17 resultados para 922
Resumo:
Background: There is growing interest in the potential utility of real-time polymerase chain reaction (PCR) in diagnosing bloodstream infection by detecting pathogen deoxyribonucleic acid (DNA) in blood samples within a few hours. SeptiFast (Roche Diagnostics GmBH, Mannheim, Germany) is a multipathogen probe-based system targeting ribosomal DNA sequences of bacteria and fungi. It detects and identifies the commonest pathogens causing bloodstream infection. As background to this study, we report a systematic review of Phase III diagnostic accuracy studies of SeptiFast, which reveals uncertainty about its likely clinical utility based on widespread evidence of deficiencies in study design and reporting with a high risk of bias.
Objective: Determine the accuracy of SeptiFast real-time PCR for the detection of health-care-associated bloodstream infection, against standard microbiological culture.
Design: Prospective multicentre Phase III clinical diagnostic accuracy study using the standards for the reporting of diagnostic accuracy studies criteria.
Setting: Critical care departments within NHS hospitals in the north-west of England.
Participants: Adult patients requiring blood culture (BC) when developing new signs of systemic inflammation.
Main outcome measures: SeptiFast real-time PCR results at species/genus level compared with microbiological culture in association with independent adjudication of infection. Metrics of diagnostic accuracy were derived including sensitivity, specificity, likelihood ratios and predictive values, with their 95% confidence intervals (CIs). Latent class analysis was used to explore the diagnostic performance of culture as a reference standard.
Results: Of 1006 new patient episodes of systemic inflammation in 853 patients, 922 (92%) met the inclusion criteria and provided sufficient information for analysis. Index test assay failure occurred on 69 (7%) occasions. Adult patients had been exposed to a median of 8 days (interquartile range 4–16 days) of hospital care, had high levels of organ support activities and recent antibiotic exposure. SeptiFast real-time PCR, when compared with culture-proven bloodstream infection at species/genus level, had better specificity (85.8%, 95% CI 83.3% to 88.1%) than sensitivity (50%, 95% CI 39.1% to 60.8%). When compared with pooled diagnostic metrics derived from our systematic review, our clinical study revealed lower test accuracy of SeptiFast real-time PCR, mainly as a result of low diagnostic sensitivity. There was a low prevalence of BC-proven pathogens in these patients (9.2%, 95% CI 7.4% to 11.2%) such that the post-test probabilities of both a positive (26.3%, 95% CI 19.8% to 33.7%) and a negative SeptiFast test (5.6%, 95% CI 4.1% to 7.4%) indicate the potential limitations of this technology in the diagnosis of bloodstream infection. However, latent class analysis indicates that BC has a low sensitivity, questioning its relevance as a reference test in this setting. Using this analysis approach, the sensitivity of the SeptiFast test was low but also appeared significantly better than BC. Blood samples identified as positive by either culture or SeptiFast real-time PCR were associated with a high probability (> 95%) of infection, indicating higher diagnostic rule-in utility than was apparent using conventional analyses of diagnostic accuracy.
Conclusion: SeptiFast real-time PCR on blood samples may have rapid rule-in utility for the diagnosis of health-care-associated bloodstream infection but the lack of sensitivity is a significant limiting factor. Innovations aimed at improved diagnostic sensitivity of real-time PCR in this setting are urgently required. Future work recommendations include technology developments to improve the efficiency of pathogen DNA extraction and the capacity to detect a much broader range of pathogens and drug resistance genes and the application of new statistical approaches able to more reliably assess test performance in situation where the reference standard (e.g. blood culture in the setting of high antimicrobial use) is prone to error.
Resumo:
A solvent-vapour thermoplastic bonding process is reported which provides high strength bonding of PMMA over a large area for multi-channel and multi-layer microfluidic devices with shallow high resolution channel features. The bond process utilises a low temperature vacuum thermal fusion step with prior exposure of the substrate to chloroform (CHCl3) vapour to reduce bond temperature to below the PMMA glass transition temperature. Peak tensile and shear bond strengths greater than 3 MPa were achieved for a typical channel depth reduction of 25 µm. The device-equivalent bond performance was evaluated for multiple layers and high resolution channel features using double-side and single-side exposure of the bonding pieces. A single-sided exposure process was achieved which is suited to multi-layer bonding with channel alignment at the expense of greater depth loss and a reduction in peak bond strength. However, leak and burst tests demonstrate bond integrity up to at least 10 bar channel pressure over the full substrate area of 100 mm x 100 mm. The inclusion of metal tracks within the bond resulted in no loss of performance. The vertical wall integrity between channels was found to be compromised by solvent permeation for wall thicknesses of 100 µm which has implications for high resolution serpentine structures. Bond strength is reduced considerably for multi-layer patterned substrates where features on each layer are not aligned, despite the presence of an intermediate blank substrate. Overall a high performance bond process has been developed that has the potential to meet the stringent specifications for lab-on-chip deployment in harsh environmental conditions for applications such as deep ocean profiling.
