The Taming of Immunohistochemistry: The New Era of Quality Control

The most critical factor for interpreting the results of immunohistochemistry is verification of antibody sensitivity and specificity. While some manufacturers supply material data sheets with this information, many do not. This paper describes a well-defined quality assurance program for testing immune reagents. This program can be used to provide commercial suppliers of antisera with analyses of their products destined for government licensure applications. This paper illustrates the protocol and explains the testing philosophy developed over the last eight years.     

How to estimate the cost of point-of-care CD4 testing in program settings: an example using the Alere Pima Analyzer in South Africa

Integrating POC CD4 testing technologies into HIV counseling and testing (HCT) programs may improve post-HIV testing linkage to care and treatment. As evaluations of these technologies in program settings continue, estimates of the costs of POC CD4 tests to the service provider will be needed and estimates have begun to be reported. Without a consistent and transparent methodology, estimates of the cost per CD4 test using POC technologies are likely to be difficult to compare and may lead to erroneous conclusions about costs and cost-effectiveness. This paper provides a step-by-step approach for estimating the cost per CD4 test from a provider''s perspective. As an example, the approach is applied to one specific POC technology, the Pima™ Analyzer. The costing approach is illustrated with data from a mobile HCT program in Gauteng Province of South Africa. For this program, the cost per test in 2010 was estimated at $23.76 (material costs = $8.70; labor cost per test = $7.33; and equipment, insurance, and daily quality control = $7.72). Labor and equipment costs can vary widely depending on how the program operates and the number of CD4 tests completed over time. Additional costs not included in the above analysis, for on-going training, supervision, and quality control, are likely to increase further the cost per test. The main contribution of this paper is to outline a methodology for estimating the costs of incorporating POC CD4 testing technologies into an HCT program. The details of the program setting matter significantly for the cost estimate, so that such details should be clearly documented to improve the consistency, transparency, and comparability of cost estimates.     

The impact of a supervised strength and aerobic training program on muscular strength and aerobic capacity in individuals with type 2 diabetes

An intervention in the clinical management of individuals with type 2 diabetes is strength and aerobic training. Limited research has been conducted that investigates the effect of a supervised strength and aerobic training program on muscular strength and aerobic capacity in people with type 2 diabetes. The purpose of this 1-group repeated-measures-designed study was to investigate the impact of a supervised strength and aerobic training program on muscular strength and aerobic capacity in subjects with type 2 diabetes. Thirteen subjects with type 2 diabetes completed the training program. Subjects met the American Diabetes Association diagnostic criteria for type 2 diabetes. For each subject, muscular strength (estimated 1 repetition maximum) and aerobic capacity (estimated maximal oxygen uptake) were measured before and after a supervised strength and aerobic training program as well as during a 6-week follow-up. Repeated-measures analysis of variance was used to compare muscular strength and aerobic capacity between pretesting, posttesting, and follow-up testing periods. Significant improvements in muscular strength (p < 0.01) and aerobic capacity (p < 0.01) were found during posttesting and follow-up testing, as compared to pretesting measures. Yet a significant loss in muscular strength (p < 0.01) and no significant change in aerobic capacity (p > 0.05) were found during follow-up testing, as compared to posttesting measures. This study indicates that a supervised strength and aerobic training program can significantly improve muscular strength and aerobic capacity in people with type 2 diabetes. Yet improvements in muscular strength due to training will not be maintained if individuals with type 2 diabetes do not adhere to a continuous training program. In addition, aerobic capacity can be improved with training, but aerobic capacity will not continue to improve if people with type 2 diabetes are not compliant with a continuous training program.     

The molecular basis of familial hypercholesterolemia in The Netherlands

Mutations in the low-density lipoprotein (LDL) receptor gene are responsible for familial hypercholesterolemia (FH). At present, more than 600 mutations in this gene are known to underlie FH. However, the array of mutations varies considerably in different populations. Therefore, the delineation of essentially all LDL-receptor gene mutations in a population is a prerequisite for the implementation of nation-wide genetic testing for FH. In the Netherlands, mutation analysis by denaturing gradient gel electrophoresis and sequencing in 1641 clinically diagnosed FH patients resulted in the characterization of 159 different LDL-receptor gene defects. The nine most common mutations were responsible for 66.5% of our FH index cases. Of these, four mutations occurred with relatively high frequencies in specific parts of the Netherlands. The remaining mutations were only encountered in single FH patients, comprising 22.2% of the patient cohort analyzed. Subsequent genetic testing of relatives of the index cases within the national FH screening program resulted in the identification of 5,531 FH patients in total. The analysis for LDL-receptor mutations is a continuing effort to update the LDL-receptor mutation catalogue. Subsequently, with the newly generated index cases, the screening program can be extended and continued to identify and treat FH patients as early as possible and reduce cardiovascular morbidity and mortality in these patients at high risk.     

Improving the care of people with traumatic brain injury through the Neurotrauma Evidence Translation (NET) program: protocol for a program of research

ABSTRACT: The Neurotrauma Evidence Translation (NET) program was funded in 2009 to increase the uptake of research evidence in the clinical care of patients who have sustained traumatic brain injury. This paper reports the rationale and plan for this five-year knowledge translation research program. The overarching aims of the program are threefold: to improve outcomes for people with traumatic brain injury; to create a network of neurotrauma clinicians and researchers with expertise in knowledge translation and evidence-based practice; and to contribute knowledge to the field of knowledge translation research. The program comprises a series of interlinked projects spanning varying clinical environments and disciplines relevant to neurotrauma, anchored within four themes representing core knowledge translation activities: reviewing research evidence; understanding practice; developing and testing interventions for practice change; and building capacity for knowledge translation in neurotrauma. The program uses a range of different methods and study designs, including: an evidence fellowship program; conduct of and training in systematic reviews; mixed method study designs to describe and understand factors that influence current practices (e.g., semistructured interviews and surveys); theory-based methods to develop targeted interventions aiming to change practice; a cluster randomised trial to test the effectiveness of a targeted theory-informed intervention; stakeholder involvement activities; and knowledge translation events such as consensus conferences.     

Elimination of type D retrovirus infection from group-housed rhesus monkeys using serial testing and removal.

Type D retrovirus was successfully eliminated from an infected population of group-housed rhesus monkeys by serial testing of all animals for virus and antibody and subsequent removal of positives. This population of 53 rhesus had been housed together for 1 year prior to the initiation of the test and removal program, with six deaths from type D retrovirus-induced immunodeficiency disease occurring during this period. No new infections were detected after four rounds of testing. Of the 47 animals present at the start of the testing program, 17 (35%) remained after the elimination of type D virus from this group. These animals and their offspring have remained healthy and antibody negative for more than 2 years. These results demonstrate that elimination of type D retroviruses from rhesus macaque colonies is feasible, and that the objective of establishing and maintaining retrovirus-free colonies is realistic and achievable.     

Mapping loci influencing blood pressure in the Framingham pedigrees using model-free LOD score analysis of a quantitative trait

This paper presents a method of performing model-free LOD-score based linkage analysis on quantitative traits. It is implemented in the QMFLINK program. The method is used to perform a genome screen on the Framingham Heart Study data. A number of markers that show some support for linkage in our study coincide substantially with those implicated in other linkage studies of hypertension. Although the new method needs further testing on additional real and simulated data sets we can already say that it is straightforward to apply and may offer a useful complementary approach to previously available methods for the linkage analysis of quantitative traits.     

Methylation blockage and other improvements to a comprehensive DNA analysis program.

A comprehensive DNA analysis computer program was described in the second special issue of Nucleic Acids Research on the applications of computers to research on nucleic acids by Stone and Potter (1). Criteria used in designing the program were user friendliness, ability to handle large DNA sequences, low storage requirement, migratability to other computers and comprehensive analysis capability. The program has been used extensively in an industrial-research environment. This paper talks about improvements to that program. These improvements include testing for methylation blockage of restriction enzyme recognition sites, homology analysis, RNA folding analysis, integration of a large DNA database (GenBank), a site specific mutagenesis analysis, a protein database and protein searching programs. The original design of the DNA analysis program using a command executive from which any analytical programs can be called, has proven to be extremely versatile in integrating both developed and outside programs to the file management system employed.     

The second generation of the International Equine Gene Mapping Workshop half-sibling linkage map

A low-density, male-based linkage map was constructed as one of the objectives of the International Equine Gene Mapping Workshop. Here we report the second generation map based on testing 503 half-sibling offspring from 13 sire families for 344 informative markers using the CRIMAP program. The multipoint linkage analysis localized 310 markers (90%) with 257 markers being linearly ordered. The map included 34 linkage groups representing all 31 autosomes and spanning 2262 cM with an average interval between loci of 10.1 cM. This map is a milestone in that it is the first map with linkage groups assigned to each of the 31 automosomes and a single linkage group to all but three chromosomes.     

Results of an innovative education, training and quality assurance program for point-of-care HbA1c testing using the Bayer DCA 2000 in Australian Aboriginal Community Controlled Health Services

This study describes the development, implementation and management of a multi-faceted quality assurance program called Quality Assurance for Aboriginal Medical Services (QAAMS) to support point-of-care HbA(1c) testing on the Bayer DCA 2000 in Aboriginal people with diabetes from 45 Australian Aboriginal Community Controlled Health Services.THE QUALITY ASSURANCE PROGRAM COMPRISED FOUR ELEMENTS: production of culturally appropriate education resources, formal training for Aboriginal Health Workers conducting HbA(1c) testing, an external quality assurance program and on-going quality management support services including a help hotline and an annual workshop. Aboriginal Health Workers were required to test two quality assurance (QAAMS) samples in a blind sense every month since July 1999. Samples were linearly related and comprised six paired levels of HbA(1c). The short and long term performance of each service's DCA 2000 was reviewed monthly and at the end of each six month testing cycle.The average participation rate over 7 six-monthly QAAMS testing cycles was 88%. 84% of 3100 quality assurance tests performed were within preset limits of acceptability. The median precision (CV%) for HbA(1c) testing has averaged 3.8% across the past 5 cycles (range 3.4 to 4.0%) and is continuing to improve. The introduction of a medical rebate for HbA(1c) testing has ensured the program's sustainability.Through continuing education and training, Aboriginal Health Workers have achieved consistent analytical performance for HbA(1c) testing on the DCA 2000, equivalent to that of laboratory scientists using the same instrument. This unique quality assurance model can be readily adapted to other Indigenous health settings and other point-of-care tests and instruments.     

The National QAAMS Program – A Practical Example of PoCT Working in the Community

The Quality Assurance for Aboriginal and Torres Strait Islander Medical Services (QAAMS) Program is the largest and longest-standing national point-of-care testing (PoCT) program in Australia. With a focus on PoCT for diabetes management, it now operates in 115 Indigenous medical services and has been funded continuously by the Australian Government for 11 years. A recent independent evaluation of the QAAMS Program concluded that the program continues to meet best practice standards for Indigenous healthcare, diabetes management and PoCT.     

Two Years of PKU Testing in California—The Role of the Laboratory

A cooperative phenylketonuria screening program involving private nongovernmental laboratories, individual physicians and local and state health departments has been in operation for two years. The system has evolved to the point where practically all newborns are tested. The accuracy of laboratory work has been verified by an ongoing evaluation program which has resulted in continual improvement in level of performance. There are two areas in which some beneficial changes might be considered. One is the reduction of costs of the testing and follow-up by increasing volume and centralization of work. The other is greater cooperation of the medical community in collecting the data necessary to evaluate the program and expedite the final diagnosis.     

The ability of plant genotoxicity assays to predict carcinogenicity

A number of assays have been developed which use higher plants for measuring mutagenic or cytogenetic effects of chemicals, as an indication of carcinogenicity. Plant assays require less extensive equipment, materials and personnel than most other genotoxicity tests, which is a potential advantage, particularly in less developed parts of the world. We have analyzed data on 9 plant genotoxicity assays evaluated by the Gene-Tox program of the U.S. Environmental Protection Agency, using methodologies we have recently developed to assess the capability of assays to predict carcinogenicity and carcinogenic potency. All 9 of the plant assays appear to have high sensitivity (few false negatives). Specificity (rate of true negatives) was more difficult to evaluate because of limited testing on non-carcinogens; however, available data indicate that only the Arabidopsis mutagenicity (ArM) test appears to have high specificity. Based upon their high sensitivity, plant genotoxicity tests are most appropriate for a risk-averse testing program, because although many false positives will be generated, the relatively few negative results will be quite reliable.     

The role of physicians as medical review officers in workplace drug testing programs. In pursuit of the last nanogram.

In discussing the role of physicians in workplace drug testing programs, I focus on the recent Department of Transportation regulations that require drug testing in such regulated industries as interstate trucking, air transportation, mass transit, and the railroads. These regulations require that applicable drug testing programs employ physicians as medical review officers to evaluate positive tests that have been screened and confirmed by different techniques to determine if there is a legal medical explanation for the result. The drug testing program tests for the presence of amphetamine, cocaine, tetrahydrocannabinol, opiates, and phencyclidine. If an employee testing positive has an acceptable medical explanation, the result is to be reported as negative. Little practical advice exists for medical review officers, and they must be aware of key elements of the regulations and potential trouble spots.     

Measuring persistence of implementation: QUERI Series

Background

We describe how we used the framework of the U.S. Department of Veterans Affairs (VA) Quality Enhancement Research Initiative (QUERI) to develop a program to improve rates of diagnostic testing for the Human Immunodeficiency Virus (HIV). This venture was prompted by the observation by the CDC that 25% of HIV-infected patients do not know their diagnosis – a point of substantial importance to the VA, which is the largest provider of HIV care in the United States.

Methods

Following the QUERI steps (or process), we evaluated: 1) whether undiagnosed HIV infection is a high-risk, high-volume clinical issue within the VA, 2) whether there are evidence-based recommendations for HIV testing, 3) whether there are gaps in the performance of VA HIV testing, and 4) the barriers and facilitators to improving current practice in the VA. Based on our findings, we developed and initiated a QUERI step 4/phase 1 pilot project using the precepts of the Chronic Care Model. Our improvement strategy relies upon electronic clinical reminders to provide decision support; audit/feedback as a clinical information system, and appropriate changes in delivery system design. These activities are complemented by academic detailing and social marketing interventions to achieve provider activation.

Results

Our preliminary formative evaluation indicates the need to ensure leadership and team buy-in, address facility-specific barriers, refine the reminder, and address factors that contribute to inter-clinic variances in HIV testing rates. Preliminary unadjusted data from the first seven months of our program show 3–5 fold increases in the proportion of at-risk patients who are offered HIV testing at the VA sites (stations) where the pilot project has been undertaken; no change was seen at control stations.

Discussion

This project demonstrates the early success of the application of the QUERI process to the development of a program to improve HIV testing rates. Preliminary unadjusted results show that the coordinated use of audit/feedback, provider activation, and organizational change can increase HIV testing rates for at-risk patients. We are refining our program prior to extending our work to a small-scale, multi-site evaluation (QUERI step 4/phase 2). We also plan to evaluate the durability/sustainability of the intervention effect, the costs of HIV testing, and the number of newly identified HIV-infected patients. Ultimately, we will evaluate this program in other geographically dispersed stations (QUERI step 4/phases 3 and 4).     

Parabolic flight experiments on physiological data acquisition and processing technologies using small jet aircraft (MU300)

The parabolic aircraft flight provides a short low gravity environment for approximately 20 seconds, which may not be sufficient for a research on the physiological phenomenon induced by actual weightlessness in space. However, the method is still useful to reveal essential and characteristic feature of physiological signs, and is available for testing hardware and also training of crew member during altered gravity. This paper reports the summary of parabolic flight experiments recently conducted as a NASDA program (1990-1992). The program is providing opportunities in low gravity research with small jet aircraft for researchers and agencies. The flight experiments in the life science area have been conducted mostly focused on a physiological changes and basic methodology which may be effective under the altered gravity condition. In this study, the following research team, NASDA, Research Institute of Environmental Medicine, Nagoya University, Toyohashi University of Technology, Tokyo Metropolitan Hospital, Torey Research Center and JSUP were involved and coordinated for the research.     

The marriage of art and science in health care

This paper invites the reader to consider the marriage of art and science as antidote to much epidemic disease, for our greater personal and societal health. The history of arts medicine is reviewed, identifying its persisting although often tenuous link with health care from pre-history to the present. The author describes his personal encounter with art at the bedside, and how it led to his establishing a comprehensive artist-in-residence program at his university hospital. The scientific evidence underscoring the efficacy of art-making for physical and psychological health are outlined, together with the physiological and biochemical data. The author describes his own program, and offers examples of healing art in action.     

Costs of Rapid HIV Screening in an Urban Emergency Department and a Nearby County Jail in the Southeastern United States

Emergency departments and jails provide medical services to persons at risk for HIV infection and are recommended venues for HIV screening. Our main objective in this study was to analyze the cost per new HIV diagnosis associated with the HIV screening program in these two venues. The emergency department’s parallel testing program was conducted at Grady Memorial Hospital in Atlanta, Georgia starting in 2008; the jail’s integrated testing program began at the Fulton County (GA) Jail in 2011. The two sites, four miles apart from one another, employed the same rapid HIV test. Ascertainment that cases were new differed by site; only the jail systematically checked identities against health department HIV registries. The program in the emergency department used dedicated HIV test counselors and made 242 diagnoses over a 40-month period at a cost of $2,981 per diagnosis. The jail program used staff nurses, and found 41 new HIV cases over 10.5 months at a cost of $6,688 per new diagnosis. Differences in methods for ascertainment of new diagnoses, previously undiagnosed HIV sero-positivity, and methodologies used for assessing program costs prevent concluding that one program was more economical than the other. Nonetheless, our findings show that testing in both venues yielded many new diagnoses, with the costs within the range reported in the literature.