Basic haemoglobinopathy diagnostics in Dutch laboratories; providing an informative test result

INTRODUCTION

After a first survey in 2001, the Dutch Association of Hematological Laboratory Research (VHL) advised its members to adopt a basic protocol for haemoglobinopathy carrier detection and to provide genetic information with all positive results to allow health-care professionals to inform carriers about potential genetic risks. This article reports on the compliance with these recommendations and their consequences.

METHODS

Clinical chemists of all 106 Dutch laboratories were invited to answer a survey on patient population, diagnostic techniques used, (self-reported) knowledge, use and effect of the additional information.

RESULTS

The average increase in diagnostic output was over 60% and the recommended basic protocol was applied by 65% of the laboratories. Over 84% of the laboratories reported to be aware of the additional recommendations and 77% to be using them. Most laboratories with limited diagnostic requests were still sending their cases to other laboratories and included the genetic information received from these laboratories in their diagnostic reports. The effect of information on subsequent 'family analysis' was estimated to be between 26 and 50%.

CONCLUSIONS

The present study shows an increase in diagnostic potential for haemoglobinopathy over the last decade, especially in the larger cities. Low 'family testing' rates were mostly found in areas with lower carrier prevalence or associated with local reluctance to pass the information to carriers. In spite of a dramatic improvement, too many carriers are still not informed because of lack of awareness among health-care providers and more education is needed.

Iron depletion: an ameliorating factor for sickle cell disease?

We report some observations from our laboratory practice that might be important for the treatment of sickle cell disease (SCD). We describe data from two cases indicating that iron depletion might have a beneficial effect diminishing the formation of HbS in favor of HbF, possibly reducing the severity of the disease. We believe that it would be worthwhile to monitor the course of the disease comparing cases with identical genotypes with and without iron depletion, and we advise to consider chelation therapy to reduce iron overload in patients with SCD.

Fixed versus variable dose of prothrombin complex concentrate for counteracting vitamin K antagonist therapy

BACKGROUND

Although prothrombin complex concentrate (PCC) is often used to counteract vitamin K antagonist (VKA) therapy, evidence regarding the optimal dose for this indication is lacking. In Dutch hospitals, either a variable dose, based on body weight, target INR (international normalised ratio) and initial INR, or a fixed dose is used.

AIM/OBJECTIVES

In this observational, pilot study, the efficacy and feasibility of the fixed dose strategy compared to the variable dosing regimen, is investigated.

MATERIALS AND METHODS

Consecutive patients receiving PCC (Cofact®, Sanquin, Amsterdam) for VKA reversal because of a major non-cranial bleed or an invasive procedure were enrolled in two cohorts. Data were collected prospectively in the fixed dose group, cohort 1, and retrospectively in the variable dose regimen, cohort 2. Study endpoints were proportion of patients reaching target INR and successful clinical outcome.

RESULTS

Cohort 1 consisted of 35 and cohort 2 of 32 patients. Target INR was reached in 70% of patients in cohort 1 versus 81% in cohort 2 (P = 0·37). Successful clinical outcome was seen in 91% of patients in cohort 1 versus 94% in cohort 2 (P = 1·00). Median INR decreased from 4·7 to 1·8 with a median dosage of 1040 IU factor IX (F IX) in cohort 1 and from 4·7 to 1·6 with a median dosage of 1580 IU F IX in cohort 2.

CONCLUSION

This study suggests that a fixed dose of 1040 IU of F IX may be an effective way to rapidly counteract VKA therapy in our patient population and provides a basis for future research.

Vaccine-induced enhancement of viral infections

Examples of vaccine-induced enhancement of susceptibility to virus infection or of aberrant viral pathogenesis have been documented for infections by members of different virus families. Several mechanisms, many of which still are poorly understood, are at the basis of this phenomenon. Vaccine development for lentivirus infections in general, and for HIV/AIDS in particular, has been little successful. Certain experimental lentiviral vaccines even proved to be counterproductive: they rendered vaccinated subjects more susceptible to infection rather than protecting them. For vaccine-induced enhanced susceptibility to infection with certain viruses like feline coronavirus, Dengue virus, and feline immunodeficiency virus, it has been shown that antibody-dependent enhancement (ADE) plays an important role. Other mechanisms may, either in the absence of or in combination with ADE, be involved. Consequently, vaccine-induced enhancement has been a major stumble block in the development of certain flavi-, corona-, paramyxo-, and lentivirus vaccines. Also recent failures in the development of a vaccine against HIV may at least in part be attributed to induction of enhanced susceptibility to infection. There may well be a delicate balance between the induction of protective immunity on the one hand and the induction of enhanced susceptibility on the other. The present paper reviews the currently known mechanisms of vaccine-induced enhancement of susceptibility to virus infection or of aberrant viral pathogenesis.

European Communities Confederation of Clinical Chemistry Working Group on Accreditation: past, present and future

During the past 10 years, many activities have taken place in the field of quality systems and accreditation in medical laboratories. Each country in Europe has a slightly different approach. The Working Group on Accreditation of the European Communities Confederation of Clinical Chemistry (EC4) tries to support harmonisation of these efforts. For this purpose, they edited the Essential Criteria for quality systems of medical laboratories and supported the forthcoming International ISO standard "Quality management for the medical laboratory". At this moment, a Model Quality Manual is nearly ready for publication. The next items are setting up criteria for auditing the quality system and criteria for the accreditation process.

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

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

Quantitative and qualitative analysis of haemoglobin variants using capillary zone electrophoresis

Capillary zone electrophoresis (CZE) has been introduced into the clinical chemistry laboratory because of its range of potential applications. In this paper, we evaluate an alkaline CZE method for the quantification of HbA2 and HbF and also assess the combination of the alkaline CZE method with an acid CZE method for the determination of haemoglobin variants in an automated fashion. Correlation of the HbA2% determined between the HbA2-CZE method (alkaline conditions) and the Helena Sickle Thal Quick Column method was good (r = 0.91). The correlation between the HbF% determined by the HbA2-CZE method and by the alkaline denaturation method was acceptable (r = 0.81). The HbA2-CZE method was able to identify a large number of haemoglobin variants. The variants HbC and HbE or HbS and HbD, however, had the same characteristics under alkaline conditions and could therefore not be discriminated from each other. The identification of these overlapping variants could be accomplished by the analysis of the blood specimens in combination with the HbA1c-CZE method (acid conditions). We conclude that the presented applications for capillary zone electrophoresis can be used for quantitative and qualitative analysis of haemoglobin variants.

Vaccination with experimental feline immunodeficiency virus vaccines, based on autologous infected cells, elicits enhancement of homologous challenge infection

Cats were vaccinated with fixed autologous feline immunodeficiency virus (FIV)-infected cells in order to present viral proteins to the immune system of individual cats in an MHC-matched fashion. Upon vaccination, a humoral response against Gag was induced. Furthermore, virus-neutralizing antibodies were detected in a Crandell feline kidney cell-based neutralization assay, but not in a neutralization assay based on primary peripheral blood mononuclear cells. Despite the induction of these FIV-specific responses, vaccinated cats were not protected. Instead, accelerated virus replication was found, an observation similar to what previous experiments using other vaccine candidates have shown. Here, the results of the present study are discussed in the light of enhancement of lentivirus infections as a complicating factor in lentivirus vaccine development.

Accelerated viraemia in cats vaccinated with fixed autologous FIV-infected cells

We have vaccinated cats with fixed autologous FIV infected PBMC to determine whether autologous presentation of antigen is capable of inducing a protective immune response against homologous challenge. To this end autologous PBMC were infected with a FIV molecular clone (19k1). When infection was established, cells were inactivated by dialysis against paraformaldehyde. Upon vaccination, cats developed a virus specific immune response as measured by ELISA against the Gag protein of FIV. No antibodies against the envelope protein were detected with a peptide ELISA. Virus neutralizing antibodies however could be detected with a neutralization assay based on infection of CrFK cells, but not in an assay based on infection of primary T-cells. Although vaccination led to the induction of these virus-specific immune responses, vaccinated cats were not protected against homologous challenge but showed an accelerated viraemia upon infection. This was shown both by PCR and cell-associated viral load. The possible mechanisms underlying this observation are discussed in this paper.

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

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

Feline immunodeficiency virus subunit vaccines that induce virus neutralising antibodies but no protection against challenge infection

Three experimental vaccines against feline immunodeficiency virus (FIV), all based on viral antigens presented via immune stimulating complexes (iscoms), were tested for their capacity to induce protection in cats from FIV infection. The respective vaccines consisted of FIV propagated in Crandell feline kidney (CrFK) cells (FIV-iscoms); FIV-iscoms spiked with recombinant vaccinia virus expressed FIV envelope glycoprotein incorporated into iscoms (FIV-iscoms + vGR657x15-iscoms) and vGR657x15-iscoms spiked with recombinant FIV Gag protein incorporated into iscoms (vGR657x15-iscoms + FIV-Gag-iscoms). Simian immunodeficiency virus envelope glycoprotein incorporated into iscoms, iscoms prepared with uninfected CrFK cells, and PBS served as controls. All cats vaccinated with vGR657x15-iscoms combined with FIV-iscoms or FIV-Gag-iscoms developed Env-specific plasma antibody responses. These antibodies neutralised FIV infection in CrFK cells, but failed to neutralise FIV infection in primary feline thymocytes. FIV-iscoms induced poor Env-specific responses and only one out of six cats developed antibodies that neutralised FIV in the CrFK cell based assay. Four weeks after challenge all cats proved to be infected, showing that none of the vaccine preparations provided protection. In contrast, 2 weeks after infection, virus infected peripheral blood mononuclear cells were only observed in cats vaccinated with FIV-iscoms + vGR657x15-iscoms or CrFK-iscoms and to a lesser extent in cats vaccinated with FIV-iscoms and vGR657x15-iscoms + FIV-Gag-iscoms, but not in cats vaccinated with SIV-iscoms or PBS. The differences found in cell associated virus loads amongst the respective groups are discussed in the light of antibody mediated enhancement of infectivity and protective effects provided by Gag-specific T cell responses.

Salmonella typhimurium aroA recombinants and immune-stimulating complexes as vaccine candidates for feline immunodeficiency virus

Two experimental feline immunodeficiency virus (FIV) vaccines were tested, either alone or in combination, in four groups of cats (A-D). One vaccine (SL3261-FIV) was composed of live attenuated Salmonella typhimurium aroA (SL3261) strains expressing the capsid (Gag) and part of the envelope (Env) proteins of FIV. The other was composed of FIV Gag and Env proteins incorporated into immune-stimulating complexes (iscom-FIV). Cats of group A were immunized four times with SL3261-FIV. Cats of group B were immunized twice with SL3261-FIV and then twice with iscom-FIV. Cats of group C were immunized twice with SL3261 expressing the B subunit of cholera toxin (SL3261-CtxB) and then twice with iscom-FIV. Cats of group D, which served as negative controls, were immunized twice with SL3261-CtxB and then twice with iscom into which the Gag and Env proteins of simian immunodeficiency virus (SIV) had been incorporated (iscom-SIV). Two weeks after the last immunization, all cats were challenged with FIV. At this time, cats immunized with iscom-FIV (groups B and C) showed strong plasma antibody responses to Gag and Env, whilst these responses were weak or undetectable in the cats immunized four times with SL3261-FIV (group A). Seven weeks after FIV challenge, Env-specific antibody responses had increased considerably in cats of all groups except group A. The mean virus loads in the cats of this group proved to be lower than those of the other groups at all time points, indicating partial protection.

Essential criteria for quality systems in medical laboratories

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

Canine distemper virus from diseased large felids: biological properties and phylogenetic relationships

Specific pathogen free (SPF) domestic cats were inoculated with tissue homogenate obtained from a Chinese leopard (Panthera pardus japonensis) that had died in a North American zoo from a natural infection with canine distemper virus (CDV). The cats developed a transient cell-associated CDV viraemia along with pronounced lymphopenia but did not show any clinical symptoms. Plasma neutralizing-antibody titres against the homologous CDV (A92-27/4, isolated from the Chinese leopard) were consistently higher than against the CDV vaccine strain 'Bussell'. The Chinese leopard CDV isolate showed in vitro biological properties reminiscent of virulent, wild-type CDV strains. Sequence analysis of the H gene of two large felid CDV isolates from the USA (A92-27/4 and A92-6) revealed up to 10% amino acid changes including up to four additional potential N-linked glycosylation sites in the extra-cytoplasmic domain as compared to CDV vaccine strains. Phylogenetic analysis was performed using the entire coding region of the H gene and a 388 bp fragment of the P gene of several morbillivirus species. Evidence was obtained that recent CDV isolates from different species in the United States (including isolates from large felids), Europe and Africa are significantly distinct from CDV vaccine strains. All wild-type CDV isolates analysed clustered according to geographical distribution rather than to host species origin. By sequence analysis a CDV epizootic among large felids in a Californian safari park was linked to a virus which most likely originated from feral non-felid carnivores.

Neutralization of feline immunodeficiency virus by polyclonal feline antibody: simultaneous involvement of hypervariable regions 4 and 5 of the surface glycoprotein

Sites involved in antibody-mediated neutralization of feline immunodeficiency virus were mapped by reciprocal exchange of envelope fragments or amino acids between molecular clones of feline immunodeficiency virus with different susceptibilities to neutralization by a polyclonal cat serum. Combinations of mutations within HV-4 or within HV-4 and HV-5 changed the susceptibility of the viruses to neutralizing antibody.

Enhancement of feline immunodeficiency virus infection after immunization with envelope glycoprotein subunit vaccines

Cats were immunized three times with different recombinant feline immunodeficiency virus (FIV) candidate vaccines. Recombinant vaccinia virus (rVV)-expressed envelope glycoprotein with (vGR657) or without (vGR657 x 15) the cleavage site and an FIV envelope bacterial fusion protein (beta-Galactosidase-Env) were incorporated into immune-stimulating complexes or adjuvanted with Quil A. Although all immunized cats developed antibodies against the envelope protein, only the cats vaccinated with the rVV-expressed envelope glycoproteins developed antibodies which neutralized FIV infection of Crandell feline kidney cells. These antibodies failed to neutralize infection of thymocytes with a molecularly cloned homologous FIV. After the third immunization the cats were challenged with homologous FIV. Two weeks after challenge the cell-associated viral load proved to be significantly higher in the cats immunized with vGR657 and vGR657 x 15 than in the other cats. The cats immunized with vGR657 and vGR657 x 15 also developed antibodies against the Gag proteins more rapidly than the cats immunized with beta-Galactosidase-Env or the control cats. This suggested that immunization with rVV-expressed glycoprotein of FIV results in enhanced infectivity of FIV. It was shown that the observed enhancement could be transferred to naive cats with plasma collected at the day of challenge.

Quality and accreditation systems in clinical biochemistry in the European Union

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

Formulation of a stable vidarabine infusion fluid

Decomposition of vidarabine in a 5% glucose infusion fluid after steam sterilization was measured by HPLC and TLC analysis. After sterilization for 60 minutes at 100 degrees C and 20 minutes at 120 degrees C no degradation could be observed. A slight but significant degradation was observed after sterilization for 60 minutes at 120 degrees C followed by storage for eight months. Assuming 5% loss of content to be acceptable, it was concluded that a vidarabine infusion fluid can be sterilized for 20 minutes at 120 degrees C and stored at room temperature for at least eight months afterwards.

Unstable glycosylated hemoglobin in patients with diabetes mellitus

Incubation of washed erythrocytes for 4 h at 37 degrees C in saline resulted in the disappearance of an unstable glycosylated fraction. In a reference group, its amount was very small, but its presence had a significant influence on the upper level of the reference range. In non-diabetic pregnant women, the unstable fraction was significantly higher than in the non-pregnant individuals, which resulted in a lower reference range for the stable HbA1. In diabetic patients, the average unstable HbA1 was about 10% of the "unincubated" level, with marked differences between individuals (0--30%), even in patients with a slightly elevated HbA1. Therefore it is important to determine the concentration of stable HbA1.

Interference of imferon in colorimetric assays for iron

Imferon (Merrell-National), an iron-dextran complex, is widely used in patients with iron deficiency. It is present in the circulation in appreciable amounts for two to three weeks after administration and interferes with all tested colorimetric iron assays, both with and without deproteinization. The amount of the plasma Imferon iron interference depends primarily on the choice of reductant. With dithionite it is essentially 100%. In the presence of ascorbic acid and hydroxylamine, the interference depends also on assay conditions, especially temperature, but also incubation time and pH. The minimum interference in a homogeneous assay was about 3%. The relative amount of interference from hemoglobin iron under the various assay conditions is different from that of Imferon iron. In the presence of a reducing agent, the dextran-iron complex decomposes--instantaneously with dithionite, and gradually with sulfite, ascorbic acid, and hydroxylamine. The freed iron becomes dialyzable, can react with bathophenanthroline, and elutes on a Sephadex G-50 or G-15 column in the same fractions as an ammonium ferrous sulfate.

Interference of imferon in colorimetric assays for iron

Imferon (Merrell-National), an iron-dextran complex, is widely used in patients with iron deficiency. It is present in the circulation in appreciable amounts for two to three weeks after administration and interferes with all tested colorimetric iron assays, both with and without deproteinization. The amount of the plasma Imferon iron interference depends primarily on the choice of reductant. With dithionite it is essentially 100%. In the presence of ascorbic acid and hydroxylamine, the interference depends also on assay conditions, especially temperature, but also incubation time and pH. The minimum interference in a homogeneous assay was about 3%. The relative amount of interference from hemoglobin iron under the various assay conditions is different from that of Imferon iron. In the presence of a reducing agent, the dextran-iron complex decomposes--instantaneously with dithionite, and gradually with sulfite, ascorbic acid, and hydroxylamine. The freed iron becomes dialyzable, can react with bathophenanthroline, and elutes on a Sephadex G-50 or G-15 column in the same fractions as an ammonium ferrous sulfate.

Interference of imferon in colorimetric assays for iron

Imferon (Merrell-National), an iron-dextran complex, is widely used in patients with iron deficiency. It is present in the circulation in appreciable amounts for two to three weeks after administration and interferes with all tested colorimetric iron assays, both with and without deproteinization. The amount of the plasma Imferon iron interference depends primarily on the choice of reductant. With dithionite it is essentially 100%. In the presence of ascorbic acid and hydroxylamine, the interference depends also on assay conditions, especially temperature, but also incubation time and pH. The minimum interference in a homogeneous assay was about 3%. The relative amount of interference from hemoglobin iron under the various assay conditions is different from that of Imferon iron. In the presence of a reducing agent, the dextran-iron complex decomposes--instantaneously with dithionite, and gradually with sulfite, ascorbic acid, and hydroxylamine. The freed iron becomes dialyzable, can react with bathophenanthroline, and elutes on a Sephadex G-50 or G-15 column in the same fractions as an ammonium ferrous sulfate.

The regulation of synthesis and storage of chymotrypsin inhibitor I in leaves of potato and tomato plants

The synthesis and accumulation of chymotrypsin inhibitor I in tomato leaflets is induced by detachment, or by destruction of petiole phloem by steam when followed by incubation of the leaflets in light. The induction process with detached tomato leaflets is similar to that found with detached potato leaflets. The large amount of inhibitor I synthesized per leaflet cell per unit time suggests either that the structural gene is redundant or that an unusually stable messenger RNA is present. In both tomato and potato leaflets the accumulation of inhibitor I is potently inhibited by actinomycin D, puromycin, and cycloheximide, but not by chloramphenicol. Indoleacetic acid is moderately inhibitory, as is 3-(3,4-dichlorophenyl)-1,1-dimethylurea. Glutamine and asparagine are both markedly stimulating. The cumulative data suggest that inhibitor I is a major depot or interim storage protein and that its existence in any particular tissue is under complex controls by both the internal and external environments of the plants.