The Immunoscan CCPlus® test kit is an enzyme-linked immunosorbent assay (ELISA) for qualitative and semi-quantitative determination of IgG antibodies to Cyclic Citrullinated Peptides (CCP) in human sera. The assay is used to detect antibodies in a single serum specimen. The results of the assay are to be used as an aid to the diagnosis of Rheumatoid Arthritis (RA), in conjunction with other laboratory and clinical findings. The analysis should be performed by trained laboratory professionals. "For in vitro diagnostic use".

Device Description

The Immunoscan CCPlus® test kit is a modification of the Immunoscan RA anti-CCP Test kit, K052133. It is an enzyme-linked immunosorbent assay (ELISA) for qualitative and semi-quantitative determination of IgG antibodies to Cyclic Citrullinated Peptides (CCP) in human sera. The assay is used to detect antibodies in a single serum specimen. The results of the assay are to be used as an aid to the diagnosis of Rheumatoid Arthritis (RA), in conjunction with other laboratory and clinical findings. The analysis should be performed by trained laboratory professionals. "For in vitro diagnostic use".

The wells are coated with Cyclic Citrullinated Peptides. During the first incubation, specific antibodies in diluted serum, will bind to the antigen coating.

The wells are then washed to remove unbound antibodies and other components. A conjugate of alkaline phosphatase labelled antibodies to human IgG binds to the antibodies in the wells in this second incubation.

After a further washing step, detection of specific antibodies is obtained by incubation with substrate solution. The amount of bound antibodies correlates to the colour intensity and is measured in terms of absorbance (optical density (OD)). The absorbance is then calculated against a calibrator curve and the results are given in arbitrary units.

AI/ML Overview

Here's a breakdown of the acceptance criteria and study information for the Immunoscan CCPlus® device, based on the provided 510(k) summary:

Acceptance Criteria and Device Performance

The Immunoscan CCPlus® device is a modification of the Immunoscan RA anti-CCP Test kit and its performance is compared to this predicate device. The acceptance criteria are implicitly set by demonstrating substantial equivalence to the predicate device, implying that the modified device's performance characteristics should be similar to or better than the predicate's.

Metric	Acceptance Criteria (Implied by Predicate Performance)	Reported Device Performance (Immunoscan CCPlus®)
Clinical Sensitivity	~75.1%	77.4%
Clinical Specificity	Between 94.1% - 100%	Between 94.1% - 100%
Intra-assay Precision (low %C.V.)	Anti-CCP: 34 - 1007 U/mL %C.V.: 4.3-12.8	Anti-CCP: 28 - 2685 U/mL %C.V.: 1.0-7.6
Inter-assay Precision (low %C.V.)	Anti-CCP: 33 - 1106 U/mL %C.V.: 6.0-17.7	Anti-CCP: 28 - 2696 U/mL %C.V.: 2.1-12.2
Lot to lot Precision (low %C.V.)	Anti-CCP: 29 - 1117 U/mL %C.V.: 3.8-12.2	Anti-CCP: 60 - 2896 U/mL %C.V.: 6.9-17.0
Detection Limit	Not explicitly stated for predicate in summary	1.6 U/mL
Positive Percent Agreement	Not explicitly stated for predicate in summary	99.3% (compared to predicate)
Negative Percent Agreement	Not explicitly stated for predicate in summary	98.6% (compared to predicate)
Overall Percent Agreement	Not explicitly stated for predicate in summary	98.9% (compared to predicate)

Study Information

Sample size used for the test set and the data provenance:
- Comparative Agreement Study (Immunoscan CCPlus® vs. Predicate):
  - Sample Size: 628 frozen retrospective sera.
  - Data Provenance: 368 samples from RA patients, 260 samples from apparently healthy blood donors. The country of origin is not specified but is likely Sweden, given the manufacturer's location. The data is retrospective.
- Clinical Sensitivity and Specificity Study (Immunoscan CCPlus®):
  - Sample Size: 1180 frozen retrospective sera.
  - Data Provenance: The origin of these samples is not specified beyond being "frozen retrospective sera with clinical characterisation." The distribution includes 399 patients with clinically defined RA and various control and disease groups. Country of origin not specified; data is retrospective.
Number of experts used to establish the ground truth for the test set and the qualifications of those experts:
- The document describes the use of "clinically defined RA" for the ground truth of RA patients and "apparently healthy blood donors" or "non-RA diseased patients" for controls.
- It does not specify the number of experts, their qualifications, or the process by which "clinical characterisation" or "clinically defined RA" was established. This suggests that the ground truth was based on pre-existing clinical diagnoses rather than a panel of experts reviewing the cases specifically for this study.
Adjudication method for the test set:
- No adjudication method (e.g., 2+1, 3+1) is mentioned or implied for establishing the ground truth of the clinical samples. The "clinically defined RA" and control groups appear to have pre-determined diagnoses.
If a multi reader multi case (MRMC) comparative effectiveness study was done, If so, what was the effect size of how much human readers improve with AI vs without AI assistance:
- No. This device is an in vitro diagnostic (ELISA) assay that directly measures antibodies. It does not involve human readers interpreting images or data alongside an AI, so an MRMC study is not applicable. The device provides a quantitative or semi-quantitative result directly.
If a standalone (i.e. algorithm only without human-in-the-loop performance) was done:
- Yes, this is a standalone device in the sense that the test results are generated by the assay without real-time human interpretation affecting the output. The assay produces a direct quantitative or semi-quantitative result for anti-CCP antibodies. The results are then used by trained laboratory professionals in conjunction with other clinical findings.
The type of ground truth used (expert consensus, pathology, outcomes data, etc.):
- The ground truth for the clinical sensitivity and specificity study was based on clinical characterization/diagnosis, specifically "clinically defined RA" for the RA group and various diagnosed control groups (e.g., SLE, IBD, blood donors, etc.) for the non-RA groups. This implies a combination of clinical symptoms, other laboratory findings, and possibly imaging, leading to a physician's diagnosis. It is not explicitly stated to be expert consensus, nor pathology or direct outcomes data, but rather an established clinic diagnosis.
The sample size for the training set:
- The document does not specify a training set. This is typical for traditional in-vitro diagnostic assays, which are usually developed using analytical methods and then validated with clinical samples, rather than "trained" in the machine learning sense. The information provided pertains solely to the validation/test sets.
How the ground truth for the training set was established:
- Since no training set is mentioned for an algorithm, this question is not applicable. For an ELISA kit, development involves optimizing reagents and protocols against known positive and negative samples, but this isn't typically referred to as "training" in the same way as AI/ML.

Summary

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K091657

510(k) Summary

NOV 1 9 2009

Euro-Diagnostica AB, " 1. Lundavägen 151, SE-212 24 Malmo, Sweden Contact person: Ms. Annika Andersson Telephone: +46 40 53 76 04 Fax: +46 40 43 22 88 Date of preparation: June 5, 2009 Revised: November 5, 2009
II. Device/Trade name: Immunoscan CCPIus® Common name: Anti-CCP test Governing regulation: 21 CFR 866.5775 Device classification: Class II Classification panel: Immunology Product code: NHX
III. Description of Device: The Immunoscan CCPlus® test kit is a modification of the Immunoscan RA anti-CCP Test kit, K052133. It is an enzyme-linked immunosorbent assay (ELISA) for qualitative and semi-quantitative determination of IgG antibodies to Cyclic Citrullinated Peptides (CCP) in human sera. The assay is used to detect antibodies in a single serum specimen. The results of the assay are to be used as an aid to the diagnosis of Rheumatoid Arthritis (RA), in conjunction with other laboratory and clinical findings. The analysis should be performed by trained laboratory professionals. "For in vitro diagnostic use".

The wells are coated with Cyclic Citrullinated Peptides. During the first incubation, specific antibodies in diluted serum, will bind to the antigen coating.

IV. Legally marketed device to which equivalence is claimed: Immunoscan RA anti-CCP Test kit, K052133.

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V. Intended use of the device: The intended use of the modified device has not changed. The Immunoscan CCPlus® test kit is an enzyme-linked immunosorbent assay (ELISA) for qualitative and semi-quantitative determination of IgG antibodies to Cyclic Citrullinated Peptides (CCP) in human sera. The assay is used to detect antibodies in a single serum specimen. The results of the assay are to be used as an aid to the diagnosis of Rheumatoid Arthritis (RA), in conjunction with other laboratory and clinical findings. The analysis should be performed by trained laboratory professionals. "For in vitro diagnostic use".
VI. Comparison of technological characteristics:

Table 1. Similarities and differences between Immunoscan CCPlus® and Predicate Device, Immunoscan RA anti CCP Test kit, K052133

Item	Modified Device Immunoscan CCPlus®	Predicate Device Immunoscan RA anti-CCP
Intended use	The results of the assay are to be used as an aid to the diagnosis of Rheumatoid Arthritis (RA), in conjunction with other laboratory and clinical findings.	The results of the assay are to be used as an aid to the diagnosis of Rheumatoid Arthritis (RA), in conjunction with other laboratory and clinical findings.
Intended user	For use by health care professionals	For use by health care professionals
Method	ELISA	ELISA
Type of test	Qualitative and semi-quantitative	Qualitative and semi-quantitative
Analyte measured	Anti-CCP	Anti-CCP
Coated antigen	Synthetic CCP	Synthetic CCP
Conjugate	Anti-human IgG	Anti-human IgG
Substrate	TMB (3, 3', 5, 5'-tetramethylbenzidin)	TMB (3, 3', 5, 5'-tetramethylbenzidin)
Wavelength	450 nm	450 nm
Incubation time	60 min + 30 min + 30 min	60 min + 30 min + 30 min
Cut-off	≥25 U/mL	≥25 U/mL
Sample	Serum	Serum
Sample preparation	Dilute 1:50	Dilute 1:50
Microtitre plate	Material: PolystyreneSurface: MaxiSorp	Material: PolystyreneSurface: MaxiSorp

Similarities

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Differences

Item	Modified DeviceImmunoscan CCPlus®	Predicate DeviceImmunoscan RAanti-CCP
Microtiter plate	96 individual wells plate	8 strips x 12 wells plate
	Note: The material andsurface of the microtitreplate are the same	Note: The material andsurface of the microtitreplate are the same

Calibrator curve		25 U/mL, 50 U/mL,200 U/mL, 800 U/mL,3200 U/mL
	Note: The same material isused to produce thecalibrator	Note: The same material isused to produce thecalibrator

VII. Summary of performance: The modified device, Immunoscan CCPlus®, is substantially equivalent to the Immunoscan RA anti-CCP Test kit. Equivalence is demonstrated by the following comparative results.
Table 2. Percent agreement of the Immunoscan CCPlus® compared to the Immunoscan RA anti-CCP Test kit. A total of 628 frozen retrospective sera were assayed. 368 were obtained from RA patients and 260 samples were from apparently healthy blood donors.

		Predicate deviceImmunoscan RA anti-CCP
ImmunoscanCCPlus®	N = 628	Positive	Negative
	Positive	275	5
Negative	2	346

Positive Percent Agreement:	275/277 = 99.3% 95% CI = 97.4 - 99.9%
Negative Percent Agreement:	346/351 = 98.6% 95% CI = 96.7 - 99.5%
Overall Percent Agreement:	621/628 = 98.9% 95% CI = 97.7 - 99.6%

The 95% confidence interval (CI) was calculated using the exact method.

Table 3. Clinical sensitivity and specificity. A total of 1180 frozen retrospective sera with clinical characterisation were assayed. The following table summarizes the results.

	n	negative	positive	Sensitivity
Patients with clinicallydefined RA	399	90	309	77.4%

Clinical sensitivity

95% Cl = 73.3 - 81.5% RA 309/399 = 77.4%

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Clinical specificity for the Immunoscan CCPlus® for non-RA diseased patients and asymptomatic individuals (healthy blood donors).

Control and	Total	Negative	Positive
Disease groups	number	< 25 U/mL	≥ 25 U/mL
Blood donors	260	257	3
RA	399	90	309
WG	20	18	2
MP	20	20	0
SLE	66	64	2
Sjögren's syndrome	13	13	0
IBD	98	95	3
Osteoarthritis	21	21	0
Thyroiditis	20	20	0
Epstein Barr Virus	5	5	0
Parvovirus	5	5	0
Mycoplasma	9	9	0
Toxoplasma	6	6	0
Tuberculosis	5	5	0
Yersinia	8	8	0
Salmonella	3	3	0
Chlamydia	5	4	1
Malaria	4	4	0
Borrelia	9	9	0
Syphilis	5	5	0
Infectious endocarditis	3	3	0
Legionella	4	4	0
AST	3	3	0
Schistomiasis	4	4	0
Rubella	5	5	0
Chaga's syndrome	3	3	0
Scleroderma	17	16	1
Multiple Sclerosis	20	20	0
IDDM	20	20	0
PM/DM	20	20	0
MCTD	20	19	1
Routine samples	80	78	2

= rheumatoid arthritis RA

= Wegener's granulomatosis WG

= microscopic polyangiitis MP

= systemic lupus erythematosus SLE

PM/DM = Polymyositis/Dermatomyositis

IBD = inflammatory bowel disease

AST = anti-Streptolysine test

IDDM = insulin dependent diabetes mellitus

= mixed connective tissue disease MCTD

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Clinical specificity

Blood donors	= 257/260 = 98.8%	95% CI = 96.7 - 99.8%
WG	= 18/20 = 90.0%	95% CI = 68.3 - 98.8%
MP	= 20/20 = 100%	95% CI = 83.2 - 100%
SLE	= 64/66 = 97.0 %	95% CI = 89.5 - 99.6%
Sjogren's	= 13/13 = 100 %	95% CI = 75.3 - 100%
IBD	= 95/98 = 96.9%	95% CI = 91.3 - 99.4%
Osteoarthritis	= 21/21 = 100%	95% CI = 83.9 - 100%
Thyroiditis	= 20/20 = 100%	95% CI = 83.2 - 100%
Infectious Disease	= 85/86 = 98.8%	95% CI = 93.7 - 100%
Scleroderma	= 16/17 = 94.1%	95% CI = 71.3 - 99.8%
Multiple Sclerosis	= 20/20 = 100%	95% CI = 83.2 - 100%
IDDM	= 20/20 = 100%	95% CI = 83.2 - 100%
PM/DM	= 20/20 = 100%	95% CI = 83.2 - 100%
MCTD	= 19/20 = 95.0%	95% CI = 75.1 - 99.9%
Routine samples	= 78/80 = 97.5 %	95% CI = 91.3 - 99.7 %

The 95% confidence interval (CI) was calculated using the exact method.

Table 4. Intra-assay precision was determined by testing six different samples eight times each.

	High			High			High
	U/mL	OD		U/mL	OD		U/mL	OD
Mean.	2672	1.421		2685	1.432		1150	1.664
S.D.	138	0.01		205	0.01		55.3	0.02
% C.V.	5.2	0.4		7.6	0.4		4.8	0.9
	Medium		Low		Low
	U/mL	OD	U/mL	OD	U/mL	OD
Mean	239	1.014	56	0.421	28	0.232
S.D.	2.3	0.01	2.1	0.01	0.5	0.01
%C.V.	1.0	0.4	3.8	2.8	3.6	1.3

Table 5. Inter-assay precision was determined by testing six .different samples eight times each. Results were obtained for three different runs.

High		High		High
U/mL	OD	U/mL	OD	U/mL	OD
Mean.	2696	1.426	2600	1.422	1168	1.706
S.D.	328	0.01	299	0.01	101.7	0.07
% C.V.	12.2	0.7	11.5	0.8	8.7	3.8
Medium		Low		Low
U/mL	OD	U/mL	OD	U/mL	OD
Mean.	242	1.031	59	0.428	28	0.232
S.D.	5.0	0.03	3.1	0.02	0.5	0.01
%C.V.	2.1	2.5	5.2	3.8	1.8	0.9

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	High		High		High
	U/mL	OD	U/mL	OD	U/mL	OD
Mean.	2896	1.408	2870	1.408	1530	1.807
S.D.	405	0.02	335	0.02	260.4	0.03
% C.V.	14.0	1.4	11.7	1.5	17.0	1.6
	Medium		Low		Low
	U/mL	OD	U/mL	OD	U/mL	OD
Mean	259	1.100	60	0.462	62	0.471
S.D.	21.8	0.04	4.2	0.02	6.6	0.04
%C.V.	8.4	3.9	6.9	4.4	10.8	8.2

Table 6. Lot to lot variation was determined by testing six different samples eight times each. Results were obtained for three different lots.

Table 7. Dilution recovery was determined by testing five serial dilutions for three different samples.

Sample	Dilution	Mean MeasuredConcentration(U/mL)	CalculatedConcentration(U/mL)	Dilution Corrected% Recovery
1	1/50	395	395	100
	1/100	195	198	98
	1/200	104	99	105
	1/400	53	50	106
	1/800	26	25	104
Sample	Dilution	Mean MeasuredConcentration(U/mL)	CalculatedConcentration(U/mL)	Dilution Corrected% Recovery
2	1/50	921	921	100
	1/100	486	461	105
	1/200	257	230	112
	1/400	124	115	107
	1/800	63	58	109
Sample	Dilution	Mean MeasuredConcentration(U/mL)	CalculatedConcentration(U/mL)	Dilution Corrected% Recovery
3	1/50	2962	2962	100
	1/100	1496	1481	101
	1/200	771	741	104
	1/400	349	370	94
	1/800	194	185	105

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Detection Limit

The detection limit of the assay was determined by running the zero standard 14 times on three different lots. The detection limit of 1.6 U/mL was calculated by finding the mean plus two standard deviations.

Interference Study

Three low positive samples were spiked with bilirubin at 0.2 mg/mL, haemoglobin at 400 mg/dl, lipid at 15 mg/mL and rheumatoid factor at 200 IU/mL. The data indicates that the assayed concentrations do not interfere with the anti-CCP results.

Summary performance characteristics:

Clinical sensitivity
Immunoscan CCPlus®	77.4%
Predicate device	75.1%
Clinical specificity
Immunoscan CCPlus®	Between 94.1% - 100%
Predicate device	Between 94.1% - 100%
Intra-assay precision
Immunoscan CCPlus®	Anti-CCP: 28 - 2685 U/mL %C.V.: 1.0-7.6
Predicate device	Anti CCP: 34 - 1007 U/mL %C.V.: 4.3-12.8
Inter-assay precision
Immunoscan CCPlus®	Anti-CCP: 28 - 2696 U/mL %C.V.: 2.1-12.2
Predicate device	Anti CCP: 33 - 1106 U/mL %C.V.: 6.0-17.7
Lot to lot precision
Immunoscan CCPlus®	Anti-CCP: 60 - 2896 U/mL %C.V.: 6.9-17.0
Predicate device	Anti CCP: 29 - 1117 U/mL %C.V.: 3.8-12.2
Detection Limit

lmmunoscan CCPlus® 1.6 U/mL
Predicate device

VIII. Conclusion
The modified device Immunoscan CCPlus® is similar in intended use and performance characteristics to the originally cleared, K052133, Immunoscan RA anti-CCP Test kit. The modification does not alter the fundamental scientific technology of the device.
· same material and surface of ELISA plate
· same production procedure
· performance characteristics are equal or better compared to predicate device

We trust that the information provided in this 510(k) will support a decision of substantial equivalence to the predicate Immunoscan RA anti-CCP Test kit.

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Image /page/7/Picture/1 description: The image shows the address for the Food and Drug Administration. The address is 10903 New Hampshire Avenue, Document Mail Center - WO66-G609, Silver Spring, MD 20993-0002. The text is left-aligned and uses a serif font.

NOV 1 9 2009

Euro-Diagnostica AB c/o Dr. Annika Andersson Regulatory Affairs Manager Lundavägen 151, SE-212 24 Malmo Sweden

Re: K091657 Trade/Device Name: Immunoscan CCPlus® Regulation Number: 21 CFR §866.5775 Regulation Name: Rheumatoid factor immunological test system Regulatory Class: Class II Product Code: NHX Dated: September 28, 2009 Received: October 1, 2009

Dear Dr. Andersson:

We have reviewed your Section 510(k) premarket notification of intent to market the device referenced above and have determined the device is substantially equivalent (for the indications for use stated in the enclosure) to legally marketed predicate devices marketed in interstate commerce prior to May 28, 1976, the enactment date of the Medical Device Amendments or to devices that have been reclassified in accordance with the provisions of the Federal Food, Drug, and Cosmetic Act (Act) that do not require approval of a premarket approval (PMA). You may, therefore, market the device, subject to the general controls provisions of the Act. The general controls provisions of the Act include requirements for annual registration, listing of devices, good manufacturing practice, labeling, and prohibitions against misbranding and adulteration.

If your device is classified (see above) into either class II (Special Controls) or class III (PMA), it may be subject to additional controls. Existing major regulations affecting your device can be found in the Code of Federal Regulations, Title 21, Parts 800 to 898. In addition, FDA may publish further announcements concerning your device in the Federal Register.

Please be advised that FDA's issuance of a substantial equivalence determination does not mean that FDA has made a determination that your device complies with other requirements of the Act or any Federal statutes and regulations administered by other Federal agencies. You must comply with all the Act's requirements, including, but not limited to: registration and listing (21 CFR Part 807); labeling (21 CFR Part 801); medical device reporting of medical device-related adverse events) (21 CFR 803); good manufacturing practice requirements as set forth in the quality systems

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Page 2 - Dr. Annika Andersson

(QS) regulation (21 CFR Part 820); and if applicable, the electronic product radiation control provisions (Sections 531-542 of the Act): 21 CFR 1000-1050.

If you desire specific advice for your device on our labeling regulation (21 CFR Part 801), please go to http://www.fda.gov/AboutFDA/CentersOffices/CDRH/CDRHOffices/ucm115809.htm for the Center for Devices and Radiological Health's (CDRH's) Office of Compliance. Also, please note the regulation entitled, "Misbranding by reference to premarket notification" (21CFR Part 807.97). For questions regarding the reporting of adverse events under the MDR regulation (21 CFR Part 803), please go to http://www.fda.gov/MedicalDevices/Safety/ReportaProblem/default.htm for the CDRH's Office of Surveillance and Biometrics/Division of Postmarket Surveillance,

You may obtain other general information on your responsibilities under the Act from the Division of Small Manufacturers, International and Consumer Assistance at its toll-free number (800) 638-2041 or (301) 796-7100 or at its Internet address http://www.fda.gov/MedicalDevices/Resourcesfor You/Industry/default.htm.

Sincerely yours,

ia M. Chan.

Maria M. Chan, Ph.D. Director Division of Immunology and Hematology Devices Office of In Vitro Diagnostic Device Evaluation and Safety Center for Devices and Radiological Health

Enclosure

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Indications for Use

510(k) Number: K091657

Device Name: Immunoscan CCPlus®

Indication For Use: The Immunoscan CCPlus® test kit is an enzyme-linked immunosorbent assay (ELISA) for qualitative and semi-quantitative determination of IgG antibodies to Cyclic Citrullinated Peptides (CCP) in human sera. The assay is used to detect antibodies in a single serum specimen. The results of the assay are to be used as an aid to the diagnosis of Rheumatoid Arthritis (RA), in conjunction with other laboratory and clinical findings, The analysis should be performed by trained laboratory professionals. "For in vitro diagnostic use".

Prescription Use × (21 CFR Part 801 Subpart D) And/Or

Over the Counter Use (21 CFR Part 801 Subpart C)

(PLEASE DO NOT WRITE BELOW THIS LINE; CONTINUE ON ANOTHER PAGE IF NEEDED)

Concurrence of CDRH, Office of In Vitro Diagnostic Device Evaluation and Safety (OIVD)

Tharai M. Chan

Division Sign-Off Office of In Vitro Diagnostic Device Evaluation and Safety

510(k) K091657

Regulation Number and Section

§ 866.5775 Rheumatoid factor immunological test system.

(a)
Identification. A rheumatoid factor immunological test system is a device that consists of the reagents used to measure by immunochemical techniques the rheumatoid factor (antibodies to immunoglobulins) in serum, other body fluids, and tissues. Measurement of rheumatoid factor may aid in the diagnosis of rheumatoid arthritis.(b)
Classification. Class II (performance standards).