Group testing, also known as pooled sample testing, was first proposed by Robert Dorfman in 1943. While sample pooling has been widely practiced in blood-banking, it is traditionally seen as anathema for clinical laboratories. However, the ongoing COVID-19 pandemic has re-ignited interest for group testing among clinical laboratories to mitigate supply shortages. We propose five criteria to assess the suitability of an analyte for pooled sample testing in general and outline a practical approach that a clinical laboratory may use to implement pooled testing for SARS-CoV-2 PCR testing. The five criteria we propose are: (1) the analyte concentrations in the diseased persons should be at least one order of magnitude (10 times) higher than in healthy persons; (2) sample dilution should not overly reduce clinical sensitivity; (3) the current prevalence must be sufficiently low for the number of samples pooled for the specific protocol; (4) there is no requirement for a fast turnaround time; and (5) there is an imperative need for resource rationing to maximise public health outcomes. The five key steps we suggest for a successful implementation are: (1) determination of when pooling takes place (pre-pre analytical, pre-analytical, analytical); (2) validation of the pooling protocol; (3) ensuring an adequate infrastructure and archival system; (4) configuration of the laboratory information system; and (5) staff training. While pool testing is not a panacea to overcome reagent shortage, it may allow broader access to testing but at the cost of reduction in sensitivity and increased turnaround time.
Background Lipaemic interference on automated analysers has been widely studied using soy-based emulsion such as Intralipid. Due to the greater adoption of fish oil-based lipid emulsion for total parenteral nutrition in view of improved clinical outcomes, we seek to characterize the optical properties of SMOFlipid 20% (Fresenius Kabi, Bad Homburg, Germany), a fish oil-based emulsion, on the Roche Cobas 6000 chemistry analyser (Roche Diagnostic, Basel, Switzerland). Method Various amounts of SMOFlipid were spiked into pooled serums. We plotted Roche Cobas Serum Index Gen.2 Lipaemia Index (L-index) against the amount of SMOFlipid added. We then studied the interference thresholds for aspartate aminotransferase, alanine aminotransferase, albumin and renal panel analytes using SMOFlipid. We subjected five levels of spiked lipaemia to high-speed centrifugation and analysed the specimens pre- and post-centrifugation. To postulate whether fish oil-based lipid emulsion interferes with laboratory results in the clinical setting, we calculated concentrations of SMOFlipid post-lipid rescue therapy and steady-state concentration of a typical total parenteral nutrition regime using pharmacokinetic principles. Results SMOFlipid optical behaviour is similar to Intralipid using the Serum Index Gen.2 L-index, with 1 mg/dL of SMOFlipid representing 1 unit of L-index. Manufacturer-stated interference thresholds are accurate for alanine aminotransferase, aspartate aminotransferase, albumin, urea and creatinine. High-speed centrifugation at 60 min 21,100 g facilitates the removal of fish oil-based SMOFlipid. Conclusion Based on the interference thresholds we verified and pharmacokinetics parameters provided by SMOFlipid manufacturer, total parenteral nutrition may not interfere with chemistry analytes given sufficient clearance, but lipid rescue therapy will interfere. Further studies assessing lipaemic interference on immunoassays are needed.
Approximately 13% of the population over the age of 65 years is estimated to have AD. The total number of cases is expected to increase over the coming decades. The apolipoprotein E (ApoE) genotype is the greatest genetic determinant for Alzheimer's disease (AD) development. The ApoE4 allele increases the risk of AD by 4 to 14 fold while the ApoE2 allele has an opposing effect; decreasing risk. Indeed many studies have demonstrated that carriers of the ApoE2 allele are associated with greater likelihood of survival to advanced age, superior verbal learning ability in advanced age, and reduced accumulation of amyloid pathology in the aged brain. In addition, it is known that ApoE proteins have different affinities for the low-density lipoprotein receptor (LDLR), with ApoE2 having the weakest binding to the LDL receptor at < 2% relative to ApoE3 and E4. Because ApoE2 has shown protective effects in regard to AD, a novel approach for ApoE4 carriers may be to create a peptide antagonist that blocks the ApoE interactions with LDLR at its 135-150 N-terminal binding domain. This peptide may create a more ApoE2-like structure by decreasing the affinity of ApoE4 for LDLR thereby reducing AD onset, memory impairment, and amyloid plaque formation. In this review, we will discuss the different detrimental effects that ApoE4 can cause. Most importantly, we will review how ApoE4 binding to LDLR promotes AD pathogenesis and how blocking ApoE4 binding may be a promising novel therapeutic approach for AD. Keywords: Alzheimer's disease, low-density lipoprotein receptor, apolipoprotein E, amyloid precursor protein, late onset Alzheimer's disease Peptide ultimately blocks the signaling and endocytosis pathway LDL receptor Cell membrane LDL receptor LDL receptor Cell membraneage, superior verbal learning abilities, improved recall memory, faster processing of information, better test performance, and reduced accumulation of amyloid pathology in the aged brain. Furthermore, a second innovative approach would be to create a more advanced antibody targeting specifically the 133-152 N-terminal binding region of ApoE to prevent interaction between LDLR and ApoE. In sum, modulation of ApoE structure to create and/or enhance ApoE2-like activity may shed light on a novel approach for AD treatment and prevention.
The management of diabetes mellitus in an insulin-dependent patient is challenging in the setting of concomitant antibody-mediated-insulin hypersensitivity. We report a case of a 62-year-old woman with pre-existing type 2 diabetes mellitus of 10 years duration who developed type 3 hypersensitivity reaction to insulin analogue detemir, and subsequently, severe diabetic ketoacidosis (DKA). She was C-peptide negative and was diagnosed with insulin-dependent diabetes. Despite increasing dose adjustments, insulin-meal matching, and compliance with insulin, she experienced episodes of unexpected hyperglycaemia and hypoglycaemia. The development of rash after detemir initiation and rapid progression to DKA suggests an aberrant immune response leading to the insulin allergy and antibody-induced interference with insulin analogues. Glycaemic control in the patient initially improved after being started on subcutaneous insulin infusion pump with reduced insulin requirements. However, after a year on pump therapy, localised insulin hypersensitivity reactions started, and glycaemic control gradually deteriorated.
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