Albumin and calcium reference interval using healthy individuals and a data-mining approach.

BACKGROUND: Harmonization of reference intervals for analytes that have a sound calibration and metrological traceability is a widely recommended practice. The UK Pathology Harmony has recently harmonized reference intervals for calcium and albumin. In this study, we have determined the reference intervals for calcium and albumin on the UK's most commonly used analytical platforms. METHOD: A prospective reference population of healthy individuals was recruited according to the IFCC CRIDL criteria. A second indirect population was collected from 14 primary care setting and measured in laboratories using various analytical platforms and methods (Roche, Abbott, Beckman and Siemens analytical platforms). RESULTS: In total, 299 subjects were recruited; the central 95th centile values for calcium for three out of four analytical platforms were in a close agreement with UK Pathology Harmony reference intervals of 2.2-2.6 mmol/L. Reference intervals of BCG methods from both cohorts and irrespective of analytical platforms were higher for both lower and upper reference limits than those for BCP. In comparison, the indirect study showed an age-related variation. The younger population reference intervals varied by up to 5.7% at the lower reference limit and up to 12% at the upper reference limit compared with Pathology Harmony reference intervals, and the older population showed a variation of up to 14% at both limits. CONCLUSION: While calcium reference intervals can be a subject for harmonization, albumin reference intervals studied showed large variation which is unsupportive of embracing a common reference interval for albumin.

The impact of the analytical performance specifications of calcium and albumin on adjusted calcium.

AIM: The generation of accurate, comparable results from traceable measurement procedures is a primary goal in harmonization efforts. In this study, the analytical performance of routine methods for calcium and albumin measurement is assessed to define the impact of the analytical bias of calcium and albumin on adjusted calcium equation performance and on reference intervals. METHOD: In collaboration with the Wales External Quality Assurance Scheme, six months' worth of anonymized data that cover a concentration range of clinical interest were collected. The data were grouped by analytical platforms/methods. RESULTS: Albumin BCG methods are positively biased (8%) to BCP methods. The overall bias for BCP methods ranges from 5.1 to -4.3% and the overall bias for BCG methods is from 2 to -6.7%. Bias for both methods is higher than the allowable minimal bias for albumin. Calcium concentrations for Roche Cobas CPC and NM-BAPTA, Beckman Arsenazo III, Abbott Architect Arsenazo III were within bias of 1.5 to -1%. However, Siemens calcium methods CPC and Arsenazo III appear to suffer from concentration-dependent bias ranging from +3 to -6%, which exceeds even the minimal allowable limits for calcium (1.3%). Adjusted calcium shows significant bias of 11%. Even with the exclusion of Siemens Advia, the scatter of adjusted calcium results exceeds that for total calcium. CONCLUSION: This study shows wider than acceptable analytical variation for albumin and calcium. This variation may contribute to overall adjusted calcium equations variation and invalidate the application of a harmonized reference interval for calcium and albumin.

The effect of different analytical platforms and methods on the performance of population-specific adjusted calcium equation.

BACKGROUND: A recent attempt to improve the diagnostic value of adjusted calcium addressed a primary care-specific adjusted calcium equation, but validated the new equation for Roche Cobas, BCG and NM-BAPTA methods only. In this study, we aim to validate a population-specific equation for other methods and platforms. METHOD: We collected retrospective patient data-sets from 15 hospital laboratories using a range of commercially available analytical platforms and methods for calcium and albumin measurements. Raw data-sets were collected and filtered according to Payne's criteria, and separate adjusted calcium equations were derived for hospitalized and primary care patients. RESULTS: Mean albumin and calcium results were significantly higher in primary care populations (P < 0.0001). The prevalence of hypocalcaemia using adjusted calcium ranged between 6% and 44% for inpatient data-sets and was higher in users of BCG methods. The application of community-specific adjustment equation to primary care data-sets reduced the prevalence of hypocalcaemia (mean 1.7%, range 0.8-3.7%). CONCLUSION: We demonstrated that the use of a community-specific calcium adjustment equation to a primary care population reduces both the percentage and the variation of hypocalcaemia between different laboratories.

Prospective study comparing the outcome of a population-specific adjusted calcium equation to ionized calcium.

BACKGROUND: Calcium circulates bound to albumin and changes in albumin concentration will therefore affect total calcium measurements. In order to mitigate this, correction factors are frequently used. The most widely used correction equation was described by Payne and colleagues in 1973. This equation was derived from well-defined hospitalized patients' data. Current clinical practice is consistent with the general application of the adjusted calcium equation irrespective of clinical setting. This study aims to assess the validity of this approach by the derivation of a community care-specific adjusted calcium equation ('community equation') and the comparison of its performance to a hospitalized patient equation and ionized calcium. METHOD: Retrospective data were collected according to Payne's criteria from an inpatient and community care setting. Data were used to derive the two equations: the in-patient equation and community equation. The outcome of these equations was compared with ionized calcium obtained from 123 healthy participants. RESULTS: The community equation correctly identified the calcium status of 92% of the 123 healthy participants, while the inpatient equation identified 46% only. Regression analysis against ionized calcium showed a higher R2 for the community equation than for the inpatient equation. Furthermore, we have shown that mean albumin and calcium concentrations are significantly different between these two populations. CONCLUSION: In this study, we found that the diagnostic accuracy of the adjusted calcium equation in ambulant patients was improved by the derivation of a population-specific equation for the community care setting.

Impaired Langerhans cell migration in psoriasis is due to an altered keratinocyte phenotype induced by interleukin-17.

BACKGROUND: Psoriasis is a common skin condition driven by increased expression of interleukin (IL)-17. Langerhans cells (LCs) are epidermal dendritic cells that regulate cutaneous immune responses. Within the uninvolved skin of patients with psoriasis, LCs display impaired migration from the epidermis. OBJECTIVES: To investigate the role of keratinocytes (KCs) in the regulation of LC function and the response of KCs to IL-17. METHODS: KCs were cultured from the uninvolved skin of patients with psoriasis and healthy individuals with or without IL-17 treatment and the conditioned medium examined for its ability to alter LC function in an ex vivo human skin explant model. Furthermore, we examined the effect of IL-17 on LC mobilization in psoriasis by neutralizing IL-17 in the same skin explant model. RESULTS: Conditioned medium from psoriasis KCs inhibited LC migration in healthy skin. Moreover, conditioned medium from healthy KCs treated with IL-17 also inhibited healthy LC migration. Finally, neutralizing IL-17 in psoriasis skin resulted in enhanced LC migration. CONCLUSIONS: Collectively, these data suggest that an altered KC secretome, driven by increased expression of IL-17, is responsible for impaired LC migration in the uninvolved skin of patients with psoriasis.

Cutaneous immunopathology of long-standing complex regional pain syndrome.

BACKGROUND: Both increased mast cells numbers and raised immune mediator concentrations indicate immune activation in the affected skin of patients with early complex regional pain syndrome (CRPS), but little is known about regional immune cell involvement in late-stage CRPS. The aim of the current study was to determine skin immune cell populations in long-standing CRPS. METHODS: Using 6-mm skin punch biopsies from CRPS-affected and non-affected tissues, and a combination of chemical and immunofluorescence staining, we examined the density and function of key cell populations including mast cells, epidermal Langerhans cells (LCs) and tissue resident T-cells. RESULTS: We found no significant differences in either overall immune cell infiltrates, or mast cell density between CRPS-affected and non-affected sub-epidermal tissue sections, contrasting recent findings in early CRPS by other groups. However, CD1a(+) LC densities in the epidermal layer were significantly decreased in affected compared to non-affected CRPS limbs (p < 0.01). T-cell clones isolated from CRPS-affected sub-epidermal tissues displayed a trend towards increased IL-13 production in ELISPOT assays when compared to T-cells isolated from non-affected areas, suggesting a Th2 bias. CONCLUSIONS: Immune cell abnormalities are maintained in late-stage CRPS disease as manifest by changes in epidermal LC density and tissue resident T-cell phenotype.

Guttate psoriasis is associated with an intermediate phenotype of impaired Langerhans cell migration.

BACKGROUND: An episode of guttate psoriasis can be an isolated event, can recur as guttate episodes, or develop into chronic plaque psoriasis (CPP). A previous study revealed that early-onset (before age 40 years) CPP is associated with inhibition of epidermal Langerhans cell (LC) migration. OBJECTIVES: To determine whether guttate psoriasis is also associated with abnormal LC mobilization. METHODS: Three groups of patients were recruited: current guttate episode (n = 5); guttate psoriasis progressed to CPP (n = 6); and resolved guttate psoriasis (n = 2). Biopsies were taken from uninvolved skin and LC migration was measured ex vivo using an epidermal explant model. RESULTS: Patients with a current episode of guttate psoriasis displayed epidermal LC migration, although the extent was significantly lower than in skin from healthy controls (P < 0·05). In contrast, in those patients in whom guttate psoriasis developed into CPP there was no mobilization of LC. Finally, in patients in whom guttate psoriasis had resolved, LC migration was normal. CONCLUSIONS: We have shown that guttate psoriasis is associated with an abnormality of LC mobilization, but a less marked inhibition compared with that seen in CPP. In resolved guttate psoriasis LC function returns to normal. These data provide further evidence that the pathogenesis of psoriasis is characterized by significant changes in epidermal LC function.

The hapten-atopy hypothesis III: the potential role of airborne chemicals.

One explanation for the large increase in the prevalence of atopic disease in developed countries during the last 50 years is the 'hygiene hypothesis'. This proposes that a reduced exposure to pathogenic microorganisms at a key period(s) during development results in the maintenance or acquisition of an atopic phenotype. Alternatively, or additionally, we have postulated that increased exposure to chemicals generally, and to irritant/haptenic chemicals in particular, during critical windows of maternal pregnancy/early life have also contributed to changes in the prevalence of atopic disease. Having previously reviewed the potential roles of oral and cutaneous exposure to chemicals on the subsequent diagnosis of atopic disease, we here consider possible evidence of a role for exposure to airborne chemicals as a contributory factor in acquired susceptibility to atopic allergy. After controlling for known confounders, five specific maternal occupations during pregnancy have been implicated as being associated with subsequent atopic disease in the offspring. Each of these occupations is characterized by high and persistent exposure to airborne chemicals. High-level exposure to volatile organic compounds in the domestic environment, either during pregnancy or in early life, is also associated with development of childhood atopic disease. Similarly, sustained exposure to airborne chlorinated chemicals from swimming pools during childhood has been associated with the development of atopic allergy. A possible immunological basis for these associations is that exposure to certain airborne chemicals, even at low levels, can result in the delivery of 'danger' signals that, in turn, bias the immune response towards the selective induction or maintenance of preferential T helper 2-type immune responses consistent with the acquisition of allergic sensitization.

Why does allergic contact dermatitis exist?

The skin immune system's propensity to produce allergic contact dermatitis (ACD) to harmless chemicals, while otherwise being an efficient defence system, represents a dermatological paradox. We postulate that a major role in signalling in ACD is played by Toll-like receptor (TLR)2 and TLR4, and arises from their activation by extracellular danger-associated molecular patterns (DAMPs). Ligand activation of TLR4/2 results in the expression of interleukins (ILs) IL-1ß, IL-6, IL-12, IL-18 and IL-23, tumour necrosis factor-α and interferon-α. These cytokines promote acquisition of sensitization, and facilitate elicitation of contact allergy via multiple mechanisms, including the recruitment of CD4+ Th1 and Th17 cells. As Th1 cells secrete large amounts of DAMPs, a DAMP immune circuit (positive-feedback loop) is created. This is an important driver of skin sensitization and skin inflammation. Pathogenic extracellular bacteria, but not commensal bacteria, produce pathogen-associated molecular pattern molecules, which stimulate the expression of Th1- and Th17-promoting cytokines via TLR2 and TLR4. This also induces an immune circuit. The ability of the skin immune system to activate host defence mechanisms and to distinguish between pathogenic bacteria and commensals provides an explanation for why skin sensitization and ACD develop, as they are processes that rely on the same biological pathways. These pathways may also shed light on the pathogenesis of chronic pustular inflammatory dermatoses (e.g. acne vulgaris). The existence of safety signals from commensal bacteria, which prevent initiation of these pathways, may provide opportunities for novel therapeutic approaches to the treatment of inflammatory skin diseases.

Reactivity of chemical respiratory allergens in the Peroxidase Peptide Reactivity Assay.

Sensitizing chemicals are commonly associated primarily with either skin or respiratory sensitization. In the Direct Peptide Reactivity Assay (DPRA), when compared with skin sensitizers, respiratory allergens have been demonstrated to selectively react with lysine rather than cysteine. The Peroxidase Peptide Reactivity Assay (PPRA) has been developed as a refinement to the DPRA. The PPRA incorporates dose-response analyses, mass spectroscopy for peptide detection and a horseradish peroxidase-hydrogen peroxide enzymatic system, increasing the potential to identify pro-haptens. In the investigations reported here, the PPRA was evaluated to determine whether it provides advantages for the identification of respiratory allergens. Twenty respiratory sensitizers, including five predicted to be pre-/pro-haptens were evaluated. The PPRA performed similarly to the DPRA with respect to identifying inherently reactive respiratory sensitizers. However, three respiratory sensitizers predicted to be pre-/pro-haptens (chlorhexidine, ethylenediamine and piperazine) were non-reactive and the general selectivity of the respiratory allergens for lysine was lost in the PPRA. Overall, the data indicate that the PPRA does not provide an advantage over the DPRA for discriminating allergens as either contact or respiratory sensitizers. Nevertheless, the PPRA provides a number of refinements to the DPRA that allow for an enhanced characterization of reactivity for both classes of chemical allergens.

Inter-relationships between different classes of chemical allergens.

Although allergic sensitization of the respiratory tract induced by chemicals is not as common as skin sensitization, it is nevertheless an important occupational health issue. Respiratory allergy to chemicals, characterized typically by rhinitis and asthma, is associated with considerable morbidity and with related socioeconomic costs. Several experimental approaches have been proposed for the prospective identification of chemical respiratory allergens, but none of these has yet been validated formally. In the absence of a widely accepted method for respiratory allergen identification, it is appropriate and relevant to explore their relationship with skin-sensitizing chemicals. A series of chemicals known to cause immune-mediated respiratory allergy in humans has been examined. The majority of the respiratory allergens tested were found to elicit positive responses in one or more standard tests used for the identification of skin-sensitizing potential (guinea pig maximization test, the Buehler test and/or the local lymph node assay). We suggest that this observation might form the basis of a potentially useful paradigm for initial characterization of the respiratory-sensitizing potential of chemicals. Specifically, chemicals that fail to elicit positive responses in accepted skin-sensitization test methods might also be regarded as lacking the inherent potential to cause allergic sensitization of the respiratory tract.

No impairment of monocyte-derived Langerhans cell phenotype or function in early-onset psoriasis.

BACKGROUND: Migration of epidermal Langerhans cells (LCs) in response to the cytokines interleukin (IL)-1ß and tumour necrosis factor (TNF)-α is impaired in uninvolved skin of patients with early-onset psoriasis. AIM: To investigate whether this impairment is a reflection of a systemic defect in dendritic cells (DCs), using an established model of monocyte-derived LC-like cells (mLCs). METHODS: CD14+ monocytes isolated from both patients with psoriasis and healthy control volunteers were cultured in a cytokine cocktail for 5 days to promote their differentiation into mLCs, then stimulated for 24 h with TNF-α, IL-1ß (both 100 ng/mL) or medium alone. Cellular surface protein expression was quantified by flow cytometry, and the ability of cells to migrate to media supplemented with C-C motif ligand (CCL)19 was assessed using a Transwell migration assay. The cytokine and chemokine content of supernatants was analysed by cytokine array. RESULTS: CD14+ cells acquired an LC-like phenotype with high expression of CD1a and major histocompatibility complex (MHC) class II. There were no differences in the expression of activation markers or in the secretion of cytokines by mLCs isolated from patients with psoriasis and those isolated from healthy controls. Moreover, mLCs isolated from both groups displayed comparable ability to migrate in vitro. CONCLUSIONS: These data suggest that the failure of LCs to migrate in response to stimulation in patients with psoriasis is not attributable to a systemic defect in DC function, but is rather a reflection of local changes in the epidermal microenvironment.

The effect of ageing on phenotype and function of monocyte-derived Langerhans cells.

BACKGROUND: With increasing age the immune system shows functional decline. In the skin this is associated with an increased incidence of epidermal malignancies and infections. Epidermal Langerhans cells (LCs) act as sentinels of the immune system, recognizing, processing and presenting antigen and inducing T-cell responses. Previous investigations have demonstrated a reduction in the number of epidermal LCs in elderly subjects. Moreover, the ability of LCs to migrate in response to tumour necrosis factor (TNF)-α, but not interleukin (IL)-1ß, is significantly impaired in the elderly. OBJECTIVES: To characterize further the changes in LC function that are associated with increasing chronological age, we have evaluated age-related changes in the response of monocyte-derived LCs (mLCs) to IL-1ß and TNF-α. METHODS: The phenotype and function of mLCs were compared in six young (≤ 30 years) and six aged (≥ 70 years) healthy individuals using a combination of flow cytometry, cytokine and chemokine array, and a Transwell migration assay. RESULTS: Monocytes from aged individuals were able to differentiate into LCs. There were no significant differences in expression of activation markers, or in baseline or inducible cytokine secretion, by mLCs derived from aged or young subjects. Furthermore, migration in response to a chemokine ligand, CCL19, was equivalent in both age groups. CONCLUSIONS: These data demonstrate that changes in LC function in the elderly are not associated with changes in systemic dendritic cell phenotype and function. Conditioning of LCs in situ by the epidermal microenvironment is likely to be more important.

The Hapten-Atopy hypothesis II: the 'cutaneous hapten paradox'.

One explanation for the striking increase in atopic disease in developed countries over the last 50 years has been the 'Hygiene Hypothesis'; a reduced exposure to pathogenic microorganisms. We have postulated previously that oral and cutaneous exposure to chemicals generally and to haptens in particular, may have also contributed to the increased prevalence of atopic disease; the 'Hapten-Atopy Hypothesis'. The purpose here is to extend further that hypothesis by consideration of the impact interplay between the innate and adaptive immune systems may have on the development of atopic allergy. It is clear that experimental cutaneous exposure to hapten can generate immune responses of different types with regard to T-helper (Th) cell phenotype. Allergic contact dermatitis is frequently associated with a selective Th1 (and Tc1)-driven inflammation, whereas atopic dermatitis is characterized by preferential Th2 cell responses. We postulate here that initial innate immune responses to chemical haptens result in the promotion of Th1 cell responses secondary to stimulation of Toll-like receptor. However, we argue also that under conditions where there is prolonged skin exposure to hapten there will be a shift of Th cell phenotype to selective Th2-type responses. The significance of such interactions is the possibility that repeated low-level skin exposure to certain types of hapten may result in the creation of an immunological environment in which the development of Th2 immune responses to third party antigens is favoured. The hypothesis is advanced that the nature and conditions of skin exposure to common haptens may impact on the quality of cutaneous immune responses such that in some circumstances the development atopic disease is favoured.

Animal models of protein allergenicity: potential benefits, pitfalls and challenges.

Food allergy is an important health issue. With an increasing interest in novel foods derived from transgenic crop plants, there is a growing need for the development of approaches suitable for the characterization of the allergenic potential of proteins. There are methods available currently (such as homology searches and serological testing) that are very effective at identifying proteins that are likely to cross-react with known allergens. However, animal models may play a role in the identification of truly novel proteins, such as bacterial or fungal proteins, that have not been experienced previously in the diet. We consider here the potential benefits, pitfalls and challenges of the selection of various animal models, including the mouse, the rat, the dog and the neonatal swine. The advantages and disadvantages of various experimental end-points are discussed, including the measurement of specific IgE by ELISA, Western blotting or functional tests such as the passive cutaneous anaphylaxis assay, and the assessment of challenge-induced clinical symptoms in previously sensitized animals. The experimental variables of route of exposure to test proteins and the incorporation of adjuvant to increase the sensitivity of the responses are considered also. It is important to emphasize that currently none of these approaches has been validated for the purposes of hazard identification in the context of a safety assessment. However, the available evidence suggests that the judicious use of an accurate and robust animal model could provide important additional data that would contribute significantly to the assessment of the potential allergenicity of novel proteins.

Inter-laboratory comparisons of assessment of the allergenic potential of proteins in mice.

Assessment of the potential allergenicity of novel proteins, including those expressed in genetically modified plants, is an important issue. In previous studies, we have shown that the IgE measurement induced by systemic exposure of BALB/c mice to a range of proteins correlates broadly with what is known of their allergenic potential in humans. The approach used a homologous passive cutaneous anaphylaxis (PCA) assay that reflects IgE-dependent biological activity and is of sufficient sensitivity to detect IgE production in the absence of adjuvant. In previous studies, the immunization phase was conducted independently in two separate facilities, and the subsequent analytical work (PCA) conducted in a single facility. The purpose here was to further evaluate the transferability of this approach. To this end, BALB/c mice were exposed to a range of doses of peanut agglutinin or ovalbumin, allergenic proteins of peanut and hen's egg, respectively, in two independent laboratories. Serial doubling dilutions of serum pooled for each treatment group were analyzed for specific IgE. At higher doses of allergen very similar, or identical, IgE titers were achieved in both laboratories, although at lower doses, responses were somewhat more variable. These data demonstrate that, although technically demanding, the measurement of protein allergen-induced IgE antibody production in mice using PCA is relatively robust and is transferable and reproducible between laboratories. This approach may provide a useful tool for the safety assessment of novel proteins and suggests that continued evaluation of the approach with a wider range of protein allergens and non-sensitising proteins is justified.

An evaluation of selected global (Q)SARs/expert systems for the prediction of skin sensitisation potential.

Skin sensitisation potential is an endpoint that needs to be assessed within the framework of existing and forthcoming legislation. At present, skin sensitisation hazard is normally identified using in vivo test methods, the favoured approach being the local lymph node assay (LLNA). This method can also provide a measure of relative skin sensitising potency which is essential for assessing and managing human health risks. One potential alternative approach to skin sensitisation hazard identification is the use of (Quantitative) structure activity relationships ((Q)SARs) coupled with appropriate documentation and performance characteristics. This represents a major challenge. Current thinking is that (Q)SARs might best be employed as part of a battery of approaches that collectively provide information on skin sensitisation hazard. A number of (Q)SARs and expert systems have been developed and are described in the literature. Here we focus on three models (TOPKAT, Derek for Windows and TOPS-MODE), and evaluate their performance against a recently published dataset of 211 chemicals. The current strengths and limitations of one of these models is highlighted, together with modifications that could be made to improve its performance. Of the models/expert systems evaluated, none performed sufficiently well to act as a standalone tool for hazard identification.