 (15%) of the suggested IFEs were subsequently requested by the attending clinicians. Almost half (46.5%) (n = 20) of the suggested IFEs that were performed revealed the presence of a paraprotein. There was no statistically-significant difference between the alpha-2-globulin/alpha-1-globulin ratio for patients with positive or negative IFEs (p-value = 0.2). Conclusions This study reveals the need for reflective addition of IFE testing by the laboratory following suspicious findings on SPEP.
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Affiliation(s)
- Verena Gounden
- Department of Chemical Pathology, National Health Laboratory Services, Inkosi Albert Luthuli Central Hospital, South Africa.,Nelson R Mandela School of Medicine, University of KwaZulu-Natal, South Africa
| | - Yashna Rampursat
- Department of Chemical Pathology, National Health Laboratory Services, Inkosi Albert Luthuli Central Hospital, South Africa.,Nelson R Mandela School of Medicine, University of KwaZulu-Natal, South Africa
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30
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Affiliation(s)
- Verena Gounden
- Department of Laboratory Medicine, National Institutes of Health Clinical Center, Bethesda, MD
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31
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Gounden V, Jonklaas J, Soldin SJ. A pilot study: subclinical hypothyroidism and free thyroid hormone measurement by immunoassay and mass spectrometry. Clin Chim Acta 2013; 430:121-4. [PMID: 24389098 DOI: 10.1016/j.cca.2013.12.034] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2013] [Revised: 12/23/2013] [Accepted: 12/23/2013] [Indexed: 11/28/2022]
Abstract
BACKGROUND The diagnosis of subclinical hypothyroidism is defined as the presence of an elevated thyroid stimulating hormone (TSH) with a normal free thyroxine (FT4) level. The commonly used direct analogue immunoassays for the measurement of FT4 have been shown to have poor performance at the upper and lower limits of the FT4 reference interval. PURPOSE The purpose of this pilot study was to investigate the percentage of individuals classified as having subclinical hypothyroidism with a standard immunoassay, that actually have low free thyroid hormone levels by mass spectrometry measurements. DESIGN Outpatient samples with elevated TSH values and normal FT4 concentrations as per standard immunoassay methods were collected. FT4 and free triiodothyronine (FT3) analyses were performed on these samples using liquid chromatography-tandem mass spectrometry (LC-MS/MS). RESULTS Sixty five percent (n=26) of patients (n=40) had (LC-MS/MS) FT4 or FT3 or both FT4 and FT3 values below mass spectrometry reference limits. CONCLUSIONS Our findings indicate that the direct analogue immunoassay method for FT4 measurement results in a significant proportion of patients being misclassified as having subclinical hypothyroidism.
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Affiliation(s)
- Verena Gounden
- Department of Laboratory Medicine, NIH Clinical Center, Bethesda, MD, USA
| | - Jacqueline Jonklaas
- Division of Endocrinology, Georgetown University Medical Center, Washington, DC, USA
| | - Steven J Soldin
- Department of Laboratory Medicine, NIH Clinical Center, Bethesda, MD, USA; Division of Endocrinology, Georgetown University Medical Center, Washington, DC, USA.
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Affiliation(s)
- Verena Gounden
- Department of Laboratory Medicine National Institutes of Health Clinical Center Bethesda, MD
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Manasanch EE, Braylan R, Stetler-Stevenson M, Yuan C, Gounden V, Korde N, Tageja N, Bhutani M, Calvo K, Maric I, Roschewski M, Staudt LM, Landgren O. Lack of MYD88 L265P in non-immunoglobulin M lymphoplasmacytic lymphoma. Leuk Lymphoma 2013; 55:1402-3. [PMID: 23915224 DOI: 10.3109/10428194.2013.831091] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Bowen RAR, Sattayapiwat A, Gounden V, Remaley AT. Blood collection tube-related alterations in analyte concentrations in quality control material and serum specimens. Clin Biochem 2013; 47:150-7. [PMID: 24240064 DOI: 10.1016/j.clinbiochem.2013.11.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2013] [Revised: 11/05/2013] [Accepted: 11/06/2013] [Indexed: 10/26/2022]
Abstract
OBJECTIVES Several previous studies have described the effects of interfering substances on clinical assay results; however, the effects of exogenous substances, particularly additives from blood collection tubes on quality control (QC) specimens and serum specimens have not been well examined. This study examines the effects of blood-collection tube additives on total triiodothyronine (TT3), and thyroxine (TT4), cortisol, and routine clinical chemistry tests in QC and serum specimens from apparently healthy volunteers. METHODS QC and serum specimens were poured or collected into different blood collection tubes. TT3 and TT4, cortisol, and routine chemistry tests were analyzed from the different blood-collection tube types. RESULTS The findings of this study demonstrate statistically and/or clinically significant blood collection tube-related alterations in the TT3, TT4, and cortisol concentrations of QC specimens and TT4 concentrations from serum specimens. CONCLUSIONS These findings have important implications for clinical laboratories, demonstrating that QC specimens should ideally, like patients' specimens, be poured into blood collection tubes. This strategy would reveal any adverse effects caused by blood collection tubes, which otherwise would not likely be detected by most routine QC practices. The results of this study also show the importance of producing blood collection tubes that contain additives that are truly inert and do not adversely affect clinical laboratory testing.
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Affiliation(s)
- Raffick A R Bowen
- Department of Pathology, Stanford University, Stanford, CA 94305, USA.
| | | | - Verena Gounden
- Dept. of Laboratory Medicine, National Institutes of Health, Bethesda, MD 20892, USA
| | - Alan T Remaley
- Dept. of Laboratory Medicine, National Institutes of Health, Bethesda, MD 20892, USA
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Affiliation(s)
- Verena Gounden
- Department of Chemical Pathology, University of KwaZulu-Natal, Durban, South Africa.
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Gounden V, George J. Multi point of care instrument evaluation for use in anti-retroviral clinics in South Africa. Clin Lab 2012; 58:27-40. [PMID: 22372343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
BACKGROUND South Africa has the largest prevalence of HIV infected individuals in the world. The introduction of point of care testing to anti-retroviral (ARV) clinic sites is hoped to fast track initiation of patients on ARVs and to allow for earlier recognition of adverse effects such as dyslipidaemia, renal and hepatic dysfunction. METHODS We evaluated six instruments for the following analytes: glucose, lactate, creatinine, cholesterol, triglycerides, HDL-cholesterol, alanine transaminase (ALT), and glycated haemoglobin. Comparisons with the central laboratory analyser were performed as well as precision studies. A scoring system was developed by the authors to evaluate the instruments in terms of analytical performance, cost, ease of use, and other operational characteristics. As one of the goals of the placement of these instruments was that their operation was simple enough to be used by non-laboratory staff, ease of use contributed a large proportion to the final scoring. RESULTS Analytical performance of the POC analysers were generally similar, however, there were significant differences in operational characteristics and ease of use. Bias for the different analytes when compared to the laboratory analyser ranged from -27% to 14%. Calculated total errors for all analytes except for HDL cholesterol were within total allowable error recommendations. The two instruments (Roche Reflotron and Cholestech LDX) with the highest overall total points achieved the highest scores for ease of use. CONCLUSIONS This pilot study has led to the development of a scoring system for the evaluation of POC instruments.
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Affiliation(s)
- Verena Gounden
- Department of Chemical Pathology, University of the Witwatersrand and National Health Laboratory Services, Parktown, Johannesburg, South Africa.
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Gounden V, van Niekerk C, Snyman T, George JA. Presence of the CYP2B6 516G> T polymorphism, increased plasma Efavirenz concentrations and early neuropsychiatric side effects in South African HIV-infected patients. AIDS Res Ther 2010; 7:32. [PMID: 20723261 PMCID: PMC2933581 DOI: 10.1186/1742-6405-7-32] [Citation(s) in RCA: 102] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2010] [Accepted: 08/19/2010] [Indexed: 01/11/2023] Open
Abstract
Background The 516G > T polymorphism in exon 4 of the CYP2B6 gene has been associated with increased plasma Efavirenz (EFV) concentrations. EFV concentrations greater than the recommended therapeutic range have been associated with the increased likelihood of developing adverse CNS effects. The aims of this study were to a) determine the presence of the 516G > T and other CYP2B6 exon 4 polymorphisms in a South African group of HIV-infected individuals b) investigate the relationship between the EFV plasma concentrations, the CYP2B6 516G > T polymorphism and the occurrence of CNS related side effects in this group of patients and c) develop and validate a rapid method for determination of EFV in plasma. Method Data from 80 patients is presented. Genetic polymorphisms in exon 4 of the CYP2B6 gene were identified using PCR amplification of this region followed by sequencing of the amplification products. EFV concentrations were analysed by UPLC-MS/MS. Assessment of the presence of CNS related side effects following EFV initiation were elicited with the use of a questionnaire together with physical examination. Results Plasma EFV concentrations displayed high inter-individual variability amongst subjects with concentrations ranging from 94 μg/l to 23227 μg/l at 2 weeks post initiation of treatment. For the 516G > T polymorphism the following frequencies were observed 23% of patients were TT homozygous, 36% GG and 41% GT. The TT homozygous patients had significantly higher EFV concentrations vs. those with the wild (GG) genotype (p < 0.05). Patients who experienced no side effects had significantly lower EFV plasma concentrations vs. the group of patients which experienced the most severe side effects (p < 0.05). Conclusion The significant association between the 516G > T polymorphism and plasma EFV concentrations has been demonstrated in this study. A rapid and sensitive method for the measurement of plasma EFV concentration was developed and validated.
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