The case for common reference intervals

The current paradigm for pathology reference intervals is for each laboratory to determine its own interval for use with each test offered by the laboratory. It is our contention that this approach does not best serve the medical community, especially at a time when electronic databases of health information are being expanded and integrated. We also believe that this approach is not performed well in many laboratories and is excessively expensive in practice. In contrast, we believe that the preferable option is to develop and apply common reference intervals throughout Australia and New Zealand, together with common reporting formats and assay standardisation wherever this is possible.

We are aware that these are neither trivial nor simple issues, however we believe that failure to achieve this goal where technically possible will be a failure of the pathology profession to meet the challenges of the modern health community.

     

Regional Variation in Analytical Techniques used in the Diagnosis and Monitoring of Porphyria: a Case for Harmonisation?

Background:The Royal College of Pathologists of Australasia (RCPA) Porphyrin Quality Assurance Program assesses the measurement of urine, faecal, plasma and whole blood porphyrins and their components plus urinary porphobilinogen and delta aminolaevulinic acid and has laboratories enrolled from around the world. It was observed that there was a wide scatter in results submitted to some subsections of the program.Methods:A detailed questionnaire covering the analytical techniques used in the diagnosis of porphyria was sent to all laboratories enrolled in the RCPA Porphyrin Quality Assurance Program. Additionally, self-enrolment data over a five year period was examined for trends/changes in standardisation, reagent sources and analytical technique.Results:Twenty of the 45 laboratories enrolled in the Porphyrin Quality Assurance Program completed the survey, providing a snapshot of the analytical techniques used world-wide. Post survey self enrolment data indicated only little or no noticeable changes to analytical standardisation of techniques despite the continual lack of agreement of results in subsections of the External Quality Assurance program.Conclusions:While some aspects of porphyria testing are relatively consistent between laboratories, other diagnostic techniques vary widely. A wide variety of individualised reference intervals and reporting techniques is currently in use world-wide. While most of the participants in the survey are regional reference centres specialising in the diagnosis of porphyria and, as such, their diagnostic capability is not in question, international guidelines or global harmonisation of analytical techniques should allow better inter-laboratory comparisons to be made, ultimately improving diagnostic accuracy.     

Plasma creatinine in dogs: intra- and inter-laboratory variation in 10 European veterinary laboratories

Background  

There is substantial variation in reported reference intervals for canine plasma creatinine among veterinary laboratories, thereby influencing the clinical assessment of analytical results. The aims of the study was to determine the inter- and intra-laboratory variation in plasma creatinine among 10 veterinary laboratories, and to compare results from each laboratory with the upper limit of its reference interval.     

Prerequisites for use of common reference intervals

The theory of reference values was developed more than 30 years ago, but its application in most clinical laboratories is still incomplete today. This is for several reasons, the most relevant ones being the lack of standardisation of the analytical methods, resulting in method-dependent values, and the difficulty in recruiting the proper number of reference subjects for establishment of reference intervals. With the recent progress in method standardisation the first problem is reducing while the second can be addressed optimally via multicentre collaborative studies that aim to establish common reference intervals. To be effective this approach requires the following prerequisites: 1) the existence of a reference measurement system for the analyte; 2) field methods producing results traceable to the reference system; and 3) a carefully planned multicentre reference interval study. Such a procedure will produce results traceable to the reference measurement system for a large number of reference subjects, under controlled pre-analytical conditions. It will also enable a better understanding of the various sources of population variability, if there is the need for partitioning of a reference interval or if there are any limitations to adopting the established reference intervals on a national or global scale. Once reference intervals are determined, clinical laboratories can adopt a common reference interval provided: 1) the population that the laboratory services is similar to the one studied; 2) methods producing traceable results are used; and 3) analytical quality is within defined targets of precision and bias. Moreover, some validation of the interval using a small sample of reference individuals from the laboratory's population is advisable.     

Biological Rhythms of Biochemical Serum Parameters in a Brazilian Population: a Three‐Year Study

A marked decrease in analytical and post‐analytical variability has been achieved in clinical laboratories by the use of automated analytical systems. Current studies are now focused on the origin of pre‐analytical variability, such as that due to intra‐individual differences and biological rhythms. The objective of this work was to evaluate the occurrence of biological rhythms in several biochemical serum parameters in a Brazilian population. A retrospective study (1996 to 1998) was carried out to collect the test results within the reference intervals of adults, from 21 to 50 yr of age (average age of 36 yr) attending the outpatient clinics of the Teaching Hospital at the University of Campinas, São Paulo, Brazil. The reference sample was 52.9% male and 47.1% female and encompassed 15,036 calcium, 7,478 phosphorus, 53,641 urea, 58,315 creatinine and 6,433 uric acid determinations (140,903 in total). Significant annual rhythms were detected in serum calcium (p≤0.001), with maximum and minimum values in fall and spring, and in serum creatinine (p≤0.002), with maximum and minimum values in summer and winter. The other parameters did not present significant annual rhythmicity. The seasonal rhythms present in the serum concentrations of calcium and creatinine observed in this large population study, although of small amplitude, should be considered a component of the pre‐analytical variation of these clinical laboratory tests.     

RCPAQAP First Combined Measurement and Reference Interval Survey

Reference intervals are commonly considered to allow for between-laboratory bias. The RCPAQAP Liquid Serum Chemistry Program has collected data on laboratory measurements as well as reference intervals. This allows assessment of the between-laboratory variation in results, reference intervals and the information transmitted by the combination of these factors. For the majority of common chemistry analytes, the between-laboratory variation in reference intervals is greater than the variation in results. Additionally the reference interval variation is generally not related to bias between the results. Use of common reference intervals, either as an average of the current intervals in use, or the intervals proposed by the AACB Harmonisation Group, improved the variation seen in the information produced by different laboratories.     

通过ISO 15189认可实验室质量指标制定及监测情况调查

目的 了解目前我国通过ISO 15189认可的实验室质量指标制定及监测情况。 方法 设计质量指标制定及监测情况调查表并下发给185家认可实验室,要求在10月31日前以邮件形式回报结果,使用Microsoft Excel 2010软件进行统计分析。 结果 共85家（占45.95%）实验室回报结果,76家临床实验室,9家独立实验室。不同认可实验室制定的质量指标数量及分布差异较大。76家临床实验室共设置质量指标1105项,每家实验室平均14.5项。9家独立实验室设置质量指标195项,每家实验室平均21.7项。临床实验室制定了更多的检验前、检验中质量指标,独立实验室在设置质量指标时还包括了较多的检验后、支持性过程和其他质量指标。 结论 目前我国认可实验室质量指标制定及监测情况尚不理想。在推进质量指标一致化的同时,实验室应加强宣贯与教育,建议一套完整、科学和实用的质量指标体系。

     

Assessing cell-specific effects of genetic variations using tRNA microarrays

Background

Short-read resequencing of genomes produces abundant information of the genetic variation of individuals. Due to their numerous nature, these variants are rarely exhaustively validated. Furthermore, low levels of undetected variant miscalling will have a systematic and disproportionate impact on the interpretation of individual genome sequence information, especially should these also be carried through into in reference databases of genomic variation.

Results

We find that sequence variation from short-read sequence data is subject to recurrent-yet-intermittent miscalling that occurs in a sequence intrinsic manner and is very sensitive to sequence read length. The miscalls arise from difficulties aligning short reads to redundant genomic regions, where the rate of sequencing error approaches the sequence diversity between redundant regions. We find the resultant miscalled variants to be sensitive to small sequence variations between genomes, and thereby are often intrinsic to an individual, pedigree, strain or human ethnic group. In human exome sequences, we identify 2–300 recurrent false positive variants per individual, almost all of which are present in public databases of human genomic variation. From the exomes of non-reference strains of inbred mice, we identify 3–5000 recurrent false positive variants per mouse – the number of which increasing with greater distance between an individual mouse strain and the reference C57BL6 mouse genome. We show that recurrently miscalled variants may be reproduced for a given genome from repeated simulation rounds of read resampling, realignment and recalling. As such, it is possible to identify more than two-thirds of false positive variation from only ten rounds of simulation.

Conclusion

Identification and removal of recurrent false positive variants from specific individual variant sets will improve overall data quality. Variant miscalls arising are highly sequence intrinsic and are often specific to an individual, pedigree or ethnicity. Further, read length is a strong determinant of whether given false variants will be called for any given genome – which has profound significance for cohort studies that pool datasets collected and sequenced at different points in time.

     

On the number of Monte Carlo runs in comparative probabilistic LCA

Introduction

The Monte Carlo technique is widely used and recommended for including uncertainties LCA. Typically, 1000 or 10,000 runs are done, but a clear argument for that number is not available, and with the growing size of LCA databases, an excessively high number of runs may be a time-consuming thing. We therefore investigate if a large number of runs are useful, or if it might be unnecessary or even harmful.

Probability theory

We review the standard theory or probability distributions for describing stochastic variables, including the combination of different stochastic variables into a calculation. We also review the standard theory of inferential statistics for estimating a probability distribution, given a sample of values. For estimating the distribution of a function of probability distributions, two major techniques are available, analytical, applying probability theory and numerical, using Monte Carlo simulation. Because the analytical technique is often unavailable, the obvious way-out is Monte Carlo. However, we demonstrate and illustrate that it leads to overly precise conclusions on the values of estimated parameters, and to incorrect hypothesis tests.

Numerical illustration

We demonstrate the effect for two simple cases: one system in a stand-alone analysis and a comparative analysis of two alternative systems. Both cases illustrate that statistical hypotheses that should not be rejected in fact are rejected in a highly convincing way, thus pointing out a fundamental flaw.

Discussion and conclusions

Apart form the obvious recommendation to use larger samples for estimating input distributions, we suggest to restrict the number of Monte Carlo runs to a number not greater than the sample sizes used for the input parameters. As a final note, when the input parameters are not estimated using samples, but through a procedure, such as the popular pedigree approach, the Monte Carlo approach should not be used at all.

     

Legionella pneumophila in Thermal Spa – Methodological Aspects of Sampling and Analysis

The aim of the study was to check the occurrence of Legionella pneumophila in thermal water and to compare different analytical methods of its determination and/or quantification used in different laboratories. The research has shown that there are noticeable differences between results from culture method, qPCR, and FISH. Significant influence on the results has got analysts qualification, samples preparation, and equipment parameters. Very important is also the homogeneousness of the samples. qPCR or FISH method can be used as a preliminary, quick study, for identification of Legionella in water samples but the results obtained should be confirmed by culture method.     

Are there infinitely many trucks in the technosphere,or exactly one? How independent sampling of instances of unit processes affects uncertainty analysis in LCA

Purpose

Product systems use the same unit process models to represent distinct but similar activities. This notably applies to activities in cyclic dependency relationships (or “feedback loops”) that are required an infinite number of times in a product system. The study aims to test the sensitivity of uncertainty results on the assumption made concerning these different instances of the same activities. The default assumption assumes homogeneous production, and the same parameter values are sampled for all instances (e.g., there is one truck). The alternative assumption is that every instance is distinct, and parameter values are independently sampled for different instances of unit processes (e.g., there are infinitely many trucks). Intuitively, sampling the same values for each instance of a unit process should result in more uncertain results.

Methods

The results of uncertainty analyses carried out under either assumption are compared. To simulate models where each instance of a unit process is independent, we convert network models to acyclic LCI models (tree models). This is done three times: (1) for a very simple product system, to explain the methodology; (2) for a sample product system from the ecoinvent database, for illustrative purposes; and (3) for thousands of product systems from ecoinvent databases.

Results and discussion

The uncertainty of network models is indeed greater than that of corresponding tree models. This is shown mathematically for the analytical approximation method to uncertainty propagation and is observed for Monte Carlo simulations with very large numbers of iterations. However, the magnitude of the difference in indicators of dispersion is, for the ecoinvent product systems, often less than a factor of 1.5. In few extreme cases, indicators of dispersion are different by a factor of 4. Monte Carlo simulations with smaller numbers of iterations sometimes give the opposite result.

Conclusions

Given the small magnitude of the difference, we believe that breaking away from the default approach is generally not warranted. Indeed, (1) the alternative approach is not more robust, (2) the current default approach is conservative, and (3) there are more pressing challenges for the LCA community to meet. This being said, the study focused on ecoinvent, which should normally be used as a background database. The difference in dispersion between the two approaches may be important in some contexts, and calculating the uncertainty of tree models as a sensitivity analysis could be useful.

     

Determination of reference ranges for elements in human scalp hair

Expected values, reference ranges, or reference limits are necessary to enable clinicians to apply analytical chemical data in the delivery of health care. Determination of references ranges is not straightforward in terms of either selecting a reference population or performing statistical analysis. In light of logistical, scientific, and economic obstacles, it is understandable that clinical laboratories often combine approaches in developing health associated reference values. A laboratory may choose to:

Laboratory reporting of urine protein and albumin

Communication between pathology laboratories and clients involves more than just a result. There may be advice on recommended specimen type as well as the units and reference intervals used to report results. Between-laboratory variability in these factors has the potential to cause unnecessary confusion and even to lead to variation in interpretation for samples sent to different laboratories. A survey of Australian and New Zealand laboratories covering sample recommendations, specimens received, units and reference intervals for urine albumin and urine protein was conducted through the Royal College of Pathologists of Australasia Quality Assurance Program (RCPA QAP). The results confirm earlier findings of wide between-laboratory variability in all these factors. It is proposed that only recommendations developed by relevant professional societies and adopted by all laboratories can lead to reduction in this variability.     

Establishing reference intervals for von Willebrand factor multimers

Backgroundvon Willebrand factor (VWF) multimers (VWF:MM) methodologies are technically difficult, laborious, time consuming, non-standardized and results vary between laboratories. A new semi automated VWF:MM assay is available for routine use (Sebia). Due to lack of reference values for VWF:MM fractions, results interpretation can be challenging in some cases. The aim of this study was to determine reference intervals for low molecular weight (LMWM), intermediate molecular weight (IMWM) and high molecular weight (HMWM) multimers.MethodsBy the international cooperation initiated between 4 countries (Estonia, Latvia, France, and USA) 131 samples of relatively healthy individuals were analyzed for VWF:MM (in total 51 males and 80 non-pregnant females aged 17-69 years). Reference intervals were calculated according to CLSI C28-A3 standard.ResultsThe proposed reference intervals for VWF:MM were calculated for LMWM 10.4-22.5%, IMWM 22.6-37.6%, HMWM 45.6-66.6%. Age related differences were seen in IMWM and HMWM (p<0.001 and 0.038). There was no gender related difference observed. Geographically LMWM results of France were different from the other regions (p<0.05).ConclusionsQuantification of VWF:MM fractions, in addition to qualitative assessment of VWF:MM patterns, has the potential to aid in differential diagnosis of von Willebrand disease (VWD) subtypes. The reference values calculated in this study can be used in future research to establish clinical decision limits.     

Evaluation of measurement uncertainties of an analytical method for the determination of aflatoxin M<Subscript>1</Subscript> in milk and milk powder

The mycotoxin aflatoxin M₁ (AfM₁) is a serious food safety hazard for which the European Commission has already established a maximum permissible level of 0.05 μg/kg AfM₁ in milk and products thereof. For control analysis laboratories are increasingly asked to submit full uncertainties of their analytical results.The evaluation of measurement uncertainties of an analytical method for the determination of AfM₁ in milk and milk powder on the basis of ‘in-house’ validation data in compliance with the ‘Guide to the Expression of Uncertainty in Measurement (GUM)’ [1] and the ‘EURACHEM Guide’ [2] is described. A similar approach will be used to assess the performance of methods employed by laboratories participating in the certification of reference materials for AfM₁ in milk powder.     

An inter-laboratory validation of methods of lipid peroxidation measurement in UVA-treated human plasma samples

Abstract

Lipid peroxidation products like malondialdehyde, 4-hydroxynonenal and F₂-isoprostanes are widely used as markers of oxidative stress in vitro and in vivo. This study reports the results of a multi-laboratory validation study by COST Action B35 to assess inter-laboratory and intra-laboratory variation in the measurement of lipid peroxidation. Human plasma samples were exposed to UVA irradiation at different doses (0, 15 J, 20 J), encoded and shipped to 15 laboratories, where analyses of malondialdehyde, 4-hydroxynonenal and isoprostanes were conducted. The results demonstrate a low within-day-variation and a good correlation of results observed on two different days. However, high coefficients of variation were observed between the laboratories. Malondialdehyde determined by HPLC was found to be the most sensitive and reproducible lipid peroxidation product in plasma upon UVA treatment. It is concluded that measurement of malondialdehyde by HPLC has good analytical validity for inter-laboratory studies on lipid peroxidation in human EDTA-plasma samples, although it is acknowledged that this may not translate to biological validity.     

Cardiovascular autonomic function tests in an African population

Background

Age- and sex-specific reference intervals are an important prerequisite for interpreting thyroid hormone measurements in children. However, only few studies have reported age- and sex-specific pediatric reference values for TSH_basal (TSH), free T3 (fT3), and free T4 (fT4) so far. Reference intervals are known to be method- and population-dependent. The aim of our study was to establish reference intervals for serum TSH, fT3, and fT4 from birth to 18 years and to assess sex differences.

Methods

2,194 thyroid hormone tests obtained from a hospital-based pediatric population were included into our retrospective analysis. Individuals with diagnoses or medications likely to affect thyroid function were primarily excluded, as well as the diagnostic groups, if different from the purely healthy subgroup (n = 414). Age groups were ranging from 1 day to 1 month, 1 – 12 months, and 1 – 5, 6 – 10, 11 – 14, and 15 – 18 years, respectively. Levels of fT3, fT4 and TSH were measured on Advia^® Centaur? automated immunoassay system.

Results

The final sample size for reference data creation was 1,209 for TSH, 1,395 for fT3, and 1,229 for fT4. Median and 2.5/10/25/75/90/97.5 percentiles were calculated for each age group. Males had greater mean fT3 concentrations than females (p < 0.001). No sex-differences were found for TSH and fT4 between age-matched serum samples. Median concentrations of fT3, fT4 and TSH were greatest during the first month of life, followed by a continuous decline with age.

Conclusion

Our results corroborate those of previous studies showing that thyroid hormone levels change markedly during childhood, and that adult reference intervals are not universally applicable to children. Moreover, differences of our reference intervals compared to previous studies were observed, likely caused by different antibody characteristics of various analytical methods, different populations or undefined geographic covariates, e.g. iodine and selenium status.     

Platelet lumiaggregation testing: Reference intervals and the effect of acetylsalicylic acid in healthy adults

BackgroundLight transmission aggregometry with lumiaggregometry are methods commonly recommended as a first-line test in platelet dysfunction diagnostic work-up. They are poorly standardized and usually performed in specialized laboratories. For proper interpretation, each laboratory should establish its own diagnostic approach in order to recognize abnormal aggregation patterns. The aim of this study was to measure plasma lumiaggregometry with basic agonists to establish the analyzer-reagent reference intervals (RI) for adults and to test the method response to aspirin.MethodsThe Chrono-Log Model 700 lumiaggregometer using Chrono-Par and Chrono-lume reagents (Chrono-Log Corp., Havertown, PA, USA) was used to measure the maximal aggregation and adenosine triphosphate release using adenosine diphosphate (2 μmol/L), collagen (2 μg/mL), arachidonic acid (1 μmol/L), epinephrine (5.5 μmol/L) and ristocetin (1.25 mg/mL), and thrombin (1 U/mL). The effect of aspirin on platelet aggregation and granule release was inspected.ResultsRIs derived from 40 healthy adults were calculated using the non-parametric approach. Wider intervals and low lower limits were determined for weak agonist as well as absence or impaired aggregation in up to one of 7 healthy controls. The response of platelets to aspirin shows response comparable to previously reported study.ConclusionsLocally established RI in our study enable us to investigate platelet function in patients with a high probability of bleeding disorders. Values are agonist and equipment specific. The variability of the method can be reduced by considering standardized preanalytical and analytical variables. Pathological results must be interpreted in the context of other hemostasis test results and clinical findings.     

Java GUI for InterProScan (JIPS): A tool to help process multiple InterProScans and perform ortholog analysis

Background  

Recent, rapid growth in the quantity of available genomic data has generated many protein sequences that are not yet biochemically classified. Thus, the prediction of biochemical function based on structural motifs is an important task in post-genomic analysis. The InterPro databases are a major resource for protein function information. For optimal results, these databases should be searched at regular intervals, since they are frequently updated.     

Closing the Gaps in Paediatric Reference Intervals: The CALIPER Initiative

Screening, diagnosis and monitoring of paediatric diseases relies on the measurement of a spectrum of disease biomarkers in clinical laboratories to guide important clinical decisions. Physicians rely on the availability of suitable and reliable reference intervals to accurately interpret laboratory test results with data collected during medical history and physical examination. However, critical gaps currently exist in accurate and up-to-date reference intervals (normal values) for accurate interpretation of laboratory tests performed in children and adolescents. These gaps in the available paediatric laboratory reference intervals have the clear potential of contributing to erroneous diagnosis or misdiagnosis of many diseases of childhood and adolescence. Most of the available reference intervals for laboratory tests were determined over two decades ago on older instruments and technologies, and are no longer relevant considering the current testing technology used by clinical laboratories. It is thus critical and of utmost urgency that a more acceptable and comprehensive database be established. There are however many challenges when attempting to establish paediatric reference intervals. Paediatric specimen collection is a major concern for health care providers as it is frequently difficult to obtain sufficient volumes of blood or urine from paediatric patients. Common reference intervals have not been widely implemented due to lack of harmonisation of methods and differences in patient populations. Consequently, clinical laboratory accreditation organisations and licensing agencies require that each laboratory verify or establish reference intervals for each method. To provide such reference intervals requires selection criteria for suitable reference individuals, defined conditions for specimen collection and analysis, method selection to determine reference limits and validation of the reference interval. The current review will provide a brief introduction to the current approach to establishment of reference intervals, will highlight the current gaps in data available in paediatric populations, and review a recent Canadian initiative, CALIPER (Canadian Laboratory Initiative on Paediatric Reference Intervals), to establish a comprehensive database for both traditional and emerging biomarkers of paediatric disease.