Clinical laboratories

Chemical kinetic methods of analysis continue to find use for the analysis of a variety of analytes, most notably in clinical laboratories, where automated methods aid in handling a large volume of samples. In this section several general quantitative applications are considered. 

National Institute of Standards and Technology (NIST). The NIST is the source of many of the standards used in chemical and physical analyses in the United States and throughout the world. The standards prepared and distributed by the NIST are used to caUbrate measurement systems and to provide a central basis for uniformity and accuracy of measurement. At present, over 1200 Standard Reference Materials (SRMs) are available and are described by the NIST (15). Included are many steels, nonferrous alloys, high purity metals, primary standards for use in volumetric analysis, microchemical standards, clinical laboratory standards, biological material certified for trace elements, environmental standards, trace element standards, ion-activity standards (for pH and ion-selective electrodes), freezing and melting point standards, colorimetry standards, optical standards, radioactivity standards, particle-size standards, and density standards. Certificates are issued with the standard reference materials showing values for the parameters that have been determined. 

Immunodiffusion and immunoprecipitation, developed ia the 1940s as a means to identify and semiquantitate specific proteias, were the direct precursors to the development ia 1953 of Immunoelectrophoresis, a method used ia many clinical laboratories (5). Single- and double-gel immunodiffusion and immunoelectrophoresis were, ia effect, the first standardized and routinely used immunoassay methods (see Electroseparations, electrophoresis). 

EIAs can be used per se or with a spectrophotometer. Traditionally, EIAs have been developed in 96-weU microtiter plates which provide the immobilization support for the assay, the reaction vessel, and, when linked to a spectrophotometer-based reader, a rapid means to detect and quantify the color resulting from interaction of a substrate with the antibody—antigen—enzyme complex. Automated immunoassay analyzers targeted primarily for use in the clinical laboratory have taken automation one step further, utilizing robotics to carry out all reagent additions, washings, and final quantification including report preparation. 

Immunosensors promise to become principal players ia chemical, diagnostic, and environmental analyses by the latter 1990s. Given the practical limits of immunosensors (low ppb or ng/mL to mid-pptr or pg/mL) and their portabiUty, the primary appHcation is expected to be as rapid screening devices ia noncentralized clinical laboratories, ia iatensive care faciUties, and as bedside monitors, ia physicians offices, and ia environmental and iadustrial settings (49—52). Industrial appHcations for immunosensors will also include use as the basis for automated on-line or flow-injection analysis systems to analyze and control pharmaceutical, food, and chemical processing lines (53). Immunosensors are not expected to replace laboratory-based immunoassays, but to open up new appHcations for immunoassay-based technology. 

Glucose [50-99-7] urea [57-13-6] (qv), and cholesterol [57-88-5] (see Steroids) are the substrates most frequentiy measured, although there are many more substrates or metaboUtes that are determined in clinical laboratories using enzymes. Co-enzymes such as adenosine triphosphate [56-65-5] (ATP) and nicotinamide adenine dinucleotide [53-84-9] in its oxidized (NAD" ) or reduced (NADH) [58-68-4] form can be considered substrates. Enzymatic analysis is covered in detail elsewhere (9). 

Assay of Enzymes In body fluids, enzyme levels aie measured to help in diagnosis and for monitoiing treatment of disease. Some enzymes or isoenzymes are predominant only in a particular tissue. When such tissues are damaged because of a disease, these enzymes or isoenzymes are Hberated and there is an increase in the level of the enzyme in the semm. Enzyme levels are deterrnined by the kinetic methods described, ie, the assays are set up so that the enzyme concentration is rate-limiting. The continuous flow analyzers, introduced in the early 1960s, solved the problem of the high workload of clinical laboratories. In this method, reaction velocity is measured rapidly the change in absorbance may be very small, but within the capabiUty of advanced kinetic analyzers. 

Enzymes, measured in clinical laboratories, for which kits are available include y-glutamyl transferase (GGT), alanine transferase [9000-86-6] (ALT), aldolase, a-amylase [9000-90-2] aspartate aminotransferase [9000-97-9], creatine kinase and its isoenzymes, galactose-l-phosphate uridyl transferase, Hpase, malate dehydrogenase [9001 -64-3], 5 -nucleotidase, phosphohexose isomerase, and pymvate kinase [9001-59-6]. One example is the measurement of aspartate aminotransferase, where the reaction is followed by monitoring the loss of NADH ... 

R. H. Liu and D. E. Gadzala, Handbook of Drug Analysis Applications in Forensic and Clinical Laboratories, Oxford University Press, New York (1997). 

An example of a modem instrument of this type is the Coming Model 410 flame photometer. This model can incorporate a lineariser module which provides a direct concentration read-out for a range of clinical specimens. Flame photometers are still widely used especially for the determination of alkali metals in body fluids, but are now being replaced in clinical laboratories by ion-selective electrode procedures (see Section 15.7). 

Labelling and other pertinent information supplied to investigators (study protoools, non-clinical laboratory data, etc.). 

Non-clinical laboratory studies used to investigate microbiological, toxicological, immunological, biocompatibility, stress, wear, shelf life, and other characteristics of the device. 

Limited results from clinical laboratory evaluations suggested that the GABAj l agonists zaleplon (Rush et al. 1999b) and Zolpidem (Rush et al. 1999a) produce effects that are consistent with abuse potential comparable to that of the benzodiazepine triazolam. The reported incidence of dependence on Zolpidem in the medical literature is low, compared with that for benzodiazepines, and is characterized by use of high doses, often in individuals with a history of substance abuse (Hajak et al. 2003 Vartzopoulos et al. 2000). 

Osawa M, Satoh F, Horiuchi H, Tian W, Kugota N, Hasegawa I Postmortem diagnosis of fatal anaphylaxis during intravenous administration of therapeutic and diagnostic agents evaluation of clinical laboratory parameters and immunohistochemistry 25 in three cases. Leg Med (Tokyo) 2008 10 143-147. 

While much care has to be used in performing competitive protein binding assays, most well-equipped and staffed clinical laboratories should have no serious problem in undertaking such assays. The biggest problem that may be encountered is the selection of a dependable and reliable manufacturer for reagents. Problems that may arise are non-purity of standards and label non-specificity of antibodies or the inability to maintain any of these characteristics from lot to lot. It therefore is a good practice to evaulate a few manufacturers before selecting one for routine use. 

Along with an effective electrolyte and screening program for genetic disease, the laboratory of Neonatology needs to have the capability of analyzing for other components in blood serum, which aid in the diagnosis of disease. These include such determinations as alkaline phosphatase, and various other enzymes, creatinine, uric acid and a host of other components which are normally assayed by the main clinical laboratory. 

Those associated with general clinical laboratory service assaying for numerous other components which are also done in the main laboratory of clinical chemistry. 

It should be apparent from the above, that the problems of the laboratory of Neonatology are distinct from the main laboratory, and it would always be advisable that it be maintained as a separate unit, or at least in a separate section of the clinical laboratory of the institution in which clinical chemistry is being practiced. 

Recently, the old alkaline phenol method has been revived, and is being widely used in clinical laboratories, without protein preclpltatlon(27). In this procedure, the serum is added to an alkaline phenol reagent, and the ammonia generated from urea is determined either after the action of urease or after strong alkaline treatment of the serum. The objection to this procedure is first, that all urease is rich in ammonia, and second, the color produced with alkaline phenol is not specific for ammonia. It will react with other compounds, especially for those that liberate ammonia. By this procedure one obtains a useful number from the point of view of determining whether the patient has nitrogen retention, but a value which is somewhere between a urea and an N.P.N. determination. 

Natelson, S Routine use of ultramicro methods in the clinical laboratory Am J Clin Path (1951),... 

Chedid, A. Haux, P. and Natelson, S. Use of thin layer chromatography on silica gel for serum lipid fractionation and measurement in the routine clinical laboratory. Clin. Chem. (1972), 13, 384 - 390. 

Electrophoretic methods of separation of LD Tsoenzymes have become routine in clinical laboratories. Efforts are now being made to standardize the methodologies used for LD isoenzymes, particularly by Rosalki (38). The preferred methods are based on electrophoresis on a solid medium, so that the several bands may be scanned instrumentally. Differential isoenzyme inhibition with urea or other inhibitors is based on the fact that the heart LD isoenzyme is more resistant to inhibition than other isoenzymes. However, the analyst then has the problem of allocating the observed degree of inhibition between the different isoenzymes of a given sample, a problem that has not been resolved satisfactorily thus far. Hence, differential inhibition is not as reliable for isoenzyme separation as is electrophoresis. 

Solberg and co-workers have applied discriminate analysis of clinical laboratory tests combined with careful clinical and anatomic diagnoses of liver disease in order to determine which combinations of the many dozen liver diagnostic tests available are the bes t ( ). These authors found that the measurement of GPT, GMT, GOT, ALP and ceruloplasmin were the most useful enzymatic tests, when combined with other non-enzymatic tests such as the measurement of bilirubin, cholesterol, hepatitis-B associated Australian antigen, etc. Another group of highly useful enzymes, not discussed in this review, are those clotting factors and the enzyme cholinesterase which are synthesized by the liver cells. 

Numerous workers have found that measurements of serum lipase activity are useful in the diagnosis of pancreatitis (83, 84, 85). Despite this, serum lipase determinations are not usually performed in clinical laboratories, probably due to inherent problems associated with the conventional methods, based on an emulsified lipid substrate. The methods are also not very suitable for manual batch analysis nor for automation due to laborious post incubation procedures. 

The purpose of this article is to present HPLC and to summarize some typical applications in the clinical laboratory. 

Successful use of modern liquid chromatography in the clinical laboratory requires an appreciation of the method s analytical characteristics. The quantitative reproducibility with respect to peak height or peak area is quite good. With a sample loop injector relative standard deviations better than 1% are to be expected. The variability of syringe injection (3-4% relative standard deviation) requires the use of an internal standard to reach the 1% level (2,27). 

Young, D.S. Thomas, D.W. Friedman, R.B..and Pestaner, L.C. "Effects of Drugs on Clinical Laboratory Tests". Clin. 

Caniatti EM, Tugnoli V et al (1996) Cryoglobulinemic neuropathy related to hepatitis C virus infection. Clinical, laboratory and neurophysiological study. J Peripher Nerv Syst 1(2) 131-138... 

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