The Need for Laboratory Medicine in the Undergraduate Medical Education Curriculum: A White Paper from the Association of Pathology Chairs

Considering laboratory results are used to make medical decisions, a fundamental understanding of laboratory medicine is paramount to enhance patient care, optimize health care cost containment, and prevent legal repercussions. With increasing laboratory testing complexity, this education is needed now more than ever. This article is a call to action to have medical schools adequately incorporate practical laboratory medicine content into their undergraduate medical education (UME) curricula. The authors discuss the definition of laboratory medicine, what it encompasses, who uses it and why it matters, and propose that a core laboratory medicine curriculum is a necessary part of UME.

A comparison of red blood cell transfusion utilization between anti-activated factor X and activated partial thromboplastin monitoring in patients receiving unfractionated heparin

Essentials Anti-activated factor X (Anti-Xa) monitoring is more precise than activated partial thromboplastin (aPTT). 20 804 hospitalized cardiovascular patients monitored with Anti-Xa or aPTT were analyzed. Adjusted transfusion rates were significantly lower for patients monitored with Anti-Xa. Adoption of Anti-Xa protocols could reduce transfusions among cardiovascular patients in the US.

SUMMARY

Background Anticoagulant activated factor X protein (Anti-Xa) has been shown to be a more precise monitoring tool than activated partial thromboplastin time (aPTT) for patients receiving unfractionated heparin (UFH) anticoagulation therapy. Objectives To compare red blood cell (RBC) transfusions between patients receiving UFH who are monitored with Anti-Xa and those monitored with aPTT. Patients/Methods A retrospective cohort study was conducted on patients diagnosed with acute coronary syndrome (ACS) (N = 14 822), diagnosed with ischemic stroke (STK) (N = 1568) or with a principal diagnosis of venous thromboembolism (VTE) (N = 4414) in the MedAssets data from January 2009 to December 2013. Anti-Xa and aPTT groups were identified from hospital billing details, with both brand and generic name as search criteria. Propensity score techniques were used to match Anti-Xa cases to aPTT controls. RBC transfusions were identified from hospital billing data. Multivariable logistic regression was used to identify significant drivers of transfusions. Results Anti-Xa patients had fewer RBC transfusions than aPTT patients in the ACS population (difference 17.5%; 95% confidence interval [CI] 16.4-18.7%), the STK population (difference 8.2%; 95% CI 4.4-11.9%), and the VTE population (difference 4.7%; 95% CI 3.3-6.1%). After controlling for patient age and gender, diagnostic risks (e.g. anemia, renal insufficiency, and trauma), and invasive procedures (e.g. cardiac catheterization, hemodialysis, and coronary artery bypass graft), Anti-Xa patients were less likely to have a transfusion while hospitalized for ACS (odds ratio [OR] 0.16, 95% CI 0.14-0.18), STK (OR 0.41, 95% CI 0.29-0.57), and VTE (OR 0.35, 95% CI 0.26-0.48). Conclusion Anti-Xa monitoring was associated with a significant reduction in RBC transfusions as compared with aPTT monitoring alone.

Physician response to implementation of genotype-tailored antiplatelet therapy

Physician responses to genomic information are vital to the success of precision medicine initiatives. We prospectively studied a pharmacogenomics implementation program for the propensity of clinicians to select antiplatelet therapy based on CYP2C19 loss-of-function variants in stented patients. Among 2,676 patients, 514 (19.2%) were found to have a CYP2C19 variant affecting clopidogrel metabolism. For the majority (93.6%) of the cohort, cardiologists received active and direct notification of CYP2C19 status. Over 12 months, 57.6% of poor metabolizers and 33.2% of intermediate metabolizers received alternatives to clopidogrel. CYP2C19 variant status was the most influential factor impacting the prescribing decision (hazard ratio [HR] in poor metabolizers 8.1, 95% confidence interval [CI] [5.4, 12.2] and HR 5.0, 95% CI [4.0, 6.3] in intermediate metabolizers), followed by patient age and type of stent implanted. We conclude that cardiologists tailored antiplatelet therapy for a minority of patients with a CYP2C19 variant and considered both genomic and nongenomic risks in their clinical decision-making.

Operational implementation of prospective genotyping for personalized medicine: the design of the Vanderbilt PREDICT project

The promise of "personalized medicine" guided by an understanding of each individual's genome has been fostered by increasingly powerful and economical methods to acquire clinically relevant information. We describe the operational implementation of prospective genotyping linked to an advanced clinical decision-support system to guide individualized health care in a large academic health center. This approach to personalized medicine entails engagement between patient and health-care provider, identification of relevant genetic variations for implementation, assay reliability, point-of-care decision support, and necessary institutional investments. In one year, approximately 3,000 patients, most of whom were scheduled for cardiac catheterization, were genotyped on a multiplexed platform that included genotyping for CYP2C19 variants that modulate response to the widely used antiplatelet drug clopidogrel. These data are deposited into the electronic medical record (EMR), and point-of-care decision support is deployed when clopidogrel is prescribed for those with variant genotypes. The establishment of programs such as this is a first step toward implementing and evaluating strategies for personalized medicine.

Ethyl arachidonate is the predominant fatty acid ethyl ester in the brains of alcohol-intoxicated subjects at autopsy

The role of fatty acid ethyl esters (FAEE), the nonoxidative ethanol metabolites, as mediators of alcohol-induced organ damage is increasingly being recognized. FAEE are detectable in the blood and in liver and adipose tissue after ethanol ingestion, and on that basis, FAEE can be used as markers of ethanol intake. In this study, 10 samples of human brain were collected at autopsy at the Massachusetts Medical Examiner's Office and analyzed for FAEE. FAEE were isolated and quantified as mass per gram of wet weight. The blood ethanol level was also obtained in each case along with the other drugs detected in routine postmortem toxicology screening tests. Ethyl arachidonate was the predominant FAEE species in the brain, representing up to 77.4% of total FAEE in the brain. The percent age of ethyl arachidonate of the total FAEE in the brain was significantly higher than what has been found in all other organs and tissues previously analyzed. Linoleate, the precursor of arachidonate, was a poor substrate for FAEE synthesis, as the percentage of ethyl linoleate of the total FAEE content was extremely low. Thus, this reflects preferred incorporation of arachidonate into newly synthesized FAEE in the brain. Since arachidonate is derived from linoleate, which is depleted in FAEE while arachidonate is enriched, the synthesis of FAEE may be linked to the desaturation and elongation of linoleate to arachidonate.

Regulations regarding reflexive testing and narrative interpretations in laboratory medicine

The use of reflexive test selection and patient-specific narrative interpretations in laboratory medicine is associated with a host of compliance issues and government regulations. Reflexive testing is associated with many advantages for patients and their physicians, but if not adequately organized it has the potential for inefficient test ordering and abuse by physicians and laboratories. Patient-specific narrative interpretations in laboratory medicine, much more than fixed comments generated by a computer with a specific test result, also provide clinical and financial benefit when done effectively. Regulations exist to ensure that the physician-provided information has clinical value. This report describes the compliance and billing regulations regarding reflex testing and narrative interpretations. The codes used for narrative interpretations in laboratory medicine are also presented, as well as the use of those codes to obtain payment for the interpretation provided.

The generation of narrative interpretations in laboratory medicine: a description of service-specific sign-out rounds

The logistical details for organizing effective interpretive rounds in a laboratory medicine subspecialty must be carefully established so that expert opinions are provided in a timely fashion in a patient-specific report, rather than as a collection of fixed comments associated with a particular laboratory result generated by a computer This report describes the test batteries for interpretations, the billing for interpretations, clinical examples of interpretations, and interpretations for which billing is not typically performed in several clinical or laboratory areas in our institution. These include coagulation disorders, hemoglobin and anemia evaluations, autoimmune disorders, serum protein analysis, toxicology, molecular diagnostics, and transfusion medicine. The information in this report should provide sufficient detail to allow development of interpretive services with successful billing for the areas in laboratory medicine described.

Narrative interpretations for clinical laboratory evaluations: an overview

As the clinical laboratory test menu has significantly expanded in volume and complexity, there is a rapidly growing need by clinicians for narrative interpretations of complex studies that resemble those provided in anatomic pathology and radiology. In this report, the impact of advice on laboratory test selection and interpretation is presented with regard to providing adequate quality of care, reducing medical error, and reducing the cost for health care. In addition, past and current attempts to address the physician's need for advice on laboratory test selection and interpretation are also described. These include curbside consultations, intelligent laboratory information systems, and medical information from the Internet. Each is presented with examples from the literature and with its advantages and disadvantages for practicing clinicians confronting large, expensive test menus and the results of esoteric assays.

Linkage of oxidative and nonoxidative ethanol metabolism in the pancreas and toxicity of nonoxidative ethanol metabolites for pancreatic acinar cells

BACKGROUND

Alcohol abuse is a major cause of pancreatic damage. Recent experimental evidence suggests that fatty acid ethyl esters (FAEE), nonoxidative ethanol metabolites, injure pancreatic acinar cells. Linkage between oxidative and nonoxidative metabolism of ethanol in the pancreas may contribute to increased FAEE levels.

METHODS

To study the association between oxidative and nonoxidative ethanol metabolism, FAEE concentration and FAEE synthase activity in rat pancreatic and liver homogenates incubated with ethanol were evaluated with and without inhibitors of oxidative ethanol metabolism. For toxicity studies, trypsinogen activation peptide synthesis as a measure of pancreatic cell injury was quantitated in unstimulated and cerulein-stimulated isolated pancreatic acinar cells incubated with ethanol or FAEE.

RESULTS

Inhibition of oxidative ethanol metabolism results in a 2- to 3-fold increase in nonoxidative ethanol metabolism to FAEE in pancreas and in liver. Both ethanol and FAEE induce increased intracellular trypsinogen activation by more than 50% in the presence of physiologic concentrations of cerulein in vitro.

CONCLUSIONS

These findings demonstrate that the inhibition of oxidative ethanol metabolism results in an increase in flux through the nonoxidative pathway and support the proposition that alcohol-induced pancreatic injury is mediated at least in part by FAEE, which are important products of pancreatic ethanol metabolism.

Fatty acid ethyl esters in liver and adipose tissues as postmortem markers for ethanol intake

BACKGROUND

Fatty acid ethyl esters (FAEEs) are nonoxidative metabolites of ethanol. FAEEs are found in liver, pancreas, and adipose tissues up to 24 h after consumption of ethanol, and on that basis, they are potentially useful markers for ethanol intake. In this study with rats, we investigated the efficacy of using FAEEs in liver and in adipose tissue as postmortem markers for premortem ethanol ingestion.

METHODS

An animal study was conducted in which test rats received injections of ethanol and control rats received injections of normal saline. The rats were killed 2 h after the injections. The bodies of the animals were stored at 4 degrees C up to 12 h, and samples of liver and adipose tissues were collected at different time intervals and processed for FAEE quantification. In another set of experiments, the rats received injections and were killed as described above, but bodies of animals from both groups were stored at 4, 25, or 37 degrees C for up to 72 h, and liver samples were collected and processed for FAEE quantification.

RESULTS

FAEEs were detected up to 12 h after death in liver and adipose tissue samples from the bodies of ethanol-treated animals stored at 4 degrees C; negligible amounts were detected in the bodies of animals that received normal saline. Adipose tissues contained higher amounts of FAEEs than liver, as well as more species: eight FAEE species in adipose tissue and five in liver tissue. Higher concentrations of FAEEs were detected in livers of treated animals stored at 25 degrees C for up to 48 h than in livers of controls stored under the same conditions.

CONCLUSIONS

For at least 12 h after death, FAEEs in liver and adipose tissues are useful postmortem markers of premortem ethanol ingestion.

Adenoviral gene transfer of Caenorhabditis elegans n--3 fatty acid desaturase optimizes fatty acid composition in mammalian cells

Omega--3 polyunsaturated fatty acids (PUFAs) are essential components required for normal cellular function and have been shown to exert many preventive and therapeutic actions. The amount of n--3 PUFAs is insufficient in most Western people, whereas the level of n--6 PUFAs is relatively too high, with an n--6/n--3 ratio of >18. These two classes of PUFAs are metabolically and functionally distinct and often have important opposing physiological functions; their balance is important for homeostasis and normal development. Elevating tissue concentrations of n--3 PUFAs in mammals relies on chronic dietary intake of fat rich in n--3 PUFAs, because mammalian cells lack enzymatic activities necessary either to synthesize the precursor of n--3 PUFAs or to convert n--6 to n--3 PUFAs. Here we report that adenovirus-mediated introduction of the Caenorhabditis elegans fat-1 gene encoding an n--3 fatty acid desaturase into mammalian cells can quickly and effectively elevate the cellular n--3 PUFA contents and dramatically balance the ratio of n--6/n--3 PUFAs. Heterologous expression of the fat-1 gene in rat cardiac myocytes rendered cells capable of converting various n--6 PUFAs to the corresponding n--3 PUFAs, and changed the n--6/n--3 ratio from about 15:1 to 1:1. In addition, an eicosanoid derived from n--6 PUFA (i.e., arachidonic acid) was reduced significantly in the transgenic cells. This study demonstrates an effective approach to modifying fatty acid composition of mammalian cells and also provides a basis for potential applications of this gene transfer in experimental and clinical settings.

The synthesis and secretion of fatty acid ethyl esters from HepG2 cells are stimulated by lipoproteins and albumin

BACKGROUND

Fatty acid ethyl esters (FAEEs) are nonoxidative metabolites of ethanol produced by the esterification of fatty acids and ethanol. FAEEs have been implicated as mediators of ethanol-induced organ damage in vivo and in vitro. They are detectable in the blood and in many organs after ethanol ingestion, and on this basis they are useful markers of ethanol intake in living patients as well as subjects at autopsy. FAEEs found in human plasma after ethanol ingestion bind to lipoproteins and albumin.

METHODS

In this study, we used a hepatoblastoma cell model (HepG2) to determine if lipoproteins or albumin stimulates the synthesis and/or secretion of FAEEs from HepG2 cells. Because FAEEs have been shown to decrease HepG2 cellular proliferation and protein synthesis, their removal from cells potentially could reestablish normal cell activity. HepG2 cells were incubated with 100 mM ethanol and 6 nM 3H oleic acid to generate 3H-FAEEs within the cells. Dose response and time course studies were performed by using low density lipoproteins, high density lipoproteins, and albumin as FAEE acceptors.

RESULTS

The results indicate that FAEEs are extracted efficiently by each of these FAEE carriers and that FAEE synthesis also is stimulated by the addition of FAEE carriers to the extracellular medium.

CONCLUSION

These observations indicate that lipoproteins and albumin can extract ethyl esters from HepG2 cells and thereby may limit alcohol-induced liver damage.

Differences in the fatty acid composition of fatty acid ethyl esters in organs and their secretions

BACKGROUND

Fatty acid ethyl esters (FAEE) are nonoxidative ethanol metabolites that have been shown to be long term markers of ethanol intake and have been implicated as mediators of ethanol-induced cell injury. Previous studies have indicated that the fatty acid composition of the FAEE found in the plasma of human subjects after ethanol ingestion is predominantly ethyl palmitate and ethyl oleate. This raised the possibility that there is some selectivity toward the fatty acid used for FAEE to be exported from the liver into the blood.

METHODS

To address the hypothesis that the fatty acid composition of FAEE secreted from organs, such as the liver and pancreas, differs from the fatty acid composition of FAEE in the organs, this study was performed using rats that received ethanol by intra-arterial infusion.

RESULTS

It was found that the fatty acids in FAEE differed significantly in plasma versus liver, bile versus liver, and pancreatic secretions versus pancreas.

CONCLUSIONS

These results indicate that organs selectively export certain FAEE species.

Preanalytical variables affecting the quantification of fatty acid ethyl esters in plasma and serum samples

BACKGROUND

Fatty acid ethyl esters (FAEEs) are cytotoxic nonoxidative ethanol metabolites produced by esterification of fatty acids and ethanol. FAEEs are detectable in blood up to 24 h after ethanol consumption. The objective of this study was to assess the impact of gender, serum or plasma triglyceride concentration, time and temperature of specimen storage, type of alcoholic beverage ingested, and the rate of ethanol consumption on FAEE concentrations in plasma or serum.

METHODS

For some studies, subject were recruited volunteers; in others, residual blood samples after ethanol quantification were used. FAEEs were isolated by solid-phase extraction and quantified by gas chromatography-mass spectrometry.

RESULTS

For weight-adjusted amounts of ethanol intake, FAEE concentrations were twofold greater for men than women (P </=0.05). Accounting for triglycerides improved the correlation between blood ethanol concentrations and FAEE concentrations for both men (from r = 0.640 to r = 0.874) and women (from r = 0.619 to r = 0.673). FAEE concentrations did not change when samples were stored at or below 4 degrees C, but doubled when stored at room temperature for >/=24 h. The type of alcoholic beverage and rate of consumption did not affect FAEE concentrations.

CONCLUSION

These studies advance plasma and serum FAEE measurements closer to implementation as a clinical test for ethanol intake.

A membrane lipid imbalance plays a role in the phenotypic expression of cystic fibrosis in cftr(-/-) mice

A deficiency in essential fatty acid metabolism has been reported in plasma from patients with cystic fibrosis (CF). However, its etiology and role in the expression of disease is unknown. The objective of this study was to determine whether alterations in fatty acid metabolism are specific to CF-regulated organs and whether they play a role in the expression of disease. A membrane lipid imbalance was found in ileum, pancreas, and lung from cftr(-/-) mice characterized by an increase in phospholipid-bound arachidonic acid and a decrease in phospholipid-bound docosahexaenoic acid (DHA). This lipid imbalance was observed in organs pathologically affected by CF including lung, pancreas, and ileum and was not secondary to impaired intestinal absorption or hepatic biosynthesis of DHA. As proof of concept, oral administration of DHA to cftr(-/-) mice corrected this lipid imbalance and reversed the observed pathological manifestations. These results strongly suggest that certain phenotypic manifestations of CF may result from remediable alterations in phospholipid-bound arachidonic acid and DHA levels.

The hydrolysis of fatty acid ethyl esters in low-density lipoproteins by red blood cells, white blood cells and platelets

Fatty acid ethyl esters (FAEE), esterification products of fatty acids and ethanol, have been implicated as toxic mediators of ethanol ingestion. In this study, we investigated the in vitro hydrolysis of FAEE reconstituted in low-density lipoproteins (LDL) when incubated with human blood, cell free plasma, red blood cells, white blood cells, and platelets. We also determined the metabolic fate of the fatty acid originally incorporated in the FAEE following FAEE hydrolysis. When FAEE were incubated with human red blood cells. white blood cells, or platelets, at physiologic cell counts, 80% of the FAEE were hydrolyzed at 2 h. The FAEE-derived fatty acid was predominantly found in phospholipid and free fatty acid fractions. Cell free plasma contained minimal FAEE hydrolytic activity. These studies demonstrate that FAEE are degraded to free fatty acids and ethanol by the cellular elements in the blood. The generation of free fatty acids from extensive hydrolysis of FAEE adds support to the growing concept that at least some of the toxic effects of FAEE are mediated by the free fatty acids generated upon hydrolysis of the ethyl esters.

Assessment of ethanol intake. Current tests and new assays on the horizon

The number of tests used for the detection of ethanol ingestion is increasing. The field is rapidly moving beyond ethanol alone as a marker of ethanol intake. The combined measurement of carbohydrate deficient transferrin, FAEEs, 5-HTOL/5-HIAA, acetaldehyde adducts, and phosphatidylethanol may one day be used to approximate the time and amount of ethanol ingestion. The ultimate configuration of a panel of tests for monitoring ethanol intake awaits the results of studies that identify the clinical usefulness of each marker.

The pool of fatty acids covalently bound to platelet proteins by thioester linkages can be altered by exogenously supplied fatty acids

The goals of this investigation were, first, to develop a chemical strategy to identify and quantitate the mass of fatty acid which is covalently bound to proteins by thioester linkage in unactivated platelets, and, second, to determine whether exogeneously added fatty acids can alter the fatty acid composition of thioester bound fatty acids. Studies with radiolabeled fatty acids cannot identify and quantitate the actual fatty acids bound to proteins because they permit analysis of only the radiolabeled fatty acids added and their metabolites. Therefore, in the absence of metabolic labeling by radiolabeled fatty acids, we isolated the thioester-linked fatty acids from platelet proteins using hydroxylamine at neutral pH to form fatty acid hydroxamates. The hydroxamates were subsequently converted to fatty acid methyl esters by acid methanolysis for quantitation by gas chromatography-mass spectrometry. Using platelet specimens from 14 subjects, 74% of the fatty acid recovered from the unactivated platelet proteins as thioester linked was palmitate. Importantly, however, 22% was stearic acid, and oleate was 4% of the total thioester bound fatty acid. There was minimal variability (2.6-fold at maximum) between the subjects in the amount of the thioester-linked palmitate and thioester-linked stearate. However, there was substantial variability (>100-fold at maximum) between subjects in the amount of thioester-linked oleate. We also demonstrated that incubation of platelets with exogenous fatty acids can alter the profile of fatty acids bound to platelet proteins by thioester linkages. Incubation of platelets with 100 microM palmitate for 3 h increased the amount of thioester-linked palmitate by up to 26%, and incubation of platelets with 100 microM stearate increased the amount of thioester-linked stearate up to 30%. In support of the observation that radiolabeled fatty acids other than palmitate were shown to be capable of binding to platelet proteins by thioester linkage, our results indicate that the fatty acids actually bound to unactivated platelet proteins include a significant amount of stearate, and variable amounts of oleate, as well as palmitate. In addition, the data show that palmitate and stearate can be increased, as a percentage of total protein-bound fatty acid, by incubation with exogenous palmitate and stearate, respectively.

D-dimers in the diagnosis of pulmonary embolism

The aim of this study was to determine if the absence of circulating D-dimers, as determined by latex agglutination assays, can correctly exclude the presence of pulmonary embolism using pulmonary angiography as the diagnostic endpoint. Blood samples were obtained prospectively at the time of angiography for suspicion of acute pulmonary embolism. Plasma was assayed for D-dimer by five different latex agglutination assays. Angiographic evidence of pulmonary emboli was found in 34% (35/ 103) of patients. The latex agglutination assays had sensitivities of 97 to 100% and specificities of 19 to 29%. The negative predictive value was 94 to 100%. However, a negative D-dimer was rare in patients with recent surgery, malignancy, or total bilirubin > 34 micromol/L (> 2 mg/dl). In 31 patients suspected of pulmonary emboli but without these confounding factors, the five D-dimer assays were negative in 46 to 55% of patients with normal pulmonary angiograms. The negative predictive value in these patients was 100% by all five latex agglutination assays tested. The latex agglutination assays for D-dimer, when the pulmonary angiogram is used as the diagnostic endpoint and in the absence of recent surgery, malignancy, or liver disease, appears to be a clinically useful test in the diagnosis of acute pulmonary embolism.

Fatty acid ethyl esters: current facts and speculations

Increasing evidence indicates that fatty acid ethyl esters (FAEE) play a role in ethanol-induced organ damage and may serve as long-term markers of ethanol intake. This report summarizes the current knowledge on the toxicity of FAEE, the enzymes associated with FAEE synthesis, FAEE as fatty acid supplements, the in vivo degradation of orally ingested FAEE and FAEE as markers of ethanol intake. A list of major unanswered questions in each of these categories is also included.

Human peripheral blood T lymphocyte proliferation after activation of the T cell receptor: effects of unsaturated fatty acids

Oils enriched in certain polyunsaturated fatty acids suppress joint pain and swelling in rheumatoid arthritis patients with active synovitis. Because T lymphocyte activation is important for propagation of joint tissue injury in patients with rheumatoid arthritis, we examined the effects of fatty acids added in vitro on proliferation of human T lymphocytes stimulated with monoclonal antibodies to CD3 and CD4. Unsaturated fatty acids reduced T cell proliferation in a dose dependent manner (dihomogammalinolenic acid > gammalinolenic acid > eicosapentaenoic acid > arachidonic acid). Removal of fatty acids from cultures before cell stimulation did not change the effects, but addition of fatty acids after cell stimulation failed to reduce T cell responses. The saturated palmitic acid did not influence T cell growth. These studies indicate that small changes in cellular fatty acids can have profound effects on early events in T cell signaling and on T cell function.

Fatty acid ethyl ester synthesis in the preparation of scotch whiskey

Fatty acid ethyl esters (FAEE), nonoxidative ethanol metabolites present in human organs commonly damaged by ethanol abuse, have been implicated as mediators of organ damage. FAEE are additives in various foods and beverages to provide flavor or fragrance, and therefore are common dietary lipid constituents. We hypothesized that FAEE could be generated during alcoholic beverage production because fatty acids are present within microorganisms and ethanol is generated during the fermentation process. In this report, we demonstrate that FAEE are present in commercially available scotch beverages, and that in the preparation of scotch, FAEE can be produced during the fermentation reaction as a result of FAEE synthase activity in the yeast. Following ingestion of scotch, preformed FAEE are delivered to GI tract. The consequences of ingestion of FAEE in scotch, if any, remain to be determined.

A method for proficiency testing of small peer groups in the College of American Pathologists Coagulation Surveys

OBJECTIVE

To develop a grading scheme for the proficiency testing of small peer groups of fewer than 10 members for the prothrombin time (PT) and activated partial thromboplastin time (APTT).

METHODS

A modified target value for small peer groups was derived based on the assumption that measurement variability in the PT and APTT is more greatly influenced by variations in reagents than in instruments. Criteria for grading were established by statistical simulation to achieve misclassification errors of less than 5% for both incorrectly passing and failing participants. College of American Pathologists Coagulation Survey data were analyzed to determine the number of additional laboratories graded using the proposed scheme, as well as the failure rates among participants in the small peer groups.

RESULTS

The modified target value for small peer groups is a weighted average between the mean of the peer group and the mean of all participants using the same reagent (reagent group). Peer groups with as few as 4 members can be graded provided that specific criteria are satisfied: there must be at least 5 peer groups for the same reagent, at least 3 of these 5 peer groups must have more than 3 members, and the coefficient of variation for the reagent group must be less than 10%. This proposed grading scheme decreased the number of ungraded laboratories by 44% to 46% for the PT and 42% to 55% for the APTT. The percentage of failing grades among participants in the small peer groups ranged from 1.3% to 4.1% for the PT and 1.4% to 7.2% for the APTT. These failure rates were 2.8- to 13.0-fold higher than the failure rates in large peer groups (P < or = .05).

CONCLUSIONS

The proposed small peer group grading scheme can improve the effectiveness of College of American Pathologists proficiency testing for the PT and APTT and may also be generally applicable to other test methods and analytes.

Laboratory evaluation of hypercoagulable states

The number of well-characterized hereditary and acquired hypercoagulable conditions is increasing, such that in many thrombophilic patients, the laboratory can now identify a hypercoagulable condition. This review describes the currently known hypercoagulable states that predispose patients to venous, and in some instances, arterial thrombosis. For each condition, the discussion includes the incidence, magnitude of the thrombotic risk in the general population in comparison with symptomatic families, synergistic interactions among the various hypercoagulable conditions, molecular pathogenesis, and interpretation of laboratory test results. In addition, recommendations for laboratory testing are summarized.

College of American Pathologists Conference XXXI on laboratory monitoring of anticoagulant therapy: the clinical use and laboratory monitoring of low-molecular-weight heparin, danaparoid, hirudin and related compounds, and argatroban

OBJECTIVE

To review the role of the laboratory in monitoring therapy with low-molecular-weight heparin, danaparoid, hirudin, and argatroban, as reflected in the medical literature and the consensus opinion of recognized experts in the field.

DATA SOURCES

Review of the medical literature and current clinical practice by a panel of 6 international experts in the field of anticoagulant therapy.

DATA EXTRACTION AND SYNTHESIS

The experts made an extensive review of the published literature and prepared a draft manuscript, which included preliminary recommendations. The draft manuscript was circulated to participants in the College of American Pathologists Conference XXXI on Laboratory Monitoring of Anticoagulant Therapy prior to the conference. The manuscript and recommendations were then presented at the Conference for discussion. Recommendations were accepted if a consensus of the 26 experts attending the Conference was reached. The results of the discussion were used to revise the manuscript into its final form.

CONCLUSIONS

This report reviews the mechanism of action and potential uses of these newer anticoagulant agents. General guidelines for monitoring these agents and 9 specific recommendations for laboratory monitoring of low-molecular-weight heparin and danaparoid are provided, along with citation of the appropriate supporting literature. Issues for which a consensus was not reached at the Conference are also discussed.

Quantitation of the mass of fatty acid ethyl esters synthesized by Hep G2 cells incubated with ethanol

Fatty acid ethyl esters (FAEE), esterification products of fatty acids and ethanol, have been increasingly implicated as mediators of ethanol-induced organ damage. The first goal of this study was to determine the mass of FAEE synthesized by Hep G2 cells exposed to a given dose of ethanol. The second goal was to determine whether all fatty acids in cells are equally available for FAEE synthesis. Hep G2 cells and essential fatty acid deficient Hep G2 cells (Hep G2-EFD) were used to study the synthesis of FAEE upon exposure to ethanol. A two-pool fatty acid model was created: (1) a "previously incorporated pool" formed by incubating the cells with 14C-labeled fatty acids for 24 hr; and (2) a "newly incorporated pool" formed by incubating cells with 3H-labeled fatty acids for 0.5 hr. The FAEE production from each pool was then determined. The total production of FAEE within 3 hr by Hep G2 cells in culture was 150 to 250 pmol/mg cell protein. The fatty acids most recently incorporated into the cells were preferred as substrates for FAEE synthesis because a higher percentage of fatty acids from the newly incorporated pool was used for FAEE synthesis than from the previously incorporated pool. Furthermore, a dose-response relationship was observed between the amount of fatty acid in the newly incorporated pool and FAEE production, but not between the amount of fatty acid in the previously incorporated pool and FAEE synthesis. Taken together, the results indicate that a relatively small amount of endogenously synthesized FAEE is generated from specific intracellular pools of fatty acid since not all fatty acids are equally available for FAEE synthesis. This indicates that if endogenous FAEE are toxic, they exert their toxic effect at very low intracellular FAEE concentrations.

Fatty acid ethyl esters and HepG2 cells: intracellular synthesis and release from the cells

Fatty acid ethyl esters (FAEE), esterification products of fatty acid and ethanol, have been implicated as mediators of ethanol-induced organ damage. To understand the molecular and cellular events in FAEE synthesis and secretion, we developed a system in which HepG2 cells synthesize and release FAEE into the culture medium upon incubation with ethanol. The synthesis of FAEE was observed within 5 min of the addition of ethanol, with a plateau for FAEE synthesis after 2 h of incubation. It was also observed that FAEE are synthesized by both a microsomal FAEE synthase, which preferentially uses fatty acyl-CoA as a substrate, and a cytosolic FAEE synthase, which accepts both unesterified fatty acid and fatty acyl-CoA as substrates with a slight preference for fatty acyl-CoA. Although the kinetics of cellular FAEE synthesis await further characterization, the intracellular fatty acid substrate appears to be derived principally from glycerolipids and other esters. FAEE were released into the culture medium by a mechanism independent of the vesicular transport pathway. Lipoprotein particles and albumin were found to be carriers of FAEE after FAEE secretion from the cell.

Collagen-induced whole blood platelet aggregation in patients undergoing surgical procedures associated with minimal to moderate blood loss

Intraoperative bleeding due to platelet disorders is a persistent problem. Therefore, a screening assay to identify patients who are likely to bleed as a result of platelet dysfunction would be useful in formulating decisions about patient care. A previous study indicated that preoperative collagen-induced whole blood platelet aggregation predicts bleeding in patients undergoing surgery with cardiopulmonary bypass, a procedure associated with substantial blood loss. In the current study, we assessed the ability of the same whole blood platelet aggregation test to predict blood loss in patients undergoing surgical procedures not associated with substantial blood loss. The study included 369 adult patients (165 men and 204 women). Patients were categorized in three groups depending on the invasiveness of the operation and the expected blood loss. The intraoperative estimated blood loss value, obtained from the operative report in the patient record, increased significantly with increasing surgical invasiveness. Patients with excessive blood loss (defined as blood loss at or above the 75th or 90th percentile of the estimated blood loss values of patients undergoing procedures of similar invasiveness) had similar platelet aggregation values as patients who did not experience excessive blood loss. Thus, for patients undergoing operations not associated with substantial blood loss, the results of preoperative collagen-induced whole blood platelet aggregation are not effective in identifying patients likely to experience excessive blood loss.

Effects of fasting and glucose infusion on basal and overnight leptin concentrations in normal-weight women

The plasma concentration of leptin is reduced in association with chronic energy restriction and weight loss in humans, but little is known about the acute effects of fasting and glucose infusion on leptin. In this study, plasma leptin, insulin, glucose, and fatty acid concentrations were measured daily in 14 healthy, normal-weight, female volunteers aged 24 +/- 4 y with a body mass index (kg/m2) of 24.2 +/- 3.6 during a 4-d fast. The mean plasma leptin concentration decreased by 54 +/- 8% with fasting (P = 0.0006, ANOVA). In a stepwise-regression model, the change in leptin concentration with fasting correlated most significantly with the change in insulin (R2 = 0.48, P = 0.0057) and to a lesser extent with the change in body fat by bioimpedance analysis (R2 = 0.19, P = 0.03). Plasma leptin concentrations measured every 20 min from 2000 to 0800 on the fourth night of the fast did not show a time-dependent rise. A continuous intravenous infusion of 5% glucose providing 1414 +/- 323 kJ/d (338 +/- 78 kcal/d) was begun after 4 d of fasting in seven subjects who continued to fast for an additional 6 d. Within 24 h of the glucose infusion, leptin concentrations increased significantly by 80 +/- 52% (P < 0.05). These data show the sensitivity of plasma leptin concentrations to small changes in energy supply and suggest a basic role of substrate metabolism in the short-term regulation of leptin.

Anticardiolipin antibodies and hepatic artery thrombosis after liver transplantation

BACKGROUND

Hepatic artery thrombosis (HAT) remains a devastating complication after liver transplantation. Various factors have been implicated in the pathogenesis of HAT, such as clotting abnormalities, increased hematocrit, and technical complications, but the role of anticardiolipin antibodies has not been evaluated. We investigated the possible association between HAT and anticardiolipin antibodies in adult patients who underwent liver transplantation.

METHODS

Seven patients with HAT after orthotopic liver transplantation, 28 liver recipients without HAT, and 35 normal blood donors were evaluated. Determination of IgM and IgG anticardiolipin antibodies was performed by enzyme-linked immunosorbent assay using pretransplant serum from all allograft recipients. Clinical information was obtained from chart review. Fisher's exact test and Wilcoxon rank sum test were used for statistical analysis, and all P-values were two-tailed.

RESULTS

Overall, 22 of 35 (63%) liver recipients had a positive anticardiolipin antibody test (either IgG or IgM titer >4 SD from the normal controls). The test was positive in 7 liver recipients (100%) with HAT compared with 15 out of 28 patients (54%) without HAT (P=0.031). As compared with liver recipients without HAT, patients with HAT also tended to have a higher mean anticardiolipin titer of IgG and IgM and a lower pretransplant platelet count; however, these differences were not significant.

CONCLUSIONS

Our findings indicate that anticardiolipin antibodies are frequently elevated in patients with liver failure and may contribute to the pathogenesis of HAT after liver transplantation. Other potential consequences of anticardiolipin antibodies in end-stage liver disease remain to be determined.

The nature and extent of training activities in clinical pathology required for effective consultation on laboratory test selection and interpretation

OBJECTIVE

The goal of this study was to identify the activities in clinical pathology training and the length of time required in each to effectively train residents as consultants on laboratory test selection and interpretation.

METHODS

The information needed to address these questions was obtained from a study of 20 residents in clinical pathology at our institution between 1990 and 1996. In the survey participants were asked to assess the value of specific training activities in developing their confidence when addressing consultative questions on laboratory test use and interpretation. Participants were also asked to assess the length of time required to gain confidence in performing this role.

RESULTS

The results of the study demonstrate that confidence in providing advice on clinical laboratory test selection and interpretation is acquired to a significant but not absolute degree after an intense 8-week experience in a single clinical laboratory subspecialty, during which time no other responsibilities are assigned. The data also indicate that interactions with clinical pathologists and formal lectures provided to the trainees during their rotations are critical components of the consultation service. There was a significant decrease in the length of time required to provide effective information on test selection and interpretation as the residents progressed through their training.

CONCLUSIONS

For all of the major subspecialties in clinical pathology, the residents gained significant confidence by 4 weeks of intense training, and by 8 weeks participants were very confident in answering consultation questions. Even after 8 weeks, however, fewer than 10% of the residents felt absolutely confident in their own decisions regarding laboratory test use and interpretation prior to discussion with senior residents and faculty. Thus, acquisition of expertise to effectively provide advice on laboratory test selection and interpretation required up to 8 weeks of focused training in each clinical laboratory subspecialty. Gaining confidence in multiple areas requires a significant commitment of full-time training. This study provides an understanding of the type and extent of training required to attain the skills necessary to effectively provide consultation in clinical pathology.

Oral administration of unsaturated fatty acids: effects on human peripheral blood T lymphocyte proliferation

Oils enriched in certain polyunsaturated fatty acids suppress joint pain and swelling in rheumatoid arthritis (RA) patients. Because T lymphocyte activation is important to propagation of joint tissue injury in patients with RA, we examined the effects of fatty acids administered by mouth in vivo on proliferation of human lymphocytes activated through the T cell receptor complex. T cell proliferation was reduced after oral administration of 2.4 g gammalinolenic acid in capsules of borage seed oil. Oral administration of oils enriched in linoleic acid, the parent n-6 fatty acid, and alpha linolenic acid, the parent n-3 fatty acid, did not influence growth of stimulated cells. Fatty acid analyses indicated that suppression of lymphocyte proliferation after gammalinolenic acid administration was associated with increased plasma and peripheral blood mononuclear cell concentrations of gammalinolenic acid and dihomogammalinolenic acid.

Posttranslational modification of proteins with fatty acids in platelets

Direct modification of proteins by fatty acid can occur as cotranslational N-myristoylation of an N-terminal glycine residue or as posttranslational thioesterification of cysteine residue(s). Platelets provide an excellent model system for studying the posttranslational type of modification in the absence of active protein synthesis and in the absence of protein synthesis-related protein modifications with lipids. Using this model system it was shown that thioesterification of proteins with fatty acid is less specific for palmitate than it was thought earlier and that other saturated, mono- and even polyunsaturated long chain fatty acids can also participate. The chain length and the extent of unsaturation of the protein-linked fatty acid moiety can, very likely, modulate hydrophobic protein-membrane lipid and protein-protein interactions. CD9, HLA class I glycoprotein, glycoproteins Ib, IX and IV, P-selectin and alpha subunits of G proteins have been demonstrated unequivocally as S-fatty acid acylated platelet proteins.

Fatty acid ethyl esters: short-term and long-term serum markers of ethanol intake

This review includes a description of short-term and long-term markers of ethanol intake and their clinical utility. The major portion of this report is a summary of studies on fatty acid ethyl ester, a new marker for monitoring both acute and chronic ethanol intake. With the markers described in the review, algorithms to assess recent ethanol intake, chronic ethanol intake, and end organ damage are included to provide a practical approach to the evaluation of the patient.

Rapid in vivo hydrolysis of fatty acid ethyl esters, toxic nonoxidative ethanol metabolites

Fatty acid ethyl esters (FAEE), esterification products of fatty acids and ethanol, are in use as fatty acid supplements, but they also have been implicated as toxic mediators of ethanol ingestion. We hypothesized that hydrolysis of orally ingested FAEE occurs in the gastrointestinal (GI) tract and in the blood to explain their apparent lack of toxicity. To study the in vivo inactivation of FAEE by hydrolysis to free fatty acids and ethanol, we assessed the hydrolysis of FAEE administered as an oil directly into the rat stomach and when injected within the core of low-density lipoprotein particles into the circulation of rats. Our studies demonstrate that FAEE are rapidly degraded to free fatty acids and ethanol in the GI tract at the level of the duodenum with limited hydrolysis in the stomach. In addition, FAEE are rapidly degraded in the circulation, with a half-life of only 58 s. Thus the degradation of FAEE in the GI tract and in the blood provides an explanation for the apparent lack of toxicity of orally ingested FAEE.

Pancreatic injury in rats induced by fatty acid ethyl ester, a nonoxidative metabolite of alcohol

BACKGROUND & AIMS

The mechanism by which alcohol injures the pancreas remains unknown. Alcohol-intoxicated humans have high levels of fatty acid ethyl esters (FAEEs), nonoxidative products of ethanol metabolism, in blood, pancreas, and liver. The aims of this study were to determine whether FAEEs are toxic to the pancreas in vivo and, if so, to assess whether this injury is specific to the pancreas and to compare it to the injury observed in acute pancreatitis.

METHODS

FAEEs were infused into Sprague-Dawley rats. Levels of FAEEs in plasma and pancreas were measured, and pancreatic injury was assessed during a 48-hour period for edema formation and ectopic trypsinogen activation and by light and electron microscopy.

RESULTS

FAEEs induced highly significant increases in pancreatic edema, pancreatic trypsinogen activation, and vacuolization of acinar cells. These findings were specific to the pancreas and were not found in liver, lung, myocardium, skeletal muscle, or subcutaneous fat.

CONCLUSIONS

FAEEs at concentrations found in human plasma produce a pancreatitis-like injury in rats, providing direct evidence that FAEEs can produce organ-specific toxicity. Thus, FAEEs may contribute to acute alcohol-induced damage to the pancreas.

Fatty acid acylation of platelet proteins

A variety of fatty acids can become covalently attached to platelet proteins by thioester linkage. These fatty acids include palmitate, myristate, stearate, arachidonate, and eicosapentaenoate. More than 20 platelet proteins can be acylated by fatty acids. Several of the acylated platelet proteins have been identified, including glycoprotein Ib beta, glycoprotein IX, P-selectin, G-protein alpha subunits, and CD9. This report reviews the fatty acid acylation of platelet proteins.

The distribution of fatty acid ethyl esters among lipoproteins and albumin in human serum

Fatty acid ethyl esters (FAEEs) are nonoxidative products of ethanol metabolism and have been implicated as mediators of ethanol-induced organ damage. Previous studies have demonstrated that FAEEs bind to lipoproteins and albumin in human plasma after ethanol ingestion. Analysis of human serum with varying blood ethanol levels and endogenously formed FAEEs revealed a positive correlation between serum FAEE concentration and the percentage of FAEEs associated with lipoproteins, predominantly very low density and low density lipoprotein. Similar results were obtained when increasing amounts of FAEEs were added to serum with zero blood ethanol. Additional studies indicated that free fatty acids and FAEEs do not compete for binding to albumin or lipoproteins. Data support the conclusion that the distribution of FAEEs among their carriers in the serum is dependent on serum FAEE concentration.

Ethyl palmitate and ethyl oleate are the predominant fatty acid ethyl esters in the blood after ethanol ingestion and their synthesis is differentially influenced by the extracellular concentrations of their corresponding fatty acids

The possibility that fatty acid ethyl esters (FAEEs), esterification products of fatty acids and ethanol, are mediators of ethanol-induced organ damage was suggested by an autopsy study in which individuals who died while acutely intoxicated were found to have FAEEs predominantly in the organs damaged by ethanol abuse. We initially observed in human subjects after ethanol consumption that there is a marked preference for the synthesis of ethyl palmitate and ethyl oleate over other FAEEs. To investigate the basis for this relative fatty acid specificity for FAEE synthesis, we used an in vitro system of Hep G2 cells incubated with ethanol. The cells were capable of synthesizing FAEEs upon exposure to ethanol and they showed a preference for synthesis of ethyl palmitate and ethyl oleate, as was found in human plasma after ethanol ingestion. This finding allowed us to explore the metabolic preference for palmitate and oleate for FAEE synthesis at the biochemical level using intact cells. We demonstrated that the preferential selection of palmitate and oleate for FAEE synthesis was not likely to be the result of specificity for palmitate and oleate by FAEE synthase or preferential uptake of palmitate and oleate by Hep G2 cells. In studies to determine whether the preference for ethyl palmitate and ethyl oleate synthesis was a result of higher concentrations of palmitate and oleate in the extracellular medium, we observed that the synthesis of ethyl oleate, ethyl linoleate, and ethyl arachidonate, but not ethyl palmitate, is influenced by the extracellular concentration of its corresponding fatty acid. The results of our studies indicate that ethyl palmitate and ethyl oleate are the predominant ethyl esters synthesized, that there is no preferential uptake or enzyme affinity for their fatty acid precursors to explain the predominance, and that ethyl palmitate synthesis is uniquely unaffected by the concentration of palmitate in the extracellular medium.

Coagulation changes during thoracoabdominal aneurysm repair

PURPOSE

The cause of coagulopathic hemorrhage during thoracoabdominal aneurysm (TAA) repair has not been well defined in human studies. We investigated changes in the coagulation system associated with supraceliac versus infrarenal cross-clamping to address this critical issue.

METHODS

Blood levels of fibrinogen, the prothrombin fragment F1.2, D-dimer, and factors II, V, VII, VIII, IX, X, XI, and XII were analyzed in 19 patients with TAAs and four patients with abdominal aortic aneurysms (AAAs) at: (A) induction; (B) 30 minutes into supraceliac (TAA) or infrarenal (AAA) clamping; (C) 30 minutes after release of supraceliac or infrarenal clamps; and (D) immediately after surgery. Preoperative and intraoperative variables, including but not limited to aneurysm type, pathologic findings, comorbid conditions, clamp times, volume and timing of blood products, and clinical outcome, were prospectively recorded. Significance was determined by analysis of variance, Student's t test, and univariate linear regression.

RESULTS

Levels of fibrinogen and factors II, V, VIII, VIII, IX, X, XI, and XII decreased (p < 0.05) at time B versus time A and returned to near baseline by time D. D-dimer and F1.2 increased starting at time B and reached significance (p < 0.05) by time D. Data points were compared for the TAA and AAA groups. Although AAA groups demonstrated a trend to factor activity reduction and increased fibrinolysis, the effect was much less pronounced than in TAA and did not approach significance. No correlation of coagulation change with clamping time was present; however, visceral clamping times were all less than 65 minutes (mean, 44 minutes). Blood and factor replacement was initiated after time B. Univariate regression analysis of factor level versus total blood replacement demonstrated a significant (p < 0.04) correlation between the reduction in the levels of factors II, V, VII, VIII, X, and XII, and the increase in the level of D-dimer at time B and subsequent total blood replacement.

CONCLUSIONS

Thoracoabdominal aneurysm repair is associated with a reduction in clotting factor activity and an increase in fibrinolytic function, which occurs after placement of the supraceliac clamp. Explanations include visceral ischemia or a greater and longer ischemic tissue burden as the likely cause of coagulation alterations. Total blood replacement during TAA procedures was correlated to the degree of factor reduction and fibrinolysis at the time of visceral cross-clamping. An aggressive approach to early blood component replacement and to coagulation monitoring could lessen blood loss during TAA repair and avoid potentially disastrous bleeding complications.

What many of us are doing or should be doing in clinical pathology: a list of the activities of the pathologist in the clinical laboratory

Mr. Paul Mango, Chief Operating Officer of a hospital-based clinical laboratory network in Pittsburgh, recently performed a survey of patients presenting for phlebotomy. The survey included the question, "What does a pathologist do?" The results were that 50% of the patients had no idea what a pathologist did, and 30% of the patients stated that pathologists examined dead bodies. It is not surprising that there is a limited understanding by patients of the activities of pathologists because patients do not usually see pathologists. However, beyond autopsy and surgical pathology, the activities of pathologists are also not well known to nonpathologist physicians and hospital administrators. A poor understanding of activities in clinical pathology have placed these clinical responsibilities of the pathologist under particular scrutiny for cost reduction. The quantitation of output from anatomic pathology, in number of slides reviewed or number of autopsies performed, is objective and easily understood. As noted in the list of clinical pathology activities that follows, the responsibilities within the clinical laboratory are highly diverse and, if the pathologist handles them successfully, highly contributory to patient care. Thus, it is timely that a compilation of activities in clinical pathology be issued for review by the pathologist community. I would hope that this list will serve as a starting point for a universally accepted group of activities that describes clinical pathology today and that it will be useful for pathologists to make their significant contributions in the clinical laboratory apparent to administrators, fellow physicians, and patients. The clinical laboratory responsibilities should also be valuable to directors of residency training programs to focus training in clinical pathology toward the development of currently desirable expertise.