June 2009
Feature Story

Anne Paxton

In recent years, the prevalence of metabolic syndrome has soared alarmingly in the U.S. With 47 million cases, there’s no doubt this combination of disorders is a troubling problem. But diagnosing it through laboratory testing has proved to be anything but straight­forward, says Ross Molinaro, MT (ASCP), PhD, DABCC, FACB, med­ical director of the Core Laboratories at Emory University Hospital Midtown in Atlanta.

“There’s a lot of confusion surrounding the criteria for metabolic syndrome. It’s a myriad of different diseases all wrapped up in one. Dyslipidemia, hyperinsulinemia, and hyperglycemia are the clinical laboratory testing criteria that are used. Together, these conditions put you at significant risk for other health-related issues.” Currently, it’s tricky to diagnose the syndrome using the criteria of some professional organizations, he says, because of the particular lab tests involved.

Dr. Molinaro’s session, “Metabolic Syndrome: An Update on Prevalence, Criteria, and Laboratory Testing,” is part of the wide-ranging agenda of AACC’s Annual Meeting and Clinical Lab Expo to be held in Chicago July 19 to 23.

With a full program geared to education, networking, and exposition, AACC leaders say the annual meeting will feature issues and innovations in pharmacogenomics, autoimmune disease, toxicology, molecular diagnostics, cancer, training of clinical lab personnel, microarray technologies, cardiac and vascular disease, interpreting lab data, and more. Attendees will learn how technological advances, new clinical approaches, and economics are shifting the roles of clinical laboratory directors and scientists. A special one-day “AACC University” with a program of short courses and interactive workshops has been arranged for those unable to attend the full convention.

And AACC’s Clinical Lab Expo, the largest in the world, will again host 600 exhibitors with about 1,800 booths. “It’s an opportunity for large and small diagnostic companies to educate clinicians and laboratory purchasing agents about their latest product offerings,” says Scott May, AACC vice president for programs and policy.

The need for standardization in many lab-related areas is one of the running themes of the AACC meeting agenda. In the case of metabolic syndrome, standards for diagnosis differ. Most everyone in the U.S. follows the diagnosis criteria established by the National Cholesterol Education Program, but the rest of the world follows those of the World Health Organization and the International Diabetes Federation. Perhaps more important, there is a lack of standardization of some of the key laboratory tests for the syndrome, Dr. Molinaro points out.

“For example, the WHO Diabetes Group criteria utilize lipid testing, glucose testing, and insulin testing for diagnosing metabolic syndrome. It’s well known that insulin assays are not standardized, though standardization efforts are underway. So, for example, an insulin level of 3 at one hospital laboratory might be 13 for the same sample at another laboratory.” Labs can use quartiles or reference ranges within their own population to formulate cutoffs for hyperinsulinemia called for by the WHO diagnosis of metabolic syndrome, he says.

The lack of standard pediatric reference ranges will be addressed in another session of the AACC meeting by Khosrow Adeli, PhD, FCACB, DABCC, head of clinical biochemistry at Toronto’s Hospital for Sick Children. “Surprisingly, there is not much valid data available for normal values of pediatric age groups from birth to 18 years,” Dr. Adeli says. “There is a real need internationally, not just in Canada and the U.S., for this type of database.”

Most clinicians fall back on adult ranges, which can be very different from children’s. “Or they rely on values that were obtained on older instruments from the ‘80s and ‘90s,” he adds. “The instrumentation and technologies have changed since then, so the numbers are really not applicable, and in many cases they can result in misdiagnoses.”

In his talk, “Closing the Gaps in Pediatric Reference Intervals: The CALIPER,” Dr. Adeli will describe the project started by a group of Canadian biochemists to address the problem. “We are currently in the process of collecting samples from children in communities. We’re not interested in hospitalized patients but in healthy children in the community. Once the blood samples have been collected, then we’ll perform a large number of tests on various instruments, analyze the data using guidelines from the Clinical and Laboratory Standards Institute, and publish this database.”

In the U.S., a huge study, National Health Status, is now following children from birth to 18 years, and will eventually result in significant information, but because it is prospective, the data won’t be available for some time. The CALIPER project will have data within the coming year, Dr. Adeli says. Its initial focus was on various vitamin and lipid levels. “Recently we’ve been focusing on some of the hormones and some of the markers of cardiovascular disease and diabetes.”

The philosophy of “servant leadership” is the subject of an interactive management workshop, “Leading with Authority Rather than Power.” “It’s the notion of building your ability to lead based on your actions, your character, and your behavior. You‘re not going to build authority with people unless they respect you and want to willingly follow, so you must first ‘serve’ in order to lead,” says Chérie Petersen, teaching specialist for the Institute for Learning, ARUP Laboratories, Salt Lake City.

Companies or institutions often encourage a management model that relies too heavily on positional power. “As a manager, you have the power to mandate, to direct people, to give responsibilities or take away opportunities. But lead­ership occurs when people willingly do what’s required based on who you are.” And leaders are not necessarily managers; they can be informal leaders who sway people within a department to meet organizational goals. Alternatively, she says, they can use their influence to demolish projects from the start.

“How do you get people to do more than just punch in and do their time, to do inspired work at their highest level, to be excited, committed, and engaged?” Petersen asks. To accomplish this goal, managers as well as team members who wish to lead must make people feel they’re contributing to something worthwhile.

As part of the interactive format, participants in this session will brainstorm about the qualities they’ve seen in leaders they admire, what objectives they have as leaders, and what they want for the people in their employ. “I want them to feel empowered, to imagine an environment where people have ownership, have responsibilities for growth, and can do new and different things,” Petersen says.

The subject of “Serum vs. Plasma: Which Specimen Should You Use?” has been a popular one on the AACC agenda for the past five years, says Jeffrey Chance, PhD, senior clinical scientist with BD Diagnostics-Preanalytical Systems. “It’s an interactive format, with a free-flowing discussion and exchange of information.”

A key advantage of using plasma instead of serum is turnaround time. “With serum tubes, you have a clot activator in the tube and you allow the specimen to clot for a certain period of time; if you don’t do that, you risk having fibrin forming after the sample is centrifuged,” Dr. Chance explains. “Many laboratories are getting tubes with less than the time required for it to clot. They’re putting them through their systems and ending up with fibrin in their serum.”

“With plasma samples, there isn’t the same problem. Instead of a clot activator, it’s an anticoagulant in the tube such as heparin, and you have a plasma sample and it can be centrifuged right away.”

While many laboratories have made this conversion, the majority of testing is still performed with serum, Dr. Chance says. “But there’s increasing interest in plasma. Some labs may use it in certain settings but not across the board; they’ll still have serum in other settings.”

Usually there is a mix of people at this brown-bag session. “Some have already switched to plasma, while some are thinking about it, so they can trade thoughts on their experiences, and on such issues as how much work is involved in doing validation.”

The plenaries, too, are always popular, and “AACC is excited to have an outstanding group of speakers this year,” says AACC’s May. The speaker for the opening plenary session, Jerome E. Groopman, MD, is chief of medicine at Beth Israel Deaconess Medical Center in Boston. His most recent laboratory research involves understanding how blood and vascular cells grow, communicate, and migrate. Dr. Groopman will address the topic of his book, How Doctors Think, which explores how physicians arrive at the correct diagnosis and treatment—and why they may not. The next day, Oliver Sacks, MD, author of Awakenings and other bestsellers, will explore, not in a plenary but in an Olympus-supported presentation, the complexities of the human mind as he discusses how individual patients have survived and adapted to various neurological conditions.

Another plenary session will be devoted to “Management of Drug-Drug Interactions,” with the speaker, Neil Sandson, MD, of Perry Point VA Medical Center in Maryland, discussing how to produce the desired serum concentrations to avoid toxicity and sub-therapeutic dosing, May says.

Full details of the AACC annual meeting are at www.aacc.org/events/2009am/conference/pages/default.aspx.