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MLO201608-COVER-nolabel.indd COVERI 7/12/2016 4:36:59 PM MAKE THE SHIFT TO MOLEC U LA R G I PAT H O G E N T E ST I N G than culture. S P E E D A N D P E R F O R M A N C E – The molecular assay for Salmonella, Shigella, Campylobacter, Shiga Toxin 1 and Shiga Toxin 2. Faster Results Streamlined Workflow Scalable Just 4 hours versus 24 to 48 hours with cultures. Use 1 protocol to test for the 5 most common gastrointestinal pathogens. Ramp up production to meet higher volumes during peak disease season. Prodesse ProGastro® SSCS assay Hologic.com ADS 015 ADS0155 1 1-00 -00 01 Re evv. 001 © 2 201 016 Hologi Ho H logi ogiic, In nc. c All All righ igh g tss res gh eser s ved. ve ved ed. 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MLO201608_AD CGM.indd 1 Visit us at AACC Booth #3719 7/8/2016 12:53:51 PM 12 FEATURES 12 The continuing case for point-of-care testing for HbA1c By Gavin Jones, BSc(Hons) | Vol. 48, No. 8 Diabetes: The current state of affairs from a population management view By Liana F. Romero, PhD, MBA, MT(ASCP) 20 EDUCATION 26 AUGUST 2016 CONTINUING EDUCATION SPECIAL REPORT 22 The Peer Reviewed Management Source for Lab Professionals since 1969 CE Test Tests can be taken online or by mail. See page 20 for testing and payment details. An update on gestational diabetes mellitus By David Grenache, PhD 28 Next-generation sequencing and the future of IVF By Lia Ribustello, BS, MS SPECIAL FEATURE 30 Individualized risk prediction in Barrett’s esophagus By Aaron D. DeWard, PhD, and Rebecca Critchley-Thorne, PhD LAB MANAGEMENT 36 External and internal QC for blood gases DEPARTMENTS 4 10 56 By Al Jordon 38 Resolving QC failures From the editor The observatory Washington report Precision medicine and the cancer “moonshot” By W. Greg Cooper, CLS, CQA, MHA 40 The role of calibration verification/linearity in the POCT market By Glenn Mitchell CLINICAL ISSUES 44 Approaches to prescription opioid abuse testing By Jenny Cybulski THE PRIMER 48 Direct molecular diagnostics for sepsis By John Brunstein, PhD PRODUCTS 58 Product focus: Automation MARKETPLACE 62 62 New products Advertiser index FUTURE BUZZ 50 The technology and clinical applications of hybrid capture NGS By John Havens, PhD 52 The transformation of pathogen diagnostics through next-generation sequencing By Crystal Icenhour, PhD MANAGEMENT MATTERS 54 Continuous quality management in the laboratory By Nancy Alers, MS, MT(ASCP)CM 2 MLO - ONLINE.COM MLO201608-TOC_MECH_AL.indd 2 EXECUTIVE SNAPSHOT 64 Leading the way in diagnostics for infectious diseases, cancer screening, and safeguarding the blood supply Stephen P. MacMillan Chairman of the Board Hologic AUGUST 2016 7/12/2016 5:34:56 PM MLO201608_AD API.indd 3 7/8/2016 12:48:44 PM FROM THE EDITOR By A lan L enhof f, Edi tor A day in the life of clinical laboratory science ONE NICE THING ABOUT MY JOB IS THAT, as part of it, I have the opportunity—and professional obligation—to read news releases about advances in laboratory medicine or the science that underlies it, and to follow the continuous flow of important advancements. One day shortly before this August 2016 issue of MLO went to press, there was an especially impressive group of news releases that came across my desk. Lab Week is in April, but July 6 was a kind of unofficial lab day, I guess, because I had the pleasure of learning that day about all of the following: • New screening test using blood biomarkers may identify risk of colon cancer recurrence. Ludwig Institute for Cancer Research scientists, working in collaboration with colleagues in Australia and the United States, have shown that fragments of tumor DNA circulating in the blood can be used to gauge the risk of colorectal cancer recurrence and the efficacy of chemotherapy following surgery. The finding, published in Science Translational Medicine, is an important step toward the development of a noninvasive and more effective test for the detection, monitoring, and treatment of cancer. • “Omics” data improves breast cancer survival prediction. Precise predictions of whether a tumor is likely to spread would help clinicians and patients choose the best course of treatment. New research reveals that profiling primary tumor samples using genomic technologies can improve the accuracy of breast cancer survival predictions compared to clinical information alone. Although this method is not ready for use in the clinic, the proof-of-principle study, published in GENETICS, shows that survival predictions improve when they incorporate comprehensive data on which genes are active in tumor samples compared to noncancerous tissues from the same patient • Blood test to detect DNA fragments shed from colon cancers predicts disease’s recurrence. Scientists at the Johns Hopkins Kimmel Cancer Center and University of Melbourne report they have used a genetic test that spots bits of cancer-related DNA circulating in the blood to accurately predict the likelihood of the disease’s return in some—but not all—of a small group of patients with earlystage colon cancer. The DNA-based test, described in the July 6 issue of Science Translational Medicine, if confirmed by further research, could eventually help clinicians decide which patients need additional treatment at the time of their initial diagnosis of stage 2 cancer. • Inexpensive blood test can discriminate between bacterial, viral infections, study finds. Researchers at the Stanford University School of Medicine have made an important breakthrough in their ongoing efforts to develop a diagnostic test that can tell healthcare providers whether a patient has a bacterial infection and will benefit from antibiotics. The team used publicly available patient gene expression data to pinpoint just seven human genes whose activity changes during an infection; their pattern of activity can distinguish whether an infection is bacterial or viral. • Genetic testing can help deliver precision medicine to men with advanced prostate cancer. Genetic testing in men with advanced prostate cancer could pick up a significant proportion whose disease may be caused by inherited mutations in genes involved in repairing DNA damage, a major new study reveals. Testing prostate cancer patients for mutations in key DNA repair genes could identify those who may benefit from precision treatments that specifically target DNA repair weaknesses in cancer cells. “Although this method is not ready for use in the clinic…” is the caveat that can be applied to all of these fascinating examples of the breakthroughs that molecular approaches may one day provide for clinical diagnostics—but that makes them no less exciting. I remember how the late Paul Harvey sometimes used to include medical research news in his daily radio commentaries, leading with “Today’s news of perhaps the most lasting significance is….” Who knows which of these items may prove to be the news of most lasting significance for July 6, 2016? 4 MLO - ONLINE.COM MLO201608-Editorial_MECH_AL.indd 4 AUGUST 2016 MEDICAL LABORATORY OBSERVER Vol.48, No.8 Publisher/Executive Editor/President Kristine Russell [email protected] Editor Alan Lenhoff [email protected] Associate Editor Lisa Moynihan [email protected] Graphic Artist Glenn Huston [email protected] Graphic Artist Emily Baatz [email protected] Ad Contracts Manager Laura Moulton [email protected] Ad Traffic Manager Kathleen Shook [email protected] Subscriptions [email protected] LABline/eProduct Insider Mary Haberstroh [email protected] Reprints Deborah Beebe [email protected] ADVERTISING East Coast/Midwest Sales (except IL) Classified/Recruitment Advertising Carol Vovcsko (941) 321-2873 [email protected] South/West Coast/Illinois Sales Lora Harrell (941) 328-3707 [email protected] MLO EDITORIAL ADVISORY BOARD John Brunstein, PhD, Biochemistry (Molecular Virology) President & CSO PathoID, Inc., British Columbia, Canada John A. Gerlach, PhD, D(ABHI) Laboratory Director Michigan State University, East Lansing, MI Barbara Strain, MA Director, Supply Chain Analytics University of Virginia Health System, Charlottesville, VA Jeffrey D. Klausner, MD, MPH Associate Clinical Professor of Medicine Divisions of AIDS and Infectious Diseases University of California, San Francisco, CA Susan McQuiston, JD, MT(ASCP) Instructor, Biomedical Laboratory Diagnostics Program Michigan State University, East Lansing, MI Donna Beasley, DLM(ASCP) Manager Huron Healthcare, Chicago, IL Anthony Kurec, MS, H(ASCP)DLM Clinical Associate Professor SUNY Upstate Medical University, Syracuse, NY Suzanne Butch, MLS(ASCP)CM, SBBCM, DLMCM Administrative Manager, Blood Bank and Transfusion Service, University of Michigan Health System Department of Pathology, Ann Arbor, MI Paul R. Eden, Jr., MT(ASCP), PhD Major, United States Air Force Toxicology Program Manager, 711 HPW/RHDJ Wright-Patterson AFB, OH NP Communications, LLC. 2477 Stickney Point Rd., Suite 221B Sarasota, FL 34231 Phone: (941) 388-7050 Fax: (941) 388-7490 www.mlo-online.com MLO - MEDICAL LABORATORY OBSERVER (ISSN: 0580-7247). Published monthly, with an additional issue in August, by NP Communications, LLC., 2477 Stickney Point Rd, Suite 221B, Sarasota, FL 34231 (941) 388-7050. Subscription rates: $127.60/ year in the U.S.; $154.88 Canada/Mexico; Intl. subscriptions are $221.43/year. All issues of MLO are available on microfilm from University Microfilms International, Box 78, 300 N. Zeeb Rd., Ann Arbor, MI 48106. Current single copies (if available) $15.40 each (U.S); and $19.80 each (Intl.). Back issues (if available) $17.60 each (U.S.); $22.00 each (Intl.). Payment must be made in U.S. funds on a U.S. bank/ branch within the continental U.S. and accompany request. 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Printed in U.S.A. 7/12/2016 9:13:04 AM ADVERTORIAL A new diagnostic approach to Mycoplasma pneumoniae A conversation with Ken Kozak, Chief Technical Officer, Meridian Bioscience, Inc., and Donna Mayne, BSMT, ASCP, (CLS)NCA, Microbiology, Serology, Molecular Lab Manager, Sacred Heart Hospital, Pensacola, FL Q: Why was a better test for Mycoplasma pneumoniae needed? A (Kozak): Traditional methods of diagnosis (including serology) have low sensitivities, are dependent on a patient’s immune response, and/or do not provide diagnostic results within a clinically relevant time frame. Specifically, serology is dependent on a patient’s immune response, which takes time to develop, so in the first week of testing you may only detect 25 percent of the positives. X-rays are the other widely used method, which cannot definitively identify the cause of infection. illumigene Mycoplasma Direct would provide physicians a definitive diagnosis and allow them to provide targeted treatment, therefore lessening the much larger issue of antibiotic resistance. respectively, which makes a rapid, targeted detection for specific treatment difficult. illumigene Mycoplasma Direct accurately detects infection on the first day of symptoms and provides the ability to avoid treating patients empirically to reduce the administration of broad spectrum antibiotics and the likelihood of antimicrobial resistance. More importantly, the increased performance of this innovative test enables a more rapid diagnosis, which in turn, provides for earlier identification of outbreaks and prevention of secondary cases through implementation of control measures. Q: What are the main barriers to diagnosing Mycoplasma Q: How does illumigene Mycoplasma Direct differ from other pneumoniae effectively, and how does illumigene Mycoplasma Direct overcome them? molecular tests? A (Mayne): Until now, Mycoplasma respiratory infections have A (Kozak): illumigene Mycoplasma Direct is the only FDAcleared standalone molecular assay for the detection of Mycoplasma pneumoniae. This new test offers a simplified procedure which lends itself for use in moderately complex laboratories. Our team worked very hard to make process improvements without compromising performance. illumigene Mycoplasma Direct features a simple three-step procedure that takes less than two minutes of hands-on time and provides final patient results in under one hour. Because illumigene Mycoplasma Direct is a single analyte test, our data has shown that it is more sensitive than the FDA-cleared multi-analyte molecular panels that include Mycoplasma pneumoniae. This allows for better patient management because it is able to detect more positives. The illumigene test utilizes our proven loop-mediated isothermal amplification (LAMP) technology, which provides a simple procedure, in conjunction with our cost-effective diagnostic platform that has the flexibility to run one or up to 10 patient samples at a time and has a small 8½-by-11 inch footprint. Since it requires no expensive capital equipment or service contracts, this innovative test is ideal for enabling a more rapid diagnosis and can be widely employed into any moderately complex laboratory. Q: How was illumigene Mycoplasma Direct tested? Who was involved in developing the clinical trials? A (Kozak): The clinical trial compared illumigene Mycoplasma Direct to illumigene Mycoplasma on 456 prospective throat swab samples from patients with upper respiratory illness at three different clinical sites in Missouri, Texas, and Florida. The overall positive percent agreement was 96.0 percent and the negative percent agreement was 97.7 percent, prior to discrepant analysis being performed. A closer look at this data showed that illumigene Mycoplasma Direct detected 10 more positives that were missed by the other assays. Prevalence was highest in the 3 to 12 year olds and 13 to 21 year olds, 15 percent and 13.2 percent, respectively. Q: How much better is your test as compared with the other testing methods for Mycoplasma pneumoniae (serology, x-ray)? A (Kozak): Current testing methodologies have low sensitivities and specificities when detecting Mycoplasma pneumoniae. Traditional testing methods, such as serology and x-ray, have documented sensitivities as low as 25 percent and 41 percent, primarily been diagnosed using clinical signs and symptoms and/or chest x-ray. These are subjective and non-specific criteria that frequently result in misdiagnosis when used alone. Until recently, we offered Mycoplasma IgM testing as an additional tool for physicians to use when considering Mycoplasma respiratory infections; however, we discontinued this test earlier this year due to lack of clinical correlation. The lack of a fast and accurate test for Mycoplasma respiratory infections had been a significant roadblock in Mycoplasma diagnosis. With the availability of molecular tests for Mycoplasma, physicians are able to rule out or diagnose Mycoplasma with confidence; however, if these tests are not able to be performed and resulted quickly, empiric therapy must be considered. If this testing is provided in a timely fashion, empiric therapy can be avoided. The illumigene Mycoplasma Direct will provide physicians with such a timely/accurate result, allowing proper diagnosis and timely treatment while practicing good antibiotic stewardship. It has been our experience that fast and accurate lab tests are both a physician and patient satisfier. This type of test builds the physician’s confidence in the laboratory and builds the patient’s confidence in both the physician and laboratory. Additionally, fast/accurate diagnosis leads to fast/accurate treatment and better patient outcomes. Q: How will illumigene Mycoplasma Direct be used in your facility? A (Mayne): At Sacred Heart, we will be offering this assay 24/7 and testing samples as they arrive in our laboratory. This “realtime” approach has been very successful for us for the GAS and Pertussis illumigene assays. Our physicians and patients benefit from these rapid and accurate results no matter what time of day the sample is received in the lab. Q: What other disease areas is illumigene involved in? A (Kozak): The illumigene expanded molecular menu includes tests in the following areas where they have proved highly accurate and are used in nearly 1,500 institutions worldwide: • Hospital Acquired Infections (Clostridium difficile) • Tropical Diseases (Malaria) • Sexual Health (Chlamydia [CT], Gonorrhoeae [NG], Group B Streptococcus, HSV 1 &2) • Respiratory (Group A Streptococcus, Pertussis) AUGUST 2016 MLO201608_AD ADVERTORIAL-Meridian Final.indd 5 MLO - ONLINE.COM 5 8/25/2016 10:38:41 AM TAGRISSO: in patients with metastatic EGFR T790M mutation–positive NSCLC, as detected by an FDA-approved test, at progression on or after EGFR TKI therapy Identify EGFR T790M mutation in patients who progress on or after EGFR TKI therapy • Nearly 2 out of 3 cases of progression with first-generation EGFR TKIs are related to the acquired T790M mutation1 • Testing at progression provides the opportunity to identify mechanisms of resistance, including the T790M mutation TAGRISSO demonstrated efficacy and safety in two clinical trials • TAGRISSO was researched in two separate, global, Phase II, single-arm, open-label clinical trials in patients with EGFR T790M mutation–positive NSCLC who had progressed on or after EGFR TKI therapy2 • A 59% objective response rate (95% CI: 54–64) observed in patients (N=411) who progressed with previous EGFR TKI therapy2 • The most common adverse reactions (>20%) observed in TAGRISSO patients were diarrhea (42%), rash (41%), dry skin (31%), and nail toxicity (25%)2 • Interstitial lung disease (ILD) was reported in 3.3% of patients and was fatal in 0.5% of TAGRISSO patients2 Visit TAGRISSOhcp.com for more information MLO201608_AD Astra-Zeneca-Spread.indd 6 7/8/2016 12:50:51 PM IDENTIFY PATIENTS APPROPRIATE FOR TAGRISSO Visit cobasEGFRtest.com today to learn how. IMPORTANT SAFETY INFORMATION • There are no contraindications for TAGRISSO • Interstitial Lung Disease (ILD)/Pneumonitis occurred in 3.3% and was fatal in 0.5% of 813 TAGRISSO patients. Withhold TAGRISSO and promptly investigate for ILD in any patient presenting with worsening of respiratory symptoms indicative of ILD (e.g., dyspnea, cough and fever). Permanently discontinue TAGRISSO if ILD is confirmed • QTc interval prolongation occurred in TAGRISSO patients. Of the 411 patients in two Phase II studies, 0.2% were found to have a QTc greater than 500 msec, and 2.7% had an increase from baseline QTc greater than 60 msec. Conduct periodic monitoring with ECGs and electrolytes in patients with congenital long QTc syndrome, congestive heart failure, electrolyte abnormalities, or those who are taking medications known to prolong the QTc interval. Permanently discontinue TAGRISSO in patients who develop QTc interval prolongation with signs/symptoms of life threatening arrhythmia • Cardiomyopathy occurred in 1.4% and was fatal in 0.2% of 813 TAGRISSO patients. Left Ventricular Ejection Fraction (LVEF) decline >10% and a drop to <50% occurred in 2.4% of (9/375) TAGRISSO patients. Assess LVEF before initiation and then at 3 month intervals of TAGRISSO treatment. Withhold TAGRISSO if ejection fraction decreases by 10% from pretreatment values and is less than 50%. For symptomatic congestive heart failure or persistent asymptomatic LV dysfunction that does not resolve within 4 weeks, permanently discontinue TAGRISSO • Advise pregnant women of the potential risk to a fetus. Advise females of reproductive potential to use effective contraception during TAGRISSO treatment and for 6 weeks after the final dose. Advise males with female partners of reproductive potential to use effective contraception for 4 months after the final dose • The most common adverse reactions (>20%) observed in TAGRISSO patients were diarrhea (42%), rash (41%), dry skin (31%) and nail toxicity (25%) INDICATION TAGRISSO is indicated for the treatment of patients with metastatic epidermal growth factor receptor (EGFR) T790M mutation-positive non-small cell lung cancer (NSCLC), as detected by an FDA-approved test, who have progressed on or after EGFR tyrosine kinase inhibitor therapy. This indication is approved under accelerated approval based on tumor response rate and duration of response. Continued approval for this indication may be contingent upon verification and description of clinical benefit in confirmatory trials. Please see Brief Summary of full Prescribing Information on adjacent pages. References: 1. Yu HA, Arcila ME, Rekhtman N, et al. Analysis of tumor specimens at the time of acquired resistance to EGFR-TKI therapy in 155 patients with EGFR-mutant lung cancers. Clin Cancer Res. 2013;19:2240-2247. 2. TAGRISSO [package insert]. Wilmington, DE: AstraZeneca Pharmaceuticals LP; 2015. TAGRISSO is a trademark of the AstraZeneca group of companies. ©2016 AstraZeneca. All rights reserved. 3216302 4/16 MLO201608_AD Astra-Zeneca-Spread.indd 7 7/8/2016 12:51:01 PM TAGRISSOTM (osimertinib) tablet, for oral use Brief Summary of Prescribing Information. For complete prescribing information consult official package insert INDICATIONS AND USAGE TAGRISSO is indicated for the treatment of patients with metastatic epidermal growth factor receptor (EGFR) T790M mutation-positive non-small cell lung cancer (NSCLC), as detected by an FDA-approved test, who have progressed on or after EGFR tyrosine kinase inhibitor (TKI) therapy. This indication is approved under accelerated approval based on tumor response rate and duration of response [see Clinical Studies (14) in the full Prescribing Information]. Continued approval for this indication may be contingent upon verification and description of clinical benefit in confirmatory trials. DOSAGE AND ADMINISTRATION Patient Selection Confirm the presence of a T790M EGFR mutation in tumor specimens prior to initiation of treatment with TAGRISSO [see Indications and Usage (1) and Clinical Studies (14) in the full Prescribing Information]. Information on FDA-approved tests for the detection of T790M mutations is available at http://www.fda.gov/companiondiagnostics. Recommended Dosage Regimen The recommended dose of TAGRISSO is 80 mg tablet once a day until disease progression or unacceptable toxicity. TAGRISSO can be taken with or without food. If a dose of TAGRISSO is missed, do not make up the missed dose and take the next dose as scheduled. Administration to Patients Who Have Difficulty Swallowing Solids Disperse tablet in 4 tablespoons (approximately 50 mL) of non-carbonated water only. Stir until tablet is completely dispersed and swallow or administer through naso-gastric tube immediately. Do not crush, heat, or ultrasonicate during preparation. Rinse the container with 4 to 8 ounces of water and immediately drink or administer through the naso-gastric tube [see Clinical Pharmacology (12.3) in the full Prescribing Information]. Dose Modification for Adverse Reactions Table 1 Recommended Dose Modifications for TAGRISSO Target Organ Pulmonary Cardiac Other Adverse Reactiona Interstitial lung disease (ILD)/Pneumonitis QTc† interval greater than 500 msec on at least 2 separate ECGsb b c † Withhold TAGRISSO until QTc interval is less than 481 msec or recovery to baseline if baseline QTc is greater than or equal to 481 msec, then resume at 40 mg dose. Permanently discontinue TAGRISSO. QTc interval prolongation with signs/ symptoms of life threatening arrhythmia Asymptomatic, absolute decrease Withhold TAGRISSO for up to 4 weeks. in LVEFc of 10% from baseline and • If improved to baseline LVEF, resume. below 50% • If not improved to baseline, permanently discontinue. Symptomatic congestive heart failure Permanently discontinue TAGRISSO. Grade 3 or higher adverse reaction Withhold TAGRISSO for up to 3 weeks. If improvement to Grade 0-2 within Resume at 80 mg or 40 mg daily. 3 weeks If no improvement within 3 weeks a Dose Modification Permanently discontinue TAGRISSO. TAGRISSO N=411 Permanently discontinue TAGRISSO. Adverse reactions graded by the National Cancer Institute Common Terminology Criteria for Adverse Events version 4.0 (NCI CTCAE v4.0). ECGs = Electrocardiograms LVEF = Left Ventricular Ejection Fraction QTc = QT interval corrected for heart rate CONTRAINDICATIONS None. WARNINGS AND PRECAUTIONS Interstitial Lung Disease/Pneumonitis Across clinical trials, interstitial lung disease (ILD)/pneumonitis occurred in 3.3% (n=27) of TAGRISSO treated patients (n=813); 0.5% (n=4) were fatal. Withhold TAGRISSO and promptly investigate for ILD in any patient who presents with worsening of respiratory symptoms which may be indicative of ILD (e.g., dyspnea, cough and fever). Permanently discontinue TAGRISSO if ILD is confirmed [see Dosage and Administration (2.4) and Adverse Reactions (6) in the full Prescribing Information]. QTc Interval Prolongation The heart rate-corrected QT (QTc) interval prolongation occurs in patients treated with TAGRISSO. Of the 411 patients in Study 1 and Study 2, one patient (0.2%) was found to have a QTc greater than 500 msec, and 11 patients (2.7%) had an increase from baseline QTc greater than 60 msec [see Clinical Pharmacology (12.2) in the full Prescribing Information]. In Study 1 and 2, patients with baseline QTc of 470 msec or greater were excluded. Conduct periodic monitoring with ECGs and electrolytes in patients with congenital long QTc syndrome, congestive heart failure, electrolyte abnormalities, or those who are taking medications known to prolong the QTc interval. Permanently discontinue TAGRISSO in patients who develop QTc interval prolongation with signs/symptoms of life threatening arrhythmia [see Dosage and Administration (2.4) in the full Prescribing Information]. Cardiomyopathy Across clinical trials, cardiomyopathy (defined as cardiac failure, pulmonary edema, ejection fraction decreased or stress cardiomyopathy) occurred in 1.4% (n=11) of TAGRISSO treated patients (n=813); 0.2% (n=2) were fatal. In Study 1 and Study 2, Left Ventricular Ejection Fraction (LVEF) decline >10% and a drop to <50% occurred in 2.4% (9/375) of patients who had baseline and at least one follow up LVEF assessment. MLO201608_AD Astra-Zeneca-D1.indd 8 Assess LVEF by echocardiogram or multigated acquisition (MUGA) scan before initiation of TAGRISSO and then at 3 month intervals while on treatment. Withhold treatment with TAGRISSO if ejection fraction decreases by 10% from pretreatment values and is less than 50%. For symptomatic congestive heart failure or persistent, asymptomatic LV dysfunction that does not resolve within 4 weeks, permanently discontinue TAGRISSO [see Dosage and Administration (2.4) in the full Prescribing Information]. Embryo-Fetal Toxicity Based on data from animal studies and its mechanism of action, TAGRISSO can cause fetal harm when administered to a pregnant woman. In animal reproduction studies, osimertinib caused postimplantation fetal loss when administered during early development at a dose exposure 1.5 times the exposure at the recommended human dose. When males were treated prior to mating with untreated females, there was an increase in preimplantation embryonic loss at plasma exposures of approximately 0.5-times those observed in patients at the 80 mg dose level. Advise pregnant women of the potential risk to a fetus. Advise females of reproductive potential to use effective contraception during treatment with TAGRISSO and for 6 weeks after the final dose. Advise males with female partners of reproductive potential to use effective contraception for 4 months after the final dose [see Use in Specific Populations (8.1), (8.3) and Clinical Pharmacology (12.3) in the full Prescribing Information]. ADVERSE REACTIONS The following adverse reactions are discussed in greater detail in other sections of the labeling: Interstitial Lung Disease/Pneumonitis [see Warnings and Precautions (5.1) in the full Prescribing Information] QTc Interval Prolongation [see Warnings and Precautions (5.2) in the full Prescribing Information] Clinical Trials Experience Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice. The data described below reflect exposure to TAGRISSO (80 mg daily) in 411 patients with EGFR T790M mutation-positive non-small cell lung cancer who received prior EGFR TKI therapy, in two single arm studies, Study 1 and Study 2. Patients with a past medical history of ILD or radiation pneumonitis that required steroid treatment, serious arrhythmia or baseline QTc interval greater than 470 ms were excluded from Study 1 and Study 2. Baseline patient and disease characteristics were: median age 63 years, 13% of patients were ≥75 years old, female (68%), White (36%), Asian (60%), metastatic (96%), sites of brain metastases (39%), World Health Organization (WHO) performance status of 0 (37%) or 1 (63%), 1 prior line of therapy [EGFR-TKI treatment only, second line, chemotherapy-naïve (31%)], 2 or more prior lines of therapy (69%). Of the 411 patients, 333 patients were exposed to TAGRISSO for at least 6 months; 97 patients were exposed for at least 9 months; however no patient was exposed to TAGRISSO for 12 months. In Studies 1 and 2, the most common (>20%) adverse reactions (all grades) observed in TAGRISSOtreated patients were diarrhea (42%), rash (41%), dry skin (31%), and nail toxicity (25%). Dose reductions occurred in 4.4% of patients treated with TAGRISSO. The most frequent adverse reactions that led to dose reductions or interruptions were: electrocardiogram QTc prolonged (2.2%) and neutropenia (1.9%). Serious adverse reactions reported in 2% or more patients were pneumonia and pulmonary embolus. There were 4 patients (1%) treated with TAGRISSO who developed fatal adverse reactions of ILD/pneumonitis. Other fatal adverse reactions occurring in more than 1 patient included pneumonia (4 patients) and CVA/cerebral hemorrhage (2 patients). Discontinuation of therapy due to adverse reactions occurred in 5.6% of patients treated with TAGRISSO. The most frequent adverse reactions that led to discontinuation were ILD/pneumonitis and cerebrovascular accidents/infarctions. Tables 2 and 3 summarize the common adverse reactions and laboratory abnormalities observed in TAGRISSO-treated patients. Table 2 Adverse Reactions (>10% for all NCI CTCAE* Grades or >2% for Grades 3-4) in Study 1 and Study 2 Adverse Reaction Gastrointestinal disorders Diarrhea Nausea Decreased appetite Constipation Stomatitis Skin disorders Rasha Dry skinb Nail toxicityc Pruritus Eye Disordersd Respiratory Cough General Fatigue Musculoskeletal Back pain Central Nervous System Headache Infections Pneumonia Vascular events Venous thromboembolisme All Grades % Grade 3-4f % 42 17 16 15 12 1.0 0.5 0.7 0.2 0 41 31 25 14 18 0.5 0 0 0 0.2 14 0.2 14 0.5 13 0.7 10 0.2 4 2.2 7 2.4 * NCI CTCAE v4.0. 7/8/2016 12:49:56 PM TAGRISSOTM (osimertinib) tablet, for oral use a b c d e f Includes cases reported within the clustered terms for rash adverse events: Rash, rash generalized, rash erythematous, rash macular, rash maculo-papular, rash papular, rash pustular, erythema, folliculitis, acne, dermatitis and acneform dermatitis. Includes dry skin, eczema, skin fissures, xerosis. Includes nail disorders, nail bed disorders, nail bed inflammation, nail bed tenderness, nail discoloration, nail disorder, nail dystrophy, nail infection, nail ridging, onychoclasis, onycholysis, onychomadesis, paronychia. Includes dry eye, vision blurred, keratitis, cataract, eye irritation, blepharitis, eye pain, lacrimation increased, vitreous floaters. Other ocular toxicities occurred in <1% of patients. Includes deep vein thrombosis, jugular venous thrombosis, and pulmonary embolism. No grade 4 events have been reported. Additional clinically significant adverse reactions occurring in 2% or more of patients treated with TAGRISSO included cerebrovascular accident (2.7%). Table 3 Common Laboratory Abnormalities (>20% for all NCI CTCAE Grades) in Study 1 and Study 2 Laboratory Abnormality Clinical Chemistry Hyponatremia Hypermagnesemia Hematologic Lymphopenia Thrombocytopenia Anemia Neutropenia a TAGRISSO N=411 Change from Baseline Change from Baseline to Grade 3 or Grade 4 (%)a All Grades (%) 26 20 3.4 0.7 63 54 44 33 3.3 1.2a 0.2 3.4 The only grade 4 laboratory abnormality was 1 patient with grade 4 thrombocytopenia. DRUG INTERACTIONS Drug interaction studies with inhibitors, inducers or substrates of CYP enzymes and transporters have not been conducted with TAGRISSO. Effect of Other Drugs on Osimertinib Strong CYP3A Inhibitors Avoid concomitant administration of TAGRISSO with strong CYP3A inhibitors, including macrolide antibiotics (e.g., telithromycin), antifungals (e.g., itraconazole), antivirals (e.g., ritonavir), nefazodone, as concomitant use of strong CYP3A inhibitors may increase osimertinib plasma concentrations. If no other alternative exists, monitor patients more closely for adverse reactions of TAGRISSO [see Dosage and Administrations (2.4) and Clinical Pharmacology (12.3) in the full Prescribing Information]. Strong CYP3A Inducers Avoid concomitant administration of TAGRISSO with strong CYP3A inducers (e.g., phenytoin, rifampicin, carbamazepine, St. John’s Wort) as strong CYP3A inducers may decrease osimertinib plasma concentrations [see Clinical Pharmacology (12.3) in the full Prescribing Information]. Effect of Osimertinib on Other Drugs Avoid concomitant administration of TAGRISSO with drugs that are sensitive substrates of CYP3A, breast cancer resistance protein (BCRP), or CYP1A2 with narrow therapeutic indices, including but not limited to fentanyl, cyclosporine, quinidine, ergot alkaloids, phenytoin, carbamazepine, as osimertinib may increase or decrease plasma concentrations of these drugs [see Clinical Pharmacology (12.3) in the full Prescribing Information]. USE IN SPECIFIC POPULATIONS Pregnancy Risk Summary Based on data from animal studies and its mechanism of action, TAGRISSO can cause fetal harm when administered to a pregnant woman. There are no available data on TAGRISSO use in pregnant women. Administration of osimertinib to pregnant rats was associated with embryolethality and reduced fetal growth at plasma exposures 1.5 times the exposure at the recommended human dose [see Data]. Advise pregnant women of the potential risk to a fetus. In the U.S. general population, the estimated background risk of major birth defects and miscarriage in clinically-recognized pregnancies is 2% to 4% and 15% to 20%, respectively. Data Animal Data When administered to pregnant rats prior to embryonic implantation through the end of organogenesis (gestation days 2-20) at a dose of 20 mg/kg/day, which produced plasma exposures of approximately 1.5 times the clinical exposure, osimertinib caused post-implantation loss and early embryonic death. When administered to pregnant rats from implantation through the closure of the hard palate (gestation days 6 to 16) at doses of 1 mg/kg/day and above (0.1-times the AUC observed in patients at the recommended dose of 80 mg), an equivocal increase in the rate of fetal malformations and variations was observed in treated litters relative to those of concurrent controls. When administered to pregnant dams at doses of 30 mg/kg/day during organogenesis through lactation Day 6, osimertinib caused an increase in total litter loss and postnatal death. At a dose of 20 mg/kg/day, osimertinib administration during the same period resulted in increased postnatal death as well as a slight reduction in mean pup weight at birth that increased in magnitude between lactation days 4 and 6. Lactation Risk Summary There are no data on the presence of osimertinib in human milk, the effects of osimertinib on the breastfed infant or on milk production. Administration to rats during gestation and early lactation was associated with adverse effects, including reduced growth rates and neonatal death [see Use in MLO201608_AD Astra-Zeneca-D2.indd 9 2 Specific Populations (8.1) in the full Prescribing Information]. Because of the potential for serious adverse reactions in breastfed infants from osimertinib, advise a lactating woman not to breastfeed during treatment with TAGRISSO and for 2 weeks after the final dose. Females and Males of Reproductive Potential Contraception Females Advise females of reproductive potential to use effective contraception during treatment with TAGRISSO and for 6 weeks after the final dose [see Use in Specific Populations (8.1) in the full Prescribing Information]. Males Advise male patients with female partners of reproductive potential to use effective contraception during and for 4 months following the final dose of TAGRISSO [see Nonclinical Toxicology (13.1) in the full Prescribing Information]. Infertility Based on animal studies, TAGRISSO may impair fertility in females and males of reproductive potential. It is not known if the effects on fertility are reversible [see Nonclinical Toxicology (13.1) in the full Prescribing Information]. Pediatric Use The safety and effectiveness of TAGRISSO in pediatric patients have not been established. Geriatric Use One hundred eighty-seven (45%) of the 411 patients in clinical trials of TAGRISSO were 65 years of age and older, and 54 patients (13%) were 75 years of age and older. No overall differences in effectiveness were observed based on age. Exploratory analysis suggest a higher incidence of Grade 3 and 4 adverse reactions (32% versus 25%) and more frequent dose modifications for adverse reactions (23% versus 17%) in patients 65 years or older as compared to those younger than 65 years. Renal Impairment No dedicated clinical studies have been conducted to evaluate the effect of renal impairment on the pharmacokinetics of osimertinib. Based on population pharmacokinetic analysis, no dose adjustment is recommended in patients with mild [creatinine clearance (CLcr) 60-89 mL/min] or moderate (CLcr 30-59 mL/min) renal impairment. There is no recommended dose of TAGRISSO for patients with severe renal impairment (CLcr <30 mL/min) or end-stage-renal disease [see Clinical Pharmacology (12.3) in the full Prescribing Information]. Hepatic Impairment No dedicated clinical studies have been conducted to evaluate the effect of hepatic impairment on the pharmacokinetics of osimertinib. Based on population pharmacokinetic (PK) analysis, no dose adjustment is recommended in patients with mild hepatic impairment [total bilirubin <upper limit of normal (ULN) and AST between 1 to 1.5 times ULN or total bilirubin between 1.0 to 1.5 times ULN and any AST]. There is no recommended dose for TAGRISSO for patients with moderate or severe hepatic impairment [see Clinical Pharmacology (12.3) in the full Prescribing Information]. 17 PATIENT COUNSELING INFORMATION Advise the patient to read the FDA-approved patient labeling (Patient Information). Interstitial Lung Disease/Pneumonitis Inform patients of the risks of severe or fatal ILD, including pneumonitis. Advise patients to contact their healthcare provider immediately to report new or worsening respiratory symptoms [see Warnings and Precautions (5.1) in the full Prescribing Information]. QTc Interval Prolongation Inform patients of symptoms that may be indicative of significant QTc prolongation including dizziness, lightheadedness, and syncope. Advise patients to report these symptoms and to inform their physician about the use of any heart or blood pressure medications [see Warnings and Precautions (5.2) in the full Prescribing Information]. Cardiomyopathy % TAGRISSO can cause cardiomyopathy. Advise patients to immediately report any signs or symptoms of heart failure to their healthcare provider [see Warnings and Precautions (5.3) in the full Prescribing Information]. Embryo-Fetal Toxicity % TAGRISSO can cause fetal harm if taken during pregnancy. Advise pregnant women of the potential risk to a fetus. % Advise females to inform their healthcare provider if they become pregnant or if pregnancy is suspected, while taking TAGRISSO [see Warnings and Precautions (5.3) and Use in Specific Populations (8.1) in the full Prescribing Information]. Females and Males of Reproductive Potential % Advise females of reproductive potential to use effective contraception during treatment with TAGRISSO and for 6 weeks after the final dose [see Use in Specific Populations (8.3) in the full Prescribing Information]. % Advise males to use effective contraception during treatment and for 4 months after the final dose of TAGRISSO [see Use in Specific Populations (8.3) in the full Prescribing Information]. Lactation Advise women not to breastfeed during treatment with TAGRISSO and for 2 weeks after the final dose [see Use in Specific Populations (8.2) in the full Prescribing Information]. Distributed by: AstraZeneca Pharmaceuticals LP Wilmington, DE 19850 TAGRISSO is a trademark of the AstraZeneca group of companies © AstraZeneca 2015 3182206 11/15 Issued 11/15 7/8/2016 12:50:22 PM NE W S T R ENDS Infectious Diseases Monkey study shows Zika infection prolonged in pregnancy. University of Wisconsin–Madison researchers studying monkeys have shown that one infection with Zika virus protects against future infection, though pregnancy may drastically prolong the time the virus stays in the body. The researchers published a study describing their work establishing rhesus macaque monkeys as a model for studying the way Zika virus infections may progress in people. The researchers infected monkeys with the type of Zika virus causing an epidemic that first became apparent in South America in 2015, and found that those monkeys resisted infection by the same Zika strain 10 weeks later. But their findings also uncovered a stark contrast in the length of infection of pregnant monkeys versus males and nonpregnant females. Though non-pregnant animals in the study were found to be free of Zika virus within 10 days of infection, the virus persisted in the blood of pregnant monkeys for 30 days to 70 days. The prolonged infection has implications for the severe impacts of Zika virus during pregnancy. One possible explanation for the persistence of the virus in pregnancy is that the immune systems of mothers-tobe are compromised, and they aren’t able to clear the virus as fast. Though the researchers have been performing ultrasounds on Zika-infected pregnant monkeys and collecting fluid from their wombs, they can’t yet say whether the still-growing fetuses themselves are infected or whether any of them are developing microcephaly. New study sheds light on how some survive Ebola. A first-of-its-kind Ebola study has yielded clues to how some people are able to survive the deadly virus and suggests possible avenues for treatments that could save more lives. Researchers at the U.S. Centers for Disease Control and Prevention (CDC), Emory University School of Medicine, and University of Nebraska Medical Center analyzed the immune responses of Ebola patients treated in the United States. Their study was recently published online in the Clinical Infectious Disease Journal. This is the first time researchers have been able to study Ebola virus disease (EVD) using samples taken from patients during both their illness and recovery. In the seven U.S. patients, researchers tracked 54 different markers of immunesystem activity from hospital admission until the day of discharge. Among the 10 MLO - ONLINE.COM MLO201608-Observatory_MECH_AL.indd 10 A N A LYSIS seven patients, five had moderate EVD and two had severe EVD requiring mechanical ventilation and dialysis. “We were able to identify the particular components of patients’ immune systems that successfully fought off the virus,” says lead author Anita McElroy, MD, PhD. “These are the parts of the immune system that we need to tap into to develop new therapies.” The results show patients with severe EVD had high levels of virus in their blood and out-of-control immune responses, leading to destruction of healthy tissues, multisystem organ failure, shock, and, in most cases, death. In contrast, patients with moderate EVD had strong, healthy immune responses that were able to control the virus. All patients with moderate illness and one patient with severe illness survived. It is unclear why some people’s immune systems respond more effectively to viruses. Possible contributing factors include genetics and whether or not a person has other illnesses or conditions. Identifying which parts of the immune system malfunction in severe EVD cases as well as the parts that function well in moderate cases could lead to the design of therapies that might theoretically inhibit the disease’s progression. Cancer HPV vaccine reduced cervical abnormalities in young women. Young women who received the human papillomavirus (HPV) vaccine through a school-based program had fewer cervical cell anomalies when screened for cervical cancer, found a new study in CMAJ (Canadian Medical Association Journal). “Eight years after a school-based HPV vaccination program was initiated in Alberta [Canada], three-dose HPV vaccination has demonstrated early benefits, particularly against high-grade cervical abnormalities, which are more likely to progress to cervical cancer,” writes study co-author Huiming Yang, MD. Alberta has both a school-based HPV vaccination program and a populationbased screening program for cervical cancer. In 2008, the province introduced HPV vaccination for Grade 5 girls (aged 10-11) and a three-year catch-up program for Grade 9 girls (aged 14-15); in 2014, it was expanded to include boys. The program provides three doses of the vaccine that protects against two strains of HPV, which account for 70 percent of all cases of cervical cancer. To determine whether HPV vaccination had an impact on Papanicolaou (Pap) test results, researchers looked at data on the first cohort of women who participated in both the school vaccination program and cervical cancer screening. Of 10,204 women born between 1994 and 1997, 1,481 (14.5 percent) were cases—that is, they had cervical anomalies detected during screening —and the remaining 8,723 (85.5 percent) were controls—with no cervical abnormalities detected. Among cases, most (1,384, 93.5 percent) had low-grade cervical abnormalities, and the remaining 97 (6.5 percent) had high-grade abnormalities. Fifty-six percent of study participants were unvaccinated, and 44 percent had received one or more doses of the HPV vaccine before being screened for cervical cancer. Of the women who had been vaccinated, 84 percent received three or more doses. Among the unvaccinated women, 16.1 percent had cervical abnormalities, compared with 11.8 percent in the fully vaccinated group. Coagulation Blood coagulation detector may help in monitoring stroke risk. Researchers at Tokyo Medical and Dental University have shown that an analyzer recently developed to measure blood coagulability has the sensitivity to detect hypercoagulatibility associated with stroke risk in those without atrial fibrillation (AF), a common risk factor for stroke.The study was reported in PLOS ONE. To estimate the risk in AF patients and determine the requirement for anticoagulation therapy, the CHADS2 predictive score was used. Because some parts of this score are also associated with atherosclerosis risk and increased blood coagulability, a high score has been proposed as linked to hypercoagulability (an increased tendency for blood clotting) in both AF and non-AF patients. However, this association has not been fully investigated, partly owing to the lack of a sensitive means of detection. The researchers used a highly sensitive technique to measure small changes in blood coagulation, and found hypercoagulability in non-AF patients with high CHADS2 scores. Several physical and chemical factors affect blood clotting; some can be measured over time to determine blood coagulability and likelihood of clot formation. Dielectric blood coagulometry (DBCM) is a recently developed test that measures changes in the dielectric permittivity of whole blood, representing clumping of red blood cells. The researchers used DBCM to detect changes in the dielectric permittivity of whole blood at 10 MHz. Comparisons between untreated blood and that with added heparin (a blood thinner) or tissue factor (a blood-clotting accelerator) enabled derivation of a coagulability index. “We calculated the end of acceleration AUGUST 2016 7/12/2016 9:00:55 AM NE W S time (EAT) as an index of coagulability from temporal changes in dielectric permittivity,” coauthor Satomi Hamada says. “This value reduced when tissue factor was added, and increased with heparin present. It was sensitive enough to detect small changes in coagulability, particularly in hypercoagulability.” The researchers found that patients receiving warfarin had a significantly longer EAT than those without, confirming the anticoagulation effect. They also showed that patients with high CHADS2 scores had a significantly shorter EAT that represented hypercoagulability compared with patients with lower scores. Genetics/Genomics Women with BRCA1 gene mutation at higher risk of deadly uterine cancer. Women who carry the BRCA1 gene mutation that dramatically increases their risk of breast and ovarian cancers are also at higher risk for a lethal form of uterine cancer, according to a study led by a Duke Cancer Institute researcher. This newly defined risk, the first to show a conclusive link between the BRCA1 gene mutation and a small but significant chance of developing an aggressive uterine cancer, could become a consideration in weighing treatment options. Currently, women with the BRCA1 mutation often have preventive surgeries to remove both breasts, as well as their ovaries and fallopian tubes, based on studies showing that the gene mutation elevates their risk for cancers in those organs. But conflicting evidence has created controversy over the need to remove the uterus. Smaller studies identified a link between the gene mutation and uterine cancer, but a larger study had been lacking until now. Says lead author Noah D. Kauff, MD, “Our study presents the strongest evidence to date that women with this genetic mutation should at least discuss with their doctors the option of having a hysterectomy along with removal of their ovaries and fallopian tubes.” In the research, published in JAMA Oncology, Kauff and colleagues from nine other institutions analyzed data from 1,083 women. All had BRCA1 or BRCA2 genetic mutations, had undergone removal of their ovaries and fallopian tubes, and were followed for a median 5.1 years. Incidences of uterine cancer in the BRCA-positive women in the study were compared to the rates that would be expected in the general population, based on data from the U.S. government’s Surveillance, Epidemiology, and End Results program. Among the BRCA-positive women, eight uterine cancers were reported within the study period—a rate that was slightly T R ENDS higher but not statistically different than the national norm. Of those cancers, however, five were of an uncommon, very aggressive subtype called serous endometrial cancer. All but one of the serous endometrial cancers occurred in women with the BRCA1 genetic mutation. Given the incidence of this cancer in the wider population, only about .18 cases would be expected among women with the BRCA1 mutation over the time period analyzed, meaning the women with the BRCA1 trait were at significantly higher risk. New Assays FDA clears test for genetic markers for antibiotic-resistant bacteria. The FDA has cleared for marketing the Xpert Carba-R Assay, an infection control aid that tests patient specimens to detect specific genetic markers associated with bacteria that are resistant to Carbapenem antibiotics. Carbapenem antibiotics are widely used in hospitals to treat severe infections. These resistant organisms are commonly referred to as Carbapenemresistant Enterobacteriaceae, or CRE, and have been reported in almost all states within the United States. Current methods to identify colonization with CRE or other resistant organisms rely on growing bacteria from fecal material in cultures, which are then subjected to antimicrobial susceptibility testing to determine in vitro susceptibility to antimicrobial agents. The Xpert Carba-R Assay tests specimens directly taken from patients, which are usually obtained by rectal swabs, for the presence of five different genetic markers that are associated with carbapenemase, the enzyme produced by CRE. The assay is intended as an aid in infection control and can be used in conjunction with other clinical and laboratory findings. Although it tests for the most prevalent carbapenemase genes associated with resistance to carbapenem antibiotics, it does not detect the bacteria, carbapenemase activity, or other possible non-enzymatic causes of carbapenem resistance. The Xpert Carba-R Assay tests only for genetic material. The assay also does not detect all types of carbapenemase genes, and it is important to recover bacteria for accurately tracking the spread of carbapenem resistance. Labs should continue to perform standard bacterial culture in conjunction with it. In addition, concomitant cultures are necessary to recover organisms for epidemiological typing, antimicrobial susceptibility testing, and for confirmatory bacterial identification. A N A LYSIS Lab-tested diagnosis needed when treating patients with persistent diarrhea. Persistent diarrhea, which is diarrhea that lasts at least 14 days, is an illness typically caused by parasites or bacteria and requires accurate diagnosis in order to determine what treatment to give, according to Herbert L. DuPont, MD, director of the Center for Infectious Diseases at The University of Texas Health Science Center at Houston (UTHealth) School of Public Health. In a literature review published recently in JAMA, DuPont advises medical practitioners to be alert when diagnosing persistent versus acute diarrhea in patients. It is common for doctors not to focus on how many days their patients have had diarrhea, he adds. “I’d like to educate doctors about the importance of taking the history and assessing duration of illness,” DuPont says. For acute diarrhea, the lab has a minimal role, restricted to patients passing bloody stools. If a patient has had diarrhea for two weeks or more, the doctor should focus on the cause of the disease through laboratory testing, with an emphasis on parasites.” Acute diarrhea lasts less than two weeks, and it is typically caused by viruses or toxins. Persistent diarrhea is most commonly caused by bacteria or parasites, including Giardia, Cryptosporidium and Cyclospora. Less common parasites include Entamoeba Cystoisospora belli, Dientamoeba fragilis, Strongloides stercoralis, and microsporidia. These parasites, all of which can be detected in laboratory testing, can be contracted through food or water or from other people, and are commonly picked up while traveling. A new testing method called multiplex polymerase chain reaction (PCR) was developed within the past year. This simultaneous, single test identifies unique DNA sequences to detect a panel of causes of diarrhea. Two platforms have been approved by the U.S. Food and Drug Administration for use. Previously, researchers would culture bacteria from a stool sample and examine it for isolated bacteria. For parasites, they would either look under a microscope or, for three of the parasites, use commercial enzyme immunoassays. Both methods were only able to identify a small number of parasites. Clarification: The July 2016 Clinical Issues article, “Automated analyzers add efficiency to laboratory testing” by Maria Luz Rodriguez, PhD, incorrectly placed the subhead that read “Microarray-based technologies” on page 32. Liquid chromatography and mass spectrometry as well as laboratory automation for other fields are not under this subhead. AUGUST 2016 MLO201608-Observatory_FINAL.indd 11 THE OBSERVATORY MLO - ONLINE.COM 11 7/13/2016 9:05:05 AM By Liana F. Romero, PhD, MBA, MT(ASCP) T he Affordable Care Act and population management have significantly changed how diabetes screening is viewed. In today’s preventive care environment, healthcare providers understand that staying ahead of the progression of the disease and associated comorbidities, minimizing the financial implications of disease progression, and improving patient outcomes and quality of life are dependent on the proactive screening for and management of at-risk patients. Laboratory and point-of-care testing (POCT), therefore, play a critical role and bring significant value in the screening, monitoring, and management of these patients. In this article, we will review the physiological implications of diabetes, risk factors, and importance of population management. We will conclude with an overview of the current Continuing Education To earn CEUs, see test on page 20 or online at www.mlo-online.com under the CE Tests tab. LEARNING OBJECTIVES Upon completion of this article, the reader will be able to: 1. List factors that are important in controlling the at-risk management of diabetes. 2. Describe symptoms, causes, and complications of various types of diabetes. 3. Describe trends, statistics, and healthcare cost dilemmas in regard to diabetes. 4. Discuss programs that have led to standardization and improvement among a variety of HbA1c testing methods and the outcomes. 12 MLO - ONLINE.COM MLO201608-CE Story_MECH_AL.indd 12 AUGUST 2016 practices for screening, diagnosis, and monitoring and how the laboratory and POCT add value in the context of healthcare reform initiatives. Physiologically, the condition of diabetes (diabetes mellitus) is characterized by elevated blood glucose or hyperglycemia, primarily driven by the deficiency of insulin production in the beta cells of the pancreatic islets or the inability of cells to respond to insulin that is produced.1,2 Elevated blood glucose is often accompanied by symptoms that include frequent urination and increased thirst and hunger. If the diabetes goes undiagnosed and untreated, short term, acute complications include diabetic ketoacidosis and hyperglycemic coma. However, the severity, complexity, and mortality of long-term complications of diabetes are of most concern from a chronic disease or population management perspective. These conditions include chronic kidney failure, cardiovascular disease, stroke, ulcerations and wounds in the lower extremities, and eye diseases including cataracts, retinopathy, and glaucoma.3,4 The National Diabetes Statistics Report (2014) from the Centers for Disease Control and Prevention (CDC) lasers in on the ever-increasing burden of diabetes. A key statistic to note is the estimated 9.3 percent of the population of the United States—29.1 million individuals—who have diabetes.5 Of those individuals, 21 million have been diagnosed, but more than eight million remain undiagnosed and therefore untreated. In 2012, diabetes and its related complications accounted for $245 billion in total medical costs and lost work and wages. This figure is up from $174 billion in 2007.5 The estimated number of individuals 20 years of age or older who are pre-diabetic is 86 million, versus 79 million in 2011, with these individuals being at increased risk of developing multiple chronic diseases and conditions over their lifetime.5 Indeed, the prevalence of pre-diabetes, diabetes, and associated chronic diseases has doubled over the past two decades, primarily as a result of the burden of obesity across the U.S. (Figure 1, pg. 14).6 continued on page 14 7/12/2016 4:01:25 PM GET MORE DONE WITH ONE TOUCH A1C TESTING Get 80 results per hour and an automated workflow. The D-100™ System delivers high-quality A1c results without a mountain of labor. All consumables are RFID-tagged for fully automated traceability and convenience. And, when it comes time, you can replace reagents without stopping the run. Contact your Bio-Rad representative at 1-800-224-6723 to see how you can get more done with the D-100™ System. Learn more at bio-rad.com/diabetes MLO201608_AD BioRad-19761.indd 13 7/12/2016 9:33:16 AM HbA1c continued from page 12 Types of diabetes Type 1 diabetes was previously called insulindependent diabetes mellitus or juvenile-onset diabetes. Although disease onset can occur at any age, most cases are diagnosed in patients’ mid-teens. In a type 1 diabetic individual, the body’s immune system has attacked and destroyed the beta cells, incapacitating the pancreas’s ability to make the amount of insulin needed to moderate glucose levels in the body. There is no way to prevent the onset of type 1 diabetes, but the disease is manageable. Treatment for type 1 diabetes includes administration of insulin by injection, pump, or orally; appropriate diet and exercise; and monitoring and control of blood pressure and lipid levels.5,7 Type 2 diabetes, which used to be called adult-onset diabetes, can affect individuals of all ages, but onset is most often seen in middle-aged and older individuals. The risk for developing disease increases among individuals who are overweight and inactive. Increased prevalence of diabetes is also seen among specific ethnic groups such as African Figure 1. Age-adjusted prevalence of obesity and diagnosed diabetes among U.S. adults Americans, Hispanics, and Native Amerimonitoring and control of blood pressure and lipid levels.5,7 cans, as well as among lower socio-economic groups in An alarming trend across the U.S. is the increasing incicertain geographical regions of the U.S. (Figure 2, pg. 16).5,7,8 dence of type 2 diabetes among individuals < 20 years of Type 2 diabetes usually begins with insulin resistance—a age (Figure 3). Additionally, the SEARCH for Diabetes in condition that occurs when fat, muscle, and liver cells do not Youth study (SEARCH) estimated that in 2001 about 154,000 use insulin to carry glucose into the body’s cells to use for individuals in the U.S. aged < 20 years were living with diaenergy.1,6 As a result, the body needs more insulin to help betes, and that each year approximately 15,000 youth aged glucose enter cells. Initially, the beta cells of the pancreas < 20 years were diagnosed with type 1 diabetes and 3,700 will produce more insulin to manage the added demand. But with type 2 diabetes).11 The most recent update from the eventually the pancreas is no longer able to produce suffiSEARCH researchers, released in 2012, shows data that type cient insulin when blood sugar levels increase, such as after 2 diabetes in 10-to-19 year-olds had increased 21 percent meals.6,9 At this point, type 2 diabetes has ensued. between 2001 and 2009.8,12 Treatment for type 2 diabetes includes use of diabetes Gestational diabetes’ cause is not known, but the Amerimedications, dietary changes, and increased physical accan Diabetes Association (ADA) speculates that hormones tivity (as diet and lack of exercise are recognized as highsecreted by the placenta block the action of the mother’s risk factors for developing type 2 diabetes), along with the insulin in the body, resulting in insulin resistance and subsequent buildup of glucose levels. A 2014 analysis by the CDC indicates that the prevalence of gestational diabetes is as high as 9.2 percent.12 Rare types of diabetes include latent autoimmune diabetes in adults (LADA), maturity onset diabetes in the young (MODY), cystic fibrosis–related diabetes (CFRD), Cushing’s syndrome, and antiretroviral-associated diabetes. These diabetes types account for one percent to five percent of all diagnosed cases.13 Diabetes and chronic health conditions Figure 3. Increase in type 2 diabetes in adolescents over select years5,7 14 MLO - ONLINE.COM MLO201608-CE Story_MECH_AL.indd 14 Diabetes is illustrative of the chronic health conditions that are currently at the source of our healthcare challenges. This is pri- AUGUST 2016 7/12/2016 4:01:42 PM marily driven by the complexity and severity of the longterm complications of diabetes. In the undiagnosed or poorly managed patient, diabetes complications may be disabling and eventually life-threatening. Complications from diabetes include the following:14 • Cardiovascular disease, including coronary artery disease with chest pain (angina), heart attack, stroke, and narrowing of arteries (atherosclerosis). • Nerve damage (neuropathy) leading to tingling, numbness, burning or pain that usually begins at the tips of the toes or fingers and gradually spreads upward, ultimately resulting in loss of sensation. For men, it may lead to erectile dysfunction. • Kidney damage (nephropathy) that can lead to kidney failure or irreversible end-stage kidney disease, which may require dialysis or a kidney transplant. • Eye damage (retinopathy) resulting in damage to the blood vessels of the retina (diabetic retinopathy), potentially leading to blindness. Diabetes also increases the risk of other serious vision conditions, such as cataracts and glaucoma. • Foot damage as a result of nerve damage leading to cuts and blisters which may become seriously infected and may ultimately lead to toe, foot, or leg amputation. • Skin conditions as a result of heighted susceptibility to bacterial and fungal infections. • Hearing impairment • Alzheimer’s disease. (Type 2 diabetes may increase the risk.) A study published in the Journal of Medical Economics estimated the 2012 U.S. patient costs per acute event for the following major complications:15 • Cardiovascular disease: myocardial infarction $56,445; ischemic stroke $42,119; congestive heart failure $23,758; ischemic heart disease $21,406; and transient ischemic attack $7,388 • Kidney disease: $71,714 for end stage renal disease • Eye disease: $2,862 blindness • Nerve/foot damage: $9,041 for lower extremity amputations and $2,147 for diabetic foot ulcers. Consider that, since 2012, healthcare costs have continued to escalate along with the number of individuals who have developed or are at risk for developing diabetes and associated chronic disease conditions as listed above. Through population management efforts, patients with diabetes or predisposition for diabetes can be identified, monitored, and managed in order to control disease, minimize the risk of complications, and reduce healthcare costs. And, indeed, these efforts begin with the laboratory. If your HbA1c results are just a number… HbA1c in diagnosis and monitoring of diabetes Hemoglobin A1c (HbA1c) is made by the non-enzymatic attachment of glucose to the N-terminal valine of the ß-chain of hemoglobin. During the normal process of red blood cells dying and breaking down, the HbA1c is released. Consequently, the level of HbA1c is reflective of the average glucose concentration to which red blood cells were exposed over their eight-to-twelve- week life span.16 HbA1c had been customarily employed in the monitoring of diabetic patients and in guiding therapy. But with the ADA’s 2010 endorsement to use HbA1c as the main criterion for the diagnosis of type 2 diabetes, HbA1c was propelled to the limelight for its utility in both the screening for pre-diabetes and the diagnosis of diabetes.9,19,20 The endorsement by ADA was founded on data demonstrating that patients with HbA1c levels of 6.5 percent or greater had the same rate of retinopathy as those diagnosed using the standard criteria of fasting blood glucose and glucose tolerance testing 9 (Table 1, page 18). HbA1c testing MLO201608-CE Story_MECH_AL.indd 15 www.sebia-usa.com [email protected] 1.800.835.6497 Because patients deserve more. 7/12/2016 4:01:50 PM HbA1c Figure 2. Diagnosed diabetes rates by race/ethnicity (2012)10 also provided key advantages over blood glucose testing including no requirement for fasting, sample draw convenience, and less susceptibility to variations in levels due to patient health, and analytical stability for laboratory testing.19 Some disadvantages of HbA1c were also considered, including increased cost and the potential to miss about 20 percent of patients with diabetes when compared to using fasting glucose and glucose tolerance testing. Additionally, HbA1c levels may vary due to patients’ race or ethnicity, and for conditions with abnormal red cell turnover, such as pregnancy, recent blood loss or transfusion, and some anemias, the diagnosis of diabetes must rely on blood glucose and not HbA1c. 19 The International Experts Committee (IEC) had also recommended the use of HbA1c. However, the IEC recognized the lack of standardization that existed among the 100-plus methods available for HbA1c testing. The IEC recommended that the testing methodologies must be certified by the National Glycohemoglobin Standardization Program (NGSP) or traceable to the Diabetes Control and Complications Trial (DCCT) or UK Prospective Diabetes Study (UKPDS). 16,17 The goal of the IEC was to ensure that the methods were able to generate highly similar results on a given blood sample. The NGSP was established by the American Association of Clinical Chemistry (AACC) to execute the protocol and establish the standardization process. The subsequent improvement in performance of HbA1c led to an increase in laboratories reporting HbA1c, from 50 percent in 1993 to approximately 99 percent by 2004, as well as simultaneous improvements in accuracy and reduced variability among laboratories.16,17 Laboratory-based HbA1c testing is well established, and numerous immunoassay, enzymatic, and ion exchange HPLC methods for HbA1c testing have been certified by NGSP. As of 2015, three POCT methods have also been certified.21 A primary advantage of HbA1c POCT, as well as glucose POCT, is expediting clinical decision by allowing providers to more quickly assess the efficacy of diabetes treatment and influence on health outcomes (Figure 4). This aids in the collective effort to lower a patient’s future HbA1c levels by enabling timely therapeutic modifications.21 The NGSP certification for POCT HbA1c tests does not mandate or account for end-user proficiency testing. How- Figure 4. Improvement in outcomes utilizing HbA1c for monitoring glycemic control23 16 MLO - ONLINE.COM MLO201608-CE Story_MECH_AL.indd 16 AUGUST 2016 7/12/2016 4:01:59 PM ever, proficiency testing materials are available from the College of American Pathologists (CAP). It is up to the specific healthcare setting to make the determination to participate in a proficiency program. Proficiency testing of POCT devices is recommended to ensure the integrity of test results and reduce testing errors.23 It’s time to take another look. Alternate markers of glycemia Fructosamine, glycated albumin, and 1,5-anhydroglucitol (1,5-AG) are three other available markers for glycemia.24 • Fructosamine reflects the average blood sugar concentration over the prior two to three weeks. • Glycated albumin reflects mean glucose levels over the prior two to three weeks. • 1,5-AG levels are associated with rapid glucose fluctuations and response within 24 hours. For purposes of diagnosis and monitoring of diabetes, the alternate markers of glycemia are recommended to be used in conjunction with HbA1c. Presently, these markers may be best suited for testing in specific subsets of diabetic patients, such as those with variant hemoglobin, iron deficiency anemia, pregnancy, and chronic liver or kidney disease.24 Toward population management of diabetes The burden of diagnosed and undiagnosed diabetes on the health of the U.S. population, coupled with the everescalating costs associated with disease management, treatment, and co-occurring conditions, can hardly be overstated. The CDC views the growing prevalence and incidence of diabetes as one of the most important public health issues of our time. Consequently, the CDC has published the “Compendium of Effective Public Health Strategies to Prevent and Control Diabetes” to educate the population on the consequences of diabetes and spearhead a call to action for screening and lifestyle improvements.25 Simultaneously, the Centers for Medicare and Medicaid Services (CMS) aims to address and curtail the burden of disease through population management initiatives, including pro-active screening, improved monitoring, and patient engagement in lifestyle changes. Risk factors such as obesity, high blood pressure, family history of diabetes, elevated lipid levels, and individuals over the age of 65 are eligible for screening. Medicare, Medicaid, and private payers advocate the pro-active screening of the general population for type 2 diabetes using such tests as HbA1c and blood glucose levels. And so the laboratory and providers performing POCT play an integral part in facilitating the testing required to achieve the goals of the CDC, CMS, and private payers in reducing the burden of diabetes in the U.S. Screening for undiagnosed diabetes, management of diabetes, management of disease progression, and monitoring for cooccurring conditions and therapeutic efficacy are contingent on the availability and accessibility of standardized and accurate HbA1c and blood glucose testing. REFERENCES 1. Sonksen P, Sonksen J. Insulin: understanding its action in health and disease. British Journal of Anaesthesia. 2000;85(1): 69–79. 2. Shoback D, Gardner DG, eds. Greenspan’s basic & clinical endocrinology 9th ed. Chapter 17. New York: McGraw-Hill Medical. 2011. 3. World Health Organization (WHO). Diabetes fact sheet N 312. 2016. http://www. who.int/mediacentre/factsheets/fs312/en/. 4. National Eye Institute. Facts about diabetic eye disease. 2016. l https://nei.nih. gov/health/diabetic/retinopathy. MLO201608-CE Story_MECH_AL.indd 17 www.sebia-usa.com [email protected] 1.800.835.6497 Because patients deserve more. 7/12/2016 4:02:08 PM HbA1c Glucose Testing and Interpretation Normal High Risk for Diabetes Diabetes FPG <100 mg/dL IFG FPG ≥100-125 mg/dL FPG ≥126 mg/dL 2-h PG <140 mg/dL IGT 2-h PG≥140-100 mg/dL 2-h PG≥200 mg/dL Random PG ≥200 mg/dL + symptoms AIC <5.5% 5.5 to 6.4% For screening of prediabetesa ≥6.5% Secondaryb Abbreviations: AIC = hemoglobin AIC: FPG = fasting plasma glucose: IFG = impaired fasting glucose: IGT = impaired glucose tolerance; PG = plasma glucose. a AIC should be used only for screening prediabetes. The diagnosis of prediabetes, which may manifest as either IFG or IGT, should be confirmed with glucose testing. b Glucose criteria are preferred for the diagnosis of diabetes mellitus (DM). In all cases, the diagnosis should be confirmed on a separate day by repeating glucose or AIC testing. When AIC is used for diagnosis, follow-up glucose testing should be done when possible to help manage DM. Table 1. Criteria for diagnosis of diabetes mellitus20 MLO201608-CE Story_MECH_AL.indd 18 7/12/2016 4:02:18 PM 5. Centers for Disease Control and Prevention. National diabetes statistics report, 2014. 2015. http://www.cdc.gov/diabetes/data/statistics/2014StatisticsReport.html. 6. John Hopkins Bloomberg School of Public Health. Pre-diabetes and diabetes nearly double over the past two decades. 2014. http://www.jhsph.edu/news/newsreleases/2014/pre-diabetes-and-diabetes-nearly-double-over-the-past-two-decades.html. Move beyond that number and see the whole story... 7. National Institute of Diabetes and Digestive and Kidney Diseases. Your guide to diabetes: Type 1 and 2. 2014. http://www.niddk.nih.gov/health-information/healthtopics/Diabetes/your-guide-diabetes/Pages/index.aspx. 8. Imperatore G, Boyle J, Thompson TJ, et al. Projections of type 1 and type 2 diabetes burden in the U.S. population aged <20 years through 2050. Diabetes Care. 2012;35(12):2515-2520. 9. American Diabetes Association. Diagnosis and classification of diabetes mellitus. Diabetes Care. 2004;27(suppl 1), s5-s10. 10. American Diabetes Association. Statistics about diabetes. 2012. http://www. diabetes.org/diabetes-basics/statistics/?referrer=https://www.google.com/. 11. Liese AD, D’Agostino RB Jr, Hamman RF, et al., SEARCH for Diabetes in Youth Study Group. The burden of diabetes mellitus among US youth: prevalence estimates from the SEARCH for Diabetes in Youth Study. Pediatrics. 2006;118:1510–1518. 12. American Diabetes Association. What is gestational diabetes? http://www.diabetes.org/diabetes-basics/gestational/what-is-gestational-diabetes.html. 13. Centers for Disease Control and Prevention (CDC). Basics: diabetes. 2015. http:// www.cdc.gov/diabetes/basics/index.html. 14. Mayo Clinic. Diabetes complications. http://www.mayoclinic.org/diseasesconditions/diabetes/basics/complications/con-20033091. 15. Ward A, Alvarez P, Vo L, Martin S. Direct medical costs of complications of diabetes in the United States: estimates for event-year and annual state costs (USD 2012). Journal of Medical Economics. 2014;17(3):176-183. 16. Sacks DB. Carbohydrates. In Tietz Textbook of Clinical Chemistry and Molecular Diagnostics. 2006. St. Louis: Elsevier Saunders. p. 837–902. 17. Sacks DB. Measurement of Hemoglobin A1c: A new twist on the path to harmony. Diabetes Care. 2012:35(12): 2674-2680. 18. Sacks DB. A1C versus glucose testing: A comparison. Diabetes Care. 2011;34(2):518-523. 19. American Association of Clinical Endocrinologists (AACE). American Association of Clinical Endocrinologists / American College of Endocrinology Statement on the use of hemoglobin A1c for the diagnosis of diabetes. 2010. https://www.aace. com/files/position-statements/a1cpositionstatement.pdf. 20. American Association of Clinical Endocrinologists (AACE). American Association of Clinical Endocrinologists / American College of Endocrinology— Clinical practice guidelines for developing a diabetes mellitus comprehensive care plan. 2015. https://www.aace.com/files/dm-guidelines-ccp.pdf. 21. Lenters-Westra E, Slingerland RJ, Three of seven hemoglobin A1c point-ofcare instruments do not meet generally accepted analytical performance criteria. Clinical Chemistry. 2014;60(8):1062–1072. 22. Whitely HP, Yong EV, Rasinen C. Selecting an A1c point-of-care instrument. Diabetes Spectrum. 2015;28(3):201-208. 23. Health and Medicine. Understanding the new IFCC HbA1c Numbers. 2009. http:// www.slideshare.net/PeninsulaEndocrine/new-hb-a1c-numbers-presentation. 24. Kalyani RR, Walker-Harris V. Alternative markers of glycemia: fructosamine, glycated kalbumin, 1,5-AG. John Hopkins Diabetes Guide. 2014. http://www.hopkinsguides.com/hopkins/view/Johns_Hopkins_Diabetes_Guide/547055/all/Alternative_markers_of_glycemia:_fructosamine__glycated_albumin__1_5_AG. 25. Centers for Medicare and Medicaid Services (CDC). 2013. Effective Public Health Strategies to Prevent and Control Diabetes: a compendium. http://www.cdc. gov/diabetes/pubs/pdf/PublicHealthCompedium.pdf. Liana F. Romero PhD, MBA, MT(ASCP), serves as Senior Director, US Strategic Marketing and Clinical Affairs, within Siemens Healthcare US Laboratory Diagnostics. Dr. Romero is focused on connecting laboratory capabilities with hospital administration to navigate and thrive in the dynamic environment driven by healthcare reform, incentive programs, quality measurements, evolving reimbursement models, and hospital consolidation. MLO201608-CE Story_MECH_AL.indd 19 ...with Sebia HbA1c testing. Patients deserve more than just a number. Other HbA1c testing methods may be prone to interference by hemoglobin variants, thalassemias, and other disease states. The Sebia HbA1c assay goes beyond the number, so you know the complete story. Easy to perform in a core laboratory — multiple-assay platform Automated — full walkaway capabilities Accurate and precise — for confidence in your results High-resolution separation of hemoglobin fractions Visual curve displays hemoglobinopathies when present Insist on results that tell you more. Insist on Sebia. www.sebia-usa.com [email protected] 1.800.835.6497 Because patients deserve more. 7/12/2016 4:02:29 PM CON T INUING E DUC AT ION T E S T DIABETES: THE CURRENT STATE OF AFFAIRS FROM A POPULATION MANAGEMENT VIEW TEST QUESTIONS MLO and Northern Illinois University (NIU), DeKalb, IL, are co-sponsors in offering continuing education units (CEUs) for this issue’s article DIABETES: THE CURRENT STATE OF AFFAIRS FROM A POPULATION MANAGEMENT VIEW. CEUs or contact hours are granted by the College of Health and Human Sciences at Northern Illinois University, which has been approved as a provider of continuing education programs in the clinical laboratory sciences by the ASCLS P.A.C.E.® program. Approval as a provider of continuing education programs has been granted by the state of Florida (Provider No. JP0000496). Continuing education credits awarded for successful completion of this test are acceptable for the ASCP Board of Registry Continuing Competence Recognition Program. Readers who pass the test successfully (scoring 70% or higher) will receive a certificate for 1 contact hour of P.A.C.E.® credit. Participants should allow three to five weeks for receipt of certificate. The fee for this continuing education test is $20. This test was prepared by Amanda Voelker, MPH, MT(ASCP), MLS Clinical Education Coordinator, School of Allied Health and Communicative Disorders, Northern Illinois University, DeKalb, IL. TEST ANSWER FORM DIABETES: THE CURRENT STATE OF AFFAIRS FROM A POPULATION MANAGEMENT VIEW 1. a. minimizing financial healthcare implications b. improving patient outcomes/ quality of life c. staying ahead of the progression of disease d. all of the above 2. B C D O OOO O OOO 3. O O O O 4. O O O O 5. O O O O 6. O O O O 7. O O O O 8. O O O O 9. O O O O 10. O O O O 11. O O O O 12. O O O O 13. O O O O 14. O O O O 15. O O O O 16. O O O O 17.O O O O 18. O O O O 19.O O O O 20. O O O O Circles must be filled in, or test will not be graded. Shade circles like this: O Not like this: O 1. 2. 3. P 4. 5. E FEE FOR THIS CE TEST IS $20. FL: Your FL license number:____________________ (required for CE credit) 6. FEE FOR THIS CE TEST IS $20 Make check payable to: Northern Illinois University 7. 8. MAILING ADDRESS HOME WORK STATE ZIP INSTITUTION/FACILITY WORK PHONE E-MAIL ADDRESS Send your check with this form to: University Outreach Services Northern Illinois University, DeKalb, IL 60115-2860 Phone: 815-753-0031 20 MLO - ONLINE.COM MLO201608-CETest_FINAL.indd 20 Type I diabetes cases are most commonly diagnosed during the mid-teenage years. at birth. in adulthood. at age three to five years. Increased prevalence of type II diabetes is seen among which ethnic groups? a. b. c. d. 9. CITY It has been reported that in 2012 diabetes-related complications accounted for $235 billion in total medical costs and lost work/wages. a. b. c. d. PRINT CLEARLY NAME 12.0% 5.3% 7.5% 9.3% a. True b. False FEE NOT REFUNDABLE OR TRANSFERABLE Tests can be taken online or by mail. Easy registration and payment options are available through NIU by following the links found at www.mlo-online.com/ce. pneumonia. eye diseases. urinary tract infections. none of the above According to the CDC’s National Diabetes Statistics Report (2014), what percentage of the U.S. population is estimated to have diabetes? a. b. c. d. CE Licensure Information for FL and CA: CA: Accrediting Agency: 0001 (for use in submitting your CE credits to CA) Long-term complication of diabetes include kidney failure, cardiovascular disease, stroke, ulcerations/wounds in extremities, and a. b. c. d. E P The most common short-term complications of diabetes are ketoacidosis and hyperglycemic coma. a. True b. False P = Poor; E = Excellent 1. To what extent did the article focus 3. How will you use on or clarify the objectives? the CE units? state license recertification 2. To what extent was the article employment well-organized and readable? other Symptoms of diabetes mellitus most commonly include a. dizziness, fever, and fatigue. b. increased thirst, joint pain, and fatigue. c. frequent urination, increased thirst and hunger. d. frequent urination, increased thirst and fever. August 2016 [This form may be photocopied. It is no longer valid for CEUs after February 28, 2017.) A In regard to population management, what good outcomes depend upon the proactive screening for and management of at-risk diabetes patients? African Americans Hispanics Native Americans all of the above The main difference in treatment for type I versus type II diabetes is a. how much exercise is to be performed each week. b. a more restricted diet in type I diabetes. c. the way in which insulin/ medication is administered. d. all of the above 10. What alarming trend has been identified in the U.S. regarding type II diabetes? a. resistance of drugs in current treatment options b. increased incidence of type II diabetes in individuals less than 20 years old c. both a and b d. none of the above 11. The ADA speculates that gestational diabetes is caused by placental hormones blocking the actions of the mother’s insulin in the body, creating insulin resistance and buildup of glucose levels. a. True b. False 12. Hemoglobin A1c (HbA1c) reflects a patient’s average glucose concentration to which blood cells were exposed over a. b. c. d. 12 to 15 weeks. 5 to 10 weeks. 8 to 24 weeks. 8 to 12 weeks. 13. Currently, HbA1c is used in both screening for prediabetes and for the diagnosis of diabetes. a. True b. False 14. The key advantage(s) of using HbA1c over blood glucose testing are a. no fasting requirement, sample draw convenience, less variation in levels, and analytical stability. b. sample draw convenience and less variation in levels. c. no fasting requirement, less variation in levels, and analytical stability. d. analytical stability only. 15. HbA1c levels vary in patients who a. are pregnant. b. have had recent blood loss/ transfusion. c. suffer from anemias. d. all of the above 16. What was established to ensure that HbA1c methods are able to generate highly similar results on a given blood sample? a. The International Experts Committee b. The Diabetes Control and Complications Trial c. The National Glycohemoglobin Standardization Program d. none of the above 17. The improvement in performance from the answer to #16 led to an increase in labs reporting HbA1c, from a. b. c. d. 50% in 1993 to 89% in 2004. 50% in 1993 to 99% in 2004. 25% in 1993 to 50% in 2004. 25% in 1993 to 99% in 2004. 18. Currently, POCT users for HbA1c must participate in a proficiency testing program. a. True b. False 19. Alternate markers to determine glycemia that are recommended to be used in conjunction with HbA1c are a. b. c. d. 1,5-AG levels. fructosamine. glycated albumin. all of the above AUGUST 2016 7/12/2016 3:57:04 PM LIQUID URINALYSIS QUALITY CONTROLS You asked. We delivered! At Quantimetrix, we listen to YOU. You asked us to enhance our already great liquid urinalysis quality controls and make them better, so we did. We beautifully engineered Calcium Oxalate Dihydrate (COD) crystals that are easily recognized by both standard and automated microscopy methodologies. We thoughtfully redesigned our packaging. Now our labels include barcodes with lot numbers and expiration dates and we've made it easier to identify each level. And coming soon, we'll deliver values for color & clarity, adding to the most complete urinalysis QC experience yet. What's next? We're listening. 10-0114 0616 Visit us at Booth 4001 – AACC Philadelphia Learn more at quantimetrix.com & download our FREE APP – Urinalysis Made Simple™ MLO201608_AD Quantimetrix.indd 21 7/8/2016 1:56:46 PM SPECIAL REPORT HbA1c The continuing case for point-of-care testing for HbA1c By Gavin Jones, BSc(Hons) T here is an ongoing conflict between traditional clinical laboratories and the relative new kid on the block, pointof-care testing (POCT). Of course, the laboratory system will likely always be king. But there is absolutely a place for POCT, especially as the way in which we approach healthcare, especially diagnostics, develops beyond the usual settings. POCT ensures the rapid provision of diagnostic information, ideally during one consultation, to enable clinical decisions to be made at the earliest opportunity. Such rapid provision of information facilitates optimization of the care process. The potential for any application of POCT can, therefore, be judged in terms of its contribution to decision making and to the process of care. In the case of the management of diabetes patients, POCT for glycated hemoglobin (HbA1c) may offer a number of advantages—as long as the performance characteristics of the analyzers used are equivalent to those employed in the central laboratory, and can be certified as such. The use of HbA1c for management of diabetes Glycated hemoglobin (HbA1c) is well-recognized as a reliable measure for glycemic control. The role of HbA1c testing in the management of patients with diabetes has been established for several decades, while its role in the diagnosis of diabetes has been documented more recently. These applications are based on the fact that HbA1c levels reflect the average circulating glucose concentration over the lifespan of red blood cells (two to three months). This is because the glycated hemoglobin molecule in blood is highly stable once it has formed after exposure to glucose, since glucose binds irreversibly in a non-enzymatic reaction to the Nterminal valine of hemoglobin A in red blood cells (Figure 1). Therefore, use of HbA1c can offer greater clinical information than a single glucose measurement taken at a particular time. Furthermore, there is evidence that HbA1c is a good predictor of an individual’s risk of developing long-term complications of diabetes, e.g., cardiovascular disease.1-3 Serial measurements of HbA1c can show how an individual’s glucose control (and hence risk of complications) change in response to alterations in management over time. It is recommended that HbA1c should be measured every two to six months, with target HbA1c levels set for individual patients and therapy adjusted accordingly.4 General targets of HbA1c for diabetic individuals, depending on their risk of severe hypoglycemia, cardiovascular status, and co-morbidities, should be set between 6.5 percent and 7.5 percent (48-58 mmol/mol), with the non-diabetic reference range being 4.0 percent to 6.0 percent (20-42 mmol/mol). Within the United Kingdom, for example, current National Institute for Health and Clinical Excellence (NICE) guidelines stipulate that, providing there is no disabling hypoglycemia, the target HbA1c concentration for children, young people, and adults with type 1 diabetes is 7.5 percent, and that additional support should be offered if HbA1c is consistently greater than 9.5 percent. One consideration is that HbA1c results may be affected by any condition that leads to a change in red blood cell survival; however, even then, HbA1c can be used to detect trends in a patient’s glycemic control rather than for target setting. The growing case for HbA1c in diabetes diagnosis The attributes of HbA1c measurement for the management of diabetes are equally applicable for use in the diagnosis of diabetes. Furthermore, the performance of HbA1c has been shown to be equal to that of fasting blood glucose tests commonly used for type 2 diabetes screening.5 Unlike glucose levels, which are affected by what a patient has eaten and drunk in the previous two to three hours, HbA1c levels do not require a patient to fast prior to the test. Consequently, as a simple and immediate test for diabetes, POC HbA1c can support early identification of at-risk individuals. This would then rapidly enable them to make changes to their lifestyle, in order to significantly reduce the risk of developing type 2 diabetes or eliminate it altogether. The ability to rapidly assess and change risk outcomes has significant health benefits for the patient and also reduces overall healthcare costs related to the complications of type 2 diabetes. It is known that patients diagnosed with diabetes Figure 1. Glycated hemoglobin (HbA1c) explained 22 MLO - ONLINE.COM MLO201608-SpecRep_MECH_AL.indd 22 AUGUST 2016 7/12/2016 4:26:19 PM HbA1c who maintain low blood HbA1c levels significantly reduce the onset of complications after diagnosis.6 The World Health Organization has recommended the use of HbA1c for the diagnosis of diabetes,7 and similar guidance has followed in several countries.8,9 In the UK, for example, NICE published guidelines in 2013 for diabetes prevention which aim to identify people at high risk of type 2 diabetes and to offer cost-effective and appropriate interventions to prevent or delay onset.8 Used in conjunction with a lifestyle health risk assessment, these guidelines advocate the use of HbA1c levels to allow healthcare providers to advise individuals on treatment regimens, depending on their classification as low, moderate, or high risk of developing type 2 diabetes. NICE has since followed up with new guidelines in 2015 for the management of type 2 diabetes in adults which suggests HbA1c levels should be tested at three-to-six month intervals and six-month intervals once a stable HbA1c level has been obtained.9 Likewise in the United States, a recent American Diabetes Association workgroup report concluded that the HbA1c assay is an accurate, precise measure of long-term glycemic levels that correlates well with diabetes complications and offers several advantages over laboratory measures of glucose.10 However, it should be noted that use of HbA1c for diabetes diagnosis is not appropriate for all individuals. The test should not be used in children, young people, pregnant women, individuals in whom type 1 diabetes is suspected, individuals whose symptoms have been of short duration, or patients who are acutely ill.11,12 It has also been suggested that the cut-off value for diabetes diagnosis generally quoted, 6.5 percent (48 mmol/mol), may not be appropriate for all populations. Additionally, individuals within the range of 6.0 percent to 6.4 percent (42-47 mmol/ mol) should be considered at high risk of developing diabetes and be advised appropriately and retested annually. Those with values less than 6 percent (42 mmol/mol) should be tested every three years.12 Current guidance, therefore, supports the employment of HbA1c measurement in both screening for type 2 diabetes and in the management of patients with diabetes. Use of POCT could improve management of patients with established diabetes in both primary and secondary care settings and also enable earlier type 2 diabetes diagnosis. HbA1c in POCT-based diabetes monitoring Early HbA1c determination was based on laboratory-based methods including ion exchange and affinity chromatographic methods, with alternative affinity and immunological methods following later, taking HbA1c into the point-of-care environment. There is certainly a strong case for employing POC-based HbA1c testing for diabetes monitoring, since lying at the heart of the concept of POCT is the principle that medical tests are convenient and immediate to the patient. Typically, patients with existing diabetes are monitored for HbA1c every three to six months. This generally involves a nurse or phlebotomist visit for venepuncture, with a follow-up appointment one to two weeks later to discuss results once they are available from the laboratory. From a patient experience perspective, use of POCT for HbA1c can enhance satisfaction levels. This is because use of POCT means that after one visit they can leave with an immediate action plan or relevant prescription, should results indicate the need. Furthermore, enabling earlier therapeutic decisions may result in improved diabetic control, better patient outcomes, and enhanced clinic efficiency, with fewer patient visits and subsequent economic benefits. For example, a Swedish before-and-after study investigated the economic costs and benefits of implementing HbA1c home testing.13,14 It confirmed a reduction in costs due to fewer clinic visits, reduction in total treatment costs, time saved resulting from reduced labor costs in both administration and sampling, and reduced travel costs—as well as a reduction in mean HbA1c levels. In addition, four observational studies of more than 5,700 patients with diabetes, in which there was immediate feedback of results to patients, also showed significant reductions in HbA1c levels.15-18 One of these studies demonstrated maintenance of improved HbA1c levels for a period of four years.17 A recent systematic review of quality improvement (QI) strategies in the management of diabetes demonstrated that QIs involving greater adherence to guidelines can help improve HbA1c levels.8 There is also good evidence to show that patient satisfaction is improved using POCT and that immediate knowledge of a patient’s HbA1c levels is associated with better outcomes, as judged by reduced HbA1c levels.16-24 What to look for in a POC HbA1c analyzer Most POC HbA1c analyzers use a drop of blood (4 to10 μL) taken from a finger prick (capillary blood) or venous sample that is applied to a reagent cartridge and then inserted into a desktop device for analysis. Time to reporting of HbA1c results is generally between three and 10 minutes, depending on the analyzer. Keys to the effectiveness of any HbA1c POC analyzer are simplicity, audit trails, certification, and methodology: Simplicity. Ensuring that a POC analyzer is as easy to use as possible will minimize the chance of user error and hence the need for retesting, with subsequent time and cost implications. An analyzer that is simple to use also ensures minimal training requirements, again contributing to affordability. Features that can support ease of use include the employment of ready-to-use reagent cartridges that can be inserted straight into the analyzer with the blood sample then added directly, without the need for sample preparation such as premixing or pipetting. Minimizing the number of steps in the procedure not only reduces the opportunity for user error but also helps to standardize results by eliminating any variation introduced by different operators, particularly when pipetting and mixing. Audit trails. For patient safety purposes, audit trails should also be available. Barcode scanning for patient and user identification, as well as for confirmation of the batch of reagents and controls used, ensures that an analyzer can provide such trails. Quality control results on two levels that are recorded and held within the analyzer’s memory are also ideal for auditing purposes. Certification. Certification of the analyzer in order to confirm delivery of accurate, standardized results should also be a key consideration. In an effort to standardize HbA1c results, the American Association of Clinical Chemistry (AACC) set up the National Glycohemoglobin Standardization Program (NGSP) in 1996. In parallel, the International Federation of Clinical Chemistry (IFCC) developed reference methods for glycated hemoglobin. In 2006 and 2007, an international consensus between IFCC and AACC was reached.25 The calibration and certification of laboratories and manufacturers to the same standards has improved the conformity of results. However, in practice differences can still be observed among technologies and among individual systems. These observed differences arise because of heterogeneity of hemoglobins, underlying differences in technologies (e.g., ion exchange, boronate affinity, immunoassay), calibration drifts, or lot-to-lot variability. However, if the manufacturer follows the recommendations of the IFCC and NGSP to ensure instruments and AUGUST 2016 MLO201608-SpecRep_MECH_AL.indd 23 SPECIAL REPORT MLO - ONLINE.COM 23 7/12/2016 4:26:29 PM SPECIAL REPORT HbA1c reagents are accurately aligned and traceable to the reference method, this should not prove problematic. Methodology. There are POC HbA1c analyzers available whose results are not affected by hemoglobin variants (which do not result in reduced erythrocyte life span), labile glycated hemoglobin, or hematocrit levels. Such analyzers use boronate fluorescence quenching technology (BFQT),26 which is associated with multiple optical measurements. This methodology is traceable to well-documented boronate affinity HPLC systems used in reference laboratories. However, as BFQT does not require chromatographic separation, the methodology allows for accurate POC measurement of HbA1c to deliver results comparable to chromatography-based techniques. Recent evidence suggests that the latest POCT systems deal with hemoglobin variants equally as well as HPLC systems.27 (Figure 2). Figure 2. Conclusion There are strong arguments for the use of POCT for HbA1c where the performance characteristics of the systems are equivalent to those employed in the central laboratory (or even better in some cases) and are certified as such. POCT offers improved access to testing, as well as enabling immediate clinical decision making, discussion with the patient, and implementation of appropriate treatment and/or lifestyle advice. Further, as POCT enables testing to be undertaken closer to patients, it affords greater convenience for them, thereby improving the likelihood of treatment compliance by empowering them. This should ensure better glycemic control, which is the ultimate goal. REFERENCES 1. Khaw KT, Wareham N, Bingham S, Luben R, Welch A, Day N. Association of hemoglobin A1c with cardiovascular disease and mortality in adults: the European prospective investigation into cancer in Norfolk. Ann Intern Med. 2004;141:413–420. 2. Selvin E, Marinopoulos S. Meta-analysis: glycosylated hemoglobin and cardiovascular disease in diabetes mellitus. Ann of Internal Medicine. 2004;141:421–431. 3. ten Brinke R, Dekker N, de Groot M, Ikkersheim D. Lowering HbA1c in type 2 diabetics results in reduced risk of coronary heart disease and all cause mortality. Prim Care Diabetes. 2008;2:45–49. 4. Diabetes UK. HbA1c Standardisation: Information for Clinical Healthcare Professionals. 2009. http://www.diabetes.org.uk/Guide-to-diabetes/Monitoring/Blood_glucose/ Glycated_haemoglobin_HbA1c_and_fructosamine/HbA1c_Standardisation_Information_for_Clinical_Healthcare_Professionals. Accessed May 21, 2013. 5. Bennett CM, Guo M, Dharmage SC. HbA(1c) as a screening tool for detection of Type 2 diabetes: a systematic review. Diabet Med. 2007;24:333-343. 6. Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications 24 MLO - ONLINE.COM MLO201608-SpecRep_MECH_AL.indd 24 in insulin-dependent diabetes mellitus. N Engl J Med. 1993;329:977-986. 7. World Health Organization. Use of glycated haemoglobin (HbA1c) in the diagnosis of diabetes mellitus. 2011. www.who.int/diabetes/publications/report-hba1c_2011.pdf. Accessed May 21, 2013. 8. National Institute for Health and Clinical Excellence. Preventing type 2 diabetes: risk identification and interventions for individuals at high risk. 2012. www.nice.org.uk/nicemedia/live/13791/59951/59951.pdf. Accessed May 21, 2013. 9. NICE Guidelines: Type 2 diabetes in adults: management. 2015. https://www.nice.org. uk/guidance/ng28. 10. American Diabetes Association. International Expert Committee Report on the role of the A1C Assay in the diagnosis of diabetes. Diabetes Care. 2009;32(7):1327-1334. 11. Inzucchi SE. Clinical practice. Diagnosis of diabetes. N Engl J Med. 2012;367:542550. 12. Farmer A. Use of HbA1c in the diagnosis of diabetes. BMJ. 2012;345:e7293. 13. Snellman K, Eckerborn S. Possibilities and advantages of HbA1c: eight years experience. Diabet Med. 1997;14(5):401-403. 14. Plüddemann A, Price CP, Thomson M, Wolsteholme J, Heneghan C. British Journal of General Practice. 2011;61:139-140. 15. Grieve R, Beech R, Vincent J, Mazurkiewcz J. Near patient testing in diabetes clinics: appraising the cots and outcomes. Health Technol Assess. 1999;3:1-74. 16. Ferenczi A, Reddy K, Lorber DL. Effect of immediate hemoglobin A1c results on treatment decisions in office practice. Endocr Pract. 2001;7:85– 88. 17. Petersen JR, Finley JB, Okorodudu AO, Mohammad AA, Grady JJ, Bajaj M. Effect of point-of-care on maintenance of glycemic control as measured by A1C. Diabetes Care. 2007;30:713–715. 18. Rust G, Gailor M, Daniels E, McMillan-Persaud B, Strothers H, Mayberry R. Point of care testing to improve glycemic control. Int J Health Care Qual Assur. 2008;21:325–335. 19. Driskell OJ, Holland D, Hanna FW, et al. Inappropriate requesting of glycated hemoglobin (Hb A1c) is widespread: assessment of prevalence, impact of national guidance, and practice-to-practice variability. Clin Chem. 2012;58:906-915. 20. Peterson KA, Radosevich DM, O’Connor PJ, et al. Improving Diabetes Care in Practice: findings from the TRANSLATE trial. Diabetes Care. 2008;31:2238-2243. 21. Laurence CO, Gialamas A, Bubner T, et al; Point of Care Testing in General Practice Trial Management Group. Patient satisfaction with point-ofcare testing in general practice. Br J Gen Pract. 2010;60:e98–104. 22. Cagilero E, Levina EV, Nathan DM. Immediate feedback of HbA1c levels improves glycemic control in type 1 and insulin-treated type 2 diabetic patients. Diabetes Care. 1999;22(11):1785-1789. 23. Miller CD, Barnes CS, Phillips LS, et al. Rapid A1c availability improves clinical decision-making in an urban primary care clinic. Diabetes Care. 2003;26(4):1158-1163. 24. Kennedy L, Herman WH, Strange P, et al; GOAL A1C Team. Impact of active versus usual algorithmic titration of basal insulin and point-of-care versus laboratory measurement of HbA1c on glycemic control in patients with type 2 diabetes: the Glycemic Optimization with Algorithms and Labs at Point of Care (GOAL A1C) trial. Diabetes Care. 2006;29(1):1-8. 25. Geistanger A, Arends S, Berding C, et al; on behalf of the IFCC Working Group on Standardization of Hemoglobin A1c. Statistical Methods for Monitoring the Relationship between the IFCC Reference Measurement Procedure for Hemoglobin A1c and the Designated Comparison Methods in the United States, Japan, and Sweden. Clin Chem. 2008;54(8):1379-1385. 26. Wilson DH, Bogacz JP, Forsythe CM, et al. Fully automated assay of glycohemoglobin with the Abbott IMx analyzer: novel approaches for separation and detection. Clin Chem. 1993;39(10):2090-2097. 27. Lenters-Westra E. An evaluation of the Quo-Test® performance against NGSP criteria and sigma-metric. 2016. Gavin Jones, BSc(Hons) in Forensic and Biomolecular Sciences, serves as Product Manager (Diabetes) at EKF Diagnostics, which specializes in the development, production, and distribution of point-of-care analyzers for use in the detection and management of diabetes, anemia, lactate, and kidney-related diseases. AUGUST 2016 7/12/2016 4:26:37 PM CAPILLARY SAMPLING SOLUTIONS With Comfort Zone Technology® pat ent comfort. gentle comfort normal extra dual 30G 28G 23G 21G 18G 1.5mm 1.8mm 1.8mm 2.0mm 1.8mm preemie full term 0.85 mm 1.0 mm DEPTH DEPTH 1.75 mm 2.5 mm LENGTH LENGTH Designed to reduce pain for a more comfortable blood sampling experience. FREE SAMPLE REQUEST To receive free samples and product literature, fax completed form to 770-977-2866 or email [email protected] NAME: Which samples would you like to receive? TITLE: FACILITY NAME: ADDRESS: Single Use Safety Lancets CITY: STATE: PHONE: EMAIL: ZIP: Heel Incision Devices No purchase necessary. Available while supplies last. Please allow 8 to 10 weeks for delivery of free samples. MLOFEBAD/OMI/0116/1/US. Take the Unistik Challenge Experience the difference Unistik can make for your patients. T: 1-800-421-6936 I E: [email protected] I W: owenmumfordinc.com MLO201608_AD OwenMumford.indd 25 7/8/2016 12:59:03 PM EDUCATION P R EGN A NC Y/ P R E N ATA L An update on gestational diabetes mellitus By David Grenache, PhD A t first glance, screening pregnant women for gestational diabetes mellitus (GDM) seems like it should be straightforward. After all, the screening tests are designed to identify pregnant woman with high concentrations of blood glucose, and laboratory tests that measure glucose are accurate and precise. So what’s the problem? Before that question is tackled, consider a few facts about GDM: • It is defined as any degree of glucose intolerance with onset or first recognition during pregnancy that isn’t overt diabetes mellitus. • Each year in the United States approximately four million women give birth, and 240,000 of these women, or six percent, develop diabetes during their pregnancy. • The incidence of GDM is a function of the screening test used to diagnose the disorder (more about this below). • Although GDM often resolves after pregnancy, it does place the mother and fetus at risk of serious health issues. For the mother these include preeclampsia and an increased chance for the development of type 2 diabetes after pregnancy. For the fetus these include macrosomia, shoulder dystocia, and increased risk of obesity during childhood. The question of how best to screen for GDM is one not easily answered because experts don’t agree on how best to screen for the disorder. While all agree that both mother and infant can experience adverse outcomes if GDM goes undetected and untreated, there is lack of consensus on the best way of identifying it. Some diagnostic dilemmas To better understand the current debate, consider how GDM screening has been done in the U.S. since 1964. Most practitioners follow a two-step process: 1. A screening test is done at 24 to 28 weeks of gestation by measuring blood glucose one hour after a non-fasting patient consumes a 50-gram dose of glucose. A result greater than 140 mg/ dL is usually used as the cutoff, although a lower cutoff of 130 mg/ dL may also be used. Those with a result greater than the cutoff undergo diagnostic testing. 2. The diagnostic test is the three-hour oral glucose tolerance test (OGTT). This test requires the collection of a fasting blood sample followed by consumption of a 100-gram dose of glucose with additional blood samples obtained every hour for four hours. The test is considered positive, and GDM confirmed, if two or more of the four glucose test results are above designated cutoffs. There are two sets of cutoffs currently used: those of the National Diabetes Data Group or the Carpenter-Coustan cutoffs. Importantly, these two cutoff sets are modifications of those developed 52 years ago that were selected to identify women who were more likely to have diabetes after pregnancy. Further, the requirement that two or more abnormal results are required to define an abnormal result was arbitrarily selected to avoid misclassifications due to “laboratory errors.” It should also be noted that in much of the rest of the world, a one-step approach is used to diagnose GDM using a two-hour, 75-gram OGTT. GDM is diagnosed when any single glucose result exceeds a diagnostic cutoff recommended by the World Health Organization (WHO). The lack of a universal protocol for diagnosing GDM has made it impossible to compare different studies of GDM. In addition, because different investigators have used different protocols for identifying women with the disorder, its true prevalence is not known. To further complicate matters, there has been ambiguity regarding the maternal and fetal morbidities associated with varying degrees of maternal hyperglycemia. To address these shortcomings, the Hyperglycemia and Adverse Pregnancy Outcomes (HAPO) study was conducted. Controversial criteria HAPO was a multicenter international study that included more than 23,000 women in nine countries who were given a 75-gram, two-hour OGTT. Results clearly demonstrated strong and continuous associations between maternal glucose and adverse outcomes such as increased birth weight, C-section delivery, and neonatal hypoglycemia. The continuous associations between glucose and outcome meant that translating the HAPO results into clinical practice would be challenging. Recognizing that, the study investigators called for a re-defining of the criteria used to diagnose GDM. As a result, the International Association of the Diabetes and Pregnancy Study Groups (IADPSG) convened to establish new diagnostic criteria for the diagnosis of GDM. Ultimately, this group settled on diagnostic cutoffs that reflected an odds ratio of 1.75 times the mean for the outcomes of increased neonatal body fat, large for gestational age infants, and an umbilical cord serum C-peptide concentration greater than the 90th percentile. They also recommended that a universal, one-step, two-hour, 75-gram OGTT be performed during pregnancy and that the diagnosis of GDM be made when any single cutoff on the two-hour OGTT was met or exceeded. It was immediately recognized that use of the IADPSG cutoffs would likely double the incidence of women diagnosed with GDM, and this alone lessened an enthusiastic adoption of the new protocol. The loudest critic was the American College of Obstetricians and Gynecologists (ACOG), which continued to support the two-step approach to screening and diagnosis and recommended that additional studies be performed before changes to GDM diagnostic criteria were adopted. Notably, the Endocrine Society, the WHO, and the American Diabetes Association (ADA) have accepted the one-step approach. (The ADA also accepts the two-step approach and so is somewhat noncommittal on the controversy.) continued on page 29 26 MLO - ONLINE.COM AUGUST 2016 MLO201608-Education-COMBINED_MECH_AL.indd 26 7/12/2016 2:34:01 PM Urinalysis Simplified AUTION HYBRID™ AU-4050 One simple solution for fully automated and integrated urine chemistry and sediment analysis. Compact Accurate Easy To use • Smallest footprint on the market r2TQXGPEJGOKUVT[CPFƃQYE[VQOGVT[ • Easy to load strips • Measures only 31.5” wide • Standardized sediment interpretations • No strip calibration • 30-50% smaller than competitors • Reliable bacteria detection • Consolidated result report Visit www.arkrayusa.com to learn how ARKRAY can simplify urinalysis in your laboratory. 877.538.8872 • [email protected] MLO201608_AD Arkray.indd 27 AH014-00 Rev 6/16 7/8/2016 12:49:20 PM EDUCATION P R EGN A NC Y/ P R E N ATA L Next-generation sequencing and the future of IVF By Lia Ribustello, BS, MS M edical laboratories play a vital role in helping patients achieve success with assisted reproductive technologies (ART) such as in vitro fertilization (IVF). Recent advances in genetic screening such as next generation sequencing (NGS) are revolutionizing how IVF will be performed in the future. NGS can sequence DNA and RNA more quickly than ever before. New applications like these technologies are raising hopes for improved IVF success rates to help patients achieve their dreams of building a family. Preimplantation genetic screening According to Centers for Disease Control and Prevention (CDC) estimates, one in eight couples have trouble achieving or sustaining a pregnancy,1 and approximately 7.4 million women in the United States have received help for infertility.2 The use of ART has doubled over the past decade.3 While these statistics provide a general overview of the frequency of fertility struggles in the U.S., they don’t address the complexity that is added by the societal trend of women waiting until later in life to start a family. As a woman’s age increases, the success rates of IVF decrease. This decline is due, in part, to the increase in chromosome abnormalities, or aneuploidy, in the eggs and resulting embryos as a woman ages. For instance, women under 35 will produce 40 percent of embryos with chromosome abnormalities; women from 35 to 39 about 70 percent; women 40 to 42 close to 80 percent; and older women 90 percent or more. 4 Aneuploidy is responsible for the majority of miscarriages and serious genetic disorders. As a result, the ability to screen for the chromosomal health of embryos is an exciting advancement in the field of ART and is the objective of preimplantation genetic screening (PGS) technologies. PGS may be recommended for women who have experienced recurrent miscarriage or are over age 35, or women for whom multiple fertility treatments have failed.5 PGS technologies have a single aim: identifying chromosomally normal embryos for transfer to the womb. Euploid embryos have a higher chance of implantation, and the resulting pregnancies have a lower chance of miscarriage. The viability of the embryo selected for transfer is one of the most important factors influencing IVF success. Over the years, genetic screening of embryos has become instrumental in helping to identify aneuploid embryos, and the field continues to advance rapidly. Fluorescence in situ hybridization (FISH) was replaced by DNA microarray analysis or array comparative genomic hybridization (aCGH) in the late 2000s, and these techniques, broadly speaking, are now being replaced by NGS. Each advance provides a more complete picture of the genetic structure of an embryo and its overall health prior to implantation. Deciphering DNA Today, NGS is gaining in popularity as costs start to decline and the technology improves. In particular, high-resolution NGS (hr-NGS) enables even more detailed examination of 28 MLO - ONLINE.COM chromosomes and thus better detection of abnormalities through high-resolution sequencing. To perform NGS for PGS, the first step is whole genome amplification of the sample obtained from the embryo, which is usually about five cells. Since every biopsy is different, the DNA is then quantified so the starting material from each sample is at the correct concentration. Next, the DNA is fragmented into smaller pieces with specific adapter sequences added to each piece. A low-cycle polymerase chain reaction (PCR) proceeds so that each sample can be individually barcoded with indexes. This is an important step because it distinguishes each sample when sequenced and is what allows attachment to the flow cell during sequencing. Size selection steps are then performed to remove unwanted library fragments and primers, and then the library is normalized to ensure equal library representation. Afterward, all samples are pooled together to create a single library that is then sequenced. High-resolution NGS has the potential to provide the whole genome sequence of an embryo, enabling detection of chromosome count as well as inherited and de novo gene defects. Also called “high throughput sequencing,” hr-NGS is more scalable and cost-effective than previous technologies as laboratories can sequence an increased number of samples simultaneously during a single experiment.6 Combined with laboratory automation technologies that increase consistency and reduce human error, hr-NGS is a significant advancement in the field of ART. A key differentiator for hr-NGS is its ability to reveal a wider range of mosaic embryos7—those that contain a mixture of normal and abnormal cells. Mosaicism is extremely common in early human development, affecting 30 percent of blastocyst-stage embryos. 8 Recent studies suggest mosaicism plays an important role in pregnancy loss, though some mosaics do go on to become successful pregnancies. Knowledge of the presence of mosaicism may be useful to select the most viable embryos during IVF, thus increasing the likelihood of pregnancy, reducing the chances of a pregnancy loss, and improving the odds of delivering a healthy child. hr-NGS in the future High-resolution NGS may be the future, and in fact it is already available. The first baby using hr-NGS was born in 2013. Some studies suggest that there may be up to 60 percent fewer miscarriages using NGS than other PGS AUGUST 2016 MLO201608-Education-COMBINED_MECH_AL.indd 28 7/12/2016 2:34:13 PM continued from page 26 9 techniques. As hr-NGS is further validated through clinical studies, future applications may involve coupling this technology with other types of tests. For instance, today it is possible to examine the mitochondrial DNA (mtDNA)—the tiny organelles that generate energy for the cell. Elevated mtDNA is associated with failure to implant.10 Women who use hr-NGS can add mtDNA testing to boost their chances even further of achieving a successful pregnancy. PGS and mtDNA analysis can be performed in parallel on a single blastocyst biopsy, providing a more thorough picture of embryo health without a significant change in workflow for the clinic or patient.10 Due to the rapid growth and advancement of PGS techniques, PGS is not yet recommended by major professional societies. That said, it is clear that the field of ART is changing, and changing in a way that favors use of these novel technologies. The American Society for Reproductive Medicine recommends no more than two embryos be implanted in women under 35—and doctors should consider using just one. The U.S. may be moving toward a single embryo transfer during IVF, similar to Europe, making the use of PGS technologies such as NGS even more important to increase the odds of a successful pregnancy. REFERENCES 1. Chandra A, Copen CE, Stephen EH. Infertility and Impaired Fecundity in the United States, 1982–2010: Data From the National Survey of Family Growth. National Health Statistics Reports. Number 67, August 14, 2013. http://www.cdc.gov/nchs/ data/nhsr/nhsr067.pdf. 2. Centers for Disease Control and Prevention. Infertility. Key Statistics from the National Survey of Family Growth, 2006-2010. http://www.cdc.gov/nchs/fastats/infertility.htm. 3. Centers for Disease Control and Prevention. National ART Surveillance System, Preliminary Data, 2014. Available at: http://www.cdc.gov/art/reports/index.html. 4. Munne S, Ribustello L, Kolb B, et al. Blastocysts needed to transfer at least one euploid embryo: data from 10,852 pre-implantation genetic screening (PGS) cycles, Fertility and Sterility. 2015;104(3):e13-e14. 5. Fact Sheet: Preimplantation genetic testing. American Society of Reproductive Medicine. http://www.asrm.org/uploadedFiles/ASRM_Content/Resources/Patient_ Resources/Fact_Sheets_and_Info_Booklets/PGT_2014.pdf. 6. Fiorentino F, Bono S, Biricik A, et al. Application of next-generation sequencing technology for comprehensive aneuploidy screening of blastocysts in clinical preimplantation genetic screening cycles. Hum. Reprod. 2014 http://humrep.oxfordjournals.org/content/early/2014/10/21/humrep.deu277.long. 7. Behjati S, Tarpey PS. What is next-generation sequencing? Arch Dis Child Educ Pract Ed. 2013 Dec; 98(6): 236–238. Published online 2013 Aug 28. doi: 10.1136/archdischild-2013-304340. 8. Fragouli E, Alfarawati S, Spath K, Tarozzi N, Borini A, Wells D. Fertility and Sterility. 2015; 104(3):Supplement, Page e96. Available at: http://www.fertstert.org/article/ S0015-0282(15)00799-2/abstract. 9. Munne, S. New methods for embryo selection: NGS and MitoGradeTM Available at: http://www.eivf.net/documents/sum_2015/Santiago_Munne.pdf. 10. Fragouli E, Cohen J, Munne S, Grifo J, McCaffrey C, Wells D. The biological and clinical impact of mitochondrial genome variation in human embryos. ASRM Scientific Program Prize Paper (unpublished). Lia Ribustello BS, MS, serves as Laboratory Supervisor in New Jersey for Reprogenetics, Inc. She is a certified scientist in Molecular Biology through the American Society for Clinical Pathology. To be clear, all experts agree that screening pregnant women for GDM is an important part of obstetrical care. Indeed, the United States Preventative Services Task Force has recommended screening all pregnant women for GDM. The controversy centers on how to best screen for the condition. Several studies have now been conducted that evaluate outcomes when GDM is identified via the one-step or two-step approach. Perhaps not surprisingly, the conclusions of these various studies are not in agreement with each other. As expected, all studies report an increased number of women diagnosed with GDM using the one-step test. However, the outcomes of these pregnancies are reported as improved in some studies, while others describe no improvements compared to GDM cases diagnosed by the two-step test. The debate, therefore, continues, as it remains unclear if the increased number of women identified as having GDM by the one-step approach have truly benefited from treatments for GDM or if they have been subjected to unnecessary (and potentially harmful) interventions. A uniform approach to identifying GDM is needed, but more data and more studies will be necessary before a consensus opinion on one that produces the greatest benefits with the least risks will be achieved. David Grenache, PhD, is a professor of pathology at the University of Utah School of Medicine and section chief of clinical chemistry at ARUP Laboratories. He is board-certified by the American Board of Clinical Chemistry and is a fellow in the National Academy of Clinical Biochemistry. He also maintains a blog, “The Pregnancy Lab” (www.pregnancylab.net), focused on the laboratory tests performed during pregnancy. For further reading American Diabetes Association. (2016). Classification and Diagnosis of Diabetes. Diabetes Care. 39 Suppl 1, S13–22. http://doi.org/10.2337/dc16-S005. HAPO Study Cooperative Research Group, Metzger BE, Lowe LP, Dyer AR, et al. Hyperglycemia and adverse pregnancy outcomes. The New England Journal of Medicine. 2008;358(19). 1991–2002. http://doi.org/10.1056/ NEJMoa0707943. International Association of Diabetes and Pregnancy Study Groups Consensus Panel, Metzger BE, Gabbe SG, Persson B, et al. International Association of Diabetes and Pregnancy Study Groups recommendations on the diagnosis and classification of hyperglycemia in pregnancy. Diabetes Care. 2010:33(3):676–682. http://doi.org/10.2337/dc09-1848. ACOG. (2011). Committee opinion no. 504: screening and diagnosis of gestational diabetes mellitus. Obstetrics & Gynecology. 118(3):751–753. http://doi.org/10.1097/ AOG.0b013e3182310cc3. Blumer I, Hadar E, Hadden DR, Jovanovic L, Mestman, JH, Murad, MH, Yogev Y. Diabetes and pregnancy: an endocrine society clinical practice guideline. The Journal of Clinical Endocrinology and Metabolism. 2013;98(11):4227– 4249. http://doi.org/10.1210/jc.2013-2465. AUGUST 2016 MLO201608-Education-COMBINED_MECH_AL.indd 29 MLO - ONLINE.COM 29 7/12/2016 2:34:25 PM SPECIAL FEATURE G A S T ROEN T E ROL OGY Individualized risk prediction in Barrett’s esophagus By Aaron D. DeWard, PhD, and Rebecca Critchley-Thorne, PhD B arrett’s esophagus (BE), which is a precursor to esophageal adenocarcinoma (EAC), is an increasing healthcare challenge in the United States, but new tools are quickly emerging to combat the uncertainty associated with the disease. Barrett’s esophagus management decisions are often based on subjective diagnoses, so better diagnostic and prognostic techniques are needed to augment BE patient care. Here, we summarize a number of tools available to clinical decision-makers to aid diagnoses and predict the risk of disease progression, which will optimize patient surveillance intervals and guide therapeutic interventions. The clinical problem There are an estimated 12 million to 17 million people who have BE in the United States.1 Although malignant progression is rare in BE, a small subset of patients will develop EAC,2,3 which has a five-year survival rate of less than 20 percent.4 Furthermore, the incidence of EAC continues to rise in the U.S. Treatment options for EAC are limited, so early detection is critical for optimal patient management. Currently, patients with BE are surveilled by endoscopic biopsies with the goal of detecting disease progression early. Diagnoses are not always clear-cut, and can be inconclusive even after review by a specialized pathologist.5 Recent guidelines published by the American College of Gastroenterology recommend endoscopic ablative therapy for patients diagnosed with high-grade dysplasia, but there is uncertainty about the surveillance interval, true risk of progression, and treatment recommendations for patients with low-grade dysplasia or who are indefinite for dysplasia, and for patients with non-dysplastic BE.6 Therefore, it can be difficult to distinguish patients with BE who are at high risk for progression to EAC from those whose disease will not progress, thus making surveillance and treatment decisions challenging. presence of columnar epithelium in pinch biopsies taken during endoscopy. While this approach is valuable, it is limited by the random nature of the sampling and observer variability in the histologic diagnosis. New sampling techniques have been developed that aim to overcome some of these limitations. One such technique is computer-assisted brush biopsy, which can be used as an adjunct to standard biopsy to detect BE and to aid in the identification of dysplasia.7,8 Brush biopsies allow for more esophageal tissue to be sampled, thus improving tissue coverage and increasing the potential to detect BE and dysplasia in a single endoscopy. Volumetric laser endomicroscopy (VLE) is an endoscopic technique that utilizes advanced imaging technology to generate three-dimensional images of tissue in vivo.9,10 Compared to other in vivo imaging methods, VLE increases imaging depth and decreases acquisition time and can be used to guide biopsy samples to locations that potentially have abnormalities, and to mark regions for therapeutic intervention. In addition, nonendoscopic tissue collection devices have been developed as a minimally invasive option to increase patient compliance and increase detection rates.11,12 The collection device is swallowed, and then it collects cells as it is removed back out of the mouth of the patient. Importantly, non-endoscopic devices have the potential to identify patients with BE that might have been overlooked if they were initially unwilling to undergo standard endoscopy. New risk prediction approaches While timely identification of patients with BE is an essential first step, subsequent monitoring and treatment recommendations are not always clearly defined. Clinical and pathologic variables are inadequate to predict which patients will progress to EAC , and over-surveillance of patients is common due to uncertainty in the diagnostic stage and anxiety relating to the unknown risk of developing EAC.13 Healthcare providers require Enhanced diagnostic techniques tools to accurately stratify patients based on their risk of disDiagnosis of BE relies on endoscopic recognition of salmease progression. Such tools will allow increased surveillance on-pink colored esophageal lining and confirmation of the and early therapeutic intervention for the subset of patients at high risk for progression to EAC, and permit longer surveillance intervals for patients at very low risk. Several approaches have been developed for risk stratification in BE. One approach, which has been validated in clinical studies and is commercially available as a laboratorydeveloped test (LDT), is a tissue systems pathology assay that quantifies multiple key biomarkers in Figure 1. Tissue system biomarkers detected in BE biopsies. Sections from BE biopsy blocks were labeled by multiplexed BE biopsies to produce an immunofluorescence and imaged by whole slide fluorescence scanning to detect markers of epithelial abnormalities (Panel individualized risk score A: p16-green, alpha-methylacyl-CoA racemase (AMACR)-red, p53-yellow) and markers of inflammation and stromal processfor progression.14 The teches (Panel B: CD68-green, COX-2-red; Panel C: HIF-1alpha-green, CD45RO-red). Hoechst labeling of nuclei is shown in blue in nology underlying this each panel. Whole slide images are analyzed by software to segment subcellular compartments and tissue structures, and assay quantifies not just to extract multiple, quantitative biomarker and morphology measurements from the relevant compartments/structures. continued on page 34 30 MLO - ONLINE.COM MLO201608-SpecFeature_MECH_AL.indd 30 AUGUST 2016 7/12/2016 9:11:36 AM COBAS® EGFR MUTATION TEST V2 The only FDA-approved test to use plasma to detect EGFR mutations in NSCLC Companion diagnostic for Tarceva® (erlotinib) and TAGRISSO™ (osimertinib) for patients with NSCLC The cobas® EGFR Mutation Test v2 is the first and only companion diagnostic test to receive FDA approval to use a liquid biopsy specimen for testing of patients with non-small cell lung cancer (NSCLC). The test can use samples from plasma or from tumor tissue to identify patients who are likely to benefit from first-line treatment with Tarceva® (erlotinib). The plasma option offers physicians a way to make testing more accessible by using a simple blood draw instead of a surgical biopsy to obtain a suitable sample. With flexible sample requirement, clinically proven broad and sensitive mutation coverage, and speed to result, the cobas® EGFR Mutation Detection Test v2 removes barriers to testing and gives physicians the information needed to make confident treatment decisions for their critically ill patients. Talk to your Roche representative or visit www.cobasEGFRtest.com for more information. COBAS and LIFE NEEDS ANSWERS are trademarks of Roche. TARCEVA is a trademark of OSI Pharmaceuticals, LLC, Farmingdale, NY, 11735, USA, an affiliate of Astellas Pharma US, Inc. TAGRISSO is a trademark of AstraZeneca AB. All other product names and trademarks are the property of their respective owners. © 2016 Roche. PP-US-07552-0616 MLO201608_AD Roche.indd 31 7/8/2016 1:58:18 PM THE THINPREP SYSTEM The first FDA-approved liquid-based Pap test that is significantly more effective than conventional.1* The first FDA approval of glandular disease labeling.1 The first FDA approval for an automated imager, the ThinPrep Imaging System. The first and only FDA-approved collection media for use with all FDA-approved HPV tests. * Th The e Th hinPr nP nPr n Prep p 2000 00 0 Sys Syst y tem m is is siignifi gni gn gnifi gnificant n can cant antlyy mo a ore rre effe effec ffective ffective ve th tha han the co con nven ntio ntion tion ion onal a Pap Pap p smear smear mea ea ffo ea for or the he ed det et etecti ee eccti ecti ect ction no off low-gr lo l w w-g w-gr -g grrade g ad de squa de qu q qua uamous mo m mou ou ouss int ntraep nt rae aep ae ep e pithe tthe he he elial lial lia al ((LS a LS SIL) SIL) L) a L) an and nd n d more mo or sev se evere evere ere lesi esi e s ons on in on n a va variety var ety ety of patie of atiti ntt popu at opul o pu a atio atio ons ns. s. s. ADSDSS0 0158 1586-00 6-00 6-0 0 1R Revv. 001 01 © 20 201 0116 Ho 0 Hologi log ogi og g c, c, Inc. ncc A Allll righ All igh ghts gh tss rreser ese eser e ved er ve Hol ved. 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S. an and o otther he er ma mark m a ets ark ets and and iiss no an ott inte nten n te en e nded de ed as as a p prro pro oduc du duct uct ct soli o cita ol citation ta ation on orr prom ro otio rom ro romotio o on on where wher ere ere e such succh ac accttiivit act vititiies ess are are e proh pro p rrohibit ib ibited. biited. bit b ed. Beca ed Because use se e Holo Holl gic giic mate ma rial ria ial a s are arre d a diistri distri stribute str but bute b buted ute utted th throug roug oug gh w websit bssitittes, bsi ess, eB es, eBr eBroadc Bo Br oad oadc adc dcas asts ast stt an ssts and a nd tra nd rades radesh ra des desh esh ho ows, itit iss not ows, ot a alway lwa lway way wa ways a sp possib ssi siible ible e to co c n ntt ol wh ntro w where ere e re e such ucch ma u mat atte eri eria rialss appea ppea p rr. For o sp pecc ficc in peci nfor nfo for o mati a io ati on n on on wh what w at produ oducts oducts cts are a ava avai va lab labl able for ab ffor sale sale e in in a part particul iccu arr count icul icu oun ou unt n ry ry, y, ple plea l ase e cconta onta ont nta actt yo our ou u loca oca oc cca al Ho Holog logi og c re og repres prre pre pres rres esenta ent nt tive tiv ive ve o ve orr writ writte to wri to d dia diag ag gnost no nos nost ost stic.s c.ssolu c.s olut o olutions lu l tions ion io ons o n .com co com om m. MLO201608_AD Hologic-SPREAD.indd 32 7/8/2016 12:55:43 PM We proudly celebrate the 20th Anniversary of the ThinPrep® Pap test. When the ThinPrep Pap test was introduced in 1996, all Pap testing was done via conventional “Pap smears,” and HPV testing was not a part of the cervical cancer screening algorithm. Since then, there has been a significant reduction in invasive cervical cancer in the U.S.2 That’s something to celebrate. Today, more than 650 million ThinPrep Pap tests have been performed, with more than 6,000 ThinPrep processors installed globally.3 The ThinPrep family has been a leader in cervical cancer screening, and it has remained the trusted choice in Pap testing for the large majority of top healthcare providers and laboratories across the U.S.3,4 Today, Pap+HPV Together™ (cotesting) is supported as the best strategy for detecting high-grade cervicovaginal lesions in women ages 30-65, according to recent studies.5,6 Guidelines also recommend the use of co-testing as the preferred screening choice for women ages 30-65.7 Hologic continues to stand behind this testing modality as the best screening strategy for women. While we celebrate our past, we continue to look to the future. The ThinPrep Pap test is the most trusted and widely used Pap test on the market. With your partnership, we have contributed to a decline in cervical cancer rates. We’re looking forward to delivering you innovative tools and advancing cervical cancer screening together for the next 20 years and beyond. Re Ref Refe eferenc renc ren enc e nces: nc es 11.. Th Thi hn hi nP nPr nPre P ep p 20 2 00 00 S Syste yste stte em [[packa [packa ack a cka ck kage ge inse nser sert]. ser t]] MANMAN AN-0 020 0206 2060-00 0 002 002 Re 00 Rev. v 001. v. 01. Marl 01 Mar arlborough, boro orough, ugh h, M MA MA: A H Hol Ho ollog o ogicc, In o Inc.; nc.; c 2011 c. 201 01 . 2 01 2.. Nat attiona at iona ona o n na al Can C Canc an nce err Ins nsti n nst stit tute sst ute ut t .S SE EER ER Stat Stat att F Fac Fact act act She Sh heets: e Cer et ets: ets Cervix Ce e vi viix Ute vix Uteri Uter ter eri Ca Cancer nccer nce ce . http:/ h htttp:/ tp p:///see /sseer.ca ssee eer.cancer r ca r.ca cancer ncer.gov .go .gov gov/sta /statfac st tfac facts/h acts/h tss/html/ tm ml//cerv ccerv ervviix.h ixx.h x.h html. tml ml Acc Acc ccesse sse s dA Ap pril r 28, ri 28 28 8, 20 2016 016. 0 3. H 3. Ho Hol o olo ogic gic, c, IIncc.. Data Data ata on at on File ile. le e 4 4.. U.S U.S. U .S. S Ne Ne New ew wss & Wo Worl W Wor orl orld Re Rep port por ort. Best Hospi o os tals osp als for a al fo Adu Ad d lt Gynec yne ology. ologyy. http: olo olog ttp ttp ttp://he //he ealth lth th.usn h.usn .u ussnews. news.com/ ew ews. ews wss com/ w com/best m best st-hos st-hos -h hosspita ho p ls pit ls ls/ ran rank ank a nkings in ing iings ngs ngs gs/gyn /gyynecol eco ecol e ccol co ology ogy. ogy. og gy. Publish Pu Pub P u ublish ish ssh hed ed 2016 016 Acc 016. Accesse ccess esse esse ssed Ap April ril 28, 2 2016 28 201 016. 5. 5 Blatt, Bla latt ttt, et al. tt, al.. Compa Compa ompariso omp riss n of C riso Ce Cer errvica viical vic cal C Ca ancer nce ce Scr Sc eeni een en n ngRe ngR gRe Resul sult ultl s Amo A Amon m mon ong 2 25 56,64 6 648 Wo 6,6 Women me men m en n in n Mu ultltt ple ulti lle e Clin Clin nica ical ic ca ca cal al Pr Pra Pra actic ctic ices. es C es Can Canc a e er Cytop patho ath t l. 2015;1 2015;1 15 15; 5 23(5 5;1 23 23( 3(5):282-8. ):28 82-8. 2--8. 8 doi do oi:10. o :10 10 1002 100 002 00 0 0 /cnc 02 /cnc cncyy.21 211544. 2 544 5 44. 6 4 6.. Z Zh Zha h o, o, e ett al Clin al. C iinica ical ca cal a Per Perform Perform forrm mance ce eo off the the th he Foo Fo Food oo od and an nd d Dr Drug Ad Dru Admini min n stra stration str tion-Ap tio -App A rove App rov oved Hi H gh-R gh-Risk h-Risk ssk HPV Te Tes Test T est stt ffor o tthe or th he Det De etecti et ec on n of H High-G gh h-G -G Grade rad d Cer Ce Cerv erv rvicov co cov ovvag agi agin aginal gin nal al L Lesio essi e esio sio ons ns [pub publ pu u lish ubl ub ishe sh sshe h d o hed online lin ine ne ahe ah h a he ad d of p print ntt Janu anu nuary aryy 15 15 2016 15, 201 016].]. Canc Cancer Cytop Cancer y a yto atho t ol. do tho doi:10.100 doi:10 i:10 0.100 10 1100 002/cn 0 2/c /cn /cncy.2 ncy cy.2 y.2 21687 168 687 6 87 7.. 7. ACOG. 7. ACO ACO AC C G G.. C Cervi errvi erv ervi vviical cca cal aC Can Canc anc an nce err Scree eening in n an and nd P Pre re event ve ven vent ve en ion. on Obstet Obs Obst bs ett G Gynec yne ynec neccol ol. 20 2016;1 2016;1 16; 6;127:e ;127 27:e 27:e1-20 7:e11-20 -2 -20 2 . do 20 doi:10 i:10 ::10 0.109 109 097/A 09 7/AO /A /AO AO A OG.00 OG.00 G 00 0 000 0000 0 00 0 0000000 00000 0000 00 001256. 0 001 0012 00 0125 56. 56 6.. 6 Learn why the world trusts the ThinPrep system at ThinPrep.com MLO201608_AD Hologic-SPREAD.indd 33 7/8/2016 12:56:05 PM SPECIAL FEATURE G A S T ROEN T E ROL OGY continued from page 30 epithelial abnormalities that are indicative of progression, but also stromal changes, such as angiogenesis and infiltration of specific immune cell subsets that play important roles in tumor development and progression.15 This approach utilizes immunofluorescence labeling to detect a series of biomarkers on formalin-fixed paraffin-embedded (FFPE) tissue sections (Figure 1, pg. 30). After capturing whole slide digital images of the tissue, specialized image analysis software automatically segments specific subcellular compartments and tissue structural components and quantifies biomarker expression patterns in the context of the cellular and tissue architecture. This imaging approach has the advantage of assessing multiple key cell types, including immune cells, and multiple pathways of malignant progression, while maintaining essential spatial and contextual information. A multivariable classifier is then used to integrate the quantitative biomarker and morphology data into a risk score, which is used to estimate the individual patient’s risk of disease progression within the next five years, as well as to identify patients who might already have prevalent HGD or EAC.14,16 Other approaches have assessed individual biomarkers or panels of biomarkers stained by immunohistochemistry on FFPE tissue and found a modest benefit for risk prediction.17,18 However, these tools rely on manual interpretation of biomarkers on tissue slides and have not yet been implemented for risk prediction in clinical practice. Other approaches have examined mutations using next generation sequencing and PCR and found that patients who progressed to HGD or EAC had an increased mutational load.19,20 While not currently commercially available for clinical testing, these methods have the advantage of high-throughput detection of multiple mutations that may indicate future malignant progression. The drawback of these methods is the loss of spatial context of molecular changes. Furthermore, these methods do not assess cellular changes in the stroma and morphologic changes that indicate risk of progression. Individualized risk prediction methods will ease the unnecessary concern of patients whose BE is at low risk of progressing while highlighting patients at high risk to ensure they receive more aggressive care. Another important benefit is the potential for cost savings by extending endoscopic surveillance intervals in low-risk patients, and by early therapeutic intervention in patients at high risk of progression, which is expected to reduce the significant cost burden associated with cancer treatment and end-of-life care.21,22 New tools and new optimism In summary, accurate risk prediction provides an opportunity to improve patient management by providing better outcomes while improving the efficiency of healthcare spending in the management of BE. Ultimately, the goal is to reduce the incidence and mortality of EAC in patients with BE, which can be accomplished by improving methods of early detection and intervention. The new tools that improve diagnostic accuracy and provide accurate risk stratification are an exciting step forward in this process. 4. Cancer Facts & Figures 2016 American Cancer Society. 5. Yantiss RK. Diagnostic challenges in the pathologic evaluation of Barrett esophagus. Arch Pathol Lab Med. 2010;134(11):1589-1600. 6. Shaheen NJ, Falk GW, Iyer PG, Gerson LB. ACG Clinical Guideline: Diagnosis and Management of Barrett’s Esophagus. Am J Gastroenterol. 2015;111(1):30-50. 7. Johanson JF, Frakes J, Eisen D. Computer-assisted analysis of abrasive transepithelial brush biopsies increases the effectiveness of esophageal screening: a multicenter prospective clinical trial by the EndoCDx Collaborative Group. Dig Dis Sci. 2010;56(3):767-772. 8. Anandasabapathy S, Sontag S, Graham DY, et al. Computer-assisted brush-biopsy analysis for the detection of dysplasia in a high-risk Barrett’s esophagus surveillance population. Dig Dis Sci. 2010;56(3):761-766. 9. Swager A, Boerwinkel DF, de Bruin DM, et al. Volumetric laser endomicroscopy in Barrett’s esophagus: a feasibility study on histological correlation. Dis Esophagus. May 8 2015, doi: 10.1111/dote.12371. 10. Leggett CL, Gorospe EC, Chan DK, et al. Comparative diagnostic performance of volumetric laser endomicroscopy and confocal laser endomicroscopy in the detection of dysplasia associated with Barrett’s esophagus. Gastrointest Endosc. 2016;83(5):880888 e882. 11. Ross-Innes CS, Debiram-Beecham I, O’Donovan M, et al. Evaluation of a minimally invasive cell sampling device coupled with assessment of trefoil factor 3 expression for diagnosing Barrett’s esophagus: a multi-center case-control study. PLoS Med. 2015;12(1):e1001780. 12. Iyer P, Johnson ML, Lansing R, et al. Discovery, Validation and Feasibility Testing of Highly Discriminant DNA Methylation Markers for Detection of Barrett’s Esophagus Using a Capsule Sponge Device. Gastroenterology. 2016;150(4):S66-67. 13. Cai JX, Campbell EJ, Richter JM. Concordance of Outpatient Esophagogastroduodenoscopy of the Upper Gastrointestinal Tract With Evidence-Based Guidelines. JAMA Intern Med. 2015;175(9):1563-1564. 14. Critchley-Thorne RJ, Duits LC, Prichard JW, et al. A Tissue Systems Pathology Assay for High-Risk Barrett’s Esophagus. Cancer Epidemiol Biomarkers Prev. 2016;25(6):958-968. 15. Prichard JW, Davison JM, Campbell BB, et al. TissueCypher: A Systems Biology Approach to Anatomic Pathology. Journal of Pathology Informatics. 2015;6:48. 16. Critchley-Thorne RJ, Davison JM, Prichard JW, et al. Sa1257 A Tissue Systems Pathology Test Detects a Field Effect Associated With High Grade Dysplasia and Esophageal Cancer in Barrett’s Esophagus Patients. Gastroenterology. 2016;150(4):S259. 17. Bird-Lieberman EL, Dunn JM, Coleman HG, et al. Population-based study reveals new risk-stratification biomarker panel for Barrett’s esophagus. Gastroenterology. 2012;143(4):927-935 e923. 18. Horvath B, Singh P, Xie H, Thota PN, Sun X, Liu X. Expression of p53 predicts risk of prevalent and incident advanced neoplasia in patients with Barrett’s esophagus and epithelial changes indefinite for dysplasia. Gastroenterol Rep (Oxf). Oct 19 2015. 19. Del Portillo A, Lagana SM, Yao Y, et al. Evaluation of Mutational Testing of Preneoplastic Barrett’s Mucosa by Next-Generation Sequencing of Formalin-Fixed, ParaffinEmbedded Endoscopic Samples for Detection of Concurrent Dysplasia and Adenocarcinoma in Barrett’s Esophagus. J Mol Diagn. 2015;17(4):412-419. 20. Eluri S, Brugge WR, Daglilar ES, et al. The Presence of Genetic Mutations at Key Loci Predicts Progression to Esophageal Adenocarcinoma in Barrett’s Esophagus. Am J Gastroenterol. 2015;110(6):828-834. 21. Gordon LG, Mayne GC, Hirst NG, Bright T, Whiteman DC, Watson DI. Cost-effectiveness of endoscopic surveillance of non-dysplastic Barrett’s esophagus. Gastrointest Endosc. 2014;79(2):242-256 e246. 22. Hao J, Snyder SR, Pitcavage JM, Critchley-Thorne RJ. A Cost-Effectiveness Analysis of A Test That Predicts Risk of Malignant Progression In Barrett’s Esophagus. Value in Health. 2016;19(3):A6-7. Aaron D. DeWard, PhD, serves as Research Scientist for Cernostics, Inc., provider of the TissueCypher Barrett’s esophagus assay. REFERENCES 1. Hayeck TJ, Kong CY, Spechler SJ, Gazelle GS, Hur C. The prevalence of Barrett’s esophagus in the US: estimates from a simulation model confirmed by SEER data. Dis Esophagus. 2010;23(6):451-457. 2. Wani S, Falk G, Hall M, et al. Patients with nondysplastic Barrett’s esophagus have low risks for developing dysplasia or esophageal adenocarcinoma. Clin Gastroenterol Hepatol. 2011;9(3):220-227; quiz e226. 3. Thota PN, Lee HJ, Goldblum JR, et al. Risk stratification of patients with barrett’s esophagus and low-grade dysplasia or indefinite for dysplasia. Clin Gastroenterol Hepatol. 2014;13(3):459-465 e451. 34 MLO - ONLINE.COM MLO201608-SpecFeature_MECH_AL.indd 34 Rebecca Critchley-Thorne, PhD, serves as Vice President, Research and Development, and co-founder of Cernostics, Inc. AUGUST 2016 7/12/2016 9:11:50 AM How efficient is your hematology workflow? Reduce sample review time for better operational efficiency and cost control Standardize morphological examination for better and more consistent results Make more efficient and flexible use of resources, staff and skills The labor-intensive and often inconsistent process of performing manual differentials can have a negative impact on your lab’s overall performance. Here’s the solution. CellaVision leads the way in digital cell morphology 15 years ago, CellaVision introduced automation and digital imaging to cell morphology. Our clinically proven product concept has been adopted by progressive laboratories all over the world and is known to improve quality, promote standardization and reduce sample review time. Visit www.cellavision.com to learn more about how automation and digital imaging can help transform your hematology workflow and help you work smarter and perform better. CellaVision is the word leader in digital cell morphology. Our unique product concept replaces manual microscopy to create an automated digital workflow for morphological cell analysis. MLO201608_AD CellaVision.indd 35 7/8/2016 12:53:20 PM LAB MANAGEMENT QC/Q A External and internal QC for blood gases By Al Jordan Q uality Control (QC) and Quality Assurance (QA) in the clinical lab have changed. The Centers for Medicare and Medicaid Services (CMS) has embraced a voluntary QC option for meeting CLIA quality control standards called Individualized Quality Control Plan (IQCP), which was implemented in January 2016 for all labs that have been utilizing Equivalent Quality Control (EQC). CLIA QC regulations will remain the same as published in 2003. All of the pre-analytical, analytical, and post-analytical systems requirements in the CLIA regulations will remain in effect. There are many different aspects of the IQCP for laboratories to consider. This article will cover the minimum requirements for use of external quality controls with regard to blood gas QC. Minimum guidelines The minimum guidelines according to CLIA 88 (2003) require laboratories to perform external quality control at least one time per eight-hour shift.1 The IQCP does not change this requirement. In addition to the daily QC requirement, the laboratory is also responsible for calibration verification for all non-waived “moderate to high-complexity” test systems. The laboratory must perform calibration verification at least twice per year, for documentation purposes, as well as whenever any of the following occurs: 1) after any major preventive maintenance; 2) when critical parts affecting an instrument’s performance are replaced; 3) after the laboratory switches lot numbers on the reagents it used in conjunction with an instrument; and 4) after the laboratory identifies an unusual trend or shift reflected in its control material, or results that fall outside of established acceptable limits. External vs. internal What qualifies as external quality controls vs. internal quality controls? Many of today’s automated blood gas (ABG) instruments now have internal onboard QC. Since January 2016 there have been questions on whether a laboratory could be cited on inspection for utilizing these internal controls to fulfill their external control requirement as per CLIA 88. One of the questions is: At what point is the QC material introduced to the ABG instrument for daily QC? If the internal QC is introduced at the beginning of the sample flow path on the ABG instrument, does it constitute an external QC? On some ABG instruments with internal QC, the QC material is entered into the sample flow path further down the line. Following the first rule of the IQCP, the risk assessment (pre-analytic phase), contains five mandatory areas to include: 1) specimen handling; 2) personnel handling the sample; 3) instrument; 4) reagent; and 5) environment.2 The laboratory runs the risk of error utilizing internal QC as its external QC requirement. Since the ABG instrument is introducing the QC sample automatically, it eliminates the specimen handling and personnel handling of the sample; the risk assessment for these two mandatory areas is eliminated by the ABG instrument; the risk of error for these areas is not tested with the use of an internal control. The pre-analytic phase, specimen/personnel handling the sample, is missed completely. Potential errors could be missed, particularly when time from patient draw to introducing the sample is a critical factor in the testing of the samples, as with blood gas testing. When considering the blood gas pre-analytic phase, metabolic changes occur rapidly after sample drawing. The most obvious 36 MLO - ONLINE.COM step to counter the metabolic change is to analyze the sample quickly. The International Federation of Clinical Chemistry (IFCC) recommends keeping transportation times to a minimum, as it will affect the values of the blood gas testing.3 Utilizing internal QC could create a potential error in the pre-analytic phase, as it does not allow the laboratory to take into consideration the sample transportation time, or that properly trained personnel is handling the sample, as well as the QC material. Since these are major factors in patient sample handling for blood gas, they should also be considered in QC material for blood gas. External QC material options When evaluating external QC material for blood gas, it is recommended that laboratories use QC material that is most like patient sample. The majority of blood gas QC manufacturers use an aqueous buffered material or perfluorocarbon emulsions solution. Although these are accepted QC matrices, they may not be the best option for blood gas QC. The other option to consider is reduced bovine hemoglobin solution (RBHS). An influential article published in 1993 established that there is a strong benefit to using blood gas QC manufactured with RBHS as the external QC material,4 and that has been widely accepted in the years since. With the enforcement of the IQCP, laboratories should consider adopting a QC plan that includes the use of material that most resembles patient samples. If labs eliminate the questions of the internal QC material qualifying as an external control, and have trained personnel introducing the QC sample, at least three levels, once per each eight-hour shift, this most mimics a safe pre-analytic practice. In order to meet laboratory requirements for calibration verification on blood gas analyzers, lab directors should consider the matrices of the material being used. RBHS-based calibration verification material will most resemble that of human samples. Using liquid stable, as opposed to lyophilized QC material, will also assist in eliminating any pre-analytical errors while reconstituting the freeze dried material. These small adjustments in a QC plan for laboratories might save the lab considerable stress at inspection time, as well as assist in meeting requirements as per CLIA 88 (2003). REFERENCES 1. American College of Physicians. CLIA and your laboratory: a guide for physicians and their staff. November 2014. https://www.acponline.org/system/files/documents/ running_practice/mle/clia-and-your-lab.pdf. 46. 2. The Joint Commission. Quality control option changing for clinical laboratories. https://www.jointcommission.org/assets/1/6/JCP0314_QC_Clin_Labs.pdf 3. Baird G. Preanalytical considerations in blood gas analysis. Biochemia Medica. 2013;23(1):19-27. 4. Mahoney JJ, Wong RJ, Van Kessel AL. Reduced bovine hemoglobin solution evaluated for use as a blood gas quality-control material. Clin Chem.1993:39(5): 874-879. Al Jordan serves as Vice President, Sales and Marketing, for Massachusetts-based Phoenix Diagnostics, a manufacturer of quality control and calibration verification material for blood gas, electrolyte, and chemistry analyzers worldwide. He has more than 30 years’ experience in the laboratory equipment and clinical diagnostics industry. AUGUST 2016 MLO201608-LabMgmt-Phoenix_MECH_AL.indd 36 7/12/2016 2:47:59 PM Once-a-day TAP INTO BIO-RAD MOLECULAR CONTROLS. IMPROVE ANALYTICAL PERFORMANCE AND PATIENT CARE. QC works just fine, until it doesn’t. How much of a risk is your lab taking? Just because you’re meeting the regulatory minimum of once-a-day QC, doesn’t mean you sleep well at night, or are confident that your laboratory has patient risk under control. Daily QC may be adequate for some tests, but using the same approach for higher risk tests could put some patients at risk for inappropriate treatment due to undetected instrument failure. Can your lab afford that risk - or the delay and costs of repeating patient samples? Bio-Rad Mission: Control is the first tool a laboratory can utilize to help assess and manage those risks objectively: calculate your current risks, and help select the right QC rules and frequency for your lab. Download our risk infographic at www.qcnet.com/mc-mlo Mission: Control is a trademark of Bio-Rad Laboratories, Inc. in certain jurisdictions. MLO201608_AD BioRad-19509.indd 37 7/8/2016 12:52:48 PM LAB MANAGEMENT QC/Q A Resolving QC failures By W. Greg Cooper, CLS, CQA, MHA M ost medical technologists and technicians, responsible for outputting test results as quickly and reliably as possible, hate it when their smooth flow of work is abruptly interrupted by an out-of-control QC rule flag. Suddenly they are faced with delayed reports, the prospect of a complicated technical investigation, and a litany of questions they must ask themselves, such as: • “Is the out-of-control condition real?” • “Do I really have a problem with the analytical system?” • “If I do have a problem, when did it start and how many patient samples are affected?” • “What should I do first?” • “What should I do next?” The laboratory would have much less of a conundrum if it were using a new QC rule proposed in a 2012 Clinical Chemistry article.1 This rule allows, as part of its process control, the possibility of a second set of QC measurements when the first results are inconclusive. The rule is called a Repeat 1:2s QC Rule, where 1:2s designates that the “run” is rejected when a single control is out 2 standard deviations (2s). This helps improve the rule’s ability to verify whether the process is out of control. If the rule triggers a second set of QC results and the repeat results are within their 2 standard deviation (SD) limits, then the laboratory can assume the condition was a random occurrence and patient results can be reported. However, if any repeated QC result is outside its 2 SD limits (regardless of the control material) the run is rejected and patient results are held for retest. The test system and control system Before troubleshooting begins in earnest, the laboratory should consider the possibility that common failure modes of the test system or the control system may be the cause of the out-of-control condition. The test system includes the reagents, hardware, and software. It may require more in-depth investigation and analy- • Random instrument malfunction • Power fluctuations • Temperature fluctuations (environment and incubation chamber) • Test operator mistake • Technique (technique-sensitive testing) • Reagent preparation (error in or inconsistent preparation of reagent, failure to consistently follow manufacturer instructions) • Control material (error in or inconsistent preparation of control material, failure to consistently follow manufacturer instructions) • Software malfunction • Possible contamination Table 1: Common causes of random error sis, but the laboratory should at least first consider those few things in the test system that are known to cause problems or have a history in the lab of causing problems. These could include such things as the reagent integrity, the tubing and pumps used for sample and dispense, and the light source. The control system includes the control materials, the mean and standard deviation used to set the LeveyJennings chart, and the process control rules applied. Any of these could be the cause of the out-of-control condition. The technologist or technician should verify the control materials are in date, have been properly stored, and have been properly prepared. Attention should be given to open vial stabilities published in the product insert. Most control materials must be kept between 2-8oC, even after reconstitution, so if the control material is kept at room temperature on the analytical bench most of the day, open vial stabilities and consequently control results may be compromised. The mean and standard deviation are key to an effective Levey-Jennings chart. Both must be calculated using sufficient data collected over a period of time, allowing for multiple calibrations, multiple reagent lots, maintenance, and multiple operators when technique may be an issue. If either the mean or standard deviation is out of synchrony with actual test performance, the Levey-Jennings chart will frequently issue out-of-control alerts. Recalibration is often the first but misguided reaction to an out-of-control condition. Keep in mind that every time the laboratory calibrates, it creates an opportunity for introduction of new or additional measurement error. Consequently, if a laboratory calibrates more frequently than recommended by the manufacturer, it is one indicator that the quality control system is likely out of synchrony with current test performance. Random error and systematic error If the quality control system is found to be appropriate and effective, then troubleshooting begins. First, the type and approximate size of the error must be characterized, because this will lead the investigator to possible specific causes which are either random or systematic. This can be accomplished using control data from previous QC events (recent and historical QC), or the laboratory may choose to take a more contemporary approach by testing multiples of additional controls at different concentrations (Ns of 2 to 8 or more) and then examining the data for clues as to the magnitude and cause of the out-of-control condition. If the control pattern suggests random error, then the laboratory should investigate common contributors to random error (Table 1). If a cause can be found, corrective action is taken. If a cause cannot be found, then the laboratory should perform comprehensive instrument maintenance followed by recalibration. The control materials are retested, and if the results are out of control, then the laboratory must continue to sequester all patient results and undertake a root cause analysis. If the control results are in control, then all patient samples are retested and reported. Remember, random error conditions occur, well, randomly, so all patient results prior to the correction are suspect. continued on page 42 38 MLO - ONLINE.COM AUGUST 2016 MLO201608-LabMgmt-COMBINED_MECH_LM.indd 38 7/12/2016 3:35:09 PM AUDIT MicroControls offers over 120 analytes for your Calibration Verification/Linearity needs. Let us help you straighten it out. Visit us at booth #749 at AACC! MLO201608_AD Audit.indd 39 7/8/2016 12:51:43 PM LAB MANAGEMENT QC/Q A The role of calibration verification/linearity in the POCT market By Glenn Mitchell “I s calibration verification/linearity required on my POCT system—or not?” If you are one of the many who have purchased an instrument for point-of-care testing (POCT), this is a very legitimate question. POCT user manuals will typically state in one form or another that the linearity of the instrument should be checked before the instrument is used for patients for the first time. The user manual may also refer to calibration verification in lieu of linearity, or it may refer to both terms. And in many instances, but not all, the manufacturer may include a calibration verification/linearity kit with the initial shipment of the test system to be used upon initial setup. The user manual will also generally state that subsequent linearity tests are to be determined by the facility operating the system. So, the question above should perhaps be reformulated as two questions. Once the test system is calibrated, controls are set and run, and calibration has been verified and/or linearity has been established: “Is calibration verification/linearity required on my POCT system moving forward? And, what exactly is the difference between calibration verification and linearity?” Let’s tackle the second question, first. Calibration verification and linearity Calibration verification is the process of assaying materials of known concentration in the same manner as patient samples to assure that the test system is accurately measuring samples throughout the reportable range of the instrument— reportable range being the range of the test results for an analyte, from minimum to maximum, which the instrument test system can accurately measure. Per Clinical Laboratory Improvement Amendment (CLIA) guidelines, at least three samples (low, middle and high) spanning the reportable range of the test are run as unknowns (performed in normal test mode, not calibration mode), and the values obtained are compared to the known values of the calibration verification material. If the calibration verification confirms that calibration settings are valid for a specified method, no further calibration actions are necessary. Calibration verification is to be performed every six months, or more often if specified in the user’s test system instructions, the facility’s QC protocol, and under circumstances outlined in CLIA 493.1255(b)(3). Linearity, as defined by CLSI’s EP-06-A guideline, is as follows: “The ability (within a given range) to provide results that are directly proportional to the concentration (amount) of the analyte in the test sample.” Linearity studies are performed to determine the linear reportable range for an analyte. Linearity is achieved when measured results are directly proportional to the concentration of the analyte in the test sample, within a given range. One reason one may find the term linearity so frequently used in analyzer package inserts is that before the final CLIA regulations were published in 2003, laboratories were required to perform linearity studies every six months for quantitative high complexity tests. Linearity studies, as 40 MLO - ONLINE.COM such, are no longer required by CLIA, as calibration verification has basically replaced the term and process of linearity studies. Please be aware, however, that linearity, as defined above by CLSI’s EP06-A guideline, is still recommended and is considered Good Laboratory Practice. Moving forward, please note also that all testing, regardless of where performed, including POCT, is regulated by CLIA. CLIA section 493.1255 requires, among other things, that laboratories verify calibration. This section also requires at a minimum that laboratories follow the manufacturer’s protocol for calibration verification. Waived and nonwaived testing Which brings us to the first question: “Is calibration verification required on my POCT system?” All laboratory clinical tests, POCT included, at a minimum are regulated by CLIA and are classified as either waived or nonwaived. Nonwaived tests are further classified as moderately complex or high complexity. The majority of POCT systems, defined as medical diagnostics testing that is performed outside of the clinical lab in close proximity to where the patient is receiving care, are classified by CLIA as waived. As defined by CLIA, waived tests are simple, easy-to-run tests with a negligible risk for an incorrect result. A CLIA-waived test system by definition is cleared for home use by the U.S. Food and Drug Administration (FDA) and requires no training for the end user. Per CLIA, COLA, The Joint Commission, and CAP, calibration verification is not required for waived testing. The only requirement for waived tests is that the user follow, at a minimum, the manufacturer’s instructions. Be aware, however, that state regulations can supersede CLIA guidelines. In Massachusetts, for example, if a doctor’s office lab is statelicensed, it is required to perform calibration verification on waived tests. Test systems, including POCT, not categorized by the FDA as waived are considered nonwaived. Per CLIA guidelines, calibration verification is required on nonwaived tests. Nonwaived tests are further classified as moderately complex or high complexity. Moderately complex nonwaived tests are continued on page 42 AUGUST 2016 MLO201608-LabMgmt-COMBINED_MECH_LM.indd 40 7/12/2016 3:35:21 PM Keep your instrument in check with The new Acusera Linearity Sets have been designed to help keep your instrument in check while conveniently meeting CLIA requirements for calibration verification and linearity assessment. markers, specific proteins and therapeutic drugs allowing effective consolidation while ultimately guaranteeing individual instrument requirements are met. Supplied liquid ready-to-use in varying levels the complete reportable range is challenged ensuring accurate patient testing. Instrument dedicated materials are available for both Roche & Beckman analyzers covering a wide range of cardiac Complementing our new linearity sets is the Acusera Verify Data Reduction Software. Easily accessed online, the software provides instant access to automatically generated charts, statistics and real-time peer group data. 866 472 6369 | [email protected] | randoxqc.com www.randox.com/keepyourinstrumentincheck MLO201608_AD Randox.indd 41 7/8/2016 1:57:32 PM LAB MANAGEMENT QC/Q A QC continued from page 38 Calibration continued from page 40 • Calibration (this is a primary cause of systematic measurement error in the test system) • Reagent integrity (new lot or newly prepared; second-most common cause of systematic measurement error) • Lack of or inconsistent instrument maintenance • A LJ chart that is improperly set (target mean or standard deviation not properly calculated) • Instrument malfunction (reagent or sample pipette malfunction) • Light source (deterioration) • Incubation chamber temperature (shift in temperature or fluctuation) • Failure to follow manufacturer instructions for performing the test • Operator technique for technique-sensitive tests • Software malfunction (recent updates can cause problems) • Possible contamination (of reagents, tubing, water flushes, ancillary equipment such as pipettes, etc.) Table 2: Common causes of systematic error If the control data pattern suggests systematic error, then the laboratory should investigate common contributors to systematic error (Table 2). Systematic measurement error is much easier to find and identify than random error. The difficulty is in determining at what point in time the systematic measurement error occurred, making the number of patient samples between QC testing events really important. For example, if a laboratory only tests quality control materials every 500 patient samples, then it faces the difficult task of deciding which and how many of the previously tested samples need to be retested. In some cases, time may be a factor as well. It is possible that the lapse in time for 500 samples may exceed the analyte stability, invalidating any chance to retest. On the other hand, a laboratory that tests a QC material every 50 patient samples is in a much better position to correct any bad patient results. Once the cause for the systematic measurement error is found and corrected, the test is recalibrated. Quality control materials are retested. If the results are out of control, then the laboratory must sequester all test results and undertake root cause analysis. If the results are in control, then all patient samples that are believed to have been affected by the out of control condition are retested and reported. REFERENCE 1. Parvin C, Kuchipudi L, Yundt-Pacheco J: Should I repeat my 1:2s QC rejection? Clin Chem, 2012;58(5):925-929. W. Greg Cooper, CLS, CQA, MHA, is a licensed clinical lab scientist in the state of California. He is an ISO 15189 auditor and has a consulting business focused on activities that improve laboratory quality. 42 MLO - ONLINE.COM performed in a laboratory setting on automated clinical lab equipment with qualified personnel who possess skills in the reading and interpretation of quantitative results. QA, QC, calibration, and proficiency may be required as well. POC tests that are classified as nonwaived fall under this moderately complex category and, as stated above, calibration verification will be required. High complexity nonwaived systems differ from moderately complex tests, as high complexity tests (such as cytology, flow cytometry, PCR, gel electrophoresis, MRI, and CT scans) typically are not quantitative and as such may require substantial training and/or specialized knowledge in the preparation, process, and interpretation of results. Even though at this point POCT systems do not fall under the high complexity heading, understanding this distinction is important. That is because, if a site develops its own procedure or chooses to modify its waived (or moderately complex) protocol, the test automatically bumps up from waived to nonwaived high complexity status, and calibration verification, among other procedures, may be required in order to be fully compliant by state and federal regulations. Modification examples could include not following manufacturers’ directions or performing tests on sample types not specified in the manufacturers labeling. Moving forward, how do end users determine the complexity designation of their POCT system? The manufacturer’s user manual or package insert should state whether the test system is waived or nonwaived. If you still cannot locate the necessary information, you can go online, call the manufacturer directly, or utilize one or more of these FDA and CMS web-based resources: • www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfCLIA/search.cfm • www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfclia/testswaived.cfm • www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfclia/analyteswaived.cfm To sum up: “POCT” is simply an acronym that is used to describe the location where testing is to be performed, such as at bedside or near the site of patient care. The complexity designation of a POCT, waived or nonwaived, categorizes the test so that proper quality control and regulatory procedures can be dictated and followed per the designation. Calibration verification, though not required by CLIA on waived tests systems, is required on nonwaived tests and under special circumstances with waived tests, including manufacturer’s directive and if states, municipalities, or other regulatory and accreditation agencies require it. Linearity, as defined above, is not required by CLIA but is recommended and is considered Good Laboratory Practice. While it is true that the vast majority of POCT systems today are waived and thus typically do not require calibration verification, nonwaived designation of POCT is sure to increase as current and future healthcare requirements and advances in technology will allow for decreased instrument footprints, an increase in turnaround time and throughput, ease of use, expanded instrument quantitative data capabilities, and thus the requirement of calibration verification. Glenn Mitchell serves as a National Accounts Manager for AUDIT MicroControls. AUDIT supplies calibration verification and daily quality controls to the clinical laboratory market. AUGUST 2016 MLO201608-LabMgmt-COMBINED_MECH_LM.indd 42 7/12/2016 3:35:31 PM K-ASSAY ®. . . 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KAMIYA BIOMEDICAL COMPANY [email protected] | 800-KAMIYA-5 www.k-assay.com/MLO.php MLO201608_AD Kamiya.indd 43 7/8/2016 12:57:26 PM DRUGS OF A BUSE CLINICAL ISSUES Approaches to prescription opioid abuse testing Urgency drives new techniques By Jenny Cybulski T he epidemic of prescription opioid abuse has been worsening for decades in the United States, but it has broken through to the public consciousness only in the past year or so. People have been sensitized to the problem by the deaths of celebrities from the misuse of opioid painkillers—most recently, of course, the celebrated musician Prince. The misuse of these drugs has also been discussed in the current presidential campaign, and federal and state efforts to combat it have frequently been in the news. The public attention is overdue; according to the Centers for Disease Control and Prevention, more than 18,000 deaths related to opioid overdose occurred in 2014.1 To combat this abuse crisis, certain states have legally mandated that healthcare providers require tests for patients receiving pain management drugs in an attempt to detect opioid misuse. This is not only to protect the patients by screening for overuse, but also to detect opioid levels below the dosage level, which could indicate that patients are reselling their drug refills. Because of the advent of these physician monitoring programs, laboratories must be able to accurately detect low levels of these drugs, in order to ultimately determine whether patients with chronic pain are abusing prescription opioids. Screening options Laboratories have a diverse choice of sample matrices to screen for opioid levels, but they ultimately need to choose the option that will maximize workflow and keep costs low. Whole blood is a unique matrix because it enables the analysis of the drug compounds in parent rather than metabolized form. However, it requires an invasive collection technique and can be challenging to pretreat due to the complexity. Oral fluid is a sample matrix that has had a lot of research focus recently. Although easy to collect, the collection devices used in oral fluid analysis can introduce their own unique challenges due to the presence of surfactants.2 Urine is a dependable sample matrix that doesn’t require the lengthy pretreatment steps that are necessary with whole blood, or the use of a collection device, which is required with oral fluid. It does, however, require a hydrolysis step to calculate correct concentrations of drug compounds. Due to the accuracy and precision associated with urine analysis and the developed methods, it’s widely considered to be the preferred sample matrix choice. It is both simple and inexpensive to perform opioid drug testing on urine. Urine Sample DILUTE & SHOOT Dilute Sample (10x-30x) PPT & FILTER SPE Add 4:1 ACN or MeOH Develop Method BETA-GLUCURONIDASE REMOVAL PRODUCT Dilute Sample in 40% MeOH Vortex Condition & Equiliberate Spin Down (optional) Filter (protein prec. plates) or Centrifuge Load Transfer to Vial Load Sample Transfer Wash Collect Pass Through Blow Down & Reconstitute (~15-25 min) Elude Transfer to Vial Transfer to Vial Blow Down and Reconstitute LC/MS Analysis Figure 1. Comparative workflows continued on page 46 44 MLO - ONLINE.COM MLO201608-ClinIssues_MECH_AL.indd 44 AUGUST 2016 7/12/2016 3:13:53 PM Accurate Results Is your Opiate Assay specific enough for Hydrocodone? Also known as Vicodin or Lortab, hydrocodone is one of the most abused prescription drugs in the United States. Toxicology laboratories have been using opiate tests to detect hydrocodone in the past and have seen inadequate performance. Our newest addition to the drug testing menu, the Thermo Scientific™ DRI® Hydrocodone Assay, provides accurate results and is specific to hydrocodone and its major metabolites in human urine. This liquid, ready-to-use immunoassay has excellent precision. Applications are available on a range of clinical analyzers and provide fully automated qualitative and semi-quantitative results. Specific Detection of Hydrocodone • Contact us at 800-232-3342 or email at sales.diagnostics.fmt@thermofisher.com © 2015 Thermo Fisher Scientific. All rights reserved. CEDIA is a registered trademark of Roche Diagnostics. All other trademarks are the property of Thermo Fisher Scientific and its subsidiaries DRI Oxycodone for ;OLYTV:JPLU[PÄJ 0UKPRV(UHS`aLY MLO201608_AD ThermoScientific.indd 45 ;OLYTV:JPLU[PÄJ CEDIA® Heroin Metabolite (6-AM) Assay Opiate Assays for the Indiko Analyzer 7/8/2016 2:03:47 PM CLINICAL ISSUES DRUGS OF A BUSE continued from page 44 ELISA vs. LC/MS Laboratories running urine drug tests have traditionally used enzyme-linked immunosorbent assays (ELISA), but a case can be made that this testing approach is outdated and can be unreliable. For example, false negatives can alter the dependability of results, and the inability to accurately quantify drug concentrations leads to unreliable analysis.3 If ELISA tests are positive, the patient method as their sample preparation technique. They take the samples with residual ß-glucuronidase enzyme and “dilute” between 10 and 30 times the original volume. The diluted sample is then injected onto the LC column. However, the large dilution factor reduces the concentration of proteins/enzymes in the sample along with the concentration of analytes, which can result in poor sensitivity and can amplify any ion suppression that may be occurring in the analysis.2 Another deficiency of the “dilute-andshoot” method is that it compromises the LC column. One way to help alleviate the enzymatic buildup during a “dilute-and-shoot” procedure is to centrifuge the sample to pellet the enzyme and collect the supernatant, but this does not completely remove ßglucuronidase from the matrix (Figure 2). One new ß-glucuronidase removal method is a sample preparation technique that removes ß-glucuronidase after enzymatic hydrolysis. The sorbent eliminates the ß-glucuronidase from the sample but does not interact with opioid analytes. While the technique requires rougly the same amount of time as a “diluteand-shoot” procedure, about one minute, the sensitivity of the analytes is increased significantly. In one study, the sensitivity of THCCOOH was compared using the two preparaFigure 2. HPLC/UHPLC Column Lifetime: Beta-Glucuronidase removal product vs. Dilute-and-Shoot tion methods, and the new technique showed more than three times the sensitivity. samples still need to be run on a mass spectrometer (MS) to quanDue to the rapid demand for results, lab leaders have to evalutify the concentration of drugs present. The time it takes to run ate methods for drug testing and choose the most efficient techan ELISA is comparable to other tests, but this method requires niques to analyze samples. Sample matrices, types of analysis a more hands-on approach for laboratory technicians as well as modes, and sample preparation techniques need to be considered separate tests for each drug analyte. It has been argued that liquid when making this critical decision. Laboratories cannot afford any chromatography with mass spectrometry analysis (LC/MS) offers mistakes or lack of sensitivity when testing patients for opioid an efficient and easy way to separate and quantify a large class abuse. Inaccurate results could negatively affect the quality of life of opioid compounds. Many labs are moving toward testing with for patients using prescribed pain management drugs. Utilizing LC/MS first as advancements make it easier to run the tests and the most beneficial techniques for the laboratory helps to guarmethod development becomes simpler. They prefer chromatograantee that patients who are required to undergo drug testing for phy over ELISA for the testing of many opioid drug compounds their medications will not only get rapid answers but also accurate because they think that it meets their needs for increased accuracy, results as well. improved workflow efficiency, and reduced analysis time. REFERENCES The metabolism of drugs must be understood in order to ana1. National Vital Statistics System, Mortality File. Number and age-adjusted rates of lyze urine by LC/MS. Before drugs exit the body through urine drug-poisoning deaths involving opioid analgesics and heroin: United States, 2000– excretion, they are tagged with a glucuronic acid, which helps to 2014. Center of Disease and Control/ National Center for Health Statistics. 2015. http:// www.cdc.gov/nchs/data/health_policy/AADR_drug_poisoning_involving_OA_Heroin_ change the polarity of the drug compound and aids in the absorpUS_2000-2014.pdf. tion into the kidneys. Before chromatography analysis can occur, 2. Edinboro LE, Backer RC, Poklis A. Direct analysis of opiates in urine by liquid chrothe glucuronide must be cleaved through hydrolysis. This can matography-tandem mass spectrometry. Journal of Analytical Toxicology. 2005;29(7): be done in two ways: acid hydrolysis and enzymatic hydrolysis. 704-710. Some labs prefer enzymatic hydrolysis because it cleaves the bond 3. Allen K. Screening for drugs of abuse: which matrix, oral fluid or urine? Annals of without introducing harsh solvents into the sample or altering Clinical Biochemistry. 2011;48(6):531-541. peaks. 4. Lynch K, Wu A Yang, H. Development and validation of a novel LC-MS/MS opioid confirmation assay: evaluation of ß-glucuronidase enzymes and sample cleanup methIn enzymatic hydrolysis, ß-glucuronidase is introduced to ods. Journal of Analytical Toxicology. 2016;40:323–329. cleave the glucuronide bond on the drug metabolite, resulting in 5. Wang P, Stone JA, Chen KH, Gross SF, Haller CA, Wu AH. Incomplete recovery of free drug compounds.4.5 While this is effective, ß-glucuronidase prescription opioids in urine using enzymatic hydrolysis of glucuronide metabolites. can precipitate out in the LC column during the run, which can Journal of Analytical Toxicology. 2006;30(8):570-575. negatively affect the column’s selectivity and lifetime and can result in buildup in the MS. Analysts employ a variety of methods to prepare hydrolyzed urine samples for LC/MS analysis includJenny Cybulski graduated from Vanguard University with a BS in ing “dilute-and-shoot,” protein precipitation, and solid phase exbiology and a minor in chemistry. traction (SPE). The workflows associated with each technique are She now serves as a Product outlined in Figure 1, page 44. “Dilute-and-shoot” vs. ß-glucuronidase removal Most analysts in toxicology and clinical laboratories who utilize chromatography for urine analysis employ the “dilute-and-shoot” 46 MLO - ONLINE.COM MLO201608-ClinIssues_MECH_AL.indd 46 Communications Manager for Torrance, California-based Phenomenex, Inc. AUGUST 2016 7/12/2016 3:14:05 PM Syndromic Testing: The right test, the first time. Respiratory • Blood Culture ID • Gastrointestinal • Meningitis MLO201608_AD BioFire.indd 47 7/8/2016 12:52:13 PM A GUIDE T O MOL ECUL A R DI AGNOS T IC S Direct molecular diagnostics for sepsis By John Brunstein, PhD D espite great strides in medical practice over the last 150 years, sepsis (bloodstream infections coupled with an excessive inflammatory response) remains a very significant problem. In fact, it’s estimated that globally, sepsis is more common than heart attack and claims more lives than any one form of cancer. In the United States alone, severe sepsis has an estimated incidence of 300 per 100,000 population (.3 percent), with approximately half of these cases occurring outside of ICU settings and up to one-quarter of patients with severe sepsis dying as a result.1 In worst cases, the time of untreated disease progression from detection to fatality can be as little as a few hours. As if these statistics weren’t sobering enough, the incidence of sepsis even in developed countries is observed to be increasing.2 Clearly, this is a medical condition for which more effective diagnosis is needed with both rapid test speed (short turnaround time or TAT) and extreme sensitivity. (Sepsis doesn’t necessarily equate to high bloodstream pathogen titers; more than half of adults with sepsis have less than one cfu/ml of associated pathogen in peripheral blood.3) Finally, identification of the causative pathogen is essential in selecting appropriate antibiotic therapy as part of the treatment. These requirements make molecular diagnostics (MDx) an attractive approach to consider for sepsis diagnostics. The conventional non-MDx workflow for sepsis diagnosis is blood culture (BC) (with various approaches to number and types of BC bottles to collect, in an effort to not be misled by insignificant transient bacteremias or sampling contamination), followed by traditional microbiology workup (plate culture for identification and antibiotic susceptibility determination) on positive BCs. The major downside to this approach is that it can take several days to perform. There are three common approaches to applying MDx to this workflow in an effort to speed up the process: direct MDx on peripheral blood (pre-BC); MDx on samples from positive BC; and MDx on individual colonies on plate culture derived from a positive BC. Of these, direct MDx on peripheral blood sample offers by far the largest potential saving in critical time to diagnosis and will be our main focus. 48 MLO - ONLINE.COM MLO201608-Primer_MECH_AL.indd 48 MDx on peripheral blood At first glance, this might seem like a simple approach. Get a blood sample, extract nucleic acids, and run some sort of PCR, and you’re done, right? Unfortunately it’s not that easy; let’s consider what some of the technical challenges are. First, there’s the issue of low pathogen titer. Most nucleic acid extraction methods take input volumes of 1 ml raw sample or less (in fact, many work on 0.5 ml or less). Sampling statistics aren’t working in our favor here, either; if a specimen has 1 cfu/ml, we would actually need to sample almost 3 ml to achieve a 95 percent probability of getting that one colony. At 0.5 ml per sample, we’d need to take six samples to get this confidence level—and bear in mind that most adult sepsis cases don’t even reach 1 cfu/ml. The bottom line: sample size is an immediate hurdle to direct MDx sepsis diagnosis. Any method looking to do this will probably need to sample on the order of 10 ml of peripheral blood, and have some sort of selective enrichment process to collect the bacteria into a workable portion for nucleic acid extraction. Fortunately, this hurdle can be handled by a variety of methods, such as selective centrifugation or microfluidic sorting; if you look to do direct sepsis MDx, expect to have to do something like that. Once we have a nucleic acid extract from a suitably large peripheral blood sample, our second challenge is “What do we look for?” In terms of causative organisms, the majority of sepsis cases arise from a handful of organisms; however, it’s a very “long tail” distribution with very many organisms contributing small numbers of cases that we’d rather not overlook. If we restrict ourselves to looking for bacterial pathogens, there is at least one molecular target in common to all of them, the 16S ribosomal RNA (rRNA) gene. Genetic pressure has maintained enough conservation in this sequence to allow for the design of PCR primer sets which can be very nearly “pan-species,” so that a single PCR reaction can confirm or deny the presence of bacterial DNA in our extracted sample. This sounds at first to be a good approach; and indeed, several commercial systems take this approach to at least rule out sepsis when bacterial DNA is not detected. In the event that DNA is detected, however, a positive 16S rRNA result is not tremendously helpful; without knowing the organism species (singular or in some cases, plural), appropriate antibiotic therapy choices cannot be informed and we have limited benefit toward the initiation of suitable therapy. Ideally then, we also wish our MDx method to provide pathogen species identification. Our 16S rRNA gene can still be used for this, if we’re willing to sequence internal “hypervariable” regions inside the conserved flanking sequences and compare these sequences against known species 16S libraries. This approach is both accurate and broad spectrum, although it is neither fast nor readily amenable to high throughput and automation. Despite these limitations, this method has been in use in some clinical settings for some time now, and it can be a powerful tool in the early detection and appropriate classification of sepsis cause and treatment selection. Peripheral blood, multiplex methods Other methods approach this by employing multiplex methods. The reader will hopefully recall from earlier installments of “The Primer” that this is the simultaneous use of multiple target-specific (in this case, likely pathogen species) primer sets within a single PCR reaction, with some form of downstream analysis such as amplicon size, melt temperature, sequencespecific array capture, or distinctive fluorophore labelling used to identify which species-specific amplicon (or amplicons) are generated from the sample. Multiple commercial methods exist which employ variations on this approach, which generally has rapid TAT coupled with good sensitivity and specificity, at the cost of less than complete coverage of potential causal organisms. If such a method is inexpensive and provides answers in a sizeable proportion of cases, while the remaining cases continue to be analyzed by traditional microbiological methods, then it has clear benefits to the “average” patient even with these shortcomings. One powerful bit of information from the classical microbiological workflow in sepsis is the antibiotic resistance profile of the infecting organism. While empirical data on the likely antibiotic susceptibility of an identified organism in a AUGUST 2016 7/12/2016 9:06:52 AM A GUIDE T O MOL ECUL A R DI AGNOS T IC S particular geographic setting is a good start for selecting antibiotic therapy, changes in antibiotic resistance profiles of various pathogen species do occur, and, given the potential rapidity of disease progression, waiting to see if a first-choice antibiotic is working may not be in the patient’s best interest. By the time an outlier with unexpected resistance is recognized, it may be too late. Some MDx methods for sepsis determination attempt to address this by including detection of common antibiotic resistance markers such as MecA, VanA, or various penicillin binding proteins (PBPs). These approaches generally share three common weakness, however. • First, there are a large number of genetic variants of these resistance genes, making it essentially impossible to screen for all of them. Compounding this, they tend to have relatively quick genetic drift, meaning the common versions of one of these genes today may not be the common form in a year, leading to potential false negative results. Addressing this through constant surveillance and revision of the suitable target primer sets for PCR-based detection approaches is costly and cumbersome from an assay validation and regulatory perspective. • Second, even if a particular antibiotic resistance marker is detected by MDx approaches, that is not strictly equivalent to meeting clinical guidelines for antibiotic resistance, which includes dose response considerations (“breakpoints”). That is, an organism may have the resistance gene, yet express it poorly or at low levels, and thus not display the associated resistance as formally defined. • Third, most MDx methods utilized in the sepsis context don’t have a way to unequivocally associate a detected antibiotic resistance marker with the bacterial species if more than one species is present (in blood culture terms, a mixed infection). This last problem is perhaps best illustrated in the context of methicillin resistance associated with MecA; peripheral blood collected by venipuncture is sometimes contaminated with coagulase-negative Staphylococcus such as S. epidermidis, which in turn frequently carries the MecA gene. If a sample is detected by MDX as positive for S. epidermidis, S. aureus, and MecA, does the patient have a MRSA infection—or an easily treatable non-MRSA, with contamination? albeit at a cost of lost TAT improvements. Sampling of blood culture bottles either before or after they have detected positive for bacterial growth by conventional methods allows us to avoid the low target titer problem; rather than < 1 cfu/ml of the original sample, a positive inoculated BC bottle will have large pathogen titers suitable for reliable collection and detection in more manageable sample sizes (0.5 ml or less). Application of MDx at this stage can still save 24 to 48 hours needed for traditional plating and colony growth, enumeration, and antibiotic susceptibility testing. As such, this is a viable compromise solution, and several commercial systems take this approach. Finally, if molecular detection of specific antibiotic resistance markers is an acceptable surrogate of phenotypic antibiotic resistance determination, but there’s a desire to be able to definitively assign detected markers to a specific species in a potentially mixed sample, then MDx may be applied subsequent to a positive BC being plated. Selection of individual colonies from such a plate ensures that any detected resistance markers are associated with the identified colony species, and may be done with exceptionally rapid and crude nucleic acid extraction techniques (such as heat lysis without further purification) followed by rapid PCR methods, which can thus still save a day or more compared to allowing colony growth in presence of antibiotic test materials required for accurate determination of phenotypic breakpoints. (Note this is also the point THE PRIMER in the traditional workflow where mass spectrometry is most commonly applied, as it can provide extremely rapid, accurate, and inexpensive species identification minutes from isolated colony to identification, although currently lacking antibiotic susceptibility data.) Molecular diagnostics offers hope for improved treatment of a common and serious condition; however, this hope is not without complexities in actual realization. Multiple MDx approaches to sepsis diagnosis are available in various markets, and it is hoped that the above consideration of the challenges each of these approaches in general face and the compromises they make in providing a solution will help to guide selection of the method(s) most appropriate to the reader’s setting. REFERENCES 1. Mayr FB, Yende S, Angus DC. Epidemiology of severe sepsis. Virulence 2014;5(1):4–11. 2. Martin GS. Sepsis, severe sepsis and septic shock: changes in incidence, pathogens and outcomes. Expert Review of Anti-infective Therapy. 2012;10(6):701–706. 3. Towns ML, Jarvis WR, Hsueh PR. Guidelines on blood cultures. J Microbiol Immunol Infect. 2010;43(4):347-349. John Brunstein, PhD, is a member of the MLO Editorial Advisory Board. He serves as President and Chief Science Officer for British Columbia-based PathoID, Inc., which provides consulting for development and validation of molecular assays. MDx further “down the path” As opposed to doing MDX direct from peripheral blood for sepsis, application of MDx further down the diagnostic path helps to resolve some of these issues, AUGUST 2016 MLO201608-Primer_MECH_AL.indd 49 MLO - ONLINE.COM 49 7/12/2016 9:07:06 AM FUTURE BUZZ NE X T GENE R AT ION SEQ UENCING The technology and clinical applications of hybrid capture NGS By John Havens, PhD C linicians are challenged with identifying variants of disease and determining appropriate treatment plans on a daily basis. The more relevant the information they have at their fingertips, the more likely a successful patient outcome. Nucleic acid testing (NAT) is a common method of detecting the presence of specific disease-associated bacteria and viruses, such as HIV, and is used in routine blood screening. Though it is inexpensive and reliable, NAT cannot always provide clinicians with all the information they need, however, which is where a more detailed analysis of samples becomes necessary. Whole genome next generation sequencing (NGS) can provide a wealth of information to direct treatment. However, it has been a costly option for clinicians, particularly for large numbers of samples. A more cost-effective option is targeted NGS, in which genomic regions of interest are enriched prior to sequencing. Targeted NGS focuses resources on acquiring relevant data and enables multiplexing, so many patient samples can be analyzed simultaneously. As such, certain applications can benefit from targeted NGS, from analyzing mutations in cancer to viral integration sites and variants. While targeted NGS can be performed cheaply via polymerase chain reaction (PCR), processing the numbers of samples common in many clinical research facilities at the required level of quality and consistency is more suited to the approach of hybrid capture. This technology uses labelled DNA probes complementary to the target region for enrichment from fragmented genomic samples. Obtaining high efficiency and accuracy, as well as minimizing cost, requires careful consideration of probe design. Optimized oligo design Quality control Oligonucleotides used for hybrid capture NGS can be designed based on a variety of technologies. One such technology, which is seeing increased use in clinical diagnostics, utilizes biotin-streptavidin interaction for enrichment. 5’ biotinylated probes are designed to hybridize to the target DNA, and isolated using streptavidin beads (Figure 1). Instead of many shorter overlapping probes, this variation of the technology uses longer 120 bp probes designed for end-to-end tiling across the target region. This maintains a high capture efficiency while reducing the number of overall probes required, saving cost. In addition, this length of probe can tolerate several mismatches and still pull down the targets, affording the detection of novel variants. The challenge with longer oligos, however, is that the coupling efficiency of each additional base affects the final yield of the full-length oligo. While obtaining a 99.6 percent efficiency results in 62 percent of products being full-length for 120-mers, losing just one percent efficiency reduces full-length yield to as little as 15 percent. Highly efficient synthesis in this variation of hybrid capture is coupled with biotinylation only of full-length product, thereby ensuring only the complete oligos are enriched, improving sequencing reliability. This method of hybrid capture also employs blocking oligos for library adaptors to maximize targeting efficiency. These blocking oligos are especially important in reducing costs via multiplexing, as libraries carry unique barcodes to associate each read with the appropriate sample, which must be obscured during pull-down. Targeting may be improved by 60 percent through this method, resulting in lower cost and the generation of highly-focused clinically relevant data. High data quality, especially when searching for specific variants of a target, is essential in targeted sequencing panels. Commercially synthesized hybrid capture oligos, such as the type described here, are produced individually, allowing more stringent and individualized QC. Specifically, electrospray ionization mass spectroscopy (ESI-MS) is used to confirm the absence of truncated species. Those samples found with truncated species can undergo re-synthesis and be QC’d again, saving waste. Interestingly, looking in more detail at quality-control data highlights the stochastic nature of synthesis failures (Figure 2, pg. 53). When analyzing an exome research panel of approximately 430,000 probes covering 39Mb, for every re-synthesis round, the number of failures decreased exponentially. This indicates that failure is random, rather than being sequence-specific, and as such, a re-synthesis approach could be applied to all oligos. This provides clinicians some assurance that their diagnostics results can be consistent regardless of target. These data suggest that when oligos undergo only a single synthesis, as is the case with array-synthesis platforms, the probe population will have varying levels of truncation. This could lead to insufficient reproducibility of enrichment and therefore inconsistent NGS results. By synthesizing, quality controlling, and normalizing every probe individually, the amount of each probe in the final pool can be determined. This benefits clinical applications through identical performance across batches. Moreover, commercial probe panels are available that conform to FDA 21 CFR Part 820 certification for medical devices (GMP), Figure 1. Biotin-based oligo design for hybrid capture NGS. This hybrid capture probe utilizes a 120 bp biotin-labelled oligo for isolation using streptavidin magnetic beads. Cot-1 DNA blocks for repetitive regions, and blocking oligos block library adaptors, increasing targeting. End-to-end tiling, coupled with individual probe synthesis and QC, provides more even coverage than overlapping designs. continued on page 53 50 MLO - ONLINE.COM AUGUST 2016 MLO201608-FutureBuzz-COMBINED_MECH_AL.indd 50 7/12/2016 3:00:49 PM There’s a lot to get excited about with OsmoPRO™, the newest multi-sample osmometer from Advanced Instruments. With OsmoPro, you can deliver the most accurate test results, streamline your workflow and do it all with the greatest of ease. Go with the PRO… OsmoPRO. Intuitive touch screen operation Integrated 2D barcode scanner 20-sample capacity Small 20μL sample volume Convenient LIS interface and data management capabilities Learn more about the latest innovations in multi-sample osmometry. Visit aicompanies.com/OsmoPRO | +1 781.320.9000 MLO201608_AD AdvancedInstruments.indd 51 7/8/2016 12:47:48 PM FUTURE BUZZ NE X T GENE R AT ION SEQ UENCING The transformation of pathogen diagnostics through next generation sequencing By Crystal Icenhour, PhD C linical laboratories have multiple methods for diagnosing infectious disease, but the fact remains that despite culture, microscopy, antibodybased testing, and molecular testing such as PCR, up to 75 percent of infections are not diagnosed in a timely manner, if at all.1,2 One of the biggest issues is that a target is needed to know which test(s) can lead to an accurate diagnosis; the laboratorian must know what pathogen is suspected. And since many pathogens exhibit common symptoms, it is often difficult to determine an appropriate target. The diagnostic challenges have resulted in a reliance on differential diagnosis and can result in spread of infectious diseases, longer hospital stays, more critical illnesses, longer recoveries, and compromised outcomes related to delayed or ineffective treatment. In addition, partly due to ineffective diagnostics, antibiotics are significantly overused in the United States. Such misuse of antibiotics is creating drug-resistant pathogens. According to the Centers for Disease Control and Prevention (CDC), “Each year in the United States, at least two million people become infected with bacteria that are resistant to antibiotics, and at least 23,000 people die each year as a direct result of these infections.”3 In the midst of these concerns is the reality that infectious disease outbreaks are no longer “local.” As large populations travel internationally, local authorities are often under-resourced in coping with identified outbreaks, and inadequate diagnostics and treatments leave us all more vulnerable. News headlines alert us to the Lyme disease season and to the risk of the Zika virus, while not so long ago people in Africa were dying by the thousands from Ebola. The confluence of all these factors makes it more important than ever to develop accurate and timely diagnostics for infectious diseases. 19,000 known pathogen genomes. Now a significant advancement in NGS is capable of yielding the most accurate and comprehensive pathogen diagnoses of any method available. In theory, it is possible to diagnose all possible pathogens utilizing the power of NGS. From a single sample, it is possible to simultaneously screen any clinical sample for all pathogens (whether bacteria, virus, fungus or parasite). The sample can be tissue, blood, swab, stool, or any sample that contains the pathogen being sought. This method not only can identify known pathogens, but is also capable of revealing the presence of unknown pathogens. In this new application of NGS, unbiased genetic sequencing provides a “genetic blueprint” from all detectable microorganisms in the sample. Sophisticated bioinformatics can make sense of the raw data by matching it against all sequenced pathogen genomes to identify the pathogens present in the sample. This system can detect the presence of multiple pathogens. Other applications of NGS include pathogen surveillance (such as in animal populations, water supplies, or food processing) and can discover previously unrecognized or never-before seen pathogens. Since all genetic information from the sample is sequenced, it is not necessary to know which microbes are suspected; a target is not necessary. Moreover, whole genome/ whole transcriptome sequencing methods can provide higher sensitivity and specificity than other diagnostic technologies in use today. NGS also has the ability to identify drug-resistance genes in identified pathogens, study the interaction between host and pathogens, and characterize the host’s immune response through gene regulation exploration. NGS: consider the possibilities Many experts see sequencing as the future for clinical laboratory diagnostics, but while this breakthrough technology holds exciting potential, there are some important cautions to consider before adopting NGS for pathogen diagnosis. Current challenges for broad implemen- Next generation sequencing (NGS) has been effectively implemented in the diagnosis of cancers and genetic disorders, including neonatal testing, but it is much easier to evaluate the human genome alone as opposed to more than 52 MLO - ONLINE.COM NGS: be aware of the challenges tation of NGS for pathogens include turnaround time (TAT) and costs—not inconsiderable real-world obstacles. The outlook is improving considerably, however. The cost for sequencing a single human genome has dropped from ~$14 million in 2006 to ~$1,500 in 2016 (it should be noted that the fabled “$1000 Genome” requires substantial instrumentation and human capital, which is not attainable by most clinical laboratories). And, while TAT is currently slowed by the time required for sample preparation and sequencing, advanced protocols for sample preparation are being introduced that can reduce it, as well as the cost of sequencing. One example of such improvements is the use of barcoding to allow multiplexing of up to 96 samples in a single sequencing run. An additional challenge is in collecting samples that include the pathogen being sought. Sample collection and stabilization is crucial for identification of pathogens; the pathogen can only be identified if it is present in the sample. Samples must be extracted and processed with robust protocols that should be conducted under appropriate quality guidelines. Further, when conducting whole genome sequencing from humanderived samples (particularly tissue and blood), it can be challenging to obtain adequate pathogen DNA/RNA due to the overabundance of host genetic material. Host cell depletion methods can be utilized, but concentrations of the remaining pathogens are often small, and it is challenging to obtain adequate sensitivity levels. Because it is crucial to obtain adequate sequencing coverage of the pathogens to ensure the best sensitivity and specificity, molecular biologists trained in NGS should be consulted with respect to sample collection, sample extraction, library preparation methods, and sequencing parameters. Another issue: while clinical laboratories are often comfortable with the wet lab techniques of extraction, library prep, and/or whole genome sequencing, it is just as important to recognize the critical role of data analysis of the complex data sets generated by NGS. Data analysis for pathogen detection AUGUST 2016 MLO201608-FutureBuzz-COMBINED_MECH_AL.indd 52 7/12/2016 3:00:58 PM Hybrid continued from page 50 is a highly complex process, as dozens or even hundreds of microorganisms must be analyzed in a single test. Further, pathogenic versus non-pathogenic determinations must be made, as all clinical samples will contain many nonpathogenic microorganisms. A few data analysis tools for pathogen detection have become available, but they have not yet been validated for clinical use. Further challenges for pathogen NGS data analysis involve the generation, safety, storage, transport, computation, and archiving of these massive data files (up to 2 terabytes). Looking ahead While these challenges may seem intimidating, engaging strong strategic partners with expertise in NGS and complex data analysis can make adoption of NGS pathogen diagnostics achievable today. The best strategic partners will be able to provide recommendations for sample collection, extraction, and preparation, as well as be able to handle the complex data analysis phase of pathogen identification. Balancing the complexities, along with engaging experts, will facilitate a complete transformation of pathogen diagnostics through NGS. Today is an exciting time for clinical laboratories as this important technology is being embraced. Imagine a world where a single clinical sample is able to yield all of the data needed for pathogen identification, pathogen drug response, and host-pathogen immune response …this world is quickly approaching! REFERENCES 1. Lyme Disease Association, Inc. National Institutes of Health study on Lyme disease reveals significant chronic symptoms and common misdiagnosis. 2005. http://www.lymediseaseassociation.org/index.php/ lda-press-releases/326-national-institutes-of-healthstudy-on-lyme-disease-reveals-significant-chronicsymptoms-and-common-misdiagnosis. 2. Tomas MY, Getman D, Donskey CJ, Hecker MT. Over-diagnosis of urinary tract infection and under-diagnosis of sexually transmitted infection in adult women presenting to an emergency department. J Clin Microbiol. 2015. http://jcm.asm.org/content/early/2015/06/05/ JCM.00670-15.abstract. 3. Centers for Disease Control and Prevention. Antibiotic resistance threats in the United States, 2013. Executive summary. www.cdc.gov/drugresistance/pdf/ Crystal Icenhour, PhD, is the founding Chief Executive Officer of Aperiomics, a Northern Virginia company currently offering the Absolute*NGSSM Pathogen Detection suite of products. further ensuring quality for clinical applications. For studies with large numbers of samples, this approach becomes highly cost-effective, especially as it allows a modular approach to probe panel design, with individual targets mixed to adapt the study for new regions of interest. Targeted NGS in cancer provide insight into patterns in HPV integration and its role in cancer. In addition to oncogenic viruses, infectious agents such as Ebola and Zika virus can be traced with targeted NGS. The ability of hybrid capture probes to tolerate several mismatches enables novel variants of rapidly mutating viruses to be detected. Different isolates can then be tracked to different geographic regions, potentially allowing the source of the outbreak to be identified. Acute myeloid leukemia (AML) is characterized by faulty differentiation of heIntegrating NGS into the clinic matopoietic stem cells, deriving from By bringing the cost of sequencing down, mutations arising at cell division. In one targeted NGS using hybrid capture probes case, on analysis of cells taken from bone can complement NAT strategies when marrow, a patient presented with four difmore detailed information is needed. ferent subclones of AML cells with varyTargeted NGS presents the latest ining prevalence, as analyzed by targeted novation in sequencing technology, with NGS. Following chemotherapy, none of cutting-edge probe and assay designs the cancerous clones could be detected that reduce costs and improve reliability. by standard blood analysis, although targeted NGS detected the clonal evolution of leukemic cells. The patient eventually relapsed as a result of the least prevalent subclone at diagnosis, which developed an additional mutation, proliferating in the absence of the others. NGS analysis allowed detection of this evolved clone before it was seen Figure 2. Oligo synthesis failures are stochastic, not sequence-specific. by standard blood The re-synthesis approach ensures a consistent probe population and characterization. therefore uniform NGS results. This example inBringing the benefits of these new techdicates how improved sequencing could nologies into the clinic requires an interincrease the chances of detecting rare canface between clinicians and genomics excerous clones. In clinical diagnostics, inperts. As these technologies proliferate, in creasing sequencing depth to 500x would addition to growing in-house expertise, bring the level of sensitivity required to it is now becoming a popular option to detect clones down to five percent prevalook toward external partnerships for a lence. Such a level of sequencing depth is complete solution, from bioinformatics to only feasible through targeted NGS, and customized NGS panels. in these types of cases helps clinicians identify clues pointing to patient relapse. REFERENCE Interestingly, it has also been indicated 1. Klco JM et al. Association between mutation clearthat diminishing the level of cancerous ance after induction therapy and outcomes in acute myclones by chemotherapy to a level below eloid leukemia. JAMA. 2015;314(8): 811-822. five percent correlates with improved pa1 * Figure 1 - Oligo refers to xGen Blocking Oligo and tient outcome, and this can be directly Probe refers to xGen Lockdown Probe, both from IDT. tracked with sensitive NGS. Viral research John Havens, PhD, serves as Vice President of Business Development at Coralville, Iowa-based Integrated DNA Technologies. Targeted NGS also has utility in virology. For example, genomic integration of the human papillomavirus (HPV) can cause several cancers. Hybridization probes designed against the 8Kb HPV genome provide detection of the integration site. Sequencing the flanking regions can also AUGUST 2016 MLO201608-FutureBuzz-COMBINED_MECH_AL.indd 53 MLO - ONLINE.COM 53 7/12/2016 3:01:07 PM MANAGEMENT MATTERS Continuous quality management in the laboratory By Nancy Alers, MS, MT(ASCP)CM I t is estimated that about 60 percent to 70 percent of clinical decisions are made based on laboratory results.1 Laboratory quality, therefore, plays a vital role in the delivery of quality patient care. But quality can mean different things to different labs and different supervisors. This article will briefly explore the concept of laboratory quality and how a closely monitored quality assurance plan can help ensure efficient laboratory operations. Quality can be an intangible, hard-to-measure concept, and it has been defined in multiple ways by different entities over the years: from a product that is free of deficiencies (ASQ); to a product whose inherent characteristics fulfill requirements (ISO 9000); to a system that gets the right care to the right patient, at the right time (HHS.gov). One recent consensus, from the Organization for Economic Cooperation and Development, stresses “that quality involves safety, effectiveness, appropriateness, responsiveness, or patient centered care, equity or access and efficiency.”2 In laboratory medicine, quality is often interpreted as adherence to regulatory standards3 or compliance with CLIA regulations. Where one might take issue with such formulations is that they seem to imply that without requirements, there would be no need for quality. In fact, there are situations in the laboratory for which there is no set regulatory standard; situations that may warrant careful evaluation and consideration from laboratory management. CLIA regulations apply to all laboratories the same,4 providing a roadmap to ensure laboratories can meet minimum quality standards. But not all laboratories are created equal, and therefore quality is much more than laboratory compliance. The World Health Organization (WHO) defines quality in laboratory medicine as the ability to produce accurate, reliable, and timely results. WHO also stresses that it is important for a laboratory to have a good laboratory quality management system (QMS) in order to achieve this goal.5 Quality management system Laboratory continuous quality monitoring is not a novel idea. Section 493.1200 (b) of the CLIA regulations states, “each laboratory’s quality system must include an assessment component that ensures continuous improvement of the laboratory’s performance and services through ongoing monitoring that identifies, evaluates and resolves problems (USDHHS, 2003).6 So what is new about laboratory quality? The Patient Protection and Affordable Care Act of 2010 has changed the laboratory landscape, and as a result quality has become more relevant than ever. The new impetus is for laboratories to think about value instead of volume, which translates into a need to have leaner processes, work more efficiently, eliminate redundant testing, and work cooperatively with the rest of the clinical patient management team.7 A QMS is an overarching system of specific policies and procedures to address all the activities within a laboratory. A QMS goes beyond Quality Control (QC) and Quality Assurance (QA), and it entails looking at the laboratory as an all-inclusive system, ensuring there are guidelines for addressing activities in all areas. A comprehensive QMS can help a laboratory ensure that all activities are monitored and evaluated, and results are accurate and reliable. There are different QMS models out there that can be used. Whichever is selected, it is essential that the QMS addresses all activities in the path of workflow from the pre-analytic to the 54 MLO - ONLINE.COM MLO201608-MgmtMatters_MECH_AL.indd 54 post-analytic testing phase. To ensure the quality of the overall system, lab leaders need to ensure the quality of the activities in the different testing phases. Quality assurance reviews A good QMS will require ongoing assessments as part of the QA plan. A QA plan is the backbone of the laboratory QMS.3 Quality assurance reviews should be tailored to the unique needs of the laboratory. Factors such as staff competency, test complexity, population served, documentation practice tendencies, test volume, etc., should be taken into consideration when determining the focus and frequency of reviews. Data obtained from QA reviews should be evaluated carefully by the laboratory director or manager, and opportunities for improvement should be realized. Data evaluation will reveal the risks or tendencies specific to your system, which can lead to errors. Once risks are identified, efforts should be guided toward corrective and preventive measures. Error detection, correction, and prevention are the ultimate goals of a well-structured QA plan. A culture of quality Promoting a culture of quality should not only be done during the inspection window; it should be an everyday effort. In addition to having competent staff, ensuring all standard operating procedures are up to date and followed, and monitoring processes everyday through quality control practices, the laboratory must have a good QA plan. A QA plan will look at all the activities performed on the path of workflow from the pre- to post-analytic phase and determine if there are opportunities for improvement. Laboratories must remember that quality is a lot more than regulatory compliance, and it includes having competent staff, streamlined processes, good communication, and constant evaluation. REFERENCES 1. The Lewin Group. The value of laboratory screening and diagnostic tests for prevention and health care improvement. http://www.chi.org/uploadedFiles/Industry_ at_a_glance/Lewin%20Report%20on%20Dx%20Tests%20(2009).pdf. 2. Anderson G, Hussey PS. Comparing health system performance in OECD countries. Organization for Economic Cooperation and Development. Health Aff (Milwood). 2001;20: 219-232 doi: 10.1377. 3. Dai SY. What defines a laboratory Quality System? www.foodsafetymagazine.com/ magazinearchive1/octobernovember-2013/what-defines-a-laboratory-quality-system 4. Harmening, D. Laboratory Management Principles and Processes. 2nd edition. Philadelphia, PA. FA Davis; 2007. 5. World Health Organization. Laboratory Quality Management System Handbook. http://apps.who.int/iris/bitstream/10665/44665/1/9789241548274_eng.pdf Published: 2011. Accessed: March 1, 2016. 6. Clinical Laboratory Improvement Amendments of 1988:42 CFR [K(1)-493.1200 (b)]. 7. Miles J, Weiss RL. The role of laboratory medicine in Accountable Care Organizations. https://www.aruplab.com/files/resources/suite/ACO%20Lab%20Strategy_whitepaper.pdf. Nancy I. Alers, MS, MT(ASCP)CM, serves as a Laboratory Manager at Fort Washington Medical Center in Fort Washington, MD. AUGUST 2016 7/12/2016 9:09:16 AM These are no ordinary caps Coming Soon! SampLok® Universal Adapter Cap Unique, self-adjusting design facilitates efficient bottle and vacuum tube collection procedures New & Enhanced! SampLok® Adapter Cap 2 Next-generation cap for easy and safe bottle and vacuum tube sample collection 1.888.411.2851 | [email protected] | itlbiomedical.com/adaptercaps SampLok® is a registered trademark of ITL Corporation, Melbourne, Australia. Copyright © 2016 ITL Corporation. All rights reserved. Sample transfer made safe Needleless Transfer of Samples from Positive Blood-Culture Bottles • Integrated safety for subculture procedure • Safe, simple transfer from culture bottles • Limits exposure to gas and culture discharge v)OH[LEOHoWZLWKDZLGHYDULHW\ of culture bottles For more information, contact ITL BioMedical today. 1.888.411.2851 [email protected] itlbiomedical.com/scu SampLok® is a registered trademark of ITL Corporation, Melbourne, Australia. Copyright © 2016 ITL Corporation. All rights reserved. MLO201608_AD ITL.indd 55 7/8/2016 12:56:56 PM WASHINGTON REPORT Precision medicine and the cancer “moonshot” What will be the impact of these initiatives on laboratory medicine? By Larry Altshuler, MD I n his State of the Union address delivered in January 2015, President Obama announced the launch of his administration’s Precision Medicine Initiative. In his 2016 Address, the president challenged medical science to commit to a “Moonshot” to find a cure for cancer. Both initiatives are extremely worthwhile, and it is invaluable for medical science to have the “bully pulpit” of the presidency behind critical research. Of course, implementing the programs will be difficult, and the impact they will have on the healthcare system will be significant. Also, the two initiatives are best understood as overlapping to some degree; cancer, after all, is one of the diseases/disorders that is most amenable to a precision medicine approach. Precision medicine and cancer Precision medicine is often defined as the process of finding a specific treatment based on the individual characteristics of each individual patient. In actuality, it is not meant to treat each person uniquely, but to find subgroups of people with the same genetic characteristics for which unique treatments are applicable. Cancer is the one disease for which precision medicine is already being applied. “Targeted” drugs have been developed based on genetic variations and mutations found in particular tumors. The president’s initiative wants to apply precision medicine to other diseases as well, including Alzheimer’s disease, obesity, diabetes, and mental illness. In fact, genetic testing is currently available for 2,000 medical conditions, although most of these will not be included in the initiatives, at least for now. So, what can we expect with the conditions that will be involved? Although there have been successes with cancer, there have also been many failures. Part of the reason is that precision medicine is more than just genetics; it also involves epigenetics, which relates to lifestyle and environmental factors that modify the expression of the genes. So it is not as simple as identifying dysfunctional genes and finding a treatment to block or modify them. With specific cancers, we may only be dealing with a 56 MLO - ONLINE.COM MLO201608-WashRep_MECH_AL.indd 56 few genes and a few epigenetic factors; other diseases may involve dozens of genes and epigenetic factors, and thus the process may be much more complex. The “Moonshot” metaphor hearkens back to President Kennedy’s 1961 challenge to the Space Program to put an American on the moon by the end of the 1960s. (The goal was met with Apollo 11 in July 1969.) As such, it is a powerful call to action. President Obama did not set a timetable to “cure” cancer, and doing so would in fact be unrealistic. This is because there are more than 100 different types of cancer, and even more subtypes of those cancers. Cancers also are very “devious”; for example, some have developed methods of preventing detection from the immune system as well and mutating to become resistant to various treatments. The failures of precision medicine in the cancer arena, and the fact that successes have been relatively few for only a handful of cancer subtypes, demonstrate the difficulties. In fact, most cancer experts doubt that cancer will ever be eliminated totally. It is also important to realize that both initiatives will require enormous amounts of money, research, and extensive collaboration among all medical providers. They may also change the way medicine is practiced and taught and how healthcare is provided to each person and reimbursed to each medical provider. They will also require a significant change in the way research is conducted and applied. The role of laboratory medicine The two initiatives will also profoundly affect laboratory medicine, as labs will play a significant role. Labs will be at the forefront of both initiatives and may reap financial benefits from their involvement. After all, both initiatives are fundamentally based on testing. First, they will involve genetic testing, which has become less expensive year by year, and in the near future may be feasibly accomplished by virtually any clinical lab. Such testing is not used only to determine individual characteristics of the patient, but also of a tumor or the tissues involved in other diseases. In addition, the effect of epigenetic variables will also have to be tested. This will involve not only newly developed lab tests, but also the correlation of present lab tests that reflect epigenetic factors. Even basic chemistries and tissue testing may eventually impact whether or not a specific treatment can be applied successfully. In addition, for the “Moonshot,” additional research will attempt to find elements in the body’s tissues (including blood) that can detect cancer before it is discovered by other means. Both initiatives will also require tests from body tissues and tumor tissues that will determine whether a specific treatment will or will not be effective. A present example is the K-ras determination for metastatic colon cancer; studies show that patients whose tumors express the mutated version of the KRAS gene will not respond to two specific chemotherapy agents. On the other hand, if a breast or esophageal cancer has a mutation in the Her2Neu gene, there are two chemotherapies that can “target” and slow or destroy the growth of the cancer. A great effort will be made to find similar gene mutations and correlate them to various treatments; this applies not just to cancer but to other chronic diseases as well. In sum, these two initiatives will significantly impact the way medicine is practiced. They both hold promise to stimulate new discoveries, but such discoveries most likely will be incremental. The process will also take a long time; we should think in terms of decades, not years. We should also realize that they are enormous undertakings and will require substantial resources, which may wax and wane depending on the progress observed and the priorities of political leadership. And, certainly, laboratory medicine will be integrally involved. Larry Altshuler, MD, is the author of DOCTOR, SAY WHAT? The Inside Scoop to Getting the Best Health Care and DOCTOR, SAY WHAT? The Guides: What Works and What Doesn’t for Over 90 Medical Conditions. He is a practicing internist, hospitalist, and integrative practitioner at a major cancer center in the Midwest. AUGUST 2016 7/12/2016 9:16:36 AM SCC Soft Computer www.softcomputer.com An authorized IBM Business Partner for 24 years, SCC Soft Computer offers systems that run on the IBM Power Systems – Power Architecture-based server line. SCC Soft Computer’s robust laboratory and genetics information system software solutions are powered by IBM’s AIX Power Series Platform. SCC’s laboratory and genetics information management systems: Personalized Solutions for Personalized Medicine The understanding of disease as a multifaceted entity—combined with the correlation of test results— has resulted in more accurate disease identification, prognosis, and treatment. This, in turn, has led to the concept of personalized medicine, where understanding a given patient’s unique disease presentation on all levels enables a physician to select the most effective treatment for that patient. Genetic research and testing can produce large amounts of data that must be analyzed, stored, and correlated— not only with drug reactions, but also with numerous patient characteristics. Attempting to accomplish this using manual methods or basic electronic applications is neither cost-effective nor efficient. Customizable and robust software must be employed to support the analysis, storage, and correlation efforts, and to establish the large number of possible test protocols. Likewise, this software should be capable of providing physicians and testing labs online availability of the most current test interpretations and recommendations, which is crucial for the successful practice of personalized medicine. At SCC Soft Computer, we’re building a foundation for personalized medicine with SCC’s Genetics Information Systems Suite®, which provides a full range of genetics information management tools designed to automate workflow. This suite can be integrated with hospital information systems and offers a selection of highly configurable modules that allow for predefined or unique, user-defined protocols. SCC’s integrated laboratory and genetics software solutions assist healthcare providers in personalizing patient disease treatments based on each individual’s unique history and genetic composition, as derived from laboratory and clinical data. Clinical evidence can be corroborated with genetic profiles, giving doctors faster turnaround times in patient treatment. With test results and genetically derived information from manual and automated sources at your fingertips, SCC’s powerful integrated information management solutions can help narrow the gap between diseases and cures. To learn more, visit us at www.softcomputer.com. To schedule a demonstration with one of our experts, please contact Ellie Vahman at [email protected]. Visit SCC Soft Computer at AACC 2016 Booth 1349 | August 2 – 4 | Philadelphia, Pennsylvania Visit SCC Soft Computer at CAP 2016 September 26 – 28 | Las Vegas, Nevada SCC’s Genetics Information Systems Suite®: ® SoftCytogenetics t4PGU.PMFDVMBS t4PGU'MPX$ZUPNFUSZ®t4PGU1BUI%Y®t4PGU)-"®t4PGU#JPDIFNJTUSZ®t4PGU(FOF1PSUBM™ MLO201608_AD SCC.indd 57 ® 7/8/2016 2:01:29 PM PRODUCT FOCUS AU T OM AT ION Laboratory automation solution Combined with state-of-the-art analyzers and intelligent informatics, Power Express provides a total laboratory automation solution that maximizes uptime, minimizes errors, and allows laboratories to achieve optimal workflow without the work. Labs can achieve both operational and clinical improvements with 1) LEAN automation that eliminates bottlenecks for consistent workflow, improves FTE utilization, and expedites delivery of results; 2) consolidated multidisciplinary workflow that employs single point of entry for all core laboratory disciplines; 3) scalable automation that provides freedom to grow menu and capacity; and 4) fast and reliable results that consistently deliver TAT <30 minutes, helping to increase physician satisfaction and speed to treatment. Beckman Coulter, www.rsleads.com/608ml-151 Automated immunohematology system The TANGO infinity automated immunohematology system maximizes workflow efficiency with minimal pre- and post-analytic operator steps. The instrument offers confidence in result accuracy by monitoring critical processes including verification of all liquid pipetting for every sample, reagent, and assay. Its intuitive software is easy to learn and use, even for intermittent operators. The proven Erytype S and Solidscreen II reagent lines minimize false positive results yet provide the appropriate sensitivity to detect clinically significant antibodies and weak antigen types. The lean and secure TANGO infinity allows generalists to confidently perform testing, freeing valuable immunohematology experts to perform complex serological tasks. Bio-Rad, www.rsleads.com/608ml-152 Simultaneous detection and identification of multiple analytes The BioPlex 2200 System combines proprietary random access multiplex testing with innovative software and QC features to maximize workflow and ensure results accuracy. The fully automated BioPlex 2200 eliminates batch testing and provides reproducible results with fast turnaround times. This system supports a variety of autoimmune, infectious disease, and specialty assays, such as the fifth-generation HIV Ag-Ab Assay. BioPlex immunoassays use magnetic beads infused with fluorescent dyes and coated with antigen and antibody ligands, allowing simultaneous detection and identification of multiple analytes from a single sample. BioPlex 2200 can process a minimum of 150 individual bead results for each assay. Bio-Rad, www.rsleads.com/608ml-153 HIV 1/2 Supplemental Assay The Geenius HIV 1/2 Supplemental Assay differentiates antibodies to HIV Types 1 and 2 in serum, plasma and whole blood. A reader and proprietary software provides automated reading and interpretation with clear, accurate onscreen results in 30 minutes with full traceability. Geenius is faster and easier than Western Blot and a walk-away alternative to the Multispot HIV-1/HIV-2 Rapid Test. It covers the second step of the HIV testing algorithm recommended by the CDC. Bio-Rad, www.rsleads.com/608ml-154 HbA1c results and hemoglobin variants The D-100 System is the future of HbA1c testing. With innovative solutions to maximize workflow efficiency, the D-100 System allows high volume laboratories to quickly and easily report HbA1c results while also detecting hemoglobin variants. With one-touch operation and streamlined result review, the D-100 delivers gold standard HbA1c results. The D-100 is a unique HbA1c testing system with no interference from common hemoglobin variants. With an impressive throughput and dramatically reduced operator hands-on time, the D-100 produces HbA1c results that are automatically reviewed and flagged. The software interface is easy to use, and designed to maintain continuous operation. Bio-Rad, www.rsleads.com/608ml-155 Barcode driven microbiology specimen processor and work-up system COPAN’s WASPLab brings microbiology out of the manual era and straight into full automation. WASPLab is a barcodedriven Microbiology specimen processor and work-up system which connects to WASP DT using a conveyor track. WASPLab moves samples from front-end processing to full specimen management, automated incubation, and digital Microbiology. With its modular design and small footprint, WASPLab can be customized to the unique needs of the lab, including robotic plate management system, smart incubators, and state-of-the-art image acquisition technology. With the revolutionary algorithms paired with sophisticated image analysis software, WASPLab is changing the way labs work and opening the door for groundbreaking digital Microbiology. Copan, www.rsleads.com/608ml-156 Blood bank automation Hemo Bioscience’s Hemo-QC is a whole blood quality control kit intended for the daily quality control of routine blood bank reagents used in manual, semiautomated and automated blood typing and antibody screening test systems. Features include 7 ml containers compatible with all instrument systems currently available in the United States; three tubes for daily quality control of ABO/Rh(D) and antibody detection; 42-day closed vial stability and 10-day open vial stability; cost effectiveness, as fewer reagent sets are used monthly; monthly shipments on standing order; and FDA 510(k) clearance. Hemo Bioscience, www.rsleads.com/608ml-157 continued on page 60 58 MLO - ONLINE.COM MLO201608-ProductFocus_MECH_GH.indd 58 AUGUST 2016 7/12/2016 4:58:05 PM KapSafe™-mini An Automated bench-Top Recapper Also available as a multi-rack system Safety & efficiency are important laboratory issues. Eliminate potential repetitive stress problems, even with smaller tube volumes, during manual recapping by using an automated and affordable recapper from the makers of the Pluggo™ Decapper. You have used us as a decapping solution, now we have a recapping solution. PROTECT YOUR HANDS Visit our website for additional information www.lgpconsulting.com Laboratory Growth & Productivity WWW.LGPCONSULTING.COM 1.877.251.9246 Accommodates all major tube sizes and a variety of analyzer racks Serving laboratories since 2002 | Contact us for literature and sales information MLO201608_AD LGP.indd 59 7/8/2016 12:57:57 PM PRODUCT FOCUS AU T OM AT ION continued from page 58 Automated bench-top recapping For safe and affordable automated benchtop recapping, the KapSafe Recapper has three models to fit both small and large volume facilities: KapSafe, KapSafe-LS, and the KapSafe-mini. Manual recapping and decapping can cause many challenges, and laboratory staff will appreciate the protection offered with automated equipment and affordable solutions. Safe recapping is essential regardless of volume. All KapSafe models have no pneumatics, no noise, small footprint, and throughput up to 1,200 tubes per hour. LPG Consulting, www.rsleads.com/608ml-158 High-volume automation solution Designed for high-throughput laboratories, cobas connection modules (CCM) offer the ability to consolidate the vast majority of a laboratory’s testing volume, at high throughputs—up to 2,000 tubes per hour, while providing predictable workflow and turnaround times. The CCM provides customers the ability to connect to the Roche standalone automation portfolio directly to Roche analytics without compromising the flexibility of the standalone automation concept. Based on its design, this high-volume automation solution provides convenient sample loading, quality and quantity checks, workflow flexibility, and multidisciplinary connectivity, such as hematology, coagulation, and the first IVD vendor to connect molecular testing solutions validated for cross-contamination compliance.*Expected Q4/16 availability in the U.S. Roche, www.rsleads.com/608ml-159 Automating primary vial preprocessing steps Improving laboratory efficiency, the cobas p 480 instrument accepts PreservCyt, SurePath liquidbased cytology vials as well as cobas PCR Media tubes; processes four vials simultaneously; and requires minimal training with intuitive interface. It reduces hands-on time and repetitive motions with four unique workflows: Decapping; Recapping; Aliquoting; and Reagent addition and heating. It improves sample reproducibility and process reliability: a) Sample chain of custody is assured with primary and secondary vial barcode matching; b) All vials are spun prior to opening to remove potentially contaminating droplets from sample caps; c) Precision pipetting using CO-RE tip, Total Aspirate and Dispense Monitoring (TADM) and AntiDroplet Control (ADC) technologies reduces opportunities for contamination and ensures sample integrity; d) No LIS or data connection is required; and e) Printable reports capture all sample IDs, sample error, and reagent lot and expiration information. Roche, www.rsleads.com/608ml-160 60 MLO - ONLINE.COM MLO201608-ProductFocus_MECH_GH.indd 60 Capillary separation for proteins, hemoglobins, and HbA1c Sebia’s CAPILLARYS 2 Flex Piercing provides high resolution capillary separation for proteins, hemoglobins, and HbA1c. The CAPILLARYS 2 Flex Piercing offers proven technology, and high throughpu, maximizing walk-away capabilities. The CAPPILLARYS 2 Flex Piercing utilizes proprietary software, PHORESIS, allowing pathology ease of use and interpretation as well as networking seamlessly proven at installations in the United States and worldwide. Sebia, www.rsleads.com/608ml-161 Automated sample processing Aptio Automation combines intelligent technologies with workflow expertise from Siemens Healthineers to deliver flexible solutions that advance laboratory productivity. Labs can leverage enhancements introduced in 2016—including more diagnostic analyzers, pre-analytical modules, and process management tools—to simplify multidisciplinary testing. Highly adaptable, needs-based Aptio Automation solutions will enable lab leaders to accelerate sample processing, achieve consistent turnaround times, and proactively control operations for better patient outcomes. Siemens Healthineers, www.rsleads.com/608ml-162 Free-standing and TLA ready automation system Sysmex XN-9000 provides comprehensive multi-discipline testing modules for hematology and HbA1c testing. The system is configurable to the level of efficiencies desired, with a combination of the following modules: advanced hematology testing analyzers (XN-10), reflexive slidemaker/stainer (SP10), automated digital cell image (DI-60), pre / post-analytical EDTA tube management (TS-10), HPLC-HbA1c testing (Bio-Rad VARIANT II TURBO Link), and integrated decision logic software (Sysmex WAM). The design flexibility of the system offers a free standing, lavender top management island, with integration to various TLA tracks available in the market today. Sysmex, www.rsleads.com/608ml-163 AUGUST 2016 7/12/2016 4:58:19 PM B E YO N D A B E T T ER B OX ™ ADVANCED HEMATOLOGY ANALYZERS TO IMPROVE YOUR LAB NEXT GENERATION DIAGNOSTICS ADVANCED TOOLS & TECHNOLOGIES PROCESS OPTIMIZATION HARMONIZED SUPPORT Sysmex has a decades-long legacy of developing better analyzers. Today, we’ve moved well beyond “building better boxes” into four key areas to create a more holistic, intuitive ecosystem that improves lab operations, promotes better care and enhances patient management practices. THEY ALL LINK TOGETHER • NEXT GENERATION DIAGNOSTICS – continuing to pioneer the future of diagnostic performance • ADVANCED TOOLS & TECHNOLOGIES – proprietary tools that drive greater insight into your lab • PROCESS OPTIMIZATION – moving beyond simple automation to a fully integrated environment • HARMONIZED SUPPORT – combining truly personalized service with a revolutionary technology platform Go Beyond a Better Box™ at W W W.SYSMEX.COM/BEYOND_MLO to see how Sysmex improves hematology and your entire lab. Join us in Philadelphia at AACC 2016, booth number 1727. © Sysmex America, Inc. 2016. All rights reserved. MLO201608_AD Sysmex.indd 61 7/8/2016 2:02:50 PM NEW PRODUCTS Pre-filled specimen jars 2.0 mL blood collection tube Surgipath AffirmSeal Pre-Filled Specimen Jars include four new sizes; 40mL, 60mL, 90mL and 120mL, and are offered in multiple packaging configurations. Pre-filled with 10 percent neutral buffered formalin, AffirmSeal jars are specifically designed for safe collection and transport of various sized specimens. The jars feature a plastic mold design that creates two clearly audible and tactile “clicks” when the lid is properly secured. This provides confirmation that the specimen is secure, helps prevent leakage, and offers an added level of safety from formalin fumes for couriers and technicians. AffirmSeal jars are made of durable plastic to prevent cracking when inadvertently dropped, and comply with 95 kPa pressure testing for safe air shipment and use in pneumatic transport systems. The packaging is made of chipboard material, making it safe for operating room use. In terms of configurations, Mini-Pak sizes allow for easy breakdown of the cases for distribution to other labs and physician offices. Alternatively, flat packs save storage space and provide added durability during transit. Cell-Free DNA BCT, a direct-draw tube for the collection and preservation of whole blood samples, is now available as a 2.0 mL draw tube. Cell-Free DNA BCT is a direct-draw blood collection tube with a formaldehyde-free preservative stabilizing nucleated blood cells. This unique stabilization prevents the release of genomic DNA, allowing isolation of high-quality cell-free DNA which can be further used for a wide range of downstream applications commonly used in clinical research studies, drug discovery, and diagnostic assay development. Cell-Free DNA BCT reduces the need for immediate plasma preparation due to its stabilization properties. Cell-Free DNA is stable for up to 14 days, while circulating tumor cells are stable for up to four days, at room temperature, allowing convenient sample collection, transport, and storage. The new 2.0 mL tube, and the 10.0 mL tube, are available in multiple kit configurations. Cell-Free DNA BCT is For Research Use Only, not for use in diagnostic procedures in the U.S. Leica Biosystems www.rsleads.com/608ml-164 CLASSIFIEDS Streck www.rsleads.com/608ml-165 Energy saving laboratory fume hood The UniFlow CE AireStream is a full duty fume hood in a compact size, which offers 50 percent energy savings over conventional hoods. The CE’s low flow constant volume by-pass design maintains consistent face velocity. CE fume hoods are offered in 30”, 36”, 48”, and 72” widths and can be equipped with a wide selection of accessories to meet specific process needs. CE fume hoods are constructed totally of composite resin for superior chemical resistance, no rust, and can be supplied with or without an exhaust blower in standard or explosion proof models. HEMCO is an ISO 9001:2008 Certified Company. HEMCO www.rsleads.com/608ml-166 MEDICAL/TECHNICAL SALES REPRESENTATIVE Helena Laboratories has four entry-level positions available as a Medical/Technical Sales Representative for medical laboratory products. The positions are based in New York, New Jersey, Pennsylvania and North Carolina. Each position has responsibility for a multi-state territory. The candidate must have a degree In Biological Sciences or Chemistry, Medical Technologist preferred. The position provides base salary, commissions, bonuses, company automobile and expenses. Contact Human Resources at [email protected] EEO/AA Employer ADVERTISER INDEX OF ADVERTISERS WEB PAGE Advanced Instruments, Inc. .........................................www.aicompanies.com ............................................................. 51 American Medical Technologists .................................www.americanmedtech.org...................................................... 18 American Proficiency Institute .....................................www.api-pt.com ........................................................................... 3 ARKRAY ..........................................................................www.arkrayusa.com .................................................................. 27 AstraZeneca ...................................................................www.TAGRISSOhcp.com .........................................................6-7 AstraZeneca ...................................................................cobasEGFRtest.com ..................................................................8-9 AUDIT MicroControls Inc..............................................www.auditmicro.com ................................................................ 39 Bio-Rad Laboratories ....................................................www.bio-rad.com/diabetes ....................................................... 13 Bio-Rad Laboratories ....................................................www.qcnet.com/mc-mlo ........................................................... 37 BioFire Diagnostics .......................................................biofiredx.com ............................................................................. 47 CellaVision .....................................................................www.cellavision.com................................................................. 35 CompuGroup Medical ..................................................www.cgm.com/us ........................................................................ 1 Hologic - HIV ..................................................................USAptimaVirology.com........................................................... IBC Hologic Inc .....................................................................www.hologic.com .....................................................................IFC Hologic, Women’s Health..............................................ThinPrep.com ........................................................................32-33 ITL BioMedical ...............................................................www.itlbiomedical.com/scu...................................................... 55 Kamiya Biomedical .......................................................www.k-assay.com/MLO.php ..................................................... 43 LGP Consulting..............................................................www.lgpconsulting.com ........................................................... 59 Meridian Bioscience Inc................................................http://goo.gl/57ZNiz ...................................................................... 5 Michigan State University ............................................www.bld.natsci.msu.edu/online-education............................. 63 Millipore Sigma .............................................................sigma-aldrich.com/clinical........................................................ BC Owen Mumford Inc .......................................................www.owenmumfordinc.com .................................................... 25 Quantimetrix Corp ........................................................quantimetrix.com ....................................................................... 21 Randox Laboratories Ltd ..............................................www.randox.com/keepyourinstrumentincheck ...................... 41 Roche Diagnostics .........................................................www.cobasEGFRtest.com ......................................................... 31 SCC Soft Computer .......................................................www.softcomputer.com ............................................................ 57 Sebia Inc .........................................................................www.sebia-usa.com .................................................................. 15 Sebia Inc .........................................................................www.sebia-usa.com .................................................................. 17 Sebia Inc .........................................................................www.sebia-usa.com .................................................................. 19 Sysmex America Inc .....................................................www.sysmex.com/beyond_mlo ............................................... 61 Thermo Fisher Scientific - Clinical Diagnostics..........www.thermoscientific.com ....................................................... 45 This index is provided as a service. The publisher does not assume liability for errors or omissions. 62 MLO - ONLINE.COM MLO201608-ProductFocus_MECH_GH.indd 62 AUGUST 2016 7/12/2016 4:58:33 PM MLO201608_AD MichiganState.indd 63 7/8/2016 12:58:32 PM EXECUTIVE SNAPSHOT By A lan L enhof f, Edi tor Diagnostics for infectious diseases, cancer screening, and safeguarding the blood supply If you were explaining Hologic to someone who is not familiar with the organization, how would you characterize its primary areas of expertise? At the highest level, Hologic is focused on enabling healthier lives, everywhere, every day, by pursuing what we call “the Science of Sure.” This means we strive to provide healthcare providers and patients progressive certainty and ever-greater peace of mind in their clinical decisions. We do this by developing, manufacturing, and commercializing premium diagnostic, medical imaging, and surgical products, many of which serve the healthcare needs of women. How does diagnostics fit in with the company’s overall business? What are the synergies between the company’s business divisions? Diagnostics is Hologic’s largest business, represent- STEPHEN P. MACMILLAN Chairman of the Board Hologic Professional I joined Hologic in December 2013 as President and CEO, and was elected Chairman of the Board in June 2015. From 2005 to 2012, I served as President and CEO of Stryker. Before that, I held a variety of roles with Pharmacia, Johnson & Johnson, and Procter and Gamble. Education I earned a BA in Economics from Davidson College, and graduated from Harvard Business School’s Advanced Management Program. Personal I serve on the boards of Boston Scientific and AdvaMed, the medical device industry’s trade association. In terms of philanthropy, I’m proud that the company has pledged to make 30 donations of up to $30,000 each to non-profit groups focused on healthcare and STEM education, to commemorate Hologic’s 30th anniversary. 64 MLO - ONLINE.COM MLO201608-ExecSnap_MECH_AL.indd 64 ing about 45 percent of revenue last year. Many of our diagnostic products, including the ThinPrep Pap test, our Aptima assays for sexually transmitted diseases, and our fFN test for preterm labor risk, address important issues in women’s health, as do our mammography systems and gynecologic surgical products. There are important synergies across our diagnostics franchises. For example, several of our Aptima molecular tests can be performed from a ThinPrep sample. Across the businesses, we call on different kinds of customers, so synergies are fairly limited, although we are exploring a few areas. For example, our diagnostics sales reps are beginning to share information about our Genius 3D mammograms with their OB/GYN customers. On your watch, Hologic has accomplished a significant corporate turnaround during the last few years. How has this enhanced the company’s ability to serve its customers? Both Hologic and our diagnostics division have returned to growth, and our recent addition to the S&P500 stock index reflects this dramatic turnaround. To make it happen, we attracted an entirely new leadership team to drive long-term, sustainable, organic growth, rather than the debt-laden acquisitions from the company’s past. Based on these acquisitions, Hologic paid more in interest expense than it invested in research and development in the year before I arrived. But as results have improved, we’ve used strong cash flows to pay down debt, and consistently increased R&D spending. And we’re beginning to reap the rewards. For example, we recently launched our viral load tests for HIV, hepatitis C, and hepatitis B in Europe, and have begun to file regulatory applications in the United States. That’s a great way to serve our customers—by introducing innovative new products. Getting back to the Aptima family of products—how do they advance diagnostics for HIV, hepatitis, and other sexually transmitted diseases? Our Aptima products include assays for sexually-transmitted infections (STIs), including chlamydia, gonorrhea, the human papillomavirus (HPV), and trichomonas. In addition to providing accurate and reliable performance, the Aptima assays run on our fully automated, random access Panther system. Panther builds on the success of our first generation automated instrument, Tigris, and incorporates customer requests for greater flexibility and walk- away time, with a small footprint. And with the addition of the viral load assays, we are actively expanding the Panther menu. Finally, we are developing a new system called Panther Fusion, which will be a “sidecar” adding PCR capabilities and a new assay format to Panther. That product will launch with our next generation of respiratory virus tests, and over time give labs the opportunity to run most of their major molecular volume on one fully automated, compact instrument. Recently there have been proposed changes to cervical cancer screening guidelines. How is that changing testing? With reference again to our ThinPrep Pap test and the Aptima HPV technology, Pap testing has contributed to a significant reduction in cervical cancer deaths over several decades, and has proven to be one of the most successful screening programs of all time. The results are even better when Pap testing is combined with a test for HPV, an approach commonly referred to as co-testing. An HPV test was approved as a primary screen for cervical cancer in 2014, but published studies support the superior performance of co-testing. A study of 8.6 million women conducted by Quest and published last year in Cancer Cytopathology demonstrated that nearly one in five cervical cancers were missed by HPV primary screening, and a recent study led by investigators at Houston Methodist Hospital supported these findings. We firmly believe that women are best served when physicians adhere to the recommendation of the American College of Obstetricians and Gynecologists (ACOG), which prefers co-testing for women between the ages of 30 and 65. How have your Procleix assays increased the safety of the blood supply by detecting the genetic material of HIV-1, hepatitis, and other viruses? Our Procleix assays, sold by our partner Grifols, were the first molecular tests approved by the FDA to screen donated blood. These tests, when combined with other screening measures, have helped reduce the risk of contracting potentially deadly viruses like HIV-1 and hepatitis C from a blood transfusion to less than one in a million. We also are developing a molecular assay to screen donated blood for the Zika virus. This demonstrates Hologic’s ability to quickly address new and emerging threats, as well as our commitment to help safeguard the donated blood supply. AUGUST 2016 7/12/2016 9:15:15 AM In viral load testing A change in direction is within sight. COMING SOON Additional Aptima target assays in development: E?SpblXeeiX\[ihƄlgXnbih• HBV viral load • HSV 1 & 2 • M. genitalium • BV • Candida Aptima assays now available: CT/NG • Trichomonas vaginalis • HPV • HPV GT To get the full picture, visit USAptimaVirology.com The Aptima HIV-1 Quant assay is not available for sale in the U.S. ADS-01484-001 Rev. 001 ©2016 Hologic, Inc. All rights reserved. Hologic, The Science of Sure, Aptima and associated logos are trademarks and/or registered trademarks of Hologic, Inc. and/or its subsidiaries in the United States and/or other countries. This information is intended for medical professionals in the U.S. and is not intended as a product solicitation or promotion where such activities are prohibited. Because Hologic materials are distributed through websites, eBroadcasts and tradeshows, it is not always possible ni[ihnlieqa]l]mo[agXn]lbXemXjj]XlΥBilmj][bƄ[bh^ilgXnbihihqaXnjli\o[nmXl]XpXbeXZe]^ilmXe]bhXjXlnb[oeXl[iohnlsΨje]Xm][ihnX[nsiolei[XeEiei`b[l]jl]m]hnXnbp]il write to [email protected]. MLO201608_AD Hologic-19998.indd COVERIII 7/8/2016 12:55:10 PM The integrity and accuracy of genetic analysis relies on the quality of the reagents and components utilized in your workflow. Every laboratory – every doctor – and every patient relies on the quality of our products to deliver certainty in their results. Learn More about our complete offering for the Genetic Analysis Workflow: Sample Preparation • GenElute™ DNA & RNA Purification Kits • Extract-N-Amp™ Kits Amplification • SeqPlex™ DNA & RNA Amplification Kits • JumpStart™ Taq Polymerase and PCR Reagents Sequencing • ISO13485 Adapters and Probes Available in package sizes to fit your needs. WE ARE QUALITY. sigma-aldrich.com/clinical 84269 1125 ©2015 Sigma-Aldrich Co. LLC. All rights reserved. SIGMA and SIGMA-ALDRICH are trademarks of Sigma-Aldrich Co. LLC, registered in the US and other countries. GenElute, Extract-N-Amp, SeqPlex and JumpStart are trademarks of Sigma-Aldrich Co. LLC. Sigma-Aldrich Corp. is a subsidiary of Merck KGaA, Darmstadt, Germany. MLO201608_AD Sigma-Aldrich.indd COVERIV 7/8/2016 2:02:18 PM