A Stable Lyophilized Reagent for Use in a Potential Reference Assay for Quantitation of Anti-D in Immunoglobulin Products

Quality control of anti-D immunoglobulins intended for in vivo clinical use requires in vitro assay of potency. A lyophilized biotinylated monoclonal anti-D (biotinylated Brad-5; 99/698) has been evaluated for its suitability to serve as a working reagent in a competitive enzyme-linked immunoassay (EIA) for anti-D quantitation. The reagent demonstrated acceptable stability in accelerated degradation tests and following reconstitution. Twelve international laboratories obtained comparable potencies for each of nine anti-D samples using 99/698 in a standardized assay procedure using erythrocytes fixed to microtitre plates. We also describe the use of trehalose for stabilization of dried erythrocyte-coated microtitre plates.     

Performance of Microscopy for the Diagnosis of Malaria and Human African Trypanosomiasis by Diagnostic Laboratories in the Democratic Republic of the Congo: Results of a Nation-Wide External Quality Assessment

The present External Quality Assessment (EQA) assessed microscopy of blood parasites among diagnostic laboratories in the Democratic Republic of the Congo. The EQA addressed 445 participants in 10/11 provinces (October 2013–April 2014). Participants were sent a panel of five slides and asked to return a routinely stained slide which was assessed for quality of preparation and staining. Response rate was 89.9% (400/445). For slide 1 (no parasites), 30.6% participants reported malaria, mostly Plasmodium falciparum. Only 11.0% participants reported slide 2 (Plasmodium malariae) correctly, 71.0% reported “malaria” or “Plasmodium falciparum” (considered acceptable). Slide 3 contained Plasmodium falciparum (109/μl) and Trypanosoma brucei brucei trypomastigotes: they were each reported by 32.5% and 16.5% participants respectively, 6.0% reported both. Slide 4 (Trypanosoma) was recognised by 44.9% participants. Slide 5 (Plasmodium ovale) was correctly reported by 6.2% participants, another 68.8% replied “malaria” or “Plasmodium falciparum” (considered acceptable). Only 13.6% of routine slides returned were correctly prepared and stained. The proportion of correct/acceptable scores for at least 4/5 slides was higher among EQA-experienced participants compared to first time participants (40.9% versus 22.4%, p = 0.001) and higher among those being trained < 2 years ago compared to those who were not (42.9% versus 26.3%, p = 0.01). Among diagnostic laboratories in Democratic Republic of the Congo, performance of blood parasite microscopy including non-falciparum species and Trypanosoma was poor. Recent training and previous EQA participation were associated with a better performance.     

Prevention of Rh-haemolytic Disease: Results of the Liverpool “Low-risk” Clinical Trial

A clinical trial is reported in which Rh-negative primiparae, just delivered of an Rh-positive ABO-compatible infant and in whom fetal cell counts after delivery suggested less than 0·2 ml of circulating fetal blood, were treated with about 200 μg of anti-D gammaglobulin. Three (0·36%) out of 844 women thus treated developed anti-D in the subsequent six months; this is 10% of the incidence in untreated controls. Three (1·8%) out of 171 treated mothers had anti-D at the end of the second Rh-positive pregnancy, and this is 18% of the incidence in controls.Possible reasons for the occasional failure of the treatment are discussed and the results of this trial are compared with those of a previous trial in which 1,000 μg or more of anti-D was given to a different group of mothers. The combined results of the two trials lead to the conclusion that the passive administration of anti-D gammaglobulin after delivery affords in this population of Rh-negative women a 95% protection rate in the postdelivery period and an 89% protection rate by the end of the subsequent pregnancy.     

International External Quality Assessment Study for Molecular Detection of Lassa Virus

Lassa virus (LASV) is a causative agent of hemorrhagic fever in West Africa. In recent years, it has been imported several times to Europe and North America. The method of choice for early detection of LASV in blood is RT-PCR. Therefore, the European Network for Diagnostics of ‘Imported’ Viral Diseases (ENIVD) performed an external quality assessment (EQA) study for molecular detection of LASV. A proficiency panel of 13 samples containing various concentrations of inactivated LASV strains Josiah, Lib-1580/121, CSF, or AV was prepared. Samples containing the LASV-related lymphocytic choriomeningitis virus (LCMV) and negative sera were included as specificity controls. Twenty-four laboratories from 17 countries (13 European, one African, one Asian, two American countries) participated in the study. Thirteen laboratories (54%) reported correct results, 4 (17%) laboratories reported 1 to 2 false-negative results, and 7 (29%) laboratories reported 3 to 5 false-negative results. This EQA study indicates that most participating laboratories have a good or acceptable performance in molecular detection of LASV. However, several laboratories need to review and improve their diagnostic procedures.     

An enzyme-linked antiglobulin test for assessing anti-D immunoglobulin preparations

Two enzyme-linked antiglobulin tests (ELAT) for assessing anti-D IgG preparations are described; one is performed in tubes and the other in microtitre plates. An anti-human IgG alkaline phosphatase conjugate and the substrate p-nitrophenyl phosphate are used. Both methods were sensitive and reproducible, with variations coefficients of 7.8 and 8.6% for enzyme immunoassay in tubes and microplates, respectively. The linear relationship between the amount of red cell-bound anti-D and the optical density shows that the method is suitable for quantitative studies. Results obtained by the two methods show a very good correlation (r = 0.99) in 12 of the 14 samples assayed, and both give good agreement with results obtained in automated haemagglutination. Since microtitre plate ELAT has numerous advantages over the tube method, it could provide an alternative method for assessing anti-D activity of specific IgG preparations in control laboratories.     

The Harbin Cohort Study on Diet,Nutrition and Chronic Non-Communicable Diseases: Study Design and Baseline Characteristics

Diet and nutrition have been reported to be associated with many common chronic diseases and blood-based assessment would be vital to investigate the association and mechanism, however, blood-based prospective studies are limited. The Harbin Cohort Study on Diet, Nutrition and Chronic Non-communicable Diseases was set up in 2010. From 2010 to 2012, 9,734 participants completed the baseline survey, including demographic characteristics, dietary intake, lifestyles and physical condition, and anthropometrics. A re-survey on 490 randomly selected participants was done by using the same methods which were employed in the baseline survey. For all participants, the mean age was 50 years and 36% of them were men. Approximately 99.4 % of cohort members donated blood samples. The mean total energy intake was 2671.7 kcal/day in men and 2245.9 kcal/day in women, the mean body mass index was 25.7 kg/m² in men and 24.6 kg/m² in women, with 18.4% being obese (≥28 kg/m²), 12.7% being diabetic, and 29.5% being hypertensive. A good agreement was obtained for the physical measurements between the baseline survey and re-survey. The resources from the cohort and its fasting and postprandial blood samples collected both at baseline and in each follow-up will be valuable and powerful in investigating relationship between diet, nutrition and chronic diseases and discovering novel blood biomarkers and the metabolism of these biomarkers related to chronic diseases.     

Is it necessary for screening irregular antibodies of blood donors?

To explore the necessity of electronic crossmatching applied to irregular antibodies from blood donors, to ensure blood transfusion safety. Irregular antibody screening was performed on blood samples collected in the Dongguan Blood Center from Apr 17, 2014 to Dec 31, 2017. Primary screening was performed on the Sanquin automatic blood group analyzer by the microcolumn gel method (Sanquin). The positive samples were analyzed again using the salt medium method, polybrene method and micro-column gel method (Diana) for the second screening. If the second screening was positive, it was used to determine irregular antibody specificity (using panel cells) and any irregular antibody titer was detected. A total of 208,004 samples were detected, of which 316 were positive (316/208,004; 0.152%). Among them, 120 alloantibodies (120/135,139; 0.088%) were detected in male donors, which was much lower than in female donors (173/72,865; 0.237%) (P<0.01). A total of 16 kinds of known irregular antibodies and 40 cases of unknown antibody specificity were detected, with 119 cases of IgG type and 197 cases of IgM type, at the ratio of 1.65:1. In female donors, the frequencies of anti-D, anti-E, anti-M and anti-Le^a were significantly higher than in male donors (P<0.01). In married couples, the frequencies of anti-D and anti-E were significantly higher than those unmarried (P<0.05). In minority nationalities, the frequency of anti-M was significantly higher than in the Han nationality (P<0.05). In non-Guangdong donors, the frequencies of anti-D and anti-Le^a were significantly higher than in Guangdong donors. 87.02% of irregular antibody positive donors’ antibody titers were lower than “++”, which was deemed as no serious hazard for clinical transfusion. The study suggests that it is unnecessary to screen for irregular antibodies in blood donors. Male donors from Guangdong may not be required to undergo screening for irregular antibodies, and anti-D and anti-E only identification is also not required to be detected in female donors.     

Cell Response to Surface Stimulation

The injection of anti-D into Rh-negative subjects who have Rh-positive red cells in the circulation results in the inhibition of immunization against the D-antigen¹. On the other hand, subjects who have had a primary anti-D response to Rh-positive red cells frequently give a good secondary response to small doses of red cells despite the presence of anti-D in their plasma. The difference in action between the passively-administered and the actively-produced anti-D might lie in the fact that the injected IgG anti-D is derived from a pool of donors and therefore contains a number of IgG antigens which are foreign to the recipient, compared with the autologous nature of the anti-D present after a primary response.     

Variation in Laboratory Reporting of Haemolysis – a Need for Harmonisation

Aim

The purpose of this survey was to determine the cut-offs being used by Australian laboratories using their instrument’s Haemolysis Index (HI), whether these cut-offs vary, and at what level of haemolysis (or haemolysis index) did laboratories stop reporting one or more analytes. This was done in response to the large numbers of haemolysed samples reported in the RCPAQAP Key Incident Monitoring and Management System External Quality Assurance program (KIMMS EQA) and lack of information in the literature at the time regarding what to do once a haemolysed sample was identified. As it was known from discussions with laboratory personnel that different instruments reported their HI differently, we asked for the results to be provided in g/L free haemoglobin.

Method

An electronic survey was conducted with participants enrolled in the RCPA Quality Assurance Programs with a total of 68 laboratories responding to this survey. Some questions attracted a lower level of response.

Results

The responses showed a poor understanding of the relationship between HI units and haemoglobin concentration. There was wide variation in the way HI results were reported and thus comparing cut-off values for reporting specific analytes based on the HI was impossible to determine.

Conclusion

There is a need to harmonise the way laboratories report analytes in the presence of haemolysis. This would involve adopting a uniform definition of HI and a protocol for laboratories to confirm for themselves the level of HI at which each analyte is no longer reported, as this is method dependent and so will vary from laboratory to laboratory.     

Molecular Genetics External Quality Assessment Pilot Scheme for Irinotecan-Related UGT1A1 Genotyping in China

Irinotecan is widely used in the treatment of solid tumors, especially in colorectal cancer and lung cancer. Molecular testing for UGT1A1 genotyping is increasingly required in China for optimum irinotecan administration. In order to determine the performance of laboratories with regard to the whole testing process for UGT1A1 to ensure the consistency and accuracy of the test results, the National Center for Clinical Laboratories conducted an external quality assessment program for UGT1A1*28 genotyping in 2015. The panel, which comprised of four known mutational samples and six wild-type samples, was distributed to 45 laboratories that test for the presence of UGT1A1*28 polymorphisms. Participating laboratories were allowed to perform polymorphism analysis by using their routine methods. The accuracy of the genotyping and reporting of results was analyzed. Other information from the individual laboratories, including the number of samples tested each month, accreditation/certification status, and test methodology, was reviewed. Forty-four of the 45 participants reported the correct results for all samples. There was only one genotyping error, with a corresponding analytical sensitivity of 99.44% (179/180 challenges; 95% confidence interval: 96.94−99.99%) and an analytical specificity of 100% (270/270 challenges; 95% confidence interval: 98.64−100%). Both commercial kits and laboratory development tests were commonly used by the laboratories, and pyrosequencing was the main methodology used (n = 26, 57.8%). The style of the written reports showed large variation, and many reports showed a shortage of information. In summary, the first UGT1A1 genotyping external quality assessment result demonstrated that UGT1A1 genotype analysis of good quality was performed in the majority of pharmacogenetic testing centers that were investigated. However, greater education on the reporting of UGT1A1 genetic testing results is needed.     

EPR dosimetry intercomparison using smart phone touch screen glass

This paper presents the results of an interlaboratory comparison of retrospective dosimetry using the electron paramagnetic resonance method. The test material used in this exercise was glass coming from the touch screens of smart phones that might be used as fortuitous dosimeters in a large-scale radiological incident. There were 13 participants to whom samples were dispatched, and 11 laboratories reported results. The participants received five calibration samples (0, 0.8, 2, 4, and 10 Gy) and four blindly irradiated samples (0, 0.9, 1.3, and 3.3 Gy). Participants were divided into two groups: for group A (formed by three participants), samples came from a homogeneous batch of glass and were stored in similar setting; for group B (formed by eight participants), samples came from different smart phones and stored in different settings of light and temperature. The calibration curves determined by the participants of group A had a small error and a critical level in the 0.37–0.40-Gy dose range, whereas the curves determined by the participants of group B were more scattered and led to a critical level in the 1.3–3.2-Gy dose range for six participants out of eight. Group A were able to assess the dose within 20 % for the lowest doses (<1.5 Gy) and within 5 % for the highest doses. For group B, only the highest blind dose could be evaluated in a reliable way because of the high critical values involved. The results from group A are encouraging, whereas the results from group B suggest that the influence of environmental conditions and the intervariability of samples coming from different smart phones need to be further investigated. An alongside conclusion is that the protocol was easily transferred to participants making a network of laboratories in case of a mass casualty event potentially feasible.     

Blood group typing among Brazilian brown-howlers (Alouatta fusca)

An attempt was made to investigate ABO, Rh and MN blood antigens of 108 monkeys belonging to the species Alouatta fusca (brown-howlers).Data concerning ABO antigens did not reveal any positive blood sample for anti-H and anti-A₁ sera.In relation to the Rh system, anti-D, anti-c, anti-C and anti-E sera were used and a different pattern of antigen response was apparent. Positive blood samples were detected only through an indirect Coomb's test among c. 50% of the subjects examined for anti-D serum; and 100% for anti-c serum. For anti-E serum, c. 40% and for anti-C serum c. 50% were positive.The serological response for anti-M and anti-N sera was invariably negative as it was also found out amongst monkeys in the New World.Several techniques were employed to demonstrate the similarity between A and B antigens of monkeys and human erythrocytes and the results indicate the presence of a non-specific antigen in the erythrocyte and a corresponding antibody in the serum of the monkeys.Brown-howler erythrocytes were agglutinated by human serum corresponding to all four ABO blood types. Conversely, the hour types of human erythrocytes were agglutinated by serum belonging to any type of brown-howler subject.It was not possible to investigate antigens of the saliva from monkeys and on attempt to detect these antigens in kidney extract had no success.As a general picture, it was concluded that, corresponding to human ABO blood types, two systems were apparent, one including two antigens and the other just one.     

Identification of bacterial strains by laboratories participating in the Deutsches Krebsforschungszentrum quality assurance programme

The quality assurance programme (QAP) of the Deutsches Krebsforschungszentrum (DKFZ) is a proficiency testing system developed to service the laboratory animal discipline. QAP comprises the quarterly distribution of two bacterial strains originating from various species of animals for identification to the species level and antibiotic susceptibility testing. We compared identification results reported by QAP participants over the years 1996-2004 with those obtained by the Dutch Bacterial Diagnostics reference laboratory on 68 samples comprising 71 bacterial strains and a fungus. Significant differences were found in the frequency of reported and correct identifications when bacteria were assigned to different groups based on morphology by Gram stain and on origin (animal versus environmental, rodent and rabbit versus other animal species, pathogen versus non-pathogens). Rodent and rabbit pathogens yielded 73% correct identifications, and with all bacterial strains only 60% of the identifications were correct. We assume that most QAP participants were from laboratory animal diagnostic laboratories. If this is true, the capabilities of laboratories in the laboratory animal discipline to correctly identify bacterial species are well below what are considered acceptable limits for human diagnostic laboratories. The distribution of cultured bacteria circumvents the most difficult step in the microbiological monitoring of animals, namely primary culture from clinical samples. We propose to set up a QAP that comprises the distribution of specimens mimicking clinical samples normally submitted to laboratory animal diagnostic laboratories.     

Determination of ochratoxin A in liquorice products using HPLC based analytical methods. Part I: proficiency test of methods commonly used by the confectionary industry

A European proficiency test series was accomplished on behalf of the CAOBISCO (Association of the Chocolate, Biscuit and Confectionery Industries of the EU) expert group on ochratoxin A to assess the performance of laboratories in measuring ochratoxin A in samples of various liquorice products. In addition, the impact of the extraction type (mainly with or without the use of halogenated solvents) was to be evaluated. Four different test samples (two liquorice powders and two liquorice pastes) were tested for sufficient homogeneity and distributed to 15 laboratories in 8 countries in Europe. The results were analysed using standard proficiency testing statistical procedures and laboratories were awarded z-scores on the basis of their reported results. The overall evaluation of the results shows a distinct variation between the participating laboratories. Based on a target standard deviation (σ-value) taken from the Horwitz equation, of the 14 laboratories that reported results, satisfactory results (z-score: |Z| ≤ 2.0) were obtained by 60% and 27% of the laboratories, respectively, for the two liquorice powders and by 93% and 53% of the laboratories, respectively, for the two liquorice pastes. Approximately equal numbers of laboratories used extraction types with and without the use of halogenated solvents. ANOVA testing of the results indicates there was no evident trend using different extraction solvents.     

Intracerebral human regulatory T cells: analysis of CD4+ CD25+ FOXP3+ T cells in brain lesions and cerebrospinal fluid of multiple sclerosis patients

Impaired suppressive capacity of CD4⁺CD25⁺FOXP3⁺ regulatory T cells (Treg) from peripheral blood of patients with multiple sclerosis (MS) has been reported by multiple laboratories. It is, however, currently unresolved whether Treg dysfunction in MS patients is limited to reduced control of peripheral T cell activation since most studies analyzed peripheral blood samples only. Here, we assessed early active MS lesions in brain biopsies obtained from 16 patients with MS by FOXP3 immunohistochemistry. In addition, we used six-color flow cytometry to determine numbers of Treg by analysis of FOXP3/CD127 expression in peripheral blood and cerebrospinal fluid (CSF) of 17 treatment-naïve MS patients as well as quantities of apoptosis sensitive CD45RO^hiCD95^hi cells in circulating and CSF Treg subsets. Absolute numbers of FOXP3⁺ and CD4⁺ cells were rather low in MS brain lesions and Treg were not detectable in 30% of MS biopsies despite the presence of CD4⁺ cell infiltrates. In contrast, Treg were detectable in all CSF samples and Treg with a CD45RO^hiCD95^hi phenotype previously shown to be highly apoptosis sensitive were found to be enriched in the CSF compared to peripheral blood of MS patients. We suggest a hypothetical model of intracerebral elimination of Treg by CD95L-mediated apoptosis within the MS lesion.     

External quality assessment of flow cytometric HLA-B27 typing

A biannual external quality assurance (EQA) scheme for flow cytometric typing of the HLA-B27 antigen is operational in The Netherlands and Belgium since 1995. We report here on the results of the first seven send-outs to which 36 to 47 laboratories participated. With the send-out, four specimens from blood bank donors, who had been typed for HLA Class I antigens by complement-dependent cytotoxicity, were distributed. Subtyping of the HLA-B27 allele was performed by PCR-SSP. Ten samples were HLA-B27(pos) (all HLA-B*2705) and 18 were HLA-B27(neg). For flow cytometry, the most widely monoclonal antibody (MoAb) used was FD705, followed by GS145.2 and ABC-m3. The majority of laboratories used more than 1 anti-HLA-B27 MoAb for typing. The HLA-B27(pos) samples were correctly classified as positive by the large majority of participants (median 95%; range 85% to 100% per send out); some participants considered further typing necessary and misclassification as negative was only sporadically seen. The classification of HLA-B27(neg) samples as negative was less straightforward. Ten samples were correctly classified as such by 97% (82% to 100%) of the participants, whereas 64% (range 53% to 70%) of the participants classified the remaining eight samples as HLA-B27(neg). There was no significant prevalence of a particular HLA-B allele among these eight "poor concordancy" samples as compared to the ten "good concordancy" samples. Inspection of the reactivity patterns of the individual MoAb with HLA-B27(neg) samples revealed that ABC-m3 showed very little cross-reactivity apart from its well-known cross-reactivity with HLA-B7, whereas the cross-reactivity patterns of GS145.2 and FD705 were more extensive. The small sample size (n = 18) and the distribution of HLA-B alleles other than HLA-B27 did not allow assignment of specificities to these cross-reactions. Finally, we showed that standardized interpretation of the combined results of two anti-HLA-B27 MoAb reduced the frequency of false-positive conclusions on HLA-B27(neg) samples. In this series, the lowest frequency of false-positive assignments was observed with the combination of the FD705 and ABC-m3 MoAb.     

External Quality Assessment of Molecular Detection of Ebola Virus in China

In 2014, Ebola hemorrhagic fever broke out in West Africa. As contact between China and West Africa is frequent, the possibility that Ebola virus would enter China was high. Thus, an external assessment of the quality of Ebola virus detection was organized by the National Center for Clinical Laboratories in China. Virus-like particles encapsulating known sequences of epidemic strains of Ebola virus from 2014 were prepared as positive quality controls. The sample panel, which was composed of seven positive and three negative samples, was dispatched to 19 laboratories participating in this assessment of Ebola virus detection. Accurate detection was reported at 14 of the 19 participating laboratories, with a sensitivity of 91.43% and a specificity of 100%. Four participants (21.05%) reported false-negative results and were classified as “acceptable.” One participant (5.26%) did not detect any positive samples and was thus classified as “improvable.” Based on the results returned, the ability to detect weakly positive Ebola specimens should be improved. Furthermore, commercial assays and the standard primers offered by the Chinese Centers for Disease Control and Prevention were found to be most accurate and dependable for Ebola detection. A two-target detection approach is recommended for Ebola screening; this approach could reduce the probability of false-negative results. Additionally, standardization of operations and punctual adjustment of instruments are necessary for the control and prevention of Ebola virus.     

An error in Rh testing in pregnancy.

Anti-D (anti-Rho) in the blood of two Rh-negative pregnant women was believed to be due to active immunization. In the first case, however, antibodies were no longer detectable 2 weeks later. In the second case they disappeared by the end of 31 weeks. It was discovered that both women had been given immune globulin (human) because of exposure to rubella. The globulin given to the first woman probably contained about 0.1 mug of anti-D per ml; that given to the second probably contained about 0.6 mug of anti-D per ml. Both babies were O Rh-positive. Both women were given Rh immune globulin after delivery. Both have completed a further pregnancy and no anti-D has been found on many tests. In tests carried out in 1971 all samples of immune globulin (human) examined contained anti-D, but usually in inconsequential trace amounts.     

External quality assessment of cytomegalovirus DNA detection on dried blood spots

Background  

Testing for viral DNA in neonatal blood dried on paper (DBS) has proved a valid means of diagnosing congenital CMV infection with both clinical and epidemiological relevance. To assess the quality of the detection of CMV-DNA on DBS in laboratories performing this test a proficiency panel consisting of nine samples with two blood spots on each filter paper was produced and distributed. Six samples were derived from whole blood, negative for CMV DNA and antibody, and spiked with cell-grown CMV Towne in various concentrations (7.3 × 10² - 9.6 × 10⁵ copies/ml), one was a CMV positive clinical specimen (3.9 × 10⁶ copies/ml), and two samples were CMV-negative whole blood.