Management of familial hypercholesterolemia in children and young adults: consensus paper developed by a panel of lipidologists, cardiologists, paediatricians, nutritionists, gastroenterologists, general practitioners and a patient organization.

UNLABELLED: Since heterozygous familial hypercholesterolemia (HeFH) is a disease that exposes the individual from birth onwards to severe hypercholesterolemia with the development of early cardiovascular disease, a clear consensus on the management of this disease in young patients is necessary. In Belgium, a panel of paediatricians, specialists in (adult) lipid management, general practitioners and representatives of the FH patient organization agreed on the following common recommendations. 1. Screening for HeFH should be performed only in children older than 2 years when HeFH has been identified or is suspected (based on a genetic test or clinical criteria) in one parent.2. The diagnostic procedure includes, as a first step, the establishment of a clear diagnosis of HeFH in one of the parents. If this precondition is satisfied, a low-density-lipoprotein cholesterol (LDL-C) levelabove 3.5 mmol/L (135 mg/dL) in the suspected child is predictive for differentiating affected from non-affected children. 3. A low saturated fat and low cholesterol diet should be started after 2 years, under the supervision of a dietician or nutritionist.4. The pharmacological treatment, using statins as first line drugs, should usually be started after 10 years if LDL-C levels remain above 5 mmol/L (190 mg/dL), or above 4 mmol/L (160 mg/dL) in the presence of a causative mutation, a family history of early cardiovascular disease or severe risk factors. The objective is to reduce LDL-C by at least 30% between 10 and 14 years and, thereafter, to reach LDL-C levels of less than 3.4 mmol/L (130 mg/dL). CONCLUSION: The aim of this consensus statement is to achieve more consistent management in the identification and treatment of children with HeFH in Belgium.

Accreditation and postgraduate training in European countries: an FESCC survey. Federation of European Societies of Clinical Chemistry.

The mission of the Federation of European Societies of Clinical Chemistry is to support and promote clinical chemistry and laboratory medicine in Europe, to aid communication between the International Federation of Clinical Chemistry and Laboratory Medicine (IFCC) and National Scientific Societies, to develop education and quality in the discipline, and to encourage young scientists to take an active role in these activities. One recent initiative of the Federation was a survey on accreditation of medical laboratories and training in laboratory medicine in Europe. Among European countries, three promote accreditation according to EN 45001, several countries apply systems based on professional and nationally defined standards (e.g. CPA in the UK) and other countries are moving to define accreditation standards at a national level. Data on vocational training demonstrate that this is based on a postgraduate education with duration ranging from 6 months to 11 years; in most countries the average length of university education is 5 years and that of postgraduate training is 4 years. A great difference, moreover, exists regarding the polyvalent versus monovalent training. Taken together, these data indicate that a great effort should be made by the Federation for promoting harmonization and coordination in Europe.

Analytical performance of a direct assay for LDL-cholesterol.

We evaluated a direct assay for the determination of LDL-cholesterol (LDL-C) L-Type assay, Wako Pure Chemicals in two laboratories. This assay is applicable to most random access clinical chemistry analyzers, allowing full automation. Between-run coefficient of variation (NCCLS EP5) varied between 1.29% and 3.13% and thus met the National Cholesterol Education Program (NCEP) goal. The assay was considered linear over a physiologically relevant range of LDL-C, 2.22 to 7.04 mmol/l (NCCLS EP6). Method comparison yielded identical results at both evaluation sites for LDL-C when assayed with the direct method. LDL-C results obtained with the homogeneous method under investigation (y) differed significantly from values from density-gradient ultracentrifugation (x) according to Chung (y = 0.87x + 0.43 mmol/l, s(yx) = 0.38 mmol/l, r = 0.91). With the latter method as a reference method, mean bias was 3.16% meeting the NCEP criteria. Diagnostic performance was excellent at a clinically relevant cut-off level of 3.37 mmol/l. Results of the direct method (y) and the commonly used Friedewald formula (x) were highly correlated (s(yx) = 0.22 mmol/l, r = 0.97), but both slope and intercept differed significantly from one and zero respectively (y = 0.90x + 0.37 mmol/l). Bilirubin, hemolysis and ascorbate did not interfere; triglycerides did not cause clinically relevant interference below 11.3 mmol/l. The direct method we investigated is user-friendly and provides an improvement in the determination of LDL-C in routine laboratories.

Serum alpha-tocopherol and selenium in Belgian infants and children.

Previous studies showed low selenium (Se) concentrations in Belgian children. Serum alpha-tocopherol, retinol, total cholesterol, high-density lipoprotein and low-density lipoprotein cholesterol, selenium (Se), and thiobarbituric acid-reactive substances were examined. In order to obtain further information on the Se status in Belgian children, Se, alpha-tocopherol, retinol, and lipid concentrations were examined and signs of peroxidative lipid damage were evaluated in a subgroup. The study was performed in 524 children (0-14 yr old) during vaccination campaigns. Three age groups were analyzed: 0-1, 1-4, and 4-14 yr. In 87 of them, where sufficient amounts of serum were available, analysis of thiobarbituric acid-reactive substances was done. Infants have high serum alpha-tocopherol concentrations: (23.2 micromol/L [median and interquartile range: 18.6-30.2]) and low Se concentrations (0.37 mol/L [0.27-0.47]). Se concentrations rise significantly during the first 4 yr (p < 0.0001) (Mann-Whitney U-test, tied p-values): 0.70 micromol/L (0.59-0.82); in the 4-14 yr olds, it was 0.75 micromol/L (0.67-0.86). These values remain low compared to results coming from other parts of the world. Alpha-tocopherol concentrations decrease significantly after infancy (p < 0.0001). The ratio alpha-tocopherol/total cholesterol is higher in infants. This is induced by the high vitamin E content of infant formulas. Signs of serum lipid peroxidation could not be detected by analysis of serum malondialdehyde concentrations. High alpha-tocopherol concentrations, as those observed in infant serum lipids, could be one of the protective mechanisms from the peroxidative lipid damages, sometimes observed in a low-Se status.

Implementation of an integrated instrument control and data management system for point of care blood gas testing.

Critical care testing in a point of care (POC) setting can be very demanding for the laboratory. Lack of continuous monitoring of the normal functioning of POC instruments leads to late response to technical problems, and frequently results in more comprehensive interventions and reduced instrument availability. As most POC instruments lack adequate data transfer capabilities, manual data entry into the medical records with a high error rate is a component of POC programs. To reduce this data handling drawback of POC testing, our hospital opted for the replacement of the existing analysers with network-ready, expandable analysers (ABL700), linked to an integrated management system (RADIANCE). This new set-up enabled us to have continuous instrument control and maximal data management. The implementation of the integrated management system was well accepted by the operators. The network connectivity has led to real time technical support while reducing the workload by automating data collection.

FESCC survey on accreditation and post-graduate training in clinical chemistry in European countries. Federation of European Societies of Clinical Chemistry.

Promotion of the professional growth and development of specialists in the field of clinical chemistry in European countries, and harmonisation of quality assessment and accreditation procedures are listed among the main goals and activities of Federation of European Societies of Clinical Chemistry (FESCC), according to its 1999-2000 strategic plan. The European countries that are members of the European Union are in the process of establishing the "European Register for Clinical Chemists", based on minimum standards of education, training and experience as defined by the European Communities Confederation of Clinical Chemists (EC4). Many other European countries would like to adapt their system of professional education to this model. Data on post-graduate training in EC4 FESCC members have already been gathered in 1998. However, at the present time, there is no detailed knowledge of pre- and post-graduate professional education of specialists in clinical chemistry in the non-EC4 European countries. FESCC launched a survey in July 1998 in order to gather this information with the hope to start a database about existing systems. All FESCC members received the same questionnaire on accreditation (seven questions) and non-EC4 FESCC members received an additional questionnaire with 11 questions related to post-graduate training in clinical chemistry. The response rate of the 35 FESCC member countries was 93% from the 15 EC4 members (14 responses/15 countries) and 80% from the 20-non-EC4 (16 responses/20 countries). The heterogeneity of the data on post-graduate training in clinical chemistry indicates that a great effort will be needed before harmonisation is reached. These results, however, will provide an interesting basis for further discussion and promotion of post-graduate training in clinical chemistry. The data provided on accreditation show that the total number of accredited laboratories was relatively low in EC4 countries and even lower in non-EC4 members. It was not surprising to see that the number of accredited laboratories was the highest in the two countries which started accreditation the earliest (i.e. Sweden and UK, 1992). This situation, however, is changing at a fast rate in most countries and the number of the accredited sites is expected to increase rapidly in the next few years.

Usefulness of EC4 essential criteria for quality systems of medical laboratories as guideline to the ISO 15189 and ISO 17025 documents. European Community Confederation of Clinical Chemistry (EC4) Working Group on Harmonisation of Quality Systems and Accreditation.

Many medical laboratories have made a start with the introduction of quality management systems. However, it is still not clear against which standards such systems should be measured. The existing ISO and CEN standards do not cover essential aspects of medical laboratories. The publication of the EC4 Essential Criteria has stimulated the development of the ISO/Draft International Standard 15189. This standard seems adequate for our type of laboratories. However, it is not easy to read. The EC4 Essential Criteria could well serve as a guide, covering additional aspects, e.g. on total quality management and budget management as required in the EFQM model, that are not (yet) included in the ISO standard. In the present article the EC4 Essential Criteria are cross-referenced with two new international ISO standards, ISO/FDIS 15189 and ISO/FDIS 17025, the latter being the successor of ISO guide 25 and EN 45000. Both new ISO documents are in compliance with the new ISO 9000:2000 standard.

Multicenter study on reproducibility of sperm morphology assessments.

Sperm morphology has always been considered an important tool in evaluating a man's fertilizing potential. The objective of this multicentric study was to evaluate intra- and interindividual variability and between-laboratory variation using the same or different criteria of sperm morphology assessment. Semen samples were obtained from 20 males and 32 smears were made of all samples. Eighty coded smears (4 per patient) were sent to 8 laboratories for morphology assessment. The centers applied different classification systems (strict criteria, WHO 1987, Düsseldorf criteria) and participants were asked to analyze the 80 smears twice, with an interval of 1 week between each participant's two analyses. Intraclass correlations between repeats showed that sperm morphology can be assessed with acceptable within observer reproducibility. Expected increases in imprecision were observed up to coefficients of variation of >30% with decreasing morphology scores, regardless of the classification system used. Agreement in correct classification of samples as normal/abnormal was obtained in 80% of cases. Differences in reproducibility between slides may reflect an important source of heterogeneity due to smear preparation. These results emphasize the importance of external quality control systems to improve the value of sperm morphology assessments in the investigation of the male partner in a subfertile couple.

Additional Essential Criteria for Quality Systems of Medical Laboratories. European Community Confederation of Clinical Chemistry (EC4) Working Group on Harmonisation of Quality Systems and Accreditation.

Essential Criteria for Quality Systems of Medical Laboratories have been published recently by the European Community Confederation of Clinical Chemistry (EC4) Working Group on Harmonisation of Quality Systems and Accreditation. The Essential Criteria address the majority of critical aspects of quality management in the medical laboratory. They have been accepted by the EC4 General Assembly and are endorsed by the Forum of European Societies for Clinical Chemistry (FESCC). However, a supplement to the Essential Criteria was necessary, addressing two aspects, which are only partly covered by the Essential Criteria: the management of resources and point of care testing. Thus, the EC4 Working Group on Harmonisation of Quality Systems and Accreditation has decided to formulate Additional Essential Criteria for Quality Systems of Medical Laboratories, directed at the issues of management of resources and point of care testing. Criteria on management of resources address financial aspects, information logistics and acceptance by clients. Criteria on point of care testing address responsibilities, education of non-laboratory staff and operational aspects. The Additional Criteria are supplementary to the previously published Essential Criteria and should be read as an integral part of these.

Essential criteria for quality systems in medical laboratories.

The introduction of total quality systems in medical and clinical laboratories and accreditation of these laboratories is gaining more and more interest. In several countries laboratories have set up quality systems, and accrediation schemes are also operating. The standards of these schemes have much in common although several differences exist. There exists uncertainty in several countries on the choice of a system. Laboratory specialists are confronted with a new way of thinking concerning the management and daily practice of their laboratories. It is not clear, which standards should be used as a basis, and certainly not how to interpret such standards. Particulary in the European Union, harmonisation of criteria for quality systems is desirable. In the present paper, the document entitled "Essential Criteria for Quality Systems in Medical Laboratories" is presented. The document has been accepted in the general Assembly of the European Communities Confederation of Clinical Chemistry (EC4) and by the working group on Good Laboratory Services of the European Council on Laboratory Medicine (ECLM). The criteria in the document are focussed on the particular situation of medical laboratories, including pre- and post-analytical aspects. Reference is made, where applicable, to EN 45001, ISO 9001 and ISO guide 25 draft 3.

Quality and accreditation systems in clinical biochemistry in the European Union.

The European Community Confederation of Clinical Chemistry (EC4) formed in Nice in April 1993 has established a working group on laboratory accreditation. The aim of the group is to explore the possibilities for harmonisation of accreditation and quality systems in clinical laboratories in the European Community (EC). It is felt essential that professions should play a key role in the process, and that the principle of subsidiarity should be observed in relation to implementation and organisation in individual member states. The first task has been to collect information concerning such systems. In September 1993 a questionnaire was distributed to the twelve IFCC related societies for clinical chemistry in the EC. By December 1994 eleven societies had responded. The questionnaire related to the existence or planned introduction of quality and accreditation systems, the basis of the standards used and requirements for analytical aspects and qualifications of staff as well as professional aspects. Questions also addressed the way in which inspection were organised, the selection and training of inspectors, the organisation of systems and what interest there was in harmonisation. The results of this study are presented in this paper.

Two automated fully enzymatic assays for lipase activity in serum compared: positive interference from post-heparin lipase activity.

The fully enzymatic Wako and Ektachem assays for pancreatic lipase in serum were found to yield precise (especially Ektachem) and consistent results that were significantly correlated (r = 0.995). Less good concordance was found with the turbidimetric aca method, results being on several occasions above normal by Wako or Ektachem but within the reference limit by the aca. Supplementation of aca packs with colipase generally increased lipase activities measured by the aca in these samples, thereby improving the correlation with Wako and Ektachem. In vitro addition experiments documented that both Wako and Ektachem were relatively insensitive to common chemical interferences. However, post-heparin lipase activities produced a positive interference in both assays, resulting in seemingly increased lipase activities that were suggestive of pancreatic disease. Substituting sodium glycocholate (6 mmol/L) for deoxycholic acid largely eliminated this positive interference in the Wako assay. Because Ektachem reagents cannot be modified in this way, we added sodium glycocholate (2-12 mmol/L) to sera; however, this failed to dissipate the in vivo effect of heparin on the Ektachem results.

Iron in granulocytes of nephrotic patients determined by Zeeman electrothermal atomic absorption spectrophotometry.

One of the major threats to patients undergoing maintenance hemodialysis is an increased susceptibility to infections caused by microorganisms, among which Yersinia or Listeria are frequently recovered. In patients receiving hemodialysis, iron overload owing to multiple transfusions plays an important role in the mechanisms underlying the susceptibility to bacterial infections, partially mediated by impaired neutrophil function. In order to assess the true role of iron at the cellular level, an AAS method was developed to measure the iron content of granulocytes. Iron levels in the granulocytes were determined in an apparently healthy population and in a population of iron-overloaded renal hemodialysis patients. Granulocytes were isolated by a method modified from Böyum. The analyses were performed using pyrocoated graphite tubes, and in one of the char steps, oxygen was used to facilitate ashing. The mean iron level found in the granulocytes from apparently normal persons was 4.07 fg/cell (n = 17) with a CV of 44%; the mean value for the dialysis patient group was 4.59 fg/cell (n = 8) with a CV of 37%. There was no significant difference between the two groups, p = 0.70.

Interstitial pneumonitis and pulmonary vasculitis in a patient taking an L-tryptophan preparation.

A case is presented of interstitial pneumonitis and pulmonary vasculitis ascribed to the ingestion of an L-tryptophan preparation. An unintended rechallenge supported the causal relationship. There was neither myalgia nor peripheral eosinophilia. Bronchoalveolar lavage fluid contained 12% eosinophils but few were present in the surgical lung biopsy specimen. Lung infiltrates receded after withdrawal of the drug and treatment with steroids. Dyspnoea and pulmonary hypertension persisted. Cyclophosphamide had no effect. Sclerodermiform skin lesions appeared as a late sequel. Chromatographic analysis of the L-tryptophan revealed no suspect impurities.

Serum cholesterol during ketanserin and propranolol administration in hypertensive patients.

The effect of ketanserin and propranolol on the serum total cholesterol (TC), and high-density lipoprotein (HDL-C) and low-density lipoprotein (LDL-C) cholesterol was studied in hypertensive patients treated for 3 months. During ketanserin administration, LDL-C decreased, whereas HDL-C and the HDL-C/LDL-C ratio increased and no significant effect in serum total cholesterol occurred. During propranolol administration, no significant effect was observed on serum total cholesterol, HDL-C and LDL-C, but the ratio of HDL-C/LDL-C increased. Intergroup comparison showed a greater increase in HDL-C (p less than 0.05) and in the HDL-C/LDL-C ratio (p less than 0.01) in the ketanserin group as compared with the propranolol group.

Effect of polyunsaturated isocaloric fat diets on plasma lipids, apolipoproteins and fatty acids.

The effect of an increased polyunsaturated fatty acid concentration in the diet on the plasma lipoproteins from a normal group of healthy persons and from a group of hypercholesterolemic patients, consuming an isoenergetic and an isocholesterolemic diet, was examined and the changes in the plasma phospholipids were measured. Nine normal and 10 hypercholesterolemic patients were treated with a polyunsaturated diet for 1 month. Controls and hypercholesterolemic patients were screened on their lipid and lipoprotein profiles and their P/S ratio in the diet was calculated and increased with a factor 4. In the control group the P/S ratio was increased from 0.35 to 1.38 and in the hypercholesterolemic group from 0.46 to 1.59. They received the diet for at least 4 weeks before a second analysis of lipids and lipoproteins. The most important results are a decrease of plasma cholesterol, followed by a significant increase of HDL cholesterol. The cholesterol-lowering effect results largely from the plasma LDL decrease, especially in the patient group. Apo A-I is decreased accompanied by a significant increase of the ratio HDL-C/apo A-I. The observed changes are most pronounced in the hypercholesterolemic group. There is no change in apo B but a significant change in the linoleic acid concentration especially in the HDL cholesterol esters. The major phospholipids in plasma are identical in both groups and there is an identical change under the PUFA diet, sphingomyelin is increased and phosphatidylcholine is decreased, which may be related to an increase of the HDL2/HDL3 ratio.