Glucose-6-phosphate dehydrogenase laboratory assay: How, when, and why?

Glucose 6-phosphate dehydrogenase (G6PD) deficiency is the most common defect of red blood cells. Although some different laboratory techniques or methods are employed for the biochemical screening, a strict relationship between biochemists, clinicians, and molecular biologists is necessary for a definitive diagnosis. This article represents an overview on the current laboratory tests finalized to the screening or to the definitive diagnosis of G6PD-deficiency, underlying the problems regarding the biochemical and molecular identification of heterozygote females other than those regarding the standardization of the clinical and laboratory diagnostic procedures. Finally, this review is aimed to give a flow-chart for the complete diagnostic approach of G6PD-deficiency.     

Impact of Laboratory Test Use Strategies in a Turkish Hospital

ObjectivesEliminating unnecessary laboratory tests is a good way to reduce costs while maintain patient safety. The aim of this study was to define and process strategies to rationalize laboratory use in Ankara Numune Training and Research Hospital (ANH) and calculate potential savings in costs.MethodsA collaborative plan was defined by hospital managers; joint meetings with ANHTA and laboratory professors were set; the joint committee invited relevant staff for input, and a laboratory efficiency committee was created. Literature was reviewed systematically to identify strategies used to improve laboratory efficiency. Strategies that would be applicable in local settings were identified for implementation, processed, and the impact on clinical use and costs assessed for 12 months.ResultsLaboratory use in ANH differed enormously among clinics. Major use was identified in internal medicine. The mean number of tests per patient was 15.8. Unnecessary testing for chloride, folic acid, free prostate specific antigen, hepatitis and HIV testing were observed. Test panel use was pinpointed as the main cause of overuse of the laboratory and the Hospital Information System test ordering page was reorganized. A significant decrease (between 12.6–85.0%) was observed for the tests that were taken to an alternative page on the computer screen. The one year study saving was equivalent to 371,183 US dollars.ConclusionHospital-based committees including laboratory professionals and clinicians can define hospital based problems and led to a standardized approach to test use that can help clinicians reduce laboratory costs through appropriate use of laboratory tests.     

Usefulness of molecular markers for detecting population bottlenecks via monitoring genetic change

It is important to detect population bottlenecks in threatened and managed species because bottlenecks can increase the risk of population extinction. Early detection is critical and can be facilitated by statistically powerful monitoring programs for detecting bottleneck-induced genetic change. We used Monte Carlo computer simulations to evaluate the power of the following tests for detecting genetic changes caused by a severe reduction in a population's effective size ( N _e): a test for loss of heterozygosity, two tests for loss of alleles, two tests for change in the distribution of allele frequencies, and a test for small N _e based on variance in allele frequencies (the 'variance test'). The variance test was most powerful; it provided an 85% probability of detecting a bottleneck of size N _e = 10 when monitoring five microsatellite loci and sampling 30 individuals both before and one generation after the bottleneck. The variance test was almost 10-times more powerful than a commonly used test for loss of heterozygosity, and it allowed for detection of bottlenecks before 5% of a population's heterozygosity had been lost. The second most powerful tests were generally the tests for loss of alleles. However, these tests had reduced power for detecting genetic bottlenecks caused by skewed sex ratios. We provide guidelines for the number of loci and individuals needed to achieve high-power tests when monitoring via the variance test. We also illustrate how the variance test performs when monitoring loci that have widely different allele frequency distributions as observed in five wild populations of mountain sheep ( Ovis canadensis ).     

A THEORETICAL NOTE ON DIFFERENCE TESTS: MODELS, PARADOXES AND COGNITIVE STRATEGIES

A simple nonmathematical introduction is given to Thurstonian modeling and its application to difference testing. The theoretical treatment explains differences in performance noted for various difference test protocols and the so-called paradox of discriminatory nondiscriminators, whereby a slight change in instructions to the judge can alter the proportion of tests performed correctly. From this, the assumptions in the use of binomial statistics for analyzing difference tests and their shortcomings, are discussed. New ideas on the generality of the paradox of discriminatory nondiscriminators are discussed, along with the effects of the cognitive strategy adopted by the judge during testing.     

A multiple comparison procedure for dose-finding trials with subpopulations

Identifying subgroups of patients with an enhanced response to a new treatment has become an area of increased interest in the last few years. When there is knowledge about possible subpopulations with an enhanced treatment effect before the start of a trial it might be beneficial to set up a testing strategy, which tests for a significant treatment effect not only in the full population, but also in these prespecified subpopulations. In this paper, we present a parametric multiple testing approach for tests in multiple populations for dose-finding trials. Our approach is based on the MCP-Mod methodology, which uses multiple comparison procedures (MCPs) to test for a dose–response signal, while considering multiple possible candidate dose–response shapes. Our proposed methods allow for heteroscedastic error variances between populations and control the family-wise error rate over tests in multiple populations and for multiple candidate models. We show in simulations that the proposed multipopulation testing approaches can increase the power to detect a significant dose–response signal over the standard single-population MCP-Mod, when the specified subpopulation has an enhanced treatment effect.     

Bioassay testing for Australia as part of water quality assessment programmes

Abstract Bioassay testing includes both toxicity (one or more effects is measured) and bioaccumulation (the phenomenon of tissue accumulation is measured) tests. Both types of bioassay tests have an important place in water quality assessment programmes, ideally beginning with initial screening and as part of tiered testing that includes contaminant analyses and field studies. Both have advantages (e. g. measure bioavailability, provide quantitative data, experimental manipulations can address cause-effect relationships) and disadvantages (e. g. laboratory exposures do not necessarily reflect field conditions, not all organisms can be tested). Both provide essential, but not all, information necessary for holistic water quality assessments. This paper provides a review of the use of bioassays including definitions, applications, advantages and disadvantages, utility and relevance. The utility of bioassays in monitoring programmes is illustrated by two case studies. The first case study, involving novel toxicity studies conducted in the high Arctic, illustrates the versatility of bioassays such that testing conducted in a tent on the ice resulted in new knowledge and a change in industrial discharge limits. The second case study further illustrates the importance of bioassays in decision making. In this case, a decision not to immediately spend hundreds of millions of dollars for sewage treatment, but rather to concentrate on source control, was made based in large part on bioassay testing conducted as part of an integrated environmental assessment.     

Understanding HPV tests and their appropriate applications

Greater understanding of the role played by human papillomavirus (HPV) in the causation of disease has led to the development of an increasing number of HPV tests with different characteristics. The bewildering choice facing healthcare professionals and providers is daunting. Clearly, HPV testing is no longer simply of research interest, but can provide information that can be used for individual patient management and at the population level for cervical screening and vaccine surveillance. This review aims to provide the background to the development of HPV tests, to explain the different technologies and to discuss the challenges of the application of these optimally in the varied contexts of disease management. Few HPV tests are approved for clinical use and it is important that clinicians understand which test can be utilized, in what circumstances, with what specimens and the meaning of the report issued. HPV testing is no longer applicable only to cervical disease, and we have suggested additional areas, such as the oropharynx, in which HPV testing services might be implemented in the near future. New tests will continue to emerge and we have identified some of the indirect measures of HPV activity, or biomarkers, that could help in the risk stratification of HPV infection and associated disease. The challenges relating to the optimal application of the various HPV technologies are compounded by the lack of evidence regarding their performance in vaccinated populations. Currently published work, including modelling studies, has been undertaken in non‐immunized populations. We therefore end by addressing the issues regarding appropriate strategies and tests for immunized populations.     

Interpretative difficulties with growth hormone provocative retesting in childhood-onset growth hormone deficiency

A review of literature demonstrates that there are many ill-understood factors that determine the results of GH provocative (re)testing, so that these results should be interpreted with extreme caution when used for diagnosis or confirmation of diagnosis of GHD. GH provocation tests are probably of no value at all for what has been called 'partial GHD'. The phenomenon of 'normalization' of test results after long-term treatment with GH needs no 'transient GHD' hypothesis as it can be largely explained by the very low reproducibility of the tests and by a regression to the mean effect. Moreover, it is possible that 'normal values' increase with age. Other determinants of normal peak values may also change from childhood to adulthood and contribute to 'normalization'.     

Computer system for assisting with clinical interpretation of tumour marker data.

OBJECTIVE--To design and evaluate a computer advisory system for the treatment of gestational trophoblastic tumour. DESIGN--A comparison of clinicians'' treatment decisions with those of the computer system. Two datasets were used: one to calibrate the system and one to independently evaluate it. SETTING--Department of medical oncology. PATIENTS--Computerised records of 290 patients with low risk gestational trophoblastic tumour for whom the advisory system could predict the adequacy of treatment. The calibration set comprised patients admitted during 1979-86(227) and the test set patients during 1986-89(63). MAIN OUTCOME MEASURES--The system''s accuracy in predicting need to change treatment compared with clinicians'' actions. The mean time faster that the system was in predicting the need to change treatment. RESULTS--On the calibration dataset the system was 94% (164/174) accurate in predicting patients whose treatment was adequate, recommending change when none occurred in only 10 (6%) patients. In patients whose treatment was changed the system recommended change earlier than clinicians in 39/53 cases (74%), with a mean time advantage of 14.9 (SE 2.02) days. On the test dataset the system had an accuracy of 91% (31/34) in predicting treatment adequacy and a false positive rate of 9% (3/34). The system recommended change earlier than clinicians in 22/29 cases (76%), with a mean time advantage of 12.5 (2.22) days. CONCLUSIONS--The computer advisory system could improve patient management by reducing the time spent receiving ineffective treatment. This has implications for both patient time and clinical costs.     

More Powerful Likelihood Ratio Tests for Isotonic Binomial Proportions

Binomial group testing involves pooling individuals into groups and observing a binary response on each group. Results from the group tests can then be used to draw inference about population proportions. Its use as an experimental design has received much attention in recent years, especially in public‐health screening experiments and vector‐transfer designs in plant pathology. We investigate the benefits of group testing in situations wherein one desires to test whether or not probabilities are increasingly ordered across the levels of an observed qualitative covariate, i.e., across strata of a population or among treatment levels. We use a known likelihood ratio test for individual testing, but extend its use to group‐testing situations to show the increases in power conferred by using group testing when operating in this constrained parameter space. We apply our methods to data from an HIV study involving male subjects classified as intraveneous drug users.     

Cost-Effectiveness of HIV Drug Resistance Testing to Inform Switching to Second Line Antiretroviral Therapy in Low Income Settings

Background

To guide future need for cheap resistance tests for use in low income settings, we assessed cost-effectiveness of drug resistance testing as part of monitoring of people on first line ART - with switching from first to second line ART being conditional on NNRTI drug resistance mutations being identified.

Methods

An individual level simulation model of HIV transmission, progression and the effect of ART which accounts for adherence and resistance development was used to compare outcomes of various potential monitoring strategies in a typical low income setting in sub-Saharan Africa. Underlying monitoring strategies considered were based on clinical disease, CD4 count or viral load. Within each we considered a strategy in which no further measures are performed, one with a viral load measure to confirm failure, and one with both a viral load measure and a resistance test. Predicted outcomes were assessed over 2015–2025 in terms of viral suppression, first line failure, switching to second line regimen, death, HIV incidence, disability-adjusted-life-years averted and costs. Potential future low costs of resistance tests ($30) were used.

Results

The most effective strategy, in terms of DALYs averted, was one using viral load monitoring without confirmation. The incremental cost-effectiveness ratio for this strategy was $2113 (the same as that for viral load monitoring with confirmation). ART monitoring strategies which involved resistance testing did not emerge as being more effective or cost effective than strategies not using it. The slightly reduced ART costs resulting from use of resistance testing, due to less use of second line regimens, was of similar magnitude to the costs of resistance tests.

Conclusion

Use of resistance testing at the time of first line failure as part of the decision whether to switch to second line therapy was not cost-effective, even though the test was assumed to be very inexpensive.     

A Multi-Tracer Push-Pull Diagnostic Test for In Situ Air Sparging Systems

This document describes the development and initial application of a multi-tracer push-pull test designed to provide near real-time point-specific measures of contaminant volatilization and aerobic biodegrada-tion rates during in situ air sparging (IAS) operation. Measured biodegradation and volatilization rates are specific to the tracers used, so the results provide relative measures useful for identifying spatial differences in treatment performance and changes in performance with changes in system operation and design. The diagnostic test involves injecting a solution containing multiple tracer compounds into the target treatment zone through a monitoring well, piezometer, or drive point. The injected solution is initially deoxygenated and can contain: (a) a nondegradable, non-volatile conservative tracer, (b) one or more nondegradable, volatile chemicals, (c) an aerobically biodegradable, nonvolatile compound, and (d) a visible dye. After some predetermined hold time, an excess quantity of groundwater is extracted from the same injection point and the change in the concentrations of the tracer compounds is measured. Volatilization and oxygen utilization rates are then estimated from mass balances on the tracer components. The development of this diagnostic tool was conducted in a controlled physical model study and then initial field tests were conducted at the U.S. Navy Hydrocarbon National Test Site (HNTS) in Port Hueneme, California. Spatial variations in oxygenation and volatilization rates were observed, with oxygenation rates varying from 0 to 51 mg-O₂/L-water/d, and tracer volatilization rates varying from 0 to 47%/d. Acetate and sulfur hexafluoride (SF₆) were used as tracers in the initial testing, and it was discovered that these are not ideal choices due to the potential for anaerobic acetate biodegradation and SF₆ partitioning into trapped gas in the aquifer.     

Simple sequential boundaries for treatment selection in multi-armed randomized clinical trials with a control

Summary .   In situations when many regimens are possible candidates for a large phase III study, but too few resources are available to evaluate each relative to the standard, conducting a multi-armed randomized selection trial is a useful strategy to remove inferior treatments from further consideration. When the study has a relatively quick endpoint such as an imaging-based lesion volume change in acute stroke patients, frequent interim monitoring of the trial is ethically and practically appealing to clinicians. In this article, I propose a class of sequential selection boundaries for multi-armed clinical trials, in which the objective is to select a treatment with a clinically significant improvement upon the control group, or to declare futility if no such treatment exists. The proposed boundaries are easy to implement in a blinded fashion, and can be applied on a flexible monitoring schedule in terms of calendar time. Design calibration with respect to prespecified levels of confidence is simple, and can be accomplished when the response rate of the control group is known only up to an interval. One of the proposed methods is applied to redesign a selection trial with an imaging endpoint in acute stroke patients, and is compared to an optimal two-stage design via simulations: The proposed method imposes smaller sample size on average than the two-stage design; this advantage is substantial when there is in fact a superior treatment to the control group.     

Methods Used in Economic Evaluations of Chronic Kidney Disease Testing — A Systematic Review

BackgroundThe prevalence of chronic kidney disease (CKD) is high in general populations around the world. Targeted testing and screening for CKD are often conducted to help identify individuals that may benefit from treatment to ameliorate or prevent their disease progression.AimsThis systematic review examines the methods used in economic evaluations of testing and screening in CKD, with a particular focus on whether test accuracy has been considered, and how analysis has incorporated issues that may be important to the patient, such as the impact of testing on quality of life and the costs they incur.MethodsArticles that described model-based economic evaluations of patient testing interventions focused on CKD were identified through the searching of electronic databases and the hand searching of the bibliographies of the included studies.ResultsThe initial electronic searches identified 2,671 papers of which 21 were included in the final review. Eighteen studies focused on proteinuria, three evaluated glomerular filtration rate testing and one included both tests. The full impact of inaccurate test results was frequently not considered in economic evaluations in this setting as a societal perspective was rarely adopted. The impact of false positive tests on patients in terms of the costs incurred in re-attending for repeat testing, and the anxiety associated with a positive test was almost always overlooked. In one study where the impact of a false positive test on patient quality of life was examined in sensitivity analysis, it had a significant impact on the conclusions drawn from the model.ConclusionFuture economic evaluations of kidney function testing should examine testing and monitoring pathways from the perspective of patients, to ensure that issues that are important to patients, such as the possibility of inaccurate test results, are properly considered in the analysis.     

Antifungal Therapeutic Drug Monitoring

A growing body of evidence suggests that patient-to-patient variability in the pharmacokinetics of some antifungals, particularly the mold-active triazoles (itraconazole, voriconazole, and posaconazole) may contribute to therapeutic failure or unexpected toxicity. As a result, many clinicians have recognized a need for therapeutic drug monitoring (TDM) to individualize drug dosing in select patients with suspected or documented invasive fungal infections. However, approaches for performing and interpreting plasma concentrations are not well standardized, and logistical issues such as the turnaround time of test results can limit the clinical usefulness of testing in acutely ill patients. This article summarizes the pharmacologic rationale for TDM of antifungal agents, with a particular focus on recently published data for the newer triazoles, voriconazole and posaconazole. Practical recommendations for TDM-guided dosing are also provided, based on a critical evaluation of literature published over the past 5 years.     

Trade-offs between cost and accuracy in active case finding for tuberculosis: A dynamic modelling analysis

BackgroundActive case finding (ACF) may be valuable in tuberculosis (TB) control, but questions remain about its optimum implementation in different settings. For example, smear microscopy misses up to half of TB cases, yet is cheap and detects the most infectious TB cases. What, then, is the incremental value of using more sensitive and specific, yet more costly, tests such as Xpert MTB/RIF in ACF in a high-burden setting?Methods and findingsWe constructed a dynamic transmission model of TB, calibrated to be consistent with an urban slum population in India. We applied this model to compare the potential cost and impact of 2 hypothetical approaches following initial symptom screening: (i) ‘moderate accuracy’ testing employing a microscopy-like test (i.e., lower cost but also lower accuracy) for bacteriological confirmation and (ii) ‘high accuracy’ testing employing an Xpert-like test (higher cost but also higher accuracy, while also detecting rifampicin resistance). Results suggest that ACF using a moderate-accuracy test could in fact cost more overall than using a high-accuracy test. Under an illustrative budget of US$20 million in a slum population of 2 million, high-accuracy testing would avert 1.14 (95% credible interval 0.75–1.99, with p = 0.28) cases relative to each case averted by moderate-accuracy testing. Test specificity is a key driver: High-accuracy testing would be significantly more impactful at the 5% significance level, as long as the high-accuracy test has specificity at least 3 percentage points greater than the moderate-accuracy test. Additional factors promoting the impact of high-accuracy testing are that (i) its ability to detect rifampicin resistance can lead to long-term cost savings in second-line treatment and (ii) its higher sensitivity contributes to the overall cases averted by ACF. Amongst the limitations of this study, our cost model has a narrow focus on the commodity costs of testing and treatment; our estimates should not be taken as indicative of the overall cost of ACF. There remains uncertainty about the true specificity of tests such as smear and Xpert-like tests in ACF, relating to the accuracy of the reference standard under such conditions.ConclusionsOur results suggest that cheaper diagnostics do not necessarily translate to less costly ACF, as any savings from the test cost can be strongly outweighed by factors including false-positive TB treatment, reduced sensitivity, and foregone savings in second-line treatment. In resource-limited settings, it is therefore important to take all of these factors into account when designing cost-effective strategies for ACF.

In this modeling study, Lucia Cilloni and colleagues simulate the cost and epidemiologic impact of active case-finding for tuberculosis in high-burden settings such as India.     

The evaluation of pollen quality,and a further appraisal of the fluorochromatic (FCR) test procedure

Summary Methods currently available for evaluating pollen quality in vitro include, (a) tests of germinability; (b) tests of the stainability of the vegetative cell contents; (c) tests for enzyme activity, and (d) the fluorochromatic procedure (FCR), which tests principally the integrity of the plasmalemma of the vegetative cell. Using germinability in vitro as a standard, a comparison has been made between histochemical methods of classes (b), (c) and (d) in application to various pollens, immature, mature, and treated in ways known to affect viability and membrane state. Predictably, the lowest correlation was obtained with tests of stainability. The highest was given by the FCR, which generally provided an excellent guide to potential germinability. The FCR procedure is subject to various limitations, however, (a) A high correlation between FCR and germinability can only be expected when mature, ripe pollen is used; with immature pollen, the FCR will predict excessively high potential germinability. (b) The FCR may also predict a higher potential level of pollen function than in vitro germinability when the germination medium is sub-optimal. In this situation, however, it will generally give a better guide to fertilising capacity, (c) The FCR is not a test of pollen viability. Like germinability in vitro, it can yield a negative score with pollen which is nevertheless capable of functioning. For example, false negatives will be obtained with some species if the pollen is not properly pre-conditioned by rehydration before testing, an important point in monitoring stored pollen. The paper includes a brief discussion of the rationale of pollen testing.     

Control of biocorrosion using laboratory and field assessments

Biofouling and biocorrosion can be significant problems in oilfield water injection systems, despite extensive use of chemical biocides. This work set out to establish relevant testing and monitoring procedures to optimise microbiological control in these systems.A combination of laboratory based sessile biocide screening trials and onsite monitoring of biofilm bacteria was developed to ensure that an effective biocontrol programme was set up. It is important to use a mixed population of bacteria freshly isolated from biofilms in the system to ensure that any biocide tolerance of the system bacteria is reflected in the laboratory tests. In general, the results are borne out by the site audits of the control regime against sessile bacteria in the system.In an industrial system, biocide resistant populations develop from time to time. In practice it was found that even a small change to the biocide formulation could improve biocontrol, with concomitant reduction in corrosion rates and maintenance costs.