BSB15 – ESR in the 2000 era

C. Franzini, R. Mozzi

PRESENTATION

The foreword by Carlo Franzini to this interesting book reminds me of a similar situation I experienced many years ago (in the early '80s) when, based on some articles published in the literature, above all by British authors, I was firmly convinced of the opportunity to replace the erythrocyte sedimentation rate (ESR) test, being an empirical measurement, with the evaluation of plasma viscosity which presented undoubted advantages for standardization purposes. This strong belief has then been weakened by a series of works, extensively reported in this book, which documented the substantial equivalence, with a few exceptions, of both parameters from a clinical utility perspective.

As exhaustively illustrated by the Authors, the ESR is a non-specific indicator of disease and this non-specificity is partly attributable to the numerous factors involved in the determination of its value. In the era of molecular medicine, this might appear as a deadly sin that should condemn the ESR test to extinction. However, just the fact that the ESR depends on several factors makes it an effective, though non-specific, "alarm", and in some cases a useful prognostic factor, still much appreciated by the Clinicians in spite of the current severe scrutiny of the "evidence-based medicine".

This book reflects the great experience and well-known methodological accuracy of Carlo Franzini and his Team. The work contains not only an exhaustive and critical review of the literature, but also personal experience providing a significant contribution to the chapter dedicated to the analytical methodology that represents, in my opinion, one of the most interesting sections of the book. The work offers an easy and enjoyable reading enriched by some witty and very pleasant remarks coming from Carlo Franzini's rucksack of. At the end of reading, I am convinced that both authors have perfectly succeeded in their intent to provide scientific and objective grounds for the maintenance of the ESR test in the biochemical clinical practice.

Finally, I wish to make a personal comment: I am glad that Carlo Franzini has happily overcome his conflicting relationship with the ESR with obvious advantages for his driving as well; now also the winding paths in Val Badia along which we often walk together will certainly be smoother.

Giampaolo MerliniPavia, march 2002

FOREWORD

Westergren with his work published in 1924 is the classical, so-to-say mandatory, reference to which the "clinical" birth of the Erythrocyte Sedimentation Rate (ESR) is attributed. However, much earlier - as herein documented - in the years 1894-1897, a Polish doctor (Edmund Faustyn Biernacki, 1866-1911) had already provided an important contribution to the topic publishing more than a dozen papers in the Polish or English language. It is therefore absolutely right to state that our ESR test is over hundred years old! This consideration then leads to a quite obvious question: should we still keep it alive?

If on the one hand this modest work represents our attempts to provide scientific and objective grounds to answer this question, on the other I also wish to briefly report herein my experience and my point of view. For such purpose, I have to start explaining that I have been living for years (precisely since 1968) quite far from my place of work, which means 20-40 minute drive every morning, depending on the traffic, to my office (I have changed several places over the years), etc. Those moments are for me the time for thinking , or better, for planning. As I travel, I plan my day: what I will do, what I won't do, the new initiatives, the new technologies and, why not, the review of analytical tests lists, the elimination of obsolete items, and so on. Even if years ago I had not actually realized that our good old ESR test was approaching its hundredth anniversary, and since the resources globally absorbed by this test in the process of collection, execution and reporting are after all no big thing, what especially bothered me was the empirical nature of the measurement. And then, in the midst of automation, pre-analytical phase, information technology, capillary electrophoresis, molecular biology, mass spectrometry, and so on, how could it be that the ESR test was still kept alive?

Going back to my morning drive, while getting closer to my destination, I ended up believing that it was time to dismiss the ESR test: "it's enough" - I said to myself - "today I'll send a circular letter to notify the end of the ESR test, within one month time". Sometimes I even used to emphasize my decision by firmly holding the steer and suddenly turning with excessive determination as if to underline the commitment I had taken with myself. Once inside the Hospital I stopped making that somewhat ridiculous but compulsory operation of "clocking-in" (that was in fact an electronic recording), a rather inconvenient duty which had nonetheless at least one positive aspect: it was a nice occasion to "socialize" with my Colleagues Clinicians. We met there, we "clocked-in", we spoke about the weather (very British style!), we talked bad about the "Administration", and then go, each of us with his day, his duties, his troubles, his enjoyable moments of reward. Well, if over the last minutes drive (vigorous sudden turns) I had essentially already taken the drastic decision to cancel out the ESR of the available tests, that was the right time to check this with my colleagues. I have to admit that I have never been looked at so pitifully as on those occasions when I tried to explain to my Colleagues Clinicians this so intelligent (so it seemed to me!) project of mine. The moral: take everything from me but not my ESR test! Not to speak of the ill-hidden pity on the part of my co-workers when I illustrated to them my brilliant intellectual position on the matter!

I must also say that on more than one previous occasion, when other laboratory tests deemed obsolete and/or excessively empirical had been abandoned, there has never been such a strong opposition. For instance, some acid glycoproteins (so-called "mucoproteins") assays, which were even held in great consideration and frequently performed as non-specific measure of inflammatory states or neoplasm, had been stopped without complaints when their analytical specificity had been questioned to be replaced with alfa-1-acid glycoprotein immunoassay. Equally, no complaint had been raised when before that it was decided to definitively abandon the "colloidal serum lability" (also named "liver function testing"), in an epoch when the proper functioning of the liver could be better investigated, for instance, with the measure of enzyme activities in the serum. Apparently in the case of the ESR test, the physicians had the feeling - that proved to be absolutely right - that the possible cancellation of this test could leave an empty space in daily laboratory diagnostics, not sufficiently covered by anything effectively adequate and equivalent, or even better. Also the proposal advocated by some to replace the ESR measurement with the C-reactive protein was not satisfactory for reasons further discussed in the following.

However, to resume the account of facts which involved me, I had to face a strong "veto", though kindly expressed, to the abolition of the ESR test.

I must admit that in the first place I found it quite difficult to accept that I had to swallow a bitter pill, as I considered it. In other words, I could hardly understand the advantages of an empirical measurement of a little reproducible phenomenon, whose cause I did not exactly know, compared to the accurate and precise measure of a defined molecular species, such as, for instance, the C-reactive protein. During that period, some friends indicated to me two papers written by "Masters" of laboratory haematology and clinical biochemistry of serum proteins. I am referring to J Stuart and SM Lewis, "Monitoring the acute phase response. Alternative tests to measuring erythrocyte sedimentation rate.", Brit J Med 1988, 297:1143-4 and to J Stuart and JT Whicher, "Tests for detecting and monitoring the acute phase response.", Arch Dis Child 1988;63:117-7. In these two works, now dating back to twelve years ago but still valuable in their conclusions, I found so clear-cut answers to my questions that some years later I decided to summarize their contents in a rather detailed manner (C. Franzini, "La misura della velocità di eritrosedimentazione (ESR) ha ancora un ruolo diagnostico?" - Does the measurement of the erythrocyte sedimentation rate still have arole in diagnostics?, Biochim Clin 1993;17:57-60.).

Now I wish to thank Diesse S.p.A. for the possibility offered to me and my assistant Roberta Mozzi to publish this book, through which I have reviewed the basic concepts of the ESR, and finally understood the reasons why my Colleagues Clinicians were against the idea of doing without this laboratory test. Now, I face my morning half-hour drive with more confidence and turn more smoothly, as it should be!

Carlo Franzini
Milano, june 2002

TABLE OF CONTENTS

Presentation
Foreword
Introduction
     Historical background
     Physical-biochemical determinants of erythrocyte sedimentation
     Notes of metrology: quantities and units
Analytical methodology
     Automation
     Standardization
     Quality control
Clinical significance of the ESR measurement
     The ESR measurement in different pathologies
     ESR and other inflammatory indexes
     Drug interference
     ESR on the web
Conclusive Remarks
Acknowledgements

H O M E P A G E  |  C O N V E G N I  |    E D I T O R I A I N T ER N E T  |  S E R V I Z I



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