[Guidelines for the management of human resources]. / Recommandations pour la gestion des ressources humaines.

The management of human resources is a major issue for laboratory accreditation, since it allows to show the proofs of competency assessment, a basis to ensure the confidence. In this paper, the main processes involved are described: the general process for the management of human resources and the authorization for personnel process. Guidelines for document control are also proposed. At least, examples are given to facilitate the implementation of these guidelines in a medical laboratory.

[Guidelines for validation of the results in laboratory medicine]. / Recommandations pour la validation des résultats d'examens de biologie médicale.

The validation of the results is defined as the review and verification of the coherency and likelihood of the whole results of the examination for a patient, taking into account needed clinical data, uncertainty of measurement and anteriority's as well. The signature of the authorized person certifies this validation according to the requirements of the French regulation and ISO standard as well. Recommendations are given for the organization of this step specially for duty periods and in case of utilization of an expert system software. Requirements about the content, the release and the signature of the reports are given. A quality indicator applied to the control of the validation process is proposed.

[Description of the processes involved in the control of point-of-care testing]. / Description des processus impliqués dans la maîtrise des examens de biologie médicale délocalisés.

Compliance to EN ISO 22870 standard for point-of-care testing (POCT) accreditation is close to those of EN ISO 15189 in central laboratory. However, it is mandatory to master the elements which are specific to POCT. In this paper, we describe the two main processes involved to help medical biologists to achieve standard requirements, particularly in the risk assessment study. The first process concerns the deployment of a POCT device in a hospital outside laboratory and the second is the classical process of medical biology testing, outlining the steps which are different from the laboratory testing process. Furthermore, we reference, in front of each sub-process described, the different articles published in the present volume detailing specific guidelines to master them.

[Guidelines for the formation of a multidisciplinary group for point-of-care testing supervision according to EN ISO 22870]. / Recommandations pour la constitution d'un groupe d'encadrement des examens de biologie médicale délocalisés.

EN ISO 22870 requires the medical laboratory director to form a multidisciplinary group for the management of point-of-care testing activities and to appoint a person responsible for this group. This article proposes to define the composition (representatives of the medical laboratory, care units owning point-of-care devices, administration), missions (introduction, follow-up and evaluation of point-of-care devices) and the decision circuit of this group and to describe the profile of the head and the tasks assigned.

[Guidelines for selection and implementation of a point-of-care testing device according to the EN ISO 22870 and French regulation]. / Recommandations pour le choix et la mise en place d'un dispositif de biologie médicale délocalisé.

Implementation is the main step of the point-of-care testing (POCT) device installation process to comply with EN ISO 22870. The multidisciplinary POCT management group is in charge to align that process with the standards but also with the French regulation (ordinance 2010-49 of 13 January 2010) which authorizes POCT only in case of urgent therapeutic decisions. This article defines two reports to be prepared during the deployment of a POCT device : a report that justifies the use of a POCT device, taking into account a risk-benefit analysis and a report that justifies the choice of the device including proofs of conformity of its installation.

[Guidelines for the management of point-of care testing pre-examination, examination and post-examination phases according to the EN ISO 22870 standard]. / Recommandations pour la maîtrise des phases pré-analytique et analytique des examens de biologie médicale délocalisés.

Quality of point-of-care examinations depends on the quality assurance system settled. This paper describes the different tools used to control the pre-examination, examination and post-examination procedures taking part in the quality of patient care according to the requirements of the standard EN ISO 22870 and EN ISO 15189 as well. They include mainly: For the pre-examination phase, the sample traceability and for the analytical phase, the practice of internal quality control and the participation in external quality assessment programme.

[Nephelometry or turbidimetry for the determination of albumin, ApoA, CRP, haptoglobin, IgM and transthyretin: which choice?]. / Turbidimétrie ou néphélémétrie: quel choix pour les dosages de l'albumine, l'ApoA, la CRP, l'haptoglobine, l'IgM et la transthyrétine?

Nephelometry, which is considered as the reference method for serum proteins determination requires a specific equipment. The majority of protein determinations are therefore carried out on biochemistry automats using turbidimetry. The objective of a CNBH group (Collège national de biochimie des hôpitaux) was to compare nephelometry and turbidimetry for 7 automats: 2 nephelometers, the BN Prospec (Dade-Behring) and Immage (Beckman-Coulter) and 5 biochemistry systems using turbidimetry, the Integra and Modular (Roche Diagnostics), the LX20 (Beckman-Coulter), RXL (Dade-Behring) and AU (Olympus). The study was based on the determination of sera collections (albumin, ApoA, CRP, haptoglobin, IgM, transthyretin) of 140 samples each: 110 limpid samples and 30 samples called HLI (hemolytic, lipemic or icteric). Fifteen hospitals took part to this work. An ANOVA analysis on limpid samples and quality control sera concluded to an "automat" effect for the 6 tested proteins but did not show a "method" effect, (i.e. nephelometry versus turbidimetry). On the other hand, the transferability of the results was expected to be better and an effort on the choice of the antibodies and the standardization procedures should be made.

[Angiotensin I-converting enzyme in cerebrospinal fluid and neurosarcoidosis]. / Enzyme de conversion de l'angiotensine I dans le liquide céphalorachidien et neurosarcoïdose.

Sarcoidosis is a disease of unknown aetiology. This granulomatous disease is essentially localized in lung and skin, but many other localizations are possible, such as in nervous system. Sometimes the neurological involvement is alone leading to a differential diagnosis from other neurological diseases. Angiotensin I-converting enzyme (ACE) is synthesized by sarcoidotic granulomas and diffuses in various biological fluids. The determination of ACE activity in cerebrospinal fluid (CSF) can help for the diagnosis of neurosarcoidosis, associated or not to its determination in serum. We developed a radiometric assay for the determination of ACE activity in CSF since the methods for serum cannot be used because ACE activity is low in CSF, as well as in pathological situations. At the analytical point of view this assay is sensitive, specific and reproducible. We established a normal range and yielded recommendations to give the results, particularly in function of the aspect of the CSF and the proteinorrachia. But increased level of ACE in CSF is not specific of neurosarcoidosis since elevations were also shown in meningitis. We can claim for the routine use of ACE assay in CSF for differential diagnosis by eliminating neurosarcoidosis, as well as for positive diagnosis of this disease, but in both cases with the confrontation to other parameters.

[Effect of August 2003 heat wave in France on a hospital biochemistry laboratory activity in Paris]. / Impact de la vague de chaleur d'août 2003 sur l'activité d'un laboratoire hospitalier parisien de biochimie.

In August 2003, France sustained an exceptional heat wave. Heat-generated pathologies (dehydratation, heat stroke, cardio-vascular diseases) were responsible for additional biological analysis orders at the Saint-Antoine Hospital biochemistry laboratory in Paris from 4 to 18 august, compared to the same period in 2002. Variations were: + 17.6% for analysis orders, + 30.1% for ionograms, + 28.9% for plasma troponins I and + 58.6% for blood gazes analysis. Women and patients older than 75 years ratios were higher in august 2003. Biochemistry results analysis showed higher frequency of elevated plasma sodium, creatinine and troponin in 2003, confirming that most of patients admitted during heat wave were affected by heat-related diseases. Finally, laboratory excess activity was performed and quality was maintained, in spite of reduced staff and unusual climatic conditions.

Cytotoxic response of sinusoidal endothelial cells to polymorphonuclear leukocytes and its potential implication in hypoxia-reoxygenation injury.

AIMS: Interactions between polymorphonuclear leukocytes (PMN) and sinusoidal endothelial cells (SEC) may contribute to ischemia-reperfusion injury. The aim of the study was to determine the influence of PMN hypoxia-reoxygenation and degranulation, on SEC toxic response. METHODS: PMNs collected from rat pleural cavity underwent hypoxia- reoxygenation or N-formyl-methionyl-leucyl-phenylalanine (fMLP) degranulation treatment, and were then separated from their conditioned medium. Rat SECs were incubated either with PMNs in coculture or with their conditioned medium, for 210 min. Oxidative metabolism in PMNs was measured by chemiluminescence. LDH release and elastase activity were measured in SEC supernatants. RESULTS: PMN-conditioned medium induced an increase in LDH release in SECs. Hypoxia-reoxygenation of PMNs induced an increase in their chemiluminescent response without increasing the cytotoxic effect of their conditioned medium. By contrast, the cytotoxic effect of conditioned medium was increased following PMN treatment with fMLP. In the latter case, cytotoxicity was combined with a rise in the elastase activity released in the supernatants, but was not reduced by inhibitors of elastase or of other proteases. CONCLUSIONS: The results indicate that toxic products are released, at least in part through degranulation, by PMNs, and induce cytotoxicity in SECs. This mechanism may contribute to SEC injury during hypoxia-reoxygenation.

Anticancer drugs induce necrosis of human endothelial cells involving both oncosis and apoptosis.

The endothelium is the first physiological barrier between blood and tissues and can be injured by physical or chemical stress, particularly by the drugs used in cancer therapy. We found that four anticancer agents: etoposide, doxorubicin, bleomycin and paclitaxel induced apoptosis in human umbilical vein endothelial cells (HUVECs) (as judged by DNA fragmentation) with a time- and concentration-dependent decrease in bcl-2 protein but without the involvement of p53. As revealed by immunoblotting, bax protein was expressed in HUVECs treated with 1 mg/ml etoposide whereas bcl-2 protein disappeared. Oncosis occurred parallel to apoptosis with the release of lactate dehydrogenase into the supernatant, and, for doxorubicin and etoposide with the inversion of the distribution of angiotensin I-converting enzyme between supernatant and cells. Among the four tested anticancer drugs, only doxorubicin induced an oxidative stress, with significative malondialdehyde production. Thus, human endothelial cells in confluent cultures seem to be in an equilibrium of resistance to apoptosis related to bcl-2 expression; this equilibrium can be disrupted by a chemical stress, such as the antiproliferative drugs known as pro-apoptotic for tumour cells. For doxorubicin and bleomycin, this cellular toxicity can be related to their unwanted effects in human cancer therapy. Low doses of doxorubicin, paclitaxel or etoposide, however, could induce apoptosis of endothelial cells of new vessels surrounding the tumour, thus leading to specific vessel regression with minimal toxic effects for the endothelium of the other vessels. These findings provide evidence of relationships between endothelial toxicity of anticancer drugs and the key role of bcl-2 for resistance of endothelium cells toward apoptosis; moreover lack of p53 and bax in quiescent cells contributes to resistance of endothelial cells to DNA-damaging agents.

Evaluation of Stratus CS stat fluorimetric analyser for measurement of cardiac markers Troponin I (cTnI), creatine kinase MB (CK-MB), and myoglobin.

Myoglobin, CK-MB, and Troponin I (cTnI) are cardiac muscle necrosis markers that are useful for detecting acute myocardial infarction (AMI). The Stratus CS (Dade Behring, Inc.) is a discrete fluorimetric immunoassay analyser designed for the determination of the three cardiac markers from a single sample of whole blood or plasma. Overall analytical performances of the Stratus CS provided by Dade Behring were evaluated according to the French Society of Clinical Biology guidelines. Within-run imprecision (n = 20) for the three parameters at three levels gave values under 5%, whereas CVs for between-run imprecision (n = 20) were under 6%. The sensitivities were 0.03 microg/L for cTnI and 0.4 microg/L for CK-MB. Linearities extended from 0-50 microg/L for cTnI, 0-140 microg/L for CK-MB, and 1-900 microg/L for myoglobin. The results, particularly those obtained on whole-blood samples, correlated well with those obtained on Stratus II. We did not find any interference with haemolysis, icterus, or lipemia. The system was very easy to use, and fulfills the requirements for the analysis of the three cardiac markers in patients with acute chest pain in emergency situations.

A reversible model of acute hepatic failure by temporary hepatic ischemia in the pig.

BACKGROUND: To evaluate new therapies for human fulminant hepatic failure, a suitable large animal model is needed. The purpose of this study was to develop a reversible surgical model of acute hepatic liver failure by transient ischemia in pigs. MATERIALS AND METHODS: Under general anesthesia, an end-to-side portacaval shunt was performed in 17 pigs and tape was laid around the hepatoduodenal ligament. Two days after construction of the functional portacaval shunt, 13 ambulant pigs underwent transient total liver ischemia by tightening of the tape around the hepatoduodenal ligament for 5.5 h. During ischemia, 10% glucose was continuously infused intravenously to prevent hypoglycemia. RESULTS: Ten animals (77%) died with hepatic coma after a mean duration of 22.5 +/- 1.9 h. The 3 remaining animals survived more than 5 days and were sacrificed. In dying animals, encephalopathy was observed 14 +/- 1.7 h after the onset of ischemia. During ischemia, similar progressive decrease of fibrinogen, platelets, prothrombin time, and factors V and VII activities was observed in dying and surviving animals. Just before death, mean prothrombin and factors V and VII activities were respectively 22 +/- 2, 21 +/- 4.4, and 24 +/- 5%. At 22 h, plasma ammonia and lactate levels were respectively 705 +/- 93 micromol/L and 10.5 +/- 0.4 mmol/L in dying animals and 249 +/- 75 micromol/L and 2.9 +/- 0.1 mmol/L in surviving animals (P < 0.01). Estimation of the percentage liver cells necrosed was 74 +/- 4.7% in the survivors and 86 +/- 5.5% in animals who died of hepatic coma (NS). CONCLUSIONS: This model is reproducible and reversible and should allow the quantitative evaluation of new technologies, such as bioartificial liver, for the support of hepatic failure in humans.

Evaluation of the clinical chemistry analyser Olympus AU400.

The Olympus AU400 analyser (Olympus, Tokyo, Japan) is an automated chemistry instrument for turbidimetric, spectrophotometric and ion selective electrode measurements. Overall analytical performances of the AU400 and the reagents provided by Olympus were evaluated according to the French Society of Clinical Biology guidelines. Twenty parameters including specific proteins, substrates, enzyme activities and electrolytes were tested. The linearity exceeded the specifications given by the manufacturer. Within- and between-run imprecision (CV%), evaluated at two levels, was below 1.5% for ion selective electrode parameters and 3% for other analytes, except for CO2, alkaline phosphatase at low levels and magnesium. Results compared well with those obtained with the analysers routinely used in our laboratory (Behring BNII, Olympus AU800 and Beckman CX3 Delta). The usual positive interferences from lipaemia and haemoglobin on total protein measurement were observed. Creatine kinase and alkaline phosphatase assays were the subject of positive and negative interference by haemoglobin, respectively. There was a negative interference by bilirubin in the uric acid, aspartate-amino transferase, creatine kinase and lactate dehydrogenase assays and a positive interference in the calcium assay. The system was found to be very easy to use and the workstation is user-friendly.

[Role of nitric oxide synthase III and guanosine 3':5'- cyclic monophosphate in the protection exerted by nitric oxide on hepatic ischemia-reperfusion injury]. / Rôle de la monoxyde d'azote synthase-III et du guanosine 3':5'-monophosphate cyclique dans la protection exercée par le monoxyde d'azote lors d'une ischémie-reperfusion hépatique.

Nitric oxide (NO) exerts cytoprotective effects against hepatic ischemia-reperfusion damage. This study was designed to evaluate which isoform of NO synthase (NOS) is implicated in the generation of cytoprotective NO and to investigate whether NO effects are mediated by cyclic GMP (cGMP). After partial ischemia for 45 min, liver damage was estimated by the release into plasma of cytolytic enzymes. Ischemia-reperfusion induced marked increases in plasma creatine kinase and lactate dehydrogenase after 1 h of reperfusion and of aminotransferases after 6 h of reperfusion. The pretreatment of ischemic rats with 8-bromo-cGMP (16 mg/kg i.v. 30 min before ischemia) or with L-arginine (the endogenous precursor of NO, 100 mg/kg i.v.) significantly diminished the ischemia-reperfusion-induced release of all these enzymes. This demonstrates that cGMP possesses hepatoprotective properties. By immunohistochemistry, we observed, after 6 h of reperfusion, an increase in endothelial NOS-III immunoreactivity, particularly in the small arteries and sinusoids. This NOS-III accumulation in endothelial cells could protect the liver against ischemia-reperfusion by the local generation of NO probably via cGMP.

[Biological monitoring of liver transplantation]. / Surveillance biologique des transplantations hépatiques.

Liver transplantation is now a widely used therapeutic option that has been proved effective, although the inadequate supply of transplants remains a problem. Laboratory tests are important at three different periods in time: prior to transplantation to aid in patient selection and to look for contra-indications to transplantation; during the transplant procedure to ensure real-time evaluation of vital metabolic parameters; and, above all, after the procedure to assist in the detection of complications. These can occur early (preservation lesions, acute rejection, side effects of immuno-suppressive agents, infections, renal failure, etc.), as a direct result of the surgical procedure (blood vessel or bile duct injury), or late (chronic rejection, recurrence of the initial disease, treatment-induced cancer).

[Biological examination in the diagnosis and monitoring of liver disease. Algorithms to aid the decision]. / Exploration biologique dans le diagnostic et la surveillance d'une maladie du foie. Schémas d'aide à la décision.

The goal of this article is to describe a rational step-wise strategy for using standard laboratory tests to obtain diagnostic orientation for a liver disorder; establish, support, or rule out a liver disorder; and monitor the course of treated and untreated patients with liver disorders.