Recommendations for the application and follow-up of quality controls in medical laboratories.

This is a translation of the paper "Recommendations for the application and follow-up of quality controls in medical biology laboratories" published in French in the journal Annales de Biologie Clinique (Recommandations pour la mise en place et le suivi des contrôles de qualité dans les laboratoires de biologie médicale. Ann Biol Clin (Paris). 2019;77:577-97.). The recommendations proposed in this document are the result of work conducted jointly by the Network of Accredited Medical Laboratories (LABAC), the French Society of Medical Biology (SFBC) and the Federation of Associations for External Quality Assessment (FAEEQ). The different steps of the implementation of quality controls, based on a risk analysis, are described. The changes of reagent or internal quality control (IQC) materials batches, the action to be taken in case of non-conform IQC results, the choice of external quality assessment (EQA) scheme and interpretation of their results as well as the new issue of analyses performed on several automatic systems available in the same laboratory are discussed. Finally, the concept of measurement uncertainty, the robustness of the methods as well as the specificities of near-patient testing and rapid tests are described. These recommendations cannot apply for all cases we can find in medical laboratories. The implementation of an objective alternative strategy, supported with documented evidence, might be equally considered.

[Recommendations for the application and the follow-up of quality controls in medical biology laboratories]. / Recommandations pour la mise en place et le suivi des contrôles de qualité dans les laboratoires de biologie médicale.

The recommendations that we formulate in this document come from LABAC, SFBC and FAEEQ. They describe the different steps from the initial application of quality controls, based on risk analysis: the changes of reagent batches or internal quality controls (IQC) batches, the course when IQC are not in accordance with references, the choice of external quality evaluation and the interpretation of its results, the comparability of results obtained in several analysers used in the same laboratory. Lastly, measurement uncertainty, robustness of methods and specificities of near-patient biology and rapid tests are described. Note that these recommendations cannot develop all cases that we could find in laboratories. It remains necessary to carry out an objective strategy, supported with documentary evidences.

Icteric human samples: Icterus index and method of estimating an interference-free value for 16 biochemical analyses.

BACKGROUND: Hemolysis, Icterus, and Lipemia constituting the HIL index, are the most common causes of interference with accurate measurement in biochemistry. This study focuses on bilirubin interference, aiming to identify the analyses impacted and proposing a way to predict nominal interference-free analyte concentrations, based on both analyte level and Icterus Index (Iict ). METHODS: Sixteen common analytes were studied: alanine aminotransferase (ALT), albumin (ALB), alkaline phosphatase (ALP), amylase (AMY), aspartate aminotransferase (AST), total cholesterol (CHOLT), creatinine (CREA, enzymatic method), fructosamine (FRUC), gamma-glutamyl transferase (GGT), HDL cholesterol (HDLc), total iron (Iron), lipase (LIP), inorganic phosphorus (Phos), total protein (PROT), triglycerides (TG), and uric acid (UA). Both the traditional 10% change in concentrations from baseline and the Total Change Level (TCL) were taken as acceptance limits. Nineteen pools of sera covering a wide range of values were tested on the Cobas® 6000 (Roche Diagnostics). Iict ranged from 0 to 60. RESULTS: Eight analytes increased (FRUC and Phos) or decreased (CHOLT, CREA, HDLc, PROT, TG, and UA) significantly when Iict increased. FRUC, HDLc, PROT, and UA showed a linear relationship when Iict increased. A non-linear relationship was found for TG, CREA, and for CHOLT; this also depended on analyte levels. Others were not impacted, even at high Iict . CONCLUSIONS: A method of estimating an interference-free value for FRUC, HDLc, PROT, Phos, UA, TG, and CREA, and for CHOLT in cases of cholestasis, is proposed. Iict levels are identified based on analytical performance goals, and equations to recalculate interference-free values are also proposed.

A Combination of Single-Nucleotide Polymorphisms Is Associated with Interindividual Variability in Cholecalciferol Bioavailability in Healthy Men.

BACKGROUND: Most people require dietary vitamin D to achieve the recommended concentration of 25-hydroxyvitamin D [25(OH)D] in the blood. However, the response to vitamin D supplementation is highly variable among individuals. OBJECTIVE: We assessed whether the variability in cholecalciferol bioavailability was associated with single-nucleotide polymorphisms (SNPs) in candidate genes. METHODS: In a single-group design, 39 healthy adult men with a mean ± SD age of 33 ± 2 y and mean ± SD body mass index (in kg/m2) of 22.9 ± 0.3 were genotyped with the use of whole-genome microarrays. After an overnight fast, plasma 25(OH)D status was measured, and the subjects then consumed a meal that provided 5 mg cholecalciferol as a supplement. Plasma chylomicron cholecalciferol concentration was measured over 8 h, and cholecalciferol response was assessed by calculating the postprandial area under the curve. Partial least squares regression was used to test the association of SNPs in or near candidate genes (61 genes representing 3791 SNPs) with the postprandial cholecalciferol response. RESULTS: The postprandial chylomicron cholecalciferol concentration peaked at 5.4 h. The cholecalciferol response was extremely variable among individuals (CV: 47%). It correlated with the chylomicron triglyceride (TG) response (r = 0.60; P < 0.001) but not with the fasting plasma 25(OH)D concentration (r = 0.04; P = 0.83). A significant (P = 1.32 × 10-4) partial least squares regression model that included 17 SNPs in 13 genes (including 5 that have been associated with chylomicron TG response) was associated with the variance in the cholecalciferol response. CONCLUSION: In healthy men, there is a high interindividual variability in cholecalciferol bioavailability that is associated with a combination of SNPs located in or near genes involved in both vitamin D and lipid metabolism. This trial was registered at clinicaltrials.gov as NCT02100774.

A chronicle of the changes undergone by a maritime territory, the Bay of Toulon (Var Coast, France), and their consequences on PCB contamination.

This study evaluated the distribution of polychlorinated biphenyls (PCBs) in 39 surface sediment samples and four cores collected in Toulon Bay, a semiclosed area submitted to various anthropogenic inputs. The concentration of PCBs in the superficial sediment samples ranged from 1.7 to 2530 ng g(-1) dry weight. The spatial distribution of these compounds suggested that the high concentrations of these contaminants are located in the small bay and are related to human activities. In the larger bay, the concentrations were in the same order of magnitude than those reported in others locations around the world. Comparison of the levels with target values from the French legislation shows that, except for four polluted sites with critical values (N2: values ≥1 mg kg(-1) dry weight) in the smaller bay, PCBs levels throughout the larger and the smaller bay are lower than the accepted values (N1: values <0.5 mg kg(-1) dry weight). The PCBs in the sediment cores ranged from 0.8 to 739 ng g(-1) dry weight dependent core. Vertical profiles indicated earlier usage of PCBs which coincided with the history of the Toulon Bay. In this study, using alkane, we could follow the PCBs pollution history over about 80 years and estimate a sedimentation rate of about 0.32 cm year in the small Bay of Toulon.

The Transcriptional Effects of PCB118 and PCB153 on the Liver, Adipose Tissue, Muscle and Colon of Mice: Highlighting of Glut4 and Lipin1 as Main Target Genes for PCB Induced Metabolic Disorders.

Epidemiological studies have associated environmental exposure to polychlorinated biphenyls (PCBs) with an increased risk of type 2 diabetes; however, little is known about the underlying mechanisms involved in the metabolic side-effects of PCB. Our study evaluated the transcriptional effects of a subchronic exposure (gavage at Day 0 and Day 15 with 10 or 100 µmol/Kg bw) to PCB118 (dioxin-like PCB), PCB153 (non-dioxin-like PCB), or an equimolar mixture of PCB118 and PCB153 on various tissues (liver, visceral adipose tissue, muscle, and colon) in mice. Our results showed that a short-term exposure to PCB118 and/or PCB153 enhanced circulating triglyceride levels but did not affect glycemia. Among the studied tissues, we did not observe any modification of the expression of inflammation-related genes, such as cytokines or chemokines. The main transcriptional effects were observed in visceral adipose and liver tissues. We found a downregulation of lipin1 and glut4 expression in these two target organs. In adipose tissue, we also showed a downregulation of Agpat2, Slc25a1, and Fasn. All of these genes are involved in lipid metabolism and insulin resistance. In muscles, we observed an induction of CnR1 and Foxo3 expression, which may be partly involved in PCB metabolic effects. In summary, our results suggest that lipin1 and glut4, notably in adipose tissue, are the main targeted genes in PCB-induced metabolic disorders, however, further studies are required to fully elucidate the mechanisms involved.

Influence of diet and sample collection time on 77 laboratory tests on healthy adults.

OBJECTIVES: We studied the effect of a standardized breakfast or lunch before blood sampling on 77 analytes. DESIGN AND METHODS: The mean difference between assays from 20 healthy adults was calculated on blood samples taken before and after food intake. Significant differences were tested using two-tailed Student t-test and compared to the acceptable limits derived from analytical and intraindividual biological variation. RESULTS: Most of the analytes investigated were not significantly affected by food intake. Six of them were influenced by breakfast or lunch: triglycerides, glucose, creatinine, C-peptide and insulin were significantly upregulated, whereas testosterone was downregulated. Fourteen parameters were more influenced by time of sampling than by meals: nine decreased during the day (total bilirubin, BNP, myoglobin, cortisol, TSH, C-telopeptide, prolactin, ACTH, uric acid) and two increased (white blood cells, neutrophils). Three parameters showed levels that were similar at 9:00 am and 5:00 pm but their lowest level at 12:30 pm (inorganic phosphorus, osteocalcin, PTH). CONCLUSIONS: Fasting is necessary for some laboratory tests. Clinicians should be aware of variations due to sampling time before ordering non-fasting tests, and in the subsequent interpretation of results.

Growth hormone level at admission and its evolution during refeeding are predictive of short-term outcome in restrictive anorexia nervosa.

The growth hormone (GH)­insulin-like growth factor-1 (IGF-1) axis is dramatically altered in patients with anorexia nervosa (AN). The aim of the present study was to investigate whether GH and IGF-1 could be predictors of outcome in patients with a restrictive form of AN. Blood levels of GH, IGF-1, adipocytokines, ghrelin, insulin, glucose, and sex and thyroid hormones were measured in eleven women inpatients with AN and in ten healthy women controls. Three stages were compared during refeeding: admission (T0), when BMI reached 16 kg/m2 (T1) and at discharge when BMI reached 17.5 kg/m2 (T2). Clinical status was assessed 6 months after discharge from hospital (T3), and remission was defined by the maintenance of a BMI > or = 17.5 kg/m2. AN patients in remission (AN-R; n 6) had significantly higher GH levels at admission than those who relapsed (AN-NR; n 5) (P < 0.05). During refeeding (delta = T2 - T0), the AN-R group differed from the AN-NR group only by both GH level decrease (P < 0.05) and BMI increase (P < 0.05). In multiple regression analysis, delta GH was associated negatively and significantly and delta leptin and delta body fat mass levels were associated positively and significantly with BMI at T3 and explained 88% of its variability (r2 0.88, P < 0.05). The present study suggests that a low GH level at admission and the absence of its decrease after weight recovery could predict short-term relapse in women suffering from a restrictive form of AN.

PCBs and DDTs in Stenella coeruleoalba dolphins from the French Mediterranean coastal environment (2007-2009): current state of contamination.

Organochlorinated compounds including PolyChloroBiphenyles, Dichloro-DiphenylTrichloroethan and metabolites are determinated in Stenella coeruleoalba (n = 37) stranded on the french Mediterranean coasts from 2007 till 2009. Studies are carried out on lung, muscle, kidney, liver, and blubber. The sought-after compounds are all detected to variable levels in each tissue and organ. In general, total PCBs are the most abundant, followed by total DDTs. The concentration (in ng g(-1) of lipid weight) in blubber of S. coeruleoalba, varied from 2,052 to 158,992 for PCBs and from 1,120 to 45,779 for DDTs. The ratios DDE/tDDTs are higher than 80% in almost all samples. The overall results of this work, compared to previous studies concerning the Mediterranean Sea, seems to confirm the tendency to a decrease of the contamination by organics compounds for the cetaceans in the Western Mediterranean Sea.

Unacylated Ghrelin is associated with the isolated low HDL-cholesterol obese phenotype independently of insulin resistance and CRP level.

BACKGROUND: Low plasma high-density lipoprotein-cholesterol (HDL-c) level is commonly present in obesity and represents an independent cardiovascular risk factor. However, obese patients are a very heterogeneous population and the factors and mechanisms that contribute to low HDL-c remain unclear. The aim of this study was to investigate the association between plasma HDL-c levels and plasma hormonal profiles (insulin, adiponectin, resistin, leptin and ghrelin) in subsets of class II and III obese patients. METHODS: Fasting plasma levels of glucose, total cholesterol, LDL-c, HDL-c, triglycerides, free fatty acids, apoproteins A-I, B-100, B-48, C-II, C-III, insulin, hs-CRP, adipocytokines (adiponectin, resistin, leptin), unacylated ghrelin, body composition (DXA) and resting energy expenditure were measured in three subsets of obese patients: 17 metabolically abnormal obese (MAO) with metabolic syndrome and the typical metabolic dyslipidaemia, 21 metabolically healthy obese (MHO) without metabolic syndrome and with a normal lipid profile, and 21 isolated low HDL-c obese patients (LHO) without metabolic syndrome, compared to 21 healthy lean control subjects. RESULTS: Insulin resistance (HOMA-IR) increased gradually from MHO to LHO and from LHO to MAO patients (p < 0.05 between MHO and MAO and between LHO and MAO). In multiple regression analysis, serum unacylated ghrelin levels were only positively and independently associated with HDL-c levels in the LHO group (p = 0.032). CONCLUSIONS: These results suggest that, in class II and III obese patients with an isolated low HDL-c phenotype, unacylated ghrelin is positively associated with HDL-c level independently of insulin resistance and CRP levels, and may contribute to the highly prevalent low HDL-c level seen in obesity.

Stability study of 81 analytes in human whole blood, in serum and in plasma.

OBJECTIVE: We studied the pre-analytical stability of 81 analytes based on the variables of delay before processing, storage as whole blood or serum/plasma, the storage temperature and the type of tube the sample was stored in. DESIGN AND METHODS: The mean difference between assays for samples from 10 subjects was calculated with the samples being kept under different storage conditions and for different times between sampling time and analysis: up to 24h for biochemistry, coagulation and hematology, and up to 72 h for hormonology. This difference was compared to the acceptable limits derived from the analytical and the intra individual biological variation. RESULTS: Most of the analytes investigated remained stable up to 24h under all storage conditions prior to centrifugation. However, some analytes were significantly affected either by delay, tube type or temperature, such as potassium, inorganic phosphorus, magnesium, LD, glucose, lactate, mean corpuscular volume, mean corpuscular hemoglobin, activated partial thromboplastin time, insulin, C-peptide, PTH, osteocalcin, C-telopeptide and ACTH. CONCLUSION: This study may be useful to help define acceptable delay times and storage conditions when a short time between sample collection and processing is not possible.

Cholesterol-absorber status modifies the LDL cholesterol-lowering effect of a Mediterranean-type diet in adults with moderate cardiovascular risk factors.

LDL-cholesterol (LDL-C) reduction may be achieved by various types of prudent diets, but their effects on surrogate markers of cholesterol absorption and synthesis have not been well studied in humans. We aimed to assess whether the extent of cholesterol absorption or synthesis, and cholesterol concentrations, are modified in adults when they shift from a Western-type diet (WD) to a combined low-fat, low-cholesterol/Mediterranean-type diet (LFCMD). Cholestanol and sitosterol, as well as desmosterol and lathosterol, surrogate markers of cholesterol absorption or synthesis, respectively, were quantified in the serum of 125 fasting, middle-aged participants at moderate cardiovascular risk. They habitually consumed a WD and then consumed a LFCMD during the 3-mo intervention. The group was stratified by serum cholestanol concentration and classified as high, intermediate, or low absorbers of cholesterol. When they consumed the WD, participants had comparable total and LDL-C concentrations, independent of absorber group and sex. After 3 mo of consuming the LFCMD, absorption and synthesis did not change or changed only slightly. The cholestanol concentration increased in low absorbers by 18% (P < 0.02) and decreased in high absorbers by 14% (P < 0.001), but these variations did not change the high- or low-absorber status. In male and female low absorbers, plasma total (-7%) and LDL-C (-9%) concentrations decreased after the 3-mo intervention and changes were 2.3- and 2.4-fold greater, respectively, than in high absorbers, independent of sex. Cholesterol synthesis/absorption status was not markedly altered by diet, but the decrease in plasma LDL-C due to the Mediterranean-type diet occurred only in low absorbers of cholesterol. This should be considered during further dietary interventions.

Cholesterol absorption status and fasting plasma cholesterol are modulated by the microsomal triacylglycerol transfer protein -493 G/T polymorphism and the usual diet in women.

An important inter-individual variability in cholesterol absorption has been reported. It could result from polymorphisms in genes coding for proteins involved in the absorption process and in interaction with dietary intakes. To assess whether the extent of cholesterol absorption or synthesis is modified in adult women according to the -493 G/T polymorphism in the microsomal triglyceride transfer protein gene (MTP) and/or the habitual diet. Cholestanol and sitosterol, as well as desmosterol and lathosterol, surrogate markers of cholesterol absorption or synthesis, respectively, were analyzed in the fasting plasma of 69 middle-aged women under a Western-type diet (WD) and after 3 months on a low-saturated fat, low-cholesterol/Mediterranean-type diet (LFLCD). Genotypes for MTP -493G/T polymorphism were determined. Under an usual WD, subjects homozygous for the MTP -493 T allele exhibited higher (P < 0.05) fasting serum concentrations of cholestanol (199.0 ± 30.0 vs. 133 ± 7.4 × 10(2 )mmol/mol cholesterol) and lathosterol (188.7 ± 21.8 vs. 147.6 ± 9.1 × 10(2) mmol/mol cholesterol), as well as total cholesterol (7.32 ± 0.22 vs. 6.63 ± 0.12 mmol/l) compared to G carrier subjects. After 3 months on a LFLCD, level of absorption markers decreased in TT subjects with no change in synthesis ones, leading to values comparable to those measured in G carriers. The lowering of plasma total and LDL cholesterol due to dietary change was 2.4- and 2.3-fold greater in TT women than in G carriers. The polymorphism -493G/T in MTP modulates the level of cholesterol absorption but not synthesis in women under a WD, an effect abolished under a prudent LFLCD.

High density lipoprotein-anionic peptide factor effect on reverse cholesterol transport in type 2 diabetic patients with and without coronary artery disease.

OBJECTIVES: To verify if HDL3 Anionic Peptide Factor (HDL3-APF) is as an apolipoprotein that promotes the reverse cholesterol transport. DESIGN AND METHODS: We investigated a possible association between plasma HDL3-APF concentration, cholesterol efflux from Fu5AH cells and cholesteryl ester transfer protein (CETP) activity in type 2 diabetic patients with coronary artery disease (CAD) (n=36), those without CAD (n=20), and 37 healthy subjects. RESULTS: Plasma APF concentrations were decreased in diabetics with CAD compared to controls (p<0.01). Cellular cholesterol efflux was decreased in diabetics without and with CAD, (p<0.01 and p<0.001 respectively). CETP activity was significantly elevated in all patient groups. Multiple linear regression analysis shows that cholesterol efflux was independently and positively related only to APF concentrations in controls. CONCLUSIONS: APF is likely to be a key independent factor for promoting cellular cholesterol efflux in healthy subjects. However this association is altered in type 2 diabetes.

Additive effect of polymorphisms in the IL-6, LTA, and TNF-{alpha} genes and plasma fatty acid level modulate risk for the metabolic syndrome and its components.

CONTEXT: Cytokine polymorphisms and dietary fat composition may influence the risk of the metabolic syndrome (MetS). OBJECTIVE: The objective of the study was to determine the relationship between lymphotoxin-alpha (LTA), TNF-alpha, and IL-6 gene polymorphisms with MetS risk and investigate whether plasma fatty acid composition, a biomarker of dietary fat intake, modulated these associations. DESIGN: Polymorphisms (LTA rs915654, TNF-alpha rs1800629, IL-6 rs1800797), biochemical measurements, and plasma fatty acids were determined in the LIPGENE-SU.VI.MAX study of MetS cases and matched controls (n = 1754). RESULTS: LTA rs915654 minor A allele carriers and TNF-alpha rs1800629 major G allele homozygotes had increased MetS risk [odds ratio (OR) 1.37 (confidence interval [CI] 1.12-1.66), P = 0.002 and OR 1.35 (CI 1.08-1.70), P = 0.009] compared with their TT homozygotes and A allele carriers. Possession of the IL-6 rs1800797 GG genotype by the LTA and TNF-alpha risk genotype carriers further increased risk of the MetS [OR 2.10 (CI 1.19-3.71) P = 0.009], fasting hyperglycemia [OR 2.65 (CI 1.12-6.28), P = 0.027], high systolic blood pressure [OR 1.99 (CI 1.07-3.72), P = 0.03], and abdominal obesity [OR 1.52 (CI 1.01-2.28), P = 0.04]. Plasma polyunsaturated to saturated fat ratio exacerbated these effects; subjects in the lowest 50th percentile had even greater risk of the MetS [OR 4.40 (CI 1.55-12.45), P = 0.005], fasting hyperglycemia, high systolic blood pressure, and abdominal obesity (P < 0.05). CONCLUSIONS: LTA, TNF-alpha, and IL-6 genotype interactions increased MetS risk, which was further exacerbated by a low plasma polyunsaturated to saturated fat exposure, indicating important modulation of genetic risk by dietary fat exposure.

Complement component 3 polymorphisms interact with polyunsaturated fatty acids to modulate risk of metabolic syndrome.

BACKGROUND: Complement component 3 (C3) is a novel determinant of the metabolic syndrome (MetS). Gene-nutrient interactions with dietary fat may affect MetS risk. OBJECTIVES: The objectives were to determine the relation between C3 polymorphisms and MetS and whether interaction with plasma polyunsaturated fatty acids (PUFAs), a biomarker of dietary PUFA, modulate this relation. DESIGN: C3 polymorphisms (rs11569562, rs2250656, rs1047286, rs2230199, rs8107911, rs344548, rs344550, rs2241393, rs7257062, rs163913, and rs2230204), biochemical measurements, and plasma fatty acids were measured in the LIPGENE-SUpplementation en VItamines et Minéraux AntioXydants (SU.VI.MAX) study in MetS cases and matched controls (n = 1754). RESULTS: Two single nucleotide polymorphisms were associated with MetS. rs11569562 GG homozygotes had decreased MetS risk compared with minor A allele carriers [odds ratio (OR): 0.53; 95% CI: 0.35, 0.82; P = 0.009], which was augmented by high plasma PUFA status (OR: 0.32; 95% CI: 0.11, 0.93; P = 0.04). GG homozygotes had lower C3 concentrations than those in AA homozygotes (P = 0.03) and decreased risk of hypertriglyceridemia compared with A allele carriers (OR: 0.54; 95% CI: 0.34, 0.92; P = 0.02), which was further ameliorated by an increase in long-chain n-3 (omega-3) PUFAs (OR: 0.46; 95% CI: 0.22, 0.97; P = 0.04) or a decrease in n-6 PUFAs (OR: 0.32; CI: 0.16, 0.62; P = 0.002). rs2250656 AA homozygotes had increased MetS risk relative to minor G allele carriers (OR: 1.78; CI: 1.19, 2.70; P = 0.02), which was exacerbated by low n-6 PUFA status (OR: 2.20; CI: 1.09, 4.55; P = 0.03). CONCLUSION: Plasma PUFAs may modulate the susceptibility to MetS that is conferred by C3 polymorphisms, which suggests novel gene-nutrient interactions. This trial was registered at clinicaltrials.gov as NCT00272428.

Plasma adiponectin in heart transplant recipients.

BACKGROUND: The association between plasma adiponectin and metabolic syndrome may be impaired in heart transplant recipients, since renal failure is frequent among these patients. Thus, we studied the relationship between metabolic syndrome and plasma adiponectin in transplanted heart recipients. METHODS: Ninety-five heart transplant recipients were prospectively included 8.3 +/- 5.6 yr after transplantation in this cross-sectional study. All patients had physical examination, echocardiography or routine biennial coronary angiography, and laboratory measurements. RESULTS: Metabolic syndrome was found in 31% of these patients. Plasma adiponectin was significantly lower in patients with metabolic syndrome (12.5 +/- 8.3 microg/mL) than in patients without (16.7 +/- 9.4 microg/mL, p = 0.03). Adiponectin levels were usually in the normal or high range (< 4 microg/mL in only two patients). Low creatinine clearance was associated with higher plasma adiponectin (R=-0.26, p = 0.01). Plasma adiponectin was not significantly different between the 28 patients with angiographic evidence of graft vasculopathy (13.9 +/- 9.5 microg/mL) and the 67 patients without (16.1 +/- 9.1 microg/mL, p = 0.3). CONCLUSIONS: Contrasting with a high frequency of metabolic syndrome in these patients, adiponectin levels were usually in the normal or high range, probably as a consequence of renal failure. This suggests that adiponectin is not a major determinant for insulin resistance among these patients.

Bacterial ventilator-associated pneumonia: bronchoalveolar lavage results are not influenced by dilution.

OBJECTIVE: This study was designed to determine if bronchoalveolar lavage (BAL) quantitative culture results can be used confidently for the diagnosis of bacterial ventilator-associated pneumonia (VAP) without taking dilution into account. DESIGN: Prospective observational cohort study. SETTING: A 12-bed medical ICU in a teaching hospital. PATIENTS: A total of 241 BAL (three 50-mL aliquots) were performed in 127 patients presenting a suspicion of VAP. INTERVENTIONS: All consecutive adults who were ventilated more than 48 h were included if VAP was clinically suspected. A dilution factor, k, was developed according to the formula: dilution factor k = concentration of urea in plasma/concentration of urea in lavage fluid recovered. Using this dilution factor, the quantitative bacterial counts were interpreted accordingly with a corrected positive threshold at 10(5) colony forming unit (CFU) mL(-1). MEASUREMENTS AND RESULTS: Eighty-nine BAL with at least one micro-organism > or = 10(4) CFU mL(-1) were identified (37%). In 176 BAL (73%), k ranged from 10 to 100. Median k was 24.4 (9.7-40.2) in VAP group and 24.6 (13.1-57.8) in patients without pneumonia (NS). Among the 25 BAL with micro-organism counts of 10(4) CFU mL(-1), 3 had a dilution factor lower than 10, resulting in corrected counts below the threshold of 10(5) CFU mL(-1). Two out of 15 patients with micro-organism counts of 10(3) CFU mL(-1) had corrected micro-organism counts of 10(5) CFU mL(-1). Finally, only five BAL (2.1%) were misclassified when the dilution correction factor was applied. CONCLUSIONS: Using urea as dilution factor, we showed that BAL dilution variations did not alter the interpretation of BAL quantitative bacterial culture when administrating three aliquots of 50 mL of saline.