You’re Doing it Wrong: Rethinking the Application of

Frederick G. Strathmann, PhD, MBA, DABCC (CC, TC)VP of QA | Assistant Laboratory Director | Director of New Technology & Innovation

NMS Labs, Willow Grove PAemail | LinkedIn | Twitter

You’re Doing it Wrong: Rethinking the Application of Available Mass Spectrometry Technologies for Toxicology

Outline

• Operational Efficiency and How We Measure• High Throughput Mass Spectrometry• Challenges to Conventional Thinking

1. Using an Example of Volume and Menu Growth

2. Marrying a High Throughput System with Mass Spectrometry Capable of “Keeping Up”

The Origin Story

Where Does Mass Spectrometry Fall?

• Continuous Flow

• Centrifugal Analysis

• Discrete Analysis

Theory of Constraints | “The Goal”

• Set in a factory• Main character learns “Socratically” how to manage his

operations from an unlikely source – his old physics professor

• Major epiphany comes form a Boy Scout hike with his son and the infamous “Herby”.

Yale Weis ©123RF

Example Test Process Workflow | 20hrs

Matching Supply with Demand: An Introduction to Operations Management (2013)

Job Shop or Flow Shop?

Matching Supply with Demand: An Introduction to Operations Management (2013)

(c) Robotiq

(c) Robotiq

Flow Shop Mass Spectrometry

Easy to automateEasy to measureEasy to optimize

InflexibleResource intensive (initially)Capacity slow to respond

PRO CON

Easy to startFlexibleCapacity quick to respond

Hard to automateHard to scheduleHard to measure/improve

PRO CON

(c) Robotiq

(c) Robotiq

Increasing Throughput | Example 1

• TDM Assay• Tacrolimus• Sirolimus• Everolimus

• 3 minute inj to inj• 96 well plate• 4 Stds, 4 QC (bookend)• 88 patients max per batch• 5 hours per batch• 2 batches per day or 176 results per day spread

across all three compounds

Adapted from Kocak et al. 2015 PMID: 26526462

Initial Capacity Assessment

Initial Capacity Assessment

Initial Capacity Assessment

A Closer Look at Utilization

Increasing Throughput | Example 1

New Capacity Assessment

Increasing Throughput | Example 2

• Opiate Assay• Morphine, Codeine, 6AM• Hydromorphone, Norhydromorphone• Hydrocodone, Norhydrocodone• Oxycodone, Noroxycodone• Oxymorphone, Noroxymorphone

• 3 minute inj to inj• 96 well plate• 4 Stds, 4 QC (bookend)• 88 patients max per batch• 5 hours per batch• 528 results per day

• 50%, 25%, 10%, 10%, 5%

1

2

3

4

5

Initial Capacity Assessment

Increasing Throughput | Example 2

1

2

3

4

5

New Capacity Assessment

Increasing Throughput | Example 2B

1 2

34

5 Panel 1

Matching Supply with Demand: An Introduction to Operations Management (2013)

New Capacity Assessment B

Increasing Throughput | Panels

Reference Mass: 121.0509922.0098

Agilent 1260 HPLC + 6230 TOF-LC/MSC18 based LC columnsPositive mode: 104 basic drugs

Courtesy of Dr. Kathryn Smith, ARUP Laboratories

Increasing Throughput | Panels

Column: Waters XSelect CSH C18 3x50 mm, 2.5 µmMP-A/Wash 1: 0.1% acetic acid in waterMP-B/Wash 2: 100% acetonitrileFlow rate: 500 µL/minInjection volume: 5 µL Column temperature: 30 °C

Positive Mode

Negative Mode

Courtesy of Dr. Zlatuse Clark, ARUP Laboratories

Downside to Panels

• Multi Calibrators and Multi QCs may tax instrument limitations while patients will not

• Reagent preparation may become problematic• Adding new compounds requires rework of existing

reagents• Statistical QC issues with low volume, unordered tests• Large size may inhibit modifications (too many moving

parts)• Concessions in compounds added together

Job Shop Mass Spectrometry

(c) Robotiq

Increasing Throughput | No LC

Displaces ions Restores ion path

Example Data | LDTD-DMS-MS/MS

XIC of -MRM (4 pairs): 319.300/191.100 Da from Sample 1 (TuneSampleID) of MT20180322105746.wiff (Turbo Spray IonDrive) Max. 5.0e6 cps.

-28 -26 -24 -22 -20 -18 -16 -14 -12 -10 -8 -6 -4 -2 0 2 4 6 8COV, Volts

0.0

5.0e5

1.0e6

1.5e6

2.0e6

2.5e6

3.0e6

3.5e6

4.0e6

4.5e6

5.0e6

5.5e6

6.0e6

6.5e6

7.0e6

7.5e6

Intensi

ty, cps

-10.32

Displaces ions Restores ion path

Mycophenolic acid

Mycophenolic acid glucuronide

Courtesy of Joseph Homan, NMS Labs

Capacity Assessment

Job Shop Mass Spectrometry

(c) Robotiq

LDTD + Mobility | Easing Throughput

What Else? | Screen with Reflex

Sample Collected

Screen w/ reflex ordered

Positive Negative

StopConfirmation

Report out NegativePositive Negative

Report out Concentration Report out Negative

Non-Specific Detection Methods

Johnson-Davis et al. (2016). Journal of Analytical Toxicology 40(2), 97-107.

Screen Only – Clinical Toxicology

Doyle, K. and F. G. Strathmann (2016). "Cost and Efficacy Assessment of an Alternative Medication Compliance Urine Drug Testing Strategy." Pain Medicine.

Screen Only | Cost as a Driver

Doyle, K. and F. G. Strathmann (2016). "Cost and Efficacy Assessment of an Alternative Medication Compliance Urine Drug Testing Strategy." Pain Medicine.

Screen Only | TAT as a Driver

McMillin, G. A., et al. (2015). "A hybrid approach to urine drug testing using high-resolution mass spectrometry and select immunoassays." Am J Clin Pathol 143(2): 234-240.

Screen with Reflex to Confirmation

• Ensure sample switches did not occur• Ensure interferences were not present

• Higher confidence in the final result• Useful with low pretest probability

• interpreting the results of a diagnostic test*• selecting one or more diagnostic tests*• choosing whether to act*

a) without further testing (treatment threshold)b) while awaiting further testing

• deciding whether it’s worth testing at all (test threshold)• The vast majority of clinical results are singlet analyses

and will likely be acted upon.

*https://www.cebm.net/2014/03/pre-test-probability/

Diagnostic Algorithms | Pretest Probabilities in Use

Pharmacogenetic Testing

Pain Management

Source: ARUP Laboratories; www.aruplab.com. Accessed July 17, 2018

Panel differences from Labs

Increasing Throughput | The Mega Screen

Reference Mass: 121.0509922.0098

Agilent 1260 HPLC + 6230 TOF-LC/MSC18 based LC columnsPositive mode: 104 basic drugs

Courtesy of Dr. Kathryn Smith, ARUP Laboratories

Unwieldy and Slow Targeted Panels

Reference Mass: 121.0509922.0098

Agilent 1260 HPLC + 6230 TOF-LC/MSC18 based LC columnsPositive mode: 104 basic drugs

Courtesy of Dr. Kathryn Smith, ARUP Laboratories

Increasing Intelligence | Panels

Courtesy of Natalie Rasmussen, Agilent Technologies

Targeted Screen by Rapid LC-TOF for enhanced specificity for Directed Confirmation including creatinine quantitation

Sensitive & Specific Rapid Screening

Rasmussen, N. N., et al. (2017). "Lowering the Bar for Mass Spectrometry: A Comparison between Immunoassay and Rapid Time-of-Flight for Presumptive Screening of Drugs in Urine." The Journal of Applied Laboratory Medicine: An AACC Publication.

Flexible Panels | Smaller Chunks

Courtesy of Brandon Nelson, NMS Labs

Rapid Injection | Trap & Elute

© Agilent Technologies

TOF and QTOF | Striking a Balance

Unknown Unknowns | Retrospective Data Analysis

https://www.forensicscienceeducation.org/resources/nps-discovery/

barry.logan@frfoundation.org

Traditional ApproachTest the sample one time.Compare the data to the database.Is one of the targeted drugs present? Report positive or negative.

What is Retrospective Analysis?Once a new drug is discoveredRetrospectively interrogate the data filesDetect drugs that were not known at the time of the physical testing.

Summary Points

• Efficiency is different depending upon the context• Capacity assessments at subsets of the analytical testing

system allow greater insight into process bottlenecks• Use of technology can allow us to be more flexible

convisum © 123RF

Acknowledgements

• NMS Labs

• Joseph Homan• Brandon Nelson

• AACC• MSSS

Zdenek Sasek © 123RF