Lower total cholesterol and triglyceride levels in ankylosing spondylitis than non-inflammatory rheumatic disease controls in a 1978-98 study: a potential effect of increased physical energetics in manual occupations in the pre-2000 chronologic era.

OBJECTIVES: No article on serum lipids in ankylosing spondylitis (AS) and control subjects has been reported from USA. The primary aim of this study was to determine if any difference occurred in serum lipid levels in AS and control rheumatic disorders in two time periods, 1978-98 and 2000-10. The secondary aim was to investigate variables associated with lipid levels and if a difference was found between AS and control disorders. METHODS: The AS patients were compared to non-inflammatory rheumatic disorders (NIRDs) in 1978-98 and 2000-10 surveys and to rheumatoid arthritis (RA) in the 2000-10 survey. Patients were matched within 5 years of age, sex, and clinic or hospital source. RESULTS: In the 1978-98 survey, entry mean (SEM) serum cholesterol level [mg/dL] was highly (p<0.001) significantly lower in 69 AS [179.0 (4.8)] than 69 matched NIRD controls [208.0 (5.6)]. In 29 pairs of AS and NIRD subjects having manual labour occupations, mean (SEM) cholesterol level was additionally lower in AS [156.7 (5.9)] and higher in 29 NIRD controls [213.3 (8.6)] (p<0.001). In manual labour workers, mean (SEM) serum triglyceride was significantly lower (p=0.004) in 15 AS [110.3 (14.1)] than 14 NIRD controls [185.2 (19.3)]. In the 2000-10 survey, no lipid difference was found between AS vs. NIRD control patients. CONCLUSIONS: In the 1978-98 survey, AS had significantly lower mean serum cholesterol and triglyceride levels than NIRD control patients. Associated manual labour occupations may have significantly contributed to results, possibly related to increased energy expenditures from physical activity in the pre-2000 era.

National Academy of Clinical Biochemistry Laboratory Medicine Practice guidelines: emerging biomarkers for primary prevention of cardiovascular disease.

BACKGROUND: Heart disease and stroke continue to be the leading causes of death in the US. As a result, investigators continue to look for new and emerging biomarkers of disease risk. Because many of these emerging biomarkers are not as well documented as those of conventional lipid and lipoprotein risk factors, their value in clinical practice needs to be critically appraised and appropriate guidelines developed for their proposed use. CONTENT: The National Academy of Clinical Biochemistry (NACB) convened a multidisciplinary expert panel to develop laboratory medicine practice guidelines for a selected subset of these emerging risk factors as applied in a primary prevention setting of heart disease and stroke. The NACB expert panel selected lipoprotein subclasses and particle concentration, lipoprotein(a), apolipoproteins A-I and B, high sensitivity C-reactive protein (hsCRP), fibrinogen, white blood cell count, homocysteine, B-type natriuretic peptide (BNP), N-terminal proBNP (NT-proBNP), and markers of renal function as biomarkers that fell within the scope of these guidelines. CONCLUSIONS: Based on a thorough review of the published literature, only hsCRP met all of the stated criteria required for acceptance as a biomarker for risk assessment in primary prevention.

A brief history of lipid and lipoprotein measurements and their contribution to clinical chemistry.

The study of modern lipid chemistry began in the 17th and 18th centuries with early observations by Robert Boyle, Poulletier de la Salle, Antoine François de Fourcroy and others. The 19th century chemist, Chevreul, identified several fatty acids, suggested the name 'cholesterine' for the fatty substance in gallstones, coined the word 'glycerine', and showed that fats were comprised of glycerol and fatty acids. The 20th century brought many advances in the understanding of lipoprotein structure and function, and explored relationships between lipoproteins and disease states. The development of the ultracentrifuge and other lipoprotein separation techniques, and reagents for accurate, standardized quantitative measurement have steadily increased our understanding of the important role of lipoprotein metabolism in both healthy and disease states.

An overview of inflammatory markers in type 2 diabetes from the perspective of the clinical chemist.

C-reactive protein (CRP), when measured by a highly sensitive method, is a measure of lowgrade, chronic inflammation and is an independent risk factor for type 2 diabetes (T2D) and cardiovascular disease (CVD). CRP also has the capacity to interact with other risk factors to increase the risk for T2D and CVD. Population distributions divided into tertiles provide the capacity to predict onset of T2D and associated CVD. Preanalytical as well as analytical sources of variation in high-sensitivity CRP (hsCRP) measurements need to be standardized in order for CRP results to be optimally useful. The Centers for Disease Control and Prevention and the American Heart Association have issued guidelines for clinical usefulness of hsCRP measurements. The Centers for Disease Control and Prevention has taken steps to standardize hsCRP assays by evaluating secondary reference materials to be used by manufacturers to calibrate their assays.

Standardization of immunoassays for measurement of high-sensitivity C-reactive protein. Phase I: evaluation of secondary reference materials.

BACKGROUND: Inflammation contributes to the development and progression of atherosclerosis, and C-reactive protein (CRP) can be used as a marker to assess risk for cardiovascular diseases. As variability among existing high-sensitivity CRP (hsCRP) assays can lead to misclassification of patients and hamper implementation of population-based medical decision points, standardization of hsCRP assays is needed. METHODS: We evaluated five proposed secondary reference materials, including two diluted preparations of Certified Reference Material 470 (CRM470), two preparations of a serum-based material with recombinant CRP added, and one serum-based material with isolated CRP added. Twenty-one manufacturers participated in the comparison with 28 different assays. We examined imprecision, linearity, and parallelism with these materials and with fresh serum. RESULTS: All materials had similar imprecision; CVs for the undiluted materials were 2.1-3.7%. None of the materials was linear across all assays. Each had between one and three cases of nonlinearity, with one preparation of CRM470 having the fewest cases of nonlinearity. Although none of the materials was parallel across all assays, the differences in slope from fresh serum were similar across all assays. CONCLUSIONS: All materials performed similarly with regard to imprecision, linearity, and parallelism. As one preparation of CRM470 had slightly better characteristics than the other materials and because CRM470 had been certified previously as a reference material for the acute-phase reactant range, it will be used in the next phase to standardize hsCRP assays.

Laboratory issues: use of nutritional biomarkers.

Biomarkers of nutritional status provide alternative measures of dietary intake. Like the error and variation associated with dietary intake measures, the magnitude and impact of both biological (preanalytical) and laboratory (analytical) variability need to be considered when one is using biomarkers. When choosing a biomarker, it is important to understand how it relates to nutritional intake and the specific time frame of exposure it reflects as well as how it is affected by sampling and laboratory procedures. Biological sources of variation that arise from genetic and disease states of an individual affect biomarkers, but they are also affected by nonbiological sources of variation arising from specimen collection and storage, seasonality, time of day, contamination, stability and laboratory quality assurance. When choosing a laboratory for biomarker assessment, researchers should try to make sure random and systematic error is minimized by inclusion of certain techniques such as blinding of laboratory staff to disease status and including external pooled standards to which laboratory staff are blinded. In addition analytic quality control should be ensured by use of internal standards or certified materials over the entire range of possible values to control method accuracy. One must consider the effect of random laboratory error on measurement precision and also understand the method's limit of detection and the laboratory cutpoints. Choosing appropriate cutpoints and reducing error is extremely important in nutritional epidemiology where weak associations are frequent. As part of this review, serum lipids are included as an example of a biomarker whereby collaborative efforts have been put forth to both understand biological sources of variation and standardize laboratory results.

The effects of errors in lipid measurement and assessment.

Accurate cholesterol and lipoprotein measurements have provided dependable and powerful basic risk factors for cardiovascular disease. A battery of total cholesterol (TC), high-density lipoprotein (HDL) and low-density lipoprotein (LDL) cholesterol, and triglycerides (TG) is recommended in the initial evaluation for classification of patients (based on lipids) into highly desirable, desirable, borderline, high, and very high lipid risk factor for cardiovascular disease. Treatment is based largely on the LDL cholesterol measurement result of the patient. The risk factor score of a patient greatly increases when other risk factors for cardiovascular disease exist, along with increased lipid risk factors. Attainment of the needed acceptable accurate lipid and lipoprotein measurements depends upon prevention or control of multiple sources of errors or variation that can exist in preanalytic, analytic, and postanalytic stages of determination of the reported result. Highly important is to control nonfasting, posture, diet, and alcohol intake in the preanalytic part, elimination of matrix effects and use of accurate calibrators in the analytic part, and check for transcription errors in preparation of reports in the postanalytic part of the measurement of lipids.

Impact of the third cholesterol report from the adult treatment panel of the national cholesterol education program on the clinical laboratory.

BACKGROUND: The US National Cholesterol Education Program has recently released the third report of the Adult Treatment Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Incorporating new evidence and more consistent with other international intervention programs, these more complex guidelines will considerably expand indications for treatment. The implications for clinical laboratories are summarized in this report. CONTENT: LDL-cholesterol (LDL-C) remains the major focus for classification and treatment, whereas diabetes, the presence of multiple risk factors, including the metabolic syndrome, and increased triglycerides (TGs), will now require more intensive management. For screening, a fasting lipoprotein profile is recommended, adding LDL-C and TGs to the previous measurements of total cholesterol and HDL-cholesterol (HDL-C). Lowering the cutpoints defining optimal LDL-C [100 mg/dL (2.58 mmol/L)] and normal TGs [150 mg/dL (1.70 mmol/L)] and raising the cutpoint for low HDL-C to 40 mg/dL (1.03 mmol/L) will select more patients for treatment. A new marker, non-HDL-C, becomes a secondary target in treating high TGs. CONCLUSIONS: Laboratories will need to adjust reporting formats and interpretations and can expect more requests for tests to characterize secondary causes of dyslipidemia, e.g., diabetes, and for the so-called "emerging risk factors", e.g., lipoprotein(a), homocysteine, and C-reactive protein.