1

QUALITY AND AUTOMATION
IN THE DETERMINATION OF THE
ERYTHROCYTE SEDIMENTATION RATE by Paolo Galiano
2

In the last 5 years many scientific works on the
TEST1 system have been published by different authors, many of them Italian, but others from
The Netherlands, New Zealand, Korea, Spain.
The state of the art of these articles provides a view of the new state of the art of the
Erythrocyte Sedimentation Rate in the world.
3

SCIENTIFIC WORKS AND PUBLICATIONS
1. M. Plebani, S. De Toni, M.C. Sanzari, E. Stockreiter, D. Bernardi (Dept. of Laboratory
Medicine, University-Hospital, Padova, Italy), “The TEST 1 Automated System: A New
Method for Measuring for Erythrocyte Sedimentation Rate”, American Journal of Clinical
Pathology , 1998, 110:334-340.
2. N. Cirilli, Z. Abu Asy, N.
Giacchè, F. Bordicchia, S. Paolucci, M. Tocchini (Dept. of
Laboratory Medicine, G. Salesi Hospital, Ancona, Italy), “TEST1: Un Nuovo Metodo per la
Determinazione della VES”, Biochimica Clinica , Vol. 22, N. 5-6, 1998, p. 339.
3. M. Plebani, S. De Toni, M.C. Sanzari, E. Stockreiter, D. Bernardi, F. Floriani (Dept. of
Laboratory Medicine, University-Hospital, Padova, Italy),
“Il Sistema Automatizzato
TEST1: un Nuovo Metodo per la Determinazione della
Velocità di Eritrosedimentazione”,
Medicina di Laboratorio , Vol. 6, N. 2, June 1998, pp. 166-172.
4. G. Soffiati (Clinical Chemistry and Hematology Laboratory, San Bortolo Hospital, Vicenza,
Italy),
“Nuovo Metodo per la Determinazione della Velocità di Eritrosedimentazione (VES)”,
August 1998, private communication.
5. L. Germagnoli, S. Lopez-Silva, M. Murone, S. Vazzana, L. Grassini, L. Calloni, V. Gioia
(Dept. of Laboratory Medicine, Scientific Institute San Raffaele, Milan, Italy),
“Evaluation of the Automatic System TEST1
™ for Measurement of the Erythrocyte Sedimentation Rate
(ESR)”, issued as scientific poster on
Clinical Chemistry , July 1999.
4

SCIENTIFIC WORKS AND PUBLICATIONS
6. K. S. Shin, J.S. Kim, B.R. Son (Dept. of Clinical Pathology, College for Medicine Chungbuk
National University, Cheongju, Korea): “Evaluation of the TEST 1 for Measuring
Erythrocyte Sedimentation Rate”
Journal of Clinical Pathology and Quality Control , Vol.
21, No. 1, 1999, pp. 223-228.
7. John Robert "Erythrocyte Sedimentation. A New Solution to an Old Problem", (Hitech
Pathology, Melbourne, Australia) issued on the official publication of the New Zealand
Institute of Medical Laboratory Science and Australian Institute of Medical
Scientists, South Pacific Congress, Christchurch, New Zealand, 23-27 August 1999, sponsored by Dade Behring Diagnostics.
8.
C. Gasparoli, D. Pulè, A. Fusco (Dept. of Laboratory Medicine, Istituto Dermopatico
Immacolata
– IRCCS, Rome), “Sostituzione di un Metodo Tradizionale per la Misurazione delle VES con il Nuovo Metodo Automatico TEST1”, October 1999, private communication.
9.
K. Taylor (Canterbury Health Laboratories, Christchurch, New Zealand), “TEST1 Evaluation
Report”, December 1999, private communication.
10.N. de Jonge, I. Sewkaransing, J. Slinger, J.J.M. Rijsdijk (Dept. Clinical Chemistry,
Leyenburg Hospital, The Netherlands), “Erythrocyte Sedimentation Rate by Test-1
Analyzer”, Clinical Chemistry, June 2000, 46: 881-882.
5

SCIENTIFIC WORKS AND PUBLICATIONS
11. M. Plebani, E. Piva, M.C. Sanzari, G. Servidio (Dept. of Laboratory Medicine,
UniversityHospital, Padova, Italy), “Length of Sedimentation Reaction in Undiluted
Blood (Erythrocyte Sedimentation Rate): Variations with Sex and Age and Reference
Limits”, Clinical Chemistry and Laboratory Medicine , May 2001, 39: 451-454.
12.D. Giavarina, S. Capuzzo, M. Carta, F. Cauduro, G. Soffiati (Clin. Chem. & Hematol.
Lab., San Bortolo Hospital, Vicenza, Italy), “Internal Quality Control for Erythrocyte
Sedimentation Rate (ESR) measured by TEST1 Analyzer”, Clinical Chemistry, June
2001, 47: 162.
13.
D. Spedding, D. Smith (Dade Behring Diagnostics, New Zealand), “Evaluation of
Agreement between the TEST1 and Starrsed Automated ESR Analysers”, November
2001, private communication.
14.M. Plebani, E. Piva (Dept. of Laboratory Medicine, University-Hospital, Padova, Italy),
“Erythrocyte Sedimentation Rate. Use of Fresh Blood for Quality Control”,
American
Journal of Clinical Pathology , 2002, 117:621-626.
15.E. Heverin (GalwayMayo Institute of Technology, Ireland), “Comparison of the
Westergren method versus the TEST1 technique for determining the Erythrocyte
Sedimentation Rate”, May 2002, private communication.
6

SCIENTIFIC WORKS AND PUBLICATIONS
16.P. Napoli, B. Montaruli, S. Plateroti, A. Martini, A. Sacchi, A. Toja. M. Saitta (Analysis
Lab, CIOV, Evangelico Valdese Hospital, Turin, Italy), “Sistema Automatizzato TEST1:
Controllo di
Qualità Interno per la Determinazione della VES”,
Biochimica Clinica ,
Vol. 26, N. 3, 2002, p. 215.
17.B.H. Lee, J. Choi, M.S. Gee, K.K. Lee, H. Park (Dept. of Laboratory Medicine,
Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul,
Korea),
“Basic Evaluation and Reference Range Assessment of TEST1 for the
Automated Erythrocyte Sedimentatioon
Rate”,
Journal of Clinical Pathology and
Quality Control , Vol. 24, No. 1, 2002.
18.D. Giavarina, S. Capuzzo, F. Cauduro, M. Carta, G. Soffiati (Clin. Chem. & Hematol.
Lab., San Bortolo Hospital, Vicenza, Italy), “Internal Quality Control for Erythrocyte
Sedimentation Rate Measured Test 1
Analyzer”,
Clinical Laboratory 2002, 48: 459-
462.
19.Romero A., Muñoz M., Ramirez G. (Dept. of Haematology, H.C.U. "Virgen de la
Victoria", Málaga & *GIEMSA, School of Medicine, University of Málaga, Spain),
"Determination of the Length of Sedimentation Reaction in Blood: a Comparison of the
Test1 ESR System with the ICSH Reference Method and the Sedisystem", Clinical
Chemistry and Laboratory Medicine 2003, 41 (2).
7

SCIENTIFIC WORKS AND PUBLICATIONS
•
20. M. Plebani (Dept. of Laboratory Medicine, University-
Hospital, Padova, Italy), “Erythrocyte
Sedimentation Rate: Innovative Techniques for an Obsolete Test?”,
Clinical Chemistry and
Laboratory Medicine , 2003, 41 (2): 115-116.
• 21. Nicoli M., Lanzoni E., Massocco A., Franceschini C.* (Laboratory of Clinical Chemistry and
Haematological Analysis, Ospedale Civile Maggiore, Verona, Italy & *Dasit, Cornaredo, Italy),
“Integrated Haematology and Coagulation Laboratory”, Poster,
Euromedlab Congress ,
Barcelona, Spain, 1-5 June 2003.
• 22. P. Galiano, “Quality and Automation in the Determination of the Erythrocyte Sedimentation
Rate, Symposium 046, 22nd World Congress of Pathology & Laboratory Medicine , 30
August-2 September 2003, Busan, Korea.
• 23. J.M. Jou, “La VSG: còmo, cuàndo y para qué puede ser ùtil”, (Hospital Clinic University of
Barcelona), AEHH/SETH Hematology Society National Congress , 23-25 October 2003,
Santiago de Compostela, Spain.
•
24. B. Olivera Alonso, M. Sirvent Monerris, M.T. Rotella Belda,
V. Ballenilla Antón, García Vidal
(M Laboratorio Hospital San Vicente y Area Sanitaria 18. Alicante, Spain), “Cambio De Método
Para La Determinación De V.S.G.: Repercusiones Sobre La Fase Preanalítica”, Generalitat
Valenciana - Conselleria De Sanitat (for Valencia Government – MOH), Spain 2004.
8

Heverin from Galway-Mayo Institute of
Technology, in describing the reproducibility of the TEST1, verifies a very important point,
“temperature”. To perform a reliable internal quality control it is absolutely needed to keep the samples into the refrigerator and to allow them to reach room temperature the day after before testing them again. I remind you that from
NCCLS 4 th edition, approved May 2001, ESR cannot be calibrated.
9

K3EDTA @ 24hrs 4°C, K2EDTA @ 24hrs 4°C
 r=0.974
From E. Heverin (GalwayMayo Institute of Technology, Ireland), “Comparison of the Westergren method vs the TEST1 technique for determining the Erythrocyte Sedimentation Rate”, May 2002 10

From E. Heverin (GalwayMayo Institute of Technology, Ireland), “Comparison of the Westergren method vs the TEST1 technique for determining the Erythrocyte Sedimentation Rate”, May 2002
Test 1 ESR results at 4hrs versus 48hrs at 4 °C
K3EDTA @ 48hrs 4°C, K2EDTA @ 48hrs 4°C
 r=0.964
11

From E. Heverin (Galway-
Mayo Institute of Technology, Ireland), “Comparison of the Westergren method vs the TEST1 technique for determining the Erythrocyte Sedimentation Rate”, May 2002
12

From E. Heverin (Galway-
Mayo Institute of Technology, Ireland), “Comparison of the Westergren method vs the TEST1 technique for determining the Erythrocyte Sedimentation Rate”, May 2002
13

Now let me make a brief list of the reference subjects described by the National Committee for Clinical
Laboratory Standards. All the topics belong to sodium citrate collected samples.
14

15

16

17

18

19

20

21

22

23

From NCCLS, 4rd ed., Vol. 20, No. 27, December 2000
Acceptable values comparing EDTA with citrate collected samples
EDTA
Fixed
20 43
20
21
22
23
24
25
26
27
28
-
36
37
38
39
40
41
42
43 s a m e s a m p l e
5-17 
6-17
6-18
6-19
7-19
7-20
8-21
8-21
9-22
-
13-29
13-30
14-30
14-31
15-32
15-33
16-34
 17-35
Citrate
Variables
5-17 17-35
24

Just from one of the points you can read from the original document, I use page 8 to see the limits of all citrate methods and instruments using this type of preservant (sodium citrate). TEST1 has a big advantage: it works with EDTA,considered to be the best blood preservant.
In fact, if you see this slide, the variation of citrate is intrinsic to the list shown above offering an acceptable range, but variable against a fixed value offered by EDTA samples.
25

26

27

28

29

SAMPLE
THE CLASSICAL ESR
ESR 1h ESR – HEMATOCRIT
20% Area requested for well mixing
Agglomerin
Normal
Pathological t=0 t=1h
WESTERGREN
35%
Normal
Hematocrit range t=12 h or Centrifugation
30

ESR is a phyisical phenomenon circumscribed on time
From NCCLS: recognised curve is a sigmoid type helped by the presence of specific proteins called agglomerins
Without these agglomerins there is no sedimentation
31

• Pathologies
– leukaemia, rheumatic polimialgy, rheumatoid arthritis, thromboflebitis, subacute endocarditis, pneumoniae, colangitis, osteomyelitis, SLE, pyelonephritis, post cardiosurgery, acute hearth stroke, lung stroke, linphoma, rheumatic fever, viral hepatitis, glomerular nephritis, infectious mononucleosis, breast cancer, lung cancer, hepatic metastatis, ipernephroma, uremia, acute meningithis, ictus, sarcoidosis, pelvic infections
(gonococcus and others), tubercolosis, Crohn’s disease, burns, bone fracture, anemia, arthrosis, gout, cholecystitis, typhus, mumps, acute allergy, ulcerative colitis, pregnancy, postpartum, menstruation, Cytomegalovirus infection, Toxoplasmosis, Rickettsiosis, fever, appendicitis.
• Drugs
– contraceptive , A Vitamin
– others: B Hepatitis vaccination
32
32

33
• Pathologies
– dehydration, hepatic necrosis, Thrichinosis, polycythemia, fibrinogenopenia and iperfibrinogenemia, cachexy, anticoagulants
• Drugs
– salicylates, cortisone, ACTH, Cyclophosphamide
(chemotherapeutic agent), chinin, oxalate
33

:
( from NCCLS Vol.20 No.27 H2-A4 )
- errors in the dilution step
- poor temperature control
- problems connected to vibrations,verticality,diameter of pipets
- test must be run within 4 hours from blood collection
- PCV adjustment (<0.35)
- No control available
- plastic tubes may interfere with red cells surface charges due to the plastic material
34

VACUTAINER TUBE IN CITRATE
Errors in the dilution phase
Correct Level
Exceeding level of blood
(fresh tubes)
NO RATIO RESPECTED insufficient level of blood
(old tubes)
NO RATIO RESPECTED
NO OK
Correct level of blood
Dilution ratio 1:4
RATIO RESPECTED
NO
35

THE IMPORTANCE OF HEMATOCRIT
DIFFERENT RESULTS OF THE SAME SAMPLE DILUTED
WITH AUTOLOGOUS PLASMA
140
120
100
80
60
40
20
0
0 20 40 60 80 100 120 140 160 180 200
TIME (minutes)
Hct of 26 Hct of 28 Hct of 34 Hct of 45
Sedimentation as a function of time with different Hct values artificially obtained adding autologous plasma
(Blood , Vol. 70, No 5, Nov. 1987: pp 1572-1576).
36

LOW INFLUENCE OF HEMATOCRIT ON TEST 1
From Thomas L.Fabry, Mechanism of Erythrocyte Aggregation and Sedimentation,
Blood, Vol. 70, No. 5 (Nov.), 1987: pp 1572-1576.
Fabry’s Formula to adjust the value of ESR
Example of adjustment for a sample with hematocrit 30.3
- Correct value = 69.2
- WG non corrected value = 114
- TEST 1 = 67
Example of adjustment for a sample with hematocrit 26.3
- Correct value = 66.3
- WG non corrected value = 127
- TEST 1 = 67
37

LOW HEMATOCRIT
The instrument indicates with an asterics (*), near the result, the samples with a low hematocrit value.
In the example reported the hematocrit value is low
38

Moreover, the commercial quality controls offered and pushed by our competitors, as you can see again, show the great variations of these values, improperly offered under this name: ranges and limits suggested in the figure show how low level is indicated from 1 to14 and high level from 15 to
55.
39

40

41

TEST1 offers much closer reproducibility as many authors have described using internal samples of their labs, tested 24 and 48 hours later. The correlations you see on the data are comparable to normal clinical chemistry controls and, finally, our statistical quality control gives you a method based on statistical data of your population. The cumulative data of any day (white circles) can be compared with the black one, that are the statistical data collected by the instrument during a month and these collected data can be considered as a standard when you have in the black circle values at least from 500-1000 results. The cumulative black circle maintains a revolving number of 6000 samples as a standard.
42

TEST 1 REPRODUCIBILITY DURING THE SAME DAY
Samples collected on January 28th and processed on January 29th
29/01/2003 29/01/2003 29/01/2003 29/01/2003
12.07.am
12.18am 12.28am
15.38 pm
ESR
52
19
59
22
7
26
16
11
2
38
76
14
2
15
42
50
17
57
22
8
25
16
11
3
41
79
13
3
16
44
47
20
55
23
7
22
16
10
4
44
79
13
3
16
40
45
18
58
24
9
23
17
11
2
42
74
15
4
14
41
R = 0,99 in the correlation between column Bcolumn C = R2 0,9944
R = 0,99 in the correlation between column Bcolumn D = R2 0,9831
R = 0,99 in the correlation between column Bcolumn E = R2 0,988
Samples were properly stored in the refrigerator
(4°C) and let them get room temperature taking them out of the refrigerator 30-40 minutes before running the tests performed with Test 1
Instrument. Samples are properly mixed in Test
1, thus aggregated cells are re-suspended in the plasma and ESR is consequently correctly measured.
alive during the training! The red column is the reference towards which the correlations of columns C, D and E have been calculated.

CORRELATION CHART
TEST 1 REPRODUCIBILITY DURING THE SAME DAY
90
80 y = 0,9798x + 0,4054
Samples collected on January 28th
R = 0,9831 y = 1,0066x + 0,0901
R
2
= 0,9944
70
ESR
60
50
40
30
20
10
29/01/2003 29/01/2003
12.07.am
12.18am y = 0,9446x + 1,2142
2
R
2
76
41
79
3
14
2
13
3
15
42
7
26
16
11
52
19
59
22
16
44
8
25
16
11
50
17
57
22
29/01/2003
12.28am
16
40
7
22
16
10
4
44
79
13
3
47
20
55
23
29/01/2003
15.38 pm
14
41
9
23
17
11
2
42
74
15
4
45
18
58
24
0
0 20 40 60 fig 1
80
R = 0.99
44

REPRODUCIBILITY AFTER 48 HOURS
Samples collected on 28/1/2003 and processed on 30/1/2003
SAMPLES HAVE BEEN STORED AT +4°C DURING THE TIME LAPSE BETWEEN 29 AND 30 JANUARY
ESR
29/01/2003 30/01/2003 30/01/2003
12.07am
26
16
11
52
19
59
22
2
15
42
7
2
38
76
14
9.21am
2
36
77
11
2
12
35
8
22
14
9
43
20
56
22
9.32am
R = 0.99 correlation between columns B- columns C R2 0,9832
R = 0.99 correlation between columns B- columns D R2 0,9844
20
15
10
44
20
55
22
2
12
39
8
2
41
75
12
The following day we took out from the refrigerator the 15 samples tested the day before and let them get room temperature for about 30-40 minutes.
Then we put samples into Test 1 and the working session started.
After 3 minutes of mixing cycle the measurement of ESR begun.
The results of two running sessions are reported on columns C and D. Column B has been copied and pasted from the previous
Excel sheet in order to have an immediate comparison among reproducibility of Test 1 and good quality of results.
45

CORRELATION CHART
90
80
ESR
70
60
50
40
30
20
10
0
0
29/01/2003
12.07am
y = 0,9557x - 0,9483
R
2
= 0,9832
2
38
R
2
10
= 0,9844
20
14
2
15
42
7
26
16
11
52
19
59
22
30
30/01/2003
9.21am
40
22
14
9
43
20
56
22
2
36
77
11
2
12
35
8
50
30/01/2003
9.32am
60
20
15
10
44
20
55
22
70
2
41
75
12
2
12
39
8
80 R = 0.99
46

I specified that the value of our control is to be interpreted upon the reproducibility of the correlation value R=0,99 and this is a real reproducibility as a clinical chemistry control, not based on the possible variation of a sample that may also give not so reproducible results the day after. This is not so frequent but if it occurred you would be able to give the correct answer: it is the reproducibility R that creates the stability of control.
Moreover, I graphically represented the normal, pathological and myeloma conditions to show the time and curve typology of the myeloma-ESR case. I have intentionally begun a discussion in which, as a first topic, I have reminded the audience that the representation of a myeloma-ESR curve is not even reported by the NCCLS, as this organisation describes only a Sigmoid-like curve to represent a physical condition, in this case the ESR testing, and not a curve that remains plain for many minutes and then precipitates.
47

Storage of blood sample at 4 °C for up 24 hours caused a decrease in ESR values obtained with the TEST1: the mean difference was 2.86 ( 95%
CI, 2.41-3.31) and 2.28 (95% CI, 1.90-2.65) respectively for two different analyzers with the same samples (n=1.140).
The decreases were of 9% and 11% .
48

STATISTICAL QUALITY CONTROL DATA REPORT
For Range 2-120 mm/h and 2-30 mm/h
Print out date
Scale of values
Value of cumulative average

(black circle)
Value of daily average O (white circle)
STD S. cumulative standard deviation
STD D. daily standard deviation
N.B. The values printed are only examples not to be considered as absolute but only indicative.

(black circle ) = 6000 data of cumulative values are equivalent to your statistical population, which can be considerd a Standard
49

STATISTICAL QUALITY CONTROL DATA REPORT
For control of population to obtain internal normal range
50

51

STABILITY OF VACUTAINER TUBE IN EDTA
From Clinical Chemistry , Vol. 47, No. 6, Supplement 2001, p. 162 -
Internal quality control for erythrocyte sedimentation rate (ESR) measured by TEST 1 analyzer by D. Giavarina, S. Capuzzo, M.
Carta, F. Caoduro, G. Soffiati, Clin. Chem. & Hematol Lab - San
Bortolo Hospital: Vicenza, Italy
52

53

54

55
New software benefits for
LAB ACCREDITATION
The unique characteristics of ALIFAX ESR analyzers provides a Statistical Internal Quality
Control useful to the certification of the lab.
The new ISO9001/UNI EN ISO 9001 – Ed. 2000 certification is used for the validation of the lab test in which the lab instrumentation, controls and, in general, the analysis system can have the recognition of a value and its maximum validation to guarantee operation functionality and reliability of the results.
TEST1 TH new software offers:
• Control of the functionality of reading sensors for each washing
•
Data control by a statistical quality system based on the control validity of the collected data of a population
•
Control of the daily value relative to a population of 6000 memorized data in the instrument
• Control of the single result scanned 1000 times by our system for each analysis
•
Control of sample reproducibility on samples tested the day after
•
Control of data reproducibility at R value equivalent to 0.98-0.99
• Control for samples improper to the test below the normal hematocrit values
< 20
•
Control of data transmission to LIS.
55

TECHNICAL CHARACTERISTICS
• Autodiagnostics
• Internal or external bar code reader
• Interfacing through RS232
• QUERY HOST Software for PC LAB management
• No dedicated tubes
• Compatible with cell counter racks (Bayer, Beckman Coulter,
Sysmex, Abbott, ABX, etc.)
• Capacity of 60 samples random batch access
• 180 samples/hr
• Automatic sample mixing
• Blood collection according to the ICSH recommendations
• Flow control to check of eventual clots
• Minimum Blood Volume > 1 ml
• Working volume 150 µL of blood
56

TECHNICAL CHARACTERISTICS
• Cell measure volume 1 µL
• Thermostation 37°C
• First result after 3 minutes and 20 seconds
• Low influence of hematocrit < 35 HCT
• No carryover
• Autowashing
• Safe-control closed cycle system
• Automatic reading and print out of the results
• Totally safe waste volume tank
• Waste production reduced (Test 1=3 L, others=1.000L)
• Waste disposal costs reduced
• Statistical internal quality control of population for normal values
• Safety check card
• Electronic calibration for alignment of results
57

• The only instrument in the world which can
the ESR values
• Remember that all other instruments on the market are simply READERS
58

• Test 1 measures the kinetics of blood sedimentation phenomenon
• all the other instruments simply read the final result of this phenomenon, that is why they need more time to give results
59

TEST1
ESR
60

CAPACITY OF SEDIMENTATION AND AGGREGATION
TEST 1 studies the sedimentation and aggregation capacity of the blood red cells via optical density
Every sample is read 1000 times in 20 seconds verifying the aggregation and sedimentation capacity of the blood red cells
Light beam before Aggregation starting t = 0
Aggregation after 1000 scans t = 20 sec.
Light beam after
61

0
Lag phase
Normal Status
0
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
Time (minutes)
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
60
62

Inflammation Status
0
Lag phase
20 seconds
Precipitation phase
Packaging phase
70
0
-
-
+
-
-
-
+
-
+
+
+
+
+
-
-
+
-
+
+
-
-
-
+
+
+
-
-
+
+
-
-
-
-
+
+
+
+
-
-
-
-
-
+
-
-
-
+
+
Time (minutes)
+
+ +
+
-
+ -
+
+
-
-
-
+
-
+ +
-
+
+
+
-
+
-
Agglomerine
-
-
-
+
-
+
-
-
-
-
-
-
+
+
+ +
-
+
+
-
-
-
-
+
+
+
+
-
-
+
-
+
+
+
+
60
63

0
Example of collapsed sample for ESR
Lag phase
Precipitation phase
70
0
-
-
+
-
-
-
+
-
+
+
+
+
-
-
-
-
+
+
-
+
+
-
-
-
+
+
+
-
-
+
+
-
-
+
+
+
Packaging phase
Time (minutes)
+
+
+
-
-
-
-
-
+
+
+
-
-
-
+
-
+
+
-
-
+
-
+
+
-
-
-
-
-
+
+
+
+
-
+
+
-
-
-
+
-
+
-
-
-
-
-
-
+
+
+ +
-
+
+
-
-
-
-
+
+
+
+
-
-
+
-
+
+
+
+
60
64

Example of a collapsed sample
From 200 mm to the ratio in percentage 100
200 mm
130
ESR
70
Corpuscular
Part
100 mm
65 ESR
35 Hematocrit or PCV
Westergren pipet
65

Myeloma
Example of collapsed sample for ESR
0 Lag phase
70
0
200 mm
-
-
-
-
+ +
+
+
-
+ +
-
-
-
-
-
-
-
-
+ +
+
+
+ +
-
+
-
-
+ +
-
+
Time (minutes)
Precipitation phase
Packaging phase
60
-
-
-
-
-
+ +
-
-
-
-
-
+
+
-
-
-
-
+ +
+ +
+
-
-
+
+
130 ESR
-
-
-
-
+ +
+
-
-
+ +
-
-
-
+
+ +
-
+
-
-
+ +
+
-
-
+ +
-
+
-
-
+ +
-
+
Westergren pipet
70
Corpuscular
Part
100 mm
65 ESR -
-
-
-
+ +
-
-
-
-
-
-
+
+
-
-
-
-
+ +
-
+
-
+
+
35 Hematocrit or PCV
66

These blood samples without “ Agglomerins” do not express a ESR value with a “sigmoid” tract, but collapse to the level of the Hematocrit. Final point of reading.
67

CALCULATION METHODOLOGY OF RESULTS
The mathematical algorithm converts the results from optical density to
ERYTHROCYTE SEDIMENTATION RATE of the microvolume analyzed from sample optical density to mm/hr Westergren
68

Test-1 ESR expresses the vitality of aggregation also 12, 24, 48 hr after collection, according to the sigmoid curve of the classic graph, that is the only curve described and represented.
69

PATENT
The world patent of Test-1 concerns the mathematic algorithm that expresses the same sigmoid function of the ESR
70

A synthetic control with no active electrical charge and with no agglomerins that induce and activate the sedimentation process is not recognized by Test-1 as these controls give no signals of vitality because they are not part of the “sigmoid sedimentation”, but a mixture of water – sand and not a measure of control.
71

72

73

74

30 µL of blood suitable for pediatric use
75

76

The only instrument that works without preservant
77

78

•
Quality Control
• Urgent diagnosis can be fulfilled
• Pediatric use
• No anticoagulant use- fresh blood for MicroTest1
• Test 1
ESR, it is not a
79

• Capillary
• Microvolume 150 or 30 microliters
(T1 or MicroT1)
• Photometric-kinetic
• Scanning rate -total scans 1000 for sample in 20 sec.
• Not influenced from hematocrit
• Rapidity of response correlated to Westergren
• Reproducibility
• Stability during time (EDTA-48 hours against Na Citrate
4 hours)
80

During 20 sec. the sample is scanned 1000 times
Ident. 05483311
ESR = 118 mm/hr
Ident. 05725053
ESR = 26 mm/hr
Ident. 05725044
ESR = 2 mm/hr
==> Time sec.
==> Time sec.
==> Time sec.
81

METHODOLOGY CHARACTERISTICS
1
It starts from 0 time to 20 sec. following and measuring the evolution of the sed rate curves.
2
It measures the optical density related to the concentration of the erythrocytes/aggregates present at the moment of the analysis.
3
Kinetics following the evolution of the curves with a frequency of 50 measures per second.
4
The capillary system simulates a invivo situation and guarantees minimal optical paths in blood subject to sedimentation which enable the detection of small variations.
82

From Clinical Chemistry and Laboratory Medicine,
February 2003, 41(2)
Romero A., Muñoz M., Ramirez G., Dept. of Haematology,
H.C.U. "Virgen de la Victoria", Málaga & GIEMSA, School of Medicine, University of Málaga, Spain, “Determination of the Length of Sedimentation Reaction in Blood: a
Comparison of the Test1 ESR System with the ICSH
Reference Method and the Sedisystem ” .
“… the correlation coefficient was 0.98…”
83

COMPARATIVE SCHEDULE
WEIGHT OF WASTE DISPOSAL
COMPANY
DIESSE
BD
TYPE OF
PRODUCED
WASTE
DEDICATED TUBE
+ BLOOD
TUBE WITH BLOOD
WASTE
PRODUCED FOR
EACH TESTING gr. 12 gr. 10
WASTE
PRODUCED FOR
20.000 TESTING
IN KG.
Kg. 240
Kg. 200
ALIFAX ON A COLLECTION
TANK
CAPACITY
2.000 TESTING gr. 0,25 Kg. 5
84

85

TEST 1
Westergren
ESR value
13.1
8.0
TEST 1
Westergren
29
25
TEST 1
Westergren
54.7
57.1
Range
12-14
8.0-10
27-32
21-30
51-58
51-60
CV%
4.86
9.68
5.30
8.45
3.37
5.04
86

• It preserves the red blood morphology.
• Does not interfere with mechanisms that lead to erythrocyte sedimentation.
• Increases specimen stability.
• Does not incur problems related to sample dilution with sodium citrate.
87

Specimens anticoagulated with EDTA:
• Are suitable for internal quality control programs.
• Allow the creation of a unique workstation for measuring ESR and performing other hematological tests (erythrocyte, leukocyte, reticulocyte counts and differential analysis in a single specimen).
88

Reference limits, 2.5
th and 97.5
th pervcentiles and their
95% confidence intervals (CI) for SRB in undiluted
EDTA-anticoagulant blood. Variation with age and sex
Age
(year) n Sex 2.5 percentiles 97.5 percentiles and 95%CI and 95%CI
0-14 80 W and M
15-50 190 Women
15-50 150 Men
51-70 120 Women
51-70 130 Men
>70 170 W and M
2 (2-2)
2 (2-2)
2 (2-2)
2 (2-3)
2 (2-2)
3 (3-3)
34 (26-41)
37 (36-39)
28 (20-30)
39 (38-45)
37 (31-44)
46 (45-55)
Clin Chem Lab Med 2001;39(5):451-4.
89

150 µL of blood
90

91

TEST 1
TH
RACK
Any kind of vacutainer tube available on the market can be used to perform the ESR, e.g.:
TEST 1
TH works by loading cell counter racks directly, eg.: Bayer,
Sysmex, Beckman Coulter, Abbott, ABX, etc…
92

Tubes lock
TUBES LOCK
Tubes unlock
93

SAMPLE ID WITH EXTERNAL BAR-CODE READER
Tube identification
With the bar code reader the ID patient is automatically assigned to the ESR result
Tube introduction into the rack
94

AUTOMATIC ID PATIENT WITH QUERY HOST SOFTWARE
Racks used:
Internal Bar Code Reader
Sample Identification with automatic selection of the tubes requiring the
ESR test both with dedicated racks.
95

WORKFLOW
Rack blocking
Tubes are blocked with an elliptic movement
Rack loading
Open the front door and insert the rack into the instrument.
Close the front door and press the
START key.
96

RACK ADAPTOR FOR BECKMAN COULTER
97

RACK ADAPTOR FOR BAYER
98

RACK ADAPTOR FOR SYSMEX - ABBOTT - ABX
99

The most recent work made by an Hospital in
Verona, Italy, is an important example of TLA
(Total Lab Automation), published at Euromedlab,
Barcelona 2003, in which the author declares what you can see in the poster (500 tubes of
ESR per day not using, as in the past, a dedicated sodium citrate tube).
100

The picture of the lab shows an integration of Sysmex cell counter and 2 TEST1 connected to the LIS. For the purpose of this automation the workflow is now available to perform the ESR test using directly the cell counter racks of Abbott, ABX, Beckman Coulter, Bayer and
Sysmex. Thus, TEST1 is loaded with special rack adaptors to contain the original hematology racks with an internal bar code reader selecting the ESR test connected to LIS.
I remind you no other author, as far as I can know, has published anything new with the old method and with the old reader systems.
101

102
INSTRUMENTS IN THE WORLD updated 26.04.04
102

103
INSTRUMENTS IN THE WORLD
TEST 1
T
O
T
A
L
734
13
12
9
5
41
40
21
20
6
1
TEST1 MicroTEST1
308
48
75
42
75
55
21
31
17
10
6
41
17
32
3
1
5
13
1
4
3
5
9
3
4
1
3
1
1
1
1
2
1
2
1
1
1
1
1
1
1
1
1
Roller 20 Country
8
14
Italy
South Africa
3
2
3
1
3
1
2
2
2
Nederlands
India
Hungary
Syria
Norway
U.S.A.
Nicaragua
El Salvador
Panama
Greece
Indonesia
Singapore
Vietnam
Chile
Japan
Spain
Korea
Brasil
Turkey
China
Belgium
Portugal
Australia
Germany
Colombia
Ireland/UK
Israel
New Zealand
Slovenia
Uruguay
Costa Rica
Malaysia
Guatemala
Micro
TEST 1
T
O
T
A
L
285
103

Sales of TEST 1 tests
12.000.000
10.000.000
10.161.000
104
8.000.000
7.104.000
6.000.000
4.000.000
2.000.000
819.000
2.218.000
3.058.500
4.580.500
0
1998 1999 2000 2001 2002 2003
104