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Advances in Clinical Chemistry, Volume Gregory S. Makowski: Books

Shopbop Designer Fashion Brands. Continuous flow analysis changed the character of clinical chemistry testing so that only minutes instead of hours or even days were needed to complete an analysis, and personnel were free to develop tests for subspecialties such as toxicology, endocrinology and molecular diagnostics. The AutoAnalyzer led to the widespread use of batch analysers, many of which only measured one analyte but could test up to samples in continuous mode. In the early s, the photodiode array for spectrophotometers with grating monochromators allowed a sample to be tested simultaneously for multiple analytes, each test detecting an analytical signal at different wavelengths.

Not long after the introduction of the AutoAnalyzer and the ascendency of continuous flow analysis in clinical chemistry, a different approach appeared in with the production of the Robot Chemist by the Research Specialties Company. The Robot Chemist was not ultimately successful because it was too mechanically complex to be practical. It went out of production in , but ironically the Robot Chemist proved to be the automation direction manufacturers would take and the discrete analysis model ultimately replaced the AutoAnalyzer and continuous flow analysis.

Another approach to automation was introduced with centrifugal analysis in , developed by Norman Anderson. Sample and reagents are pipetted into rotor compartments and mixed when the rotor spins and they flow over the walls of the compartments into a reaction chamber.

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Several manufacturers introduced centrifugal analysers and these models proved successful for about 20 years in clinical laboratories. Just as important as the development of automated analytical systems was the introduction in the s by the Sigma Chemical Company in St. The era of automation blossomed after the introduction of the AutoAnalyzer. Doumas observed that the edition of Tietz Fundamentals of Clinical Chemistry included a chapter on automation, covering 13 automated analytical systems, one of them the DuPont ACA, an unique and revolutionary analyser that enjoyed a long life.

The second edition of the Tietz textbook deleted from the automation chapter the Technicon SMA and another one-time standard system, the Beckman Astra, but included point-of-care testing POCT and specialised immunoassay analysers, reflecting the then current situation. Spectrophotometry, previously known as colorimetry, was now being used in a wide variety of photometric techniques: By the s, batch analysers, such as autoanalysers and centrifugal analysers that performed the same assay simultaneously on all samples, were on the wane.

Batch analysis still has a role to play, but discrete analysers can be used in this mode in addition to performing any number of tests in the random access mode. It is instructive to review some terms to appreciate the various approaches to automation. In contrast, sequential analysis means samples are tested one after the other and results are reported in the same order. With discrete analysis, each sample is tested in a separate cuvette or other reaction chamber with reagents added to each individual sample container.

With random access analysis, specimens are tested in or out of sequence with each other, as reaction vessels are available and without regard to accessioning order, although testing of designated specimens, such as stats, may be given priority. Assays are either end-point tests reaction is complete after a fixed time or continuous monitoring tests multiple data points recorded over a specified time interval. The AutoAnalyzer continuous flow, batch analysis paradigm was displaced by discrete systems using positive-displacement pipettes, with various volumes possible, or fixed volume, for sample processing and reagent dispensing, with some kind of washing step in between sample dispensing to avoid carryover contamination.

Mixing is performed by forceful dispensing, magnetic stirring, or mechanical stirring rods or piezo-electric mixers. Temperature is controlled by waterbaths, heating blocks, or heated air compartments air bath. Cuvettes are glass or plastic; the glass cuvettes intended to be permanent and the plastic cuvettes made to be disposable after a single use or after extended use with replacement after a set number of tests. Various types of detectors are used, with a variety of lamp types tungsten, quartz halogen, mercury, xenon, and lasers. The monochromators use interference filters, prisms, or diffraction gratings.

The majority of analysers use liquid reagents, either received as liquid, ready to use, or reconstituted by the laboratory after receipt.

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Reagents were reconstituted with diluent and mixed with the specimen during analysis. The disadvantage was that the dry reagents were more expensive than liquid reagents, although they were more stable and minimised reagent wastage. Ortho has offered generations of analysers that use a unique slide technology. The reagents are dispersed in emulsions on the slides and the reaction is activated as the sample diffuses through the layers on the slide. The spectrophotometric reading is taken using reflectance technology.

The slides for the electrolytes contain miniature ion-selective electrodes. The slides are conveniently stored in refrigerators or freezers and are recognised for their convenience. However, it is difficult to develop slides for the wide variety of analytes and specimen matrices now tested and slide systems have of necessity been supplemented by adding conventional open liquid channel options.

Typical modern clinical chemistry analysers use automated discrete systems, as opposed to batch analysis instrumentation, which allows for an almost unlimited mix of analyses on a single instrument, combining routine clinical chemistry and immunoassay tests and fewer analysers requiring less floor space and greatly improving operational efficiency.

Benefits of replacing manual procedures with automation include: As emphasised by Melanson et al.

Fully automated low, medium, and high volume analysers are available as independent units and it is with these systems that a clinical laboratory typically begins the automation process. These analysers are designed for a wide range of sample workloads, and range from small or modest sized benchtop units or large to very large floor models.

They can offer a large menu of assays or, if used for high volume work in reference laboratories, may be dedicated to a relatively small number of assays, such as test profiles. Typically, the manufacturer of the analyser also provides the reagents for them. Assay applications for closed systems are optimised for them and verified by the manufacturer. Laboratories need to perform method validation for every assay they adapt to an open system. It is usually considered desirable for an analyser to have open system capability. During the development and proliferation of fully automated, stand-alone analysers, a dichotomy emerged: They did not patent RIA, making it easier for others to further develop the technique.

Monoclonal antibodies developed by Millstein and Kohler Nobel Prize in , improved specificity of antibodies. Fluorescent and chemiluminescent tag assays are also available, allowing quantification at lower analyte concentrations, but they require specialised detection systems and typically separate analysers.

EMIT, using non-isotopic labels, allowed for practical automation of immunoassay. Homogeneous assays such as EMIT do not separate bound from unbound constituents, but heterogeneous sandwich assays use a separation step to improve selectivity and sensitivity by separating the antibody bound analyte from the other constituents of the assay mixture. Sandwich immunoassays use a capture antibody first and a second labeled antibody to generate the analytical signal.

Automated systems now use variations of both techniques. Some analysers may even employ more than one immunoassay methodology, such as the Siemens Vista. Immunoassay moved away from dedicated special chemistry laboratories to the general core laboratory as fully automated systems were made available that allow both homogeneous and heterogeneous immunoassays to be performed on general purpose chemistry analysers. Examples included the Abbott TDx, a successful automated batch FPIA analyser, later replaced by the IMx which could perform multiple immunoassay tests in a single analytical run, both now retired.

Multiplex, or multivariate, analysis through various techniques allows two or more analytes to be measured simultaneously. Multiplexing offers an obvious advantage in speed of analysis however a potential disadvantage is reimbursement for clinical laboratory testing may not allow for payment of analyte test results that are not specifically ordered. Adding an immunoassay unit with a different methodology dramatically increased the spectrum of assays that could be offered. Of course a laboratory could maintain separate clinical chemistry and immunoassay analysers if it desired instead of using integrated systems.

Large integrated systems provide advantages over multiple smaller systems but, if they are disabled for any reason, a laboratory may lose the ability to perform testing unless it has back-up systems although some can continue to operate either the clinical chemistry or immunoassay module if the other is inoperable.

Thus laboratories must carefully consider their options if they rely almost totally on a single integrated system. Multiple smaller systems provide for redundancy, but require more maintenance and cross-analyser method comparisons to establish and maintain equivalency of test results. Open channels for assays not available from the instrument manufacturer are also desirable. Sample throughput and turn-around-time TAT of automated systems vary with the size and capability of analysers and the complexity of the assay mix and test volume. Integrated systems offer the advantage of consolidation.

It is preferable to place as many assays on a single analyser than to maintain two or more analysers because each instrument will require separate QC, preventive maintenance, record keeping, etc. For a laboratory large enough to need multiple analysers or for an integrated delivery system a medical care network consisting of two or more laboratories, it is highly desirable to use a family of analysers.

This might consist of duplicate instruments or a mixture of analysers from the same manufacturer but designed for different sized workloads. Analysers belonging to the same family, use common calibrators, controls, reagents, cuvettes or reaction vessels, disposables, methodology, and software, which is distinct advantage. Most important, the commonality of analysers belonging to the same family should guarantee equivalent test results so that it makes no difference which instrument is used to test a patient sample.


The reference intervals and medical decision levels are equally suitable for all analysers. There are two approaches to automation: TLA is distinguished by the presence of some sort of track system that connects the various components. Stand-alone automation provides most of the major benefits of TLA without the cost of a track. The stand-alone options offer a smaller footprint some components are even bench top modules and lower cost, and thus may be good choices for laboratories with limited floor space.

Beginning in the s, the clinical laboratory saw the introduction of robotics and informatics allowing for great leaps forward in automation, leading to the development of TLA. In the early s, Dr. Masahide Sasaki at the Kochi Medical School, Kochi, Japan, developed conveyor belt systems, robots to load and unload analysers, and process control software, and is credited with the first attempt at TLA. Some clinical chemists fielded their home-made, in-house TLA systems, but they were limited to the facility in which they were created and their sustainability was questionable without the key personnel who developed and supported them.

TLA combines a wide variety of processes, including accessioning and sorting specimens, decapping tubes, centrifugation, aliquoting, delivery to analysers, recapping tubes, and storage and archiving of samples. TLA also allows for the reduction of sample handling steps, decreasing the likelihood of handling errors and improving patient safety.

In addition, TLA increases productivity, decreases and standardises turnaround time TAT , improves safety, and allows manpower to be reallocated for optimisation of those tasks that cannot be automated. Laboratories adapt TLA to handle ever-increasing workloads and demands for quicker TATs and standardisation of laboratory operations.

TLA is ideally suited to core laboratories that conduct a wide spectrum of testing using highly automated systems coupled with sophisticated laboratory information systems LIS. The challenge for laboratory directors is to balance cost with the goals of analytical quality, patient safety and clinical service needs.

TLA offers a potential solution and has been adapted in various forms by clinical laboratories world-wide. The important considerations to be examined when considering TLA include: The first step towards TLA is to conduct a thorough, detailed analysis of the current laboratory processes, i. It will demonstrate the strengths and weaknesses of the current system, whether it be manual, semi-automated, or automated, and identify the steps that can be eliminated or improved by TLA. The old saw is true: Hawker very appropriately notes that failure to properly analyse the needs of the laboratory and understand the current state and processes in the laboratory are the primary reasons why automation projects are not successful, or at least do not live up to the initial expectations of the adapters.

Hawker lists ten reasons why automation can fail to deliver on its promise: TLA involves some kind of track system that connects the pre-analytical, analytical, and post-analytical components. A track system is integral to TLA. Specimen carriers should be standardised and racks, typically with capacity for five samples, are routine. The sample handling module must provide error free specimen identification using barcodes or RFID labels. Software must allow the sample ID to be read and to obtain associated patient information, including the tests requested, from the LIS.

LAS or middleware includes autoverification and autoretrieval capability for repeat or reflex testing and dilution testing. The racks and the track must be able to handle a wide variety of primary collection tube sizes and types and also sample cups placed in tube adapters. The major instrument manufacturers provide track systems and tracks and they are also available from independent automation vendors as well.

Laboratoriess must confirm that a track is compatible with analysers other than those from the track manufacturer. The theoretical throughput claimed by a manufacturer may not match reality.

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This is not necessarily a false claim by the manufacturer as throughput and TAT will logically be affected by the actual sample volume and the exact number and type of tests requested for each sample. Expert rules based software allows for automatic release of test results without issues and flags results that require human attention and review.

Laboratories must be realistic and recognise that TLA is not a panacea. They should use only as much automation as is necessary and appropriate. A laboratory can mix and match modules to achieve the desired configuration. Does TLA deliver on its promise or is it overkill? That is a question each laboratory must answer, and the conclusion should be based on hard data. The introduction of a robotics system for perianalytical automation brought large improvements in productivity together with decreased operational costs, even though the workload increased significantly and the number of personnel decreased.

In their analysis, productivity increased by A dramatic reduction in total cost per test was due almost entirely to the reduction of labour due to increased productivity and spare capacity in the system allowed for a significant increase in volume without any increase or minimal increase of personnel. This is the kind of hard data required to objectively evaluate the return on investment of TLA. In addition IA suffers from the high cost of antibodies, lot-to-lot differences, calibration bias, and crossreactivity.

The initial cost of equipment is high, but the cost of reagents for extraction and analysis are typically lower than that of IA. Ready to use methods from vendors are not yet widely available.