Sepsis infection determination systems and methods

Abstract

Embodiments may include an automated method for evaluating a sepsis status associated with a blood sample obtained from an individual. Methods may include determining a standard deviation of monocyte volume associated with the blood sample. Methods may include determining a white blood cell count (WBC) associated with the blood sample. Methods may include evaluating, using a data processing module, the sepsis status associated with the blood sample. The data processing module may include a processor and a computer application. This computer application may cause the processor to compare the standard deviation of monocyte volume with a first cutoff value to provide a comparison. The computer application may cause the processor to compare the WBC to a second cutoff to provide a second comparison. The computer application may also cause the processor to evaluate the sepsis status associated with the blood sample based on the first comparison and the second comparison.

Claims

1. An automated method for evaluating a sepsis status associated with a blood sample obtained from an individual, the method comprising: presenting the blood sample to a transducer module; determining a standard deviation of monocyte volume and a white blood cell count (WBC) associated with the blood sample using the transducer module, wherein the transducer module comprises: an interrogation zone; and an illumination source configured to illuminate, and at least one light sensor configured to detect illumination from cells from, the blood sample in the interrogation zone; and evaluating, using a data processing module, the sepsis status associated with the blood sample, wherein the data processing module comprises a processor and a tangible nontransitory computer readable medium, and the computer readable medium is programmed with a computer application that, when executed by the processor, causes the processor to compare the standard deviation of monocyte volume from the transducer module to a first cutoff value to provide a first comparison, to compare the WBC from the transducer module to a second cutoff value and a third cutoff value to provide a second comparison, and to evaluate the sepsis status associated with the blood sample based on the first comparison and the second comparison.

2. The automated method of claim 1, wherein evaluating the sepsis status indicates suspicion of sepsis if the first comparison is higher than the first cutoff value, and the second comparison is either lower than the second cutoff value or higher than the third cutoff value.

3. The automated method of claim 1, wherein first cutoff value is from 19 to 22.

4. The automated method of claim 1, wherein the first cutoff value is 20.

5. The automated method of claim 1, wherein the second cutoff value is from 3,000 to 5,000 cells/μL.

6. The automated method of claim 1, wherein the third cutoff value is from 11,000 to 13,000 cells/μL.

7. The automated method of claim 1, wherein the processor compares the standard deviation of the monocyte volume to the first cutoff value by determining whether the standard deviation of the monocyte volume exceeds the first cutoff value.

8. The automated method of claim 1, further comprising altering a test reporting process based on the evaluation of the sepsis status.

9. The automated method of claim 1, further comprising treating the individual from whom the blood sample was obtained if the sepsis status indicates sepsis.

10. The automated method of claim 1, further comprising: delivering a hydrodynamically focused stream of the blood sample toward a cell the interrogation zone; and measuring, with an electrode assembly, current (DC) impedance of cells of the blood sample passing individually through the cell interrogation zone; wherein the transducer module determines the standard deviation of monocyte volume based on the DC impedance measurement of cells of the blood sample.

11. An automated system for evaluating a sepsis status associated with a blood sample obtained from an individual, the system comprising: a transducer module configured to determine a white blood cell count (WBC) and a standard deviation of monocyte volume of the blood sample, the transducer comprising an interrogation zone, and an illumination source configured to illuminate, and at least one light sensor configured to detect illumination from, cells from the blood sample in the interrogation zone; and a data processing module in connectivity with the transducer module, the data processing module comprising a processor and a tangible non-transitory computer readable medium, the processor programmed with a computer application that, when executed, causes the processor to compare the standard deviation of monocyte volume which the transducer module is configured to determine to a first cutoff value to provide a first comparison, to compare the WBC the transducer module is configured to determine to a second cutoff value and a third cutoff value to provide a second comparison, and to evaluate the sepsis status associated with the blood sample based on the first comparison and the second comparison.

12. The automated system of claim 11, wherein the processor compares the standard deviation of the monocyte volume by determining whether the standard deviation of the monocyte volume exceeds the first cutoff value.

13. The automated system of claim 11, wherein the first cutoff value is from 19 to 22.

14. The automated system of claim 11, wherein the second cutoff value is from 3,000 to 5,000 cells/μL.

15. The automated system of claim 11, wherein the third cutoff value is from 11,000 to 13,000 cells/μL.

16. The automated method of claim 8, wherein: the data processing module is comprised by an analyzer programmed to use a first test reporting process for non-sepsis samples, wherein the first test reporting process comprises transmitting test results to an endpoint selected from a group consisting of: (a) a laboratory information system, and (b) a health information system; the method comprises evaluating the sepsis status associated with the blood sample as having a sepsis indication; and altering the test reporting process based on the evaluation of the sepsis status comprises applying a second test reporting process based on the sepsis indication.

17. The method of claim 16, wherein the second test reporting process comprises flagging a test result associated with the blood sample for review.

18. An automated method for evaluating a sepsis status associated with a blood sample obtained from an individual, the method comprising: presenting the blood sample to a transducer module; determining a first parameter, wherein the first parameter is standard deviation of monocyte volume associated with the blood sample; determining, using the transducer module, a second parameter, wherein the second parameter is a white blood cell count (WBC) associated with the blood sample, and wherein the transducer module comprises an interrogation zone and an illumination source configured to illuminate, and at least one light sensor configured to detect illumination from cells from the blood sample in the interrogation zone; and using a processor programmed with a computer application stored on a nontransitory computer readable medium to perform acts of: obtaining a first comparison by comparing the first parameter to a first cutoff value; obtaining a second comparison by comparing the second parameter to a second cutoff value and a third cutoff value; and evaluating sepsis status associated with the blood sample based on the first comparison and the second comparison, wherein evaluating sepsis status associated with the blood sample based on the first comparison and the second comparison comprises determining if the blood sample indicates sepsis based on the first comparison and the second comparison.

19. The automated method of claim 18, wherein: obtaining the first comparison comprises determining that the first parameter exceeds the first cutoff value; obtaining the second comparison comprises determining that the second parameter either exceeds the second cutoff value or is less than the third cutoff value; and evaluating sepsis status associated with the blood sample based on the first comparison and the second comparison comprises determining that the blood sample indicates sepsis based on the first parameter exceeding the first cutoff value and the second parameter either exceeding the second cutoff value or being less than the third cutoff value.

Description

BRIEF DESCRIPTION OF THE DRAWINGS

(1) FIG. 1 illustrates aspects of blood cell analysis, according to embodiments of the present invention.

(2) FIG. 2 schematically depicts aspects of a cellular analysis system, according to embodiments of the present invention.

(3) FIG. 3 provides a system block diagram illustrating aspects of a cellular analysis system according to embodiments of the present invention.

(4) FIG. 4 illustrates aspects of an automated cellular analysis system for assessing a likelihood of infection in an individual, according to embodiments of the present invention.

(5) FIG. 4A shows aspects of an optical element of a cellular analysis system, according to embodiments of the present invention.

(6) FIG. 5 depicts aspects of an exemplary method for evaluating an infection status of an individual, according to embodiments of the present invention.

(7) FIG. 6 provides a simplified block diagram of an exemplary module system, according to embodiments of the present invention.

(8) FIG. 7 depicts an example screen shot of a differential count screen, according to embodiments of the present invention.

(9) FIG. 7A schematically shows a technique for obtaining blood cell parameters, according to embodiments of the present invention.

(10) FIG. 8 illustrates aspects of a method for assessing likelihood of infection based on a biological sample obtained from an individual, according to embodiments of the present invention.

(11) FIG. 9 shows a method of evaluating a sepsis status of a blood sample, according to embodiments of the present invention.

(12) FIG. 10 shows receiver operating characteristic (ROC) curve for evaluating a sepsis status using monocyte distribution width (MDW), according to embodiments of the present invention.

(13) FIG. 11 shows ROC curves for evaluating a sepsis status using MDW and white blood cell (WBC) count, according to embodiments of the present invention.

DETAILED DESCRIPTION

(14) Diagnostic markers for sepsis have been researched for many years. Even so, there has not been a clear diagnostic test or biomarker for determining sepsis available. It was previously believed that a series of seven blood-cell-related factors could be reviewed in order to determine possible septic infection. See, for example, Park et al., “Screening of sepsis using leukocyte cell population data from the Coulter automatic blood cell analyzer DxH800,” International Journal of Laboratory Hematology, 2011, 33, 391-399 at 397-98. As recently as a few years ago, it was believed that parameters or indices based on a calculation including at least two of the seven factors were needed in order to make a septic infection prediction. The present inventors have determined that, rather than requiring a formula to calculate a parameter or index using the parameters, it is unexpectedly possible to predict onset of a possible septic infection through simple and efficient comparisons with cutoff values. In other words, a binary analysis of one or two measures may be used to determine sepsis without calculating an index based on two or more factors and then evaluating sepsis status based on a non-binary value of the index.

(15) Embodiments of the present invention thus include systems and methods that assess the likelihood of infection, including sepsis, in a patient using cell count and cell population data. Data about the cell population, such as the standard deviation of the monocyte volume or monocyte distribution width (MDW) may be compared to a cutoff value for determining if an individual has sepsis. Data about the white blood cell count may then be used as a secondary check to the initial determination/testing. Evaluation of MDW sequentially with WBC (before or after, but as distinct, binary evaluations), may provide a clinical indicator with sensitivity and specificity about 0.80. The effectiveness of this simple, sequential evaluation is surprising at least in part because WBC has consistently been identified in the literature as a non-specific observation. That is, irregular (low or elevated) WBC measures may be associated with a variety of conditions, many of which have no relation to sepsis or SIRS. It was therefore unforeseen that a sequential evaluation of routine WBC cut-offs for normal/abnormal WBC measurements would have any bearing on whether a high MDW observation is indicative or predictive of sepsis.

(16) The definition of sepsis itself has changed, illustrating additional difficulties in conclusively diagnosing sepsis. Under the Sepsis-2 definition, sepsis was defined based on systemic inflammatory response syndrome (SIRS).” SIRS may refer to a clinical syndrome that results from a dysregulated inflammatory response to a noninfectious insult, such as an autoimmune disorder, pancreatitis, vasculitis, thromboembolism, burns, or surgery. SIRS criteria include temperature, heart rate, respiratory rate, and white blood cell count. SIRS criteria are described in Kaukonen et al., “Systemic Inflammatory Response Syndrome Criteria in Defining Severe Sepsis,” New England J. of Med., 372:1629-38 (2015) (doi: 10.1056/NEJMoa1415236) and the Supplementary Appendix, the contents of both of which are incorporated herein by reference for all purposes. “Sepsis” may be the clinical syndrome that results from a dysregulated inflammatory response to an infection. Under Sepsis-2, sepsis includes two SIRS criteria and infection. “Severe sepsis” may refer to sepsis-induced tissue hypoperfusion or organ dysfunction resulting from infection. “Septic shock” may refer to a condition of severe sepsis plus hypotension persisting despite adequate fluid resuscitation, which may be defined as infusion of 20-30 mL/kg of crystalloids.

(17) In 2016, Sepsis-3 updated the definition of sepsis, which is described in Singer et al., “The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3),” JAMA, 315(8):801-810 (2016) (doi: 10.1001/jama.2016.0287). Sepsis-3 defines sepsis as a life-threatening organ dysfunction caused by a dysregulated host response to infection. Organ dysfunction can be identified using a Sequential [Sepsis-related] Organ Failure Assessment (SOFA) score. The SOFA “score grades abnormality by organ system and accounts for clinical interventions.” “Septic shock” is considered a subset of sepsis, when “underlying circulatory and cellular/metabolic abnormalities are profound enough to substantially increase mortality.” There is no “severe sepsis” in Sepsis-3. As Sepsis-2 and Sepsis-3 definitions are not identical, even defining “sepsis” is challenging. Nonetheless, certain patient sample measurements, alone or in combination, may identify patients who meet the criteria for Sepsis-2 and/or Sepsis-3, or are at elevated risk of meeting the criteria for Sepsis-2 and/or Sepsis-3 in the near future (e.g., within 24 hours, or within 48 hours, of sample testing), as described herein.

(18) As sepsis is defined based on a set of clinical signs and symptoms, sepsis is not detectable in the blood the way a parasite or a low hemoglobin concentration may be detected. Methods and systems described herein may enable a clinician to identify or determine sepsis when clinical conditions are vague or non-specific (e.g., flu-like symptoms, which may be symptoms of sepsis). If “detecting” or a form of the word is used herein with sepsis, the term should be understood to mean determining, diagnosing, or assessing sepsis, rather than measuring a specific component definitively indicating sepsis.

(19) Conventional systems and methods for diagnosing sepsis may be inefficient and/or time consuming. In current practice, clinical criteria may be used to diagnose sepsis by detecting systemic inflammation that accompanies sepsis. The clinical criteria, however, may be common to both sepsis and SIRS, which may be associated with non-infectious conditions. An individual who may have sepsis may undergo laboratory tests, including but not limited to a test to generate a complete blood count (CBC) with differential (CBC-diff); measurements of C-reactive protein (CRP), serum lactate, erythrocyte sedimentation rate (ESR), and Procalcitonin (PCT); and cultures for bacteria. These technologies may result in poor sensitivity and/or specificity when used to diagnose sepsis. Other systems and methods may be limited to leukocyte cell population data (CPD) and may still be lacking in sensitivity and/or specificity. Some conventional methods may use CPD parameter(s) (e.g., monocyte volume) that lack the sensitivity and/or specificity of CPD parameters used herein. In some cases, conventional methods may require the use of multiple CPD parameters to show an increased sensitivity or specificity. Some of these tests may be expensive and may not be run routinely on individuals, and as a result, individuals who are infected and potentially septic but not yet symptomatic may not be diagnosed promptly or not diagnosed at all. The lack of an efficient and accurate method and system to evaluate the infection status may lead to a clinician administering antibiotics as a precautionary measure, resulting in overuse of antibiotics. Adverse drug events, adverse treatment interactions or side effects that might be easily managed in a healthy patient can present significant problems in a patient with SIRS, sepsis or similarly severe clinical conditions. Medicating all potentially septic patients with antibiotics, therefore, is not an ideal clinical strategy.

(20) On the other hand, waiting for test results may endanger an individual's life. Analyzing a blood culture to definitively diagnose sepsis may take three to four days. In that time, an individual can develop sepsis, develop organ failure, be past the point of recovery, and eventually die. A quick and accurate method to evaluate sepsis would improve patient outcomes and save lives. Any time saved in identifying sepsis or potential sepsis may improve patient outcomes.

(21) Generally, total white blood cell count and absolute neutrophil count increase with bacterial infection. Neutrophil percentage of white blood cells may also increase with infection. Even so, a significant proportion, up to 40%, of patients, may not exhibit these increases. As a result, WBC may not be a sensitive or specific marker for sepsis. Additionally, elevated white blood cell count (WBC) may be associated with conditions other than sepsis (e.g., trauma, burns, and inflammatory disorders), and accurately differentiating between sepsis and the other conditions would not be possible with WBC.

(22) Other tests may also be inadequate. CRP may not be specific to bacterial and viral infections. Serum lactate may not be specific to sepsis and may be used more as a prognostic biomarker in sepsis instead of a diagnostic biomarker. ESR may represent physical properties associated with inflammatory processes but has poor specificity for infection. Blood cultures may be too time consuming to allow physicians to make immediate or timely treatment decisions. Additionally, antibiotic drugs and/or fastidious pathogens may limit the sensitivity of blood cultures. PCT, lacking sufficient sensitivity and specificity in symptomatic patients, may not reliably differentiate sepsis from other non-infectious causes of SIRS in critically ill patients. Furthermore, because PCT may be a separate test that may be performed only upon clinician request, the test may not be administered early and may not be an early identifier of septic patients.

(23) Conventional systems may include computers, which are not able to evaluate the infection status with sufficient sensitivity and specificity even if the computer had all the information provided from a blood sample. Embodiments of the present invention may improve computer-related technology by allowing the computer to perform evaluation of the infection status, including the evaluation of a sepsis status. Embodiments of the present invention may also decrease programming complexity, processing power requirements, storage requirements, and bandwidth requirements. Embodiments of the present invention may not include computational complexity beyond a determination of cell population data parameters in the sample and a comparison of two numbers, thereby increasing computational efficiency and lowering cost.

(24) Embodiments of the present invention include comparing the standard deviation of monocyte volume (SD-V-MO) to a cutoff value. Monocytes are a subset of white blood cells, so the use of a parameter related to monocytes was not expected to improve sensitivity and specificity for sepsis. These results may be double-checked using white blood cell count (WBC) data. WBC has been shown to increase in some cases with sepsis. Without intending to be bound by theory, it is thought that dissemination of infection leads to activation of circulating immune cells, such as the monocyte. The activation of circulating immune cells may be associated with a change in cell volume. Activated monocytes may play a role in the pathophysiology of sepsis. WBC may increase with SIRS in addition to sepsis, and thus, has low specificity for sepsis. SD-V-MO may be used alone to diagnose sepsis, however, the combination of WBC with SD-V-MO may lead to significant improvements in the determination of sepsis.

(25) Embodiments of the present invention may evaluate the sepsis status. The sepsis status may indicate that an individual has sepsis. If an individual is evaluated to have sepsis, clinical criteria may be used to confirm whether the individual has sepsis. Clinical criteria may include heart rate, body temperature, presence of a fever, and mental status. Individuals diagnosed with sepsis may receive closer monitoring, hospital admission, aggressive IV fluids, repeated blood cultures, and prioritized diagnoses and treatment.

(26) Analysis Techniques and Systems

(27) Turning to the figures, FIG. 1 illustrates aspects of an example analysis technique. As shown here, and as discussed elsewhere herein, a whole blood sample 100 may include cells such as platelets, white blood cells (WBCs), and red blood cells (RBCs), including nucleated red blood cells (NRBCs). Various RBC, WBC, and NRBC parameters, obtained from channel processing mechanisms such as a CBC module 110 or transducer 120, can be evaluated to assess the infection status of an individual. The transducer may obtain current data for blood samples as the sample passes through an aperture. The aperture may part of a flow cell.

(28) FIG. 2 schematically depicts a cellular analysis system 200. As shown here, system 300 includes a preparation system 210, a transducer module 220, and an analysis system 230. While system 200 is herein described at a very high level, with reference to the three core system blocks (210, 220, and 230), one of skill in the art would readily understand that system 200 includes many other system components such as central control processor(s), display system(s), fluidic system(s), temperature control system(s), user-safety control system(s), and the like. In operation, a whole blood sample (WBS) 240 can be presented to the system 200 for analysis. In some instances, WBS 240 is aspirated into system 200. Exemplary aspiration techniques are known to the skilled artisan. After aspiration, WBS 240 can be delivered to a preparation system 210. Preparation system 210 receives WBS 240 and can perform operations involved with preparing WBS 240 for further measurement and analysis. For example, preparation system 210 may separate WBS 240 into predefined aliquots for presentation to transducer module 220. Preparation system 210 may also include mixing chambers so that appropriate reagents may be added to the aliquots. For example, where an aliquot is to be tested for differentiation of white blood cell subset populations, a lysing reagent (e.g. ERYTHROLYSE, a red blood cell lysing buffer) may be added to the aliquot to break up and remove the RBCs. Preparation system 210 may also include temperature control components to control the temperature of the reagents and/or mixing chambers. Appropriate temperature controls can improve the consistency of the operations of preparation system 210.

(29) In some instances, predefined aliquots can be transferred from preparation system 210 to transducer module 220. As described in further detail below, transducer module 220 can perform direct current (DC) impedance, radiofrequency (RF) conductivity, light transmission, and/or light scatter measurements of cells from the WBS passing individually therethrough. Measured DC impedance, RF conductivity, and light propagation (e.g. light transmission, light scatter) parameters can be provided or transmitted to analysis system 230 for data processing. In some instances, analysis system 230 may include computer processing features and/or one or more modules or components such as those described herein with reference to the system depicted in FIG. 6 and described further below, which can evaluate the measured parameters, identify and enumerate the WBS constituents, and correlate a subset of data characterizing elements of the WBS with an infection status. As shown here, cellular analysis system 200 may generate or output a report 250 containing the evaluated infection status and/or a prescribed treatment regimen for the individual. In some instances, excess biological sample from transducer module 220 can be directed to an external (or alternatively internal) waste system 260.

(30) FIG. 3 illustrates in more detail a transducer module and associated components in more detail. As shown here, system 300 includes a transducer module 310 having a light or irradiation source such as a laser 310 emitting a beam 314. The laser 312 can be, for example, a 635 nm, 5 mW, solid-state laser. In some instances, system 300 may include a focus-alignment system 320 that adjusts beam 314 such that a resulting beam 322 is focused and positioned at a cell interrogation zone 332 of a flow cell 330. In some instances, flow cell 330 receives a sample aliquot from a preparation system 302. As described elsewhere herein, various fluidic mechanisms and techniques can be employed for hydrodynamic focusing of the sample aliquot within flow cell 330.

(31) In some instances, the aliquot generally flows through the cell interrogation zone 332 such that its constituents pass through the cell interrogation zone 332 one at a time. In some cases, a system 300 may include a cell interrogation zone or other feature of a transducer module or blood analysis instrument such as those described in U.S. Pat. Nos. 5,125,737; 6,228,652; 7,390,662; 8,094,299; and 8,189,187, the contents of which are incorporated herein by references. For example, a cell interrogation zone 332 may be defined by a square transverse cross-section measuring approximately 50×50 microns, and having a length (measured in the direction of flow) of approximately 65 microns. Flow cell 330 may include an electrode assembly having first and second electrodes 334, 336 for performing DC impedance and RF conductivity measurements of the cells passing through cell interrogation zone 332. Signals from electrodes 334, 336 can be transmitted to analysis system 304. The electrode assembly can analyze volume and conductivity characteristics of the cells using low-frequency current and high-frequency current, respectively. For example, low-frequency DC impedance measurements can be used to analyze the volume of each individual cell passing through the cell interrogation zone. Relatedly, high-frequency RF current measurements can be used to determine the conductivity of cells passing through the cell interrogation zone. Because cell walls act as conductors to high frequency current, the high frequency current can be used to detect differences in the insulating properties of the cell components, as the current passes through the cell walls and through each cell interior. High frequency current can be used to characterize nuclear and granular constituents and the chemical composition of the cell interior.

(32) Incoming beam 322 travels along beam axis AX and irradiates the cells passing through cell interrogation zone 332, resulting in light propagation within an angular range a (e.g. scatter, transmission) emanating from the zone 332. Exemplary systems are equipped with sensor assemblies that can detect light within three, four, five, or more angular ranges within the angular range a, including light associated with an extinction or axial light loss measure as described elsewhere herein. As shown here, light propagation 340 can be detected by a light detection assembly 350, optionally having a light scatter detector unit 350A and a light scatter and transmission detector unit 350B. In some instances, light scatter detector unit 350A includes a photoactive region or sensor zone for detecting and measuring upper median angle light scatter (UMALS), for example light that is scattered or otherwise propagated at angles relative to a light beam axis within a range from about 20 to about 42 degrees. In some instances, UMALS corresponds to light propagated within an angular range from between about 20 to about 43 degrees, relative to the incoming beam axis which irradiates cells flowing through the interrogation zone. Light scatter detector unit 350A may also include a photoactive region or sensor zone for detecting and measuring lower median angle light scatter (LMALS), for example light that is scattered or otherwise propagated at angles relative to a light beam axis within a range from about 10 to about 20 degrees. In some instances, LMALS corresponds to light propagated within an angular range from between about 9 to about 19 degrees, relative to the incoming beam axis which irradiates cells flowing through the interrogation zone.

(33) A combination of UMALS and LMALS is defined as median angle light scatter (MALS), which is light scatter or propagation at angles between about 9 degrees and about 43 degrees relative to the incoming beam axis which irradiates cells flowing through the interrogation zone.

(34) As shown in FIG. 3, the light scatter detector unit 350A may include an opening 351 that allows low angle light scatter or propagation 340 to pass beyond light scatter detector unit 350A and thereby reach and be detected by light scatter and transmission detector unit 350B. According to some embodiments, light scatter and transmission detector unit 350B may include a photoactive region or sensor zone for detecting and measuring lower angle light scatter (LALS), for example light that is scattered or propagated at angles relative to an irradiating light beam axis of about 5.1 degrees. In some instances, LALS corresponds to light propagated at an angle of less than about 9 degrees, relative to the incoming beam axis which irradiates cells flowing through the interrogation zone. In some instances, LALS corresponds to light propagated at an angle of less than about 10 degrees, relative to the incoming beam axis which irradiates cells flowing through the interrogation zone. In some instances, LALS corresponds to light propagated at an angle of about 1.9 degrees±0.5 degrees, relative to the incoming beam axis which irradiates cells flowing through the interrogation zone. In some instances, LALS corresponds to light propagated at an angle of about 3.0 degrees±0.5 degrees, relative to the incoming beam axis which irradiates cells flowing through the interrogation zone. In some instances, LALS corresponds to light propagated at an angle of about 3.7 degrees±0.5 degrees, relative to the incoming beam axis which irradiates cells flowing through the interrogation zone. In some instances, LALS corresponds to light propagated at an angle of about 5.1 degrees±0.5 degrees, relative to the incoming beam axis which irradiates cells flowing through the interrogation zone. In some instances, LALS corresponds to light propagated at an angle of about 7.0 degrees±0.5 degrees, relative to the incoming beam axis which irradiates cells flowing through the interrogation zone.

(35) According to some embodiments, light scatter and transmission detector unit 350B may include a photoactive region or sensor zone for detecting and measuring light transmitted axially through the cells, or propagated from the irradiated cells, at an angle of 0 degrees relative to the incoming light beam axis. In some cases, the photoactive region or sensor zone may detect and measure light propagated axially from cells at angles of less than about 1 degree relative to the incoming light beam axis. In some cases, the photoactive region or sensor zone may detect and measure light propagated axially from cells at angles of less than about 0.5 degrees relative to the incoming light beam axis less. Such axially transmitted or propagated light measurements correspond to axial light loss (ALL or AL2). As noted in previously incorporated U.S. Pat. No. 7,390,662, when light interacts with a particle, some of the incident light changes direction through the scattering process (i.e. light scatter) and part of the light is absorbed by the particles. Both of these processes remove energy from the incident beam. When viewed along the incident axis of the beam, the light loss can be referred to as forward extinction or axial light loss. Additional aspects of axial light loss measurement techniques are described in U.S. Pat. No. 7,390,662 at column 5, line 58 to column 6, line 4.

(36) As such, the cellular analysis system 300 provides means for obtaining light propagation measurements, including light scatter and/or light transmission, for light emanating from the irradiated cells of the biological sample at any of a variety of angles or within any of a variety of angular ranges, including ALL and multiple distinct light scatter or propagation angles. For example, light detection assembly 350, including appropriate circuitry and/or processing units, provides a means for detecting and measuring UMALS, LMALS, LALS, MALS, and ALL.

(37) Wires or other transmission or connectivity mechanisms can transmit signals from the electrode assembly (e.g. electrodes 334, 336), light scatter detector unit 350A, and/or light scatter and transmission detector unit 350B to analysis system 304 for processing. For example, measured DC impedance, RF conductivity, light transmission, and/or light scatter parameters can be provided or transmitted to analysis system 304 for data processing. In some instances, analysis system 304 may include computer processing features and/or one or more modules or components such as those described herein with reference to the system depicted in FIG. 6, which can evaluate the measured parameters, identify and enumerate biological sample constituents, and correlate a subset of data characterizing elements of the biological sample with an infection status of the individual. As shown here, cellular analysis system 300 may generate or output a report 306 containing the evaluated infection status and/or a prescribed treatment regimen for the individual. In some instances, excess biological sample from transducer module 310 can be directed to an external (or alternatively internal) waste system 308. In some instances, a cellular analysis system 300 may include one or more features of a transducer module or blood analysis instrument such as those described in previously incorporated U.S. Pat. Nos. 5,125,737; 6,228,652; 8,094,299; and 8,189,187.

(38) FIG. 4 illustrates aspects of an automated cellular analysis system for evaluating the infection status in an individual, according to embodiments of the present invention. In particular, the infection status can be evaluated based on a biological sample obtained from blood of the individual. As shown here, an analysis system or transducer 400 may include an optical element 410 having a cell interrogation zone 412. The transducer also provides a flow path 420, which delivers a hydrodynamically focused stream 422 of a biological sample toward the cell interrogation zone 412. For example, as the sample stream 422 is projected toward the cell interrogation zone 412, a volume of sheath fluid 424 can also enter the optical element 410 under pressure, so as to uniformly surround the sample stream 422 and cause the sample stream 422 to flow through the center of the cell interrogation zone 412, thus achieving hydrodynamic focusing of the sample stream. In this way, individual cells of the biological sample, passing through the cell interrogation zone one cell at a time, can be precisely analyzed.

(39) Transducer module or system 400 also includes an electrode assembly 430 that measures direct current (DC) impedance and radiofrequency (RF) conductivity of cells 10 of the biological sample passing individually through the cell interrogation zone 412. The electrode assembly 430 may include a first electrode mechanism 432 and a second electrode mechanism 434. As discussed elsewhere herein, low-frequency DC measurements can be used to analyze the volume of each individual cell passing through the cell interrogation zone. In some instances, the standard deviation of the volume of monocytes may be derived with low-frequency DC measurements. Relatedly, high-frequency RF current measurements can be used to determine the conductivity of cells passing through the cell interrogation zone. Such conductivity measurements can provide information regarding the internal cellular content of the cells. For example, high frequency RF current can be used to analyze nuclear and granular constituents, as well as the chemical composition of the cell interior, of individual cells passing through the cell interrogation zone.

(40) The system 400 also includes a light source 440 oriented to direct a light beam 442 along a beam axis 444 to irradiate the cells 10 of the biological sample individually passing through the cell interrogation zone 412. Relatedly, the system 400 includes a light detection assembly 450 optically coupled with the cell interrogation zone, so as to measure light scattered by and transmitted through the irradiated cells 10 of the biological sample. The light detection assembly 450 can include a plurality of light sensor zones that detect and measure light propagating from the cell interrogation zone 412. In some instances, the light detection assembly detects light propagated from the cell interrogation zone at various angles or angular ranges relative to the irradiating beam axis. For example, light detection assembly 450 can detect and measure light that is scattered at various angles by the cells, as well as light that is transmitted axially by the cells along the beam axis. The light detection assembly 450 can include a first sensor zone 452 that measures a first scattered or propagated light 452s within a first range of angles relative to the light beam axis 444. The light detection assembly 450 can also include a second sensor zone 454 that measures a second scattered or propagated light 454s within a second range of angles relative to the light beam axis 444. As shown here, the second range of angles for scattered or propagated light 454s is different from the first range of angles for scattered or propagated light 452s. Further, the light detection assembly 450 can include a third sensor zone 456 that measures a third scattered or propagated light 456s within a third range of angles relative to the light beam axis 444. As shown here, the third range of angles for scattered or propagated light 456s is different from both the first range of angles for scattered or propagated light 452s and the second range of angles for scattered or propagated light 454s. The light detection assembly 450 also includes a fourth sensor zone 458 that measures axial light 458t transmitted through the cells of the biological sample passing individually through the cell interrogation zone 412 or propagated from the cell interrogation zone along the axis beam. In some instances, each of the sensor zones 452, 454, 456, and 458 are disposed at a separate sensor associated with that specific sensor zone. In some instances, one or more of the sensor zones 452, 454, 456, and 458 are disposed on a common sensor of the light detection assembly 450. For example, the light detection assembly may include a first sensor 451 that includes first sensor zone 452 and second sensor zone 454. Hence, a single sensor may be used for detecting or measuring two or more types (e.g. low angle, medium angle, or high angle) of light scatter or propagation.

(41) Automated cellular analysis systems may include any of a variety of optical elements or transducer features. For example, as depicted in FIG. 4A, an optical element 410a of a cellular analysis system transducer may have a square prism shape, with four rectangular, optically flat sides 450a and opposing end walls 436a. In some instances, the respective widths W of each side 450a are the same, each measuring about 4.2 mm, for example. In some instances, the respective lengths L of each side 450a are the same, each measuring about 6.3 mm, for example. In some instances, all or part of the optical element 410a may be fabricated from fused silica, or quartz. A flow passageway 432a formed through a central region of optical element 410a may be concentrically configured with respect to a longitudinal axis A passing through the center of element 410a and parallel to a direction of sample-flow as indicated by arrow SF. Flow passageway 432a includes a cell interrogation zone Z and a pair of opposing tapered bore holes 454a having openings in the vicinity of their respective bases that fluidically communicate with the cell interrogation zone. In some instances, the transverse cross-section of the cell interrogation zone Z is square in shape, the width W′ of each side nominally measuring 50 microns±10 microns. In some instances, the length L′ of the cell interrogation zone Z, measured along axis A, is about 1.2 to 1.4 times the width W′ of the interrogation zone. For example, the length L′ may be about 65 microns±10 microns. As noted elsewhere herein, DC and RF measurements can be made on cells passing through the cell interrogation zone. In some instances, the maximum diameter of the tapered bore holes 454a, measured at end walls 436a, is about 1.2 mm. An optical structure 410a of the type described can be made from a quartz square rod containing a 50×50 micron capillary opening, machined to define the communicating bore holes 454a, for example. A laser or other irradiation source can produce a beam B that is directed through or focused into the cell interrogation zone. For example, the beam may be focused into an elliptically shaped waist located within the interrogation zone Z at a location through which the cells are caused to pass. A cellular analysis system may include a light detection assembly that is configured to detect light which emanates from the optical element 410a, for example light P that is propagated from the cell interrogation zone Z which contains illuminated or irradiated cells flowing therewithin. As depicted here, light P can propagate or emanate from the cell interrogation zone Z within an angular range a, and thus can be measured or detected at selected angular positions or angular ranges relative to the beam axis AX. Relatedly, a light detection assembly can detect light scattered or axially transmitted in a forward plane within various angular ranges with respect to an axis AX of beam B. As discussed elsewhere herein, one or more light propagation measurements can be obtained for individual cells passing through the cell interrogation zone one at a time. In some cases, a cellular analysis system may include one or more features of a transducer or cell interrogation zone such as those described in U.S. Pat. Nos. 5,125,737; 6,228,652; 8,094,299; and 8,189,187, the contents of which are incorporated herein by reference.

(42) FIG. 5 depicts aspects of an exemplary method 500 for evaluating an infection status associated with a blood sample obtained from an individual. Method 500 includes introducing a blood sample into a blood analysis system, as indicated by step 510. As shown in step 520, the method may also include preparing the blood sample by dividing the sample into aliquots and mixing the aliquot samples with appropriate reagents. In step 530, the samples can be passed through a flow cell in a transducer system such that sample constituents (e.g. blood cells) pass through a cell interrogation zone in a one by one fashion. The constituents can be irradiated by a light source, such as a laser. In step 540, any combination RF conductivity 541, DC impedance 542, first angular light propagation 543 (e.g. LALS), second angular light propagation 544 (e.g. AL2), third angular light propagation 545 (e.g. UMAL), and/or fourth angular light propagation 546 (e.g. LMALS) may be measured. As depicted by step 547, the third and fourth angular light propagation measurements can be used to determine a fifth angular light propagation measurement (e.g. MALS). Alternatively, MALS can be measured directly. In some examples, step 540 may include DC impedance 542 and may exclude any combination of the other measurements. In step 550, the white blood cell count in a blood sample may be measured. The blood sample may be a second blood sample from the individual or may be the same blood sample that is flowed through the flow cell. As discussed elsewhere herein, certain measurements or combinations of measurements can be processed, as indicated by step 560, so as to provide a likelihood of infection. Optionally, methods may also include determining a treatment regime based on the predicted likelihood of infection.

(43) A cellular analysis system may be configured to correlate a subset of DC impedance, RF conductivity, angular light measurements (e.g. first scattered light, second scattered light), the axial light measurements from the cells of the biological sample with an infection status, which may include sepsis status. As discussed elsewhere herein, in some instances at least a portion of the correlation can be performed using one or more software modules executable by one or more processors, one or more hardware modules, or any combination thereof. Processors or other computer or module systems may be configured to receive as an input values for the various measurements or parameters and automatically output the predicted evaluated infection status. In some instances, one or more of the software modules, processors, and/or hardware modules may be included as a component of a hematology system that is equipped to obtain multiple light angle detection parameters, such as Beckman Coulter's UniCel® DxH™ 800 Cellular Analysis System. In some instances, one or more of the software modules, processors, and/or hardware modules may be includes as a component of a stand-alone computer that is in operative communication or connectivity with a hematology system that is equipped to obtain multiple light angle detection parameters, such as Beckman Coulter's UniCel® DxH™ 800 System. In some instances, at least a portion of the correlation can be performed by one or more of the software modules, processors, and/or hardware modules that receive data from a hematology system that is equipped to obtain multiple light angle detection parameters, such as Beckman Coulter's UniCel® DxH™ 800 System remotely via the internet or any other over wired and/or wireless communication network. Relatedly, each of the devices or modules according to embodiments of the present invention can include one or more software modules on a computer readable medium that is processed by a processor, or hardware modules, or any combination thereof.

(44) FIG. 6 is a simplified block diagram of an exemplary module system that broadly illustrates how individual system elements for a module system 600 may be implemented in a separated or more integrated manner. Module system 600 may be part of or in connectivity with a cellular analysis system for evaluating the infection status according to embodiments of the present invention. Module system 600 is well suited for producing data or receiving input related to evaluate the infection status. In some instances, module system 600 includes hardware elements that are electrically coupled via a bus subsystem 602, including one or more processors 604, one or more input devices 606 such as user interface input devices, and/or one or more output devices 608 such as user interface output devices. In some instances, system 600 includes a network interface 610, and/or a diagnostic system interface 640 that can receive signals from and/or transmit signals to a diagnostic system 642. In some instances, system 600 includes software elements, for example shown here as being currently located within a working memory 612 of a memory 614, an operating system 616, and/or other code 618, such as a program configured to implement one or more aspects of the techniques disclosed herein. Each of the calculations or operations described herein may be performed using a computer or other processor having hardware, software, and/or firmware. The various method steps may be performed by modules, and the modules may comprise any of a wide variety of digital and/or analog data processing hardware and/or software arranged to perform the method steps described herein. The modules optionally comprising data processing hardware adapted to perform one or more of these steps by having appropriate machine programming code associated therewith, the modules for two or more steps (or portions of two or more steps) being integrated into a single processor board or separated into different processor boards in any of a wide variety of integrated and/or distributed processing architectures. These methods and systems will often employ a tangible media embodying machine-readable code with instructions for performing any one or more of the method or process steps described herein.

(45) In some embodiments, module system 600 may include a storage subsystem 620 that can store the basic programming and data constructs that provide the functionality of the various techniques disclosed herein. For example, software modules implementing the functionality of method aspects, as described herein, may be stored in storage subsystem 620. These software modules may be executed by the one or more processors 604. In a distributed environment, the software modules may be stored on a plurality of computer systems and executed by processors of the plurality of computer systems. Storage subsystem 620 can include memory subsystem 622 and file storage subsystem 628. Memory subsystem 622 may include a number of memories including a main random access memory (RAM) 626 for storage of instructions and data during program execution and a read only memory (ROM) 624 in which fixed instructions are stored. File storage subsystem 628 can provide persistent (non-volatile) storage for program and data files, and may include tangible storage media which may optionally embody patient, treatment, assessment, or other data. File storage subsystem 628 may include a hard disk drive, a floppy disk drive along with associated removable media, a Compact Digital Read Only Memory (CD-ROM) drive, an optical drive, DVD, CD-R, CD RW, solid-state removable memory, other removable media cartridges or disks, and the like. One or more of the drives may be located at remote locations on other connected computers at other sites coupled to module system 600. In some instances, systems may include a computer-readable storage medium or other tangible storage medium that stores one or more sequences of instructions which, when executed by one or more processors, can cause the one or more processors to perform any aspect of the techniques or methods disclosed herein. One or more modules implementing the functionality of the techniques disclosed herein may be stored by file storage subsystem 628. In some embodiments, the software or code will provide protocol to allow the module system 600 to communicate with communication network 630. Optionally, such communications may include dial-up or internet connection communications.

(46) It is appreciated that system 600 can be configured to carry out various aspects of methods of the present invention. For example, processor component or module 604 can be a microprocessor control module configured to receive cellular parameter signals from a sensor input device or module 632, from a user interface input device or module 606, and/or from a diagnostic system 642, optionally via a diagnostic system interface 640 and/or a network interface 610 and a communication network 630. In some instances, sensor input device(s) may include or be part of a cellular analysis system that is equipped to obtain multiple light angle detection parameters, such as Beckman Coulter's UniCel® DxH™ 800 Cellular Analysis System. In some instances, user interface input device(s) 606 and/or network interface 610 may be configured to receive cellular parameter signals generated by a cellular analysis system that is equipped to obtain multiple light angle detection parameters, such as Beckman Coulter's UniCel® DxH™ 800 Cellular Analysis System. In some instances, diagnostic system 642 may include or be part of a cellular analysis system that is equipped to obtain multiple light angle detection parameters, such as Beckman Coulter's UniCel® DxH™ 800 Cellular Analysis System.

(47) Processor component or module 604 can also be configured to transmit cellular parameter signals, optionally processed according to any of the techniques disclosed herein, to sensor output device or module 636, to user interface output device or module 608, to network interface device or module 610, to diagnostic system interface 640, or any combination thereof. Each of the devices or modules according to embodiments of the present invention can include one or more software modules on a computer readable medium that is processed by a processor, or hardware modules, or any combination thereof. Any of a variety of commonly used platforms, such as Windows, Mac, and Unix, along with any of a variety of programming languages, may be used to implement embodiments of the present invention.

(48) User interface input devices 606 may include, for example, a touchpad, a keyboard, pointing devices such as a mouse, a trackball, a graphics tablet, a scanner, a joystick, a touchscreen incorporated into a display, audio input devices such as voice recognition systems, microphones, and other types of input devices. User input devices 606 may also download a computer executable code from a tangible storage media or from communication network 630, the code embodying any of the methods or aspects thereof disclosed herein. It will be appreciated that terminal software may be updated from time to time and downloaded to the terminal as appropriate. In general, use of the term “input device” is intended to include a variety of conventional and proprietary devices and ways to input information into module system 600.

(49) User interface output devices 606 may include, for example, a display subsystem, a printer, a fax machine, or non-visual displays such as audio output devices. The display subsystem may be a cathode ray tube (CRT), a flat-panel device such as a liquid crystal display (LCD), a light-emitting diode (LED) display, an organic light-emitting diode (OLED) display, a projection device, or the like. The display subsystem may also provide a non-visual display such as via audio output devices. In general, use of the term “output device” is intended to include a variety of conventional and proprietary devices and ways to output information from module system 600 to a user. The results of any method or operation described herein (e.g. an infection status) may be displayed on an output device.

(50) Bus subsystem 602 provides a mechanism for letting the various components and subsystems of module system 600 communicate with each other as intended or desired. The various subsystems and components of module system 600 need not be at the same physical location but may be distributed at various locations within a distributed network. Although bus subsystem 602 is shown schematically as a single bus, alternate embodiments of the bus subsystem may utilize multiple busses.

(51) Network interface 610 can provide an interface to an outside network 630 or other devices. Outside communication network 630 can be configured to effect communications as needed or desired with other parties. It can thus receive an electronic packet from module system 600 and transmit any information as needed or desired back to module system 600. As depicted here, communication network 630 and/or diagnostic system interface 642 may transmit information to or receive information from a diagnostic system 642 that is equipped to obtain multiple light angle detection parameters, such as such as Beckman Coulter's UniCel® DxH™ 800 Cellular Analysis System.

(52) In addition to providing such infrastructure communications links internal to the system, the communications network system 630 may also provide a connection to other networks such as the internet and may comprise a wired, wireless, modem, and/or other type of interfacing connection.

(53) It will be apparent to the skilled artisan that substantial variations may be used in accordance with specific requirements. For example, customized hardware might also be used and/or particular elements might be implemented in hardware, software (including portable software, such as applets), or both. Further, connection to other computing devices such as network input/output devices may be employed. Module terminal system 600 itself can be of varying types including a computer terminal, a personal computer, a portable computer, a workstation, a network computer, or any other data processing system. Due to the ever-changing nature of computers and networks, the description of module system 600 depicted in FIG. 6 is intended only as a specific example for purposes of illustrating one or more embodiments of the present invention. Many other configurations of module system 600 are possible having more or less components than the module system depicted in FIG. 6. Any of the modules or components of module system 600, or any combinations of such modules or components, can be coupled with, or integrated into, or otherwise configured to be in connectivity with, any of the cellular analysis system embodiments disclosed herein. Relatedly, any of the hardware and software components discussed above can be integrated with or configured to interface with other medical assessment or treatment systems used at other locations.

(54) In some embodiments, the module system 600 can be configured to receive one or more cellular analysis parameters of a patient at an input module. Cellular analysis parameter data can be transmitted to an assessment module where an infection status is evaluated, predicted, analyzed, or determined. The infection status can be output to a system user via an output module. In some cases, the module system 600 can determine an initial treatment or induction protocol for the patient, based on one or more cellular analysis parameters and/or the evaluated infection status, for example by using a treatment module. The treatment can be output to a system user via an output module. Optionally, certain aspects of the treatment can be determined by an output device, and transmitted to a treatment system or a sub-device of a treatment system. Any of a variety of data related to the patient can be input into the module system, including age, weight, sex, treatment history, medical history, and the like. Parameters of treatment regimens or diagnostic evaluations can be determined based on such data.

(55) Relatedly, in some instances a system includes a processor configured to receive the cell population data as input. Optionally, a processor, storage medium, or both, may be incorporated within a hematology or cellular analysis machine. In some instances, the hematology machine may generate cell population data or other information for input into the processor. In some instances, a processor, a storage medium, or both, can be incorporated within a computer, and the computer can be in communication with a hematology machine. In some instances, a processor, a storage medium, or both, can be incorporated within a computer, and the computer can be in remote communication with a hematology machine via a network.

(56) Cell Population Data

(57) In addition to a differential count, once the WBC sub-populations are formed, the mean (MN) and standard deviation (SD) values for the grades of various morphologic parameters (e.g. volume, conductivity, and angles of light scatter or propagation) can be calculated separately for leukocytes and other blood cells. For example, a WBC differential channel can provide measurement data for neutrophils, lymphocytes, monocytes, eosinophils, and/or basophils and an nRBC channel can provide measurement data for non-nucleated red blood cells or a non-nucleated red blood cell parameter, as described elsewhere herein. As a result, a vast amount of data directly correlating to blood cell morphology can be generated. This information can be called collectively “Cell Population Data” (CPD). Table 1 depicts a variety of Cell Population Data parameters which may be obtained based on a biological sample of an individual. SD-V-MO may be a parameter used in embodiments. Embodiments may exclude any subset of the parameters listed in Table 1. Embodiments may include or exclude any parameters for basophils. Additionally, embodiments may include any subset of the parameters listed in Table 1.

(58) TABLE-US-00001 TABLE 1 Cell Population Data parameters Non-nucleated Monocyte red blood cell Neutrophil Lymphocyte MO (mo or Eosinophil NNRBC (nnr or NE (ne) LY (ly) mn) EO (eo) nnrbc) Cell SD-C-NE SD-C-LY SD-C-MO SD-C-EO SD-C-NNRBC Conductivity MN-C-NE MN-C-LY MN-C-MO MN-C-EO MN-C-NNRBC (C) high freq. current Cell Volume SD-V-NE SD-V-LY SD-V-MO SD-V-EO SD-V-NNRBC (V) MN- V-NE MN-V-LY MN-V-MO MN-V-EO MN-V-NNRBC low freq. current Axial light SD-AL2-NE SD-AL2-LY SD-AL2- SD-AL2-EO SD-AL2- loss or MN-AL2- MN-AL2- MO MN-AL2- NNRBC absorbed NE LY MN-AL2- EO MN-AL2- light (AL2 or MO NNRBC ALL) Low-angle SD-LALS- SD-LALS- SD-LALS- SD-LALS- SD-LALS- light scatter NE LY MO EO NNRBC (LALS) MN-LALS- MN-LALS- MN-LALS- MN-LALS- MN-LALS- NE LY MO EO NNRBC Upper SD- SD- SD- SD- SD-UMALS- median-angle UMALS-NE UMALS-LY UMALS- UMALS-EO NNRBC light scatter MN- MN- MO MN- MN-UMALS- (UMALS) UMALS-NE UMALS-LY MN- UMALS-EO NNRBC UMALS- MO Lower SD- SD-LMALS- SD- SD- SD-LMALS- median-angle LMALS-NE LY LMALS- LMALS-EO NNRBC light scatter MN- MN- MO MN- MN-LMALS- (LMALS) LMALS-NE LMALS-LY MN- LMALS-EO NNRBC LMALS- MO Median- SD-MALS- SD-MALS- SD-MALS- SD-MALS- SD-MALS- angle light NE LY MO EO NNRBC scatter MN-MALS- MN-MALS- MN-MALS- MN-MALS- MN-MALS- (MALS) NE LY MO EO NNRBC [UMALS + LMALS]

(59) CPD values can be viewed on the screen of an instrument, such as that depicted in FIG. 7, as well as automatically exported as an Excel file. Hence, white blood cells (WBCs) can be analyzed and individually plotted in tri-dimensional histograms, with the position of each cell on the histogram being defined by certain parameters as described herein. In some instances, systems or methods can grade the cell in a range from 1 to 256 points, for each of the parameters.

(60) Because WBCs of the same sub-type, for example granulocytes (or neutrophils), lymphocytes, monocytes, eosinophils, and basophils, often have similar morphologic features, they may tend to be plotted in similar regions of the tri-dimensional histogram, thus forming cell populations. The number of events in each population can be used to generate a differential count. FIG. 7 depicts an exemplary screen shot of a differential count screen. As illustrated here, the WBC sub-populations are in clearly separated groups at different locations on the histogram, and are defined by different colors. The histogram shown here provides cell size (volume) in the y axis and light scatter in the x axis.

(61) By clicking on the “Additional Data” tab, users can view the CPD values. Such CPD values can correspond to the position of the population in the histogram, and to the morphology of the WBCs under the microscope. For example, monocytes are known to be the largest of all WBCs, and have the highest mean volume. Lymphocytes are known to be the smallest of all WBCs, and have the lowest mean volume. Lymphocytes also have the lowest level of cytoplasmic granularity and the least complex nuclear morphology, and have the lowest mean light scatter, called MALS).

(62) CPD parameters can be used to analyze cellular morphology in a quantitative, objective, and automated manner, free from the subjectivity of human interpretation, which is also very time consuming, expensive, and has limited reproducibility. CPD parameters can be used for improving the value of the CBC-diff in the diagnosis of various medical conditions that alter the morphology of WBCs.

(63) FIG. 7A illustrates aspects of a biological sample analysis system 700a, according to embodiments of the present invention. As depicted here, infection status analysis techniques may include determining both a WBC count and a standard deviation of monocyte volume using VCS technology. Further, techniques may include determining an RBC count using an RBC aperture bath of a CBC module.

(64) As shown here, the sample analysis system 700a includes a sample aspiration module 710a, a CBC module 720a (which incorporates Coulter technology), and a VCS module 730a (which incorporates VCS technology). The CBC module 720a includes a blood sampling valve 721a, which receives sample from aspiration module 710a. Further, the CBC module 720a includes a WBC aperture bath 722a which receives sample from BSV 721a (and can be used to determine a WBC count) and an RBC aperture bath 723a which receives sample from BSV 721a (and can be used to determine an RBC count). The VCS module 730a includes a sample distribution valve 731a, which receives sample from aspiration module 710a, and which can be used to transfer sample to a reticulocyte chamber 732a for processing with a flow cell transducer 740a. Sample distribution valve 731a can also be used to transfer sample to a WBC differential chamber 734a for processing with a flow cell transducer 740a. What is more, sample distribution valve 731a can be used to transfer sample to an NRBC chamber 736a for processing with a flow cell transducer 740a.

(65) According to some embodiments, sample may or may not be lysed depending on where the sample is processed in the system. For example, in many instances, sample is lysed when processed using the WBC aperture bath 722a, the WBC differential chamber 734a, and the NRBC chamber 736a. In contrast, in many instances, sample is not lysed when processed using the RBC aperture bath 723a or the reticulocyte chamber 732a. Hence, as depicted in FIG. 7A, the uncorrected white blood cell count (UWBC) can be determined based on sample which is not lysed. The standard deviation of monocyte volume may be obtained from data from WBC differential chamber 734a.

(66) According to some embodiments, a CBC module can be used to determine both a WBC count (via a WBC aperture bath) and an RBC count (via an RBC aperture bath). The parameter from the CBC module which is used in FIG. 7A is the WBC count 742. In some instances, the parameter from the CBC module may be a neutrophil count or neutrophil percentage of the WBCs. In some examples, an RBC aperture bath of a CBC module may not be required. Some embodiments may compute NE % using Beckman Coulter's UniCel DxH™ 800 System and not use the WBC aperture bath.

(67) As discussed herein, embodiments of the present invention encompass automated systems for evaluating an infection status in a biological sample, where the system includes a first analyzer module (e.g. implementing Coulter technology) configured to determine a white blood cell count 742 of the biological sample, a second analyzer module (e.g. implementing VCS technology) configured to determine a standard deviation of monocyte volume 744 of the biological sample, and a data processing module configured to evaluate the infection status based on the Coulter white blood cell count 742 and the VCS standard deviation of monocyte volume 744.

(68) FIG. 8 schematically illustrates a method 800 for evaluating an infection status according to embodiments of the present invention. As depicted here, the method includes obtaining blood samples from individuals (e.g. during routine examinations), as indicated by step 810. Complete Blood Count (CBC) data, Volume Conductivity Scatter (VCS) data, or combinations thereof, can be obtained from these biological samples, using a cellular analysis system that is equipped to obtain cellular event parameters, such as Beckman Coulter's UniCel DxH™ 800 System, as indicated by step 820. CBC parameters, VCS parameters, or combinations thereof from analyzed samples can be used to evaluate the sepsis status, as indicated by step 830. As described herein, the WBC count and the standard deviation of monocyte volume may be the only parameters or derived parameters used from the CBC and VCS parameters. Methods may also include outputting an index of the likelihood of sepsis, as indicated in step 840.

(69) FIG. 9 shows an automated method 900 for evaluating a sepsis status associated with a blood sample obtained from an individual according to embodiments of the present invention. The method may include determining a standard deviation of monocyte volume associated with the blood sample (block 902). The determining operation may use a transducer module as described herein. The method may include determining a white blood cell count (WBC) associated with the blood sample (block 906). This determining operation may use a CBC module as described herein. The module may include evaluating, using a data processing module, the sepsis status associated with the blood sample (block 906).

(70) Diagnostic Accuracy

(71) Embodiments may involve different measures of diagnostic accuracy. Diagnostic accuracy involves the degree of agreement between a test and a reference method or clinical outcome measure. Diagnostic parameters of a test may not be intrinsic properties of the test and instead may depend on the clinical context of the test.

(72) A test, compared to a reference method or clinical outcome measure, may have different outcomes: true positive, false positive, false negative, and true negative. Table 2 illustrates the relationship.

(73) TABLE-US-00002 TABLE 2 Outcomes of a test result compared to a reference method. Reference Standard or Clinical Outcome Measure Disease present Disease absent (Sepsis) (Non-Sepsis) Total Test positive True positive (TP) False positive (FP) TP + FP Test negative False negative (FN) True negative (TN) TN + FN Total TP + FN TN + FP Total

(74) Sensitivity, or sometimes called “positivity in disease,” refers to the proportion of subjects who have the target condition (reference standard or clinical outcome measure shows that the disease is present) and give “test positive” results. As a formula, sensitivity can be expressed as the following:

(75) $\mathrm{Sensitivity}=\frac{\mathrm{TP}}{\mathrm{TP}+\mathrm{FN}}$

(76) Specificity, or sometimes called “negativity in health,” refers to the proportion of subjects without the target condition (reference standard or clinical outcome measure shows that the disease is absent) and give “test negative” results. As a formula, specificity can be expressed as the following:

(77) $\mathrm{Specificity}=\frac{\mathrm{TN}}{\mathrm{TN}+\mathrm{FP}}$

(78) Positive predictive value (PPV) refers to the proportion of positive results that are true positives. In other words, PPV may indicate a proportion that actually have the target condition. As a formula, PPV can be expressed as the following:

(79) $\mathrm{PPV}=\frac{\mathrm{TP}}{\mathrm{TP}+\mathrm{FP}}$

(80) Negative predictive value (NPV) refers to the proportion of negative results that are true negatives. Put simply, NPV may indicate a fraction that do not have the target condition. As a formula, NPV can be expressed as the following:

(81) $\mathrm{NPV}=\frac{\mathrm{TN}}{\mathrm{TN}+\mathrm{FN}}$

(82) Predictive values may vary depending upon the prevalence of the target condition in the population being studied, although sensitivity and specificity remain the same.

(83) A cutoff point may be created to condition the values of sensitivity and specificity of the test. An ROC curve may be a way to graphically display true positives versus false positives across a range of cutoffs and may aid in selecting a desired cutoff to achieve a clinical utility of the test. Examples of ROC curves are shown in FIG. 10 and FIG. 11, which will be discussed in detail in the examples below. An ROC curve may help determine cutoffs in determining the presence or absence of a target condition. The y-axis indicates the sensitivity of a test, and the x-axis indicates 1—specificity of the test. The area under curve (AUC) for an ROC curve may be used to compare test performance. The AUC may quantify the overall ability of the test to discriminate between individuals with the target condition and those without the target condition. A perfect test results in a curve that extended to the (0,1) point with an AUC of 1. A worthless test has an AUC of 0.5, indicating that the test may be no better than randomly determining whether an individual has the target condition. A line of y=x is shown in the graph to illustrate an AUC of 0.5.

(84) Often, the distribution of test results indicating the presence of a target condition may overlap with the test results indicating the absence of the target condition. A cutoff may be set high so that the test may be unlikely to diagnose the target condition in someone who does not have the target condition (i.e., low false positive, high specificity). However, with a high cutoff, the test may be more likely to misdiagnose a person who has the target condition as someone who does not have the target condition (i.e., high false negative, low sensitivity). On the ROC curve, the choice of a high cutoff may be represented by a point near the origin.

(85) If the cutoff is set too low, the test may diagnose correctly all or almost all the people with the target condition (i.e., high true positive, high sensitivity). However, a low cutoff may result in diagnosing the target condition in more people who do not have the target condition (i.e., high false positive, low specificity). On the ROC curve, the choice of low cutoff may be represented by a point near (1,1).

Examples

(86) A blinded, prospective, observational, multicenter cohort study was conducted at three sites comprised of both academic and community hospital emergency departments in the United States. The study enrolled a total of 2,160 consecutive adult emergency-department patients (18 to 89 years of age) meeting inclusion criteria for: Having a CBC-DIFF performed upon presentation and Subjects remaining in the hospital (emergency department or in-patient) for at least 12 hours.

(87) The prevalence of sepsis as defined by the Sepsis-2 (ACCP/SCCM 2001 consensus criteria) was 17.8%. This prevalence is higher than the general prevalence of sepsis in emergency department patients; the septic population was likely enriched by the inclusion criteria. The emergency-department population demographics based upon presenting clinical status are summarized in Table 3.

(88) TABLE-US-00003 TABLE 3 Emergency Department Population Demographics Based on Presenting Diagnosis Site Case Control SIRS Infection Sepsis Total 1 320 111 95 139 665 2 440 222 60 115 837 3 328 108 89 131 656 Total 1088 441 244 385 2158

(89) The subject categories included: Non-SIRS—case controls, subjects having 0 to 1 SIRS (Systemic Inflammatory Response Syndrome) criteria and no infection SIRS—subjects having ≥2 SIRS criteria Infection—subjects having suspected or confirmed infection Sepsis—subjects having infection plus SIRS Severe sepsis—subjects having sepsis with one or more organ failure Septic shock—subjects having sepsis with severe hypotension.
In Table 3, sepsis includes sepsis, severe sepsis, and septic shock.

(90) Samples collected in K2 EDTA were analyzed within two hours of venipuncture. MDW results were compared to the clinical adjudication of sepsis per Sepsis-2 Criteria (defined as a documented or suspected infection together with two or more SIRS criteria). Sepsis criteria had to be met within 12 hours of presentation. Infection diagnosis was determined by retrospective chart review for microbiological, radiological, and molecular results available for up to five to seven days post-emergency-department presentation. Diagnosis was adjudicated at each site by two independent physicians and discordances were arbitrated by a third independent physician.

(91) MDW Alone

(92) FIG. 10 shows an ROC curve for determining sepsis using only monocyte distribution width (MDW). A cutoff value of 20.0 units for MDW effectively differentiated sepsis from all other conditions in emergency-department patients. The ROC analysis yielded an area under the curve (AUC) of 0.788 (95% CI 0.762 to 0.815).

(93) Table 4 summarizes the sensitivity, specificity, positive and negative predictive values, and positive and negative likelihood ratios with their respective 95% confidence intervals based on a cutoff value of 20.0.

(94) TABLE-US-00004 TABLE 4 Performance of MDW for Sepsis MDW Cutoff at 20.0 Predictive Values Likelihood Ratios Sensitivity Specificity Positive Negative Positive Negative Estimate 0.740 0.720 0.365 0.927 2.646 0.361 Lower 95% CI 0.694 0.699 0.332 0.912 2.406 0.304 Upper 95% CI 0.782 0.741 0.399 0.940 2.911 0.428

(95) MDW values between 19.0 and 19.5 have a higher sensitivity for predicting sepsis, but lower specificity (for example, more false-positive results). The impact on sensitivity and specificity for early detection of sepsis at different MDW cut-offs is provided in Table 5.

(96) TABLE-US-00005 TABLE 5 Sensitivity and Specificity at Various MDW Cutoffs 95% 95% Confidence Confidence Intervals Intervals Cutoff Sensitivity Lower Upper Specificity Lower Upper 19.0 0.821 0.779 0.856 0.594 0.571 0.617 19.5 0.784 0.741 0.823 0.661 0.639 0.683 20.0 0.740 0.694 0.782 0.720 0.699 0.741 20.5 0.683 0.635 0.728 0.771 0.751 0.790

(97) MDW and WBC

(98) FIG. 11 shows an ROC curve for using MDW and WBC to determine sepsis. The AUC for using both parameters together was statistically greater than the AUC for WBC alone. The results are summarized in Table 6.

(99) TABLE-US-00006 TABLE 6 AUC for WBC and Combined WBC&MDW Standard 95% Confidence Limits Parameter AUC Error Lower Upper WBC 0.75 0.02 0.72 0.78 WBC & MDW 0.85 0.01 0.83 0.88 Difference 0.10 0.01 0.08 0.13

(100) WBC and MDW Decision Rules

(101) The following decision rules were used to evaluate a sepsis status: WBC>12×10.sup.3 cells/μL is abnormal WBC<4×10.sup.3 cells/μL is abnormal MDW>20 indicate for having or developing sepsis (WBC>12×10.sup.3 cells/μL or WBC<4×10.sup.3 cells/μL) & MDW>20 strong indication for sepsis

(102) Post-test probability (Pi) was calculated based on the positive likelihood ratio (LR) and pre-test probability. Pre-test predicted probability depends on the physical/clinical conditions of each patient. Prevalence can be used as the average pre-test probability (P.sub.0). In this example, P.sub.0=17.8%. Post-test probability was calculated as

(103) $P_1=\frac{P_0\times \mathrm{LR}}{1-P_0\left(\mathrm{LR}-1\right)}.$

(104) Positive likelihood ratios were calculated for WBC (abnormal; WBC>12 or WBC<4) and WBC (abnormal; WBC>12 or WBC<4) & MDW (abnormal MDW>20).

(105) Pre-test and post-test probabilities are shown in Table 7. An abnormal WBC result increased the probability of a patient having or developing sepsis to 44.7% when the pre-test probability is 17.8%. The post-test probability increased to 63.5% when both WBC and MDW were abnormal.

(106) Positive likelihood ratios were also calculated for WBC (normal; 4≤WBC≤12) and WBC (normal; 4≤WBC≤12) & MDW (normal MDW<20).

(107) A normal test results reduced the probability of sepsis. Post-test probability of a normal WBC test was 7.9% but this value decreased to 2.9% if both WBC and MDW are normal.

(108) TABLE-US-00007 TABLE 7 Pre-Test and Post-Test Probabilities for Different Combination of Tests Likelihood Test Ratio Probability Pre-Test 17.8% Post-Test: Positive test results WBC abnormal 3.72 44.7% WBC & MDW abnormal 8.01 63.5% Post Test: Negative test results WBC normal 0.39 7.9% WBC & MDW normal 0.14 2.9%

(109) In the preceding description, for the purposes of explanation, numerous details have been set forth in order to provide an understanding of various embodiments of the present technology. It will be apparent to one skilled in the art, however, that certain embodiments may be practiced without some of these details, or with additional details, or in varied combinations or sub-combinations of features of the embodiments.

(110) Having described several embodiments, it will be recognized by those of skill in the art that various modifications, alternative constructions, and equivalents may be used without departing from the spirit of the invention. Additionally, a number of well-known processes and elements have not been described in order to avoid unnecessarily obscuring the present invention. Additionally, details of any specific embodiment may not always be present in variations of that embodiment or may be added to other embodiments.

(111) Where a range of values is provided, it is understood that each intervening value, to the tenth of the unit of the lower limit unless the context clearly dictates otherwise, between the upper and lower limits of that range is also specifically disclosed. Each smaller range between any stated value or intervening value in a stated range and any other stated or intervening value in that stated range is encompassed. The upper and lower limits of these smaller ranges may independently be included or excluded in the range, and each range where either, neither, or both limits are included in the smaller ranges is also encompassed within the invention, subject to any specifically excluded limit in the stated range. Where the stated range includes one or both of the limits, ranges excluding either or both of those included limits are also included.

(112) As used herein and in the appended claims, the singular forms “a”, “an”, and “the” include plural referents unless the context clearly dictates otherwise. Thus, for example, reference to “a method” includes a plurality of such methods and reference to “the transducer” includes reference to one or more transducers and equivalents thereof known to those skilled in the art, and so forth. The invention has now been described in detail for the purposes of clarity and understanding. However, it will be appreciated that certain changes and modifications may be practice within the scope of the appended claims.