clin icsh recommendations for measurement erythrocyte ... · the term erythrocyte sedimentation...

9 Clin Pathol 1993;46:198-203

ICSH recommendations for measurement oferythrocyte sedimentation rate

International Council for Standardization in Haematology (Expert Panel on BloodRheology)

IntroductionTests of erythrocyte sedimentation provide ameasure of the acute phase response toinflammatory disease' and reflect the sedi-mentation of red cells in autologous plasma.The term erythrocyte sedimentation rate(ESR) is retained because of traditionalusage, although a single measurement after60 minutes is not a rate; in recording the ESRit is assumed that the reading is made at 60minutes unless a different time is specified.Sedimentation is accelerated by an increase inthe plasma concentration of acute phase pro-teins of large molecular size but sedimenta-tion is also accelerated by anaemia which mayor may not be part of inflammatory disease.The ESR may therefore reflect both thehyperproteinaemia and the anaemia ofinflammatory disease and differs from tests,such as plasma viscosity, which reflect onlythe protein component of the acute phaseresponse.The increased mobility of patients and the

benefits to laboratories of sharing their expe-rience has led to the need for measurementsbetween laboratories to be comparable. Thiscan be achieved by using a reference method.ICSH has defined this as an exactly describedtechnique which, in the opinion of an ExpertPanel, provides sufficiently accurate and pre-cise measurement for it to be used to assessthe validity of other such laboratory methods.The original ICSH reference method formeasuring the ESR2 was based on themethodology of Fahraeus3 and Westergren4using diluted blood (4 vols blood plus 1 volcitrate) in open ended glass tubing of 300mm in length, mounted vertically in a rack orstand. Modifications of these specifications,in particular the use of undiluted blood, arenow recommended as the basis of a newICSH reference method.

Recent developments, including biohazardawareness and difficulty in obtaining equip-ment to perform the reference method, haveprompted ICSH to introduce a standardisedmethod as an alternative to, and potentialreplacement for, the reference method.

For working (routine) methods, ICSHnow recommends specifications for selectedmethods. These are procedures whose reliabil-ity has been verified against the reference orstandardised method and which minimise thebiohazard risk of the test procedure.

ICSH reference methodIn 1988 ICSH proposed, for purposes ofintermethod comparability, an ESR per-

formed on undiluted blood samples of haema-tocrit of 0 35 or less under standardised con-ditions in a Westergren open ended glasspipette that meets ICSH specifications.'These undiluted blood samples are anticoag-ulated with EDTA (dilution less than 1%)but not diluted with citrate anticoagulant.This method will now be recognised by ICSHas its reference method. The referencemethod, and the standardised methoddescribed below, exist to allow users to pre-pare ESR reference material for verificationor quality control purposes in their own labo-ratories. The results from both methodsshould be expressed as ESR = (undiluted) xmm. For comparison with the traditionalmethod using diluted blood, a correction for-mula' can be applied: diluted blood ESR mm= (undiluted blood ESR m x 0 86) - 12.

ICSH standardised methodAIMThe ICSH standardised method should bedirectly comparable with and traceable to theICSH reference method and used as an alter-native to it for verification or quality control,or both, of working (routine) methods.

BLOOD SAMPLEBlood of haematocrit (or PCV) of 0 35 or lessshould be obtained by clean venepunctureover a maximum period of 30 seconds andwithout excessive venous stasis. Blood ofhigher haematocrit should not be usedbecause reproducibility of sedimentation maybe poor in narrow tubes. A manual or vacu-um extraction venepuncture technique can beused and the blood should be taken intoEDTA anticoagulant (dilution less than 1%)without further dilution in citrate. The ESRshould be set up within 4 hours of vene-puncture.

MIXING OF BLOOD SAMPLEMixing of blood with EDTA anticoagulant(1 5 mg/ml blood) is necessary at the time ofvenepuncture, but further mixing immediate-ly before the ESR test is set up is criticallyimportant for reproducibility. For standardtubes (10-12 mm x 75 mm containing 5 mlblood and with an air bubble comprising atieast 20% of the tube volume) there shouldbe a minimum of eight complete inversions(1800 x 2) with the air bubble travelling fromend to end of the tube. Mixing must notcause haemolysis. Non-standard tubes,particularly when narrower, may requiremore than eight inversions and the required

Members of Expert Panel:B S Bull (USA), M Caswell(UK), E Ernst (Austria),J M Jou (Spain), A Kallner(Sweden), J A Koepke(USA), SM Lewis (UK),G D 0 Lowe (UK),MW Rampling (UK),J Stuart (UK) Chairman.Correspondence to:Professor J Stuart,Department ofHaematology, The MedicalSchool, University ofBirmingham, BirminghamB15 2T7Accepted for publication26 August 1992

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ICSH recommendations for measurements ofESR

number should be determined. Mixingshould be continued until immediately beforethe ESR pipette is filled at the start of thetest.

SEDIMENTATION PIPETTE SPECIFICATIONSThe pipette (tubes) should be colourless, cir-cular, and of sufficient length to give a 200mm sedimentation scale. The scale may bemarked on the pipette or separately andshould comprise clearly marked lines at 1 mmintervals and be numbered from 200 at thebottom up to 0 at appropriate intervals. Ifseparate from the pipette, the scale must bepart of a pipette holding device that ensuresprecise and reproducible alignment of thepipette and scale. If reading of the pipette isoptico-electronic rather than visual, a markedscale is unnecessary.The bore of sedimentation pipettes for the

Westergren ESR has traditionally been 2-55mm + / - 0v 15 mm.5 ICSH now recommendsthat the pipette diameter should be not lessthan 2-55 mm (no upper limit is specified butthe volume of blood required should be min-imised). The bore should be constant (within5%) throughout its length and the interior ofthe pipette should be circular (differencebetween long and short axes not exceeding0 1 mm).The ESR pipette should be disposable.

Glass or plastic may be used but, if plastic,should not show adhesive properties towardsblood cells and should not release plasticisersthat affect blood or alter sedimentation. If amould release agent is used in the manufac-turing process, this must similarly not affectblood or alter sedimentation.The pipette should be filled with blood to a

height of at least 200 mm. Adjustment of theblood column or scale should be possible toallow correction for slight variation in thenominal volume and ensure an initial readingof zero. During the sedimentation period, andduring subsequent disposal, the system mustprevent blood spillage or aerosol generation.

PIPETTE HOLDING DEVICEThe pipette should be held vertical (con-firmed by a plumb line or equally effectivedevice), protected from direct sunlight,draughts and vibration, and kept at a con-stant temperature (+ / - 1 °C) within therange 18-25°C during the period of sedimen-tation.

EXPRESSING THE RESULTThis should be recorded as the sedimentationoccurring at 60 minutes from the beginningof the test and expressed as: ESR (undiluted)= x mm (as for reference method above).

COMPARABILITY BETWEEN ICSH STANDARDISEDAND ICSH REFERENCE METHODSThis procedure requires analysis of referencematerial (fresh human blood) on which theESR has been determined by the ICSH refer-ence method. The standardised methodshould be verified by comparison with the

ICSH reference method over a range of ESRvalues of 15-105 mm. In this comparison95% of the differences should be 5 mm orless, with the larger differences associatedwith higher ESR values.

ICSH selected methodsAIMICSH wishes to promote the use of ESRmethodology that minimises biohazard risk; itis especially important to avoid blood spillageor aerosol generation during the test proce-dure. The purpose of designating working(routine) methods as ICSH selected is pri-marily to specify criteria that will allow mean-ingful comparison of results betweenlaboratories. ICSH also considers that suchcriteria will encourage development of newmethods of low biohazard risk that give com-parable results with those of the ICSH refer-ence method. A manufacturer who wants aworking method to be recognised as ICSHselected should undertake a study of compa-rability with either the ICSH referencemethod or the ICSH standardised method. Asimilar study should be performed by anindependent expert. The studies should bedocumented and readily available for scrutinyon request to the manufacturer.

For verification or quality control of anICSH selected method in'routine use, com-parability checks against the ICSH standard-ised method are recommended.

BLOOD SAMPLEBlood should be obtained by clean venepunc-ture over a maximum period of 30 secondsand without excessive venous stasis. A manu-al or vacuum extraction venepuncture tech-nique can be used. The ESR test should beset up within 4 hours of venepuncture. Bloodsamples can be stored for more than 4 hoursat 4 °C, but any such longer period of storagemust be validated and the evidence beavailable from the manufacturer for scrutiny.If certain types of blood sample-from casesof hyperlipidaemia or hyperbilirubinaemia,for example-are unsuitable for testing, thisshould be stated.

For blood samples that are diluted atvenepuncture, 4 vols of blood may be takendirectly into 1 vol of sterile sodium citrateanticoagulant-diluent. Vacuum tubes andtubes containing liquid anticoagulant for thispurpose have a finite storage life whichshould be carefully defined by the manufac-turer. Storage conditions must also be clearlyspecified. Alternatively, the blood may betaken first into a primary anticoagulant(EDTA) that does not cause significant dilu-tion (<1%) of plasma protein, followed bydilution in sterile sodium citrate. For theabove purposes, the concentration of trisodi-um citrate dihydrate (Na,C6H507.2H20)should be within the range 0-10-0-136 mol/l.This solution should be discarded if itbecomes turbid; if kept in a reusable contain-er, particular care must be taken to remove alltraces of any detergent used for cleaning the

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ICSH Expert Panel on Blood Rheolog

container. If an alternative anticoagulant,diluent (such as saline), or dilution factor isused, comparability of the result with thatobtained using the ICSH standardised (orreference) method should be documentedand readily available from the manufacturerfor scrutiny.

MIXING OF BLOOD WITH ANTICOAGULANT-DILUENTImmediately before the ESR test is set up, theblood sample should be mixed as specified forthe standardised method-at least eight com-plete inversions (1800 x 2) for a 10-12 mmx 75 mm blood container and more inver-sions if the interior diameter of the containeris smaller. If the working method incorpo-rates an automatic mixing device, its effec-tiveness should be validated by themanufacturer.

SEDIMENTATION PIPETTE SPECIFICATIONSPipette (tube) dimensions are not specifiedfor ICSH selected methods but comparabilityof the test result with the ICSH standardised(or reference) method must be validatedusing the protocol described below. In theinterests of safety, it is preferable that thepipette be disposable but, if reused, specialattention must be paid to cleaning, withremoval of all contaminants and an appropri-ate verification check made thereafter. Thetube may be made of plastic or glass but, ifplastic, should not show adhesive propertiestowards blood cells and should not releaseplasticisers that affect blood or alt&r sedimen-tation. Comparability data with the ICSHstandardised (or reference) method should bereadily available from the manufacturer.

PIPETTE HOLDING DEVICEA rack or stand should be provided to holdthe sedimentation pipettes motionless. If notheld vertical, the angle of incline should bespecified and comparability of the result withthat of the ICSH standardised (or reference)method should be validated. The pipettesshould be protected from direct sunlight,draughts and vibration, and be maintained ata constant temperature (± 10C) within therange 18-25 °C for the duration of the test. Ifapplicable, adjustment of the blood columnto zero should be possible to correct for slightdeviation in the nominal volume and ensurean initial reading of zero.

RECORDING THE END POINTThe traditional Westergren method estab-lished that the end point should be read at 60minutes. However, some systems allow read-ings at other times, which currently rangefrom 20 to 120 minutes, or at multiple inter-mediate times (every 5 minutes, for example.The clinical usefulness of these alternativetimes is yet to be evaluated. At present, ICSHrecommends that measurement be made at60 minutes or normalised to 60 minutes.

EXPRESSION OF RESULTThe result should be expressed as: ESR = xmm (where 1 mm for diluted blood is equiva-lent to 1 mm for undiluted blood at 60 min-utes according to the ICSH reference orstandardised method; see reference methodfor correction formula for lack of dilution inreference/standardised methods). If an alter-native method of recording the end point isused and the result is expressed asWestergren equivalent units, this must beclearly stated. If the result is adjusted mathe-matically for initial height of the blood col-umn, haematocrit, ambient temperature, orduration of sedimentation, the method ofadjustment should be described. The ESRresult for the working method, whetherrequiring mathematical correction or not,should therefore be expressed so as to achievecomparability with the ICSH referencemethod.

VERIFICATIONVerification of any working (routine) ESRmethod using diluted blood should be per-formed against the ICSH standardisedmethod at a rate determined by the laborato-ry's standard operating procedure and espe-cially when a new batch of tubes or freshstock of citrate is used. Verification againstthe ICSH standardised method, which is per-formed on undiluted blood, will detect errorsin the volume or quality of the diluent and inthe adequacy of mixing the diluent withblood in the working method. The ICSHstandardised method can therefore also beused for quality control purposes.To obtain blood for the verification exer-

cise it may be convenient to select a patientEDTA sample of haematocrit of 0-35 or lessthat contains an adequate residue of blood,after all other tests are completed, and has anincreased ESR value (range 15-105 mm) asknown from testing or as judged by clinicaldetails or the extent of sedimentation afterthe sample has stood undisturbed for 30-60minutes. The EDTA blood in the tubeshould then be mixed by at least eight com-plete inversions. After filling the pipette of thestandardised method, another aliquot ofblood from the same, or a duplicate, EDTAsample should be analysed by the laboratory'sworking method after dilution (4 vols bloodplus 1 vol citrate).

If the blood sample for the working ESRmethod was taken by venepuncture directlyinto a ESR tube containing citrate, or if sucha dilution was performed in the laboratory,the blood sample for the ICSH standardisedESR should be taken from a separate EDTAsample without dilution. This sample is usu-ally available because a routine blood count isnormally requested in parallel with the ESR.This blood sample should again have an ESRvalue between 15-105 mm and a haematocritof 0-35 or less.

If a manufacturer wishes to demonstratecomparability of a new working method withthe ICSH standardised (or reference)

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ICSH recommendations for measurement ofESR

method, the verification exercise may be per-

formed using normal blood with added fib-rinogen to achieve an adequate range ofincreased ESR values (see protocol below).This verification should be followed by a sim-ilar exercise, in collaboration with an externalclinical laboratory, using patients' blood sam-

ples. The results for both exercises should bedocumented and readily available for scrutinyon request to the manufacturer.

Verification of a working method isachieved if 95% of the results obtained fallwithin the limits shown in the table.

REFERENCE VALUESReference values should be established locallyin accordance with the ICSH recommenda-tion on reference values67 and expressed as

for diluted blood (see selected methodabove). In view of the progressive rise in ESRwith age, separate values should be estab-lished for each decade of adult life in men

and women. Several other clinical variablesinfluence the ESR and may therefore affectphysiological reference values: haemoglobinconcentration, medication, menstrual cycle,pregnancy, and smoking.

MICROMETHODSMicromethods may be introduced for use inchildren or to reduce the draw volume foradult patients. Documented evidence of com-parability with the ICSH reference or stan-dardised method must be readily availablefrom the manufacturer.

Protocol for evaluation of working ESRmethods against the ICSH reference or

ICSH standardised methodThis protocol is based on ICSH recommen-

dations for type testing equipment and appa-

ratus used for haematological analysis,6 ICSHguidelines on selection of laboratory tests formonitoring the acute phase response,' ICSHrecommendations for measuring the ESR ofhuman blood,5 and this document.

In this protocol, the ESR equipment whichis the subject of the evaluation will be referredto as the "test system". The reference methodis that of ICSH' using Westergren type glasstubes without anticoagulant diluent. TheICSH standardised method is as described inthis document for undiluted blood.

PRELIMINARYThis is general information provided by themanufacturer and confirmed when the testsystem is installed in the evaluation laborato-ry. It should include the following:

1 Brand name and model, manufacturer,and distributor.

2 Suggested local price and cost of main-tenance contract

3 Terms of guarantee4 Overall dimensions and bench area

requirement5 Details of electrical supply and other

necessary services, computer and roboticinterface requirements, and requirement forwaste disposal

6 Instruction manual giving principles ofoperation, degree of automation, data presen-

ESR values (mm) for verification of comparability of working (routine) method with ICSH standardised method

Working Working WorkingStandardised Method Standardised Method Standardised MethodMethod* Limitst Method* Limitst Method* Limitst

15 3-13 45 18-37 75 40-6816 4-14 46 18-38 76 40-6917 4-15 47 19-38 77 41-7018 4-15 48 20-39 78 42-7119 5-16 49 20-40 79 43-7220 5-17 50 21-41 80 44-7321 6-17 51 22-42 81 45-7422 6-18 52 22-43 82 45-7623 6-19 53 23-44 83 46-7724 7-19 54 24-45 84 47-7825 7-20 55 24-46 85 48-7926 8-21 56 25-47 86 49-8027 8-21 57 26-48 87 50-8228 9-22 58 26-49 88 51-8329 9-23 59 27-50 89 52-8430 10-24 60 28-51 90 53-8531 10-25 61 29-52 91 53-8632 11-25 62 29-53 92 54-8833 11-26 63 30-54 93 55-8934 12-27 64 31-56 94 56-9035 12-28 65 32-57 95 57-9136 13-29 66 32-58 96 58-9337 13-30 67 33-59 97 59-9438 14-30 68 34-60 98 60-9539 14-31 69 35-61 99 61-9640 15-32 70 35-62 100 62-9841 15-33 71 36-63 101 63-9942 16-34 72 37-64 102 64-10043 17-35 73 38-65 103 65-10144 17-36 74 39-66 104 66-103

105 67-104

* Standardised method: EDTA anticoagulated but undiluted whole blood of haematourit of 0-35 or lesst Working method: 4 vols EDTA blood plus 1 vol citrate diluentThe values incorporate a correction for dilution of blood by citrate in the working method. Proposed working method valid if95% of results are within indicated limits.

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tation, method used for specimen mixing,volume of specimen, maintenance procedureand trouble shooting

7 Certificate of electrical conformity to arecognised standard (for example IEC10:10:1: 1990).

SAFETY ASSESSMENT1 Microbiological: to test for aerosol or dropletcontamination during normal operation, oneof the following two procedures, or an equiv-alent alternative, should be used:

(a) A series of tubes should be filled with asuspension of a marker organism (such asSerratia marcescens) and treated as blood spec-imens. Petri dishes containing nutrient agarare placed appropriately in the vicinity of thetest system which is allowed to operate in itsusual way. Petri dishes are then incubatedand examined for growth of the markerorganism.

(b) A few drops of a fluorescent chemicalmarker are added to blood samples which arethen handled in the usual way for the ESR.Sheets of white absorbent paper are placedover possible areas of contamination in thevicinity of the test system. These are thenexamined under ultraviolet light for evidenceof droplet contamination.

2 Mechanical: any potential hazard arisingfrom the design of the test system and fromany moving parts should be noted.

3 Waste disposal: any potential hazard(microbiological, chemical, or other) shouldbe assessed.

TECHNICAL ASSESSMENTBefore the evaluation is formally started, thestaff who will carry it out should have a pre-liminary period of training or familiarisation.This may include a pilot study.

1 Fresh human blood specimens are col-lected directly into the specified containerscontaining anticoagulant diluent, accordingto the manufacturer's instructions. Alterna-tively, blood can be collected into EDTA andsubsequently diluted according to the manu-facturer's instructions. Specimens shouldcover the range of results 15-105 mm withabout the same number of specimens in eachquartile. Blood for ESR tests should be storedat ambient temperature (18-250C) until test-ed and the tests should begin within 4 hoursof collection. If the test system does notincorporate an automatic mixing device, thespecimens should be mixed as specified forthe standardised method: at least eight com-plete inversions (1800 x 2) for a 10-12 mmx 75 mm blood container and more inver-sions if the interior diameter of the containeris smaller.

2 Precision should be based on replicatemeasurements (10 if possible) of a specimenfrom each quartile. The precision of theICSH standardised (or reference) methodshould similarly be determined for compara-tive purposes.

3 Comparability between the test systemand the ICSH standardised (or reference)method should be tested in parallel on at least

100 samples from patients with a wide varietyof diseases and with ESR results distributedevenly in the range 15-105 mm. Occasionalblood samples fail to give a clear plasma-ery-throcyte interface after sedimentation; if thisoccurs in either the test system or standard-ised (reference) method, the pair of valuesshould be eliminated from the data set.When blood specimens for the test system

are diluted (4 vols blood plus 1 vol citrate),the undiluted ESR values for the ICSH stan-dardised (or reference) method must be cor-rected for lack of dilution. The ICSH (1988)formula' can be used for this purpose but ver-ification of comparability of the test systemmay be determined with more accuracy overthe range (15-105 mm) of ESR values byusing the table which already incorporates acorrection for dilution. Validation is achievedif 95% of the test system results fall withinthe limits shown in the table. Use of the table,rather than the formula, is now recommend-ed.

Paired results should be plotted on lineargraph paper, with differences of the test sys-tem ESR from the ICSH standardised (or ref-erence) ESR plotted on the vertical axis andthe means of the two methods on the hori-zontal axis.8

4 Sensitivity of response to added fibrino-gen should be determined. A concentratedsolution of fibrinogen of about 20 g/l is madeby dissolving human fibrinogen (such as KabiPharmaceuticals, Sweden) in distilled water.This is dialysed overnight against phosphatebuffered saline (PBS; pH 7*4, normosmotic)to remove the high salt content. This is thestock fibrinogen solution whose fibrinogenconcentration should be measured. To eachof 5 aliquots of 5 ml normal blood is added 1ml of PBS alone, or mixtures of PBS andstock fibrinogen, equivalent to adding 0, 5,10, 15 and 20 mg of fibrinogen.

Calculation of correlation coefficient andslope gives an assessment of linearity ofresponse and sensitivity.

5 If the test system does not demand onespecified specimen container, a comparisonmust be made between alternatives, includingcomparison of glass and plastic. Paired resultson 20 tests should be analysed as above.

EFFICIENCY ASSESSMENT1 The clarity, ease of reference, and com-

prehensiveness of the instruction manualshould be evaluated.

2 Operational timing is established. This isbased on a study carried out on a batch of atleast 10 specimens and extends from speci-men registration to result printout.

3 The level of training required by theoperator should be assessed.

4 Reliability and maintenance: a writtenrecord is kept of any incidents during theperiod of evaluation, especially noting any"down time" due to failure of the test system.

5 Cost analysis should include capital costover a nominal 5 year amortisation and costof annual service/maintenance contract; con-sumables; and labour costs, taking account of

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the required seniority of the operator and theoperational timing, as above. Financial com-parison with the laboratory's current workingmethod should be calculated on the basis of10, 30, 50, 100, and 300 tests per day.

CONCLUSION OF EVALUATIONThis should take account of the technical andfunctional reliability of the test system, cur-rent laboratory practice, the impact of the testsystem on the organisation of the laboratoryand staff reaction to its introduction, andresource implications of the cost analysisdescribed above.

SummaryThe Expert Panel on Blood Rheology of theInternational Council for Standardization inHaematology (ICSH) has prepared new rec-ommendations for measurement of the ery-throcyte sedimentation rate (ESR) under thefollowing categories:

1 ICSH reference method-ICSH nowrecognises, as its reference method for theESR, the sedimentation of EDTA-anticoagu-lated but undiluted blood in traditionalWestergren pipettes that meet ICSH specifi-cations.

2 ICSH standardised method-ICSH rec-ommends specifications for a new standard-ised method for the ESR based on thesedimentation of EDTA-anticoagulated, butundiluted blood in pipettes with a 200 mmscale and which are designed to avoid spillage

of blood or aerosol generation. This stan-dardised method may be used for verificationor quality control of other ESR methods and,in future, may replace the reference method.

3 ICSH selected methods-ICSH recom-mends specifications for working methods,using diluted or undiluted blood, which maybe considered as ICSH selected methods forroutine use. A protocol is outlined for evalua-tion of such working methods against theICSH reference method or the new ICSHstandardised method.

Comments on these recommendations are invited and shouldbe addressed to the ICSH Executive Secretary and to theChairman of this panel.

1 International Committee for Standardization inHaematology (Expert Panel on Blood Rheology).Guidelines on selection of laboratory tests for monitor-ing the acute phase response. J Clin Pathol 1988;41:1203-12.

2 International Committee for Standardization inHaematology. Reference method for the erythrocytesedimentation rate (ESR) test on human blood. Br JHaematol 1973;24:671-3.

3 Fahraeus R. The suspension-stability of the blood. ActaMed Scand 1921;55: 1-228.

4 Westergren A. Studies of the suspension stability of theblood in pulmonary tuberculosis. Acta Med Scand1921;54:247-82.

5 International Committee for Standardization inHaematology. Recommendation for measurement oferythrocyte sedimentation rate of human blood. Am JClin Pathol 1977;68:505-7.

6 International Committee for Standardization inHaematology. Protocol for type testing equipment andapparatus used for haematological analysis. J Clin Pathol1978;31:275-9.

7 International Federation of Clinical Chemistry (IFCC)and International Committee for Standardization inHaematology (ICSH). Approved recommendation(1986) on the theory of reference values. J Clin ChemClin Biochem 1987;25:337-42.

8 Bland JM, Altman DG. Statistical methods for assessingagreement between two methods of clinical measure-ment. Lancet 1986;1:307-10.

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THE EPIC STUDY Continuing Education BuildingSpringfield Mount

The largest pan-European point preva- Leeds LS2 9NGlence study of nosocomial infection in Telephone (0532) 333233intensive care units (ICUs), the EPICStudy, took place on the 29 April 1992in 1472 ICUs throughout 17 western 19th Annual Lukes Conference: or ectionsEuropean countries. The initial data Diagnostic Approaches toalready provide an international Lymphoproliferative Disordersoverview of nosocomial infection in theICU, and the comprehensive results of Monday to Fridaythe 10 000-patient EPIC Study database October 15-19, 1993 Our apologies are extended to Drs Cooke,were presented at the 13th International Jenkins and Stevens for duplication of textSymposium on Intensive Care and Sponsored by Scrpps Clinic and Research in their submissions to the Corres-Emergency Medicine in Brussels, on 24 Foundation pondence section of the Journal (SentinelMarch 1993. This course is designed for haematolo- and Bactec blood culture systems; J ClinThe EPIC Study results will be sub- gists, oncologists, and pathologists who Pathol 1993;46:286.

mitted for publication in an internation- are involved in the histological diagnosis We also apologise to Drs Cooke andal journal later this year. Each or clinical evaluation of patients with Jenkins for the inadvertent inclusion ofparticipating ICU will receive an indi- malignancies of the lymphopoietic sys- unnecessary text in Dr Stevens' reply.vidual unit report followed by an tem. The conference will be held at theadvance copy of the special report on Sheraton Grande Torrey Pines Hotel in Owing to printers' errors, incorrect formu-the European results of the study which La Jolla, California. The course will lae were published in the ICSM recommen-will be available to non-participating offer 27 credit hours of Category I CME dations for measurement of erythrocyteICUs in due course. credit. sedimentation rate; J Clin Pathol 1993;46:

For further information on the EPIC For fiurther information contact: 198-203. Diluted blood ESR mm = (undi-Study final results meeting, please con- Department of Academic Affairs, 403C, luted blood ESR mm x0W86) -12 is thetact the EPIC Study Co-ordinator, Scripps Clinic and Research correct version. Whenever this formula isMedical Action Communications, Foundation, repeated throughout the text the multiplica-Action International House, Crabtree 10666 N. Torrey Pines Road, La Jolla, tion sign should be read as x. A correct ver-Office Village, Eversley Way, Thorpe, CA 92037. sion of the recommendations has now beenEgham, Surrey, TW20 8RY, UK. Telephone: (619) 554-8556 reprinted.

Fax: (619) 554-6310 We apoligise to Professor Stuart for anyinconvenience caused.

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clin icsh recommendations for measurement erythrocyte ... · the term erythrocyte sedimentation...

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