WO1990006055A1

WO1990006055A1 - Antimicrobial agents and uses thereof

Info

Publication number: WO1990006055A1
Application number: PCT/GB1989/001421
Authority: WO
Inventors: Sherburne M. Edmondson; Carlos E. Luna
Original assignee: Unilever Plc; Unilever Nv
Priority date: 1988-11-29
Filing date: 1989-11-28
Publication date: 1990-06-14
Also published as: AU636591B2; AU4659989A; JPH03503171A

Abstract

Antimicrobial reagents based on EDTA and optionally including sodium fluoride, useful for example in a method for diluting blood, the method and diluent being especially suitable for use in enumeration and sizing of blood cells. The antimicrobial agent in the blood diluent is potent, but relatively non-toxic to humans, and inexpensive. Furthermore, it does not interfere with blood analysis performed on an automated, blood-analysis instrument.

Description

Antimicrobial agents and uses thereof

This invention relates to antimicrobial agents and uses thereof, for example in methods for diluting blood and blood diluents, especially suitable for use in enumeration and sizing of blood cells, including white blood cell

subpopulations.

The invention will be particularly described, by way of example only, in relation to the analysis of blood.

Analytical data of blood is important as an index of health and well being. The analysis of blood cell

populations provides useful information for diagnosis and treatment, since they show a rapid response to variation in medical condition. Most analytical methods rely on the fundamental cell property of volume regulation. Each type of cell in the circulating blood has its own characteristic volume, ranging from as small as 2 cubic microns for platelets to over 450 cubic microns for polymorphonuclear cells. Automated, blood-analysis instruments have been developed to accomplish the measurement of blood cells and related components with simplicity and rapidity. Such measurements include white blood cell count (WBC), red blood count (RBC), platelet count (PLT), hematocrit (HTC), hemoglobin (HGB), the mean

corpuscular volume (MCV), the mean corpuscular hemoglobin (MCH) , and the mean corpuscular hemoglobin concentration (MCHC), as well as WBC subpopulations such as lymphocytes, monocytes, and granulocytes. Before making blood cells counts by means of an

automated, blood analysis instrument, the blood is diluted to a certain concentration. The diluent comprises a stable water solution of chemical salts providing an electrolytic solution capable of conducting current to which a blood sample can be added so as to dilute the red blood cells, white blood cells, platelets and other blood components to be measured, counted and evaluated. See, for example, US Patent Nos. 4,213,876, 4,244,837, 4,521,518 and 4,745,071. In analysing blood by an automated, blood-analysis instrument or other analytical method (including manual microscopic evaluations), it is essential that the diluent not adversely affect the chemical and physical integrity of the blood cells during the analysis. For instance, if the blood diluent is not isotonic and osmotically balanced with respect to the blood, the blood cells may shrink or expand. Importantly, the diluent should not adversely affect the blood analysis itself. The diluent must also be free from particles which may interfere with the analysis of the blood. While the diluent is normally filtered to remove particles larger than 0.2 micron in diameter at the time of its manufacture, the diluent may be susceptible to the support of microorganism grown after the manufacture and packaging of the diluent. The presence of microorganisms may result in inaccurate and non-reproducible results.

It is common practise to include an antimicrobial agent in blood diluents to retard the growth of microorganisms. The antimicrobial agent, as with other components of the diluent, must not adversely affect the blood cells or

adversely affect or interfere with the analyses. Thus, while antimicrobial agents in blood diluents are desirable, caution must be observed in their selection and use.

An antimicrobial agent which has been employed for many years in blood diluents is sodium azide. Its use has not, however, been without significant problems. First, the presence of sodium azide has been found to influence the formation of cyanmethemoglobin, a chromogen formed for determining hemoglobin in a blood sample. For instance, without sodium azide in the diluent, the hemoglobin as determined photometrically may be significantly different than that with the azide present. Secondly, aqueous

solutions of sodium azide are highly toxic (toxicity level of 6 on a scale of 1 to 6). See Gossselin et al,. (eds.),

Clinical Toxicology of Commercial Products, The Williams and Wilkins Company, Baltimore, 5th Edition, 1984, (Section IID, position III). Finally, the disposal of sodium azide through copper or lead-containing plumbing systems may result in the formation of heavy metal azides and their build-up over extended period of time. Despite the need for alternatives to sodium azide as an antimicrobial agent in blood diluents, few alternatives have been proposed. An attempt has been made to substitute other preservatives for sodium azide, and an example of this is shown in US Patent Nos. 3,962,125 and 4,102,810 where

2-phenoxyethanol is used as an antimicrobial agent. There are disadvantages to the use of phenoxyethanol as well. First, phenoxyethanol is a rather weak antimicrobial agent. It has been found to be more effective when used in conjunction with other preservatives, such as the

hydroxybenzoates. Martindale, the Extra Pharmacopoeia (27th edition, The Pharmaceutical Press, London, 1977, page 1281). Second, while less toxic than sodium azide, phenoxyethanol is still toxic, (toxicity level of 4 on a scale of 1 to 6). See Gosselin et al., supra (Section IID, position 463). Finally, in US Patent Nos. 3,962,125 and 4,102,810, sodium fluoride is essentially included along with phenoxyethanol in the

proposed diluent to enhance hemoglobin chromogen formation. Sodium fluoride is only slightly less toxic than sodium azide (toxicity level of 4-5). See Gosselin et al., supra

(Section IID, position 100).

A further attempt to substitute other preservatives for sodium azide can be found in US Patent Nos. 4,248,634, in which sodium dehydroacetate is used as an antimicrobial agent. Sodium dehydroacetate, a fungicide, is toxic at high doses but is less toxic than sodium azide, sodium fluoride, and phenoxyethanol (toxicity level of 3). See Gosselin et al., supra (Section IID, position 1187). Thus, one object of the present invention is to provide a biocidal agent for general use which is potent,

inexpensive, and preferably non-toxic.

Another object of the present invention is to provide an antimicrobial agent for a blood diluent that does not

interfere with the blood analysis.

Still another object of the present invention is to provide an antimicrobial agent for a blood diluent that is potent but relatively non-toxic. Objects and advantages other than those above set forth will be apparent from the following description when read in connection with the accompanying drawings. The invention provides an antimicrobial agent, e.g. a fungistatic and/or fungicidal agent comprising an effective concentration of EDTA, typically a concentration of between approximately 0.02 grammes/litre and 1.0 grammes/litre.

Preferably the antimicrobial agent also comprises an

effective concentration of sodium fluoride, typically a concentration of between approximately 0.02 grammes/litre and 0.5 grammes/litre.

The antimicrobial agent of the invention may be in the form of a blood diluent.

The invention also provides a method for determining the cell number and/or size of a cell subpopulation in a blood sample, comprising the steps of:

(a) diluting the blood sample with a diluent containing a fungicidally and/or fungistatically effective

concentration of EDTA (and preferably also an effective concentration of sodium fluoride),

(b) measuring the cell number and/or size of the cell

subpopulation.

The invention also encompasses the general use of EDTA, preferably together with sodium fluoride, as an

antimicrobial, fungicidal or fungistatic agent.

The invention therefore generally comprises an

antimicrobial agent and/or a fungistatic agent comprising EDTA, or EDTA and sodium fluoride, and uses thereof, and methods therefor. In a preferred embodiment the invention is directed to a method for diluting blood, a blood dilutent, and antimicrobial agent or reagent for use in a blood

diluent. Most generally, e.g. in biocidal methods for sterilization, the improvement comprises the use of EDTA alone, or EDTA and sodium fluoride together as an

antimicrobial reagent. More specifically, in a method of determining the number and/or size of cells or cell

subpopulations in a blood sample wherein blood is diluted in an osmotically balanced solution, the improvement comprises employing EDTA alone, or EDTA and sodium fluoride together, as an antimicrobial and/or fungistatic reagent.

A blood diluent according to the invention generally comprises an organic buffer adjusted to an appropriate pH, a cell stablilising agent, an inorganic salt to adjust

conductivity, ionic strength and osmolality, and, as an antimicrobial agent, either EDTA alone or a mixture of EDTA and sodium fluoride wherein together they serve as an

antimicrobial reagent.

Figures 1A, 1B and 1C are histograms showing the number of cells versus cell volume analysed on an automated

blood-analysis system using a standard diluent without any antimicrobial agents.

Figures 2A, 2B and 2C are histograms showing the number of cells versus cell volume analysed on an automated

blood-analysis system using a standard diluent containing only sodium fluoride as an antimicrobial agent.

Figures 3A, 3B and 3C, are histograms showing the number of cells versus cell volume analysed on an automated

blood-analysis system using an embodiment of the present invention; and Figures 4A, 4B and 4C, are histograms showing the number of cells versus cell volume analysed on an automated

blood-analysis system using an alternative embodiment of the present invention.

In one embodiment the present invention is directed to an antimicrobial agent for use in a diluent for analysing population and subpopulation differentiation of blood cells in a sample of blood. Routinely, such analysis can be performed on an automated, blood-analysis instrument, such as, eg, a Sequoia-Turner CELL-DYN 2000 blood-analysis

instrument, used in accordance with the instruments provided by the manufacturer. Of course, the properties of the present diluent make it multi-purpose, ie useful for other analytical methods for cells (including manual microscopic evaluations).

As note above, it is a common practice to include an antimicrobial agent in blood diluents to retard the growth of microorganisms. The diluent used as a control in the

experiments described below (hereinafter "the control

diluent") uses 1-hydroxypyridine-2-thione as an antimicrobial agent and has the composition set forth in Table 1 of US Patent No. 4,745,071, which is hereby incorporated by

reference. The control diluent has been used extensively and successfully for the analysis of blood cell populations on an automated, blood-analysis instrument, such as, eg, a

Sequioa-Turner CELL-DYN 2000 blood-analysis instrument.

Nonetheless, in the course of using the control diluent, some microbial growth was observed.

Preliminary visual analysis of the microbial growth in the control diluent suggested that it was not bacterial growth but was, rather, fungal growth. The presence of fungal growth and the absence of bacterial growth indicated that the antimicrobial agent of the control diluent,

1-hydroxypyridine-2-thione, is an effective bacteriostatic or bacteriocidal agent but not a fungistatic or fungicidal agent.

The present invention prevents microbial growth, and in particular fungal growth, in general circumstances, for example in a blood diluent. The blood diluent utilizing the invention comprises an aqueous solution of a cell stabilising agent, an antimicrobial agent, an organic buffer adjusted to an appropriate pH, a fungistatic agent or reagent(s), and additional ionic components to provide a suitable ionic strength, and osmolality to maintain the normal volume of the cells.

The present diluent is a solution which includes various components well known in the art of blood cell analysis. For example, water is routinely used as the solvent, as it is inexpensive, safe and generally compatible with the sample to be analysed.

The presently preferred cell stabilising agent is

1,3-dimethylurea, and the presently preferred organic buffer is N-(2-acetamido)-2-iminodiacetic acid (ADA). While these are the preferred compounds, either presently known or equivalent compounds hereafter developed, might be

substituted in their place. The pH of the buffered diluent is conveniently adjusted to approximately 6.9 with, eg, sodium hydroxide, but other bases may be substituted and the pH may vary between at least 6.5 and 7.5 without

substantially interfering with the proposed use of the diluent.

In addition, sodium chloride is routinely used to adjust the osmolality of the diluent to approximately 320 milliosmoles, which is known to be appropriate for

maintaining normal blood cell volume. Obviously, other salts and other osmolality levels are possible. Sodium sulfate is generally used to give the diluent an appropriate ionic strength. However, other compounds with this property can be substituted.

The antimicrobial and/or fungistatic agents or reagents of the present invention are 1) ethylenediaminetetraacetic acid (EDTA) alone or 2) EDTA in combination with sodium fluoride. The presently preferred composition of the diluent employing the former is illustrated in Table 1, while the preferred composition of the diluent containing the mixture of agents is illustrated in Table 1, while the preferred composition of the diluent containing the mixture of agents is illustrated in Table 2.

Sodium fluoride is known as an excellent preservative blood (Med J. Aust. 1:1939, 1968). Sodium fluoride is classified as a toxic substance (toxicity level 4-5 on a maximum scale of 6). See Gosselin et al., supra (Section IID, position 100).

By contrast, both EDTA as its own and EDTA in

combination with sodium fluoride are not known for any antimicrobial properties. EDTA on its own is relatively non-toxic; this acid and many of its salts bind metal cations tightly and so render them essentially innocuous. See

Cosselin et al., supra (Section IID, position 1506). The calcium salt of EDTA is used intravenously to detoxify and enhance the renal excretion of lead. The calcium derivative (chelate) has a low toxicity in experimental animals

(toxicity of 2 on a scale of 6) and the disodium salt can be tolerated at doses as higher than 1 gm/kg in mice (toxicity of approximately 3). In order to further describe the present invention, the following experiments were carried out to demonstrate the efficiently of EDTA and EDTA with sodium fluoride as

antimicrobial agents by their impact on 1) automated

blood-analysis results and 2) microbial growth in culture.

All quantities labelled per cent (%) are grams per

100 millilitres, unless otherwise indicated. All weights are given in grams (g) or milligrams (mg), all concentrations are given as millimolar (mM) or micromolar (μM) and all volumes are given in litres (L) or millilitres (ml) unless otherwise indicated. BLOOD ANALYSIS

Example 1

Routine analysis of the white blood cell (WBC), red blood cell (RBC) and platelet (PLT) populations, as well as analysis of WBC subpopulations, of blood samples was

performed on an automated, blood-analysis instrument

(CELL-DYN 20000 blood-analysis instrument, Sequoia-Turner Corp., Mountain View, California), used in accordance with the instructions provided by the manufacturer.

Figures 1-4 show the impact of the antimicrobial agents of the present diluent on the analysis of population and subpopulation differentiation of blood cells. Because the cell volume of RBCs and WBCs overlap considerably, it is not possible to count one in the presence of the other by size discrimination alone. Thus, the diluent of the present invention must also serve as a diluent for a lytic reagent. A standard lytic reagent and method, such as that described in US Patent No. 4,745,071 is used to analyse each population separately and is hereby incorporated by reference.

Following the lysis step to separate WBCs from RBCs, WBC subpopulations can be examined. WBC subpopulation

characterisation is known in the art; see eg, US Patent

No. 4,485,175. Again, cells are differentiated on the basis of cell size. In this manner, three subpopulations can, in most instances, be identified. These three subpopulations can, in most instances, be identified. These three

subpopulations are (in order of increasing size) lymphocytes, monocytes, and granulocyutes. Granulocytes are a

heterogeneous group that include neutrophils, eosinophils and basophils. Blood cell population and subpopulation characterisation, is most useful in identifying pathological conditions.

Pathological conditions may give rise to at least three types of variations in blood cell profile. First, the size of existing populations and/or subpopulations may be altered (eg larger WBCs). Second, the number of normal sized cells of an existing population or subpopulation may be altered (eg more monocytes). Finally, a completely different population or subpopulation may emerge (eg appearance of promyelocytes).

Figure 1A shows the WBC histogram achieved on the instrument using the preferred diluent of Table 1, except that EDTA was not included. Three WBC subpopulations can be identified. The lymphocyte subpopulation peak (10) shows a mean cell volume of approximately 62 cubic microns. The monocyte subpopulaiton (11) ranges in size between

approximately 80 and 180 cubic microns. The granulocyte subpopulation peak (12) shows a mean cell volume of

approximately 320 cubic microns. Note that there is a relatively low level of cell stroma (13).

Figure 1B shows the RBC histogram using the same diluent as in Figure 1A. The mean cell volume for the RBC

populations peak (14) is approximately 86 microns. The histogram shows only this peak which rises sharply and drops softly.

Figure 1C shows the PLT histogram using the same diluent as in Figures 1A and IB. The mean cell volume for the PLT population peak (15) is approximately 7 cubic microns.

Figures 2A-2C show the results of an experiment designed to assess the impact on the analysis of sodium fluoride alone. The diluent is the preferred diluent of Table 2, except that EDTA was not included. It was hoped that sodium fluoride could be used to prevent microbial growth.

Unexpectedly, the addition of sodium fluoride causes the lymphocyte subpopulation peak (20) to shift to the right relative to the (control diluent) WBC population peak (10) of Figure 1A; the mean cell volume is approximately 85 cubic microns. In this manner, the lymphocyte subpopulation peak (20) intrudes into the monocyte subpopulation range (21).

Furthermore, the level of stroma (23) is dramatically and unacceptably increased. From Figure 2B it appears that the RBC population peak (24) position is unchanged. Also, from Figure 2C, a distinct shift of the platelet population peak (25) to the left is observed.

From the results shown in Figures 2A-2C it is clear that when used alone, sodium fluoride interferes with the analysis by causing overlap between WBC subpopulations. As noted above, the identification of pathological conditions depends on the ability to detect variations in normal blood cell parameters. Overlap between WBC subpopulations would prevent such an identification.

Clearly, sodium fluoride, when used alone, is not a solution to the microbial growth problem. Nonetheless, further experiments revealed that sodium fluoride, when used in a diluent of a particular composition, could be used to prevent microbial growth. Surprisingly, while studying sodium fluoride in other diluents, it was discovered that the interference by sodium fluoride could be eliminated. Figures 3A-3C show the results of an experiment where sodium fluoride is used in the presence of -EDTA. The. diluent is the preferred diluent of Table 2. Figure 3A shows that, in the presence of EDTA, the addition of sodium fluoride does not cause the lymphocyte subpopulation peak (30) to intrude into the monocyte subpopulation range (31); the mean cell volume for the lymphocyte peak (30) is approximately 61 cubic microns. There is a very low level of cell stroma (33).

Figures 3B (RBC population peak (34)) and 3C (platelet peak (35)) are similarly unchanged.

This surprising result prompted further experiments where the concentration of EDTA was held constant (0.3 gm/L) and a range (0.1 gm/L - 0.5 am/L) of sodium fluoride

concentrations were assessed in separate diluents otherwise identical to the Table 2 preferred diluent. No interference with the analysis was observed.

The impact, if any, of EDTA used alone is evaluated in Figures 4A-4C. The diluent was the preferred diluent

subpopulation peak (40) to be unchanged relative to the comparable peak (10) of Figure 1A; the mean cell volume is approximately 60 cubic microns. Again, Figures 4B (RBC population peak (44)) and 4C (platelet peak (45)) are

unchanged.

MICROBIAL GROWTH

Example 2 Microbial growth was assessed in culture experiments

performed at Laboratory Services, Inc., San Jose, California. Samples were taken from diluents identical to that of Table 2 except for the concentrations of EDTA and sodium fluoride. Cultures were inoculated and incubated for fungus growth on Sabourahd Dextrose and Mycosel slants according to McGimis, Laboratory Handbook of Medical Mycology. Academix Press, 1980, pi. 74-77. This method was, thus, a "direct culture".

Samples were also used to inoculate thioglycollate broth. If growth was observed in the thioglycollate, samples from the broth were then used to inoculate Sabouraud Dextrose and Mycosel slants as a "subculture".

If growth appeared to be a yeast, standard methods were used to proceed with yeast identification. If growth

appeared to be a fungus, the growing colony morphology was observed, a Lactophenol Cotton Blue prep was carried out according to Laboratory Methods in Medical Mycology. US Dept. of HEW, Public Health Service, CDC, June 1978, pp. 29-30 and a slide culture was performed. The slide culture involved gently removing and mounting the coverslip of the Lactophenol Cotton Blue prep to observe the fruiting bodies of the fungus. Under a hood, two square plugs from a cornmeal agar plate are placed on the surface of the same plate with a sterile wood stick. A small portion of unknown fungus colongy, again with a sterile wooden stick, is then placed inside of the square "holes" and the top edges of the square plugs. Glass coverslips are then placed on top of each of the two square inoculate plugs and the plate is incubated at 30 °C. When sufficient growth is observed, the reverse side of the plate is examined so that the inside edges of the square "holes" might be observed for fruiting bodies.

The results from these microbial studies are shown in Table 3 (only the concentrations of EDTA and sodium fluoride are shown).

From the data it is clear that, when the diluent is formulated with only 1-hydroxypyrideine-2-thione (0.1 gm/L) as an antimicrobial agent, growth of microorganisms occur. In a 7 day culture at 30 °C, the primary microorganism is

Paecilomyces. The most surprising result of Table 3 is that both 1) EDTA alone and 2) EDTA and sodium fluoride together are effective at stopping growth in the direct cultures. This is unexpected in view of the fact that no antimicrobial property of EDTA has been heretofor described, either in the context of blood diluents or elsewhere.

The subculture technique appears from the data of Table 3 to measure a different level of growth. This is probably due to the lower concentration of the antimicrobial agents when the diluent is put into the thioglycollate (1 ml into 15 ml). Interestingly, the combination of EDTA and sodium fluoride is effective in stopping growth in the subcultures when used in higher concentrations.

CONCENTRATION ANALYSIS

Example 3

The results of Table 3 prompted the study of higher concentrations of EDTA and sodium fluoride on arresting growth. Effective concentrations of EDTA and sodium fluorid that did not adversely impact the blood analysis were found to be: EDTA (above 0.02 gm/L up to 1.0 gm/L)

Sodium Fluoride (above 0.02 gm/L up to 0.5 gm/L)

Thus it can be seen that the present invention provides a novel and improved method for determining the cell number and size of cell populations and subpopulations in a blood sample wherein the blood is diluted in an osmotically

balanced solution. The invention also provides a novel blood diluent containing an antimicrobial agent for a blood diluent that does not interfere with the blood analysis, is potent, but relatively non-toxic and inexpensive.

It is hereby demonstrated by the examples, in particular Example 2, that both EDTA and EDTA in combination with sodium fluoride in effective concentrations may provide heretofore unknown antimicrobial agents and/or fugistatic agents, of wide general utility, but of particular utility in blood diluents.

It should be understood that various alternatives to the methods and materials herein disclosed may be employed in practising the present invention. It is intended that the following claims define the invention, and that the materials and methods within the scope of these claims and their equivalents be covered thereby.

Claims

C L A I M S

1. An antimicrobial agent comprising an effective

concentration of EDTA.

2. A fungistatic and/or fungicial agent comprising an effective concentration of EDTA.

3. A blood diluent comprising a fungicidally and/or

fungistatically effective concentration of EDTA.

4. An antimicrobial agent, fungistatic and/or fungicidal agent, or blood diluent as claimed in claim 1, claim 2 or claim 3, characterised in that the EDTA is present at a concentration of between approximately 0.02 grammes/litre and 1.0 grammes/litre.

5. An antimicrobial agent comprising an effective

concentration of EDTA and sodium fluoride.

6. A fungistatic and/or fungicidal -agent comprising an effective concentration of EDTA and sodium fluoride.

7. A blood diluent comprising fungicidally and/or

fungistatically effective concentration of EDTA and sodium fluoride.

8. An antimicrobial agent, fungistatic and/or fungicidal agent, or blood diluent as claimed in claim 5, claim 6 or claim 7, characterised in that EDTA is present at a

concentration of between approximately 0.02 grammes/litre and 1.0 grammes/litre, and sodium fluoride is present at a concentration of between approximately 0.02 grammes/litre and 0.5 grammes/litre.

9. Method for determining the cell number and/or size of a cell subpopulation in a blood sample, comprising the steps of; (a) diluting the blood sample with a diluent

containing a fungicidally and/or

fungistatically effective concentration of EDTA, and (b) measuring the cell number and/or size of the

cell subpopulation.

10. Method according to claim 9, characterised in that EDTA is present in the blood diluent at a concentration of between approximately 0.02 grammes/litre and 1.0 grammes/litre.

11. Method for determining the cell number and/or size of a cell subpopulation in a blood sample comprising the steps of; (a) diluting the blood sample with a diluent comprising a fungicidally and/or fungistatically. effective concentration of EDTA and sodium fluoride, and

(b) measuring the cell number and/or size of the cell subpopulation.

12. Method according to claim 11 characterised in that the concentration of EDTA is between approximately

0.02 grammes/litre and 1.0 grammes/litre, and the

concentration of sodium fluoride is between approximately 0.02 grammes/litre and 0.5 grammes/litre.

13. Method of diluting blood with a blood diluent wherein the diluent employs a fungicidal and/or fungistatic agent to prevent the growth of microorganisms, characterised in that the agent comprises EDTA.

14. Method of diluting blood with a blood diluent wherein the diluent employs a fungicidal and/or fungistatic agent to prevent the growth of microorganisms, characterised in that the agent comprises a mixture of EDTA and sodium fluoride.

15. Use of EDTA as an antimicrobial, fungicidal or

fungistatic agent.

16. Use accordingly to claim 15 in a blood diluent.

17. Use accordingly to claim 15 or claim 16 characterised in that the EDTA concentration is between approximately 0.02 grammes/litre and 1.0 grammes/litre.

18. Use of a mixture of EDTA and sodium fluoride as a fungicidal or fungistatic agent.

19. Use according to claim 18 in a blood diluent.

20. Use according to claim 18 or claim 19 characterised in that the EDTA concentration in between approximately

0.02 grammes/litre and 1.0 grammes/litre, and the sodium fluoride concentration is between approximately

0.02 grammes/litre.